Policy Research In Egypt s Health Sector Reform

Transcription

1 Policy Research In Egypt s Health Sector Reform June 2002 Mahmoud A. Salem The contents of this document are the sole responsibility of the authors do not reflect a position on the part of the Alliance for Health Policy andand Systems Research The Alliance for Health and Systems ResearchPolicy 13

2 Contents Executive summary...3 Acronyms...4 Prologue...5 Introduction...8 Information for reform...8 The DDM project in Egypt...9 Partnerships for Health Reform studies...11 Pilot projects...12 Project oversight...13 The role of USAID...14 Designing instruments...15 The Basic Benefit Package (BBP)...15 Accreditation...16 Conclusions...17 General considerations...17 Basic Benefit Package...17 Accreditation programme...17 References

3 Executive summary During the 1990s, Egypt was looking for better ways of organizing and financing health care. This search was motivated not only by economic, political and technical factors, but also by the need to find answers to the complex problems of the policy-making process. How was technical advice developed and actually used in decision-making? The roles of the Data for Decision Making project (United States Centers for Disease Control), Partnerships for Health Reform project (United States Agency for International Development) and other international actors are analysed in the context of monitoring reforms and developing policy. One of the main benefits of this technical support at the formulation stage was to demonstrate that Egypt could solve its own problems and greatly strengthen its health system performance, thus helping to revitalize the Ministry of Health and Population as a guardian of this sector in the coming decades. The policy reform strategies aimed to improve access to health services and their financing, efficiency and quality over a four-year period at a cost of US$500 million, of which US$143 million was allocated to technical assistance of various kinds, including implementation of pilot projects. The effectiveness of this technical assistance was greatly influenced by the content of the policies proposed, as shown by the proposal for a basic package of services compared with that for regulation of accreditation. Research and analysis for the former failed to produce a consensus and had little impact on policy: this was largely because of the difficulty of restricting the supply of services on the basis of cost-effectiveness criteria. In the case of accreditation, the recommendations provided a very clear and powerful incentive for improvement in the quality of care and therefore received a high level of support from policy-makers and health staff. This, in turn, led to a further building of research and analysis capacity and the establishment of a dependable research team and accreditation experts with a well-developed and motivating professional career path. The prevailing context of health-sector reforms and weaknesses in project monitoring undermined the potential value of research and analysis. These conclusions point to the need to strengthen research capacity at the national level and to improve links with policy-making. 3

4 Acronyms BBP CCO DDM HIO MOHP/MOH PHR TSO TST USAID Basic Benefits Package Alexandria Curative Care Organization Data for Decision Making project (US Centers for Disease Control) Health Insurance Organization Ministry of Health and Population Partnerships for Health Reform Project (USAID) Technical Support Office Technical Support Team United States Agency for International Development 4

5 Prologue The aim of the Alliance for Health Policy and Systems Research (AHPSR) is to contribute to health development and the efficiency and equity of health systems through research on and for health policy. Its objectives are as follows: to promote capacity for health policy and systems research (HPSR) on national and international issues to collect information for policy decisions in the health sector and other sectors influencing health to stimulate the generation of knowledge which facilitates policy analysis and improves understanding of health systems and the policy-making process to strengthen international research collaboration, information exchange and learning across countries to identify global-level influences on health systems and promote appropriate research. As we pursue these objectives, we have realized that we do not know enough about how research actually affects policy in lower-income countries. How are research topics identified and priorities set? How are funding and other resources mobilized to produce evidence? What have been the consequences of exercises in priority-setting in the past? What has been the impact of research on policy? What are the factors affecting this process? In order to answer these questions, in early 2001 the Alliance launched two series of case-studies. The first dealt with the enabling environment, relating donors, clients, users and producers of research throughout the life of a research project. The second approach concentrated on the structure of innovative, research-based policy development institutions in relation to the external environment. Different processes were followed to produce the case-studies, although all produced working papers which were peer-reviewed. Enabling environment These case-studies identified relevant indicators for assessing effectiveness in the relationship between research funding, production and utilization. The studies would also be used for training in the research-to-policy process, forming part of a curriculum being developed in an international collaboration. Case-studies were prepared to encourage discussion about the processes and mechanisms which affect support for research and its impact. To achieve this, the case-studies followed the management school format, where specific decision situations are described. Researchers were trained to undertake and write case-studies for this purpose. The case-studies then sought to identify challenges in the setting of research priorities, decision-makers support for research and the benefits they gained from the research process and its results. They investigated the interplay of institutional mechanisms which 5

