egy-roadmap-sj-health (2).pdf

 A Roadmap to Achieve Social Justice in Health Care in Egypt January 2015  © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202 473 1000 Internet: www.worldbank....

 A Roadmap to Achieve Social Justice in Health Care in Egypt January 2015  © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202 473 1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202 522 2422; e-mail: [email protected]. CONTENTS Acknowledgments viii Acronyms x Executive Summary 1 1. Aim: How can social justice be achieved in healthcare in Egypt? 17 2. Objectives: What are the objectives for achieving social justice in healthcare in 23 Egypt? 3. Diagnoses: What are the Challenges to Achieving the Goals for Social Justice? 29 3.1 Objective 1: Improve health of disadvantaged groups 32 Challenge 1: Poor maternal and child health inequitably distributed in rural, remote, and slum 32 areas Challenge 2: High burden of Hepatitis C overall with increased prevalence among poor, rural, 34 and low-education populations Challenge 3: High rates of undernutrition across wealth quintiles and geography 36 Challenge 4: Rising burden of NCDs, with higher prevalence of risk factors by gender and income 37 Challenge 5: Increasing prevalence of substance abuse and mental health issues, especially 39 among youth and women Challenge 6: High burden of disabilities especially among illiterate and rural populations 40 3.2 Objective 2: Increase financial protection for disadvantaged groups 41 Challenge 7: Limited coverage of healthcare costs for disadvantaged patients 41 Challenge 8: Lack of a strategic purchaser to enable a transition to SHI coverage for 43 disadvantaged groups Challenge 9: Lack of provider readiness for a strategic purchaser of services 45 3.3 Objective 3: Improve quality of healthcare delivery in public facilities 45 Challenge 10: Lack of responsiveness of health systems to disadvantaged groups 45 Challenge 11: Limited citizens’ participation, including grievance redress mechanisms at facility, 47 district, governorate, or national levels, especially for disadvantaged groups 4. Recommendations: How can Egypt achieve social justice in its healthcare 49 system? 4.1 Recommendations to improve health of disadvantaged groups 52 4.1.1 Addressing maternal and child health concerns 53 4.1.2 Tackling Hepatitis C 54 4.1.3 Understanding the drivers of undernutrition 56 4.1.4 Addressing NCDs 57 4.1.5 Prioritizing mental health and addiction 58 4.1.6 Addressing the needs of the disabled 59 4.1.7 Main strategies for moving forward 59 4.2 Recommendations to increase financial protection for disadvantaged groups 60 4.2.1 Equitable revenue collection 61 v  4.2.2 Pooling for equitable distribution 61 4.2.3 Purchasing strategically 62 4.2.4 Main strategies for moving forward 62 4.3 Recommendations to improve quality of care in health facilities, especially in 66 lagging regions 4.3.1 Create responsive, accountable, and accredited providers, especially in lagging regions 67 4.3.2 Increase citizen’s participation in financing, service delivery and monitoring of quality and 68 satisfaction, especially in lagging regions 4.3.3 Main strategies for moving forward 68 4.4 The Family Health Model: Supporting one social justice program in healthcare 71 for Egypt 4.4.1 Envisioning a model of “Family Healthcare Services for All by 2030” 71 4.4.2 How should Egypt implement the model? 73 5. Implementation: How should these recommendations be implemented? 77 5.1 Consideration 1: What are the enabling conditions to be addressed? 79 Cross-cutting condition 1: Developing an integrated referral system 79 Cross-cutting condition 2: Reforming the pharmaceutical sector to reduce costs and improve 80 quality 5.2 Consideration 2: Who are the actors and what are their roles for 80 implementation? 5.3 Consideration 3: How will the recommendations be funded? 83 5.4 Consideration 4: What legal provisions are recommended? 84 5.5 Consideration 5: What governing bodies need to be created or strengthened? 86 5.6 Consideration 6: What further research and studies are needed? 87 5.7 Consideration 7: How will implementation be measured? 87 6. Conclusion 89 References 92 vi Boxes Box 1: The “Right to Health” as captured in Egypt’s Constitution of January 2014 22 Box 2: Who are the “Disadvantaged” Groups? 27 Figures Figure 1: Twin goals proposed for Egypt to Achieve Universal Health Coverage 21 Figure 2: Three overarching objectives to achieve social justice in healthcare in Egypt 26 Figure 3: Eleven main challenges to achieving social justice objectives in healthcare 31 in Egypt Figure 4: Trends in early childhood mortality, Egypt, 2008-2014 32 Figure 5: Differences in MCH outcomes between most and least advantaged children, 33 Egypt Figure 6: Trend in the total fertility rate, Egypt, 1980-2014 34 Figure 7: Prevalence of HCV among different subgroups in Egypt 35 Figure 8: Trends in nutritional status of young children, Egypt, 2000-2014 36 Figure 9: Leading causes of mortality and morbidity in Egypt and their change 39 between 1990-2010 Figure 10: Cause of disability/difficulty in Egypt (%) 40 Figure 11: Health financing indicators in Egypt 41 Figure 12: Percent of household income spent on healthcare by income quintile, 42 Egypt Figure 13: Sources of health financing in Egypt 43 Figure 14: Choice of providers for outpatient care by income quintile 46 Figure 15: Factors contributing to dual practice 47 Figure 16: Recommendations to improve the health of disadvantaged groups 53 Figure 17: Recommendations to increase financial protection for disadvantaged 61 groups Figure 18: Recommendations to improve quality of healthcare in public facilities 66 Figure 19: Model of “Family Healthcare Services for All by 2030” 72 Figure 20: Short-, medium-, and long-term strengthening of the “Family Healthcare 75 Services for All by 2030” model Figure 21: Implementation arrangements for proposed roadmap 79 Tables Table 1: Average premium and costs of HIO beneficiaries (LE) 44 Table 2: Key healthcare actors in Egypt and their roles 81 Table 3: Current and expected future fiscal space for health based on the 83 Constitutional mandate vii  ACKNOWLEDGMENTS This paper was coauthored by Aaka Pande (Health Economist, GHNDR), Alaa Hamed (Senior Health Specialist, GHNDR), and Amr Elshalakani (Health Specialist, GHNDR). We are grateful for the leadership, guidance and encouragement from Enis Barış (Practice Manager for the Middle East, North Africa and the Caribbean, GHNDR). We gratefully acknowledge the support received from the incumbent Minister of Health and Population, His Excellency Dr. Adel El-Adawy, and his predecessor Dr. Maha El- Rabbat. This roadmap was developed at their direct request, and we greatly value their continuous support, input, and leadership. The content of the paper was enriched by discussions with Ministry of Health and Population (MOHP) leadership and staff, whom we thank for their time and expertise. These include: Dr. Hanaa Amer, Deputy Minister; Dr. Wagida Anwar, Advisor to the Minister; and Sector Heads Dr. Mohammed A. Rahman, Dr. Hisham Atta, Dr. Emad Ezzat, Dr. Atef El-Shitany, Dr. Mohammed Sultan, and Dr. Amr Kandil. We also appreciate the valuable inputs from MOHP officials: Dr. Soad Abdel-Maguid, Dr. Hala Zayed, Dr. Hala Massekh, Dr. Desiree Labib, Dr. Kawthar Mahmoud, Dr. Ahmed El-Ansary, Dr. Omaima Metwally, Dr. Ali Gadallah, Dr. Hanaa Moustafa, Dr. Nagwa El-Ashry, Dr. Hala Youssef, Dr. Samia El- Nahas, Dr. Naira Niazi, and Dr. Abou-Bakr El-Mekkawy. This appreciation is extended to the leadership and staff at the Regional Health Directorates, Family Health Funds, and various facilities at Cairo, Luxor, Menoufia, and Alexandria governorates, who welcomed us and shared their rich experiences during the field visits. We thank health experts in Egypt who shared their candid views to help strengthen the format and recommendations of the paper through multiple engagements. This includes, but is not restricted to, a spectrum of academicians, senior health professionals, policymakers, and representatives of professional associations. We thank Dr. Alaa Ghannam, Dr. Mostafa Hunter, Dr. Sahar El-Tawila, Dr. Fatma El-Zanaty, Dr. Waleed El- Feky, Dr. Emad El-Azazy, Dr. Salah Shady, Dr. Ahmed Rashad, Dr. Ayman Sabae, Dr. Heba Nassar, Dr. Naglaa Arafa, Dr. Yasmin Abbas, and Dr. Amal Shafik. Valuable arguments and inputs for health care financing were provided by Dr. Mohammed Maait, Ms. Mai Farid, and Ms. Nada Sonalla. Moreover, credit is due to the staff at the Higher Public Health Institute of Alexandria University, led by Dr. Ibrahim Kharboush, for their high panel discussions and strategic comments. Many CSOs contributed and enriched the discussions during the consultations, namely: Misr El-Kheir Foundation, Egyptian Initiative for Personal Rights (The Right to Health Division), Nebny Foundation, Al-Hassan Foundation for Spinal Cord Injuries, Bashayer Helwan, Association of Upper Egypt for Education and Development, Tamkin Association, and Lifemakers - Insan Project. This work benefited from several fruitful discussions with international development partners, including the following colleagues: Dr. Henk Bekedam, Dr. Magdy Bakr, and Mr. Riku Elovainio (WHO); Dr. Magdy El-Sanady and Dr. Moataz Saleh (UNICEF); Dr. Magdy Khaled (UNFPA); and Dr. Mohammed Hamad (UNODC). viii  We appreciate the inputs of our World Bank colleagues: Moustafa Abdalla (Social Protection Specialist, GSPDR) for his insightful views; and Souraya El-Assiouty (Program Assistant, GHNDR) and Mariam Ghaly (Administrative Assistant, CAIWB) for their overall support of the activities culminating in this paper. A very warm Thanks goes to Mohammed Duban, who assisted with review and typesetting of this document, and to Amy Gautam for doing a meticulous editing job in a very expedient time frame. Thanks due also to the professional photographers Amira Nour and Sara Fouad. A special thank you to the team at the Minister›s Technical Office of MOHP for its persistent and endless support in organizing consultations and field visits for the authors. We thank Dr. Ghada Nasr, Dr. Omkolthoum El-Sayed, Dr. Yasser Omar, Dr. Makram Atef, and the wonderful team assistants Leila Hessien and Amira Ahmed for their help. Finally, this paper is grateful to the many people who shared their stories with us— the old man selling vegetables in Luxor, the pregnant lady in Menoufia, the teenager in Alexandria, and the felucca sailor in Cairo, to name a few--and to all the people of Egypt whose bravery and expression in change over the past few years have sparked the impetus for this document. With this roadmap paper, we aim for a new partnership