About two years ago, Ahmed Nabil, who works as a microbus driver, was informed that he had to submit the identity documents of his family, who live in Port Said Governorate, in order to benefit from the health services provided by the health units and hospitals affiliated with the Universal Health Insurance system. However, he was not informed that he was obliged to pay monthly subscriptions for himself, his wife and his two children, until the subscriptions had accumulated against him. When he went last year to change the third-class driving licence he holds for a second-class licence, he was surprised to learn that he had an outstanding debt of EGP 20,000 and that he would not be able to renew his driving licence before paying it. This forced him to ask for the amount to be split into semi-annual instalments, and to borrow money to pay the first instalment of EGP 7,000 in order to obtain the licence. Several months later, Ahmed got a job opportunity at a company, but the company’s management informed him that he would not be hired before closing his insurance file and paying his debts to Universal Health Insurance, as his father tells Zawia3.
Nabil says: “No one told us that we were supposed to pay subscriptions. We used to pay one pound as the fee for a medical examination at the health insurance hospitals, and ten pounds to renew the health card. Now we are being obliged to pay large subscriptions, and we do not know how they are calculated. My son is a microbus driver who charges three and a half pounds per passenger; he has no fixed monthly income and his financial circumstances do not allow him to pay these sums, but the employees made payment the price for allowing him to carry out any government procedure. This problem is not his alone: there are many affected people who visit the social insurance office every day because they cannot carry out government procedures without paying the debt. At the same time, we do not receive good health care under the new system, as we suffer from mistreatment and shortages of medicines for chronic diseases.”
Last January, the young Osama Khamis, from Ismailia Governorate, discovered that he had a debt of four thousand and 400 pounds to pay, of which he had known nothing, resulting from the accumulation of Universal Health Insurance subscriptions against him, as he works in the informal sector: he is a cook at a small pizza restaurant, for a daily wage of only EGP 150, which barely covers the monthly rent for his home and the upkeep of his wife and two children, who are in primary school.
For a year now, Osama’s family has found itself deprived of the healthcare services it used to receive from the health unit it is registered with, until it pays the debt that has weighed it down, at a time when its total monthly income does not reach the minimum wage, set at EGP 6,000, and it cannot afford the luxury of treatment at private hospitals and clinics.
He tells Zawia3: “The demands of life have become very heavy and difficult. I started working extra hours in the hope of raising my daily wage to about EGP 200. My wife does not work, and my two children are in the second and fourth grades of primary school. We are barred from entering the health unit because of the debt. It was four thousand and 400 pounds last year, and I do not know how much it has grown by now.”
The House of Representatives approved the health insurance law at its session on 18 December 2017, after attempts to issue it since 2005. Universal Health Insurance is a compulsory system based on social solidarity, whose umbrella covers all citizens of the Arab Republic of Egypt, with the family as the main unit of insurance coverage within the system. The state bears its costs for those unable to pay, in accordance with exemption rules set by a decision of the Prime Minister. The system is based on separating financing from service provision, and the authority may not provide treatment services or take part in providing them, as stipulated in Article (2) of the Universal Health Insurance System Law No. 2 of 2018. The public treasury is obliged to pay the authority the subscriptions of those unable to pay, which under the law include the subscription value of insured persons from the categories of those unable to pay, including unemployed people who are unable to pay and who are not entitled to, or have exhausted the period of entitlement to, unemployment compensation, as well as every dependent member of the family. The treasury bears (5%) of the national minimum wage announced by the government per month for each of them.
The Ministry of Health and Population had announced that the Universal Health Insurance system would be implemented in six phases. The first phase included the governorates of Port Said, Suez, South Sinai, Ismailia, Aswan and Luxor, at a cost of EGP 51.2 billion; the second phase includes the governorates of Qena, Matrouh, the Red Sea and North Sinai; the third phase covers Alexandria, Beheira, Damietta, Sohag and Kafr El-Sheikh; the fourth phase comprises Assiut, New Valley, Faiyum, Minya and Beni Suef; the governorates of Dakahlia, Menoufia, Sharqia and Gharbia join in the fifth phase; and the sixth phase covers Cairo, Giza and Qalyubia.
On 16 February 2021, Egyptian President Abdel Fattah El-Sisi gave the signal to begin the trial operation of the Universal Health Insurance system in the governorates of Ismailia, Luxor and South Sinai, as part of the system’s first phase.
