A qualitative study of the government’s implementation of the Universal Health Coverage in Egypt: stakeholders’ perspective

Abstract

Background

Egypt has made significant strides in strengthening its healthcare system, guided by Vision 2030 and aligned with the United Nations’ Sustainable Development Goals (SDGs). Despite progress, challenges persist, including a high burden of non-communicable diseases, strained resources and a fragmented health system. The Universal Health Insurance System (UHIS), launched in 2018, aims to address these issues by providing equitable access to quality health services while ensuring financial protection.

Objective

This study explores stakeholders’ perspectives on implementing Universal Health Coverage (UHC) in Egypt, focusing on the relationships and resources required, successes and challenges and its impact on citizens’ access to care.

Methods

A qualitative, cross-sectional study was conducted between 2021 and 2022, involving in-depth interviews with eight key stakeholders from government bodies and international organizations. Data were analyzed using thematic content analysis to identify critical themes underpinning Egypt’s UHC implementation.

Results

Stakeholders highlighted that strong political will, alignment with the SDGs and existing infrastructure, including digital systems and healthcare education programs, were pivotal in launching UHC. This study’s key contribution is to provide qualitative insights from these key stakeholders, demonstrating how their experiences with the Port Said pilot implementation revealed successes in increased service accessibility and improvements in governance. However, challenges remain, including financial sustainability, workforce shortages and gaps in public awareness and cultural adaptation. While infrastructure and governance reforms have enhanced health service access, further efforts are needed to sustain and scale these improvements nationally.

Conclusions

Egypt’s UHC reforms demonstrate the potential to transform health outcomes, aligning with goals of equity and financial sustainability. The study’s findings provide specific policy recommendations and implications, highlighting the need to focus on the financial sustainability of the system, reform governance and prioritize public awareness for effective execution. Lessons from the Egyptian experience, particularly the phased rollout, serve as valuable insights for other countries. Maintaining momentum requires adaptive strategies integrating global best practices to ensure UHC’s long-term success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-025-01412-x.

Background

Egypt has accelerated the strengthening of its health system on many fronts, as guided by the health pillar of Vision 2030. Egypt’s 2021 Voluntary National Review highlighted that key health indicators have improved or maintained progress [1].

However, despite these overall improvements, Egypt’s health sector has faced many key challenges, both from the demand (population) and supply (health system) sides. While striving to cater to the health needs of its slightly more than 105 million population [2], who are facing a growing burden of non-communicable diseases (NCDs), which now account for 85% of all deaths [3], high population growth, and a longer life expectancy [4].

These rapidly increasing diverse demands for quality health services have burdened and strained the seriously underfunded service delivery system, which is highly fragmented with suboptimal provider payment mechanisms that offer low quality of care and lack adequate, well-trained and motivated human resources for health. [5].

In 2015, the world adopted the Sustainable Development Goals (SDGs), a roadmap for achieving peace and prosperity for people and the planet, both now and in the future. At the heart of these 17 goals lies indicator 3.8.1 for achieving Universal Health Coverage (UHC), which calls for all people to have access to the full range of quality health services they need, when and where they need them, without financial hardship [6]. In 2019, 56.9 million Egyptians had medical insurance coverage, up from 51.1 million in 2015 [1].

As a significant milestone, the new Egyptian Constitution explicitly recognizes health as a fundamental human right. It declares a commitment to covering the entire population with comprehensive, high-quality health services as a human right. Universal Health Insurance (UHI) was mandated in the Egyptian new constitution and the health pillar of the National Sustainable Development Strategy, formulated in 2015, SDS-2030, as the means for achieving UHC. [7]. Egypt endorsed the UHI law in 2018 and has initiated a 10-year strategy to implement the UHI system.

The UHI law defined a more extensive health system reform to Egypt’s health sector, entailing a significant transformation with profound institutional, functional and regulatory restructuring. It entailed forming three new organizations: the Universal Health Insurance Authority (UHIA) as a payer, a separate health care provider organization (indicating a split in service provision from the Ministry of Health) as the Egyptian Healthcare Authority (EHA), and the General Authority for Healthcare Accreditation and Regulation (GAHAR) for setting quality standards, monitoring quality and granting accreditation in addition to two supporting authorities: Unified Purchasing Authority (UPA) and the Egyptian Drug Authority (EDA).

