The organizational structure of the Project Implementation Unit

The organizational structure of the Project Implementation Unit and internal controls
129. The organizational structure of the Project Implementation Unit and internal controls: Tracking and Project Implementation Unit General Authority for Health Insurance in organizational terms, the government covers the full coverage of their employees’ salaries.
130. The unit will consist of project implementation team of the unit manager, director of procurement, procurement staff, and Chief Financial Officer, who will report to both the project manager and director of the Finance Department of the General Authority for Health Insurance. In addition, it will allow the financial director of the Health Sector Reform Project, which was closing in March / March 2009 – support and training for the new financial director during the period of 12 months from the life of the project to ensure the transfer of knowledge from the projects financed by the World Bank.
131. be entrusted to the Chief Financial Officer of the Project Implementation Unit as soon as his appointment and before the date of the project shall enter into force – a process of renovation Administration Guide Finance with the support of the financial director of the Project Health Sector ending repair work done, as is the person who originally prepared this guide which will explain what will be applied in the project of controls in addition to the accounts, authorization agenda, session and documentary, and review cycle.
132. reserves and project implementation unit of the documents and the documents all have financial manager of the project responsible for preparing monthly settlement document with the site “link collaborators” with the World Bank, where the Director of the Finance Department of the General Authority for Health Insurance reviewing this document and adoption.
133. preparation of reports and registration: The project applies the cash basis accounting method, where the purchase is simple automated accounting system and use it to support the registration work and the preparation of budgets and reporting project to develop health insurance systems.
134. CFO of the Project Implementation Unit shall be responsible for the registration of all accounting operations and reporting. In addition, this is Chief Financial Officer and tracing paper monthly obligations which each of the project manager and director of the Finance Department in the General Authority for Health Insurance reviewed and approved.
135. must be a management information system, which will purchase the project able to produce the required financial reports, including the sources and uses of funds, cash withdrawals, cash and expectations. As has been discussed during the mission, it will prepare the financial director of the project reports and the project manager and director of the Finance Department in the General Authority for Health Insurance reviewed and approved.
136. Based on the instructions of the World Bank directory, you must prepare the following reports in this project:
137. Every six months: the project must prepare interim financial reports half-yearly and brought to the World Bank within the framework of the progress report to the project or independent as reports. This consists of the following reports:
a. Statement of sources and uses of funds by project component, including references to funds received from various sources – if any – cash and expectations, and report expenses compares actual expenditures and planned by activity – if that is true – and the data allocated to the settlement of accounts.
B. List of contracts: include all contracts, clarify the amounts committed and disbursed in each contract in the history of the preparation of the report.
C. Is a list showing when signing a contract supplies of goods received (by type and location) on the date of preparation of the report and distributed.
138. These reports must be sent to the World Bank within 45 days of the end of the half year, according to the project loan agreement.
139. annually: the financial manager of the project implementation unit annually prepare financial statements for the project and that the cash basis method of accounting will follow them, and then decline and then submitted to the World Bank within six months of the end of the year. The consolidated financial statements of the project and include the following:
Dr. A statement on the sources and uses of funds, shows the funds received and expenses of the project sources
e. Appropriate tables classified project expenses by component, and describes the annual and cumulative balances
And. Settlement allocated – accounts if applicable – which explains the settlement between the opening balances and balances at year-end data
G. Statement for the project links, any unpaid balances depending upon what is out of the question the contracts signed for the project.
H. Placement of the equipment received and distributed at the end of the year
140. Budgeting. The chief financial officer of the project implementation unit of the project a year to prepare budgets and plans Exchange reflect the cash requirements for the project every three months. The initial plan shall be based on the initial procurement and implementation schedules and courses discretionary payments plan, and then revise afterwards. The budget will be utilized as a monitoring tool for the disparity and cash management analysis. It is the responsibility and unity of the implementation of the project, the General Authority for Health Insurance responsible for updating of the annual budget.
141. Posting inventory control and assets on the central and provincial levels: All project assets being purchased through your inventory system at the General Authority for health insurance and that they should retain disease inventory is based on the manual registration system entry. Based on the equipment that will be purchased for the purpose of this project scope, the will of the General Authority for Health Insurance installing a system that facilitates the equipment management, which will be purchased and also facilitate the distribution, so that the hold separate records for the purpose of recording the information, maintain and relating with equipment distributed by location, including the number of equipment received in the various offices of the three governorates and kind. It was also agreed to take additional measures during appraisal to ensure the sound management of the project assets.

