, minister of health and population, tells Reem Leila that healthcare provision is in dire need of a radical overhaul became minister for health and population last December, receiving a baptism of fire when, less than two months later, the first cases of avian flu were detected in Egypt. He says it will take years to stamp out the potentially fatal virus. He also has ambitious plans to radically overhaul a broad range of health services, and to ensure that all Egyptians are covered by medical insurance. Most countries in Europe rapidly eliminated the bird flu virus but in Egypt it continues to attack poultry. Why was there no effective plan in place to combat the virus? The government had prepared a national plan to combat avian flu last October and presented it to President Hosni Mubarak, though I was not involved, only becoming minister in December. Since then I have held weekly meetings with the Supreme National Committee to Combat Bird Flu (SNCCBF) to launch awareness campaigns about the dangers of coming into close contact with infected birds. Starting 1 January, the SNCCBF began working closely with the World Health Organisation (WHO) and the Food and Agriculture Organisation (FAO) to develop plans for prevention and containment. Avian flu was first found in Egypt in mid-February, and within days of being detected the committee ordered the mass culling of poultry in urban and rural areas. A week later we solicited the help of the armed forces in supervising the culling and sanitation measures. Within nine weeks rates of infection fell by 97 per cent on poultry farms. The WHO acknowledges this as a significant achievement. To date, millions of birds have been slaughtered, which was a necessary evil. Does this mean we will soon hear of the end of the virus in Egypt? I did not say that. Reducing the incidence of infections is not the same as eradicating the virus. It means we are getting the virus under control. Why is poultry still infected, and why are there cases of human infection? The public should know that the virus is likely to remain in Egypt for many years, and as a consequence should not be surprised by more reports of human infection. It will recur by October or November, but in fewer numbers because birds have been immunised. There are several factors that contribute to the persistence of the virus in Egypt. Bio- security at half of Egypt's poultry farms is slipshod; farm owners and breeders refuse to follow the sanitation instructions issued by the government. The population lives on only five per cent of Egypt's total area and such overcrowding helps the spread of the virus. Also, nearly 30 per cent of the population depends on poultry as a source of income, and the ignorance of veterinarians. These are the reasons why we had so many infected birds, as well as human cases, in such a short span of time. What are the challenges facing the pharmaceutical industry in Egypt? There are domestic challenges, involving the regulatory framework, quality control, research and development, market fragmentation and limited health insurance coverage. External challenges include implementing the General Agreement on Tariffs and Trade (GATT), Trade-Related Aspects of Intellectual Property Rights (TRIPS), as well as international competition. Despite the challenges the local pharmaceutical market is expected to expand rapidly. Strong investment opportunities exist, and e-commerce is increasing. Egyptian medicines are currently exported to 81 countries and the trade is worth $80 million annually and that figure is set to increase once the challenges facing the industry are resolved. Egypt imports 80 per cent of medicinal components, which increases prices and can sometimes lead to scarcity. Can the Ministry of Health intervene to alleviate the problems? The pharmaceutical industry should have been overhauled a decade ago. The industry shares the weaknesses of the wider economy, and the investment record is poor. Yet at the same time drugs remain affordable and are widely available. The Health Ministry maintains a list of essential and non-essential drugs, and since it is committed to guaranteeing the interests of low-income Egyptians, it controls drugs on the essential list, including insulin, antibiotics, cardiac, hyper-tension and hypo-tension drugs. These medications are available at reasonable prices because they are considered strategic products and the government subsidises them. Other drugs, such as vitamins, are on the non- essential list, and the ministry controls the pricing, and is responsible for the availability, of only one or two kinds. Other drugs are not regulated by the ministry at all, because they are considered non-vital to the people's well being. We do intend to impose additional controls on drug pricing and also facilitate the registration of new drugs, but this will be accompanies by increased random testing. If products do not comply with international standards the producing factory will be immediately closed. Local drugs are not as effective as imported ones. How can local products be improved? This is a gross generalisation, although it is true that some local