tag:blogger.com,1999:blog-37774205959198574872023-11-15T15:58:56.909+02:00Reflections on Egypt's HealthPublic Health. Human Development. Social JusticeAnonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.comBlogger14125tag:blogger.com,1999:blog-3777420595919857487.post-82088120435994806062013-04-19T13:23:00.002+02:002013-04-19T13:28:27.769+02:00Does Egypt adopt pro-poor health policies?<br />
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<b><span style="font-family: "Trebuchet MS", sans-serif;">Towards a fairer and accountable Egyptian health care
system<o:p></o:p></span></b></div>
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<span style="font-family: "Trebuchet MS", sans-serif;">In an event, organized on March
1-3, 2013 in the beautiful city of Sharm El-Sheikh in Egypt, debating the theme
of “health insurance for the poor”, one of the distinguished <span style="mso-spacerun: yes;"> </span>presenters, Dr. Cristian Baeza,<span style="mso-spacerun: yes;"> </span>stated the following “ a segregated system
for the poor proved to be a poor system”. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Later
in his presentation, he followed by stating “universal means the entire
population, but paying particular attention to the poor is critical as they are
historically postponed and not prioritized”.<span style="mso-spacerun: yes;">
</span>Cristian was presenting lessons learned from countries from Latin
America on their experiences in expanding universal health insurance coverage.<span style="mso-spacerun: yes;"> </span>The question begged itself, “What does this
mean for Egypt?”<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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</span><span style="color: black; mso-bidi-font-family: Helv;"><span style="font-family: "Trebuchet MS", sans-serif;">Before the January 25<span style="font-size: small;"><sup>th</sup> revolution, national health
policy was applied universally with no particular priority set for improving health
outcomes of the poor.<span style="mso-spacerun: yes;"> </span>Allocations of
budgetary funds for the health sector followed Ministry of Finance budget lines
with no priority set for lagging regions or for those falling behind across
population groups. With expected upcoming reforms to Egypt’s subsidy system, poverty
rates would increase by several percentage points warranting putting in place a
pro-poor health policy for protection of the poor and the vulnerable.<o:p></o:p></span></span></span></div>
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</span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;">Traditionally, Egypt’s budget
allocations are fragmented among a number of competing publicly-funded programs
that hinder Egypt’s ability to pool risks and compromises Egypt’s path towards
achieving universal health coverage.<span style="mso-spacerun: yes;"> </span>The
results of the health care system reflect evidence of unfairness.<span style="mso-spacerun: yes;"> </span>In terms of health status, the nationwide progress
made in reducing mortality among women, infants and children is not evenly
distributed resulting in growing disparities in achieving MDG 4 (child
mortality) and MDG 5 (maternal health) across geographic regions and income
quintiles.<span style="mso-spacerun: yes;"> </span>In terms of financial protection,
the inability to protect the Egyptians from the impoverishing effects of health
expenditures, especially against catastrophic illness is significant: <span style="mso-spacerun: yes;"> </span>(i) the ongoing Social Health Insurance (SHI) excludes
the poor as well as those who are in the informal sector, self-employed farmers
or rural residents; and (ii) access to the Program for the Treatment on Expense
of State (PTES) is also inequitable.<span style="mso-spacerun: yes;"> </span>All
resulted in three fourth of total health expenditure being spent out of pocket.
In terms of client satisfaction and system responsiveness, service utilization by
the poorest quintile of the population is the lowest for all types of health
services, although the poor are more likely to utilize public health facilities
than the better-off groups.<span style="mso-spacerun: yes;"> </span>These are
all consequences of the lack of a specific pro-poor health policy.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "Trebuchet MS", sans-serif;">
</span><span style="font-family: "Trebuchet MS", sans-serif;">Following the revolution for the
last two years, governments and ministers of health were struggling to find
ways to translate social justice into health programs that could reach the
poor.<span style="mso-spacerun: yes;"> </span>We’ve witnessed an active civil
society movement organizing events and seminars, writing blogs and facebook
threads going deep into discussing the nature of these programs and presenting
serious proposals.<span style="mso-spacerun: yes;"> </span>On the governmental
side, A social health insurance law is in the making promising to cover the
cost of premiums for the poor, however, with uncertainty about its sources of
funding.<span style="mso-spacerun: yes;"> </span>Already, a Law for expanding
health insurance coverage of female-headed households has been issued; however,
with a low turnout of beneficiaries showing up for enrollment.<span style="mso-spacerun: yes;"> </span>A social justice budget was proposed to inject
more funds in ongoing programs perceived to be underfunded such as Free Health
Care, Program for the Treatment on the Expense of State, or for subsidized
drugs and milk formula, and possibly fund school feeding programs.<span style="mso-spacerun: yes;"> </span>However, the question remains: are these good
examples of pro-poor programs?<span style="mso-spacerun: yes;"> </span>Would
they lead to a fairer health care system? </span></div>
<span style="font-family: "Trebuchet MS", sans-serif;"><o:p></o:p></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;">
<span style="font-family: "Calibri","sans-serif"; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><span style="font-family: "Trebuchet MS", sans-serif;">Recognizing the need for developing health
policies and programs that promotes fairness and accountability in Egypt is
essential and a first step.<span style="mso-spacerun: yes;"> </span>A following
and needed second step is to examine the ongoing health programs through a lens
that can judge if these policies and programs are pro-poor or not. A third step
will be to develop a health policy that keeps and consolidate those programs
which are not only pro-poor but also efficient and effective, and ensuring that
they are an integral part of the overall health care system.</span> </span></span><br />
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Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-44826108827398135192012-02-06T16:49:00.000+02:002012-02-06T17:09:42.524+02:00Egypt’s Stunted Children: A Silent Cry of Social Injustice<br />
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<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; font-family: 'Trebuchet MS', sans-serif; font-size: 13.5pt;">Improving Health Outcomes of the Poor – A
Social Justice Agenda for Egypt (2)<o:p></o:p></span></b></div>
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<br /></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">While Egypt has
made impressive progress on each of the MDGs especially MDG 4 and 5, it
continues to face challenges with MDG 1 relating to the eradication of extreme
poverty and hunger. Moreover, regional disparities and gender inequalities
continue to persist across governorates. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<b><i><span style="font-family: 'Trebuchet MS', sans-serif;">Malnutrition in Egypt is increasing.</span></i></b><span style="font-family: 'Trebuchet MS', sans-serif;"> In
2008, the prevalence of malnutrition increased than those figures reported in both
2000 and 2005. Nationwide, 29% of
children under the age of five are stunted, 6% are underweight, and 7% are
wasted. The situation is likely to have further deteriorated since the
continuing political instability following Egypt’s revolution at the start of
2011 as recently announced by CAPMAS indicating an increase in unemployment rates
to 11.9% in September 2011 and poverty to 25% in 2012. National averages,
however, obscure vast regional differences in undernutrition prevalence. <o:p></o:p></span></div>
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<b><i><span style="font-family: 'Trebuchet MS', sans-serif;">Nutrition is </span></i></b><b><i><span style="font-family: 'Trebuchet MS', sans-serif;">central to </span></i></b><b><i><span style="font-family: 'Trebuchet MS', sans-serif;">human and economic development.</span></i></b><span style="font-family: 'Trebuchet MS', sans-serif;"> </span><span style="font-family: 'Trebuchet MS', sans-serif;"> Malnutrition </span><span style="font-family: 'Trebuchet MS', sans-serif;">frequently escapes full attention, </span><span style="font-family: 'Trebuchet MS', sans-serif;">and as a result is </span><span style="font-family: 'Trebuchet MS', sans-serif;">referred to as
“the silent disaster.” </span><span style="font-family: 'Trebuchet MS', sans-serif;"> It </span><span style="font-family: 'Trebuchet MS', sans-serif;">rarely attracts
the attention </span><span style="font-family: 'Trebuchet MS', sans-serif;">of policy and
decision makers and never was on their agenda.
T</span><span style="font-family: 'Trebuchet MS', sans-serif;">he most aff</span><span style="font-family: 'Trebuchet MS', sans-serif;">ected people are the poor, who</span><span style="font-family: 'Trebuchet MS', sans-serif;"> lack </span><span style="font-family: 'Trebuchet MS', sans-serif;">a political voice
preventing</span><span style="font-family: 'Trebuchet MS', sans-serif;"> them from
adequately demanding interventions to combat malnutrition</span><span style="font-family: 'Trebuchet MS', sans-serif;">, even if they realize that the problem exists</span><span style="font-family: 'Trebuchet MS', sans-serif;">. </span><span style="font-family: 'Trebuchet MS', sans-serif;"> </span><span style="font-family: 'Trebuchet MS', sans-serif;">Malnutrition is a barrier for development</span><span style="font-family: 'Trebuchet MS', sans-serif;">, and </span><span style="font-family: 'Trebuchet MS', sans-serif;">a determinant for
economic development and poverty reduction, health status, and educational
attainment, and its reduction is central to achieving these broader development
goals.</span><span style="font-family: 'Trebuchet MS', sans-serif;"><o:p></o:p></span></div>
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<b><i><span style="font-family: 'Trebuchet MS', sans-serif;">The Window of Opportunity must be sized to avoid irreversible
damage.</span></i></b><span style="font-family: 'Trebuchet MS', sans-serif;"> Children who are
undernourished between conception and age two are at high risk for impaired irreversible
cognitive development and stunting, which adversely affects the country’s
productivity and growth. Interventions outside this window of opportunity would
only provide relief measures but will not be able to reverse the damage that
happened.</span><span style="font-family: 'Trebuchet MS', sans-serif;"><o:p></o:p></span></div>
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<b><i><span style="font-family: 'Trebuchet MS', sans-serif;">The Cost of malnutrition is high for Egypt.</span></i></b><span style="font-family: 'Trebuchet MS', sans-serif;"> Over one-third of child deaths are due to
undernutrition, mostly from increased severity of disease. The economic costs
of undernutrition and overweight include direct costs such as the increased
burden on the health care system, and indirect costs of lost productivity.
