The roots of the Egyptian health system stretch back to the mid-19th century, when it was first established by the viceroy of Egypt, Mohammed Ali. It is a centralized system, operating through the Health Ministry since its establishment in April 1936, supported by health directorates on the governorate level and district-level health offices in every governorate.
The health system is not integrated, having developed haphazardly over various historical periods without an overarching vision or coordination. As such, today it consists of multiple, fragmented axes of administration, regulation, financing, and service provision through governmental, public, private, and civic outlets.
<h3>The current health system comprises:</h3>
The government health sector: the Ministry of Health (MOH), the body authorized to regulate, administer, and supervise health care and provide it to citizens; the General Authority for Teaching Hospitals; the General Authority for Health Insurance (a public, quasi-governmental, economic body established in 1964 to provide health care to insured citizens; finance and service provision is carried out through subsidiary or contracted clinics, centers, and hospitals); the Treatment Institution; university hospitals; other ministries (which provide health services to employees and their families such as units and hospitals operated by the Ministries of Defense, Interior and Electricity and others serve citizens); and the system for treatment at state expense (a financing system that does not provide treatment directly; it largely covers treatment for catastrophic illness and provides exceptional coverage for the uninsured).
The private medical sector: a network of private clinics, hospitals, and medical centers that provide treatment for citizens who can pay. Since prices and service levels in this sector vary in line with operational costs and considerations, their prices put their services beyond the reach of the vast majority of Egyptians.
The civic and charitable medical sector: services are provided through non-profit, tax-exempt civic associations, which offer services at lower prices than the private sector. These associations also often collect donations. The sector has expanded to fill the gap between poor-quality public services and costly private services.
The health reform program was outlined in early 1997. It laid out a practical vision and roadmap to reform and restructure the health system.
<h3>Primary challenges facing the system</h3>
<ol>
<li style="text-align: justify;">High rates of out-of-pocket (OOP) health spending by individuals and families.</li>
<li style="text-align: justify;">Financial barriers to health service access, particularly among poor Egyptians in rural areas.</li>
<li style="text-align: justify;">The relatively poorer quality of health service offered by MOH health clinics, particularly in rural and urban Upper Egypt.</li>
<li style="text-align: justify;">Inefficient use of available public health resources.</li>
</ol>
Figure 1: Uninsured Egyptians based on the 2014 Demographic and Health Survey
<img style="display: block; margin-left: auto; margin-right: auto;" src="https://api-aps.aucegypt.edu/uploads/tinymce/1653572123imagefig1.png" alt="" width="500" height="255">
Source: Egypt DHS, 2014.
Figure 2: Births delivered in a health facility (private or governmental)
<img style="display: block; margin-left: auto; margin-right: auto;" src="https://api-aps.aucegypt.edu/uploads/tinymce/1653572151imagefig2.png" alt="" width="500" height="213">
Source: Egypt DHS, 2014.
<h3>Health inequality and social justice gaps</h3>
Health inequalities can be observed in geographic disparities (north/south and rural/urban) in under-5-year-old child mortality, maternal mortality, and prenatal health, and in social disparities (poor/rich) in infant mortality. They are also apparent in the higher rates of stunting among poor children, as well as higher rates of infectious and noninfectious diseases like hepatitis B and C among the poor, the burden of which only compounds their poverty.
Figure 3 : Deliveries in which mothers received prenatal care from a trained practitioner
<img style="display: block; margin-left: auto; margin-right: auto;" src="https://api-aps.aucegypt.edu/uploads/tinymce/1653572184imagefig3.png" alt="" width="500" height="213">
Source: Egypt DHS, 2008 and 2014.
The lack of financial protection against the burden of disease is clearly illustrated by catastrophic health spending, or direct OOP spending that exceeds a family&rsquo;s financial capabilities, and impoverishing health spending, when, due to an adverse health event, a family must divert its non-health budget, earmarked for items like food, housing, and clothing, to health spending, dragging the family below the poverty line. It is also apparent in the fact that 50% of the citizenry&mdash;the poorest half&mdash;are without any health or social insurance and enjoy unequal access to treatment at state expense. As a result, more than 72% of total health spending is OOP (Ghannam, 2012), which reflects less ability to pay than necessity and compulsion.
In fact, based on studies of disease burden, Egypt faces a double burden of both communicable and non-communicable diseases like diabetes, heart disease, and cancer, although the health system is increasingly geared toward the latter insofar as it is the major cause of death in Egypt. It is estimated that non-communicable disease is responsible for 82% of all deaths in Egypt and 67% of early deaths (WHO EMRO, n.d.).
<h3>Importance of the universal health insurance law</h3>
All these figures underscore the importance of the universal health insurance law as a lever for addressing inequities and achieving health justice in Egypt. The law aims to make available and provide high quality healthcare for all citizens without discrimination, regardless of their ability to pay, relying on a strong, effective financing mechanism that pools risk and is supported by premiums paid by citizens based on their income,<a href="#_edn1" name="_ednref1">[i]</a> in order to provide care and treatment for all. Those unable to pay premiums will be supported by the state treasury from various revenue sources. This group constitutes on average 32.5% of citizens, but varies from year to year (Qabeel, 2019).
