Egypt is embarking on a new universal health insurance (UHI) system to cover all Egyptians by 2032, in line with the UHI law (Ahram Online, 2019).<a href="#_edn1" name="_ednref1">[i]</a>The implementation of the first phase started in Port Said in 2019 with gradual geographic expansion to follow (Mathauer et al., 2019). When fully implemented, the system is expected to ensure quality health services and adequate levels of financial protection for all. UHI is a compulsory system based on social solidarity, where those who cannot afford contributions will be exempted, based on a decree issued by the prime minister to regulate exemptions (UHI law, Article 2). The family is the main insurance coverage unit within the new system, in contrast to the existing system,<a href="#_edn2" name="_ednref2">[ii]</a>which provides uncoordinated, separate coverage to each family member, leaving some uninsured (Nassar &amp; El-Saharty, 2010).
Coverage of the informal sector has been one of the challenges facing the current health insurance scheme and previous attempts to expand insurance coverage. The current system, operated and administered by the Health Insurance Organization (HIO), the main public insurer, is highly fragmented, making it difficult to ensure equity, quality of health services and financial protection. Moreover, the system does not cover informal workers, irregular workers, the unemployed, and out-of-school children (Nassar &amp; El-Saharty, 2010). The new UHI is thus a major step in expanding coverage to include vulnerable groups and to leaving no one behind.
<h3>The informal economy, informal sector, and informal employment in Egypt</h3>
The term &ldquo;informal economy&rdquo; refers to all economic activities by workers and economic units (i.e. informal firms, households) that are not covered or are insufficiently covered by formal arrangements in law or practice. It comprises two components: all workers in the informal sector and workers in informal employment outside the informal sector. The informal sector refers to a set of household activities that do not maintain a complete set of accounts and/or are not registered under national legislation. They produce goods or services for sale in the market, even if partly, and are not constituted as separate legal bodies independent of their owners. Employees are considered informal workers when their employment relationship is not subject to income taxation, national labor legislation, social protection, or entitlement to certain employment benefits (OECD/ILO, 2019).
The World Bank has estimated that 55% of workers aged 15&ndash;64 in Egypt are informally employed, of whom one in five are irregularly employed and have intermittent or occasional work (2014). International Labor Organization statistics of 2018 show that informal employment represents 63.3% of Egypt's total employment (2018). The size of the informal economy is estimated at EGP4 trillion, equivalent to about 60% of GDP according to a study conducted by the Federation of Egyptian Industries in 2018 (Sobhy, 2019). Efforts have been made by the government to facilitate integrating informal workers and economic units into the formal economy. This would not only provide social protection for them, but also ensure health benefits and coverage (Sobhy, 2019). Attempts to consolidate the size of informal employment in Egypt included launching an electronic registration system, by the Ministry of Manpower, for irregular employment not registered on its labor force database.<a href="#_edn3" name="_ednref3">[iii]</a> This could facilitate their identification, inclusion, and enrollment in the UHI system (Ghannam, 2019).
Social insurance for informal workers
The new Social Insurance Law 148/2019<a href="#_edn4" name="_ednref4">[iv]</a>extended social insurance protection to new groups of employees and unified all the&nbsp; previous social insurance laws. Although it requires official registration for coverage, the new law offers insurance to some groups of informal workers such as those temporarily employed in farming, animal husbandry, and land reclamation, as well as small self-employed workers like street vendors, newspaper distributors, domestic workers, and similar groups, but it excludes many others.
<h3>Informal employees in the UHI law</h3>
Under the UHI law, all Egyptians have the right to coverage, obtained by directly registering in the system using their national ID according to their geographical location. In practice, however, workers in the informal sector are likely to face challenges. Some workers in this group will be able to pay and others might not be. While the UHI law provides exemptions for those who cannot pay, informality makes it difficult to accurately determine eligibility for exemptions. Certain groups in the informal sector might be at risk of exclusion if they are not eligible for exemption and are obliged to pay the mandatory contributions.
In August 2019, the Prime Minister issued Decree 1948/2019<a href="#_edn5" name="_ednref5">[v]</a>defining categories of people exempted from contributing payments to the new UHI system and setting forth the criteria for exemption. The decree enumerated general criteria for evaluating the ability to pay, such as the average consumption of electricity, real estate owned by the person or household, and any direct or indirect income, but there was no specific mention of informal workers within the exempted categories.
