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 …