With every statement that the Health Ministry puts out on the number of new coronavirus cases in Egypt and the number of additional deaths, questions abound. Where are we headed? Is our healthcare system capable of handling this pandemic? Are we prepared?
It’s been eight weeks since the first coronavirus case was detected in Egypt, a period during which other countries where the virus spread earlier witnessed a steep rise in infection rates. The numbers in Egypt have so far not spiked dramatically, though the spread of the virus is steadily increasing.
Alaa Ghanam, an expert in healthcare reform and the director of the Right to Health program at the Egyptian Initiative for Personal Rights is well versed on the strategy the Health Ministry has adopted to confront the crisis.
We asked him about the capabilities of Egypt’s healthcare system, its course of action and the Health Ministry’s track record in dealing with epidemics in the past.
Mada Masr: Is our healthcare system able to continue the fight against the novel coronavirus?
Alaa Ghanam: We are still in the trial phase and it’s too early to evaluate now, but the initial steps taken were neither negligent nor exaggerated. We are on the right track. We started at the appropriate time and the measures taken so far have been reasonable, and we are escalating measures in parallel with the escalation of the infection rate on the local, regional, and global scale.
It is important to note that Egypt has always been a crossing point for contagion between the East and the West. Cholera was transmitted to Europe through us; it moved from India to Jeddah to Mekkah, and from there to Suez then to Cairo and Alexandria, and finally to Marseille and London.
The Health Ministry’s preventative medicine department has been able to overcome previous crises successfully. This even rings true for Egypt’s preventative medical care before the ministry was established by Mohamed Ali [in the 19th century]. In some cases, they overdid it in the preventative measures they took. This happened with the swine flu in 2009 when the ministry decided to cull all pigs and to buy a huge supply of Tamiflu medication, even though the infection rate was not that high.
The ministry’s success in dealing with COVID-19 so far harkens back to the ministry’s original purpose when it was first established a century and a half ago. When Mohamed Ali created the ministry, his main goal was to fight epidemics. Since then, the healthcare system has gone through various changes, but the preventative medicine sector in the Health Ministry has remained the strongest sector, especially in terms of experienced and trained personnel that the World Health Organization also turns to.
Although the sector has been neglected over the past 10 years, COVID-19 has restored its relevance — and this revival is not happening in a vacuum. There are dozens of healthcare units and offices in neighborhoods, towns, and cities across the country. It is one of the primary tools of the preventative medicine sector through which Egypt was able to enforce compulsory vaccination programs that eliminated diseases like smallpox, measles, tuberculosis, and polio, a serious disease that was prevalent in Egypt. In this regard, Egypt outperformed many countries.
MM: And what can the preventative medicine sector do once we pass the threshold of 1,000 coronavirus cases? [Note: This interview was conducted before the number of confirmed cases in Egypt officially crossed one thousand on April 4, which the government had previously suggested might trigger ‘Stage Three’ measures to be taken]
AG: We all know that the public health sector suffers from a major shortage of doctors and nurses. This is why the Health Ministry was forced to change its traditional strategy in combating epidemics. The ministry shut down outpatient clinics in all hospitals and transferred the medical staff to primary care units. This marks a shift in strategy in order to deal with the crisis and make the most use of available human resources.
So instead of all hospitals acting as the frontline of combating the disease, which would have turned them into hotbeds of infection due to the large number of patients coming in everyday from across the country, the primary care unit in each neighborhood or town now acts as the frontline. The efficiency of these facilities should increase with the provision of medical staff, x-rays, and laboratory equipment to be able to assess the probability of COVID-19 infections with almost 90 percent accuracy. The health unit should then refer the suspected case to the closest chest or fever hospital to do a PCR test. If the test result comes back positive, the person is then taken to a quarantine hospital.
MM: How can primary care units confirm the probability of COVID-19 infection without a PCR test?
AG: There is no one single way to diagnose the novel coronavirus. Apart from the PCR test, there are several methods. Normal chest x-rays and bloodwork can indicate whether a person has COVID-19 with an accuracy of up to 90 percent. Even the PCR itself is not 100 percent accurate.