in Egypt that will foster the reality of a fair and accountable health system based on the principle of social justice. ix  ACRONYMS CSO Civil society organization DALY Disability-adjusted life-years DHS Demographic and Health Survey ESCWA Economic and Social Commission of Western Asia FGM/C Female genital mutilation/cutting FHF Family Health Fund FHS Family Health Service FSC Family Smart Card GDP Gross domestic product GoE Government of Egypt GRM Grievance Redress Mechanism HCV Hepatitis C Virus HHEUS Household Health Expenditure and Utilization Survey HIO Health Insurance Organization HMIS Health monitoring information systems IMCI Integrated Management of Childhood Illnesses KPI Key performance indicator MCH Maternal and child health MDG Millennium development goal MENA Middle East and North Africa MOF Ministry of Finance MOHP Ministry of Health and Population LE Egyptian pound LMIC Low and Middle Income Countries NCD Noncommunicable disease NGO Nongovernmental organization OOP Out-of-pocket PBR Patient Bill of Rights PTES Program for Treatment at the Expense of State SHI Social health insurance UHC Universal health coverage UN United Nations WHO World Health Organization x EXECUTIVE SUMMARY Figure ES1: Overview of roadmap to achieve social justice in healthcare in Egypt AIM OBJECTIVES KEY CHALLENGES RECOMMENDATIONS Maternal & child health Creating or supporting National Action Plans Hepatitis C Supporting an integrated Improve health Under nutrition family health services model of Monitoring and surveillance disadvantaged Non Communicable Diseases of high risk groups groups Supporting key disease Mental health Social Disability specific interventions Justice in Separation of provision and Health Increase Limited coverage for poor purchasing Reforming existing payers financial Defining and costing package of services protection for Lack of strategic purchaser Defining provider payment disadvantaged mechanisms groups Preparing providers for Lack of provider readiness contracting Improve quality of health care in public facilities Training of providers Lackofofresponsiveness Lack responsiveness Independent accreditation Performance based Limited citizen’s participation financing Creating avenues for citizen’s participation Establishing grievance redress mechanisms Source: Authors. This paper lays out a roadmap to achieve social justice in healthcare by prioritizing areas related to service delivery, financial protection, and quality of care. The aim is to assist the Government of Egypt (GoE) in realizing the principle of social justice in the provision of healthcare. In doing so, the roadmap aims to prioritize key areas of focus for Egypt, including describing which existing programs to continue supporting and which new programs to consider for development, all under an integrated and interdependent structure. This paper is not meant to be an assessment of all the challenges facing the entire Egyptian healthcare system, but instead is a focused assessment of how the overarching aim of “social justice” can be achieved in the healthcare sector through an emphasis on improving services for the most disadvantaged groups. This is done in four stages: 1. Objectives: The paper lays out the three objectives that need to be reached to ensure that social justice in healthcare is achieved. 2. Challenges: Next, it drills down to diagnose the eleven challenges currently preventing these objectives from being realized. 3. Recommendations: Then, it presents a series of fourteen recommendations by which these challenges can be overcome, drawing from successful pilots and programs in Egypt and global best practice. 1  4. Implementation arrangements: Finally, it puts forth a detailed description of seven implementation arrangements necessary to operationalize the proposed roadmap. The time horizon for this roadmap is the next three to five years (2015-2020). This roadmap suggests recommendations that will result in incremental improvements in Egypt’s healthcare system in the short to medium term with a focus on disadvantaged groups. Achievement of these results should situate Egypt on the path to achieving social justice in healthcare in the long term. The paper comes as the final product of a year full of hard work by the team involving the review of all available literature, field visits and interviews to the remotest villages in the far north and south of the country as well as multiple consultations with experts, officials, civil society and ordinary citizens themselves. 1. Aim: How can social justice be achieved in healthcare in Egypt? Achieving social justice is a pressing priority for both the people and the government of Egypt. To achieve social justice, a commitment must be made to ensure that the most disadvantaged have access to the same services as the average Egyptian—i.e., that everyone has the same “equality of opportunity” (World Bank 2012a). In the field of healthcare, this translates to all Egyptians, irrespective of income, gender, or geographic location, having access to the same standards of affordable, equitable, effective, and efficient healthcare. Attaining universal health coverage (UHC) is a commitment of the Government of Egypt (GoE) and is one way to ensure social justice in healthcare. To ensure fair, progressive realization of UHC, prioritization of services must take place, with mechanisms to ensure that disadvantaged groups are not left behind. Social justice in the healthcare sector can be achieved by ensuring universal access to health coverage for all Egyptian citizens through the provision of an affordable package of essential health services within Egypt’s fiscal space and as per its Constitutional mandate (see Box 1: Right to Health as Captured in Egypt’s Constitution of January 2014), with a special emphasis on disadvantaged groups (see Box 2: Who are the “Disadvantaged” Groups?) To ensure fair, progressive realization of UHC, prioritization of services must take place, with mechanisms to ensure that disadvantaged groups are not left behind. To achieve UHC, countries must advance in at least three dimensions. They must expand priority services, expand populations covered, and reduce OOP payments (WHO 2014). In each of these dimensions, countries are faced with a critical choice: Which services should be expanded first? Which populations should be included first? How can payments be shifted from OOP expenditure to a pooled prepayment scheme? This roadmap paper aims to assist GoE with this prioritization process to ensure progressive realization of UHC. Expansion of family health services (FHS) to all Egyptian citizens by 2030, with a focus on disadvantaged populations, is a concrete way to realize the principle of UHC and work toward social justice in healthcare. Family health services should comprise a package of essential health services related to Egypt’s burden of disease and would 2 include: maternal and child health (MCH); reproductive health and family planning services; prevention, screening, and treatment of noncommunicable diseases (NCDs); mental health; and nutrition. This package should be integrated into all levels of care, from primary health centers to district hospitals. Further, expanding mandatory social health insurance (SHI) to all Egyptian citizens by 2030, with a focus on disadvantaged populations, will ensure that Egyptians will be financially protected in an equitable fashion. This will ensure that no Egyptian will be pushed into or kept in poverty by paying for healthcare. SHI should ensure comprehensive risk pooling across various population segments and will expand health insurance coverage to include the poor at first, and then gradually, the informal sector. It should separate the institutional responsibilities for the purchasing function from service provision and will transform currently passive practices of payers into active purchasing 2. Objectives: What are the objectives for achieving social justice in healthcare in Egypt? Every health system can be thought to have three objectives—to improve health status, to provide financial protection, and to ensure patient satisfaction. Analysis of Egypt’s current health system through these lenses suggests that these objectives have only been partially met for certain outcomes or specific populations. With respect to health status, Egypt’s population has become healthier in the last 20 years, with an increase in overall life expectancy from 64.5 years to 70.5 years, though the benefits have not accrued equally (World Bank 2014b). Similarly, with respect to financial protection, while more than half of the population has access to some form of health insurance, 72 percent of all healthcare costs are still covered out of pocket (OOP; Rafeh et al. 2011). Finally, with respect to patient satisfaction, while patients in a recent survey generally ranked all facilities moderately high, but differences persisted by facility type (Rafeh et al. 2011). Consequently to achieve social justice in healthcare in Egypt, the following three objectives would have to be met: 1. Objective 1: Improve health of disadvantaged groups 2. Objective 2: Increase financial protection for disadvantaged groups 3. Objective 3: Improve quality of healthcare delivery in public facilities 3. Diagnoses: What are the challenges to achieving social justice in healthcare? Eleven challenges need to be addressed to ensure that social justice in healthcare is achieved. These challenges are based on an analysis of the gaps remaining in achieving the three health system objectives, identified through a detailed review of qualitative and quantitative data, peer-reviewed and grey literature, and national plans as well as discussions with health experts. Consensus on these challenges was based on several 3 in-depth interviews, rounds of consultations, and special workshops with experts from Ministry of Health and Population (MOHP), Ministry of Finance (MOF), Health Insurance Organization (HIO), civil society, NGOs, the private sector, donors, and academia during a yearlong process in 2013 -2014. For each challenge, there are particular groups who are particularly vulnerable; to assist them, additional effort is necessary. These challenges are: For Objective 1, (i) inequitable maternal and child health (MCH) in rural, remote, and slum areas; (ii) high burden of Hepatitis C overall with increased prevalence among poor, rural, and low-education populations; (iii) high rates of under nutrition across wealth quintiles and geography; (iv) rising burden of non-communicable diseases (NCDs), with higher prevalence of risk factors by gender and income; (v) increasing prevalence of