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Egyptian medical system is mired in patronage

Organised to help the poor, "treatment at the expense of the state" has become a purview of the nation's wealthy.

Ragab Moawad Abdullah, left, and his family visit his wife, Awataf, who sits in a wheelchair at Ain Shams University Hospital as she recovers from heart surgery. Victoria Hazou for The National
Ragab Moawad Abdullah, left, and his family visit his wife, Awataf, who sits in a wheelchair at Ain Shams University Hospital as she recovers from heart surgery. Victoria Hazou for The National

CAIRO // Ragab Moawad Abdullah grinned widely as he stood in the visiting lounge of Ain Shams University Hospital. His wife, Awataf, was recovering last week from a risky heart surgery that had been paid for almost entirely by the government, and Mr Abdullah had a scandal in Egypt's parliament to thank.

"I was surprised because before, it was not easy to get such [treatment], but now the system is well organised and easy," Mr Abdullah, whose government pension does not cover his wife, said of the recent bureaucratic victory that allowed him to bill the state for his wife's surgery. It was perhaps the perfect moment for Mr Abdullah's wife to get sick. Months earlier, some of the same funds the state had used to pay for Awataf's surgery had been entrusted to members of parliament, many of whom used the money as gifts for influential constituents or to line their own pockets.

That all changed when media reports implicated parliamentarians in the improper use of medical treatment "decisions" for everything from cosmetic procedures to luxury hospital stays abroad and gift treatments for political allies. When stories of the abuses broke, the ministry reined in the programme, referred to as "treatment at the expense of the state" (TES). If then limited the discretionary health ministry funding parliamentarians were supposed to use to award treatment "decisions" to poor constituents, such as Mr Abdullah, who lack insurance coverage.

The scandal has added urgency to calls to reform Egypt's broken healthcare regime, a chronically underfunded system that has provided ample opportunity for malfeasance while leaving more than half of the country without medical insurance, health-rights activists say. Samir Fayad, a physician and the deputy head of the leftist El Tagammu Party, said TES "was created as a corrective tool for the inability of the ministry of health to fund the hospitals or the peripheral health units from the government".

That the system survives demonstrates the lack of political will to reform Egyptian health care, activists say. The National Democratic Party, which has dominated Egyptian politics for decades, resisted calls to double or triple health care's share of the budget - the percentage growth experts say would be necessary to care for the estimated 38 million people who lack insurance. Gamal Abdel Nasser, the second president of Egypt, started TES in 1959 as a way of allowing any Egyptian - rich or poor - to petition the ministry of health for state funding to seek sophisticated treatments abroad for "catastrophic" conditions, such as chronic illnesses. More than a decade later, market-based economic reforms laid bare the inherent problems in Nasser's socialist healthcare system.

In 1975, Anwar Sadat, Egypt's reform-minded president, shifted the aim of TES to provide ordinary medical treatment in Egypt for "the most vulnerable and uninsured" patients, said Alaa al Din Ghanaam, the health and human-rights programme director at the Egyptian Initiative for Personal Rights, a Cairo-based non-governmental organisation. By the mid-1990s, TES had evolved from a temporary, stop-gap funding measure into a full-grown institutional fixture that allowed the government to cheaply fund individual treatments instead of meeting the full financial demands of comprehensive health care for what are now 80 million Egyptians.

Wealthier patients began to avail themselves of the process, turning to their representatives in parliament to speed through the bureaucracy required to secure funding "decisions" from the health ministry. "It was intended for the indigent and the poor, mainly," Dr Fayad said. "But gradually it becomes the right of the middle class. And finally, it gets to be the right of the high class. As usual."

By last year, two-thirds of the six million Egyptian pounds (Dh4m) the programme disbursed daily were distributed through MPs. Some used the decisions to purchase medical equipment abroad to sell to Egyptian medical firms. Others filed claims for dead "patients", according to newspaper reports. Government investigators said 250m pounds was squandered. When the programme had reached bursting point this year, the ministry of health cut funding by about half, to 1.1 billion pounds from 2.2bn pounds the previous fiscal year.

It was then that the problem "exploded" in the media, said Hamdy al Sayed, the chairman of the People's Assembly's health and environment committee and a prominent member of the ruling party. "They claim that the reason is that there is an abuse of this service and that some members of parliament are responsible for it," Dr al Sayed said. "My own feeling is that this is not really true. I don't believe that a member of parliament would try to make a business out of this paper," he said, referring to the treatment authorisation decisions.

The TES guards against corruption because the decision "papers" can only be redeemed for specific medical procedures prescribed by at least three doctors, Dr al Sayed said. They are not liquid cash. But for those who have managed to wrangle some of the remaining funds from the embattled TES system, the decisions amount to last-minute clemency. "I wish the hospital administration would help people learn where to go and get this help. There are people from villages who don't know how to get this treatment," Mr Abdullah said.