Preventative Medicine and Accessibility to Healthcare in

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PREVENTATIVE MEDICINE AND ACCESSIBILITY TO HEALTHCARE IN EGYPT

By

NOURHAN F. MUSTAFA

______

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors degree

With Honors in

Physiology

THE UNIVERSITY OF ARIZONA

May 2010

Approved by:

______Dr. C. Eugene Settle Department of Physiology

Abstract:

This paper serves to examine the healthcare system in modern day Egypt in relation to the healthcare system present in the United States. It is a compilation of information gained from travelling to Egypt and observing and independent research. The role of preventive medicine and early access to healthcare in Egyptian society are analyzed in order to gain a better understanding of the early steps that are taken towards a healthier society. The focus is particularly on the health and well being of women and children and how the healthcare system is addressing their issues. This paper serves as an as an intro for later works where each of the issues that addressed, women’s health, children’s health, and the role of preventive medicine will be studied in greater depth. These analyses will be important so that one may understand what issues a healthcare professional will face when providing healthcare to people in the region.

Statement of Purpose:

After spending many summers in Egypt visiting family, I knew that I wanted practicing medicine in this region to be an essential part of my future. Upon travelling to Egypt during the summer of 2009,

I was given the opportunity to volunteer in a hospital in Cairo. From this experience I was able to observe first-hand what healthcare, what being a physician in Egypt was really like. From spending a few weeks in Al-Fath Hospital, a run private hospital, I was able to see the differences that there were between the Egyptian healthcare system, and the United States system I was so use to.

At the hospital I learned phlebotomy, and was able to spend a lot of time in the Women’s

Surgery, observing vaginal births, c-sections, and hysterectomies. From the entire experience though, I was struck by one case. A young woman, in her late 20’s came into surgery to remove the removal of abnormally large uterine fibroid tumors. Upon watching the surgery and talking to the doctor, it was clearly evident that this problem could have been resolved early on. This woman’s chance at having a family was put in jeopardy because she did not pursue, or was not provided with early access to healthcare. The doctor discussed with me that this case that I had just observed was not a rare one, but rather surprisingly common. From this I really began to think about how paramount preventative medicine and giving people access to healthcare early on is to disease prevention. I began to see that these were two of the many important aspects of successful healthcare. Without early disease prevention and readily accessible healthcare, all the advancement in technology in the field of science will be of no use. Groundbreaking research leading to life saving drugs and medical procedures will not be capable of helping anyone, or eventually saving lives if patients do not have access to healthcare.

In the past the curative approach to healthcare was the most prevalent, and it was more likely that people did not see a doctor until they were severely ill, which led to people getting diseases that were preventable. In the wake of recent events there has been a push to lead this nation towards a more preventative healthcare measures and one way to do that was to provide access to healthcare.

It’s now clearer than ever how important it is to provide patients with healthcare regardless of their financial, cultural or socioeconomic status.

In the developing world, access to healthcare and preventative medicine are the two most affordable, and easiest approaches to ensuring the health and well being of the population. The country of Egypt can be considered to be a more economically developed country, but that does not mean that it excels in its healthcare status and epidemiological measures (Londen). For this reason it is important to analyze and to understand the role of preventative medicine and healthcare accessibility in the Egyptian Healthcare system. Following are some important questions to ask when trying to better understand this system.

1) How accessible is healthcare? This question can be answered by asking the following:

a. How is healthcare delivered to the people?

b. Are there gaps in healthcare delivery between classes?

c. Do rural areas have less access to healthcare facilities?

d. Overall which of these accessible healthcare systems provide the best care, and are

these necessarily the most accessible and most affordable for the patient?