substance abuse and mental health issues, especially among youth and women; and (vi) high burden of disabilities especially among illiterate and rural populations. For Objective 2, (i) limited coverage of healthcare expenses for the disadvantaged; (ii) lack of a strategic purchaser to enable a transition to social health insurance (SHI) coverage for disadvantaged groups; and (iii) lack of provider readiness for a strategic purchaser of services. For Objective 3, (i) lack of responsiveness of health systems to disadvantaged groups; and (ii) limited citizens’ participation, including lack of grievance redress mechanisms at facility, district, governorate, or national levels, especially for disadvantaged groups. Objective 1: Improve the health of disadvantaged groups Challenge 1: Poor maternal and child health (MCH) inequitably distributed in rural, remote, and slum areas Egypt has seen gains in MCH outcomes, as demonstrated by reductions in the last 10 years in the maternal mortality ratio by one-third, from 100.0 to 66.0 maternal deaths per 100,000 live births; and the under-five mortality rate by half, from 41.9 to 22.0 infant deaths per 1,000 live births (World Bank 2014a). However, neonatal mortality represents half of infant mortality and is disproportionately higher among those living in rural Upper Egypt. Concurrently, Egypt is witnessing an increase in fertility with a decline in the contraceptive prevalence rate. In addition, rates of female genital mutilation/cutting (FGM/C) remain extremely high, with 91 percent of all women aged 15- 49 circumcised (El-Zanaty and Way 2009). To address this, Egypt has developed a National Acceleration Plan for Child and Maternal Health (2013 -2015) (MOHP 2013) to speed up the progress in further reduction of maternal and child deaths, but it can be better targeted to disadvantaged groups. Challenge 2: High burden of Hepatitis C overall with increased prevalence among poor, rural, and low-education populations Egypt has the highest prevalence of Hepatitis C virus (HCV) globally, with the prevalence rate among 15- to 59-year-olds estimated at 14.7 percent (El-Zanaty and Way 2009). Groups with higher prevalence rates include lower educated populations, rural populations, low- 4 income groups, and men (Awadalla 2011; Mahmoud et al. 2013). Egypt developed a Plan of Action for the Prevention, Care and Treatment of Viral Hepatitis (2014- 2018) with several international best practices in place pertaining to prevention, treatment, screening, and surveillance. To our knowledge, the prior strategy on which this was based (2007- 2012) has not yet been formally evaluated and as a result, potential lessons that could have been learned have not been captured. Challenge 3: High rates of undernutrition across wealth quintiles and geography In terms of macronutrient deficiencies, around one in five children under the age of five are classified as stunted and one in ten are classified as severely stunted (El-Zanaty and Associates 2014). Wasting (weight-for-height) increased in the last 15 years, while the rate of underweight (weight-for-age) children saw no significant change (El-Zanaty and Associates 2014). More than one in four children in Egypt suffer from some degree of anemia, and rural children are more likely to be anemic than urban children (29 percent and 23 percent, respectively) (El-Zanaty and Associates 2014). As a result, Egypt is not on target to meet the World Health Assembly Nutrition targets. Presently, Egypt has a 10-year Food and Nutrition Policy and Strategy (2007–2017) in place, but MOHP does not have a nutrition unit (MOHP 2007). Challenge 4: Rising burden of noncommunicable diseases (NCDs), with higher prevalence of risk factors by gender and income Egypt is undergoing an epidemiological transition, with 72 percent of all mortality and morbidity in 2010 (captured in units of disability-adjusted life-years, or DALYs) due to NCDs (IHME 2013). The distribution of NCDs tends to be concentrated in older and wealthier populations, though a latent undiagnosed burden of NCDs is likely in poorer, less educated groups, who have reduced access to health services. Risk factors differ by gender and age. Presently, Egypt does not have a unified and costed national NCD plan and does not collect regular data on NCD risk factors, prevalence, and complications. Challenge 5: Increasing prevalence of substance abuse and mental health issues, especially among youth and women Unipolar depressive disorders and anxiety are among the main causes of disability and death (as measured in DALYs) among women aged 15 -49 (IHME 2013), while addiction, often a coping mechanism for mental health conditions, is rising among men (Hamdi et al. 2013). The lifetime prevalence of substance abuse is thought to vary between 7.3 and 14.5 percent with a prevalence of 13.2 percent in males and 1.1 percent in females (Hamdi et al. 2013). The government’s national mental health plan, developed in 2003, needs to be updated to reflect current needs (WHO 2010b). In addition, mental health services are woefully underfinanced and make up only 2 percent of the total government health budget; only 5 percent of undergraduate training hours at medical school are devoted to mental health teaching (WHO 2010b). Challenge 6: High burden of disabilities especially among illiterate and rural populations Estimates of disability in Egypt vary from 0.7 percent (ESCWA and League of Arab States 5 2014) to 10 percent of the population with up to 25 percent of the population thought to be indirectly affected either as family members or as caregivers (UN, date unknown). Disabled populations are more likely to be male, unmarried, illiterate, and rural. Egypt has a national council for disability affairs and provisions in the Constitution to address disabilities, but implementation of a national strategy has been weak. While disabled populations are entitled to certain services, disadvantaged disabled populations tend to be excluded. Objective 2: Increase financial protection for disadvantaged groups Challenge 7: Limited coverage of healthcare costs for disadvantaged patients Egypt spends less on healthcare than its regional peers, resulting in high OOP expenditures. Despite the presence of multiple public and semi-public health providers, around half of the population does not enjoy any type of formal coverage, especially those who are poor or employed in the informal sector (HIO 2011). In recent years, MOHP introduced interventions aiming to provide better access to health services targeted to disadvantaged groups, but they are yet to materialize into effective financial protection. Challenge 8: Lack of a strategic purchaser to enable a transition to SHI coverage for disadvantaged groups Egypt’s current health system is fragmented with a number of financing agents. Four key financing players are present and were designed to complement each other; in some cases, there are overlaps of coverage and provision of different packages of health services. In addition, inefficiencies remain within each institution. Challenge 9: Lack of provider readiness for a strategic purchaser of services Significant centralization, line item budgeting, and lack of service costing mechanisms have made providers unresponsive to local needs. Even with the creation of a strategic purchaser, most public providers lack the ability to interact with that purchaser. Objective 3: Improve quality of healthcare delivery in public facilities Challenge 10: Lack of responsiveness of health systems to disadvantaged groups Public health facilities are not considered responsive to patients, leading patients to pay for private sector care. Inequities persist by income, across governorates, and by gender. Supply-side payment mechanisms along with low wages for physicians and other health staff provide little incentive for better performance. Dual practice remains a pressing problem, with almost 80 percent of doctors working in both the public and private sector (Giuliano Russo 2013). 6 Challenge 11: Limited citizens’ participation, including lack of grievance redress mechanisms at facility, district, governorate, or national levels especially for disadvantaged groups Citizens’ participation in the delivery of health services is limited, hampered by the absence of formal grievance redress mechanisms (GRMs). While some facilities have complaint boxes or Patient Bill of Rights (PBRs), this is not uniform across all public facilities and ways of dealing with complaints or infringements of rights are ad hoc. No medical malpractice law exists and if a patient has a grievance with a physician, his complaint is usually referred to the Doctors Syndicate, a semi-autonomous union of all doctors, which may lack the impartiality necessary to assess such cases. 4. Recommendations: How can Egypt achieve social justice in its healthcare system? For Egypt to achieve social justice in its healthcare system and so attain its three overarching objectives, a multi-pronged approach is proposed. 1. Providing an integrated package of family health services mapped to the growing burden of disease, and targeting the scaling up of health services to lagging areas; 2. Expanding financial protection through social health insurance coverage for the poor and those in the informal sector; 3. Advocating for the separation of purchasing of healthcare services from service provision to enhance accountability in the health system, especially for disadvantaged groups; and 4. Increasing quality of healthcare and ensuring equitable distribution of a responsive health workforce through performance based incentives and accreditation; and improving citizen’s engagement in delivering, financing, and monitoring of services with a focus on service delivery to disadvantaged groups. Specifically, the multi-pronged approach consists of fourteen key recommendations. For Objective 1, the recommendations are the following: (i) creating or supporting targeted national plans to tackle high-priority health concerns; (ii) supporting an integrated family health services model care with appropriate referral mechanisms; (iii) monitoring or surveillance of high risk groups; and (iv) supporting key risk factor specific interventions, especially with respect to disadvantaged populations. As for Objective 2, it is recommended to ensure the following, especially for coverage of disadvantaged populations: (i) separation of purchasing and provision functions; (ii) reforming existing payers; (iii) defining and costing price of package of services; (iv) defining provider payment mechanism; (v) and preparing providers for contracting. To achieve Objective 3, the