13 - 19 April 2000
Issue No. 477
|Published in Cairo by AL-AHRAM established in 1875|
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Curing the customers
Is Egypt applying global quality standards in its healthcare system? As Gihan Shahine discovers, efforts are being exerted to improve medical services, but there are still many obstacles to negotiate
Nabiha underwent a hysterectomy -- an unpleasant experience, at best. Only a month later, however, when she began to suffer from a continuous high temperature and severe stomach pains, did she discover that the surgeon had left two swabs inside her body during the operation.
"I went to another doctor, who X-rayed me, and I was immediately taken to the operating theatre," she recounts angrily. "Had I waited any longer, I would have had septicemia."
Nabiha survived, but Ghassan didn't. He had undergone an operation at an upmarket private hospital in Heliopolis to mend a broken leg. A week later, he had an infection, and was running a high fever. He was transferred back to the same hospital, where he was given antibiotics. This treatment allegedly led to his death. A doctor himself, Ghassan had refused the medication at first, but was told that it was the only treatment that would work.
"Although the hospital was big and very expensive, the doctor was never there. He prescribed medication over the phone," Ghassan's daughter says. "There was no one to talk to, and we were dealing with a nurse all the time. The doctor did not arrive until 10.00pm, when it was already too late to save my father. We thought of suing the hospital, but the whole thing is just too much to bear."
In a series of articles titled "From the hospital to life after death," writer Abdel-Azim Ramadan opened the Pandora's box of medical care in Egypt by recounting his own experience in the public healthcare system. In a severe state of hypoglycemia, Ramadan slipped into a coma and was rushed to a public hospital. There, he claims, the doctor in charge -- a specialist in endemic diseases -- diagnosed an embolism and requested a brain scan. Ramadan's wife, horrified by the news, transferred him to a specialised hospital, where a bottle of glucose brought him back to consciousness.
Healthcare has recently been the focus of much attention. Many experts believe that a majority of health institutions worldwide are still below standard, and efforts can be detected to improve medical services the world over.
(photos: Salah Ibrahim)
Egypt is no exception. Promoting quality in healthcare has been a major concern on the public and official level. The new health insurance law has inspired a heated public debate, while conferences are being organised and efforts exerted by both the government and NGOs to find the means to improve standards in healthcare facilities.
"I used to receive many complaints of poor health services and malpractice when I was still at the ministry," notes Dr Ali Abdel-Fattah, former minister of health and chairman of the Egyptian Society for Quality in Healthcare (ESQua), a non-profit organisation working to promote better standards. Following a ministerial change, Abdel-Fattah decided to establish ESQua in 1995, with the aim of creating awareness among healthcare providers about the importance of quality.
"I felt there was an urgent need for a non-profit organisation that would work independently," Abdel-Fattah explains. ESQua coordinates its efforts with those of relevant organisations to develop and mobilise human resources. "We increase awareness of patients' rights and expectations, and tell the public how and where to complain in case of medical malpractice. We also try to convince health providers that improving service will definitely reduce the costs incurred by malpractice."
Quality, however, cannot be improved in the absence of well-trained medical staff. A recent graduate from Ain Shams medical school, now in her pre-residency year, puts it this way: "We hardly receive any training after graduation beyond passing on requests for blood transfusions, blood counts, analyses and X-rays. We are not allowed near the patients, and doctors are always too busy to pay us any attention."
Once the pre-residency year is over, only 20 per cent of post-graduates are appointed to universities -- some as academic staff and the majority as resident doctors in hospitals affiliated to the university. The other 80 per cent spend their three years of residency in training hospitals or hospitals affiliated to the Ministry of Health, where, as one doctor puts it, "they learn almost nothing."
"We actually don't have a working system or any criteria to follow," complains one doctor, who prefers to have her name withheld. She has been working in various public sector hospitals for seven years. "The haphazard nature of the system explains why mortality rates are high in many public hospitals."
Experts agree that poor training is due principally to the large number of students admitted to medical schools every year.
"The number of students is huge, and it's simply impossible to provide them all with proper training," complains Hamdi El-Sayed, head of the Physicians' Syndicate. In an attempt to address the problem, the Ministry of Health and Population (MOHP) has established the Higher Council for Training, through which training programmes in seven fields of specialisation have been implemented to date. But as El-Sayed and other experts insist, these efforts are negligible when set against the numbers of medical students, which must be reduced if any improvement is to be achieved.