financial sustainability and efficiency of the operations of its own social health insurance

Health Insurance Systems Development Project

95. This project aims to assist the borrower in improving the financial sustainability and efficiency of the operations of its own social health insurance. Will be the main mechanism for achieving this is the goal is to design and use of management information system modern, as well as related devices in the facilities and equipment of health insurance body, where the initial focus will be on three provinces implemented in each of which a pilot project is the Suez and Sohag, Alexandria. It is planned as soon as the project is implemented successfully expand the program to include all provinces. The project consists of a single component called “Run information system and management point of payment shall pay the costs of the service arrangement (the National Authority for health insurance).”
96. characterized by information management systems, particularly in the health care environment, extreme complexity, which are difficult to design and implementation process, because they are often exposed to external influences that can delay successful or prevented altogether implementation, therefore, to maximize the chances of success the project has been designed in three basic contracts . Respect of the main contract to develop the information management system and its implementation, and the second decade of physical buying necessary equipment of the pilot project to be implemented in some provinces and the National Center, and the third is concerned with the contract to oversee the project and to confirm the quality of contract hardware and software. The third contract also provides for the provision of independent technical advice to the Insurance Commission on specific technical issues whenever the need arose, and holds the Project Implementation Unit operations by management and reports to the General Authority for Health Insurance (or its successor body).
97. The design and implementation of information management system (~ US $ 45 million). Information Management System consists of a number of units required of the General Authority for Health Insurance; and in order to play its role to the fullest, and include:
i. Management Service Providers Affairs. This includes the creation of an accurate record of service providers, including the functions associated with receiving services to join the insurance program applicants, and evaluating these requests in exchange for agreed standards, and registration of contracts concluded later on that detail.
ii. Management of the affairs of the beneficiaries. This creates an accurate record of the beneficiaries, including the functions associated with the receipt to participate in the insurance program applications, eligibility and evaluation, and any print-related eligibility cards, choosing the beneficiaries of Family Physicians, the management of complaints includes.
iii. Benefits package management. This includes the creation / and maintain a record of the services to be provided through the program as well as any shared payments related, prices, and any other conditions.
iv. Claims Management. This includes the provision of several types of claims of different types of service providers, and then processed, mechanism and efficient manner, to the extent possible. Will be several options available to make claims in order to maximize the participation of service providers who have different levels of technical capability. The rules will automatically apply the evaluation of claims, so be sure to comprehensive and strict implementation of the rules, approved by the transfer of funds electronically to the service providers.
v. Management benefit from the services and quality management, and measures to combat manipulation and fraud. It will be implementing a number of activities to monitor the management levels use the services affairs, and identified, and influence. And it will not include excessive use of services, but also include the lack of benefit from them and those services that appear to be inconsistent with the best clinical practices. It will be the information system of monitoring a large variety of performance criteria, including – for example – the number of visits per beneficiary per year, and the number of days in hospital bed occupancy per physician shall issue instructions to enter the patient’s hospital in a year, ect. In addition, it will be the system to track the number of quality indicators such as Quick prescribing drugs carried out by the service providers, and enterprise-level indicators such as infection rates hospitals. The identification of cases of manipulation and fraud, manage the issue of separate but equal in importance and other matters, and will be greatly improved upon through the application of payment destination information system, which will enable investigators to determine the manipulation and fraud cases possible and examined in an orderly manner.
vi. Case management. The system will allow the registration of referral of patients, followed by the top levels of care, thus ensuring access to health care by the appropriate level.
vii. Supporting work activities. The system also will support the insurance body through a variety of jobs and types of businesses, such as finance and accounting resources, human resources and payroll plans, legal affairs, and fixed asset management, communications, and management of documents. In addition, the system will support the very important issue of collecting insurance contributions, registration and management, will also enable the efficient use necessary to raise money management tools to the optimum level, including, for example, the proportion of medical waste management, and accountability of funding, and provision of medical precautions and actuarial tools and forecasting models.
98. This contract includes a requirement for a supplier to establish a testing lab to make sure the software worked satisfactorily.
 