The UHI system is currently being implemented in six governorates: Port Said, Ismailia, Luxor, Suez, South Sinai and Aswan; part of its first phase within the government plan is to roll out the system geographically in six phases, where all Egyptians are to be covered on a mandatory basis through whole family membership and family health model of care, building up the social solidarity concept through including vulnerable groups whom the government will subsidize. In addition, the UHIL offers optional coverage for Egyptians residing abroad and comprehensive coverage for all foreign residents, contingent upon reciprocal agreements with their respective countries.

The UHC reform aims to break the cycle of poor health outcomes and poverty at both the individual and national levels, a connection emphasized during the coronavirus disease-19 (COVID-19) pandemic, which highlights how health system vulnerabilities can lead to economic instability. The UHI law mitigates financial hardship by covering premiums and co-payments for poor and vulnerable populations, providing essential financial risk protection.

While the UHI law reflects the government’s commitment to achieving UHC, its realization demands extensive transformation and restructuring of the health system. The initial 5 years of implementation, since 2018, have been a critical learning phase, highlighting the requirements for effectively scaling UHIS, particularly in more extensive, populous, and underserved governorates.

However, there is a lack of qualitative research examining the perspectives of stakeholders involved in system implementation. Thus, in this study, we explored the impact of implementing UHC from the perspectives of stakeholders and international development agencies to fill this research gap. We conducted this observational cross-sectional study with a qualitative component to investigate the stakeholders’ perspectives on implementing UHC in Egypt.

Methods

Study design

This cross-sectional, exploratory study utilized a qualitative approach to examine the impact of Universal Health Coverage (UHC) in Egypt. It focused on capturing the perspectives of diverse stakeholders within the Egyptian healthcare system, spanning the planning to implementation phases. The study assessed the successes and challenges encountered during the implementation of UHC between 2021 and 2022.

Sample size and sampling technique

The study conducted in-depth interviews with eight key stakeholders, all prominent policymakers and instrumental figures in the planning and implementation of UHC in Egypt. Participants were selected using a purposive sampling technique to ensure the inclusion of individuals directly involved in the Universal Health Insurance System (UHIS) rollout. Over 1 month, a uniform interview guide was employed to gather insights into stakeholders’ experiences, perspectives and challenges during the UHC implementation process.

Data collection tools

Eight semi-structured, in-depth interviews were conducted to explore stakeholders’ perspectives on UHC in Egypt comprehensively. The interviews featured open-ended questions designed to encourage detailed responses and were guided by a framework developed through consultations with key informants and a thorough review of relevant literature. All interviews were recorded, transcribed verbatim and translated to facilitate accurate analysis and interpretation. The interviews lasted around 60–90 min, in person and follow-up was done through email. The interview guide is provided in Annex 1.

Data analysis

Data processing was based on the three main phases of the thematic content analysis technique [8]. Relevant quotations were organized, analyzed and evaluated throughout the following stages. The first stage is pre-analysis, which involves organizing materials to facilitate understanding of ideas through comprehensive readings of data transcripts. The second is a selection of the interviewed participants’ relevant statements and organization of categories. The third stage involves processing the results and their interpretation. Participant quotes were used to illustrate the meaning of themes and summaries through descriptive, critical narration.

Our inductive analysis yielded four main themes that describe significant elements of Egypt’s Universal Health Coverage system. The themes represent the relationships and resources that enabled Egypt to establish the UHC system, as well as the program’s launch and its current operations, including its successes and challenges.

In-depth interviews were analyzed using an inductive, conventional content analysis approach. [9]. A subset of transcripts was initially “open coded” to inductively abstract patterns and themes in the data related to the central research questions. This resulted in a set of draft codes piloted, revised and finalized into a codebook. Software DEDOOSE coded transcripts; coded data were inductively analyzed to establish draft thematic categories that linked the data to the central research questions. These categories were then labelled and elaborated. These draft categories were further revised and refined by examining relationships within and between categories to develop a theory about crucial relationships and draw conclusions substantiated by the data. This resulted in three themes, as reported below.

Results

Participant characteristics

Six of the eight stakeholders were males, and six were also members of the Egyptian government, including two participants from the Ministry of Health and Population (MOHP), one from the Ministry of Finance (MOF) and one from the Ministry of Telecommunication (MOT). In addition, one is from the Egyptian Healthcare Authority (EHA) and the other is from the Universal Health Insurance Authority (UHIA), which are two of the three authorities that govern the UHC operation in Egypt. The last two participants were members of international development partnering agencies, including one from the World Bank and the other from the World Health Organization (WHO).

