Impact of Social Health Insurance on Challenges Facing Egyptian Health Sector and Healthcare System Performance

This article discusses the impact of social health insurance on the challenges facing the Egyptian health sector and healthcare system performance. It covers the history of health insurance in Egypt, the new comprehensive health insurance system, and the challenges faced by the healthcare system in Egypt.

The Impact of Social Health Insurance (SHI) system on the relationship between
Challenges Facing Egyptian Health Sector and Healthcare System Performance
1. Introduction
1.1 Background
Public health occupies an important place in assessing the state’s commitment to human
rights standards. The state’s health status is assessed according to the number of citizens
who receive appropriate treatment for free under the umbrella of health insurance, the level
of medical services provided and treatment paid for free, as well as the general health level
of citizens. The state is often obligated to cover all the health costs that the citizen needs in
order to receive appropriate care to enable him to enjoy his right to belonging to the country,
as well as the capacity of productivity, which in turn raises the status of in a decent life in a
way that positively affects his patriotism or the state economically.
The health care system in Egypt is characterized by a multiplicity and complexity that brings
together service providers and funders from the public and private sectors. The government
has committed to providing health care to the poor; However, with an inherently pluralistic
system, healthcare providers compete, and clients are free to choose services based on their
needs along with the ability to pay (WHO-EMRO, 2006).
The beginning of social health insurance in Egypt as the main system for providing health
care services goes back to 1964, as many legislations were issued primarily for the workforce
of workers and employees and the work environment and concerned with work injuries and
compensation, and some models for sick care (El-Adawy et al., 1997).
The first health insurance document was issued in the world in Germany in 1883 (Federal
Ministry of Health, 2020). As for the Arab world, the first document written in Arabic to
ensure medical treatment appeared in 1957 in Egypt between “the United Insurance
Company” and Bank of Alexandria, and another document was issued in the same year
between the Egypt Company Insurance and “Asustander Petroleum Services Company” (El-
Adawy et al., 1997).
In recent years, the state has submitted several drafts for a new health insurance law that
has passed two cycles, the first (1997 to 2002) and the second (2006 to 2010) the first phase
has developed a model for health insurance as part of an experimental framework to
separate the service from its delivery units, and family health units have been established,
which are 400 units in three The pilot governorates, which are Alexandria, Menoufia, and
Sohag, and they managed a financial insurance fund for family health. The second phase of
the reform was from 2006 to 2010. Conferences were held to discuss reform plans and start
a new pilot experience, but it failed (Haley and Beg, 2012; WHO-EMRO, 2006).

After the January 25, 2011 revolution, Egypt began dramatic measures to improve the
country's various systems, including the Social health insurance system. Several published
reports identified the challenges facing the health system to achieve the Ministry of Health
and Population's goal of improving the health of all citizens (MOHP, 2015).
Those actions were end by the launching of the comprehensive health insurance system
which includes an integrated package of diagnostic and therapeutic services, and allows the
beneficiary to choose health service providers. It also reduces the personal spending of
citizens on health services, reduces poverty resulting from illness, and this new system
contributes to setting prices. Medical services in a fair manner, and allow patients to access
these services without additional procedures. The new social health insurance system will
be applied in six phases over a period of 15 years (Almasry Alyoum,2019).
In July 2019, President Abdel Fattah El-Sisi launched the actual start signal for the
implementation of the largest national health project in Egypt, the "New Health Insurance
Law", from Port Said Governorate, marking the establishment of the foundations of an
integrated health system that includes one hundred million Egyptians according to the latest
international standards, in a historic event. He has flirted with the aspirations and dreams of
Egyptians over the past long decades.
The health insurance system is a giant project launched by the Egyptian government in order
to improve the medical service and provide it to Egyptians without discrimination, in
implementation of the directives of President Abdel Fattah El-Sisi, as it represents a social
solidarity system, through which high-quality medical services are provided to all groups of
society without discrimination, and the state guarantees treatment in it that is not Those
who are able, through an integrated package of diagnostic and therapeutic services, and
allows the beneficiary the freedom to choose the health service provider. The cost of the new
health insurance bill is between 80 and 120 billion pounds, and it will be applied within 15
years in all governorates, starting from 2019.Participation in the comprehensive health
insurance law is compulsory for all Egyptians, as it brings together all groups of society
under one insurance umbrella, and all forms of health insurance, whether governmental or
private, are canceled, and also the treatment system ends at the expense of the state with its
application in every governorate.
The most important features of the law are that every citizen has a special file with the family
doctor on which his medical history is written, and that he does not treat individuals but is
responsible for treating the entire family, and that the patient’s contributions to patients
’contributions in surgical operations are 5%, with a maximum of 300 pounds, and medicines,
x-rays, and analyzes. 10%. In addition, each health unit provides medical services to 20,000
patients, and private hospitals are contracted after obtaining the accreditation and quality
certificate, after the pricing of the health services that they will purchase from the private

