Just as in the 1950s and 1960s Egypt was the first to champion the public sector as the driving force behind development, in the mid-1970s it became the first Arab country to embark upon an economic liberalisation policy (Ayubi, 1995:129). The adoption of an open door policy, commonly known as the Infitâh, was characterised by a geographical reorientation from promoting trade with the Eastern bloc to Western countries, as well as an attempt to attract capital from the Gulf oil states, lure western investment and technology and promote a greater role for the private sector (Richards and Waterbury, 1990:241). Egypt's increasingly chronic economic problems led the government to open negotiations with the IMF which culminated in a Stand-by Agreement in 1977. This agreement focused on devaluing the Egyptian pound, decreasing the budget deficit and most significantly, reducing subsidies (Momani, 2003:1). In the same year, the government sought to implement some of the conditions made by the IMF. The public announcement of the increase in basic consumer goods led to widespread uprisings – known as the bread riots. Many other North African countries such as Morocco, Algeria, Tunisia and Jordan experienced mass protests after the announcement of austerity measures associated with structural adjustment programmes (Lubeck, 1998:298). The impact of these adjustment programmes on poverty and social inequity have been documented extensively in previous editions of this journal (ROAPE, Vol. 21, No. 60 1994; Vol. 26, No.82, 1999).
The bread riots of 1977 led the Government of Egypt (GoE) to rescind its policy of reducing subsidies on bread and renegotiate the implementation of economic reform measures with the IMF. The GoE premise was that harsh, sweeping reforms would only lead to chaos and violence as the bread riots testified and convinced the GoE to adopt a gradualist approach towards liberalisation in a bid to avoid social unrest. The resistance of the Egyptian government to implement IMF conditions on schedule no doubt influenced the length of the negotiations between the two parties. Another stand-by agreement was signed with the IMF in 1986 but was later abandoned. In the meantime, by the mid-1980s, the budget deficit had risen to 10 per cent of the GDP, inflation was high, and growth rates had plummeted from the previous decade. Negotiations continued between the Egyptian government and the IMF, with the latter insisting on an Egyptian commitment to the implementation of macro-economic reform. It was not until 1991 that Egypt signed an agreement with the IMF to embark upon the Economic Reform & Structural Adjustment Program (ERSAP), and even then, the government insisted on pursuing a gradualist approach (Badran and Wahby, 1996; El Mahdi, 1997; ESCWA, 1998; Ibrahim, 1996). While the pace of economic reform has picked up since ERSAP, the official policy vis-à-vis welfare provision and subsidy support continues to be that the Egyptian government has no intention of introducing cutbacks that will impact adversely on the poor. There has been much debate on whether the implementation of ERSAP has actually led to the dismantling of the welfare state. Ayubi argued that ‘the welfare functions of the state bureaucracy … have not been significantly curtailed’ (Ayubi, 1995:131). However, critics of SAP (Korayem, 1996; Zaytoun, 1998; El Laithy, 1999; Eissa, 1998) argue that it has led the state to relinquish many of its welfare responsibilities towards the poor.
Adopting a micro-approach I now compare the predicament of the poor prior to adjustment and afterwards. In so doing, I decipher how their access and use of welfare services (in the areas of education and health) have changed in the past thirty years. My case study is of the low income urban settlement in Cairo, Bulaq el Dakrour. The data are based on daily interaction with the poor as a participant observer living in the community for over a year. This was complemented with interviews with high level and locally-based officials in both the Ministries of Education and Health to gain an understanding of the dynamics influencing policy making.
Education & health: the pre-adjustment years
Until the early 1950s, Egypt did not have a government policy for universal provision of education and health services. They had been partly provided by the government, partly by the private sector and significantly by charities and associations established under the patronage of the aristocracy, missionaries and indigenous religious and secular organisations (Kandeel and Ben Nefissa, 1994; Badran, 1995:50; Sorial, 1981; Centre for Development Services, 1995). While there were several plans to expand education and introduce rural health units, they never materialised because they were of low priority.
In education, prospects for equity enhancement and upward mobility were restricted through the dual system: a free system, called elementary and another, called primary, for those who could afford to pay. It was only after the successful completion of primary school that students could go on to university and higher institutions of learning (Boktor, 1963:27). The system inherently undermined the principle of equity, since only those who could afford to enrol in primary school could further their education. It also rendered meaningless the 1924 decree which stipulated that primary education was compulsory for all, especially since there was no budget allocated for the provision of affordable education for the poor (Cochran, 1986:23). Education remained highly skewed in favour of the rich until 1953.
