Introduction

Daniel is working on enhancing the quality of services provision across the healthcare system in Egypt by developing a new community-based methodology, which is thought of as a better monitoring and evaluation practice of health service provision in a very pluralistic health care system that makes the performance assessment mechanisms and quality assurance really troublesome.

The idea behind “The Community Monitor for Health Service Quality” is to promote active citizenship and social accountability through continuous community monitoring of health service provision in Egypt. The idea is unique and distinctive in the way it promotes community monitoring of services in general and the healthcare service in specific, in addition to the heavy emphasis that it places on social accountability, citizen engagement, community organization/ co operatives, and youth empowerment within the healthcare framework.

Regarding social accountability, the bias of the government being both the “evaluated” and the “evaluator” makes unbiased assessments virtually impossible, thereby hindering improvement of service quality. Daniel’s project, being managed and operated by unbiased community members, tackles this issue by restoring the accountability chain to the main stakeholders of the services, namely the citizens. Furthermore, citizen engagement and community participation are the main prerequisites that ensure success of any intervention. Amplifying the input of the citizen and magnifying its impact on the service quality will stimulate more active engagement and contribution to the development process. As such, the role of the citizens should not stop at involvement in concept design but should extend to participation in implementation and its monitoring. By empowering non-expert citizens to lead the changes they want to see in their healthcare system, and by opening channels of direct communication and feedback provision, citizens become a motor in the process instead of an obstacle that needs confrontation. They become more aware of the available resources and more vigilant to poor quality and waste of resources. Moreover, the project also promotes youth empowerment. It mainly targets the youth population by attempting to enhance and promote their active participation in monitoring and guarding the civil and social rights of their societies. Trainings that involve capacity building activities will prepare the participants for local, national and international experiences and will enable them to apply their learnt values in different fields of public work.

The objectivity of the monitoring process is what enables the idea to impose a systemic and structural change upon the healthcare system in Egypt as it addresses the problems pertaining to corruption influences, government biases as well as quality of health care data and services. Moreover, enunciating a basic set of expectation and standards according to the level of quality provides a strong foundation for reestablishing trust between the patients and the hospitals.

The idea tackles the healthcare system from a new perspective. It allows the monitoring process to be community/patient based. Management of public hospitals has to be done by a set of patient based indicators and the patient’s ranking for the services and quality of health care. Accordingly, this new framework empowers patients to make informed decisions about their choice of health service providers while also enforcing the preference of community assessors. Moreover, the project also aims to recruit and equip ordinary citizens with a set of basic tools to assess hospital care and service quality. (i.e. monitors or assessors do not necessarily have to be doctors or have experience in the health sector.

It must also be noted that Daniel’s idea is not associated with technology, talent or money. The important issue that Daniel is more concerned with is for the patients to focus on the quality of care, accountability and transparency. Creating a system that can be transparent, accountable and informative to patients will ultimately create a paradigm shift by allowing citizens to put pressure on the system.

Health service providers suffer from a multitude of challenges. Between their attempts to cover large numbers of patients & their lack of resources, a lot of health services are mismanaged, misused, misallocated, or even glossed over completely. The lack of social accountability to citizens has made poor quality of services the norm. Moreover, patients limited access to any patient-centered, standardized & understandable evaluation system. On their quest to find satisfactory medical facilities, they are usually left with little to no help as to where best to go. Policy makers have witnessed sporadic community initiatives that expose the state of public hospitals. Yet, these initiatives lacked scientific basis, planning, reliability, objectivity & a constructive attitude. Therefore, they were not sustainable enough to prevail and were never taken seriously.

With an estimated total life expectancy at birth of 72.3 years in 2008 and an infant mortality rate of 19 per1000 live births9. The general health profile of the Egyptian population is characterized by considerable discrepancies and lack of equality both in access to care and quality of services. Egypt’s healthcare system is a very pluralistic one. It relies on many sources of funding with the heavy reliance of 72% of total health spending incurred by households. The National Health Accounts (NHA) for the year fiscal 2007/08 estimate that Egypt spent 42.5 billion Egyptian pounds (LE) on healthcare, representing 4.75% of the country’s gross domestic product (GDP). This translates to a per capita health spending of 566.4 LE. Financing of healthcare is characterized by the presence of mutually exclusive tracts (silos) and a multitude in sources of financing. This makes the coordination and effective management of the healthcare sector a heavy burden across the public and private funders and providers.