sector is set. The role of the Ministry of Health depends on ambulance services and
preventive medicine after the implementation of the new health insurance law.
Moreover, The Ministry of Health revealed that more than 527,132 of Port Said citizens have
registered in the new system since the start of registration last July through 29 units and a
family health center, in addition to more than 3,234 major surgeries and 611 surgeries that
were performed for the first time in the governorate. And the health insurance system
announced the completion of waiting lists for pediatric heart surgeries in Port Said
Governorate, which are the surgeries that were performed by the hospital’s pediatric heart
surgery team, free of charge.
In October 2019, the Ministry of Health announced the start of the first preparations for
launching the health insurance system in the remaining governorates of the first phase of the
system, including: Ismailia, Suez, South Sinai, Luxor and Aswan.
The door for registration and the family file was opened since the first of October, after the
actual operation began in Port Said. During this period, the system succeeded in registering
486,873 citizens and opening 120,210 family files in each of Ismailia: (207,267 citizens),
Suez (48,344 citizens), Luxor (127088 citizens), Aswan (92,277 citizens) and South Sinai
(11897 citizens). And that is through more than 117 units and family health centers in the
five governorates.
Healthcare System Performance in Egypt
Egyptian Healthcare System is not positioned to deliver high-quality health services to meet
the most pressing needs of its population. Although more than 95% of the population lives
within 5 km of a health facility, facilities are often ill-equipped to respond to the real needs
of the population in their catchment areas, grim conditions at dilapidated state-run facilities,
regular medication stock-outs due to outdated and inefficient supply chains, lack of updated
and enforced clinical guidelines for managing chronic diseases and limited numbers of
specialists have been widely reported. As such, quality of care is often poor, leading to low
utilization and reduced health benefits.
The Egyptian health system faces multiple challenges affecting its performance in improving
and ensuring the health and well-being of the Egyptian people resulted in declined quality of
healthcare services due to serious budget shortage, lack of medicines at medical facilities,
and low salaries of healthcare workers.
Despite MOH in Egypt took many positive steps towards improving the health sector
performance, there are still many negative issues requiring actions to improve the
performance of healthcare system. Rise in non-communicable diseases (NCDs) and a high
birth rate combined with a longer life expectancy is putting additional pressure on the
system and expected to increase healthcare costs.

Most healthcare jobs are low paid and provide no incentive for performance. Medical
providers receive life-time licensing with no continuous medical education (CME)
requirements. Dual practice is allowed with no restrictions by law and therefore rampant.
Also, Egypt is one of the lowest healthcare spenders in the Middle East and North Africa
(MENA) region and more than half of the total health expenditure (THE) is out-of-pocket
(OOP). In addition to low health spending, systemic inefficiencies and inequities in health
financing limit the effectiveness of the healthcare system.
First, it is necessary to mention some important indicators that illustrate the extent of the
deterioration of the health care system performance in Egypt. World Bank data show that
the infant mortality rate was very high in 2009, while it tends to slowly decline until it
reached 17.3 in 2019, which is still high as well. It also shows that Egypt was and still suffers
from a shortage of hospital beds, which include inpatient beds available in the public and
private sectors, public and specialized hospitals, and rehabilitation centers, as shown in
Figure 3 and Figure 4.
Figure 3: Egypt infant mortality rate
Source: By author using WB Data
0
5
10
15
20
25
30
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
25.1 24.1 23.1 22.2 21.4 20.6 19.9 19.2 18.5 17.9 17.3
infant mortality rate (in deaths per 1000 live births) in
Egypt

Figure 4: Hospital beds in Egypt
Source: By author using WB Data
Despite the deterioration of the health care system in Egypt, the death rate per 1,000 people
annually has decreased dramatically since the seventies, reaching 5.8 in 2018, as shown in
Figure 5.
Figure 5: Death rate in Egypt (per 1,000 people)
Source: By author using WB Data
2.1 2.1 2.1 2.17 2.17 2.2 2.2 2.1 2.08
1.73 1.73
0.52 0.52 0.52
1.56 1.56 1.43 1.43
0
0.5
1
1.5
2
2.5
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Hospital beds (per 1000 people)
15.96
14.19
12.1
10.16
8.43
7.25 6.54 6.34 6.21 5.97 5.81
0
2
4
6
8
10
12
14
16
18
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2018
death rate

