Dr Ehab Abul Magd v Chairman of Egyptian

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

The Currant Public Health Insurance System in Egypt Dr. Ehab Abul - Magd

▪ The social health insurance system (HIO) in Egypt has been in existence since 1964 ▪ HIO was the outcome of many legislations started in the early decades of the 20 th century Dr. Ehab Abul - Magd

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 ▪ HIO Hospitals are accredited training centers EFB, ABHS, RCSI & Cairo Faculty of Medicine. Dr. Ehab Abul - Magd by

Challenges Facing HIO Dr. Ehab Abul - Magd

Challenges Facing HIO 1 - Incomplete coverage (population – services - costs) Dr. Ehab Abul - Magd

Challenges Facing HIO 2 - Multiple Laws & Systems Dr. Ehab Abul - Magd

Current Insurance Coverage Laws q Law 32/1975 (Government Employees) q Law 79(1)/1975 (Government & Private Employees) q Law 79(2)/1975 (pensioners) q Prime Minister Decree 1/1981 (Widows) q Prime Minister Decree 10/1981(Beneficiary Family members) q Law 99/1992 (School Students) q Law 23/2012 (Women Headed Households) q Law 86/2012 (Preschool Children) replaced minister decree 380/1997 q Law 127/2014 (Farmers) Dr. Ehab Abul - Magd

Challenges Facing HIO 3 - Unrealistic rates of premium HIO L 23 1% + 200 EGP L 99 L 79(2) L 79(1) L 32 4+ 12 EGP 1% 4% pension T salary 2% B salary L 86 8+ 12 EGP PM 10 2% pension 1% + 0. 5% Dr. Ehab Abul - Magd

Challenges Facing HIO 4 - Low revenue collection rate HIO L 23 L 99 L 79(2) L 79(1) L 32 L 86 PM 10 4% 99% 75% 96% 92% 13% 95% 100% 87% 75% 73. 65% Dr. Ehab Abul - Magd

Challenges Facing HIO 5 - Fund Pooling Fragmentation Dr. Ehab Abul - Magd

Challenges Facing HIO 6 - Voluntary enrolment of some groups(diverse selection) Subsidization Compulsory S. H. I. Dr. Ehab Abul - Magd

Challenges Facing HIO 7 - Opt out strategy (High salaries / Low health risk Group) Dr. Ehab Abul - Magd

Challenges Facing HIO 8 - Unclear Benefit Package (Implicit Benefit Package) Dr. Ehab Abul - Magd

Challenges Facing HIO 9 - Continuous advances in Healthcare Industry (Medicine – Diagnostics – interventions …) Dr. Ehab Abul - Magd

Challenges Facing HIO 10 - Technology & Knowledge Revolution ; a paradigm shift Dr. Ehab Abul - Magd

Challenges Facing HIO 11 - Progressive increase in service utilization by beneficiaries q Economic Status q Unavailable free treatment (MOH – Universities) q More HIO Services Dr. Ehab Abul - Magd

Challenges Facing HIO 12 - Cost of poor quality q. Inefficient Use of Resources q Moral Hazards Dr. Ehab Abul - Magd

Challenges Facing HIO 13 - Fraud Dr. Ehab Abul - Magd

Challenges Facing HIO 14 - Limited Decentralization Dr. Ehab Abul - Magd

Challenges Facing HIO 15 - Unwillingness of young physicians to working in HIO. Dr. Ehab Abul - Magd

Challenges Facing HIO 16 - Working in hospitals is undesirable to nurses. Dr. Ehab Abul - Magd

Challenges Facing HIO 17 - Patients dissatisfaction in some areas (as OPD) Dr. Ehab Abul - Magd

Challenges Facing HIO 18 - Patient can neither choose treating doctor nor treatment facility Dr. Ehab Abul - Magd

Challenges Facing HIO 19 - Extension of Occupational diseases list (financial Burden) 48 29 35 Dr. Ehab Abul - Magd

Challenges Facing HIO 20 - Court Decisions (unregistered medicines – transportation allowance – reimbursement …) Dr. Ehab Abul - Magd

