Risks and Challenges in Financing and Delivery of Primary Health Care Services Under Egypt's Universal Health Insurance System (UHIS)

Background: In social and national health insurance systems, personalized primary health care services are often funded through strategic purchasing arrangements, typically financed from taxes rather than insurance premiums. This ensures equitable access to care for the entire population. These services are integral to the overall health system, focusing on personalized care that addresses individual health needs.

Other components of comprehensive primary care—such as population-based public health services, health intelligence, and enabling functions—should be supported by the Ministry of Health (MOH) through tax-based funding. However, Egypt's implementation of the Universal Health Insurance System (UHIS) deviates from this model, presenting several key risks that could potentially lower primary care service utilization rates negatively impacting Egypt's public health indicators.

Source: Christoph Kurowski, Global Lead of Health Financing, World Bank, Putting People at the Center: Lancet Global Health Commission on Financing Primary Health Care, 2022

Key Risks facing the financing, delivery and utilization of primary care services under Egypt’s UHIS

1. The Risk of Exclusion of Selective Preventive Services from the Package: The UHIS law excluded two key essential primary care services from the UHIS package, namely immunization and family planning. This resulted in partially fragmenting the financing and delivery of the package of primary care services. Understandably, the reason to do that was to preserve the long-term achievements of committing the government to allocate budgets for the procurement of vaccines and family planning methods. This was a request demanded for many years by developmental organizations to sustain the delivery of immunization and family planning services. Apparently, the utilization of immunization services during the implementation in phase I governorates of the UHIS seems to not have been affected. This is probably due to having a separate service delivery structure in primary health care units supported by well-trained and experienced MOHP nurses. However, anecdotal reporting from the Ministry of Health and Population (MOHP) at governorate level indicates early signs of lower utilization of family planning services. Budgets for the procurement of family planning methods are preserved under the control of MOHP, however, as primary care services are delivered by primary care physicians by EHA, the responsibility for the delivery of family planning services in primary health care units becomes unclear since EHA is not paid to deliver these services under the capitation system being used to pay for their services.  

2. The Risk of non-adherence to Primary Care Protocols: For decades, primary health care physicians and nurses under the MOHP have been trained and monitored to faithfully deliver primary health care services nationwide adhering to WHO guidelines, technically supported and closely monitored by organizations in the field such as UNICEF, UNFPA and notably funded by USAID covering gaps in financing primary health care. In doing so, the MOHP has gained and accumulated considerable experience in the delivery of primary health care services. With the transition of the delivery of these services to the public provider, EHA, in phase I governorates of the UHIS, we cannot observe the same level of support provided to primary care physicians under the UHIS. The primary care concepts from the MOHP don’t seem to be integrated into the delivery of primary care services by the public provider, EHA, and the future private providers under the UHIS. Without building the necessary technical capacities of primary care providers and monitoring their performance, the delivery of primary care services risks becoming narrowly focused on treatment of sickness, rather than prevention of disease and wellness services. With the transition to the UHIS, the following should be expected by the key UHIS organizations:

i) A Stewardship Role by MOHP to Develop Capacity and Monitor Performance. The MOHP, the stewardship lead agency, is expected to assume a new role to provide technical support, capacity development for public and private providers as well as to ensure adherence to following protocols for delivery of primary care services. The MOHP will need to monitor the performance of providers and monitor the achievements gained in public health indicators to ensure they are preserved. 

ii) Accreditation of Quality of Delivery of Primary Care Services by GAHAR. With the emergence of new organizations such as the General Authority for Healthcare Accreditation & Regulation (GAHAR), it is expected that a new role should be identified to go beyond accrediting service providers for structural quality to accredit them for knowledge and following of protocols for diagnosis and treatment of primary care services.  

iii) A Change in the Mindset of UHIA Officials in the Manner Primary Care Services are Purchased. A key distinction between Egypt's old Health Insurance Organization (HIO) system and the current UHIS is the approach to financing and delivering primary care. Under the HIO system, primary care was not included in the insurance package and instead was the responsibility of the MOHP, which provided primary care services nationwide. The transition to the UHIS, which aims to include primary care in the insurance package, faced the challenge of the lack of understanding among Universal Health Insurance Authority (UHIA) officials (many of whom come from insurance backgrounds) of the importance of delivering primary care services in accordance with WHO guidelines. This requires a transformational change in the mindset of UHIA staff to prepare them for a role they are not familiar with to achieve health status goals that they are not usually trained to achieve. In addition, strategic purchasing practices for primary care services will need to move to a more efficient system incentivizing providers to better delivery primary care services and pay based on provider performance.

