Pursuing Universal

Health Coverage in the

Middle East and North

Africa: Lessons for Low and Middle Income Countries in Asia

Presented by: Dr. Eduardo Banzon

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not

necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of

Governors, or the governments they represent. ADB does not guarantee the accuracy of the data

included in this paper and accepts no responsibility for any consequence of their use. Terminology used

may not necessarily be consistent with ADB official terms.

Universal Health Coverage

all people with access to needed health services (including prevention, promotion, treatment and rehabilitation) that is of sufficient quality to be effective

use of these services does not expose the user to financial hardship

three dimensions of coverage

Population

Services

Financial (protection)

Three dimensions of UHC

Inputs & processes

Health Financing

Health workforce

Infrastructure

Information

Governance

Service Delivery

Outputs

Service access

and readiness

Service quality

and safety

Service

Utilization

Prepaid funds

Outcomes

Coverage of

interventions

Coverage with a method of

financial risk protection

Risk factors

Impact Health Status

Household Financial well-

being Responsiveness

Level and distribution (Equity)

Social Determinants

UHC is not only about

Health Financing

Middle East and North Africa

(Eastern Mediterranean Region)

Share of out‐of‐pocket expenditure in total

health expenditure, 2010

0

10

20

30

40

50

60

70

80

90

‘Services’ coverage

MDG health services

7

Country

Group Measles

coverage (Vaccination

services)

DOTS

coverage (anti-TB

services)

ART

coverage %

>15 yrs (Treatment of

HIV cases)

Antenatal

visits

coverage (ANC

services)

Births by

SBA (Maternal

Health

services)

CPR (contraceptive

services)

High

income 98–100 100 NA 98–100 98–100 24–37

Middle

Income 91–99 100

13-56

(data from 4

countries)

66–100 74–100 38–60

Low

Income 64–88 47–100

9-35

(data from 6

countries)

17–79 19–87 4–38

DOTS – Directly observed therapy for tuberculosis; ART – Antiretroviral therapy; SBA – Skilled birth

attendants; CPR – Contraceptive prevalence rate

Population coverage – prepayment arrangements

Country

Group

Government

revenue

Social health insurance

schemes (SHI)

Private health

insurance schemes

(PHI)

Other prepayment

arrangements

High Income

All nationals are

covered for

most/all needed

services

Nationals are subsidized

into SHI schemes in

some countries

Mandatory for

expatriate population

in some countries

–

Middle Income

All citizens are

covered to a

limited set of

services

Formal sector employees,

para-statal organizations,

vulnerable population but

covered services are

variable

Primary and/or

supplementary health

insurance for formal

private sector

employees

Employees of Large

employers- through

directly provided

services

Limited community

health insurance

schemes

Low Income

All citizens are

supposed to be

covered to a

limited set of

services

Formal sector employees

in some countries

Formal private sector

employees but limited

in scope

Limited community

health insurance

schemes

LESSONS

RAPIDLY INCREASE POPULATION COVERAGE by TARGETING

POPULATION GROUPS

All primary and secondary students

Egypt’s School Health Insurance Program (SHIP)

Managed by the Health Insurance Organization (HIO)

Comprises 41% of the 57% of the population covered by HIO (23% of total population)

Annual premium

Family pays 4 LE

Government pays 12 LE per student

Earmarks of 0.10 LE per cigarette pack as supplemental funding

Benefits/Providers

HIO benefits + preventive care funded by Ministry of Health

HIO runs around 6000 school clinics

All rural population

Iran’s Rural Health Insurance program

Managed by Iran’s Health Insurance Organization

In 2005, all people in rural communities with less than

20,000 people were covered with government subsidies

23 million people currently covered

Nearly a third of Iran’s total population

Family practice benefit combined with MoH’s primary health

care services

All children less than six years

of age

Egypt’s Pre-school children coverage

Managed by the Health Insurance Organization (HIO)

Comprises 32 % of the 57% of the population covered by HIO (18% of total population)

Jordan’s under 6 coverage

Managed by the Civil Insurance Program

CIP covers 41.25% of the total population in 2011 (from 26.4% in 2006)

