The Egyptian Swiss Radiology Project [ESRP]
Ministry of health and population

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Egypt has been accelerating its effort in the past years to rehabilitate and reform its healthcare system. While impressive results have been achieved in many areas of medical care, basic needs are not yet covered in many areas of medical care. Frontline basic diagnostic radiological services are being targeted by this project. In 2001 a study was done to assess the status of radiology services in the Egyptian MOHP hospitals. The results revealed lack of: Radiology equipments Trained radiology staff Standardized infrastructure Accurate information systems Adequate radiation safety means The need for improved basic radiology services offered in the public hospitals for the poor and underserved population could be clearly justified, as nowadays, due to insufficient capacities in the public hospitals, patients frequently need to wait a long time for X-ray examination, travel long distances to other public facilities or are compelled to have X-Rays done at private clinics which raises another economic and social problem for this category of patients. The lack of equipments and associated hardware is only one reason for the poor quality of public radiology services. In addition, the X-rays are not taken according to standards of good practice and the same is true for the film development process. This results in waste of consumable materials and a sub-optimal quality of images that can lead to false interpretations of patient’s health condition and ultimately to erroneous treatment . There is also blatant disregard for radiation safety due to lack of awareness, know-how and carelessness causing serious health risks for both patients and staff. Good procedure practices and proper radiation safety would also require the rehabilitation of X-Ray and film development rooms. An intervention had to be made to offer a quality of service that is indiscriminate to all Egyptians irrespective of their economic or social status and most importantly location as the more patients are decentralized from the urban areas the more they can be underserved. A comprehensive approach to improve all essential aspects of radiological services had to be taken into consideration when designing the project executive plan.

B. Strategic Approach

 2. What was the solution?
The Egyptian Swiss Radiology Project [ESRP] is a co - financing project between the Arab Republic of Egypt and Switzerland a Memorandum Of Understanding [MOU] was signed between the 2 parties for this regard with a strong conviction of improving the services offered to the underserved patients. Each of the Radiology departments involved in the Egyptian-Swiss radiology project (ESRP) went through upgrading of their facilities, systems and philosophies in order to make progress as a quality operated radiology department which resulted in many changes for management, employees, and the medical staff alike. There are many goals that have been achieved through the implementation of ESRP which could be concluded through the following results: Rehabilitation of radiology departments, including; renovation, applying standard radiation safety measures and equipping with new x-ray machines. Applying standard practice procedures for radiology departments through issuing of a set of standard guidelines concerning all operations and procedures according to international standards and local requirements. Drawing a strategy for technology management and maintenance of radiology equipment, in addition to introducing quality assurance policies and procedures for improving the quality of radiology services provided. Increasing the capabilities of radiology service providers through training of all targeted categories involved in providing radiology service according to the issued standard guidelines. Formulating a concept and methodology for supervision and follow up of radiology departments. Applying a set of studies and researches for assessment of the situation of radiology services. Objectives Supply of radiology Equipment (x-ray units and darkroom equipment) Sites rehabilitation including the necessary additional materials as electrical installation, generators and necessary air conditions. The basic preparation for the installation of the new equipments. Radiation safety enhancement in the X-Ray defined sites. Financing of the consumables necessary for the X-Ray equipments. Recruitment of the specialized staff Allocate the necessary budget for the general maintenance. Preparation of the sites defined for workshops and seminars Creating an information system for each site where the equipments will be installed to be used for costing, pricing, maintenance and quality control. Production of guideline, standard operations procedures. Audience: The Egyptian health policy aims at providing health services to all citizens in grade levels, starting with primary care then specialized health care, ultimately leading to coherent and integrated system of health care