3. The Risk of Inadequate Budgeting for Primary Care under the UHIS: The budget for personalized primary care services, which was historically managed by the MOHP and funded through taxes, remains under the control of MOHP for primary care services provided in phase I governorates. This budget should have been transferred to the UHIA as part of the UHIS financing package. However, this critical point was overlooked in the UHIS law, leaving the MOH in control of funds for services that are now under the UHIA’s mandate in the first phase of implementation across six governorates. As a result, the UHIA will increasingly rely on insurance premiums to fund these primary care services. This reliance may lead to higher premiums or additional earmarked taxes, pushing informal sector workers to avoid enrollment in the UHIS. In turn, this could increase informality and exacerbate underutilization, as individuals may feel they are being "double-charged" for the same services through taxes and premiums.

Recommendations to Maintain and Improve the Financing, Delivery and Utilization of Primary Health Care Services

1.  Study the Current Pattern of Utilization of Primary Care Services under the UHIS: Conduct a comprehensive study on primary care service utilization in phase I of UHIS governorates, including maternal, child, NCDs and other primary care services. This analysis should be compared to ongoing utilization of similar services in comparable non-UHIS governorates in order to assess if difference in utilization exists.

2.  Establish a Monitoring System for Measuring Periodically the Performance of Primary Care Services: To better understand primary care service utilization, it is essential to monitor not only the overall number of visits per capita but also to disaggregate data by service type. Key metrics include the rate of visits for maternal care, child care, non-communicable diseases (NCDs) and others as relevant. Family planning should be added once the delivery of this service is included under the UHIA. Utilization should also be tracked by gender, urban-rural divide, type (formal vs. informal sector), income level, and governorate.

3. Ensure that the UHIA Provider Payment System is based on Incentivizing Performance. Payments to providers based on simple capitation need to shift to blended capitation mixing capitation with fee for services for selected services, while payments are paid based on the performance of providers to ensure utilization and referral of services don’t fall below targeted levels. Selected remote and underserved geographic areas should be rewarded by an incentive paying an additional percentage to serve in these areas. Incentives for maintaining quality apart from volume should also be considered.  

4. Define the Primary Care Services Package and ensure it includes family planning services: Amend the UHIS law to explicitly reintegrate preventive services, such as immunization and family planning. The package of primary care services should be clearly and explicitly defined to understand its content and delivered in line with WHO's primary health care requirements as part of the UHIS package.

5.  Define the Role of Quality Accreditation and Monitoring of Primary Care Services and Capacity Development: Define the role of both the MOHP and GAHAR in monitoring the implementation of protocols of primary care services, and that accreditation standards ensure that providers have the knowledge and capacity of these protocols. This should avoid any overlap or duplication of efforts between both organizations. Additionally, healthcare providers should be trained to deliver personalized primary care services according to WHO guidelines, with the MOH and/or GAHAR playing a crucial role in this capacity-building effort. Who will be taking the lead in capacity development of service providers, public and private, and how this will be financed should be clear.

6.  Transfer the Budget Allocated for Personalized Primary Care for MOH to UHIA per governorate included in the UHIS: Establish mechanisms to transfer the budget for personalized primary care services from the MOH to the UHIA, in line with the intentions of the UHIS of moving to strategic purchasing. This will reduce the UHIA’s reliance on premiums to finance primary care services and improve the financial sustainability of the system, ultimately leading to better access to and utilization of primary care services.