Childhood anemia alone is associated with a 2.5% drop in adult wages. The
current economic crisis and its potential impact on the poor make investing in
child nutrition more urgent than ever to protect and strengthen human capital
in the most vulnerable groups in Egypt. <o:p></o:p></span></div>
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<b><i><span style="font-family: 'Trebuchet MS', sans-serif;">What is Stunting?</span></i></b><span style="font-family: 'Trebuchet MS', sans-serif;"> Stunting implies
long-term undernutrition and poor health among young children, measured as
height-for-age. It is a striking form of social injustice. It means that
stunted children were not allowed to attain their potential height and will be
shorter than their peers. Their IQ could
probably be lower than their peers and will be less able to learn and
accordingly will be less able to compete for jobs. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Three in ten
Egyptian children under the age of five are stunted. Of these three, at least one
is severely stunted. Lower Egypt Governorates have the highest rates of
stunting, where one third of children U5 living in rural areas are stunted, and
four in ten children U5 in urban areas are stunted. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Surprisingly, neither
the mother’s education nor the wealth quintiles, the usual suspects of bad
indicators, affected the prevalence of stunting amongst children U5. The
question remains: “<b><i>why almost one third of Egypt’s children are stunted and
on the increase, when all other health indicators are improving?</i></b>” Maybe because it is not a health problem. Unicef
concludes that socioeconomic factors do not seem to have effect on the chronic
malnutrition levels observed amongst Egyptian children and may suggest that
there are a number of complex factors interfering with the proper nutrition of
children. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">This means that
more food or cash is probably not the solution, and it might be behavior
related. An intervention is needed that
combines (i) behavior change including promotion of breastfeeding, appropriate
complementary feeding practices (but excluding provision of food), and proper
hygiene, specifically handwashing; and (ii) complementary and therapeutic
feeding for the prevention and treatment of moderate malnutrition among
children 6–23 months of age, and management of severe acute malnutrition among
children under five years of age. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">The key demand
side package of service for such a problem is the promotion of optimal <u>Infant
and Young Child Feeding (IYCF) practices and adequate nutrition during
pregnancy</u>. It proved to be of a high
potential to reduce malnutrition at relatively low cost and most effective if
applied during the first 1000 days of life, from conception to 24 months as the
effects of malnutrition are still reversible. However, these programs are difficult
to implement without an adequate incentive for behavior change and usually
better implemented by NGOs at community level.
<o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Beneficiaries
would use existing health services provided by the MOHP for supply side
services for treatment of moderate and severe malnutrition, for which the
poorest districts with good functioning primary health care services would be
selected. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Egypt, starting with Lower Egypt, will
need an intervention that address both the demand and supply side of the
problem at the same time with strong referral system between them through
public private partnerships established between those implementing demand side
services and those implementing supply side services. </span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again...</span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com2tag:blogger.com,1999:blog-3777420595919857487.post-46668904708930877732012-01-25T12:32:00.001+02:002012-01-26T08:56:59.323+02:00Improving Health Outcomes of the Poor – A Social Justice Agenda for Egypt<br />
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<span class="Apple-style-span" style="font-family: Calibri, sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;">Health outcomes are usually
measured in terms of the ability of health systems to introduce improvements in
three areas: </span><span style="font-family: 'Trebuchet MS', sans-serif;">(i)
health status; (ii) financial protection; and (iii) client satisfaction and
dignity.</span><span style="font-family: 'Trebuchet MS', sans-serif;"> The challenges related to these health
outcomes reflect an attention and priority to be provided to the poor and those
potentially who could fall in poverty, an opportunity for
adoption of a social justice agenda.</span></span><span class="Apple-style-span">
</span></div>
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<br /></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">These challenges, which mainly
indicate unfairness to the least advantaged group of the society, could
be shortly summarized as follows:<o:p></o:p></span></div>
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<br /></div>
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<i><span style="font-family: 'Trebuchet MS', sans-serif;">In terms of h</span></i><i><span style="font-family: 'Trebuchet MS', sans-serif;">ealth status</span></i><i><span style="font-family: 'Trebuchet MS', sans-serif;">, </span></i><span style="font-family: 'Trebuchet MS', sans-serif;">inequity that </span><span style="font-family: 'Trebuchet MS', sans-serif;">could be observed </span><span style="font-family: 'Trebuchet MS', sans-serif;">in disparities in achieving
MDG 4 (child mortality) and MDG 5</span><span style="font-family: 'Trebuchet MS', sans-serif;"> </span><span style="font-family: 'Trebuchet MS', sans-serif;">(maternal health) across geograph</span><span style="font-family: 'Trebuchet MS', sans-serif;">ic regions and income
quintiles. Inequity is demonstrated by the</span><span style="font-family: 'Trebuchet MS', sans-serif;"> persistent </span><span style="font-family: 'Trebuchet MS', sans-serif;">prevalence of </span><span style="font-family: 'Trebuchet MS', sans-serif;">high level of stunting, </span><span style="font-family: 'Trebuchet MS', sans-serif;">strongly linked to poverty</span><span style="font-family: 'Trebuchet MS', sans-serif;">. </span><span style="font-family: 'Trebuchet MS', sans-serif;">With t</span><span style="font-family: 'Trebuchet MS', sans-serif;">he expected increase of
non-communicable diseases and the high prevalence of hepatitis C</span><span style="font-family: 'Trebuchet MS', sans-serif;">, the burden of disease is
expected to increase on Egyptians, especially the poor and probably would drive
more people into poverty</span><span style="font-family: 'Trebuchet MS', sans-serif;">.<o:p></o:p></span></div>
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<br /></div>
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<i><span style="font-family: 'Trebuchet MS', sans-serif;">In terms of f</span></i><i><span style="font-family: 'Trebuchet MS', sans-serif;">inancial protection</span></i><i><span style="font-family: 'Trebuchet MS', sans-serif;">, </span></i><span style="font-family: 'Trebuchet MS', sans-serif;">the i</span><span style="font-family: 'Trebuchet MS', sans-serif;">nability to protect the
Egyptians from the impoverishing effects of health expenditures especially
against catastrophic illness is significant. This is presented by coverage of about half of
the population with Social Health Insurance (SHI), inequity to access to Program
for the Treatment on Expense of State (PTES), and that three fourths of total
health expenditure is out of pocket.<o:p></o:p></span></div>
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<br /></div>
<div class="Body1" style="font-family: Calibri, sans-serif; margin-left: 36pt; text-align: justify;">
<i><span style="font-family: 'Trebuchet MS', sans-serif;">In terms of client
Satisfaction and system responsiveness</span></i><span style="font-family: 'Trebuchet MS', sans-serif;">, a nationwide dissatisfaction with the health
care system presented by the high utilization rates and number of visits at
private sector providers and the very low utilization rates at public health
facilities. Further, utilization rates of the poor are the lowest among
different income quintiles for all types of health services, although the poor
are more likely to utilize public health facilities than the better off groups
emphasizing the phenomenon of inequity. <o:p></o:p></span></div>
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<br /></div>
<div class="Body1" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">There are other c</span><span style="font-family: 'Trebuchet MS', sans-serif;">ross cutting developmental
challenges that would affect the outcomes of the health sector</span><span style="font-family: 'Trebuchet MS', sans-serif;"> that are important to
consider such as</span><span style="font-family: 'Trebuchet MS', sans-serif;">
stagnated fertility rates, high level of illiteracy, poor outcomes of the
education system, high unemployment rates especially among the youth and in
particularly among women, low rates and inequitable sanitation coverage, the
rise and potential endemicity of avian flu, lack of proper social safety net to
the poor, strong social and cultural factors expected to increase that would
affect women empowerment. These would emphasize that parallel attention should
be provided equally to the least advantaged in other sectors.<o:p></o:p></span></div>
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<br /></div>
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<div style="font-family: Calibri, sans-serif;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Positioning
social justice at the center of the health sector agenda, taking in
consideration the slogans that were raised by the January 25<sup>th</sup>
revolution and its context, would present a non-controversial theme to set
related goals for the next five-year strategy as part of Egypt’s transition in
the health sector. This theme would be
presented as <b><i>Improving Health Outcomes of the Poor, </i></b></span><span style="font-family: 'Trebuchet MS', sans-serif;">as the least advantaged group of people in the society. </span></div>
<div style="font-family: Calibri, sans-serif;">
<br /></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A social justice agenda would naturally focus on the poor based on principles of distributive justice, a key principle would be <b><i>the Difference Principle</i></b>. This principle stipulates that social and economic
inequalities would be allowed in a community as long as they work to satisfy
two conditions: <i>(a) a fair equality of opportunity for all to compete for positions
and offices; and (b) they are to be to the greatest benefit of the least
advantaged members of society.</i> Its main
moral motivation is to provide equal respect for persons whatever their social
or natural status. In order for that to
happen, the least advantaged members of the society will be prioritized by
redistributing resources to benefit them from the better off to raise their
health status to a level equal to those in higher quintiles of income of the
population, and that as a result this would allow them to have equal
opportunity to compete for jobs and earn income. As well as it presents a favorable
redistribution to those most affected group of the population in terms of poor
health outcomes.</span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Improving
the health outcomes of the poor would significantly contribute to improve Egypt's
health goals and indicators in total, as the concentration of poor performance of the health system resides in poor areas. </span><br />
<div style="font-family: Calibri, sans-serif;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div style="font-family: Calibri, sans-serif;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Setting goals under this theme would then focus on three elements
that could be quantified: <o:p></o:p></span></div>
</div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoListParagraphCxSpFirst" style="font-family: Calibri, sans-serif; margin-left: 54pt; text-align: justify; text-indent: -36pt;">
<span style="font-family: 'Trebuchet MS', sans-serif;">(i)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span style="font-family: 'Trebuchet MS', sans-serif;">improving the health status of the poor in
specific regions (Regions such as Upper Egypt, Lower Egypt, Frontier governorates; or governorates such as Sohag, Assiut, Sharkia; or districts such as urban slums)<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="font-family: Calibri, sans-serif; margin-left: 54pt; text-align: justify; text-indent: -36pt;">
<span style="font-family: 'Trebuchet MS', sans-serif;">(ii)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span style="font-family: 'Trebuchet MS', sans-serif;">protecting the population and especially the poor from the impoverishing effects of
health expenditure and the near poor from getting poor<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="font-family: Calibri, sans-serif; margin-left: 54pt; text-align: justify; text-indent: -36pt;">
<span style="font-family: 'Trebuchet MS', sans-serif;">(iii)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span style="font-family: 'Trebuchet MS', sans-serif;">seeking
the poor’s satisfaction of service provision and treating them in a manner that preserves their dignity<o:p></o:p></span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">If
we pursue that route, we should be looking for improvements to be achieved at
the health systems level to achieve the theme of improving health outcomes of
the poor that would represent a possible continuation to the earlier efforts of
reform of the health sector that started in 1996/1997 and hopefully coincides with
it but with a more sharpened focus on the poor. This will be the subject of future posts<o:p></o:p></span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again....</span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<br /></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br /></b></span></div>
<div class="MsoNormal" style="font-family: Calibri, sans-serif; text-align: justify;">
<br /></div>
<br />Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-92139927251497880822011-12-25T15:13:00.003+02:002011-12-25T15:46:32.149+02:00Egypt’s Transition in the Health Sector: The Need for a Transition Plan for Universal Coverage<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; font-size: medium;"><span class="Apple-style-span" style="line-height: 18px;"></span></span><br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"></span></span><br />
<div class="MsoNormal" style="font-size: large; font-weight: bold; text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span class="apple-style-span"><b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; font-family: 'Trebuchet MS', sans-serif; font-size: 13.5pt; line-height: 115%;">Egypt's Transition towards a Third Wave of
Health Sector Reform (3)</span></b></span><span style="font-family: 'Trebuchet MS', sans-serif;"><o:p></o:p></span></span></div>
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">
</span><br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;">Egypt’s
Transition is currently understood and related to the role of a transitional
government until an elected government is in place. A Minister of Health’s role in a transitional
government is difficult to define and if defined challenging to achieve. This role was proposed in an earlier <a href="http://reflectionsonegyptshealth.blogspot.com/2011/11/egypts-transition-in-health-sector.html?utm_source=BP_recent">post</a>
to focus on restoring people’s confidence in the health sector, raising health
staff moral, and paving the way for a third wave of health sector reform. In all cases and after two waves of pilot
health sector reforms as explained in an earlier <a href="http://reflectionsonegyptshealth.blogspot.com/2011/11/egypts-transition-to-third-wave-of.html?utm_source=BP_recent">post</a>
, an elected government would be expected to lead a third wave of reform based
on a health care system suitable for Egypt that would replace the existing
pluralistic and fragmented health care system.
