Risks and Challenges in Financing, Delivery and Utilization of Primary Health Care Services Under Egypt's Universal Health Insurance System (UHIS)

Background: In social and national health insurance systems, personalized primary health care services are often funded through strategic purchasing arrangements, typically financed from taxes rather than insurance premiums. This ensures equitable access to care for the entire population. These services are integral to the overall health system, focusing on personalized care that addresses individual health needs.

Other components of comprehensive primary care—such as population-based public health services, health intelligence, and enabling functions—should be supported by the Ministry of Health (MOH) through tax-based funding. However, Egypt's implementation of the Universal Health Insurance System (UHIS) deviates from this model, presenting several key risks that could potentially lower primary care service utilization rates negatively impacting Egypt's public health indicators.

Key Risks facing the financing, delivery and utilization of primary care services under Egypt’s UHIS

1. The Risk of Exclusion of Selective Preventive Services from the Package: The UHIS law excluded two key essential primary care services from the UHIS package, namely immunization and family planning. This resulted in partially fragmenting the financing and delivery of the package of primary care services. Understandably, the reason to do that was to preserve the long-term achievements of committing the government to allocate budgets for the procurement of vaccines and family planning methods. This was a request demanded for many years by developmental organizations to sustain the delivery of immunization and family planning services. Apparently, the utilization of immunization services during the implementation in phase I governorates of the UHIS seems to not have been affected. This is probably due to having a separate service delivery structure in primary health care units supported by well-trained and experienced MOHP nurses. However, anecdotal reporting from the Ministry of Health and Population (MOHP) at governorate level indicates early signs of lower utilization of family planning services. Budgets for the procurement of family planning methods are preserved under the control of MOHP, however, as primary care services are delivered by primary care physicians by EHA, the responsibility for the delivery of family planning services in primary health care units becomes unclear since EHA is not paid to deliver these services under the capitation system being used to pay for their services.  

2. The Risk of non-adherence to Primary Care Protocols: For decades, primary health care physicians and nurses under the MOHP have been trained and monitored to faithfully deliver primary health care services nationwide adhering to WHO guidelines, technically supported and closely monitored by organizations in the field such as UNICEF, UNFPA and notably funded by USAID covering gaps in financing primary health care. In doing so, the MOHP has gained and accumulated considerable experience in the delivery of primary health care services. With the transition of the delivery of these services to the public provider, EHA, in phase I governorates of the UHIS, we cannot observe the same level of support provided to primary care physicians under the UHIS. The primary care concepts from the MOHP don’t seem to be integrated into the delivery of primary care services by the public provider, EHA, and the future private providers under the UHIS. Without building the necessary technical capacities of primary care providers and monitoring their performance, the delivery of primary care services risks becoming narrowly focused on treatment of sickness, rather than prevention of disease and wellness services. With the transition to the UHIS, the following should be expected by the key UHIS organizations:

• A Stewardship Role by MOHP to Develop Capacity and Monitor Performance. The MOHP, the stewardship lead agency, is expected to assume a new role to provide technical support, capacity development for public and private providers as well as to ensure adherence to following protocols for delivery of primary care services. The MOHP will need to monitor the performance of providers and monitor the achievements gained in public health indicators to ensure they are preserved.
• Accreditation of Quality of Delivery of Primary Care Services by GAHAR. With the emergence of new organizations such as the General Authority for Healthcare Accreditation & Regulation (GAHAR), it is expected that a new role should be identified to go beyond accrediting service providers for structural quality to accredit them for knowledge and following of protocols for diagnosis and treatment of primary care services.  
• A Change in the Mindset of UHIA Officials in the Manner Primary Care Services are Purchased. A key distinction between Egypt's old Health Insurance Organization (HIO) system and the current UHIS is the approach to financing and delivering primary care. Under the HIO system, primary care was not included in the insurance package and instead was the responsibility of the MOHP, which provided primary care services nationwide. The transition to the UHIS, which aims to include primary care in the insurance package, faced the challenge of the lack of understanding among Universal Health Insurance Authority (UHIA) officials (many of whom come from insurance backgrounds) of the importance of delivering primary care services in accordance with WHO guidelines. This requires a transformational change in the mindset of UHIA staff to prepare them for a role they are not familiar with to achieve health status goals that they are not usually trained to achieve. In addition, strategic purchasing practices for primary care services will need to move to a more efficient system incentivizing providers to better delivery primary care services and pay based on provider performance.

