Improving access to health care for children in street situation in greater Cairo

©Hajar Masoud

Improving Access to Health Care for Children in Street Situation in Greater Cairo Médecins du Monde’s Programme in Greater Cairo

“When I get older, I would like to be a doctor because many people get sick and they don’t have money, so I want to help them” Aya, 14 year-old girl – participant in Médecins du Monde’s health education activities in Cairo

When we talk about Children in Street Situation (CSS) we refer to a social phenomenon that Egypt clearly identified around the 1980s and that, since then, NGOs and governmental institutions have been trying to address through different types of programmes.

These programmes have tackled legal, social and economic aspects of this crisis in order to impact on its causes as well as to improve the children’s living conditions, which are characterized by danger and risk.

The lack of evidence-based data regarding CSS at international and national levels can explain the huge gaps in assessing the magnitude of the phenomenon and the variety of situations it covers.

In Egypt, in the governorates where the majority of CSS is concentrated (Cairo, Alexandria, Giza and Qalioubiya), the numbers of CSS should be assessed carefully, as they vary according to different surveys, from 10 000 to 200 000.

The definition of CSS is also a subject of ongoing debate, as there are many different definitions in use. Therefore, it is essential to clarify the definition according to Médecins du Monde’s programme in Egypt: the term “children in street situation” refers to children under 18 years old, boys or girls, who spend most of their time in the street, without any supervision, with or without links with their families.

Stakeholders working to improve the lives of CSS agree that recently the number of CSS has been growing. According to them, the CSS average age is changing. The average age used to be between 13 and 16, nowadays, the average age is less than 12 years.

Recreational activities organized by MdM for CSS

Profile of CSS in Greater Cairo The main causes of the CSS phenomenon in Cairo are multidimensional and intertwined, and include:

A survey conducted in April 20091 , using in-depth interviews with about 250 CSS, gives some indication of the characteristics of this highly-fluid population:

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Difficult family situations, linked to parents’ separation, divorce, remarriage or death (and frequently involving violence, abuse or neglect);

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60% of the children in the sample were aged 10-15 years;

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85% of the children interviewed were boys. Economically active girls are more often employed in factories or as domestic in private houses, and therefore are less present on the streets;

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Deteriorating economic conditions, putting pressure on children to provide for themselves by working and/or leaving the family; and

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63% of the children in the sample return home at night, especially the girls. On the contrary, 29% declare sleeping outside (pavement, railway platforms, abandoned houses, garages, incomplete buildings…) alone or with friends, particularly older children;

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Rapid migration, from rural to urban areas as well as from the south of Egypt to the north, resulting in family breakdowns and cities that are incapable of integrating this flow of migrants.

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68% of the children interviewed have been in the street for at least one year; and

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90% of the children in the sample carry out some activity in the street to earn money and that is also their main reason for staying in the street (e.g. begging, washing cars and shop windows, selling paper tissues and other items).

Policies and interventions for CSS Egyptian society has been trying to manage the increasing CSS situation by using different approaches, from a straightly punitive one, portraying CSS as delinquents, to a more curative and protection oriented approach, considering the children as victims.

Nowadays, the Egyptian community is more aware that CSS are children in need of protection and support, although still a great majority of people look at them with fear and suspicion.

The immense efforts NGOs have made using a protection approach has had a strong impact on national policies and laws.

For example, in 2003, a new national strategy was established for the protection and rehabilitation of street children. In 2008, Egypt’s Child Law was amended in order to protect children from being stigmatized as criminals, by holding parents responsible for their children’s behavior, and using a rights-based approach.

Egypt - General indicators

Total population 81 121 077 inhabitants2 Greater Cairo population (Cairo, Giza and Qalyubia governorates) 19 622 652 inhabitants3 Urban population 42,8% of total population4 Age structure 31,5% of total population ages 0-145 Population living below the national poverty line 22% of total population6 Economically active children 11,5% of male / 4,3% of female children aged 7-147 Perceived level of public sector corruption 2,9 on a scale of 0 (highly corrupt) to 10 (very clean)8

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1

Guarcello L., Koseleci N., A profile of Cairo street children, Understanding Children’s Work Project Working Paper Series, November 2009; a joint ILO, World Bank and UNICEF project.

