Reem Leila tries to find out whether a plan to improve health insurance will truly help the needy There is no disputing that there is an urgent need for a more effective health insurance system capable of providing citizens with high-quality treatment at their outlet of choice. Only 37 million people actually benefit from healthcare and health insurance. According to Decree 637 issued by Prime Minister Ahmed Nazif in March, a holding company is to be established to bring all 40 health insurance hospitals, 600 clinics and several health units under its umbrella as part of the government's plan to develop the health insurance sector. The new universal social health insurance law is supposed to enhance coverage for all, with the rich shouldering a large part of the financing, while the government covers the treatment of the poorest, who constitute 22 million people, by allocating LE60 million of its budget. The new legislation separates financial, managerial and auditing tasks so that they no longer hinder the bodies charged with providing healthcare service. It also specifies providing additional funds over and above the premiums paid by the beneficiaries of health insurance. Under the new system, all Egyptians will be insured, thus helping narrow the gap between rural and urban areas. "Establishing such a holding company does not mean privatisation of the health insurance sector but provides quality services for remedy," Said Rateb, head of the Health Insurance Organisation (HIO), said. Rateb said the system is undergoing changes in order to provide better services to the huge number of users. Some 200 HIO clinics are currently being enhanced in order to fit into the new system. Meantime, all insurance money is being kept at the National Investment Bank. Rateb dismissed any talk of mishandling insurance money or transferring its funds to the Finance Ministry, adding that the government is willing to discuss all relevant details with various sectors of the society. Minister of Health and Population Hatem El-Gabali has announced several times in the media that this new universal social health insurance will be implemented in 2010-2011. The bill has been presented to several political parties for debate. A draft will be presented to the Peoples' Assembly for discussion at the start of its next parliamentary session in November. The current health insurance system is a product of the 1960s, when populist policies were developed to eventually extend basic services to all citizens. The 1962 law stipulated that everyone would be covered by health insurance but did not define a concrete plan for implementation and gave no schedule or deadline for accomplishing the task. In 1964, the HIO was set up to provide compulsory health insurance for workers in the public sector. The service was supposed to reach the entire population but so far the HIO covers only 52 per cent of the population. "Sixty per cent of those who are insured are not satisfied with current healthcare services," said Abdel-Rahman Shahin, official MOHP spokesman. The range of coverage is not the only problem; the lack of quality service is undeniable. "The inefficiency of the present system is the main factor creating a dire need for a new and more competent alternative system," Shahin told Al-Ahram Weekly. The cost of medical care has escalated dramatically, Shahin noted, and will only increase with time. "Today we are confronted not only with poor quality service, but also a gross financial deficit," Shahin said. "The overall HIO budget is LE2.2 billion, while what is being spent on Egypt's health sector is LE37 billion including what people pay from their own pocket. The aim is to increase the HIO budget to a figure close to LE10 billion." The essence of the new system, says Shahin, is "managed care" which he describes as being based on "modern management techniques and competition as a means towards quality and cost effectiveness." Private and military hospitals and clinics will be included in the new system. "Only those which will meet with and apply international quality control standards will be included in the new system. Others will be prohibited from joining," Shahin said. The HIO would have both direct and indirect resources to fund its programmes. Direct income comes from the premiums and co- payments paid by beneficiaries, as well as contributions from the state treasury. The amount will be LE10 to be paid by the low- income bracket, LE15 for the middle class and LE20 for the higher class. Indirect funds would come from taxes to be imposed on particular industries and goods considered hazardous to people's health, including cigarettes and alcohol. Abdel-Moneim Ebeid, an anesthesiologist at Cairo University and a member of the Specialised National Council (SNC), said that under the new system poor patients who cannot afford to fully pay for either health services or medicine will find themselves obliged to pay one- third of the medicine's cost, one-third of the cost of an operation if needed, and one-third of the examination fees. "Under the current system patients only pay from LE3 to LE5 all inclusive. Will the society's poor be able to afford higher costs?" Ebeid asked. He said before a draft is prepared, it should have the backing of a wider range of professionals and be the subject of extensive debate and recommendations from scholars, healthcare providers and the people most often left out of the decision-making process. Not surprisingly, the bill has created heated debate as to the means, schedule and priorities of upgrading healthcare services. "If we expand an already deteriorating health insurance system, the results will be disastrous," predicted Mohamed Abu El-Ghar, founder of the Professors' March movement and a gynecologist at Cairo University. "It can only mean an overall spreading of poor quality medical services," Abu El-Ghar said, noting that at the very least, a 10-year programme of reform would first need to be implemented to improve the existing system and prepare it for more radical changes. The real challenge facing health officials explained Ebeid, is that the new system will be obligatory for all Egyptians, meaning that people will have to pay for it. "According to the new bill, a certain percentage will be deducted from the public's total income i nstead of the gross national income," Ebeid said. "The system will cover only what is called the basic benefit package, but surgeries such as open heart, and liver and kidney transplants are not included in the package. People will have to also pay for an insurance policy in order to cover major operations." Ebeid said the health insurance draft is a project presented by USAID, one which will provide technical assistance and funds to the government in order to privatise the service presented by the HIO and to transform MOHP's role from providing free service to the poor to a supervising entity. The key to reform, according to Ebeid, is full-time jobs for physicians with adequate remuneration. The only hope is healthcare reform. Opponents of the bill believe that by utilising all the health facilities available, the country can begin to expand healthcare coverage to more people, starting with governorates that already have sufficient medical facilities. Ebeid added that over the next five years, medical systems and resources in other governorates would be adjusted to accommodate the new setup. Indeed there was a high-level conference held on 17 July to discuss the draft. The conference was headed by Gamal Mubarak, deputy chairman of the National Democratic Party (NDP), and was attended by El-Gabali, as well as Madiha Khattab, dean of the Faculty of Medicine at Cairo University. Participants along with health experts and officials agreed on several points in order to guarantee that the new law is enforced properly. New taxes are to be added without affecting the social and economic status of the public. Extra taxes are to be added through health insurance stamps on marriage contracts, birth certificates, mobile phone bills, car licences and work permits abroad. All ministerial decrees will also be amended to allow people to pay the required amount of money needed to benefit from the new service.
