Where does Egypt Stand in terms of “Deliver Strategy”, from WHO’ Progression Pathway for Private Sector Engagement in Health

Egypt has made reference in many policy documents that provide for some sort of directions for private sector participation in healthcare.

Documents such as the health articles of the constitution, the recommendations of the national dialogue, the government ownership policy document, the government health plan 2024-2-26 emphasizes that the government maintains a strong emphasis on public health infrastructure while encouraging private sector participation in service delivery, pharmaceutical production, and facility management. Key strategies include promoting competition within the Universal Health Insurance System (UHIS), enhancing service quality across both public and private sectors, and implementing PPPs to increase accessibility and efficiency.

The 2019 Universal Health Insurance Law delineates a clear path for private providers participation, with the objective of enhancing healthcare accessibility and quality, while the 2024 Public Private Partnership Concession Law provides guidelines for private sector investment and operation in healthcare facilities.

However, the extent of private sector engagement varies across different policy areas, and there's a need for a more unified approach to fully leverage the potential of public-private collaborations in achieving universal health coverage or more focused approach to focus on universal health insurance coverage. In essence, Egypt is striving to create a healthcare system where the public and private sectors complement each other, ultimately benefiting the population.

Assessing and Rating the Progression of Private Sector Engagement - Deliver Strategy

In my opinion, in reference to the “Deliver Strategy” governance behavior, the first in WHO’s progression pathway for private sector engagement, Egypt could be rated Nascent.

The progress assessment of Egypt's health strategy using guiding questions reveals that the 2023-2023 MoHP Strategic Directions Report outlines the government's strategic health goals but falls short in clearly articulating strategic objectives for the private health sector that align with established health system goals of ensuring equitable access to healthcare without financial hardship within a Universal Health Insurance System or even broader within universal health coverage, compared to heavy emphasis on the public sector. The documents do not specify policy mechanisms to achieve these objectives or explain how they will influence the private health sector's operations and performance. Additionally, there are no identified arrangements for implementing these goals, such as resource allocation, tracking changes, or evaluating impacts, highlighting significant gaps in the strategy's comprehensive execution and monitoring.

For Egypt to move from Nascent to Developing grade, Egypt needs to develop up-to-date policy statements articulating the role of the private health sector within the context of universal health coverage broadly and in relation to the universal health insurance system in particular.

The Way Forward

· Prioritize and Define a Program Boundary for Private Sector Engagement that Focuses on the Universal Health Insurance System. Clearly define the program boundary of the scope of private sector engagement in the next five years to fall within the boundary of the UHI system as part of achieving universal health coverage, while ruling out the engagement of the private sector in other areas.

· Articulate Strategic Roles for Private Sector Engagement. Clearly define the strategic roles of the private sector in UHI system objectives, distinguishing between for-profit and not-for-profit sectors.

· Develop Policy Mechanisms. Specify the policy mechanisms needed to influence the private sector's operations and performance.

· Allocate Resources and Track Performance. Establish specific arrangements for resource allocation, performance tracking, and evaluation of policy impacts.

By addressing these gaps and progressing through the outlined stages, Egypt can create a healthcare system where the public and private sectors effectively complement each other, ensuring high-quality, accessible healthcare for all its citizens.

 

Is Egypt Committed to Private Sector Engagement in Health: An Overview of its Policy Statements

Egypt's Universal Health Insurance Law and associated policy documents outline an attempt to present a framework for private sector engagement in the health sector, reflecting the extent Egypt is committed to enhancing healthcare delivery through different forms of public-private partnerships. The level of Egypt's commitment could be documented across several key areas, including constitutional provisions, strategic frameworks, specific legislation.

However, this commitment does not converge towards a unified and integrated approach for private sector engagement, focusing on service delivery ignoring many much needed for engagement. The policy statements supporting private sector engagement ranged from that of the overall health sector to universal health insurance coverage. Further, the language of support is leaning towards putting more emphasis on supporting Egypt’s healthcare service delivery through its public sector as the primary source of health care while allowing a space for the private sector to participate. In some cases, the statements are contradictory in terms of defining the role of the private sector especially that related to the delivery of primary health care services.

We have selected a few policy documents to demonstrate Egypt's level of commitment.

Health Articles in the Constitution.

In principle, Egypt's constitution explicitly supports private sector participation in healthcare. Article 18 encourages the involvement of both private and public sectors in providing health care services, while Article 36 promotes the private sector's social responsibility in serving the national economy and society. However, Article 18 emphasizes the state's role in maintaining and enhancing public health facilities, ensuring their efficiency and equitable distribution, and subjecting all health-related activities to state oversight.

