Magda Iskander

Ashoka Fellow
Illustration of a person's face depicting a fellow
Egypt
Fellow since 2003
This description of Magda Iskander's work was prepared when Magda Iskander was elected to the Ashoka Fellowship in 2003.

Introduction

Magda Iskander is creating the profession of home healthcare in Egypt and training a cadre of providers to offer high-quality, affordable services to the elderly and others who are homebound.

The New Idea

Traditionally, younger members of extended families cared for the elderly, but in recent years the responsibility has shifted to inefficient, expensive private hospitals and nursing wards. Magda, a doctor, sees that important aspects of care–companionship and love–have been lost in this shift. Many older people are made to feel like a burden, their potential for contribution somehow spent. To provide high-quality care and assistance to the elderly and others who are homebound, Magda is creating a new professional niche: home healthcare. She selects smart, compassionate recruits and teaches them, motivates them, and gives them a respectable job and an important chance to contribute positively to those in their care. Her idea is clear, efficient, and appealing to everyone. It creates jobs without burdening the government, provides a desperately needed service at an affordable cost, and sets a professional and compassionate tone for caregiving. To support and spread this new profession, Magda arranges partnerships with private hospitals to offer both an institutional shelter to home healthcare providers and secure employee benefits like insurance.

The Problem

Of Egypt's 70 million people, about six percent are 60 or older. Of these, an estimated 10 percent, or 42,000, need or will soon need some form of assisted-living or home healthcare. Others–people with disabilities and patients recovering from injury–could also benefit from such services.
The services currently available to the homebound are few. There are no nursing homes or assisted-living facilities in Egypt. Older people sometimes squeeze into the homes of their children, but living spaces, especially in cities like Cairo and Alexandria, are typically cramped. Long-term hospitalization is an option for some, but most Egyptians agree that medical care here is a disaster. Egypt's spending on healthcare (private and public) is 3.8 percent of its GDP, significantly less than in most other countries: 8.3 percent in Brazil, 6.8 percent in Hungary, 13 percent in the United States. This means that doctors are scarce, nurses scarcer, and all are paid very little and stretched thin on the job.
There is also misunderstanding about what and who is needed to meet the demand for care. As Magda points out, trained doctors and nurses are not the ones best equipped to help the elderly and others who have difficulty leading independent lives. After all, many in this group are in stable health and do not require hourly monitoring of heart rate, blood glucose levels, or white blood cell counts. Reliability, security, companionship–these are the things that homebound patients need most. They need to feel confident that their caregiver will show up on time, want to spend time with them, provide for their comfort, and make sure everything is in order before leaving at the end of a shift.

The Strategy

Magda offers a comprehensive curriculum for training home healthcare providers and teaching the best of them to train others. The heart of her curriculum is a four-month certification course that draws together 15 to 20 students–20 percent men, 80 percent women–from all walks of life and age groups. Many are unskilled and generally considered unemployable. Most come looking for a job and find a career, a profession, and a life's purpose. The curriculum offers a well-balanced mixture of theory in the classroom, lab training where the trainees are coached to acquire and practice needed basic skills, and practical field experience where they apply what they have learned and can gain confidence and hands-on experience. Primary subjects include public health and nutrition awareness, body systems, communications, daycare skills, first aid, and common diseases.
Magda believes that a deep, personal commitment to caring for another human being must underlie health knowledge and technique in order for care to be effective. Trainees–who are Muslims and Christians–are taught to give care with love, using the basic value system of their religions in their interactions with patients. Magda teaches her students that people are born free, that they are free to make choices throughout their lives, and that each choice carries a price. She inspires students to always offer their best for those in their care, and she teaches that if students do not find the work satisfying, they ought to leave the profession and do something else. Magda says that 60 percent of students are transformed by the course; 20 percent do fine; and 20 percent demonstrate through their behavior and attitude that they are not suited to the field. She cuts the latter group from the program. In her view, a new profession cannot afford to include the unconcerned, uninterested, or inept.
Prior to certification, Magda arranges one-month internships with seasoned home healthcare providers who offer guidance, close and supportive supervision, and evaluation. In fact, evaluation by more senior providers and by clients is an ongoing part of Madga's effort, not only to ensure mastery of technique but also to monitor and provide helpful feedback on maturity, personal growth, and adjustment. Following completion of the course, students take an exam, and the 80 percent who pass don graduation robes and attend a formal ceremony recognizing their achievement. For most graduates this is an important moment of personal transformation. But Magda sees that emphasizing this moment of passage is about more than acknowledging personal achievement. Importantly, this emphasis enhances the image of the profession she is building. To date, all graduates have been employed and are earning a good income. The first graduates received degrees in 1997; there are now 600 certified home healthcare professionals serving homebound clients primarily in the greater Cairo area, with a few working in other areas: Alexandria and the North coast. Magda is arranging professional supports to stabilize this new profession over the long term. She has arranged for health institutions where the graduates will work to cover the cost of training or offer loans to students, payable in installments following graduation. She has secured an offer from the Ministry of Health to provide an institutional shelter for home health providers, granting them full insurance and employment benefits as hospital employees. She hopes to get the Office of Labor to acknowledge home healthcare providers as well.

The Person

Magda was born in a village in the south of Egypt, a child of parents who believed that girls should be independent and think critically. She was raised to understand that helping out–caring for older people, the sick, and others in need–was simply part of what one did. It was no great act of charity or display of self-sacrifice.
At 18, Magda desperately wanted to study music. Unable to pass exams for admission to the music faculty, she settled on medicine and found in radiology a fascinating new science. After studying for a period in the United States, she returned to Cairo in 1984 and found that ultrasound–by this time widely used in some other countries–was not yet available in Egypt. She brought the technique home with her and set about the task of establishing training centers in Cairo hospitals. This first experience incorporating something new and useful to the Egyptian medical system would prove useful to her efforts, years later, in introducing and institutionalizing home healthcare.
When her sister broke her leg, Magda had an opportunity to see, from the patient's perspective, the inadequacies and dysfunction of the national healthcare system. Rather than keep her sister in the hospital during her two-week recovery, Magda hired a trusted house worker to take care of her and gave this worker a brief but thorough tutorial on what she would need to do. Everything worked out perfectly. This experience, coupled with Magda's daily encounters with elderly patients in the hospital, contributed to her resolve to build a home healthcare profession in Egypt.
Magda's organization, Care with Love, is based in Cairo.