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An ailing healthcare system

Nadine Shams was admitted to a hospital to remove two fibroids, or benign tumours, in her uterus. Basic as the procedure was, two weeks later the 41-year-old scriptwriter lost her life to what many claim was the negligence of her doctors and the hospital.

Her husband Nabil al-Kot describes the conditions at the private Misr International Hospital in Dokki. “Hygiene standards were poor and the hospital staff did not provide her with any attention.”     

“Conditions were terrible for a private hospital,” Kot adds.

Shams was screaming in pain 12 hours after she had her surgery last March, but doctors dismissed any requests for follow-ups and denied that any complications had taken place. Three days later, they admitted to perforating her colon, which led to fecal peritonitis, an inflammation of the thin tissue lining the abdomen’s inner wall, and septicaemia, an infection in the blood stream. Only then did they agree to operate on her once more. But as the second surgery was unsuccessful, and doctors were unable to find the hole in her colon, Shams’ condition worsened.

The hospital ignored any requests by Shams’ family to perform further tests. During her stay, nurses also provided her with little attention. “I was checking Nadine’s blood pressure and bathing her myself because they were so careless,” says Kot.

Moreover, any requests to get second opinions from other doctors were denied by the hospital administration and doctors on her case until the day before she died. One doctor requested an immediate computed tomography (CT) x-ray scan, but by then, on the tenth day in her stay at the Intensive Care Unit, it was too late.

Kot accused the hospital administration and doctors of malpractice and gross negligence, as well as forging Shams’ death report.

Shams, who underwent surgery at a private hospital, is one of many who have suffered from negligence and failures in the Egyptian healthcare system. Her case also shows that negligence is not limited to the public sector.

Ayman al-Sebaie, a researcher on the right to health at the Egyptian Initiative for Personal Rights (EIPR), claims that hospital staff and doctors violated several rights in accordance with the European Charter for Patient’s Rights. He claims that Shams was not treated with transparency throughout, her demands for further check-ups and follow-ups were denied and that the hospital failed to abide by quality standards, adding that they also forged her death report.

Hendrik Bekedam, the World Health Organization (WHO) representative in Egypt, noted that since most Egyptians live within 5 km of a hospital, the infrastructure of the healthcare system is amongst the best in the developing world. He laments, however, that many of these hospitals remain poorly monitored, under-resourced and are operated by poorly trained staff and doctors.  

Since the 2011 uprising, many doctors have engaged in protests and partial strikes demanding better wages and an increase in the state budget for healthcare from 5 percent to 15 percent.

With wages as low as LE890 per month in public hospitals, many doctors have been forced to earn a living at private hospitals or their own private clinics, leaving public hospitals further neglected. In contrast, some higher ranking Ministry of Health public workers have wages of LE2,000 or more, in addition to other full-time jobs.

Critics of the healthcare system highlight a need for national standards in decision-making, monitoring and recording of data.

Separate medical centers under the authority of the health, education, interior and defense ministries, and an adjacent private healthcare industry, cause decision-making and nationwide data to be fragmented.  

“There needs to be a higher council, or an independent body, for the decision-making process,” says Sebaie. “This should include authorities, stakeholders, civil society, the private sector and even patients.”

With Egypt now under its sixth government since the 2011 uprising, many ministers fail to implement a short and long-term vision for reform of the healthcare system – another flaw which critics claim could be avoided through a higher regulatory body.

Striking doctors are also protesting higher-level mismanagement, which leaves many doctors misplaced. While some hospitals are overcrowded with medical staff, others, especially in rural areas, experience staff shortages. The same occurs with the allocation of resources.

In the past 10 years, authorities launched a LE1.5 million campaign to establish 14,500 new healthcare centers. However, irresponsible financing resulted in abandoned buildings following futile renovations such as floor tiling and dental healthcare machinery.  

In addition to the poor nurse training, the general culture of negligence has infiltrated all aspects of the healthcare system.

“Doctors are human and can make mistakes but they must ensure they follow international standards to reduce risks,” says Sebaie. Bekedam agrees and believes a culture of coaching must be introduced in hospitals.

Kot believes that ignorance and lack of scientific knowledge are also to blame for his wife’s death.

Many patients have complained of lack of attention from doctors, while others claim to have undergone life-long battles with the Egyptian healthcare system.

For 14 years, a 27-year-old marketing associate, who asked not to be named, was desperate after constant heart palpitations, shortness of breath, visits in vain to over nine doctors and more than LE30,000 spent. She was struggling with a disease called supra-ventricular tachycardia in the sinus node of her heart, a form of rapid heart rhythm. Each year her symptoms worsened.

“One doctor once refused to give me treatment because I arrived to the hospital at 1 am, was wearing a dress and was accompanied by two young boys,” she says as she recounts an experience from her teenage years.  

