About two years before this investigation, minibus driver Ahmed Nabil was asked to submit documents for his family in Port Said so they could use clinics and hospitals in Egypt’s Universal Health Insurance System. His father says nobody explained that monthly contributions would be due for Ahmed, his wife and their two children.
The charges accumulated. When Ahmed went in 2024 to upgrade his driving licence from the third to the second category, he was told he owed EGP 20,000 and could not complete the procedure before payment. He requested six-monthly instalments and borrowed money to make an initial EGP 7,000 payment to obtain the licence.
Months later, a company offered him work, but told him he first had to close his existing insurance file and settle the health-insurance debts, his father tells Zawia3.
“Nobody told us we were supposed to pay contributions,” Nabil says. “We used to pay one pound for an examination at health-insurance hospitals and ten pounds to renew the health card. Now we are required to pay large contributions without understanding how they are calculated.”
His son collects EGP 3.50 from each minibus passenger and has no fixed monthly income, Nabil explains. He says officials made payment a condition of completing government procedures, and that many other residents visit the social insurance office daily because debts prevent them doing the same. Meanwhile, he complains of poor treatment and shortages of medicines for chronic conditions.
In January 2025, Osama Khamis from Ismailia discovered EGP 4,400 in accumulated contributions that he says he had known nothing about. An informal-sector worker, he cooks in a small pizza restaurant for EGP 150 a day, barely enough for rent and the needs of his wife and two primary-school children.
For a year, Osama’s family had been unable to use the local health unit until the debt was paid. Their monthly income did not reach the EGP 6,000 minimum wage cited in the report, and private treatment was unaffordable.
“Life’s demands have become extremely heavy. I started working extra hours, hoping to raise my daily pay to around EGP 200. We cannot enter the health unit because of the debt. It was EGP 4,400 last year, and I do not know how much it has increased.” — Osama Khamis
Parliament approved the health-insurance legislation on December 18, 2017, after efforts dating back to 2005. Under Law No. 2 of 2018, universal health insurance is a compulsory, solidarity-based system intended to cover all Egyptian residents. The family is the principal unit of coverage, and the state bears the cost for people classified as unable to pay.
The framework separates financing from service provision: the insurance authority itself does not provide treatment or participate in delivering it. The Treasury pays contributions for eligible people unable to pay, including qualifying unemployed people and their dependants, at a monthly rate equivalent to 5% of the nationally announced government minimum wage for each covered person.
The Health Ministry set out a six-phase rollout. The first covered Port Said, Suez, South Sinai, Ismailia, Aswan and Luxor, at a reported cost of EGP 51.2 billion. Phase two comprised Qena, Matrouh, the Red Sea and North Sinai; phase three Alexandria, Beheira, Damietta, Sohag and Kafr El Sheikh; and phase four Assiut, the New Valley, Fayoum, Minya and Beni Suef.
Dakahlia, Menoufia, Sharqia and Gharbia were assigned to phase five, followed by Cairo, Giza and Qalyubia in phase six. This is the rollout plan cited at the original publication date in February 2025.
On February 16, 2021, President Abdel Fattah El Sisi launched trial operation in Ismailia, Luxor and South Sinai as part of the first phase.
Working in one governorate, living in another
In June 2024, insurance officials visited Ayman El Gendy’s workplace in Taba, South Sinai, to issue cards to employees whose contributions had been deducted since the local system was activated in August 2022.
Ayman and some colleagues did not receive cards because they lived in Ismailia, Port Said or Luxor, which were also covered by the first phase. They were instructed to take their documents to health units in their home governorates and pay contributions there, unlike colleagues living outside the system’s first-phase areas.
Ayman says his local unit demanded EGP 14,000 in retrospective contributions for his son, born in 2019, and daughter, born in 2013, despite monthly deductions from both his salary and his wife’s salary in Ismailia.
Officials told him to ask his employer to deduct the children’s contributions. The employer replied that its payment platform did not yet allow employees’ children to be added.
At the insurance authority’s financial office, Ayman says, an employee offered payment over only four months with what he described as 100% interest. When he objected, he was told non-payment would block access to government-linked transactions, including renewing his identity card, driving licence or vehicle licence. He says he met other residents facing similar problems.
Ayman called the authority’s hotline and submitted cabinet complaint No. 8270348 on July 8, 2024, as well as an email to the unified government complaints system. His problem remained unresolved, he says.
“I became ill with heart and blood-pressure problems while working in South Sinai. At a hospital in the system, they made me pay the full cost because I had not settled the children’s debts,” he says. “My complaints produced evasive answers or poor treatment. I refuse retrospective charges enforced by threatening to block government services.”
Mohamed Ahmed, from Ismailia, has worked for about 15 years in a private factory in Tenth of Ramadan City, Sharqia. Although health and social insurance are deducted from his pay, he says he cannot use the older health-insurance services where he works because he is not a local resident, or the universal system in Ismailia.
