Will Egypt’s New Law Make Cesarean Sections Exclusive to the Wealthy?

We reveal in this investigation the potential impact of Egypt’s new law to lease public hospitals on cesarean section costs and access to healthcare.
Rasha Ammar

Inside the crowded reception hall of a government hospital in the Old Cairo area of Cairo Governorate, Alfet Mohamed (a pseudonym) nearly collapsed when an administrator informed her that the cost of a cesarean delivery at the hospital had reached about 6,000 EGP / 126.2 USD. Her shock was compounded when an employee sitting nearby told her that free healthcare services had ended, and prices would increase significantly after the approval of the (privatization/leasing of public hospitals) bill.

In early May, the Egyptian Parliament approved a draft law granting the private sector and investors the right to manage, establish, develop, and operate health facilities, excluding primary healthcare centers and family health units, as well as blood collection centers and plasma collection units (subject to the provisions of the Blood Operations and Plasma Collection for Manufacturing Derivatives and Export Regulation Law No. 8 of 2021), except for blood operations considered complementary services under the law.

The law, which awaits the president’s approval, has caused widespread concern among large sectors of Egyptians who rely heavily on free or reasonably priced public health services. This comes at a time when Egyptians are facing a significant shortage of medical supplies, officially increased by 40%, according to the Drug Authority, and varying increases in health service prices provided by public and educational centers. This is happening in a country where more than 33.3% of its population lives below the poverty line and is experiencing a severe economic crisis with unprecedented inflation rates and a record low value of the local currency (the pound) against the dollar.

In recent years, there has been a sharp increase in the prices of cesarean deliveries, which are performed for 80% of pregnant women annually. According to our research, prices in public hospitals, which used to offer the service for free, range between 3,000 to 6,000 EGP (about 63-162 USD), while prices in private clinics and centers have risen to about 30,000 EGP / 631 USD. Medical sources predict that these figures could double in the second half of this year due to rising drug and medical supply prices, in addition to the potential activation of the privatization law.

Sources who spoke to Zawia3 and preferred to remain anonymous said that if the bill to privatize public sector hospitals is passed, birth prices in Egypt could soar, potentially exceeding 50,000 EGP / about 1,000 USD, depending on the investors and the sector running those hospitals, which would create a significant crisis for citizens.

Women, being the most impoverished and unemployed, would be the most affected by the law if implemented. Unemployment rates for women in Egypt exceed 17.3% compared to 4.8% for men, according to the Central Agency for Public Mobilization and Statistics (CAPMAS) 2023 data. Studies also indicate that women are the poorest in Egypt.

Humanitarian Catastrophe

Despite repeated observations about the inefficiency of Egypt’s public health system, millions of Egyptians benefit from the health services provided by these institutions. According to CAPMAS estimates, the total number of beneficiaries of health insurance reached 57 million citizens by 2020. The number of health facilities affiliated with the public and private sectors in Egypt in 2020 was approximately 2,034, and the cost of developing infrastructure and medical equipment for 18 model university hospitals, including emergency departments and hospitals, was 2.7 billion EGP.

Egypt operates 662 public hospitals at a cost of 147.8 billion EGP, providing health services to citizens for nominal fees, according to CAPMAS data. The fiscal year 2023-2024, ending in June 2024, allocated 147.8 billion EGP to health sector spending, equivalent to 3.1 billion USD, which is an increase from the previous fiscal year 2022-2023, where the health budget was 128.1 billion EGP.

Medical and political sectors fear that the law will increase the cost of health services provided to citizens, marginalize, or possibly eliminate, the state’s role in providing healthcare, contrary to the provisions of the Egyptian Constitution. The Egyptian Medical Syndicate has called on President Abdel Fattah el-Sisi to reject the law and not sign it in consideration of the citizens.

Mona Mina, former Secretary-General of the Medical Syndicate, describes the bill as a “disaster.” In an interview with “Zawia3,” she says that the health sector in Egypt is full of problems, with a lack of funding and medical supplies, and low wages, but “what is happening today with the attempt to pass this law is a turning point for the worse, and its effects will be catastrophic and dangerous for citizens.”

Mina asserts that if this law is passed, it will effectively end free healthcare in Egypt. Even though most services have been paid for recently, the prices remain affordable for citizens. However, turning the public health system into an investment system with the primary goal of profit will crush ordinary citizens, preventing them from obtaining their basic constitutional rights to healthcare provided by the state.