The universal health insurance system, set to be implemented in all Egyptian governorates over the next ten years, will entirely restructure the system, curtailing the private sector and its market dominance by funding governmental hospitals, thereby enabling them to compete with the private sector in the provision of good quality treatment. As the new health insurance system is based on a separation of service providers, funders, and oversight and quality control, the governmental health system will be reconfigured in three new bodies, in addition to the MOH.
The mission of the first body (the General Authority for Health Insurance) is to collect and administer premiums and purchase medical services. The second, the General Authority for Health Control and Oversight, which is subordinate to the president, is responsible for ensuring and improving the quality of health services. The third body, the Authority for Health Care, is subordinate to the health minister and will oversee the administration of MOH hospitals, other governmental hospitals, health insurance hospitals, the Treatment Institution, and teaching hospitals, after they are all re-fitted and certified based on quality standards.
In the new universal insurance system, the role of the MOH will be to act as the general regulator and &nbsp;constitutionally responsible party for public health; it will work to combat epidemics, take preventive health measures, and monitor nutrition and the adverse environmental, nutritional, and other impacts for public health. It will abandon its role as financer, service purchaser or provider, and quality control monitor, all of which will gradually devolve onto the other three bodies.
The new health insurance system was piloted in the Port Said governorate in July 2019, and is scheduled to be expanded to the other Suez Canal governorates and Sinai. The government has announced that it has collected the financial resources stipulated by the law for this purpose, and various international donors have provided additional resources and the technical and technological support needed to implement the law in Port Said.
The Egyptian Initiative for Personal Rights released a report on the pilot program in November 2019, in concert with the Community Monitoring Portal of Health Service Provision in Egypt&lrm; and a diverse team of field researchers. The report is based on the analysis of community assessments of hospitals and health services in the Port Said governorate, carried out by a team of civil society organizations prior to the development of the hospitals in line with the new system. The team repeated the assessment three months after the new health insurance system officially went into effect in the governorate. Covering ten hospitals, the assessment considers 128 different indicators of health service quality from the perspective of the service recipient. Assessments were collected through practical experiences with service provision and a set of interviews with patients and service providers, conducted by several teams covering the hospitals included in the survey. Hospitals were assessed based on a field survey by a three-member team that related its observations to the team analyzing and comparing the data and assessments collected before coming to a final conclusion.
The report discussed both positive and negative findings. On the positive side, service users noted a marked development in infrastructure, buildings, and equipment. For example, there was sufficient administrative and security presence to limit problems or disputes and maintain the safety of patients and medical staff, which was lauded by citizens. Reception workers cooperated well, assisted patients with registration and orientation, and answered questions appropriately. There was a team responsible for quality that regularly monitored performance indicators, and interest was consistently shown in citizens&rsquo; complaints. Work guidelines also included the need to maintain constant hygiene. There was a marked improvement in the proficiency of specialist doctors and an interest in examining citizens as necessary, and it was clear that doctors were involved in continuing training to improve their effectiveness. Nursing staff at all hospitals were required to wear appropriate clothing and offered assistance. There was a system in place to process patients and adequate waiting spaces.
On the negative side, the most important conclusions were as follows: referral procedures from the first to the second level of care were overly complicated and time consuming, often making it practically impossible to access services. The distribution of services and specialties across different facilities on the second level (which includes patient diagnosis followed by hospitals and specialized centers at all levels) was onerous for citizens, many of whom were compelled to use multiple means of transport to receive services they were accustomed to receive at more accessible locations. In addition, despite multiple waiting areas, registering with the system and the initial examination involved long waits and much red tape.
The major conclusion of the community assessment (which is not a full academic review) is that the marked development of services offered by the new insurance system reflects a degree of seriousness in the implementation of the system, but there remains&nbsp; shortcomings&mdash;namely, the lack of a declared, detailed master plan that includes procedures and frameworks for administration, oversight, information systems, education, and mechanisms for accountability, community participation in monitoring services, and raising citizens awareness of how these instruments work. These issues are basic obstacles that will increasingly affect citizens&rsquo; satisfaction, and if they persist, they will be the biggest threat to their trust in the new system.
<hr>
<a href="#_ednref1" name="_edn1">[i]</a> The percentage of income to be paid was defined by CAPMAS based on income and expenditure reports for 2017/18.
<hr>
References
<ul>
<li>
Egyptian Initiative for Personal Rights. (2018, April). <a style="color: #333333;" href="https://eipr.org/publications/%D8%A7%D9%84%D8%B9%D8%AF%D8%A7%D9%84%D8%A9-%D8%A7%D9%84%D8%A7%D8%AC%D8%AA%D9%85%D8%A7%D8%B9%D9%8A%D8%A9-%D9%88%D8%A7%D9%84%D8%B5%D8%AD%D8%A9-%D9%81%D9%8A-%D9%85%D8%B5%D8%B1-%D8%AA%D9%82%D8%B1%D9%8A%D8%B1-%D8%AD%D8%A7%D9%84%D8%A9">Social justice and health in Egypt</a>. [In Arabic].
