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.

 

Where does Egypt Stand in terms of “Deliver Strategy”, from WHO’ Progression Pathway for Private Sector Engagement in Health

Egypt has made reference in many policy documents that provide for some sort of directions for private sector participation in healthcare.

Documents such as the health articles of the constitution, the recommendations of the national dialogue, the government ownership policy document, the government health plan 2024-2-26 emphasizes that the government maintains a strong emphasis on public health infrastructure while encouraging private sector participation in service delivery, pharmaceutical production, and facility management. Key strategies include promoting competition within the Universal Health Insurance System (UHIS), enhancing service quality across both public and private sectors, and implementing PPPs to increase accessibility and efficiency.

The 2019 Universal Health Insurance Law delineates a clear path for private providers participation, with the objective of enhancing healthcare accessibility and quality, while the 2024 Public Private Partnership Concession Law provides guidelines for private sector investment and operation in healthcare facilities.

However, the extent of private sector engagement varies across different policy areas, and there's a need for a more unified approach to fully leverage the potential of public-private collaborations in achieving universal health coverage or more focused approach to focus on universal health insurance coverage. In essence, Egypt is striving to create a healthcare system where the public and private sectors complement each other, ultimately benefiting the population.

Assessing and Rating the Progression of Private Sector Engagement - Deliver Strategy

In my opinion, in reference to the “Deliver Strategy” governance behavior, the first in WHO’s progression pathway for private sector engagement, Egypt could be rated Nascent.

The progress assessment of Egypt's health strategy using guiding questions reveals that the 2023-2023 MoHP Strategic Directions Report outlines the government's strategic health goals but falls short in clearly articulating strategic objectives for the private health sector that align with established health system goals of ensuring equitable access to healthcare without financial hardship within a Universal Health Insurance System or even broader within universal health coverage, compared to heavy emphasis on the public sector. The documents do not specify policy mechanisms to achieve these objectives or explain how they will influence the private health sector's operations and performance. Additionally, there are no identified arrangements for implementing these goals, such as resource allocation, tracking changes, or evaluating impacts, highlighting significant gaps in the strategy's comprehensive execution and monitoring.

For Egypt to move from Nascent to Developing grade, Egypt needs to develop up-to-date policy statements articulating the role of the private health sector within the context of universal health coverage broadly and in relation to the universal health insurance system in particular.

The Way Forward

· Prioritize and Define a Program Boundary for Private Sector Engagement that Focuses on the Universal Health Insurance System. Clearly define the program boundary of the scope of private sector engagement in the next five years to fall within the boundary of the UHI system as part of achieving universal health coverage, while ruling out the engagement of the private sector in other areas.

· Articulate Strategic Roles for Private Sector Engagement. Clearly define the strategic roles of the private sector in UHI system objectives, distinguishing between for-profit and not-for-profit sectors.

· Develop Policy Mechanisms. Specify the policy mechanisms needed to influence the private sector's operations and performance.

· Allocate Resources and Track Performance. Establish specific arrangements for resource allocation, performance tracking, and evaluation of policy impacts.

By addressing these gaps and progressing through the outlined stages, Egypt can create a healthcare system where the public and private sectors effectively complement each other, ensuring high-quality, accessible healthcare for all its citizens.

 

Is Egypt Committed to Private Sector Engagement in Health: An Overview of its Policy Statements

Egypt's Universal Health Insurance Law and associated policy documents outline an attempt to present a framework for private sector engagement in the health sector, reflecting the extent Egypt is committed to enhancing healthcare delivery through different forms of public-private partnerships. The level of Egypt's commitment could be documented across several key areas, including constitutional provisions, strategic frameworks, specific legislation.

However, this commitment does not converge towards a unified and integrated approach for private sector engagement, focusing on service delivery ignoring many much needed for engagement. The policy statements supporting private sector engagement ranged from that of the overall health sector to universal health insurance coverage. Further, the language of support is leaning towards putting more emphasis on supporting Egypt’s healthcare service delivery through its public sector as the primary source of health care while allowing a space for the private sector to participate. In some cases, the statements are contradictory in terms of defining the role of the private sector especially that related to the delivery of primary health care services.

We have selected a few policy documents to demonstrate Egypt's level of commitment.

Health Articles in the Constitution.

In principle, Egypt's constitution explicitly supports private sector participation in healthcare. Article 18 encourages the involvement of both private and public sectors in providing health care services, while Article 36 promotes the private sector's social responsibility in serving the national economy and society. However, Article 18 emphasizes the state's role in maintaining and enhancing public health facilities, ensuring their efficiency and equitable distribution, and subjecting all health-related activities to state oversight.

Government Ownership Policy Document

The government’s ownership policy underscores a more restrictive approach, aiming to maintain or increase current governmental investments in the health sector while simultaneously allowing for private sector participation.

Strategic Directions Framework for Health 2023-2030

The Ministry of Health and Population (MoHP) report, "Strategic Directions Framework for Health in Egypt 2023-2030," outlines the government's strategic goals, with a primary focus on achieving universal health coverage. The document went into more details outlining key strategies to include:

- Strengthening the new Universal Health Insurance System (UHIS) by promoting competition and choice among public and private service providers.

- Enhancing the quality of healthcare services across all levels in both public and private sectors.

- Promoting public-private partnerships (PPP) to improve healthcare accessibility and efficiency.

- Collaborating with the private sector to enhance the production and quality of health products, including local pharmaceutical manufacturing.

- Strengthening health system governance by reviewing and updating health-related laws and regulations.

Conclusions of the National Dialogue

The national committee was concerned with accelerating the expansion of the Universal Health Insurance System and recommended to horizontally expand primary health care nationwide This expansion, targeted within 3 to 5 years, emphasizes the state's role in upgrading health facilities while enhancing private sector and civil society participation, thus fostering a comprehensive healthcare network.

Government Health Plan 2024-2026

The 2024 health plan includes incentives for health sector investors, facilitating their access to special benefits in the modern healthcare sector. It encourages the private sector to expand initiatives like "hospital at home" and hospital-to-hospital care paths to reduce hospitalization rates, showcasing the government's stance in integrating private sector solutions to enhance healthcare delivery in a rather limited scope.

Egypt’s Universal Health Insurance Law

The Universal Health Insurance Law establishes a more inclusive approach for private sector engagement. Article 10 allows the Universal Health Insurance Authority to purchase health services from both public and private entities at standardized prices. Article 16 enables private hospitals to provide services once they meet accreditation standards, and Article 36 requires all health facilities to obtain accreditation within three years, ensuring compliance with quality standards. Collectively, these measures aim to improve service delivery and health outcomes through a regulated and integrated private sector. However, there are other articles that were not clear on the relationship between Egypt's public provider, the Egypt Healthcare Authority, and private sector providers.

PPP Concession Law

The PPP law specifies regulations for private sector engagement in establishing and operating health facilities. Operators are responsible for maintaining facilities and equipment, ensuring compliance with health laws, and employing experienced personnel. The commitment period ranges from three to fifteen years, after which facilities and equipment are transferred back to the state in good condition. Operators must also provide a portion of health services at state-determined prices and continue employing a significant percentage of the facility’s staff, safeguarding their financial and employment rights. However, the law prohibited the involvement of operators in the delivery of primary health care services.

In conclusion, Egypt's policy statements demonstrate an attempt to commit to integrate the private sector into the national healthcare system that would require additional efforts to make this commitment stronger and clearer. By balancing public and private sector roles, the country could aim to enhance healthcare accessibility, quality, and efficiency, ultimately achieving its goal of universal health coverage.