Furthermore, with regard to insurance coverage to protect citizens from catastrophic health
expenditures, the Health Insurance Organization (HIO) provides compulsory health
insurance for workers in the formal sector. It was established to cover the entire population,
and so far, coverage has been expanded to include three groups: government employees,
public and private sector employees, and widows and retirees. A separate program, the
Student Health Insurance Program (SHIP), covers school children. Since its inception, SHI's
coverage has increased through HIO to cover more than half of the population as shown in
figure 6, HIOs are financed mainly through the installment system and co-payments for the
services provided, in addition to transfers from the Ministry of Finance (MoF).
Figure 6: Share of population covered by SHI
Source: By author using data from HIO Annual reports and CAPMAS 2017
Although nearly 60 percent of Egyptians are covered by the SHI program, the system
continues to be funded primarily out of pocket (Figure 7). According to health care financing
theory, health expenditures are defined as all expenditures for prevention, reinforcement,
rehabilitation, care, population activities, nutrition, and emergency programs to improve
health. In the last round of the NHA published in Egypt (NHA, 2011), the rate of spending on
health in Egypt increased from 7.5 billion Egyptian pounds (Egyptian pounds) in 1994/1995
to 61.4 billion Egyptian pounds in 2008/2009, with the growth of health spending per capita
as well. During this period from 127 EGP to 800 EGP (Figure 8). The per capita income
continued its upward trend over the years, reaching 1,273 EGP in 2014.
10%
37%
45%
51%
57% 58%
0%
10%
20%
30%
40%
50%
60%
70%
1990 1995 2000 2004 2010 2017
Share of pop. Covered by SHI

Figure 7: Share of payment in THE
Source: by author using data from Egypt NHA and WB Data
In addition, according to the WB database Egypt invests a smaller proportion of GDP on
health care, as shown in Figure 9, also The WHO Global Health Expenditure Database (GHED)
shows that as a percentage of GDP, THE in 2018 was 4.95 per cent in Egypt.
Figure 8: Total Health Expenditure Per Capita (EGP)
Source: by author using data from Egypt NHA and WB Data
0%
20%
40%
60%
80%
100%
120%
1995 2002 2008 2009 2011 2014
Share of payment sources in Total Health Expenditure
% OOP Payments % Gov. Spending % Other
127
346
566
820
1273
0
200
400
600
800
1000
1200
1400
1994/95 2001/02 2007/08 2011 2014

Figure 9: Health care spending % of GDP
Source: by author using data from Egypt WB Data
Another ongoing crisis the Egyptian health sector is facing is the sharp decline in the number
of healthcare professionals. Financial problems have been cited as a reason for many
healthcare workers resigning and moving abroad. As per MOH, 67% of Egyptian doctors
work overseas. Figure (10) shows the density of skilled healthcare professionals (physicians,
dentists, pharmacists, and nurses) in Egypt per 10,000 population which was 22.5 in 2014
out of them, as per The Economist, only 11 doctors per 10,000 which became lesser in 2018
to reach only 5 doctors per 10,000 population.
Figure (11) shows the density of skilled healthcare professionals per 10,000 population
distributed per WHO regions.
5.4 5.5 5.2 4.9 4.9 4.8 4.4 4.5 4.4 4.2 4.4 4.7 4.9 5.0 5.3 5.4 5.6
4.9
0
1
2
3
4
5
6
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020

Figure 10: Skilled Health Professionals Density (Per 10,000 Population)
Source: by author using data from WHO

Figure (11): Skilled Healthcare Professionals Density (Per 10,000 Population)
Source: by author using data from WHO
A study prepared by the Supreme Council of Universities and the Technical Office of the
Egyptian Ministry of Health in mid-2019 found that out of 213,000 registered physicians in
Egypt, only around 82,000 – just 38% - are still in the workforce. Many doctors blame the
government for not adhering to the provisions of the 2014 Egyptian Constitution that bind
the state to spend 3% of its annual GDP on healthcare.
After reviewing some important points about the health care system in Egypt, it appears that
there is many data and information about it but the social health insurance system and
especially the new one still need further study to be conducted about it. Therefore, this study
tackles to fit this gab by examining the impact of Social Health Insurance (SHI) system
implementation on the relationship between challenges of Egyptian health sector reform
and healthcare performance moderated by governmental decisions.
Social Health Insurance Policy Network in Egypt
Health insurance policies are deemed one of the main pillars of the society and an essential
basis for its stability and satisfaction, especially, as the development and prosperity of a
society cannot be achieved independently of an effective system of health care. Therefore,
52.82
12.79
82.59
25.71
115.34
25.19
65.34
SKILLED HEALTH PROFESSIONALS DENSITY
(PER 10,000 POPULATION)
Global Africa Americas