Workers in other governorates
In June last year, a committee from the Universal Health Insurance Authority came to the workplace of Ayman El-Gendy in the Taba area of South Sinai Governorate and issued cards for the employees whose monthly subscriptions had been deducted from their salaries since the activation of the first phase of Universal Health Insurance in August 2022. However, he and a number of his colleagues did not receive them because they live in governorates (Ismailia, Port Said and Luxor) where the first phase of the system is applied, and they were told to go to the health units they belong to in their own governorates, with their identity documents, to pay the subscriptions, unlike their colleagues living in other governorates outside the system.
Ayman was surprised when the health unit demanded that he pay EGP 14,000 in retroactive Universal Health Insurance subscriptions for his son, born in 2019, and his daughter, born in 2013, even though monthly deductions were taken from his salary and from that of his wife, who is an employee in Ismailia Governorate. They told him to go back to his employer so that it would deduct the children’s subscriptions monthly from his pay, but his employer’s management told him that the platform through which employees’ subscriptions are paid was still not open for adding employees’ children. Ayman then went to the office of the financial administration of the Universal Health Insurance Authority to look into the possibility of paying the amount in instalments, and the employee told him that it had to be paid in instalments over only four months, with 100% interest. When he objected, he was told that if he did not pay the amount he would be cut off from government linkage, leaving him unable to carry out government procedures such as renewing his national ID card, his driving licence or his car licence, as had happened to many of the affected citizens he met there. This prompted him to submit complaints by telephone to the electronic hotline of the General Authority for Universal Health Insurance, and he submitted a complaint to the Cabinet on 8 July 2024, number (8270348), without his problem being resolved. He also submitted a complaint to the email address of the unified government complaints system, as he tells Zawia3.
He says: “I fell ill with heart and blood pressure problems while working in South Sinai Governorate, and when I was admitted to the hospital affiliated with the Universal Health Insurance system in the governorate, they made me pay the full cost of the treatment and health services, on the pretext that I was not a subscriber because I had not paid the children’s debts. I submitted complaints without my problem being resolved, and the responses I received ranged from evasion to mistreatment. I refuse to pay the subscriptions retroactively and to be bargained with under the threat of being cut off from government linkage.”
For his part, Mohamed Ahmed, from Ismailia Governorate, suffers from the problem of accumulated Universal Health Insurance debts, even though health and social insurance subscriptions are deducted from his monthly salary. He has worked at a private-sector factory in 10th of Ramadan City in Sharqia for about 15 years, but he does not receive the health services of the old health insurance because he is not from the city, nor do he and his family benefit from Universal Health Insurance in Ismailia. When he wanted to enrol his daughter in school, the employees asked him to bring her health card, which requires the daughter to be subscribed to the Universal Health Insurance system, and he was asked to bring an “insurance printout” from his workplace. He was then informed that he had accumulated debts of EGP 8,000 for not paying the monthly subscriptions.
He tells Zawia3: “I told them that my insurance subscriptions are deducted from my monthly salary, but they told me that health insurance is a different system from Universal Health Insurance and has a separate financial administration. I submitted a complaint to the Cabinet, number (7869883), and an employee from the Al-Salam medical unit contacted me and asked me to come and submit my papers to update my data. But when I went, I was told that I had to pay the debt now, because no decision exempting us from payment has been issued so far.”
Meanwhile, Saeed Ibrahim (a pseudonym), from Port Said Governorate, who works as a researcher at the National Research Centre in Dokki, Giza Governorate, complains that the Universal Health Insurance health unit stopped dispensing the monthly medication of his wife, who has diabetes, and demanded that she bring a confirmation letter to update her data, even though he had applied months earlier to update his own data and his family’s, had submitted the required documents, and the monthly subscriptions were being deducted from the salary he receives from his government employer. When Ibrahim went to the Universal Health Insurance building, located opposite the railway station, the employees informed him that he had not been paying Universal Health Insurance subscriptions for the family since the system began operating, and that he owed a debt estimated at more than EGP 34,000, which had to be paid for the service to continue.
Ibrahim says: ” Universal Health Insurance was supposed to write to my government employer so that it would deduct the subscription, or to write to me so that I could submit a request for the monthly subscription to be deducted by my employer, and this did not happen. Who is responsible for this mistake? And why are the system’s beneficiaries held to account for mistakes made by those working in the Universal Health Insurance system?”
