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Universal Health Insurance: Challenges and Aspirations

Reforming the health sector is a gruelling process and notching up success in it is quite challenging. Yet, Egypt took on this challenge. Towards that end, Egypt approved the Universal Health Insurance (UHI) Law 2/2018 in December 2017 and its implementing regulations in May 2018. De facto implementation of the law started upon instructions from President Abdel-Fattah Al-Sisi to be first rolled out in Port Said in early July 2019.

The UHI is a social solidarity scheme, through which high-quality medical services are provided to all members of the society without discrimination and irrespective of their income level. Under the scheme, the government undertakes to treat those who are unable to afford health services, through an integrated package of diagnostic and therapeutic services. Subscribing to the UHI system is mandatory for all Egyptians, meaning the system brings together all individuals and communities under one insurance umbrella. Compulsion ensures sustainability and securing funding for the system. A voluntary insurance scheme would see the affluent reluctant to participate in it rendering it limited to the poor. Whereas the membership fee is proportional upon the income, this denies the insurance system substantial resources which may hinder its sustainability.  

Enrolling in the system is made obligatory by making payment of the premium a requirement for getting public services. With the full implementation of the scheme, all healthcare-targeted resources would be pooled and complementary and parallel systems, including treatment at the expense of the state, would come to a halt.      

The funding and sustainability of the UHI system is contingent on household subscriptions, a proportion of the total income of the household to be paid by the breadwinner. A household subscription would typically include the non-working wife and children. Working wives pay on their behalf 1 percent of their income. The household contribution for family men working in the public and private sectors amounts to 7 percent of the entire income. As for the impoverished people, accounting for 30-35 percent of all households, the state’s public treasury will pay for them. To prevent abuse of the medical services provided, the beneficiary will bear a fraction of the cost of examinations, tests, and x-rays.

The essence of the UHI law

According to the UHI law, each citizen will have a medical file that includes their entire medical history. Family physicians examine patients and refer them to specialized hospitals to get the medical care needed. Patients can’t head to the hospitals or private clinics unless examined and referred to the hospital through the family physician. A family physician would oversee the patient’s treatment protocol as well as drug management. The UHI scheme covers diagnostic, therapeutic, and rehabilitative services as well as medical and laboratory tests including the services of family physicians, medical specialists, in-home care, hospitalization, surgeries, medical tests, physiotherapy, drug prescribing and dispensing, pre-employment and periodic medical check-ups, and treatment abroad if treatment isn’t available locally. However, the UHI scheme doesn’t cover public and preventive health services, paramedic services, family planning services, natural disasters and epidemic-related health services, and similar services provided by the state free-of-charge. 

According to the UHI law, implementing regulations, full implementation of the UHI will be delivered in 6 stages over 15 years, allowing for the efficient management of financial resources and providing an opportunity to capitalize on experience and learn from mistakes to avoid them in successive stages. Implementation phases will be as follows: 

Phase 1Port Said, Ismailia, Suez, South Sinai, Luxor, and Aswan
Phase 2Matrouh, the Red Sea, Qena, and North Sinai
Phase 3Alexandria, Beheira, Damietta, Sohag, and Kafr El-Sheikh
Phase 4Beni Suef, Assiut, Minya, New Valley, and Fayoum
Phase 5Daqahliya, Sharqiya, Gharbiya, and Menoufiya
Phase 6Cairo, Giza, and Qalyubia

The UHI law is based on the separation of powers, meaning it adopts the provider-funder-monitor split model for service delivery to be applied through the following three bodies:

  • The General Authority for Healthcare (GAH), responsible for providing different health services, through hospitals, primary care clinics, medical laboratories, radiology and physiotherapy centers, pharmacies, etc.
  • The General Authority for Healthcare Accreditation and Regulation (GAHAR), responsible for quality assurance of health services provided. The GAHAR establishes standards for health service delivery and accreditation of hospitals besides, carries out regular controls to health facilities, and ensures enforcing the law against facilities violating quality standards.
  • The Health Insurance Organization (HIO), responsible for administering and financing health coverage, including collecting insurance premiums and paying for the GAH for services provided.

Hurdles to Implementing the UHI Scheme 

The successful implementation of the UHI scheme may be faced by major hurdles that could hold progress back. These hurdles include:

  • Competent and Sufficient Healthcare Workers: Providing competent and adequate human resources is a big challenge to the successful implementation of the UHI scheme. The poor financial conditions of medical staff in Egypt, compared to neighboring countries, led substantial numbers of doctors and nurses to seek opportunities abroad resulting in a serious shortage of physicians in general, particularly family physicians who are the bedrock of the project as well as medical specialists, including intensive care specialties and anesthesiologists. If we suppose, for example, a physician is needed for every 10,000 people, every million people will need about 100 family physicians, let alone nursing and assistant teams, which is extremely difficult to provide.
  • Cost: Roll out of the scheme in any governorate will require high initial cost to restructure the majority of facilities to conform to the established quality and safety standards. However, in the long-term, premiums and service revenues will cover the operating costs.
  • Digitalization and Mechanization: Large-scale digital transformation is currently a priority for Egypt. As far as the UHI system is concerned, mechanization and digital transformation would mean managing patients’ data electronically, having it registered on the system and linked to their respective health units, creating electronic patient records, and e-handling of the financial claims of service providers.
  • Awareness-building: This includes educating citizens about the law, its relevance, and the benefits that families and the the entire state will obtain upon implementing the UHI scheme, building up confidence in the credibility and commitment of the state to apply the law, improving citizens’ knowledge of the penalties for failure to pay the stipulated insurance premium. 

In sum, providing healthcare services through the UHI scheme ensures achieving sufficient social security for citizens and develops a sense of national affiliation. To that end, the political leadership gives rapt attention to the speedy implementation of the UCI as planned. To ensure the project is viable, the challenge will not be about providing the UHI to the entire population, but providing it with high quality to ensure a decent and safe life for all.

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