2) What steps are being taken towards a preventative medicine approach?

a. What steps are being taken to make healthcare more accessible as a form of

preventative medicine?

b. What are the biggest maternal health problems, and are they preventable?

c. What are the biggest issues facing children’s health, and are they preventable?

d. What are the major diseases, and are they preventable?

e. What role does sanitation play in disease prevention? In this paper some of these questions will be addressed, and possible solutions to some of the major healthcare problems in Egypt will be discussed in an additional this will serve as a brief overview of the

Egyptian Healthcare System.

Delivery of Healthcare

The first step in understanding any healthcare system is to first know how healthcare is delivered to the people, what type of system is in place in terms of healthcare facilities and inpatient and outpatient services. In the United States the system in place is, and this comes with its own set up problems, which is evident in the wake of current events. With the U.S. government projecting to spend

940 billion dollars over the next ten years, in order to reform the current healthcare system, it not only shows how much there is left to be done, but it also shows how important accessibility to healthcare is even in a fully developed country(Jackson). This is because a big part of the plan for healthcare is to expand coverage to the 35 million uninsured Americans, in other words, to expand accessibility to healthcare (Jackson). It is clear that no one has developed has developed a so-called “perfect” healthcare system, where everyone is covered and has access to the healthcare they need but this does not mean thought that the healthcare system that is set up is one of the main determining factors in the accessibility that patients have to healthcare professionals when they are in need of them. Additionally that the healthcare system in place is an essential component of disease prevention.

Egypt is no exception to this. Following is a description of the Egyptian healthcare system.

“Egypt has a highly pluralistic healthcare system, with many different public and private providers and financing agents.” According to the NHA, the National Health Accounts, the Egyptian healthcare system can be identified to have the following providers:

Ministry of Health Facilities and Services

Teaching Hospitals

University Hospitals

Other national health agencies

Other Public Medical Providers

Health Insurance Organization

Private Hospitals

Private Clinics

Pharmacies

Traditional Providers

(EMRO). For this paper healthcare system will be broken down into only two main categories, private, and public. In Egypt the main provider of healthcare is the Ministry of Health, “which runs a nationwide system of health services ranging from outpatient clinics to large urban-based hospitals and providing a mix of inpatient and outpatient care” (Rannan-Eliya). Overall the “health services in Egypt are currently managed, financed, and provided by agencies in all three sectors of the economy: the private and public sector and the parastal sector.”(Ministry). Following is a general overview of each of the sectors.

Public Sector/Parastatal

When an Egyptian chooses between what care they want to be provided with, they are essentially deciding between a private and public options. The public option which includes government facilities, the Ministry of Health and other public facilities, compose the bulk of “hospital care in Egypt but its share is rapidly declining.”(EIU). This public or government sector receives its funding from the Ministry of finance. The main component of the public sector is the Ministry of Health and Population(MHOP), in fact the MHOP is “currently the major provider of primary preventive and curative care in Egypt with around 5000 health facilities and more than 80,000 beds spread nationwide.”

(Ministry). The MHOP provides a wide array of services and public health programs, in an attempt to

“target many health priorities in Egypt through vertical programs” these programs relying a great deal of support from private donors. These programs include The Population, Reproductive Health and Family

Planning program, The Control of Diarrheal Diseases and Acute Respiratory Infection Programs, and The

Expanded Program on Immunization, and the Maternal Health Program(Ministry).

Another healthcare provider that can be clumped in with the public option, are the parastatal organizations, which are “composed of a quasi-governmental organizations in which government ministries have a controlling share of decision making, including the Health Insurance Organization

(HIO), the Curative Care Organization (CCO), and the Teaching Hospitals and Institutes Organization

(THO). “ (Ministry). This sector is also run by the state but in general is given more autonomy, in terms of operation and finance, since they are governed by their own rules and regulations, but from a political perspective, “the MHOP has a controlling share of decision making” in these organizations.

(Ministry).

