It was two years ago that Helmi Al-Sewidi, an Egyptian family doctor, started a new page in his medical career under the umbrella of Egypt's new unified healthcare system (UHCS) that was then being introduced in his hometown of Port Said. Having been in a primary-care practice for close to six years after having graduated from Cairo University in 2011, Al-Sewidi was well set to start his new job that came with the launch of a project that promises to revolutionise the health service and working conditions of doctors in Egypt within the 10-year timeframe of its nationwide execution. Throughout his pre-UHCS years, Al-Sewidi had seen the many problems of his profession. "I saw tough days of 12 hours working every day in small primary-care clinics in the Delta, where along with another young colleague I had to attend to over 300 patients in around 90 minutes. I saw clinics where we had no chance of getting basic X-rays or simple blood tests done, and I saw patients and doctors who had no faith in the role of the family doctor," he said. The beginning of the UHCS allowed Al-Sewidi to experience "a big shift" in how he practises medicine and how he feels about his profession. "I am not saying it offers the perfect remedy, but things became significantly different," he said. In the UHCS, the role of the family doctor is central. Every patient being treated under the system has to first be examined by a family doctor. It is the family doctor who decides whether the patient needs referral to a specialist or whether he could be treated at the primary-care clinic. Primary care is a relatively new discipline in most schools of medicine in Egypt. It is mostly popular among young female doctors who wish to reduce their working hours and to work near their homes. Or it is the pursuit of male doctors who do not have plans or the means, particularly financial, to pursue the long and hard route of post-graduate studies. "It is the kind of discipline that is mostly appreciated in rural areas, where a doctor would be based in the clinic of the village and would be able to manage a wide range of health issues either at the clinic or at the houses of the patients. He would only ask someone to go to the city to be treated in a hospital if the situation required a thorough medical intervention," Al-Sewidi said. But with the exception of Ismailia, which was always an exception because it was where primary healthcare was first introduced as a discipline, in every city, small or big, the family doctor was almost always looked down upon, he said. "But now this is changing dramatically because the new system gives prominence to the family doctor," he added. The higher status that Al-Sewidi is now finding is only one of the good things that this young physician is experiencing with the introduction of the UHCS in Port Said and as part of a first phase that will include Luxor, Ismailia, Aswan and South Sinai within the coming two years. A more tolerable workload is also something that he says is coming with the UHCS. Working for a primary-care centre in a village might have allowed Al-Sewidi to be treated with respect, but it also meant that on some days he would have to run from a possible delivery to an acute case of diabetes and then to a possible stroke or heart attack. "Because the family doctor is effectively step one in the system, the UHCS has doubled and even tripled the number of primary-care platforms in Port Said, with each clinic equipped with two doctors and associated with a medical unit with another physician," Al-Sewidi said. He added that every centre or clinic is only responsible for a certain number of patients. "This is one of the primary rules of providing decent healthcare. A doctor, of any specialisation, cannot be expected to be working 12 hours non-stop every day for six days a week and be expected to provide thorough care," he said. DOCTORS' DILEMMA: Forcing doctors into over-work, and the impact of this on quality, was diagnosed in a recent report by the Egyptian Initiative for Personal Rights (EIPR), a think tank, as one of the main ailments that the vast majority of physicians suffer from, especially those who work in the clinics and hospitals of the Ministry of Health and to a lesser degree those who work in the hospitals of leading universities in Egypt. Launched last Tuesday under the title of The Dilemma of Egyptian Doctors Before and After Covid-19, the report rings alarm bells on the working conditions that many doctors have to deal with and the impact of these on their willingness to stay within the public healthcare system or even to stay in Egypt. While noting that the pandemic has complicated the difficulties for almost all physicians, the EIPR report stresses that already existing problems are such a challenge that they force the vast majority of physicians into overtime and exhaustion. According to the statistics in the report, only one third or a little more of the overall number of physicians registered in the country actually practise medicine in Egypt, either in the public or the private systems. The rest are working overseas, be it in the neighbouring Arab countries or elsewhere in the world. "Of 213,000 registered doctors, only 82,000 are working in Egypt," the report says. The reasons are mostly to do with working conditions. They include the workload, the availability of equipment, the levels of salaries, and the chances for continued education. There is also the question of the personal safety of doctors. Alaa Mahmoud is an oncologist who graduated from Ain Shams University in Cairo, which she attended after leaving her hometown of Aswan. A few years after taking mandatory training and specialisation studies after her graduation, Mahmoud had the chance to head back south, "where most doctors would not want to go, but where I wanted to go because I was going home," she said. The opportunity for Mahmoud to work at a newly established cancer centre in Aswan in 2014 was not exactly a dream come true, however. The fact of the matter was that for a full five years this Aswan centre had been there for cancer patients from across the five governorates of Upper Egypt. For the patients who have to put up with the pain and worry of cancer, this was an added nightmare. "You don't know what it is like for a cancer patient who is probably suffering from the side effects either of the cancer or of the therapy to have to travel for a few hours to access a medical consultation," Mahmoud said. "But you also don't know what it is like for an oncologist to have to work for 12 hours a day to examine close to 150 cancer patients, one after the other, and then to have to worry about getting them to have the right tests and the right medication, and to get these done and provided on time," she said. "When I once literally collapsed and had to