Challenges Facing HIO 21 - Purchaser / Provider Integration. (Passive Vs. Strategic Purchaser) Dr. Ehab Abul - Magd

Challenges Facing HIO 22 - Media Attacking HIO (concentrates on weaknesses and ignoring Strengths. ) Dr. Ehab Abul - Magd

Despite Challenges Renovations Equipment Interferon B DI Stent Cochlear Implants HCV 1 ry PCI Cancer target therapy Dr. Ehab Abul - Magd

How to overcome those Challenges? Dr. Ehab Abul - Magd

Solutions ▪ Purchaser / Provider SPLIT (financial efficiency – better healthcare quality – more accountability – more Responsibility) ▪ Moving from Passive to Strategic purchaser ▪ Unifying the Laws (Single Law) ▪ Compulsory scheme ▪ Subsidization of poor ▪ No opt out Dr. Ehab Abul - Magd

Solutions ▪ Design Benefit Package ▪ Establish an integrated Payer Information Management System (PIMS) ▪ Fund Pooling Defragmentation (large – single – risk mix) ▪ Realistic premiums & contributions (including occupational diseases ▪ Provision of high quality & safe healthcare services Dr. Ehab Abul - Magd

Solutions ▪ Control Fraud, Moral Hazards & Costs of Poor Quality ▪ Decentralization (financial decisions) ▪ Nation-wise salary scale to all healthcare professionals. ▪ Magnification of the role of the GPor Family Physician (Gate Keeper) Dr. Ehab Abul - Magd

Universal Health Coverage (UHC) Dr. Ehab Abul - Magd

Universal Health Coverage (UHC) Definition: • Provide ALL people with access to needed health services (including promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective; • Ensure that the use of these services does not expose the user to financial hardship“ World Health Report 2010, p. 6 Dr. Ehab Abul - Magd

Dimensions of UHC (UHC Cube) Three dimensions to consider when moving towards UHC Source: WHO Dr. Ehab Abul - Magd

Why UHC? “International Key Facts” • All UN member states need to achieve UHC by 2030 as part of SDGs • At least 400 million people lack accessto one or more essential health services. • Every year 100 million people are pushed into poverty, and 150 million people suffer financial catastrophe because of OOP expenditure on health services • World OOPs in year 2014 was 45. 5% (World Bank) Dr. Ehab Abul - Magd

On September 25 th 2015, UN member-states adopted a set of GOALS(17) to: 1. END POVERTY 2. PROTECT the PLANET for ALL 3. ENSURE PROSPERITY Each Goal has specific targets to be achieved over the next 15 years. Dr. Ehab Abul - Magd

Goal 3: Ensure healthy lives and promote well-being for all at all ages Target 3. 8: Achieve UHC Think of UHC as a Direction & not a Destination Dr. Ehab Abul - Magd

Why UHC? “National Key. Facts” • As UN member state, Egypt has to achieve UHC by 2030 as part of SDGs • Egypt has a strong Political Commitment for UHC through SHI (Article 18 in Constitution (2014), White paper) • 25% of population poverty line below • OOPs is 64% of THE (NHA 2018) international

Health Insurance Organization (Main Features) Population Coverage 58. 8% Voluntary / Optout Beneficiari es allocation to specific providers Single Payer Provider Integration (Fragmented) Complete Fiscal Autonomy Limited Cost Sharing Unit of Enrolment: Individual & others Unclear (Implicit) Benefit Package Public Providers Domination Provider Payment system (FFS) Dr. Ehab Abul - Magd

Challenges & UHC Approach Dr. Ehab Abul - Magd

Challenges & UHC Approach Categories: A. Structural / Stewardship B. Resources C. Financial D. Service Delivery Dr. Ehab Abul - Magd

Overcoming those Challenges? Dr. Ehab Abul - Magd

New UHI Law (2018) Main Features: Population Coverage ALL Compulsory No Opt-out Defined Benefit Package Single Payer (Defragme nted) Payer Provider Split Public Private Partnership Complete Fiscal Autonomy Free Choice Providers Unit of Enrolment: Family Provider Payment system (Cap. – CB) More Cost Sharing Dr. Ehab Abul - Magd