Following the 1952 revolution, there were efforts at universalising education and, to a lesser extent, health. In education, a national strategy for making education accessible to all was instituted in 1953. There were high ambitions for the expansion of schools, increased intake of students and more teachers. In order to redress the inequities in the educational system, Law 214 was issued in 1953 exempting all pupils from payment of school fees. All levels of education were made free of charge (Boktor, 1963:38) and primary school was made into one single system for all. The earlier results were impressive, going beyond the increase in the overall population (Cochran, 1986:36; Boktor, 1963:6). For example, enrolment expanded from one million pupils in 1952 to three million a decade later (Boktor, 1963:204). There were continued increases in the budgetary allocation to education, reaching almost 48 per cent of the total budget by 1959 (Boktor, 1963:29).
Prior to the 1952 revolution, many hospitals and clinics were established as philanthropic initiatives under the patronage of aristocratic women. The most notable were the Mabarrat Muhammad ‘Ali and the Red Crescent Society, both NGOs which played an important role in fighting the malaria and cholera epidemics that swept through the country in the 1940s (Gallagher, 1990). The new Nasserite government announced a change of policy. Medical care provision was to become the responsibility of the state and not of private charities. An ambitious plan was introduced to build rural health units and public hospitals around the country. Use of rural health units increased and in the 1960s, many of the earlier societies and associations were nationalised as well as 13 private hospitals (Gallagher, 1990:171). By 1962, ‘public health had become an idiom in the national discourse’ and the government promulgated its charter that stated:
The first right of all citizens is health care – not the bare treatment and drugs like goods bought and sold, but rather the unconditional guarantee of this care to every citizen in every corner of the country under conditions of comfort and service (Gallagher, 1990:175).
From 1960 to 1965, the emphasis was on technical and primary education (Cochran, 1986:49). The intention was to ‘spread educational benefits to low income groups’ (Abdel Fadil, 1982:366; Badran, 2003:207). Yet the gains in equity were slowed down in the late 1960s due to a number of factors: the huge proportion of the budget directed to rearming the military following the 1967 defeat in the war with Israel and the rapid population growth and the stagnation in the economy. The adoption of the Infitâh policies in the 1970s also meant that equity concerns were deprioritised. Sadat moved quickly away from Nasserism and its association with socialism as a state policy (Badran, 2003:247). Nevertheless government rhetoric was not accompanied by severe budget cuts:
For all the talk about increased efficiency, benefit-cost criteria and belt-tightening and so forth, Sadat actually increased the flow of resources into welfare programmes that sustain[ed] high levels of consumption (Waterbury, 1983:218).
There was an official tolerance of policies of benign neglect of basic welfare programmes, and the acceptance of growing inequity in the distribution of income and in the quality of social services (Waterbury, 1983:223).
Education & health services after ERSAP
Structural adjustment and stabilisation packages can affect the poor by impacting on their primary and secondary incomes (Stewart, 1995:21). Meso-policies can affect the primary incomes of the poor through taxation or social spending. However, the main effect of meso-policies on the poor is through public expenditure on goods and services consumed by the poor, not taxation, i.e. on their secondary income (Stewart, 1995:51). Meso-policies after adjustment will be discussed through an assessment of the social spending policy vis-à-vis education and health. To decipher changes in the levels of government commitment to the poor during adjustment I examine the ratio of public expenditure to GDP and the social allocation ratio, the proportion of total government expenditure going to social sectors. I also look at the social priority ratio or the ratio of expenditures on the social sectors allocated to priority services which reach the poor (Stewart, 1995:51). Intra-sectoral breakdown of data is not publicly available in Egypt. The first two ratios, however, continued to improve for health and education even after adjustment.
The budget for social spending in 1999/2000 comprised 38.8 per cent of public expenditure, and rose slightly during 2000/2001 to 40 per cent (Hassanein, 2000).1 The increase in social spending is not necessarily synonymous with a commitment to equity, especially if cost recovery measures are introduced. Proponents of cost recovery measures contend that in addition to reducing waste, cost recovery measures will enhance efficiency as the additional funds can be invested in improving services. Yet the assumption that the increased revenues accruing from fees will in fact be spent upon increased provision of services, rather than upon other budgetary heads is often misplaced (Colclough, 1997:19). In the case of Egypt, all the funding collected from user-charges goes directly to the Ministry of Finance which decides how the money will be allocated. My analysis of spending on education and health contests Galal's findings that ‘public expenditure in Egypt has improved access to health care and education’, and that the ‘government is committed to the poor’ (Galal, 2003:21).
Education
The privatisation of education in Egypt is evidenced by the expansion of private tuition that has had a big impact on the poor. One of the World Bank and IMF's earlier prescriptions in the 1980s for reforming the educational system under adjustment was the introduction of cost recovery measures.2 Some advocates argue that cost recovery measures can contribute to an improvement in the quality of education, discouraging not-so-serious students from wasting precious resources and putting pressure on the educational administrators and teachers to improve the internal running of the educational system (World Bank, 1991). Yet many studies have indicated that the introduction of cost recovery measures have had a regressive impact on both equity and efficiency (Colclough, 1997; Tilak, 1997; Appleton, 2001:160). Since 1986 and in compliance with the World Bank, the GoE has increased fees four times (El-Laithy, 1999:19; ESCWA, 1998:25). Private expenditure on education, according to the Egypt Human Development Report (EHDR), has increased considerably over the period 1990-91 to 1996-97 with the poor bearing the greatest share of this increase (Institute of National Planning (INP), 1998). Education eats up 19.7 per cent of household total spending which the poor mentioned in surveys as a major financial burden on their budget (Institute of National Planning, 2000:37).
