Cablegate: The Mysteries of Egypt's Health Care Reform

DE RUEHEG #2320/01 3511559
P 171559Z DEC 09

C O N F I D E N T I A L SECTION 01 OF 02 CAIRO 002320



E.O. 12958: DECL: 12/16/2019


Classified By: Minister-Counselor for Economic and Political Affairs Donald A. Blome for Reason 1.4 (b)
1.Key Points --The Ministry of Health (MoH) is spearheading a series of national health care reform programs, including connecting private clinics and hospitals to public heath care programs, upgrading the infrastructure at health care facilities, improving medical training, and most importantly, expanding health insurance for poor Egyptians. --Two years into implementing a pilot program that incorporates these programs in the Delta governorate of Suez, progress is difficult to measure yet MoH still plans to introduce similar programs to the Upper Egypt governorate Sohag in 2010 and Alexandria in 2011. --Egyptian government (GoE) officials intend to introduce legislation to expand government-provided health insurance to 25 million of Egypt's poorest citizens in the next Parliament session. --(C) The GoE has neither explained how it will fund its programs nor offered any evaluation of the effectiveness or demand for its new programs. Opposition critics have begun mounting protests and legal challenges aimed at these and other aspects of the proposed reforms. -------------------- New Reform Structure -------------------- 2.(SBU) The centerpiece of MoH's reform policies is a new national health insurance bill, designed to meet President Mubarak's 2005 call for universal health care. The culmination of nearly 15 years of MoH health care planning, the legislation's main goal is to provide insurance for Egyptians without any form of coverage. Approximately 54% of the population is currently covered by the Health Insurance Organization (HIO), the GoE's government insurance provider, with most of those individuals government employees. Under the new legislation, MoH estimates 85-90% of the population would receive coverage in the next 10-15 years; 25 million individuals without any insurance (approximately 30% of the population and identified as among the country,s poorest citizens) will be brought in the new system via financial support from the government.

3.(SBU) While the expansion of coverage is the Ministry's primary goal, it is also seeking to overhaul other elements of its health care services. MoH seeks to enroll primary health care plan participants in a family health model, which essentially would allow them to pay family rather than individual rates. Decentralization is another key goal: state-owned hospitals would become independent entities, operating loosely under MoH direction instead of following strict management and economic direction. ---------------------- Out of Pocket Concerns ----------------------

4.(SBU) The GoE hopes that these improvements will lower the out-of-pocket health costs borne overwhelmingly by its poor and uninsured. Currently 62% of all health care spending is paid by individuals. The Ministry of Finance (MoF) projects that without reform, this figure will rise to above 70% in the next decade. ---------------------- Ground Zero for Reform ----------------------

5.(C) Even though it has yet to introduce health reform legislation in Parliament, MoH has used Suez governorate as the testing ground over the last two years for its reform programs. MoH chose Suez due to its close proximity to Cairo, stable employment, and low poverty levels. Health Minister Hatem El-Gabaly has failed to disclose any results - ranging from increase in insurance enrollment to improvement in primary health care. Despite this, MoH intends to extend its new system to Sohag next year and to Alexandria in 2011. According to Dr. Alaa Hamed, senior health specialist at the World Bank, Sohag was selected as the next governorate because MoH needed to prove it could operate in a more "difficult environment" and not just bring services to more "prosperous areas." Sohag, one of the poorest governorates, has both high unemployment and poor insurance coverage. CAIRO 00002320 002 OF 002 Hamed said both Sohag and Alexandria were selected for "political reasons" as the GoE looks towards elections in 2010 and 2011. ----------------------- Looming Challenge Ahead -----------------------

6.(C) What ultimately may determine the success of health care reform is program financing. Other than estimating in an October speech that MoH would require LE 7-17 billion (USD 1.3 to 3.15 billion) to provide medical care Egyptians can "look forward to," El-Gabaly has ceded responsibility on the issue to the Ministry of Finance (MoF). Dr. Mohammed Maait, Deputy Finance Minister for Social Insurance, told Econoff that MoF has not identified a funding source for MoH's reforms. Maait further explained MoF is considering several options ) including increasing taxes on employee salaries (and concurrently lowering the amount employers pay into the health insurance system) and raising the cigarette tax potentially as much as fivefold. Maait mused that shisha ) a popular flavored tobacco smoked in water pipes in cafes across the country ) is not taxed but quickly noted that this was not currently an option. While it is unclear which if any of these proposals will be included in the health care bill, Maait emphasized that the GoE plans to address these questions in the current Parliament session.

7.(SBU) Sporadic protests against the proposed legislation have already begun in Cairo. On December 6, a 500 person demonstration at Parliament demanded that Speaker Fathi Sorour oppose the law. On the same day, El Badri Forgharty, the head of a loosely organized group of pensioners, complained to several newspapers that MoH was planning to "privatize" health care. On December 10th, the State Council - one of Egypt's highest judicial bodies responsible for reviewing legislation - returned the bill to the government with multiple objections, explaining that the law failed to explain what new health care services Egyptian would receive and what costs they would have to bear.

8.(C) Comment: Since launching what El-Gabaly has labeled the "Suez Model," there is no mechanism to evaluate the overall effectiveness of the reforms. More importantly, MoH has repeatedly failed to discuss whether or not the services it is offering match the health needs of Suez,s citizens. Questions over how these reforms programs will be financed and sustained, coupled with the difficulty in convincing an increasingly skeptical public, have failed to deter MoH from continuing plans to expand the new system in two more governorates and eventually to the rest of the country. NDP political pressure, notably from Gamal Mubarak (Ref A) - labeled the "driving force" in the NDP on health care reform by a member of the Party's Policy Committee - continues to drive the new legislation presumably, in hopes of bolstering the party's slim record of accomplishment as 2010 elections approach. Scobey

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