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.

 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.

Is It Time For Egypt To Consider Expanding Universal Health Insurance Coverage Based on Needs: The Better Path To Replace Geographic Expansion

Expanding universal health insurance coverage in Egypt is a pressing necessity, but the method of implementation is crucial for its success. Egypt's current strategy involves a phased geographic rollout of the Universal Health Insurance System (UHIS), which focuses on gradually expanding coverage region by region, and governorate by governorate withing a region. While this approach aims to manage the transition smoothly and ensures that the cost does not exceed the budget, it falls short in addressing the urgent needs of the population comprehensively and equitably. Instead, a phased approach based on needs within the means we have, aligned with guidance from both the World Health Organization (WHO) and the World Bank, promises a more effective and fair solution.

The Limitations of the Geographic-Based Approach

The geographic-based approach currently adopted by Egypt involves a step-by-step implementation of UHIS across different governorates. While this method has its advantages, such as easier management of resources and logistics in smaller increments, it also has significant drawbacks:

1. Inequitable Coverage: Regions included later in the rollout suffer from prolonged periods of inadequate healthcare services and lack of adequate financial protection exposing these population to continue to spend on their healthcare out of pocket. This creates and perpetuates disparities between early and late adopters, exacerbating existing inequities in healthcare access and quality. With the slow rate of expanding universal health insurance by region and by governorate, this gap in coverage is increasing in absence of effective alternatives to serve those populations not covered by the UHIS.

2. Resource Allocation Challenges: Focusing on entire regions rather than areas with the highest need can lead to inefficient use of resources. Regions with less pressing healthcare needs may receive new services that are not based on need before areas experiencing critical shortages, resulting in misallocation of limited resources. On the other hand, the UHIS continue to accumulate reserves in a strict risk averse strategy to build resilience fearing what it seems an undefined risk not capitalizing on its actuarial and national health account studies.

3. Delays in Health Improvements: The geographic approach inherently delays health improvements for many citizens. People in later phases continue to face the same healthcare challenges, potentially for years, until the rollout reaches their region. These people, probably representing the majority of Egypt’s population, continue to lack access and to spend out of pocket suffering from the problems of the old health insurance system and the program for the treatment on the expense of state driving more people to opt out of the system.

The Needs-Based Approach: A Superior Alternative

A phased approach based on need, rather than geography, offers a more equitable and efficient path to expanding healthcare services. This strategy aligns with WHO guidance on making fair choices on the path to universal health coverage and World Bank guidance on expanding services gradually based on affordability and need. Here's why a need-based approach is superior:

1. Equitable Distribution of Resources: By prioritizing areas with the greatest healthcare deficiencies, a need-based approach ensures that those most in need receive attention first. This aligns with WHO's emphasis on equity, ensuring that vulnerable and underserved populations are not left behind.

2. Improved Health Outcomes: Targeting regions with the highest health burdens—such as high rates of disease, inadequate medical facilities, and poor health indicators—can lead to more significant and immediate health improvements. This method addresses the most pressing health issues first, reducing overall morbidity and mortality rates more effectively.

3. Efficient Use of Resources: A need-based rollout allows for better allocation of resources, ensuring that investments in healthcare infrastructure and services yield the maximum benefit. This prevents wastage and ensures that every dollar spent contributes to substantial health improvements.

4. Flexibility and Responsiveness: This approach is inherently more flexible and responsive to changing health landscapes. As new data on health needs emerges, resources can be reallocated to address emerging hotspots or crises, maintaining a dynamic and adaptive health system.

WHO and World Bank Guidance on Expanding Coverage of Healthcare Services

Both the WHO and the World Bank provide essential guidance for expanding coverage of healthcare services:

1. WHO Guidance on Making Fair Choices:

- Progressive Universalism: This principle advocates for prioritizing the most disadvantaged groups first to ensure that everyone, especially the most vulnerable, can access essential health services. A need-based approach aligns perfectly with this principle by targeting areas with the greatest healthcare deficiencies.

- Equity in Resource Distribution: WHO emphasizes the importance of fair resource distribution to achieve health equity. A need-based approach ensures that resources are directed where they are most needed, reducing disparities in healthcare access and quality.

- Financial Protection: WHO's guidance highlights the need to protect individuals from financial hardship due to health expenditures. By focusing on regions with the highest health burdens and the least capacity to pay, a need-based rollout can provide greater financial protection for the most vulnerable populations.

2. World Bank Guidance on Gradual Expansion:

- Affordability: The World Bank stresses the importance of expanding services gradually based on what is financially sustainable. A need-based approach ensures that resources are used where they can have the greatest impact, making the expansion more affordable and sustainable.

- Needs-Based Prioritization: The World Bank supports prioritizing services based on the greatest need, which aligns with WHO's emphasis on equity and efficiency. This ensures that health improvements are targeted and impactful.

- Sustainable Financing: By focusing on affordability, the World Bank's guidance helps ensure that health system expansions do not overburden the country's finances, leading to a more stable and sustainable healthcare system.