 3. How did the initiative solve the problem and improve people’s lives?
The applied new standards within the different components of the project in sites rehabilitation and equipping also through capacity building has helped MOHP to implement those standards in all health care facilities not just the ones rehabilitated through ESRP in order to improve all areas of basic diagnostic radiology services. The conversion of a radiology department required guidance in numerous planning and technical assistance areas. This applied guidance through standard guidelines was evaluated for its efficiency and effectiveness to identify what to upgrade or modify and the ability of integration of these guidelines during implementation. Also applying quality standards for practicing and providing quality radiology services was followed by introducing quality improvement policies for the applied new system which introduced new concepts and strategies to preserve good quality radiology services. Patient satisfaction guided all the development processes in radiology services, so; applied field researches and studies were of critical importance to approach and evaluate the applied new systems and to reveal the required modification and upgrading of these applied systems. After that was the role of monitoring and evaluation of radiology departments for decision making support concerning radiology services, processes indicators and main indicators for the department developed and measured continuously to follow up the progress of department processes and to identify the possible deviation and the appropriate solutions to achieve the desired goals.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
ESRP main components and activities with the chronology of the steps taken are: 1-Site Rehabilitation: Prepare a primary list of targeted hospitals. Audit facilities against the standards. Elaborate the final list of selected hospitals (120 MOHP hospitals). Draw radiation protection plan and renovation plan. Facility upgrading according to the standards and specific needs for the new X-Ray equipment. Execute renovation and prepare sites for equipment installation. 2-Equipment Procurement and Installation: Define specifications for the required equipments (100 conventional x-ray equipment and six mammography equipments and no. of digital x-ray equipment). Equipment tendering. Equipment installation. General user training on the modes of equipment operation. 3-Maintenance and Technology Management: Enacting and implementation of the elaborated maintenance and technology management strategy for radiology equipment. Improvement and development of 1st line maintenance standards of radiology equipment to be suitable for general implementation in all MOHP facilities according to the results of applying the 1st line maintenance standards in the selected pilot centers. Train personnel in regular machine (user) maintenance. Building suitable capacities for maintenance of radiology equipment, capable of providing the required support for preserving and maximizing the benefit of radiology equipment. Strengthen MOHP planning department and technical advisors in cost beneficial technology management for radiology equipments 4-Standard Practice Guidelines: Field testing of the elaborated standard practice guidelines. Improvement and development of the guidelines according to the results of field testing. Updating the guidelines according to the new concepts, methodologies & techniques in diagnostic radiology. Training of radiologists and radiographers on the developed guidelines. 5-Quality Improvement and Supervision Scheme: Introduce quality improvement programs. Train officials from MOHP in quality improvement of radiology services. Enacting the elaborated supervision scheme. Train supervisors at all levels of supervision (according to the supervision scheme) on monitoring and supervision skills. 6-Radiology Human Resources Management: Define priorities for radiology human resources management strategy. Formulate adequate strategy for management of radiology human resources. Draw long term and short term executive plans. Orientation and collaboration with other administrations of MOHP involved in human resources management. Enact and implement executive plans. 7-Policies Enforcement: Define a strategy for enforcement of policies concerning radiology services. Draw plans for integration and collaboration with MOHP decision makers to enforce the required policies. Form a committee for radiology policies to control and organize radiology policies enforcement at all levels of decision making in MOHP. 8-Monitoring and evaluation: Define processes indicators for radiology departments. Elaborate measuring tools for processes indicators. Regular assessment and update (if needed) of the applied monitoring and evaluation system. Applied field researches and studies: Define the objectives of required researches and studies. Define methodology and executive plans. Elaborate data collection tools. Train research teams. Execute field researches and studies.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
ESRP has a steering committee comprising of the Egyptian partner Ministry of Health & Population [MOHP] and the Swiss partner which is the State Secretariat for Economic affairs [SECO]. I-ESRP team itself: Following the committee ESRP has 2 managers an Egyptian executive project manager and a SECO Swiss manager. Here the project support structure is divided into 3 parts: A-Project operations coordinators [task force]: 1-The sites rehabilitation coordinator 2-The equipment procurement coordinator 3-The maintenance coordinator 4-HR development and training coordinator 5-Supervision and quality management coordinator 6-Monitoring and information coordinator 7-Standard and guidelines coordinator B-Administrative support office: 1-Administrator 2-Computer operator 3-Data entry assistant 4-Cleaning person C-Project implementation assistant office: 1-coordination assistant 2-bookkeeper II-MOHP: 1-The curative sector 2-The planning department 3-The purchasing department III-Others: 1-universities bodies through the different consultancy aspects 2-Local authorities at the different governorates 3-Other ministries namely the ministry of planning, ministry of international cooperation and ministry of finance
 6. How was the strategy implemented and what resources were mobilized?
ESRP is a Mixed Financing project between Egypt [50%] and Switzerland [50%], a Memorandum of Understanding between the Government of the Swiss Confederation and the Government of the Arab Republic of Egypt was signed where the Swiss State Secretariat for Economic Affairs (SECO) assisted the MOHP in its efforts through the financing of radiology equipments and film processors. In addition, SECO financed a Technical Assistance Program [TAP] through a grant. 1-General Provisions •MOHP took all actions, including the equipment, trained personnel, guidelines, offices and the monitoring system provision of sites, facilities, services, consumables, means of transport (in addition to the transportation van and other travel expenses already included in the TAP) and other measures, necessary for the successful implementation of the Project i.e., the upgrading of radiology services in an additional number of hospitals of the MOHP as well as the Technical Assistance Program. •All equipment, material and services provided out of the Swiss funding, comprising the Mixed Financing and the TAP 2-Project Organization •The MOHP provided qualified and experienced personnel for the PIU Chair and the Task Groups for the duration of the project implementation as well as A furnished office and training facilities of the ESRP. 3-Sites Rehabilitation •The rehabilitation of the sites is financed by the MOHP. These costs include, but are not limited to, devices such as electric installation, IT-cabling, which are reflected in the estimated construction/refurbishment costs for new radiology departments. 3-Equipment and Services •The Egyptian authorities supported and facilitated efficient customs release of imported equipment financed under this Project. •MOHP organized the local procurement of furniture and accessories required for the Project. •SECO financed the procurement of additional radiology equipment, accessories, consumables and related services. Also provided professional project management support and specific expertise. 4- Financial Sustainability •MOHP allocated the budget required for personnel, in-house maintenance and maintenance contracts with suppliers (after the warranty period allocated in the contracts), consumables, after sales services and continuous staff training required for a medium and long-term operation of the radiology equipment. 5-Training •MOHP provided appropriate training facilities, arranged the travels for the trainees and took an active and leading role in the organization of training courses. 6-Maintenance and Technology Management •MOHP assigned an official in charge of clinical equipment maintenance and technology management also supported the set-up of an information system for the equipment and material acquired in the frame of the Project. 7-Technical Assistance Program SECO financed: •a Technical Assistance Program (TAP) through a grant this budget includes financing for administrative project implementation support as well as local and international expertise •Contribution in for the operational costs of the training courses. •The development, elaboration and review of the standard guidelines. •Radiation Safety strengthening of radiation safety technique and practices and its monitoring by the relevant Egyptian authorities.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Output 1: Sites Rehabilitation: ESRP has rehabilitated sites in almost all the governorates of Egypt, we have renovated almost 45% of the radiology departments in all of the hospital types whether general, chest or fever hospitals. All the rehabilitated sites match exactly the defined standards by the project. Also MOHP follows these defined standards for rehabilitation in all the new renovated or newly established radiology departments Output 2: Equipment procurement & Installation: ESRP supplied 385 different types of radiology equipments with their accessories and currently more equipments are being purchased to reach a total of 422. ESRP has also upgraded the types of equipments supplied from the mere analogue to full field digital equipments which was a great corner stone to start adopting the latest technology for radiology reporting which is the Picture Archiving & Communication System PACS as well as Tele-Radiology. Training was done on these new equipments to help in raising the levels of knowledge and awareness. Output 3: Radiation Safety: An initial baseline assessment study was done which revealed a gap between what is applied in the hospitals and what the national standards are. Actions were taken through adopting modified international standards to fit the Egyptian culture and coming up with lists of recommendations, then applying these standards which caused the level of safety to be raised. Calibrations for equipments was done, radiation shielding was reconsidered, safety brochures and protection aprons were handed to the different hospitals Output 4: Quality Assurance & Supervision Schemes: Baseline assessment was done and guidelines for the quality of radiology services were set and applied after training on these guidelines, this caused the level of service quality to be raised from an initial of 48%to 65%. Currently we are working on updating these guidelines to be able to be accredited. Output 5: Maintenance & Technology Management: Lots of efforts were exerted in this output in many levels to enable us now to have a full plan where a tracking tool is present for the monitoring of equipments breakdowns, maintenance contracting and all other related information. MOHP has adopted this tool and now is following the standards set by the ESRP for this output.

