Egypt Healthcare and Military Domination (1)

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The term “military hegemony” has been defined as the process of transforming society categories into military units mostly based on a conflict management method. Unfortunately, the military seize all affairs of power, in reliance on their ranks, in absence of any laws that may qualify them to attain such status, or constitution articles that may allow them to operate in places they have no experience therein, especially those to sensitive jobs such as health and education.

Militarization is mainly based on glorification of the army and military power, with intervention with administration of the country’s ministries and politics, replacing politicians, managers and personnel in the private and public sectors alike. In this regard, the Egyptian model is considered an apparent example of such military hegemony. With General Abdel-Fattah El-Sisi’s seizure of power after the military coup on 3 July 2013, Egypt witnessed a significant increase in militarization of civilian sectors, that it has become clear that the army’s militarization of the country would continue long decades[1].

Military dominance of health care:

The dominance of the Egyptian military over health care has extended, starting from the vision, manifested in setting policies, through the domination of top management, middle management and terminal management; up to operative management with directly dealing with citizens at service delivery outlets, within the framework of a desire to control all joints and dynamics of health care services materially, financially, morally and humanly.

The paper will address this important topic in two parts: the first part will discuss the law establishing the Egyptian Health Council and the military dominance over top management, manifested in the Ministry of Health’s central office; and the military dominance over middle management, including managers of model hospitals.

Then the second part will address: the military dominance over the outlets that provide health care services to citizens, as well as domination of provision of health services to citizens through increasing numbers of military doctors.

Here is the first part:

First: The law establishing the Egyptian Health Council

So that it could tighten the military grip on the entire health system in Egypt, starting from setting policies and drafting strategies up to issuance of executive decisions and appointing graduates of colleges and institutes of medical professions, the Egyptian regime in March 2022 issued Law 12 of 2022 for the establishment and organization of the Egyptian Health Council[2], which highlighted that:

1- Military authorities have become a basic component in composition of the Egyptian Health Council, as Article (1) states: “A public service body under the name of the “Egyptian Health Council” shall be established, having a legal personality, and reporting to the President of the Republic, with its headquarters located in Cairo. It may establish branches in other governorates, where the Armed Forces’ Department of Military Medical Services (including the Military Medical Academy,  the Armed Forces College of Medicine) shall be one of the health council’s branches, which is referred to in articles of this law as the Council.” – which means a clear allusion to militarism in drafting the law, definition of terms, and presentation of detailed articles and clauses.

The idea of ​​establishing a supreme council for health is an old project, which is between now and then updated amidst a media frenzy in each time, where reference to the council’s establishment was made for the first time by Republican Decree No. 61 of 1966 during the rule of President Gamal Abdel Nasser, with its amendments No. 81 of 1978 during the rule of President Anwar Sadat[3], then re-emerged for the third time in 1993 during the era of President Hosni Mubarak, and finally it was reactivated under the directives of Abdel Fattah al-Sisi in 2019[4], where practical experience confirmed that the Supreme Council of Health, whose membership was limited to representatives of the government’s executive authorities, and its role was limited to coordination between the participating civil authorities. Due to the nature of its structure and limited objectives, in addition to its subordination to the Ministry of Health, which made it hostage to the desires of the ministry, the supreme council of health had not fulfilled its role or achieved its objectives.

Therefore, there was much media hype and official welcome of the birth of the new Egyptian Health Council, which for the first time included military health institutions, reporting directly to the President of the Republic, with the presence of the Minister of Defense as a prominent member of the Council’s Board of Trustees, which means that it is a sovereign and effective institution.

2- Broadening the circle of domination and pursuit of profitability; where Article (2) states: “The Council aims to regulate the fields of health in Egypt in areas of post-university education, specialized training, qualification and development of the scientific and clinical level of doctors and workers in various health fields, and in particular it undertakes:

A- Developing level of medical and health training of doctors and workers in various medical specialization, and for graduates of medical and health colleges, including testing them to verify that they meet adequate qualifications for safe medical and health practice, and to ensure the improvement of health services in the Arab Republic of Egypt, in accordance with the state’s general health and medical policy.

B- Achieving integration and cooperation in the field of health training between the Council and various scientific bodies and councils in the same areas of specialization inside and outside the Arab Republic of Egypt, to achieve international standards for safe health practice, and for the Council to keep pace with scientific progress.

Article 4 states: The Council grants an accredited certificate called the “Egyptian Board” for all health sector college graduates after passing the training program and the standardized test for each health specialization subject to the provisions of this law.

The financial catastrophe was prominent through Article 12 that imposed a fee of a maximum of eighty thousand Egyptian pounds, the categories of which were determined by the executive regulations, set for the following services:

1- Approval of professional certificates issued by the granting authorities for all trainees.

2- Approving and licensing health training places.

3- Approval of supervisors.

4- Adopting continuous health and vocational training programs.

5- Holding the national test for licenses to practice the profession and approving the passing certificate with a maximum of two thousand Egyptian pounds.

6- Holding the Egyptian Board exam and approving the passing certificate.

The Council collects these fees in accordance with the provisions of the law regulating the use of non-cash payment methods promulgated by Law No. 18 of 2019.

Linking the Council to those articles of Law 18 of 2019 – related to fundraising – means that the Egyptian Health Council is considered an economic institution that seeks profitability from collecting fees from members of the medical professions for the “Egyptian Board” program, as an alternative to the Egyptian fellowship program that was adopted and backed by the Ministry of Health and was available to a large number of scholars and trainees, with very low fees, even almost free.

