Egypt health strategy dec 25, 2016

Going Universal:
Strategic Directions for
Egypt’s Health Sector
Alaa Hamed
Sr. Health Specialist
2016-2030

Outline
Alaa Hamed, Sr. Health Specialist, the World Bank, December 2015 2
I. Sector Diagnostics
II. Country Strategic Priorities
III. Proposed Strategic Directions
IV.Short-Medium Term Transformational Programs
V. Potential Areas for WB Support for Egypt

HEALTH, NUTRITION,
POPULATION DIAGNOSTICS

Life Expectancy falling below global levels

NCDIs are Egypt’s main cause of premature mortality and burden of
disease; Cirrhosis from hepatitis B and C are ten times higher than
average
Alaa Hamed, Sr. Health Specialist, the World Bank, December 2015
Ischemic heart
disease
Cerebrovascular
disease
Chronic
obstructive
pulmonary
disease
Cirrhosis due
to hepatitis C
Congenital
anomalies
Lower
respiratory
infections
Other
cardiovascular
and circulatory
diseases
Diabetes
mellitus
Chronic
kidney
disease
Cirrhosis due
to hepatitis B
Egypt 3,165.9 3,140.0 1,319.1 1,301.9 1,169.0 1,053.6 884.5 781.2 774.3 735.7
Comparison
group average
2,921.4 1,487.6 476.9 105.2 816.2 574.0 263.8 702.4 474.7 89.5
Indistinguishable from mean Significantly higher than mean
5

Child and Maternal mortality are plateauing, the first few
days of birth matters…

… with inequitable outcomes by income and region
EDHS 2014
Note: ECCE stands for Early Childhood Care and Education
7

Under-nutrition contributes to half of children’s deaths and loss
of cognitive skills, in absence of relevant interventions: ECDs
8

Getting older, Egyptians get overweight then obese, more
prone for NCDs
Ever-married Women Age 15-49Girls and Boys Age 5-19

During the period 2010-2015, the
Egyptian population grew by 9.5
million people (1.9 million per year,
the most rapid absolute increase
ever registered in the country).
Gets complicated with a population expected to reach
150 million in 2050, with a very young structure
Source: UNPD (2015) Population Prospects
A very young structure, half
under 24 years, and 5% above
65 years (4.3 m person),
requiring expensive care to treat
NCDs
Egypt’s Population Pyramid
10

Challenging situation: TFR returned to 2000 levels, a desire for
three children, with a declining CPR …
3 3.5 2.1
Desired Fertility TFR Replacement
Rate
11
19
15
56
51
0
10
20
30
40
50
60
U5 Mortality Neonatal Mortality
Birth Spacing and Child Mortality
Birth Spacing more than 4 years Birth Spacing less than 2 years
174
84
75
68
59 55
50 52 52
24.2
37.8
47.1 47.9
56.1
59.2
60.3
58.5
20
25
30
35
40
45
50
55
60
65
20
40
60
80
100
120
140
160
180
200
1992 2000 2002 2004 2006 2008 2012 2013 2014
Maternal Mortality CPR

… with opportunities to do more on supply and demand side
services
30.10
12.6
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
Discontinuation Rates Unmet Need
10.9
5
14.3
1.3
3.2
7.9
16.3
27.4
18.118.7
9.2
10.8
19
13.1
4
0
5
10
15
20
25
30
30.5
22.4
34.6
36.6
26.1
42.7
36.2
30.6
25
18.4
0
5
10
15
20
25
30
35
40
45
CONSANGUINITY
3.0
2.6
2.9
2.6
3.0
3.4
3.0
3.6
3.5
2.5
3.4
3.0
3.6
3.8
3.2
4.1
Total Egypt Urban
Governorates
Total Urban Rural Total Urban Rural
Births per women
2008 EDHS
2014 EDHS
Upper EgyptLower Egypt
CHILDHOOD PREGNANCY

HNP Diagnostics: Conclusions
Change in disease
burden: NCDIs, Hepatitis
Plateauing of MDGs;
inequitable outcomes
Reversal in Fertility;
persistence Malnutrition
13

FINANCIAL PROTECTION
DIAGNOSTICS

More than 40% of the Egyptians are unprotected;
protection is inequitable

The poor, relatively, pays more

OOPs didn’t really decrease much

Over the year, GHE slightly increased...

