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Dr. Ehab Abul – Magd Chairman of Egyptian Health Care Management Society.

Explore the strengths and challenges of the current health insurance system in Egypt. Discover potential solutions to overcome these challenges and move towards Universal Health Coverage (UHC).

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Dr. Ehab Abul – Magd Chairman of Egyptian Health Care Management Society.

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  1. Dr. Ehab Abul– Magd • Chairman of Egyptian Health Care Management Society. • Board’s Member of the Universal Health Insurance Authority. • Ex. Manager of the Afro\Asian Congress for Medical Insurance & Managed Care. • Chairman of Platinum Holding for Health Care. • Head of Health Insurance & Health Policies Studies – New Giza University.

  2. The Currant Public Health Insurance System in Egypt

  3. ▪ The social health insurance system (HIO) in Egypt has been in existence since 1964 ▪ HIO was the outcome of manylegislations started in the early decades of the 20thcentury

  4. Strengths of Current HIO ▪ Big number of OPDs & Hospitals owned by HIO ▪ Enormous expertise in different managerial & technical aspect of Health Insurance ▪ HIO is considered as a Reference for Health Insurance in the region ▪ Covers more than Half of the population by ▪ HIO Hospitals are accredited training centers EFB, ABHS, RCSI & Cairo Faculty of Medicine.

  5. ChallengesFacing HIO

  6. Challenges Facing HIO 1- Incompletecoverage (population – services - costs)

  7. Challenges FacingHIO 2- MultipleLaws & Systems

  8. Current Insurance Coverage Laws • Law 32/1975 (Government Employees) • Law 79(1)/1975 (Government & Private Employees) • Law 79(2)/1975 (pensioners) • Prime Minister Decree 1/1981 (Widows) • Prime Minister Decree 10/1981(Beneficiary Family members) • Law99/1992 (School Students) • Law23/2012 (Women Headed Households) • Law86/2012 (Preschool Children) replaced minister decree 380/1997 • Law127/2014 (Farmers)

  9. Challenges Facing HIO 3- Unrealistic rates of premium HIO L79(2) L79(1) L86 L32 L23 L99 PM 1 PM 10 4 + 12 EGP 1% + 200EGP 8 + 1% + 0.5% 1% pension 4% T salary 2% B salary 2% pension 12 EGP

  10. Challenges Facing HIO 4-Lowrevenue collection rate HIO L79(2) L79(1) L86 L32 L23 L99 PM 1 PM 10 4% 99% 13% 95% 75% 96% 100% 87% 92% 100% 75% 73.65%

  11. Challenges Facing HIO 5- FundPooling Fragmentation

  12. Challenges Facing HIO 6- Voluntaryenrolment of some groups(diverse selection) S.H.I. Compulsory Subsidization

  13. Challenges Facing HIO 7- Optout strategy (High salaries / Low health risk Group)

  14. Challenges Facing HIO 8- UnclearBenefit Package (Implicit Benefit Package)

  15. Challenges Facing HIO 9- Continuous advances in HealthcareIndustry (Medicine – Diagnostics – interventions …)

  16. Challenges Facing HIO 10- Technology & KnowledgeRevolution ; a paradigm shift

  17. Challenges Facing HIO • 11- Progressive increase in service utilization by beneficiaries • Economic Status • Unavailable free treatment (MOH – Universities) • More HIO Services

  18. Challenges FacingHIO 12- Cost of poor quality • Inefficient Use of Resources • Moral Hazards

  19. ChallengesFacing HIO 13- Fraud

  20. Challenges FacingHIO 14- LimitedDecentralization

  21. Challenges Facing HIO 15- Unwillingnessof young physicians to working in HIO .

  22. Challenges Facing HIO 16- Workingin hospitals is undesirable to nurses.

  23. Challenges Facing HIO 17- Patientsdissatisfaction in some areas (as OPD)

  24. Challenges Facing HIO 18- Patient can neitherchoose treating doctor nor treatment facility

  25. Challenges Facing HIO 19- Extension ofOccupational diseases list (financial Burden) 48 35 29

  26. Challenges Facing HIO 20 - Court Decisions (unregisteredmedicines – transportation allowance – reimbursement …)

  27. Challenges Facing HIO 21 - Purchaser / Provider Integration.(Passive Vs. Strategic Purchaser)

  28. Challenges Facing HIO 22- Media Attacking HIO (concentrates on weaknesses and ignoring Strengths.)

  29. DespiteChallenges Renovations Equipment Interferon B DI Stent Cochlear Implants HCV 1ry PCI Cancer target therapy

  30. Howto overcome those Challenges?

  31. Solutions ▪ Purchaser / Provider SPLIT (financial efficiency – better healthcare quality – more accountability – more Responsibility) ▪ Moving from Passive to Strategicpurchaser ▪ Unifying the Laws (SingleLaw) ▪ Compulsory scheme ▪ Subsidization of poor ▪ No opt out