</span></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;">That system that was not able to achieve two of its health outcomes: (i)
financial protection; and (ii) client satisfaction considering that Egypt is
progressing fairly well on achieving many of the Health Millennium Development
Goals. </span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<br />
<span class="Apple-style-span" style="color: #444444; font-family: 'Trebuchet MS', sans-serif;">A
longer transition to achieve universal coverage that depends on a major health
care sector system that leads (more likely dominates) the financing and
delivery of health care services in Egypt will be required. The decision of that kind of health care
system is expected to be one of two options as explained in an earlier <a href="http://reflectionsonegyptshealth.blogspot.com/2011/11/is-social-health-insurance-right-health.html?utm_source=BP_recent">post</a></span><span class="Apple-style-span" style="color: #444444; font-family: 'Trebuchet MS', sans-serif;">: </span><br />
<span class="Apple-style-span" style="color: #444444; font-family: 'Trebuchet MS', sans-serif; font-size: x-small;"><br /></span><br />
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;"><b>The
first option is a social health insurance led system that is more reliant on
tax revenues and is capturing some of the tax-based finance system functions.</b></span><span style="font-family: 'Trebuchet MS', sans-serif;"> In that case, SHI will be based on financing
from contributions from those who can afford to contribute based on their
ability to pay subsidized by government contributions to cover the premiums and
co-payments for those who cannot afford to pay either totally or
partially. In that case, government’s
contributions should be expected to come from the country’s general revenues
and to be tax-based, preferably not based on ear-marked taxes. This would represent a natural continuation
of the second wave of reform and its pilot in Suez. </span></span></div>
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">
</span><br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Universal
coverage would likely be achieved in stages as explained in a related <a href="http://reflectionsonegyptshealth.blogspot.com/2011/10/expanding-universal-population-coverage.html?utm_source=BP_recent">post</a>.
However, The speed of this coverage would
depend on Egypt’s ability to face a number of challenges, as discussed in a
previous <a href="http://reflectionsonegyptshealth.blogspot.com/2011/11/factors-facilitating-egypts-transition.html?utm_source=BP_recent">post</a>,
in terms of: (i) its ability to recover from the aftershocks of the revolution
and resume its pre-revolution high growth rate, as well increase its level of
GNI; (ii) its ability to formalize its economy with protected jobs; (iii) its
ability to become more urbanized; (iv) its ability of building its health
insurance administration system; (v) its level of poverty and society’s
willingness to cross-subsidize the poor; (vi) its ownership of an efficient and
functional provider network; and (vii) its ability to regulate. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">There
will be additional specific key factors related to Egypt and its historical
path to achieve universal coverage such as its payroll salary scale. Current employer and employees contributions
are based on basic salaries. Once
contributions are calculated on the basis of total salary (basic + variable),
not only will the employee will pay much higher contributions, but also the
employer will also need to carry the burden of higher expenditures. In many cases, the employer will be the
government which will mean additional burden on its already very tight budget,
and in some cases it will be the public and private sector which will create
burden on its products cost structure and will increase its prices, probably pushing
inflation higher and driving more of the small enterprises into informality to
evade its insurance contribution. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><b>The
second option is a national health led system which is tax-based with a
directly managed provider network shifting to a purchaser-provider-contracting
model</b></span><span style="font-family: 'Trebuchet MS', sans-serif;"><b>.</b> In that
case, NHS will be based on financing from general revenues. This system is more likely to declare
universal coverage at a national scale in an earlier phase than a health care
system based on SHI but probably will not be able to do that in reality. The reality will be the same as an SHI based
system, actual universal coverage will also happen in stages. The key major challenge is that the NHS would
require much more funding from the government to replace the contributions from
employers and employees that would ease the funding. This would mean that the government will need
to allocate more budgets from the general revenues. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">On
the positive side, an NHS might spend less based on some claims, produce better
health outcomes due to its better ability to integrate with public health
programs, would require less complicated structures to run the system, and
would less impact the labor markets than SHI.
It is also a system that MOH would prefer to pursue given its proximity
to its thinking and given the familiarity of its staff with its service delivery
mechanism. People might be more
comfortable with this system as it doesn’t require them to contribute, unless
user fees and co-payments are applied.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;">The
purchase-provider-contracting model, within an NHS, might be a solution to
resolve many of the inherent problems of an NHS in terms of system performance
and client satisfaction, if it is complemented with strong regulation and
quality standards. Payment for Performance
mechanisms would then represent a key feature of paying public health providers
in the form of performance based financing.
As well, contracting not for profit non-governmental organizations that
have access to the general population for secondary health care would be
another key feature in the form of performance based contracting. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><b><u>In
both cases</u></b>, described above, a transition plan will need to be in place before
embarking on its implementation and before that an explicit decision will need to be made by the
elected government and the people’s assembly about the health care system to be
adopted. </span><span style="font-family: 'Trebuchet MS', sans-serif;">A transitional government would be expected not to adopt one of the above mentioned systems before
allowing a broad discussion among health sector stakeholders and the people about
their system of preference as they will have to live with its consequences and
will be obliged to commit funds for its financing probably by sacrificing other
developmental priorities.<b style="font-size: large;"> <o:p></o:p></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><b style="font-size: large;"><br /></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
Until we meet again....</div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b style="font-size: large;"><br /></b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b style="font-size: large;"><br /></b></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;"><b style="font-size: large;"><br /></b></span></div>
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</div>
</span></div>
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</div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-4328038727497369262011-11-28T19:11:00.001+02:002012-02-07T10:03:14.345+02:00Egypt’s Transition in the Health Sector: Opportunity for Raising Staff Moral & Restoring People's Confidence<br />
<div class="MsoNormal" style="line-height: 13.5pt; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 15.0pt; mso-outline-level: 3;">
<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; font-size: 13.5pt;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Egypt's
Transition towards a Third Wave of Health Sector Reform (2)<o:p></o:p></span></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Egypt’s health sector has entered into a
transition since its Cabinet has resigned in January 2011. The spirit of the
revolution empowered health sector staff and a number of activists to raise a
number of issues on their priority list.
A number of facebook groups interested in the health sector were formed
allowing extensive exchange of views and in some cases lobbying for their
views. Monitoring feedback from these
groups, the key issues raised were related to: (i) health workforce management
and compensation; (ii) organization, governance and leadership of the health
sector; (iii) health sector finance; (iv) responsiveness of the health system;
and (v) quality of service delivery. A
common theme presented dissatisfaction with the performance of the health
sector and an explicit sense of low morale.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">On the positive side, these groups
proposed solutions for the problems raised by them. One specific group, the <a href="http://www.facebook.com/groups/eghreform/">Egypt Health Sector Reform Group</a>, on its page proposed a list of priority actions
to be tackled during Egypt’s transition.
Some of these are of short-term nature potentially capable of producing
quick wins, as well could pave the way for a third wave of health sector reform
once an elected government is in place.
