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There is no doubt that a more effective health insurance system capable of providing citizens with high-quality treatment at their outlet of choice is much needed now. Only 37 million Egyptians actually benefit from healthcare and health insurance. According to Decree 637 issued by Prime Minister Ahmed Nazif in 2007, a holding company is to be established to bring all 40 health insurance hospitals, 600 clinics and around 5,000 health units under its umbrella as part of the government's plan to develop the health insurance sector.

The new and controversial universal social health insurance law is supposed to enhance coverage for all, with the rich shouldering a large part of the financing, while the government covers the treatment of the poorest, who constitute 16 million people, by allocating LE60 million of its budget. The legislation, whose broad features were drawn up by the international company McKenzie Insurance Agency, separates financial, managerial and auditing tasks so that they no longer hinder the bodies charged with providing healthcare service. It also specifies providing additional funds over and above the premiums paid by the beneficiaries of health insurance.

The new draft, to be presented to the People's Assembly for discussion next month, annuls any other insurance system and all Egyptians are to be obligatory insured. The bill will annul Law 10/1967 which deals with medicine provided by the Health Insurance Organisation (HIO), Law 32/1975 regarding the insurance system of state employees, and Law 99/1992 on the health insurance of school students.

Marian Ragheb, administrative prosecutor and a member of the legislative committee of the National Council for Women (NCW), opposes the draft, saying it was created for the sole purpose of "taking money from people's pockets." More than 90 per cent of private, public companies and associations, as well as syndicates have their own health insurance systems. Under the new regulations citizens will have to pay up to 25 per cent of the cost of medical treatment and up to 30 per cent of the cost of prescriptions. According to Ragheb, the current insurance systems do not cost the government any extra money and at the same time provide good health insurance system to their employees. "So why, then, deprive them of this privilege and force citizens to join a system forcing them to pay extra money in return for a lesser health service?" asked Ragheb.

Said Rateb, head of the HIO, said the aim was to improve the standard of service provided to the public, "which is why we are creating a separate government entity to oversee the administration of health insurance. It also aims at ensuring that government funds reach the people who really need support while letting those who can pay for services to do so." The poorest, who form nearly 20 per cent of the country's population, Rateb stated, would be exempted from charges, and hospitals would continue to treat those in critical condition regardless.

The draft will first be tested in the governorate of Suez, to be followed by Sohag and Alexandria until gradually generalising the new system to all of Egypt's 29 governorates over eight years.

Secretary-General of the Pharmacists' Syndicate Mahmoud Abdel-Maqsoud told Al-Ahram Weekly that syndicate members were strongly opposed to the changes. The new law, Abdel-Maqsoud argues, places tremendous power in the hands of the new insurance entity which will allow it to favour certain drug manufacturers over others and drive up the price of drugs. The law, he said, "marginalises a large percentage of the population, especially the unemployed, and could easily lead to a two-tier system of insurance: one for those who can pay and another for those who can't."

In addition, the new insurance entity will have the right to invite other companies to help it administer and provide services, especially account work. "Who will pay for these private companies to do their job? It will be paid from the fund which collects people's subscriptions. The bottom line is that the citizen will pay for the cost of these private companies. Why doesn't the government assign any governmental company to do the job?" asked Abdel-Maqsoud.

In response, Abdel-Rahman Shahin, official spokesman of the Ministry of Health, said all multinational companies in the country resort to private bureaus to do their accounting. "This will allay people's concerns that their money is being spent in the right way. This is to guarantee transparency with the people," Shahin said.

Minister of Health Hatem El-Gabali announced several times in the media that the new universal social health insurance will be implemented gradually starting this year. The bill has been presented to several political parties for debate.

Mohamed Hassan Khalil, consultant cardiologist at Nasr City Health Insurance Hospital and a vocal opponent of the decree, argued that it was the first step towards privatising the health sector. "The decree has transformed a non-profit- based service into a profit seeking one. It stripped the HIO of all its assets and transferred them to a profit-oriented holding company which has the right to sell these assets. The next step is the current draft law."

Khalil pointed to "a number of detrimental aspects in the law." It attempts to impose different service packages with different premiums which will move the basis of health provision to "people's means rather than their needs." It also gives the prime minister and minister of health the prerogative to change the contractual relationship between the HIO and its clients when this should be the subject of a clear and regulated legal process. The new law also fixes patients' contributions as a percentage of service fees at a level beyond the reach of a majority of the population.

Both the government and its opponents agree that the health system has deteriorated to such an extent that a radical overhaul is now essential. What separates them is the direction the needed reforms should take. According to Shahin, in order to guarantee the continuity of the service, financial funds for the system must be secured. "The whole system will collapse if it is not funded properly. The government cannot do the whole job; people who will enjoy the services of the new system must pay their share, too."

Abdel-Moneim Ebeid, an anesthesiologist at Cairo University and a member of the Specialised National Council (SNC), previously raised a crucial point: that according to the new system, poor patients who cannot afford to fully pay for either health services or medicine, will find themselves obliged to pay one-third of the medicinal cost, one-third of the cost of an operation if needed, and one-third of medical examination fees.

In response to Ebeid's fears, Shahin said the draft will ensure equality value, which means providing excellent services which require quality levels for all people without taking into consideration their social class or income. He said the draft stipulated that the Ministry of Social Solidarity will be responsible for paying monthly subscriptions on behalf of the 16 million people who live under the poverty line. The ministry will also help people who started paying their subscription but stopped because they were no longer able to pay.

Ebeid has also claimed the system would cover only what is called the basic benefit package. Surgeries such as open heart, and liver and kidney transplants are not included in the package. Shahin denies Ebeid's claims saying that the new draft will cover not only the basic health requirements but also all kinds of surgeries. "All types of cancer including medication and surgeries will be covered by the new health system. Liver and kidney transplants will be covered by the National Liver Programme (NLP)," Shahin said. The only remaining challenge is open heart surgeries whose cost is tremendously high. Shahin said health officials are still discussing the issue but would shortly come up with a "convenient solution".

Because all government and private clinics and hospitals will be included in the new system, they will compete to attract patients. "The final result is a better health service provided to citizens. Any private clinic or hospital which is not willing to join the system will face bankruptcy in the end. Who will go to a private hospital or clinic and pay a lot of money whereas he can enjoy the same service for lesser amount of money?" Shahin asked.

The spokesman said each individual who subscribes to the new health system will have a family doctor, mainly a general practitioner. "The GP will have the authority to refer the patient to a specialist of the patient's own choice," Shahin added. In case of operations, according to the new health system, a patient will have the right to select the hospital in which he wants to undergo the operation and to be placed in a double bedroom. "But if a woman asks for an epidural during delivery she will be charged for it," Shahin stated while maintaining that pensioners are to pay one-third of the cost of the medicine and any healthcare service a maximum of LE200, while employees and other subscribers are to pay a third of the cost without any maximum limit.

"The aim is to provide broader and better healthcare for the public. By having these fees and splitting the service and management aspects, we can achieve this. It's that simple," Shahin said. "People want real service, one that can meet their needs, and this is what we are providing here, for the first time in quite a while," he said, adding that the government knows very well that there are people who cannot afford the new fees and who must be exempted. "I see no need to scare people."

Counsellor Ragaa El-Arabi, head of the Shura Council's Legislative and Constitutional Affairs Committee and former state prosecutor-general, said any health body which will not properly provide its services to patients will be fined from LE1,000 to LE5,000 and the entity will be shut down. "Regarding private clinics and hospitals, inefficiency could mean being crossed out of the health insurance system altogether," stated El-Arabi.