6 bring stakeholders together in an enabling environment. Attention was therefore given to the factors which bring actors together to agree on funding, support and utilization of research. The Alliance launched a call for proposals and selected six researchers from five countries: C.A.K. Yesudian (Tata Institute of Social Sciences, Maharashtra, India) Francisco Yepes (Colombia) Mahmoud Abdel Latif Salem (Egypt) Absatou N'Diaye Soumare (Mali) Godfrey M. Mubyazi and Joseph Mwanga (Tanzania). In each country, a policy issue was identified and at least one research project undertaken. Policy issues were selected according to various criteria: relevance for the health sector within countries, diversity across countries, and the researcher s familiarity with the policy process and research in question. Within each policy and research area, researchers were given the choice of focusing narrowly on priority-setting, project financing or utilization, or covering all three aspects in a single case-study. Particular attention was paid to describing the influences shaping project selection and the establishment of research programmes, the role of diverse mechanisms and actors, and the incentives available to increase relevance for national and local problems. The financial and human resources available to support the research-to-policy process were also described by examining resource flows for specific projects and stages of the project. The impact of HPSR was analysed by observing research inputs and decision outputs in specific policy development situations. Research inputs would be studied from the supply side by analysing problems of HPSR dissemination, and from the demand side through an examination of the participation of researchers as part of the policy-making process. The influence of different types of knowledge from empirical findings in data-driven design situations to broad conceptual frameworks, for example for health sector reforms was to be explored. Case-studies would focus on policies with explicit decision points, ample choices and scope for technical design, as well as on those which operated in a more restricted or political environment. Research institutions The second series of case-studies focused much more closely on a single institution, with the primary aim of influencing the policy process through research and analysis. The main perspective was therefore the institution s internal organization and its relations with the external environment. Four Alliance partner institutions were selected to develop the case-studies: Health Systems Research Institute (HSRI), Thailand (researcher: Wiput Phoolcharoen) Mexican Health Foundation (Guillermo Soberon et al.) Health Systems Trust in South Africa (Gcinile Buthelezi) 6

7 Colombian Health Association (ASSALUD) (Francisco Yepes). These institutions have in common a focus on policy development based on research. Three of them are private, non-profit agencies with close links and working relationships with ministries of health and other government units, while HSRI is a public agency with a Board of Directors including non-government participants. The terms of reference of the papers were quite broad, asking a member of the institution to describe its structure and organization as well as its relationships to decision-makers in the country concerned. More specifically, the researcher was asked to identify promising HPSR management strategies, to analyse their benefits and challenges, and to discuss the applicability of research management innovations for other developing countries and the lessons to be learned. 7

8 Introduction The author was closely involved in the research and policy analysis activities narrated in this case-study. During this period, he was project officer, health economics officer and benchmarks coordinator for the Technical Support Office of the health-sector reform programme in the Ministry of Health and Population. He was also coordinator of Egypt's Data for Decision Making project, in charge of planning and training for the national health account and budget tracking system. While the case-study is based on the author's personal experience, efforts were made to validate and enrich his views by documentary analysis (referenced in the text) as well as by peer review. However, the case-study does not aim to provide a comprehensive or necessarily unbiased account that would be shared by all participants. Rather, the intention is to highlight processes that were significant in the author's view and to offer them for discussion of more general issues in the research-to-policy process. A personal view It was a very hot day in the summer of 1993 when I went to say hello to a close friend, then the Director for Planning at the Ministry of Health and Population of Egypt. After catching up on the latest news, she surprised me by saying: Why don't you come to work with me as researcher in a new project? It's called Data for Decision Making. She didn't take long to convince me since my salary would be doubled, I would be able to concentrate on a single job, and an old dream of travelling and learning abroad would become a reality. On the downside, it troubled me that I didn't feel expert at the job, it had no clear career path and the project had a limited life span. Nevertheless, the opportunity was in stark contrast to my many years as a specialist clinician at a Ministry of Health and Population general hospital, having to supplement my earnings with many other jobs. My trust in my friend, her constant encouragement and the belief that this project was going to make a big difference convinced me to hang up my white coat, at least for the time being. It took me a long time to understand and adjust to the new job; everything was completely different from surgery. Budget, expenditure, accounts, policy, economics and many other words became familiar language. This is the first experience for the Ministry of Health and Population in this kind of project. Information for reform We should see health-sector reform in Egypt in the context of a highly urbanized middleincome country of 64.5 million people, where 38% of the population are below 15 years of age. While adult illiteracy remains high at 39%, important advances have been made in health, as demonstrated by the 42% decline in the infant mortality rate from 108 (between 1978 and 1982) to 63 (between 1991 and 1995). The Egyptian economy is the second largest in the region, and has expanded steadily over recent decades. The per capita income is US$1 440 and health expenditure is 4% of GDP. Constitutionally, every citizen is eligible for health services, and this has created a large public-sector health service. However, as in so many other countries, public services are of poor quality and are normally avoided by those who can afford private care. 8

