10 P4P Oct 19 2018

Payment for Performance
The Egyptian Experience
HCM 742: Financing and Insurance Schemes

Spring 2018 – Fourth Semester, Second Quarter – Week Ends
Isaac El-Mankabadi; BSc, MPH
Overview
• HRH in Egypt
• Financing of the Egyptian Health Care System
• Performance Based Incentives in Egypt
– Driving force (Why)?
– Implementation – indictors and FHF
– Contracting and role of donors
– Impact on quality, customer & provider
satisfaction, efficiency and sustainability (financial
and organizational)
HCM 742: Financing & Insurance Schemes
Suhag 19/10/2018 2
Spring 2018 - Fourth Semester, Q2 - WE
HRH working in MoH in 2009 (main
categories)
HRH Category Numbers
Physicians 51,491
Dentists 8,856
Pharmacists 11,953
Nurses (various categories) 107,717
Source: NICH Statistical Report 2011; MoH - Data of 2009

Suhag 19/10/2018 3
The Gap: Health Workforce &
Infrastructure
Nurses & Pharma. Hospital
Country/Region Physicians Dentists
Midwifery personnel Beds
Globe 14.2 28.1 2.2 4 30
UK 27.4 101.3 5.3 6.6 33
Canada 19.8 104.3 12.6 9.2 32
EMR 10.9 15.6 2 5.4 12
Lower Mid. Income 7.8 15.1 1 4.3 12
Syria 15 18.6 7.9 8.1 15
Egypt 28.3 35.2 4.2 16.7 17
Bahrain 14.4 37.3 3.6 2.4 18
Jordan 24.5 40.3 7.3 14.1 18
Morocco 6.2 8.9 0.8 2.7 11
All figures are per 10,000 population
Source: World Health Statistics 2012 – WHO. Data of 2010
Suhag 19/10/2018 4
Challenges facing HRH
• Dual practice even among faculty members
• Mal distribution:
– among governorates
– Rural and Urban area (FHU staff 12-14 and 22-27
respectively)
• Demoralized and demotivated HRH due to poor
remuneration package
• Absenteeism and reduced working hours that affects
accessibility
• Urgent need for trainings (technical and
management) within comprehensive HR policy
Suhag 19/10/2018 5
Financing of health care systems
THE as TGHE as PHE as % TGHE as Per-capita Per-capita
% of % of THE of THE % of TGE THE TGHE
GDP *(US$) (US$)*
Globe 9.4 59.1 40.8 14.3 900 549
Eastern 4.7 50.9 49.1 7.1 175 96

Med. R
Low. Mid. 4.4 39.0 61.0 5.5 62 25
Income
Syria 3.5 46.0 54.0 6.0 95 Djib 44

outi
Egypt 4.8 39.5 60.5 5.6 114 94 45
•At average exchange rate THE: Total Health Expenditure

•Source: World Health Statistics 2012 - TGHE: Total Governmental Health Expenditure
data for19/10/2018
Suhag 2009 PHE: Private Health Expenditure
6
Major challenges facing the Egyptian
Health Sector
• Insufficient funding
• System depends on out of pocket spending (72%)
• Lack of motivation for various categories of HR
• Lack of efficiency
• Poor quality of care and non motivating work
environment
• Frail regulatory function
• Ineffective information systems
Suhag 19/10/2018 7
Performance Based Incentives PBI
• Implemented as a part of Health Sector
Reform Program (HSRP) in 2000
• Elements for PBI
– Establishment of the Family Health Fund (FHF) in
1999 as a purchaser
– Contracting process
– Performance Indicators
– Internal distribution of incentives – point system
– Impact evaluation