products, though not the majority, need to be more effective. Only the ministry's specialised laboratories, and those of the Faculty of Pharmacy, can measure the bio-availability factor of medicines and hence their efficacy. The ministry is tracing and testing drugs all the time. Some physicians, of course, are contracted by drug companies to convince their patients that the imported product is the only effective medication for their condition. How can investment in the pharmaceutical industry be increased? The price of exported medicine -- especially to Arab countries, the biggest consumers -- must be changed. Arab countries effectively import Egyptian drugs at subsidised prices; in some Arab countries they are sold for less than chewing gum. Why should the Egyptian government subsidise Saudi or Kuwaiti patients? Egypt should export medicines at market prices and not at the subsidised price. The industry also needs to open new markets. For example, the Memphis Company for Pharmaceutical Industries manufactures a drug for AIDS patients. There are only 850 AIDS patients in Egypt, while in South Africa there are more than 65,000. We can produce this medicine and export it to them at market prices. Are pharmaceutical companies going to be privatised? The issue is currently being studied by the minister of investment, so I am in no position to say anything. But I would stress that privatisation must be discussed objectively, and in an informed way. Privatisation has pros and cons. We should work on making it a success, and avoid obstacles that might hinder the process. Many Egyptian businessmen have the capability to turn loss-making public sector companies around. A few large pharmacies and private pharmaceutical companies appear to monopolise certain drugs and thus control prices... This applies to smuggled drugs which bring in huge profits for these pharmacies and companies. The ministry is working on resolving the problem by speeding up registration of imported drugs and imported raw pharmaceutical material. Instead of taking four years to register a new medicine, we will shorten the period to a matter of months which should prevent such exploitation of the patient. What are the main problems facing healthcare provision in Egypt? There are many. The quality of medical and nursing services needs to be upgraded and the health insurance system overhauled. In order to do this we need to learn from the experience of other countries. Healthcare provision in rural areas, particularly in Upper Egypt, is in dire need of improvement. Hospitals and clinics in remote areas need to be completely renovated. Investment in the health sector needs to grow, and greater incentives offered to doctors in underdeveloped areas. But overhauling the health sector requires time as well as the identification of both short- and long-term goals. Short-term policy objectives include broadening the training of physicians, increasing the number of nurses and providing them with proper training courses to improve performance, and increasing physicians' salaries in order to encourage them to work in remote areas. Longer term reforms include an overhaul of the healthcare infrastructure and of health insurance programmes. Medical services in both urban and rural areas need to be revamped, existing hospitals and medical centres supplied with up-to-date equipment and new hospitals built. The budget for research and development in universities and research centres needs to be increased. The ministry already plans to build 1,200 medical units in rural and remote areas in cooperation with the European Union. Much more needs to be done but funds are low. The provision of comprehensive basic healthcare, covering the poor and most vulnerable stratas of society, will require around LE30 billion over the next coming five years. How are you planning to tackle the quality of nursing? The Ministry of Health, in cooperation with the Ministry of Higher Education, has a three- phase plan to improve the performance of nurses. Four new nursing faculties will be created in different governorates, including Qena and Marsa Matrouh, open to university graduates who can become qualified nurses within two years. Nurses with secondary school diplomas will undergo a two-year training scheme to improve their performance, which will be judged by stringent international standards. And what about health insurance? There is an urgent need for a more effective health insurance system, capable of providing citizens with high-quality treatment at their outlet of choice. The new system of insurance should enhance coverage for all, with the rich shouldering a large part of the financing, while the ministry covers the payment for treatment to the poorest. And it is essential to separate the administration from the source of funding. We plan to provide citizens a choice of where they go for healthcare, encouraging competition among private, state-owned and military hospitals. At present only 52 per cent of the population, 35 million people, are covered by health insurance. Under the new system all Egyptians will be insured, which will help enormously in narrowing the gap