Also, the law stated inclusion of the Egyptian Compulsory Training Authority, a body established by Prime Minister Decree No. 210 of 2016 and affiliated with the Council of Ministers (with one third of its members were military physicians) in the Egyptian Health Council.

3- Dominance over issuance of medical licenses and re-accreditation of health workers: as Article (3) states: “Without prejudice to provisions in all laws and decisions regulating the practice of health professions, to obtain a license to practice the profession, the license applicant must successfully pass an examination held by the Council for qualification to practice the profession, and that the license granted to practice the profession shall be for a period of five years, renewable for similar periods, provided that the licensing authorities specify the conditions, controls and standards required to renew this license.

These articles mean robbing the Ministry of Health of its most important powers in granting medical licenses to members of the medical profession, which means complete control over the appointment and follow-up of workers in the health care sector, which completely cancels the role of the Ministry of Health in appointing, following up and supervising its workers.

4- The Egyptian Health Council law excludes the Egyptian Medical Syndicate, as a civil society organization, from the Board of Trustees, which means absence of the role of stakeholders, the doctors, in management of the health scene, as they have been excluded from the Board of Trustees, the supreme and dominant body over the activity of the Egyptian Health Council.

The new law stipulates existence of three supreme bodies running the Egyptian Health Council, namely the Board of Trustees, the Board of Directors, and the General Secretariat[5]. Also, it was strange that the Board of Trustees included the ministers of Defense, Interior, Finance, Health and Higher Education, as well as two members from those interested in training, while the board of directors included all above members in addition to the president of the Military Medical Academy, the dean of the Armed Forces Medical College and a representative of each of the medical professions unions. This clearly confirms the philosophy of the military domination of the council and exclusion of stakeholders from civil society, which negatively affects the fate and future of health care, as well as the fate of civilian medical team members.

Second: Military hegemony over senior management level at the Ministry of Health’s general office:

There is clear administrative penetration of the Ministry of Health’s Office by the military, with control over the financial, administrative and technical movement, whether with respect to regular leaders or to other leaders within the ministry departments. It is noteworthy that I have experienced that situation, based on my job capacity as representative of the Health Directorate of Damietta Governorate, north of Cairo, attending periodic meetings with the former Minister of Health Dr. Ragheb Dwidar in 1992, who was a former army officer, then through my direct dealing with the military heads of sectors at the end of the nineties and beyond. I was also witness to presence of military leaders in their official uniform, heading the largest articulated sectors in the Ministry of Health, such as the general secretariat, financial and administrative affairs, engineering projects management and other central departments such as primary health care in rural and urban areas and other influential public administrations. I was also witness to presence of other military leaders assuming administrative functions after reaching retirement age, most prominently a retired officer who is currently imprisoned in a case of corruption and bribery among others working in the Ministry Office’s General Department of Free Treatment and Licensing[6].

Third: Military hegemony at the level of middle administrations, including directors of model hospitals:

On 22 December 2018, Dr. Hala Zayed, the former Minister of Health, announced that directors of model hospitals that would be developed (48 hospitals, including 29 affiliated with the Ministry of Health and 19 affiliated with Ministry of Higher Education) will be from among the military, where Khaled Megahed, then official spokesman for the Ministry of Health, stated on 22 December 2018: “The Minister of Health directed the selection of administrative directors for model hospitals from among former military personnel, provided that this would be announced through an ad in newspapers to ensure of transparency of the selection[7].

The idea of ​​the ‘managing director’ means allowing appointment of a director not necessarily from among doctors; but instead, the position was limited to the military according to the statement. It is noteworthy that the position of managing director’ is considered to be the most powerful and actually influential position in the administrative structure of hospitals, which is usually occupied by an administrative employee with a university degree and experience in management; and herein lies the danger in the administrative militarization, as the managing director’ is the controller of all administrative work inside a hospital, and he is the decision-maker and the neutral reference to all personnel. He distributes tasks and competencies to each department according to the nature of the work that he determines. He is responsible for following up the workflow and maintaining the hospital’s activity with high quality, setting the main objectives to be achieved, and upgrading the name, position and value of the hospital[8]. In fact, this simply means transforming the civilian medical institution into a kind of military unit mechanism.

To highlight seriousness of this matter, it suffices to state that on 6 July 2022, a republican decree was issued and published in the Official Gazette, stating: “… granting civilian degrees to graduates of various military colleges” (), a role assumed to be played by the Ministry of Higher Education, which grants these degrees to university students. However, the decree did not mention any role for the Ministry of Higher Education, and when a source in the Supreme Council of Universities was asked about this, he said that it is a “sovereign” decision that they have nothing to do with, adding that perhaps there will be coordination later on teaching the civil subjects covered by the decision[9]. Based on this, the Egyptian Minister of Defense will have the authority to grant graduates of the “Military Academy” a bachelor’s degree in economics and political science, while graduates of the “Air Force Academy” will obtain a bachelor’s degree in commerce and business administration, specializing in aviation and airport management. Dr. Mostafa Kamel El-Sayed, a professor of political science at Cairo University, told the Middle East Eye that, “This decision violates the Constitution, as the Minister of Defense is not constitutionally entitled to grant civilian university degrees.”

This clearly means that in the future it will not be possible to challenge the qualifications or efficiency of a managing director of a government-owned hospital from among the military, before the administrative judiciary, as the republican decree has granted him immunity according to terms of the job description for his position in a hospital or any health institution, where this phenomenon has been consolidated in health institutions since 2013[10].