20 mars, 2022

Analysis of the Tunisian health system structure and financing and recommandations to achieve Universal Health Coverage

Tunisian context:

•Tunisia is classified by the WB as a low-middle income country.
•Total population in 2020: 11 818 618 (1)
•GDP in 2020 was 39.236 billion US dollars (2)
•GDP annual growth in 2020 is -8.6% (3)
•National debt in relation to gross domestic product (GDP) in 2021 is 91.19% (4)

Historical evolution of the health system in Tunisia:

        The history of the health system in Tunisia dates back to Carthage. This period had known 55 Carthaginian doctors, including a few women.

The 8th century saw the Kairouanese school of medicine, with Ibn Al Jazzar (5) who wrote several works of central medicine a great social predisposition unusual at the time, in particular with his work of medicine intended for the poor.

In the 14th century, Tunisia knew the "Al-TabibAl-Skolli" which was a line of Tunisian doctors who taught medicine at the Zeitounaand practiced in "Moristan" founded by the King of Tunis AbouFares AbdelAzizfor the benefit of the poor. 
Among the “Tabibs As-Skoly” some wrote the best medical and pharmacy treatises of their time.

Then, in a more recent history, in the 16th century, we retain the fight against maraboutismvia the creation of health structures such as the Aziza Othmena hospital, the first example of a psychiatric hospital in the Tunisian context, initially housed in the rue des Tunisians "AZZAFINS" (musicians), where the patients received upon their discharge, sums of money to compensate for their time of inactivity due to hospitalization and where musicians played music to brighten the minds of the sick.

The Tunisian health system experienced during colonization, the introduction of new Western medical concepts, with a new way of doing medicine as well as the creation of new health structures mainly for the colonizers and the Pastor reaserchInstitute.Therehas been a « transplantation of the hospital-basedhealthcare system to developingcountries and the lackof emphasison prevention» (6)

During this period the democratization of access to health was not on the agenda since the colonial context did not lend itself to it. Thus, health structures had only been developed in regions of economic interest to colonizers.

After the 2nd World War, the dynamic of national liberation allowed the development of national health systems with the provision of public services and the establishment of national programs.

This patriotic ardor was accompanied by a political desire for equality which allowed the construction of the Tunisian health system with the development of several small local health structures and the development of many regional and district hospitals as well as the design and establishment of national prevention and reproductive health programs.

Post-colonial Tunisia had adopted, like all southern countries, the biomedical model preached by Western countries in the 19th century and reinvigorated with scientific discoveries and technological innovations post WWII.

As in otherafricancountries, Primaryhealthcare wasfavoredby the spread of national, anti- imperialist, and leftistmovements. (6)

In the first years of independence, the health system therefore focused on disease management and epidemic control. A social system has been implemented and the health system was directly conceptualized as a 2ndgeneration health system insisting on the the promotion of primaryhealthcare as a route to achievingaffordableuniversalcoverage, usingmainlysmallproximal structures; in orderto  ensurea minimum levelfor all of healthservices. There has alsobeen a focus on education(7).

In 1987, a putchhas been doneby Ben Ali (second president) andsincethentherehas been a change in the approach.

Politicalwillcontinuedworkingon adequatesupplyof safewater and basic sanitationbut therehas been a change in the social securitysystem thatopenedthe doorsto corruption, makingfundingsno more earmarked. In addition, therehas been a greatpromotion of privatesectorwiththe implementationof severalprivatepractices and privateclinicsin the country.

In 2011, therehas been a revolutionwithan importance politicalchanges and a climateof instability. Thehealthsystem continuedto bea societalbased  mixed type witha strongtendencytowarda marketdrivenapproach.

Corruption and badgovernancehavenegativelyimpactedthe healthsystem.


Since the independance, Tunisia's demographic situation has changed with an increase in life expectancy (went from 42 years in 1960 to 76.7 years in 2019) (8) and an increase in the population which rose from 4.178 million in 1960 to 10.694 million in 2019 (9).