7. Stakeholder Education and Coordination: Launch a stakeholder education program targeting UHIA officials to improve their understanding of primary care delivery. Formal coordination mechanisms between the MOH, UHIA, GAHAR, EHA and representatives of private providers for profit and not for profit should be established to ensure a smooth transition and prevent duplication of services.

Conclusion: A well-financed, preventive-focused primary health care system is critical to the success of Egypt's UHIS. To achieve this, strategic reforms are needed to address the legal, budgetary, and operational challenges currently hindering the delivery of comprehensive primary care. Collaboration between the MOH and UHIA, underpinned by clear policies and financial mechanisms, will ensure that primary care functions as intended and contributes to improved health outcomes for all Egyptians.

 Addressing the Persistent Urban-Rural Health Divide in Egypt: Twenty Years Later

Over the past two decades, Egypt has made significant strides in improving health outcomes, as evidenced by the reduction in fertility rates, maternal and child mortality, and increased access to healthcare services. However, a substantial urban-rural divide persists, impacting the overall health equity in the country.

This article highlights key disparities between urban and rural areas based on the 1998 Egypt Demographic Health Survey (EDHS) and the 2021 Family Health Survey, and outlines strategic recommendations for decision-makers to address these challenges. It shows that improvement in urban areas in many case equals that in rural areas thus maintaining the urban-rural divide. To make an impact on this divide, more investments and efforts need to be devoted to decrease the gap.  A one-size-fit-all strategy will only maintain the gap as the health indicators continue to improve.

Key Findings

1. Fertility Rates: Although fertility rates have declined, rural areas continue to have higher TFRs indicating the need for enhanced family planning services and education in rural regions.

·       1998 EDHS: The Total Fertility Rate (TFR) was 3.5 children per woman nationally, with urban areas at 2.9 and rural areas at 4.2.

·       2021 Family Health Survey: The TFR decreased to 2.8 children per woman nationally, with urban areas at 2.4 and rural areas at 3.2.

2. Infant and Child Mortality: Despite national improvements, rural areas still experience higher infant and child mortality rates. Targeted interventions are required to improve healthcare access and quality in rural regions.

·       1998 EDHS: Nationally, the Infant Mortality Rate (IMR) was 54 per 1,000 live births, with urban areas at 40 and rural areas at 66. The Under-5 Mortality Rate (U5MR) was 70 per 1,000 live births, with urban areas at 55 and rural areas at 86.

·       2021 Family Health Survey: The IMR decreased to 22.4 per 1,000 live births nationally, with urban areas at 18 and rural areas at 27. The U5MR decreased to 27.8 per 1,000 live births nationally, with urban areas at 23 and rural areas at 32.

3. Maternal Mortality: The reduction in maternal mortality is commendable, but the higher rates in rural areas highlight the need for improved maternal healthcare services, including access to skilled birth attendants and emergency obstetric care.

·       1998 EDHS: The Maternal Mortality Ratio (MMR) was 174 per 100,000 live births nationally, with urban areas at 130 and rural areas at 200.

·       2021 Family Health Survey: The MMR decreased to 37 per 100,000 live births nationally, with urban areas at 25 and rural areas at 48.

4. Access to Healthcare Services: Continued investment in healthcare infrastructure in rural areas is essential to ensure equitable access to services.

·       1998 EDHS: Urban areas had better access to healthcare services, with 80% of women receiving antenatal care from a skilled provider compared to 60% in rural areas. Vaccination rates were also higher in urban areas, with 89% of children fully vaccinated compared to 72% in rural areas.

·       2021 Family Health Survey: While access has improved nationally, with 94% of women receiving antenatal care from a skilled provider in urban areas and 82% in rural areas, significant disparities remain. Vaccination rates increased to 95% in urban areas and 85% in rural areas.

5. Contraceptive Use: While the gap in contraceptive use has narrowed, further efforts are needed to increase access and education around family planning in rural areas.

·       1998 EDHS: Nationally, the contraceptive prevalence rate among married women was 56%, with urban areas at 62% and rural areas at 51%.