Regardless of all these programs, and the funding that the public sector gets from the government, according to EIU many of these public facilities are badly underfunded and maintained, many of them functioning very poorly. This may be part of the reason why though public healthcare is available for free, or minimal costs 60% of primary care visits ie outpatient service take place private clinic and hospitals. This makes one ask the question of what is it about the private healthcare providers that have more appeal to the general public, and whether this is translated into both inpatient and outpatient services

Private Sector

The private sector of healthcare in Egypt “includes for profit and non-profit organizations and covers everything from traditional midwives, private pharmacies, private doctors, and private hospitals of all sizes. Also large number of NGOs providing services, including religiously affiliated clinics and other charitable organizations, all of which are registered with the Ministry of Social Affairs.”( Ministry) The private sector has 2024 inpatient facilities with a total of about 22647 beds. This accounts approximately

16% of the total inpatient bed capacity in Egypt (Ministry). Even though the private sector does not make up overwhelming portion of the healthcare system, it is still where 60% of patients go for outpatient, and primary care (Egdon). The system though does not come without its challenges and problems

According to ERMO some of the problems and challenges that private healthcare in Egypt is facing are:

“Inadequate quality of private services

Presence of some unreachable areas

Insufficient public budget allocated for quality private health care services

Distribution of health facilities and services according to community needs

Deficiencies in the private health care referral system

Providing required number of qualified family physicians Implementing health insurance system covering all community members and providing

sufficient resources

Upgrading the quality of undergraduate medical education for physicians and nurses.

Developing a strong health system having the ability of accrediting, monitoring and evaluating

the provided services. “

(Ministry 2003)

The question then becomes, whether it is better to have more options available for people, citizens can choose between both a public options to get their healthcare vs. a private option. The issue is ultimately quality of healthcare provided through each of these. Since so much of the Egyptian public still prefers to go to a private facility and pay money, then to go to a public facility and be offered a lower standard of care. Is this still an issue that the rich get the best care while the poor are left with an alternative that may need their needs, but in the sacrifice of quality?

Equality of Healthcare Distribution

One issue of extreme importance when looking at the accessibility of healthcare is to analyze how equal these resources that the public has access to are distributed. One of the problems internationally is that there isn’t always equal distribution of healthcare resources because some don’t have the financial means to buy insurance, and therefore cannot always get the care that they desperately need. One can see this as inequality of distribution as a classic case of the rich gaining more access than those who are not as well of. This clearly has been a problem in the United States in particular and for that reason in the past programs such as Medicaid, and State Children’s Health Insurance Program (SCHIP) was put in place. In more recent events, President Obama implemented a new healthcare plan, to ensure equality through accessibility. One way equality is described is that “Equity as a goal can be contrasted with efficiency, and in essence relates to a concept of social justice (Rannan-Eliya). There is no agreed definition of what constitutes equity with respect to health systems. This lack of an agreed and consistent definition stems from underlying differences in philosophical approach- egalitarian and libertarian. Poverty alleviation through the re-distributive effect of public health spending is another important welfare goal in many countries” (Rannan-Eliya).

Distribution of health care utilization by income level:

In Egypt one of the biggest differences between utilization in healthcare can be seen when comparing income levels to private and public, and outpatient and inpatient services utilization. “Richer using higher volumes of both inpatient and outpatient services, with the exception of MOH outpatient services which are used more by poorer Egyptians” (Rannan-Eliya). If it can be assumed that poorer

Egyptians are sicker than rich Egyptians, and are thus in greater need of healthcare, then this distribution does not indicate that access to health care is equal for those of equal need (Rannan-Eliya). “Only MOH expenditures are equally distributed across income groups, and that is largely due the higher use of MOH outpatient services by the poor, which compensates for the higher use of MOH inpatient services by richer Egyptians.”(Rannan-Eliya).

