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Evaluating Impact:Evaluating Impact:Turning Promises into
EvidenceTurning Promises into Evidence
Dr. Dr. LailaLaila MoustafaMoustafa, Dr. Isaac El, Dr. Isaac
El--MankabadiMankabadi, Dr. , Dr. HalaHala ZayedZayed, Dr. , Dr.
WaelWaelElEl--RaiesRaies, Dr. Mohamed Nouh, Dr. Mohamed Nouh
January 2008January 2008
Extension Phase ofExtension Phase ofHealth Sector Reform Program
HSRPHealth Sector Reform Program HSRP
(Identification and exemption of poor)(Identification and
exemption of poor)
Group 11Group 11
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In early 1996, the MOHP launched a re-assessment of the health
sector situationand recognized a need to explore alternatives for a
comprehensive reform.
As a result MOHP adopted the HSRP for Egypt , which lays out a
framework for undertaking a comprehensive reform of the health
sector over the medium- and long-term.Having made situational
analysis in details , highlighting points of weakness and strengths
and defining actual needs.
1. Background
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Family Health Model
The selection within each region was based on criteria
1. Level and depth of poverty 2. health status; concentration
of
women, children and other vulnerable groups
3. existing delivery capacity; 4. commitment to reform;
administrative capacity5. representativeness and
replicability
The implementation of the Family Health Model started in five
pilot governorates which presented the three major regions in
Egypt,
namely, urban, Lower and Upper Egypt as each has different
characteristics and constitutes a different market.
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CHALLENGES FACING NATIONAL ROLLOUT
Financial sustainability is crucial for the continuation of the
Family Health Model quality standards. Without maintaining the
financial flow, the Family Health Model will be considered as
service improvement rather than a component of a health reform
process. After termination of donor funding, covering service
recurrent costs will require substantial new commitments of public
funds, which will have to progressively increase as the model
expands. .
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Egypt Health Insurance
Egypt has health insurance system covering about 52% of
population.Health financial reform has been launched to address the
problem of uninsured population specially the poor.This was done
through establishing Family Health Funds (FHF) in pilot
governorates aiming at providing universal insurance coverage.
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What Do FHF Do?
P u r c h a s e r P u r c h a s e r P r o v i d e rP r o v i d e
r
P u r c h a s e r P u r c h a s e r
P u r c h a s e r P u r c h a s e r
B e n e f i c i a r yB e n e f i c i a r y
B e n e f i t sB e n e f i t s
R o s t e r i n g
E l i g i b i l i t y
C o n t r a c t
R e g i s t r a t i o n
B B P
P u r c h a s e r P u r c h a s e r P r o v i d e rP r o v i d e
r
P u r c h a s e r P u r c h a s e r
P u r c h a s e r P u r c h a s e r
B e n e f i c i a r yB e n e f i c i a r y
B e n e f i t sB e n e f i t s
R o s t e r i n g
E l i g i b i l i t y
C o n t r a c t
R e g i s t r a t i o n
B B P
Core Business Functions of Family Health Fund
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THE FAMILY HEALTH FUND CONTRACTED FACILITIES DELIVERS BETTER
PRIMARY CARE THAN TRADITIONAL MOHP MODEL
After reformBefor e reform
Quality indicators significantly increased after
reformAccreditation score in reformed clinics
After reformBefor e reform
Quality indicators significantly increased after
reformAccreditation score in reformed clinics
Reformed clinic
Unreformed clinic
Patient satisfaction has significantly increased after reform of
MoHP clinicsPatient satisfaction score
Indicators of ongoing improvements in performance are
encouragingAccreditation score (%), Alexandria
Initial assessment1-year assessment2-year assessment
Similar Improve-
mentsobserved in Sohag, Menoufiaand Suez
Indicators of ongoing improvements in performance are
encouragingAccreditation score (%), Alexandria
Initial assessment1-year assessment2-year assessment
Similar Improve-
mentsobserved in Sohag, Menoufiaand Suez
39
1911
2835
00
2933
0
677170
8377
5652
767572
Laundry
Lab services
Emer-gency services
House-keeping
Patient rights
Patient care
Sterili-zation
Infection control
Em-ployee health
Pharm-acy
656358656265
8085
7282
8790 8392
8188
80
92
Clinic 1
Clinic 2
Clinic 3
Clinic 4
Clinic 5
Clinic 6
16.210.7
29.833.2
10.4
42.4
19.2
86.6
66.0
88.881.6
92.796.895.1
Physical standard of facility
Quality of clinical service
Dentistr yLab services
Phar macy
Manage-ment
Overall satisfaction
Source: FHF, MoHP, team analysis
Better clinical quality
Better patient
satisfac-tion
Ongoing improve-
ment
Quality of care: metrics in reformed FHF clinics are more than
double that of unreformed clinics (hygiene, appropriate treatment
and consistency)
Service impact: Patient satisfaction in reformed clinics is
double that of unreformed clinics (standard of facilities, standard
of treatment and availability of treatment)
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FHF were piloted in 2 governorates (Alexandria and
Menoufia).
