Preparation of this report was faced with the almost insurmountable difficulty in obtaining the necessary statistical data. Acess to information from the Minstry of Health (MOH) is virtually impossible and details or the ministry;s expenditure are simply "not available". Nationally, a poverty eradication plan does not exist and the recommendations of the Social Summit are on nobodys agenda. This contrasts somewhat with the governments position towards the recommendations of the two other UN conferences held during the past two years, the ICPD and the Beijing Womens conference. The first follow up meeting for the implementation of the ICPD Plan of Action took place in January of this year and some selective recommendations of the Beijing conference are being discussed here and there in a number of seminars. A national conference on women scheduled for next March, of which NGOs are yet to be informed, or to be invited to take part in. One attempt at following up the Social Summit had been planned a few months ago but the meeting was banned, allegedly in view of the fact that the organizing NGO was not registered with the Minstry of Social Affairs. Nevertheless,the same NGO, two weeks later, organized a large conference on the rights of women parliamentarians and met with no government interference.
The following overview of the impact of SAPS on health in Egypt is thus based on some limited data resources that we could get hold of with the help of friends and personal relations, as well as from a Poverty Watch report that is currently being drafted by an Egyptian NGO, the Centre for Trade Union and Workers Services (CTUWS), and the writers personal experience of 17 years of work in a university hospital, which at one time provided freeofcharge service for thousands of patients and their families from Cairo and the rest of the country.
The World Development Report, 1993 (Investing in Health World Development Indicators) states that: "As far as clinical services are concerned, the principal government failing in most countries is the attempt to provide everything to everybody, with no distinction between more or less essential care or the more or less needy patients".
This assumes that everybody in Egpt, needy or not, is using public sector state subsidized health services. This has been the rationale used by the Egyptian government to launch a process of privatizing the health services by adopting a policy of restricting subsidized public health care to those who cannot afford unsubsidized care. In fact, the poor quality of health care as provided by the vast base of primary health care centers, usually lacking in equpiment and trained staff. This government policy has always restricted the use of those services to those who cannot afford other more expensive services. The private sector (whether in clinics or private hospitals), although expanding in the last ten years, has always been an integral part of the seven different health systems operating in Egypt, of which six provided only paid service, irrespective of whether the payment was made by the client or an insurance system that covered limited sectors of the community.
People whose incomes allowed it, have always opted to resort to private sector clinics, because of a reputation for better service. There is no foundation for the claim that public sector or free health service was ever used in any significant way by people who could afford to pay for their health needs. Indeed, people who used to come to the outpatient clinics of university hospitals in the late seventies and early eighties had little need to prove their poverty and lack of resources it was obvious at first glance. And it has been this category of patients, the poorest of the poor, which has all but disappeared now from among the attendants of the semiprivatised university hospitals.
SAPs and Health
Egypt was incorporated into the SAP network in fiscal year 1985/86, when it entered into negotiations with the World Bank/IMF. An integral part of SAPs in Egypt has been the states gradual withdrawal from subsidizing essential goods and basic services. Within the latter education and health care have suffered the greatest reductions.
A salient feature of the effects of SAPs on health has been the encouragement of private sector enterprises in health. This took place in two ways (Cost Recovery Projects of Health, project number 2630170)
Privatizing Public Space in Public Sector Hospitals
As early as 1988 the vast sum of $95 million was allocated for a project called "Cost Recovery Programs for Health". This project was presented to parliament in Arabic language then under a flagrantly mistranslated heading where cost recovery was translated as convalescence. The project was approved by parliament in a single session. What it entailed was that the MOH and USAID would implement this project through a performancebased disbursement system which pursues cost recovery policy changes and implementation plans which would institute cost recovery user fees and management systems in 50 Ministry of Health facilities. All 50 would ben be converted under component one to cost recovery institutions, which utilize user fees and improved management systems.
The ultimate goal of the project was to improve the health of the Egyptian people. The measurements that were adopted therefore were a progressive increase in life expectance and a decrease in infant and under 5 mortality. Access to health or the lack thereof was not set as an indicator in the assessment of the project.
The cost recovery project was managed by a "cost recovery project executive steering committee" which was appointed by the Minister of International Cooperation to provide policy, advisory and coordination assistance to project activities and participants. Membership consisted of representatives from the Ministry of Health, Ministry of International cooperation, the Egyptian Credit Guarantee Corporation, the Health Insurance organization, the Curative Care Organization, the Medical Syndicate, a private health care provider and a USAID provider. Represented beneficiaries on this board, therefore, involved the government, the health institutions, the medical professions, the banks and the donors. The consumer, was, of course, not represented.