99. physical equipment in the three pilot provinces (~ US $ 25 million). Respect of the second decade of physical buying necessary equipment to run a pilot program for the management information system in the three provinces and the National Center. The suppliers of the management information system developed specification equipment.
100. expected at this stage that includes the physical composition of equipment on a number of features:
a. Areas of data centers and the center of the national data. The implementation of the system at the provincial level operations such as the involvement of the beneficiaries, and the accession of service providers, claims management, and case management, with the establishment of data centers at the end of

several major donors providing support to the health sector

92. activities and partnerships donors. There are several major donors providing support to the health sector. And is still the European Commission and the US Agency for International Development, constitute the most important actors. The European Commission launched the current support on Reform of the health sector in partnership with the World Bank, and made commitments worth about 83 million euros in the form of budget support, to be paid in three segments, based on a matrix of indicators or targets to be achieved in each of the three stages of this support. The World Bank and worked closely with the European Commission in order to develop a range goals are compatible with the new design of the project. These indicators relate to changes in the governance and management of the sector system, financing, and a package of benefits, and protect the poor and who can not, and improved levels of standards and quality, and incentives tied to performance. Budget support has reached the level of initial targets.
93. The United States Agency for International Development, and is a partner of the Ministry of Health for a long time, gradually ending its support for the health sector, and also reduced the support for the process of reform of the health system significantly. But at the same time it will play an active role in the issue-specific areas as programs targeted capacity to train health sector building managers, especially at the level of service providers (hospitals).
94. There are several programs and agencies of the United Nations (World Health Organization, and the World Food Programme and UNICEF) focuses on basic services and primary health care and the fight against bird flu. The United Nations Population Fund is focused at the same time on reproductive health and family planning.
 
Appendix 3: Results Framework and monitoring
 The Egyptian Arabic Republic
Health Insurance Systems Development Project
Results Framework
Project Development Objective indicators project outputs use project outputs Information
Assist the borrower in improving the financial sustainability and efficiency of the operations of its own social health insurance. 1. New operating procedures for the management of contributions, claims processing, and management levels use the services, including the formal adoption of measures to combat manipulation and fraud
2. The percentage of claims of social health insurance to be drawn and processed through the new work management systems in terms of payment in the three pilot provinces
3. The percentage of claims processed electronically, which are rejected or escalation based on the medical relevance compared to the rates that are monitored through manual review in the three pilot provinces
4. The annual reports of the Steering Committee for Social Health Insurance system of the government – backed by the data produced by the systems
5. point staff ratio of payment for the insured population in the provinces of the three pilot projects. Year 1: probably indicates delays in the delivery of documents to the delay in the delivery of the product

2-3 two years: should the new system can draw all the data, it means failure to do so that the design of the system may be insufficient

Year 3: may mean mismatches between electronic claims Enquirer reported levels, for the results of manual review, electronic systems that need further improvement.

Two years 3-4: signifies a failure in the preparation of reports produced by systems that are likely not to achieve the benefits of the new system.

Year 4: should the relative administrative costs go down in the provinces of pilot projects.
Outputs ICs
Outputs progress indicators to monitor the use of interim outputs
Output 1:
Detailed design Output 1:
Percentage of all documents and system design, which has been completed and adopted. Output 1:
Year 1: will result in delays in the delivery of design documents to the delay in the delivery of the product
Output 2:
Functional and operational testing. Output 2:
Successful completion of operational testing in the areas of:
• Manage Subscriptions
• Claims Management
• management levels use the services (including anti-manipulation and fraud measures)
• Reporting Output 2:
2-3 two years: the delay in the first pilot to maintain in the test may indicate a delay in the delivery of a complete system
3-4 two years: the delay may result in the test in the two provinces experimental second and third to the delay in the delivery of a complete system
Output 3:
Enter service providers claims data remotely
Output 3:
Percentage of all claims that are received electronically directly from the service providers to all claims which are processed Output 3:
Year 2 – Year 3: Advanced low levels of claims by electronically may indicate that the service providers or suppliers of their programs are not involved in the system properly