<o:p></o:p></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The purpose of this blog is to present an
excerpt of this brainstorming, as I understood it. Following
a health systems framework, <b>TWO</b> proposed priority actions were selected under each element of this framework possibly feasible to be accomplished
during the transition. </span></span><span class="Apple-style-span" style="background-color: white; font-family: 'Trebuchet MS', sans-serif;">It’s a message to those who are or will be
in a decision making position in the health sector from those who are interested in the future of that sector.</span></div>
<div class="MsoNormal">
<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></b></div>
<div class="MsoNormal">
<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Objectives<o:p></o:p></span></span></b></div>
<div class="MsoNormal">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Two key objectives to be achieved during the transition could
be defined:<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
</div>
<ol>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Raising the morale of health sector staff
and restoring people’s confidence in the management of the health sector
and its services provision</span></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Preparing for the period after the
transition</span></span></li>
</ol>
<br />
<div class="MsoNormal">
<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Activities<o:p></o:p></span></span></b></div>
<div class="MsoNormal">
<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></b></div>
<div class="MsoNormal">
<u><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Objective 1: Raising Staff Moral and Restoring People’s Confidence in the Health Sector<o:p></o:p></span></span></u></div>
<div class="MsoNormal">
<u><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></u></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">1.<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Increase responsiveness of the health
service delivery system in terms of improved coverage, utilization, and quality
of health services and accordingly client satisfaction and people’s confidence
in the health sector</span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level1 lfo5; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Through introducing improvements in the
public health system by addressing priority gaps in service delivery and
treating patients with respect.<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level1 lfo5; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Through expanding health service delivery
by partnering with the civil society and contracting NGOs for a minimum quality
of service delivery agreed upon for a defined package of services <o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level1 lfo5; text-indent: -18.0pt;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">2.<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Motivation of health workforce and raising
staff morale<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l5 level1 lfo3; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Introduction of payment for performance
for the health workforce to improve staff compensation for better performance,
quality, and system responsiveness taking in consideration different incentives
for different geographic locations.<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l5 level1 lfo3; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Training of middle management for preparation
of calibers needed for management and potential for staffing for senior
management.<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l5 level1 lfo3; text-indent: -18.0pt;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">3.<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Making available funds by reallocation
from other sources <o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l2 level1 lfo6; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">From the newly allocated budget for the
Program for Treatment on the Expense of State; and from investment budget lines
for payment for services for CSOs (as mentioned above), payment for performance
for public health sector staff, and procurement of drugs, supplies,
maintenance, and training.<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l2 level1 lfo6; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Postponing the social health insurance law
until an elected people’s assembly is in place to decide about the health
system appropriate for Egypt<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l2 level1 lfo6; text-indent: -18.0pt;">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l4 level1 lfo4; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="color: black;">4.<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Improving Governance<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level1 lfo2; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Establishing of an independent Quality
Organization to accredit public and NGO providers for a defined package of
services</span></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level1 lfo2; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span><span dir="LTR"></span><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">The separation between the payor and
provision functions within the organizational structure of the Health Insurance
Organization.</span></span></div>
<div class="MsoNormal">
<span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span></span></div>
<div class="MsoNormal" style="text-decoration: underline;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><u><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><br /></span></u></span></div>
<div class="MsoNormal" style="text-decoration: underline;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><u><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Objective 2: Preparing the Health Sector for the period after
transition<o:p></o:p></span></u></span></div>
<div class="MsoNormal" style="text-decoration: underline;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><u><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;"><br /></span></u></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
</span><br />
<div class="MsoListParagraphCxSpFirst" style="margin-left: 54pt; text-indent: -18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="textexposedshow"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span></span><span dir="LTR"></span><span class="textexposedshow"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Broad participation by key health stakeholders in discussions
on Egypt’s health sector problems and its possible solutions including reaching
a consensus on the health system that
Egypt should adopt (National Health System or Social Health Insurance) based on
the society’s values and expectations.<o:p></o:p></span></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
</span><br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54pt; text-indent: -18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="textexposedshow"><span style="color: black;">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span></span><span dir="LTR"></span><span class="textexposedshow"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Joint Expert/Politician Reviews to the health sector to prepare
a paper on Egypt’s vision for the health sector<o:p></o:p></span></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
</span><br />
<div class="MsoListParagraphCxSpLast" style="margin-left: 54pt; text-indent: -18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="textexposedshow">·<span style="font: normal normal normal 7pt/normal 'Times New Roman';">
</span></span><span dir="LTR"></span><span class="textexposedshow"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: black;">Based on the health sector vision, an Expert team to prepare
a Health Sector Strategy. </span><u><o:p></o:p></u></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
<span class="Apple-style-span" style="font-size: 15px; line-height: 17px;"><u><br /></u></span></span><br />
<div class="MsoNormal">
<u><br /></u></div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-17676633646076163332011-11-25T10:38:00.001+02:002012-11-24T18:32:32.315+02:00Egypt's Transition towards a Third Wave of Health Sector Reform<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Following the January
25<sup>th</sup> 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. </span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">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.<o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><b><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><b><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Pre-reform
Phase (Before 1997)<o:p></o:p></span></span></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">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. <o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="apple-style-span"><b><span style="background-color: white;">The First Wave
of Health Reform (1997-2005).</span></b></span><span class="apple-style-span"><span style="background-color: white;"> <o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Irrespective
of its original design, this wave adopted a<b> national health system </b>(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. <o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><b><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The Second
Wave of Reform (2006-2010)<o:p></o:p></span></span></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">This phase adopted
a <b>social health insurance system </b>(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.<o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></span></div>
<div class="MsoNormal">
<span class="apple-converted-space"><b><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The Transition<o:p></o:p></span></span></b></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="apple-style-span"><span style="background-color: white;">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.</span></span><span class="apple-converted-space"><span style="background-color: white;"> Two
sets of questions will need to be posed:</span></span><span style="background-color: white;"><o:p></o:p></span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="apple-converted-space"><span style="background-color: white;"><br /></span></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="textexposedshow"><b><u>Are
the people willing to ac</u></b></span><span class="textexposedshow"><b><u><span style="background-color: white;">commodate the
idea that reform will take longer than what they would expect, a</span>nd are </u></b></span><span class="textexposedshow"><b><u><span style="background-color: white;">they willing to work in stages or phases with realistic
objectives instead of full blown reforms? <o:p></o:p></span></u></b></span></span></div>
<div class="MsoNormal">
<span class="textexposedshow"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="background-color: white;"><br /></span></span></span></div>
<div class="MsoNormal">
<span class="textexposedshow"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="background-color: white;">If so,</span><o:p></o:p></span></span></div>
<div class="MsoNormal">
<span class="textexposedshow"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="background-color: white;"><br /></span></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="textexposedshow"><b><u><span style="background-color: white;">What would be the priorities for the
transition period and its minimum objectives, and how to measure its success?</span></u></b></span><span class="apple-converted-space"><b><u><span style="background-color: white;"> </span><o:p></o:p></u></b></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span class="textexposedshow"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span class="textexposedshow"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Two areas of
priority could be identified to be demanded by the people and health sector
staff during transition. These are: <o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span class="textexposedshow"><span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 54pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">(1)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span><span dir="LTR"></span><span style="background-color: white;">Governance and Anticorruption<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 54pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">(2)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span><span dir="LTR"></span><span style="background-color: white;">Health Workforce. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">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. </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again....</span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="margin-left: 18pt;">
<span style="background-color: white;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-32020328754687092072011-11-20T14:15:00.001+02:002011-11-20T16:20:04.884+02:00Is Social Health Insurance the Right Health Financing System for Egypt?<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; font-family: 'Trebuchet MS', sans-serif; font-size: 10pt; line-height: 115%;">Egypt's Road towards Social Health Insurance -
The Road to be Traveled (7)</span></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<i><br /></i></div>
<div class="MsoNormal" style="text-align: justify;">
<i><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">At a time when Egypt is doing relatively
well in reducing its child and maternal mortality, while facing extreme pressure
on its budget to meet various demands by the public, in presence of notable inefficiencies in the health system presented
mainly by fragmentation in the financing and the delivery of health services, and
at a time when a draft social health insurance is presented for public
discussion in a post-revolutionary situation that might allow to revisit health
strategies designed in an earlier phase of reform, a question might be posed before a final decision is made. Should
Egypt stick to Social Health Insurance (SHI) as its main health financing
strategy or could a better alternative scheme be available for Egypt to adopt. Is
it too late to ask that question? <o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-align: justify;">
<i><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></i></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Governments usually aim to achieve
universal coverage for health care for their people and people usually demands a
health care system that meet their needs in terms of improved health, financial
protection, and a system that is responsive and treat them with dignity. To achieve that in Egypt, continues efforts
have been put to reform the health care system increasingly since 1997;
however, with modest efforts to include the public in that reform. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Looking back, it is intriguing to
note that during the last 60 years almost every attempt to reform the health
sector in Egypt aiming to achieve this universal coverage promoting one health
system or another as a means to achieve this end, ends up with an application
of mixed and fragmented systems that were not able to meet the expectations
demanded by the people. I’ve always encountered
this statement recurring in many international and national reports describing
the health system in Egypt as “a pluralistic health system, consisting of a number of parallel public
and private health care delivery systems and multiple financing
intermediaries”. The attempts to reform
were not able to address this plurality and usually lead to more fragmentation
of the system either at the delivery and/ or at the financing side ending up in
a health system with multiple personalities. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The origin of this fragmentation
has started a few decades ago, probably in the 50s and 60s, when two sets of parallel
legalizations established the foundation for treatment on the expense of state
(Presidential Decree 1754 in 1959 followed by Presidential Decree 1069 in 1964)
and social health insurance (Law 75 in 1963 and Presidential Decree 1209 in 1964),
probably trying to satisfy the demand of the people for better health care as
well as a translation to Egypt’s constitutions placing the responsibility of
provision of health care (Constitution 1956) and social insurance (Constitution
1964) including health to all Egyptians on the state. These were followed by multiple additional
decisions that further fragmented the delivery side that led to the
proliferation of a number of governmental and public services delivery systems
in addition to those of the Ministry of Health. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">And the question is “why is this
happening?” Which system would be better for Egypt? A system based on general
revenues and taxes or a system based on social health insurance?</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Those who are in favor of
tax-based systems argue for their system based on three points: (i) SHI
discourages firms from hiring workers, and hence reduces employment and encourages
informal labor markets; (ii) lack of coverage among certain groups during the
often long period between establishing SHI and achieving universal coverage,
and (iii) systematic variations in benefit packages and quality of care across
subpopulations. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">On the other hand, those who
promote SHI do that based on two points: (i) SHI provides an important
additional source of revenue for the health system; (ii) by separating the
purchasing of health care from its provision and encouraging selective
contracting between providers (including private sector ones), SHI systems are
able to achieve better quality health care at a lower cost than tax-financed
health systems. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Certain <a href="http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2009/01/21/000158349_20090121101737/Rendered/PDF/WPS4821.pdf">studies</a> focusing on
studying the impact of these health systems on health outcomes in OECD
countries suggested that SHI systems, on balance (i) have certain characteristics
that make them more expensive than tax-financed systems, (ii) do no better in terms of most health
outcomes that are amenable to medical care despite the extra spending, (iii) may
do worse in respect of outcomes that require strong population-level public
health programs, and (iv) do worse in terms of encouraging informal labor markets
and discouraging employment. The
findings of this study raise the following questions: </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
</div>
<ul>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><span dir="LTR"></span>Why do we apply a system
that could cost us more with no additional improvement in health outcomes at a
time when budgets are tight? Would this contribute to efficiency?</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><span dir="LTR"></span>Why do we apply a system
that could increase informality in the employment sector when already two
thirds of those working are informal workers without protection? Would this
contribute to financial and social protection?</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Are there dangers on our
achievements in public health? As SHI systems focus on individual members, or
even families, would we lose the focus on the entire population by public
health programs financed by tax-financed systems? Would this contribute to improved health
status and outcomes?</span></li>
</ul>
<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">All of the above would lead to
the following question, and another two subsidiary questions?</span></div>
<div class="MsoNormal" style="text-align: justify;">
<b><u><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></u></b></div>
<div class="MsoNormal" style="text-align: justify;">
<b><u><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Can we apply in Egypt a
system that can capture the better of the two systems and avoid their problems?
