info@HealthSystems2020.org www.Hea l thSys tems2020.org

Health Systems 20/20, USAID’s Flagship Project for Health System StrengtheningSince its inception in 2006, the Health Systems 20/20 project has worked in more than 40 countries, implementing new and proven interventions that address health system constraints and increase the use of priority health services. The project works in eight strategy areas: organizational capacity building, financial risk protection/health insurance, governance, human resources for health, measuring and monitoring health systems performance, resource tracking/National Health Accounts, performance-based incentives/pay for performance, and costing and sustainability planning. These areas interface with the World Health Organization’s six health system building blocks: service delivery, health workforce, information systems, financing, governance, and pharmaceutical management. Health Systems 20/20 tailors interventions to each country’s needs and priorities, as determined with country stakeholders, and works in one or more of the strategy areas to strengthen the country’s health system.

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efI. IntroductIon In Egypt, the Health Systems 20/20 project,

funded by the U.S. Agency for International Development (USAID), has been working closely with the Ministry of Health and Population (MOHP) since 2008 to:

y Plan health workforce distribution using clinical standards and facility data on current staff and patient needs

y Improve the national insurance program’s performance as a payer and provider by reducing unnecessary costs and improving quality and responsiveness

y Strengthen capacity to produce and use health financing information to inform policy and decision making

Health Systems 20/20’s strategy is to institutionalize and widen the use of performance improvement systems that reduce costs, increase equity, and improve quality and responsiveness at multiple levels. The political transition in Egypt and the U.S. Government’s declaration of renewed support calls for building local capacity to implement lasting solutions.

Now is a good time to take stock of the MOHP-Health Systems 20/20 project activities, for which Egypt’s new government has expressed support. This Country Brief describes how the collaboration is strengthening the Egyptian health system, highlighting key achievements and lessons learned.

Health Systems 20/20 at Work in Egypt

2 HealthSystems20/20

II. BackgroundEgypt, a lower-middle income country in the Asia/Near

East region, has a gross domestic product (GDP) per capita of US$1,785 (2008) and a predominantly young population of nearly 81 million people (2008).1 The country has witnessed notable improvements in several health indicators including reduction in the under-five mortality rate (U5MR), which has gone from 176 (per 1,000 live births) in 1980 to 23 in 2008, and the maternal mortality ratio (MMR), which has fallen from 220 (per 100,000 births) in 1990 to 82 in 2008 (Figure 1) (USAID 2009). Egypt has already met the Millennium Development Goal (MDG) of 28.3 for U5MR and is on track to achieve its MDG of 43 for MMR by 2015. Contraceptive prevalence also has improved, from 24 percent in 1980 to 60 percent in 2008, but achieving the MDG of 70 percent among women in need by 2015 will be challenging. The fertility rate fell from 5.6 in 1980 to 2.86 in 2008.

This progress in health outcomes has been largely achieved from domestic financing. Egypt’s health system is less dependent on donor funds – less than 2 percent of total health expenditure in Egypt comes from donors – than are countries in the Middle East and North Africa (MENA) region2 overall (at 4 percent).

Egypt has a higher density of physicians, nurses, and pharmacists than the average for the MENA region (Figure 2). Nevertheless, it has key health system challenges that include child malnutrition, a rise in chronic and noncommunicable diseases, and complex health governance institutions (USAID 2009). A survey of more than 6,000 users of maternal and child health and family planning services3 highlighted concerns about quality, confidentiality of client information, and the availability of drugs.

1 Unless otherwise noted, data in the background section are from the Health Systems Database (healthsystems2020.healthsystemsdatabase.org), which uses data from multiple international sources.2 The World Bank regional definition is used here to compare Egypt with the average value for other countries in the MENA region.3 Preliminary findings from the Health Systems 20/20 Egypt Preventive Sector Assessment.

FIgurE 2: dEnSIty oF EgyptIan HEaltH WorkErS comparEd to rEgIonal avEragES 2005

Source: Health Systems Database (healthsystems2020.healthsystemsdatabase.org)

0

5

10

15

20

25

30

35

Physicians per 10,000 population

Nursing and midwifery personnel

per 10,000 population

Pharmacists per 10,000 population

Egypt Regional Average

FIgurE 1: u5mr and mmr trEndS In Egypt

Source: Health Systems Database (healthsystems2020.healthsystemsdatabase.org) using data from World Bank World Development Indicators 2010.