Part One of the Universal Health Insurance System Law stipulates that the subscription wage is everything the insured person receives in cash from his employer or employers, in particular the wage set out in the tables attached to employment regulations and the bonuses added to it, the wage set out in the employment contract and the bonuses added to it, or the daily wage due, incentives, official commissions and allowances, except for the transport allowance, the travel allowance and other allowances paid to the insured person in return for costs his job requires him to incur. Excluded from this are the representation allowance, the housing allowance, the clothing allowance, the meal allowance, the car allowance and other allowances paid in return for benefits in kind, as well as allowances due to the insured person to meet the costs of living abroad, provided that the total value of the excluded allowances does not exceed (25%) of the insured person’s total wage.
The financial resources of the Universal Health Insurance Authority consist, according to Article (40), of the share of the insured and their dependants (where a person holds more than one job, the insured person is bound by the subscription values for all the income he earns), and the subscriptions that the head of the family is obliged to pay for a wife who does not work or has no fixed income and for the children and dependants living in his care, with the subscription for children and dependants continuing until they take up a job or, for females, until marriage. Employers specified in the social insurance laws are obliged to pay their share of their workers’ subscriptions at a rate of (4%) per month of the insured worker’s subscription wage, and no less than fifty pounds per month, in return for sickness, treatment and work-injury insurance services. Those unable to pay, whose subscriptions are borne by the public treasury, and people with chronic diseases and tumours are exempt from paying the contributions, in accordance with the Prime Minister’s decision regulating the exemption rules. In addition, there is the return generated from investing the funds and reserves available to the authority in line with its investment strategy, along with external and domestic grants and loans concluded by the government for the authority, gifts, subsidies, donations and bequests accepted by the authority’s board of directors, and other sources such as fees imposed on tobacco derivatives, cigarettes, highways and the renewal of driving licences.
Debts of Egyptians abroad
It is 15 years since Mohamed Ibrahim, an employee of the electricity company in Ismailia, obtained unpaid leave to work abroad, and he has not received any healthcare services from health insurance throughout those years. But when he wanted to move his daughter from primary to preparatory school, he was shocked to be obliged to buy a health certificate, and the employee told him at the time that he had to pay about EGP 30,000 in retroactive Universal Health Insurance debts dating from the start of the system’s application in Ismailia Governorate. After negotiations, he was allowed to pay only the fees for the health certificate and the medical examination, estimated at EGP 600, but the employees told him that on his return to work in Egypt he would be obliged to pay his debt to Universal Health Insurance.
He tells Zawia3: “My colleagues who are still working in Egypt are forced to pay an estimated one thousand and 300 pounds, deducted monthly from their salaries since the start of Universal Health Insurance in August 2022. As for me, I do not benefit from the Universal Health Insurance system, and neither my wife, my children nor I go to its hospitals and clinics, because the electricity company provides us with health insurance and treatment at large hospitals. So why am I being forced to pay the subscriptions? Is it not enough that every year I pay more than a thousand dollars to pensions and insurance as fees for renewing my unpaid leave?”
The subscription of Egyptians abroad to the system is optional: Article (1) of Universal Health Insurance Law No. 2 of 2018 stipulates that the provisions of the law apply compulsorily to all citizens residing within the Arab Republic of Egypt, and optionally to Egyptians working abroad and to those residing with their families abroad.
Flaws in the law
Meanwhile, Dr Mohamed Hassan Khalil, head of the Committee for the Defence of the Right to Health, accuses the government of being responsible for the Universal Health Insurance subscription debt crisis because of flaws in the law, despite warnings from the Committee for the Defence of the Right to Health, while the law was being drafted, that the law, which was supposed to be universal and cover all citizens, had a problem with insuring workers in irregular employment. What happened, he says, is that the proportion of insured people covered by health insurance rose from 66% to 79%, instead of the system covering all citizens, and he suggests that the increase was due only to the addition of wives. While school children were insured free of charge under the old health insurance, their parents now bear the burden of paying their children’s subscriptions instead of the state. He adds that the worker’s subscription used to be 1% of his salary and the employer’s 3%, in addition to 1–3% for the work-injury subscription, paid by each party within social insurance; now, however, the employer’s subscription has been limited to only 4% (a 3% subscription and only 1% for work injuries), while the worker’s subscription has multiplied until it exceeds the employer’s: he pays 1% as a subscription for himself, 3% for his wife if she does not work, and 1% for each child he supports. What the worker pays is not limited to the subscription; on top of it come the contributions, meaning a percentage of the price of every service he receives: 10% of the price of medicines, tests and X-rays, up to a maximum of EGP 750 for each. Egypt thus becomes the first and only country in the world in which the worker’s subscription is twice the employer’s, even though the worker is the economically weaker party.