Maternal Health

Maternal health is paramount to the health and well-being of not only an expecting mother, but also her child, thereby it affects the future health of the future populations. In the past, even in the

United States, one of the leading causes of death for women was birth/pregnancy. In many developing nations maternal morbidity is still one of the major causes of death among women. It is not just important that there be a skilled physician during the delivery process in order to ensure the health and well being of the mother and the child, but it is important that that there be consistent from when the woman first realizes that she is pregnant. It is important to monitor the health and well being of pregnant women, because “about 15% of all pregnant women experience life-threatening complications as a result of their pregnancy.”(Ministry). If there is one instance where preventative healthcare and healthcare education are crucial to saving lives, it is in the case of maternal health. Because of the international focus on maternal health, and maternal morbidity and mortality, there have “been shift in the emphasis placed on some tradition maternal health interventions.”(Ministry). More attention has been given to the following areas, antenatal care (ANC), delivery care, postnatal care, and newborn care

(Ministry).

Egypt has gotten on board with the international community, to make policy changes to work on this issue. This was an essential step in the right direction, especially when one looks at studies down before the year 2000, analyzing maternal morbidity and mortality. In the late 1980’s a study was done by several Egyptians to analyze “Women’s understanding of Pregnancy-Related Morbidity in Rural

Egypt”(El-Mouelhy). The study looked at what the attitudes of women were to their own pregnancies and what they saw as normal and what wasn’t, when they sought out medical attention, and how often they had prenatal care. From the study it became evident that “among many of the barriers to reducing maternal mortality and morbidity are that women and /or their families fail to or delay seeking medical care, and that health services provide inadequate antenatal care.” (El-Mouelhy) Many of the issues that arise later and lead to morbidity or mortality could have been prevented with early care, in fact the main reasons for maternal death in Egypt according to the Egyptian Ministry of Health are hemorrhage, pregnancy induced hypertension, and sepsis. Regarding high blood pressure, this study noted that

“some women did not have their blood pressure checked at all during pregnancy,” additionally regarding hemorrhage and sepsis “a third of the women with bleeding during pregnancy did not do anything about it” though, even spotting could be an indication of a severe problem, and “postpartum fever and heavy discharge were perceived not to warrant medical care in more than 50% of cases” this is clearly concerning because sepsis is an important cause of maternal mortality(El-Mouelhy). Though this particular case was of a rural community where the women were less educated, it can still be taken away from this study the need for more healthcare education programs and antenatal care was illustrated. How has Egypt tried to resolve these issues? In 1994 Egypt was the host of the International

Conference on Population and Development where the government began to “endorse a comprehensive approach to women’s health with a focus on reducing maternal mortality”(Regional).

As part of the MOHP public programs which were mentioned early the Maternal Health Program was developed and a reduction in the maternal health mortality was the key to a five year plan that was developed. This was all of great importance considering the following conclusions that the national mortality study that the MOHP preformed in 2000:

“Lack of Antenatal care contributed to 19% of maternal deaths, and the poor quality of

15% of maternal deaths.

26% of maternal deaths in Egypt occurred during delivery or the first 24 hours after

delivery.

34% of direct causes of maternal deaths in Egypt were due to postpartum hemorrhage.

In total 26% of death occurs postpartum

Cardiac diseases were the leading indirect cause of maternal deaths (13%), and the most

common cardiac problem was rheumatic fever.

62% (most) maternal deaths occurred in health facilities, 29% occurred at home, and 9%

occurred during transportation, with 93% of women who died having sought medical

help for their problems. Of those who delivered in a health facility, a disproportionate

number of postpartum hemorrhage and caesarean section deaths occurred in private

facilities (37% and 47% respectively), possibly because of lack of blood, poor backup, or

delays in transferring patients to hospital

Substandard care (poor diagnosis and management) by health providers, in particular

obstetricians and general practitioners, remains the most important avoidable factor,

contributing to 54% of maternal deaths. Substandard care in the private sector is of particular concern, since deliveries in the private sector have overtaken deliveries in the

public sector (26% and 22% respectively).

