Transforming Health Financing Systems in the Arab World Toward Universal Health Coverage

Abstract

Universal Health Coverage has been a goal since at least 2010 for the international health community, but each country worldwide requires a sound health financing system to operationalize it. This chapter analyzes the progress of 20 Arab countries in transforming their systems, and finds that most of them are still struggling. Some of the main challenges are that health spending in real terms can outpace economic growth, alongside an increasing incidence of noncommunicable diseases and injuries. Drawing on experts in the field, the chapter offers a four-point analytical framework – revenue generation, pooling, purchasing, and benefit package design – to review their progress in reforming their health financing systems, which is empirically measured by selected performance indicators. The key findings, generally for 2017, are that: overall per capita health spending is low, both absolutely and as a share of gross domestic product, but with wide variations across countries; whether high-, medium-, or low-income, most governments invest less on health as a share of GDP than their global income peers; many governments do not invest enough in health despite having fiscal space; and financial risk protection is low. The main recommendation is to develop a “financial resource mix” that would allow stability in funding flows, facilitate subsequent pooling, and ensure long-term sustainability. The COVID-19 pandemic is set to place greater pressure on already-low public financing, likely increasing out-of-pocket spending, unless governments “exploit” the crisis to reimagine and reinvigorate their health financing system.

A. Annexes

Annex 1 Purchasing Arrangements, Selected Arab Countries

Country	Institutional structure and reform	Pooling
Algeria	Current: Purchaser–provider integration Funds of the Ministry of Health, Population, and Hospital Reform (Ministère de la Santé de la Population et de la Réforme Hospitalière, MSPRH) flow through the integrated system by rigid line-item budgeting based on historical trends (passive purchasing) Recipients of the funds (hospital managers) have very limited autonomy over their internal financial resources except for some teaching hospitals and the experimental teaching hospital in Oran Social health insurance schemes make a global (lump-sum) contribution to the MSPRH budget. They contract also with private providers for certain services such as dialysis and cardiovascular therapies	Horizontal separation
Bahrain	Current: MOH (provider and purchaser) Reform: New health insurance fund (Social Health Insurance Fund Authority) created to administer new dedicated taxes for the health sector under revenue generation reforms.	Horizontal separation
Egypt	Reform: The Universal Health Insurance (UHI) Authority will be the main purchaser for UHI-covered services	Horizontal separation
Jordan	MOH without a new purchasing structure; it purchases on behalf of the Civil Insurance Program. Royal Medical Services has its own centralized management system There is no single legal entity that consolidates all funds and is mandated with the task of revenue pooling and purchasing The health system has multiple entities such as the Civil Insurance Program fund and the Royal Medical Services fund, undermining economies of scale and better bargaining power There are no clearly defined roles and responsibilities or a charter that defines the relationship between payer, provider, and regulator	Horizontal separation
Kuwait	Current: MOH (provider–purchaser integration)	Horizontal separation
Lebanon	Hospital oriented, capital intensive, and requiring large-scale imports of medicines and medical equipment. All public agencies contract out for hospital care, which makes them the main payer	Horizontal separation
Morocco	Current: Law 65-00 obliges purchasing–provider separation. The National Health Insurance Agency (l’Agence Nationale de l’Assurance Maladie) is not a fully-fledged purchasing agency Private insurance companies manage nonsubsidized health insurance schemes for their beneficiaries by collecting their contributions and purchasing healthcare services	Horizontal separation
Oman	Current: MOH (provider–purchaser integration)	Horizontal separation
Qatar	Previously: SEHA, the national health insurance scheme Current: Private insurance companies act as the main purchaser	Horizontal separation
Saudi Arabia	MOH without a new purchasing structure (provider–purchaser integration) for nationals New health insurance funds (Compulsory Employment-based Health Insurance) created to administer new dedicated taxes for the health sector under revenue-generation reforms	Horizontal separation
Sudan	Previously: There was no purchasing–provider separation Current reform: The previous health insurance fund (NHIF) purchases and administers new dedicated taxes for the health sector under revenue-generation reforms in one pool	Previously: Vertical separation. Current: No separation
Tunisia	The National Health Insurance Fund purchases health services from public and private providers, and directly provides services at facilities for its beneficiaries	Horizontal separation
United Arab Emirates: Abu Dhabi	DAMAN and Thiqa act as main purchasers (with no separation between pooled funds and purchasing) The Health Authority of Abu Dhabi acts only as a regulatory authority	No separation

