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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 3  |  Page : 237-242  

Does implementation of the universal health insurance affect the quality of referral in the healthcare system? A cross-sectional comparative study in Egypt


1 Associate Professor, Department of Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Professor, Department of Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
3 Lecturer, Department of Family and Community Health Nursing, Faculty of Nursing, Port Said University, Port Fuad, Port Said 42526, Egypt
4 Lecturer, Department of Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission19-Jan-2021
Date of Decision09-Aug-2021
Date of Acceptance13-Aug-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Nesrine Saad Farrag
Dr. Nagy Abdel-Razik Street, Gamaa District, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_50_21

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   Abstract 


Background: The Universal Health Insurance System (UHIS) has currently entered into service in July 2019 in Port-Said, a small governorate in Egypt, as a pilot to be generalized in 5 phases. Objectives: The study aimed to compare the quality of referral practice under the UHIS and the traditional system (Mansoura). Methods: A comparative cross-sectional study that was conducted in the duration from July 2019 to June 2020, targeted all physicians and nurses working in primary health care (PHC) sites and hospitals within the UHIS (204 doctors, 396 nurses) with an equal number from PHC sites and hospitals in Mansoura (205 doctors and 395 nurses). A predesigned validated self-administered questionnaire was used to collect data. Results: The study included 1200 physicians and nurses. Results showed that receiving referrals without letters and referrals not conforming with the rules were significantly lower in the UHIS (13.4% vs. 50.2%, and 39.5% vs. 60.7%, respectively). Denying a referral was significantly higher in the UHIS (38.8% vs. 21%, P ≤ 0.001). The drawbacks in the referral system were less reported in the UHIS (P ≤ 0.001 for most items). There were no significant differences regarding the presence of rules for referral or attending training courses related to the referral process (P = 0.269, P = 0.188, respectively). Conclusions: The study indicates that considerable improvements in the quality of the referral process were achieved. However, the system needs more efforts related to in-service training of the staff, feedback letter.

Keywords: Egypt, health system reform, quality, referral, universal health coverage, universal health insurance


How to cite this article:
Farrag NS, El-Gilany AH, Ibrahim AM, Abdelsalam S. Does implementation of the universal health insurance affect the quality of referral in the healthcare system? A cross-sectional comparative study in Egypt. Indian J Public Health 2021;65:237-42

How to cite this URL:
Farrag NS, El-Gilany AH, Ibrahim AM, Abdelsalam S. Does implementation of the universal health insurance affect the quality of referral in the healthcare system? A cross-sectional comparative study in Egypt. Indian J Public Health [serial online] 2021 [cited 2021 Dec 7];65:237-42. Available from: https://www.ijph.in/text.asp?2021/65/3/237/326395




   Introduction Top


Universal health coverage (UHC) means that all people can receive quality healthcare services without experiencing financial hardship linked to paying for the service.[1] The UHC is a long journey rather than being an end goal.[2] Egypt's Sustainable Development Strategy Vision 2030 sets UHC as a priority goal. Formidable challenges face the implementation of UHC in Egypt. However, the Egyptian government has been working hard, with the support of the WHO Country Office in Egypt, to implement this principle and make UHC a truth.[3]

In 2018, Egypt approved a reform act that includes a Universal Health Insurance System (UHIS) covering all over the country.[4] The new UHIS implies a major change in the referral practice. Bylaw, the UHIS determines the type of health care providers that would provide the healthcare service package for the insured. Specifically, it determines the entrance points and levels of healthcare. It is predicted that patients can only enter into the UHIS through PHC facilities which provide primary package of services or which refer to higher levels. Administratively, the UHIS assigns people to PHC facilities by branches according to geographical distribution, but for higher levels of healthcare, patients can choose between different care providers taking into consideration gradual referral between different levels.[5]

The referral process is a complex process in which the general practitioner plays an important role as a decision-maker or gatekeeper.[6] It remains a challenge whether people in Egypt, would accept these new “gatekeeping” rules and enter the new health system at the lowermost level.