There is a general consensus that within the educational system the steady process of privatisation is continuing (Al-Laithy, 1999; Korayem, 1997; Eissa, 1997; Baradei, 1997). ‘Unregulated privatisation’ of this process may limit access of the poor to a presumably better quality education imparted through private lessons (Institute of National Planning, 1998:34). There is also evidence to suggest that the school system is being insidiously privatised from expenditure on private tutoring as well as donations and extra-curricular books which in turn puts increased pressure on household budgets;3 private tutoring is perhaps the greatest burden on the poor.
The parallel education system in Bulaq el Dakrour
The EHDR 1997-98 indicates that almost half of Egypt's poor students were taking private lessons compared with 60 per cent of the rich students (Institute of National Planning, 1998). Nonetheless, according to an INP survey (2000), private tutoring represents a higher percentage of the poor's total spending (59.96 per cent) on education than it does for the middle class (53.4 per cent) or the rich (55.9 per cent) (2000:34).
The reasons behind the rise and growth of the private lessons initiative are usually attributed to the Infitâh. Inflation in the 1970s stood at around 30 per cent while increases in salaries were negligible. This had an impact on teachers' pay and their ability to meet subsistence living standards. It also gave them a strong incentive to seek additional work in the form of private tuition (Cochran, 1986:59; Waterbury, 1983:236). On the supply side, the desperate struggle to do well in the highly competitive secondary school examination certificate gave birth to a parallel system of secondary education. Up until the 1980s, education was more or less restricted to the wealthy as the poor could not afford intensive one-to-one tutoring. Gradually, the informal, private tutoring educational system began to rapidly expand to the poorer schools as well, where over-crowding and the deteriorating quality of teaching in classrooms drove pupils to seek education elsewhere (Abdel Fadil, 1982:368; Al-Issawi, 1982:114; Badran, 2003:250). Anis (1995:43) and Abdel Fadil (1982:369) attribute the growth in private lessons to the increased weight of market values brought about by the Infitâh. As a result, Egypt's national educational services were ‘denationalised’ (Abdel Fadil, 1982:371).
From interviews and focus groups with parents in Bulaq el Dakrour, it became conspicuously evident that additional tutoring for their children was one of the greatest financial burdens on the household. ‘Out of class’ tutoring has become virtually obligatory for all students, rich and poor. Parents describe it as the ‘ransom payment’ where they pay teachers in order to ensure that their children pass exams. Parents who were not paying for some form of extra school tutoring in Bulaq el Dakrour were rare. One middle-aged teacher at the Khairîyya Association attributed the rise of private lessons to the time when
the price of everything went up, supervision on education was relaxed, and market values became predominant. Before that, teachers managed to live off their salaries; afterwards, it became virtually impossible.
An analysis of perceptions of people in Bulaq el Dakrour suggests that the nature of private lessons and its nuances have changed. The objective of taking private lessons was initially to help improve the performance of weak pupils or those who wanted to excel in examinations. But from interviews with parents, students, school teachers and NGO workers it seems that whether the student is doing well or not, private lessons have become compulsory. In addition, pupils are forced to take lessons at a much earlier stage than before. Private lessons were usually taken in preparation for the general preparatory examination and the years following that in preparation for the general secondary examination. It is now the case ‘From the day you enrol your child in first grade primary, you enrol him (sic) in extra tutoring’. There were indeed many cases where children in first and second primary school were enrolled in additional classes out of school hours. Parents also complained of a drastic rise in the price of private tuition, especially in subjects like English where there is a shortage of teachers.
Former Minister of Education (MoE) Hussein Bahaaeddin acknowledged that private lessons are a serious problem undermining the educational system, and vowed to deal ruthlessly with it (Bahaeddin quoted in Al-Ahram, 25 October 2002). He called for its criminalisation by law (although this never materialised), and allowed for modest increases in teachers' fees. He also introduced the concept of majmû'ât (Al-Seiba'i, Al-Ahram, 27 January 2002). The majmû'ât were supposed to bring an end to informal education by offering extra-class tutorials at set prices under the supervision of the school. It was an attempt at institutionalising the practice, and thereby regulating it.