Stakeholder analysis

		Authority
		Has	Doe not have
Interest	Has	MOHP, MOF, EHA, UHIA	WHO, WB
	Does not have		MOT

High Authority & High Interest (upper-left): MOHP, MOF, EHA, UHIA—institutions that both shape decisions and are actively engaged

High Interest & Low Authority (upper-right): WHO, WB—actors with strong engagement but without formal decision-making power

Low Authority & Low Interest (lower-right): MOT—limited role and engagement within this policy area

Low Authority & High Interest (lower-left): (none identified)—quadrant intentionally left blank

MOHP – Ministry of Health and Population; MOF – Ministry of Finance; EHA – Egyptian Health Authority; UHIA – Universal Health Insurance Authority; WHO – World Health Organization; WB – World Bank; MOT – Ministry of Transport

Findings

The current study yielded two key results: the first part discusses the necessary relationships and resources that made it possible for Egypt to establish the UHC system, the second describes the successes and challenges in Egypt’s UHC implementation from the perspective of key stakeholders and the final result discusses the impact of UHC on citizens’ access to care.

Theme 1: relationships and resources required to establish UHC

Three of the iteratively derived themes from our qualitative analysis describe the relationships and resources that enabled Egypt to establish its UHC system.

All the interviewees agreed that UHC in Egypt emerged due to a clear vision for supporting the population’s health. One of the ministry representatives stated, “Egypt took all the goals of the SDGs, worked on them, and put them at a higher level. The government also used a more detailed level through which every SDG sector has micro-goals with KPIs measured by 2030. And to accomplish our vision in the health sector, we needed to start by implementing comprehensive health insurance.” Revealing a conceptual shift from disease-centered care to population-centered equity. Stakeholders perceive UHC not just as a financial or service expansion, but as a moral and social commitment to inclusivity.

Another ministry representative mentioned, “Equity is the keyword of the UHIS. I see that the most important thing about Universal health insurance is that it covers all citizens. It does not cover a certain group but is for everyone. I see that this is the real meaning of the word "Universal," which means covering the population’s health more than it covers the diseases, with no differences between them.”

Egypt also targeted various public health initiatives, such as eliminating the hepatitis C virus, to provide the proper database to achieve the final goal of UHC. One of the EHA representatives mentioned that: “Haya Karima initiative started in 2019. It means a decent life, and you can say that it is a complete project that satisfies not only health but all the SDGs, like health, housing and water. It tackles health in all policies in the sense of social determinants of health because health is not just about medicine and cure; you have to take care of this aspect that is concerned with health, but it isn’t health itself.” Recognizing the importance of addressing upstream determinants and that UHC is being used as a vehicle for broader social reform, not just healthcare delivery.

Political leadership is seen as a catalyst for reform; UHC has been a presidential priority since 2014. Strong political will for UHC has also been reflected in other ministers outside of health in the government, who share the goal of covering all citizens under the UHC umbrella in an equitable manner. An international developmental representative stated, “Political will is paramount because we did not have it before. The political will pushed the people and the implementers to achieve and deliver on the ground.”

Stakeholders view the reform as evolutionary rather than revolutionary. Interviewees noted that numerous resources were available within the national healthcare infrastructure, which were readily utilized to promote UHC implementation. Some participants mentioned that the widespread network of primary and secondary healthcare facilities already provided a robust infrastructure for health services across the country. Others explained that Egypt had a robust medical education program to train the number of providers needed to deliver healthcare services under the new UHC system. Finally, infrastructure was already in place to facilitate the digital transformation required to implement UHC fully. A ministry representative stated “There were many things that can help us do this. You are not building a health system from scratch. You are rebuilding it based on foundations that existed before. Human Resources and service delivery outlets were already available. All we need to do is develop and improve these resources to match the quality progress.”

Another resource of the UHIS is a steering committee, assigned by the Ministry of Health and Population, to discuss and present the UHC law draft in a preface to parliament, emphasizing inclusive governance and multisectoral coordination and indicating an effort to democratize policy – making and ensuring buy-in from various stakeholders. It also reflects a structured approach to legislative and operational planning. This committee comprised diverse members from various backgrounds and entities within the Egyptian healthcare sector. Moreover, MOHP began assessing the infrastructure of health facilities in the governorates during the first phase of implementation. An international developmental representative stated, “The plan for the development of health facilities is moving at a fast and good pace and has resulted in excellent facilities. Sure, it will take some time, but that is normal.”

Another international development representative stated that he believes that excellent steps have been taken regarding the different health financing schemes that are relatively new in Egypt. However, there are still some challenges that require further attention, such as the development of new resources for health insurance. “I think Egypt will reach a stage within the next 2 years where it will be necessary to create resources other than those mentioned in the law to achieve the system’s financial sustainability. This requires effort and intensification from all sides to think about these new resources, how to pass them and how to get community approval for their development. This, of course, will be a challenge in itself.” This highlights the tension between ambition and feasibility. Stakeholders acknowledge that financial sustainability is a moving target and requires innovation beyond statutory provisions.

