Egypt Health Sector Reform

1
Egypt Health Sector Reform

• A Best Practice Case of EC World Bank
  Collaboration

2
Political Background

• In 1996 a dynamic new Minister of Health was
  appointed, who wanted to reform the health system
• Given Egypts political importance, some 22
  donors where active in the health sector, and
  there was a very active donor group chaired by
  DANIDA
• Among the donors, USAID had been one of the most
  active in terms of spending with multi-million
  dollar grant programs heavily targeted in
  reproductive health, primary care, information
  systems, cost recovery for hospital services, and
  developing a framework for health reform
  strategies
• There was political commitment to expand social
  health insurance to new groups
• In the early 1990s only 6 out of 60 million
  Egyptians were covered, then 12 million students
  were added over three years, which exacerbated
  the financial strain

3
Political Background

• While there had been significant reforms in the
  maternal and child health area, very little had
  been done at the systems level, perhaps because
  total health spending being less than 4 percent
  of GDP with only 40 percent public was not
  perceived as a drain on the public budget (about
  4 percent of the GOE budget)
• Given the interests of the new Minister as well
  as the strategic importance of Egypt in MENA
  (both politically and size wise), the Bank, EC,
  USAID, and DANIDA were particularly interested in
  assisting the GOE in the development of a
  comprehensive but phased reform strategy which
  could also serve as the base to coordinate the
  support of all 22 donors
• While the system had certain strengths, despite
  the low levels of spending, the system had
  significant structural weaknesses

4
Health System Was Fragmented and Complex
5
Strengths of System

• Access to health care was a basic right for all
  Egyptians
• 95 percent of the population had physical access
  to care
• The MOHP functioned as the social safety net
  insurer for the entire population
• There was an extensive health infrastructure
• State of the art technology and pharmaceuticals
  were generally available
• Over 80 percent of the population had access to
  safe water and sanitation
• 80 percent of children were immunized
• Population growth had been brought down
  significantly

6
System Deficiencies

• Health outcomes were mediocre with large regional
  disparities
• The organization and management of the system was
  fragmented and inefficient
• Too little was spent on health
• Money was spent on health inefficiently and
  inequitably
• The system was financed inequitably (over half
  the population had no formal insurance coverage,
  largely the unemployed, informal sector workers,
  farmers, housewives, and children not attending
  school)
• There were too many beds (hospital occupancy rate
  below 40) and physicians (four times as many as
  other comparable income countries) yet, there
  were serious shortages in some rural areas
  creating access problems
• Quality of care in public and private sectors was
  problematic
• There were few incentives for efficiency
• There were efficiency and quality problems in the
  pharmaceutical sector

7
Need for Reform

• Health outcomes needed to be improved
• Organizational structure and management of the
  system needed to be reformed
• The financing system needed to be more equitable
  and efficient
• The service delivery system needed to be
  restructured
• The distribution, efficiency, and quality of the
  human resource base needed to be improved
• The pharmaceutical sector needed to be more
  efficient and of higher quality

8
Donor GOE Process

• EC, Bank, USAID, and DANIDA (D-4) indicated an
  interest to work together with the GOE to develop
  a comprehensive health sector reform program
  (HSRP)
• These organizations brought in 20 staff and
  consultants to work with 50 Egyptians who had
  been assigned by the Minister to one of 6 working
  groups -- management and organization, health
  services, health infrastructure, human resources,
  the pharmaceutical sector, and health care
  financing

9
Donor GOE Process

• Technical advisors from the D-4 donors assisting
  Egyptian work group chairpersons and group
  members produced six detailed papers laying out
  the reform programs in the six areas
• The six papers were all based on a thorough
  situation analysis and spelled out in varying
  degrees of detail the policy reform needs and
  strategic options
• There was ownership by the work groups, and the
  papers reflected input by the Minister who was
  briefed by each work group halfway through the
  process
• The Minister was also briefed at the end of the
  process, where he provided the strategic policy
  directions based on the analyses and options
  contained in the six papers
• The entire 22 donor community was briefed several
  times by the D-4

10
Results

• The six papers were combined into a 200 page HSRP
  which also dealt with the cross cutting issues
• The HSRP was the first comprehensive health
  reform strategy developed by the Egyptian's that
  addressed all aspects of health sector reform
  needs
• The GOE adopted the HSRP as its reform program
• Both the D-4 and the Minster briefed all 22 of
  the donors to indicate the priorities, coordinate
  efforts and eliminate duplication

11
Project Features of First Phase of the Reform

• Provide universal access to a basic package of
  primary care and public health services
• Restructure and rationalize the primary care
  delivery system through a needs-based master
  planning process
• Restructure HIO
• The project would serve as a pilot by being
  implemented in 3 Governorates that represented
  the different regions Alexandria (urban),
  Menoufia (Lower Egypt), and Sohag (Upper Egypt)

12
Bank, EC, and USAID Funded the First Phase of the
Reform

• Bank, EC, and USAID funded the first phase of the
  reform
• Bank project provided 90 million in IDA
• EC provided 110 Euros in the form of parallel
  financing
• USAID targeted 80 million to support the effort
• The African Development Bank ultimately invested
  16 million in Suez and Qena based on the same
  reform program

13
Collaboration During Implementation

• DANDIA and Bank focused on development and
  implementation of a needs-based masterplan
• USAID focused on the service delivery model
• EC focused on training and HR
• Bank and USAID focused on MIS
• EC and Bank focused on construction and rehab,
  both in Alexandria, Bank in Minoufia, EC in Sohag

14
Project Status

• Implementation delays caused by internal Egyptian
  politics resulted in the primary insurance
  component being dropped and delays in other
  project components which resulted in both the EU
  and Bank extending their projects
• The Minister could not get Parliamentary backing
  for the the new health insurance law that would
  have unified the existing fragmented institutions
  and legislation

15
Lessons Learned on Donor Collaboration

• Donors all had strong interest in investing in
  Egypts health sector
• Consensus among the D-4 that a significant
  injection of funding in the form of TA in
  upstream policy analysis was a prerequisite for
  establishing the parameters and priorities of
  the reform program
• The D-4 all provided generous support both
  analytically and financially
• Working together on the sector work with the
  Government provided a very strong basis for
  collaboration, trust, and ultimately projects

16
Lessons Learned on Donor Collaboration

• Having a very determined and strong Minister at
  the helm of the MOHP, who was willing to
  aggressively facilitate the process and push his
  own staff and the countrys political leadership,
  was a key ingredient for success
• Technical credibility, political savvy and
  knowledge of the local situation provided by the
  D-4 based on their different comparative
  advantages and experiences was a winning
  combination
• The personal chemistry, respect, and trust among
  the leaders of the D-4 helped surmount numerous
  obstacles