9 About 35% of the population are insured with health insurance organizations, which offer better care but have their own limitations, such as patient overload and overprescription. The private sector is therefore a large and rapidly expanding business, yet physicians do as they wish, with little oversight by government or their peers. Often the same low-paid professionals who offer poor-quality care in the mornings open their doors to dissatisfied patients in the afternoon to supplement their incomes. The multiplicity of governmental and private entities, and their dubious interconnections, has become a problem in itself. In a health system characterized by dwindling resources, wasteful and lacking appropriate structures and incentives, we were all convinced that health-sector reform should be directed towards making better use of what resources there are. Yet how could such an ambitious reform move forward without valid and reliable information on health needs, service costs and utilization, and on the economic burden borne by the Government, families and employers? Many departments and ministries within the Government of Egypt expend considerable effort in collecting and compiling data on various aspects of the health care system. However, in practice, much of this information is not widely disseminated or accessible, even to high-level officials. Even when information is available, it is often contradictory, because of standardization problems and unreliable data collection. The Ministry of Health and Population soon realized the importance of reliable data for decision-making and set about obtaining it. Little did it know that, without an appropriate research-to-policy environment, this considerable investment would not provide as much as it had promised. The DDM project in Egypt The Data for Decision Making (DDM) project in Egypt started in 1993 as a three year, US$3 million, USAID-funded technical support project in collaboration with the Harvard School of Public Health and the Research Triangle Institute of North Carolina, United States of America. The project was designed to improve planning and policy development capacity in the Ministry of Health and Population's Directorate of Planning. Its major goals included: development of a computerized budget-tracking system to enable the Ministry to monitor the allocation of public spending to various programme categories estimation of national health accounts to identify health-sector funding sources and usage identification of essential clinical services and public health interventions by means of a cost-effectiveness analysis a national household health and expenditure survey, linked to a provider survey, to clarify the factors governing the use of public and private health care services assessment of the actors and events in the health-sector decision-making process, with political mapping. During the project s lifetime, a mass of research findings was made available and very serious health system analysis was undertaken, including: national health accounts cost-effectiveness of 30 priority health interventions 9

10 household surveys on health care utilization and expenditure health care provider surveys political mapping of strategies for policy change analysis of equity, quality of care and demand for care tracking of Government budget and expenditure. Egypt was already engaged in major system change initiatives prior to the DDM studies, including the expansion of social health insurance coverage to schoolchildren and the introduction of cost-recovery in Government hospitals (1). But the Ministry of Health and Population was still lacking essential information needed to assess the situation and design of the initiatives and to monitor reform strategies. One of the main benefits of DDM's studies and reports was that they provided convincing evidence that Egypt could solve its problems and greatly strengthen its health system performance. This was an enormous boost to morale within the Ministry. As one report stated (2):... Although Egypt s performance cannot be characterized as exceptionally poor in comparison with other developing countries, there is considerable room for improvement If the distribution of public health care subsidies in Egypt more closely resembled that of MOH services, then Egypt would be performing better than most developing countries. The national health accounts and budget tracking system provided robust evidence to support health care spending (3,4). The evidence made it clear that Egypt was dealing with a range of problems that could not be solved merely by throwing money at the system. Careful and risky changes requiring political commitment would be needed. Preliminary findings In June 1995, the preliminary DDM findings were presented to the Minister of Health and Population and senior Ministry officials at a major workshop. The findings were very detailed and, inevitably, controversial. Curative care was swallowing up more than three-quarters of the health budget, while preventive care was accounting for less than 10%, and expenditure on salaries was 3-4 times that on medicines. The workshop engendered an enormous amount of enthusiasm and discussion, in spite of the fact that the subject was very new and the language of the presentations, mostly by Harvard professors speaking in English, was a barrier. The discussion focused on the need for substantial changes in the functions carried out by the Ministry of Health and Population, to be backed up by new health policies and strategies. Ministry participants, assisted by DDM, drafted a list of goals, strategies and actions to improve the performance of the national health system through new investment and better use of existing resources (5). These proposals focused on the needs of the poor groups in society and the need to ensure access to high-quality and affordable essential services for all Egyptians. The major objectives emerging from the meeting were: to revitalize the Ministry of Health and Population so that it could maintain its leadership role in the sector in the coming decades to prepare for social health insurance 10

