Former Egyptian Minister of Health Adel Adawy discusses the reforms needed in the Egyptian healthcare system and the progress made in the fight against HCV over the last two years.
What structural changes need to be made in the Egyptian healthcare system?
First of all, Egypt needs to have three independent healthcare authorities: a healthcare services monitor, responsible for overseeing all hospitals in Egypt; an auditing and validation authority, tasked with accrediting all healthcare facilities that meet well defined national standards; and an institutionalized public payer.
Creating each of these institutions would have an enormous positive impact on the quality and value of healthcare services in Egypt. A proper healthcare services monitor would help to ensure compliance and prevent malpractice amongst all hospitals in Egypt, both private and public, and help to ensure that critical protocols such as HCV infection prevention protocols are followed across the entire Egyptian healthcare system. With hundreds of public healthcare facilities and thousands of private hospitals and clinics in Egypt, not all have the necessary equipment, training and infrastructure to safely provide certain healthcare services. An Egyptian medical facilities authority would be able to accredit different facilities according to their capabilities, categorizing hospitals as primary, secondary, or tertiary care facilities, and give patients and payers a better understanding which facilities are equipped to provide what level of care. Finally, a single national public payer would be able to address many of the funding issues currently plaguing the Egyptian healthcare system; first, it would be in a position to raise additional funding from individuals, perhaps as contributions of one to two percent of one’s income, and have the responsibility of paying the health expenses of all publically insured patients. As an entity completely separated from public healthcare providers, this payer would have the duty and incentive to make sure that resources were used effectively and responsibly, and competition would help to ensure fair prices for healthcare services.
The reforms necessary to create this sort of system are immense, and would be extremely politically challenging. This is why I have previously advocated for the establishment of a “supreme council of health” under the Prime Minister’s office; as such reforms would have to be coordinated at a very high level. For example, while most public hospitals are administered by the Ministry of Health and Population, the Ministry of Higher Education funds and manages university hospitals across Egypt, while several other ministries operate hospitals independently of the Ministry of Health. A coordinated effort at the highest levels of government will be necessary to unify national standards, protocols and treatment guidelines, and to improve the financial efficiency and capacity of Egyptian healthcare systems at a national level.
How would you assess the progress that Egypt has made in combating Hepatitis C over the last two years?
We took some great steps forward during my time at the ministry, and it is these accomplishments that I am most proud to have been a part of. That said, a lot remains to be done to reach the final step, which is the eradication of HCV from Egypt. This is a personal dream of mine, and day by day I pray that we are coming closer to seeing a measurable decrease in HCV prevalence and towards seeing the balance towards newly added cases and treated cases shift towards the side of the treatments.
It was only after being nominated to be minister the third time that I accepted, and at this time I prayed for an innovative idea or opportunity to come to me so I could do something impactful to fight this disease. Then, on just my second day as minister, I had the chance to meet Mr. Samuel, the vice president of Gilead, and this was in March 2014 just three months after the FDA had approved Sovaldi. From that first day we began discussions over how we could take a significant step towards solving the HCV epidemic by bringing Sovaldi to Egypt at an affordable price. I, as minister, did not allow Egyptian producers to manufacture generic sofosbuvir products except with the permission of Gilead, and thus it was necessary to negotiate a suitable arrangement with Gilead. We had a lot of support from stakeholders including the WHO director general, the medicine patent pool, and the WHO HCV committee to convince the Gilead board to cooperate for humanitarian reasons. The result was a proposal for a governmental purchase program that he took to the board of Gilead, and on July 2nd 2014 we signed a formal memorandum of understanding.
Three months later, in October 2014, the first patient was treated. This is an astounding feat for Egypt as having a product registered, priced, and brought to market in less than four months is something that had never happened before and will likely never happen again.
The major challenge that had to be overcome to make this possible was to establish controls to prevent patients from selling the medication they were given on the black market. Thus, the National Committee for Control of Viral Hepatitis (NCCVH) had to establish treatment centers where doctors could watch the patient take the first pill of their monthly dose, and then return that exact bottle at the end of the month.
Another major challenge we had to solve stemmed from the fact that Sovaldi has such a high cure rate that every patient wanted access, and we weren’t able to provide for them all immediately. As such, we had to find a way to organize patients, and ensure those in the greatest need got access first, and to do so in such a way that didn’t allow large crowds to form which was a concern due to the political situation at the time. This was accomplished by requiring all patients to sign up via a website, then get an appointment at one of the treatment centers run by the NCCVH for a proper examination, and received a scheduled start date for their treatment depending on urgency. We established guidelines to ensure that those most in need of treatment got it first, and the process ran quite smoothly overall. Most importantly, we ensured that the entire process was free from interference by individuals in the ministry and that that the protocols were followed for all cases, and this was the first fully transparent treatment program in Egypt.
What were some of the other significant steps aside from the Sovaldi deal?
I have always had the strong belief that treatment is not enough, because this situation arose due to preventative protocols. So when we started treatment on October 15th 2014, that day I also announced a new Action Plan for Prevention Care and Treatment that we had prepared over the previous six months. This preventative protocol depended mostly on seven pillars; infection control, injection safety, blood safety, screening methodology, communication strategy, awareness campaign, and scientific research. I distributed this plan to the entire WHO executive board, and in general they supported it and congratulated Egypt for this innovative step. With the application of this plan and the increased treatment under the national treatment campaign, we can hopefully reach a point where more people are being treated than becoming newly infected.
We also announced the “Liver of Egyptians’” project on World Hepatitis Day, and this campaign advocated that all Egyptians should support the plan for getting rid of HCV, starting by improving safety and infection control in dental clinics, health barber shops, and of course in medical facilities.
One challenge is that while we have a plan for treating patients in the public sector, the many patients who are treated in the private sector are not incorporated into our plans for monitoring. As such, I passed a ministerial decree that controlled and regulated the prescription of medications for treating HCV such that the prescriptions and patients must be registered, with the eventual goal of being able to establish a national liver and hepatitis registry with information about the patient pool, the stage of the disease, treatment protocols, the treating physicians, and treatment outcomes and follow up.