It was important to add the primary care units into the four-step coronavirus strategy. This begins with quarantining at home, then going to the health unit [if showing symptoms], which is then responsible for referring people to pulmonary and fever hospitals, after which they might be sent to a quarantine hospital. This way, the medical staff in the hospitals are not overwhelmed and only receive patients with respiratory infections. The pulmonary or fever hospital’s role is to assess whether the respiratory infection is bacterial — in which case the person is admitted and treated inside the hospital — or COVID-19 related, in which case the person is transferred to a quarantine hospital and receives treatment there.
MM: Why are health units not provided with PCR tests?
AG: We will never have the ability to do PCR testing on millions of potential cases. The United States cannot do it, nor any other healthcare system in the world. Let us suppose we have one million suspected cases. We will not be able to have one million test kits for all of them, not even six months from now. The minister said that they had conducted 25,000 thousand tests by March 25, and the number of confirmed positive cases was only 450.
MM: Are the human resources, from doctors to nurses, in a fair fight with the pandemic?
AG: Of course we have a shortage of doctors and nurses. And health units suffer from a lack of trained personnel at the moment. The entire health sector is in need for training to face this crisis. This is why the ministry’s call for volunteers was a good decision to counter the shortage. It could significantly lessen the burden on the healthcare system because it allows other specialists, from science graduates, veterinarians, and dentists, to play a supplementary role in quarantine hospitals, referral hospitals, as well as the field investigation and follow-up teams.
This decision will also make room for volunteers who can work on raising community awareness around the importance of staying at home and not seeking medical help unless you have coronavirus-related symptoms 70 to 80 percent of the time (e.g. high fever, dry cough, and difficulty breathing). Those volunteers can also deliver essentials to households, especially to the elderly and those with chronic diseases, since they are more at risk.
MM: Will our logistical resources, from care beds to ventilators, be able to withstand Stage Three?
AG: The number of hospital beds in Egypt as a whole, in both the public and private sectors, does not exceed 130,000, of which there are no more than 13,000 ICU beds. This is absolutely not enough to face a pandemic. Of course we have a shortage, but so does the entire world.
Due to the lack of resources, the biggest challenge for Egypt is to exert all efforts to curb the outbreak of the virus and not let it reach the stage of community infection, where thousands will contract the disease.
MM: What does the coronavirus tell us about our healthcare system?
AG: The pandemic has exposed two issues. The first is the need to reverse the Health Ministry’s policy of commodifying healthcare services and medical work at the expense of prioritizing primary care and health units, which provide family planning services, record births and deaths, and regularly offer vaccinations and health education. The preventative medicine sector — which is responsible for preventing outbreaks of infectious diseases and epidemics, treating endemic diseases, and managing quarantines — has also been neglected throughout the past decade.
The second issue is the need for the rapid implementation of the universal health insurance system, which will effectively reform the entire healthcare system in Egypt. In short, the comprehensive health insurance system, which is set to be gradually implemented throughout all of Egypt over the next ten years, will limit the ministry’s role to what the preventative medicine sector currently does — fighting epidemics. The insurance system will restructure the entire health sector by limiting the private sector dominance of the market and extending substantial funds to public hospitals, so that the latter can compete with the private sector in the provision of quality medical services.
There will also be three other entities besides the ministry: A general authority for health insurance, whose role will be to collect and manage financial resources as well as purchase medical services; an authority for accreditation and oversight, which will be under the supervision of the president and will oversee the quality of healthcare services; and finally, a ministry-affiliated agency to manage public hospitals, health insurance hospitals, the Curative Care Organization and university hospitals that are accredited based on quality standards.
MM: We are waiting for the new state budget to come out in a few days. Do you expect an increase in healthcare spending? [Note: The draft budget includes health spending of around LE96 billion, up from LE73 billion in the current budget]
At the moment, we have to focus on the pandemic and line up our priorities in a scientific way. But after this crisis, the state must reevaluate the healthcare budget, the wages for doctors and nurses, and the hazard pay for healthcare workers. The latter has to fairly correspond to the dangers that healthcare workers face in their job, and this will encourage doctors to work in the public sector and not move abroad or to the private sector.