these policies received considerable attention from both the state and those who are
concerned with health issues.
Since the mid-1990s and after the deterioration of health services, there have been frequent
attempts to reform the health system in Egypt, especially with the support of donor entities
and the emergence of a number of new actors such as international organizations, the private
sector and civil society organizations working in the health sector.
The mutual influence enabled these actors – by working together within a network of social
health insurance policies – to have a prominent role in the policymaking process. Although
Law No. 2 of 2018 on comprehensive health insurance has been enacted and put into effect,
scant studies examined the lawmaking and the impact of policy networks on its
development. The available studies, however, focused on health insurance policies with
regard to public satisfaction, outsourcing, funding, restructuring, etc. To fill this gap in
research, this study attempts to investigate the impact of policy networks on the making of
comprehensive health insurance law in Egypt.
1.2 Research problem
The key role of the new SHI is to provide medical services of high quality for all segments of
society without discrimination. Aims to reduce poverty and disease and focuses on the
provision of full medical protection for all members of the family in exchange for payment of
contributions. The current SHI system can get more advantages from the accumulation of
previous reforms of improving health system in Egypt, increasing surveillance, and reducing
communicable disease incidence (WHO 2010).
However, due to Egypt's lower middle-income status, the overall health of its population is
relatively poor compared to other lower middle-income countries. Moreover, despite some
improvements, the burden of non-communicable diseases has increased, adding to the
pressure on the health system in Egypt, which has undoubtedly led to the clarity of the
importance of having a system to achieve universal health care (Roberts et al. 2013).
A question that remains of paramount importance in a majority of the world’s countries is
how the health systems can provide sufficient healthy protection from epidemics and
diseases to all of the population without any burden of costs of healthcare and also without
discrimination between them (Ileana et al., 2020).
Therefore, the study will shed the light on how assessing the new social health insurance
program through four main pillars:
1. Pros and cons of implementing the new social health insurance program.
2. The concerns facing the implementation process.
3. The primary results of implementing the new social health insurance program.

4. Emergence and evolution of the concept of social health insurance policy network in
Egypt and its impact on the stages of health insurance policymaking.
Research Questions
This work aims to address the following research problem:
I. What is the current situation concerning healthcare system in Egypt?
II. What are the basic features of social health insurance and how it will
contribute in solving the problem?
III. What are the main challenges and opportunities associated with the
implementation of the new social health insurance system in Egypt?
IV. What are the main processes of implementing a high-quality universal SHI in
developing countries?
V. How did the policy network affect the stages of health insurance
policymaking in Egypt?
VI. What are the most important recommendations through which we can
benefit from these networks in the development of the health sector?
Research aims and Objectives
The main objective of this study is to evaluate the impact of the implementation of Social
Health Insurance (SHI) system on the relationship between challenges of Egyptian health
sector reform and healthcare performance moderated by governmental decisions.
This paper includes a description about the characteristics of the new Egyptian social health
insurance system, the pillars underpinning it and the main obstacles which hamper its
implementation and how to overcome it to achieve a better progress towards sustainable
development for Egypt and the developing countries as well. This document will also
present, in addition to the SWOT analysis for the Egyptian social health insurance system,
detailed instructions for measuring its performance and an annex including its different
initiatives.

2. Theoretical Framework
2.1 Research Variables
Health System: All activities and structures that determine or influence health in a
given society. This includes social, environmental, and economic determinants of
health.
Healthcare System: Combined functioning of public health and personal
healthcare services that are under the direct control of identifiable agents especially
ministries of health.
Healthcare System Performance (DV): The efficiency and equitability of the
professional public health and personal healthcare services within a system,
including a cost-benefit analysis measured by Infant Mortality Rate (IMR), Hospital
Beds per Population, Healthcare Spending % of GDP, Share of Payment sources in
Total Health Expenditure (THE), and others.
Challenges of Health sector Reform (IV): Identifying the major obstacles facing
the reform program which negatively affect the healthcare system performance
(inadequate expenditure on health, inefficient management of health system at the
strategic level, catastrophic health expenditure, shortage in basic public services,
and shortage in resources in health facilities).
Social Health Insurance (IIV): Social Health Insurance (SHI) is one of the possible
organizational mechanisms for raising and pooling funds to finance health services
along with tax financing, private health insurance, community insurance, and
others. The impact of these funding schemes will be explored using primary data by
questionnaire through conducting interviews with healthcare providers, publics,
and policy makers.
Government Policies and Decisions (MV): How the government rules will
hopefully better guide decisions to implement, regulate, and finance the new
system. The moderating impact of these policies and decisions will be explored
through two roles:
1. Financing Role: issued in Law No. 2/2018 Promulgating The Law on The
Comprehensive Health Insurance Schemes.