He criticises the law for compelling irregular workers, who have lower and less stable incomes, to pay subscriptions every three months, which has left them unable to pay and reluctant to subscribe to the service. He stresses that these are the features of commercial, not social, health insurance, since it forces parents to pay their children’s subscriptions instead of the state, which is supposed to be responsible for all children up to the age of 18, and he considers that this will destroy the health of future generations.
He adds: “While the law was being prepared, the Right to Health Committee asked about the mechanism that would force citizens to pay the subscriptions, and officials at the Universal Health Insurance Authority told us that citizens would be compelled by being prevented from renewing their ID card, passport or driving licence, or from paying their children’s school fees, unless they paid the subscriptions, under the law. Responsibility for this crime therefore lies with the authority, not with the governors. Moreover, it did not notify citizens of the value of the subscriptions and left them to accumulate. The law also did not stipulate that Egyptians abroad are obliged to subscribe, so there is no mechanism in the law for determining the value of their subscriptions.”
For his part, the human rights lawyer Malek Adly, director of the Egyptian Center for Economic and Social Rights, denies that the regulations and laws on Universal Health Insurance in Egypt forced citizens to subscribe and obliged them to pay retroactive debts without their being beneficiaries of the health service, and considers that this may be a misapplication of the system by some governors.
He affirms that blackmailing citizens to force them to pay the debt in exchange for allowing them to carry out government transactions and obtain identity documents is illegal and amounts to a crime, stressing that the purpose of Universal Health Insurance is to cover all citizens and provide health services to those unable to pay, and that the Egyptian government received external grants from the World Bank to apply the system to all citizens without discrimination.
In June 2020, the World Bank approved a project worth $400 million to support the Universal Health Insurance system that Egypt is implementing as part of its drive towards universal health coverage for citizens and better health outcomes.
For his part, Alaa Ghannam, a member of the Universal Health Insurance Law committee, head of the right-to-health programme at the Egyptian Initiative for Personal Rights (EIPR) and an expert in health-sector reform, believes that cutting off government linkage for Universal Health Insurance subscribers who have not paid the subscriptions due is a legal deterrent against those who refrain from paying of their own free will, and does not contravene the text of the Universal Health Insurance Law or its executive regulations. As for those unable to pay, they must go to the Ministry of Social Solidarity to undergo a social survey and be included among the categories exempted from paying the fees. He points out that it was citizens who went of their own free will to the Universal Health Insurance Authority to subscribe to the service and obtained subscriber cards, or who were transferred to it from the old health insurance system.
Ghannam explains that an employee who works in a governorate outside the first phase of Universal Health Insurance, while he and his family live in a governorate covered by the system, must register himself and his family with Universal Health Insurance and pay the subscriptions set out in the regulations, and the old health insurance subscription should not be deducted from his monthly salary. He can request an exception so that he can receive health services from the health insurance hospitals and units in the governorate where he works.
Exempting those unable to pay
A responsible source at the Universal Health Insurance Authority, who declined to be named, explains to Zawia3 that the Universal Health Insurance system differs from the old health systems that emerged in the sixties, which covered employees, school students and pensioners in return for monthly deductions or annual fees, in that it came to fill the gap in health coverage in Egypt, amid high rates of informal employment and unemployment and the unsuitability of the old health insurance for the growing number of patients with chronic diseases. The new system treats the family as the unit of subscription, and subscriptions are calculated on the subscriber’s total income, retroactively from the date the service was launched in the governorate where the subscriber lives. He points out that there are challenges preventing all citizens from joining the insurance umbrella and preventing the system from reaching the exempted categories who are unable to pay, even though the Universal Health Insurance Law covers all groups in society.