World development indicators – 2010 Population 1 January 2010 estimates Egyptian Statistics 4 World Development Indicators – 2010 5 World Development Indicators – 2010

World Development Indicators – 2008 World development Indicators – 2005 8 Corruption Perceptions Index – 2011

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6

3

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Health status and access to health of the CSS of Cairo

Common health problems affecting CSS The main health issues CSS are facing are related to aspects of street life: promiscuity, lack of hygiene, violence (physical, psychological, and sexual), addiction.

During interviews conducted by Médecins du Monde (MdM) with 100 CSS in February 20129 , children mentioned having been affected by the following health problems in the previous three months: •

Upper respiratory diseases (cold, respiratory symptoms…),

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Trauma, wounds and burns, and

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Gastro intestinal diseases (abdominal pain, intestinal worms…).

“We identified skin and eye diseases as major health problems faced by street children, but they don’t declare it. Because it’s coming from a lack of hygiene, which is a permanent problem, children might not consider these diseases anymore as health problems and they will not look for health care services for such problems.

We also fear that children don’t dare to talk about sexually transmitted diseases, which are a major problem among street children, but are still a huge taboo in Egyptian society.”

Dr Rozenn Le Meliner, Medical Coordinator, MdM mission in Egypt

Egypt - Health indicators

World Development Indicators

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Health indicator

Egypt

Tunisia

France

World

Life expectancy at birth (2009) (f / m)

72,7 years

74,5 years

81,1 years

69,4 years

(74,7 / 70,9)

(76,5 / 72,5)

(84,5 / 77,8)

(71,5 / 67,4)

Under five mortality rate (per 1000 live births) (2010)

21,8

16,1

4,1

57,9

Infant mortality rate (per 1000 live births) (2010)

18,6

13,8

3,4

41,0

Adolescent fertility rate (births per 1000 women ages 15-19) (2009)

44,2

5,1

6,7

53,9

Health expenditure per capita for one year (2009)

113,3 current US$

240 current US$

4 798 current US$

863,6 current US$

Maternal mortality ratio (modeled estimate, per 100 000 live births) (2008)

82

60

8

260

Médecins du Monde, Report on the third Knowledge, Attitudes and Practices and Health Access Survey, February 2012

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Barriers to healthcare access for CSS

Social Worker presenting smoking impacts to CSS during an event organized by MdM

Access to public health care is difficult for CSS for the main following reasons: •

Public health structures tend to reject CSS at admission, in line with the common negative perceptions of CSS among society;

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CSS are almost always reported to the police;

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Medical care is expensive and not suitable or adaptable for the street context.

As a consequence, CSS generally do not want to go alone to Health Care Centres, which increase the probability that they would not be treated at all.

The only chance for them to receive care relies on their contact with NGOs, and with the social workers they refer to when feeling sick.

“I don’t go to the hospital alone, I always go to an NGO first.”

Ahmed, 13 year-old boy, NGO Caritas - Cairo

“We do check-ups at the hospital but children are often afraid to go there, they are afraid of mistreatment. We try to encourage them to go, they generally go with a social worker.”

Merihane, Social Worker, NGO Ma’wa

Health care services provided by NGOs are usually not adequate. In general, NGOs do not have enough, or sometimes, any medical personnel, or any information on health issues. However, social workers can at least accompany children to health care facilities.

“Children think that NGOs provide a high quality of health care. They are natural medical referral points for children, who turn to the staff of NGOs for any kind of care. That’s why the training of NGO staff is crucial.”

Dr Ahmed Hisham, Medical Officer, MdM mission in Egypt

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Médecins du Monde’s intervention in Greater Cairo

A growing number of Egyptian and international NGOs are implementing protection-oriented programmes for the CSS of Cairo, providing them with food, shelter and education. But few of these programmes include a health component and even fewer are concerned with comprehensive medical and psycho-social dimensions. Since January 2009, MdM has been supporting six Egyptian NGOs (Ma’wa, Caritas-Cairo, Egyptian Association for Societal Consolidation, Nour el Hayat, Banati, Ana el Masry) in order to integrate these essential health aspects in their daily activities.

