This is the latest in a series of articles about transparency and governance. For more, click here.
Transparency between health practitioners and patients is integral to a functioning health care system, as the relationship already represents a fundamental imbalance of knowledge. However, 73% of the Egyptian population qualify their medical and health services as either corrupt or extremely corrupt. Without trust in the government, change must come from the people. Ayman Sabae, with the support of a seed grant from the 16th International Anti-Corruption Conference’s (IACC) Social Entrepreneurs Initiative, is developing a community-monitoring tool through the organization Shamseya to hold health service providers in the public and private sectors accountable.
The project, which is still in the development phase, will provide patients with a set of user-friendly and objective quality indicators to evaluate service quality. As these indicators come into common use, they will create a comparative overview of the different public and private in-patient and out-patient clinics, hospitals and pharmacies that will aid patients in making a more informed choice of medical service providers.
Ayman Sabae is a founding partner of Shamseya, a not-for-profit initiative that supports and empowers the creation of sustainable, innovative, community-run health care systems. They work with the belief that no one can overcome the “collective effort of a group of people with a common interest, need or goal.” The project’s sustainability will come from its community origins, with indicators that are conceived by citizens and provide an outlet for their voices and experiences.
There is a desperate need for transparency and social accountability as these do not exist within the Egyptian medical system. Patients are not provided with sufficient information on their medical condition or available treatments, which makes them extremely vulnerable. Despite complaints ranging from invasion of privacy to refusal of treatment to malpractice, it is nearly impossible to hold facilities or staff accountable through the legal system as there is no proper law penalizing health care negligence. The other recourse, an investigation by the Egyptian Medical Syndicate’s Grievances Committee, very rarely finds a physician liable. The inquiry is internal and informally peer-led, with a maximum penalty of a limited term license suspension.
Egypt’s health care system has faced years of ineffective government-led reforms created with minimal transparency and without any community dialogue, participation or debate. Healthcare spending is fairly low, at 4.9% of their GDP – it is 17.9% in the U.S. – but the expenses are unmonitored and without basic levels of transparency. Hendrik Bekedam, the World Health Organization (WHO) representative in Egypt, laments that despite their health infrastructure being among the best in the developing world, many “hospitals remain poorly monitored, under-resourced and are operated by poorly trained staff and doctors.”
The inadequate good governance mechanisms are draining limited resources, and even the primary health care facilities that pass the government’s accreditation mechanism have issues with quality of service and management. According to Transparency International’s 2013 Global Corruption Barometer, 21% of respondents admit to paying a bribe to medical and health services, furthering the inequality of the system.
This project provides the opportunity for the Egyptian people to take control of their health and demand accountability. It is clear that the people do not trust the government. Only 22% believe that the Egyptian government is at all effective at combating corruption and organizations, such as the World Bank, are suggesting that the empowerment of beneficiaries on the demand-side has a higher potential to increase quality of care. 64% agree or strongly agree that ordinary people can make a difference, and a project such as this has the potential to show that power of the collective.
As said by Sabae, “Just like the constitution of the country, the voice of the people must be the origin of all needed reforms in the upcoming period. Healthcare reform is no exception.”
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We spoke with Shamseya about this project. The following is that discussion:
How do you ensure that the community development of the indicators is representative?
The initial research phase aims at having a preliminary understanding of the service user’s perspective. At first, a thorough stakeholder mapping was carried out, followed by focus interviews with selected representatives from different income levels, ages, habitats and genders. They included doctors, nurses, health service managers, administrators, technical staff and, most importantly, patients, relatives of patients and service users in general.
However, these indicators were conceived to be a perpetual work in progress. They will be adapted based on the feedback and new learned information from their practical applications.
The more the tool is being used, the more assessments there are of hospitals and health service centres. The more we engage community members by having them carry out these performance appraisals, the more mature, representative and focused the indicators become.
With the strongly restricted freedom of information in Egypt, does a project like this have any limitations?
This project is aimed at addressing the restricted access to information by placing the retrieval of data in the hands of community members. It provides additional information that is not collected by policy makers and makes this data available to the public and decision makers.
It is foreseen, however, that as this tool becomes stronger and more influential, new limitations may arise from bureaucratic attempts to prevent these community assessments, but we believe transparency and visibility of the tool will make these attempts ineffective.
Is it a possibility that health care providers will bribe patients to provide favourable reviews?
Patients will not be carrying out the reviews on their own. Community monitoring will be by those who have received basic training on how to carry out the performance appraisal and how to use the tool. They will be supported by our team. In addition, the final data and review of a hospital will be the collective consensual findings of more than one community monitoring group. The data will be collected and validated centrally and additional audits can be conducted if findings show significant differences.
From our practical experience so far, however, we have been faced with a most interesting finding. In our testing of the tool in public hospitals, we have been shocked that public hospital staff and managers actually rushed to SHOW the community inspectors the defects that the hospital has. They were keen to document and report these defects in an attempt to get them fixed. This went all the way up to the hospital’s director, who blamed higher decision makers in the government for these shortages.
Does the difficult environment for non-profits in Egypt cause any difficulties for this project?
For the time being, this is not causing any additional problems, although it is not helping.
How does this project help those who don’t have the luxury of choosing a different clinic/hospital?
We will use the results of these assessments in a name-and-shame approach and pass on these findings to the media. Public officers in charge of the facilities will be forced to carry out the necessary service. By making this data available to the public, we are also making it available to decision makers and the media.
How do you plan on encouraging and enabling a broad spectrum of people to provide reviews?
By continuously working to improve and simplify the community-monitoring tool and by targeting underrepresented populations to be trained and recruited as community-monitors. Generally speaking, we believe that youth and women are the idea candidates for this and we are putting particular attention in our plan to ensure their full representation.