The concept of UHC in Egypt is not entirely new. Many previous attempts have been made to make health insurance available to the entire population over the past few decades. Stakeholders recognize past limitations and view the current reform as a corrective effort. One of the key differences in this latest implementation is that many stakeholders have been involved throughout the process. This includes the MOHP, different ministries and other authorities across Egypt. An International Development representative mentioned, “Health insurance in Egypt is not new. It began in the 1960s with the creation of the Health Insurance Organization to cover government employees. After that, over the years, various societal categories of health insurance were introduced, reaching a mere 58% of the population. Still, it did not achieve the goal of universality in funding or universality in the desired services, in addition to the fact that people were getting out of the system.”

Out of Egypt’s 27 governorates, Port Said was chosen as the pilot for implementing the UHIS. There were many reasons for choosing Port Said, including the low population and good infrastructure. Finally, Port Said is a digitally advanced city, which one of our participants called the first “smart city” in Egypt. An International Developmental member thought, “In any new experience, you need an example of success. I think that Port Said’s choice was successful for several reasons. No. 1: Port Said has more than 90% of its population as urban residents, with a minimal rural area. It is the highest local national product per capita among the governorates in Egypt. In terms of funding, it was not a huge burden on the government, even in supporting people experiencing poverty. Their percentage of the population was small, plus the percentage of the old insurance coverage in Port Said was more than 60%. So, this helped when applying the new system, as people already knew what health insurance meant; they knew the benefits, which contributed to their integration into the new health insurance system.”

The Egyptian government has established a plan to reduce out-of-pocket catastrophic health expenditures for its citizens. This plan could be achieved by equitably implementing the UHC to ensure the availability of proper health services to the whole population. “Of course, it was a priority. In the last few years, out-of-pocket expenditure in Egypt has massively increased. This negatively affects individual financial protection indicators, consequently leading to what is called catastrophic health expenditure and also poverty due to expenditure on health. Money paid in taxes or premiums is proportional to individual income, which does not negatively impact the citizen. The negative impact is mainly due to direct deductions or payments while receiving the service because the risk is not distributed among the healthy and the sick,” said the International Developmental representative. The actuarial studies and income-based premiums show a deliberate effort to design a fair and sustainable financing model.

Most interviewees mentioned that financial solvency was imperative for this vast national project, which led the Egyptian government to establish actuarial studies for UHC. These actuarial studies provide the necessary additional financial resources required by the UHC to ensure the economic stability of the new health system. In addition, the law established a specific premium percentage for citizens on the basis of their monthly income and the co-payment for health services. Regular updates to the benefits package demonstrate responsiveness to changing needs and cost structures, as well as efforts to institutionalize transparency and accountability in service provision.

Moreover, a committee of stakeholders from different medical backgrounds oversees pricing and updates the medical benefits package. All of these procedures have been implemented to ensure the continuity of UHC’s financing. An International Development representative stated: “In Egypt, taxes on tobacco and alcohol are applied, but there are no taxes, for example, on sugar or sugary drinks. There are also taxes on polluting industries. I believe these are other sources of income that can benefit from health insurance.”

Theme 2: successes and opportunities of UHC implementation

The participants expressed the need for overhauling the old, fragmented health system, which affects both citizens as service recipients and medical staff as they deliver care under the new UHC program. This suggests that the reform was not only a policy imperative but also a practical necessity. An Egyptian Healthcare Authority representative stated that the system’s digital transformation, including the change to electronic medical records, was imperative to a strong health system. “The information system is improving, and there is a good job in the orientation on electronic medical records. The Healthcare Authority mandates that primary care have electronic medical records, and secondary care is starting to use electronic medical records. There is a misunderstanding regarding electronic medical records; people think they are paperless, which is impractical. No matter how advanced they are in all systems worldwide, there is less paper, but not paperless. The nurses are writing by hand, and the doctors, too, are handwriting their notes. That is what the authority is trying to do: apply universal concepts. Therefore, some things have improved, and some are still in the pipeline.”

The participants compared the previous health system with the new one; the main differences they explained were the governance model and the separation between healthcare provision, financing and auditing by the three leading authorities in the UHC law. The general budgets of hospitals were previously distributed without considering the unique financial demands of each facility or governorate. Under the new system, budgets direct funds to facilities according to more data-driven metrics that reflect actual demand. The stakeholders acknowledge the importance of digital transformation but also highlight the challenges of implementation and public perception.