2. Implementation and Regulation Role: by interviewing healthcare providers
and publics in order to explore to what extent these policies and decisions
reflected on healthcare system performance.
Policy Network: A set of relatively stable relationships, which are of non-
hierarchical and interdependent nature linking a variety of actors (Government,
Private Sector, Civil Society Organizations, and International Organizations).
2.2 Literature Review
Based on different studies, the Social Health Insurance system is one of the
significant new systems that should be addressed when studying the health care
system at any country. Therefore, there are many studies that tackle the SHI from
different perspectives.
Eriangga et al. (2019) used EBSCO's Medline, Embase, Econlit, CINAHL Plus via
EBSCO, and Web of Science and grey literature databases to search for
observational studies conducted between July 2010 and September 2016. They
focused on the role of Public health insurance to accomplish a number of desirable
goals, including expanding access to healthcare facilities, lowering the possibility
of catastrophic healthcare costs, and optimizing health outcomes. The findings
showed that health insurance schemes in low- and middle-income countries
(LMICs) have been found to improve access to health care as measured by
increased utilization of health care facilities. There also appeared to be a favorable
effect on financial protection, although several studies indicated otherwise. There
is moderate evidence that health insurance schemes improve the health of the
insured.
World Bank (2015) illustrated a roadmap to achieve social justice in the Egyptian
health care system by prioritizing areas related to service delivery, financial
protection and quality of care. The goal is to assist the Egyptian government in
achieving the principle of social justice in providing health care. In doing so, the
roadmap aims to prioritize Egypt's main focus areas, including a description of
current programs that must continue to be supported and new programs that must

be considered for development, all within an integrated and interconnected
structure. This was done in four different stages: objectives, challenges,
recommendations and the Implementation arrangements.
Multiples group (2015) issued a report which aims to provide an overview of the
healthcare sector in Egypt in addition to highlighting the current investment
potential in this sector. The report analyzes the market and the participation of
various stakeholders. It also identifies the drivers of supply and demand in the
sector, the future investment plans of the Egyptian government in this sector, by
doing a SWOT Analysis for the Egyptian health care investments, and the set of
relevant current regulations and laws. Finally, the report provides
recommendations for investment in the health sector.
El Rabbat & Bossert (2020) analyzed the Health sector reform and the family
health model introduced in 1999 to strengthen the existing primary health care
(PHC) service delivery system in Egypt. The study showed that FHM revised the
basic package of integrated services in primary health care facilities, including
Rural Family Health Units (FHUs), which serve clustering areas with fewer than
20,000 residents, and Urban Family Health Centers (FHCs), which serve the biggest
cities of Egypt. The model was initially piloted in three governorates, and as of
2008, it had been implemented in 26 governorates. In 2009, preparations for
further expansion were on the way to cover 4,591 healthcare units and centers
across Egypt. The results showed that while the original primary health care model
included only basic primary health care services, the Ministry of Public Health
expanded its services to include family planning, maternal and child health, the
expanded program of immunization (EPI), and the integrated management of
childhood illness (IMCI). This new approach focused on: strengthening the
physical infrastructure, raising the capacity of employees in new service areas and
improving the quality of services.
Al Bahnasy et. al (2016) evaluate the effectiveness and the efficiency of the
Egyptian Health Sector Reform Program in achieving universal coverage for all

citizens with high-quality basic health services. In 1997, Egypt's government
initiated the Health Sector Reform Program. The family health model is introduced
as a reform concept, with the aim of ensuring equal care for all people with a basic
set of health services. The study used a simple random sampling of 10 family health
units was chosen from a total of 220 units in the Menoufia Governorate for the
analysis. Each chosen unit was subjected to data collection and review in the areas
of facilities, inventory control, quality metrics, referral scheme, coverage, and
usage, as well as a satisfaction survey conducted to a sample of patients and
providers.
The findings of the study showed that the coverage rate of the Family Health Fund
was 83% for the insured, 86% for the uninsured, and 77% for the exemption. The
active enrollment rate was 44% for the insured, 60% for the uninsured, and 14%
for those exempts. The average visit to the benefit of the population is 1.1 visits per
year. The percentage of different therapeutic use visits out of the total treatment
visits was 47% for the insured, 49% for the uninsured, and 4% for the exemption.
There was a low use of medical tools. Overall patient satisfaction was 66%, and
only 11% of service providers were satisfied with their salaries. The percentage of
final evaluation of all aspects of quality indicators according to the Egyptian
Accreditation Program is 55%. The average total cost of a visit is 33 pounds, and
the average return per visit is 6 pounds.
Elden et. al (2016) the goal of the study is to improve the health system in Egypt
through utilizing information derived from the perspectives of the health service
providers towards the health system. An exploratory study of health system
research was conducted in Cairo governorate. An appropriate sample of 225
physicians working in the Ministry of Health and private facilities was included.
The results showed that more than half of physicians agree that there are shortages
in the health system resources: (70.6%), (53.7%) and (25%) in private, secondary
health care (SHC) and primary health care (PHC), respectively, P=0.04. (71.2%)
and (49.7%) say there is bias in human recruitment and no clear job description,
respectively, with no significant difference by place of work. Moreover, about