The official notes that the regulations of the Universal Health Insurance Authority set subscription brackets based on income and the number of family members. Individuals who work for their own account in industrial, agricultural or commercial professions pay 5% of the insurance wage or of the income stated in the tax return, 3% for a non-working wife and 1% for each child. Civilian employees in the state’s administrative apparatus and workers in the private sector, the public sector and the public business sector pay 1% of their wage, 3% for a non-working wife and 1% for each child. Those engaged in work related to domestic service (those who work for cleaning companies), except for those working inside homes, pay 1% of the wage, and the same percentage is paid by members of the employer’s family who work for him and whom he actually supports. Meanwhile, individuals who carry out commercial, industrial or agricultural activity for their own account, craftsmen, general partners in partnerships and partnerships limited by shares, business owners, chairs and members of boards of directors and managing directors of private-sector joint-stock companies, managers of limited liability companies, owners of single-person companies, workers bound by personal employment contracts, owners and holders of agricultural land of one feddan or more, owners of built property, owners of motorised means of transporting people or goods, including land, river, sea and air transport, commercial agents, owners of motorised or sailing fishing boats, sharia marriage registrars and delegated notaries who are not monks, village mayors and sheikhs, guides, tourist guides and trackers, writers and artists, heirs of business owners, owners of home-based, environmental, rural and family industries, itinerant labourers, small self-employed workers such as street vendors, parking attendants, newspaper distributors, itinerant shoe shiners and other similar categories and craftsmen, domestic workers, teachers and reciters of the Holy Quran, cantors, sextons and other church servants, temporary agricultural workers, emigrants and seafarers pay 5% of the insurance wage, or of the wage according to the tax return, or of the maximum insurance wage, whichever is greater, 3% for a wife who does not work or has no fixed income, and 1% for each dependant or child.
The official stresses that it is difficult to identify informal, uninsured workers. The income of those who hold a professional practice certificate is estimated on the basis of the nature of their crafts or professions, while seasonal “day-earner” workers fall under the category of those unable to pay, whether they receive the Takaful and Karama pension or have applied to the Universal Health Insurance Authority to prove that they are below the poverty line. He notes that there are six categories exempted from subscription fees, but most citizens do not know this, owing to a lack of information available to the public and to the authority’s own staff on the one hand, and the difficulty of the procedures for proving that a citizen is unable to pay, which include obtaining an insurance printout and a social survey from an NGO, on the other; as a result, they do not subscribe to the service.
Article (41) of the executive regulations of the Universal Health Insurance Law, published in the Official Gazette on 8 May 2018, stipulates that the Ministry of Social Solidarity is responsible for determining the numbers and data of those unable to pay, including unemployed people who are unable to pay and who are not entitled to, or have exhausted the period of entitlement to, unemployment compensation, as well as every dependent member of their families. On 28 November 2023, Prime Minister’s Decree No. 4586 of 2023 was issued on identifying those unable to pay and the rules for exempting them from the burdens of the Universal Health Insurance system. It included: the individual or family entitled to the Takaful and Karama, social security and child pension programmes; the unemployed individual or head of family who is unable to pay and is not entitled to, or has exhausted the period of entitlement to, unemployment compensation, as well as every dependent member of the family; the individual or head of family deprived of family care, living in social and health care institutions, with no provider or income, including homeless children and adults and children sponsored by foster families; the individual or head of family with a disability who is unable to earn a living and has no source of income, in a manner that does not conflict with the aforementioned law on the rights of persons with disabilities, as well as every dependent member of the family; individuals and families living in specific geographical areas who are temporarily affected by a natural or man-made disaster; and the individual or head of family whose average total income is not enough to meet his own basic needs or those of his family.
The official, who refused to be named, attributes the Universal Health Insurance subscription debt crisis to the existence of categories of subscribers who are supposed to pay the subscriptions themselves, since they are not deducted from their salaries because they are not insured employees, and who were not aware that there were fees to be paid to renew their subscriptions, as well as to changes in the financial situation of some citizens, who left their jobs or moved away from their place of residence. He adds that the authority did not issue a decision to suspend government linkage for citizens who have not paid their subscriptions and to prevent them from renewing identity cards and driving licences and from registering their children in schools; rather, it was some governors who gave such instructions, and it is an illegal measure.
While some lawyers and health-systems experts consider depriving citizens of government linkage services until they pay their Universal Health Insurance subscriptions to be unlawful, other experts believe it is a legal measure intended to deter wealthy people who evade payment, while those unable to pay can turn to the Ministry of Social Solidarity. This leaves citizens caught between two fires: the bureaucracy of the procedures to prove their poverty, or financial burdens that weigh heavily on their families, so as not to be deprived of government linkage services.