During this period, public health facilities did not see any noticeable improvement. This stagnation has been accompanied by serious operational problems, affecting the availability, quality and safety of services.

By keeping a vertical and centralized management mode, no autonomy was possible for public health establishments created in the mid-1990s.

At the same time, the private sector has been strongly encouraged. Private clinics were establishing themselves in increasing numbers in advantaged areas which were still urban and coastal areas.

This same health policy continued after the revolution of 2011; the growing deterioration of public structures goes hand in hand with the increase in the number of beds in the private sector, which has even more than doubled since 2011, while still remaining outside disadvantaged areas.

Following the independency many fact had an impact on tunisian demography:

The abolition of polygamy, whichtookplace sinceindependence(1956) associated with a family planning policy and progress in the health system lead to a demographic and an epidemiological transitions.

The demographic transition in Tunisia:

•A growth in the country's total population: from 3,780 in 1956 to 11 818  million in 2020 (nearly4 times).(10) 
•A change in the age structure of the population: the number of over 60 years was 6.7% in 1984 to 12.96% in 2019 (11)
•The decline in infant mortality has resulted in an increase in life expectancy at birth, which went from 37 years at the end of the 1940s to 52 years at the end of the 1960s and to 74.5 years in 2009(10) and 76.699 in 2019 (12)
Epidemiologic transition in Tunisia:
•Decline/ eradicationof "traditional" transmissible diseases(malaria, bilharzia, trachoma, tuberculosis, infectiousdiarrhea...) and thoseof infancy(polio, tetanus, neonatal, diphtheria...). 
•In 2002, non-communicable diseasesconstituted79.7% of deathsand 70.8% of the diseaseburden(10)
•Emergence of non-communicable diseasesof chronicand degenerativetype, witha multifactorialetiologyand at a high costof treatment. 
•An upsurge in road accidents with their consequences in terms of mortality and morbidity

Basic indicators in 2018: 

-Total expenditureon healthfor Tunisiawas2,909 million US dollars. Expenditureon healthof Tunisiaincreasedfrom1,701 million US dollars in 2004 to 2,909 million US dollars in 2018 growingat an averageannualrate of 4.10%. (13)

-THE (Total Health Expenditure) was 7.292% as a share of the GDP. (14)

-Domestic general government expenditure on health as a share of current health expenditure is 57.4% including voluntaryhealthinsurancefor privateworkersand obligatorysocial healthinsurancefor public sectorworkers(15)

-Health expenditure per capita is 252 dollars (15)

-Governmental health expenditure per capita is 144 dollars (15) 

Financing of the health system is based on 4 types of funds (2014)(16)

1-Social insurance:

When considering total health spending by the public sector(defined as spending by the State and by compulsory social insurance schemes), there is a noticeable decrease in public spending, replaced by an increase in the portion of private spending. 

2-Out of Pocket paiement:

•The OOP isthe mostimportant formof financingthe healthsystem in Tunisiaand constitute39.4% of the THE in 2014 (16)
•Itismade of direct full paiement, Co-paiement and User feesand doesnot takeintoconsiderationinformalpaiement.
•Thisveryhigh levelof expenditureleads to foregoinghealthcareand sometimesleads to insurmountabledebt. As a result, each year more than100 thousand people fall into poverty due to catastrophic health expenses.


Public Fundingfromthe Ministry of Healthisthe main public fundingand constitues 24.1% of the THE in 2014 (16) It is a global operating budget.

4-Private healthinsurance:

There is a very low enrollement in private insurances in Tunisia.

Private health insurance and some fundings from other ministries like social affairs had a share of current health expenditure of 1.3% in 2014 (16)

Social insurance: Different types of coverage

•Twomodes of financingcoexist: a Bismarckiansystem compulsoryhealthinsuranceand a Beveridgiensystem targetingthe poorand low-incomepopulation. Historically, the latter wasthe predominantmode and has been graduallyreplacedby the former, since1995. (17)
•Most of the Tunisianpopulation benefitsfromhealthcoverage, accordingto variable modalities: compulsorysocial securityschemes, free medicalassistance (free of charge or withreducedrates). 
•Additionalinsurances(group and mutualinsurance) have been developedto compensatefor the inadequaciesof the healthinsuranceof social securityfunds.