Participants explained the governance of the transformed health system and the integration and strong collaboration between the governmental entities, ministries and authorities, illustrating these entities’ roles in the preparation and implementation phases. They credited the UHC’s success to the macro-level collaboration, which started from the president and the parliament to the whole government by the legal framework of the UHC law. This marks a shift from centralized, uniform budgeting to decentralized, needs-based financing.

They also explained how the quality of service differs from the old to the new health system in Egypt. “Quality was not one of the goals of the old system. It has become an inherent goal, and the contract and payment are based on it. This did not exist in the old system,” as stated by an International Developmental representative. This reflects a paradigm shift in healthcare delivery. Quality is now embedded in contracts and payment mechanisms, signaling a move toward performance-based accountability.

A ministry representative described the newly transformed health system in Egypt, starting with well-defined and declared responsibilities and rights of everyone involved. He said: “It will also be easy to introduce all the concepts needed to enhance the service, like increasing salaries to encourage more physicians to specialize in family medicine and defining the guidelines to be followed, whether for referral or treatment. All the next governorates will quietly follow the rules because they already heard about them.”

An International Developmental representative stated, “Legal frames define the responsibilities of all parties involved. It also separates the roles of the parties. Service, in the present law, is separated from funding and, of course, all separated from governance. Each authority also performs governance in a specific sector. All of this facilitated the implementation of the law.”

The interviewees continued to discuss how the pursuit of UHC in Egypt was quite distinguished, as the support for the system was not coming only from the government and the politicians. The support has also come from the community, whether through the population or the civil society. This community engagement helps the government implement the culture change toward the new health insurance system. The community’s resistance has decreased over the past 4 years. On the other hand, civil society interacted with the universities and different people to discuss the law and the new health system, which helped the government get updated feedback on the UHC. The emphasis on collaboration across ministries and authorities suggests that UHC is not just a health sector reform but a whole-of-government initiative.

The interviewees explained the support offered to the new health system by different international organizations including the World Health Organization (WHO), World Bank, Japan International Cooperation Agency (JICA) and the French Development Agency (AFD) that supported the UHC from the planning and law draft discussions until the implementation and monitoring phases. These organizations support the system’s different pillars, such as digital transformation and technical and financial support. The ministry representative stated: “I believe that those bodies, although many organizations and bodies provided some assistance, were the ones that provided the most effective assistance, as we say, to the system’s success.”

Theme 3: sustainability and challenges of the UHC

The main challenges that threaten the progress of the UHC

The interviewees illustrated the main challenges or obstacles faced and continue facing the progress and sustainability in the UHC, which range from change management from the old health system to UHIS to the citizens’ acceptance and the staff shortage. This change contains the institutional health system in Egypt, such as governance, which appeared for the first time in healthcare. In addition to the governance problems between the stakeholders (collaborators in the system), there is a challenge in the healthcare workforce, especially the family physicians, who are considered one of the main components of the new health system. The interviewees also noted the funding challenges and automation through the digital transformation challenges. Finally, they also discussed guaranteeing the quality of medical services in all health facilities.

Box 1: challenges as specified by the Ministry of Health representative.

“Challenges accompany any change. Here, one of the major challenges is the existence of the PHC as the system’s gateway. An International Developmental representative mentioned, "Of course, the biggest obstacle is funding. I think the government is under the economic reform regime currently taking place in the country in light of the other economic priorities that are taking place in the country and, of course, the increasing tax burdens and the increasing social burdens on people. We are trying to provide adequate financial support for health insurance. I think this was a great and strong challenge, and the challenge is still that the actuarial study is carried out every once in a while to see whether the system will achieve financial sustainability. I believe this is a challenge that will persist for a long time. It is a challenge that faces many health insurance systems worldwide, not just in Egypt, but the whole world.” This reflects a structural shift in how care is accessed. Stakeholders recognize that positioning PHC as the entry point requires not only infrastructure but also cultural adaptation and public education. Stakeholders are aware that UHC must compete with other national priorities, and that rising social and tax burdens complicate public support for it “The second challenge, I think, is the efficiency and quality of the health services provided, especially in the government sector and even in the private sector, but more so in the government sector, as it was not at the required level, and it required investments and time to raise the efficiency of hospitals from infrastructure plus training of cadres on services and quality in proportion to a health insurance system that aims to provide services that are much better than the previous ones.” This reflects a recognition that UHC is not just about coverage – it must also deliver value and trust “The third challenge, I think, is the workforce. Egypt has workforce rates that are lower than the global average and below the World Health Organization’s recommendations, presenting a challenge. Moreover, it is not just about quantity; it is also about developing the quality of the workforce and building its capabilities. It will take time to provide it with the quantity and efficiency required, and I think this is another challenge.” This points to a dual challenge: insufficient numbers and inadequate training. Stakeholders understand that scaling UHC requires not just more health workers, but better-prepared ones