… with the intention to be increased more
FY 2013/14
Actual
FY 2014/15
Preliminary
FY 2015/16
Budget
FY 2016/17
GDP (billion LE) 1997.6 2431.1 2833.4 ─
Amount pledged for health via Constitutional
mandate (3 percent GDP; billion LE)
─ 72.9 85.0 ─
Phased annual increase to health (billion LE) ─ 6.4 7.8 ─
General budget (billion LE) 701.5 733.4 864.6 ─
Health budget (billion LE) 30.8 37.2 45.0 ─
Healthcare as % of budget 4.4% 5.1% 5.2% ─
Healthcare as a % of GDP 1.5% 1.5% 1.6% 3.0%
Source: MOF
19

Coverage and risk pools are fragmented in the
absence of a strategic purchaser

Financial Protection Diagnostics: Conclusions
Inequitable protection; the poor
and the vulnerable the least
protected
OOPs not decreasing, despite
increase in government
spending
Risk Pools fragmented; lack of
strategic purchaser
21

DIAGNOSTICS ON HEALTH
SYSTEM RESPONSIVENESS

Improving health care is a priority of the people
Source: International Republican Institute, 2011
23

People choose to go to private providers..
Source: 2006 Egypt Health Insurance Survey & Team Analysis
24

.. and prefer specialists…
Cold
Page 25
Hot!
Multiple visits
to specialists
Vs. limited
visits to
general doctors
High appealLow appeal
Multiple visits
to general
doctors Vs.
limited visits
to specialists

People recognize three barriers to utilize public
services…
Financial constraint
Lack of trust
Negative experience
26

Health System Responsiveness Diagnostics:
Conclusions
Health is a people’s priority
People prefer private providers
and specialists
Public services associated with
negative experiences, lack of
trust, and financial constraints
27

EGYPT’S STRATEGIC
PRIORITIES

Sustainable Development Goals by 2030
GOAL 3:
Ensure Healthy lives
and promote wellbeing
for all at all ages
Reduce global maternal mortality ratio
End preventable deaths of newborns and
children under 5 years of age
End the epidemics of AIDS, tuberculosis,
malaria, neglected tropical diseases;
combat hepatitis, water-borne diseases,
other communicable diseases
Ensure universal access to sexual and
reproductive health-care services
Reduce premature mortality from non-
communicable diseases
Strengthen prevention and treatment of
substance abuse
Halve global deaths and injuries from road
traffic accidents
Achieve universal health coverage
Substantially reduce number of deaths and
illnesses from hazardous chemicals and air,
water and soil pollution and contamination
29

Egypt’s Constitution 2014
Every citizen has right to health,
comprehensive health care, with
quality standards
Crime to refuse providing medical
treatment in emergency or life-
threatening situations
Allocation, at least, 3% of Gross
National Product (GNP) of
government spending to health
Comprehensive health insurance
system for all Egyptians
Controls public health facilities,
enhances efficiency, equitable
geographical distribution
Improves conditions of physicians,
nurses, health sector workers
Private and non-governmental sectors
to provide health care services
Citizen Rights Role of State
30

Egypt’s Goals 2030

SCD Government Priorities
1. Restoring Macro Stability
and Supporting Growth
2. Improving Public Service
Delivery
3. Fostering Social Justice
and Inclusion
 Achieve annual real growth of at
least 6 percent by end of the
medium-term and bring
unemployment below 10
percent ;
 Restore investors confidence,
improve the business
environment, and expand
investments;
 Bring the fiscal deficit and public
debt on a downward trajectory;
 Bring down annual inflation to
6-8 percent;
 Address growing energy needs
and raise energy use efficiency
through ongoing structural
reforms
 Enhance effectiveness and
efficiency of public
administrative bodies and public
spending;
 Improve quality and
accessibility of services and
products to beneficiaries;
 Enhance the capacity of civil
servants;
 Reinforce equity and
transparency of public services;
 Strengthen accountability and
citizen empowerment as well
as engagement;
 Ensure efficient management of
public assets by establishing a
unified database (Fixed Assets
Register).
 Increasing spending that
empower and enable the poor
and promote human capital;
 Better targeting of subsidies
including programs that target
the poor and vulnerable;
 Expansion of the SSNs;
 Expand in efficient manner
public spending on health and
education sectors to improve
outcomes and quality;
 More and better targeting of
social services, and more
gender equality.

