Egypt's draft healthcare bill dogged by concerns about much-needed overhaul

Ayat Al Tawy , Wednesday 20 Jan 2016

Gamal Abdel Naser Hospital
File Photo: A patient lies on a rickety bed in the Gamal Abdel Naser Hospital in the Mediterranean city of Alexandria (Photo: 'So That He Doesn't Get Surprised' Facebook page)

Many Egyptians have for decades suffered from poor service and grim conditions at dilapidated state-run hospitals, while an overhaul of the healthcare system remains a longstanding demand.

Some observers argue, however, that a new draft health insurance bill falls short of hopes for better healthcare in a country where 26 percent live below the poverty line.

Leading Egyptian doctor Mona Mina says the long-awaited law portents control by the private sector of the country's ailing healthcare, while officials and lawmakers argue it will bring inclusive coverage and much-needed cash to improve the badly under-resourced system.

In place since the early sixties, the current state insurance scheme has benefited over half of Egypt's population of 90 million, mainly the underprivileged.

The new system meanwhile will cover the entire populace by imposing compulsory monthly subscriptions on all Egyptians. The government will enter into contracts with private and public hospitals alike based on quality standards, something critics believe will tilt the scales in the private hospitals' favour.

They fear this will eventually lead to the privatisation of substandard state-run hospitals which are believed to be less likely to survive the tough competition.

"This would be a crime," Mina, Secretary General of the Egyptian Medical Syndicate said.

"Most of the government's hospitals are in decay because of the lack of spending and corruption to the core," said Mina, who is also a long-time prominent activist and played a role in the 2011 revolution.

"This means they will be less likely to win such contracts, leaving the field dominated by the private sector which will seek to raise prices at some point."

"Health should not be a product. It's a right," Mina added.

The Private Sector

The country's official census authority says Egypt has 657 state-run hospitals and 937 private facilities, according to 2013 figures.

Officials say incorporating privately-owned hospitals in the scheme will expand healthcare coverage and prompt development of state-run facilities to beat off the competition.

"The state facilities are never enough to provide regular service for everyone," Tarek Kamel, a physician who co-drafted the bill, said.

Egyptian doctors and patients have long voiced grievances of lack of special units, inadequate medicines and a shortage in well-trained staff at state-run hospitals--things that have for years affected the flow of service.

Private hospitals offer superior care only for those who can afford it- not much relief to many in a country where one in four live below a poverty line of $1.65 a day.

"Even if you develop state hospitals so they become like 5-star hotels. You'll still be in need of private facilities to be able to cater for a population of 90 million," says Kamel.

Kamel dispelled fears of a possible rise in healthcare costs, saying service providers will have to comply with prices the government sets--even though a quarter of the pricing committee will be representatives from those service providers including privately-owned hospitals, as the law states.

The government will also decide every five years whether to renew or revoke licenses of hospitals involved in the scheme.

Five years in the making, the draft bill was drawn by a 22-strong committee of health insurance officials, finance leaders and academic physicians. It was referred to the cabinet in December and is now being looked at by a ministerial committee. If approved, the law will then be sent to parliament for the final go-ahead.

Dozens of labour unions and professional syndicates as well as several political parties have expressed rejection to the proposed law.

'Inclusive' Scheme

Under the current system, mainly state employees, farmers, and school students benefit from the state-sponsored insurance which fails to cover all family members. The private sector pays a meagre premium to the government and insures its own employees.

Egypt's health minister Ahmed Emad El-Din Rady says the country is spending around LE 120 billion on health in the current fiscal year. Almost 60% of the figure is private expenditure, mainly out-of-pocket, according to latest data from the World Health Organization.

The new bill will make everyone but the armed forces subject to compulsory "subscriptions" based on certain categories including business owners, expatriates, and casual workers.

But updating databases of everyone, including unregistered employees or vulnerable citizens operating in the bloated informal sector, which officials have little data of, will be a major challenge to the government, kamel, of the law-drafting committee, says

The payments range from 1 to 4% of the monthly take-home pay excluding specific allowances.  This constitutes a greater percentage than that under the current system that is calculated from only a slice of the employee's salary--called 'insurance salary' (maximum LE2100), according to Kamel.

The breadwinner will also pay monthly subscriptions for their family members, including an unemployed wife and each of the kids (2% and 0.5% respectively).

Without a proof of the subscription payment, Egyptians won't be able to complete administrative procedures including renewing driving licenses, private and public school enrollment and occupational permits.

Aside from subscriptions, citizens will also pay "contributions" for additional medical services they receive including medicines (20% of the price) X-rays (10%) and analyses (5%).

Those suffering chronic diseases and pensioners will be exempted.

The bigger revenues predicted to be generated through the new scheme will help provide a fully inclusive coverage and boost healthcare spending, officials say.

"[The government] is now collecting peanuts and is required to provide good service," Kamel said.

"The law introduces a takaful-based system which will achieve social justice. Even those who enjoy excellent medical care will pay so we can get money to treat the poor," he added.

Other key concerns

The bill states that the government coffers will completely cover those "who cannot afford it," an estimated 42% of the population, according to the Health Ministry.

But Mina and other critics say the draft law provides loose definition of those groups and states that the ministry of social solidarity will have the final say on who falls under that classification.

Aside from the share of medication costs paid by patients, which is aimed to curb overprescription by doctors, Mina argues that other contributions would undermine the basic idea of medical insurance and limit access to the service for the underprivileged.

Another major concern is that the law stipulates that citizens' payments can be "modified" by the parliament in case of "budget deficit."

The draft law states that three bodies for financing, supervising and providing the service to citizens will be set up, with members appointed by the cabinet.

But in a country with low levels of transparency and restricted access to data, the absence of representation by civil society, independent syndicates, and beneficiaries in such bodies makes segregation meaningless and undermines the aspect of independent supervision, Mina says.

The law also makes hospitals entailed in the scheme subject to new regulations by one of the new authorities, something observers say might threaten enshrined rights granted to staff, including permanent contracts.

The new system, if adopted, will initially be implemented in six governorates, including the border north and south Sinai regions and later rolled out across the country over the span of six years. 

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