The purpose of this page is learning, information dissemination, and scientific debate for those interested in Egypt's public health and its linkages to human development and social justice. In doing so, this page is committed to have a neutral stand and to present all views equally. This blog is based on the work of different experts in their field.

Sunday, September 25, 2011

Is a century required to universally cover Egyptians with Social Health Insurance (SHI)?

Egypt's Road towards Social Health Insurance - The Road to be Traveled (2)

How much time to be expected for the Egyptians to be covered by health insurance? It took Egypt almost half a century to reach half of the Egyptians with health insurance coverage. Does it need Egypt another half of a century to cover its other half of population?

Some experts predict that it would take between 35-50 years to achieve universal coverage depending on the status of economic development of the country. Another group states that these predictions are based on historical world experience and therefore could be labeled “conservative”.  Let’s have a look at the experience of some of the well known countries for implementing social health insurance systems.

It took Germany more than a century (127 years) to achieve universal health insurance coverage following its establishment by Bismarck in 1883 by passing its first sickness law and it seems to be still developing. The largest part, almost 85% of the population, is covered by a basic national health insurance plan provided by the state, providing a standard level of coverage. The remainder 15% opted for private health insurance, which frequently offers additional benefits. It is claimed that only 0.3% or about 250,000 people in Germany are not insured.  A few of these uninsured people are extremely rich, not needing insurance, and most of them are poor unable to afford it.

In Japan, it took about 39 years to achieve universal coverage ignoring that many community-based health insurance schemes prevailed before that for decades.  The first health insurance law was issued in 1922, delayed its implementation to 1927 because of the Great Kanto Earthquake of 1923. The first “region-based” national health insurance law was issued in 1938, and was revised a number of times until universal coverage was declared in 1961 and the establishment of a Social Insurance Agency in 1962. However, development and revision of laws continued until maybe 1997 indicating that the process of development of social health insurance does not stop by achieving universal coverage but there would be room for further improvement probably to introduce more efficiency. Still you could note a lot of ongoing debate about health insurance coverage and costs.

In the Republic of Korea (ROK), it took 26 years to achieve universal population coverage from the inception of the statutory Health Insurance Act in 1963. ROK introduced compulsory health insurance program in 1977, and universal coverage was claimed in 1989. However, this was preceded by a voluntary program in 1965.  The relatively fast transition to universal coverage is mainly attributed to unexpected impressive increase in the average annual growth rate in GNP per capita of 13.3 per cent during the period 1977-89.

Further, it took 118 years in Belgium, 79 years in Austria, 72 years in Luxembourg, 48 years in Costa Rica to achieve universal health insurance coverage. As could be concluded from the above, not only universal health insurance needs time to grow, develop, and expand, it also happens on stages mainly depending on a country’s economic development, its ethical value system and other factors.  For example, it took 40 years in Austria (from 1890 to 1930) for population coverage to grow from 7 to 60 percent, and then another 35 years (from 1930 to 1965) to reach 96 percent. Further, it took 20 years for SHI to reach population coverage of 17 percent in Costa Rica (from 1941 to 1961), another 5 years to double coverage to 34 percent (1966), another 12 years to again double coverage to 74 percent (1978), and then another 13 years to attain 83 percent coverage (1991). 

It could be stated that Egypt introduced its health insurance scheme in 1936 and not as commonly known in 1964 by issuing Law 64/1936 that established employer’s responsibilities for work injuries.  Additional 5 laws were issued during the period 1936-1964. A Health Workers Organization was established in 1961 to provide health care services for the workers, which later became the Health Insurance Organization (HIO).  However, 1964 was considered the benchmark for the formal launching of health insurance through issuing a presidential decree 1209/1964 establishing the HIO taking over the responsibilities from the General Authority for Social Insurance and building on two laws defining the SHI premiums for government employees (Law 75/1964) and for public and private sector employees (Law 63/1964). The HIO started working in Alexandria with the intention of expanding SHI geographically to other regions and to the entire population.  Later, premiums were decreased for government employees (Law 32/1975). In the same year 1975, another law was issued defining additional benefits to government, public and private sector employees, as well as extending benefits to pensioners and widows (Law 79/1975). The latter two groups were covered without an employer contribution. It was not until 1992, that coverage was extended to school children (Law 99/1992), and followed by extending coverage to pre-school children (Law 380/1997).  If we take in consideration the evolvement of social health insurance since 1936, then some people might consider that it took Egypt about 75 years to reach coverage of health insurance of 57% based on HIO statistics.