The new UHIS has currently entered into service in July 2019 in Port-Said, a small governorate in Egypt, as a pilot to be generalized in 5 phases. The new health insurance laws together with infrastructure and financial arrangements have been prepared to assure successful implementation of the system. Furthermore, political leadership is a driving force in this promising plan.[4] Having clear limits between the levels of health care in the new system, the referral between these levels should be mandatory and has its rules. These rules are not present elsewhere in Egypt where patients can obtain health care from secondary and tertiary levels directly. Therefore, the current study aimed to compare the quality aspects of the referral process under the new UHIS (in Port-Said) and the traditional system (Mansoura city as an example) and to find out drawbacks of the referral system under the new UHIS and the traditional system.


   Materials and Methods Top


Study design, study area/setting, study population

A comparative cross-sectional study was conducted from July 2019 to June 2020.

It was conducted in Mansoura (Dakahliah governorate) and Port-Said governorate in which the new health insurance system has been recently implemented. The UHIS in Port-Said includes: 6 PHC centers, 14 PHC units - at the primary healthcare level (PHC), 5 general hospitals - at the secondary healthcare level, and 2 specialized hospitals - at the tertiary level. From Port-Said, the current study included. All PHC centers (6), seven PHC units, two general hospitals and two specialized hospitals. As a comparative group, PHC sites and general hospitals, specialized hospitals were included from the Dakahlia governorate.

The target study population included all physicians and nurses working in the included sites in Port-Said. Hence, we contacted all physicians and nurses in UHIS and all who accepted to participate in the study were included. An equal number of nurses and doctors were recruited from randomly selected Dakahlia healthcare sites. No exclusion criteria were set except the refusal to participate in the study.

Sampling

The study aimed to target all physicians and nurses in the included sites in Post-Said (UHIS) with an equal number from Dakahlia's comparative group. The sample included 600 participants (204 doctors, 396 nurses) from Port-Said with a response rate of 70.6% (total number of 850). Hence, we included 600 participants from Dakahlia, with more or less the same ratio of physicians to nurses, and PHC sites to hospitals.

Study tools/techniques

After extensive reviewing of literature,[6],[7],[8],[9] a predesigned self-administered questionnaire was developed by the researchers to collect data. The questionnaire included – (i) personal information as hospital/PHC, department, age, gender, position, work experience since graduation, postgraduate qualification, duration of working in the hospital, (ii) information about the quality of healthcare referral from different aspects, for eample, the presence of standardized referral form, transport facilities for patient referral, guideline of referral, communication between PHC and other levels of care, (iii) inquiry of physicians at general and specialized hospitals about their experience with referral, for example, inappropriate referral, rejected referral, referral without letters, (iv) drawbacks of the referral system, (v) data specific for primary healthcare physicians and is related to logistics related to the decision of referral.

The questionnaire of the study was tested in a pilot study that included 20 healthcare workers from Port-Said to assess clearness and easy understanding. The test was assessed by a jury of five public health experts to assess its validity. The content validity index of both relevance and clarity of items ranged from 0.75 to 1.0.

Statistical analysis

The collected data was organized tabulated and statistically analysed using the IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Frequencies and proportions were used to present categorical data. While medians with (minimum–maximum) were used to present nonparametric continuous data. Chi-square and ManWhitney U-tests were used for testing significance, where appropriate. There were no missing data. The level of significance was set at P ≤ 0.05%.

Ethical considerations

To report this study, we followed STROBE guidelines for observational studies in epidemiology. This study was approved by the Committee of Ethics and Scientific Research of the authors' institution. Informed written consent was obtained from healthcare workers that participated in the study. All research procedures were steered in accordance with the principles of the Declaration of Helsinki.


