Egypt's Transition towards a Third Wave of Health Sector Reform

Following the January 25^th revolution, Egypt’s health sector started a period of transition which will be difficult to define how long it will take.  Since then, three Ministers were in charge with no success of being approved by the public or health sector staff posing an immense challenge for whoever will be in charge during the transition.  Dissatisfaction is due to presence of high expectations, absence of priority setting on few areas that could be accomplished, and absence of indicators to measure success of a transition. 

This transition is expected to be followed by a third wave of reform.  Lack of presence of strategic directions for a potential third wave of reform will hinder efforts to design and implement the transition.  A third wave of reform will be expected if we will look backwards at history of reform Egypt encountered. Reform phases could be classified as; (i) Pre-reform phase (before 1997) focusing on improving maternal/child health and fertility outcomes; (ii) First Reform Wave (1997-2005) focused on universal coverage through adopting a national health system; and (iii) Second Reform Wave (2006-2010) focused on expanding universal coverage through adopting social health insurance.

Pre-reform Phase (Before 1997)

This phase focused on improving health outcomes at primary health care targeting improvements in maternal and child health as well as fertility outcomes implemented by a number of vertical programs at primary health care level. Efforts towards efficiency focused on integration of child health services at primary health care level and on cost recovery at hospital care level, while efforts towards universal coverage and protection focused on expanding health insurance coverage, compulsory to school children and voluntary to pre-school children. 

The First Wave of Health Reform (1997-2005). 

Irrespective of its original design, this wave adopted a national health system (NHS) approach to achieve universal coverage – starting a pilot in five governorates.  It was led by the Ministry of Health (MoH), which was convenient given the ministry’s familiarity with NHS considering this reform as a natural continuation of its original work.  On the other hand, the Health Insurance Organization (HIO), which also was envisaged to be reformed, was not much involved and continued its role as originally assigned to it.  This phase introduced: (i) Family Health Services and its accreditation; (ii) needs based health facility planning; and (iii) payment for performance using Family Health Funds partially, an attempt to separate provision of services from its management.  Training of health workforce and quality were key factors increasing utilization, while user fees reversed gains in utilization. 

The Second Wave of Reform (2006-2010)

This phase adopted a social health insurance system (SHI) approach to achieve universal coverage - starting a pilot in one governorate; however, design was developed “as we go” and with a tendency to be conservative in expanding coverage.  The characteristic explicit shift in strategy from NHS to SHI was based on a policy paper prepared by the previous National Democratic Party (NDP), followed by a Presidential declaration in Sohag in 2005.  This shift forced a new stakeholder, the Ministry of Finance (MoF), to have a significant role in decision making during this phase.  This phase was partially led by HIO, with difficulties to reach consensus and the recognition for the need of additional studies to understand the fiscal implications of SHI on the budget.  Regretfully, a number of features developed under the first wave were dropped along the way.

The Transition

We are now in a transitional period, before a third wave of reform starts.  It might be prudent during this period to set modest objectives for this phase instead of trying to reform the whole system or passing critical laws such as SHI law.  It might be worthy to reach consent on the health system that would reflect the values of the people before embarking on Egypt’s third wave of reform.  Two sets of questions will need to be posed:

Are the people willing to accommodate the idea that reform will take longer than what they would expect, and are they willing to work in stages or phases with realistic objectives instead of full blown reforms?

If so,

What would be the priorities for the transition period and its minimum objectives, and how to measure its success? 

Two areas of priority could be identified to be demanded by the people and health sector staff during transition.  These are:

(1)    Governance and Anticorruption

(2)    Health Workforce. 

These are two broad areas that need to be further defined to ensure feasibility and successful implementation and to fairly hold a Minister of Health accountable for his or her performance of this period. Improvements in these two areas could reflect substantially on improvement in the provision of health care that could be favorably received by the people. 

Until we meet again....