On 2 October 2023, President al-Sisi suggested that the government can build hospitals and transfer them to the private sector for management due to the government’s poor management of public hospitals

A new law privatizing healthcare in Egypt will jeopardize the accessibility and availability of health services, particularly for those lacking health insurance and/or living in poverty, Amnesty International said today.

On 23 June, President Abdel Fattah al-Sisi ratified Law 87 of 2024 on health facilities, passed by Egypt’s parliament on 20 May, that allows the private sector to operate and manage public health facilities on a for-profit basis. The law does not include any price regulations, granting private investors and the government the discretion to determine prices on a case-by-case basis.

Millions of people in Egypt, including those who are uninsured or cannot afford the high fees of private medical services, currently rely on the country’s public health facilities. Yet Egypt’s parliament expedited the adoption of the law in just a month without adequate consultations with stakeholders, and despite serious concerns raised by the Doctors’ Syndicate. According to the law itself, regulations on the implementation of the law should have been issued within a month of enacting the law, but to date there has been no announcement of their completion. 

“The new law is another blow to people’s social and economic rights, which continue to deteriorate with no end in sight under President al-Sisi’s government which has seen record inflation and cost of living skyrocket. Instead of protecting people’s right to health amid the ongoing economic crisis, the government is attempting to evade its obligations at the expense of the poorest who will be most impacted,” said Mahmoud Shalaby, Amnesty International’s Egypt Researcher.

“The government of Egypt cannot simply hand over the keys of a struggling public healthcare system to the private sector without clear regulations to ensure that all people living in the country have access to affordable and quality healthcare.”

The government of Egypt cannot simply hand over the keys of a struggling public healthcare system to the private sector without clear regulations to ensure that all people living in the country have access to affordable and quality healthcare.

Mahmoud Shalaby, Amnesty International's Egypt Researcher

In Egypt only 66% of the population have public health insurance coverage according to 2023 estimates by the Ministry of Health and Population (MoHP), likely leaving millions in Egypt without coverage. Those insured under public health insurance include school students, public and private sector workers, widows and pensioners. There are no official figures on people who have private health insurance in the country, but rising poverty levels in Egypt particularly since the significant currency devaluation has placed this beyond the reach of many.

Under international law, states have an obligation to protect the right to health, including by ensuring that privatization in the health sector does not pose threats to the availability, accessibility, acceptability and quality of healthcare, especially for those marginalized. Privatization of healthcare often poses significant risks to the equitable availability and accessibility of healthcare for people in poverty and other marginalized groups and can lead to higher out-of-pocket expenditures, according to the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Amnesty International spoke with three experts including Mona Mina, former deputy head of Egypt’s Doctors Syndicate, Ahmed Hussein, a former board member of the syndicate, and a worker at a healthcare local NGO who spoke on condition of anonymity. Amnesty International also reviewed the new law and several expert reports on Egypt’s healthcare system.

People without insurance or those poorest left to fend for themselves

The new law allows the private sector, through public-private partnerships, to establish new public health facilities and to manage and operate existing public health facilities under the jurisdiction of the MoHP, which accounts for 80% of all public hospitals in the country and a little less than half of all hospitals. The law excludes primary healthcare centres and, according to the law itself, should not affect curative and ambulance services, disaster services, blood operations and Plasma collection, and epidemics.

The new law does not address the risk that people, including those without insurance and those living in poverty, might not be able to afford healthcare, in cases when new, private sector management increase prices previously charged on a non-profit basis.

In 2018, President al-Sisi ratified a bill to ensure universal health insurance for all Egyptians. By 2023, the new scheme had only been implemented in six governorates, although the government announced a goal of expanding it in all 27 governorates by 2028 according to President al-Sisi’s directives.

“Even those insured under public health insurance will be affected by the increase in prices of health services in public hospitals because this will likely lead to an increase in their expenses when receiving treatment,” Mona Mina told Amnesty International.

Out-of-pocket (OOP) expenditures, which are costs that an individual is responsible for paying that may or may not be reimbursed later, are already high in Egypt, burdening the poorest in the country, and pushing many families below the poverty line, according to the World Bank.

Murky public-private conditions

The new law stipulates that public hospitals that would be managed by the private sector must allocate a certain percentage of their total health services to people who have public health insurance, universal health insurance coverage, or others eligible for treatment at the state’s expense. But the law leaves the percentage of services that must be reserved for these categories of patients unspecified. This means that there are no safeguards against these for-profit public hospitals reserving the bulk of their services to fee-paying patients, affecting availability of health services for those unable to pay. The law fails to provide for any safeguards to ensure non-discrimination between patients based on their insurance or ability to pay out-of-pocket.   

Given these concerns, Egypt’s Doctors’ Syndicate in May 2024 urged President al-Sisi to not ratify the law also citing the threats the law poses to staff working in public hospitals.

The new law obliges the private sector to keep only 25% of the staff working at public hospitals, allowing for the dismissal of up to 75% of the staff once hospital management is transferred to the private sector.

TheEgyptian government must introduce and implement strong regulatory frameworks and legislative to ensure that safeguards for equal access to quality healthcare for the poorest and marginalized groups are in place at public health hospitals managed by the private sector; and ensure that relevant stakeholders, including healthcare workers, are meaningfully consulted.

Background

On 2 October 2023, President al-Sisi suggested that the government can build hospitals and transfer them to the private sector for management due to the government’s poor management of public hospitals.

Egypt’s public healthcare system has been struggling with a shortage of public hospital beds, offering only 1.4 beds per 1,000 people, which is significantly below the global average of 2.9 beds per 1,000 people.

Since 2014, the Egyptian government has failed to meet the constitutionally mandated allocation of at least 3% of GDP to health.