The healthcare providers’ market is even more fragmented: A network of inpatient and outpatient facilities are owned by the Ministry of Health (MOH) in addition to public sector facilities operated by the Health Insurance Organization, the Curative Care Organization, Universities and Teaching Hospitals and Institutes Organizations as well as exclusive facilities managed and owned by the police and the military forces. There is also a heavy reliance on a growing private market of hospitals, outpatient clinics, pharmacies, and traditional healers. Contrary to global homologues, out-of-pocket spending in relation to total healthcare spending has been dramatically increasing over the past decade. It may be true that there is a pressing need to increase the state healthcare spending to cope with the persistence of infectious diseases and high burden of chronic conditions on the population’s welfare, but it is important to note that even without raising the government’s investments in health, there is much to be done in terms of efficient use of the currently available resources through radical restructuring of the healthcare sector that, if done properly, is capable of achieving outstanding results in terms of outcomes, decreased burden of disease and cost-savings.

There are a number of root problems that Daniel is attempting to address. These problems include the following; 1) There is a significant, unshakable lack of trust from the general population in governments and authorities. Government’s reports to the public rarely reflect the realistic service quality consequently community reaction to it has been either negative or ignoring. 2) All proposed or attempted solutions for healthcare quality monitor were highly dependent on governments and authorities. This is highly unlikely to deliver real tangible outcomes due to a very unstable and immature democracy, high bureaucracy and lack of efficiency. 3) Most healthcare monitors are done by “experts”, in many cases it translate the sold knowledge which, in many cases, assess the internal work dynamics while leave the customer satisfaction unaddressed. 4) Money is not always the problem! False stereotype that any public facility present low quality service while any private facility has better standards creates a state of unjustified imbalance. Public sector has a wide infrastructure and manpower that would permit presentation of high quality service if managed reasonably. 5) The burden of healthcare delivery has been thrown entirely on governments. Although governments should focus on the most important role of regulating and monitoring the healthcare delivery system as well as directly control and push forward preventive care, yet, total dependence on the government in actual healthcare delivery is a source of impending failure, especially in Egypt. 6) The diversity and multitude of healthcare providers available in Egypt has always been looked upon as an obstacle in front of monitoring or reform and rarely as something that can be used to create smarter ways of organizing service delivery. 7) The accountability sequence in the Egyptian healthcare system has always given the upper hand to top management (heads of departments, hospital directors, and government officials, ministers of health). Lower levels of healthcare deliverers (who directly provide the service), have to obey, report to these top managers and follow their instructions whether it’s about healthcare delivery, financial constraints or policy. An entire paradigm shift in this perspective is in order. To completely invert this scheme turning the primary stakeholder (the patient) on top of this sequence, having top managers seeking to satisfy his needs reaching the highest level of the minister of health, becoming the ultimate obeyed and servant to the entire system, instead of the primary focus of attention and respect.

Daniel has conducted field research that resulted in the creation of a set patient-centered performance appraisal indicators and measures that were later compared to international standards and assembled in 116 standardized assessments criteria.

He has also developed a Smartphone assessment tool that accommodates these criteria and displays them to the assessor via a user-friendly interface. Moreover, 6 training sessions have been performed that yielded 15 active, trained community assessors.16 hospitals covered in different locations in Egypt, including Cairo, Giza, Matrouh, and the Red Sea area.

In addition, Daniel has designed and developed the online portal www.eghospitals.com displaying the assessment criteria and results to the public and a back-end interface for data entry. He has also validated, analyzed and published 12 hospital profiles on the web portal, and initiated social media accounts and organic growth plan, displaying and promoting the website and the hospital assessment results.