Rapid expansion partly due to government subsidies for all children less than 6 years of age

Total Population and estimated migrants in GCC countries 2010

All Expatriates

Mandatory health insurance in UAE, Saudi Arabia and Qatar

for all expatriates

PRE-PAYMENT

EMPOWERS the

POOR and

VULNERABLE

POINT of CARE

COVERAGE FAVORS

the NON-POOR

Pre-Paying the Poor Morocco’s Le Regime d’ Assistance Medicale (RAMED)

28% of the total population

Poor

3 year card – free care in government services

Near poor (Vulnerable)

pay 120 Dh/person/year with a celling of 600 dh/HH

Free care in government facilities

Tunisia’s Assistance Medicale Gratuite (AMG)

24% of the total population

Poor

5 year Free care card (in government facilities)

Near poor (Vulnerable)

Reduced rates/ subsidized in government facilities

Pays 20% of the cost of every treatment/admission

Point of Care Coverage

Egypt’s Program of Treatment for the Expense of the State

Ended up covering routine hospital care

Jordan’s Royal Court exemption

Heavily used by non-insured non-poor

Iran’s “Iranian” point of care enrolment with the Health Insurance Organization

Dis-incentivizes insurance enrolment by the informal sector

CONVERGE MoH-funded

PRIMARY HEALTH CARE and

HEALTH INSURANCE-

financed FAMILY PRACTICE

Family Practice and PHC

“benefits”

Iran’s Rural Health Insurance program

Converges insurance and MoH funded services

HIO funds:

Family practice benefits provided by a general practice physician

Includes outpatient consultation, medicines, diagnostics

Gatekeeper for inpatient benefits

MOH finances primary health care service

Building on the Berhaz and the PHC teams of Iran

Vaccinations, TB, malaria and other “public health” services

FOCUS ON MEDICINES

improves FINANCIAL RISK

PROTECTION

Different approaches

Pooled procurement

Turkey

Jordan

Drug price as part of drug labels

Subsidies for drug expenses

Iran (multiple sclerosis, blood disorders, costly illnesses)

Tunisia (list of 24 conditions)

Jordan ( chronic blood diseases)

Palestine (chronic blood diseases)

Drug expenditure as percent of GDP (Jordan),

2007-2011

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

20112010200920082007

2.09% 2.26%

2.66%

3.08% 3.10%

OOP expenditure as percent of THE,

Jordan (2007-2011)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

20112010200920082007

22.6% 22.4% 22.7%

31.6%

35.8%

CHANGE IN PUBLIC PHARMACEUTICAL

EXPENDITURE (%) in TURKEY

Number of Pillboxes (million)

1994 2002 2012

539 699 1.769

Public Pharmaceutical Expenditure

(2012 Prices - million TL)

1994 2002 2012

6.244 14.624 14.484

Rate of increase in

number of pillboxes

Rate of Increase in

Pharmaceutical Expenditure

%153

RE-DEFINE ‘FREE CARE’ IN

GOVERNMENT HEALTH

FACILITIES

NOT LIMITED TO THE POOR No co-payment

Jordan’s CIP

Morocco’s RAMED

Tunisia’s AMG and CNAM’s public option

Sudan’s NHIF

Egypt’s HIO’s Law 79

Fixed co-payment (usually 10%)

Iran’s HIO and SSO

Morocco’s CNOPS and CNSS

Lebanon’s CNSS

PROVIDING CHOICE in a

SINGLE FUND

Tunisia’s CNAM Government provider choice (70% of members)

Services provided by MOH health facilities + CNSS polyclinics and military hospitals

No co-payments for members

Private provider choice (13% of members)

Members are are assigned a private family physician who will refer to specialist care and hospitalization (usually also private providers)

30% co-payment

Reimbursement of providers choice (17% of members)

Members pay private or public providers first and are then reimbursed by CNAM

Reimbursement up to a ceiling (beyond that- member pays)