There are 2 Funds as a social insurance: (18)

-The National Social Security Fund (CNSS) which is responsible for elderly, invalidity, survivors, supplementary retirement, death and unemployment insurance and provides family benefits,

-The National Health Insurance Fund (CNAM) which manages health, maternity, industrial accidents and occupational diseases insurance.

Protection against the financial risk of illness was strengthened with the creation of the CNAM during the 90s, which was to support both public and private sector services. 

However, it is the private sector that benefits the most. 

Health insurance is compulsory for workers in the public sector and it is voluntary for workers in the private sector.(19)

The contribution of the CNAM as a share of current health expenditure was 34.6% in 2014 (16)

The state guarantees free or subsidized healthcare to the lowest income groups under two public medical assistance schemes: (10)

•Free care: This categoryisdefinedaccordingto the povertyline and ismade up of the targetfamiliesof a permanent assistance program.
•Beneficiariesof reducedrates: The grantingof reducedrate cardsisgrantedon the basis of annualfamilyincome, takingintoaccountthe size of the family.
•Thecoveragerate is100% for civil servants (CNRPS) and reaches95% of eligibleworkersin the privatesector.
•Arecentstudypublishedin 2019 shows that17.2% of the Tunisianpopulation (estimatedat 11,295,787 people in 2016) do not have anysocial coverageagainstthe disease.
•There are marked inequalities in access to healthcare: the latest studies report that17% (nearly2 million Tunisians) are neither covered by the National HealthInsuranceFund(CNAM) nor by Free MedicalAssistance (AMG) and therefore do not have any social health coverage.

The fragmented, complex health insurance system is inequitable and generates corruption.

“Access to health services differs depending on the protection regime: beneficiaries of free healthcare and reduced rates are entitled only to public health structures, while social insured have the choice between three channels giving them access either to public providers or those in the private sector. »

beneficiaries of free healthcare cannot access healthcare in the private sector and sometimes have difficulty obtaining or renewing cards.


A variety of provider payment methods is used by the different payers of care (17)

MOH pays regional and university hospitals on the basis of a global operating annual budget.

The social security which covers public employees pays for care in regional and university hospitals on the basis of a simple case-based fee system but within the context of a global budget. 

Individuals and many private insurance companies, pay on a fee-for-service basis. 

Provider payment mechanisms in the health sector tend to be dominated by fee-for-service, salary, and global budgets.

Financial flow and Health expenditure(10)

The private sector is rather flourishing but very unevenly distributed over the territory. It remainsfinanciallyinaccessible for the vastmajorityof Tunisians.

The public sector provides the majority of health services: two-thirds of consultations and 90% of hospitalizations but has less funds than the private sector.

And has a limited service package because of rationing and shortages due to budgetary constraints, linked to the inadequate use of resources and the insufficient and capped contribution of the CNAM.

Without forgetting that the funds of the CNAM are often used to makeup the deficit of the social funds and are thus deviated from their real objective.

The public sectoristhe unique provider of Preventiveand promotionalactivities.

These activities are marginalized in a public sector which has become very hospital-centered and oriented towards curative care. 

According to national health accounts, even the budget allocated to prevention in Tunisia is very marginal.

OOP expenditure are mainly directed to the private sector and is distributed as follows:

Pharmacy: 34.81%

Privateclinics: 28.04%

MD and dentists: 13.52%

Otherproviders: 14.51%

Labs and radiology: 9.13%

It is also interesting to note that there is no data about the informal paiements knowing that these tend to be more frequent in a corrupted system.