WHAT DOES IT MEAN TO BE
TRANSFORMATIONAL IN
EGYPT’S HEALTH SECTOR?

Transforming Egypt’s Health Sector - Strategic
Pillars
Wellness
Package
Pro Poor
Coverage
Protection from
Impoverishment
Equitable,
Quality, Efficient,
Access
Strengthened
Accountability
34

• infectious diseases, reproductive and child health
care services, and essential NCDs and injuries based
on treatment protocols, predicted risk and estimated
cost.
• other important diseases of burden: hepatitis
• Incrementally expand outpatient and inpatient
services
Adopt a pro-poor cost-
effective WELLNESS
benefit package of
preventive and
curative family health
services
Family Health
Services to include
primary, secondary
care as a basis for
Wellness
The Core: Beyond Basic Benefits to Wellness
Services
Cost
Tertiary Care
Secondary Care
Primary Care
35

I. Pro-poor Coverage
Progressive Coverage
The Risk Pool
Investments for the Poor and Vulnerable
Public financing for “Family Health Services” for all
Egyptians

Moving from
regressive
inequitable
trickle-down
coverage..
… to a progressive bottom-up health care system that
prioritize coverage for left behind lower-income populations
From Regressive to Progressive Coverage
Coverageexpansionfromhetopdown
Formal
sector
Non-poor
Informal sector
Vulnerable
Poor
Coverageexpansionfromthebottomup
Poorest
Income
Richest
Poverty line
Vulnerability
line
Need for
public
subsidization
Highest
Lowest
Trickle-Down and Bottom-Up Expansion of Health Care
37

From Fragmented to Universal Coverage
38

• Reforming/ upgrading production of healthcare
services, prioritizing poor and vulnerable; through
geographic targeting, emphasis on primary care,
and on services they often use
Addressing the
provision gap/
Supply Side
Programs
• Reducing economic barriers for prioritized
subpopulations, expanding access to more/better
services, wider choice of providers, and modalities
to improve financial protection
• Link the supply side to conditional cash transfers
Addressing the
financing gap/
Demand Side
interventions
Prioritize investments for the poor and the vulnerable
39

Guarantee financing for
“Family Health Services” for
all Egyptians
Start with poor regions
gradually expanding it to all,
and purchase it strategically
General
Taxes
Ear Marked Taxes
Prepayments
40

II. Protection from Impoverishment
The poor and vulnerable
The non poor informal sector
Payers and Risk pools
Pooled financing/ prepayments Schemes
User fees/ copayments
Out of Pocket Expenditures

Fully subsidize the premiums for
poor, the vulnerable through
general taxes based on
individual targeting
Enroll gradually the non-poor
informal sector population
through contributory (mandatory)
and/or non-contributory (full or
partial subsidy) funding, probably
using group enrollment
Identify, target, and enroll the poor and the vulnerable
Expand coverage to the non-poor informal
42

Consolidate risk pools within HIO,
improve beneficiary enrollment,
allocate funds per head enrolled
U5
Children
Formal
Employees
Female
Headed
Househ
olds
HIO
Beneficiaries
School
Children
Farmers
Consolidate different payers,
physically or virtually, into one risk
pool to strategically purchase
health services
Other
HIO
Family
Health
Fund
Strategic
Purchaser
PTES
Program
for the
Poor
43

• Move gradually from a system based on out of
pocket spending to pool financing based on public
financing and prepayments for a Health Insurance
Package based on progressivity and cross-
subsidization from taxes and general revenues
Increase public and
pooled financing
• User fees and copayments used for rationalization
are decreasing utilization substantially, to be
replaced by protocols
Eliminate/ Lower user
fees, copayments
• Main cause of OOPs is pharmaceuticals/ direct
access to pharmacies, other reasons relate to lack
of strategic purchaser, lack of contracting
arrangements for NGOs and private clinics.
Analyze causes of
OOPs, develop
relevant policies
44