Muhammad al-Husseini, director of the Safiyya Zaghlul Public School in Bulaq el Dakrour explained that there are two types of primary majmû'ât: there is the ‘distinguished’ majmû'ât at a cost of LE12.40 a month, and the ‘regular’ majmû'ât at LE5.40 a month. At the preparatory and secondary stages, a regular majmû'ât is set at a monthly rate of LE7.40 and a distinguished majmû'ât is for LE12.40 a month. The distinguished majmû'ât is supposed to be held for a class of no more than 12 pupils, while the ‘normal’ is supposed to have no more than 20 pupils per class. Two places are supposed to be reserved in each class for orphans whose fees are waived. Yet parents, children and NGO workers noted common violations of this policy as prices were not adhered to. Neither was the maximum class size respected, nor exemptions made for orphans. In many cases in Bulaq el Dakrour pupils paid twice as much as the fixed rate (sometimes three times) and the majmû'ât were twice as large as they should be. The policy of exempting orphans from payment of fees was not applied if there were more than two orphans in one class.
Attempts at fixing the prices for extra coaching through the institutionalisation of the majmû'ât have not solved the problem of equity. It has not put an end to the sweeping commercialisation of the practice. Moreover, it has not introduced greater efficiency in the educational system since the majmû'ât, often suffering from overcrowding, do not offer a significantly superior quality of education as compared to that offered during school hours. This is commensurate with findings on other developing countries that have introduced cost recovery measures (Tillak, 1991, 1997).
The majmû'ât are often no more than an official policy of income-generation for the teachers and others in the educational hierarchy. Al-Hussaini explained that according to the MoE's policy, the income generated from the majmû'ât is supposed to be distributed as follows: 85 per cent to the teacher and 15 per cent to the administration. The 15 per cent allocated to the administration is then divided as follows: 30 per cent to the school manager, 50 per cent to the administration and one per cent to the teachers' union. The outcome is that there are more incentives for the school administration and teachers to enforce a policy of expanding majmû'ât for all than to keep it strictly as an extra coaching class for pupils with weaker performance. Al-Husseini, a teacher working at a public school in the morning and giving group private lessons in the evening at an NGO was also sceptical about the system of majmû'ât:
There is pressure on all pupils to take majmû'ât, even the clever ones. Everyone benefits from the majmû'ât, starting from the head of the district department, the headmaster, the teacher and the MOE officials.
In practice, teachers identify pupils who can afford to take private lessons and pressure them to do so; they then pressure the rest to join the majmû'ât. Al-Husseini blamed parents who are convinced that their children will not pass unless they take private lessons. Parents' deep-seated belief in the absolute necessity of extra coaching for their children to pass is very evident and it stems from pupils' experience with teachers. Almost every parent whom I met in Bulaq el Dakrour in focus groups or individual interviews mentioned exposure to pressure for not taking extra coaching classes. And teachers admitted it had become ‘part of the system’ to insist that pupils enrol in majmû'ât or private lessons. A wide range of tactics were cited by parents and pupils for enrolment in majmû'ât and private tuition classes. Students were subject to threats to force them to enrol in the additional course. They were also subjected to corporal punishment if they did not enrol in private lessons. Physical violence has always been part of the educational system in Egypt, and the increased privatisation of education has heightened pressure on pupils to attend private lessons. Pupils also cited threats from the teachers to fail them in examinations or throw them out of school. These threats are not pro forma: they are carried out. One informant, Amal Abdel Sayid, a widow who has six children and works as a cleaner in the local council, was particularly distressed that her daughter was forced to sit outside school after her mathematics teacher threw her out of class and told her not to return until she had paid the LE40 for the majmû'ât. She feared for her 11-year-old daughter's safety when she was obliged to sit outside the school.
Another pupil mentioned that a teacher threatened to mark her down as absent for 10 consecutive days (even if she was actually there), thus automatically disqualifying her from sitting for the end of year examination. Four other pupils mentioned being thrown out of class because they did not take any form of extra coaching with their school teachers.
Measures to pressure parents into enrolling and paying for the majmû'ât also include physical punishment of pupils, relegating students to the back of the (very crowded) classroom, the forced detention of pupils after school hours (i.e. refusing to let them depart until after they have attended the majmû'ât) so that the issue is presented to their parents as a fait accompli. Other measures include withholding pupils' examination seat numbers until they have paid any remaining school fees and private lessons money in full. Before the end of year examination, each pupil is given an examination seat number, without which pupils cannot enter examinations.
Many of the abuses cited here might not have occurred had it not been for the privatisation of education. Student vulnerability has increased to teachers' exploitation of the asymmetrical power relations existing between them in order to pressure pupils to take extra coaching. Moreover, there is a gap between government policies and their actual implementation. The former minister of education has repeatedly announced that enrolment and the disbursement of books should not be contingent upon a poor student's payment of fees at the beginning of the year. Parents should also be given the option of paying in instalments (Al-Ahram, 14 September 2002). Nonetheless, not only do headmasters sometimes refuse to distribute books until the money is paid in full, they also make payment of school registration fees a condition for access to medical insurance. Schools also demand other additional informal expenses. For example, parents pointed out that they are often required to provide for maintenance costs of the school, and teachers regularly collect money from pupils for the purchase of items such as chalk.