<o:p></o:p></span></u></b></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></b></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Question 1:</b> <b>Can we have a tax-based system with a
directly managed provider network shift to a purchaser-provider-contracting model?<o:p></o:p></b></span></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><br /></b></span></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Under this
scenario purchaser organizations contract with providers rather than manage
them directly. This can be done by
adopting the SHI purchaser-provider split model where purchaser organizations
contract with providers, including those which are not public providers. This could lead to lower expenditures and
better health outcomes. However, to what
extent this can be done without risking coherence and integration in its public
health programs? The Egypt experience in introducing the Family Health Funds,
governorate health insurance organizations that were established to do the
purchasing function, is an example of an attempt in that regard. The ownership
of these organizations between the Ministry of Health and the Health Insurance
Organization remained for a long time and it failed to elaborate a national
organization that would provide oversight for such decentralized bodies called
the National Family Health Fund. Further,
this was countered by the Ministry of Health by establishing provider
organizations at district level called the District Provider Organizations to
ensure the flow of funds through its organization, which were dismantled later
as the Egyptian health system geared more towards social health insurance..</span></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></b></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Or Question
2: Can SHI system increase its reliance on tax revenues and capture some of the
tax-based finance system functions?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></b></div>
<div class="MsoNormal" style="margin-left: 18.0pt; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">This seems to be feasible to be done and the latest versions of the new social
health insurance law provides different articles that attempt to increase its
tax base and revenues from sources other than that from payroll taxes, although earmarked taxes is being proposed. This is
the new experience that has been facing long debate before and after the
January 25<sup>th</sup> revolution, and seems to continue for a while. The
linkage of health insurance to family health services could be the basis for
protecting the screening functions of public health programs. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">At the end, a decision will need
to be made by those who will represent Egypt in the new People’s Assembly and
will then need to be implemented by the newly elected government in a few
months to come. This decision will need
to select the system, SHI systems or tax-financed systems, which on balance would
spend less, achieve better health, easier to go through the transition, and lead to better labor market
outcomes. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again...</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com1tag:blogger.com,1999:blog-3777420595919857487.post-48542058235754644362011-11-13T10:22:00.001+02:002011-11-13T15:26:21.005+02:00A Framework for Reading Egypt’s Social Health Insurance Law<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="apple-style-span"><b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; line-height: 115%;">Egypt's Road towards Social Health Insurance -
The Road to be Traveled (6)</span></b></span><i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; line-height: 115%;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="apple-style-span"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; line-height: 115%;"></span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 17px;"></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><i>This blog is based on the work of international experts in the field of
social health insurance that was adapted to Egypt's situation. <a href="http://reflectionsoneygptshealtharabic.blogspot.com/">Arabic</a>
versions of this blog will dig into more details of the framework but might not
follow the same sequence of this blog. Because of limitations of space, some
ideas presented in this blog will be discussed separately in future blogs.<b><o:p></o:p></b></i></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><i><br /></i></span></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">The recent news about the upcoming law for social health insurance in
Egypt and the messages transmitted about its potential modifications to ensure
its achievement of social justice raised the question about how to read such laws
and what should be included in it. To
help read this kind of social laws, once officially published for public
dialogue, the presence of a reference framework could assist in that regard. In
this blog, we will try to contribute some inputs that may assist in the preparation
of such a framework, which we do not claim it will be comprehensive. This blog
will not attempt to review or criticize the content of the currently circulated
versions of SHI law. As well, this blog
will not differentiate between what should be mentioned as articles of the law
itself or articles of its executive regulations due to their complementarily
nature.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><i><br /></i></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><b></b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">The logic of a social health insurance law would probably
include the following: </span></div>
<span class="Apple-style-span" style="color: #666666;"></span><br />
<ul><span class="Apple-style-span" style="color: #666666;">
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Definition of the <i>social health insurance system</i></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">How to make effective the <i>mandatory</i> and <i>universal</i> features of the system</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-weight: bold;"><span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span dir="LTR"></span>Principles that the govern the system</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Transition from the current
situation to an integrated and unified system</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Definition of terms</i></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Who are the <i>Beneficiaries</i></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>What to finance</i></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">How to <i>finance</i> the new system</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Definition and main
characteristics of the <i>institution</i>
that will manage the system, including governance, functions, powers, financial
management, and accountability</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Purchasing health care goods and services</i></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Consumer protection</i></span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Role of </span><i><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Voluntary health insurance</span></i></li>
</span></ul>
<span class="Apple-style-span" style="color: #666666; font-style: italic;"><b style="font-weight: bold;">The Definition. </b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-style: normal;">In defining the social health insurance
system three aspects are to be considered<b>:</b></span></span><br />
<div>
<div class="MsoListParagraphCxSpFirst" style="color: #666666; margin-left: 54pt; text-align: justify; text-indent: -18pt;">
</div>
<ol style="color: #666666;">
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-style: italic; font-weight: bold;"><span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span dir="LTR"></span>The nature of the social
health insurance system</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The objective of the social
health insurance system</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The institutional structure
to implement the social health insurance system.</span></li>
</ol>
<div class="MsoNormal" style="color: #666666; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Also three main characteristics
of the system would need to be taken into account:</span></div>
<div class="MsoNormal" style="color: #666666; text-align: justify;">
</div>
<ol>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Universal</i></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">, meaning that it includes all Egyptian citizens</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Mandatory</i></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">, that is, all Egyptian citizens must participate (there
is no opting out from paying into the system); </span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i><span style="line-height: 115%;">Gradual</span></i><span style="line-height: 115%;">,
full inclusion of all citizens (with few exemptions) into the system over a
defined period of time, OR <i>Abrupt</i></span></span></li>
</ol>
<div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; font-style: italic; line-height: 18px;"><b>The Principles. </b></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">These usually refer
to: solidarity; unit of subscription (family or individual); basis on need or
demand; scope of services (primary, secondary, tertiary); subscription basis
(mandatory?), financing not provision and separation of financing from
provision; role of private for profit and non-profit in service provision based
on contracting; role of state in financing the poor and near poor (partially or
fully); tax exemptions for subscriptions; role of private health insurance (duplicative,
complementary, supplementary)</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">
</span></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><b><span style="line-height: 18px;"><i>The Transition. </i></span></b></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">A a
transition plan from a presently fragmented institutional structure dominated
by the HIO to a single institutional structure in the future will be required. Details for this transition could take place and developed in regulatory decrees.
An article in the law might state the principles for transition. The transition would describe the way forward to
arrive over time at an “integrated” (meaning
putting in one place a social health insurance system. Four issues related to transition would need to be noted:</span></div>
</div>
<div>
<ol>
<li><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">The responsibility of management
of the system during transition</span></li>
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">
<li style="text-align: justify;">The management of
enrollment of all non-covered citizens;</li>
<li style="text-align: justify;">The management of those
already covered by the existing HIO system and their enrollment into the new
SHI if required, under a one “unified” system (in that case meaning the system
managed by a single organization); </li>
<li style="text-align: justify;">The relationship to other
existing parallel health care financing systems such as the Program for
Treatment on the Expense of State (PTES) and those funds flowing for public health
services provision for curative care in Egypt.</li>
</span></ol>
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;">
</span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; font-style: italic; font-weight: bold;"><b>The Institution. </b></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">Social health
insurance systems can only be implemented through an institutional
structure. A future entity might be
established, which could be (a) a re-structured HIO, or (b) a totally new
entity transformed into the unified entity for the management of the integrated
social health insurance system with its own legal autonomous status. The law
and/or its regulations will need to define the aspects that will be mandated
for the future organization such as governance, autonomy, structure, functions,
powers or attributes, contracting, and regional offices.</span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666;"><i style="font-weight: bold;"><br /></i></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><i style="font-weight: bold;"><b><span style="line-height: 18px;">What to Finance. </span></b></i></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;">The law will need to
refer to a unified set of social health insurance benefits, the health care
goods and services covered by social health insurance for health care. The set
of benefits usually is to be determined and updated by regulatory decrees to be
provided by participating providers and for secondary care on referral of the
gatekeeper. The law also should require
that the set of benefits is to be determined on an actuarial analysis to
project financial implications. Finally,
there is a need to entrust the decision-making on defining and updating the set
of benefits into the social health insurance entity to preclude political
influence that could disturb the goal of fiscal responsibility</span></span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;"><br /></span></span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><b><span style="line-height: 18px;"><i>How to Finance. </i></span></b></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 115%;">Financing would better be presented in the form of groups to be covered classifying
those into three sectors (formal; informal; and targeted subsidized). The
figures for financing, preferably and if the constitution allows, should not be
included in the law itself as they would be subject for future change; however, this might be </span><span class="Apple-style-span" style="line-height: 18px;">difficult</span><span class="Apple-style-span" style="line-height: 115%;"> in Egypt. To mitigate that articles will need to indicate that it will reviewed on periodic basis based on actuarial studies conducted by the Government. This applies to contributions and subsidies,
as well as for co-payment levels</span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;"><b><span style="line-height: 115%;"><span style="line-height: 115%;"><br /></span></span></b></span></span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><b><span style="line-height: 18px;"><span style="line-height: 18px;"><b><span style="line-height: 18px;"><i>Providers and Suppliers - Contracting. </i></span></b></span></span></b></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;">Articles should
stipulate that the social health insurance entity is a financial institution
that funds the provision of health care goods and services to public and
private providers. Selection of
providers and suppliers should be stated for those who meet the requirements for contracting with the
entity to ensure that providers and suppliers meet licensing and
certification requirements, among others, and for improving quality of care.</span></span></span></span></span></span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="font-weight: 800; line-height: 18px;"><br /></span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold; line-height: 18px;"><b><i>Consumer Protection.</i> </b></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;">Articles that protect the interest of consumers will need to be included that reflects a framework for a system of consumer
protection that could be part of the regulations. </span></span></span></span></span></span></span><br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span class="Apple-style-span" style="font-weight: 800;"><br /></span></span></span></span></span></span></span></span></div>
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;"><span style="line-height: 115%;">
</span></span></span></span></span></span></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; font-weight: bold; line-height: 18px;"><b><span style="line-height: 18px;"><b><span style="line-height: 18px;"><i>Voluntary Health Insurance. </i></span></b></span></b></span><span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">If the policy is to
have a private/public mix in health care financing and delivery, then articles
that allow individuals to purchase voluntary health insurance will need
to be included. These services could be duplicative,
supplemental or complementary, but only after certified satisfaction of payment
of social health insurance contributions</span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><br /></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">Until we meet again....</span><br />
<span class="Apple-style-span" style="color: #666666; font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span></div>
<div>
<span class="Apple-style-span" style="color: #666666;"><i style="font-weight: bold;"><br /></i></span></div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-74424983901077915742011-11-04T17:52:00.003+02:002011-11-30T06:30:35.351+02:00The factors facilitating Egypt’s transition to Universal Coverage<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="text-align: justify;">
<b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; font-family: 'Trebuchet MS', sans-serif; font-size: 10pt; line-height: 115%;">Egypt's Road towards Social Health Insurance -
The Road to be Traveled (5)</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">What
could be the factors that would speed Egypt’s transition to expand universal
coverage using social health insurance? We
will try to respond to this question based on the experiences of other
countries and opinions of international experts. In principle, the lower the country has in
terms of income per capita, the smaller the formal sector, the higher the prevalence
of poverty, and the higher the dependency ratio, the more it would be
challenging to initiate or scale up SHI.
<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Economic Development, </b>in terms of a country’s annual
general level of income (GNI) and growth rate. The greater the income per capita the more capacity enterprises and
citizens will have to prepay SHI contributions. The higher the wages and salaries, the more
opportunity to finance a broader benefit entitlements and the less there could
be an economic burden of payroll tax. Tax revenues are likely to increase with
income, facilitating the subsequent channeling of any
government subsidies into SHI. Steady economic growth, therefore, is likely to
enhance the capacity to prepay.