1. MOH, Ministry of Health

Annex 2 Summary of Compulsory Pooling Arrangements in Selected Countries in the Arab world

Country	Single or multiple “insurance” fund/s	Type of reform	Year	Implications of reform
Algeria	Multiple social security funds, National Health Insurance Fund for Salaried Workers and their Dependents (Caisse Nationale des Assurances Sociales des Travailleurs Salariés, CNAS); and National Health Insurance Fund for Non-Salaried Workers and their Dependents (Caisse Nationale des Assurances Sociales des Non-salariés, CASNOS)			Fragmentation
Bahrain	Single Social Health Insurance Fund Authority responsible for implementing the National Social Health Insurance Program (SEHATI)	Creating a new pooling agency	2018	To be fully implemented mid-2020, so impact is unknown
Djibouti	Single National Social Security Fund (Caisse National de la Sécurité Sociale, CNSS), which segments population groups
Egypt	Universal Health Insurance Authority merging different pools previously under the Health Insurance Organization	Creating a new pooling agency	2018	Considerable defragmentation
	Parallel to ongoing old system: Health Insurance Organization has separate fund pools for their different population groups		Earlier years	Fragmentation due to options and linking entitlements by income. Inefficiencies. High out-of-pocket spending Existing system still fragmented
Iraq	Efforts to create health insurance in Kurdistan government
Jordan	Multiple pools (Civil Insurance Program via Ministry of Health, Royal Medical Services, Social Security Corporation, private insurance). Populations segmented by socioeconomic group			No reform: likely double coverage of citizens Fragmentation
Kuwait	Single pool via DAHMAN segments population in two schemes: Afya for retired nationals management by DAHMAN (private entity) and funded by the government	Creating a new pooling agency	2016	Further fragmentation
Lebanon	Multiple social insurance funds (National Social Security Fund, civil service, army, security forces) and Ministry of Public Health as “insurer” for the uninsured
Morocco	Multiple social security agencies for different population segments: Health Insurance Fund for Civil Servants (Caisse Nationale des Organismes de Prévoyance Sociale, CNOPS); Health Insurance Fund for Formal Sector Salaried Workers (Caisse Nationale de Sécurité Sociale, CNSS); and subsidized Social Health Insurance Program (Régime d’Assistance Médicale, RAMED), with phased expansion to the poor nationally since 2012
Oman	Multiple pools: Ministry of Health’s Dhamani health insurance scheme Planned: Unified Health Insurance Policy for private sector employees	Social health insurance	2019	Further fragmentation
Qatar	Multiple competitive private pools		2015	Further fragmentation
Saudi Arabia	Multiple pools Compulsory Employment-based Health Insurance	Creating a new pooling agency	2006	Fragmentation
Sudan	Multiple funds: National Health Insurance Fund (NHIF), HIKS Several other pools at state level, armed forces, police, and Ministry of Interior	Centralizing formally decentralized pools (but reform is pending)	2016	New NHIF mandates coverage to all including coverage of vulnerable groups (pensioners, poor), and is subsidized by public funds. In 2019, first medical coverage of Sudanese returnees launched under the NHIF
				Boards of various state branches were abolished in order to unify all pools
Tunisia	Creation of National Health Insurance Fund (Caisse Nationale d’Assurance Maladie, CNAM) as a merger of CNSS and CNRPS Within CNAM, segmented public sector, family doctor, reimbursement Assistance Médicale Gratuite (AMG) 1 and AMG 2 being expanded	Creating a new pooling agency	2004	Considerable defragmentation
United Arab Emirates
Abu Dhabi	Single quasi-publicly run fund (DAMAN) segments population into three insurance schemes: Thiqa cover, available only for Emirati nationals; Basic cover, mainly for unskilled laborers and lower-paid employees; and Enhanced cover, mainly for higher-skilled expatriate workers	Creating a new pooling agency	2007	Equity concerns. Fragmentation
Dubai	Multiple private pools	Mandatory private insurance	2014	Inequity/overutilization. Fragmentation

1. Note: Empty cells mean no detailed information found