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...
A related article:
ReplyDeletehttp://www.bmj.com/content/325/7362/488?view=long&pmid=12202334