·       2021 Family Health Survey: The contraceptive prevalence rate increased to 59% nationally, with urban areas at 64% and rural areas at 56%.

Strategic Recommendations

1.       Move from One-Size-Fit-All Strategy to Targeted Investments and Interventions in Lagging rural regions

·       Enhance Family Planning and Reproductive Health Services: Expand the availability and accessibility of family planning services in rural areas. This includes community-based education programs and mobile health clinics to reach underserved populations.

·       Invest in Rural Healthcare Infrastructure: Allocate resources to build and upgrade healthcare facilities in rural areas. This should be coupled with training and deploying more healthcare workers, particularly skilled birth attendants and pediatric care providers.

·       Targeted Maternal and Child Health Programs: Implement targeted interventions to reduce maternal and child mortality in rural regions. This could include improving emergency transport services, providing financial incentives for healthcare workers in rural areas, and expanding immunization coverage.

2.       Leverage the Universal Health Insurance (UHI) System: Use the ongoing rollout of the UHI system as a platform to address regional disparities. Ensure that rural populations are prioritized in the UHI expansion, with a focus on covering essential health services and reducing out-of-pocket expenditures.

3.       Promote Public-Private Partnerships (PPPs): Encourage partnerships between the government and private sector to deliver healthcare services in rural areas. PPPs can help bridge gaps in service delivery and introduce innovative healthcare solutions.

Addressing the urban-rural divide in health outcomes is crucial for achieving health equity in Egypt. By implementing the above recommendations, decision-makers can ensure that all Egyptians, regardless of where they live, have access to high-quality healthcare services. The success of these initiatives will be pivotal in closing the gap and improving the overall health and well-being of the nation.

 Egypt’s “One-Size-Fits-All” Hinders its Efforts to Achieve Health Equity

Egypt's health agenda has consistently emphasized health equality, aiming to provide the same level of healthcare access and services to all citizens, regardless of their socio-economic status. This focus on equality is evident in the design of national health policies, including the commitment to universal health coverage (UHC) through initiatives like the Universal Health Insurance System (UHIS). However, despite these intentions, Egypt has struggled to achieve health equality, unable to conceptualize health equity.  

Several factors contribute to this persistent gap:

1. Historical Approach and Structural Gaps

The Egyptian health system has, for decades, adopted a centralized, top-down approach to health coverage. From the early efforts to provide insurance for formal workers in the 1960s to the gradual inclusion of other population groups, the focus was more on expanding coverage uniformly than addressing varying health needs across different communities. This “one-size-fits-all” approach ignored disparities in healthcare access, especially in rural and underserved areas. Health facilities, resources, and qualified personnel are disproportionately concentrated in urban centers, leaving rural areas with poor-quality services and access challenges.

2. Urban-Rural Divide

The geographic distribution of healthcare resources in Egypt remains a key issue. Although the aim has been to ensure equal access to services, significant differences in health infrastructure, availability of healthcare professionals, and service quality persist between urban and rural areas. The expansion of services has not kept pace with population growth in densely populated regions or remote areas, leading to disparities in health outcomes.

3. Public Sector Resource Constraints

The Egyptian public healthcare system, which serves the majority of the population, has long been underfunded, leading to limited capacity and inefficiencies. Despite attempts to extend services uniformly across the population, the public sector struggles with inadequate funding, outdated infrastructure, and shortages of medical supplies. These constraints result in long waiting times, low-quality care, and the inability to meet the population’s diverse health needs.

4. Inequities in Health Outcomes

Despite policies aimed at equal access, health outcomes vary significantly by income, region, and education level. For example, maternal and child health indicators show stark differences between wealthier urban areas and impoverished rural regions. Non-communicable diseases (NCDs) are on the rise, with limited prevention programs targeting low-income groups, exacerbating health inequalities.

5. Neglect of Vulnerable Populations

Equality-focused approaches often overlook vulnerable populations such as those with disabilities, the elderly, and low-income groups. These populations face systemic barriers that prevent them from accessing healthcare services even when they are theoretically available. For instance, informal sector workers, who constitute a large part of the workforce, have historically been excluded from formal insurance schemes, leading to gaps in coverage.