(66.2%) and (57.6%) of all participants physicians, respectively, say that there is
neither supervision for their performance nor records with performance
indicators. Subsequently, (58.9%) of the physicians see that the health status of the
Egyptian is: “unaccepted”.
They concluded that the health care system continues to face multiple challenges
in improving the health status of all Egyptians. There is a shortage of healthcare
resources, at different levels of care. Doctors are of the opinion that the
organizational structure and system management still need to be reformed.
Equally improving the distribution and quality of human resources. Doctors were
aware of the problems with the system. For this, their views must guide
policymakers to devise effective strategies to improve the health system.
World Bank & the Global Financing Facility (2019) examined first, the merits and
demerits of SHI to finance health systems in LICs and MICs when compared with
other coverage schemes; second the likely challenges for a country that tries to
move forward with SHI; and third potential solutions. The analysis showed that
even if countries reach nearly universal coverage, compulsory insurers manage a
relatively small share of national health financing. This could be a matter of
concern for governments that have been hoping to increase revenues through
health insurance. Insurance returns tend to be lower than expected due to the
smaller formal sector, lower contribution payments, contribution evasion, and
lower enrollment rates. High expenditures resulting from high utilization of
service, provider demand for unnecessary care, generous benefits, and high
administrative costs further jeopardize the financial position of these schemes. In
addition, precisely defined benefit packages, insufficient consumer information,
inadequate quality of care, and belittling behaviors of service providers are all
pitfalls that contribute to lower usage rates and higher out-of-pocket payments
among covered individuals.
The paper found that apart from equity and labor market distortions resulting
from enrollment and contribution payments, these pitfalls affect all coverage

schemes and also argues that SHI performs better in countries with a strong
government commitment to financing universal coverage and increasing
government effectiveness.
Jacobs &Goddard (2000) investigated the role of social health insurance in four
European countries: Germany, Switzerland, France and the Netherlands. It tries to
clarify the organizational structure, organization and management of social
insurance plans, as well as the relationships between insurance companies, service
providers and consumers in different countries with the aim of uncovering some
of the strengths, weaknesses and inherent trade-offs that exist within social
insurance systems. They concluded that most of the countries surveyed face a
similar set of urgent problems. Growth in demand, due to population aging,
improvements in medical technology and real income growth outstrips the supply
of healthcare. Healthcare systems do not have sufficient incentives for patients or
service providers to curb excessive use. There is general dissatisfaction with
current approaches to financing and healthcare delivery and there is no quick
solution to the challenges.
Myint et. al (2018) explored the knowledge, perceptions, willingness to pay, and
preferences of potential health insurance beneficiaries about health insurance in
Myanmar. The study used a Cross sectional survey data were collected among two‐
samples: the general population and Social Security Scheme (SSS) member. Mann‐
Whitney U test and independent sample t test were applied to compare the two
samples. The data on willingness to pay for health insurance were analyzed using
regression analysis.
The results showed that low level of knowledge and weak positive perception are
found in both samples. More than 90% of the SSS sample and 75% of the general
sample are willing to pay health insurance premiums. The largest shares of both
samples are willing to pay for monthly premiums between 2000 and 4000 MMK
(1.8 3.6 USD). Health‐ status, age, gender, income, and trust are significantly
associated with willingness to pay for health insurance among general sample

while occupation, civil status, income, and positive perception on prepayment
principle are found among SSS sample. The study concluded that the government
of Myanmar should be aware of the preferences of beneficiaries to pay a relatively
low level of monthly health insurance premiums without co payment.‐
Grun &Ayala (2008) conducted an evaluation of the impact of different
interventions within the framework of the reform, focusing on the service delivery
component. The evaluation examined the impact of HSRP on targeting those in
need; Primary health care coverage and utilization, quality of service, and maternal
and child health. It also compared the costs and benefits of the interventions and
the lessons learned in order to advance the policy. The study used both
quantitative and qualitative analysis, the econometric methods combined the
different data sources into two generic panel data sets: 1- a quarterly, revolving
panel at the facility level, and 2- a two-year full panel at the district level. The first
data set mainly feeds on outcome indicators from the Ministry of Health (MOH) s‟
Monitoring & Evaluation data from 2002 to 2005, and the second one on the
Demographic and Health Survey (DHS) panel 2000-2005. The study proposed
some important suggestions, which include: 1) human resource development
should be expanded to include recruitment mechanisms, 2) oversight of care
quality can be strengthened locally by empowering citizens, 3) co-payments can
support the shift toward primary care - if carefully designed, and 4) no impact of
the HSRP on antenatal and natal care calls for a rethinking of the focus of outreach
activities.
Fink et. al (2013) explored the random timing of insurance offering resulting from
the stochastic design of the tiered wedge array to assess the well-being and health
impact of an insurance program. From 2004 to 2006, a Community Health
Insurance (CHI) system was launched in Nona Region, Burkina Faso, with the aim
of improving access to health services and population health. The findings of the
study showed that insurance had limited effects on average personal spending in
target areas, but significantly reduced the likelihood of catastrophic health
spending. The introduction of the insurance system had no effect on the health