Egypt Health System; the Vision • 15 years • 10 years – 100% of • 5 years – • Today – – – Avg. family is 4 people, <2 insured Not meeting expectations Few standards – – – 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 – – 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 – Providers have achieved internationall y-recognized levels of quality – Universal coverage with safety net for the poor sustained Dr. Ehab Abul - Magd

Conclusion • Egypt is committed to attain UHC by 2030 • Transition period of UHChas beendefined • Egypt is not waiting for implementation of the new UHI, but started moving towards UHCto shorten the gap • Early steps has been started to establish HTA (no UHCwithout priority settings, and no priority settingswithout HTA) Dr. Ehab Abul - Magd

• Private health insurance’s role in implementing universal health coverage Dr. Ehab Abul - Magd

Type of financing mechanisms Dr. Ehab Abul - Magd

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

Different Roles that PHI can play under umbrella of UHC v. Private health insurance can support the implementation of universal health coverage through covering the areas in which the BBP of the public insurance is not fully functioning. v. If the UHC does not cover 100% of the population, the PHI can extend the number of insured by offering primary private health insurance. v. To extend the number and quality of services covered by the public health insurance, private health insurance can offer supplementary and complementary services. v. To reduce cost sharing (the co-payment paid to receive a service), private health insurance can cover the co-payments for patients. This is called complementary (user charges) Dr. Ehab Abul - Magd

Potential role of private health insurance (PHI) in different benefit packages Package s Minimu m package Essenti al package II. Equity package Nonreimbu rsed services Public health insurance • Population: all citizens • Restriction: no copayment and list all patients with • waiting Population: insurance • Restrictions: copayment, waiting list, second-line, low quality, no • Population: all patients with choice insurance • Restrictions: coverage only for subgroup, copayment, waiting • list, Population: selected patients second-line with insurance • Restrictions: strict diagnostic criteria, monitoring Source: Zoltan Kalo Private health insurance • Supplementary: Immediate access, better quality • Complementary (user charges): copayment • Complementary (services): Choice • Complementary (services): coverage for patients with no access Dr. Ehab Abul - Magd

Currant situation in Egypt Additional definitions for primary Private Health Insurance • Duplicate PHI: PHI that offers coverage for health services already included under governmental health insurance, while also offering access to different providers (e. g. private hospitals) or levels of service (e. g. faster access to care). It does not exempt individuals from contributing to government health coverage programs. • Substitutive PHI: An alternative to statutory insurance and is available to sections of the population who may be excluded from public cover or who are free to opt out of the public system Dr. Ehab Abul - Magd

Coming new insurance products WHO definitions: • Supplementary services: Offers faster access to service, greater choice of health care provider or enhanced amenities • Complementary services: covers services excluded from the publicly financed benefit package • Complementary user charges: covers user charges for goods or services in the publicly financed benefits package Dr. Ehab Abul - Magd

Potential Role of Private Health Insurance schemes Complementa ry (user charges) Supplementary, & Complementary (services) Primary PHI (if UHC is not 100%) Source: Syreon Research Institute / adapted from WHO Dr. Ehab Abul - Magd

Learnings from other countries Dr. Ehab Abul - Magd

Perspectives of Supp. HI and Comp. HI in Egypt Supplementary and complementary private health insurance can play a significant role in the Egyptian healthcare system based on: 1. 2. 3. Large proportion of out of pocket payments Small proportion of private health insurance expenditures Incomprehensive basic benefit package (even if UHC is implemented) Dr. Ehab Abul - Magd

How to implement the new healthcare system? • Alignment of private health insurance with the development of universal health coverage (UHC) • Objectives of PHI development should be determined by the government 1. Political: satisfaction of different subgroups of Egyptian citizens (and expatriates) 2. Direct financial: provide promising business model for private health insurance companies 3. Indirect financial: reduce the financial pressure on the implementation of UHC • Strategic team of multidisciplinary stakeholders should develop midterm and long-term policy framework to adjust the role of private health insurance to UHC • Special pilot areas (e. g. disease area, special technologies or services, geographical region) may be selected to facilitate alignment on the short run Dr. Ehab Abul - Magd

Thank you