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MIS Comments concerning the draft of the social health insurance law

Article (1) Definitions:
The insured: The beneficiary employee or worker of the health insurance settled in an employment or a permanent degree and who paid subscription fees of health insurance.

We note from above definition that the beneficiary of the health insurance must be an employee or worker in a permanent employment and has paid the subscription fees and therefore the employee family is not covered by the health insurance ( as per the proposed bill ) or any employee who fails to pay premiums in addition to the unemployed as the experiences of the low income countries emphasize that expanding the social health insurance is very difficult even in countries with average income higher than Yemen such as Indonesia which started this type of insurance since the sixties and until now the coverage is not exceeding 13% of the population although the average income in Indonesia is double that in Yemen. In Bolivia the health insurance started in the thirties and the coverage level is not exceeding 18% and in Salvador it started since the sixties and the coverage is not exceeding 11% although the average income is four folds that of Yemen and similarly in Namibia and Thailand.


The essay was unsuccessful except in a limited number of countries such as South Korea and the Argentine because the average income in both is more than Yemen in twenty folds (exceeds eight thousand USD) and in addition to that the project started since twenty years ago" started in Argentine since eighty years" and is not covering all citizens until now" and how many centuries do we need to achieve our goals in covering all citizens of the republic with the health insurance through reliance on this method of insurance?


Employer: The administrative organ of the state and the public and mixed sectors units as well as each natural or legal person employing one or more workers against wages.

We note from the definition of the employer that all employers even those with limited income (owners of small stores) who employ one or two employees are required to insure their employees by the law although the experiences of other countries obligate the owners of establishments whose employees exceed a certain number to cover them with health insurance.


Article (7):
Services of health insurance of the insured include the preventive services:
It is a common practice that preventive services are not included under most of the health insurance services and in Yemen they are considered one of the tasks of the primary health care in the ministry as all preventive services and activities must be free of charge and not linked to any premiums paid by the beneficiaries but the cost is borne by the state especially as our country is still one of the countries still infected with many epidemics and it is unreasonable to make the basic preventive measures such as vaccination and mother and child care linked to any insurance scheme still contained in a limited number not exceeding 5% of the total number of citizens (official employees) . Does this mean that preventive services shall be limited to those who pay premiums or will it cover all? If it is limited to them we commit a crime against others by depriving them from the basic preventive services? And if services are to cover all, which is the ideal situation, then why should the employees only bear the cost of these services and how should we deduct from their salaries to provide them with preventive services which are provided freely to others? The preventive services also become valueless in certain cases if they do not cover all targeted categories either they be employees or not who are committed to pay from their salaries or not and therefore there is no way to avoid the freeness of all preventive activities to all and not to subject them to health insurance.


Article (8):
The patients insurance is funded from the following resources:

First: Monthly Subscriptions (6% employer or government and insured share from wages 5%):
1- Employees salaries (in public and private sectors) are very low and could not bear more deductions.
2- Employer shall deduct his share (imposed on him) of the total employee wages even though deduction is not immediate.
3- Together with the negative impact which the deduction shall have on the employees especially if the resulting service was unexpected, however the financial return of these deductions in the best conditions will not reach the volume of the budget of the Ministry of Public Health and Population and in this instance how do we aspire to achieve what the Ministry failed to do?!


Second: Contributions of the Insured (with a third outside the hospital):
This percentage is considered very high as a common practice the percentage of tolerance of the insured is not exceeding 10% especially in the government health insurance. Usually, this limited percentage is taken not as an additional source of funding but as a precautionary measure to limit waste or exaggeration to use free services provided. However this high percentage may form a real impediment facing the low income people, which makes them abstain from referring to doctors even though their health conditions require doing so.


Third: Other Sources (duty on cigarettes):
Together with the additional charge this source may be detrimental to a big category of citizens, therefore it is primordial when including additional duties on this cursed bane that it should be in favor of the health insurance particularly if it is located to treat chronic diseases related to this commodity particularly cancer diseases although this proposal bears difficulty of implementation as tobacco companies shall refuse that as it previously happened when the Parliament discussed a draft bill of fighting smoking.


Fourth: Resources Investment Return
It is natural to invest the surplus of resources and resources shall not increase as long as we aim at gradual or geographic expansion of the social health insurance application which requires creating appropriate health facilities all over the country which completely lacks them. It is unnatural to think about the occurrence of any surplus while we need decades to reach an acceptable level of health services provision in accordance to the proposed insurance pattern.


Article (13):
The stop of insurance effectiveness:
• It may be natural that the insurance application on the insured be stopped  during his absence outside the country in a private visit but the insured has the right to obtain a suitable compensation if he was in an official mission for his employer.
• It is also natural that the private leaves are included in the insurance as long as there is deduction from the salary of the insured to support the health insurance resources unless the leave is unpaid.


