Shatbi tragedy: negligence or fundamental problem?
The story of the Shatbi hospital angered everyone who read about it. It also reminded us all of the appalling healthcare system in Egypt. The dreadful situation of care is a symptom of the grave situation of decades of governments ignoring the rights of their citizens.
Health care is a refection of what society believes about the rights of its members. If people are considered as citizens then health care is considered as a right guaranteed by the state. However if people are considered consumers, then health care becomes a commodity available for those who can pay for it.
Soon after independence, most developing countries, including Egypt, invested in providing free and public basic health care for all citizens. During the eighties, the Worldbank lead the world into fixing economies via the Structural Adjustment Policies (SAPS), which centred around diminishing the role in the state and commodityfying social services especially health and education. Massive cuts in public expenditure on health and education led to deteriorating conditions in the public services and erosion of health workers remuneration. Meantime user fees were introduced and privatisation was promoted.
This resulted in a tiered system of care where expensive private hospitals/clinics catered for rich people while degraded public service was supposed to serve poor people. In between those extremes, a variety of private services mushroomed everywhere with little attention to quality or affordability. Health workers were badly paid in the public sector and therefore relied on providing private services for their income. Deterioration of the public service was running so fast that in many hospitals, patients have to pay even for gloves and all medical supplies.
Egypt has been trying a series of damaging health policies to treat the symptoms of the deteriorating health care system rather than rectify its fundamental problems. According to WHO recent work (2011 World Health Report)[1] solidarity financing based on tax is the fairest system of financing health care. Yet “Egypt has one of the lowest shares of national health expenditure funded from public financing in the Middle East and North Africa region”[2].
While the country has more doctors than needed for the facilities it has, there are many areas (usually rural and remote), which are under served by health workers. Health care lacks strategic planning that links the education/training of health workers to country needs. There is hardly any specialised training in health care management and administration as a recognised discipline and therefore strategic planning and proper management are inefficient. Health information systems have improved but are still far from producing reliable information, let alone providing basis for decision-making process. IN addition, evidence based medicine and health care policy is not part of decision making at strategic or clinical decision- making. This may be a contributing factor to the low attention to prevention medicine especially for non communicable diseases-apart from some ad hoc media interest.
We can write essays about the diagnosis of the health care problems in Egypt-some have already been written. However, the key to change is not to continue with headline “reforms” that only serve to stick plaster on the big wound and not treat its fundamental causes.
For a start health care has to be recognised as a basic right and therefore the state becomes duty-bound to ensure that every citizen has that right. Based on evidence, the government need to:
- Scale up public financing for a basic package of health service available for all. The govt should set up a target % of national income to be dedicated to health care and have a plan to achieve it via measurable incremental increase/year. The govt could increase tax on tobacco to help financing health care
- Strengthen the health information system in collaboration with relevant academia and commit to use HIS for decision- making processes at all levels. Epidemiological data are used to decide on the basic package and scientific evidence is used as a base for all decisions
- Basic services should be free
- Reinvigorating the concept of Primary Health Care so that PHC units in all villages are upgraded and supported to provide the basic health package. Hospitals should function as tertiary service only which will increase efficiency of care.
- Embark on a massive programme on in service training of ALL health workers to improve clinical skills, gender and human rights perspectives, performance management, planning and strategic planning and evaluation
- Conduct studies to inform the restructuring of health/medial education at all levels in order to respond to the epidemiological data and rapidly moving health sciences
- Design and implement a decent remuneration system for all health workers that prioritise rural and remote areas
- Designing and implementing prevention programmes especially for NCDs in collaboration with other sectors: education, transport, sport, media, local governments, private sectors and others
- Design and implement a strategic plan to improve production, quality, and use of pharmaceutical products. This includes consultation with academics and national companies in order to create supportive environment for R&D of quality medicines
- Implement a good system of quality control on all health facilities both public and private to ensure that citizens receive effective and quality care that they need
I hope to have time to write more on all the issues included in this piece later on.
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