large and important improvements to the quality of government services

82. You can enter a large and important improvements to the quality of government services. The sponsors have initiated health care services in the implementation of several programs on quality improvement in the recent past, but none of them did not take an institutional nature. The recent focus on improving quality to develop a new system for the adoption of facilities and installations in Egypt. There are already made for a limited subset of primary care clinics (family) health funds, as the International Assembly adopted the quality of health care to adopt all of the primary health care and hospital standards. The draft law has been developed in order to establish an independent body to manage these criteria. In parallel with these efforts, there are granting licenses to private sector enterprises system is currently being applied to public utilities.
83. In the public sector, being allocated the necessary resources for items Kalmsthoudrat pharmaceutical and maintenance of restrictions or crowding out other spending such as wages and salaries items. Do not actually sick burden remains on the shoulders of the General Authority for Health Insurance providers taking to increase, while difficult to increase the budget and the appointment of new staff allocations. This may detract from the quality of care and user satisfaction Authority facilities. One of the other common problems in the body program is the delay suffered by the beneficiaries in access to physicians with reasonable quality at a reasonable time. For beneficiaries of the body to go to a specific doctor them and then turn them later this doctor to a specialist doctor. And the lack of ability to deal with qualified doctors is one of the major bottlenecks in the current system. In general, shares of misallocation of resources and the lack of a strategic approach to improving the quality of services until recently the loss of patient satisfaction for public health services. As a result, it is very much what most Egyptians, including those living in the most impoverished areas to get health services from the private sector seeks.
84. private health insurance market is growing rapidly, in Cairo alone, according to the Ministry of Investment, there are forty-eight driven health care plan in advance covers two million beneficiaries. And created the majority of coverage through employer groups (70 per cent), including the Ministry of Finance and other government bodies. There is a single destination for the reinsurance market. But shallow coverage, and sets a ceiling for most plans cover at around 10 thousand Egyptian pounds (US $ 2,000 approx.). The paid plans reflect the increase in advance the establishment of a lot of contractual relationships with local clinics or private hospitals to work in the private sector entities to provide health care services for their employees – and thus “opt out” practically under the umbrella of participation in the General Authority for Health Insurance. One successful example is the “Medicare” program for the Nile Badrawi Hospital in Cairo, which meets the needs of customers with high incomes.
85. provide health insurance policies for the time being also the largest life insurance companies in Egypt, represented by: the east, and Egypt to secure, and private. It also provides Bupa (BUPA) Insurance and based in the United Kingdom-based health insurance programs aimed at affluent. It is worth mentioning here that health insurance in Egypt is no longer subject to many regulations in the past five years. A new law allows the opening of a foreign private insurance companies has been issued. Moreover, it was also the minimum capital required to start reducing the insurance company, under the General Agreement on Tariffs and Trade (GATT). And applied as well as tax exemptions on employers and employees who pay premiums above a certain limit.
86. complement more traditional newly clinics and facilities located in the private market employers own emerging market. Many of the large enterprises in Suez, for example, allows employers and families in the health care facilities of the employer institution itself or nearby. The challenge addressed by the new social health insurance initiative would be to integrate the emerging and rationalize the public sector, the private sector through a combination of calls to the closure of some facilities and to upgrade the necessary public facilities.
87. One of the critical steps in the reform process is the adoption of a new law of social health insurance. This legislation is envisaged that there will be a new destination shall pay for services arrangements, which will accommodate the beneficiaries of the General Authority for Health Insurance and administrative resources that you pay the costs of services. The World Bank has provided technical assistance to the authorities responsible with regard to funding standards, legislative and dimensions, and the reforms involved in the provision of services. It has also been an actuarial model to estimate the costs of preparing the reform process. The aim of the social health insurance system reforms to the inclusion of all citizens universal health care. This would be achieved by broadening the scope of risk-sharing, and improve service quality and efficiency, and to prevent the fragmentation of financing arrangements and the provision of services.
 

Appendix 2: Main related projects financed by the World Bank and / or other agencies
 The Egyptian Arabic Republic
Health Insurance Systems Development Project