<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In 2010 before the January 25<sup>th</sup>
revolution, Egypt’s GNI was about USD 2,440 and its growth rate ranged between 5-7%
annually. As a result of the slow in economic activity post the revolution, growth
rate is predicted to go down to 2% or less for 2011. Egypt’s current GNI is
similar to the GNI of those countries adopting SHI at the time of its introduction
such as Germany (USD 2,237 in 1883), Austria (USD 2,420 in 1887), Belgium (USD
1,808 in 1851), and Japan (USD 2,140 in 1922). The same applies to growth rates. Economic growth was either high or at least
steady for each of these countries during the transition period. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b>Structure of the Economy</b>, in terms of the relative
sizes of the formal sector and informal economy. Many developing countries do
have sectors where a notable part of employment is informal, thus facing difficulties
in assessing incomes and collecting contributions from workers who do not
receive a formal salary. This hampers protecting those working in the informal economy
as SHI scheme relies on contributions. The larger the formal sector employment,
the ease it would be to administer mandated payroll tax on employers and
employees.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In Egypt, informality has been on the rise mainly due to two
reasons: (i) a reduction in employment by the public sector and replacing those
by employment using temporary contracts; and (ii) creation of most of the jobs in
the private sector that are informal. More than half of those working are in
the informal economy (53%) with an increased estimation of 20% of pre-revolution
level. Looking more in-depth, 58% of those working don’t contribute to any
social security scheme, 63% are working without contract, and 13% are working
without being paid. As the public sector is shrinking and being perceived as
the place providing “safer” jobs, and given the private sector’s inability to
produce formal sector jobs, the challenges for coverage by social health
insurance increase. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><span style="font-family: 'Trebuchet MS', sans-serif;">Urbanization</span></b><span style="font-family: 'Trebuchet MS', sans-serif;">, determined by the
distribution of the population intended to be covered. Population living in
urban areas, with minimum quality of infrastructure and communications, and
higher population density, is likely to be easier to cover than a widely
dispersed rural population. About 43% of Egypt is urbanized with governorates
ranging from high as 100% urbanized such as Cairo to a low as 22.5% such as
Sharkia. The more urbanized the
governorate the more insured people would be present.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><b><span style="font-family: 'Trebuchet MS', sans-serif;">Ability to administer,</span></b><span style="font-family: 'Trebuchet MS', sans-serif;"> in terms of availability of skilled
labor force with capacities in bookkeeping, banking, and information processing;
and related markets, such as in financial services, other insurance businesses that
can provide appropriately trained personnel, actuarial, and legal services. Presence of a sound administration
of social security system is in place would be a favorable factor.</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
Although HIO has been present for about half a century, yet most
of its experience is in service provision and has lost a number of experts who
understood insurance without being properly replaced. The HIO payer functions
will need efforts to be built and investment in this area would be a
pre-requisite if Egypt would continue to pursue health insurance as a financing
scheme for universal coverage. <o:p></o:p><br />
</span><br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<b><span style="font-family: 'Trebuchet MS', sans-serif;">Poverty Prevalence</span></b><span style="font-family: 'Trebuchet MS', sans-serif;">, in terms of size of
government’s contribution to subsidize their premiums and co-payments. The
higher prevalence of poor and near poor Egyptians, the more the government
would need to contribute and the higher the burden is on the government’s
budget. The society as a whole, and not only the government, would need to
define what appropriate level of solidarity it is ready to contribute to cross
subsidize the services of its poor people either fully or partially for the
near poor. The higher the level of solidarity,
the more SHI is able to provide protection to its most vulnerable segment of
its population. While policymakers could impose solidarity; however, without a
society that believes in solidarity, it will be difficult to sustain SHI. </span><span style="font-family: 'Trebuchet MS', sans-serif;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Two more important factors that need to considered. The first is the presence of efficient
functioning provider networks, in terms of (i) ability to provide an improved
access to members; (ii) ability to provide greater choice of providers to
members, and (ii) ability to provide an environment that allows for
quality-based competition among providers. The second is the government’s capacity to
regulate for quality and manage grievance procedures.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;">In summary, Egypt’s ability to
expand universal coverage through SHI will depend mainly on the following: (i)
its ability to recover from the aftershocks of the revolution and resume its
pre-revolution high growth rate, as well increase its level of GNI; (ii) its
ability to formalize its economy with protected jobs; (iii) its ability to
become more urbanized; (iv) its ability of building its health insurance
administration system; (v) its level of poverty and society’s willingness to
cross-subsidize the poor; (vi) its ownership of an efficient and functional
provider network; and (vii) its ability to regulate. </span><span style="color: black; font-family: 'Trebuchet MS', sans-serif;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again...</span></div>
<br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
</div>
</span></div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-80968498375275834532011-10-22T21:09:00.000+02:002011-10-22T21:42:44.602+02:00Expanding Universal Population Coverage through Social Health Insurance in Egypt<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="apple-style-span"><b><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial; color: #666666; font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">Egypt's Road towards Social Health Insurance -
The Road to be Traveled (4)</span></b></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><br /></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">Today, the focus will
be on the breadth of coverage of universal coverage; i.e. population coverage.
The other two elements of universal coverage are: (i) the depth of coverage; i.e. the
content of package of services provided; and (ii) the height of coverage; i.e.
financial protection.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><br /></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">Financing of universal
coverage could be achieved through a number of options, where essentially two
of them are usually used: (i) a general tax revenue system; and (ii) a social
health insurance scheme. Under general
tax revenue, health services will be provided by a network of public and in
some instance private providers may be contracted, often referred to as a
national health service or commonly known as NHS. A classical example is the National Health
System in the United Kingdom. </span><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">We will
focus on population coverage using social health insurance.</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;"><br /></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">S</span></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">ocial health insurance,
or commonly known as SHI, usually requires contributions and to succeed would
require compulsory enrollment of all population. However, this is not always the case
applied. The easiest groups to enroll,
and usually the first, are the workers (civil servants and employees) in the
government and public sector organizations, followed by employees in the
private sector organizations and enterprises.
Contributions are necessary to fund the system and these come from the
worker’s salary and the employer’s share of contribution. It gets more difficult when enrollment of
those self-employed starts as they need to pay both shares, being themselves
the worker and the employer. As they are
sometimes better off, they would resist to get enrolled and according them pay
more than others. It becomes more
complicated when enrollment of those working in the informal sector starts to
happen. These are difficult to know as
well as difficult to reach. Many of them do not earn enough, usually not on a
regular basis. If they have an employer, usually the first thing an employer would
do is evade payment of his/her contribution.
Lastly, there are the poor who cannot afford to pay any contributions at
all, and the government is expected to cover the cost of their contributions.
The government could also consider covering fully or partially the cost of
contributions of those workers in the formal sector. </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><br /></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">In Egypt, at this
stage in 2011, we have all these mixes. Part
of the population is covered though general tax revenue. They are either
accessing health care directly through the public health network, or indirectly
financed through the Program on the Expense of State. Workers in government, public and private
organizations, school children, pensioners, widows are covered through the SHI system.
Pre-school aged children are covered
through a voluntary system. The Health Insurance Organization owns its health
care network of providers and to some smaller extent contracts other public
health sector care organizations and the private sector. Accordingly, those who are not covered by SHI
(but theoretically covered by the system financed by general tax revenue) are
the self-employed, those working in the informal sector, and the poor. In
addition, an important group exists that don’t fall under the above mentioned
categories, the dependants of HIO workers.
This group resulted because expansion of coverage did not follow the
above mentioned trend and started to cover certain categories separately outside
their families (preschool and school children).
To complicate the situation, there is a particular group that the law
allowed to opt out of SHI, i.e., they are allowed to get covered either by
their own network of service providers or they purchase insurance coverage from
the private sector. These are the public
and private sector organizations and enterprises that pay a minimum percentage
about 1%. A main problem with that is that once the
employees retire they are dumped back on the public system that is financed
from general tax revenue, when they are sick and less able to pay and when the
cost of their care is most expensive. </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;"><br /></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">Looking forward, extending
SHI to new groups takes a long time usually decades and depends on the economic
development of the country, in addition to other factors. It usually happens on stages. A strategy for population coverage will need
to be developed and should be publicly discussed. Efforts for building a consensus need to be devoted
and decision need to be reached who should be covered first and in which
sequence. In the next few paragraphs, I would
like to describe one of many possible scenarios to do that. The priory setting for population coverage
and the scenario for sequencing to be adopted by the Egyptians will need to be
based on the country’s</span><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">
social, economic, fiscal, and political considerations at the time of
decision. <o:p></o:p></span>A scenario is proposed below:</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">
<span class="Apple-style-span" style="line-height: 18px;"></span></span><br />
<div class="MsoListParagraph" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">(1)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><span dir="LTR"></span><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">The
first group recommended to be targeted is the dependants of HIO workers. This could
be the easiest group to start with since the head of the household would
already be registered and contributing through the HIO contribution
system. It would practical to use the
existing social insurance system to extend HIO coverage to the dependents of its
workers. </span><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">They could contribute towards
their coverage at revised rates according to the size of the household and the
defined benefits package for the new beneficiaries.</span></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;"><br /></span></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">
</span></span><br />
<div class="MsoListParagraph" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">(2) The
second group is the poor, the unemployed, and other vulnerable groups. It is estimated that one out of every five
Egyptians is living in poverty in 2009. This group of beneficiaries should, in
principle, be eligible for exemption from premium contributions and
copayments. Their contributions will
need to be fully subsidized through the government budget. In
order to target the exemptions effectively to minimize both leakage (extending
benefits to the ineligible) and gaps (denying benefits to the eligible), the
system used by the Ministry of Social Solidarity to identify the poor should be
the basis for enrollment of the poor, even if there are questions about its
targeting ability. This would need to be closely linked with the reforms in the
social safety net and social assistance programs to ensure that the targeting
system is actually reaching the poor. The subsidization of the poor under the SHI
requires adequate and sustainable fiscal resources. A significant portion of
the resources required is already available in the form of the historical
supply-side subsidization of government health care providers. The challenge
lies in shifting from supply-side subsidization to subsidization of premium
payments for the poor. Another significant portion of the resources is available
in the other types of subsidy, the energy subsidy.</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">
</span></span><br />
<div class="MsoListParagraph" style="margin-left: 18.0pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;"><span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">(3) The third group and the most difficult to enroll is the currently do not
contribute to or participate in the social insurance system. Their health care
needs are covered through PTES for catastrophic illness, the public health care
system, or through direct purchase of private health services especially if
they are non-poor. To the extent that the recent tax reforms succeed in giving the
informal workforce legal status, a segment of these workers will be brought
into the formal social insurance system. Participation in the social insurance system
would require either enforcing a contribution system (means-tested) that estimates
their income or assets, or establishing a contribution system (risk-rated)
designed to encourage voluntary participation. Both systems involve
administrative costs and certain risks. These risks could be mitigated if the self
employed and informal sector workers could be organized into groups such as affinity
groups and associations that could form the basis for a collective contribution
mechanism. Finally, their willingness to contribute will depend on the
perceived value of the benefits offered through social insurance. If the
benefits are perceived to be inadequate and of poor quality, then the incentives
would be to avoid contributions.</span><o:p></o:p></span></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">