There are marked contrasts between the experience of parents who send their children to school within Bulaq el Dakrour and those who send to schools in higher income districts. Most parents who succeed in enrolling their children in schools outside the neighbourhood are sent to schools in the wealthy district of Mohandeseen and in the middle class district of El Haram. Although they pay for additional transport costs, they cost far less than the money paid in private tuition fees by those who educate children in Bulaq.
Privatisation of education
Parents in Bulaq el Dakrour deal with the rising cost of education in a number of different ways. Those who can pay do so. As long as they can afford it, they pay up to avoid the hassle, humiliation and risks to their children's education. To do so, they borrow, participate in jam' îyyât (informal rotating saving and credit schemes), sell household goods and seek assistance from welfare-providing NGOs. But the fact that parents in Bulaq el Dakrour are willing to pay does not necessarily reflect their purchasing capacity. As Colclough (1997:19; 1996:597) suggests: ‘Even if poor people chose to pay the increased fees, it might be that they would be replacing their consumption of other goods which we would prefer them to retain.’ In many cases, parents confided that they have had to sell household goods or take another member of the family out of school to be able to afford the ‘fees’. Others have had to compromise on their expenditure on personal health (especially mothers).
Parents have adopted a variety of strategies in an attempt to ease the financial burden of paying for their children's education. These include bargaining with the teacher to reduce the set fee, restricting lessons to the month(s) immediately preceding examination time and engaging in open confrontation. Another coping strategy is to simply remove the child from school.
Bargaining with the teacher: Teachers often set unusually high rates for both private lessons and majmû'ât expecting that some will pay, while others will come to negotiate. Often parents bargain with the teachers to the point of getting the set fee cut sometimes as much as by half. Pleading desperation and inability to pay is one way of trying to claim entitlements. It is not articulated in a discourse of rights, but rather is an appeal to pity and compassion. Parents put their case before teachers and headmasters, hoping that there will be exemptions or compromises reached to make education more affordable. They know that employing the concept of rights and their violation will be unsuccessful as a strategy for achieving their goal. Teachers and headmasters are likely to be bemused and ignore statements such as ‘what you are doing is against the law, you are violating my children's right to a free education’. This is because education is not free but also, there is no system of accountability.
Another strategy used by parents is to restrict extra coaching to the bare minimum. Many parents who cannot afford to give their children lessons from the beginning of the school year save up for the month before examinations are due and allow their children to attend regularly in the hope that this may somehow appease the teacher. There are three general examinations which are externally prepared, administered and marked by the Ministry of Education: they are at the end of the primary (five years), preparatory (three years) and secondary (three years) stages. Teachers at school have no power to pass or fail students in those years. However, for all the other school years, they administer and correct examinations and consequently, yield a lot of power over students. It is particularly in those years that parents try to appease teachers before examination time.
Some parents resort to confrontation with teachers and the school administration but they tend to be the exception rather than the rule. Most parents would resort to open confrontation if they felt that the bargaining power of the teacher was weak or that the teacher had gone beyond what was seen as being reasonable. This threshold varied from one parent to another.
Mona, for instance, is a mother of two; she went to speak to her daughter's fourth grade primary teacher about the fact that she could not afford to pay for private lessons and that the she should stop harassing Mayada, her daughter. The teacher told her that Mayada was doing very poorly, and to prove it, she called her to the blackboard to solve a mathematics sum. The teacher told her that Mayada solved the sum incorrectly. Mona recounted the rest of the story with pride:
She thought I was completely illiterate and could not read what is on the board. So I told her: ‘No, she solved it correctly. How dare you do this? I am going to get you into a lot of trouble, I am going to take this matter to the headmaster and tell him you are not fit to be a teacher, and you don't deserve to be one, you butcher.’ And that was the end of that, she never harassed my daughter again.
The line represented more or less what they can realistically pay to keep their children at school. Hala, whose father is a civil servant, recounted the following incident relating to her sister:
At the beginning of this year, the teacher demanded LE50 for private lessons and LE40 for the majmû'ât. My father was furious and went and had a fight with the teacher, because my sister was detained and forced to attend the majmû'ât. The teacher told my father she has to attend the majmû'ât because her standard is poor. She then agreed that he can pay LE20 instead of LE40 for the majmû'ât. My father told her ‘you are not going to give me a bakshîsh [a tip]’. He went down to the headmaster and asked him how much does the majmû'ât cost and discovered they were actually for LE15.
Confrontational strategies are mostly avoided by parents who are generally in weaker positions of power and fear the consequences for their children. The reasons for this are many, but the most salient is perhaps the lack of accountability on all levels of the school administration, and not just with teachers. Those who choose not to pay for extra coaching are faced with two highly undesirable outcomes. The first is succinctly put by Sukara:
You can tell them it is your right and all that, and they will say, fine, your child doesn't have to take private lessons – but in class, they will make life so miserable for your child that he will hate school and not want to go there anymore. The second likely outcome is that they will have to pay afterwards anyway especially if they want their children to pass.
