1. Dr. Ehab Abul – Magd
Chairman of Egyptian Health Care Management Society.
Board’s Member of the Universal Health Insurance Authority.
Ex. Manager of the Afro\Asian Congress for Medical Insurance & Managed Care.
Chairman of Platinum Holding for Health Care.
Head of Health Insurance & Health Policies Studies – New Giza University.
Dr. Ehab Abul - Magd

2. The Currant Public Health Insurance System in Egypt

3. Egypt has been in existence since 1964
▪ The social health insurance system (HIO) in
Egypt has been in existence since 1964
▪ HIO was the outcome of many legislations started in the early decades of the 20th century

4. Strengths of Current HIO
▪ Big number of OPDs & Hospitals owned by HIO
▪ Enormous expertise in different managerial &
technical aspect of Health Insurance
▪ HIO is considered as a Reference for Health
Insurance in the region
▪ Covers more than Half of the population by
▪ HIO Hospitals are accredited training centers
EFB, ABHS, RCSI & Cairo Faculty of Medicine.

5. Challenges Facing HIO

6. Challenges Facing HIO
1- Incomplete coverage (population – services - costs)

7. Challenges Facing HIO
2- Multiple Laws & Systems

8. Current Insurance Coverage Laws Law 32/1975 (Government Employees)
Law 79(1)/1975 (Government & Private Employees)
Law 79(2)/1975 (pensioners)
Prime Minister Decree 1/1981 (Widows)
Prime Minister Decree 10/1981(Beneficiary Family members)
Law 99/1992 (School Students)
Law 23/2012 (Women Headed Households)
Law 86/2012 (Preschool Children) replaced minister decree 380/1997
Law 127/2014 (Farmers)

9. Challenges Facing HIO 3- Unrealistic rates of premium HIO L23 L99
PM 1
PM 10
1% +
200EGP
4 +
12 EGP 1%
pension 4%
T salary 2%
B salary 8 + 2%
pension
1% +
0.5%
12 EGP
Dr. Ehab Abul - Magd

10. Challenges Facing HIO 73.65% 4- Low revenue collection rate L23 L99
PM 1
PM 10 4%
99%
75%
96%
13%
95%
100%
87%
92%
100%
75%
73.65%

11. Challenges Facing HIO
5- Fund Pooling Fragmentation

12. S.H.I. Challenges Facing HIO
6- Voluntary enrolment of some groups(diverse selection)
S.H.I.
Compulsory
Subsidization

13. Challenges Facing HIO
7- Opt out strategy (High salaries / Low health risk Group)

14. Challenges Facing HIO
8- Unclear Benefit Package (Implicit Benefit Package)

15. Challenges Facing HIO
9- Continuous advances in Healthcare Industry (Medicine – Diagnostics – interventions …)

16. Challenges Facing HIO
10- Technology & Knowledge Revolution ; a paradigm shift

17. Challenges Facing HIO
11- Progressive increase in service utilization by beneficiaries
Economic Status
Unavailable free treatment (MOH – Universities)
More HIO Services

18. Challenges Facing HIO 12- Cost of poor quality
Inefficient Use of Resources
Moral Hazards

19. Challenges Facing HIO
13- Fraud

20. Challenges Facing HIO
14- Limited Decentralization

21. Challenges Facing HIO
15- Unwillingness of young physicians to working in HIO .

22. Challenges Facing HIO
16- Working in hospitals is undesirable to nurses.

23. Challenges Facing HIO
17- Patients dissatisfaction in some areas (as OPD)

24. Challenges Facing HIO
18- Patient can neither choose treating doctor nor treatment facility

25. Challenges Facing HIO
19- Extension of Occupational diseases list (financial Burden) 48 35 29

26. Challenges Facing HIO
20 - Court Decisions (unregistered medicines – transportation allowance – reimbursement …)

27. Challenges Facing HIO
21 - Purchaser / Provider Integration. (Passive Vs. Strategic Purchaser)
Dr. Ehab Abul - Magd

28. Challenges Facing HIO 22- Media Attacking HIO
(concentrates on weaknesses and ignoring Strengths.)

29. Despite Challenges Renovations Equipment Interferon B DI Stent
Cochlear
Implants
HCV
1ry PCI
Cancer
target
therapy

30. How to overcome those Challenges?

31. Solutions better healthcare quality – more accountability – more
▪ Purchaser / Provider SPLIT (financial efficiency –
better healthcare quality – more accountability – more
Responsibility)
▪ Moving from Passive to Strategic purchaser
▪ Unifying the Laws (Single Law)
▪ Compulsory scheme
▪ Subsidization of poor
▪ No opt out
Dr. Ehab Abul - Magd

