Every year, thousands of medical school graduates in Egypt are assigned by the Ministry of Health to two years of mandatory service at a primary health care facility, a policy known as “takleef.”
The assignments are the first step doctors take in their careers at the health ministry and are the main supplier of physicians to primary care units in underserved rural areas. The primary care units also play a pivotal role in Egypt’s new universal healthcare system, which aims to expand insurance coverage to all Egyptians and is a key component of the government’s broader healthcare policy.
This past October, the Health Ministry announced in a surprise move that it was merging the takleef system with the Egyptian Fellowship Program, a professional training program coordinated by the ministry.
Under the new system, doctors immediately join the fellowship program after graduation for a period of three years instead of two, where they specialize in a particular field. Doctors spend nine months each year in a hospital, where they receive training, and the remaining three months serving in a primary care unit where they rotate with other doctors. Doctors who specialize in a less common field — such as anesthesia, emergency, or intensive care — are excluded from serving in a primary care unit and instead spend the entire length of their training period in the hospital. Meanwhile, doctors enrolled in family medicine spend three months of their first year serving in the hospital’s emergency ward before completing the rest of the training program.
While the old takleef system was highly problematic and riddled with problems — including issues of meager pay, poor facilities, inexperienced doctors overseeing care and high resignation rates — critics, including senior officials at the Doctors Syndicate, warn that the sudden policy change was made too abruptly and with no clear mechanism for implementation.
Questions abound over whether the fellowship program will have the capacity to handle a surge of thousands of new doctors, and whether the transition might actually lead to an increased shortage of physicians available to provide care at both primary care units and hospitals.
The history of the takleef system
The takleef system began 58 years ago when President Gamal Abdel Nasser issued a law for the assignment of doctors, pharmacists and dentists to work in locations selected by the state for a renewable two-year period. Decree 183/1961 was the first of a series of similar decrees that involved workers in other fields, including engineers, architects, and teachers. The main purpose of the system was to funnel professionals into various state institutions for a compulsory period of work.
The system was similar to military conscription in that the law stipulates punitive measures for doctors who evade their mandatory assignments. These measures came under President Anwar al-Sadat in Law 29/1974, which reorganized the takleef system and punished violators with a prison sentence of up to six months and a fine between LE200 to LE500. The penalties would be doubled in times of war or epidemic.
The philosophy behind the takleef system was based on a tradeoff between free education and public service, according to Mohamed Hassan Khalil, a doctor and the coordinator of the Right to Healthcare Committee, a non-governmental group.
“The state, which spends on free education through medical schools, has the right to impose a condition that doctors serve society for a specific number of years,” Khalil says. Citizens receive medical care from doctors whose education was financed by taxpayer money, while fresh graduates gain work experience and receive compensation that was fair when the system was first put in place, he adds.
Over the years, the takleef system was gradually abandoned or significantly constricted in most professions, except in medicine, where the mandatory two-year assignment policy remained firmly in place. In the nearly six decades since its initial implementation, the system has devolved into one that is neither appealing nor beneficial to doctors.
A shortfall in doctors and care
In Egypt, there are around 5,300 primary care units distributed mostly in rural villages throughout the country. Every year, approximately 9,000 doctors who graduate from medical school are assigned to serve in these units for a mandatory two-year period, after which they move on to become general practitioners.
The system provides an “army of doctors” to villages, particularly those in remote areas — such as parts of Upper Egypt or near the border — that are usually unappealing to experienced doctors who prefer to remain in the cities where they live, according to Rashwan Shaaban, the Assistant Secretary-General of the Doctors Syndicate.
“New doctors gain technical skills in these remote areas because they come into direct contact with patients, and also gain managerial skills because they have to oversee the healthcare units they are assigned to,” Shaaban says.
During their final year of medical school, students receive two months of training in each hospital department, in addition to a brief training in managerial skills. However, critics argue this is hardly sufficient experience to go on and manage a primary healthcare unit and personally handle 60 to 70 percent of incoming patients. Khalil believes that before being assigned to a primary healthcare unit, medical school graduates should work as assistants to senior doctors at hospitals for a year or two to gain the necessary experience.
Recent graduates find themselves having to oversee the provision of healthcare services to thousands of citizens “in an isolated location without sufficient logistical capabilities or any real support from Egypt’s healthcare system,” Shaaban says. “We have long called for these primary health care units to be connected to central hospitals in nearby cities and towns. That way there is a constant link for new doctors to pose questions and have consultations with more senior doctors in central hospitals.”
Regular visits by senior doctors in central hospitals are also crucial in supporting doctors on assignment at primary healthcare units, Shaaban says. In practice, this matter is left up to each central hospital or health care department, many of which are coping with their own shortage of doctors.
Another issue affecting the level of healthcare in primary units that graduates are assigned to is the lack of proper resources and equipment. The Secretary-General of the Doctors Syndicate, Ahmed Bakr, says the units have low stocks of medicine and lack of laboratories to help with diagnosis. Additionally, a shortage of assigned doctors often means that some are responsible for more than one unit in different areas at the same time.
Pay is also very meager with assigned doctors receiving a monthly salary of just LE2,000 to LE2,400. Doctors eventually evade their assigned work at the primary healthcare units and turn to private practice during their two-year stint, according to Alaa Ghanem, the director of the Right to Health Program at the Egyptian Initiative for Personal Rights.