Article (15):
Treatment of the insured and treatment facilities defined by the Authority:
Upon the imposition of the health insurance, carrying out treatment of all by the Insurance Authority in selected contracted facilities or facilities selected by the Authority has a great disadvantage on the private medical sector as a whole, physicians, hospitals, diagnostic centers and pharmacies, taking in consideration that the private sector is currently outmatching the government sector but if the Authority officials don’t contract with any private entity they may decide the failure of that entity as they control the treatment of about one million employee (governmental and private) which shall be a cause for administrative corruption, bribes and many encroachments more than what may be imagined and on the account of the provided service quality and consequently the result shall be the regression of the private health sector even though the Authority creates criteria based on which contracting is made. There shall remain the evaluation of the proper facilities for contracting as a fertile ground for bargaining. It is easy to avoid such criteria particularly in the absence of qualified cadre and an active association or authority which groups the owners of private facilities to protect their rights and the absence of any role for doctors' syndicate or union for the paramedical professions.


Article (16):
The insurance of work accidents form an additional charge on the employer and consequently an additional charge on the little salaries and that involved also interference with the work and responsibilities of the Ministry of Insurances and Insurance Funds.


Article (26):
The Council of Ministers may adjust the value of premiums and contributions:
If the worst part of the draft is the obligatory deduction with the monopoly of service provision this article gives the Council of Ministers the right to increase premiums and contributions without any need to amend the law or the ratification of the parliament and consultative council. Therefore, if the applications are insufficient to enable the Authority to carry out its tasks and instead of charging the deficit to the government it is easy for it to double the percentage of premiums and contributions by a resolution from the Council of Ministers upon presentation from the Minister of Public Health and Population taking in consideration that the Ministry of Health agreed with experts that only a percentage of 5% shall be deducted (3% from the employer and 2% from the employee) while the law appeared with a percentage more than double that agreed upon and it is not excluded that a resolution shall be issued to increase the percentage even before proceeding to provide services although in the majority of states that rely on the contribution of its employees this contribution of the employees is not exceeding 2% in countries such as Egypt, Australia, China, Bulgaria, Finland, Guatemala, Panama and other countries.


Comments on the draft republican resolution to establish a health insurance general authority

Article (9):
If the Authority provides health services to the insured throughout the Republic including the preventive services and health education what role shall remain to be carried out by the different sectors and several departments of the Ministry of Health?

• When the Authority contracts with physicians and other medical professionals shall it resort to expatriate professionals and in this instance the salary budgets shall be insufficient and if contracting is made with local professionals shall the Authority stick to low salaries determined by civil service regulations? And at this point how will it guarantee their loyalty and seriousness in their work? And if they are granted suitable and satisfactory allowances shall salaries of their colleagues in the Ministry remain without adjustment?


Article (12):
If the state commits to pay any deficit of the Authority funds what are the controls that prevent the Authority from being indebted permanently even though its yields were billions. However, if the duties of the state are to support the Ministry of Health with appropriate budget to provide the citizens with basic services that will be infeasible if not associated with activation of reward and punishment principle and doing justice to qualified cadre and in the absence of that what shall be new shall not exceed increasing corruption and waste whenever allocations increase.


Article (24):
As long as the chairman of the Board of Directors (the Minister of Public Health and Population) has all main tasks and competencies in his hands including the final decision upon offers and tenders related to the activity and projects of the authority his role surpasses the supervision of the Authority to the direct responsibility thereupon and consequently there is no reason to establish the Authority and it may be sufficient to strengthen the role of the General Department of Health Insurance and that may save expenditure instead of creating branches in all governorates and a number of general departments within the Authority in order that the General Department of Health Insurance carries its role through the facilities of the Ministry of Public Health and Population in governorates.


General Remarks on the draft bill of Social Health Insurance

1- The authors of the bill try to make use of the experiences of some countries which already used this kind of insurance but they ignored the substantial differences between our country and those countries and among the most important differences is the availability of specialized national cadre in those countries and their lack in our country especially outside the main towns in addition to limited dissemination of health facilities particularly with different geographical natures which make more than half the population in Yemen out of the reach of any health facility (private or governmental).
2- If we suppose the possibility of this project success even partially that is based on an assumption of exaggerated efficiency and idealism in the insurance authority with its different leaderships. What are the guarantees that will make the Authority distinct and financially and administratively different and what shall guarantee that the law will not be merely used as a means for collecting huge amounts from destitute employees under the force of law to transfer to a limited number of officials in the Authority and some providers of medical services as far as the employee is committed to pay the premium and receive service, if any, notwithstanding the standard and quality (Who will guarantee quality? Who will monitor, make accountable and punish?).
3- If the social health insurance emerged to solve the problem of weak classes this law makes them weaker by deducting part of their salaries especially as it does not observe the limited income employees as is the case in certain countries such as Belgium and Australia where deduction starts from salaries when a salary exceeds a certain limit and the limited income people are exempted and nevertheless they are provided with health services. If one of the characteristics of the social health insurance is to achieve justice and provide all people with comprehensive health coverage this is a far reaching objective at present time. Yet the application of the social health insurance in Yemen as it is presently is far from achieving justice as the experts of social health insurance assumed that this insurance shall start in Yemen by the year 2003 and shall achieve overall coverage by the year 2035 and that a category of permanent employees in the public and private sectors shall be covered by the social health insurance by the year 2020. In my opinion these are very optimistic periods as by using this type of insurance we need decades to provide suitable health services in the main towns only. Is it of justice to deduct from salaries of employees against services that may reach them after decades or probably will never reach them? Therefore, to achieve justice we have to liaise between deduction from salaries for the account of insurance and the time it may be possible to provide suitable health service in order that deduction from salaries shall not be unjustified.