in provision between rural and urban areas. You promised to clamp down on corrupt hospital administrators. What has been done so far? Frequent checks on private hospitals by the Ministry of Health has resulted in more than 30 hospitals being closed in Giza and a similar number in Cairo for failing to apply Good Manufacturing Practice (GMP) regulations. Soon public hospitals will be included too, and they as well will face closure for failing to apply GMP regulations. GMP regulations address issues including record keeping, personnel qualifications, sanitation, cleanliness, equipment verification, process validation, and the handling of complaints. They are largely common sense practices which help hospitals and physicians improve their performance. In Egypt, only 14 per cent of physicians wash their hands before and after examining a patient, a figure I find very distressing. Some private hospitals are exorbitantly priced. Does the ministry have a role in reducing prices? They are not excessively high prices, but they are unaffordable for low-income families. In medicine when you pay peanuts you get monkeys. Good medical services cost a lot; if you want a good doctor and decent service then you have to pay for it. Only greater competition and building more private hospitals will reduce prices. What about low-income families? Private sector hospitals are an option not a necessity; low-income families are not the responsibility of private sector hospitals, they are our responsibility. As the minister of health I am responsible for providing ordinary citizens with a decent medical service. In January 2008 a three-phase plan will begin, continuing until 2023, to improve the services of public hospitals. In the first phase staff performances will be improved by providing physicians, nurses and technicians with regular training. The ministry has already started this. Then GMP regulations will be implemented in all hospitals, which will be provided with advanced medical equipment. Finally, a flexible administration system will be put in place in public hospitals, capable of taking immediate decisions. There are 2,600 public hospitals and 41 hospitals affiliated to the Health Insurance Authority. Are these enough? More than enough. Average occupancy rates are only 42 per cent. What we need to do is renovate existing hospitals, and close those that are inefficient, including the "integration hospitals", established in cooperation with the World Bank and which cost the government LE500 million annually, money that could be used to renovate hospitals. Is it true that you stopped the national blood donor scheme? No. What I did was ask for violations of the ministerial decree prohibiting the export or import of blood, and blood derivatives, to be investigated. Blood was being collected from Egyptian donors and exported, re- manufactured abroad and then re-sold to Egyptians. Is there a strategy to locally produce vaccines? Vaccines have been produced by the Holding Company for Biological Products and Vaccines (VACSERA), in cooperation with an international company, since 2000. The Ministry of Health stopped the production line last September because the products did not meet international standards. Insulin was also being manufactured inside the VACSERA building, contravening GMP regulations. Both companies are making their operations GMP compliant and the production line will probably restart in August. The ministry is about to establish a reliable laboratory, approved by WHO, which, when in operation, will allow for the export of locally produced vaccines. The launch is expected in February 2007. President Mubarak issued a decree for this lab in 1995, but there was strong resistance and nothing has been done until now. Once it is in operation the lab will certify vaccines produced for export by VACSERA. What is the most chronic problem facing the health sector? Financing, financing and financing. The budget for the health sector needs to increase by LE7 billion for five successive years. If these funds are not available, then Egypt will have to look at the British strategy of allowing the private sector to finance government health projects and then repay them over 30 years. In the last decade, since adopting the system, the UK has built almost 17 times the number of hospitals that it did in the preceding 20 years. If we are able to get the infrastructure right for such a system in Egypt by the end of 2008, then there should be a lot more well- equipped hospitals and medical units all over the country within six years. What projects currently top the Health Ministry's agenda? The ministry will launch two initiatives in a matter of months. The once intermittent medical convoys will now operate throughout the year and cover all governorates. After the first three months we will gather information about the requirements of these convoys, in order to better cover villages and remote areas. And beginning in December we will launch a preventive health programme for women in Giza and Cairo, providing check-ups and mammograms in order to identify problems at an early stage which will reduce medical costs later on.