The difficult working conditions and poor pay have led to increasing numbers of Health Ministry doctors requesting unpaid leave or resigning from their positions over the past few years. Many of the doctors that do remain often reschedule their working hours to work shifts in the more lucrative private sector, leading to significant staff shortages at ministry-run health facilities.
“The takleef system does give people access to medical professionals, but it does so by keeping them as virtual slaves with miserable salaries and conditions,” Khalil says.
Merging into the fellowship program
Coordinated by the Health Ministry, the Egyptian Fellowship Program provides training to doctors from between three to six years, depending on their field of study. Doctors choose their area of specialization and receive training from a trainer accredited either by the program or in a hospital accredited for training.
By folding the takleef system into the fellowship program, medical school graduates are able to specialize early on instead of having first to work as a general practitioner for two years, Shaaban says. Additionally, doctors spend nine months of each year in the fellowship in a hospital where they receive technical training, and the remaining three months serving in a primary care unit where they rotate with other doctors.
In spite of these advantages, there are questions over whether the program is equipped to take on the huge influx of doctors now that the takleef system has been merged into it.
The fellowship program used to receive around 1,800 to 2,200 doctors each year. That number is now expected to jump to over 9,000 annually, a figure Shaaban says will be difficult for the program to handle given the number of accredited trainers and equipped hospitals currently available.
The health ministry responded to this issue by posting ads for new medical trainers, noting that applicants would be trained in partnership with Harvard University in the United States. Yet Shaaban says he is doubtful that a sufficient number of trainers can be accredited in time to handle the influx. The plan also calls into question whether there are enough hospitals to train doctors in each region without having to transfer doctors out of their home governorates and far from their place of residence.
The first batch of trainers — some 200 doctors — left to Harvard in December to receive their training, according to the health ministry. The ministry is also accepting new applicants to become trainers in the fellowship program.
Each accredited trainer will be responsible for training four to six doctors, according to Shaaban, meaning that the first batch will be able to train up to 1,200 doctors. This would satisfy the September 2019 graduates who number just over 800 and are the first class of graduates entering the new system.
Yet the next class, which will graduate in March 2020, is far larger with 8,000 graduates, requiring that an additional 1,350 to 2,000 trainers be accredited.
The monthly salary of a trainer in the fellowship program is around LE3,000, according to Shaaban, which raises questions about how the ministry will fund the new system. The ministry also bears most of the costs of the fellowship program itself, paying LE6,000 annually for each doctor in the program, while the trainees must pay LE600.
The health ministry’s budget for fiscal year 2019/2020 is LE73 billion, according to Ghanem of the Right to Health Program, and does not account for the expected additional costs of the fellowship program.
Another major concern, Shaaban says, is the increased shortage of doctors available to provide care both in primary care units and in hospitals over the coming four years as the takleef system transitions to the fellowship program.
Each doctor in the fellowship program spends just three months of each year at a primary healthcare unit, which means during the first year of the new system there will be a 75 percent deficit of doctors at these units. If everything goes according to plan, the deficit will decrease to 50 percent the following year as a new class of doctors in the fellowship begin their three-month shifts. The deficit will then fall to 25 percent in the third year, and be eradicated by the fourth year with all three month shifts covered by doctors in the program.
The health ministry has pledged to cover the deficit by transferring doctors from hospitals to primary healthcare units, yet Shaaban says this could exacerbate the shortage in both.
A study completed in June by a committee that included secretariats of public hospitals and the Health Ministry’s technical office along with a group of specialists found a severe shortage of doctors in Egypt.
The study also concluded that the number of doctors in government, university, and private hospitals was just 38 percent of the total licensed practitioners, noting that 62 percent of doctors licensed in Egypt work abroad, or have resigned from their government jobs or are on unpaid leave.
Health Ministry hospitals would need to nearly double their current workforce of 57,000 doctors to address the shortage, according to the study.
Talks with the Doctors Syndicate
A more gradual transition out of the takleef system along with clear mechanisms for the change, as opposed to a sudden overhaul, may have sidestepped some of the expected problems.
“[The new system] looks good on paper but it lacks a clear mechanism for execution,” Ghanem says. “There is nothing worse than the current takleef system, but that doesn’t mean we should abruptly abolish it at a time when there is a shortage of doctors, because this will cause a major crisis.”
Ghanem also stresses the need to restructure doctors’ pay scales to make them fairer and provide an incentive for them to remain in the Health Ministry.
Talks are currently underway between the Doctors Syndicate and the ministry over the transition. When the ministry first announced that it would merge the two programs in October, the syndicate rejected the move altogether, pointing to the lack of details and the fact that the syndicate was not consulted beforehand.
The ministry then held several meetings with syndicate leaders and organized a day to present the fellowship program to the first class that would participate in it, prompting syndicate head Hussein Khairy to say at the time that he was “optimistic” over the program.
Yet the ministry has been vague in its responses to concerns raised by the syndicate. It said there was “a comprehensive plan in place to qualify enough doctors in hospitals and trainers to train the first class,” according to Ghanem, but it did not clarify any details of the plan or the number of doctors it was referring to.
Ghanem says the talks between the syndicate and the ministry are “critical” to the success of the program in order to set out the details of the transition and its execution.