Internationally renowned healthcare quality and safety expert Dr Ashraf Ismail explains the concept behind the Egyptian General Authority for Healthcare Accreditation and Regulation (GAHAR), its work in setting and implementing standards as well as accrediting healthcare institutions in Egypt, and his hopes for the country's transformational rollout of universal health insurance.
Could you begin by outlining your career trajectory and how you came to specialise in health system management and administration?
Before becoming chairman of GAHAR I was the executive director for the Middle East and Africa of the Joint Commission International (JCI)- a US non-profit organisation in charge of accrediting hospitals. Prior to that, I was an associate professor with George Mason University and Johns Hopkins University in the US, also spending time as director for Asia, Europe, and the Near East for Johns Hopkins’ international education program.
I spent a good deal of my life in the US system as a quality director and was one of the pioneers in implementing quality and safety in healthcare there. This trend started in other industries but in the late ‘80s and early ‘90s we started to implement it in healthcare, first in the US before it spread to the Middle East.
Going back to the start, I began my career as a physician and worked extensively in paediatric intensive care. Having witnessed many cases of children dying because of things related to public health, I began to realise the importance of disease prevention. This led me to specialize in public health in addition to paediatrics and eventually obtaining a Master of Public Health (MPH) from Tulane University in the US. From there, I also realised the importance of health systems management and administration, as well as the scientific and systematic introduction of quality and safety to healthcare provision.
Can you explain how the concepts of quality and safety were first introduced into healthcare?
Back in the early ‘90s, many US industries were starting to think about Total Quality Management (TQM) [a management framework based on the belief that an organization can build long-term success by having all its members, from low-level workers to its highest-ranking executives, focus on improving quality and, thus, delivering customer satisfaction – Ed.].
We took note of this and began to introduce elements across healthcare, building on the Donabedian model [a conceptual model that provides a framework for examining health services and evaluating the quality of health care – Ed.]. This covered structure, process, and outcome, with the idea that the outcome of a given process is dependent on how well the process is conducted. For a process to be done well it should be designed well, with high-quality inputs that help avoid defects in the outcome.
A focus on having high-quality inputs necessitated an examination of the range of suppliers and service providers that healthcare relies on and meant that healthcare began to be considered an industry itself. Beyond the hospital, physician, and patient, healthcare is also about the technology used, the medication given, the food introduced, and the buildings where healthcare is provided. These days, we also consider topics such as environmental impact.
To ensure the best healthcare outcomes with zero defects, we need all components to be done correctly, with quality and safety considered every step of the way. This requires the work of a whole host of stakeholders.
Is GAHAR a completely new body or a remodelling of an existing institution?
President Sisi laid out a new strategy for the healthcare sector as part of Egypt’s Vision 2030 national transformation plan explicitly stating that the country would pursue universal health insurance. Our constitution also states that healthcare must be provided to the highest international quality standards. When the universal health insurance law was passed in 2018, three new organisations were established.
The first was GAHAR, which reports directly to the President. This is a breakthrough in terms of thinking and shows the prioritisation that is now being given to healthcare quality standards from the very top. Myself and the other members of our full-time Board have built GAHAR’s capacity according to international standards so it can best fulfil its mission, that is: to set the standards for all healthcare facilities in the country. These standards must be accredited internationally by the International Society for Quality in Health Care (ISQUA), which accredits accreditors and sets standards.
It is also worth noting that GAHAR is an organization accredited by ISQUA as the first governmental organization in Egypt and the second in Africa to attain their distinguished accreditation.
In three years, we successfully created six sets of standards, which already have international accreditation. The standards we have developed cover the full domain of healthcare facilities, from primary care to ambulatory care, hospitals, laboratories, imaging services, and physical therapy. This is an unprecedented amount to have accomplished in less than 30 months. There are three sets of standards under process which are mental health hospitals, long-term care, and blood banks that will be accredited by ISQUA in the future
How do the socioeconomic means of individual countries factor into this international accreditation process?
Egypt has a unique mix of healthcare infrastructure, with certain hospitals dating back hundreds of years and others that are very modern. Because these facilities were built at different times, there is a lack of consistency across the system; some are well designed, equipped, and staffed, while others are barely fit for purpose because of the old infrastructure.