"Qualified personnel is pivotal to the improvement of health services in Egypt, and is still hard to find given poor training and the sheer number of students," El-Sayed adds. He gives examples of two medical schools in Upper Egypt which are not affiliated to teaching hospitals. Students must therefore travel all the way to Qasr Al-Aini to get a glimpse of practical training. "Can anyone imagine a medical graduate who has never been to a hospital?" he exclaims. The emergence of private medical schools, where students with lower grades are accepted in return for high tuition, will deal a more severe blow to the medical profession, he adds.
"The standard of medical education is really at stake," El-Sayed concludes. "Now that we're about to implement the GATT [General Agreement on Tariffs and Trade], competition will be fierce. If we don't improve fast, I'm afraid we'll soon be lagging even further behind international healthcare standards."
Mohamed Awad Tageddin, of the Ministry of Higher Education, however, believes the picture is not so dim. He dismisses all claims of inadequate medical education and training as unfounded. "There are many indications that Egyptian doctors are up to the international standard," Tageddin retorts, citing the posts that many doctors hold in Arab and foreign countries and the success they have achieved in support of his argument. "There is no doubt, however, that there are negative issues that the ministry, in cooperation with the MOHP, have been tackling for the past few years." The national programme to combat tuberculosis is one case in point. The government has trained doctors in that field so well, it is now exporting expertise to foreign countries, according to Tageddin.
Health Minister Dr Ismail Sallam concurs. He stresses the fact that the MOHP has been working closely with 11 other ministries, besides health facilities, NGOs and skilled individuals, to design and implement programmes enhancing quality in healthcare. "Quality in medical services has been a high national priority and a main component of the ministry's health reform policy," Sallam maintains. When he took over the ministry, he recounts, he found a lot of research work on healthcare quality; the challenge, however, was practical implementation.
To achieve this goal, the ministry established quality criteria, trained doctors to apply them and designed checklists to assess performance in health plants. Family planning centres were a high priority. Around 1,624 of those centres improved so much, they received an honorary "Gold Star," according to Sallam. The ministry has also launched programmes to assess "customer satisfaction," tightened control over the distribution of drugs and vaccines, and applied quality measures at 600 newly built health units, where other social activities were introduced to encourage a higher flow of patients. In the very near future, Sallam asserts, the family doctor project will be applied in 500 villages nationwide, and a medical, social and economic record will be established for each of the families the project targets.
Mother-and-child health has also been a major concern. The past decade has witnessed significant improvements in the health of Egyptian women and children at the national level. Infant, child and maternal mortality rates have declined markedly due, in large part, to the efforts of the MOHP and projects supported by donors, according to Dr Ali Abdel-Meguid, deputy chief of John Snow Inc., a USAID-funded private consultancy firm working in the field of maternal and child care.
Despite these advances, however, problems persist. According to 1997 estimates, Egypt still has high mortality rates -- 52.7 per thousand and 174 per 100,000 -- of all living infants and mothers respectively. Maternal mortality rates are higher in rural than urban areas. In Upper Egypt, a staggering 217 of every 100,000 pregnant women die, compared to 132 cases recorded in Lower Egypt. Infant mortality rates are also the highest in Upper Egypt: 89.3 deaths per 1,000 infants were recorded, compared to 27.5 in urban areas, 39.7 in the countryside and 55.1 in lower Egypt. Neonatal mortality has declined less rapidly than mortality among other age groups, accounting for 40 to 70 per cent of all infant mortality.
The five leading causes of maternal mortality are bleeding with pregnancy, hypertensive diseases, genital sepsis, ruptured uterus and complications from C-sections. These are the findings of a study conducted by John Snow Inc. in cooperation with the MOHP to assess health needs and the standard of performance in Upper Egypt mother-and-child care units. The study reveals that none of the units surveyed had standard protocol on essential maternal case management, or a training programme regarding essential obstetric and maternal case management. Poor prevention and/or control procedures were observed in the management of obstetric cases. Health providers do not monitor delivery by pantograph, since this facility is not available in the first place.
