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, November 13, 2011

A Framework for Reading Egypt’s Social Health Insurance Law

Egypt's Road towards Social Health Insurance - The Road to be Traveled (6)

This blog is based on the work of international experts in the field of social health insurance that was adapted to Egypt's situation. Arabic versions of this blog will dig into more details of the framework but might not follow the same sequence of this blog. Because of limitations of space, some ideas presented in this blog will be discussed separately in future blogs.

The recent news about the upcoming law for social health insurance in Egypt and the messages transmitted about its potential modifications to ensure its achievement of social justice raised the question about how to read such laws and what should be included in it.  To help read this kind of social laws, once officially published for public dialogue, the presence of a reference framework could assist in that regard. In this blog, we will try to contribute some inputs that may assist in the preparation of such a framework, which we do not claim it will be comprehensive. This blog will not attempt to review or criticize the content of the currently circulated versions of SHI law.  As well, this blog will not differentiate between what should be mentioned as articles of the law itself or articles of its executive regulations due to their complementarily nature.

The logic of a social health insurance law would probably include the following:

  • Definition of the social health insurance system
  • How to make effective the mandatory and universal features of the system
  •  Principles that the govern the system
  • Transition from the current situation to an integrated and unified system
  • Definition of terms
  • Who are the Beneficiaries
  • What to finance
  • How to finance the new system
  • Definition and main characteristics of the institution that will manage the system, including governance, functions, powers, financial management, and accountability
  • Purchasing health care goods and services
  • Consumer protection
  • Role of Voluntary health insurance
The Definition. In defining the social health insurance system three aspects are to be considered:
  1.  The nature of the social health insurance system
  2. The objective of the social health insurance system
  3. The institutional structure to implement the social health insurance system.
Also three main characteristics of the system would need to be taken into account:
  1. Universal, meaning that it includes all Egyptian citizens
  2. Mandatory, that is, all Egyptian citizens must participate (there is no opting out from paying into the system); 
  3. Gradual, full inclusion of all citizens (with few exemptions) into the system over a defined period of time, OR Abrupt
The Principles. These usually refer to: solidarity; unit of subscription (family or individual); basis on need or demand; scope of services (primary, secondary, tertiary); subscription basis (mandatory?), financing not provision and separation of financing from provision; role of private for profit and non-profit in service provision based on contracting; role of state in financing the poor and near poor (partially or fully); tax exemptions for subscriptions; role of private health insurance (duplicative, complementary, supplementary)

The Transition. A a transition plan from a presently fragmented institutional structure dominated by the HIO to a single institutional structure in the future will be required.  Details for this transition could take place and developed in regulatory decrees.  An article in the law might state the principles for transition.  The transition would describe the way forward to arrive over time at an “integrated” (meaning putting in one place a social health insurance system. Four issues related to transition would need to be noted:
  1. The responsibility of management of the system during transition
  2. The management of enrollment of all non-covered citizens;
  3. The management of those already covered by the existing HIO system and their enrollment into the new SHI if required, under a one “unified” system (in that case meaning the system managed by a single organization);  
  4. The relationship to other existing parallel health care financing systems such as the Program for Treatment on the Expense of State (PTES)  and those funds flowing for public health services provision for curative care in Egypt.
The Institution. Social health insurance systems can only be implemented through an institutional structure.  A future entity might be established, which could be (a) a re-structured HIO, or (b) a totally new entity transformed into the unified entity for the management of the integrated social health insurance system with its own legal autonomous status. The law and/or its regulations will need to define the aspects that will be mandated for the future organization such as governance, autonomy, structure, functions, powers or attributes, contracting, and regional offices.

What to Finance. The law will need to refer to a unified set of social health insurance benefits, the health care goods and services covered by social health insurance for health care. The set of benefits usually is to be determined and updated by regulatory decrees to be provided by participating providers and for secondary care on referral of the gatekeeper.  The law also should require that the set of benefits is to be determined on an actuarial analysis to project financial implications.  Finally, there is a need to entrust the decision-making on defining and updating the set of benefits into the social health insurance entity to preclude political influence that could disturb the goal of fiscal responsibility

How to Finance. Financing would better be presented in the form of groups to be covered classifying those into three sectors (formal; informal; and targeted subsidized). The figures for financing, preferably and if the constitution allows, should not be included in the law itself as they would be subject for future change; however, this might be difficult in Egypt. To mitigate that articles will need to indicate that it will reviewed on periodic basis based on actuarial studies conducted by the Government. This applies to contributions and subsidies, as well as for co-payment levels

Providers and Suppliers - Contracting. Articles should stipulate that the social health insurance entity is a financial institution that funds the provision of health care goods and services to public and private providers.  Selection of providers and suppliers should be stated for those who meet the requirements for contracting with the entity to ensure that providers and suppliers meet licensing and certification requirements, among others, and for improving quality of care.

Consumer Protection. Articles that protect the interest of consumers will need to be included that reflects a framework for a system of consumer protection that could be part of the regulations. 

Voluntary Health Insurance. If the policy is to have a private/public mix in health care financing and delivery, then articles that allow individuals to purchase voluntary health insurance will need to be included.  These services could be duplicative, supplemental or complementary, but only after certified satisfaction of payment of social health insurance contributions

Until we meet again....

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