Egypt is about to begin a massive enterprise in the shape of the new comprehensive health insurance law, which has been in the making for almost two decades. The law is set to fulfill the aspirations cited in Article 18 of the 2014 Constitution: “Every citizen has the right to health and to comprehensive health care that complies with quality standards ... The State shall establish a comprehensive health insurance system covering all diseases for all Egyptians; and the law shall regulate citizens' contributions to or exemptions from its subscriptions based on income rates.” This translates to health insurance that covers 100 per cent of the population under one umbrella. It will increase equitable access to high-calibre health services. Based on a solidarity scheme, under which the prosperous assist those who are less prosperous, the intention of the law is to reduce the medical care burden of Egyptian families. The system that has been used thus far entails multiple scattered and fragmented insurance laws, each geared to serving a particular segment of society, be it students, workers or women. Though the current system covers 58 per cent of the population, only 10 to 15 per cent actually use it, according to Wagida Anwar, a professor of public health and a member of the High Committee for Drafting the Health Law. It does not cover many segments of society, especially those working in the non-formal sector, and neither does it cover their families, accounting for the lack of health services for a huge segment of society. According to a 2011 report, Egyptian families bear the brunt of such costs, or 60 per cent of the cost of treatment Egypt-wide. Meanwhile, many patients remain dissatisfied by the quality of the medical services they receive. According to the new law, three separate organisations will form the new health system, being in charge of financing, provisioning and supervision. The financing organisation will be in charge of revenue collection and the pooling and purchasing of services. It will amass revenues from all sources, whether in the form of subscriptions, subsidies or revenues raised from taxed items such as tobacco. It will also provide expertise via the private and public sectors and universities in costing and purchasing. The provisioning organisation is the service arm of the new system. It will include all Ministry of Health hospitals and health insurance organisation hospitals. Private hospitals, NGO facilities, civil society clinics and university hospitals will be contracted by the financing organisation as needed. The third organisation is the supervision organisation, whose task is to evaluate and accredit services. It will guarantee that the various service arms are at par with the guidelines. In splitting the financing, provisioning and supervision of the new system, adequate levels of scrutiny and transparency will prevail. The cost for individuals and families will be equitable. Formal-sector workers will pay one per cent of their salaries, while their employers will pay three per cent, making a four per cent levy. Workers will pay 2.5 per cent for their spouses covered by the scheme, and 0.75 per cent for each child or dependent. Pensioners will pay two per cent of their pensions, and those beneath the poverty line will make no payments. For those working in the informal sector, depending on tax payments, they will pay four per cent of income. As a result, an average Egyptian household will pay up to five per cent of its income for health insurance, unless there is also a working spouse. Much about the new law is pending final approval, including from the president, government and parliament. Once the law passes these stages, implementation will be staggered, first in the smaller governorates and then in the larger ones. The intention is to start with the governorates of Suez, Ismailia, North Sinai and South Sinai, and then move on from there. The law is not without its challenges, however. For one thing, the cost is prohibitive at LE120 billion. However, much of this cost is being spent already in one form or another, since the National Health Accounting Organisation has estimated that 60 per cent of total healthcare costs are already coming out of people's pockets, while the private sector already pays approximately LE30 billion for health services. This is in addition to subscriptions and subsidies and taxes earmarked from various commodities and services such as cigarettes, tobacco, entertainment outlets, alcohol, car licences, nights spent by tourists in Egypt and much more, all of which will help support the new system. However, even with such financial juggling, implementing the new health insurance law will definitely be an extra financial burden, primarily on the government and on both the public and the private sector. Another challenge is how to include the informal sector under this health umbrella, for example the street traders, day workers and farm workers who form a large segment of society, at around 40 per cent of all labourers. Though the Ministry of Social Solidarity will be responsible for providing a database of the informal sector, in cooperation with the Ministry of Agriculture and the Ministry of the Interior and others under the new law, keeping track of all these people's payments will be a logistical nightmare. Nevertheless, a similar database was created and successfully implemented for the smart card rationing system. The services sector is also not quite on board. Change is never accepted uncritically and is always looked upon with suspicion by those affected. Concerns over payments, salaries, and the roles of physicians and others, together with the accreditation of outlets, the implementation of the law itself, and the distinction between the private and public sectors are all disconcerting for the services sector. According to Anwar, the private sector will not be excluded from the new system. If the private sector can reach the required accreditation level, the intention is to equate doctors in the private and public sectors across Egypt. Other challenges exist. Opting out of the new system will not be an option, and every Egyptian will be covered. Yet, the able-to-pay will still expect the best treatment, doctors, and stays in hospital. Today, the calibre of healthcare services in Egypt ranges from the exceptional to the abysmal, and those who can afford the best will want to maintain the best. Will their needs be met? If so, will this create a two-tier system? The average Egyptian may also have his doubts about the new system. He may be reluctant to pay approximately five per cent of the income he has earned towards a medical system that has not been proven. Will the final outcome of the law be what is proposed? Will the logistical nightmares expected from transforming the existing institutions, service facilities and regulations into one system be overcome? Finally, people don't yet know enough about the law. An awareness-raising campaign to inform people about the new law will help alleviate worries about the unknown. The fears of the services sector also need to be addressed, which could be realised via the open dialogue that the health minister has promised to partake in with all those concerned, particularly doctors. Together, they can close the loopholes and erase the wrinkles that may exist in the new law. Most importantly, as a result of the new health insurance law, will health services in Egypt in general improve in terms of access, availability and quality? It remains to be seen. The writer is a political analyst.