11 to develop an appropriate public/private sector partnership. The presentation of the DDM results opened up a heated debate, which intensified the need for change. The pluralistic and inefficient nature of the health sector meant that health reform would bring substantial economic benefits. There was general agreement that drastic action had to be taken. There was a widespread debate about the size, shape and cost of the Government's new vision. Inspired by DDM's early findings and the success of the first presentation workshop, the Government of Egypt began to prepare for large-scale reform of the health system. One of its first steps was to obtain financial support, which in turn led to further analyses. Partnerships for Health Reform studies Between June and September 1996, in response to a request by the Ministry to USAID in Cairo, the USAID-funded international project Partnerships for Health Reform (PHR) conducted short-term analyses to support and inform the design of programme assistance for the forthcoming health-sector policy reform. This assistance was intended to provide technical and financial support for the Government of Egypt in planning and implementing a series of health policy reforms. The analyses included economic, social, legal, political and institutional studies designed to answer two questions: Are the proposed reforms feasible? What will be their impact? (6-12). The economic analysis (7) concluded that the Government of Egypt should use the reform agenda and health-sector programme assistance as opportunities to reduce inefficiency in the health sector and reap the substantial economic benefits and gains in efficiency that would accompany the reforms if they were implemented properly. The social vulnerability analysis (8) established that most aspects of the policy reform agenda would have positive effects on socially vulnerable populations. The legal analysis (9) pointed to the need for presidential and ministerial decrees or amendments to existing laws in order to implement some of the activities effectively. Political mapping indicated there was room to move forward with health-sector reforms and policy changes deemed politically safe (10). The analysis of health care providers' institutional capacity (11) concluded that institutional obstacles could be overcome and that implementation should be encouraged. In its summary (12), the report noted that the diversity and intensity of existing problems were ideal for a sectoral approach to reform. It suggested several ambitious, yet feasible, strategies to improve financing, efficiency, access to and quality of health services. The analyses attempt to estimate the impact of the reforms on the health sector, and several of them offer specific suggestions for refining reform strategies in order to achieve the best results. The overall findings suggested that the policy reform strategies (aimed at improving financing, efficiency, access to and quality of health services in Egypt) comprised an ambitious, yet feasible, reform agenda. The reports also emphasized several major challenges for successful health-sector reform in Egypt, and recommended refining the strategies in order to achieve the best results. This analytical background provided guidance for the process of policy and change management, with principles for implementing health policy reform. 11

