THE GOOD IS THE ENEMY OF THE ADEQUATE

EDITORIAL

THE GOOD IS THE ENEMY OF THE ADEQUATE

BY

Raouf Sallam

     At a time when Egypt is embarking on restructuring it's health care services, it is appropriate and even necessary to ask the basic questions that need be answered when planning any activity. These questions are the well known 5 Ws: when, where, who, why, what and to add to them how.

     Let us start by answering the easy ones.

When: it has already been decided that the implementation will start by the end of this year 2017 by the Suez Canal and Sinai governorates to spread gradually afterwards to the rest of Egypt 

Where: every part of Egypt will be included and covered by this national system.

Who: all the Egyptians will be covered by the new system. Joining the system is obligatory.

Why: three main reasons why should the system cover all Egypt and all Egyptians. The political reason is social justice, the moral reason is to keep everybody healthy and happy. Equally important is the economic reason, we know that the main resource of Egypt is its man power and the main resource of an individual is his health. The development of any community is largely dependent on the health of its individuals, a healthy person is more productive. A healthy person is an asset to his community, while a sick person is a liability.

      We are now left with the difficult ones......what sort of health care are we planning to offer and how are we going to implement it. It is obvious that how will depend on what. So let us concentrate on what kind of health care do we intend to serve? It is also obvious that the main determinant of the type of health care that can be offered is how much is available to spend on it, i,e the total health care expenditure.

This derives almost totally from two sources, the government budget for health care and the people's out of pocket spending to join a health care insurance, or as a fee for service when needed. Realizing this, let us consider some of the figures.

      Government health care budget for this year is 8 billion E.P. ( Egyptian pounds), this represents 40 % of the total health care expenditure of the country, the other 60% come directly from the public. As such we have 20 billion E.P. to cater for the health of 90 million Egyptians. An average of 222 E.P. Per person per year. Is this enough? and if not, how short it is? Let us see.

      The national health service ( N.H.S.) of England had a budget of 120 Billion Sterling pounds for the year 2016 to cater for the health of 55 million persons. People's out of pocket spending on health in England is minimal. So we will consider only the government budget which amounts to 2182 Sterling  per person per year. With the current exchange rate, this is equivalent to approximately 50000 E.P. Which means that the health care expenditure per person per year in England is more than 200 times that of Egypt.

      If one argues that we can get the same service in Egypt much cheaper than it is in England, I can assure him that this does not apply to health care. We have cheaper labour but more expensive machinery, instruments and most of the drugs since these are,almost all, imported from the west. In a research paper which I presented in Italy few years ago, I used a standard German cost calculation model for surgical operations and I found that laparoscopic cholecystectomy costs the same in Egypt as it is in England . If the hospital bed per day is much cheaper in Egypt than it is in England, this is only because the services offered per bed is much less in Egypt than it is in England. If we offer the same services in quantity and quality the cost will be the same.

     The minister of health said recently that we have 8 billion E.P. For the health care budget and to deliver an international standard health care we need 90 billion. This last figure is more than ten times that allocated and would make a great difference, but let us ask, is it enough to deliver a health care of an international standard for the 90 million Egyptians? Let us see.

       The health care in England is good but it is not ideal, this is in spite of the fact that they spend 8.5% of their GDP (gross domestic product) on health care . The rest of Europe spends 10.1% of GDP on health care. Economic reality tells us that we cannot spend the same amount of money on health care, but at least we should spend the same percentage. A fair share of what little we have got. 10% of our GDP would be more than 10 times of what is currently spent on health care. This would give the health care a very long leap forward. But even this amount of money is not enough, and why is that?  Let us see.

       Medical practice in Egypt is run by doctors who copy the western style medicine, and no blame, they find it evidenced, progressive and effective, and they know no other medicine. Guide lines for diagnostic work-up, indications for intervention, detailed steps of the intervention and follow-up protocols are all imported from the west. This is o.k. For the 5% of the population who can afford it. But if we are talking about a health care for the 90 million- and still increasing- we must be realistic and accept the simple fact that if we cannot spend as much as the west does on health care, we will not be able to deliver the same health care. What to do then ? Let us see. 

      While insisting that the government and the public should spare 10% of GDP for health care, we doctors should develop alternative protocols of management. I am not talking about alternative medicine, no, I am suggesting alternative protocols of the same medicine. Protocols that embrace reduced investigations, reduced indications and reduced treatment interventions. These alternative protocols should concentrate on eliminating such medical activities that are mainly defensive in nature and are meant only to avoid possible litigation. Also to eliminate many of the redundant activities in the western style health care, activities that are created by the pressure of the medical equipment and drug industry. Such pressure that does not stop at promoting over use but extends also to directing research to serve their industrial financial objectives. The effect of these protocols on health care quality should be small and on effectiveness should be minimal while cost saving should be significant.

       Let me explain by examples from my speciality ( general surgery) how we can reduce standard protocols of Management :-

Investigations:

      We do not need brain c.t.scan for every patient with head injury. Few hours of clinical observation will separate the few who need it from the very many who do not with no effect on the outcome.

      We do not need an x-ray for every patient with a twisted ankle. Only one in a thousand of those who can put weight on the affected limb will prove to have a fracture.

Indications:

      Asymptomatic gallstones in an elderly is not an indication for surgery. Such a patient may not develop symptoms for the rest of his life, and we know that complications develop only in symptomatic gall stones.

      Direct Inguinal hernia in an elderly is not an indication for repair unless clearly symptomatic which is very unusual.

Interventions: 

      When local anesthesia is an option, it should be used with the main advantage of being cheaper,and on many occasions safer.

      Closure of the abdominal wall in one layer is cheaper than the standard closure in layers, and though less tidy is equally effective.

       If the rich west has realized and accepted the for long fact that the ideal is the enemy of the good and settled for a good- but not ideal- health care, we, considering the scale of our economy, should realize that the good is the enemy of the adequate. Let us be content-for now- by an adequate health care for all rather than an ideal or good health care for the few and a pseudo health care for the many. Let us remember that a missed non essential benefit for one, may save enough budget to treat many others.

      These alternative protocols need experts to create and produce them. The expert tank of any specialty is its society. Although all medical societies in Egypt are non governmental and voluntary but I am sure they would - in fact they should- be willing to participate in a national health project organized by the ministry of health and the medical syndicate with the purpose of producing these protocols in all different specialties. In fact this is the forgotten duty of these societies. They are doing a very good job in promoting the vertical component of medical practice and very little in the way of spreading the service horizontally.

      The implementation of an adequate health care nationally should not deprive those who can afford the ideal or the good health care from having it. Those are probably about 5% of the population.

To sum up:

1. The government and the public should provide 10% of the country's GDP for health care.

2. The medical societies should develop the alternative reduced protocols of management to enable such an amount of money to offer an adequate health care for the 90 million plus Egyptians.

Prof. Raouf Sallam F.R.C.S.

Editor-in-Chief