Is Egypt's Geographic Phased Rollout of its Universal Health Insurance System Fair and Equitable?

The introduction of Egypt's Universal Health Insurance System (UHIS) under Law No. 2 of 2018 marks a significant advancement towards ensuring that every Egyptian has access to quality healthcare services without financial hardship. However, the strategy for its implementation—a phased geographic expansion—raises questions about its equity and alignment with the principles of universal health coverage (UHC) as outlined by the World Health Organization (WHO). This article examines the fairness of this approach for all Egyptians, using WHO's UHC Cube and the expert report on making fair choices on the path to UHC as frameworks.

The Phased Rollout Strategy

Egypt’s UHIS is planned to be gradually implemented across different governorates. This phased approach aims to manage the complexities of a nationwide rollout and to pilot the system in smaller areas with lower concentrations of population before scaling up. The phased geographic roll out is being explained to match capacity to finance and to implement. With eight years remaining until the year 2032, the year targeted to achieve universal health insurance coverage, and after four years of implementation, the implementers of the UHIS system are still struggling to complete an effective the coverage in its first phase of implementation comprising six low density populated governorates. It might look challenging to achieve this target, thus posing the question if further delays would make it fair for those not covered to wait longer without receiving effective coverage.

WHO’s UHC Cube: A Framework for Analysis

The WHO’s UHC Cube provides a comprehensive framework for assessing health coverage along three dimensions: population coverage (who is covered), service coverage (which services are covered), and financial protection (how much of the cost is covered). Evaluating Egypt's phased rollout strategy through this lens highlights key equity considerations:

1. Population Coverage: Who is Covered?

The phased geographic expansion risks creating disparities in population coverage. Early adopter regions receive immediate benefits, while others wait, potentially exacerbating existing regional inequities. To align with WHO’s equity principles, prioritizing the most vulnerable and underserved regions is crucial. This approach ensures that those who need UHC the most are not left behind. Those who are living in those regions that are not included in the first phase of implementation might wait longer than expected in the absence of an effective alternative.

2. Service Coverage: Which Services are Covered?

Ensuring that the essential health services are accessible to all regions from the start is fundamental. The UHIS must guarantee that the basic health needs of the population are met uniformly across all governorates, regardless of the phase of implementation. Insisting on adopting a generous health benefit package waste precious resources on non-essential services providing them to populations living in regions prioritized for early implementation getting more than what they need while depriving populations in other regions from essential health services that they need.

3. Financial Protection: How Much of the Cost is Covered?

Effective financial protection involves covering insurance premiums for the poorest citizens through government subsidies, as outlined in the UHIS law. However, limited resources from the Ministry of Finance can hinder this goal, potentially leaving many without necessary support. A recent evaluation of the Takafoul program indicates that this program covers only 16 percent of the population instead of the projected 30 percent poor as shown in national surveys. Adequate funding and efficient resource allocation are imperative to prevent out-of-pocket expenses that can lead to financial hardship for the poor.

WHO’s Fair Choices Framework

The WHO's expert report on making fair choices on the path to UHC emphasizes the importance of equity, priority-setting, and inclusiveness. Applying these principles to Egypt’s phased rollout strategy involves:

1. Priority-Setting

Resources should be directed first to priority essential health services and to the most disadvantaged regions and populations. This means focusing early phases on areas with the highest levels of poverty and the greatest health needs with the right services. Such an approach aligns with the WHO’s recommendation to prioritize those who are worst off based on need.

2. Inclusiveness and Participation

Ensuring that all citizens, especially the poor and vulnerable, are informed and can participate in the UHIS is crucial. Simplifying the enrollment process and enhancing communication can help overcome barriers related to manual registration and bureaucratic obstacles. Automatic enrollment for known vulnerable populations can further enhance inclusivity.

3. Continuous Monitoring and Adaptation

Regularly reviewing and adjusting the implementation strategy based on feedback and emerging data is essential. This adaptive approach can address any inequities that arise and ensure that the UHIS effectively serves all Egyptians, particularly the poorest and most vulnerable.

Better Synergy between Takaful and Karama with the UHIS

The Takaful and Karama cash transfer programs are vital components of Egypt's social protection strategy, providing support to the poorest families. However, limited funding and stringent eligibility criteria result in significant portions of the poor being excluded. Better linkage of these programs with the UHIS can enhance equity by ensuring that beneficiaries of cash transfers are automatically covered by health insurance, thereby providing comprehensive support.

The Way Forward

Egypt could consider models that accelerate the nationwide coverage of the poor with essential health services alongside its phased geographic approach being currently adopted.

Conclusion

Egypt’s phased rollout strategy for UHIS, while practical for managing logistics and scalability, must be carefully managed to ensure equity. Aligning with WHO’s UHC Cube and the fair choices framework involves prioritizing the most vulnerable regions, ensuring equitable service coverage, providing adequate financial protection, and continuously adapting the strategy based on real-world data. By addressing these challenges, Egypt can move towards a more equitable and inclusive healthcare system that truly serves all its citizens, particularly the poor and vulnerable.