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Egyptian Initiative for Personal Rights. (2019, December). <a style="color: #333333;" href="https://eipr.org/publications/%D8%B9%D8%B1%D8%B6-%D9%86%D8%AA%D8%A7%D8%A6%D8%AC-%D8%A7%D9%84%D8%AA%D8%B4%D8%BA%D9%8A%D9%84-%D8%A7%D9%84%D8%AA%D8%AC%D8%B1%D9%8A%D8%A8%D9%8A-%D9%84%D9%85%D9%86%D8%B8%D9%88%D9%85%D8%A9-%D8%A7%D9%84%D8%AA%D8%A3%D9%85%D9%8A%D9%86-%D8%A7%D9%84%D8%B5%D8%AD%D9%8A-%D8%A7%D9%84%D8%B4%D8%A7%D9%85%D9%84-%D8%A8%D9%85%D8%AD%D8%A7%D9%81%D8%B8%D8%A9-%D8%A8%D9%88%D8%B1%D8%B3%D8%B9%D9%8A%D8%AF">Pilot operation of the universal health insurance system in Port Said governorate (transitional community assessment and necessary reforms)</a>. [In Arabic].
</li>
<li style="font-size: 10pt;">
Ghannam, Alaa. (2012, March). <a style="color: #333333;" href="https://eipr.org/blog/%D8%B9%D9%84%D8%A7%D8%A1-%D8%BA%D9%86%D8%A7%D9%85/2012/03/%D9%86%D8%AD%D9%88-%D9%85%D9%86%D8%B8%D9%88%D8%B1-%D8%B4%D8%A7%D9%85%D9%84-%D9%84%D8%A5%D8%B5%D9%84%D8%A7%D8%AD-%D8%A7%D9%84%D9%82%D8%B7%D8%A7%D8%B9-%D8%A7%D9%84%D8%B5%D8%AD%D9%8A-%D9%8A%D9%83%D8%B1%D8%B3-%D9%85%D8%A8%D8%A7%D8%AF%D8%A6-%D8%A7%D9%84%D8%B9%D8%AF%D8%A7%D9%84%D8%A9-%D8%A7%D9%84%D8%A7%D8%AC%D8%AA%D9%85%D8%A7%D8%B9%D9%8A%D8%A9">Toward a comprehensive perspective of health sector reform that cements social justice principle</a><a style="color: #333333;" href="https://eipr.org/blog/%D8%B9%D9%84%D8%A7%D8%A1-%D8%BA%D9%86%D8%A7%D9%85/2012/03/%D9%86%D8%AD%D9%88-%D9%85%D9%86%D8%B8%D9%88%D8%B1-%D8%B4%D8%A7%D9%85%D9%84-%D9%84%D8%A5%D8%B5%D9%84%D8%A7%D8%AD-%D8%A7%D9%84%D9%82%D8%B7%D8%A7%D8%B9-%D8%A7%D9%84%D8%B5%D8%AD%D9%8A-%D9%8A%D9%83%D8%B1%D8%B3-%D9%85%D8%A8%D8%A7%D8%AF%D8%A6-%D8%A7%D9%84%D8%B9%D8%AF%D8%A7%D9%84%D8%A9-%D8%A7%D9%84%D8%A7%D8%AC%D8%AA%D9%85%D8%A7%D8%B9%D9%8A%D8%A9">s</a>. Egyptian Initiative for Personal Rights. [In Arabic].
</li>
<li style="font-size: 10pt;">
Qabeel, May. (2019, November). <a style="color: #333333;" href="https://eipr.org/blog/%D9%85%D9%8A-%D9%82%D8%A7%D8%A8%D9%8A%D9%84/2019/11/%D9%82%D8%B1%D8%A7%D8%A1%D8%A9-%D9%81%D9%8A-%D8%A8%D9%8A%D8%A7%D9%86%D8%A7%D8%AA-%D8%A8%D8%AD%D8%AB-%D8%A7%D9%84%D8%AF%D8%AE%D9%84-%D9%88%D8%A7%D9%84%D8%A5%D9%86%D9%81%D8%A7%D9%82-20172018">Reading income and expenditure data 2017/2018</a>. Egyptian Initiative for Personal Rights. [In Arabic].
</li>
<li style="font-size: 10pt;">
WHO EMRO. (n.d.). Egypt: <a style="color: #333333;" href="https://eipr.org/blog/%D9%85%D9%8A-%D9%82%D8%A7%D8%A8%D9%8A%D9%84/2019/11/%D9%82%D8%B1%D8%A7%D8%A1%D8%A9-%D9%81%D9%8A-%D8%A8%D9%8A%D8%A7%D9%86%D8%A7%D8%AA-%D8%A8%D8%AD%D8%AB-%D8%A7%D9%84%D8%AF%D8%AE%D9%84-%D9%88%D8%A7%D9%84%D8%A5%D9%86%D9%81%D8%A7%D9%82-20172018">Noncommunicable diseases</a>.
</li>
</ul>

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