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Challenges
After FHF implemented cost-sharing mechanism, since 2004 till
now, the following points were observed:
Low enrollment rate of poor and uninsured.Poor Facilities’
Utilization rate.Inadequate purchasing capacity of FHF.
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Trend in pilot Governorates
Trend in Av. Number of Tickets in FHUs & FHCs in All
Governorates in Six Months Period Before & After
Implemetation of MD 147
0.0
500.0
1,000.0
1,500.0
2,000.0
2,500.0
3,000.0
Jan Feb Mar Apr May Jun
Month
Av.
Num
ber o
f Tic
kets
Av. FHUs Before Av. FHCs Before Av. FHUs After Av. FHCs
After
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Program Description
The program was designed to Identify the poor and offer them
free enrollment in health insurance scheme and conduct promotional
campaigns for the non-poor uninsured in Alexandria and
MenoufiaGovernorates.
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Objectives
The program was designed to achieve the following Project
Development Objectives:
To increase the enrollment of the poor and the uninsured in
Alexandria and Menoufiabased on achievable quarterly targets To
improve the efficiency and performance of the delivery of family
health servicesTo strengthen the purchasing capacity of FHF in both
governorates
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2. Results Chain
InputsInputs ActivitiesActivities OutputsOutputs
OutcomesOutcomes ImpactImpact
• HR
• Health care facilities (providers), Infrastructure
•Financial resources …
•Training
•Establish &/or renovate facilities
•MIS (FHIS), CIS
•Coordination with other agencies as MOSS, MOF
•Review BBP content
•Costing & Pricing
•Promotion campaigns
• …
•Better health status of poor & uninsured
•Less impoverishing effect
•Improved efficiency…
•Increase average utilization rate (2.5 visit/person/year)
•Contracts on output basis
•…
•Enrollment of poor & uninsured (targeted groups)
•Accredited/Contracted HC facilities /providers
•Developed FHF
•Targeting tool or cooperation protocol with MOSS & MOF
•Exemption policy
•Model contracts with various PPMs
•…
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3. Primary Research Questions
Does Identifying the poor and offering free enrollment in health
insurance scheme to them, will increase Health services
utilization?Will promotion campaigns of FHF insurance schemes,
increase the enrollment of the non-poor uninsured.
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4. Outcome Indicators
287 FH facilities (100%)
191(66.5%)
Percentage of targeted FH facilities contracted with FHF
24(100%)
16.2(67%)
Average no. of daily encounter per physician
2.5(100%)
2(80%)
Utilization Rate of Family Health Facilities (all enrolled
beneficiaries/ exempted poor/ un-exempted uninsured)
1086600(100%)
437189(40.2%)
Number of enrollment uninsured beneficiaries
825816(100%)
126607(15.3%)
Total No. of exempted (uninsured) poor beneficiaries covered by
the FHF to receive the B.B.P. of PHC services
Target(Mar. 2009)
Baseline(Dec. 2007)
Indicator
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5. Identification Strategy/Method
Randomized Promotion Method will be used in each
governorate.
Promotion campaigns will be implemented in randomly selected
districts in each governorate.
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6. Data Management
ME system is used tocollect required dataData originate
fromfacility level and FHF level and aggregated atMOHP
(TSO)Monitoring Data iscollected on quarterlybasisData Quality is
assuredby external concurrentauditor on quarterlybasis
Alexandria
FHF
Menoufia
FHF
MOHP (TSO)
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Data Analysis and Report elaborationand dissimination
Impact Evaluation will be conducted
121211111010
Monitoring data will be collected andaudited quarterly
Implement the program and thepromotion campaigns
Deploy CIS in FH facilities
Develop Enrollment and UtilizationMIS and implement in FHF
Update Data collection forms(Operational Templates)
Baseline Data is available (Dec. 2007)
ActivitiesActivities 44332211 88776655 1199 22 33
7. Time Frame/Work Plan2008 2009
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Thank You …