|Year : 2016 | Volume
| Issue : 4 | Page : 979-983
The successes and the challenges of Egyptian Health Sector Reform Program
Rabei A Al Bahnasy, Omaima A Mohamed, Hewida A El-Shazly, Azza A Abdel-Azeem, Rasha M Khedr BSc
Department of Public Health and Community Medicine, Faulty of Medicine, Menoufia University, Shebeen El-Kom, Menofia Governorate, Egypt
|Date of Submission||13-Jan-2015|
|Date of Acceptance||26-Feb-2015|
|Date of Web Publication||21-Mar-2017|
Rasha M Khedr
Quality Department, Menoufia Health Directorate, Ministry of Health and Population, Shebin El-Kom, Menoufia Governorate, 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the effectiveness and the efficiency of the Egyptian Health Sector Reform Program in achieving universal coverage for all citizens with high-quality basic health services.
The Government of Egypt launched the Health Sector Reform Program in 1997. The program introduces the family health model as the principle for reform, and aims to insure universal coverage of all citizens with a basic package of health services.
Participants and methods
A simple random sample of 10 family health units was selected from the total 220 units in Menoufia Governorate. Each selected unit was subjected to data collection and analysis of infrastructure, resources management, quality indicators, referral system, coverage, and utilization, and questionnaire was administered for a sample of patients and providers to measure their satisfaction.
Coverage with family health fund was 83% for insured, 86% for uninsured, and 77% for exempted. Active enrollment was 44% for insured, 60% for uninsured, and 14% for exempted. The average utilization visit of the population was 1.1 visits per year. The percentage of different curative utilization visits as regards total curative visits was 47% for insured, 49% for uninsured, and 4% for exempted. There was low utilization of medical instruments. The overall patient satisfaction was 66%, and only 11% of providers were satisfied with their salaries. The final evaluation of all aspects of quality indicators according to the Egyptian Accreditation Program was 55%. The average total cost per visit was 33 LE, and the average revenue per visit was 6 LE.
Our study results show that the rate of active enrollment was low. There is underutilization among coverage people and low-quality indicators. Thus, there is a need for regular monitoring and evaluation to improve these indicators and increase customer satisfaction.
Keywords: exempted, family health fund, health sector reform, insured, quality, uninsured
|How to cite this article:|
Al Bahnasy RA, Mohamed OA, El-Shazly HA, Abdel-Azeem AA, Khedr RM. The successes and the challenges of Egyptian Health Sector Reform Program. Menoufia Med J 2016;29:979-83
|How to cite this URL:|
Al Bahnasy RA, Mohamed OA, El-Shazly HA, Abdel-Azeem AA, Khedr RM. The successes and the challenges of Egyptian Health Sector Reform Program. Menoufia Med J [serial online] 2016 [cited 2020 Mar 29];29:979-83. Available from: http://www.mmj.eg.net/text.asp?2016/29/4/979/202500
| Introduction|| |
Egypt has a highly complicated healthcare system, with many public and private providers and financing agents . Health services in Egypt are currently managed, financed, and provided by agencies in the various sectors of the government under different laws. Health services are also provided by private providers of variable categories and at variable levels of intervention .
Health Sector Reform Program (HSRP) is a program to transform Egypt's health sector between 1997 and 2020, with the overall goal of shifting the focus of healthcare from a high dependence on vertical programs and inpatient care to a more integrated and less expensive, quality, universally accessible, and sustainable primary healthcare ,.
The basic goals of a healthcare system reform are as follows: improving population health status and social well-being, ensuring equity and access to care, ensuring efficiency in the use of resources, enhancing clinical effectiveness, improving quality of care and consumer satisfaction, and assuring the system's long-term financial sustainability ,.
Building blocks of HSRP are as follows: establishment of a new family healthcare model, separation of finance from provision of healthcare, decentralization, focus on better business planning (BBP), application of quality and accreditation, and coverage of new population groups with insurance scheme .
Family health model is a network of public and private family health units (FHUs) and family health centers that, together with the district referral hospital, can offer comprehensive package of integrated health services .
The reform activity in Egypt is still young and has limited in scope. Information on important issues remains unavailable, and many aspects of the reform have still not been tested or implemented .
| Aim|| |
The aim of this study was to evaluate the effectiveness and the efficiency of the Egyptian HSRP in achieving universal coverage for all citizens with high-quality basic health services.
| Participants and Methods|| |
A simple random sample of 10 FHUs was selected from the total 220 units in Menoufia Governorate. Each selected unit was subjected to the following:
- Data collection and analysis of infrastructure, coverage and utilization, human resources, preventive and curative system, referral system, and training programs, and measuring of quality standard using Egyptian accreditation standards.