6. Policy Focus on Services Over Social Determinants

The focus on providing equal access to health services often neglects the broader social determinants of health, such as education, housing, and income disparities. Without addressing these root causes, even well-designed health equality initiatives cannot achieve their desired impact. For example, urban areas with better education, infrastructure, and economic opportunities naturally see better health outcomes even if the same health services are technically available in rural areas.

7. Failure to Transition from Equality to Equity

Health equity requires recognizing that different populations have different needs and starting points, and therefore require tailored interventions to achieve the same level of health. Egypt’s persistent emphasis on equality has led to missed opportunities in designing policies that could reduce the disparities that arise from socio-economic and geographic factors. A needs-based approach that focuses on directing resources to where they are most needed—such as underserved regions, low-income communities, and high-risk populations—remains limited in implementation.

Moving Forward

Achieving health equity in Egypt requires a shift from uniform service delivery towards more targeted interventions that consider the specific needs of different population groups. This involves:

- Adopting a needs-based approach in the UHIS rollout.

- Enhancing resource allocation to underserved areas.

- Developing tailored health programs for marginalized and vulnerable groups.

- Integrating health equity principles into the broader social and economic development agenda.

Addressing the deep-rooted inequities in Egypt’s health system would involve not only more strategic investments but also a commitment to transforming the way services are delivered, with a focus on social justice, inclusivity, and responsiveness to diverse needs.

 Introducing the Concept of Wellness Healthcare in Egypt: A New Paradigm for a Healthier Nation

Egypt's healthcare landscape could introduce a transformative shift with the introduction of Wellness Healthcare—a holistic approach that emphasizes prevention, healthy living, and proactive care. As the country continues to grapple with the dual burdens of communicable and non-communicable diseases, Wellness Healthcare presents a promising avenue to improve the health of the population, reduce healthcare costs, and enhance the quality of life for all Egyptians. It could be the base for accelerating its plan to expand its universal health insurance coverage for all Egyptians.

What Is Wellness Healthcare?

Wellness Healthcare is a comprehensive approach that goes beyond the traditional medical model, which primarily focuses on treating illness. Instead, it promotes a balanced and healthy lifestyle, aiming to prevent diseases before they occur and to manage existing conditions through lifestyle modifications, mental health support, and community engagement. The core components of Wellness Healthcare include:

1. Preventive Care: Emphasizing regular check-ups, screenings, and vaccinations to detect and prevent diseases early.

2. Healthy Lifestyle Promotion: Encouraging balanced nutrition, regular physical activity, and smoking cessation as key elements of maintaining health.

3. Mental Health and Wellbeing: Addressing mental health issues through counseling, stress management, and social support, recognizing the integral role mental wellness plays in overall health.

4. Community and Environmental Health: Fostering healthy environments and communities by promoting safe public spaces, access to healthy foods, and pollution control.

5. Chronic Disease Management: Providing education and support for individuals with chronic conditions to manage their health proactively and prevent complications.

The Need for Wellness Healthcare in Egypt

Egypt faces significant health challenges, including rising rates of non-communicable diseases (NCDs) such as diabetes, heart disease, and cancer. These conditions are often driven by lifestyle factors like poor diet, lack of physical activity, and smoking. Additionally, the country's healthcare system has traditionally been reactive, focusing on treating diseases after they occur rather than preventing them. This approach has led to high healthcare costs and a strain on resources, as the system struggles to keep up with the growing demand for medical care.

Wellness Healthcare offers a solution by shifting the focus from treatment to prevention. By addressing the root causes of ill health, this model can help reduce the incidence of chronic diseases, lower healthcare costs, and improve the overall well-being of the population.

Benefits of Wellness Healthcare

1. Reduced Healthcare Costs: Preventive care and healthy living can significantly reduce the need for expensive medical treatments and hospitalizations, leading to lower overall healthcare costs.