III. Equitable, Quality and Efficient Access
Integrated Care: Continuum of Care
Availability of Health Workers in Remote/ Rural Areas
Community Health Workers
Operations of Primary Health Care
Outreach Services in Remote/ Rural Areas
Participation of Private Providers
Accreditation and Quality

• Integrate delivery of family health
services at PHC level starting with
MDGs services
• Bring more services at PHC, the
first point for client’s contact
• Link PHC to population-based
programs
• Establish PHC units gatekeeper
for referral for higher levels
• Establish Health Centers as mid-
level referral, between primary
units and district hospitals, deliver
specialized services nearer to
communities
• Provide outpatient and inpatient
care at District hospitals based on
referral, serve as gatekeeper for
3ry care
Move
towards
Integrated
Care:
Continuum
of Care
Tertiary
Care
Secondary
Care
Primary Care
Community-based/ Outreach
Population-based
46

• Create incentives for health care providers
to work in rural areas and with vulnerable
populations: financial incentives, non-
monetary incentives, career opportunities
• Contract private medical professionals to
serve in public facilities in rural areas
• Consider task shifting/ sharing
Attract and Retain
Health Workers in
Remote Areas
• Integrate Raedat, Morshedat in common
community based services system
• Expand their role beyond MDGs to NCDs
and hepatitis C, the Wellness package,
ECDs, Population
• Expand their role for enrollment
• Develop a career development path
Integrate
Community Health
Workers in service
delivery
47

• Allow facility financial autonomy to cover
shortages in drugs and supplies, pay
incentives for performance outside the
strict line-item budget lines.
Improve Operations
of Primary Health
Care Facilities in
Rural areas
• Use mobile teams in areas with no
providers in fixed facilities in rural areas
• Use mobile clinics in areas with no
available fixed facilities in remote areas
Provide Outreach
Services in Areas
with no Functional
Services
48

• For profit and non-for-profit providers
(NGOs)
• Start in areas with no public providers,
urban slums
• Level the field between public and private
providers to deliver the same package of
services
Contract Private
Providers for
Service Delivery
• MoH to set standards
• Set accreditation as condition for
contracting providers (public and private)
• Create incentives for providers to pursue
accreditation
• Separate between provider and accreditor
Accredit Health
Facilities for Better
Quality
49

IV. Strengthened Accountability
Purchaser-Provider Split
Roles and Responsibilities
Provider Payments
Provider Autonomy
Measurement and Enforcement
Citizen Engagement

• Gradually move from integrated public sector
financing and delivery
• Establish a Strategic Purchaser for health
services
• Purchase services from both public and
private providers based on accreditation
Move towards a
purchaser-provider
split
• Move from implicit rationing to an explicit
positive guaranteed benefit package based on
systematic prioritization for clear expectations
• Provide clarity on the role of national and
subnational levels with proper delegation
Define Explicit
Roles and
Responsibilities

• Shift from input based financing to more
output- and results-based approaches.
• Pay for Performance, with caution, for
selected diseases (NCDs)
Define Provider
Payments
• Grant public providers more autonomy
starting with hospitals
• Provide oversight
Move Towards
Provider Autonomy

• Build strong reliable health information
systems
• Conduct audits, technical and financial; third
party verification: externally and internally.
• Monitor performance and evaluate impact
Measure
Performance;
Enforce
Rewards/Sanctions
• Information Interventions: access-to-
information legislation, information
campaigns, report cards, scorecards, social
audits
• Grievance Redress Mechanisms
• Choice of Provider
Engage citizens for
social accountability

WHAT COULD BE DONE IN THE
SHORT- MEDIUM TERM: 2016-
2020?

