The Executive Regulations of the Ne

On 11 May 2018, the Official Gazette published the long awaited Executive Regulations (“ER”)[1] of the new Universal Healthcare Insurance Law (the “Law”).[2] The Law, which received both positive and skeptical responses, was issued in January 2018 and created a compulsory insurance system that is mandatory for Egyptians in Egypt and optional for Egyptians living abroad and foreigners living in Egypt. Many had argued over the controversial gaps and questions in the Law and it was hoped that the ER would address some of these controversies.

Background

Amongst the reasons behind the massive impact the Law is expected to have on both the healthcare sector as well as many other sectors is its new approach of separating the insurer from the service provider. This was done in the hopes of creating a more financially sustainable system. The Law also aimed to create a unified system through which all Egyptians can participate – as opposed to the previous system wherein a variety of laws governed providing insurance to certain categories of citizens such as students, breadwinners, children below the age of schooling, farmers and agricultural workers. Whereas previously, the Health Insurance Organization (HIO) was the entity primarily responsible for the provision of health insurance, the new Law dismantles the HIO and its system gradually over a period of up to 15 years and replaces it with three main bodies to address three separated issues: insurance, healthcare provision, and quality control.

 The Law: Contributions and Scope

As mentioned above, subscription to the system is compulsory for all Egyptians. The employed ‘head of the household’ shall pay 1% of his wages to the insurance provider (if his income exceeds the national minimum wage). He is also to pay 3% of his wages for his wife if she is unemployed, and 1% for each of their children. Employers are to pay 4% for their employees. Egyptians living abroad are to pay 5% of their wages should they opt into the system, although their family contribution shall be capped at 7% of the breadwinner’s wage. Pensioners shall pay 2% of their wages, 3% for their wife if she is unemployed, and 1% for every unemployed child. Widows are to pay 2% of their wages. The value of patient contributions for medical services are shown in the below table. The Law also imposed extra taxes on certain products and services (such as cigarettes, tobacco, and renewal of vehicle licenses) and a general fee of 0.025% on revenues to be levied on all businesses. According to the ER, such fees will be collected by the sector’s relevant ministry.

The ER: Scope and Services of the New Insurance System

The ER of the Law begins with various articles reiterating the purposes of the Law, its compulsory nature, and its intended scope of afforded services, outlined above. It also elaborates on the scope of services covered as it defines the three degrees of healthcare as follows: 1) prevention, i.e. first line of defense, 2) diagnosis and treatment, 3) readmission of special cases. Access and allocation of these services shall be further elaborated on through various decrees to be issued by the Board of Directors of the General Authority for Universal Health Insurance (GAUHI) The ER also states that patients may choose whichever doctor/hospital’s services they would like to use, and that if certain conditions are met, insured citizens may seek medical treatment abroad if it is not available in Egypt. Article 14 of the ER states that patients may choose to upgrade service while bearing the cost themselves or having it borne by private insurers. In case of emergencies, patients may use services external to the system and later apply for a refund of their payment. Moreover, the ER provides for the establishment of an electronic database, an accessible and efficient system of payment, and an online website.

The ER: Fees

The Ministry of Health shall collect EGP 1,000 when contracting with a medical clinic licensed to a doctor with an MD in Medicine. This amount increases to EGP 3,000 if the doctor has a PhD acquired three or more years prior to contracting, and EGP 5,000 for doctors who acquired a PhD five years prior to contracting. Centers for physiotherapy, scanning, and labs shall pay a fee of EGP 10,000 upon contracting. Contracting pharmacies shall pay EGP 5,000 for each branch, while pharmaceutical companies wishing to contract shall pay EGP 10,000 to do so.

The ER: Medication and Pharmaceuticals

Article 3 of Chapter One of the ER stipulates that the new plan for the regulation of pharmaceuticals includes the banning of commercial names of medications, but instead will be labelled according to their chemical/scientific names, and will only be accessible to buy by prescription. The ER highlights that pharmacies will be obliged to contract with the new system, and that the existing body of laws pertaining to pharmaceuticals will remain enforceable.