A progressive health system (20)

Kakwani index is positive in Tunisia indicating a progressive healthcare financing system. The rich pay more than the poor for their health services and the country established free healthcare services for people below the poverty line and reduced wages for people earning the minimum wage(20)

Equity in health financing

•When it comes to fairness in financial contribution, Tunisia is ranked between108 and 111 from a total of 191 countries according to the WHO report. (7)
•There is a very high level of OOP expenditure that leads to foregoing healthcare and sometimes leads to insurmountable debt. As a result, each year more than100 thousand people fall into poverty due to catastrophic health expenses in Tunisia.

Recommendations for sustaining or achieving Universal Health Coverage

•It seems compulsory to consider restructuring the debt of the country in order to have a stronger state' input into the health system..
The fight against corruption has to be done to eliminate malfunctioning and let the system evolve.
•It is necessary to put in place a comprehensive health reform with a health financing reform which should aim to increase the resources devoted to health and reduce the share of direct house hold expenditure. 
This financial reform should also include the CNAM to implement a system of universal health coverage. 
It is essential to extend health risk coverage to those currently not covered and to abolish the different classifications in order to adopt a single universal health coverage.
•Benchmark of good practices that could limit over-medicalization due to the commercial dimension that underpins private sector development.

1.Population, total - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited21 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.POP.TOTL?locations=TN
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COVID epidemic in Tunisia: a breathless market


Tunisia is a North-African, low-middle income country which had its independence in1956.

During the 1960s, the state directed development as described by WALT and GILSON (1), with a very important governments' role: free and compulsory education, development of a national health system with a strong provision of public services, adoption of a Beveridgien system (2) …

Following the independency, there has been demographic (population that tripled (3), life expectancy increased and infant mortality that declined (4) (5)) and epidemiological transitions (decline and even eradication of some transmissible diseases and a rise in the non-communicable diseases (3)).


Following the two oil crises (in 1973 (6) and in 1978 (7)), the government decided to start austerity reforms and tried implementing SAP[1]conditionalities which were poorly received by the population (8).


Despite the improvement in health indicators, there have been dramatic deterioration of living conditions and extending inequalities (1) that were associated with an “insurmountable” debt. 


During the 1980s and 1990s, under the influence of “Internationally minded organizations” (Bollini and Reich. 1994), the country had to implement some neo-liberal reforms in the Healthcare system with a more market-oriented provision and gradually replaced the Beveridgien system by a predominantly Bismarckian one (2).

During this period, the gaps between the rich and the poor worsened and the level of unmet needs in healthcare increased. The overall healthcare system kept a normative notion of health care need (9) with a paternalistic approach going along with the biomedical model. There have been serious operational problems, affecting the availability, quality and safety of services. Public health facilities did not see much improvement and market-oriented policy led to a flourishing private sector localized only in advantaged areas.

In this article, we will try to describe the Tunisian health system, to assess its capacities, to analyze how it has adapted or not during the COVID-19 epidemic and to offer recommendations aiming the improvement of access to care in the context of the pandemic and for the upcoming years.


Health care system in Tunisia:

Tunisian Health system Framework:

The WHO framework (10) will be used to describe the organization of the Tunisian health system.

Figure 1: The WHO health system framework


Health services:

Healthcare provision’ organization has a traditional taxonomy (11). Public is state owned with some structures belonging to public non-state organizations (12). The private sector is made of an important majority of for-profit providers made of GP and specialists owned businesses as well as corporations. For-non-profit providers are a minority (NGOs).


The private sectoris rather flourishing but very unevenly distributed over the territory. It remains financially inaccessible for a vast majority of Tunisians.


The public sector is designed in 3 levels of care (12): Primary, secondary and tertiary.




Number of structures


Public Health Establishments University hospital center



Specialized centers 



Regional Hospitals 



District Hospitals



Basic Health Groups



Basic Health Centers/ PHCs 



Regional centers for school and university medicine 


University hospitals are located in areas of solvency. There is a lack of healthcare provision in second level structures located in rural and sub-rural areas.