Egypt’s Transitional Programs: 2016-2020
• Canal/ Sinai SHI Initiative (The Big Bang Approach)
• Upper Egypt UHC Initiative (Progressive Coverage
for Poor Regions)
• Remaining Regions (The Transition towards SHI)
Adopt multiple
paths towards
Universal Health
Coverage
• Prevention, Control and Treatment of Hepatitis C
Program
Address the Key
Communicable
Disease in Egypt:
Hepatitis C
• Population and Early Childhood Development
Program
Address other
Determinants of
UHC: Population &
Nutrition

I.I Progressive Coverage for Poor Regions:
Upper Egypt UHC Initiative
• Prioritize and coordinate investments and
recurrent budget for service delivery of primary
and secondary health care in Upper Egypt
• Improve providers skills: technical, responsiveness
Upgrade Supply
• Consider a merger between the Program for the
Poor and the Family Health Fund in Upper Egypt
as a single purchaser agency
Establish Strategic
Purchaser for Family
Health Services
• Include the poor, the vulnerable, and the non-poor
informal sector workers in Upper Egypt
• In follow up phases, expand to Lower Egypt
Enroll All Citizens
based on Geographic
Residence
56

I.I Progressive Coverage for Poor Regions:
Upper Egypt UHC Initiative
• Include services with positive externalities, public or quasi
public goods
• Fund it from general, earmarked taxes; prepayments from
HIO beneficiaries
Guarantee Financing
for Primary and
Secondary care
• Establish access to HIO/PTES coverage for treatment for
expensive services on the basis of enrollment in Upper Egypt
UHC initiative
Link Coverage for
Tertiary Care,
Catastrophic Illness
To HIO and PTES
• Gradually change payment from budget lines to capitation
• Plus pay for performance/results to incentivize utilization,
quality of preventive services, improved provider’s
performance, availability, and retention
Pay Based on
Capitation and
Performance
57

I.2 The Big Bang Approach:
Canal & Sinai Social Health Insurance Initiative
• Introduce health insurance functions within the NHIS
including beneficiary management, provider
management, claims management, utilization
management and medical audits, fraud detection, price
setting.
Build Capacity on
Health Insurance
Functions
• Define a positive package of services
• Establish common qualified public and private providers
lists, with classification
• Define provider payment and contracting mechanisms
• Align beneficiary enrollment mechanisms and registration
• Establish Pricing Committee and develop negotiated
price list
Unify Rules and
Regulations
• Train providers on fiduciary management such as
costing, contracting, claims generation, and auditing.
• Train providers on delivering the contracted package of
services as per guidelines for diagnosis and treatment
Build Capacity of
Providers for
Contracting
58

I.3 Social Health Insurance Transition Program:
Remaining Regions
• HIO to separate its internally purchasing and
provision functions as part of two different
departments/sectors, or preferably as two separate
organizations.
Establish a
Purchaser-Provider
Split within HIO
• In the interim, move towards family enrollment
by expanding contributory mechanisms to enroll
families of formal employees for additional
contribution.
Expand Enrollment
to Families of HIO
Formal Employees
• Conduct communication campaigns, establish
enrollment mechanisms/ venues to enroll more
female headed households, under five children,
school aged children, farmers; decrease adverse
selection.
Improve Enrollment
of Other
Beneficiaries within
HIO
59

I.3 Social Health Insurance Transition Program
• In the interim, introduce policies to discourage
opting out and encourage those opted out to
enroll in social health insurance
Decrease
Opting out from
HIO
• Apply unified provider payment equally between
HIO providers, including HIO hospitals/centers
• Expand contracting to fairly select both public and
private providers based on competition,
accreditation, and a fair price list
Define Provider
Payment
Mechanisms
within HIO
60

• Contract providers based on negotiated price
list instead of providing financial support
Upgrade Purchasing
Functions within
PTES
• Prioritize access to disadvantaged groups and
limit access to the financially better off
Improve Targeting
Beneficiaries by PTES
• Enroll all groups that are currently being not
covered by HIO
Enroll the Poor, the
vulnerable, and the
non-poor informal
workers in PTES
61