  32. Solutions ▪ Design Benefit Package ▪ Establish an integrated Payer InformationManagement System (PIMS) ▪ Fund Pooling Defragmentation (large – single – riskmix) ▪ Realistic premiums & contributions (including occupational diseases ▪ Provision of high quality & safe healthcare services

  33. Solutions ▪ Control Fraud, Moral Hazards & Costs of Poor Quality ▪ Decentralization (financial decisions) ▪ Nation-wise salary scaleto all healthcare professionals. ▪ Magnification ofthe role of the GP or Family Physician (Gate Keeper)

  34. Universal HealthCoverage (UHC)

  35. Universal Health Coverage(UHC) • Definition: • Provide ALL people with access to needed health services (includingpromotion, treatment, rehabilitation, and palliation) ofsufficient quality to beeffective; • Ensure that the use of these services doesnot expose the user to financialhardship“ • World Health Report 2010,p.6

  36. Dimensions ofUHC (UHCCube) Three dimensions to consider when moving towardsUHC Source:WHO

  37. Why UHC?“International Key Facts” • AllUNmemberstatesneedtoachieveUHC by 2030 as part ofSDGs • At least 400 million people lack accessto one or more essential healthservices. • Every year 100 million people are pushed into poverty, and 150 million peoplesuffer financial catastrophe because of OOP expenditure on healthservices • World OOPs in year 2014 was 45.5%(WorldBank)

  38. On September 25th 2015, UN member-states adopted a set of GOALS (17)to: • ENDPOVERTY • PROTECT thePLANET • ENSUREPROSPERITY forALL Each Goal has specific targets to be achieved over the next15years.

  39. Goal3:Ensurehealthylivesandpromotewell-beingforallatallages Target 3.8: AchieveUHC ThinkofUHCasaDirection&notaDestination

  40. Why UHC? “National KeyFacts” • As UN memberstate, Egypt has to achieve UHC by 2030 as part ofSDGs • Egypt has a strong Political CommitmentforUHC through SHI (Article 18 in Constitution (2014), Whitepaper) • 25% of population below internationalpoverty line • OOPs is 64% of THE (NHA2018)

  41. Health Insurance Organization (MainFeatures) Population Coverage 58.8% Single Payer (Fragmented) Payer Provider Integration Unit of Enrolment: Individual &others Public Providers Domination Complete Fiscal Autonomy Voluntary /Optout Beneficiari es allocation to specific providers Unclear (Implicit) Benefit Package Provider Payment system (FFS) Limited Cost Sharing

  42. Challenges & UHCApproach

  43. Challenges & UHCApproach Categories: • Structural /Stewardship • Resources • Financial • ServiceDelivery

  44. Overcoming thoseChallenges?

  45. New UHILaw(2018) Main Features: Single Payer (Defragmented) Population Coverage ALL Payer Provider Split Unit of Enrolment: Family Provider Payment system (Cap. –CB) Public Private Partnership Free Choice Providers Compulsory NoOpt-out Complete Fiscal Autonomy Defined Benefit Package MoreCost Sharing

  46. Egypt Health System; the Vision • 15 years • Providers have achieved internationally-recognized levels of quality • Universal coverage with safety net for the poor sustained • 10 years • 100% of country is covered and poor fully exempted from paying for healthcare • Providers have mastered quality improvement – can adapt to standards on own • System delivered and funded through public /private partnerships • 5 years • Whole family insured at an affordable price • 50% of the country is covered • Insured can choose between public and private providers • Providers have learned the basics of quality • Today • Avg. family is 4 people, <2 insured • Not meeting expectations • Few standards

  47. Conclusion • Egypt is committed to attain UHC by2030 • Transition period of UHC has beendefined • Egypt is not waiting for implementationof the new UHI, but started moving towards UHC to shorten thegap • Early steps has been started to establishHTA • (no UHC without priority settings, and no priority settingswithout • HTA)

  48. Private health insurance’s role in implementing universal health coverage

  49. Type of financing mechanisms

  50. Private health insurance in UHC systems • Many Low and Middle Income Countries (LMICs) move toward the extension of Universal Health Coverage (UHC). • Due to the lack of resources it is difficult to sufficiently finance a comprehensive health care coverage. • The role of private health insurance has to be adjusted to the benefit package in the public health care system • Private health insurance (PHI) can have a new role, in the form of providing complementary (CompHI) and supplementary health insurance (SuppHI) in addition to the public health insurance scheme.

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