PHC structures have a good territorial distributionbut provision of care is insufficient.

The public sector provides 2/3 of consultations and 90% of hospitalizations but has less funds than the private sector and a limited service package. 


Preventive and promotional activities are marginalized with a very low budget (13).



Health workforce: 

SAP inspired policies offering voluntary departure programs, early retirements and vulnerable contracts for health providers (14) seems to have accelerated the massive departure of doctors also justified by unfavorable working and living conditions (15).  

Meanwhile, European countries have migration policies that promote qualified migration. Qualified migrants are paid less than Europeans for the same work, are poorly unionized and are assigned to positions where the workload is heavier. However, people migrate because there is still an improvement in their socio-economic status and better respect of their human rights.

On the other hand, many autochthone health providers have unregulateddual membership in both public and private sectors, opening the doors to corruption. 

Health financing:

Public health expenditure was below 4% in 2017 and Health expenditure was around 7% during the past years. 

There are 4 types of funds for the healthcare system (13) : 

-34.6% Social insurance 

-39.4% OOP payment (full payment, Co-payment and User fees)

-24.1% Taxation

-1.3% Private insurances

More than 80% of Tunisians have some coverage (16). The state guarantees free or subsidized health care to the lowest income groups (3).

The coverage rate is 100% for public sector workers and reaches 95% in the private sector and unemployed are excluded. 

Equitable access:

National horizontal health programs are free. Access to other health services varies:

-Insured can choose public or private providers. Reimbursements are capped. 

-Beneficiaries of free health care and reduced rates are entitled only to public providers. 

Health information system:

Tunisian Health information system is evaluated by the WHO as being underdeveloped (17).

Leadership and governance:

The context is instable: there have been 5 health ministers during 2020. 

Political responses were often reactive and neither met the needs, nor had prospects for lasting solutions.

Marked corporatism bogs an already complicated situation.


In addition to the structural governance problems, corruption seems to affect the various links of the chain.

The traditional and centralizing administrative burden does not allow an effective and adequate use of modern technologies, which intensifies the administrative compartmentalization, the lack of traceability and the lack of data. 



In conclusion, many obstacles add up to the deficiencies in governance, management, regulation, financing and participation to make the health system inefficient and inequitable.



Barriers to access health services:

The main barrier is financial: poor people are entitled to public health structures that are underfunded and poorly managed, while the well-off have can chose the private sector, producing a Two-tier health system. In addition, corruption produces an added financial barrier since patients are facing money extortion in public structures in order to access services and might be directed to private sector with its financial implications.

The second barrier is structural: lack of specialists and medical technologies pushes patients to turn to university hospitals with all that this implies in terms of access difficulties and prolonged waiting times or again to private sector.


Performance of the healthcare system:

The WHO defines performance as the evaluation of the achievement of the objectives of a health system in comparison with “what it should be able to accomplish”if it was efficient (18). 

Improving its own performance is one of the objectives of a health system. Performance assessment is based on the analysis of specific indicators considering various dimensions like effectiveness, fairness in financial contribution and responsiveness(19):



Indicators show that the Tunisian health system is insufficiently contributing to better health in the population. 



Year 2000

Year 2017

MMR[2](per 100 000LB) (20)



IMR[3](per 1 000 LB) (21)



LEB[4](years) (4)



MMR is relatively high (22) and noncommunicable diseases are the cause of more than 8 out of 10 premature deaths and contribute to more than 63% of current health expenditure in 2014 A recent study shows that six (6) in ten (10) hypertensive people are unaware of their situation today and only one (1) in four (4) diabetics are balanced(23). 

We can conclude that the effectiveness of the Tunisian healthcare system isn’t satisfying. 

Fairness in financial contribution:

Tunisia was ranked between 108 and 111 from a total of 191 countries according to the WHO report when it comes to fairness in financial contribution (24). 

Indeed, though Kakwani index indicate a progressive healthcare financing system (25), the latter fails to have its redistributive role since the tax administration doesn’t work appropriately (16).