Suhag 19/10/2018 8
PBI – contracting process
Two tier system
• Pre accreditation Phase
– From 3 to 6 month prior final accreditation
(provisional)
– Up to 100% of basic salaries of facility team
according to staff pattern
• Accreditation Phase
– Up to 275% of basic salaries of facility team
according to staff pattern
• Fee for Service in case of inefficiency
Suhag 19/10/2018 9
Contracting Process – Flow of Funds
Roster Copaym Donors Investment
HIO
fees ents (EU/WB) Revenues
Family Health Fund FHF (pooling & Contracting)
Contracting – Performance Based Incentives and Fee for Service
Health Care facilities:

District District Provider
- MoH (FHUs, FHCs, Dis. Hospitals)
Supervisory Teams Organizations DPO
- HIO (FHCs) - NGOs - Private
Internal distribution of incentives – Payment For Performance
Various categories of HRH in contracted facilities and districts

Suhag 19/10/2018 10
PBI - Indicators
• National targets as immunizations coverage,
utilization of FP methods, Ante and post natal
care, etc.
• Productivity
• Quality and documentation/flow of data
• Efficiency/utilization of resources
• Customer satisfaction (quarterly)

Suhag 19/10/2018 11
Model of indicators
• National Programs (Targets)
– Immunization Coverage (not less than 95% of
target population)
– Antenatal care (Av. 4 visits during pregnancy)
• Quality of Care
– Adherence to Clinical Guidelines
– Patient rights and documentation
– Clinical and environmental safety (infection control
and management of contaminated waste)
Suhag 19/10/2018 12
Model of indicators – Productivity
• Average number of daily visits per physician
Total number of curative cases treated by the Physician

Number of working days of same Physician
Av. No. of
(11 -15) or (16 – 20) or From 21 to
daily visits <10 or >36
(33 – 35) (30 – 32) 29
per Physic.
Score/Points
Zero 50% 75% 100%
(% of weight)

Suhag 19/10/2018 13
Definition of curative cases
• Outpatient cases for non insured (roster and non
roster)
• Outpatient cases for insured patients (roster only)
• Antenatal care for new and risk cases (roster
only)
• Family Planning (IUDs and injections)
• Immunization (BCG only)
• Emergency cases

Suhag 19/10/2018 14
Financial indicators – efficiency /
utilization of resources
• Average number of prescriptions per visit;
• Average cost per visit;
• Percentage of collection of roster fees;
• Percentage of complete data of insured
persons.
• Accuracy of claims sent to the HIO

Suhag 19/10/2018 15
PBI – Internal distribution of
incentives (point system)
Main factors determining amount of incentives
paid for each member of facility staff:
• Qualifications (Basic, high schools as nurses,
technical, University, Higher Diploma, and MD)
• Management position;
• Years of experience;
• Position (Family Physician vs. other specialties)
• # of working days & productivity
Suhag 19/10/2018 16
PBI – Impact on HRH
• Better income (from average income of 600 LE
to more than 1800 LE)
• Better working environment
• Improved provider satisfaction
• Questionable Equity among various categories
of HR
– Mainly between family physicians and other
specialists
– Pharmacists
Suhag 19/10/2018 17
PBI – Impact on beneficiaries and
quality of care
• Improved accessibility – extended working
hours
• Better quality of care
• Good customer satisfaction

Suhag 19/10/2018 18
Impact on Customer Satisfaction
How satisfied were you with the facility? Percentage
Extremely satisfied 75.5%
Somewhat satisfied 20.3%
Neutral 2.6%
Somewhat dissatisfied 1.2%
Extremely dissatisfied 0.4%

Source: Management and Service Quality in PHC facilities in Alexandria and Menoufia at the Completion of the Health Sector Reform
Program; Survey Report – WB, April 2009

