Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean.

Countries of the Eastern Mediterranean Region (EMR) of the World Health Organization have never been as committed as they are today to ensure that all people have access to needed health services without the risk of financial hardship – the message of universal health coverage (UHC) (1). The average share of out-of-pocket payments for EMR countries stands at around 40% and in some countries is close to 70% of total health expenditure (2). This constitutes a major hindrance to pursue the goal of UHC and calls for establishing prepayment and pooling arrangements that guarantee financial protection to all population groups. In their quest for equitable, efficient and sustainable forms of prepayment, countries can choose from multiple arrangements that include allocations from general government revenues, obligatory health insurance, and modalities such as voluntary health insurance and medical saving accounts. Traditionally, obligatory health insurance financed through premium contributions (from employers and/ or employees) was called social health insurance (SHI), but these days SHI describes a variety of ways of raising and pooling money that involves a mix between obligatory insurance contributions and general government revenues. This change has come about in high-income countries as populations have aged and the ratio of those who pay contributions to those who do not has fallen, so general government revenues have been mixed with obligatory contributions. Similarly, in lowand middle-income countries – with their large informal sector1 and vulnerable populations, the concept of SHI has evolved into a prepayment arrangement that is not only funded by premium contributions but also financed from government allocations to subsidize contributions on behalf of the poor and vulnerable populations, including those in the informal sector. Many elements of this new definition of SHI make it an attractive arrangement that countries worldwide are employing or considering implementing. This is also the case with most EMR countries. In EMR, countries have been distributed into three groups2 that are at different stages of introducing or expanding this new vision of raising and pooling funds for health, frequently called SHI. Many countries in Group 2, which are mostly middle income, have a long tradition of obligatory health insurance contributions and have managed to expand coverage to the poor and part of the informal sector using government subsidies; for example, the Islamic Republic of Iran. As an alternate approach, Morocco and Tunisia implement a separate subsidized SHI scheme to cover the poor and vulnerable population. As for Jordan and Palestine, SHI is managed by the Ministry of Health. Despite the multitude of SHI arrangements, the share of out-ofpocket spending remains unacceptably high in many Group 2 countries due to a relatively small benefit package, substantial co-payments, and vulnerable population groups who are not covered. Group 1 or the Gulf Cooperation Council countries rely mainly on general government revenues generated primarily from natural resources to cover a generous package of health services for their citizens. In recent years, Qatar and the United Arab Emirates – in particular in Abu Dhabi and Dubai – have shifted from general government revenue to SHI to cover nationals for all or selected services. The large expatriate populations in these countries are either covered by private health insurance or are granted access to a limited package against nominal payment and in