Egypt's Road towards Social Health Insurance - The Road to be Traveled (7)
At a time when Egypt is doing relatively well in reducing its child and maternal mortality, while facing extreme pressure on its budget to meet various demands by the public, in presence of notable inefficiencies in the health system presented mainly by fragmentation in the financing and the delivery of health services, and at a time when a draft social health insurance is presented for public discussion in a post-revolutionary situation that might allow to revisit health strategies designed in an earlier phase of reform, a question might be posed before a final decision is made. Should Egypt stick to Social Health Insurance (SHI) as its main health financing strategy or could a better alternative scheme be available for Egypt to adopt. Is it too late to ask that question?
Governments usually aim to achieve universal coverage for health care for their people and people usually demands a health care system that meet their needs in terms of improved health, financial protection, and a system that is responsive and treat them with dignity. To achieve that in Egypt, continues efforts have been put to reform the health care system increasingly since 1997; however, with modest efforts to include the public in that reform.
Looking back, it is intriguing to note that during the last 60 years almost every attempt to reform the health sector in Egypt aiming to achieve this universal coverage promoting one health system or another as a means to achieve this end, ends up with an application of mixed and fragmented systems that were not able to meet the expectations demanded by the people. I’ve always encountered this statement recurring in many international and national reports describing the health system in Egypt as “a pluralistic health system, consisting of a number of parallel public and private health care delivery systems and multiple financing intermediaries”. The attempts to reform were not able to address this plurality and usually lead to more fragmentation of the system either at the delivery and/ or at the financing side ending up in a health system with multiple personalities.
The origin of this fragmentation has started a few decades ago, probably in the 50s and 60s, when two sets of parallel legalizations established the foundation for treatment on the expense of state (Presidential Decree 1754 in 1959 followed by Presidential Decree 1069 in 1964) and social health insurance (Law 75 in 1963 and Presidential Decree 1209 in 1964), probably trying to satisfy the demand of the people for better health care as well as a translation to Egypt’s constitutions placing the responsibility of provision of health care (Constitution 1956) and social insurance (Constitution 1964) including health to all Egyptians on the state. These were followed by multiple additional decisions that further fragmented the delivery side that led to the proliferation of a number of governmental and public services delivery systems in addition to those of the Ministry of Health.
And the question is “why is this happening?” Which system would be better for Egypt? A system based on general revenues and taxes or a system based on social health insurance?
Those who are in favor of tax-based systems argue for their system based on three points: (i) SHI discourages firms from hiring workers, and hence reduces employment and encourages informal labor markets; (ii) lack of coverage among certain groups during the often long period between establishing SHI and achieving universal coverage, and (iii) systematic variations in benefit packages and quality of care across subpopulations.
On the other hand, those who promote SHI do that based on two points: (i) SHI provides an important additional source of revenue for the health system; (ii) by separating the purchasing of health care from its provision and encouraging selective contracting between providers (including private sector ones), SHI systems are able to achieve better quality health care at a lower cost than tax-financed health systems.
Certain studies focusing on studying the impact of these health systems on health outcomes in OECD countries suggested that SHI systems, on balance (i) have certain characteristics that make them more expensive than tax-financed systems, (ii) do no better in terms of most health outcomes that are amenable to medical care despite the extra spending, (iii) may do worse in respect of outcomes that require strong population-level public health programs, and (iv) do worse in terms of encouraging informal labor markets and discouraging employment. The findings of this study raise the following questions:
- Why do we apply a system that could cost us more with no additional improvement in health outcomes at a time when budgets are tight? Would this contribute to efficiency?
- Why do we apply a system that could increase informality in the employment sector when already two thirds of those working are informal workers without protection? Would this contribute to financial and social protection?
- Are there dangers on our achievements in public health? As SHI systems focus on individual members, or even families, would we lose the focus on the entire population by public health programs financed by tax-financed systems? Would this contribute to improved health status and outcomes?
All of the above would lead to the following question, and another two subsidiary questions?
Can we apply in Egypt a system that can capture the better of the two systems and avoid their problems?
Question 1: Can we have a tax-based system with a directly managed provider network shift to a purchaser-provider-contracting model?
Under this scenario purchaser organizations contract with providers rather than manage them directly. This can be done by adopting the SHI purchaser-provider split model where purchaser organizations contract with providers, including those which are not public providers. This could lead to lower expenditures and better health outcomes. However, to what extent this can be done without risking coherence and integration in its public health programs? The Egypt experience in introducing the Family Health Funds, governorate health insurance organizations that were established to do the purchasing function, is an example of an attempt in that regard. The ownership of these organizations between the Ministry of Health and the Health Insurance Organization remained for a long time and it failed to elaborate a national organization that would provide oversight for such decentralized bodies called the National Family Health Fund. Further, this was countered by the Ministry of Health by establishing provider organizations at district level called the District Provider Organizations to ensure the flow of funds through its organization, which were dismantled later as the Egyptian health system geared more towards social health insurance..
Or Question 2: Can SHI system increase its reliance on tax revenues and capture some of the tax-based finance system functions?
This seems to be feasible to be done and the latest versions of the new social health insurance law provides different articles that attempt to increase its tax base and revenues from sources other than that from payroll taxes, although earmarked taxes is being proposed. This is the new experience that has been facing long debate before and after the January 25th revolution, and seems to continue for a while. The linkage of health insurance to family health services could be the basis for protecting the screening functions of public health programs.
At the end, a decision will need to be made by those who will represent Egypt in the new People’s Assembly and will then need to be implemented by the newly elected government in a few months to come. This decision will need to select the system, SHI systems or tax-financed systems, which on balance would spend less, achieve better health, easier to go through the transition, and lead to better labor market outcomes.
Until we meet again...