Suhag 19/10/2018 19
Demand for Primary Health Care
Accessibility: Preferred visiting times
0.6
0.5
Morning
Percentage of Respondents
0.4
Afternoon
0.3
Evening
0.2
0.1
0.0
All Users Male Female ALEX MON URBAN RURAL
Source: Management and Service Quality in PHC facilities in Alexandria and Menoufia at the Completion of the
Health Sector Reform Program; Survey Report – WB, April 2009
Suhag 19/10/2018 20
PBI – impact on efficiency
• In urban areas:
– dense population, high utilization of facilities =
efficient utilization
• In rural areas
– less population density, low utilization rate and
inefficient utilization.
– Overcome through reducing number of staff
• Payment mechanisms
– From PBI to FFS

Suhag 19/10/2018 21
PBI – Impact on sustainability
• Financial sustainability
• Structural/organizational sustainability
through Purchaser Provider Split(PPS)
• From PBI to other payment mechanisms

Suhag 19/10/2018 22
Sustainability of FHF 2006-2012
in Cost Recovery Percentage CRP
300%
268.2%
250%
199.0%
200%
163.2%
150%
123.1% 126.6%
120.7%
116.7%
110.2% 108.7% 112.3%
107%
102.6%
100% 86.3%
77.2%
69.9%
46%
50% 40.6% 41.0%
33.9%
29%27% 26.7% 22.9%
18.3%
0.00%
0%
Suez
‫السويس‬ ‫صندوق‬ ‫صندوق سوهاج‬
Sohag ‫صندوق المنوفية‬
Menoufia ‫صندوق قنا‬
Quena ‫صندوق االسكندرية‬
Alexandria
2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012
Source: The Family Health Fund - Analysis of Current Situation and Future Vision; Central Family Health Fund,
Nov. 2012 HCM 742: Financing & Insurance Schemes
Suhag 19/10/2018 23
Needs for sustainability – Critical
Success Factors
• Restructuring of health sector with necessary
legal changes
• Enhancing the regulatory role of the MoH
• Ensuring sufficient financial resources to cover
services for the poor

Suhag 19/10/2018 24
MoF
Collection
MoSAL
Premiums Ear marked Taxes Subsidy for the Poor

Financing
Pooling
Premiums National Health Insurance Fund NHIF Health Taxes
(Bismarkian) (Beveridgian)
Pooling & Allocation of Resources
(Money Follow the Patient)
Purchasing
Purch1 Purch 2
Contracting – Provider Payment Mechanisms
PO1 PO2 PO3 PO4 POx

Provision
Co-payment
Services
BENEFICIARIES
Suhag 19/10/2018 25
THANK YOU

Suhag 19/10/2018 26

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Payment for Performance

The Egyptian Experience

HCM 742: Financing and Insurance Schemes

HCM 742: Financing & Insurance Schemes

Eastern 4.7 50.9 49.1 7.1 175 96

Syria 3.5 46.0 54.0 6.0 95 Djib 44

•At average exchange rate THE: Total Health Expenditure

HCM 742: Financing & Insurance Schemes

Family Health Fund FHF (pooling & Contracting)

Contracting – Performance Based Incentives and Fee for Service

Health Care facilities:

Internal distribution of incentives – Payment For Performance

Various categories of HRH in contracted facilities and districts

HCM 742: Financing & Insurance Schemes

HCM 742: Financing & Insurance Schemes

Total number of curative cases treated by the Physician

HCM 742: Financing & Insurance Schemes

HCM 742: Financing & Insurance Schemes

HCM 742: Financing & Insurance Schemes

HCM 742: Financing & Insurance Schemes

How satisfied were you with the facility? Percentage

Extremely satisfied 75.5%

Somewhat satisfied 20.3%

Somewhat dissatisfied 1.2%

Extremely dissatisfied 0.4%

HCM 742: Financing & Insurance Schemes

HCM 742: Financing & Insurance Schemes

• From PBI to other payment mechanisms

HCM 742: Financing & Insurance Schemes

2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012

HCM 742: Financing & Insurance Schemes

Premiums Ear marked Taxes Subsidy for the Poor

Contracting – Provider Payment Mechanisms

PO1 PO2 PO3 PO4 POx

HCM 742: Financing & Insurance Schemes

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