Participants explained that converting an idea into a mega project required working at many levels, or “pillars.” To create such a project on a national scale, one had to employ numerous individuals, which required significant human resource management. Management of different stakeholder entities required working together as a team, and participants emphasized the importance of management skills in transforming a project from a theoretical idea to a national-level, implemented project. A ministry representative mentioned, “One of the most important experiences I gained from such a project is teamwork. This used to be a slogan on the theoretical level, but it was practically implemented in this project, being the best means to execute such a big project.”

Setting a geographical target

Interviewees explained that one unique factor defining the rollout of UHC in Egypt is that their initial target was geographical rather than population-oriented. This strategic choice reflects a pragmatic approach to implementation. An International Development Representative stated, “Until now, the results are good, so it is a lesson in implementing it for other countries. There is a plan to accelerate implementation in Egypt. The period during which the implementation will take place will be a little less than planned by law, so that we will see this impact on geographical targeting in the next few years.”

The referral system in the UHC

Compared with the old health system, the interviewees discussed how beneficiaries previously went directly to hospitals before the implementation of UHC. Still, after implementation, anyone needing care must go directly to a family physician to obtain a referral letter to the hospital, meaning the Primary Health Care (PHC) units have become the gateway to the new health system. A ministry representative stated, “The referral system in healthcare is one of the concepts that has majorly changed. Under the UHI, there’s a certain order for examination. First, a patient has to visit a family physician or a PHC to be initially examined. According to the diagnosis of the physician, it is determined whether the patient needs further investigation and referral to a secondary or tertiary health facility, or if it’s something simple that only requires medication prescribed by the family physician. This system makes the best utilization of available resources. But traditionally, patients visited a specialist clinic directly, a major waste of resources as patients get services and investigations they didn’t need.” The new system prioritizes resource efficiency and structured care pathways, but requires public buy-in and trust in family physicians. Stakeholders recognize that this change is both operational and cultural, and that success depends on patient education and system reliability.

Under the UHC, a new authority has been established by the UHI law, whose primary responsibility and role is to set accreditation criteria and standards for health facilities. For these facilities to remain included in the system, they must adhere to the established quality standards. With this new focus on quality, the system is designed to encourage the facility to provide high-quality services that attract and retain patients. The ministry representative said: “More priority is given to beneficiaries’ satisfaction and quality of care; things people were not familiar with before, more attention is given to costs and resources management. Even though we are not yet where we aim for, at least providers now understand the concept of limited resources.” An International Developmental representative stated, “I believe that one of the most important things that altered people’s perspectives on this is that it is a participatory system rather than a system that the government must fund, and I believe that this is one of the most significant changes that occurred over time.”

The interviewees also noted that the family became the primary unit of insurance, as individuals were the primary unit in the old health system. “When the person and his family are registered, the data about every family member is sorted and filed; the family physician is responsible for medical history review, diagnosis, orientation and referral if needed. After that, the patient has the right to choose from service providers available in the system. These concepts are relatively new to Egyptian patients, and increasing their awareness will accelerate the system implementation,” as stated by a ministry representative.

Participants agreed that the public’s awareness of this new health system was limited and had not been disseminated nationwide. They also demonstrated that every governorate must have its own methodology for accepting and understanding the UHC concepts. “In the areas where the implementation took place, such as Port Said, Luxor, etc., the media and societal coverage were impressive, but I think that in some areas of Egypt with a high population density or far from implementation, people are still unaware. They have heard about it, but still do not understand the full scope of the benefits and duties of the new system. I believe awareness will grow over time as more governorates implement the program.” The need for localized strategies reflects Egypt’s diversity in population, culture and infrastructure.

Interviewees illustrated the effects of the UHC on the citizens. Stakeholders recognize that technical improvements must be matched by efforts to build trust and change perceptions. They discussed changing the citizens’ culture and building trust between citizens and public health facilities. This cultural change will lead citizens to pay premiums and co-payments. They stated that the most important thing for any citizen is to receive a health service of better quality and greater accessibility. A ministry representative stated, “The citizen does not understand this. He thinks you withheld a certain service from him. He does not get the idea of having a doctor who knows your file, your family’s file from when your children are born, everything about your illness and knows how to relate things together.” Another ministry representative mentioned: “Building citizens’ trust to eventually make them believe they can receive proper healthcare through the system, whether in public or private hospitals, is very important. We should be fully responsible for our promise to provide proper, safe and sustainable services.” (Table 1).