12 At that time (early 1996), a new Minister for Health, Professor Ismail Sallam, was appointed. The Minister held intensive meetings with PHR and other donors to review the recommendations and the options for the new policy strategy (13). He endorsed a set of broad benchmarks based on PHR recommendations, and was particularly enthusiastic about the research and information components (6). The Minister's response led to agreements with the World Bank, USAID and the European Union, which provided a basket full of cash and technical assistance for a giant million health-sector reform programme of over $400 million 1. Out of this, US$143 million were for technical assistance of various kinds, of which USAID provided US$20 million (14). It is worth noting that the proposed amount for technical assistance was initially US$7 million, but early in 1998 the Ministry of Health and Population received US$13 million from USAID through the Ministry of International Cooperation to implement the pilot projects. The technical support was targeted on the development and implementation of health-sector policy reforms through support for a data-based policy process; technical assistance to monitor and verify the achievements of policy measures, and task forces to assist in targeted health policy reform areas 2. Donors went on to establish a cooperative agreement that laid the foundations for the project's operation manual, defining the project components and activities with terms of reference for technical assistance. It also described the role of the Ministry of Health and Population in the proposed institutional and implementation arrangements. Pilot projects Early in 1997, several task groups were established by the Minister and the major donors to examine strengths and weaknesses and identify the potential for reform in specific areas. The groups were composed of Ministry staff and technical advisers, both national and international, provided by DDM, and were led by senior Ministry officials 3. The task groups drew up recommendations and proposals for new policies and strategies in the areas of financing, health service mix, infrastructure, pharmaceuticals and human resources. One of their main conclusions was that the reform strategy should aim to achieve universal coverage of a package of effective primary care services through changes in health-sector financing, the establishment of economic incentives for providers and reliance on both public and private providers (15). Initial estimates suggested that a well-designed system would actually increase coverage and benefits while reducing total health expenditure. The task groups deliverables were supposed to reflect the Egyptian vision and needs for reform, help to set reform priorities and answer the question: Where do we begin?. 1. Donations by USAID, the European Community, the Japan International Cooperation Agency (JICA) and the Danish Agency for Development Assistance (DANIDA) added up to nearly US$200 million, while loans from the African Development Bank and the World Bank came to just over US$100 million. These contributions were matched by a local contribution of US$100 million. 2. USAID project no , Technical support for health policy. Amount: US$20 million planned. Initiated: financial year The author was a member of the Health Finance and Insurance Group. 12

13 The Minister made the decision, based on the groups recommendations, to focus the first phase of the health-sector reform on the primary health care delivery system (15). The plan called for a new health service delivery system, making use of both public and private facilities in a family health approach. A family health model was proposed, which would coordinate family health units, family health centres and district hospitals at the district level. Family health units were to deliver a basic benefits package to an identified population and physicians there would act as gatekeepers to the higher levels of care. A new Family Health Fund would purchase services from the newly developed and accredited facilities and offer performance-based incentives to encourage provider efficiency and quality. Resource standards for the units and centres would be developed by the Ministry through a master plan to be supported technically and financially by the World Bank. This would first be piloted in three governorates: Alexandria, Menoufia and Sohag, and later extended throughout the country. USAID was to help the Ministry to test this new service delivery model to decide what worked and what did not before it was extended to other areas. The European Union would furnish a team of advisers to assist the Ministry in addressing training and workforce issues. Project oversight The operation manual (16) called for the creation of several entities at the central and local levels to assist the Ministry in the management and implementation of the reform. A Health Policy Forum was to be set up as an informal ad hoc advisory committee for the Minister that would ensure full participation of all stakeholders. A Planning and Monitoring Committee would be established with Ministry undersecretaries, the director of the Technical Support Office of the Ministry s health-sector reform programme and senior representatives from the Health Insurance Organization 1, the Alexandria Curative Care Organization (CCO) and the Egyptian Medical Syndicate 2. Its main role was policy formulation and planning, as well as monitoring of the overall outcome of the reform. A Technical Support Office (TSO) would be established at the national level to provide liaison between the donors and the Minister and to manage the financial and procurement aspects of each part of the reform, in line with donor requirements. The Technical Support Office would also provide technical support in health economics, information systems, health facility planning and public health, and would be responsible for monitoring and documenting the achievement of specific benchmarks (see below). Finally, Technical Support Teams (TSTs) would be established in each of the three pilot governorates to provide liaison between official health staff and the Technical Support Office in coordinating all implementation activities. For PHR, the research and monitoring activities of these units fell far short of expectations. The PHR assessment of the Technical Support Office and Technical Support Teams concluded that: the groups were often unclear about their purpose as well as how to work together to accomplish it effectively (17). The Planning and 1. The Egyptian social health insurance authority, an autonomous Government organization under the supervision of the Ministry of Health and Population. 2. The Egyptian physicians association. 13