When he tried to enrol his daughter in school, officials requested a health card, requiring registration in the universal system. After he supplied an insurance record from his workplace, they told him EGP 8,000 in monthly contributions had accumulated.
“I said my insurance contributions were already deducted,” he tells Zawia3. “They said the old health insurance and universal health insurance are different systems with separate financial administrations.”
Mohamed filed cabinet complaint No. 7869883. A worker at El Salam health unit asked him to attend and update his records, but on arrival he was told the debt still had to be paid because no exemption decision had been issued.
Saeed Ibrahim, a pseudonym, lives in Port Said and works as a researcher at the National Research Centre in Dokki, Giza. His wife’s monthly diabetes medicines were stopped while the health unit requested a confirmation letter to update the family’s data.
He says he had already submitted the necessary documents months earlier and that contributions were deducted from his government salary. At the authority’s office opposite the railway station, officials told him family contributions had not been paid since the system began and that he owed more than EGP 34,000 to maintain service.
“The authority should have contacted my government employer to deduct the contributions, or told me to request that deduction. Who is responsible for this mistake? Why are beneficiaries being made to pay for errors by the system’s staff?” — Saeed Ibrahim
The law’s definition of contributory pay includes monetary earnings from one or more jobs: basic contractual or statutory pay, increments, daily wages, incentives, official commissions and relevant allowances. Certain travel and work-expense allowances, benefits in kind and allowances for living abroad are excluded under the specified rules. The total excluded allowances may not exceed 25% of earnings.
Under Article 40, the authority’s resources include insured people’s and dependants’ contributions. People with several jobs contribute on the income from each. Heads of households pay for non-working wives or wives without fixed incomes and for dependent children, with the stated continuation rules until employment or, for female dependants, marriage.
Employers contribute 4% of contributory pay each month, subject to a minimum of EGP 50, for sickness, treatment and work-injury coverage. Funding also comes from investment returns, government-arranged loans and grants, donations and charges on products or services including tobacco, toll roads and licence renewals.
Regular contributions are distinct from co-payments charged when treatment is received. Article 40 exempts qualifying people unable to pay, whose contributions are Treasury-funded, and people with chronic illnesses or cancer from the specified service co-payments, under the relevant exemption rules.
Debts demanded from Egyptians working abroad
Mohamed Ibrahim, an employee of Ismailia’s electricity company, took unpaid leave to work abroad 15 years earlier. He says he received no treatment through the health-insurance system during those years.
When transferring his daughter from primary to preparatory school, he was required to buy a health certificate and told he owed about EGP 30,000 in retrospective universal health-insurance contributions dating from the system’s local introduction. After negotiations, he paid only EGP 600 for the certificate and examination, but officials said the debt would be due when he returned to his Egyptian job.
Colleagues working in Egypt, he says, have had around EGP 1,300 deducted monthly since August 2022. He questions why he should pay when his family does not use the new system and his employer provides other health coverage. He already pays more than $1,000 annually towards pensions and insurance as part of renewing unpaid leave, he says.
Article 1 of the enacting law makes coverage compulsory for citizens resident inside Egypt, but optional for Egyptians working abroad and those living abroad with their families. That distinction is central to Mohamed’s complaint.
Conflicting views on the law
Dr Mohamed Hassan Khalil, chair of the Committee to Defend the Right to Health, holds the government responsible for the debts, arguing that flaws in the law were identified during its preparation. A universal system needed a workable way to cover irregular workers, he says.
He estimates that insured coverage rose from 66% to 79%, rather than reaching everyone, and suggests much of the increase came from adding wives. He criticises moving children’s contributions onto parents instead of the state, contrasting this with schoolchildren’s treatment under the old scheme.
Khalil describes the previous arrangement as a 1% employee contribution and 3% from the employer, alongside separate work-injury contributions of 1–3%. Under the newer scheme, he says, the employer’s share is 4%, while an employee pays 1% for themselves, 3% for a non-working wife and 1% for each child.
Consequently, a family’s contribution can exceed the employer’s share. For example, an employee with a non-working wife and two dependent children contributes 6% before service co-payments, compared with the employer’s 4%. The precise comparison depends on family size; it is not a uniform doubling for every employee.
Khalil also criticises service co-payments, citing 10% charges for medicines, tests and imaging and an EGP 750 ceiling in his account. His criticism concerns the overall burden, while the applicable charge depends on the service and the rules in force. His further description of Egypt as uniquely burdening workers in this way is an assessment, not a comparative international finding established in this investigation.
Requiring financially insecure irregular workers to pay every three months makes payment difficult and discourages enrolment, he says. He considers these features closer to commercial than social insurance and argues that the state should ensure children’s coverage up to 18.
During the law’s preparation, Khalil says, his committee asked how payments would be enforced. Officials allegedly told them identity cards, passports, driving licences and school-related procedures could be blocked until contributions were paid.
He blames the authority for allowing unannounced charges to accumulate. He also notes that the law does not make enrolment compulsory for Egyptians abroad.