   Results Top


The study included 1200 physicians and nurses, (600 from Port-Said, 600 from Mansoura). [Table 1] shows no statistically significant differences regarding the ratio of PHC sites to hospital, ratio of physicians to nurses, and age of the included groups. However, work experience since graduation and duration of working in the current site was significantly higher in the traditional system than the UHIS (median [minimum–maximum]: 18 (1–40) vs. 11 [1–40] and 10 [1–34] vs. 4 [1–40], respectively P ≤ 0.001). On the other hand, there was a significantly higher postgraduate qualification in the UHIS (42.8%) compared to the traditional system (8.2%, P ≤ 0.001).
Table 1: Comparison between the characteristics of the physicians and nurses of the Universal Health Insurance System and the traditional system

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[Table 2] shows that the referral rate in the UHIS was higher than the traditional system (P ≤ 0.001). There were significant differences between both systems regarding the causes of referral (P ≤ 0.001, each of them). Results also showed that sending a referral without referral letter was much lower in UHIS (15.8% vs. 77.2%, P ≤ 0.001). The transport facility for patients' referral and the communication within the system was higher in UHIS than the traditional system (48% vs. 31.5%, and 50.8% vs. 33.5%, respectively P ≤ 0.001).
Table 2: Characteristics of the referral process under the new Universal Health Insurance System and the traditional system as reported by doctors/nurses

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Receiving referrals without letters and referrals not conforming to the rules were significantly lower in the UHIS (13.4% vs. 50.2%, and 39.5% vs. 60.7%, respectively, for each P ≤ 0.001). Denying a referral was significantly higher in the UHIS (38.8% vs. 21%, P ≤ 0.001). All logistics considered by PHC physicians during taking a referral decision were significantly less reported in the UHIS than in the traditional system (P ≤ 0.001 for each them, except for travel distance). There were no significant differences regarding the presence of rules for referral or attending training courses related to the referral process (P = 0.269, P = 0.188, respectively).

The drawbacks in the referral system were less reported in the UHIS, compared to the traditional system (P ≤ 0.001 for all items). However, the differences were wider for some items, for example, no family physician at each PHC centers (0% vs. 88.7%), no communication between PHC centers and hospitals (43.5% vs. 89.3%), absence/poor referral letter [24.7% vs. 86.3%, [Table 3]].
Table 3: Drawbacks of the referral system under the new Universal Health Insurance System and the traditional system as reported by doctors/nurses

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   Discussion Top


The referral process in the healthcare system in Egypt as in many other developing counties is suboptimal or ineffective.[9],[10] Referral system is a core concept in processing the new UHIS. The current study found that the referral rate in the new HIS was significantly higher than the traditional system. This is justified, as the referral should be the only way to see a specialized doctor or have a more specialized service. Results showed the new system had significantly improved many aspects of the referral process, starting from the higher qualification of workers, use of referral letters, transport facilities, communication between the two poles of the referral process. Furthermore, many of the drawbacks of the traditional system were much improved in the new UHIS.

Healthcare workers' number, distribution and qualification, knowledge can greatly affect the quality of the referral process.[9] Our study results showed that, although healthcare workers in the National Health Insurance Scheme had, on average, less years of work experience, they had higher postgraduate qualifications, what should be positively reflected on the quality of referral process within the new system. Furthermore, although no difference was found between the staff of both systems, with regard to receiving in-service training related to the referral process, all staff in UHIS implied the importance of keeping records of referral process; what was significantly higher than staff in the traditional system. Other than self-referral, receiving a patient without referral letter may be the result of malpractice of some doctors who sometimes refer cases without referral letters. Our results showed that sending a referral without letter was much more prevalent among staff in the traditional system compared to the UHIS (77.2% vs. 15.8%).

The quality of healthcare provided at the PHC facilities is the main reason why people skip this level of care to higher level (i.e., self-referral). Kahabuka et al. found that people are ready to travel long distances to receive a better-quality service. They stated that improving the quality of the existing healthcare sites is more important than increasing the number of units providing the service.[10],[11] The unfulfilled expectations of patients when contacting healthcare services are the same main drivers of self-referral.[12] These drivers are related to the quality of service, availability of medications, availability of diagnostic tests, attitude of the healthcare workers, waiting times, affordability of the service.[13],[14] Our study found that referring cases for further evaluation, diagnosis of difficult cases, or for receiving treatment is much less reported in the UHIS; what indicates that more services are available at the healthcare sites. Furthermore, referral on a patient's request is nearly half that reported in the traditional system; A good indicator of the quality and applying the rule of referral. Higher quality means higher utilization of healthcare services.[15]