take two days off, it was very difficult for the patients and the centre," she added. Mahmoud said that more often than not doctors who work under incredible pressure also have to worry about finding a clean bathroom and a clean dining place at the doctors' residence to catch a meal or get a quick shower. On top of that, they have to worry about making ends meet on a small salary that does not suffice to cover the expenses of a PhD or further studies. According to Ahmed Al-Hawari, a gastrointestinal surgeon in Mansoura, things can get worse because of "safety issues". These, he said, can start with facing the dismay of a family member of a patient who has a hard time with an illness or with the treatment, "sometimes simply due to the lack of adequate diagnosis equipment or the lack of some essential drugs." They can also be the result of "disturbing legal problems" when a patient has gone through tough complications of surgery or unanticipated side effects of a post-operative medication. "These things happen not because the doctor wants them or is being negligent, but because every operation comes with certain risks. Sometimes the doctor explains all the possible scenarios at length to the patient, but the patient isn't listening," he said. According to the EIPR report, overall a physician working for the public healthcare system in Egypt receives a starting salary of around LE2,000, an amount that many doctors say would not cover the cost of studies for a single month at the Faculty of Medicine during the past 10 years. A doctor, the report noted, would have to work for close to 40 years to get an extra zero added to this double-digit amount. The report also noted that in cases of medical error, a doctor can be punished under the criminal law with no consideration given to the nature of the profession which requires at times risky interventions in poorly equipped medical set-ups. "This legal aspect is particularly disturbing because a doctor who faces a lawsuit, even if eventually cleared of wrong-doing, risks losing his reputation for good," Al-Hawari said. PURSUIT OF REMEDIES: According to the EIPR report, the UHCS provides a partial answer to the problem of salaries in as much as it raises the starting salary of most physicians from LE2,000 to LE10,000, as it factors in incentives. According to Mahmoud, this amount remains way beneath the average monthly salary that most doctors would start their careers with in some of the Arab countries. However, she added, "there are ways to compensate." "If we are really looking for an end to the drain of doctors from Egypt, there could be added incentives like helping doctors to do post-graduate studies and to pursue further studies at reasonable fees, providing them with packages on buying apartments and cars, and other things to help them resist the temptation of opting for a career outside of Egypt." In a seminar hosted by the EIPR to launch the report, Osama Abdel-Hayy, a member of the council of the Physicians Syndicate, said that the added challenges that the Covid-19 pandemic had brought to the medical community in Egypt had prompted a number of resignations from the public healthcare system. He said that in the absence of a clear plan of action, the drain of doctors would continue. According to several doctors who worked under the tough challenges of the pandemic, it was disturbing that they had had to worry about having the necessary protective equipment. Many said that the growing openings that the pandemic had brought in the healthcare systems of several Western countries had provided an excellent opportunity for doctors to opt out of the Egyptian system. Member of parliament Farid Al-Baidi, who took part in the EIPR seminar, said the issue would be brought to the attention of parliament to help doctors meet the many challenges they have to go through while practising medicine in Egypt. According to Ayman Sebaai, the author of the report, while the UHCS certainly provides some answers, at least partial, to some of the problems that the doctors of Egypt have to go through, the system will take around ten years before it covers the entire nation. This was not a short time if one considers the current level of dilapidation. "We cannot expect to fix our healthcare system if we are not going to address the problems of doctors," he said. Sebaai agreed that there were other problems that relate to the state healthcare budget and to the problems of assisting teams, nursing and others. However, he insisted that the doctors' problems remain a huge concern for the quality of the health service. According to Sebaai, for the past few decades the founding concepts behind the education and practice of medicine in Egypt have been questionable. "We get students to leave their cities around the country to come to the big cities where they learn, and then we tell them after a full decade of tough and expensive studies that they need to go back to their homes and work in poorly equipped conditions for very little money and without any chance of further education," he said. Meanwhile, he added, there are many parallel systems that create quite different working conditions from the government hospitals, including the university and private hospitals. He argued that while the public healthcare service is the least attractive for medical doctors, it is the one that covers the vast majority of patients across the country, and it is the only one that has wide accessibility and facilities. This was one reason why the UHCS was part of the answer to Egypt's healthcare problems, he said, as it would allow most people to get treated under the same system and get most doctors integrated within the same set-up. "This is not to say that all private hospitals and clinics will be eliminated or that patients will only have one option to access medical care," Sebaai said. University and private healthcare facilities, he added, would be working alongside the UHCS because they could opt for integration in it. According to Al-Sewidi, it is only a matter of time before the UHCS will be the overarching healthcare provider. "The success of the pilot project, as has been adopted in Port Said, shows that more and more people are having faith in the system and more and more private clinics are trying to be integrated in it," he said. Ultimately, Sebaai said, private services will continue to operate for those who may wish for one reason or another to access healthcare outside of the UHCS, including possible waiting lists. However, he added that the wider operation of the UHCS would cause the state to be more prompt and more effective in introducing regulations for the private sector to work under. "This has been missing up to now," he said.
*A version of this article appears in print in the 8 July, 2021 edition of Al-Ahram Weekly