For most of those years, doctors dismissed her symptoms as being caused by stress and young age. Some doctors prescribed antidepressants, while others prescribed medication that gave her allergic reactions and aggravated her symptoms.

In another instance, during a trip to the coastal city of Marsa Alam when she was in her early 20s, she experienced a heart attack, low blood pressure and fast-paced palpitations from her disease. She was rushed to the nearest public hospital, which was an hour away.

“The conditions in the emergency room were horrendous and hospital staff was not even able to give me basic medication for my vomiting. The doctor was going to give me an atropine shot, which was meant to raise my blood pressure, which, however, would also raise my heart rate. Eventually, due to my background in pharmacology, I managed to solve the situation on my own because the doctor’s suggestion would have given me a fatal heart attack.”

Finally, after several grave experiences at local hospitals, at 26 and at the hefty price of LE40,000, she finally found a capable doctor who was able to treat her at the private Dar Al-Fouad Hospital.

Contributing to the weak healthcare system is the feeble, one-year minimum required training of nurses. Prevention and disease control are also great factors.

According to estimates by the WHO, Egypt uses as many as 281 million injections per year. Out of these, approximately 7-8 percent, or 23 million, are unsafe, thereby increasing chances of infection.

“Many patients with minor illnesses often leave hospitals with serious chronic diseases, such as Hepatitis C,” says Bekedam.

However, the greatest burden in the healthcare system remains on patients themselves, as up to 79 percent of funding to the healthcare system comes from their own pockets.

Sebaie claims that basic treatment can cost between LE1,000–10,000 for patients at private hospitals.

Public health insurance is not always put into practice, leaving many with costly bills after turning to expensive private hospitals in the hopes of better treatment. 

“The main issue here is that the doctor has spending power over his patient, who often complies due to a lack of medical knowledge,” said Sebaie.

Kot paid up to LE90,000 for the procedures his wife underwent when she was hospitalized and is set to pay further expenses for legal procedures. 

Following the death of his nephew after his nine-day stay at the public Qasr al-Aini Hospital, 42-year-old elementary school teacher Mostafa Shehata was left at the mercy of the bureaucratic and often corrupt intricacies of the Egyptian healthcare system. His 18-year-old nephew, Ahmed, died after being hospitalized following a head injury sustained from playing soccer. He was also told to travel from Minya to Cairo for better treatment.

Ahmed stayed in a five-meter squared room with eight other patients and experienced grim conditions. Shehata says nurses were selling tea rather than monitoring his nephew.

Even after death, the burden remains on the family of the deceased.

“We had to fight for a death report to be given to us by the hospital,” says Shehata, who claims that he had to pay a total of approximately LE500 in bribes to various staff, including medical staff and forensics, in order to be heard.

“He went to the hospital walking and came out lifeless,” says Shehata, who claims that doctors were absent throughout his nephew’s entire stay, and his oxygen supply was cut off at one point.

An absence of a proper law penalizing healthcare negligence makes it nearly impossible to hold hospitals and staff accountable. “Victims of healthcare negligence are treated like others who experienced an accident, like a car accident,” says Sebaie.

Many victims of malpractice, therefore, have little faith in the legal system and often do not even consider filing a court case. 

Human rights groups have launched the “Rights of Patients” campaign to raise awareness on the rights of patients with the public, and to lobby relevant authorities to reform the healthcare system. 

The silver lining, however, is that infant mortality and life expectancy have improved in the past few decades.

Egypt also has the highest prevalence of Hepatitis C virus (HCV) in the world, with 10-14 percent – 8 to 10 million people – infected with HCV, and an approximate 1.5 million in need of treatment.  However, the WHO says that Egypt is one of only two developing countries, along with Brazil, that provides free universal healthcare for HCV. With over 23 centers in Egypt developed over the past six years for the treatment of Hepatitis C, approximately 300,000 infected individuals have been treated free of charge, and more are set to be treated as Egypt is set to have a new cure from pharmaceutical companies in the coming year. 

As per the new constitution, government authorities have vowed to increase budget spending on healthcare, a step that Bekedam lauds.

Sebaie and Bekedam both note that there has been development recently as each successive minister of health has learned from the mistakes of their predecessor.

“Health is a huge sector and cannot be changed overnight,” Bekedam says. “But there needs to be not only a short-term plan but also a collaborative effort for a long-term plan for the next 15-20 years.”

Moreover, Bekedam has noted that many countries, some of which on the lower-income end in comparison to Egypt, are beginning to realize that healthcare is not a spending sector, but is a long-term investment necessary to maintain a healthy populace.

“This is an opportunity for governments, as they need to realize it is time to prioritize healthcare.”