Government Ownership Policy Document

The government’s ownership policy underscores a more restrictive approach, aiming to maintain or increase current governmental investments in the health sector while simultaneously allowing for private sector participation.

Strategic Directions Framework for Health 2023-2030

The Ministry of Health and Population (MoHP) report, "Strategic Directions Framework for Health in Egypt 2023-2030," outlines the government's strategic goals, with a primary focus on achieving universal health coverage. The document went into more details outlining key strategies to include:

- Strengthening the new Universal Health Insurance System (UHIS) by promoting competition and choice among public and private service providers.

- Enhancing the quality of healthcare services across all levels in both public and private sectors.

- Promoting public-private partnerships (PPP) to improve healthcare accessibility and efficiency.

- Collaborating with the private sector to enhance the production and quality of health products, including local pharmaceutical manufacturing.

- Strengthening health system governance by reviewing and updating health-related laws and regulations.

Conclusions of the National Dialogue

The national committee was concerned with accelerating the expansion of the Universal Health Insurance System and recommended to horizontally expand primary health care nationwide This expansion, targeted within 3 to 5 years, emphasizes the state's role in upgrading health facilities while enhancing private sector and civil society participation, thus fostering a comprehensive healthcare network.

Government Health Plan 2024-2026

The 2024 health plan includes incentives for health sector investors, facilitating their access to special benefits in the modern healthcare sector. It encourages the private sector to expand initiatives like "hospital at home" and hospital-to-hospital care paths to reduce hospitalization rates, showcasing the government's stance in integrating private sector solutions to enhance healthcare delivery in a rather limited scope.

Egypt’s Universal Health Insurance Law

The Universal Health Insurance Law establishes a more inclusive approach for private sector engagement. Article 10 allows the Universal Health Insurance Authority to purchase health services from both public and private entities at standardized prices. Article 16 enables private hospitals to provide services once they meet accreditation standards, and Article 36 requires all health facilities to obtain accreditation within three years, ensuring compliance with quality standards. Collectively, these measures aim to improve service delivery and health outcomes through a regulated and integrated private sector. However, there are other articles that were not clear on the relationship between Egypt's public provider, the Egypt Healthcare Authority, and private sector providers.

PPP Concession Law

The PPP law specifies regulations for private sector engagement in establishing and operating health facilities. Operators are responsible for maintaining facilities and equipment, ensuring compliance with health laws, and employing experienced personnel. The commitment period ranges from three to fifteen years, after which facilities and equipment are transferred back to the state in good condition. Operators must also provide a portion of health services at state-determined prices and continue employing a significant percentage of the facility’s staff, safeguarding their financial and employment rights. However, the law prohibited the involvement of operators in the delivery of primary health care services.

In conclusion, Egypt's policy statements demonstrate an attempt to commit to integrate the private sector into the national healthcare system that would require additional efforts to make this commitment stronger and clearer. By balancing public and private sector roles, the country could aim to enhance healthcare accessibility, quality, and efficiency, ultimately achieving its goal of universal health coverage.

 Why Defining a Program Boundary for Private Sector Engagement in Health is Crucial for Egypt

Engaging the private sector in healthcare is a pivotal strategy for enhancing health system performance and achieving universal health coverage (UHC). However, to harness the full potential of the private sector, it is imperative to first define a clear program boundary as part of the Deliver Strategy governance behavior outlined by the World Health Organization (WHO). This blog will debate why establishing these boundaries is essential for Egypt and the benefits it brings to its health system, including how it supports the other five governance behaviors of the WHO progression pathway.

The Importance of a Program Boundary for Egypt

1.       Strategic Alignment with UHC Goals

By clearly defining program boundaries, Egypt can ensure that private sector involvement aligns with the strategic goals of UHC. Documents like the "Strategic Directions Framework for Health in Egypt 2023-2030" should have explicitly outlined how private sector roles will contribute to UHC, including expanding access to quality care and enhancing service delivery. Clear boundaries help prioritize areas within UHC, such as universal health insurance coverage, ensuring that resources are directed towards achieving equitable healthcare access for all Egyptians.

2.       Prioritizing the Scope of Engagement

Establishing program boundaries also involves prioritizing the scope of private sector engagement. It is crucial to differentiate between issues within the health sector, such as universal health insurance system (UHIS), and those outside the health sector, such as medical tourism. In Egypt, the primary focus should be on integrating the private sector to support UHC and UHIS, ensuring that every citizen has access to essential health services without financial hardship. While medical tourism can contribute to economic growth, it should not overshadow the critical need to address domestic health challenges.