 8. What were the most successful outputs and why was the initiative effective?
ESRP succeeded in tailoring a system which monitors the project activities and tasks this system is web based called "Dotproject" which can only be accessed by the team members and management. The system is a combination of color codes each reflecting the progress of each single task. The colors are like the traffic lights. The system has green light for the on-time and ongoing tasks. Yellow color is for the recently delayed tasks. And the red color is for the tasks far beyond the deadline of the plan or indicating no achievement. In addition, there is a general meter where the overall project progress is indicated. This is useful for the project management to screen the percentage of activities progress with just one click. Moreover, it gives the decision makers the weakness sites with only quick one look. Recently it was found that it would be more realistic and beneficiary to have a system where the project activities and tasks can be monitored and measured as well as the radiology departments' key performances and tasks. The system is currently being upgraded to include the other activities of the radiology department. The monitoring system is a web based system to help the Swiss partner managers to follow up the project activities from their place and help in giving the decisions at once. This way we overcame the time gap between sending the activities’ measures and the final agreed upon decisions. On the other hand, the system gives levels of permissions where all the team members can access and use it for their own activity and tasks. The team member can monitor their own progresses as well. This supports the self corrections and is more responsible. The web based system also has a section for the files explorer. Such explorer has the option to link each single document to a task as output, deliverable or input. The project is currently working on updating the key performance indicators. This will lead to upgrade the monitoring system according to the latest updates. This system also allows all members stay connected and updated with all new tasks as an automatic e-mail is generated and sent to all the involved parties as soon as a new event is created.

