Egypt passed a reform act in 2018 that will see a universal health insurance system rolled out across the country and will place family medicine (FM) as its bedrock.1 Egypt has a population of over 90 million, the third largest in Africa, with its people densely packed on 7% of its land along the Nile valley and delta. Two-thirds of Egyptian citizens are under the age of 29, with 28% living in poverty. With an estimated 120 million population by 2030, good-quality education and primary health care (PHC) represent huge challenges.2
MAIN CURRENT PROVISION
Currently the Ministry of Healthcare and Population provides FM through PHC units that cover almost every neighbourhood and village in the country. They deliver acute and chronic illness care, vaccinations, contraceptive services, and antenatal care, yet most people obtain primary care from the outpatient clinics of public hospitals. University hospitals, NGOs, and military hospitals also offer primary care. Consultations, basic tests, and prescriptions are free in PHC units. A strong private sector probably accounts for up to 60% of all services.2 Patients prefer to see secondary care specialists directly. FM was first included in undergraduate education in the Suez Canal University in 1978, and in postgraduate education in Cairo University in 1998, yet people have little understanding of what FM actually is. Consequently, most family doctors do not have their own clinics but work in polyclinics.
FAMILY DOCTORS
There are three routes to working in PHC units. All medical graduates may start at a temporary, non-training grade that becomes permanent for some. The residency programme requires 3 years of work in a PHC unit under supervision, with limited training in a university hospital, some hospital rotations, and attendance at FM clinics. Residents take a Master’s degree that designates them as FM specialists. A landmark was the creation of the Egyptian Fellowship Board in 1998, which established specialist training for the first time. Graduates of the Fellowship programme become FM specialists, a standard that is recognised throughout the region, making the graduates highly attractive to employers abroad.
TRAINING
Trainees on the Fellowship programme rotate through PHCs, designated for training and hospital posts over a 4-year period. Each training PHC unit, which serves a population of over 20 000, will have several trainees and trainers. Each trainee has a nominated trainer throughout the programme. Each trainer is responsible for up to nine trainees at any one time. Formal training is provided on weekly teaching and scientific days in the PHC units, which bring together trainees from several PHC units and hospital posts. In addition to the workplace-based assessments and written and clinical exams familiar to many countries, trainees submit a dissertation in their final year. RCGP International has been privileged to contribute to the development of the qualification exam, and the robustness of the Fellowship qualification was accredited for MRCGP International in 2009.
WORKING CONDITIONS
The lure of higher wages and better conditions leads many family doctors and FM trainers to emigrate, mostly to the Gulf states. Migration places huge pressure on the remaining doctors and trainers. A typical working day for an FM specialist starts at 8am seeing 30–40 patients until 2pm. Wages are low in the public sector so many family doctors undertake private work in the afternoons or other days of the week in polyclinics or private hospitals.
THE FUTURE
Under the reforms, coverage will be expanded to include the 50% of Egyptians currently without insurance and the 30% who cannot pay the annual insurance subscriptions.1 To see secondary care specialists, patients will need a referral from primary care. If the reforms are to succeed, many more FM specialists and trainers will be needed. The task ahead is enormous. Undergraduate exposure to FM is sparse. Only 5% of undergraduates aspire to FM, and 86% aim to emigrate after qualification.3 To recognise the worth of primary care and to retain those qualified as FM specialists, the reforms will raise monthly salaries from $140 to $1680. The training programme will be expanded but the attitudes of the public and of undergraduates will need to change. The government has wisely given itself 14 years to implement the reforms.
- © British Journal of General Practice 2019
REFERENCES
- 1.↵
- 2.↵
(2014) Egypt Demographic and Health Survey, Ministry of Health and Population Cairo, Egypt, 2015.
- 3.↵