She adds: “What is happening today is that we are killing the patient instead of treating them. The state has a strength in its good infrastructure, with hospitals across the country that are valuable assets that should be utilized, developed, and provided with the necessary services and needs to enhance their efficiency and provide appropriate services to patients, instead of selling, leasing, or privatizing them, regardless of the terminology used in the law, which would destroy the health system.”

Mina criticizes the argument that the current state of hospitals is “dilapidated” and that the law is necessary to address the health sector’s problems. She questions: “Should we sacrifice assets and give them up instead of working on finding solutions for the health system in Egypt?”

Circumventing the Constitution

The Egyptian Constitution guarantees the right to healthcare for all citizens without exception. Article 18 of the 2014 Constitution, amended in 2019, states: “Every citizen has the right to health and to comprehensive healthcare in accordance with quality standards. The state shall preserve public health services facilities that provide services to the people and support them and work to improve their quality and equitable geographic distribution.”

The state is also obligated under the Constitution to allocate a percentage of government spending to health not less than 3% of the Gross National Product, which gradually increases to meet global rates. The state is committed to establishing a comprehensive health insurance system for all Egyptians covering all diseases, with citizens contributing to its subscriptions or being exempted from them according to their income levels.

Mina argues that what is happening in the health sector is a circumvention of the Constitution and the law, as the 3% allocated includes expenditures on all aspects of the health system, not just the service and care sector. For example, it includes the cost of sanitation and water consumed in hospitals, among other things.

Mina also points out that the state has allocated a share for health from the public debt, which is disastrous because it places additional and illogical burdens on the health system.

Medical staff are also threatened, according to Mina, as the current bill allows investors to dismiss about 75% of the current staff and replace them with foreign teams. She explains that privatizing the health sector is a direct attack on Egyptian national security, as health and education are the pillars of the Egyptian state. She points to a dark side of the law that does not clearly define what is targeted by the law, assuming it grants the investor the right to manage, but “we do not know the nature of the regulations governing this management.”

Mina condemns the disposal of assets built with taxpayer money and state resources, which are a legitimate right of the Egyptian citizen. Allowing foreign investment in the sector without conditions or specifying the identity of the investors may open the door for companies and investors whose interests conflict with the requirements of Egyptian national security, and possibly for hostile entities.

Mina states: “Opening a highly sensitive sector directly related to national security to foreign entities with broad privileges and without conditions and regulations is dangerous, so we appeal to the President of the Republic not to approve it at all.”

Cesarean Surgeries: A Hard Reality and a Grim Future

Egypt ranks among the highest globally in cesarean delivery rates, with cesarean births accounting for 63% in public health facilities and 81% in private health facilities, totaling 1.375 million cesarean deliveries annually, 77.6% of which occur in private sector hospitals.

The prices of cesarean deliveries in public hospitals range between 3,000 to 7,000 EGP (about 63-147 USD), while in some private centers, they reach 50,000 EGP (1,051 USD) for cases requiring special care, and between 15,000 to 30,000 EGP (315-631 USD) for standard cases, depending on the center and the service provided.

Zawia3 contacted several individuals who have undergone or are about to undergo cesarean surgeries during this period. They all agreed on the excessive rise in prices and the decline in the quality of health services in most public hospitals, especially outside Cairo. They also expressed serious concerns about the proposed project doubling the prices in the coming months.

Sherine Salem (27 years old), a housewife whose husband is a construction worker from Giza Governorate, said she underwent a cesarean delivery two months ago at a public hospital that is supposed to offer free services, which cost her 5,000 EGP / 105 USD.

When asked about the relatively high cost, she said: “It is supposed to be a government hospital, and the delivery should not exceed 600 EGP / 12.6 USD, but the hospital lacks many medical supplies. They informed my husband to buy anesthetic

materials, suture wire, and some medications, as well as tips for the nurses and other costs in the hospital. The total amount exceeded 5,000 EGP / 105 USD. The service was average; I can’t say it was bad, but I heard that in some other hospitals, the service is much worse.”

Hanan (32 years old), who works at a beauty salon (coiffeur) in Sohag Governorate, said: “The stories about giving birth in government hospitals are scary. My husband and I decided to save a monthly amount from the household expenses so I could give birth in a private hospital with better services, especially since I was scared for my baby because I had a delayed pregnancy for more than eight years.”