Egypt might not be different from other countries and would need to own the enabling environment that allows social health insurance coverage to expand to the other half of the population. This would be the subject of a future blog.  

Until we meet again…

Sunday, September 18, 2011

Egypt's Road towards Social Health Insurance - The Road to be Traveled (1)

In 2005, Egypt formally declared universal health insurance coverage of its population as its objective through the adoption of social health insurance (SHI).  This was an expansion to the original program that was introduced to Egypt's workers in 1964.  This coverage was expanded to those working in formal jobs in the public and private sector at different rates of contribution, allowing rich companies to opt out of the system. In addition, coverage was expanded to pensioners and widows. The latter coverage imposed additional burden on the system and it’s financing given the absence of contributions similar to those paid by the employers and due to the fact that these services are more expensive. All these measures might have disrupted the risk pooling function of the scheme limiting its capacity to raise enough funds to finance the system and its ability to provide the protection it is supposed to do. Thirty years later, with the inability of the system to cope with its expenses, SHI coverage was further compulsory expanded to Egypt's school children, and later, voluntary expanded to Egypt's preschool children. 

To date, insurance coverage has reached about half of the population, however; inequity is still a concern.  At the household level, a head of a family who is a civil servant and his daughter at school would be insured, while his housewife and his son in college wouldn’t be. Usually the poor and those working in the informal sector would not have access to health insurance services and would be expected to receive services at public health facilities.

The delay in expanding SHI coverage to the remaining half of Egypt’s population was blamed mainly on the underfunding of the health sector. Projections of a few billions of Egyptian pounds were quoted to be needed to fund the system in a sustainable manner.  While this remains true in case cost projections were built on estimating the cost per person for a certain package of services for a period of time; however, more money might not always mean better health; there might be room to introduce efficiency in the current system and make more funds available through running the system better.  Besides efficiency, there could be other areas that need to be examined.  Data indicates that the percent of Egypt’s GDP spent on health increased from 3.7% in 1995 to 5.9% in 2009; however, during the same period, the percentage of public health expenditures (which is what the government spends on health) from total expenditures on health decreased from one third to one fourth. Significantly, out-of-pocket expenditures (which are what the people spend on health) increased from half of the total expenditures on health in 1995 to nearly three quarters in 2009. These are considerably huge amounts of funds floating out of the pool of funds of SHI and decreasing more its ability of expanding its coverage.  Further and consistently, Egyptians spend one third of their treatment costs on pharmaceuticals. All of that suggest that there could be other factors that present obstacles on Egypt’s path to reach universal health insurance coverage.

But why do nations resort to SHI schemes in the first place? The most direct answer is to mobilize additional funds for health care. Underfunding of health care will lead to poor health outcomes, one of three main objectives of a health system.  The other two are usually rarely mentioned or given attention by those running health care systems, namely financial protection and client satisfaction, sometimes referred to as dignity. Financial protection means protection from large health expenditures that could bankrupt families leading to their impoverishment. Health expenditures were shown to be a primary cause of impoverishment, even for the rich and better off. Client satisfaction usually means to be treated in a humane form by your health care provider; in addition to many other things such as the perception that you are receiving quality care.  There are other reasons that a nation would resort to social health insurance.  William Hisao, the SHI guru mentioned some of these below, which could be valuable objectives by themselves
  • to subsidize premiums for the poor rather than financing and providing universal health care for all, in case tax revenues are inadequate to fund health care of a reasonable quality for everyone
  • to free up public funds so they can be targeted to public health goods and services;
  • to separate the responsibilities for collecting and managing SHI financing from the responsibilities for providing health care to patients, whereby services are contracted from providers that are separate entities to be accountable to patients for the quality of services;
  • to use the capacity of nongovernmental organizations (NGOs) and private providers to improve access by the insured to health care by means of contracting.
He concludes that SHI is a financing approach for mobilizing funds and pooling risks. The newly mobilized funds should be allocated for the poor and near-poor to improve their financial access to health care. SHI may be a solution for a critical part of a nation’s systemic health care problem, but is not necessarily a solution for the whole problem.

This is the first of a series of blogs that will discuss the application of social health insurance in Egypt and its feasibility within the guidance provided by international literature.

Until we meet again...