Building self-esteem during an Information, Education and Communication event organized by MdM for CSS

Health education for CSS “Ma’wa has changed since we started working with MdM, before that, education to CSS was obligatory and in the form of orders, now it’s not the same , no shouting, just explaining what are side effects, signs and symptoms, complications and give them the choice without interfering in their decisions.”

Hanaa, Social Worker and Coordinator, NGO Ma’wa

Considering that children – and, in particular, CSS - are active agents in their own lives, MdM has been seeking to improve their knowledge, attitudes and practices towards their own health. Three years of complete and comprehensive activities led to tremendous achievements, including: •

58 social workers from NGOs fully trained on Information, Education and Communication (IEC) concepts and health education tools; and

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653 Information, Education and Communication and health message sessions held by social workers, with an average participation of six children per session. Children who attended the sessions are now able, for example10: • to react appropriately when they have a cold or cough: 66% of the children would either drink something hot, with citrus, eat honey or wear warmer clothes; and • to treat a wound: 80% of the children would either press it to avoid bleeding, clean it, apply antiseptic or cover it with a bandage.

“I enjoy the treasure hunting. I learned to avoid bad things and how to stay protected. I learned how bad things are transmitted.”

Ezzat, 13-year old boy, NGO Ma’wa

Other achievements in this area include: •

Development of an Information, Education and Communication manual and health messages booklet;

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Two IEC events, gathering 104 children in total, with activities and games around health; and

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Theatre workshops for 18 children and six social workers, giving them new tools to express themselves and strengthen their self-esteem.

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Médecins du Monde, Report on the third Knowledge, Attitudes and Practices and Health Access Survey, February 2012

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IEC event and theatre performance

Last rehearsal before the theatre performance

In November 2011, closing the 2nd IEC event organised by MdM in Cairo, CSS and social workers presented a short play that they had been working on for months with the support of three theatre professionals. For these children, theatre skills are new tools to express themselves. Talking about themselves is often far from easy because of their hard living conditions and the different psychological problems that can result from this environment.

Aya, a 14-year-old girl explained: “At the beginning, I was embarrassed but I got rid of this”.

The final result was a success!

“At the beginning, I was afraid because I was thinking that the play was bad and the people won’t like it. But, at the end, it was good and the people were clapping their hands. When I saw the people happy, it made me happy.

And I was also happy from the inside” describes Khalid, one of the CSS who was in the play.

The play was inspired by the CSS’s own stories. It showed how the children tackle obstacles in their lives, related to family or their living conditions in the streets. The play also expressed their hope to reintegrate into the community through an NGO. Laughs and clapping hands were heard throughout the performance, and the children embraced the health messages in the play. “The information stays in their heads” declared one social worker.

Medical and psycho-social capacity-building towards NGOs Over three years, MdM also worked closely with its partner NGOs in order to improve their capacities to provide comprehensive and quality healthcare and health prevention to CSS. Numerous training sessions and field follow-up created sustainable results for the project: •

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55 social workers fully trained in the management of CSS health issues and the use of medical and reproductive health guidelines; Medical consultations in partner NGOs in order to provide on the job training to the social workers for basic health problems; Training sessions and field follow-up for social workers on psycho-social topics;

“The behavioural therapy training session helped me to communicate better with the children, understanding their behaviour and dealing with their problems.”

Marehan, Social Worker, NGO Ma’wa

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93 debriefing sessions with social workers, providing psychological support for the NGOs staff to help them cope with work pressure;

“I like the debriefing sessions, as they improve our communication inside the NGO, help us to discuss problems at work in a mature way.”

Ameer, Psychologist, NGO Ana el Masry

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Development of sexual violence guidelines, present and currently used in the six NGOs; and

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Provision to NGOs, Basma Clinic (dedicated to CSS) and Health Care Centres of medicines and medical material and equipment.

“I’ve been working with MdM since 2004, with the previous project. I took all the trainings and now I do IEC activities for the children myself. The MdM team gave me a lot of information, helped me in all aspects related to the health field because we are not doctors. We call them when a child has a medical problem. MdM really helped all the NGOs working with street children and helped them do awareness for the children’s right to health.”