Another study conducted at the Minya University Faculty of Medicine found that 30.8 per cent of urban pregnant women and 27.5 in rural areas had high-risk pregnancies. Urban mothers had more abortions (13.8 per cent) than rural ones (8.7 per cent). Hypertensive disease due to pregnancy was significantly more common among urban women (7.4 per cent) than rural ones. Almost 90 per cent of rural women delivered at home, compared to 80.5 per cent in urban areas. The daya (midwife) ranks the highest in assisting deliveries in both urban and rural areas (47.9 per cent and 52.3 per cent respectively). The assessment also revealed a high percentage of deficient or missing registration of important data, as well as abnormal findings.
In an attempt to reduce maternal and infant mortality rates, the MOHP and John Snow Inc. have launched a jointly funded "Healthy Mother/ Healthy Child" (HM/HC) programme to improve medical services in Upper Egypt, where mortality rates rank the highest. According to Dr Esmat Mansour, the MOHP supervisor of HM/HC, the project's overall strategy is to provide an integrated package of services for the reduction of maternal and prenatal mortality among the high-risk populations of Upper Egypt.
One of the HM/HC programme's main achievements is assessing health and training needs in Upper Egypt governorates. Governorate, district and facility management teams have been trained in how to use service standards and to monitor and improve the quality of essential service provision. Facilities have been renovated, well-equipped management teams organised and trained and service providers trained to a level of clinical skill mastery.
"We have trained 800 people in eight hospitals in Upper Egypt so far," Abdel-Meguid boasts.
When the programme was initiated in 1996, however, many problems were encountered: poor-quality maternal and child health services, irregular and unregulated quality of care in the private sector, lack of management training for health service managers (who are often doctors assigned by seniority), insufficient funding and internal allocation of resource leading to unsustainable services and limited community participation in the health sector.
"The obstacles to the application of quality measures are almost the same in all health sectors," Abdel-Meguid says. "People are simply not used to the concept of quality and medical doctors are barely trained." Has the HM/HC programme reduced maternal and infant mortality rates in Upper Egypt? "Tangible results take a long time to materialise, but the project has definitely improved medical services in the field of mother-and-child care. We hope the programme will be adopted nationwide," Abdel-Meguid confidently replies.
Quality healthcare means doing the right thing, at the right time, in the right way, for the right person -- with the best possible results. Clinical performance is only one of two main types of quality criteria. The other is consumer ratings, or consumer satisfaction, information that looks at healthcare units from the consumer's point of view. For example, do doctors in the plant communicate well? Do patients get the health services they need?
"Gathering information about patients' perception and experiences with care helps healthcare providers and organisations find ways to be more responsive to patients' needs," maintains Hanan Ali El-Sayed, a lecturer at the Theodore Bilharz Research Institute in Imbaba. "There are few studies on this issue, however, in developing countries, especially for government-run health facilities. The studies and their application depend on policy-makers' concern, whether or not researchers are interested and, to a large extent, on the cultural makeup of the customers -- here the patients -- themselves."
The Institute has launched a study to develop a satisfaction questionnaire for patients using government-operated health facilities, to be used as a quality-measurement tool.
The study came up with some interesting results. High rates of dissatisfaction were related to doctors' eagerness to end the consultation (64 per cent), the absence of thorough explanations (51.5 per cent), and the time patients spend waiting for the doctor's final decision (38.5 per cent). In-patients were especially dissatisfied with regard to continuity of care (82.9 per cent), the cleanliness and maintenance of sanitary facilities (around 60 per cent), the number and duration of encounters with doctors during a hospital stay (57.1 per cent) and information given by doctors (37.1 per cent).
"Although the customers are not accustomed to these questionnaires, the response rate was fair," El-Sayed maintains. "The experiment proved that patient satisfaction is necessary in health facilities if we really aim at quality."
Many experts agree that family healthcare should be a high priority. By 2015, they estimate that at least 10,000 five-to-six-member families will be in need of quality healthcare.
Is the Egyptian health system prepared to meet that target? "Yes, if we assert the importance of quality as a national demand and a shared responsibility," maintains Essam El-Antabli, executive manager of ESQua. "Everybody has to take part in upgrading healthcare services: clients, medical staff, management, quality control teams, care providers, hospital owners, the media, the religious establishment, syndicates, NGOs, educationalists, environmentalists... Everyone has to know the meaning and value of quality. These values should be instilled in children at school. This is where we should start."