Understanding the Current Situation and Challenges in the Public Private Mix (PPM) of Human Resources for Health (HRH) in Selected Areas in Egypt

Background: Human Resource for Health (HRH) is one of the most important building blocks of the health system. The performance of the health systems is substantially impacted by the performance of health workers. Egypt has a highly fragmented health care system. Health services in Egypt are currently managed, financed, and provided by agencies in both public and private sectors. Egypt's health system has limited government oversight of the private sector and more open-ended healthcare market, which has contributed to a complexity of Public Private Mix (PPM). Since 1996, Egypt has been undergoing the Health Sector Reform Program (HSRP) with the aim of achieving universal healthcare coverage of the country. This study was conducted to contribute to the evidence in understanding the PPM of HRH in Egypt, towards contributing to the national dialogue to address related issue with its governance and development. Methods: This study uses qualitative method and literature review to approach the research topic. We visited 4 public hospitals and 3 private hospitals in Cairo, Benha and Fayoum in May to July, 2014. We conducted 45 in-depth interviews with health workers and 5 key-informant interviews with health policy experts. Document reviews were conducted from December 2013 to February 2015. Documents relevant to the country context and health profile were retrieved through PubMed and Google Scholar. Government activity and statistics were retrieved through openly published government report and reports from international organizations. An interview guide was developed and pretested. Interviews were recorded and transcribed. Data analysis began while data collection was still ongoing. Using a grounded theory approach, we reviewed the transcripts of interviews and coded with a table of key words. Codes and transcripts were double-checked for accuracy, based on which relevant themes were decided. We also compared the codes and transcripts among different stakeholders. Results: Egypt has a highly fragmented health care system. Health services in Egypt are currently financed and provided by a mix of agencies in both public and private sectors. The uncontrolled growth of private sector has impacted the performance of health workers. Dual practice, the practice of a health worker simultaneously engaging in both the public and private sector, is a prevailing phenomenon in the health workforce in Egypt. Dissatisfaction with the public salary is considered as the main reason which drives health workers to private sector. While pursuing private practice, most people still hold their position in public sector for a variety of reasons. Perceived as a mechanism to compensate the low salary in public sector, dual practice is accepted in the current Egyptian health system despite well-recognized negative impacts on the quality of care. Conclusions: A vast majority of doctors in Egypt has been involved in dual practice, while the prevalence of dual practice is much lower in nurses than in doctors. Financial concerns drive Egyptian doctors to conduct private practice. Meanwhile, most of them still hold their public posts, with various reasons including to gain clinical experience, academic titles, professional reputation, etc. Comparing with doctors, smaller proportion of nurses engage in dual practice as nurses tend to have longer shift time, less significant difference between public and private salaries, and more family responsibility. Dual practice helps to compensate the low salary in public sector although it is considered to negatively impact the quality of care in public sector. However, there is lack of rigorous regulations being implemented to govern the dual practice in Egypt. The weakness in health workforce management in public sector, especially in retention and performance evaluation, is interacting with the regulation and impact of dual practice in the country. The international experience indicates that definitive answer to cope with dual practice is not available and there is no uniform recipe to deal with the issue of dual practice. Further research is needed for the design of the approach to break the vicious circle of weak public capacity and unregulated dual practice, and to make use of HRH as a potential component to bridge public and private sector. It is also necessary to quantify and evaluate the impact of dual practice on social welfare from the perspectives of different stakeholders. Additionally, structural interventions are sorely needed in strengthening public sector and integrating private sector into the overall health system reform.