Sali, Social Worker, NGO Caritas

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CSS learning about child’s rights during an Information, Education and Communication event organized by MdM

Advocacy and networking towards medical, social and institutional stakeholders As many CSS also do not have regular access to an NGO that can help them with their health issues or bring them to Health Care Centres, MdM is fighting for the rights of CSS to increase their access to public Health Care Centres. Among the activities carried on and the results achieved by MdM and its partners at this advocacy and coordination level are: •

Complete medical training (physical and mental health) and Training-of-Trainers for the staff of Basma Clinic, enabling them to conduct 2976 consultations of CSS during the three years of the programme;

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265 participants from the teams of nine primary Health Care Centres (under the Ministry of Health and Population) in training sessions on physical and mental health;

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A qualified pool of trainers formed by 11 doctors, psychiatrists and social workers started training sessions on health issues of CSS towards different stakeholders, independently from MdM;

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Active referral system between NGOs, six Health Care Centres and the Basma Clinic, with a contact list of CSS-friendly structures for CSS, NGOs and Health Care Centres. For mental health problems, referral system is now fully functioning between NGOs, Helwan Hospital Child Department and Abu el Rish Mental Health Department;

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Regular meetings of a ‘Health Taskforce’ group composed of NGOs and Health Care workers to discuss obstacles and solutions to improve health care access for CSS, recognized participation of this taskforce in the Egyptian Child Protection Network;

“I participated in some of the network meetings; it was very helpful to have this exchange of information because Health Care Centres were not involved in CSS issue and the network meetings introduced us to this issue and decreased a lot the gap between NGOs and Health Care Centres.”

Mohamed Hasanin, Physician, El Mounib Health Care Centre

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Advocacy workshops for operational and institutional partners focusing on health care access for children and on child protection, with the diffusion of MdM Child Protection Policy; and

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Regular contacts and meetings of MdM with authorities and institutions leading to the publication of a decree allowing CSS to have access to public health facilities for free, without the need of an identification paper.

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Médecins du Monde’s partners in Egypt

‫ﻋﻴﻦ ﺷﻤﺲ‬ Heliopolis

‫اﻣﺒﺎﺑﺔ‬

Embaba

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‫اﻟﻘﺎﻫﺮة‬ Cairo

3 2 ‫ﻛﻔﺮ ﺳﻴﺴﻲ‬ Kafr Sissi

5

‫اﻟﺠﻴﺰة‬ Giza

1

‫اﻟﻤﻨﻴﺐ‬

El Munib

6

‫ اﻛﺘﻮﺑﺮ‬6

6 October

‫ﺣﻠﻮان‬

Helwan

Operational partners in the project

Institutional partners in the project

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Basma Clinic (Centre for Social and Preventive Medicine of Abu el Rish Hospital)

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NGOs

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Six Health Care Centres of the Ministry of Health and Population (team composed of two doctors, nurse, pharmacist and social worker) National Council of Childhood and Motherhood (NCCM)

1. Ma’wa - day care centre (boys and girls)

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School-age Health Care Department (MoHP)

2. Caritas-Cairo - day care centre (boys and girls) and shelter (boys)

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Network of NGOs working to support CSS health care access (Ma’wa, Bustan el Tifl, HEEA, EASC, Caritas Cairo and Caritas Alexandria, Nour el Hayat, Tofulty, FACE, Samu social International, Ana el Masry, Banati)

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Egyptian Child Protection Network (ECPN): a group of active INGOs, working to promote advocacy actions to support Egyptian NGOs in child protection initiatives

5. Banati - two day care centres (Embaba and Old Cairo) and shelter (girls only, and young boys)

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Childhood and youth mental health clinic of Abbasiya Hospital (General Secretariat of Mental Health)

6. Ana el Masry - shelter (boys and girls)

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Mental health clinic in Abu el Rish Hospital

3. The Egyptian Association for Societal Consolidation (EASC) - day care centre (boys and girls) 4. Nour el Hayat - day care centre (boys) and shelter (girls)

Press contact: Médecins du Monde - France in the Middle East Middle East Office: +962 (06) 568 7984 Mariem Omari or Cécile Génot coord.cominfo.mdm.me@gmail.com assist.progcom.mdm.me@gmail.com

Médecins du Monde - France in Egypt Cairo Office: 0020 279 501 23 genco.mdmegypt@gmail.com Médecins du Monde - France Headquarters Paris Office: +33 (0)1 44 92 14 32 www.medecinsdumonde.org