0

20

40

60

80

100

120

140

160

180

200

0

50

100

150

200

250

Maternal mortality ratio (per 100,000 births) Mortality rate under-5 (per 1,000 live births)

Maternal Mortality ratio (per 100,000 births)

Mortality rate under 5 (per 1,000 live births)

MM

R

U5M

R

HealthSystems20/20 3

The various rounds of National Health Accounts (NHA) estimations (Table 1) reveal increased inequity due to high out-of-pocket health expenditures despite rising insurance coverage, increased spending on pharmaceuticals, and low levels of public investment in health.4

4 Egypt spends a lower portion of its budget on health compared with other countries in the region (Egypt NHA).

III. kEy projEct acHIEvEmEntSHealth Systems 20/20’s portfolio in Egypt (Table

2) covers five of the six World Health Organization (WHO) building blocks: service delivery, health workforce, information systems, financing, and governance. This brief focuses on the achievements of three project activities – workforce planning, support to the Health Insurance Organization (HIO), and NHA – as these illustrate the breadth and depth of Health Systems 20/20’s technical

assistance in Egypt.

taBlE 1: SpEndIng on HEaltH In Egypt 1994/95 2001/02 2007/08 2008/09

Total population (million) 59.2 66.7 75.1 76.8Total health expenditure per capita (THE) in LE 127.0 346.0 566.4 800.1Percentage of GDP spent on health 3.7% 6.0% 4.8% 6.2%Public health expenditure as percentage of THE 33.0% 30.0% 33.0% 24.8%Out-of-pocket expenditures as percentage of THE 51.0% 62.0% 60.0% 71.8%Pharmaceuticals as percentage of THE 36.0% 37.0% 26.0% 34.2%Public spending on health as percentage of Government of Egypt expenditures

5.0% 5.0% 4.3%

Source: Egypt NHA. Results for 2008/09 are preliminary.

taBlE 2: portFolIo oF HEaltH SyStEmS 20/20’S actIvItIES In Egypt activity purpose

Workforce planning •Enable the MOHP and facility managers to distribute health workers based on standards and patient needs

• Institutionalize the capacity for long-term workforce planning at the MOHP and other institutions toreducestaffingshortagesandsurpluses

HIO • ImprovehealthsystemefficiencyandqualitybybuildingHIOcapacityasapayerandprovider,laying the ground for expansion of health insurance coverage.

NHA and costing studies

• Improve stewardship of the health system by generating and using evidence to monitor health system performance and to inform for policy and planning

Assessment of USAID’s impact on prevention

•Review the impact and sustainability of USAID’s cumulative investment in preventive services (maternalandchildhealth,familyplanning,andinfectioncontrol)andproviderecommendationstoinstitutionalize achievements

Leadership Academy

•Support initial steps to establish Leadership Academy•Support to design courses and training of trainers

Health sector reform case study/ teaching materials

•Develop case studies and teaching materials on the successes and challenges of Egypt’s health sector reforms to date in order to inform and guide the sector’s new leadership

4 HealthSystems20/20

Workforce Planning

An adequate number, distribution (geographic and by specialty), and quality of health workers is associated with improved diagnosis and treatment, including higher rates of immunization coverage, greater outreach of primary health care, and improved infant, child, and maternal survival (WHO 2006). While Egypt has a higher density of health workers than other countries in the MENA region (Figure 2), there are gaps and imbalances in the health workforce. Improving the distribution of health workers can enhance equity, quality, and access to services.

Since 2008, Health Systems 20/20 has:

y Adapted the WHO’s Workload Indicators of Staffing Need (WISN) model to Egypt

y Developed, for the first time in Egypt, activity standards and standard workloads for all staff types for 26 hospital specialties, with the support of 188 Egyptian experts

y Applied the model in 30 hospitals in three pilot governorates (Assiut, Gharbia, and Luxor) allowing directors to redistribute staff to reduce shortages and surpluses

y Begun building MOHP capacity to institutionalize workforce planning as a sector tool.