outcomes of children and youth, but it appears to have increased the mortality rate
among individuals 65 years and over. The negative health impacts of the program
appear to be primarily driven by negative provider incentives resulting from the
system and the resulting decline in the quality of care received by patients.
Cheng et. al (2015) investigated the effects of the New China Cooperative Medical
Scheme (NCMS) on health outcomes and healthcare expenditures for elderly
people in rural China, using panel data from 2005 and 2008 waves from the China
Health Longevity Survey. The results showed that NCMS significantly improved the
elderly's activities in daily life and cognitive function but did not lead to an
improvement in self-assessed general health status. The study found no significant
effect of NCMS on the mortality rate of previously uninsured seniors in NCMS
counties, although there is moderate evidence that it is associated with a lower
mortality rate for the elderly. The study also find that elderly participants are more
likely to receive appropriate medical services when sick, providing a good
explanation for the beneficial health effects of NCMS. However, there is no evidence
that the National Center for Immigration Management has reduced its personal
spending. Moreover, the study also find that lower-income seniors benefit the most
from NCMS participation in terms of health outcomes and perceived access to
healthcare, indicating that NCMS helps reduce health inequalities among rural
seniors.
Abrokwah et al. (2014) examined how Ghana's social health insurance program
impacts the use of antenatal care and out-of-pocket expenses, using a two-part
model for antenatal care expenditures modeling. We are testing whether social
health insurance in Ghana improved the use of antenatal care, reduced out-of-
pocket expenditures, and increased the number of antenatal care visits. District-
level differences in implementation timing provide external variation in health
insurance access, and thus a strong identification. Those with access to social
health insurance have a higher likelihood of receiving care, more antenatal care
visits, and fewer out-of-pocket expenses conditional on spending on care.

Babiarz (2010) examined whether the New China Rural Cooperative Medical Scheme
(NCMS), which aims to provide health insurance to 800 million rural citizens and correct
distortions in rural primary care, individual policy features have affected the operation
and use of village health clinics. The study used variance analysis using multivariate linear
regression, control of clinical and individual characteristics in addition to village and year
effects, and collected data from 100 villages in 25 rural provinces across five Chinese
provinces in 2004 and 2007. Participants 160 village primary care clinics and 8339
Individuals.
The study found that for village clinics, the National Center for Physiotherapy was
associated with a 26% increase in weekly patient flow and a 29% increase in monthly
gross income, but the annual net income or percentage of monthly income from drug
revenues was unchanged. For individuals, participation in NCMS was associated with a 5%
increase in village clinic use, but no change in Medicare overall use. Out-of-pocket medical
spending decreased by 19% and the measure of financial risk exposure decreased by 24-
63%. These changes occurred across heterogeneous district programs, even in those with
minimal feature packages. They concluded that NCMS provides some financial risk
protection to individuals in rural China and has partially corrected the distortions in
Chinese rural healthcare (reducing the over-supply of specialized services and
prescription drugs). However, the scheme may have also transferred new unpaid
responsibilities to village clinics. Given the renewed interest among Chinese policymakers
in promoting primary care, the impact of NCMS deserves greater attention.
Gotsadze et. al (2015) evaluated the impact of the new health financing reform in Georgia-
'medical insurance for the poor (MIP)'-which uses private insurance companies and
delivers state-subsidized health benefits to the poorest groups of the Georgian population.
The study used a difference-in-difference method and collected data from two nationally
representative Health Utilization and Expenditure Surveys (2007 and 2010). The results
showed The MIP medical insurance program was not found to have a significant impact
on the growth of service use nationwide, but in the capital, MIP insureds were 12% more
likely to use formal health services and 7.6% more likely to use hospitals compared to
other regions of the country. The effect of the health insurance program on personal health
expenditures was greater in reducing the costs of accessing services. The cost reductions
were significant and most pronounced among the poorest people. Finally, MIP