 9. What were the main obstacles encountered and how were they overcome?
1-Political and governmental changes: so far almost 9 ministers were changed and a lot of governmental heads We overcame this because we have a well planned design with malleability to different perspectives. 2-Shortage and sometimes no budget allocations: we overcame this by working on separate levels with the different governorates so that each one finances their hospitals till we succeeded in bringing the fund centrally from MOHP. 3-Tender problems: at the 1st tender issued one of the bidding companies complained and caused us to stop for 1.5 yr till the issue was solved, again due to our malleable plan we were able to stretch the time frame 4-Owing to the agreement with the Swiss partner we had to get 100% Swiss equipments and when assessing our needs compared to the specifications of the Swiss equipments there was a gap that could have potentially stopped the collaboration, we overcame this by convincing the Swiss part to reduce the Swiss added value or share in equipments manufacturing to only 49%. 5-Sometimes we face a conflict between ESRP plan and the whole MOHP plan like we both want to rehabilitate the same site, so we overcome such situations by suggesting that MOHP renovates the hospital but ESRP renovates the radiology department as we already have the guidelines for that, we always try to by find a way to have a win/win situation with MOHP .

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Key benefits from ESRP: 1-Upgrading the diagnostic radiology services in 88.3 % of the Egyptian general hospitals with effective essential radiological services in all selected project governorates 2-Development of standards and guidelines for all the work done in ESRP from the rehabilitation guidelines to the technology and quality management and this was adopted the MOHP after the success of ESRP and is now generalized whenever there is a renovation to any radiology department 3-One of the most influential impacts for ESRP was introducing the idea Tele-radiology as an optimum solution to overcome the shortage in the quantity as well as the quality of radiologists and services. ESRP was used to design a Tele-radiology model with basic requirements to test whether a basic Tele-radiology design with the minimum costs could serve the same function of the full blown expensive one or not. Also to guide the path of a bigger and national project called the national PACS project adopted by MOHP that is dedicated mainly for the Tele-radiology implementation in the different Egyptian governorates. This was a very important step that paved the way for the National PACS project to kick off 4-ESRP has developed a maintenance strategy and contracting system to all of the radiology equipments supplied by the project and after the success of this strategy it was adopted by the MOHP to all of the radiology equipments 5-A web based tracking tool was developed by the project to track the different equipments situations which is very helpful in knowing the overall equipments conditions through monitoring of the statuses of equipments to tracking all of the breakdowns and maintenance actions. This was adopted by MOHP to become part of its activities helping in capturing the full picture in the different governorates 6-Elevating the level of the different HR categories that offer the radiology services in the general hospitals from the radiologists to the radiographers and secretarial support through the different training categories and levels offered through the ESRP 7-Capabilities building of the staff working with ESRP as they originally work for the MOHP through the directorate general of radiology by offering them technical support and transferring the know how and those people would then benefit the MOHP with the different experiences that they acquired 8-Quality related to radiology work was done at the different hospitals rehabilitated by the ESRP and this has introduced 9-Increasing the levels of radiology services in the small hospitals affiliated to the MOHP and this was a major contribution as small hospitals were to some extent overlooked so ESRP took the initiative to improve the levels of services there