32. Solutions System (PIMS) occupational diseases ▪ Design Benefit Package
▪ Establish an integrated Payer Information Management
System (PIMS)
▪ Fund Pooling Defragmentation (large – single – risk mix)
▪ Realistic premiums & contributions (including
occupational diseases
▪ Provision of high quality & safe healthcare services

33. Solutions (Gate Keeper)
▪ Control Fraud, Moral Hazards & Costs of Poor Quality
▪ Decentralization (financial decisions)
▪ Nation-wise salary scale to all healthcare professionals.
▪ Magnification of the role of the GP or Family Physician
(Gate Keeper)

34. Universal Health Coverage (UHC)
Dr. Ehab Abul - Magd

35. Universal Health Coverage (UHC)
Definition:
Provide ALL people with access to needed health services (including promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective;
Ensure that the use of these services does not expose the user to financial hardship“
World Health Report 2010, p.6
Dr. Ehab Abul - Magd

36. Dimensions of UHC (UHC Cube)
Three dimensions to consider when moving towards UHC
Source: WHO

37. Why UHC? “International Key Facts”
All UN member states need to achieve UHC by as part of SDGs
At least 400 million people lack access to one or more essential health services.
Every year 100 million people are pushed into poverty, and 150 million people suffer financial catastrophe because of OOP expenditure on health services
World OOPs in year 2014 was 45.5% (World Bank)

38. for ALL END POVERTY PROTECT the PLANET ENSURE PROSPERITY
On September 25th 2015, UN member-states adopted a set of GOALS (17) to:
END POVERTY
PROTECT the PLANET
ENSURE PROSPERITY
for ALL
Each Goal has specific targets to be achieved over the next 15years.

39. Think of UHC as a Direction & not a Destination
Goal 3: Ensure healthy lives and promote well-being for all at all ages Target 3.8: Achieve UHC
Think of UHC as a Direction & not a Destination
Dr. Ehab Abul - Magd

40. Why UHC? “National Key Facts”
As UN member state, Egypt has to achieve UHC by as part of SDGs
Egypt has a strong Political Commitment for UHC through SHI (Article 18 in Constitution (2014), White paper)
25% of population below international poverty line
OOPs is 64% of THE (NHA 2018)

41. Health Insurance Organization (Main Features)
Population Coverage %
Single Payer
(Fragmented)
Payer Provider Integration
Unit of Enrolment: Individual & others
Complete Fiscal Autonomy
Public Providers Domination
Voluntary
/ Optout
Beneficiari es allocation to specific providers
Unclear (Implicit) Benefit Package
Provider Payment system (FFS)
Limited Cost Sharing

42. Challenges & UHC Approach

43. Challenges & UHC Approach Categories:
Structural / Stewardship
Resources
Financial
Service Delivery

44. Overcoming those Challenges?

45. New UHI Law (2018) Main Features :
Single Payer (Defragme nted)
Population Coverage ALL
Payer Provider Split
Unit of Enrolment: Family
Provider Payment system (Cap. – CB)
Public Private Partnership
Free Choice Providers
Compulsory No Opt-out
Defined Benefit Package
Complete Fiscal Autonomy
More Cost
Sharing

46. Egypt Health System; the Vision
10/9/2019
Of course, I see this evolving over time. Take the average family today…
Average family is 4 people, 1-2 people are insured
The quality of insured services is not meeting their expectations both in terms of healthcare quality and provider/insurer customer service
Providers follow few standards
“In 5 years – I see dramatic change has started and is felt”
Whole family is insured at moderate cost, but at an affordable price
Insured people have the freedom to choose between public and private providers
70% of the country is covered
Providers have learned the basics of quality
“In 10 years…”
100% of country is covered
Strong social safety net with 100% of poor fully exempted from paying for healthcare
Providers have mastered the fundamentals of quality [HOW DO ‘FUNDAMENTALS’ DIFFER FROM ‘BASICS’?]
Full fledged, much improved, socially based medical system with public /private partnerships and significant public and private funding to system
“In 15 years, providers have gone further and achieved international levels of quality
Egypt Health System; the Vision
Today
Avg. family is 4 people, <2 insured
Not meeting expectations
Few standards
5 years
Whole family insured at an affordable price
50% of the country is covered
Insured can choose between public and private providers
Providers have learned the basics of quality
10 years
100% of country is covered and poor fully exempted from paying for healthcare
Providers have mastered quality improvement – can adapt to standards on own
System delivered and funded through public /private partnerships
15 years
Providers have achieved internationally-recognized levels of quality
Universal coverage with safety net for the poor sustained
Dr. Ehab Abul - Magd