</span></span><br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">Because this scenario would significantly expand the number of HIO
beneficiaries, this step would also require concurrent capacity building and
reforms within the HIO to absorb these new beneficiaries. Within SHI, a number of health insurance
functions need to be operational. For
example registration, collection of contributions, contracting and reimbursement
of providers usually should be executed. Finally, we would like to emphasize that the
SHI requires enrollment to be compulsory, to the extent possible. Accordingly, for SHI to be more likely
financially sustainable, the government would need to ensure that the premiums
for preschool children are paid from government tax revenues and that those who
opted out should pay their full share of premiums (employers and workers).</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">In summary, coverage of the dependants
of HIO workers seem to be the most likely and feasible group to start with on
the short term. This is followed by
coverage of the poor, which would require much longer time based on the
available fiscal space; i.e. how much funds would be allocated for coverage of
the poor or how much funds could reallocated from other sources such as energy
subsidy or the PTES. The last groups,
which are usually the most difficult groups to enroll and cover are the
self-employed and those working in the informal sector. </span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">Until we meet again...</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><span style="font-size: 12pt;"><br /></span></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><span style="font-size: 12pt;"><br /></span></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><span style="font-size: 12pt;"><br /></span></span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">
</span></span></div>Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-52801008544547714302011-10-04T17:27:00.004+02:002012-11-24T18:09:24.398+02:00Analyzing Universal Coverage of Health Care in Egypt<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="text-align: justify;">
<b><span style="background-color: white; color: #666666; font-family: 'Trebuchet MS', sans-serif; font-size: 10pt; line-height: 115%;">Egypt's Road towards Social Health Insurance - The Road to be Traveled (3)</span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span><br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Coverage could be analyzed in terms of breadth, depth, and height, with breadth indicating coverage in terms of population; depth indicating coverage in terms of service provided; and height indicating coverage in terms of the extent of financial protection. A universal coverage system can be evaluated as effective when the above three dimensions are completely filled securing access to adequate healthcare for all at an affordable price. I will try to compile below from different sources some of their findings about universal coverage of health care in Egypt.</span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> </span><br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In terms of breadth of coverage, coverage in terms of population, Egyptians' coverage is provided through a combination of social health insurance and subsidized government health services. Currently, Social health insurance coverage, provided through the Health Insurance Organization (HIO), covers about 42.3 million person, representing 57 percent of the population (as per the information provided by HIO official website). The bulk of the population under HIO coverage (74 percent) is schoolchildren and infants, and the smallest bulk (6% percent) is widows and pensioners. The remaining 20% insured are from the active labor force. The Ministry of Health and Population (MoHP) and other government agencies function as an “insurer of last resort” providing free or substantially subsidized health services to the citizens not covered under HIO. Further, a Program of Treatment at the Expense of State (PTES) was established to extend financial assistance to all Egyptian citizens for expenses incurred for government spending on health care. Originally, it was designed to cover those not covered by HIO for catastrophic illness, however, its current coverage extended to those who can access it and its funding has been and still expanding. </span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> </span><br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Taking a closer look at coverage by social health insurance, we can conclude that its coverage is fragmented by beneficiaries. For historical reasons, Egypt’s social insurance system has developed into multiple programs with different coverage and benefits package for various segments of the population, resulting in a patchwork of coverage. In a typical Egyptian family, the father, a public or private sector employee, will be covered by HIO Law No.79/1975; his wife, a government employee, would be covered by Law No.32/1975 or not covered if she is a housewife; his son, a university student, will not be covered; his daughter, a school student, will be covered by HIO Law No. 99/1992; and his infant child would be covered by a decree 380/ 1997. About one-half of the population, mostly the unemployed, self-employed, and informal sector workers and out-of-school children, are not covered under the HIO system.</span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> </span><br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In terms of depth of coverage, coverage by services provided, population are receiving different package of services based on the health care system they are accessing. The uninsured population depends on free or subsidized government health services through a nationwide network of government health care providers based on the package provided ranging from primary to tertiary health care services. The main factors for determining access are services availability, quality, and level of funding. In the early years of 2000, MOHP introduced the concept of family medicine/family health services with the purpose of rationalizing of health services; reorganizing the delivery of primary health care services around families instead of individuals; establishing of family health services as the gatekeeper for the delivery of health care services, a clear referral system to be linked at a future point of time to health insurance; establishing quality standards for service delivery; and ensuring the availability of adequate funding for it through establishing family health funds.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The insured population receives an unlimited package of package of services as defined by law. The different laws in effect under the HIO result in different systems of benefits and copayments, which complicate the effective administration of the program. Members of the same household have different coverage depending on their status within the household.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The “uninsured” population has access to the PTES for hospitalization and related high-cost health services. However, the PTES is a passive reimbursement scheme not related to any contribution systems or to a well defined benefits package. In a limited number of governorates access to primary care services is financed through the Family Health Fund, but this remains a pilot program without a clear institutional base.</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
</span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;">In terms of height of coverage, the extent of financial protection, the best way to measure that is out-of-pocket expenditures. Out-of-pocket expenditures represents the share of household spending on health care either paid directly to private health providers or pharmacies, or paid indirectly in terms of additional cost paid to receive public health services. The more it increases the more the population is at risk and less covered by financial protection. </span><span style="line-height: 115%;">Despite the presence of different types of health coverage provided by the MoHP and the HIO, between 1996 and 2009 the share of direct household spending increased from 50 percent of total health spending to 72 percent. Based on an international report, the reasons for that were presented as follows: First, the level of benefits covered under the HIO or provided by MOHP and other government public health network could be perceived as limited in scope and requires beneficiaries to make additional payments to obtain services not covered. Second, the proportion of the labor force participating in HIO with ability to contribute regularly is low (only 20 percent). Third, the cost containment exercised by HIO could be shifting costs onto households. Fourth, the PTES requires a significant level of cost-sharing by patients; therefore, the expansion of PTES would be accompanied by a concomitant increase in household spending to cover the balance of payments. Fifth, the quality of subsidized government health services may be inadequate (shortage of drugs in health facilities, lack of responsiveness), forcing many households to seek private providers. Recent trends in budget allocation in government health services show that operating and maintenance costs have not kept pace with needs, possibly contributing to inadequate supply of drugs and other essential materials at government health care providers. This would leave many households heavily reliant on out-of-pocket spending and vulnerable to financial stress in the event of a catastrophic illness or injuries.</span></span></div>
<div style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;"><br />
</span></span></div>
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;">Until we meet again...</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br />
</span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="line-height: 18px;"><br />
</span></span></div>
Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com1tag:blogger.com,1999:blog-3777420595919857487.post-18330405028168743602011-09-25T16:41:00.000+02:002011-09-30T21:33:50.988+02:00Is a century required to universally cover Egyptians with Social Health Insurance (SHI)?<div dir="ltr" style="text-align: left;" trbidi="on">
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Egypt's Road towards Social Health Insurance - The Road to be Traveled (2)</span></b><br />
<br />
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">How much time to be
expected for the Egyptians to be covered by health insurance? It took Egypt
almost half a century to reach half of the Egyptians with health insurance coverage. Does it need Egypt
another half of a century to cover its other half of population? </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Some experts predict that it
would take between 35-50 years to achieve universal coverage depending on the
status of economic development of the country. Another group states that these
predictions are based on historical world experience and therefore could be
labeled “conservative”. Let’s have a
look at the experience of some of the well known countries for implementing social
health insurance systems.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">It took Germany more than a
century (127 years) to achieve universal health insurance coverage following
its establishment by Bismarck in 1883 by passing its first sickness law and it
seems to be still developing. The largest part, almost 85% of the population,
is covered by a basic national health insurance plan provided by the state,
providing a standard level of coverage. The remainder 15% opted for private
health insurance, which frequently offers additional benefits. It is claimed
that only 0.3% or about 250,000 people in Germany are not insured. A few of
these uninsured people are extremely rich, not needing insurance, and most of
them are poor unable to afford it.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In Japan, it took about 39 years
to achieve universal coverage ignoring that many community-based health insurance
schemes prevailed before that for decades.
The first health insurance law was issued in 1922, delayed its
implementation to 1927 because of the Great Kanto Earthquake of 1923. The first
“region-based” national health insurance law was issued in 1938, and was
revised a number of times until universal coverage was declared in 1961 and the
establishment of a Social Insurance Agency in 1962. However, development and
revision of laws continued until maybe 1997 indicating that the process of
development of social health insurance does not stop by achieving universal
coverage but there would be room for further improvement probably to introduce
more efficiency. Still you could note a lot of ongoing debate about health
insurance coverage and costs.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In the Republic of Korea (ROK),
it took 26 years to achieve universal population coverage from the inception of
the statutory Health Insurance Act in 1963. ROK introduced compulsory health
insurance program in 1977, and universal coverage was claimed in 1989. However,
this was preceded by a voluntary program in 1965. The relatively fast transition to universal
coverage is mainly attributed to unexpected impressive increase in the average
annual growth rate in GNP per capita of 13.3 per cent during the period 1977-89.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Further, it took 118 years in Belgium,
79 years in Austria, 72 years in Luxembourg, 48 years in Costa Rica to achieve universal health
insurance coverage. As could be concluded from the above, not only universal
health insurance needs time to grow, develop, and expand, it also happens on
stages mainly depending on a country’s economic development, its ethical value
system and other factors. For example, it
took 40 years in Austria (from 1890 to 1930) for population coverage to grow
from 7 to 60 percent, and then another 35 years (from 1930 to 1965) to reach 96
percent. Further, it took 20 years for SHI to reach population coverage of 17
percent in Costa Rica (from 1941 to 1961), another 5 years to double coverage
to 34 percent (1966), another 12 years to again double coverage to 74 percent
(1978), and then another 13 years to attain 83 percent coverage (1991). </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">It could be stated that
Egypt introduced its health insurance scheme in 1936 and not as
commonly known in 1964 by issuing Law 64/1936 that established employer’s
responsibilities for work injuries.
Additional 5 laws were issued during the period 1936-1964. A Health
Workers Organization was established in 1961 to provide health care services
for the workers, which later became the Health Insurance Organization
(HIO). However, 1964 was considered the
benchmark for the formal launching of health insurance through issuing a
presidential decree 1209/1964 establishing the HIO taking over the responsibilities
from the General Authority for Social Insurance and building on two laws
defining the SHI premiums for government employees (Law 75/1964) and for public
and private sector employees (Law 63/1964). The HIO started working in
Alexandria with the intention of expanding SHI geographically to other regions
and to the entire population. Later, premiums
were decreased for government employees (Law 32/1975). In the same year 1975,
another law was issued defining additional benefits to government, public and
private sector employees, as well as extending benefits to pensioners and
widows (Law 79/1975). The latter two groups were covered without an employer
contribution. It was not until 1992, that coverage was extended to school
children (Law 99/1992), and followed by extending coverage to pre-school
children (Law 380/1997). If we take in
consideration the evolvement of social health insurance since 1936, then some
people might consider that it took Egypt about 75 years to reach coverage of
health insurance of 57% based on HIO statistics. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Egypt might not be different from
other countries and would need to own the enabling environment that allows
social health insurance coverage to expand to the other half of the population.