14 Monitoring Committee did not develop the tools or indicators required, and donors were not sufficiently supportive of this work. The main role of the Committee was policy formulation, planning and monitoring of the reform outcome. It was also responsible for evaluating the impact of the project in terms of health outcomes, access, efficiency and quality (14). Nevertheless, no research for the establishment of methodologies or indicators for monitoring and evaluating the reform were included, although funding was available. Consequently, the Committee did not assume an effective role in the evaluation of the project. While there were plenty of earmarked resources and staff were willing to participate in research and analysis, training was sporadic and disordered. The absence of a realistic training plan and the rapid turnover of staff greatly weakened the Technical Support Office s technical capacity for research and analysis. Here again, research was relegated to second place because of the magnitude of the core financial and administrative tasks. The limitations in capacity-strengthening were recognized in PHR's report (17): The TSO and TST were established as reform implementation organizations at the suggestion of the major donors. However, no one donor assumed clear responsibility for capacity building and team development for the TSO and TST. As a result, the groups were often unclear about their purpose as well as how to work together to accomplish it effectively. At the same time both groups were responding to significant support requests from ministry counterparts, donor technical teams, and other government officials. They did not control sufficient resources, of time or personnel, to allow in-depth participation in extensive capacity building activities. The role of USAID USAID had a history of over 20 years of support for the Egyptian health sector. It was thus decided very early in the reform process that this donor would play a lead role in providing technical support to develop and pilot-test the reform in the following areas: strengthening the role of the Ministry of Health and Population in providing and financing preventive medicine and primary health care rationalizing the Ministry s role in providing and financing curative care reforming personnel policy developing the Ministry s role in regulation and accreditation and its capacity for national health planning and management supporting strategic planning, policy analysis and management ensuring the viability of the Health Insurance Organization as the instrument for the expansion of social insurance expanding social health insurance coverage, with adequate administrative and financing mechanisms. Each of these areas was to be developed and evaluated with regard to specific benchmarks, defined as a number of broad outcomes and specific measurable indicators. Achievement of these benchmarks would trigger subsequent tranches of USAID financial support. Benchmarks were a mixture of legal and legislative changes, Government policy reforms and changes in administrative and management procedure. 14

15 It was recognized that, if they were to influence policy, these indicators had to be further developed and discussed with the Ministry of Health and Population at national level. However, according to PHR (17): the process for setting, communicating, and achieving the benchmarks was essentially a top-down activity. As such, local champions of change and change agents felt little or no ownership for their accomplishment. Discussions between the minister and USAID did not involve local change agent groups and there was no formal process in place for the minister, as the champion of change, to communicate his commitment to achievement of the benchmark indicators to these important local change agents. (t)he TSO has not developed a mechanism for formal assessment of progress and impact, or implemented an approach to bring together MOHP change agents to openly discuss lessons. This process led to the serious drawback that Ministry officials had no opportunity to assume responsibility for a specific element of the reform and its associated indicators of success. A consequence of this was a lack of commitment to the reform process, reflected in the delay in the achievement of benchmarks (18). According to PHR (17): the resultant resistance to the Benchmarks was unavoidable since there was no ownership of this process by local change agents who actually did the work of the reform implementation. Designing instruments In 1998, USAID requested PHR to provide technical assistance to demonstrate an effective system for primary health care in Alexandria, one of the three pilot governorates. The pilot project comprised the following three components: provision of a basic package of services using the Family Health Care model financing through the Family Health Fund regulation of finance, accreditation, information and contract management. The Basic Benefit Package (BBP) This instrument was designed in late 1997, primarily by the Ministry s Quality Improvement Unit, assisted by PHR. Ministry officials and vertical-programme directors were first consulted to establish a preliminary list of interventions. In early 1998, the World Bank developed a restricted list of services for primary health care. Several discussions took place from this point forward involving USAID, PHR, World Bank officials, Ministry counterparts and vertical-programme directors in order to develop this list into a benefits package of services. The advisers later trimmed the preliminary list down. mainly for budgetary reasons. The BBP design did not benefit greatly from previous analyses undertaken by the DDM project, although the latter was designed precisely to identify service priorities and costs on the basis of actual facility data and demand for services (19). Part of the reason was that DDM data was limited to costing studies for a number of primary health care centres and hospitals, and did not analyse effectiveness because of the absence of 15