- Administration of questionnaire for a sample of patients and providers for measuring their satisfaction.
- Follow-up referral process from units to the chosen hospitals.
Data processing and statistical analysis
Data were transferred to a personal computer, classified, and analyzed with SPSS (SPSS Inc., Chicago, Illinois, USA).
| Results|| |
[Table 1] shows that for the different types of population, there is a big difference between coverage with family health fund and active enrollment. Moreover, the percentage of coverage was significantly higher in the uninsured nonexempted (86%) and insured populations (83%) compared with the uninsured exempted population (77%) (P< 0.001). The percentage of active enrollment was significantly higher in the uninsured nonexempted (60%) and insured populations (44%) compared with the uninsured exempted population (14%) (P< 0.001).
|Table 1 Comparison between insured, uninsured, and exempted population as regards coverage with family health fund and active enrollment|
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[Table 2] shows that according to the Egyptian Accreditation Program, the average of final quality standard evaluation of the FHUs in the present study was 55%, whereas the mean of final quality standard evaluation of the FHUs at the time of accreditation in 2010 was 83%.
|Table 2 Trend of final quality evaluation in the year 2012 and at the time of accreditation according to Egyptian Accreditation Program|
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The average evaluation of each quality aspect for all 10 FHUs was as follows: 85% for sterilization and infection control; 82% for cleanness and housekeeping; 80% for environmental safety; 75% for patients' rights; 44% for facility management program; and 41% for quality improvement program standard. The present study reveals that the average rate of patient care indicators of all units was 39% ([Table 3]).
|Table 3 Total evaluation of each quality aspects in all selected 10 units according to the Egyptian Accreditation Program|
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The average cost per visit during the year 2012 was 33 LE, whereas the fund target in 2007 was 18 LE. The average operational cost per visit during the year 2012 was 8 LE, whereas the fund target in 2007 was 4 LE. The average revenue per visit was 6 LE, whereas the fund target in 2007 was 3 LE. The percentage total revenue/total cost was 19%, whereas the fund target in 2007 was 100% LE ([Table 4]).
|Table 4 Average of financial indicators (cost and revenue indicators) of the 10 selective family health units in comparison with family health fund target at year 2007|
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There was a significant difference in the distribution of instruments at the FHUs. The average number for each instrument type was as follows: two ECGs, one ultrasound, two instruments used to measure blood sugar, one dental unit, nine computers, and two autoclaves ([Table 5]).
|Table 5 Average number of present instrument in the 10 selected family health units|
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There was a significant positive correlation between evaluation of quality indicators and overall patient satisfaction (P< 0.0001) [Figure 1].
|Figure 1: Correlation between average overall patient satisfaction and final evaluation of quality indicators for each unit.|
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Only 11% of the referral cases provided feedback information to FHUs from the referred hospitals, and 89% of them did not provide any feedback information [Figure 2].
|Figure 2: Numbers and percentage of referral cases based on acceptance or refusal of the referral process and having feedback information.|
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| Discussion|| |
The overall results from this study show us the degree of effectiveness and efficiency of HSRP in achieving its goals and principles.
The Government of Egypt has articulated its long-term goal for the achievement of universal coverage of basic health services for all its citizens. It has also stated as its priority objectives the importance of targeting the most vulnerable population groups .
To meet these principles and ensure universal coverage, the exemption policy has been implemented since 2006 as a part of the Ministerial Decree 231 for the year 2006. Target exempted is established by the World Bank as 17% of the total population .
Our study shows that there is a low coverage of the exempted population compared with the insured and uninsured populations. The percentage of coverage was significantly higher in the uninsured (86%) and insured populations (83%) compared with the exempted population (77%) (P< 0.001). The percentage of active enrollment was significantly higher in the uninsured (60%) and insured populations (44%) compared with the exempted population (14%) (P< 0.001) ([Table 1]).
Uninsured beneficiaries are the category of individuals who pay by themself. It is very important to calculate the active enrollment to uninsured, as it gives us a much accurate image about the pattern of healthcare utilization and the degree of patient satisfaction and convenience about the health services .