recommendations, especially for lagging regions, are: (i) training of providers in line with the new healthcare demands; (ii) attaining independent accreditation for public facilities; (iii) scaling up performance-based financing and other incentives; (iv) creating avenues for citizen’s participation in service delivery; and (v) 7 establishing grievance redress mechanisms and progressive legislature such as Patient Bill of Rights. Recommendations to improve the health of disadvantaged groups Provide an integrated package of family health services mapped to the growing burden of disease with targeted scale up in lagging areas. Egypt should promote an essential package of family health services delivered at the relevant level of care that would: (i) include cost-effective interventions related to maternal health; family planning and reproductive health, including nutrition and management of sexually-transmitted diseases; child health and immunizations; outpatient management of diabetes, hypertension, and cardiovascular disease; and tuberculosis treatment; (ii) be linked to public health programs for critical diseases like Hepatitis C and NCDs; and (iii) be linked to higher level of care through referrals. This would result in a revision of the expanded primary healthcare service delivery model proposed in 1999 so as to better meet the needs of the population include the package of services which will be covered by SHI. Specifically, this would entail adopting the following recommendations: Recommendation 1: Creating or supporting targeted national plans to tackle high-priority health concerns To prioritize the six health status challenges, it is important to either support existing national plans or draft new costed national action plans where they do not exist. For example, the existing National Acceleration Plan for Child and Maternal Health and recently launched Plan of Action for the Prevention, Care and Treatment of Viral Hepatitis in Egypt 2014- 2018 should be supported and enhanced to include a renewed focus on disadvantaged groups. However, national action plans for NCDs and disabilities do not exist at present and should be prioritized. Recommendation 2: Supporting an integrated family health services model of care with appropriate referral mechanisms, with a focus on disadvantaged groups To effectively and efficiently tackle the six priority health issues, an integrated family health service delivery model is required with a priority to expand its coverage to disadvantaged groups. This would result in a revision of the expanded primary healthcare service delivery model proposed in 1999 and include a basic package of services for MCH, NCDs, nutrition, mental health, and disabilities to better meet the needs of the population include the package of services which will be covered by SHI. Prevention, screening, and basic treatment (e.g., antenatal care visits, growth monitoring and promotion, and screening for NCDs and mental health) would take place at the primary level with a robust referral system to secondary and tertiary care facilities for more complicated cases (e.g., emergency obstetric care and NCD-linked complications) targeted to disadvantaged groups. Recommendation 3: Monitoring and surveillance of high-risk groups To effectively combat high-priority health conditions, it is important to have reliable, up- 8 to-date estimates of baseline disease prevalence and changing trends in incidence. These need to be representative at the governorate and, if possible, district level, and available for vulnerable subgroups. This would include a perinatal and neonatal surveillance system for maternal deaths; surveillance of NCDs (both risk factors and disease prevalence), nutrition, mental health, and disabilities; continued national surveillance of HCV among general and high-risk groups as part of the Demographic and Health Survey (DHS); and creation of a national registry of disabled persons. Recommendation 4: Supporting key risk factor specific interventions among disadvantaged populations Apart from the general recommendations, each disease also requires risk factor specific actions among disadvantaged populations. Some examples include: targeted demand creation through employing female community workers, and vouchers for family health services or conditional cash transfer schemes for nutrition; awareness campaigns around FGM/C, disabilities, mental health, and addiction; promotion of physical activity and good nutrition practices, including exclusive breastfeeding; distribution of new chemotherapies and promotion of infection control and blood safety for HCV; continuing food fortification programs for iron and Vitamins A and D in government food subsidy programs and encouraging the roll-out of fortified foods in the commercial sector; raising tobacco taxes further and extending and enforcing legislation to create a “100 percent smoke- free environment” in all indoor workplaces and public spaces; screening for tobacco use and obesity among high-risk groups; increasing the number of training hours devoted to mental health and the number of nutritionists and dieticians to deal with the growing dual burden of under nutrition and obesity; and creating disability accessible spaces. Recommendations to increase financial protection for disadvantaged groups To ensure financial protection to Egypt’s most disadvantaged groups, the system must provide adequate coverage plans for Egypt’s poor and then those working in the informal sector. This coverage should be dual: (i) state funded health coverage plans for a package of essential family health services; and (ii) support for enrollment in SHI to cover higher levels of service. This approach aims to mitigate the financial impact of enrolling those groups in any pooled funding mechanism, providing them with financial protection against healthcare costs while minimizing costs incurred by the community. In addition, to increase system efficiency and open up fiscal space to provide coverage to the most disadvantaged, payment and provision of care should be separated through demand-side financing using strategic purchasing and contracting, or through supply- side financing using performance-based financing schemes, or both. Specifically, this would entail adopting the following recommendations: Recommendation 5: Separation of purchasing and provision functions to increase accountability and efficiency for disadvantaged populations Separation of functions aims to improve efficiencies in service delivery. HIO should separate its internal payment and provision functions. The “Payer” division would assume 9 the roles of contributions management, provider management, claims processing, utilization management, and reporting. The “Provider” division would work on achieving efficient and quality services in HIO facilities. While this separation is challenging in a fiscally constrained environment, it must be prioritized to increase efficiencies in the system and allow for transition to a strategic payer. The new SHI organization should be established to assume the responsibilities of a payer without service provision. Recommendation 6: Reforming existing payers who provide coverage to disadvantaged populations Egypt is committed to achieving UHC as reflected in language on the “Right to Health” in the Constitution, and expanding SHI coverage is one way to achieve this aim. A multi-payer scheme could be introduced to upgrade the existing payers in preparation for a future merge into a strategic purchaser. During the transition, HIO could continue as the payer for formal sector workers, while another payer could be responsible for the poor and informal sector workers. The latter could be the Program for Treatment at the Expense of the State (PTES) as it was established to serve the uninsured. This requires introducing short- to medium-term reforms in all these organizations. This system is similar to ones used in other countries that have worked towards achieving UHC, such as Mexico, Chile, Thailand, and Colombia. In the long term, these two payers could be merged once their packages and rules and regulations are unified. For PTES: Upgrade purchasing functions to contract service providers based on different providers’ prices instead of providing financial support based on reimbursement; improve targeting mechanisms to limit access of the financially better off segments of the population; and gradually become a purchaser for informal sector workers (based on contributions that could be partially subsidized for the near poor) and the poor (based on non-contributory government subsidies). For FHFs: Become the entry governorate-level structures for strategic purchasing of a defined package of essential family health services at the primary and secondary healthcare levels based on payment for performance especially for disadvantaged populations; become the entry point for access to services provided under PTES and HIO, and later the national SHI fund; unify rules, regulations, and payment schemes at regional FHFs; and improve their efficiency by decreasing administrative cost. For HIO: Improve efficiency of HIO to create fiscal space to allow for an increase in coverage for the disadvantaged groups. To achieve this create a preliminary internal separation between purchasing and provider functions within the organization; introduce provider payment mechanisms applied uniformly and equally between HIO providers as well as with other public, university, and private providers; expand contracting practices to more fairly select both public and private providers based on a competitive process for those meeting minimum quality standards; upgrade health insurance functions such as beneficiary management, provider management, claims processing, and utilization management; move from a scheme dependent on individual enrollment to one based on family enrollment with the possibility of expanding coverage to formal sector workers’ dependents; unify the premium structure for formal workers, especially those covered under Law 32 and Law 79; encourage those who opted out of the system to return for 10 coverage against catastrophic illness; and establish partnerships with private health insurance companies to provide complementary packages. Recommendation 7: Defining and costing price of package of services, especially for healthcare needs of disadvantaged populations Egypt already enjoys a basic package of family health services at the primary care level as defined in 1999. Yet insufficient roll-out, lack of financial sustainability, and segregation into different vertical programs prevent it from providing UHC. Reviving