Health Insurance on Farmers Day is a Partial Step in the Wrong Direction
In a sudden move by the state to mark Farmers Day, a law was issued by presidential decree number 127 for 2014 to institute health insurance for farmers who have no insurance protection under any other law.
The law states, “A farmer is anyone who practices agricultural activity as a profession and whose primary source of income is agriculture.” Under the law, the General Agency for Health Insurance will oversee the provision of medical treatment and care services by specified treatment bodies in and out of farmer units, in accordance with the levels of health service and rules regulating them issued by order of the health minister. To fund the system, the law requires the Ministry of Agriculture to meet annual premiums borne by farmers, assessed at 1 percent of net income up to a maximum of LE120 annually per person, as well as premiums paid by the state treasury in the amount of LE200 annually per individual.
Although health insurance for farmers can be viewed as a measure to bring justice to a class of people long denied health protections, at the current time this measure is a hasty step in the opposite direction from the strategies for the radical overhaul of the health system, recently announced by the Ministry of Health and Population in a strategic paper issued with the support of civil society and the World Health Organization. Moreover, the law appears to have been stripped of any meaningful content insofar as it lacks clearly defined enforcement mechanisms, and there are real doubts about available funding sources and their capacity to realize effective health services for a group that constitutes 40 percent of the workforce in Egypt.
In this context, we believe the law is politically designed to appease a broad swathe of those most in need of health protections. It is an extension of other decrees issued over the last three years to extend health insurance protections to female heads of households and pre-school children—projects that have not offered genuine health coverage to those most in need of it, despite laws issued two years ago, due to the lack of instruments for enforcement and a clear vision. The plan for health coverage for farmers has the same technical problems as these previous laws. If these are not addressed, the law will provide only a semblance of coverage for one of the largest cohorts most in need of health coverage but without the actual coverage.
The law also runs counter to the course marked out by the comprehensive health insurance law, which is currently the subject of a prolonged social debate. The law separates the funding bodies from service providers and creates a new insurance umbrella using the model of family medicine and relying on an incremental geographic expansion rather than the proposed expansion of eligible classes. This only further fragments the system, contributing to the multiplication of health systems and squandering financial resources. It also precludes the construction of integrated structures that permit the formation of an effective, mutually beneficial insurance fund to distribute the financial risk of illness and achieve a method for mutual support that includes various ages and social cohorts, which in turn will guarantee financial sustainability.
This sudden decision raises numerous questions about realistic means of enforcement that will actually bring health coverage to farmers. For example, where will farmers access these health services? In poorly staffed family health centers and units in the countryside, or in district hospitals that suffer from deteriorating services, poor resources, and a lack of human health resources necessary for operation? Is the Health Insurance Agency actually capable of providing these services, even as it currently struggles to meet its obligations to only 8 percent of its insured beneficiaries?
Moreover, what is the fate of state-financed treatment system, whose resources go to treating cohorts denied health insurance for catastrophic, costly illnesses? What guarantees are there that these laws will later be incorporated into the new comprehensive health insurance law if the systems are oriented in different directions? There are also numerous questions about mechanisms of implementation, involving how to join the system, how to define the targeted farmers, how to collect premiums, and how to open an independent, special account for farmers with the General Agency for Health Insurance, despite the need for a unified fund to pool risk and distribute it efficiently and fairly, as well as questions regarding how the cohorts targeted by the law will be identified and defined.
It should also be noted that this decree was drafted in a relatively short period without even being brought before the health insurance law committee and without any discussion or debate with other social actors. It has been insulated by political support at the highest level, in contrast to the proposed law for comprehensive health insurance.
These are all legitimate reservations and questions. If these questions remain unanswered, in the end this will be a well-intentioned law that lacks any real enforcement mechanisms.