significantly increased the odds of obtaining free benefits by insured individuals compared
to the control group. This increase was most noticeable for the poorest third of the
population.
The study concluded that Marginal changes in access to services and the geographically
diverse influence of the health insurance program on service use refer to other factors that
influence the health seeking behavior of the insured. These other factors include the
behavior of the private insurance company that may have used strategies to reduce claims
and manage usage. The equity impact of the health insurance program and the
improvement of financial protection, especially for the poor, are benefits that government
policies must preserve when UHC is universalized nationwide and all citizens will be
covered. The role of private insurers as financial intermediaries for the publicly funded
program needs to be further evaluated before moving forward.
Piroozi et al (2016) published a study in the International Journal of Health Policy and
Management aimed to explore the behavior of catastrophic health expenditure (CHE) after
the implementation of health sector evolution plan which has been implemented in 2014
in order to achieve universal health coverage in Iran. The study concluded that the
implementation of recent reforms has reduced catastrophic health expenditure at the
household level and that having supplemental insurance would result in more financial
protection for the household. Since using rehabilitation, dental, and inpatient services
increase the possibility of facing catastrophic health expenditures, therefore, households
should try to use preventive services more in order to need expensive services less in the
future.
In 2005, the International Labor Organization (ILO) studied the impact of social health
protection on access to healthcare, health expenditure, and impoverishment in South
Africa. The results of the study revealed that social health protection can help to reduce
health-related impoverishment. However, existing forms of social health protection are far
from being perfect. This confirms the importance of political strategies, which set
priorities in extending coverage of schemes to the poor. Further, in order to avoid
devastating financial consequences of healthcare costs, it will be necessary to revisit with
stakeholder’s national social health protection policies and strive for covering the poor
against catastrophic healthcare costs.

It has been documented that government health financing plays a vital role in protecting
households from financial catastrophe. In a study of 59 countries, Xu et al. (2007) found a
negative correlation between the extent of catastrophic expenditure and the size of public
health spending. In addition, reducing reliance on OOP payments in financing healthcare
also contributes to the protection of households from financial catastrophe resulting from
illness. Xu et al. identified three preconditions for catastrophic health expenditure:
expensive healthcare, poor population, and the lack or failure of health insurance to cover
health expenses.
2.3 Conceptual Framework
2.4 Research Hypotheses
H1: There is a significant positive relatively strong relationship between challenges
facing the Egyptian health sector and the need to implement social health insurance
system.
H2: There is a significant positive strong impact of health insurance scheme on
improving access to healthcare and efficient healthcare facility utilization.
H3: the higher the challenges facing the Egyptian health sector, the lower the
performance of the healthcare system.
Challenges of
Health Sector
Reform
SHI
Implementa
tion
Performance of
Healthcare
System
Government
Policies and
Decisions
+
H1
+
H2
-
H3
+
H4
+
H5

H4: There is a significant positive strong intervening impact of SHI on the relationship
between challenges facing Egyptian health sector and the performance of the
healthcare system.
H5: There is a significant positive strong moderating impact of government decisions
on the relationship between SHI implementation and healthcare system performance.
3. Planned research methodology
The study adopts both qualitative and quantitative approaches as the research basically examines
some important indicators for healthcare system performance in Egypt. Also, it will explore
attitudes and experiences of target population about healthcare system performance and their
expectations for the role of social health insurance system in achieving high quality, low-cost
healthcare services for all the Egyptian society. The study is cross-sectional survey study that
includes collection of data of both primary and secondary sources.
▪ Healthcare System Performance: using secondary data gathered from World Bank reports,
Health Insurance Organization reports, and National Health Accounts reports.
▪ Social Health Insurance System: using primary data gathered by questionnaire from
healthcare providers (public and private), Public, and Policy Makers to explore their
experience about healthcare performance and also their expectations about the new social
health insurance system.
Data Collection: The research will use survey using self-administered questionnaire through
unstructured interviews, amil survey, and online survey. The questionnaire will contain questions
that delineate information about the social health insurance system components
▪ Management of Resources in health facilities and hospitals.
▪ Pros and cons of the new system.
▪ Main challenges facing the implementation of the new system.
▪ Effect of social health insurance services on the community regarding health status.
Then, the data will be transferred to the Statistical Package of Social Science (SPSS). Simple
statistical methods were used.
The study also uses a descriptive analysis for the main principles of social health insurance system
implementation in Egypt and its weakness and strengths points and its threats and opportunity by
using SWOT analysis.
4. Research Limitation
The study is applied to the Egyptian healthcare system and how its performance will be
affected by the implementation of the new social health insurance system in the way that
allows overcoming the health sector challenges specially those affecting efficiency,
equity, and equitability of the Egyptian healthcare system.

The study population consists of service recipients (patients and beneficiaries) and
service providers (doctors, nursing, technicians, etc.) as well as policy makers (Ministry
of Health, the General Authority for Health Care and the General Authority for Health
Insurance), so the sample will include representative numbers for each respondent from
the study community until The sample is well representative of the community, so that
the researcher can generalize these results to other governorates.
The sample will be given priority for the governorates in which the new comprehensive
health insurance system has already been implemented, such as: Port Said, Ismailia,
Luxor and South Sinai. The sample will also include other governorates to be a
representative sample, which will include: Cairo, Alexandria, Beheira, Damietta and
Assuit with two hospitals from the governmental sector and another two from the private
sector in each governorate.
The total number of the sample will be about 350 respondents divided into: 180 for
service recipients, 150 for service providers and 20 for policy makers.
The respondents are described in terms of the following variables such as: Name, Age,
Gender, marital status, employment status and health status.
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