the package requires efforts more on the operationalization level and adjustment of the package of services included to be responsive to the needs of disadvantaged populations. Costing of the different components must be revisited to determine actual unit costs that could be translated into programmatic budgets through MOF allocations. In addition, the package should be upgraded to meet the new health needs of Egypt including prevention and treatment of NCDs, disabilities, and mental health conditions. Specifically, the family benefits package should ensure the integrated provision of three groups of services, selected based on priority problems and cost-effectiveness of interventions at primary and secondary health care level such as maternal healthcare services (family planning, safe motherhood interventions, nutrition); child health services (such as integrated management for childhood illnesses, IMCI, for acute respiratory illness, diarrhea, and malnutrition; immunization); and adult and all age group services (outpatient management of diabetes, hypertension, and cardiovascular disease; mental health; tuberculosis treatment; sexually-transmitted disease management; disabilities; and emergency care). Recommendation 8: Defining provider payment mechanism, especially for services required by disadvantaged groups It is recommended that primary care services offering the comprehensive FHS package be paid in fixed capitation amounts that cover the fixed costs of operations; while a complementary pay-for-performance scheme finances the variable costs based on volume, quality, and incurred hardship for services provided. Recommendation 9: Preparing providers for contracting, especially those targeting disadvantaged groups Given their historical reliance on line item budgeting, self-generated revenues, and less attention to efficiency, Egyptian hospitals (public and private alike), especially those which provide services to disadvantaged groups, must develop the ability to cost their provided services. This would entail training of fiduciary staff; and introduction of health monitoring information systems (HMIS) to track expense and capture physician behavior, prescribing practices, and ancillary costs. Recommendations to improve quality of care in healthcare facilities, especially in lagging regions Increase the quality of healthcare through performance-based incentives, 11 accreditation, training, and citizens’ engagement, especially for disadvantaged populations. Structuring a payment system with performance-based incentives for providers has been shown to be successful at improving quality of care both globally and in Egypt through reforms introduced as part of the Family Health Model in 2001. This should be scaled up to lagging regions. In addition, citizens should be more directly engaged in the provision of care by establishment of grievance redress mechanisms (GRMs) and active monitoring of the quality of and satisfaction with healthcare services. Finally, quality and safety can be further improved through mandatory accreditation for FHSs and improved training resulting in greater compliance with clinical guidelines, standards, and treatment protocols in healthcare facilities. Specifically, this would entail adopting the following recommendations: Recommendation 10: Training of providers in line with new healthcare demands, especially in lagging regions The current skill mix of Egypt’s medical workforce may not allow them to adequately respond to increasing healthcare demands, therefore task shifting and retraining is necessary especially in lagging regions. In Upper Egypt, where physicians’ availability is lowest, nursing staff could be further trained to perform basic procedures to improve health outcomes, after appropriate training and legal frameworks are in place. Training providers on domains of responsiveness is essential to increase patient satisfaction. Dual practice can be regulated through different staggered “global fixes” such as allowing private practice in public hospitals, increasing basic wages and incentives, and then gradually banning dual practice. Recommendation 11: Attaining independent accreditation for public facilities, especially those in lagging regions Egypt should start working towards at least foundation-level accreditation for its public providers to ensure better quality and as a prerequisite for eventual contracting with a strategic payer(s). Only facilities that meet at a minimum the Foundation Accreditation Level for hospitals and the Provisional or Full Accreditation Level for primary healthcare units and centers will be eligible for contracting. Recommendation 12: Scaling up performance-based financing and other incentives, especially in lagging regions Structuring a payment system with performance-based incentives for providers has been shown to be successful at improving quality of care (Scott et al. 2011). Through the reforms introduced as part of the Family Health Model in 2001, Egypt integrated pay-for-performance incentives in FHF-contracted facilities in five governorates, which was shown to be successful in improving the quality of care and resulted in increased satisfaction levels for both healthcare providers and beneficiaries (Huntington et al. 2009). Other positive incentives include accelerated career progression, exposure to training facilities at nearby centers of excellence, and government-guaranteed and pre- negotiated contracts for working within or outside of the country for higher pay after a set number of years in service. Negative incentives to discourage professionals from working 12 in non-lagging regions include caps on available job openings, frequent staff rotations, and stipulation of service in a lagging region for a set period of time as a precondition for eligibility for payment bonuses. Recommendation 13: Creating avenues for citizens’ participation in service delivery, especially in lagging regions Citizens’ participation in service delivery can be increased by drafting a national strategy for citizens’ engagement in healthcare that includes creating an office for engagement with civil society at the national level and establishing a Committee for Patient Rights at the facility level. Information on performance must be linked with mechanisms that allow citizens, service providers, and officials to share and act on it. Collecting feedback on public services from users, benchmarking service delivery and local governance performance and disseminating information on performance can also provide a rigorous basis for citizen action (World Bank 2015b forthcoming). Recommendation 14: Establishing grievance redress mechanisms and progressive legislature such as a Patient Bill of Rights Legislative recommendations should be considered to provide grievance redress, including considering the development of a medical malpractice law, creation of a uniform Patient Bill of Rights (PBR), and harmonization of existing laws and decrees related to health. Based on global best practice, the PBR should consider including areas on patients’ right to accurate and easily understandable information; choice of healthcare provider; emergency services; taking part in treatment decisions; respect and nondiscrimination; confidentiality and privacy of health service and information; and fair, fast, and objective review. The current health system is governed by a series of outdated and sometimes contradictory decrees and laws that should be aligned. The Family Health Model: Supporting one social justice program in healthcare for Egypt With its existing network of population- and community-based services, albeit of variable strength and quality, Egypt is not starting from scratch in the implementation of a family health model. It has a strong preventive program and a geographically widespread primary care infrastructure. Availability of an adequate quantity and quality of trained healthcare workers is a cornerstone of the model’s success. Finally, the model should mount an increasing focus on helping lagging regions achieve the MDG targets and tackle Hepatitis C and the rising burden of NCDs. Since the “Family Healthcare Services for All by 2030” model is a supply-side mechanism, adequate measures to enhance demand for its services should also be sought. How should Egypt implement the model? In the short term (2017), Egypt should aim to provide the package of family health services to the most lagging regions in terms of health outcomes and financial protection, covering initially an estimated 20 percent of the poor. Following the footsteps of the GoE’s program to upgrade and enhance the living conditions in the poorest 1,000 governorates would be a good start. This immediate measure would provide a much needed sense of 13 equity among the population. In the medium term (2020), it should expand the service to include the poorest 40 percent of the population, covering nearly all of Upper Egypt with gradual introduction of a referral system. In the long term (2030), all citizens should enjoy family health services as an integral part of their basic rights. The financial cost of the model should optimally be borne by the state through tax-based pooled funds. 