This would be the subject of a future blog. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again…</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
</div>
Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-56041792325207756592011-09-18T20:37:00.000+02:002011-09-30T21:34:25.318+02:00Egypt's Road towards Social Health Insurance - The Road to be Traveled (1)<div dir="ltr" style="text-align: left;" trbidi="on">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;">In 2005, Egypt formally declared universal health
insurance coverage of its population as its objective through the adoption of social
health insurance (SHI). <span class="Apple-style-span" style="font-size: small;">This was an
expansion to the original program that was introduced to Egypt's workers in
1964.</span> </span><span style="line-height: 115%;">This coverage was expanded to
those working in formal jobs in the public and private sector at different
rates of contribution, allowing rich companies to opt out of the system. In addition, coverage was expanded to </span></span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">pensioners and widows. </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">The latter coverage imposed additional burden on the system and it’s financing given the absence of contributions similar to those paid by the employers and due to the fact that these services are more expensive.</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"> All t</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;">hese
measures might have disrupted the risk pooling function of the scheme limiting
its capacity to raise enough funds to finance the system and its ability to provide
the protection it is supposed to do. Thirty years later, with the inability of
the system to cope with its expenses, SHI coverage was further compulsory
expanded to Egypt's school children, and later, voluntary expanded to Egypt's
preschool children. </span><br />
<div class="MsoNormal" style="text-align: justify;">
<span style="line-height: 115%;"><span style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">To
date, insurance coverage has reached about half of the population, however;
inequity is still a concern. At the
household level, a head of a family who is a civil servant and his daughter at
school would be insured, while his housewife and his son in college wouldn’t be.
Usually the poor and those working in the informal sector would not have access
to health insurance services and would be expected to receive services at
public health facilities. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif; line-height: 18px;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;">The delay in expanding SHI coverage to the remaining half
of Egypt’s population was blamed mainly on the underfunding of the health
sector. Projections of a few billions of Egyptian pounds were quoted to be
needed to fund the system in a sustainable manner. While this remains true in case cost projections
were built on estimating the cost per person for a certain package of services for a period of time;
however, more money might not always mean better health; there might be
room to introduce efficiency in the current system and make more funds available
through running the system better. Besides
efficiency, there could be other areas that need to be examined. Data indicates that the percent of Egypt’s
GDP spent on health increased from 3.7% in 1995 to 5.9% in 2009; however,
during the same period, the percentage of public health expenditures (which is
what the government spends on health) from total expenditures on health decreased
from one third to one fourth. Significantly, out-of-pocket expenditures (which
are what the people spend on health) increased from half of the total
expenditures on health in 1995 to nearly three quarters in 2009. These are considerably
huge amounts of funds floating out of the pool of funds of SHI and decreasing more its ability of expanding its coverage. Further and consistently, Egyptians spend one
third of their treatment costs on pharmaceuticals. All of that suggest that there could be other factors that present obstacles on Egypt’s path to reach
universal health insurance coverage. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: 'Trebuchet MS', sans-serif; line-height: 115%;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span style="line-height: 115%;">But why do nations resort to SHI schemes in the first
place? The most direct answer is to mobilize additional funds for health care.
Underfunding of health care will lead to poor health outcomes, one of three
main objectives of a health system. <span class="Apple-style-span" style="font-size: small;">The
other two are usually rarely mentioned or given attention by those running
health care systems, namely financial protection and client satisfaction,
sometimes referred to as dignity. Financial protection means protection from
large health expenditures that could bankrupt families leading to their
impoverishment. Health expenditures were shown to be a primary cause of
impoverishment, even for the rich and better off. Client satisfaction usually
means to be treated in a humane form by your health care provider; in addition to
many other things such as the perception that you are receiving quality care. </span> <span class="Apple-style-span" style="font-size: small;">There are other reasons that a nation would
resort to social health insurance.</span> </span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="line-height: 115%;">William
Hisao, the SHI guru mentioned some of these below, which could be valuable objectives by </span></span><span class="Apple-style-span" style="line-height: 18px;">themselves</span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="line-height: 115%;">: </span></span></span></div>
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<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">to subsidize premiums for the
poor rather than financing and providing universal health care for all, in case
tax revenues are inadequate to fund health care of a reasonable quality for everyone</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">to free up public funds so
they can be targeted to public health goods and services;</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">to separate the
responsibilities for collecting and managing SHI financing from the
responsibilities for providing health care to patients, whereby services are
contracted from providers that are separate entities to be accountable to patients
for the quality of services;</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">to use the capacity of
nongovernmental organizations (NGOs) and private providers to improve access by
the insured to health care by means of contracting.</span></li>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">He concludes that SHI is a financing
approach for mobilizing funds and pooling risks. The newly mobilized funds
should be allocated for the poor and near-poor to improve their financial
access to health care. SHI may be a solution for a critical part of a nation’s
systemic health care problem, but is not necessarily a solution for the whole
problem.</span><br />
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<span style="font-family: 'Trebuchet MS', sans-serif;">This is the first of a series
of blogs that will discuss the application of social health insurance in Egypt
and its feasibility within the guidance provided by international literature. <o:p></o:p></span></div>
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<span style="font-family: 'Trebuchet MS', sans-serif;">Until we meet again...</span></div>
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Anonymoushttp://www.blogger.com/profile/14748924606185904529noreply@blogger.com0tag:blogger.com,1999:blog-3777420595919857487.post-15847128861253962422011-08-29T15:25:00.004+02:002011-09-21T12:45:27.261+02:00Engagement of Social Change Agents in Improving Women's Health in Egypt<div dir="ltr" style="text-align: left;" trbidi="on">
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5016.0: Wednesday, November 07, 2007 - Board 9</div>
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Engagement of Social Change Agents in Improving Women's Health in Egypt</div>
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<b>Alaa Hamed, MD</b><sup>1</sup>, Irene Anne Jillson, PhD<sup>2</sup>, Mostafa Mohamed, PhD<sup>3</sup>, and Maged ElSetouhy, MD<sup>3</sup>. (1) World Bank, Cairo Office in care of, 1818 H Street, N.W., Washington, 20433, Egypt, (202) 473-1000,<a href="mailto:alaahamed@worldbank.org" style="color: #003399; text-decoration: underline;">alaahamed@worldbank.org</a>, (2) School of Nursing and Health Studies, Georgetown University, 3700 Reservoir Road, N.W., St. Mary's Hall, Washington, DC 20057, (3) Egyptian Smoking Prevention Research Institute, 10 Kaser Al-Aini Street, Cairo, Egypt</div>
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One of the key questions in women's health is the degree to and ways in which community-based health and/or social interventionists impact on women's empowerment, and in particular on women's health practices and treatment-seeking behavior. In two recent World Bank projects, Social Change Agents (SCAs) were found to have had demonstrable impact on the women and families of the households with which they interacted: playing a vital role in improving health practices and treatment-seeking behavior. A qualitative study conducted by Georgetown University School of Nursing and Health Studies (GU-NHS), in collaboration with the Egyptian Smoking Prevention Research Institute (ESPRI), was carried out to explore the role that SCAs played in influencing women's health seeking behavior within the household and the community. The study included analysis of secondary data and in-depth interviews conducted with key World Bank project team members, officials from the Ministry of Health and Population and Social Fund for Development (SFD), twenty-five SCAs and 20 household members. Through household visits and other activities during which they delivered health education messages and engaged with the women and their families, they helped the women to 1) increase their use of reproductive health services; 2) increase and improve access to and appropriate use of health centers and self-care for themselves and their family members; 3) increase their, and their family's, acceptance of male physicians as caregivers for women; and 4) discuss health issues and “healthy alternatives” with their husbands and other family members, including the issue of child spacing and female circumcision. Factors that facilitated the ability of the SCAs to carry out their roles included availability of accessible health centers and MOHP mobile health units, clear and integrated project and component design relevant to needs of villages, availability of loans for income-generating projects. The study findings have implications for public policy in Egypt, for donor funding of community-level and other programs targeting women's health, and for local government engagement with community NGOs and faith communities to engender their support for strengthening women's capacity to engage in appropriate health practices and treatment-seeking behavior.<br />
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<a href="https://docs.google.com/document/d/16jZS_wSD_2nPK0AHD48poUrSuUv5hkQRTWrItoAVfTg/edit?hl=en_US">The Full Report</a><br />
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الملخص العربي:</div>
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دور "وكلاء التغيير الاجتماعي" (المرشدات الصحيات) في تحسين صحة المرأة في مصر. </div>
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قامت مدرسة دراسات التمريض و الصحة التابعة لجامعة جورج واشنطن، بالتعاون مع المعهد المصري لابحاث الوقاية من التدخين، بإجراء دراسة عن الدور الذي لعبته المرشدات الصحيات في التأثير علي سلوك المرأة الصرية في اتباع السلوك الصحي داخل المنزل و في المجتمع. جاءت هذه الدراسة لتجيب علي احد الأسئلة الهامة عن نوعية التدخلات الصحية المرتكزة علي المجتمع و التدخلات الاجتماعية و مدي تأثيرها علي تمكين المرأة، وخاصة على الممارسات الصحية للمرأة والسلوك الساعي إلى العلاج.</div>
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وقد خلصت الدراسة الي ان "وكلاء التغيير الاجتماعي" (المرشدات الصحيات) لهم أثر ملموس على النساء والأسر الذين تم التفاعل معهم: فهم لعبوا دوراً حيويا في تحسين الممارسات الصحية والسلوك الساعي إلى العلاج. فمن خلال الزيارات المنزلية وغيرها من الأنشطة قاموا من خلالها بتقديم رسائل التوعية الصحية، وتفاعلوا مع النساء وأسرهن، فهم ساعدوا المرأة إلى 1) زيادة استخدام خدمات الصحة الإنجابية؛ 2) زيادة الاتاحة وتحسين الوصول إلى الاستخدام المناسب لمراكز الصحة و وزيادة قدراتهم علي الرعاية الذاتية لأنفسهم وأفراد أسرهم؛ 3) زيادة قبولهم وافراد أسرتهم للأطباء الذكور كمقدمين للرعاية للمرأة؛ و 4) مناقشة القضايا الصحية و "البدائل صحية" مع أزواجهن وأفراد الأسرة الآخرين، بما في ذلك قضية ختان الإناث والمباعدة. </div>
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