To adapt WHO’s WISN methodology to Egypt, local experts defined clinical and nonclinical activities and developed activity standards. These standards were

combined with estimates of available working time and data on the actual volume of services at a hospital or primary care facility to estimate numbers of workers needed by type and specialty (Figure 3). The first round in 30 hospitals revealed a clear deficit of skilled health workers in emergency care, neonatal, and other selected specialties, and a surplus in OB/GYN and pediatrics. In response to these findings, facility directors are using the results to redistribute staff internally within their facility and to negotiate with another facility to temporarily second a staff person when needed. The MOHP proposed a decree in 2010 that would suspend residency programs for OB/GYN and pediatrics due to the marked surplus; however, since the revolution, the decree has not been enacted. The MOHP staff are able to conduct workforce planning in the future.

Looking ahead, the project will:

y Engage policymakers to address policy implications of the workforce assessment findings.

y Support the MOHP to expand workforce planning to primary care facilities and additional hospitals.

y Assist Egypt’s National Training Institute to design and offer trainings in the deficit skill areas identified in the workforce assessment.

y Assist the MOHP to develop a human resources strategy that integrates workforce planning as part of its future operation. The human resources unit in the MOHP is newly established and will need time to be more functioning.

FIgurE 3: WorkForcE plannIng: Input and output mEaSurES oF Egypt’S WISn modEl

Input measures

•Clinicalandnonclinicalactivities:cleardefinitionsofeach type of work routinely performed

•Activitystandards:averagetimethatahealthworker,workingtoanacceptablestandardofcare,shouldspendonaspecificactivity

•Total available working hours: total number of hours health workers should work in a year according to labor laws and human resource rules and regulations

•Standard workload: maximum amount of work that couldbeundertakeninayearbyeachhealthworker,provided they adhere to activity standards

•Actual workload: actual amount of work at each facility in a year measured as volume of services actually performed at the facility

output measures

•Staffingneeds:numberoffull-timehealthworkersrequiredtohandlefacility’sactualworkload

•Workforce gap: difference between the current numbersofworkersandtherequirednumbersasestimated by the model

•Workforceratio:ratioofcurrentsupplytorequirednumber that shows where workforce pressure is the greatest

HealthSystems20/20 5

y If feasible, assist the MOHP to integrate the workforce planning model into its management information system.

Some key lessons learned from workforce planning include the following:

y Imbalances in the health workforce are best identified and resolved by facility directors; however, these directors are constrained by a limited authority over new staff and residents assigned to their facilities.

y A workforce plan should be comprehensive and provide for multi-level approaches (central, governorate, and facility interventions) that collectively provide complementary solutions.

y The analysis has exposed gaps in other management support systems that affect the model inputs and users’ ability to take action, for example, inconsistent patient record keeping and registration and lack of a MOHP personnel database.

HealtH insurance organization Medical Management

Despite an expansion of insurance coverage, out-of-pocket health spending has continued to rise, indicating an underperforming social health insurance system.5 Egypt has disparities in access to quality health care across geographic and income groups (World Bank 2010). While 95 percent of the population lives within 5 kilometers of a health facility, lack of basic equipment, supplies, and drugs as well as imbalances of medical personnel reduce service quality (World Bank 2010). Household out-of-pocket spending as a percentage of total health expenditure in Egypt (at 60 percent) is the highest in the region (Ministry of Health, Egypt, and Health Systems 20/20 2010). The HIO covers 57 percent of the population, including formal sector workers, widows, school-age children, and neonates. As the second largest purchaser and provider of health services (after the MOHP), the HIO can play a major role in promoting efficiency, access, and quality.

Since 2008, Health Systems 20/20 has begun to institutionalize medical management tools within the HIO to improve the ability of providers to deliver safer, more efficient, better quality care and be more responsive to patients. The tools are:

5 Only 8 percent of those insured by the HIO use it for outpatient care (Egypt Household Health Care Utilization and Expenditure Survey, 2011).

y Utilization and case management systems at the central and hospital levels to speed up the delivery of lab and imaging tests to the attending physician, reduce excessive lengths of stay, and discharge planning with the patient and his or her family to reduce readmissions. The number of HIO staff trained and certified to review medical records so far comprises 91 case and utilization managers in hospitals and 31 case and utilization managers in referral/primary health care units.

y A medical audit program at central and HIO branch levels to improve patient care and health outcomes by systematically evaluating compliance with HIO contract requirements and accreditation standards that support the HIO’s mission and responsibilities. A group of physicians, nurses, pharmacists, and dentists have been trained and certified as 88 hospital auditors and 21 auditors of primary health care and outpatient clinics.