5. Implementation: How should these recommendations be implemented? Implementation of these recommendations requires several components to be in place—seven of which are laid out below. Implementation considerations include (i) creation of enabling conditions; (ii) definition of roles for different actors; (iii) consideration of different avenues for funding of recommendations (iv) promulgation of new legal provisions; (v) creation and strengthening of different government bodies; (vi) commissioning of further research and studies; (vii) and agreement on a uniform set of metrics to track overall progress. Consideration 1: What are the enabling conditions to be addressed? Reforms in two cross-cutting areas –creating integrated referral systems, and pharmaceutical reform – are important to enable implementation of roadmap. Creating an integrated referral system with incentives to refer patients by creating lower copayments should be encouraged through the recommended health financing reforms. Egypt should also create a national pharmaceutical regulator to track supply, demand, and quality. Consideration 2: Who are the actors and what are their roles for implementation? MOHP should not be considered the sole actor involved in shepherding the health system through a transformation process in a climate of social and economic uncertainties. Each of the multiple actors involved in the regulation, financing, and provision of healthcare should have a clear role and set of recommendations to follow in the reform process. This will provide for complementarities, synergies, and a national sense of ownership, all of which will enable smooth implementation. Consideration 3: How will the recommendations be funded? In general, fiscal space for health can be increased in five ways: a favorable macroeconomic climate, resulting in overall increases in government revenue; reprioritization of health within the government budget; an increase in health-specific foreign aid; an increase in health-specific resources; and increased efficiency of government outlays (Tandon 2010). Given the current economic climate in Egypt, the first way may not be realistic in the next five years. However, the latter four are all possible ways to finance the short- and medium- term recommendations proposed. Consideration 4: What legal provisions are recommended? Egypt may need to harmonize and modify its various laws and governing decrees related 14 to healthcare. Such changes must be carried out in a prioritized manner and include the passage of the SHI law, passing a medical malpractice law, creating a unified national Patient Bill of Rights, amending the medical cadre law, and reforming the FHF and PTES legal frameworks. Consideration 5: What governing bodies need to be created or strengthened? To ensure implementation of the short- and medium-term recommendations, two governing bodies in particular need to be created or strengthened. A Supreme Health Council should be created to set the overall strategy, oversee the functionality of the health system, and ensure that the privileges and obligations of all players are respected and maintained. The National Accreditation Committee should be strengthened to be independent and oversee a national accreditation program, which will be needed as part of the transition to a strategic payer. An Independent Regulatory Authority should be created at the national level to ensure that providers maintain a certain level of quality of care at facilities; provide services at pre-agreed fixed prices; uphold the governance and social accountability rights of citizens and workers; and provide relevant feedback to policymakers towards a smooth running of the system. At the minimum such a body should be an umbrella body for regulation for health organizations, professionals, and food and drug supplies. Consideration 6: What further research and studies are needed? Although several studies have examined the major challenges facing the Egyptian healthcare system, critical gaps remain in the understanding of their root causes. Further studies should be undertaken on the causes and determinants of malnutrition; drivers and cost of NCDs; disease burden and provider mapping for mental health; allocative efficiency of healthcare programs; and effective decentralization of the health system. Consideration 7: How will implementation be measured? Continuous monitoring and periodic evaluations of the reform program will be critical to its success. At the national level, key performance indicators should track higher-level outputs and outcomes that measure health status, financial protection, and quality of care both at the national level and disaggregated for disadvantaged groups. Thirteen suggested indicators are presented below— specific targets and timelines should be set based on consultations with stakeholders, who will both implement programs and closely monitor their progress. Objective 1: Improve health of disadvantaged groups (national aggregate and among disadvantaged groups) 1. Child mortality rate 2. Maternal mortality ratio 3. Number of doses of new Hepatitis C drug regimens (simeprevir or sofosbuvir) distributed 4. Percent of children immunized 15  5. Percent of women receiving assisted delivery 6. Percent of children classified as stunted (height-for-age) 7. Percent of adult women classified as obese 8. Percent of male tobacco smokers Objective 2: Increase financial protection for disadvantaged groups ((national aggregate and among disadvantaged groups) 9. Incidence of catastrophic health expenditure due to out of pocket payments 10. Incidence of impoverishment due to out of pocket payments 11. Poverty gap due to out of pocket payments Objective 3: Improve quality of healthcare delivery in public facilities (national aggregate and among disadvantaged groups) 12. Number of public sector facilities accredited 13. Number and percentage of complaints to grievance redress channels that are solved. 6. Conclusion Despite several gains in healthcare in previous decades, Egypt has progress to make still to ensure that social justice is realized in healthcare. While the “Right to Health” is recognized in the new Constitution, health outcomes continue to be unequally distributed and certain populations (defined by income, education, gender, or geography) remain excluded from gains in health outcomes, increases in financial protection, and improvements in healthcare quality. By supporting a “Family Healthcare Services for All by 2030” model with a focus on disadvantaged populations and commitment to ensure that all Egyptians have mandatory health insurance by 2030, current challenges to achieving social justice in health can be addressed. Based on evidence from pilots in Egypt and global best practice, short- and medium- term recommendations to achieve these objectives can be feasibly implemented (World Bank 2013b). Coupled with the commitment of multiple stakeholders with well-defined roles, increases in fiscal space through improvements in prioritization and efficiency, and a rigorous and regular monitoring and evaluation system, social justice in healthcare can be available to all. The World Bank stands committed to partnering with Egypt to assist with the development and implementation of these reforms, in line with its strategy of creating fair and accountable health systems in the region and overarching commitment to reduce poverty and increase shared prosperity (World Bank 2013a). 16 1 AIM: HOW CAN SOCIAL JUSTICE BE ACHIEVED IN HEALTHCARE IN EGYPT? 1. AIM: HOW CAN SOCIAL JUSTICE BE ACHIEVED IN HEALTHCARE IN EGYPT? This paper lays out a roadmap to achieve social justice in healthcare by prioritizing areas related to service delivery, financial protection, and quality of care. The aim is to assist the Government of Egypt (GoE) in realizing the principle of social justice in healthcare. In so doing, the roadmap aims to prioritize key areas of focus for Egypt, including describing which existing programs to continue supporting and which new programs to consider for development, all under an integrated and interdependent structure. This paper is not meant to be an assessment of all the challenges facing the entire Egyptian healthcare system, but instead is a focused assessment of how the overarching aim of “social justice” can be achieved in the healthcare sector through an emphasis on improving services provided to disadvantaged groups. This is done in four stages: 1. Objectives: The paper lays out the three objectives that need to be reached to ensure that social justice in healthcare is achieved. 2. Challenges: Next, it drills down to diagnose the eleven challenges currently preventing these objectives from being realized. 3. Recommendations: Then, it presents a series of fourteen recommendations by which these challenges can be overcome, drawing from successful pilots and programs in Egypt and global best practice. 4. Implementation arrangements: Finally, it suggests a detailed description of seven implementation arrangements necessary to operationalize the proposed roadmap. The time horizon for this roadmap is the next three to five years (2015- 2020). This roadmap suggests recommendations that will result in incremental improvements in Egypt’s health system in the short to medium term with a focus on disadvantaged groups. Achievement of these results should situate Egypt on the path to achieving social justice in healthcare in the long term. The paper comes as the final product of a year full of hard work by the team involving the review of all available literature, field visits and interviews to the remotest villages in the far north and south of the country as well as multiple consultations with experts, officials, civil society and ordinary citizens themselves. Achieving social justice is a pressing priority for both the people and the government of Egypt. The call for social justice was the rallying cry heard from Tahrir Square in 2011 ("Aish, Horreya, Adala Egtema'eya") and this call has continued through successive political transitions, as enshrined in Egypt’s Constitution (see Box 1). To achieve social justice, a commitment must be made to ensure that the most disadvantaged have access to the same services as the average Egyptian—i.e., that everyone has the same “equality of opportunity” (World Bank 2012a). In the field of health, this translates to all Egyptians, irrespective of income, gender, or geographic location, having access to the same standards of safe, affordable, equitable, effective, and efficient healthcare. Presently, a child born in rural Upper Egypt is only half as likely to survive till age five as a child born in urban Lower Egypt (El-Zanaty and Associates 2014). 