Inappropriate referrals can be either: made to the wrong specialist or service, have insufficient information, or not conforming with rules.[16] All these types were less reported in the UHIS, especially, referrals not conforming with the rules (39.5% vs. 60.7%). Also, receiving referrals without letters was much less reported in the new system compared to the traditional system (13.4% vs. 50.2%). While rejecting a referral in the UHIS was nearly double that in the traditional system. These figures indicate that conforming with the rules of referral is a characteristic of the new system. Improving the referral system implies improving the awareness of public regarding the protocols of referral and clarifying that it's the right of the hospital to reject referrals not conforming with the rules. According to one study in Nigeria, more than two-thirds of participants felt that it's unreasonable for any hospital to reject patients, being unreferred to their facility.[17]

Referral should be a two-way process of communication between the referring physician and the referral site. Communication within the new UHIS was higher than the traditional system (50.8% vs. 33.5%). However, there was no improvement in the rate feedback letter to the referring site. Actually, the absence of feedback notes to the referring doctor is a common malpractice in other health systems.[7],[18] Mohammad AlGhamdi et al. reported that 52% of physicians never issued a feedback letter to the PHC units regarding the referral.[11]

When taking the referral decision to a specialist, a PHC doctor may consider several factors such as previous experience with the specialist, insurance coverage or patients' cost, appointment timeliness, patients' convenience. However, different doctors characteristics may also affect how much weight is given by the doctor to each of these factors.[8] In our study, these factors were taken into consideration by all doctors in the traditional system. But these factors became to some extent less important in the UHIS, as the cost, the referral site, and specialist available are already planned for in the new system. Changes in the healthcare system and predetermined referral plans already restricts the choices of the PHC physician during the referral decision, making him/her a gatekeeper.[8]

The referral process in the traditional healthcare system suffers a lot of drawbacks related to the referral process as poor or absent referral letters, poor communication between both ends of the referral process and limited transfer services available, limited number of family physicians, insufficient training of the healthcare staff, and lack of resources. All these drawbacks were less reported by the staff in the UHIS, indicating that some improvements had been achieved, especially related to the availability of FM doctors at each unit, and the communication between healthcare sites, the use of referral letter.

On the other hand, results showed that the UHIS was not superior to the traditional system regarding the in-service training of healthcare workers, the use of feedback letters, and the presence of protocol of referral. More efforts should be devoted to improve these items, especially the in-service training of workers to maximize the benefits and the improvements achieved through the new UHIS. The protocols and the standard referral letter should be central to any training given to the healthcare staff in the UHIS.[9]

However, some of the limitations of the study should not be overlooked. The study is a cross sectional study that is liable to reporting bias, recall bias. Also, the study didn't include the records of referral due to limitations related to the quality of recording.


   Conclusion Top


Results showed that the new UHIS is a promising plan for eliminating the fragmentation of the healthcare system in Egypt. Considerable improvements in the quality of the referral process have been achieved, especially those improvements related to the infrastructure, the communication within the system, the referral letter, conforming to the rules of referral. The system still needs more efforts related to in-service training of the staff, feedback letter, and improving awareness of the public. Despite the huge challenges in Egypt, the pilot phase was implanted successfully. This indicates that other similar healthcare systems in developing countries could benefit from such health system reform.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Department of Health: Republic of South Africa. National Health Insurance Policy - Towards Universal Health Coverage. Published Online; 2017. p. 1-67. Available from: https://www.gov.za/sites/default/files/gcis_document/201707/40955gon627.pdf. [Last accessed on 2021 Jul 13].  Back to cited text no. 1
    
2.
World Health Organization - Western Pacific Region. Universal Health Coverage: Moving Towards Better Health - Action Framework for the Western Pacific Region; 2016. p. 1-92. Available from: http://iris.wpro.who.int/bitstream/handle/10665.1/13371/9789290617563_eng.pdf?ua=1. [Last accessed on 2021 Jul 13].  Back to cited text no. 2
    