The tools enable case managers to affect physician practices and medical auditors to improve hospital systems such as infection control. Since the implementation of the tools in three pilot governorates, HIO managers have measured positive impact on quality and costs. For example, in response to poor infection control, a common practice among surgeons was to prescribe IV antibiotics a week before and a week after surgery, contributing to bacterial resistance and avoidable patient side effects. In one hospital that adopted evidence-based standards of practice, the length of stay of patients who underwent joint replacement surgery was reduced by 50 percent.

Another wasteful practice is surgical patient admission the day before the weekend resulting in two extra inpatient days for no reason and an unmanageable queue of patients for the operating room on the first workday, causing more delays. Another hospital reduced the number of tonsillectomies by 50 percent after determining that the majority of the cases were not medically necessary. The governorate of Gharbia measured a 36 percent decline in the use of medications in 2009/10 compared with the previous year, and a 24 percent reduction of payments to hospitals contracted by HIO (Table 3).

Based on the success and lessons learned of the audit and case and utilization management training, the HIO will continue to scale up medical management. To support this, Health Systems 20/20 developed an audit guide and two utilization and case management manuals, one for use in

6 HealthSystems20/20

hospitals and the other for use in referral/primary health care clinics, and trained and certified 27 trainers. All manuals are available in both English and Arabic.

Next steps include instituting a formal case management office that will be responsible for instituting utilization and case management in two additional hospitals in 2011 and at least another five in 2012. Also in 2011, case management offices will be established in three HIO branches, as part of institutionalizing a formal case management role.

Financial Management

The HIO has frequently run a deficit that must be covered by the national treasury or other external sources. Health Systems 20/20 is currently working to strengthen the financial management and forecasting capacity within the financial departments of the Cairo and Alexandria HIO branches. Health System 20/20 has:

y Set standards for budget planning and planning

y Set processes for forecasting medical and administrative costs

y Built the capacity of the HIO staff at central and branch levels in pricing services and forecasting

y Trained staff in the Cairo and Alexandria HIO branches to produce monthly, quarterly, and annual financial and cost reports

y Trained 155 accountants and mid-level managers in financial management

Health Systems 20/20 is currently working with the HIO headquarters staff to establish a costing center that can routinely develop costing reports using the internationally recognized principles of cost accounting.

Next steps include building on World Bank investments in software and hardware to streamline the processing and payment of claims (medical bills) submitted to the HIO.

National Health Accounts

To evaluate and develop more effective, evidence-based health policies, it is essential to understand the flow of resources through the health system. Health Systems 20/20 is assisting the MOHP to implement and institutionalize NHA, the internationally recognized resource tracking methodology. With USAID support, the MOHP has completed three rounds of NHA since 1994/95. Health Systems 20/20 is currently working closely with the MOHP to complete the 2008/09 NHA.

Egypt’s third NHA, in 2007/08, led senior officials to highlight the need to increase public investments in health and reduce the burden of out-of-pocket spending. While donor spending as a percentage of total health expenditure has decreased substantially, public spending has not increased to compensate (Figure 4).

FIgurE 4: SourcES oF HEaltH carE FInancIng 2008/09

Source: Egypt NHA 2008/09

25%

72%

2%1%

Ministry of Finance Households Firms Rest of the World

taBlE 3: Impact oF HIo managEmEnt toolS In gHarBIa govErnoratE (lE 000)Indicator 2006/07 2007/08 2008/09 2009/10 difference last 2

yearsPayments to subcontracted hospitals 50 396 80 649 95 517 72 342 -24%Spending on medications 6 030 7 666 7 901 5 095 -36%

HealthSystems20/20 7

Preliminary findings from the 2008/09 NHA show that:

y Households continue to remain the single largest source of health financing at 72 percent.

y Expenditures at private clinics and pharmacies account for half of all health spending in Egypt. The private sector remains the primary provider of outpatient services accounting for 80 percent of all visits.

y The MOHP and other public providers account for 62 percent of all inpatient admissions (Figure 5).

y Insurance is not significant in explaining either outpatient or inpatient use, but insurance status is associated with higher use of MOHP, HIO, and other public providers. Of those who are insured, only 8 percent use HIO facilities for outpatient care.

y Differentials in utilization between urban and rural areas have dramatically declined – residents of rural areas actually use more acute and preventive care visits per capita than do residents of urban areas.