What this project entailed was literally the selling out of public sector health facilities to those who can pay. The role of civil society in the field of health was restricted to the role of a feeforservice provider in the private sector or contribution to health care through NGOs which apply for their own project funds to deliver such services which last as long as the project lasts. Primary health care centers often host those projects if they are jointly done by the government, upon which the location flourishes for a few years and then once again deserted. People in the circle of those projects use terms like "before the project", "after the project", etc. to stress difference in personnel, service, care, etc. A stark example for this selective pouring of project related funds can be seen in university hospitals. Departments hosting some foreignfunded health projects stand out like posh districts among slum areas, the latter being those departments which did not manage to host similar projects or establish "economic" units within them based on the cost recovery principle. In the absence of allocation of resources to university hospitals, patients and their families are continuously being asked to complement their treatments in these hospitals, either buying medication, or surgical instruments, etc. In surgery departments, whether the patient will be operated on or not, family members have literally to pay with their own blood (i.e., act as compulsory blood donors) for their patients to be admitted.
Encouragement of Public Practices
The second component of the above mentioned project involves the encouragement of doctors initiatives in establishing private practice. Doctors in the public health services (whose salaries are too low to maintain the bare minimum of a decent living standard) are encouraged to apply for small loans to establish private clinics which they establish in urban slums and impoverished rural areas. The concern of such doctors is solely the generation of income. Their enumeration among health care providers to serve the poor is a farce as their fees and the standard of service they provide are determined by the principle of maximum possible profit.
According to the Ministry of Planning Summary of the third fiveyear economic development plan, the health sector (public and private) has been allocated the least investment expenditure among the other sectors (1.5%). The total health expenditure in 1990 was $921 million, or $18 is the per capita (Ministry of Planning Summary of the third Five year Plan. 1992/1993 1996/1997. MOP, July 1992, p.3 Appendix). The curative sector ranks the first among the different sectors concerning the total amount of monetary and physical components allotted to it from both local and foreigndonor sources. This is followed by the basic health sector which receives about a third of the total expenditure. (Heba Nassar, Health and Human Development, part of the study conducted by INP and UNDP on HDR of Egypt, 1993).
The Human Development Report 1995 ranks Egypt among countries with medium human development. However, public expenditure on health dropped from 3% to 2.8% of total expenditure and 1% of GPD (Egypt Human Development Report, 1994). This is below the subSaharan Africa average of about four per cent. (Poverty Watch Report, CTUWS, in preparation). 65% of this budget is consumed by salaries, which begin at a very low level and cannot keep pace with inflation (DANIDA, 1994). With this expenditure on health and with a population of which 33.9% are poor and 7.6% ultrapoor, access to costrecoverybased health services becomes almost impossible.
In 1994 Egypt was the only Arab country that would not or could not provide the Population Council with data on the general populations access to health services (Poverty Watch report, CTUWS, in preparation). And yet the UNDPs 1994 Human Development report and the Egyptian Human Development Rport 1994 claim that the accessibility of the health service stands at 99%. In rural areas and 100% in urban areas. This almost 100% health coverage of the the country is based on a theoretical geographical distribution of health care centers established in the 60s and 70s which meant to, and at one point did, cover the whole country and confirm the constitutional right to free health service for all. The fact ofthe matter is that most of those health facilities are at present terribly under utilized. A background paper on DanishEgyptian cooperation in the health sector states: "it is easy to find completely deserted health units, with neither patients nor physicians in attendance". The paper proceeds: "The desertion of the rural health care units has become significant enough that the current USAIDfunded child survival program is not even attempting to work through rural health units, but instead is concentrating its interventions directly on government hospitals, in recognition of the fact that these hospitals are the first line care providers for a large part of the population. This is enormously problematic: first the purposes of hospitals and private practitioners do not include primary health care not to mention preventive care, second the use of general and specialized hospitals as first line care providers is hardly cost effective".
Such observations are doubly significant when we realize that USAID is by far the largest donor to the health sector in Egypt. Its choices as to where to channel its money not only draws the map of the health service institutions in Egypt but also determines thereby who and how many are to benefit from the health services and who do not.
The conditionality of aid to health has been questioned and debated by several NGOs working in the field of health and human rights. A meeting on reproductive health priorities hosted by the Population Council was attended by a MOH Official who was challenged on the narrow use of the concept of reproductive health and its restriction to familyplanning and birth control which ignoring of all other components of primary health care for women of all ages. The officials reply was that the aid received in health is conditioned by the donor by the area of expenditure and is very frequently in kind, leaving no space for reallocation depending on priorities. As far as women are concerned birth control methods are THE priority seen through Donors eyes.