Protection against sickness is insufficient: 17% of the population isn’t covered and important OOP without any possibility of reimbursement, lead to pushing 100 thousand people into poverty every year.

Regional disparities are also significant: in disadvantaged areas, almost a third of the population (32.3%) have no social health coverage.



Responsiveness has two major sections: the first is ‘‘respect for persons’’ including therespect of dignity, individual autonomy and confidentiality; the second is named ‘‘client orientation’’ and is about satisfaction (26). 

According to WHO, Tunisia is ranked between 60 and 61 when it comes to the distribution of responsiveness (evaluating inequalities) and its health system level of responsiveness is the 94thamongst the total member-countries (27).


COVID-19 epidemic:


Tunisia faced a tremendous 4thwave in June 2021. The delta variant touched all the territory. Mortality rate due to COVID-19 was the highest in Africa (28).

The delta variant of the virus quickly gained ground to affect the vast majority of the territory. The daily cases reached more than 9 200 cases on daily basis, incidences were very high (the highest was 538.07 new infections /100,000 inhabitants/ 7 days on the 14/07/2021), testifying to the failure of measures taken to contain the spread of the epidemic.


New challenges plagued the healthcare system since therewas a “huge gap" (WHO 2021) between the needs and the resources available: the number of ICU beds was insufficient (29), there have been many shortages in Oxygen Supply… The situation was critical and the spokesperson for the ministry of health publicly announced the collapse of the health system (30). 

            The adaptation of health services provision during the COVID-19 epidemic had the theoretical objective of increasing the number of beds for potential patients in respiratory distress. There was a cancellation of all scheduled and routine activities. Sexual and reproductive health services have been seriously impacted with a significant decline in access for women: pregnancy follow-ups have been interrupted, some deliveries have taken place at home, family planning services have been completely interrupted.

The prioritization went hand in hand with the conservative anti-contraception and anti-abortion tendencies of the minister at the time (31).

            Thanks to an international mobilization, provision of healthcare has been adapted through implementation of buffer hospitals and the vaccination program, but these adaptations happened when Reff was firmly inferior to 1(28). 

The COVID-19 epidemic exposed the pre-existing failures of the Tunisian healthcare system.

Policy recommendations:


It is important to have comprehensive policies to ensure the protection of the health of the population.


There are barriers that doesn’t allow the Tunisian health system to evolve and upon which the state needs to act:

-Regulation of the entire health sector including public and private sectors in order to fight corruption should be a priority. Several elements combine to make the health system prone to corruption in order to establish the principle of accountability to the population served.

On a practical level, the computerization of management systems and patient records would allow traceability and thus impose transparency by making reliable, available and usable information on the nature of the services and the conditions of their use over time and in the space.

-The adaptation of regulations and laws in the health sector is necessary in order to give health authorities the mandate and the means to regulate the entire health sector, public and private. This regulation should have as a priority the reduction of direct household expenditure and the extension of health coverage to the entire population without exclusion, by guaranteeing a package of essential services provided in a complementary manner by the public and private sectors.


Once the effect of the barriers to change begins to wear off, a health system performance enhancement can really take place.


Stakeholders must assume their responsibilities in the promotion and protection of health. It is therefore necessary to increase the budget allocated to health but also to take health into account in economic, environmental and development policies.





Health is a human right; it is also a constitutional right. Health cannot be thought of and managed through a market-oriented approach.

Until now the health sector has been managed as a department in charge only of diseases and hospitals. This constitutes a bias which has done a lot of harm. Protection and promotion of health must be a transversal concern of all sectors.

The current crisis should serve as an opportunity for the implementation of a patient-oriented health system with an effective consideration of health protection as well as the consideration of equity, solidarity and quality in access to services.



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[1]Structural Adjusment Programs

[2]Maternal Mortality Ratio

[3]Infant Mortality Rate

[4]Life Expectancy at Birth