She continued: “Unfortunately, the amount we saved did not cover the operation costs, which exceeded 25,000 EGP / 526 USD. So we borrowed money from a charity that offers loans with easy conditions but high interest. We borrowed 10,000 EGP / 210 USD, and we are now repaying it at 15,000 EGP / 315.5 USD.”

She added: “Another problem we faced was the shortage of medicines in the market. Most of the postnatal medications were not available in pharmacies, not even the alternatives, as well as baby formula. My son suffers from acid reflux and needs a specific medication, which we couldn’t find. The shortage of medicines and baby formula was perhaps the hardest thing we went through during childbirth.”

As for Abir (25 years old), an employee at a medical lab in Beheira Governorate, who is a few weeks away from her second delivery, she told Zawia3 jokingly: “Delivery prices are constantly rising. I hope to give birth soon and not wait until the last week of the ninth month as in my first delivery.”

She added: “I decided to give birth in a private hospital this time because my first experience with a government hospital was not good. I don’t think all government hospitals are bad because my colleagues had much better experiences and received good care. Maybe I was just unlucky, or the hospital where I had the surgery had a high rate of negligence.”

Regarding the prices, Abir said: “The prices are constantly rising. It was about 15,000 EGP, but the last time we checked, it had reached about 25,000 EGP, and the staff told us there might be a potential increase due to the rise in medicine prices. I think private hospitals will double the prices if the privatization project is passed because it will become a competitive investment, and government prices will surpass the current rates multiple times.”

Why Are Cesarean Surgeries Increasing in Egypt?

Reem Hamad, a consultant in obstetrics and gynecology at Ahmed Maher Hospital, one of the largest hospitals affiliated with the General Authority for Teaching Hospitals and Institutes in Cairo, said that Egypt ranks first globally in cesarean surgeries, with an 80% rate for cesarean deliveries compared to 20% for natural births.

According to Hamad, several factors contribute to this, some of which are related to the women themselves. A large percentage of women have started to prefer cesarean delivery over natural birth in recent years, leading to a significant rise in cesarean surgeries.

Hamad added: “Some women decide from the beginning of pregnancy that they will undergo a cesarean delivery. In such cases, they cannot be forced to have a natural birth. Another reason might be the fear of mothers or families for the daughters. For instance, we often find mothers insisting that their daughters cannot bear the pain of natural childbirth.”

Hamad believes that the fear of natural childbirth has increased significantly in recent times, driven by several factors, such as women’s experiences with difficult births or the portrayal of natural childbirth in drama as unbearable pain, all of which contribute to heightened fear among pregnant women.

Natural childbirth, according to Hamad, requires an internal conviction by the mother of her ability to endure pain, and many discouragements make her unable to go through the experience.

In some cases, medical necessity requires performing a cesarean surgery, such as in cases of difficult natural birth, or if the mother or fetus is at risk of complications that could threaten their safety, or any other medical reason. In these cases, cesarean surgery is the safest option to ensure the safety of the mother and her baby.

She points out that obesity and some diseases caused by poor nutrition or lack of exercise are also fundamental reasons that drive doctors to recommend cesarean surgeries, as natural birth in several cases can be dangerous. She notes that Egyptian women lack awareness about the importance of physical exercises that help with natural childbirth, unlike other Arab nationalities who only resort to cesarean sections in limited cases. Hamad does not rule out that some doctors may prefer cesarean deliveries to achieve financial gains, as the price of cesarean surgeries is higher and may be much easier than natural childbirth.

Hamad said that in recent times, the prices of cesarean deliveries have been increasing almost daily due to several reasons, including the rise in medicine and medical supply prices, anesthetic materials, and other medical items used in these surgeries.

In early May, Egypt recorded a rise in medicine prices in the local markets, ranging between 20% and 50%, due to an increase in production costs for companies by up to 70% after the rise in dollar exchange rates in banks with the start of applying the flexible exchange rate policy, according to Ali Awf, head of the Pharmaceutical Division at the Cairo Chamber of Commerce.

Hamad said that the costs of cesarean surgeries could increase in some private hospitals to 30,000 EGP, divided between hospital costs and the doctor’s fee. She expects significant increases in cesarean surgery prices if the “privatization/leasing of hospitals” law is approved because healthcare will become an investment. She pointed out that some government hospitals, which used to offer completely free services, now charge for consultations, tests, and scans. Therefore, costs might increase significantly in the coming period if the law is passed.

Rasha Ammar
Egyptian journalist who has worked for several Egyptian and Arab news sites, focusing on political affairs and social issues