Removing the child from school: One informant hinted at the possibility that many parents were being lured into pulling their children out of school because of the costs of private lessons and waiting until they reached the age of 13 to enrol them in literacy classes since the latter are free. The percentage of pupils dropping out of primary school at a very early stage do seem to be rising.5 One estimate is that 51 per cent of the children who enrol drop out of school and are likely to count among the adult illiterates later on (Korayem, 1996:41, 47).
Health
Cost recovery in MOHP
One of the recommendations of the World Bank for Egypt was the introduction of differential user fees for cost recovery purposes in the health sector. It suggested that ‘to mobilise additional resources and increase equity in the curative health system, the government's programme to introduce gradually user fees for both outpatients and in-patients in selected general and central hospitals should be strengthened’ (World Bank, 1991:135). The same argument is made elsewhere:
in poor countries, there may be potential benefits from user charges both in mobilising additional resources and in setting price signals to encourage more efficient behaviour by purchasers and providers (Creese and Kutzin, 1997:40).
the few empirical observations that have been made so far indicate that the increased use of user fees has not led to any detectable extension of health care in rural Africa(Svedberg, 2000:262).
The poor are paying more on health than they did prior to adjustment. For example, in urban areas, the share of health expenditure in total expenditure of low income groups rose from 1.8 per cent in 1981/82 to 3.3 per cent in 1990/91 and to 4.79 per cent in 1995/96. During this period, the same share increased from 1.8 per cent to 3.5 per cent in rural areas (Institute of National Planning, 1998:60). It is assumed that the poor who cannot afford to pay for private medical care continue to rely on public health services since they are cheaper than those provided by the private sector (Zaytoun, 1998:40). The outcome of policies which have been biased against the poor has been a marked deterioration in health service provision, while insufficient funds have meant that there is often a serious shortage of drugs and material essential for medical and surgical interventions (Institute of National Planning, 1998:62). The government seems to have deliberately allowed the deterioration of some health services in order to encourage the non-poor to go to the private sector and consequently have fewer clients to care for. The privatisation of health care has meant increased out-of-pocket expenditure, and that has affected the poor far more than the rich. This is because private spending, particularly out-of-pocket spending, tends to be related to income and wealthier households are able to spend more in absolute terms than poorer households, although as a proportion of household income, richer households may spend less than poorer ones (Rannan-Eliya, Blanco-Vidal and Nandakumar, 1999:24). While most people in Bulaq el Dakrour spoke about education being the greatest burden on their everyday lives, sickness can lead to a real crisis in terms of expenditure.
There are two principal government health providers in Bulaq el Dakrour: the Bulaq Public Hospital and the Urban Health Centre;6 this is an outpatient health centre providing very basic services. Bulaq Public Hospital is the oldest and main service provider. The people of Bulaq el Dakrour have a wide plethora of health service providers to choose from, given the central location of the neighbourhood. Bulaq is near the largest hospitals: Kasr el Aini Hospital can be reached in 10 minutes by public transport; Agouza in 15, Umm Al-Masriyyin Public Hospital in Giza in 15 minutes while the Fever Hospital can be reached in about 30 minutes. Not all public hospitals are the same in quality or cost; variations are dramatic. Other than public health services, there are services provided by NGOs, political parties, private clinics and private hospitals. For example, a woman from Bulaq el Dakrour might have her blood pressure taken in the nearby pharmacy; her glasses done at the Wafd Party Health Centre, her blood tests taken at a private clinic, dental care sought at a government teaching hospital while sending her daughter to the female doctor at a Muslim association (a registered service-providing NGO) for gynecological treatment. Despite the diversity in health providers, the government continues to be the main provider of services for a large section of the poorest of Bulaq el Dakrour, especially with respect to in-patient care and treatment of chronic diseases. The most common chronic diseases encountered in Bulaq el Dakrour were respiratory, kidney and liver diseases.
Bulaq Public Hospital is the closest venue in the neighbourhood, but because its reputed poor quality and high costs, patients often refuse to be treated there and instead try to use a wâsta (contact) to have them accepted at the Kasr el Aini Teaching Hospital – one of the most frequently used public hospitals, especially for in-patient care. Public hospitals are by no means free of charge, yet, they are called ‘abu balâsh’(with all its negative connotations associated with being ‘free of charge’). The negative images that the free public health service conjures are not new. It was always assumed that fee-paying private health service is superior. Nevertheless, it was also recognised that public health services are there if you cannot afford to go anywhere else. This is no longer the case.
Limited access to the cheapest ‘tickets’ in the out-patient hospital clinics, purchase of medication externally from pharmacies, payment for X-rays, blood tests and other medical requirements and the failures of the exemption system from waiving the fees of the poor have all meant that treatment requires payment, sometimes in substantial amounts. This has had its implications on the propensity for the poor to use health services in times of sickness, and led to increased vulnerability in patron-client relationships in public facilities.