Malek Adly, director of the Egyptian Center for Economic and Social Rights, offers a different interpretation. He disputes that the legal framework authorises retrospective debts for people who have not benefited from the service, suggesting some governorates may be applying the system incorrectly.
Adly considers coercing residents to pay debts in order to obtain documents or carry out government transactions unlawful. The purpose of universal insurance, he says, is to cover everyone, including those unable to pay.
He refers to international support for the rollout. Reporting cited in the original article described a $400 million World Bank project approved in June 2020. The Bank’s announcement confirms the funding, while its project document identifies it as a proposed IBRD loan, rather than simply a grant.
Alaa Ghannam, a member of the health-insurance law committee, health-rights lead at the Egyptian Initiative for Personal Rights and health-sector reform specialist, takes another position. He considers restrictions on linked government services a lawful deterrent for registered subscribers who deliberately refuse to pay.
People unable to pay should seek a social assessment through the Social Solidarity Ministry and inclusion in the exempt categories, he says. He notes that some citizens registered themselves and obtained cards, while others were transferred from the old scheme.
For employees working outside the first-phase governorates but living with their families inside one, Ghannam says the family should register and pay under the universal scheme. Contributions to the old system should not also be deducted. Employees can request an exception allowing treatment through the older system where they work.
Exemptions that many people do not know about
An official at the Universal Health Insurance Authority, who requested anonymity, tells Zawia3 that the new system differs from arrangements dating back to the 1960s, which covered employees, schoolchildren and pensioners through payroll deductions or annual fees.
The newer scheme was intended to close coverage gaps amid informal employment, unemployment and rising chronic disease. It treats the family as the enrolment unit and calculates contributions on total income, with charges dating from the service’s introduction in the subscriber’s home governorate, the official says.
Nevertheless, identifying and enrolling everyone, particularly exempt households, remains difficult. The official describes contribution categories based on occupation, income and family size.
Civil servants and employees in private, public and public-business sectors generally contribute 1% of pay for themselves, 3% for a non-working wife or wife without a fixed income, and 1% per dependent child.
The official describes a 1% employee rate for workers in cleaning-service companies outside private homes and family members genuinely employed and supported by an employer. Self-employed industrial, agricultural and commercial workers fall within categories generally charged at 5% of the applicable contribution base, plus the family shares.
The broader 5% categories cited include craftspeople, business owners, general partners, private-company board members and managers, sole-owner companies, people working under individual employment contracts, and owners or holders of at least one feddan of agricultural land.
They also include owners of buildings and passenger or freight vehicles, commercial agents, fishing-boat owners, authorised marriage officials and delegated notaries, village heads and sheikhs, tourist guides and trackers, writers and artists, and heirs of business owners.
Further categories named by the official include home-based and rural producers, seasonal labourers, street vendors, parking attendants, newspaper sellers, shoeshiners, domestic workers, Quran teachers and reciters, church workers, temporary farm workers, migrants and maritime workers.
For the broader 5% categories, the official describes a comparison between insurable pay, income in the tax declaration and the maximum insurable wage, with the higher figure used. This is the official’s description of the calculation, rather than an independently calculated assessment for any of the families interviewed. This extensive classification illustrates the administrative complexity of assessing people with unstable or informal incomes.
People holding a vocational certificate may have income estimated according to their occupation, the official says. Seasonal day labourers may qualify as unable to pay, either through Takaful and Karama eligibility or an application establishing income below the poverty threshold.
Many citizens do not know that six exemption categories exist, the official says. Limited information among the public and some staff, alongside difficult evidence requirements such as an insurance record and a social assessment, can prevent enrolment.
Article 41 of the implementing regulations, published on May 8, 2018, assigns the Social Solidarity Ministry responsibility for identifying people unable to pay, including qualifying unemployed people and dependent family members.
Prime Ministerial Decision No. 4586 of 2023, issued on November 28, 2023, identifies the exemption categories: people or families eligible for Takaful, Karama, social-security or child-pension programmes; qualifying unemployed people and dependants; and people without family support or income in social or healthcare institutions, including homeless children and adults and children in alternative-family care.
It also includes people with disabilities who cannot earn and have no income, with their dependants; people temporarily affected by natural or human-caused disasters in specified areas; and individuals or households whose average total income cannot meet basic needs.
The official attributes debts partly to subscribers who must pay directly rather than through insured employment and did not understand the recurring charges. Changing employment, finances or residence can add to the problem.
The official says the authority had issued no decision blocking identity-card renewals, driving licences or school registration for unpaid contributions. In the official’s account, some governors directed these restrictions, and the practice is unlawful.
The investigation reveals sharply conflicting interpretations. Some lawyers, experts and the official interviewed reject blocking government services; others defend it as a deterrent for people able to pay. For residents struggling with accumulated charges, the choice can become one between burdensome procedures to prove poverty and debts their families cannot afford.
