Improving Health Outcomes of the Poor – A Social Justice Agenda for Egypt

Health outcomes are usually measured in terms of the ability of health systems to introduce improvements in three areas: (i) health status; (ii) financial protection; and (iii) client satisfaction and dignity.  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.

These challenges, which mainly indicate unfairness to the least advantaged group of the society, could be shortly summarized as follows:

In terms of health status, inequity that could be observed in disparities in achieving MDG 4 (child mortality) and MDG 5 (maternal health) across geographic regions and income quintiles.  Inequity is demonstrated by the persistent prevalence of high level of stunting, strongly linked to poverty. With the expected increase of non-communicable diseases and the high prevalence of hepatitis C, the burden of disease is expected to increase on Egyptians, especially the poor and probably would drive more people into poverty.

In terms of financial protection, the inability 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.

In terms of client Satisfaction and system responsiveness, 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.

There are other cross cutting developmental challenges that would affect the outcomes of the health sector that are important to consider such as 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.

Positioning social justice at the center of the health sector agenda, taking in consideration the slogans that were raised by the January 25^th 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 Improving Health Outcomes of the Poor, as the least advantaged group of people in the society.  

A social justice agenda would naturally focus on the poor based on principles of distributive justice, a key principle would be the Difference Principle.  This principle stipulates that social and economic inequalities would be allowed in a community as long as they work to satisfy two conditions: (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.  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.

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.  

Setting goals under this theme would then focus on three elements that could be quantified:

(i)     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)

(ii)     protecting the population and especially the poor from the impoverishing effects of health expenditure and the near poor from getting poor

(iii)     seeking the poor’s satisfaction of service provision and treating them in a manner that preserves their dignity

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

Until we meet again....

Egypt’s Transition in the Health Sector: The Need for a Transition Plan for Universal Coverage

Egypt's Transition towards a Third Wave of Health Sector Reform (3)

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 post 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 post , 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.  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. 

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 post: 


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.  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. 

Universal coverage would likely be achieved in stages as explained in a related post. However, The speed of this coverage would depend on Egypt’s ability to face a number of challenges, as discussed in a previous post, 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. 

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.

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. 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.  

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.

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. 

In both cases, 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.  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. 

Until we meet again....

Egypt’s Transition in the Health Sector: Opportunity for Raising Staff Moral & Restoring People's Confidence

Egypt's Transition towards a Third Wave of Health Sector Reform (2)

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.

On the positive side, these groups proposed solutions for the problems raised by them. One specific group, the Egypt Health Sector Reform Group, 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.  

The purpose of this blog is to present an excerpt of this brainstorming, as I understood it.  Following a health systems framework, TWO proposed priority actions were selected under each element of this framework possibly feasible to be accomplished during the transition. 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.

Objectives

Two key objectives to be achieved during the transition could be defined:

1. Raising the morale of health sector staff and restoring people’s confidence in the management of the health sector and its services provision
2. Preparing for the period after the transition

Activities

Objective 1: Raising Staff Moral and Restoring People’s Confidence in the Health Sector

1.       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

·         Through introducing improvements in the public health system by addressing priority gaps in service delivery and treating patients with respect.

·         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 

2.       Motivation of health workforce and raising staff morale

·         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.

·         Training of middle management for preparation of calibers needed for management and potential for staffing for senior management.

3.       Making available funds by reallocation from other sources

·         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.

·         Postponing the social health insurance law until an elected people’s assembly is in place to decide about the health system appropriate for Egypt

4.       Improving Governance

·         Establishing of an independent Quality Organization to accredit public and NGO providers for a defined package of services

·         The separation between the payor and provision functions within the organizational structure of the Health Insurance Organization.

Objective 2: Preparing the Health Sector for the period after transition

·         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.

·         Joint Expert/Politician Reviews to the health sector to prepare a paper on Egypt’s vision for the health sector

·         Based on the health sector vision, an Expert team to prepare a Health Sector Strategy.

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

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

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

Pre-reform Phase (Before 1997)

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

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

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

The Second Wave of Reform (2006-2010)

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

The Transition

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

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

If so,

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

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

(1)    Governance and Anticorruption

(2)    Health Workforce. 

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

Until we meet again....