3.
World Health Organization (WHO). Egypt Laying the Foundations: Making UHC a Reality. Published Online; 2020. Available from: https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/egypt/stories_from_the_field_issue2_egypt.pdf. [Last accessed on 2021 Jul 13].  Back to cited text no. 3
    
4.
Soliman SSA, Hopayian K. Egypt: On the brink of universal family medicine. Br J Gen Pract 2019;69:82.  Back to cited text no. 4
    
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Egypt Today. 32.5% of Egyptians Live in Extreme Poverty: CAPMAS - Published Online; 2019. Available from: https://www.egypttoday.com/Article/1/73437/32-5-of-Egyptians-live-in-extreme-poverty-CAPMAS. [Last accessed on 2020 Jul 06].  Back to cited text no. 5
    
6.
Central Agency for Public Mobilization and Statistics. Published Online; 2020. Available from: http://capmas.gov.eg/HomePage.aspx. [Last accessed on 2020 Jul 06].  Back to cited text no. 6
    
7.
Mathauer I, Khalifa AH, Mataria A. Implementing the Universal Health Insurance Law of Egypt: What are the Key Issue on Strategic Purchasing and Its Governance Arrangments. Published Online; 2019. Availale from: https://apps.who.int/iris/handle/10665/311781. [Last accessed on 2021 Jul 13].  Back to cited text no. 7
    
8.
Devi S. Universal health coverage law approved in Egypt. Lancet 2018;391:194.  Back to cited text no. 8
    
9.
Pillay I, Mahomed OH. Prevalence and determinants of self referrals to a District-Regional Hospital in KwaZulu Natal, South Africa: A cross sectional study. Pan Afr Med J 2019;33:4.  Back to cited text no. 9
    
10.
Mohammad Albattal S. Management of inappropriate referrals in wazarat health center, Riyadh, Saudi Arabia. Int J Med Sci Public Health 2014;3:269-276. [doi: 10.5455/ijmsph. 2013.141220131].  Back to cited text no. 10
    
11.
Mohammad AlGhamdi O, AlMalki B, EidNahhas A, AlMalki A. Rate of referral from primary health care to secondary health care among governmental hospitals in Taif governorate, KSA. Int J Med Sci Public Health 2015;4:1457.  Back to cited text no. 11
    
12.
Kinchen KS, Cooper LA, Levine D, Wang NY, Powe NR. Referral of patients to specialists: Factors affecting choice of specialist by primary care physicians. Ann Fam Med 2004;2:245-52.  Back to cited text no. 12
    
13.
Omole VN, Mora AT, Yunusa I, Audu O, Jatau AI, Gobir AA, et al. Knowledge, attitude, and perception of the referral system among tertiary health-care workers in Kaduna metropolis, Nigeria. Int J Med Sci Public Health 2017;6:1481-8. [doi: 10.5455/ijmsph. 2017.0307617082017].  Back to cited text no. 13
    
14.
Kahabuka C, Kvåle G, Moland KM, Hinderaker SG. Why caretakers bypass Primary Health Care facilities for child care - A case from rural Tanzania. BMC Health Serv Res 2011;11:315.  Back to cited text no. 14
    
15.
Kahabuka C, Moland KM, Kvåle G, Hinderaker SG. Unfulfilled expectations to services offered at primary health care facilities: Experiences of caretakers of underfive children in rural Tanzania. BMC Health Serv Res 2012;12:158.  Back to cited text no. 15
    
16.
Kuwawenaruwa A, Mtei G, Baraka J, Tani K. The effects of MCH insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: A mixed methods analysis. J Health Popul Nutr 2016;35:37.  Back to cited text no. 16
    
17.
Pillay I, Mahomed OH. Prevalence and determinants of self referrals to a District-Regional Hospital in KwaZulu Natal, South Africa: A cross sectional study. Pan Afr Med J 2019;33:4.  Back to cited text no. 17
    
18.
Liu L, Leslie HH, Joshua M, Kruk ME. Exploring the association between sick child healthcare utilisation and health facility quality in Malawi: A cross-sectional study. BMJ Open 2019;9:e029631.  Back to cited text no. 18
    



 
 
    Tables

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