Conclusion

While Egypt's current geographic-based phased rollout of UHIS aims to systematically expand healthcare services, it falls short in addressing urgent needs equitably and efficiently. Adopting a phased approach based on healthcare needs would better align with both WHO and World Bank guidance on universal health coverage and gradual expansion based on affordability and need. This strategy ensures equitable distribution of resources, improved health outcomes, efficient use of funds, and a more responsive health system. For Egypt to achieve true universal health coverage, prioritizing need over geography is not only preferable but essential.

 Enhancing Egypt’s Primary Care System: The Gateway for Universal Health Insurance

Egypt is on the brink of a transformative journey in healthcare with the Universal Health Insurance System (UHIS). Egypt could set an ambitious initiative aims to bolster the country's primary care system by harnessing the potential of private sector engagement. Let's explore how this can be achieved and why it matters.

The Objective

The UHIS could set forth clear goals:

·       Strengthen Egypt's Primary Care System: Enhance private sector involvement to improve accessibility and ensure equitable healthcare delivery.

·       Expand Healthcare Access: Create a robust primary care system that efficiently refers patients to higher levels of affordable care.

The Current Landscape

Egypt’s primary care system, a cornerstone for effective healthcare delivery, faces significant challenges. Many Egyptians opt to bypass primary care providers, choosing pharmacists or specialists for their medical needs. This preference stems from perceived convenience, affordability, and accessibility, but it ultimately undermines the primary care system and leads to inefficiencies in patient referrals to higher levels of care.

Why Primary Care is Underutilized

Several factors contribute to the underutilization of primary care in Egypt:

· Accessibility and Convenience: Patients often find it easier to visit pharmacists or specialists directly rather than primary healthcare (PHC) providers.

· Self-Diagnosis and Seeking Specialists: Many individuals self-diagnose and consult specialists, bypassing the primary care system entirely.

· Fragmentation: The primary care sector is fragmented, with many small, informal clinics located in residential buildings, making it challenging for larger clinics to compete.

A Multifaceted Approach Forward

Enhancing Egypt’s primary care system under UHIS requires a comprehensive strategy. By integrating private providers, expanding primary care networks, and addressing regulatory hurdles, Egypt can create a stronger primary care sector, ensuring better health outcomes for all its citizens. Here’s how this can be done:

1. Regulatory Overhaul: Leveling the Playing Field

· Tackling Regulations: Address the regulatory environment that currently favors small, informal clinics, which creates an uneven playing field for larger clinics with higher operational costs and stricter regulations.

· Unified Rules: Create a unified set of rules and regulations for both public and private providers.

· Contractual Expansion: Allow providers to offer services from both public and private facilities, broadening the reach of primary care.

2. Addressing Sector Fragmentation: Building Networks

· Cohesive System Design: Develop a cohesive and efficient primary care system that integrates providers into a primary care network to enhance accessibility and coverage.

· Robust Networks: Establish primary care networks, including standalone clinics and integrated facilities with other providers like pharmacies, laboratories, and radiology centers, to improve access to high-quality, affordable care, especially in underserved areas.

· Expanded Services: Offer a broader range of services to make primary care more appealing and accessible to patients.

3. Value Creation Models: Linking Care Networks

· Affordable Care Hospitals: Invest in hospitals that provide affordable care to make healthcare accessible to a wider population.

· Spoke-Hub Model: Implement a system where primary care clinics (spokes) are connected to central hospitals (hubs), ensuring streamlined patient referrals and comprehensive care.

4. Private Health Insurance Market Development

· Complementary Services: Develop a list of non-essential health services to be covered under complementary private health insurance.

· Supplementary Services: Define rules for private insurers to develop supplementary insurance for essential health services and for private providers to deliver these services.

5. Supporting SMEs in Healthcare

· Financial Support and Incentives: Create financial support packages and offer tax incentives for small and medium-sized enterprises (SMEs) participating in UHIS.

· Simplified Processes: Simplify registration and accreditation processes for SMEs and address their unique challenges.

· Training and Technical Assistance: Implement training programs for clinical and managerial skills and offer technical assistance for best practices and regulatory compliance.

· Fair Contracting: Establish transparent contracting and reimbursement processes, promoting collaborative networks between SMEs and larger healthcare providers.

· Digital Health Solutions: Support the adoption of digital health solutions like electronic health records (EHRs) and telemedicine, and create innovation hubs for healthcare startups and SMEs.

· Public-Private Partnerships (PPPs): Promote collaborative PPP projects involving SMEs in UHIS delivery and facilitate shared resources and infrastructure to reduce costs and improve efficiency.

To turn this vision into reality, Egypt needs to:

· Engage Stakeholders: Work with private healthcare providers, policymakers, and patients to gather insights and foster collaboration.

· Launch Pilot Projects: Test and refine the proposed strategies through pilot projects.

· Monitor and Evaluate: Establish a framework for monitoring and evaluating the impact of these initiatives on primary care utilization and health outcomes.

By taking these steps, Egypt can create a primary care system using the private sector that is not only robust and efficient but also accessible and equitable, ensuring better health outcomes for all its citizens.