2. Improved Quality of Life: By promoting healthy lifestyles and early intervention, Wellness Healthcare can help Egyptians live longer, healthier lives with fewer health complications.

3. Increased Productivity: A healthier population is a more productive one. By reducing the burden of disease, Wellness Healthcare can contribute to a stronger, more vibrant economy.

4. Strengthened Healthcare System: By alleviating the pressure on hospitals and clinics, Wellness Healthcare can help create a more sustainable healthcare system that is better equipped to handle both existing and emerging health challenges.

How to Deliver a Healthcare System That Provides a Wellness Package

To effectively deliver a healthcare system that encompasses a wellness package, Egypt must adopt a strategic and coordinated approach that integrates wellness into all levels of care. Here’s how this can be achieved:

1. Primary Care as the Foundation:

   - Role of Family Physicians: Family physicians and primary care providers should be the cornerstone of the wellness package, offering continuous and comprehensive care. They should be trained not only to treat illnesses but also to guide patients in making healthier lifestyle choices and preventing disease.

   - Routine Wellness Checks: Implement regular wellness checks and screenings as part of primary care visits. These should include assessments for common risk factors like high blood pressure, obesity, and smoking, alongside mental health evaluations.

2. Integration of Wellness Services:

   - Wellness Clinics: Establish wellness clinics within existing healthcare facilities where patients can access services such as nutritional counseling, physical activity programs, and stress management workshops.

   - Mental Health Integration: Incorporate mental health services into the wellness package, ensuring that psychological well-being is addressed alongside physical health. This could involve on-site mental health professionals in primary care settings and community-based support groups.

3. Public Health Initiatives and Community Outreach:

   - Health Education Campaigns: Launch nationwide campaigns to raise awareness about the benefits of wellness and preventive care. These campaigns can utilize media, schools, workplaces, and community centers to reach a broad audience.

   - Community Health Workers: Deploy community health workers to deliver wellness education and services directly to underserved populations. These workers can provide valuable support in managing chronic diseases, promoting healthy behaviors, and connecting individuals with healthcare services.

4. Incentives and Support for Healthy Living:

   - Workplace Wellness Programs: Encourage businesses to implement workplace wellness programs that promote physical activity, healthy eating, and mental well-being. These programs could offer incentives such as discounted gym memberships, healthy meal options in cafeterias, and mental health days.

   - Government Incentives: The government could provide tax breaks or subsidies for individuals and organizations that adopt and promote wellness initiatives, such as purchasing healthy foods, participating in fitness programs, or establishing smoke-free environments.

5. Technology and Digital Health Solutions:

   - Telemedicine and E-Health Platforms: Leverage telemedicine and e-health platforms to extend wellness services to more people, especially those in remote or underserved areas. These platforms can offer virtual consultations, wellness coaching, and online support groups.

   - Mobile Health Applications: Develop mobile apps that help individuals track their health metrics, set wellness goals, and receive personalized recommendations for improving their health.

6. Policy and Regulatory Support:

   - Healthy Environment Policies: Enact policies that support healthy environments, such as regulations on food labeling, restrictions on the sale of unhealthy foods, and initiatives to reduce pollution and improve public spaces for physical activity.

   - Comprehensive Health Insurance Coverage: Ensure that the wellness package is covered under Egypt’s Universal Health Insurance System (UHIS), making preventive and wellness services accessible and affordable for all citizens.

7. Monitoring and Evaluation:

   - Outcome Tracking: Implement systems to monitor the outcomes of wellness initiatives, tracking improvements in public health metrics such as reduced incidence of chronic diseases, lower healthcare costs, and increased life expectancy.

   - Continuous Improvement: Use data from monitoring and evaluation to continuously refine and improve the wellness package, ensuring that it remains responsive to the population’s needs and delivers the best possible outcomes.

