The issue of subsidised infant milk formula became front news recently when families started complaining that they were unable to buy subsidised formula on the market. On 1 September satellite TV channels showed long queues of women waiting for hours to obtain their allowance of baby milk. When an issue surfaces that involves a war between State officials and the press, especially if it directly affects the smallest and most vulnerable members of our society, there needs to be a thorough investigation so as to uncover the truth.
Minister of Health and Population Ahmed Rady denied claims that there was a shortage of milk formula and in a statement the Health Ministry confirmed that the subsidised milk was available in 1,005 government-run outlets in the ministry’s maternal and child healthcare centres. He said the ministry plans to increase the number of these outlets to 1,600 by the end of September.
EGP450 million subsidy
According to the Ministry of Health, more than 18 million packages of the formula were sold during the current year. Those who complained about the shortage, the minister said, were simply trying to buy it from the wrong outlets. Most of these people massed at the Egyptian Pharmaceutical Trading Company (EPTC) in the belief that it was a government-authorised outlet for the distribution of baby milk formula, even though there were eight legitimate outlets in the vicinity. In an attempt to solve the problem the minister temporarily allowed the distribution outlets to permit sales on sight of the child’s birth certificate, although the new system, introduced in August to ensure that the infant formula reached its intended beneficiaries, normally requires the use of government-issued smart cards.
In a country with high birth rates, the infant milk subsidy system eats up about EGP450 million of the State Budget. In the past the subsidised formula was sold through the EPTC and private pharmacies. However, rampant corruption was discovered with some health employees and pharmacists making huge profits by selling the EGP5-subsidised formula at as high a price as EGP60. To put an end to such illicit practices, the smart card distribution system was adopted and a ministerial decree was issued prohibiting the sale of subsidised formula in EPTC outlets and pharmacies and restricting sales to government-run outlets in maternal and child healthcare centres.
The implementation of the new system entailed a reduction in distribution outlets and brought heavy criticism from the Pharmacists’ Syndicate. The launch of the system was especially difficult in that it was misunderstood by the public, especially with regard to the use of smart cards and the change in the formula distribution outlets. Hence the claim by the media of a severe shortage in subsidised formula, the ministry says.
To further ensure that the subsidised milk reached its intended end-users, the categories of beneficiaries of the system were specified by the Health Ministry. These include mothers whose milk production has completely stopped; mothers whose milk production is insufficient; mothers who have given birth to twins or more; mothers suffering from such conditions as diabetes and hypertension or requiring the use of medications which are considered dangerous for the baby, such as rheumatoid arthritis, mental illnesses, breast infections and cancer; and of course in case of the mother’s death. These conditions were set with the purpose of encouraging breastfeeding, which is considered the healthiest option.
Despite the ministry’s reassuring statements, the Pharmacists’ Syndicate accused the Health Ministry of setting unrealistic conditions which made obtaining the infant formula allowance next to impossible. As the crisis escalated, Watani decided to investigate and visited a distribution centre located in the densely populated neighbourhood of Shubra in North Cairo.
The centre is divided into three smaller units for the distribution of the formula, each unit consisting of an examination room and a storage room for the cartons of formula. It is staffed by doctors, nurses, pharmacists and administrative assistants. Although the centre serves a highly populated area, there was no queue on our visit.
We spoke to Dr Mary Girgis, who told us the centre had been distributing infant milk formula for almost five years.
“The Health Ministry’s instructions are being meticulously followed,” Dr Girgis said. “There is absolutely no shortage of infant formula; it is being distributed according to the child’s age. The first age group includes infants younger than six months; the formula available for this group is fully subsidised by the government and is sold at EGP5. The monthly allowance given to this age group varies between four to eight boxes according to the child’s age. The second age group is for babies from six to twelve months who are by that age dependent on foods other than milk; the formula available for this group is partially subsidised and is sold at EGP26. The monthly allowance is two to four boxes of formula.
“When a mother comes to the centre I must examine her to check whether she has sufficient milk to breastfeed her baby and whether she has a disease which could prevent her from doing so,” Dr Girgis said. “Sometimes a mother’s milk production is sufficient but she still opts for formula feeding. In these cases, it is my duty to explain the benefits of breastfeeding for both mother and child. Women often get angry with us when a doctor decides that she is perfectly fit for breastfeeding and tells her she is not entitled to subsidised formula. In such situations, we sometimes have to endure insults and even assaults from the mothers. Another problem that we face is that some women believe that the two boxes of milk formula that we give older babies are not enough and accuse us of refusing to sell them the formula.”