19  Attaining universal health coverage (UHC) is a commitment of the Government of Egypt (GoE) and is one way to ensure social justice in healthcare. UHC is defined as all people receiving quality healthcare services that meet their needs without being exposed to financial hardship in paying for the services (WHO 2013; WHO 2014; World Bank 2013c; World Bank 2014c). Given resource constraints, this does not entail all possible services, but a comprehensive range of key services that is well aligned with other social objectives (WHO 2014). The objectives of UHC are to ensure that all people can access quality healthcare services; safeguard all people from public health risks; and protect all people from impoverishment due to illness, whether from out-of-pocket (OOP) payments for healthcare or loss of income when a household member falls sick (Maeda et al. 2014; World Bank and WHO 2014). A 2012 U.N. resolution urged governments to move toward providing all people with access to affordable, quality care. Egypt shares this global commitment to attain UHC and is currently working towards achieving this goal. Reaching UHC is also central to ending extreme poverty by 2030 and boosting shared prosperity. To ensure fair, progressive realization of UHC, prioritization of services must take place, with mechanisms to ensure that disadvantaged groups are not left behind. To achieve UHC, countries must advance in at least three dimensions. They must expand priority services, expand populations covered, and reduce OOP payments (WHO 2014). In each of these dimensions, countries are faced with a critical choice: Which services should be expanded first? Which populations should be included first? How can payments be shifted from OOP expenditure to a pooled prepayment scheme? For the fair, progressive realization of UHC, the following strategy has been suggested (WHO 2014): (i) categorizing services into priority classes, taking into consideration relevant criteria including cost-effectiveness, priority for the worst off, and financial risk protection; (ii) expanding coverage for high-priority services to everyone, by eliminating OOP payments, increasing mandatory, progressive prepayment, and pooling funds; and (iii) ensuring that disadvantaged groups are not left behind, including low-income groups and rural populations. This roadmap paper aims to assist GoE with this prioritization process to ensure progressive realization of UHC. Social justice in the health sector can be achieved by ensuring universal access to health coverage for all Egyptian citizens through the provision of an affordable package of essential health services within Egypt’s fiscal space and as per its Constitutional mandate. Social justice in the health sector would ensure that the most disadvantaged Egyptians have access to the same level and quality of services as the average Egyptian without financial hardship. This can be achieved by ensuring that the Egyptian health system enables UHC and is fair and accountable. A fair system provides the same level of quality health services to people with the same need, regardless of socioeconomic status, gender, place of residence, or any other potential difference, while an accountable system demonstrates and takes responsibility for performance to create high-quality healthcare (World Bank 2013a). Expansion of family health services (FHS) to all Egyptian citizens by 2030, with a focus on disadvantaged populations, is a concrete way to realize the principle of UHC and work towards social justice in healthcare. Family health services would comprise a package of essential health services related to Egypt’s burden of disease and would 20 include: maternal and child health (MCH); reproductive health and family planning services; prevention, screening, and treatment of noncommunicable diseases (NCDs); mental health; and nutrition. This package would be integrated into all levels of care, from primary health centers to district hospitals. Further, expanding mandatory social health insurance to all Egyptian citizens by 2030, with a focus on disadvantaged populations, will ensure that Egyptians will be financially protected in an equitable fashion. No Egyptian will be pushed into or kept in poverty by paying for healthcare. Social health insurance (SHI) will ensure comprehensive risk pooling across various population segments and will expand health insurance coverage to include the poor at first, and then gradually, the informal sector. It will separate the institutional responsibilities for the purchasing function from service provision, and will transform currently passive practices of payers into active purchasing. Figure 1 presents proposed twin goals for UHC for Egypt. Figure 1: Twin goals proposed for Egypt to Achieve Universal Health Coverage Egypt’s Universal Health Coverage Goals All Egyptians have All Egyptians have access to quality mandatory social family health services health insurance by by 2030 2030 Source: Authors. 21  Box 1: The “Right to Health” as captured in Egypt’s Constitution of January 2014 The commitment to achieving social justice in healthcare is coined in Egypt’s new Constitution of January 2014. Article 18 enshrines the “Right to Health” and ensures that “every citizen is entitled to health and to comprehensive healthcare with quality criteria. The state guarantees to maintain and support public health facilities that provide health services to the people, and work on enhancing their efficiency and their fair geographical distribution.” To ensure this commitment is translated into action, the state has committed to allocating a percentage of government expenditure of no less than 3 percent of Gross Domestic Product (GDP) to health, almost double its current allocation. The percentage is expected to increase gradually to reach global rates with improvements in the economy and better targeting of subsidies to the poor. Right to Health in the Egyptian Constitution: Article 18 “Every citizen is entitled to health and to comprehensive healthcare with quality criteria. The state guarantees to maintain and support public health facilities that provide health services to the people, and work on enhancing their efficiency and their fair geographical distribution. The state commits to allocate a percentage of government expenditure that is no less than three percent of GDP to health. The percentage will gradually increase to reach global rates. The state commits to the establishment of a comprehensive healthcare system for all Egyptians covering all diseases. The contribution of citizens to its subscriptions or their exemption therefrom is based on their income rates. Denying any form of medical treatment to any human in emergency or life-threatening situations is a crime. The state commits to improving the conditions of physicians, nursing staff, and health sector workers, and achieving equity for them. All health facilities and health related products, materials, and health-related means of advertisement are subject to state oversight. The state encourages the participation of the private and public sectors in providing healthcare services as per the law.” Source: Arab Republic of Egypt 2014. 22 2 OBJECTIVES: WHAT ARE THE OB- JECTIVES FOR ACHIEVING SO- CIAL JUSTICE IN HEALTHCARE IN EGYPT? 2. OBJECTIVES: WHAT ARE THE OBJECTIVES FOR ACHIEVING SOCIAL JUSTICE IN HEALTHCARE IN EGYPT? Every health system can be said to have three objectives—to improve health status, to provide financial protection, and to ensure patient satisfaction. Health status refers to the level and distribution of health outcomes among citizens; financial protection is the degree to which citizens are protected from financial risks; and patient satisfaction is the degree to which citizens are satisfied with the services provided by the health sector (Roberts et al. 2004). Analysis of Egypt’s current health system through these lenses suggests that these objectives have only been partially met for certain outcomes or in specific populations. With respect to health status, in the last 20 years, Egypt’s population has become healthier, with an increase in overall life expectancy from 64.5 years to 70.5 years, though the benefits have not accrued equally (World Bank 2014b). Due to expansions in availability of basic health services including for maternal child health (MCH), Egypt is on track to reach the Millennium Development Goals (MDGs) related to MDG 4 (child mortality) and MDG 5 (maternal health); however, disparities in achievement of these targets exist across geographic regions and income quintiles, 1, 2 such as in rural Upper Egypt (El-Zanaty and Way 2009; El-Zanaty and Associates 2014). On closer examination by governorate, Cairo, Alexandria, and Port Said are unlikely to meet the target for child mortality and Sharkia, Kalyoubia, Beni Suef, and Minya are unlikely to meet the target for maternal mortality (UNICEF 2013). Similarly, with respect to financial protection, while more than half of the population has access to some form of health insurance, 72 percent of all healthcare costs are still covered OOP (Rafeh et al. 2011). The current scheme excludes the poor 3 as well as those in the informal sector. In addition, there is inequity in access within programs devoted to provide coverage for the uninsured, such as the Program for Treatment at the Expense of State (PTES). The groups with the highest coverage rates include those: aged 5 -15 (93.5 percent); in the highest wealth index (66.8 percent); residing in urban Lower Egypt (56.4 percent); and living in urban areas (54.4 percent) (Rafeh et al. 2011). Finally, with respect to patient satisfaction, while patients in a recent survey generally ranked all facilities moderately high, but differences persist by facility type (Rafeh et al. 2011). Over 60 percent of surveyed representatives stated they were “completely satisfied” with the quality of health services received (Rafeh et al. 2011). On closer examination, variation existed in the level of satisfaction by type of facility: 66.4 percent of patients 1 Infant mortality among the poorest quintile is 42.1/ 1,000 compared to 16.8 /1,000 among the wealthiest quintile; similarly, under-five mortality among the poorest quintile is 59/ 1,000 compared to 18.9/ 1,000 among the wealthiest quintile (El-Zanaty and Way 2009). 2 Assisted delivery, the key proxy indicator for maternal mortality, among the poorest quintile is 55 percent compared to 97 percent among the wealthiest. In addition, delivery at any health facility is 45 percent among the poorest compared to 95 percent among the wealthiest (El-Zanaty and Way 2009). 3 Based on the 2008 Demographic Health Survey, only 14 percent of the poorest quintile are covered by any health insurance compared to 47 percent among the wealthiest (El-Zanaty and Way 2009). 25 were completely satisfied with service delivery at Ministry of Health and Population (MOHP) hospitals compared to 76.0 percent of patients using private hospitals (Rafeh et al. 2011). However, publicly-funded healthcare services showed much lower utilization rates than those in the private sector. Further, the lowest utilization rates were among the poor4. Similarly, inpatient services provided at Health Insurance Organization (HIO) facilities were characterized as having the lowest levels of responsiveness compared to outpatient and inpatient services in the private sector (Mosallam 2013). Consequently, to achieve social justice in healthcare in Egypt, the following three objectives must be met (Figure 2): Objective 1: Improve health of disadvantaged groups Objective 2: Increase financial protection for disadvantaged groups Objective 3: Improve quality of healthcare delivery in public facilities Figure 2: Three overarching objectives to achieve social justice in healthcare in Egypt AIMAIM OBJECTIVES OBJECTIVES Improve health of disadvantaged groups Social Justice in Health Increase financial protection for disadvantaged groups Improve quality of health care in public facilities Source: Authors. 