Table 1.

Summary of findings

Theme	Subtheme	Key points	Recommendations
1. Relationships and resources required to establish UHC	Vision	UHC is driven by Vision 2030 and SDG goals; strong political support ensures progress	Align UHC initiatives with international human rights protocols and SDG frameworks
1. Relationships and resources required to establish UHC	Infrastructure	The existing healthcare infrastructure and robust medical education programs supported the rollout	Expand and enhance the primary healthcare facilities network to improve accessibility
1. Relationships and resources required to establish UHC	Steering committee	Diverse committees drafted UHC laws and oversaw implementation phases	Include financial and economic experts in steering committees to optimize resource pooling Encourage cross-sector collaboration between health, economic and social sectors Foster inter-governmental collaboration to streamline governance roles and responsibilities
2. Successes and opportunities of UHC implementation	Successes	With its urban population and strong infrastructure, Port Said served as a pilot for UHC	Document and share successful practices from the UHC pilot in Port Said for replication and dissemination Strengthen collaboration between governmental authorities, communities and development partners
2. Successes and opportunities of UHC implementation	Opportunities	Maintaining financial sustainability is identified as a significant long-term challenge Workforce training and retention Governance	Address workforce challenges by focusing on recruitment and retention strategies Promote a phased approach to digital transformation with adequate staff training Develop innovative financial mechanisms, such as taxes on sugary drinks and pollution Strengthen internal accountability mechanisms across UHC governance structures
3. Sustainability and challenges of the UHC	Main challenges threatening progress	Promote financial accountability and transparency within healthcare services	Promote financial accountability and transparency within healthcare services Utilize data-driven insights from pilot regions to optimize resource allocation Foster effective public–private partnerships to leverage resources and expertise Promote the Green Health Insurance System as part of the sustainability agenda
3. Sustainability and challenges of the UHC	Referral system in UHC		Enhance public awareness of the referral system’s benefits to reduce resistance to it
3. Sustainability and challenges of the UHC	Quality improvement		Focus on quality improvement initiatives to enhance patient satisfaction and overall well-being Increase public awareness campaigns to build trust and understanding of UHC concepts

Discussion

Political will and forward-looking vision aligned with the SDGs were a substantial part of Egypt’s launch of the UHIS and its pursuit of UHC. From our research results, the interviewees noted the clarity of the vision of Egypt toward healthcare in Egypt, which allocates available resources including human resources or infrastructure, and determines the required economic or financial resources to start UHC in Egypt.

We compared the UHC in Egypt’s vision and the Egyptian constitution with a focus on assessing the UHC target in SDGs from the human rights perspective [10]. Both studies align with international human rights protocols and their impact on the sustainability of UHC in countries, protecting individuals experiencing poverty and vulnerable communities.

The findings illustrated earlier attempts to achieve UHC in Egypt, which were reflected in studying the financial sustainability and solvency to decrease out-of-pocket health expenditure, which was very high in the old health system. This occurs in the new UHIS by following the financial approaches of reducing out-of-pocket health expenditures and conducting actuarial studies, which increase additional resources to the health budget in Egypt through extra taxes on hazardous health products, such as tobacco.

In a survey about the pooling of the financial resources for UHC [11], the authors highlight how the model pools financial resources by mandating coverage for all citizens with a strategy already in place. They also point to another approach, which is integrating funding from both economic and health sectors to create a more complementary and sustainable system. This blended model helps strengthen financial solvency and long-term viability, similar to Egypt’s new model.

A study in Turkey, a country with a similar context to Egypt, demonstrated similar findings on the impacts of health system reform and implementation of UHC in Turkey. [12]. The study results showed an increase in service utilization, and this increase in usage, owing to insurance coverage, coincided with an increase in access to health facilities.

The study results indicate that collaboration among the community, international development partners and Egyptian government ministries and authorities was essential for the UHC national project in Egypt. Qualitative findings indicate an improvement in the quality of health facilities following the implementation of UHC; the next step is to promote access and enhance the quality of medical services within these facilities. The Ministry of Health and Population can continue promoting access, which is already improving and increasing the quality of medical services for UHC.