Conclusion

The introduction of Wellness Healthcare in Egypt, supported by a healthcare system that delivers a comprehensive wellness package, holds the potential to revolutionize the nation’s health. By focusing on prevention, healthy living, and early intervention, Egypt can build a more resilient, equitable, and sustainable healthcare system. With the right strategies in place, Wellness Healthcare can lead to a healthier, more productive population, ultimately contributing to a brighter future for all Egyptians.

 

Acknowledging the Limitations of Geographic-Based Population Expansion: A Crucial First Step Towards Needs-Based Health Insurance Coverage in Egypt

As Egypt strives to achieve universal health insurance coverage (UHIC) by 2032, the current approach of geographic-based population expansion has shown significant limitations. While this strategy initially seemed pragmatic, it is becoming increasingly clear that it may not meet the ambitious goals of equitable and comprehensive healthcare and health insurance for all Egyptians. Acknowledging these shortcomings, including a thorough evaluation of what has been achieved so far, is the first critical step in transitioning towards a technically sound needs-based approach, which is better suited to address the diverse health challenges across the nation.

The Geographic-Based Expansion: A Strategy with Constraints

The geographic-based population expansion strategy aimed to gradually roll out health insurance coverage across Egypt by systematically targeting specific governorates in phases. This approach was designed to manage the enormous logistical and financial challenges of implementing UHIC in a country as populous and diverse as Egypt. However, several key issues have emerged, casting doubt on the viability of this method to achieve UHIC by the 2032 deadline:

1. Uneven Progress and Regional Disparities:

- The geographic approach has led to uneven progress across the country, with few governorates advancing while all other lag significantly behind. This has exacerbated existing inequalities and delaying benefits, particularly in regions that include remote and underserved areas that are typically left out of the initial phases.

- A drawback of this strategy is that regions with better infrastructure and healthcare systems could benefit faster than other regions with poor infrastructure as this is the case in remote and underserved areas. These with poor infrastructure will face prolonged delays in receiving coverage, which could lead to irrevocable disparities in access to essential health services.

2. Inflexibility to Address Emerging Needs:

- The rigid nature of geographic expansion does not allow for dynamic responses to emerging health crises or changing population needs, it deprives the nation from its resilience. Health challenges such as outbreaks of infectious diseases, rising non-communicable diseases (NCDs), and fluctuating population demographics require a more flexible approach that the current strategy cannot provide.

- By focusing solely on geographic boundaries, the strategy fails to account for areas with critical health needs that may not align with the predetermined rollout schedule or require a cross-boundary response.

3. Resource Allocation Inefficiencies:

- The geographic approach often leads to inefficient allocation of resources, as funding and services are distributed based on administrative boundaries rather than actual health needs, thus fragmenting the health financing strategy. This can result in over-resourcing in some areas while others remain underserved, wasting valuable resources and failing to optimize health outcomes.

- The cost-effectiveness of healthcare delivery under this model is questionable, particularly in regions where health needs are lower but receive the same level of resources as high-need areas.

4. Selection of Low-Density Populations in the First Phase:

- The first phase of the geographic expansion strategy focused on governorates with lower population densities. While this may have been intended to ease the implementation process, it has significant drawbacks. The health needs of these populations may not be representative of the broader national picture, limiting the applicability of lessons learned from this phase.

- Additionally, the lower population density in these regions means that the impact on overall coverage is minimal, further delaying the realization of universal insurance coverage.

5. Challenges in Achieving Universal Coverage by 2032:

- With the current pace and challenges associated with geographic expansion, it is unlikely that Egypt will achieve its goal of universal coverage by 2032. The slow and uneven rollout process means that many Egyptians may remain uninsured or underinsured for the foreseeable future.

- The geographic approach does not adequately address the systemic issues within Egypt’s healthcare system, such as workforce shortages, inadequate infrastructure, and the need for better health information systems.

Evaluating the Progress So Far: A Necessary Step

Before making the shift to a needs-based approach, it is crucial to conduct a comprehensive evaluation of the geographic-based expansion to date. This evaluation should focus on the following areas:

1. Assessment of Coverage Achievements:

- Evaluate the extent to which the geographic-based rollout has expanded health insurance coverage in the targeted regions. This should include an analysis of the number of people covered, the range of services provided, and the accessibility of these services.