The UHI law provides for two ways of collecting contributions for enrollment and coverage (UHI law, Article 41):
<ol>
<li style="text-align: justify;"> For informal workers subject to the social insurance and pension laws: The National Authority for Social Insurance (NOSI) is responsible for collecting their contributions or covering them.</li>
<li style="text-align: justify;"> For informal workers who are not subject to social insurance laws: This includes all informal workers not under the social insurance law umbrella. The informal worker or household can pay its contribution on bi-annual basis to the Universal Health Insurance Organization (UHIO), which manages prepaid funds and purchases health services on behalf of the insured population (UHI law, Article 4). In this case, the head of the household pays for himself and his family members without a fixed income. In other cases, worker cooperatives, such as in agriculture, collect health insurance contributions from insured workers and their dependents in quarterly installments and submit them to the UHIO.</li>
</ol>
<h3 style="text-align: justify;">While expanding coverage to the informal sector, it is important to consider:</h3>
<ul>
<li style="text-align: justify;">A plan to avoid risk of exclusion: Contributions for the new UHI scheme will be deducted from individuals&rsquo; total income, unlike the current system which deducts contributions from the basic salary.<a href="#_edn6" name="_ednref6">[vi]</a> In terms of affordability, heads of households who pay contributions for themselves and their families will end up paying a significant amount of their total income, and several population groups in the informal sector who are not eligible for exemption will be obliged to pay to the system (Mathauer et al., 2019). This puts them at risk of exclusion and inability to register in the UHI, especially low-income workers who work occasionally and are considered temporarily unemployed.</li>
<li style="text-align: justify;">Possibility of transition from the formal to the informal sector: Evidence has shown that social health insurance schemes focus on formal-sector workers because it is more feasible to enforce compliance through salary deductions (Okungu et al., 2018). Consequently, experiences from developing countries have shown that health insurance schemes that subsidize services may prompt formal workers to switch to informal employment, where it is difficult to estimate the actual income, to avoid the mandatory contributions (Bitran, 2014). It is therefore important to identify an acceptable mechanism that would encourage prepayment for health care among this population group.</li>
<li style="text-align: justify;">Administrative challenges: Administrative costs are often overlooked despite being an important spending category in total health insurance expenditure. Looking at variations between countries, one of the context factors with an upward effect on administrative costs is a large informal sector (WHO, 2010). Due to the significant size of the informal sector in Egypt, the insurance system is likely to face administrative difficulties in assessing incomes and incurring costs associated with collecting contributions (Okungu et al., 2018). It is thus important to ensure that the system has the capacity to address the administrative challenges, that might lead, under certain conditions, to inefficiencies in revenue collection (Carrin&nbsp;&amp; James, 2005). If these challenges are capacity related, addressing them requires a sufficiently skilled labor force. Based on lessons from other countries, related markets such as other health insurance businesses and financial services could be a source for appropriately trained personnel. They could also be involved in the capacity building and training of UHI staff (Bitran, 2014).</li>
</ul>
In conclusion, further efforts are required to address barriers and challenges on two fronts: coverage of the informal sector and on-the-ground implementation of the UHI system. Information gleaned from the first phase of implementation should inform a comprehensive vision for the incorporation and coverage of the informal sector; in particular, working conditions in the informal sector, current access to health services, and financial barriers merit study. This should be in parallel to the government's plans and strategies to encourage formalizing the informal sector. Additionally, it is necessary to provide a variety of health care options that are not conditional on employment status during the transition period to full UHI, especially since the old and new systems will exist in parallel for as long as 13 years (Mathauer, 2019). 
<hr>
<a href="#_ednref1" name="_edn1">[i]</a> Law 2/2018 on universal health insurance, published in the Official Gazette on January 11, 2018. <a href="#_ednref2" name="_edn2">[ii]</a> For more information on the existing health insurance scheme, see <a href="http://www.hio.gov.eg/">www.hio.gov.eg</a>. <a href="#_ednref3" name="_edn3">[iii]</a> More information on the database: Ministry of Manpower <a href="http://www.manpower.gov.eg/">www.manpower.gov.eg</a> <a href="#_ednref4" name="_edn4">[iv]</a> Published in the Official Gazette on August 22, 2019, the law came into effect in January 2020. <a href="#_ednref5" name="_edn5">[v]</a> Published in the Official Gazette in August 25, 2019. <a href="#_ednref6" name="_edn6">[vi]</a> For example if a household's basic income is EGP1,000 and its total income is EGP2,000, contributions to the existing HIO health insurance scheme are deducted from the LE1,000; in contrast, under the new UHI system, contributions will be deducted from the entire EGP2,000, which will make a substantial difference to many households.