The present study reveals active enrollment for uninsured people to be 60%, which is higher than that for insured people (44%) to target ([Table 1]). This shows that even insured patients have no interest in active registration and in visiting the units, although their visits are free. This explains that the cause of such low active registration and low utilization is not due to financial burden or high registration fees, but due to the quality of services and the degree of convenience of family health model.
The present study reveals that according to the Egyptian Accreditation Program there is a big gap between the evaluation of quality standard at the time of accreditation (2010) and the results of our evaluation in the present study. The mean of final quality standard evaluation of the FHUs in the present study (2012) was 55%. The mean of final quality standard evaluation of the FHUs at the time of accreditation was 83% ([Table 2]).
One of the objectives of HSRP was to provide safe services. HSRP ensures introduction of quality services in health facilities with satisfactory infrastructure, including environmental safety, clinical safety, and basic requirements such as good location and accommodation, good accessibility, surveyed land, functional hygienic high building standard, electricity supply, availability of transportation, clean surrounding environment, good services by qualified staff, and provide facilities for waste disposal .
Our study shows that the best indicators are those which are related to infrastructures, environmental safety, clinical safety, sterilization, infection control, and cleanness. The average evaluation of sterilization and infection control was 85%. The average evaluation of cleanness was 82% and of environmental safety was 80% ([Table 3]).
The basic goals of a healthcare system reform are as follows: improving population health status and social well-being, ensuring equity and access to care, and enhancing clinical effectiveness .
The present study reveals that the average patient care indicator of all units was 39% ([Table 3]). This was very low and shocking result, as it is the main indicator, which related to clinical services and did not achieve the previous mentioned basic goals of a HSRP of improving population health status and social well-being.
Increasing the healthcare budget without performing cost analysis and looking into cost effectiveness will not improve the situation, as investing more money into an inefficient system might lead to greater financial problems in the Egyptian healthcare system. Absence of cost analysis, inappropriate incentives, and inadequate accountability are the major causes of problems throughout Egypt's health system, including the health insuring organization .
The results of our study are in agreement with this, as we found that the last cost analysis was performed in the year 2007 by Menoufia family health fund, and until now no cost analysis has been performed. Moreover, no monitoring and evaluation of financial indicators were carried out for FHUs to follow-up and measure the degree of achievement from the target and evaluate the efficiency of the HSRP to achieve the sustainability.
Performance measurement can be done by comparing current costs with those who were expected or standard costs to the degree of knowing which of them have been controlled. Deviations of expected with the current (variances) can be identified, evaluated, and discussed by managers .
Our study shows that the FHUs cannot achieve the target for cost indicators that was set in 2007. We are far from achieving these targets. The present study shows that the average cost per visit during the year 2012 was 33 LE, whereas the fund target in 2007 was 18 LE. The average operational cost per visit during the year 2012 was 8 LE, whereas the fund target in 2007 was 4 LE. The average revenue per visit was 6 LE, whereas the fund target in 2007 was 3 LE. The percentage total revenue/total cost was 19%, whereas the fund target in 2007 was 100% LE ([Table 4]).
Patient satisfaction is an important outcome of healthcare services and can affect the compliance with medical advice, service utilization, and the clinical–patient relationship . Patients' positive perception of the given care is of fundamental importance in measuring quality of care; it could give information about the success in meeting patient's values and expectation .
This study shows that there is a significant positive correlation between evaluation of quality indicators and overall patient satisfaction (P< 0.0001) [Figure 1].
According to HSRP, there are standards for the equipment and furniture document, which include list of names and number of items per family health facility room and description of equipment/furniture for each item .
Our study shows that there is a significant difference in the distribution of instruments at the FHUs. The average number of instruments in FHUs was as follows: two ECGs, one ultrasound, two instruments to measure blood sugar, one dental care unit, nine computers, and two autoclaves ([Table 5]).
One of the negative characteristics of the health sector reform in Egypt is the referral process. There is no nationwide referral system in the MOHP delivery system; however, there are a number of pilot referral systems in some districts belonging to various health projects, and most of them are dysfunctional .
The majority of referrals were for services not covered by the BBP. This has important implications for customer satisfaction .
Our study reveals that only 11% of the referral cases provided feedback information to FHUs from the referred hospitals and 89% of them did not provide any feedback information [Figure 2].
| Conclusion|| |
The family health model should be modified for achieving its goals and objectives and find a solution for increasing coverage, improving quality of care, improving customer satisfaction, enhancing human resources development, reallocation of infrastructure, improving human resources, and involving the private sectors and specialist not just for a referral process.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]