The surgeon came out of the room to tell the family that he needs to insert an arterial stint in the heart of their loved one, who was lying under light anaesthesia in a neighbouring makeshift room in a residential building-cum-hospital in Cairo.
"This will cost you 42,000 pounds," the well-known heart surgeon said. He and the hospital had adamantly refused to give the family a cost estimate for this scheduled and routine procedure.
The family members were shocked as their doctor friends had confirmed to them a much lower rate for a stint. They protested. The surgeon, agitated, offered to pull out his catheter so they could take the patient home with his clogged artery
Worried about a repetition of the trauma, they succumbed to the unethical doctor. Later on, they managed to pay around 30,000 pounds for a 45-minute procedure that would have cost probably less than half of this exorbitant fee elsewhere in the utterly disorganised healthcare industry in Egypt.
Despite the unethical behaviour and humiliating experience, this was a lucky family. They could afford the hefty payment for a procedure that was recommended days earlier in a relatively good clinic in Cairo.
The majority of patients in Egypt are not as lucky. The country is rife with horror stories about patients dying or unnecessarily suffering because they cannot afford surgeries or medicines. Even worse, there are well-documented stories of patients who could afford the services but died due to alleged malpractice by irresponsible care providers who can get away with fatal blunders because the regulatory system is broken, at best, and conducive to such murderous behaviours at worst.
The lack of appropriate and affordable healthcare could be the number one killer in Egypt. Hundreds have died in terrorist attacks in Egypt in the past few months, some of them innocent civilians (including tourists) who were collateral damage, but thousands die every passing day or suffer irreparable loss to their health and income due to preventable diseases, medical negligence and infections.
Think of the millions of Egyptians who suffer from Hepatitis C, a disease that spreads through blood due to the negligence of private and public healthcare providers in abiding by simple protocols.
A fraction of citizens can afford the expensive medicines that cost nearly 10,000 pounds. Or consider the trials and tribulations of the millions of Egyptians who are on regular treatment for kidney problems, hypertension and diabetes.
Substandard healthcare and inadequate nutrition have together left each fifth child under five in Egypt stunted (short for their age or chronically malnourished). Stunting means those children are forever physically and mentally compromised.
On average, an Egyptian spends nearly 72 per cent of health costs out of pocket in a chaotic market.
When thousands of police personnel demonstrated and organised an armed sit-in last month, one of their top demands was a better healthcare system.
One of the last bureaucratic skirmishes between the Egyptian judiciary and the executive branch was about its healthcare entitlements. The police personnel wanted to be treated in hospitals only open to higher ranking police officers, while the judges secured the monthly payment of 3,000 Egyptian pounds each as additional coverage for medical needs. These groups have sought and secured special solutions for themselves, leaving behind tens of millions of Egyptians with unaffordable and shoddy services.
Egypt is in bad need of a functioning health insurance system.
Egypt first regulated a national health insurance system in 1964. Twenty years ago, this system expanded to cover school children (nearly 14 million at the time). Then in 1997, another seven million kids under school age were brought under coverage.
All these magnanimous government decisions were simply PR stunts, not backed by feasibility studies or actual sustainable resources to see whether the existing system can provide the needed minimum service.
By 2000, the system started to collapse. The Egyptian Health Insurance General Agency does not cover the poorer half of the population, but even among those covered, it is estimated that the agency is able to provide services to no more than 12 percent of them.
Those who can afford it opt for private providers who remain prohibitively expensive for some despite their unreliable quality. The 2014 Egypt’s Demographic and Health Survey showed that only eight percent of ever-married women aged 15-49 are covered by any insurance.
The current health insurance system is all but fully broken. It is no longer truly financially solvent. The service quality is unpredictable and unsupervised by an independent body.
For several years, the state has been considering a new system to be introduced through a comprehensive health insurance law. Several drafts of this bill have been produced with restricted but vital input from civil society (political parties, nongovernmental organisations, universities and trade unions) in the past 15 years. One government after another failed to reform a system that continued to decay and unravel.
Almost all drafts, with the exception of the current one, were fixated on decreasing the state's burgeoning liability and addressing the crumbling finances of the healthcare system. One minister tried to privatise the Health Insurance General Agency by turning it into a holding company, but the decision was frozen by a court after it was legally challenged by the Egyptian Initiative for Personal Rights.
The current draft, however, finds adequate solutions and compromises for the most important issues: financing, accreditation and regulation for service providers and overall policies.
Each of the three suggested structures would handle one or more of these functions independently.
The Health Insurance Agency would be responsible for raising funds and paying providers, the Ministry of Health would ensure quality and monitor providers, while a Supreme Health Council would put together strategies and policies, leaving accreditation and licensing of health providers to an independent council.
The law also calls for establishing or remodelling existing community-based healthcare units to be the first port of call for the insured before referrals to specialists and/or hospitals. Each unit is envisioned to serve up to 3,000 families.
There are many challenges to implementing such a law. One of them is to find the necessary 20,000 family doctors to staff this system at a time when Egypt has only 4,000 such physicians, mostly in Cairo and Alexandria provinces.
Another challenge would be funding. Alaa Ghannam, a former senior official at the Ministry of Health who currently leads the "right to health" team at EIPR, believes the average annual budget for the system will be around 100 billion pounds a year.
However, the law, which he helped draft, outlines a detailed funding system that should cover this cost with money made available from the insured, employers, special taxes on tobacco, alcohol, construction materials industries, licensing fees, etc. Moreover, the state is committed to raising expenditure on health services to 3 percent of the GDP by 2016 in line with the constitution.
This healthcare bill, which has been meandering through the Ministry of Health for over a year, is unlikely to be promulgated any time soon despite the fact that President Abdel Fatah Al-Sisi has issued over 150 laws through decrees in the absence of a parliament since he took office 14 months ago.
The law will be delayed most probably because it will challenge vested bureaucratic and private sector interests, revealing bottomless corruption and putting an end to astronomical profits made by the upper echelons of the private healthcare industry.
But pressure from those who no longer can afford or trust the decaying system could change this. In a one-day session on this draft at Upper Egypt Society in Cairo attended by over 20 representatives of independent trade unions, a participant from Alexandria lamented that the ruling regime ends up doing what it wants without paying any attention to the many millions who are struggling to make ends meet.
But another trade unionist sitting next to him intercepted. “No, they cannot do that anymore. They will fail and we will not acquiesce.”
He is probably right, because acquiescence in such issues is tantamount to succumbing in silence to a preventable death.