3.       Clarity in Roles and Responsibilities

Defining program boundaries helps delineate clear roles and responsibilities for both public and private sector players. In Egypt, where the health system is undergoing significant reforms, having well-defined boundaries ensures that the roles of private entities are clearly articulated in relation to public health goals. Without such boundaries, overlapping functions and unclear mandates can lead to inefficiencies and confusion. Clear boundaries ensure that each sector understands its responsibilities, leading to more coordinated and effective healthcare delivery.

4.       Efficient Resource Allocation

With well-defined program boundaries, resource allocation becomes more efficient. The Egyptian government can direct funding, human resources, and infrastructure investments to areas where private sector involvement is most needed, such as underserved regions or specialized medical services. This prevents the duplication of efforts and ensures that public funds are used optimally to complement private sector contributions, enhancing overall health system efficiency.

5.       Risk Management and Accountability

Program boundaries are vital for risk management and accountability. By clearly defining the scope of private sector engagement, Egypt can establish robust regulatory frameworks and monitoring mechanisms to mitigate risks such as compromised quality of care, inequities, and increased out-of-pocket expenses for patients. Clear boundaries also facilitate the tracking of private sector performance against defined benchmarks, ensuring accountability and transparency.

6.       Building Trust and Collaboration

Defining program boundaries fosters trust and collaboration between public and private sectors. Clear boundaries provide a framework for partnership agreements, delineating how both sectors can work together towards common health goals. This collaborative approach builds mutual trust, encouraging more private sector investment and participation in the health sector.

Supporting Other Governance Behaviors

Defining clear program boundaries for private sector engagement in health is crucial for supporting the other five governance behaviors of the WHO progression pathway.

Firstly, it helps in developing targeted regulations and financing mechanisms that govern private sector activities (Enable Stakeholders). With clearly defined roles, the government can create specific regulations that ensure patient safety, maintain quality of care, and protect health interests, making private sector contributions more effective and aligned with public health goals.

Secondly, clear boundaries foster inclusive policy processes, where the private sector is actively involved in decision-making (Foster Relations). This inclusion encourages better cooperation and collaboration between public and private entities, essential for the effective formulation and implementation of health policies. When the private sector is clearly understood and integrated into the strategic vision, policy processes become more transparent and participatory.

Thirdly, establishing program boundaries facilitates access to comprehensive, up-to-date data on the private sector's operations and performance (Build Understanding). This data is critical for strategic and operational decision-making, and having clear boundaries ensures that the information collected is relevant and aligned with national health goals. Accurate data enables the government to make informed decisions and adjustments to health policies and strategies.

Fourthly, clear program boundaries help create organizational structures that support the coordination between public and private sectors (Align Structures). These structures are vital for ensuring operational alignment with national strategies, improving service delivery, and enhancing the overall efficiency of the health system. Coordinated efforts between sectors lead to better resource utilization and service provision.

Finally, clear boundaries establish accountability standards that apply to both public and private sectors, building public trust in the health system (Nurture Trust). When the private sector operates within the same accountability framework as the public sector, it ensures that patients' rights and welfare are protected, regardless of the service provider. This consistency in standards and accountability fosters trust among the population, making them more confident in the health system's ability to meet their needs.

Challenges of Undefined Program Boundaries

1.       Overlapping and Redundancy

Without clear boundaries, there is a risk of overlapping functions and redundant efforts. This can lead to wastage of resources, inefficiencies, and gaps in service delivery. For instance, if both sectors invest in similar health services without coordination, it may result in underutilization of resources in some areas and overburdening in others.

2.       Regulatory Ambiguities

Undefined boundaries create regulatory ambiguities, making it challenging to enforce standards and ensure quality of care. This lack of clarity can result in a fragmented health system where the private sector operates with varying degrees of oversight, potentially compromising patient safety and care quality.

3.       Inequitable Access

Ambiguous program boundaries can exacerbate inequities in health service access. Without clear guidelines on the roles of the private sector, there is a risk that private providers may focus on more profitable services or populations, leaving vulnerable groups underserved. Clear boundaries help ensure that private sector engagement aligns with the broader goal of equitable access to healthcare for all.

Conclusion

Defining program boundaries for private sector engagement in health is a foundational step in the Deliver Strategy governance behavior of WHO, especially for a country like Egypt. It provides clarity, enhances strategic planning, manages risks, ensures efficient resource allocation, and fosters trust and collaboration between sectors. Prioritizing the scope of engagement ensures that private sector efforts are aligned with the critical goals of UHC, such as universal health insurance coverage, rather than being diverted to less critical areas like medical tourism. Furthermore, clear program boundaries support the effective implementation of other governance behaviors, enhancing the overall health system's performance. As Egypt strives towards UHC and better health outcomes, establishing clear program boundaries for private sector engagement is not just beneficial but essential. By doing so, the government can create a more coordinated, efficient, and equitable health system that leverages the strengths of both public and private sectors.