The World Bank’s synthesis of 11 country case studies, which showed similar findings to this study result, including pooling financial resources through mandatory coverage, is a common strategy among countries pursuing UHC. Egypt’s approach aligns with this model by requiring universal enrollment. The report also emphasizes the importance of integrating funding streams from both health and economic sectors to build a more resilient and complementary system. [13] Egypt’s strategy of mandatory enrollment for all citizens reflects a global trend toward risk pooling to ensure financial protection and equity. This mirrors approaches in countries such as Thailand and Turkey, where universal enrollment helps distribute health costs across the population and reduce out-of-pocket spending.

As reviewed in this study, Egypt’s efforts to integrate funding from both health and economic sectors, such as taxes on tobacco or sugary drinks, are consistent with multi-sectoral financing models seen in countries such as Brazil and Rwanda. These models aim to diversify revenue sources and enhance financial sustainability. [13] In addition, positioning PHC as the gateway to the health system is a cornerstone of Egypt’s UHC reform. This aligns with WHO recommendations and global best practices, where PHC is used to improve access, continuity of care and cost-effectiveness. Countries including Ghana and Ethiopia have similarly prioritized PHC in their UHC strategies.

This study highlighted Egypt’s separation of service provision, financing and regulation into distinct authorities reflects a modern governance model. This mirrors reforms in countries such as Chile and Colombia, which have adopted similar structures to enhance transparency, accountability and efficiency. Egypt’s investment in electronic medical records and digital infrastructure is part of a broader global movement toward eHealth. Countries such as Estonia and South Korea have demonstrated how digital tools can enhance service delivery, data management and patient engagement. [13].

Finally, this study emphasizes building public trust and awareness, especially through civil society and the media, which aligns with the global recognition that community buy-in is essential for UHC success. Participatory approaches have been key in countries including Mexico and the Philippines. [13].

To our knowledge, this study is one of the few that addresses UHC in Egypt at the time of its formulation, and the only one from a qualitative perspective of key stakeholders involved in health system implementation. As the study is cross-sectional, there is a primary limitation. There is no evidence of a temporal relationship between the exposure and the outcome. [14], as the exposure and the result of the UHC are assessed simultaneously. Another limitation of the study was the time required for data collection for the qualitative participants, who had a busy and tight schedule. Despite the small number of qualitative interviews, each interviewee was carefully chosen to represent a specific authority or entity that is intensely involved in the system, ensuring that saturation was reached, the point at which no new themes or information emerged from the interviews. In addition, further studies should capture the views of citizens. Finally, the end beneficiaries were not included in this study owing to logistical challenges, yet they were targeted through other surveys for monitoring and evaluation.

This study highlights the promising potential of UHC to improve health outcomes for Egyptian citizens by making health services more equitable and accessible. While there have been encouraging steps forward, particularly in infrastructure development and governance reform, the journey towards comprehensive UHC is far from complete. Achieving lasting impact requires sustained political commitment, strategic investments and collaborative efforts across all levels. Egypt’s journey aligns closely with the SDGs, and innovative policies, such as the Green Health Insurance System and data-driven resource allocation, reflect a forward-looking approach. At the same time, persistent challenges such as workforce shortages, financial sustainability and the need for robust public–private partnerships continue to be critical areas that must be addressed. Moving forward, a realistic yet optimistic strategy will be key to ensuring that UHC becomes a sustainable reality for all Egyptians.

Key recommendations for advancing UHC in Egypt include enhancing infrastructure to improve accessibility and quality, particularly for underserved populations. Financial sustainability can be achieved by developing innovative funding mechanisms and strengthening financial accountability within the healthcare system. Public awareness campaigns should be expanded to educate citizens about the benefits and responsibilities associated with UHC, focusing on building trust among vulnerable groups. Governance reforms should strengthen internal accountability mechanisms and clarify roles across UHC authorities to streamline operations and ensure transparency. Finally, fostering partnerships with private sector entities and international partners will enhance resource pooling and expertise, ultimately benefiting the organization. As Egypt expands its UHC, maintaining momentum will require adaptive strategies that integrate global best practices and local needs. The lessons learned thus far provide a strong basis for achieving health equity and social justice for all Egyptians, making UHC a cornerstone of Egypt’s vision for sustainable development.

Author contributions

AH collected the data. AH and AFM conducted the analysis. All authors drafted and reviewed the manuscript.

Funding

No funding was received for this study.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Before data collection, the Egyptian IRB was approved by the National Research Ethics Committee at the Ministry of Health and Population. All research participants provided verbal consent prior to participating in the face-to-face interview.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.