This constitutes a challenge in terms of implementing standards. Nevertheless, we do have a national code, first issued in 2015 and updated in 2022 based on GAHAR’s international standards – which all healthcare facilities must meet to be built or licensed. GAHAR registered and accredited 195 facilities in the last three years. These standards are attainable and cannot be dropped to ensure quality and safety and reach the best performance. In fact, national standards are often of a higher standard than their international equivalents, which must be applicable in all countries.
Is this accreditation process running in parallel to the rollout of universal health insurance across Egypt?
Around 3,500 diseases registered in the world are covered by the universal health insurance with the aim of covering all 100 million plus Egyptians (a number that will rise to 120 million by 2030) across the entire country, and at all times. While not all healthcare facilities are yet part of the universal health insurance, we are encouraging all of them (governmental and private) to apply for accreditation and registration in parallel, so that the entire process is expedited.
As soon as healthcare facilities are registered and accredited by GAHAR, they become eligible to sign a contract with the Universal Health Insurance Authority (UHIA) and provide services through the network to insured people.
How is GAHAR being financed?
GAHAR is directly financed by the Egyptian government and operates like a service organization, with annual payments from the government in return for services, i.e., the development and publishing of standards.
Why are the concepts of quality and safety particularly important within Egypt’s healthcare transformation process?
In essence, quality is vital because we simply cannot afford to re-do procedures. Without this, patients will be re-admitted to hospitals, have to change their medications, or have more operations; all of which come with a significant cost.
The other side of the coin is safety. Of the 274 hospital standards we have set, half refer to safety and no healthcare facility can be accredited without fully meeting GAHAR’s 28 strict national safety requirements.
How is GAHAR looking to ensure the implementation of the standards it sets?
There are a number of programs, measures and initiatives that GAHAR follows and adopts to ensure continuous compliance. Healthcare facilities are subject to denial of accreditation if they violate the accreditation standards.
In addition, there is the geographical information system-GIS- that aims to identify the distribution of services according to the needs, gender, education…..etc
We have performed well on implementation so far. For example, on venous thromboembolism (VTE), a silent killer that affects a lot of patients post-operation, we have created a standard but also guidelines, protocols, training, and, incentives around it. GAHAR is now engaging in a similar undertaking around diabetes, with guidelines for the priority areas in every hospital.
The culture of implementing the guidelines and the protocols has already started to spread, with a greater stakeholder awareness of what needs to be done. GAHAR continues to monitor this and has the power to deny or suspend accreditation as well as impose penalties if these standards are not implemented correctly.
How resilient will Egypt’s healthcare transformation plans be to global, regional, and national volatility?
Despite all the economic turbulence worldwide and the various global crises – from COVID to supply chain challenges, the war in Ukraine, and now recession – President Sisi and his government have continued to prioritise the rollout of universal health insurance for the Egyptian population with no compromise on quality.
We need to work within existing circumstances. For example, if we run into issues with exports we can overcome them via local manufacturing or alternatives. However, it should be remembered that Egypt is very rich in resources, with big domestic pharmaceutical companies and a thriving industry able to supply the majority of the medications that we need. Additionally, Egypt also boasts large construction companies that can build great hospitals with whom we work to implement our code and ensure the safety of the design. Medical technology is also a strong suit as is Egypt’s most valuable resource – its people.
Egypt’s healthcare industry is stable and moving in the right direction, with greater collaboration between private and public sectors than ever before.
Moreover, we are now creating maps for potential investors about where to invest and what to invest in to avoid oversupply in certain areas.
What will success look like for GAHAR?
We are determined to bring the healthcare system up to the highest international standards via hard work and inter-sector collaboration. The doors are open for more collaboration, more investment, and the future is very promising. Egypt is a very big country, with a very big population, where healthcare has become a priority, and people appreciate modern medicine. Moreover, Egyptian human resources are of very high quality and we are always working to improve and produce more healthcare professionals in all categories. Medical tourism will also be a relevant area to explore, and GAHAR has partnered with Temos – the most prestigious global organisation in medical tourism accreditation – on mutual recognition of accreditation.
Egypt is keen to have an excellent location on the map of medical travel.