The ER: Elaboration on Role of Authorities 

• The General Authority for Universal Healthcare Insurance (“GAUHI”) is to handle administration and funding of the system, contract with hospitals and bring them into the new system, determine prices of medical services through its own pricing committee, and create a database of the medical records of subscribers to the system, and renew or revoke contracts to hospitals every three years. The ER stipulates that GAUHI is to establish its own internal Investment Board, which is to include investment experts and set investment targets and fully abide by the existing legal framework regulating investment. Furthermore, according to Articles 10-11 of the ER, GAUHI’s Board of Directors shall establish a pricing committee (comprised of 9-15 individuals) which shall determine the pricing of healthcare services and periodically check if prices need updating. GAUHI shall also include a department specialized in economic and actuarial studies.

• The General Healthcare Authority (“GHA”) is comprised of public medical service providers, and introduces a new system whereby families (the unit of measurement used under the new Law, as opposed to the individual under the previous system) shall have a General Practitioner (GP) or ‘family doctor’ which refers them to specialists. This will be assigned depending on the patients’ geographical location. GHA will also undertake regular inspections for employees in high-risk industries. In collaboration with the Ministry of Manpower, GHA will also conduct regular checkups on workers who are vulnerable to certain diseases as well as workplace health and safety inspections. Moreover, Article 3 of Chapter One of the ER provides a special system for students, wherein they are to receive periodical checkups at the start of every educational phase.

• The General Health Accreditation and Supervisory Authority (“GHASA”) is the primary body responsible for quality control. It is to ensure that hospitals contracting with the new system are assessed for a certain standard of quality and to maintain this minimal standard of quality by making random visits to hospitals. GHASA also has the authority to grant and revoke licenses from healthcare providers, but it must notify hospitals within 15 days of a decision. If a decision is taken to revoke a hospital’s license, it shall have six months to improve and be reassessed. GHASA shall compile a detailed guide to quality standards in healthcare by collaborating with the International Society for Quality in Healthcare (ISQua). GHASA shall have a Committee for Dispute Resolution, which must be contacted first before any court becomes involved in a case. The Committee will have to make a decision within three months of taking a case.

The ER: Timelines and Implementation

Issuing Article four of the ER states that the timeline for full implementation of the Law shall not exceed 15 years. The Law had left clarification of the timeline and gradual process of implementation for the ER. The ER also states that GAUHI shall prepare a detailed timeline for action to ensure that full implementation takes place within the Law’s specified time-period (which is divided into six phases, each containing a group of designated governates). The plan is to include alternative options in case there is any hindrance in practice to the original plan. According to the ER, GAUHI shall accomplish this through its collaboration with the Ministry of Social Solidarity and the Ministry of Finance, amongst others. The ER states that the government is to ensure that healthcare services are of a certain quality standard before implementation of the Law in every governate. Different stakeholders are to cooperate to achieve this purpose under the supervision of the Minister of Health. This means that hospitals wishing to contract with the system shall begin incorporating the minimum quality standards before the system is fully applied to their governate. The below graph demonstrates the six different phases and the percentage of the population covered by each phase.

The ER: Those ‘Unable to Pay’ 

Reiterating the Law, the ER states that the Ministry of Social Solidarity shall determine who fits under the category of those ‘unable to pay’, and how they are to be covered under the new system. These databases shall then be provided to the Ministry of Finance so that the contributions are borne by the state’s treasury.

Conclusion

Although the ER of the Law do clarify some of the ambiguities left after the issuance of the Law, some questions still remain regarding the logistics of implementation. One such issue is the question of the implementation of the Law, with regards to its compulsory nature, in Egypt’s informal sector. Moreover, while the ER states that patients may choose the doctor/hospital from whom they wish to receive healthcare services, it is unclear how the system will deal with increased demand on the most sought-after hospitals. Furthermore, while patients have the right to seek medical treatment abroad if it is not available in Egypt, the process outlined in the ER is a lengthy one, which involves the patient providing evidence to a Committee which requires the patient to be present unless proven physically unfit to do so. Will the prices of services vary depending on the quality standards of certain hospitals? How will the Ministry of Social Solidarity determine who can be considered ‘unable to pay’ in a country with a significantly large informal sector? Although the ER does complete many of the Law’s aims in theory, actual application might prove significantly more complicated.   [1] Prime Ministerial Decree No. 909/2018 enacting the Executive Regulations of Law No. 2/2018 on the Universal Healthcare Insurance, Official Gazette, Issue No. 18 (bis) (b), 8 May 2018. [2] Law No. 2/2018 on the Universal Healthcare Insurance, Official Gazette, Issue No. 2 (cont.) (b), 11 January 2018.