At Bulaq el Dakrour hospital, the ‘economical’ tickets are for LE1.25 and the ‘higher quality’ tickets are for LE3. The latter involve a shorter wait and are more readily available. The LE1.25 charge for the ticket is not considered expensive by the people of Bulaq el Dakrour; however, it is only available in limited numbers and for limited hours of the day. Sharbat pointed out a problem I experienced myself when I took Mona and her mother to Bulaq hospital: namely, that the LE1.25 tickets are only made available from 8 a.m. to 10 a.m. and in limited numbers. Once the ticket office has sold out, there is nothing to be done except buy the more expensive ticket.
Nonetheless, the price of the ticket is the least worrisome for the poor. The problem is the cost of medicine and other unpredictable medical expenses. Patients pay for the most basic of medical necessities. For example, a few years ago, Fawziyya had to take her son to hospital after he broke his leg. At Bulaq Public Hospital, the doctor told her to go buy three rolls of plaster and a roll of bandages so that he could plaster his leg. She bought them from an external pharmacy for a lot of money. She asked him for the remaining plaster, but he said the hospital would keep the rest.
There is often a shortage of medical supplies but often too, medicine is simply not disbursed to the poor, even when it is available. An informant in the hospital told me that it is often kept for relatives and friends. Laila went to the dispensary to collect the eye ointment prescribed to her by the doctor at Kasr el Aini Hospital. They told her they did not have it. She informed the doctor and only after he accompanied her was the medicine dispensed. Laila was lucky in that she was being treated by a sympathetic doctor. However, others often can do nothing when medicine is not dispensed to them. The majority of women in Bulaq el Dakrour revealed that they will pay the LE1.25 ticket at the hospital but if there are treatment charges they will not pursue it; they needed the cash for other life necessities and their health is the first thing they will compromise on.
The commission system
The World Bank contends that if a system of exempting the poor from the payment of fees were established, it would mitigate the effects of cost recovery measures in developing countries (Akin, 1985). However, Watkins observed that such targeting systems often miss out on helping those that are most in need (2000). In practice, the exemption system that was established recently has not succeeded in securing free of charge health care for the poor, for a multitude of reasons discussed below.
The Ministry of Health established a special ‘Commission’ in 2000 to grant waivers for payment of medicine and in-patient care for the poor. All applications for waiving health care expenses in public hospitals must go through the Commission. The first step is for the patient to request a report from the social worker stating their inability to pay and from the doctor at the local hospital stating the kind of treatment the patient needs. These documents together with a long list of other requirements are then taken by the patient to the Commission which determines the amount of money that will be allotted and the duration of the treatment. They then present these papers to the hospital in which they are being treated. Patients do not have the freedom to decide where they wish to be treated.
Once patients manage to acquire the necessary papers from the hospital to refer them to the Commission (which is not always easy or possible) they are then faced with the next obstacle: getting through the Commission. Samira went to the Commission located at the headquarters of the Ministry of Health in downtown Cairo. Samira suffers from diabetes and usually bought the required injections from the pharmacy for LE6.5 an ampoule. However, there was a shortage in insulin in pharmacies for a period extending over nine months and she could not afford the expensive alternative which cost LE30 per ampoule. She was told the cheaper kind is now only available through government hospitals. When she went to buy them, she was told she would have to first get a referral from the Commission. Once at the Commission, there were hundreds of people queuing in two lines with only two employees standing at the booths. They shouted, gave them the wrong information, never looked them in the face and were many bureaucratic delays.
There was also another problem: a large number of applicants were illiterate, and there were new papers to be filled out and no government employee to help with such a task. The majority of those at the Commission were overwhelmingly women. Access to medication is one of the main obstacles facing people on the Commission. Acquiring the referral for treatment at a hospital does not mean that patients will actually get the treatment required free of charge. Samira's problem in accessing the diabetic medicine was not settled. Although they gave her the medication the first few times, they stopped on the pretext that they had run out. An alternative medicine was given that was unsuitable for her condition and she was forced to borrow from neighbours to buy the expensive alternative from pharmacies.
Those whose fees are waived for in-patient treatment through the Commission also find themselves paying a lot of money. Once free of charge, hospitalisation now means that patients pay roughly half the cost of treatment. For example, a patient is required to purchase bandages, injections, syringes, cotton and most medication in addition to tipping the nurses (and sometimes even paying for using the bed sheets). In many cases medicine is not disbursed, or only partially, on the premise that it is unavailable. In such circumstances patients have to pay from their own resources.