Several reports estimate the health care coverage of Egypt at 100%. One does not even have to move out of the city to realize that this is not the reality. Several indicators challenge this figure: 75% of Egyptian pregnant women suffer from anemia and maternal mortality rate lies at 270/100.000 live births. Also, 49% of births are unattended whether by medical or trained personnel, only one third is attended by doctors or nurses and one fifth of women deliver in institutions. Another challenge to the alleged 100% population coverage with health care services is an infant mortality rate at 67 per 1000 and underfive mortality rate at 59/1000 live births. Field workers in rural and slum areas suggest infant mortality rates to be higher than recorded in official documents. They stress the high rate of underregistration which they estimate between 11 and 25%. The main cause of neonatal deaths is complications of pregnancy such as neonatal tetanus and birth trauma. This proportion drops down to around 20% for infant deaths, where diarrhea diseases and acute respiratory infections account for 58% of the total infant deaths, all of which are diseases that should be both preventable and treatable on the primary care level. (Egypt Human Development Report, 1994)
Health and Unemployment
According to World Bank data unemployment rates have now reached 17% affecting 2.8 million people. Among the documented unemployed the hardest hit are women, youth and those with no prior job experience who have a 75.4 % unemployment level. In this group women proportionately fare the worst. For young high school graduates unemployment is estimated at 65.4 % (Povery Watch, CTUWS, in preparation) Womens overall unemployment is thought to be around 60 per cent although the UN 1991 statistical unit records a much higher level of 89 per cent. (Nahe Toubia, ed. In: Arab women, A profile of diversity and change, the Population Council, Cairo, 1994, p.47). Those unemployment rates are expected to increase with the selling out of public sector factories and companies and laying off of workers, initially benefiting from the health insurance provided by their work places. Workers who were not covered by company insurance, and those are many and are expected to increase with the implementation of the new labour law, find themselves with no insurance umbrella and have to resort to the available fee for service health care. Findings of the case studies done in preparation of the poverty watch report with individual members from 150 families reveal that heads of households working in the formal sector, usually men, resort to their work institutions for health care, while their wives and children have to use free fro service health facilities. In the majority of the cases the expenditure on health, usually meaning doctors visits and medication may reach a sum of 20 to 30 pounds per month apart from families where a member suffers a chronic illness where the sum of money needed may reach higher than that. If we consider that 40% of the Egyptian population live under poverty line (estimated at 831 LE/year in urban areas around 680 LE in rural areas according to annexes of World Bank report no. 8515EGT on poverty alleviation and adjustment in Egypt), it becomes clear that those 10 30 pounds are not a mean part of the familys budget. The inaccessibility of health care to large sections of the population becomes even more serious when we take into account the fact that pharmaceuticals prices have risen by up to 300% during the past five years, and that the national drugs industry is facing highly unequal competition from international drug corporations and is, through privatisation, being replaced by these international corporations on the domestic market. The DANIDA report on the situation of the health sector in Egypt notes that the rise in both pharmaceuticals prices and the cost of care in the public sector is forcing the poorest sections of the society to postpone treatment due to lack of funds.
In practice the laying off of workers means a loss of a salary and a loss of subsidized health care. Women who previously had put their health needs second to those of their children now have to put them in third place after responding to the health needs both of their children and their husbands (Reproductive Rights Research New Woman research Center, (NWRC) 1994).
For the Egyptian health planner health services for women are always associated with family planning services. The expressed motive behind this concern is not the empowerment of women with decision making possibilities as regards their reproductive rights and choices but a control over the rate of population growth which is the major cause behind all of the countrys economic and social hardships (Reproductive Rights and SAPs, Critical Links, NWRC, 1994). Women are targets of the health policies in their reproductive years only. Concern about their health in earlier and later years remains solely the concern of NGOs, recently gaining interest on the issue.
Quoting the DANIDA report: the January 1994 Consultative Group Meeting in Paris enumerates many of the important health issues in Egypt and stresses the need to protect the health of the poor. The World Bank then suggested that more targeted welfare systems needed to be developed with no indication as to how and when this might transpire. However, it provides little insight into ways and means of ealing with either the sequencing of reforms in the health sector or to ways and means of ensuring that policy statements concerning the safety net for the poor are translated into reality before the worst consequences of structural adjustment became manifest.
The report of the consultative meeting assigns to NGOs those sections of the population with the least access to health services. It fails to indicate, however, which NGOs are able to undertake such a responsibility, where funding for such activities will come from, or even who and where these groups are. The report then proceeds to question the relevance of such a strategy given the Extreme control exerted by the Ministry of Social Affairs over all NGO activity, particularly fundraising.
The strategy, thus, allocates to NGOs the role of filling in the gaps created by SAP driven governments as they withdraw from supporting and subsidizing basic services for the citizens. NGOs are supposed to do this and keep silent on policy, indeed, every effort is made to prohibit them from addressing decision makers and donors and reacting to their plans and strategies.
The new labour law, which is to be presented to parliament shortly, has been drafted behind the backs of workers organisations and other institutions of civil society. In this law, workers rights are being sacrificed in the interest of the market economy and capital. Women are specifically targeted by the new law which acts to deprive them of their maternity and reproductive rights in order to compel them to abide by the states population policy which demands control of childbirth.
This draft for that law as well as other documents, which are necessary to access NGOs to processes of negotiation, and lobbying are never made public and our access to them remains dependent on personal connections. However, if personal connections may sometimes grant access to information the access to participate in planning, decision making and follow up remains entirely in the domain of donors and government, which is constantly increasing its restrictions on the spaces allocated to civil society institutions. Partnership relations with NGOs in general inclusive of the health sector remains in the domain of service provision only.