88. succeeded health sector reform program, which has been closing in March / March 2009, to extend the umbrella of coverage of a package of primary health care services and public health to include the poor, who are unable in the two provinces, and in the broader offered by multilateral donors to support the framework of (the United States Agency international development, the European Union, the World Bank, the African development Bank) for the first phase of the health sector reform program (in five provinces, including three rural provinces). This project aims to expand health coverage through a basic package of primary health care and public health services in two pilot. This project supported two main activities: (a) restructuring health care and rationalize services in a network of family health facilities, and (b) the establishment of health funds at the level of the province (family health funds) to fund tied to the performance level of payments provided to health care facilities for the family that have undergone reform and got approval certificates. One of the results achieved by the adoption of the project and the Ministry of Health for this model to be a national model for primary health care, and will be integrated into the new social health insurance system in Egypt as the first level of service. The project will also work to facilitate dialogue between the Ministry of Health and the Ministry of Social Solidarity, and also led to the establishment of a procedure to recover the performance is based upon the application of social targeting of the Ministry of Solidarity mechanism costs, in order to identify the poor and who are not able, and to involve them, and exempting them from paying user fees. Moreover, there is an agreement with the Ministry of Finance to support the services provided to the poor, who are unable costs of those who are identified under this mechanism. The development of the new health insurance systems project a continuation of this project.
89 are currently being implemented two programs of technical assistance to recover their costs with the Ministry of Finance to support the Government in the development agenda of effective reforms on pensions and social health insurance, respectively. These programs have enabled us to accomplish great work with the Finance Ministry, such as the availability of international reference in the design of legislation and review the impact of the proposed reforms on the state budget scenarios standards, as well as that they can be an important tool in the future in order to work with the government and support.
90. also contributed to the previous health projects financed by the World Bank to bring about a dramatic reduction in the incidence of diseases and fertility rates. Schistosomiasis Control Project has supported (No. 2403, and it was closed in 2002), a national program successful schistosomiasis control allowed coverage for all residents of rural areas in Egypt with a treatment aimed at reducing the spread of this disease parasite painstaking, who barely acknowledges him one of the rural population poor and unable ago the era of the pharaohs. This project has contributed to the occurrence of a massive reduction in the prevalence of the disease of 35 per cent of the population in 1983 to less than 5 per cent in 2002.
91. Implementing the project of the population (No. 2830, and it was closed in 2005), a unique partnership between the Ministry of Health and Social Fund for Development, where the targeted communities in Upper Egypt with high fertility rates. This project has contributed to a significant increase in the prevalence of the use of contraceptives and the increased utilization of family planning clinics in targeted areas quadrupled rates. Among the key elements for the success of this project are: the crowd for effective cadres concerned with social change enthusiastic and committed and well-trained, which got support active in the targeted areas, non-governmental agencies, as well as close coordination between these interventions on the part of the demand backed by the Social Fund for Development and interventional procedures of the show, backed by the Ministry of Health along.

Health Insurance Systems Development Project

Background information about the country and the sector or program
 
Health Insurance Systems Development Project

73. The health system in Egypt fragmented system, consisting of a number of health care are going in parallel lines systems, owned by the public and private sectors and funded entities and institutions, multi-funded (Table 1). Most of the total expenditure in the health sector of the petty cash payments directly to households, which account for more than half of all spending on health care in Egypt comes. The government’s budget is funded about 30 per cent at a time when funded health insurance contributions in the other 10 percent. Less than one per cent of private health insurance and contribute to the total expenditure on health care in the country. It is clear from these figures that the risk-sharing level (risk) assembling and financial protection against any personal health disaster emergency afflict the Egyptian citizen is limited level.

Table 1: Distribution of health care spending, according to authorities and institutions funded 0.2004
Authorities and institutions funded by millions of Egyptian pounds Percent
A 7927 government budget 28.1
      With its own treatment at state expense b 1,323 4.7
Social insurance (PAHI) A 2020 7.2
Households (incidental expenses directly) c 16 703 59.2
Private insurance d 169 0.6
A further 54 0.2
TOTAL 28,196
a. Spending data released by the Ministry of Finance in respect of the government economic and devices for the fiscal year 2004.

C. BI Egyptian households have access to health care and spending it, 2002. 2004 estimates are based on a linear extrapolation of the household expenses in 2002 process.
Dr.. National health accounts for the year 2002: The 2004 estimates are based on the assumption of a constant rate of coverage.