Failure of the woman and her family to recognize danger signs, resulting in a delay in

seeking care, was the second most important avoidable factor, contributing to 30% of all

maternal deaths. Shortage of blood was the most frequently avoidable health facility

factor, contributing to 16% of maternal deaths.”

(Ministry 2003)

All of these conclusions that the study came to made it clear the importance of taking certain preventative measures to prevent maternal mortality.

Antenatal Care

One of the key factors of importance in preventing maternal and infant mortality is providing early antenatal care for pregnant women. According to the Maternal and Neonatal Health Project (MNH), antenatal care “should focus on early detection and skilled in timely interventions for factors having proven impacts on maternal and infant outcome” (Ministry). When studying the following are the key findings:

“53% of women who had been pregnant during the 5 year period preceding the survey had

received some type of ANC

4 ANC visits with services provided by a trained provider (the MOHP definition for ANC) were

received by an average of 37% of pregnant women, during the 5 year period preceding the

survey.

Almost 2/3 of women receiving ANC received their ANC from private service providers, and 1/3

from public service providers Utilization of ANC is urban regions was more than twice from rural regions

Slightly less than 50% of births were in a medical facility, although 61% gave birth with the

assistance of a trained provider.”

(Ministry 2003)

Delivery Care

With every birth there are potential complications, many of them unexpected. Because of this one of the essential ways to prevent maternal and infant death is ensuring there is a trained professional delivering the child. This important especially when one takes into consideration that “the level of skill among ‘skilled birth attendants’ is lower than is ‘safe’ for safe motherhood” (Ministry).

Without someone who is truly competent in delivering a child, and dealing with complications that arise, the risk of the mother dying in childbirth drastically increases.

Some of the key findings by the NHA in terms of delivery care are as follow:

“Equipment for assisting complicated deliveries is available primarily in general service hospitals.

Thus referrals for most complications are required

Among general service hospitals offering delivery services, less than half had equipment to

support inefficient labor

The vacuum extractor is not available in most urban Hospitals.

While 71 percent of general service hospitals offered caesarean section, only 60 percent offered

blood transfusion services”

(Ministry 2003)

Women’s Health

Female Genital Mutilation (FGM)

In a discussion of the issues that are faced relating to women’s , it would be unfitting to not discuss one particular problem that has plagued Egypt and much of the developing world, which is the issue of Female Genital Mutilation (FGM), or female circumcision. The issue of female circumcision is of great concern because of the potential health problems that arise when it is performed. A study done in Egypt in 1995 showed that “97% of never-married women” had been circumcised (Obermeyer). At first glance it may seem then that this is an issue of religious practice, but when comparing the incidence of FGM in the more secular Egypt vs. the religiously conservative Saudi

Arabia, it becomes clear that this is a more deep rooted cultural practice. In fact “the practice of FGM dates as far back as 5th century BC and today transcends all religious, racial and social boundaries. FGM is supported by centuries of tradition, culture and false beliefs and is perpetuated by poverty, illiteracy, low status of women and inadequate healthcare facilities” (Squire). Currently in Egypt there is a large movement against the practice of FGM trying to dismiss popular belief about the practice, especially in less modernized areas of Egypt.

One of the main problems with female circumcision, from a healthcare standpoint is the immediate and long term complications that can result from it. Following is a table listing some of these potential problems:

Immediate Complications Hemorrhage from dorsal artery, shock, pain, retention of urine, and infection and tetanus that can lead to death

Intermediate/Long Term Complications Cysts, keloid scar formation, damage to urethra resulting in urinary incontinence, and sexual dysfunction.

(Squire 2009) Children’s Health

Just as important as maternal well-being is to the overall health of future populations, children’s health is just as paramount. One of the main problems in terms of children’s health is that “many children who are brought to the attention of healthcare providers do not receive adequate assessment and treatment” (Ministry). This problem is not specific to Egypt, but the international community in regards to children’s health. The main issue is that many times healthcare providers may just treat the symptoms that a child has without looking at the underlying cause of these symptoms, they do not necessarily “conduct a full assessment of the health status of the child” (Ministry). This leads to future health problems that could have been prevented early on with earlier detection. For this reason the

World Health Organization has been working with the international community to promote preventative measures so that children’s diseases can be detected and prevented earlier on.

