Lessons From Egypt’s Social Health Insurance
Author: Sikhumbuzo Hlabangane
Vice Chairman of the Health Insurance Organization (HIO), Egypt, Mohsen George, shares some insights on Egypt’s Social Health Insurance (SHI), challenges and lessons learned. He was speaking at the 19th Annual Board of Healthcare Funders of Southern Africa (BHF) Conference held in Sun City.
With a population of 95.6 million, and a GDP of USD 336.3 billion in 2016, Egypt is considered a reference country in the Middle East for health insurance, which currently covers more than half of the population.
The Egyptian national health insurance is characterised by the integrated functions of purchasing and service delivery and has a highly centralised administrative and financial structure, while the government provides free healthcare services for uninsured population through several coverage programmes.
The country has a mix of health financing options including SHI, general government revenues, private health insurance and others. Egypt has a fragmented fund pool and mixed provider payment mechanisms, as line item budget, fee for service, per diem and case-based payment.
First steps to Universal Health Coverage (UHC)
The first steps to adopting the SHI system in Egypt were made in 1964 and HIO was the outcome of much legislation which started in the early decades of the 20th century.
In 1965, its first year, HIO had 140,000 beneficiaries, representing 0.5 % of the population. By the end of 2017 the HIO had 54.1 million beneficiaries out of a population of 95.6 million, representing 58.8 % of the population.
Challenges and lessons learned
We cannot implement a SHI plan outside of other components of the health system like governance, health workforce, medical products and technologies, information system, research and service delivery. Health insurance needs to have control on the provision of the primary healthcare services which acts as the gate keeper to avoid unnecessary referrals to secondary and tertiary levels of care. We still have challenges with the health workforce, where physicians prefer to work in big cities and urban areas, while nurses do prefer working in rural areas rather than big cities.
One of the main challenges in Egypt has been providing healthcare coverage for 54 million people. The limited automation of the information system in both purchasing as well as service provision functions also limits the control we have on fraud, abuse and over utilisation of services.
In some population groups, financing is inequitable as the high-income families paid a much lower percentage of their income as contribution to health insurance, while the poor paid a higher percentage of their income as contribution to health insurance. We realised that this was regressive financing and corrections were considered in the new SHI law which was approved last January.
UHC should address the three most important dimensions of coverage, namely population, services and costs, so that to provide all people with access to needed health services of sufficient quality to be safe and effective and ensure that the use of these services does not expose the user to financial hardship. SHI should be looked at as a stepping stone to UHC, and we need to think of UHC as a direction and not a destination. UHC is an on-going process, where we continuously apply learnings to improve the system to ensure achieving national-based healthcare reform. In Egypt, the new social health law has been designed to be the financial instrument for the implementation of UHC.
Interestingly, we have learnt the important role that the media plays as a partner to the UHC implementation plan, because media can play an important role in supporting the health reform. We now have media communication strategy to engage media around the different elements of the new law and what it means for the country. We are still working towards moving from the line item budget and fee for service as provider payment system to capitation and case based payment.
Egypt realised the importance of the health technology assessment for the implementation of UHC, as there is no UHC without priority settings and no priority settings without health technology assessment.
The current health insurance model has limited partnership with the private sector as a service provider, yet the situation will be different in the implementation of the new law with strong and effective engagement of the private providers.
The new Egyptian healthcare system
In January 2018, Egypt approved the new SHI law which is considered as a reform of the whole health system. The new system is characterised by covering all population, defragmentation of the fund pooling as well as the public service provision, and separating the purchasing function from delivering the services which improves the efficiency, quality, accountability and responsiveness to people needs.
The founding principles of the new SHI are based on need rather than ability to pay, and the two main pillars of SHI are compulsion of enrolment and subsidisation of the poor. With the new Egyptian social health system everyone is enrolled on the system, and no one can opt out. Government has committed to cover whoever is not able to pay for healthcare. While health financing is the linchpin of UHC reform, we also need to address other components of the health system for the reform to be effective and successful.