74. have the health coverage of the population in Egypt from the public through a combination of social health insurance, government health services subsidized (Figure 1). It covers social health insurance offered by the General Authority for health insurance of about 48 per cent of the population, including one-third of the active labor force. The vast majority of the population who are covered by the General Authority for Health Insurance (80 per cent) understanding of school children and children under school age. The Ministry of Health and other governmental bodies network of providers of government health-care services throughout the country all, and who perform the role of “insurance of last resort” by making provision of free or subsidized health services strongly in support of citizens who are not covered by the General Authority for Health Insurance. The Ministry has in the past decade, the expansion of large-scale treatment program at the expense of the state, which provides financial assistance to all Egyptian citizens to pay expenses incurred by government spending on health care in the last ten years (the last 10).
75. The public sector is divided into government agencies and economic bodies. And it includes health care institutions that fall under the category of government bodies and administrative offices and health care facilities that follow the Ministry of Health in terms of operation, which includes the General Diwan of the Ministry (central headquarters) in Cairo, and the directorates of health affairs in the governorates of Egypt twenty-seven (27), specialized medical centers and cancerous tumors. It includes investments in these specialized centers, which was founded in 2001 and affiliated to the Ministry of Health, a network of about 34 university hospital, which contributed to a major increase in capital and operating expenses of the Ministry of Health. And recover the costs of these services in part through the treatment program at the expense of the state. In addition, government agencies include hospitals that follow the General Authority for hospitals and educational institutions, which operates nine specialized research institutes and nine large teaching hospitals, as well as university hospitals run by the Ministry of Higher Education, which play a key role in medical education and medical training, research and clinical.
Figure 1: The coverage of health care benefits in Egypt
 
Source: Ministry of Health and the World Bank experts, the review of public spending 0.2006

76. include health care institutions that fall under the category of the General Authority for Health Insurance Authority and therapeutic institutions and economic bodies. General Authority for Health Insurance was founded in 1964, the issuance of Health Insurance Law No. 61, which was granted a historic powers to this body that extends health insurance to cover all Egyptians. But, after four decades of history that still falls short of this objective investigation. General Authority for Health Insurance and operates at present several independent programs of compulsory health insurance on the formal sector workers, pensioners, widows, school children, and children under school age, who have health insurance are covered on an optional basis based on the decree. The Commission has 13 branches, where the body – manages traditionally – a network of health care facilities for the benefit of Mentfieha in all parts of the country. This network has recently separated beneficiaries of the body for a network of service providers to allow for better service on both sides: the service buyer and foremost.
77. General Authority for insurance contracts used to in the past with service providers from the public and private sectors to enable Mentfieha services that can be provided to them through the network is. Body and hired more specifically with particular individual doctors to work in their facilities (about 25 per cent of the total staff), and with service providers and pharmacies from both the public and private sectors to meet the medical needs of Mentfieha. Contracts and provide services from outside the body has represented about a third of their total expenditure. In addition to the above, the therapeutic institutions Authority was established in 1964 as an independent body for the purposes of the national hospital management. And founded the first two institutions belonging to the body in Cairo and Alexandria, and established four other institutions in the mid-nineties of the twentieth century. But that happened in 2000, three institutions were closed and hospitals transferred to the Ministry of Health, bringing down the general importance of therapeutic institutions in the provision of health care services. While the scope and size of the expanded health care providers that operate services Khaiat government over the past decade, the shrinking number of providers of these services running economic Khaiat.
78. There are important issues of equity and efficiency in this sector. Total spending increased to health services from public and private sources in urban provinces increased by 2.5 times for total spending in rural counties and provinces level (Figure 2). There is also an unfair preference for urban governorates of the richest in the distribution of health resources in relation to the number of hospitals and health facilities in the public sector family. The per capita in Upper Egypt – Egypt’s poorest areas – always the lowest number of hospital beds (Figure 3) and doctors.

80. provide government health care system productivity rate was still low in terms of efficiency. One of the low productivity in the very low rate of bed occupancy standards, which indicates a lack of good use of a large part of the fixed capital. Although the absorptive capacity clinical in Egypt similar to other countries with similar income levels, the average bed occupancy rates of 25 per cent at the national level, and 35 per cent in the Ministry of Health hospitals. If possible, raise the average occupancy rates to the best of 80 per cent level of international practices (as is the case, for example, in the European Union countries) will increase the existing assets of the infrastructure of hospitals more than doubled. The government has in the past few years, the implementation of an investment program that would have increased the number of hospitals and specialized centers that operate within government bodies greatly increased.
81. The incentives to improve the delivery of low government health care system productivity. Government bodies are dependent on key provisions of the state budget, not be held accountable for financial performance, and with little autonomy and limited ability to generate revenue. And based financing public service providers mostly on historical method of funding from the supply side, without making any link between the revenue the service provider and the provision of services to patients. The inertia that is characteristic of the civil service management and bureaucracy one of constraints to health providers, Ministry of Health and other government bodies, including low wages and fixed salary is tied to performance. And it works about 89 per cent of private doctors dual functions of (the government and the public sector), which makes it possible to exploit the public hospital facilities in the practice of the profession to take advantage own without the state to recover these costs.