Every country in the world is responsible for providing services, security and sustaining wellbeing for all its people. As a consequence, all nations have policies that focus on ensuring the provision of healthcare services for their population, even if in many countries that remains a work in progress. A well-functioning health care system is considered one of the key indicators of the strength of a country. A resilient healthcare system is also key (though not sufficient) to ensure the right to health. In a nutshell, a strong healthcare system shows the productivity of a country, helps improve the quality of life, boosts life expectancy, and is a vital ingredient of the social contract in a country.
According to the World Bank classification, Egypt is considered a lower-middle-income country (LMIC), with a GDP per capita of 3100 dollar in 2019. With a rapidly growing economy and also improving human resources, the reform of Egypt’s healthcare sector became a priority of the country’s development agenda in recent years. That’s why the government has been steadily working towards the implementation of Universal Health Coverage (UHC) in accordance with the Sustainable Development Goals (SDG) agenda and the Sustainable Strategy for Egypt (Egypt vision 2030).
For decades, the healthcare system in Egypt has been facing multiple challenges such as low quality of public healthcare services, brain drain, and fragmented health policies that affect people’s health and well-being. Among others, the system has to deal with the burden of illness related to lack of education and widespread poverty, inadequate (public) health funding, geographical imbalance of skilled healthcare workers, insufficient integration of services into primary healthcare. The Egyptian healthcare system has also increasingly been forced to respond to emerging illnesses as well as noncommunicable diseases linked to modern, urban lifestyle (such as cardiovascular diseases).
The new Universal Health Insurance bill (2017)
After a number of failed reforms in the 2000s, Egypt made another serious effort to reform the healthcare sector after 2015. In December 2017, the Egyptian parliament passed a bill to ensure Universal Health Insurance (UHI) for all Egyptians; soon after, president Abdel Fattah El-Sisi ratified it. The new Universal Health Insurance Law puts Egypt on the road towards progressive realization of UHC and aims to cover the whole Egyptian population with the quality health services they need without suffering hardship. That should include the most vulnerable populations, such as the elderly, disabled people, the poorest Egyptians, and those working in the informal sector. Implementation of the bill was initially expected to take a maximum of 15 years, but the president has reduced this period to 10 years.
The (new) health insurance system is the foundation of a healthcare system developed in the mid-1960s. Reforms introduced at the time, during the regime of president Nassar, aimed for complete central control of the health sector. Nasser’s government proposed providing UHC through services free at the point of delivery and making it accessible to all Egyptians. This “national health service” was funded by transfers from the Ministry of Finance to the Ministry of health, and integrated provider and financing functions under the same organizational structure. But by 1964, the government had more or less abandoned this approach as a result of increasing financial pressure, shortages in medicines and equipment, health workforce shortfalls (including the challenge of low salaries), and low maintenance of public health facilities. Instead, the government opted for a mixture of fee-for-services and public funding. This shift in health financing accelerated under the government of president Sadat, when there was a broader economic climate of liberalization and deregulation. The national Health Insurance Organization (HIO) was created as a public, social insurance body in 1964 and was key in this new system. Over time, population coverage increased but mid-2000s, it was still not more than 59%.
Implementation of the new bill
But now there’s thus increased momentum with the recent UHI Bill. For the new governance structure of the UHI system, as envisaged by the UHI law, see WHO, 2019.
Since the passing of the bill, Egypt has started making a number of concrete implementation decisions which have to cover the operationalization of various health system functions, including health system financing, governance arrangement, health service delivery, health information systems, health workforce, access to essential medicines.
Health system financing is a key instrument towards achieving UHC. Its main functions are: raising revenue (sources of funds, contribution methods and collection arrangements); pooling (accumulation of prepaid funds on the population’s behalf); purchasing (allocation of the prepaid resources from the pool to the providers for the provision of service benefits). The World Bank and WHO have both been supporting the new UHI system through providing technical and financial support since the beginning of the bill’s implementation.
Till now, the country spent around 5.5 % of its general government expenditure on public health financing, with the Ministry of Finance funding approximately one third of the overall health spending. So, there were major household out of pocket payments (OOP). But from now on, under the 2017 UHI law, the new UHI system will predominantly rely on public sources of funds. It’s financed through several sources such as citizen-paid premiums, state budget, government subsidization of the poor (30-35 % of the population), general tax, tobacco earmarked tax, co-payments (service fees), a contribution of 0.25% of total annual revenues, and fees ranging between EGP 1000 ( $32.31 ) and EGP 15,000 ($484.65 ) paid by hospitals, medical clinics, treatment centers, pharmacies, and pharmaceutical companies to subscribe to the new health insurance system.
All Egyptians will be covered on a mandatory basis through family membership. The new citizen-paid premiums are: employers are expected to pay a 4% premium of every employee’s wages into the fund ( 3% for medical insurance+ 1% for occupational diseases and work injuries insurance). Employees need to pay another 1% premium, which would come from their salary. In addition, the family provider would pay premiums of an additional 1% for every dependent and 3% for their housewives, thus ensuring that all family members’ insurance would be covered. Finally, the government is responsible for the treatment costs of people who are unable to pay their share, and this will be fully determined by the Ministry of Social Solidarity in accordance with the Prime Minister decree number 1948 in 2019.
The cost of UHI for one citizen will range from EGP 1300 ($42.14 ) to EGP 4,000 ($129.66), from a mere figure of EGP112 in the current insurance system, in line with Egypt’s macroeconomic target to increase spending on health, education, and research and development to at least 10% of GDP.
The UHI system is going to be progressively rolled out in six phases over a 10-year period. The scheme is expected to have an annual cost of $12.9bn by the time it is fully implemented.
UHI implementation started in Port Said in July 2019. The Port Said governate was selected as a pilot because of its small size, limited population, and existing capacity in the health system in comparison to other governorates in Egypt. The UHI system is currently operating in four cities: Port Said, Luxor, Ismailia, and South Sinai. The first phase will finish when Aswan and Suez join the UHI. The UHI is currently already operating in 297 healthcare facilities, and around 21.777.000 healthcare services have been provided. According to a public presentation, so far almost 5 million people have joined the UHI (in stage 1). At the end of stage 3, in 2023, 15m to 17m people are expected to be covered in these governates – if the economy allows, that is.
Next steps?
As implementation is ongoing, what are the next steps for the UHIS to work on ensuring social health protection for all Egyptians, in particular with the economic challenges that the country is currently facing?
Well, the new UHI system ought to focus more on a truly people-centered health system by ensuring the inclusion of individuals, families, and communities in the decision-making, in order to respond to their needs humanely and holistically. The UHI system should also work faster towards automation and digital transformation processes to strengthen the governance of the health system and service provision. In addition, the UHI system should invest in (and retain) its HRH to ensure sustainable and quality health care service provision. Finally, the Egyptian government should adopt sustainable health financing models by addressing the political economy of the health financing reform – a lesson which should have learnt well from the failed reform attempts in the 2000s.
A hospital room in one of the UHI hospitals