<hr>
References
<ul>
<li style="font-size: 10pt;">
Ahram Online. (2019, September 1).<a style="color: #333333;" href="http://english.ahram.org.eg/NewsContent/1/64/344918/Egypt/Politics-/Egypts-new-health-insurance-system-launched-in-Por.aspx"> Egypt's new health insurance system launched in Port Said.</a> Ahram Online.
</li>
<li style="font-size: 10pt;">
Bitran, R. (2014). Universal health coverage and the challenge of informal employment: Lessons from developing countries (HNP discussion paper). International Bank for Reconstruction and Development/World Bank.
</li>
<li style="font-size: 10pt;">
Carrin, G.&nbsp;&amp; James, C. (2005). Social health insurance: Key factors affecting the transition towards universal coverage.&nbsp;International Social Security Review&nbsp;58(1), 45&ndash;64.
</li>
<li style="font-size: 10pt;">
Ghannam, A. (2019, May 24). <a style="color: #333333;" href="https://www.shorouknews.com/columns/view.aspx?cdate=24052019&amp;id=963a69a8-6316-4515-9349-b919117425d6">Insurance health protection and irregular employment</a> (al-Himaya al-Sihhiya al-Ta&rsquo;miniya wa-l-&lsquo;Amala Ghayr al-Muntazima). Shorouk News. [In Arabic].
</li>
<li style="font-size: 10pt;">
International Labor Organization. (2018). <a style="color: #333333;" href="https://www.ilo.org/global/publications/books/WCMS_626831/lang--en/index.htm">Women and men in the informal economy: A statistical picture (third edition)</a>.
</li>
<li style="font-size: 10pt;">
Mathauer, I.,&nbsp;Khalifa, A.Y.,&nbsp;&amp;&nbsp;Mataria, A.&nbsp;(&lrm;2019)&lrm;.&nbsp;Implementing the universal health insurance law of Egypt: What are the key issues on strategic purchasing and its governance arrangements?&nbsp;World Health Organization.&nbsp;
</li>
<li style="font-size: 10pt;">
Nassar, H. &amp; El-Saharty, S. (2010). Evidence from the past: Egypt. In A. Preker, P. Zweifel, &amp; O. Schellekens (Eds.), Global marketplace for private health insurance: Strength in numbers (pp. 163&ndash;188). World Bank.
</li>
<li style="font-size: 10pt;">
Organization for Economic Cooperation and Development/International Labor Organization. (2019).&nbsp;<a style="color: #333333;" href="https://doi.org/10.1787/939b7bcd-en.">Tackling vulnerability in the informal economy</a>. Development Center Studies.&nbsp;
</li>
<li style="font-size: 10pt;">
Okungu, V., Chuma, J., Mulupi, S.&nbsp;et al.&nbsp;(2018). <a style="color: #333333;" href="https://doi.org/10.1186/s12913-017-2805-z">Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy.</a>&nbsp;BMC Health Serv Res&nbsp;18(13).
</li>
<li style="font-size: 10pt;">
Sobhy, M. (2019, August 22). <a style="color: #333333;" href="https://www.youm7.com/story/2019/8/22/%D9%83%D9%85-%D8%AA%D8%A8%D9%84%D8%BA-%D9%82%D9%8A%D9%85%D8%A9-%D8%A7%D9%84%D8%A7%D9%82%D8%AA%D8%B5%D8%A7%D8%AF-%D8%BA%D9%8A%D8%B1-%D8%A7%D9%84%D8%B1%D8%B3%D9%85%D9%89-4-%D8%AA%D8%B1%D9%8A%D9%84%D9%8A%D9%88%D9%86-%D8%AC%D9%86%D9%8A%D9%87-%D8%AD%D8%AC%D9%85/4383639">How much is the value of the informal economy?</a> (Kam Tablugh Qimat al-Iqtisad Ghayr al-Rasmi?). Youm7. [In Arabic].
</li>
<li style="font-size: 10pt;">
World Bank. (2014). <a style="color: #333333;" href="https://www.worldbank.org/content/dam/Worldbank/Feature%20Story/mena/Egypt/Egypt-Doc/egy-jobs-issue-brief-2-ENG-ARA.pdf">Informal is the new normal</a> (Egypt World Bank Issues Brief No. 2).
</li>
<li style="font-size: 10pt;">
World Health Organization. (2010). <a style="color: #333333;" href="https://www.who.int/health_financing/documents/dp_e_10_08-admin_cost_hi.pdf">Administrative costs of health insurance schemes: Exploring the reasons for their variability</a> (Discussion Paper No. 8).
</li>
</ul>

آراء

Commentaries

الوصول إلى الرعاية الصحية والتغطية

Read Also