The fact that patients are willing to pay should not be confused with an ability to pay. The World Bank consistently highlights that out-of-pocket payments for health represent a willingness to pay. Yet as Watkins suggests from the examination of the negative impact on Zimbabwe's poor of introducing fees for health care, there ‘is confusion between the concepts of willingness to pay and ability to pay’ (2001:246). He explains that ‘an individual may be willing to pay for something in principle but unable to do so in practice except under duress and at considerable cost to long-term welfare’. Some of the implications on household budgets in Bulaq el Dakrour have been disastrous. For example, Zainab was betrothed (katb kitâb) to a lorry driver. Three months before the date of their marriage, he was hit by a van and transferred to hospital. She was obliged to spend hundreds of pounds in medication for him. To pay for his medication, she had to a sell off a small income-generating project which was her only source of income: selling make-up and cheap accessories. Thus, the payment of fees led to her deprivation of the only source of livelihood. This is essentially because the Commission only pays for a limited amount of medication, while the rest has to be bought on a fee-paying basis. Many women receiving treatment in Bulaq el Dakrour pointed out that under the Commission referral, only the inexpensive medication is dispensed, while the more costly types have to be bought externally from pharmacies.
The failure of the Commission exemption system has not only increased the financial burden on the household budget, but also affected the interaction between patients and health staff. Patron-client relationships between patients and doctors are not new to Egyptian public hospitals. If one has a wâsta in hospital, one's chances of receiving better treatment have always been higher. However, the privatisation of the health services has exposed the poor and marginalised to increased vulnerability to those in positions of power in the medical institutions. This is because the change in the dominant paradigm to a market-oriented economy has not just led to changes in policies, but also in group behaviour (Stewart, 2002:49). Group behaviour changes on the local level have been affected by the dominant paradigm's emphasis on monetary incentives (Mackintosh and Gilson, 2002:266).
For example, eligibility for applying to the Commission for exemption of fees requires the doctor's signature, thus giving him enormous power over poor patients' treatment. Amal, an informant, was in a state of crisis the last time I met her. Her son, a house painter, fell down while on the job and broke his leg. They transferred him (through a wâsta) to Kasr el Aini Teaching Hospital. He was told he needed an operation which would cost LE1,600. Given that she is a widow with six children and a monthly income of LE255, she certainly did not have the money. A social worker at the hospital interviewed her and said the government could pay for the operation (through the Commission system), but that she would have to get the signature of the orthopedic doctor who diagnosed his case. She tried to track the doctor down but they always told her that he was very busy and if she wanted to see him, she should go to his private clinic. A visit to his private clinic costs LE120. This was still beyond her budget, given that she was already paying for her son's pain relief injections, which each cost LE15. She went to see the general manager there and she told him that this was a hospital for the ghallâba(the poor and marginalised) and that her son must be treated for free. She explained that he told her that they didn't have the money, and that if they didn't like it, she should take her son out and go complain to the health minister.
Doctors working in public hospitals in Egypt are also allowed to simultaneously run private clinics. Doctors' encouragement of patients to visit them in their private clinics is a practice that predates economic reform. Nevertheless, given that exemptions now require the doctor's signature for the Commission transfer, there is increased pressure on patients to pay at private clinics. Amal did not know the doctor's name, she was given the directions to his clinic, and that is what she has learnt by heart. Were it not for the fact that having the doctor's signature was a prerequisite for applying for a waiving of fees from the Commission for operations, Amal would not have been exposed to an indirect form of extortion at the hands of the doctor treating her son.
The exemption system also makes the poor vulnerable to abuse at the hands of others in the hospital hierarchy. Social connections facilitating the avoidance of exposure to exploitation and excessive payment become increasingly important in the context of the marketisation of health services. Unfortunately, this can sometimes work as a means of excluding the very poorest who do not have such social capital. It means that they have to resort to strategies of winning the pity and sympathy of the public health providers instead.
Conclusion
While the government continues to be the main provider of welfare services, especially with respect to education and in-patient health care, such services are no longer free. The manifestations of privatisation are many: a parallel education system based on a fee-paying policy institutionalised in school through the majmû'ât system and practised on a more informal basis in the form of private tuition, the increased payment on medicine, basic medical supplies in public hospitals. The consequences of the privatisation of these services has had its toll on the poor people of Bulaq el Dakrour, reducing access to and use of affordable care, and affecting equity. These findings are commensurate with studies conducted elsewhere in many other countries where adjustment policies have been implemented.
Studies have shown that a market-based approach has resulted in lower utilisation of social services, worsened equity, and reduced human capital formation in many low income countries (Mwabu, Hjerppe, Ugaz and White, 2001:3).
Similarly, in health, people believe that the quality of services in Bulaq Public Hospital and the old Kasr el Aini Hospital have deteriorated so much that those requiring in-patient care would rather die at home than be admitted for in-patient care. Moreover, the exemption policies devised to mitigate the impact of cost recovery measures have failed. There is a conflict of incentives when the dominant ideology and its ensuing practices are based on market values, while exemptions are supposed to be driven by equity considerations. This is evident in schools where the poor are still obliged to pay for the majmû'ât and for full fees at the beginning of the school year, and in hospitals, where those whose fees are officially waived often find they have to pay up to half the costs of treatment.