47. Conclusion Egypt is committed to attain UHC by 2030
Transition period of UHC has been defined
Egypt is not waiting for implementation of the new UHI, but started moving towards UHC to shorten the gap
Early steps has been started to establish HTA
(no UHC without priority settings, and no priority settings without
HTA)

48. Private health insurance’s role in implementing universal health coverage

49. Type of financing mechanisms
Dr. Ehab Abul - Magd

50. Private health insurance in UHC systems
Many Low and Middle Income Countries (LMICs) move toward the extension of Universal Health Coverage (UHC).
Due to the lack of resources it is difficult to sufficiently finance a comprehensive health care coverage.
The role of private health insurance has to be adjusted to the benefit package in the public health care system
Private health insurance (PHI) can have a new role, in the form of providing complementary (CompHI) and supplementary health insurance (SuppHI) in addition to the public health insurance scheme.
Dr. Ehab Abul - Magd

51. Different Roles that PHI can play under umbrella of UHC
Private health insurance can support the implementation of universal health coverage through covering the areas in which the BBP of the public insurance is not fully functioning.
If the UHC does not cover 100% of the population, the PHI can extend the number of insured by offering primary private health insurance.
To extend the number and quality of services covered by the public health insurance, private health insurance can offer supplementary and complementary services.
To reduce cost sharing (the co-payment paid to receive a service), private health insurance can cover the co-payments for patients. This is called complementary (user charges)

52. Potential role of private health insurance (PHI) in different benefit packages
Public health insurance
Private health insurance
Minimum package
Population: all citizens
Restriction: no copayment and waiting list
Essential package I.
Population: all patients with insurance
Restrictions: copayment, waiting list, second-line, low quality, no choice
Supplementary: Immediate access, better quality
Complementary (user charges): copayment
Complementary (services): Choice
Essential package II.
Population: all patients with insurance
Restrictions: coverage only for subgroup, copayment, waiting list, second-line
Complementary (services): coverage for patients with no access
Equity package
Population: selected patients with insurance
Restrictions: strict diagnostic criteria, monitoring
Non-reimbursed services
Source: Zoltan Kalo

53. Currant situation in Egypt
Additional definitions for primary Private Health Insurance
Duplicate PHI: PHI that offers coverage for health services already included under governmental health insurance, while also offering access to different providers (e.g. private hospitals) or levels of service (e.g. faster access to care). It does not exempt individuals from contributing to government health coverage programs.
Substitutive PHI: An alternative to statutory insurance and is available to sections of the population who may be excluded from public cover or who are free to opt out of the public system

54. Coming new insurance products
WHO definitions:
Supplementary services: Offers faster access to service, greater choice of health care provider or enhanced amenities
Complementary services: covers services excluded from the publicly financed benefit package
Complementary user charges: covers user charges for goods or services in the publicly financed benefits package

55. Potential Role of Private Health Insurance schemes
Supplementary, &
Complementary (services)
Complementary (user charges)
Primary PHI
(if UHC is not 100%)
Source: Syreon Research Institute / adapted from WHO
Dr. Ehab Abul - Magd

56. Learnings from other countries

57. Perspectives of SuppHI and CompHI in Egypt
Supplementary and complementary private health insurance can play a significant role in the Egyptian healthcare system based on:
Large proportion of out of pocket payments
Small proportion of private health insurance expenditures
Incomprehensive basic benefit package (even if UHC is implemented)
Dr. Ehab Abul - Magd

58. How to implement the new healthcare system?
Alignment of private health insurance with the development of universal health coverage (UHC)
Objectives of PHI development should be determined by the government
Political: satisfaction of different subgroups of Egyptian citizens (and expatriates)
Direct financial: provide promising business model for private health insurance companies
Indirect financial: reduce the financial pressure on the implementation of UHC
Strategic team of multidisciplinary stakeholders should develop mid- term and long-term policy framework to adjust the role of private health insurance to UHC
Special pilot areas (e.g. disease area, special technologies or services, geographical region) may be selected to facilitate alignment on the short run

59. Thank you
Many LMICs define their benefit package as being comprehensive and free of charge, however in reality the access is limited by implicit (e.g. long waiting lists) or explicit (e.g. eligibility criteria) methods. Mid-term and long-term policy framework to adjust the role of private health insurance to UHC via political, direct and indirect financial objectives should be determined. Pilot disease and therapeutic areas to provide CompHI and SuppHI should be selected to facilitate alignment on the short run.
Dr. Ehab Abul - Magd