16 epidemiological data. Furthermore, a burden-of-disease study that would have furnished this data was dropped at an early stage by the DDM foreign advisers. The BBP was therefore based on more generic models developed by the World Bank, using projections of burden of disease, while PHR adjusted the model to fit its cost estimation. The result was a restricted set of services that was met almost immediately with opposition, as there was a constant pressure from the MOHP counterparts to add more services to the package (17, p.53). Ministry officials and analysts favoured additional services supported by demand data obtained from previous surveys. Foreign advisers argued that it would not have been possible to include these services at the beginning of the pilot project with the required quality, given budgetary, time and human resource limitations. Disagreements became a bone of contention between national and foreign advisers, leading to rather acrimonious discussion of the package contents 1. While a few interventions were eventually added as a result of negotiations, the BBP came to be locally perceived as foreign and impracticable. Accreditation The Ministry s Quality Directorate developed the necessary policies, standards and accreditation procedures with assistance from PHR. Public and private facilities were to be assessed for technical and interpersonal quality. Accredited facilities would then be allowed to enter into contracts with the Family Health Fund, thus providing a very clear and powerful incentive for improving the quality of care. A methodology would also developed to allow the facilities' staff and management to use the results of the assessment to identify priorities and develop workplans for improvement. PHR held introductory seminars for the Quality Directorate staff on the principles and philosophy of accreditation, first to build awareness and interest and then to achieve commitment to the accreditation standards. PHR blended and adapted standards from the internationally recognized, United-States-based Joint Commission on Accreditation of Healthcare Organizations and from the Egyptian vertical programmes and directorates to meet the unique requirements of the pilot districts. Research support at this stage was through the development of a facility level pre- and post survey. Research and analysis capacity was built up at the Quality Directorate and a dependable research team and accreditation experts were established. This effort succeeded in establishing a committed body for research and accreditation with a well-developed and motivating professional career path. This commitment was rapidly reproduced in the accreditation committees set up in the pilot facilities, leading to clear responsibilities for data collection and reporting. Consultations were very successful, involving a wide range of actors. 1. Alexandria meeting, September 1998, attended by PHR representatives (Dr Hassan Salah and Ahsan Sadik), Technical Support Team members, the health director of Alexandria (Dr Mahmoud Khedr) and Technical Support Office members Dr Emad Ezat, Dr Ibrahim Moustafa and the author). Unofficial meeting between World Bank representative (Akeko Mayeda), Technical Support Office representatives (Dr Hosny Tammam and the author) and Technical Support Team representatives (Dr Azza and Dr Sonia) during the World Bank Flagship course, Washington, D.C., October

17 Conclusions General considerations Piloting health-sector reform was more a good idea than a practical reality. Political considerations were introduced right from the start: it was considered that an early impact was required, so the launch date was advanced by six months (17, p.55). Furthermore, the best equipment, nurses and specialists available were directed to the pilot site to ensure its success. Because of the rush, the reform was implemented under the old regulations, thus delaying the implementation of the economic incentives which had attracted the best staff. Physicians and nurses were required to work long hours and devote themselves to the programme. They worked months without incentives, and when incentives did come they did so haphazardly. Many staff became disillusioned and some even quit, complicating the evaluation of the experience (17, p.59; 20). Health centres affiliated to the Health Insurance Organization were brought in later, suffered fewer staff changes and enjoyed the economic incentives, making their experience more valuable overall. Basic Benefit Package The Alexandria pilot made clear the limitations of the BBP. As PHR put it (17, p.57): The concept of a restricted basic benefits package was not practical. Patients could not be turned away by the family physician because their condition did not match the package list The most frequent diagnosis, arthritis, was not included in the BBP. In addition, the BBP was not clearly laid out and there were no boundaries between the level at which service should be provided and when it should be referred. Nevertheless, there was no effort to refine the BBP, as no detailed indicators had been designed as benchmarks for disbursement of further funds. All that the benchmarks required was to demonstrate that the BBP had been complied with when designing and providing quality care through a basic health benefit package in pilot facilities. As the evaluators put it, this was quite appropriate to a demonstration project, rather than one whose goals include broader major policy reform (17, p.65). Wisely, then, the PHR evaluation report advised not waiting for formal outsider verification of benchmarks to assess, evaluate and improve. However, the research system to enable this learning process was simply not in place. Accreditation programme The accreditation programme was perceived as a big success right from the start of the pilot. From the start and for the first time we felt that we were doing real work on the ground. Every member in the team has an input in the accreditation programme, we built it with our hands (21). The accreditation programme showed significant improvements after six months of implementation. The survey also identified specific strengths and weaknesses, supported the development of improvement plans and served to educate and involve new facilities in the process. The success of the accreditation system convinced the Ministry of Health and Population of the need to establish a national accreditation body. As the Minister put it: quality in medical services has been a high national priority and a main component of the Ministry's health reform policy (22). 17