- Identify regions where the rollout has been successful and areas where it has fallen short, paying particular attention to underserved populations and regions with significant health challenges.

2. Impact on Health Outcomes:

- Analyze the impact of the geographic expansion on health outcomes in the covered regions. This includes assessing improvements in key health indicators, such as maternal and child health and management of NCDs.

- Compare the health outcomes in regions covered by the geographic phase to those not yet included, to determine the effectiveness of the approach in improving overall health.

3. Resource Utilization and Cost-Effectiveness:

- Review the allocation and utilization of resources in the regions covered by the geographic expansion. This should include an analysis of the efficiency of spending, the adequacy of health infrastructure, and the availability of trained healthcare personnel.

- Assess whether the resources allocated have been used in a cost-effective manner, and identify any areas of waste or inefficiency that need to be addressed.

4. Stakeholder and Public Perception:

- Gather feedback from key stakeholders, including healthcare providers, local authorities, and the general public, on the effectiveness of the geographic rollout. This will provide valuable insights into the strengths and weaknesses of the current approach.

- Evaluate the level of public satisfaction with the services provided under the geographic expansion and identify areas where improvements are needed.

The Case for Needs-Based Population Coverage

Given the limitations identified through the evaluation, it is essential to pivot towards a needs-based population coverage strategy. This approach prioritizes the allocation of resources and services based on the specific health needs of different populations, rather than their geographic location. The advantages of a needs-based approach include:

1. Targeted Resource Allocation:

- Resources can be directed to areas with the greatest health needs, ensuring that the most vulnerable populations receive the care they require. This not only improves health outcomes but also enhances the cost-effectiveness of healthcare spending.

- By focusing on needs rather than geography, the health system can be more responsive to changes in population health, such as the rise of NCDs or the emergence of new health threats.

2. Greater Equity in Healthcare Access:

- A needs-based approach helps to reduce disparities in healthcare access by ensuring that all populations, regardless of their location, receive the necessary services. This is particularly important for marginalized groups, such as those living in rural or impoverished areas.

- Equity in access to healthcare is a cornerstone of universal health coverage and is essential for achieving health justice in Egypt.

3. Improved Health Outcomes and System Efficiency:

- By aligning services with population health needs, the healthcare system can deliver more effective interventions, leading to better health outcomes. This approach also helps to prevent and manage chronic conditions, reducing the overall burden on the healthcare system.

- The efficiency gains from needs-based coverage can free up resources for further investments in healthcare infrastructure, workforce development, innovation and probably expansion of services provided.

4. Flexibility to Adapt to Changing Health Landscapes:

- A needs-based strategy is inherently flexible, allowing the healthcare system to adapt quickly to new challenges, such as pandemics, economic crises, or demographic shifts. This adaptability is crucial for maintaining a resilient and responsive health system.

Conclusion

The first step in moving towards a more effective and equitable health insurance system in Egypt is to acknowledge that the current geographic-based population expansion strategy is not working as intended. This requires a thorough evaluation of the progress made so far, identifying both successes and shortcomings. It is increasingly clear that the geographic approach is failing to address the complex and varied health needs across the country and is unlikely to achieve universal health insurance coverage by 2032.

One particular limitation is the selection of low-density populations in the first phase, which, while perhaps easier to implement, does not adequately address the needs of the broader population or provide a solid foundation for scaling up the UHIC program. High-density urban areas, where healthcare needs are more pressing, remain on the periphery of the current rollout strategy.

By recognizing these limitations and shifting to a needs-based population coverage model, Egypt can build a healthcare system that is more equitable, efficient, and capable of meeting the health challenges of the future. This transition will require strong political will, stakeholder engagement, and a commitment to health equity, but it is a necessary step to ensure that all Egyptians have access to the healthcare they need and deserve. Lessons learned from the initial geographic phase can serve as a foundation for designing a more effective needs-based strategy, ensuring that no one is left behind on the path to Universal Health Coverage.