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 Egypt’s 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 1990’s 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 Egypt’s 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 country’s 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