Comparison:

Both personal experience and the information I was able to collect from personal research, allowed me to more easily pinpoint some of the key similarities and differences between the Egyptian healthcare system and its U.S. counterpart. There are three main similarities and differences that I found to be most relevant to the work that I eventually want to do. They are the following:

In both Egypt and the US the leading causes of death are preventable

Though the U.S. healthcare system provides better overall care because of technological

advancements, Egypt’s healthcare system provides patients with more options in terms of

facilities, providing more people with more care

Both systems are making changes in their policies in order to prevent more diseases and allow

more people to have access to healthcare.

Next Steps:

For the next step in this project, I am going to take one particular issue of a great importance and focus on it in more detail. With the number of orphans and street children growing, it is necessary to look at the health well being of this population. How are orphans treated, what kind of doctors do they go to for care, who cares for them when they are sick? All of these issues are of great value because these are the most vulnerable members of the society, and how they are cared for reflects greatly on the overall healthcare system.

In May and June of 2010 I intend to return to Egypt to look at this problem. With the experience that I had last time I tried to do research there, I will be more equipped to handle many of the issues that I will undoubtedly face. During the summer I intend to work as a volunteer with the Dar el Orman foundation. This foundation was started in 1993 and its mission statement is to “Aim to support the underprivileged with care and support and to contribute towards building a stronger economy through small developmental projects that generate income for each under privileged person capable of earning their own income” (Dar Alorman). As a volunteer for the organization I will be able to work one on one with those providing care for the orphans at the Dar el Orman orphanage in El-Maadi, a suburb of Cairo.

During my volunteer experience I hope to be able to discuss with those working at the orphanage what kind of healthcare the children there are receiving. From this experience I hope to also gain a greater understanding of the way orphans are treated in Egypt and what kind of steps are taken to help them integrate into society once they become adults.

Personal Experience

After researching the healthcare system in Egypt, I was able to better understand the experience that I had in Egypt. From the hospitals that I visited I was really able to get a sense of the vast array of the hospital care that was offered. When I visited the Children’s public hospital, I could automatically tell that there were more patients then there were physicians to treat them. The hallways were lined with many patients waiting to receive care.

One hospital that I visited was particularly striking. The Children’s Cancer hospital located in downtown was one of the most “westernized” hospitals I saw in Egypt. The thing that was the most surprising was that the hospital was built and supplied purely through donations. It did not receive funding from the government, and it was fascinating to see how much private donations alone could do.

Everything was so carefully thought out, from the architecture of the building, to trying to using color schemes that would make the children feel like that they were at home. The hospital enforced rules ensuring that parents stay with children at the hospital. After touring the hospital, one of the most surprising things was that all of the children were treated with no cost. From what I saw this hospital should serve as a model for the rest of the Egyptian healthcare system and it showed that there was a way for there to be a successful model of a hospital in Egypt.

Conclusion

In conclusion, from the beginning steps of this ongoing research project I have been able to not only understand more about the way that the healthcare system functions overseas in Egypt, but I have also been able to understand more about the healthcare system here in the United States. One thing that I found to be universal was that each system has its own weaknesses and strengths. Overall it became evident that no matter what healthcare system is implemented, or where it is implemented there is one thing that will make it either a complete success or a completely failed system. How well the system in place works to provide access to healthcare to the public, and what the overall system does in order to ensure early disease prevention is what defines the success or failure of any healthcare system. Though there will never be a perfect healthcare system, ensuring the current systems we have in place strive to achieve these two elements, will help to better perfect the healthcare systems that are in place. References

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