First: from the recommendation of the health and population committee of the Consultative Council:
- The committee recommended the implementation of the health insurance system by stages.
- The monitoring and accountability element should be tightened to protect the insured from mistreatment and exploitation.
- The experience should be judged in accordance to scientific criteria and bases (volume and standard of services, opinion of the insured, service providers and cost compared to impacts).


Second: from the recommendations of the Consultative Council members after reading the report:
- The state should take all legal and administrative measures to guarantee increased health care to citizens.
- The law should be reviewed in order not to contradict the social security law and to avoid duplicity.
- To go step by step in health insurance in order to accommodate malignant and dangerous diseases at the beginning.
- Discuss the report and the two bill drafts and the decision with the General Federation of Trade Unions in the Republic.
- Transparency and clarity in the management of the existing insurance funds to secure the rights of subscribers.


Third: recommendations as a result of review of all above remarks:

1- Staging and gradation of the application of health insurance
We recommend delaying the issue of the law pending the application of a practical experience (experiment study) and it is appropriate to start by trying the content of the law on the employees of the Ministry of Public Health and Population so that the Ministry of Public Health and Population shall deduct from its budget an equivalent of 11% of its employees wages and shall endeavor through its institutions to provide health insurance service under the supervision of the General Department of Health Insurance for all the employees of the Ministry of Health and their families.

If the service required to provide for them is unavailable in the institutions of the Ministry it may be possible to get the assistance of other health institutions on the expense of the health insurance and after six months the experience shall be evaluated in accordance to scientific criteria and basis under supervision of specialized parties within the Ministry and outside and based on that if that experience failed with employees of the Ministry of Health its failure in the remaining ministries and different work authorities shall be an absolute and sure result but if the experience succeeded then it shall be generalized to all employees of the state and their families towards obligatory health insurance taking in consideration upon implementation of the experience that the provision of the service to the employee as an individual without his family shall not realize the employment satisfaction and family security even if that requires the contribution of the employee to the cost of his independents treatment.

Before and during the implementation of the experience the Ministry of Public Health and Population must carry out its real role to rehabilitate its hospitals in order to provide services through them and not to resort in future to sending the difficult cases for treatment abroad on the expense of the health insurance of the employees of the Ministry.


2- Raising the standard of the available health services to citizens
It is possible to create the opportunity for the competition of health services providers to provide the best care when opportunities are equal to all providers of the service. When the citizen and his employer are free to select the health institution which they desire to refer to, either this institution is government or private, and in any governorate whatever it is that will encourage all health institutions (including hospitals, clinics and diagnostic centers) to excel in the provision of better services with the least possible cost. Seeking the achievement of this objective the following must be followed:
• Make the mandatory health insurance to the employees of the state and those working in companies and establishments which the number of permanent employees is more than five.
• Give complete freedom of employers to select the insuring company on its employees provided that this company is permitted to practice health insurance either that may be a local, foreign, government or private company.
• The Ministry of Health may adopt a project to establish a private company for health insurance under the supervision of the General Department of Health Insurance to compete with other companies and this company may be prioritized in providing the service to the state employees through bilateral contracts between the company and the state institutions so that the state institutions may contract with others in case the insurance company violates its obligations including the failure of the company to provide a distinct standard of health services which makes the company always keen to provide the best possible level of services with self monitoring and self funding (by installments paid voluntarily by government authorities when they find distinct services against what they pay).


3- Tasks that must remain entrusted to the Ministry of Health
With gradual expansion of the health insurance based on free competition principle in the provision of health services that shall alleviate the burdens of the Ministry of Health but shall not excuse it from undertaking its role  in all preventive activities that should be free and not linked to any deductions, insurance or otherwise as it is a right for all and no area should be deprived of vaccination, education, motherhood and childhood services and other preventive services by reason that they are not listed under the social health insurance. Additionally, it is important that the Ministry undertakes the following:
• Treatment of chronic cases supported by the state in most states of the world such as cancer and kidney failure and similar cases.
• Provide drugs to chronic diseases such as hypertension, diabetes and epilepsy.
• Treatment of destitute patients who have no sources of income and not subscribed to any insurance entity.

For the importance of these tasks and their high cost (especially treatment of cancer) it is possible to allocate duties imposed on cigarettes to implement these tasks as there is a direct relationship between smoking and the occurrence of malignant diseases. It is also possible to make use of international donations and grants and local donations to make the Ministry play its role completely and therefore we may stop thousands of beggars (in mosques and roads) by reason of disease or disability.