Dr Girgis said that there had never been any crowds waiting for formula distribution at the centre and, on average, ten cases of formula distribution were handled every day. “If a mother is already registered with the system she is given the formula right away,” she said, “but the process takes longer for newcomers who have first to be examined by a physician to assess their need.”
At the same centre Watani met Marina Malak, the pharmacist in charge of the distribution. “I give the mother her monthly allowance of formula only when I receive the approval of the examining physician,” she said. She confirmed that there was absolutely no shortage of the milk. “We receive 600 cartons of the fully subsidised infant formula and 400 cartons of the partially subsidised one on a monthly basis. Most of the formula we receive is imported from France and Switzerland. Each distribution centre has its own storage room which must comply with the storage conditions set by the Ministry of Health. For instance, the room must be well ventilated and its temperature must not exceed 25 degrees Celsius, and the cartons must be stored at least 15cm from the walls to protect them from heat and humidity.”
Most of the problems faced by the centre’s personnel result from the public’s lack of understanding of the system. “Many people don’t understand that the number of boxes given to a certain family depends on the baby’s age, not on the healthcare provider’s personal judgement,” Dr Malak said. “Many mothers also believe that an allowance of two boxes of formula for the older babies isn’t enough.” Dr Malak also believes that the Ministry of Health should allow for more flexibility in the implementation of the system. “In some cases, the judgement of the doctors must be taken into consideration rather than strictly abiding by the rules,” she said. In the course of her experience she had encountered cases where the mother’s milk production was sufficient but it was the baby who, for some unknown reason, refused the breast. “If a mother finds herself in this situation she is not allowed subsidised milk and has no option but to buy unsubsidised formula from pharmacies. This constitutes a prohibitive burden on low-income families.”
Conversely, a pharmacist who asked for his name to remain anonymous said that in his opinion the latest supply crisis was fabricated by certain corrupt pharmacists who had been profiting from the old system. He accused some pharmacists working in the EPTC, helped by employees responsible for the company’s information and database system, of importing shipments of infant formula in the name of some non-operating pharmacy and selling them illicitly for a huge profit. EPTC was the company that imported the subsidised formula under the old system.
“Before the new system, the subsidised formula was sold in private pharmacies,” he told Watani. “Some pharmacists used to sell the milk exclusively to their regular customers at a higher price.”
In Alexandria governorate on Egypt’s Mediterranean coast, the directorate of health affairs has informed local residents that subsidised formula will only be available though government-run maternal and child healthcare centres. Alexandria’s Deputy Health Minister Magdi Hegazi told Watani that 40 outlets covering all the districts of the governorate had been allocated for the distribution of formula. “To ensure that subsidy reaches its intended beneficiaries the distribution of the formula is only allowed via smart cards which contain the data of the child and his parents,” Dr Hegazi said. “Smart cards are issued within 15 days of presentation of the application at any maternal and child healthcare centre, and following the mother’s examination and approval by the centre’s physician in compliance with the conditions established by the Ministry of Health.”
At the maternal and child healthcare centre in Muharram Bey, Alexandria, Watani met Manal Badreddin, director of the centre, and her deputy Dr Reem al-Rifai. They both explained that the centre was open for morning and evening sessions during working days in order to be best accessible to mothers. They confirmed that the ministry’s rules were followed precisely, and that there were no queues.
In Upper Egypt, Watani reporters visited several of the 49 maternal and child healthcare centres in Minya governorate, some 250km south of Cairo. At none of the centres did they see any queuing that might indicate a shortage. Pharmacists at the centres confirmed that the available supply was more than enough to cover local needs.
To ensure that there will be no future shortages in infant formula, the Ministry of Health has announced plans for the construction of an infant milk formula factory in collaboration with the industrial sector of the Armed Forces using international expertise. In the meantime, the Armed Forces has imported 18 million boxes of formula which the Ministry of Health will allow pharmacies to distribute at the price of EGP30 per box. This should effectively end all problems on that score.
21 September 2016