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
ESRP is the result of collaboration of experiences of two countries and this project is carried out as a part of the activities done by the directorate general of radiology [DGR] which is responsible for all the work done related to radiology in all of the Egyptian public hospitals, a lot of investments were done in this project where a lot of equipments were supplied to renovated radiology departments. What the ESRP has succeeded in doing is that it has incorporated the project within the divisions of the DGR by recruiting the DGR employees and have them working as coordinators for the project so that they know all the aspects of the project and have the proper experience of running the different activities done at the project as they have had continues capability building over the years. Also what the project did was actually reshuffling the whole way the DGR works and making it run in the same manner of the ESRP where the different things done at the project are done almost the same way and with the same system as ESRP from the maintenance up to training and the equipments distribution. The system of work established in the different hospitals has made it easier for the staff working there and this would guarantee that they will always prefer to use the system that was standardized by ESRP. Regarding the financial part and because we are a governmentally affiliated project our yearly budget comes from the grand plan of the DGR as part of the program of upgrading the diagnostic radiology services. Our initiative comes parallel to what the MOHP does for upgrading the public radiology services and what we do here is that we offer the guidance for MOHP through passing the know-how that we have experienced over the years and by supplying all the valuable project outputs from the guidelines in how to establish a radiology department to the optimum way of running it, trainings that can be offered to the staff working. So now we have reached a status where we are always asked for guidance before starting to establish a radiology department. Also MOHP adopted the web based tracking tool developed by ESRP to become part of its activities helping in capturing the full picture in the different governorates.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
What we learnt while working in ESRP can be summarized in the following: 1-Thorough and good situational analysis for exact problem identification is the key when starting any initiative as when we did this before starting we were able to design the different activities on exactly what we lacked in our hospitals and thus became the "project's components" 2-Proper strategic planning from the start that puts into consideration all the risk factors that are to be faced and allowing the plan to be malleable and flexible to cope with the different situations faced e.g. political changes that we faced a lot during the past years 3-Proper team selection where there is a combination of older experts and fresh younger ones with diversity of opinions and experiences then taking this team and developing them with different knowledge and skills, also we have learnt the value of keeping these members and trying as much as possible to decrease any turnover within our team 4-Good management and team leading makes all the difference in the outcome as a good manager would both maintain good relations with the different stakeholders as well as the team 5-Proper infrastructure of all the aspects not just the equipments as this alone will not guarantee the good quality but we mean here the soft components as well like the human resources management and the guidelines for the different operations as well as the quality, maintenance, monitoring and evaluation and that is what we did from the very start of the project which leaves the MOHP with valuable assets of both hard and soft components. 6-Adopting and applying a successful model from any other country without considering the special nature of the place intended for the project will not guarantee the success of this model on the contrary it might actually hinder the progress that can be done. ESRP has succeeded because it took into consideration the special nature of Egypt in all of its details from the very first planning steps up to having some sort of modified guidelines for the different project's aspects that puts into consideration the various details.

Contact Information

Institution Name:   Ministry of health and population
Institution Type:   Government Agency  
Contact Person:   Sarah Abd Almaksoud
Title:   PACS & Teleradiology coordinator  
Telephone/ Fax:   +2-02-2365-4224
Institution's / Project's Website:  
Address:   1053 korniche elnile FoumAlkhalige
Postal Code:   1053
City:   Cairo

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