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
2.GDP (currentUS$) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited22 October2021]. Availablefromhttps://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=TN
3.GDP growth(annual%) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited22 October2021]. Availablefromhttps://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=TN
4.Tunisia - national debtin relation to grossdomesticproduct(GDP) 2016-2026 | Statista[Internet]. Statista. 2021 [cited22 October2021]. Availablefromhttps://www.statista.com/statistics/524541/national-debt-of-tunisia-in-relation-to-gross-domestic-product-gdp/
5.tasci u. Ibn al Jazzaridentifiedcontagiousdiseases1,000 yearsago[Internet]. TRTWORLD. 2020 [cited21 October2021]. Availablefromhttps://www.trtworld.com/magazine/ibn-al-jazzar-identified-contagious-diseases-1-000-years-ago-35581
6.Cueto M. The ORIGINS of PrimaryHealthCare and SELECTIVE PrimaryHealthCare. American Journal of Public Health. 2004;94(11):1864-1874.
7.The World healthreport 2000 Healthsystemsimprovingperformance. Geneva; 2000
8. Life expectancyat birth, total (years) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited21 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=TN
9.Population, total - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited21 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.POP.TOTL?locations=TN
10.Achour N. LE SYSTEME DE SANTE TUNISIEN : « ETAT DES LIEUX ET DEFIS » [Internet]. Fphm.rnu.tn. 2011 [cited22 October2021]. Availablefromhttp://www.fphm.rnu.tn/sites/default/files/Annexe%202%20Le%20système%20de%20santé%20tunisien%202011%20Noureddine%20Achour.pdf
11. Tunisie - Pyramide des âges 2020 [Internet]. countryeconomy.com. 2021 [cited22 October2021]. Availablefromhttps://fr.countryeconomy.com/demographie/structure-population/tunisie
12.Lifeexpectancyat birth, total (years) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited22 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=TN`
13.TunisiaExpenditureon health, 2000-2018 - knoema.com[Internet]. Knoema. 2021 [cited22 October2021]. Availablefromhttps://knoema.com/atlas/Tunisia/topics/Health/Health-Expenditure/Expenditure-on-health
14.Currenthealthexpenditure(% of GDP) - Tunisia| Data [Internet]. Donnees.banquemondiale.org. 2021 [cited21 October2021]. Availablefromhttps://donnees.banquemondiale.org/indicateur/SH.XPD.CHEX.GD.ZS?locations=TN
15.Tunisie General governmentexpenditureon healthas a shareof currenthealthexpenditure, 1960-2020 - knoema.com[Internet]. Knoema. 2021 [cited21 October2021]. Availablefrom: https://knoema.fr/atlas/Tunisie/topics/Santé/Dépense-de-santé/General-government-expenditure-on-health-as-a-share-of-current-health-expenditure
16.Ben Abdelaziz A, HAJ AMOR S, AyadiI, KhelilM, ZoghlamiC, Ben Abdelfattah S. Article medicaleTunisie, Article medicaleFinancement des soins de santé - Dépenses de santé - Participation aux coûts- Financement du gouvernement - Financement individuel - Soutien financier à la planification et au développement de la santé - Assurance maladie - Couverture d'assurance - [Internet].Latunisiemedicale.com. 2018 [cited21 October2021]. Availablefromhttps://www.latunisiemedicale.com/m/article-medicale-tunisie_3467_fr
17.Republicof TunisiaHealthsectorstudy[Internet]. Documents1.worldbank.org. 2006 [cited22 October2021]. Availablefromhttps://documents1.worldbank.org/curated/en/201241468312891649/pdf/410180ENGLISH010Sector0Study10Final.pdf
18.La sécurité sociale des salariés en Tunisie [Internet]. Cleiss.fr. 2020 [cited21 October2021]. Availablefromhttps://www.cleiss.fr/docs/regimes/regime_tunisie_salaries.html
19. Les cotisations en Tunisie [Internet]. Cleiss.fr. 2020 [cited21 October2021]. Availablefromhttps://www.cleiss.fr/docs/cotisations/tunisie.html
20.RostampourM, NosratnejadS. A SystematicReviewof Equityin Healthcare Financingin Low- and Middle-IncomeCountries. Value in HealthRegionalIssues. 2020;21:133-140.

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