3. The Risk of Inadequate Budgeting for Primary Care under the UHIS: The budget for personalized primary care services, which was historically managed by the MOHP and funded through taxes, remains under the control of MOHP for primary care services provided in phase I governorates. This budget should have been transferred to the UHIA as part of the UHIS financing package. However, this critical point was overlooked in the UHIS law, leaving the MOH in control of funds for services that are now under the UHIA’s mandate in the first phase of implementation across six governorates. As a result, the UHIA will increasingly rely on insurance premiums to fund these primary care services. This reliance may lead to higher premiums or additional earmarked taxes, pushing informal sector workers to avoid enrollment in the UHIS. In turn, this could increase informality and exacerbate underutilization, as individuals may feel they are being "double-charged" for the same services through taxes and premiums.

Recommendations to Maintain and Improve the Financing, Delivery and Utilization of Primary Health Care Services

1. Study the Current Pattern of Utilization of Primary Care Services under the UHIS: Conduct a comprehensive study on primary care service utilization in phase I of UHIS governorates, including maternal, child, NCDs and other primary care services. This analysis should be compared to ongoing utilization of similar services in comparable non-UHIS governorates in order to assess if difference in utilization exists.
2. Establish a Monitoring System for Measuring Periodically the Performance of Primary Care Services: To better understand primary care service utilization, it is essential to monitor not only the overall number of visits per capita but also to disaggregate data by service type. Key metrics include the rate of visits for maternal care, child care, non-communicable diseases (NCDs) and others as relevant. Family planning should be added once the delivery of this service is included under the UHIA. Utilization should also be tracked by gender, urban-rural divide, type (formal vs. informal sector), income level, and governorate.
3. Ensure that the UHIA Provider Payment System is based on Incentivizing Performance. Payments to providers based on simple capitation need to shift to blended capitation mixing capitation with fee for services for selected services, while payments are paid based on the performance of providers to ensure utilization and referral of services don’t fall below targeted levels. Selected remote and underserved geographic areas should be rewarded by an incentive paying an additional percentage to serve in these areas. Incentives for maintaining quality apart from volume should also be considered.  
4. Define the Primary Care Services Package and ensure it includes family planning services: Amend the UHIS law to explicitly reintegrate preventive services, such as immunization and family planning. The package of primary care services should be clearly and explicitly defined to understand its content and delivered in line with WHO's primary health care requirements as part of the UHIS package.
5. Define the Role of Quality Accreditation and Monitoring of Primary Care Services and Capacity Development: Define the role of both the MOHP and GAHAR in monitoring the implementation of protocols of primary care services, and that accreditation standards ensure that providers have the knowledge and capacity of these protocols. This should avoid any overlap or duplication of efforts between both organizations. Additionally, healthcare providers should be trained to deliver personalized primary care services according to WHO guidelines, with the MOH and/or GAHAR playing a crucial role in this capacity-building effort. Who will be taking the lead in capacity development of service providers, public and private, and how this will be financed should be clear.
6. Transfer the Budget Allocated for Personalized Primary Care for MOH to UHIA per governorate included in the UHIS: Establish mechanisms to transfer the budget for personalized primary care services from the MOH to the UHIA, in line with the intentions of the UHIS of moving to strategic purchasing. This will reduce the UHIA’s reliance on premiums to finance primary care services and improve the financial sustainability of the system, ultimately leading to better access to and utilization of primary care services.
7. Stakeholder Education and Coordination: Launch a stakeholder education program targeting UHIA officials to improve their understanding of primary care delivery. Formal coordination mechanisms between the MOH, UHIA, GAHAR, EHA and representatives of private providers for profit and not for profit should be established to ensure a smooth transition and prevent duplication of services.

Conclusion: A well-financed, preventive-focused primary health care system is critical to the success of Egypt's UHIS. To achieve this, strategic reforms are needed to address the legal, budgetary, and operational challenges currently hindering the delivery of comprehensive primary care. Collaboration between the MOH and UHIA, underpinned by clear policies and financial mechanisms, will ensure that primary care functions as intended and contributes to improved health outcomes for all Egyptians.