4 16 percent of the poorest quintile did not seek care for acute illness and 18 percent did not seek care for chronic illness because it was considered costly compared to 0.7 percent for acute illness and 4 percent for chronic illness among the wealthiest quintile (Rafeh et al. 2011). 26 Box 2: Who are the “Disadvantaged” Groups? The key to achieving the three overarching objectives is successfully identifying disadvantaged groups and then targeting programs and policies to address their unique needs. Groups in Egypt that can be considered disadvantaged with respect to healthcare coverage and utilization include: 1. Households in the lowest wealth quintiles 2. Populations situated in certain geographic locations or “lagging regions” such as rural Upper Egypt and the Frontier Governorates (and in certain habitations like slums 3. Populations with low parental education, particularly with respect to mother’s education 4. Workers in the informal sector who are specifically not covered through health insurance schemes 5. Women (for specific health outcomes related to maternal and reproductive health, malnutrition, etc.) 6. Disabled populations For example, for the purpose of this paper, the least advantaged individual could be defined as a woman with illiterate parents, from the poorest wealth quintile, living in rural Upper Egypt. To identify and target these groups, several interventions from the health sector as well as other sectors can be used. In the last few years, Egypt has introduced a number of instruments to improve targeting the poor with services. These include: developing poverty maps to determine where the poorest villages are located; collecting household data using proxy means tests to identify the poorest households; and recently, creating a targeting mechanism that relies on linking between multiple databases to filter and identify the poor in Egypt. All are critical to ensure that health services are targeted to these populations. Egypt intends to build on its current Family Smart Card (FSC) system to target benefits to poor and vulnerable households. In addition to the current food ration program, the government is introducing additional benefits to the FSC, including bread and cash transfers. This system can also be used to target disadvantaged individuals with health services. 27 3 DIAGNOSES: WHAT ARE THE CHALLENGES TO ACHIEVING SO- CIAL JUSTICE IN HEALTHCARE? 3. DIAGNOSES: WHAT ARE THE CHALLENGES TO ACHIEVING SOCIAL JUSTICE IN HEALTHCARE? Several priority challenges need to be addressed to ensure that the three objectives articulated in this framework paper are achieved. These challenges are based on an analysis of the gaps remaining in achieving the three health system objectives, identified through a detailed review of qualitative and quantitative data, peer-reviewed and grey literature, and national plans as well as discussions with health experts. Consensus on these challenges was based on several in-depth interviews, rounds of consultations, and special workshops with experts from MOHP, Ministry of Finance (MOF), HIO, civil society, NGOs, the private sector, donors, and academia in 2013- 2014. In this section, a situational analysis consisting of three parts is presented for each of the eleven challenges. First, the main challenges in Egypt are identified through the use of national-level data. Second, since aggregate data can often mask within-country variation, especially among vulnerable groups, the status of disadvantaged groups for each challenge area is presented. Finally, a description of current programs and policies to address these challenges is provided. Figure 3: Eleven main challenges to achieving social justice objectives in healthcare in Egypt AIM OBJECTIVES KEY CHALLENGES Maternal Maternal&&child childhealth health Hepatitis HepatitisCC Improve health of Under Undernutrition nutrition disadvantaged Non Non CommunicableDiseases Communicable Diseases groups Mental Mentalhealth Social health Disability Disability Justice in Health Increase Limited coverage for poor financial protection for Lack of strategic purchaser disadvantaged groups Lack of provider readiness Improve quality of health care in public facilities Lack of responsiveness Limited citizen’s participation Source: Authors. 31 3.1 OBJECTIVE 1: IMPROVE HEALTH OF DISADVANTAGED GROUPS Challenge 1: Poor maternal and child health inequitably distributed in rural, remote, and slum areas Egypt has seen gains in MCH outcomes, as demonstrated by reductions in the last 10 years in: the maternal mortality ratio by one-third, from 100.0 to 66.0 maternal deaths per 100,000 live births; and the under-five mortality rate by half, from 41.9 to 22.0 child deaths per 1,000 live births (Figure 4). However, challenges still remain (UNFPA 2013; World Bank 2014a). At the national level, Egypt is on track to achieve the MDGs related to MCH. With regard to maternal health, 80 percent of women received regular antenatal care (i.e., four or more checkups) and 90 percent had skilled attendants at delivery (El- Zanaty and Associates 2014). With regard to child health, 92 percent of all children are immunized against all main preventable childhood diseases5 (El-Zanaty and Associates 2014). Figure 4: Trends in early childhood mortality, Egypt, 2008-2014 Source: El-Zanaty and Way 2014. But certain lagging regions and populations continue to have poor MCH outcomes. For example, 46 percent of births in the poorest quintile took place without trained staff and 55 percent of births took place outside of health facilities (El-Zanaty and Way 2009). Children in least advantaged groups half as likely to have a trained attendant at delivery and twice as likely to die in their first month compared to their more advantaged peers (Figure 5; World Bank 2014b). Neonatal mortality represents half of infant mortality and is disproportionately higher among those living in rural Upper Egypt. Neonatal mortality marginally declined 5 “Immunized against all major preventable childhood diseases” is defined as children having received a BCG, three DPT and three polio immunizations, and a measles vaccination (El-Zanaty and Associates 2014). 32 in the last six years, from 16 deaths to 14 deaths per 1,000 live births (Figure 4; El-Zanaty and Way 2014), and represents almost half of all infant deaths. A child born in rural Upper Egypt has a 50 percent greater likelihood of dying from neonatal causes than a child born in urban Upper Egypt and is twice as likely to die from neonatal causes than a child in urban Lower Egypt (El-Zanaty and Way 2014). Figure 5: Differences in MCH outcomes between most and least advantaged children, Egypt 96 Note: ECCE stands for Early Childhood Care and Education. Source: World Bank 2014b. Concurrently, Egypt is witnessing an increase in fertility with a decline in the contraceptive prevalence rate. While the total fertility rate (TFR) decreased over the last 30 years, an uptick is now being observed, especially among women aged 20 -24 (Figure 56; El-Zanaty and Way 2014). The age-specific fertility rate in this cohort is 26 percent higher than the rate found among the same age group six years ago. The highest fertility rates are seen among women in rural Upper Egypt (TFR=4.1) and the lowest among women in urban Lower Egypt (TFR=2.5). This is reflected in the rate of contraceptive use flat lining. There are differences in the level of current use of family planning methods by residence. Urban women are somewhat more likely to use contraceptives than rural women (61 percent and 57 percent, respectively). Usage rates are higher in Lower Egypt (64 percent) and the Urban Governorates (63 percent) than in Upper Egypt (50 percent) and the three Frontier Governorates (Matruh, Red Sea, and New Valley) (55 percent) (El- Zanaty and Way 2014). In addition, rates of female genital mutilation/cutting (FGM/C) remain extremely high, with 91 percent of all women aged 15- 49 circumcised (El-Zanaty and Way 2009). The prevalence is found to be slightly lower among younger age cohorts, suggesting that this practice may be declining. However, it is found to be higher among girls in the lowest income quintile, who are 2.5 times more likely to have undergone FGM/C by age 18 than those in the highest quintile (El-Zanaty and Way 2009). 33  Figure 6: Trend in the total fertility rate, Egypt, 1980-2014 Total Fertility Rate (Births per woman) Source: El-Zanaty and Way 2014. To address this, Egypt has developed a National Acceleration Plan for Child and Maternal Health (2013- 2015) (MOHP 2013) to speed up the progress in further reduction of maternal and child deaths. The plan identifies concrete measures in terms of prioritizing interventions in lagging regions, with funding gaps that need additional financing. CHALLENGE 2: HIGH BURDEN OF HEPATITIS C OVERALL WITH INCREASED PREVALENCE AMONG POOR, RURAL, AND LOW-EDUCATION POPULATIONS Egypt has the highest prevalence of Hepatitis C virus (HCV) globally, with the prevalence rate among 15- to 59-year-olds estimated at 14.7 percent (El-Zanaty and Way 2009). Chronic HCV is the main cause of liver cirrhosis and liver cancer and one of the top five leading causes of death (IHME 2013). It is believed that the epidemic spread due to poor injecting practices during mass-treatment campaigns for parenteral- antischistosomal-therapy (PAT). This is supported by prevalence rates of up to 84 percent among schistosomiasis patients treated with PAT during the time of these campaigns 20- 30 years ago (El-Sabah et al. 2011; Mahmoud et al. 2013). Prevalence of HCV differs by socioeconomic factors and among specific groups. Groups with higher prevalence rates include lower educated populations, rural populations, low-income groups, and men (Figure 7; Awadallah 2011; Mahmoud et al. 2013). For example, the overall prevalence in rural areas averaged about 20 percent, higher than the national average (Mahmoud et al. 2013). A study conducted in Kalama, a village in the Nile Delta, reported HCV prevalence of 40 percent among village residents (Darwish et al. 2001). Based on a synthesis of several studies, Mamhoud et al. (2013) report a high prevalence of HCV among pregnant women and children, with a reported prevalence of about 8 percent among pregnant women in Assiut and Benha, and as high as 15.8 percent in rural villages of the Nile Delta. Studies conducted among rural schoolchildren reported an average prevalence of about 7 percent. High prevalence was also observed among select subgroups such as blood donors, tourism workers, army recruits, and fire brigade personnel. Worryingly, little evidence exists of a decline in HCV prevalence, either among the general population or among high-r