Key policy implications include:

y Address the high out-of-pocket burden of households. This will involve increasing government spending on health and comprehensive insurance reform.

y Improve quality of care and ensure increased use of primary health care facilities

y Put in place a comprehensive pharmaceutical policy

y Leverage the private sector.

An Expenditure Tracking System (ETS) for three key programs − maternal and child health, family planning, and infection control − has been implemented in three governorates, and is capable of cross-governorate comparisons. ETS will streamline the translation of government expenditure categories into program categories so Egypt can evaluate the program’s efficiency, return on investment, and sustainability. Hospital costing studies have been implemented in seven hospitals to better understand the cost of the resources used to provide services within a facility. Both of these analyses provide hospital directors with accurate, detailed picture of what their services cost and relation to outputs.

The new Minister of Health and Population has decided to transition NHA and all health financing work to the MOHP Health Economics Unit that will be reporting directly to his office. The project will build the unit’s capacity in health financing and health policy, organize a major event to disseminate the key findings from the NHA estimates for 2008/09, and ensure that Egypt is proactively engaged in the Global Strategic Action Plan to institutionalize NHA.6

concluSIonThe political transition in Egypt and the U.S.

Government’s declaration of renewed support offer a historic opportunity. Egypt’s new political leadership wants the public sector, including the health sector, to be more productive and responsive to the people. In partnership with the new leaders in Egypt, Health Systems 20/20’s strategy is to enable the new MOHP and other local health institutions to manage the health system to improve access, efficiency, equity, and quality of health care services.

6 The Global Strategic Action Plan is an effort coordinated by the World Bank with funding from the Bill and Melinda Gates Foundation. It is supported by USAID, WHO, the Inter-American Development Bank, and other development partners. The objective is to develope a global vision for institutionalizing NHA and its use for policy purposes.

FIgurE 5: cHoIcE oF InpatIEnt provIdEr: InSurancE StatuS 2008/09

35.1

21.2

12.7

27.6

3.5

41.6

0.5

13.7

38.2

6.1

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

MOH Hospitals HIO Facilities Other Government Private Others

Insured Not InsuredSource: Egypt NHA 2008/09

HealthSystems20/20Brief

Health Systems 20/20 (2006-2012) is USAID’s flagship initiative for strengthening health systems. The project helps USAID-supported countries address health system barriers to the use of life-saving priority health services. Health Systems 20/20 focuses on improving the financing, governance, operations, and capacity-building constraints that impede the delivery of health services, particularly those related to HIV/AIDS, tuberculosis, malaria, maternal and child health, and reproductive health. Abt Associates Inc. leads a team of partners that includes: | Aga Khan Foundation | Bitrán y Asociados | BRAC University | Broad Branch Associates | Deloitte Consulting, LLP | Forum One Communications | RTI International | Training Resources Group | Tulane University School of Public Health

www.healthsystems2020.org | E-mail: info@healthsystems2020.orgAbt Associates Inc. | www.abtassociates.com4550 Montgomery Avenue, Suite 800 North | Bethesda, MD 20814 USA June 2011

The author’s views expressed here do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government.

rEFErEncESFouad, Samir. Egypt National Health Accounts 2001-2002.

Bethesda, MD: Partnerships for Health Reformplus, Abt Associates Inc.

Ministry of Health, Egypt, and Health Systems 20/20. September 2010. National Health Accounts 2007/2008: Egypt. Bethesda, MD: Health Systems 20/20, Abt Associates Inc.

Rannan-Eliya, Ravindra, Khaled H. Nada, Abeer M. Kamal, and Ahmed Ibrahim Ali. Egypt National Health Accounts 1994-95. Bethesda, MD: Partners for Health Reform, Abt Associates Inc.

Regional Health Systems Observatory. n.d. Health System Reforms. Cairo: World Health Organization Office of the Eastern Mediterranean Region.

United States Agency for International Development. 2009. Takamol Midterm Evaluation. Washington, DC: Global Health Technical Assistance Program.

World Bank. 2010. Intensive Learning Implementation Completion and Results Report: Health Sector Reform Program. Washington, DC.

World Health Organization. 2008. Annual Joint Reporting Form.

———. 2006. Working Together for Health. World Health Report. Geneva.