Choice is made annually

ENGAGE the PRIVATE SECTOR

and RELIGIOUS CHARITIES

INNOVATIVELY

Beyond tariffs and banning

dual practice

Private sector “third party administrator” (Medexa) engaged to deal with private hospitals in Jordan

Private health insurer (Munich Re) brought in as minority partner (20% equity) in Abu Dhabi’s National Health Insurance Corporation (DAMAN)

All UAE nationals in Abu Dhabi are enrolled with Daman through the Thiqa health insurance scheme

It also covers expatriates who avail of the Basic Health Package/ Plan

Sudan’s National Health

Insurance Fund and Zakat

Social Initiative Project

Zakat (religious alms) trustees and Basic Zakat Communities identify the poor

Subsidizes one third of those enrolled through the Social Initiative project

Ministry of Welfare and Social Security (MoWSS) covers the other two third

By 2016, it is expected that

Zakat will sponsor 380,000 families

MoWSS will sponsor 760,000 Families

Currently, 400,000 families are covered through the SIP

46% of total membership of NHIF

CREATE SYNERGIES with

SOCIAL SECURITY

ORGANIZATIONS

Different Approaches

Morocco’s Obligatory Health Insurance law (AMO)

Created a government agency (AMAN) to supervise all health insurance

CNSS (for private sector) and CNOR (for government) benefits are based on AMO.

AMAN manages the RAMED scheme

Tunisia’s outsourcing of premium collection

Social security organizations CNSS (for private sector) and CNOR (for government employees) collect the premiums as part of social security contributions then transfers it to CNAM

CNAM manages engagement with health care providers for CNSS, CNOPS and AMG (for the poor) members

“UHC” REFORMS CAN

RAPIDLY IMPROVE HEALTH

OUTCOMES

2003 2005

2006

2007

2008

2009

2010

Green Card holders

covered for outpatient care

Performance-based

payments piloted in ten

MoH hospitals

Green Card holders

covered for outpatient

prescription drugs

SSK hospitals transferred to

the MoH

Family medicine pilot

first implemented in

Duzce

Global budget implemented for MoH

hospitals

Family medicine implemented in

Eskisehir, Edirne, Denizli, Adiyaman

and Gumushane provinces

Implementation of Law 5502

(integration of social security

institutions) begins

Family medicine

implemented in

Elazig, Isparta,

Samsun, and Izmir

provinces.

Amendments to Social

Security and UHI Law

adopted by the Grand

National Assembly and

signed by the President

Green Card holders to

receive same benefits

as enrollees in other

health insurance

schemes under UHI

Family Medicine

implemented in the

provinces of Rize,

Trabzon, Tunceli, Uşak

and Bursa

Health payments of

civil servants and their

dependents relocated

to SSI

Family Medicine

implemented

countrywide, including

Ankara and Istanbul

SSK pharmacies closed and

members allowed to access

private facilities Individual performance-

based supplementary

payment system

implemented in MoH

institutions

2004

Decree in Force of Law

no. 663 on the

Organization and

Duties of the Ministry of

Health and Its Affiliates

passed establishing the

Public Health Institution

and Public Hospitals

Union and moving the

MoH into a stewardship

role and away from

provision and financing.

Decree also

establishes positive

incentives for NCD

prevention and control

in family medicine.

Green Card

program

transferred to

SSI

2012

2011

TURKEY HEALTH TRANSFORMATION

FINANCE SERVICE

PROVISION

General Government

Budget (MoF) MoH

Primary

Health

Care

Emergency

Transport

Public

hospitals /

Dent.

Clinics

Social Security

İnstution (SSI)

PUBLIC

Private Hospitals

And Small

Centers

Private Physician

Offices

Pharmacies

Public

University

Hospitals

Premiums

And

Co-pays

(Managed by Council of Higher Education)

Regulation

6

By 2012 in TURKEY

Health outcomes improved….

70

61

19,418,4

16,415,5

0

25

50

75

1998

2003

2006

2007

2008

2009

2010

2011

Maternal Mortality Rate (in 100.000)

42,7

29

12,110,2

7,8 7,7

0

25

50

1998

2003

2005

2008

2009

2010

2011

Infant Mortality Rate (in 1000)