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The Ethiopian Health Insurance Agency, which runs the country’s universal health insurance (UHI) scheme, is set to implement its health services in two months. The UHI is aimed at expanding health service coverage in the country to accelerate socio-economic development, according to Doctor Mengistu Bekele, Vice Director of the Agency. “In addition, the social health insurance system is needed to achieve universal healthcare coverage via cost sharing between beneficiaries and the government,” the Vice Director said. Furthermore, it is needed because it is a sustainable health care financing mechanism that enhances equitable access to improved health services through cross-subsidization.
The UHI proclamation was issued in August 2010, making health insurance mandatory to government employees, pensioners and private employees.
The Ethiopian Health Insurance Agency was established in July 2011 to undertake the universal health insurance system of the country. According to higher officials at the agency, it will be operational in January this year.
Financing for the health service facility under the social health insurance system is to be acquired through contributions from employees, employers, the government, investment income and other related sources.
Both employees and employers will contribute 3 percent of the former’s monthly salary to the social health insurance scheme, while pensioners each ought to contribute 1 percent of pensioners’ monthly income, Mengistu said. The percentage of contribution for the health insurance system might change if the agency finds it necessary, according to Mengistu. “It will likely increase,” said Mengistu.
Employers shall be expected to withhold the contributions of their employees from their monthly salaries and timely transfer it to the agency together with their own matching contributions. The Social Security Agency also will have to transfer the monthly contributions of pensioners, together with the matching contributions of the government, to the agency.
Under the new scheme, institutions that have hired more than 10 people are obliged to provide health insurance to their employees. Any failure of employer or the relevant social security agency to transfer the monthly contributions, will lead to fine.
Those insured will enjoy essential health services and curative services-out patient care, inpatient care, delivery services, surgical services and diagnostic tests and generic drugs included in the drug list of the agency, and prescribed by medical practitioners-.
However, treatments outside the country, treatment of injuries resulting from natural disasters, social unrest, epidemics, and high risk sports, treatments related to drug abuse or addiction and periodic medial check-up unrelated to illness are not included in the health service package.
Occupational injuries, traffic accidents and other injuries covered by other laws, cosmetic surgeries, organ transplants, dialysis except acute renal failure, provision of eyeglass and contact lenses, in vitro fertilization, hip replacement, dentures, crowns, bridges, implants and root canal treatments except those required due to infections, provision of hearing aids and health services provided to any beneficiary free of charge are also excluded from the scheme by another regulation issued in November 2012.
According to the scheme public health facilities will be selected to provide the service.
Health facilities with the required quality standards and commitment to offer services with the tariff stated in the contractual agreement to be entered with the agency can provide the services.
Health service providers will have to submit the aggregate health service bills to the agency within 45 days after the end of the month in which service is provided. The agency then will verify and pay the amount of the health service bills to the health providers not later than three months from submission of the bill.
Beneficiaries of the social health insurance scheme are members and their families. Members need however to provide accurate information about their family composition and use the service properly.
Beneficiaries are subject to follow the referral system of the social health insurance scheme and bypassing the system, except for emergency cases, will make beneficiaries liable to pay 50 percent of the total medical expense