18 Survey research in relation to the accreditation programme was also able to demonstrate the specific areas where patient satisfaction had been improved (23). These were the additional time given to the patient, the availability of drugs, and the general level of comfort. It also demonstrated the difficulty of implementing a comprehensive family medicine concept in the face of high patient turnover and family segmentation due to coverage of the family by overlapping providers (24). References 1. International Health Systems Group. Health sector analysis and the development of a primary care reform strategy in the Arab Republic of Egypt. Boston, MA, Rannan-Eliya, R. The distribution of health care resources in Egypt. Implications for equity: an analysis using a national health accounts framework (Harvard School of Public Health Publications Report No. 81). Boston, MA, Harvard School of Public Health Publications, Cressman, G & M Abdel Latif. Health budget tracking system Egypt phase I: Final report (Harvard School of Public Health Publications, Report No. 49). Boston, MA, Harvard School of Public Health Publications, Raviandra, P et al. Egypt National Health Accounts 1994/95. Cairo, Department of Planning/Ministry of Health/Data for Decision Making Project, Berman P et al. Egypt: strategies for health sector change. Boston, MA, DDM Publications, Setzer, JC. Suggested national health sector reform strategies, benchmarks, and indicators for Egypt (PHR Technical Report No. 5, vol. I). Bethesda, MD, Partnerships for Health Reform, Knowles, J & D Hotchkiss. Economic analysis of the health sector policy reform program assistance in Egypt (PHR Technical Report No. 5, vol. II). Bethesda, MD, Partnerships for Health Reform, DeRoeck, D et al. Social vulnerability analysis of the health sector policy reform program assistance in Egypt (PHR Technical Report No. 5, vol. III). Bethesda, MD, Partnerships for Health Reform, Hassouna & Abou Ali. Legal analysis of the health sector policy reform program assistance in Egypt (PHR Technical Report No. 5, vol. IV). Bethesda, MD, Partnerships for Health Reform, Hafez, N. Analysis of the political environment for health policy reform in Egypt (PHR Technical Report No. 5, vol. V). Bethesda, MD, Partnerships for Health Reform, Hafez, N. Analysis of the institutional capacity for health policy reform in Egypt (PHR Technical Report No. 5, vol. VI). Bethesda, MD, Partnerships for Health Reform, Partnerships for Health Reform. Assessing health sector policy reform strategies in Egypt: a summary of PHR analyses (PHR Technical Report No. 5, vol. VII). Bethesda, MD, Partnerships for Health Reform, Berman, P et al. A reform strategy for primary care in Egypt (PHR Technical Report No. 9). Bethesda, MD, Partnerships for Health Reform, World Bank. Project appraisal document for a proposed credit in the amount of SDR 66.8 million (US$90 million equivalent) to the Arab Republic of Egypt for a health sector reform program (World Bank Report No EGT). Washington, D.C., El-Khoby et al. Egypt health sector reform program: Reports of working groups on primary health care, curative care, and health finance/insurance. Cairo, Ministry of Health and Population, World Bank. Egypt health reform, operation manual. Cairo, Sadiq, A et al. Evaluation of the demonstration project for the financing of primary health care in Egypt (PHR Technical Report No. 60). Bethesda, MD, Knowles, JC. Egypt trip reports, February 6-March 23, MEASURE Evaluation. 18

19 19. Frère, J-J et al. Costing the Basic Benefit Package (Abt Associates Working Paper No. 2). Bethesda, MD, Abt Associates, Terrell, N, A Mahfouz & NM Soliman. Focus group results: family health pilot test in Alexandria, Egypt (PHR Technical Report No. 55). Bethesda, MD, Interview with Dr M. F., Quality Improvement Directorate, Ministry of Health and Population, Cairo, July Al-Ahram weekly, No. 477, April Rafeh N. Accreditation of primary health care facilities in Egypt: Program policies and procedures (MOHP Technical Report No. 65). Cairo, Ministry of Health and Population, Interview with R.T., quality improvement programme manager. Beirut, Abt Associates, August