This chapter examines the institutional and political economy contexts of Egypt’s universal health coverage, emphasizing implications for health equity. It traces the health sector’s evolution from the 1960s to the enactment of the 2018 Universal Health Insurance (UHI) Law, identifying key institutional factors that shaped its trajectory. The chapter compares the current system’s coverage, structure, and financing with the new UHI system, highlighting its potential to address existing gaps. Drawing on findings from various studies, the latest National Health Accounts (2019/20), and pilot surveys, the analysis identifies main institutional and political economy challenges to implementing the new system. It concludes that achieving equitable UHI requires a prudent approach prioritizing inclusive policymaking and strong public support. Strategies for enhancing the system’s sustainability include increasing public awareness of its benefits, adjusting financial mechanisms to be more progressive, and delivering quick outcomes. Without these considerations, the system risks reverting to its previous trajectory.