Daniel’s organization is running as a hybrid model company, registered as a limited liability company at the ministry of investment. The organization has two main sources of revenue; 1) funding partners (i.e. World Health Organization and Transparency International), 2) beneficiaries. Our revenue model is based on providing more advanced and detailed patient-centered performance appraisal services to private hospitals upon their request, supplying them as well with a set of recommended actions to improve their services. These services are provided as a consultancy and generate revenues that enable assessments of public hospitals. In addition, insurance companies, HMOs and large health cooperatives contract us to carry out periodic assessments of hospitals they have in their providers’ network to periodically update their databases and have the data they need to better negotiate their rates.

Daniel’s current plan for this year is to 1) Cover 60 hospitals (12 already published), 2) Build the network of assessors that will carry out the hospital performance appraisals (Team of 15 community assessors are active), 3) Further develop the training tools and dynamics, 4) Seek new project partnerships. 5) Validate and enrich the tool through a series of meetings with national and international quality experts.6) Disseminate www.eghospitals.com to the public following the soft launch of the 20th of August 2015.

Within the next five years, Daniel plans to accomplish the following goals; 1) Propagation of the social accountability culture, 2) Coverage of all hospitals around Egypt annually or bi annually through a sustainable continuous assessment cycle, 3) Initiation of feedback loop between hospitals’ administration and local communities based on the updated scores. 4) Hospitals comply and react to assessment results, 5) Replication of the model in other services.

Within the next 10 years, Daniels aims to integrate hospitals’ score into the full picture of a functional healthcare system in Egypt that accounts for the scarce resources. A system that is designed & managed by citizens, possesses the flexibility to adapt to each community’s preferences, insures choice of providers, guarantees work sustainability & pushes towards accountability to citizens. Enabling universal health coverage through local ownership & improving service quality through regulated market dynamics. Expansion and scaling up will be attempted through 4 different paths: a- Traditional expansion: By recruiting and training more teams, expanding the network of assessors to cover the country based on the already set plan. b- Expansion through partnerships with NGOs and initiatives: by transferring knowledge and assessment dynamics to all interested active entities working on health. With a strict and smart monitoring system, eghospitals.com can grow using the effort of hundreds of collaborations across the country. c- Further development and simplification of the assessment tool so that it can be mainstreamed and used by the majority of patients. Adding innovative elements that would allow sustainable, systematic and national evaluation process by all service users without affecting the objectivity of the results.

Daniel grew up in a family of a father working as a surgeon, a mother who is an artist and a three-year-older sister working as a graphic designer. He grew up with the belief that health and education are key means for a nation’s progress and it was this strong belief that shaped his career at later stages. When considering a path to pursue, his passion for medicine motivated him to join medical school, where as a student, he was engaged in various activities and experiences that gave him insight on the Egyptian health system. While approaching the initiation of a clinical career it occurred to him that the key problem with the Egyptian health system is not the lack of skilled physicians but rather the functionality of the system. As such, five years into the undergraduate program, Daniel came to the conclusion that by practicing medicine he would not be contributing to the improvement of the health system as much as he had once believed. This urged him to explore the options that would allow him to achieve his original ambition.

Daniel graduated from a public high school named “El Farouk Omar” in Sadat City located on the Cairo-Alexandria desert road. Due to the geographical distribution rules, he was allowed a place at the Menoufia School of Medicine for the first two years. After finishing the two years he moved back to a university closer to home, namely Ain Shams University. Overall, the change of cities, universities and schools, such as the shift from a private preparatory school to a public one, taught him to adapt to various conditions, and exposed him to different cultures and behaviors. His years as a student at Ain Shams entailed diverse activities and experiences that shaped and refined his personality. Activities ranged from photography and arts to leadership roles and international representation of medical students, all of which allowed him to acquire flexibility, open-mindedness and adaptability.

Daniel has been an active member in the Egyptian Medical Students’ Association (EMSA) since the beginning of 2012. From his first days as an EMSA member, he always took the lead in managing difficult situations. Daniel voluntarily took the role of the students’ exchange program officer at the association, where he learned to pay attention to details, manage a team and solve problems immediately as they arose. During his term as the managerial president of EMSA, for which the majority of members elected him, the organization achieved its vision and all the organizational values were realized in multiple activities. After completing his term, Daniel was invited to be part of the administrative board as vice president. This allowed him to sustain his responsibility in the association but through different roles.