• Establish it autonomous, independent to
accredit public and private providers
Establish Independent
Accreditation
Organization
• Strengthen internal departments within MoH
and HIO, and other provider organizations to
assure quality at central and peripheral levels
Build Providers’
Capacity for Quality
Assurance
• Establish accreditation as a requirement for
contracting, renewable based on maintaining
accreditation to maintain providers motivated
Accredit Providers for
Contracting
62

II. Prevention, Control and Treatment of Hepatitis C
Program
• Allocate sustainable resources for infection control and blood
safety
• Launch and scale up the use of disposable syringes
• Establish compliance with infection control protocols as a
mandatory requirement for funding and/or contracting health
facilities
Strengthen Infection
Control and Blood
Safety
• Conduct screening and early detection for hepatitis C
• Sensitize citizens to conduct voluntary testing and counseling
• Organize communication outreach campaigns to inform citizens
about modes of transmission, mechanism for registration,
treatment options, etc.
• Establish grievance mechanism for those denied treatment
Early Detect and
Reach More
Patients
• Continue efforts to decrease drug prices
• Subsidize the poor, the vulnerable
• Establish health insurance avenues to protect their beneficiaries
• Establish third party monitoring mechanism to ensure patients are
receiving drugs and follow up compliance
Treat and Follow Up
Patients
63

III. Population and Early Childhood Development
Program
• Select problems of priority for Egypt that requires multi-
sectoral intervention, demand side and supply side
services, engagement of both government and civil
society
• Examples: malnutrition, population growth, girl’s
education, women empowerment, child marriage,
consanguinity, female genital mutilation
Select Priority
Problems for
Interventions
• Fund the facility from public financing and contributions/
participation from civil society
• Support interventions that works across sectors: health,
education, social protection, others; and across
organizations including government and civil society
• Plan, program, monitor, evaluate, verify results centrally;
implement at decentralized levels
Establish a
Multi-sectoral
Financing
Facility
64

HOW COULD THE BANK
ASSIST EGYPT?

Improving Public
Service Delivery
Fostering Social
Justice and Inclusion
 Enhance effectiveness
and efficiency of public
administrative bodies and
public spending;
 Improve quality and
accessibility of services
and products to
beneficiaries;
 Enhance the capacity of
civil servants;
 Reinforce equity and
transparency of public
services;
 Strengthen accountability
and citizen empowerment
as well as engagement;
 Increasing spending that
empower and enable the
poor and promote human
capital;
 Better targeting of
subsidies including
programs that target the
poor and vulnerable;
 Expansion of the SSNs;
 Expand in efficient manner
public spending on health
and education sectors to
improve outcomes and
quality;
 More and better targeting
of social services, and
more gender equality.
CPF: Relevant PillarsSCD: Relevant Priorities
 Addressing geographical inequities in
basic services
 Enhancing access to health services
 Ensure better targeting and more
transparency of the social protection
systems
Improving service delivery
and social protection

67
Development Diagnostics
• Changing Burden of Disease
• Unfinished MDGs Agenda
• High Fertility and Malnutrition
• Financial Protection/ High OOPE
• Fragmented risk pools
• Unsatisfied beneficiaries
World Bank
Comparative
Advantage
• Global Experience
• Country Presence
• Instruments for financial and
technical assistance
• Multisectoral approach
Government Priorities
• Expanding universal health
coverage/ SHI
• Hepatitis C
• Population Growth
Egypt’s Health Sector: Diagnostics and Priorities

WB Potential Areas for Engagement 2016-2020
• Ongoing TA: Role of Community Health Workers in
Expanding UHC
• Ongoing IPF: Healthcare Quality Improvement Project
• Government and/or IBRD Financing
Upper Egypt UHC
Initiative
• TA: SHI Transition
SHI Program (Current/
Transition)
• Ongoing TA: Strengthening Response to Viral Hepatitis
• Government and/or IBRD FinancingHepatitis C Program
• Ongoing TA: Allocative Efficiency of Social Expenditures
Population and ECD
Program

Egypt health strategy dec 25, 2016

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Egypt health strategy dec 25, 2016

Similar to Egypt health strategy dec 25, 2016 (20)

More from Alaa Hamed

More from Alaa Hamed (11)

Recently uploaded

Recently uploaded (20)

Egypt health strategy dec 25, 2016