ECO320- Development Economics

Human Capital: Health System

Questions:

• Tunisian public health system.

Is it accessible to the majority of the population? How is the medical quality?

Does it cover all the expenses? Does it cover all family members? Overall, do
Tunisians have access to a performing Health System?

Public Health System in Tunisia

1- The Development of Tunisia’s Public Health:

• Historically, Tunisia's public health system has undergone several changes since the
country's independence from France in 1956:

At that time, the country's health system was primarily focused on providing care for urban
residents, leaving rural areas underserved. However, in the decades since, Tunisia has made a
concerted effort to expand and improve its public health system.

• One of the key initiatives in this regard was the creation of the National Health
Insurance Fund (CNAM) in 1983:

The CNAM was established to provide universal health coverage for all Tunisian citizens,
regardless of their income or employment status. The program is funded through a
combination of government contributions, employer contributions, and individual
premiums.

• Another important development in Tunisia's public health system was the

introduction of the Health Sector Reform Program in 1997:

This program was designed to improve the quality of health care in the country by
promoting the decentralization of health services, encouraging greater participation by
civil society organizations, and strengthening the role of the private sector.

• Today, Tunisia's public health system is one of the most advanced in the region:

The country has a relatively high life expectancy of 75 years, and its infant mortality rate
has declined significantly in recent decades.
→ According to the World Health Organization, Tunisia's health system is characterized
by "a high degree of integration and coordination of health services," The country has
made significant investments in training healthcare professionals and developing new
technologies and treatments.

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 In terms of specific health indicators, Tunisia has made progress in several areas,
for example:

1- The country has reduced its maternal mortality rate by over 80% since 1990.
2- It has achieved nearly universal vaccination coverage for children.
3- Tunisia has also implemented several programs aimed at reducing the
incidence of chronic diseases, such as diabetes and hypertension, which are
major public health concerns in the country.

2- Challenges in the Public Health Sector:

Despite these achievements, however, Tunisia's public health system still faces several challenges.
One of the most significant of these is the unequal distribution of health resources nationwide. While
urban areas have access to high-quality healthcare services, rural areas are often underserved, with
limited access to healthcare professionals and facilities. Additionally, there are concerns about the quality
of care provided in some public hospitals, and there is a shortage of specialized medical personnel in
certain fields.

1- Inequality in the social determinants of health:

The people most vulnerable to health deterioration are those who suffer from poverty and
unemployment, and lack adequate housing, safe drinking water, and sanitation.

- Statistics have shown that many Tunisians, especially in the west and south of the
country, still lack these social needs and that most of them are women.

The rapid urban expansion witnessed by the country led to the existence of phenomena with
negative aspects such as environmental pollution, a diversified diet, and high vulnerability
to chronic diseases.

From here, priority must be given to prevention before treatment, by adopting effective
national programs in which many actors participate in the 'education, economy, agriculture,
environment, and equipment sectors'... This is to strengthen the health sector and ensure the
safety of citizens from diseases, including chronic diseases and epidemics, and ensure that there
are no negative repercussions on the country's development and the balance sheet.

2- Inequality and imbalance in the distribution of health services:

The geographical distribution of health institutions in Tunisia is fairly good. However, the
major obstacle remains the inequality in the health services provided by the concerned
institutions.
Many citizens complain about not having access to a nearby health facility, and if they reach
one, he does not take care of meeting their needs and does not suit their aspirations. The reason
is that half of the basic health canters “provide only one ration per week for medical clinics, and
most local hospitals do not provide appropriate medical equipment and supplies, and regional
hospitals suffer from a severe shortage of specialized doctors.”
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 This is in addition to the abuses that health and hospital institutions are exposed to due
to the practice related to private medicine in the absence of administrative and supervisory
controls.

As for the private medical and health sector, it remains mainly concentrated in the major
cities and in the coastal areas of the country, in which it has witnessed rapid and continuous
growth.
At this point, we can talk about the lack of objectivity and lack of justice in the
establishment of private and public health institutions, which led to a lack of integration if
we talk about the services provided in the public and private sectors, which is detrimental to the
proper functioning of the health system.

In general, the health map represents the guarantor of health equality, the preserver of its
quality, and the guide to the future of this sector, which represents the heart and pillar of the
state. Therefore, priority must be given to adopting the method of a fair and
comprehensive national health map for all sectors and taking the necessary measures to
ensure the quality of services.

3- Difficulty obtaining essential medicines:

The pharmaceutical sector is characterized by waste and a lack of medicines.

→ Although 39% of the health sector’s budget is spent on providing medicines, according to
2013 statistics, we note that the health sector’s structures suffer from a severe shortage of
medicines, and their stocks are depleted at all levels.

The reason is due to:

➢ The absence of a policy of rational use of medicines, which is based mainly on

the national list of essential medicines determined by the health authorities and
adopted by all doctors in the public sector and the private sector.

➢ Lack of sufficient funding, which is the main reason, but not the only one, for the
depletion of medicines in public health institutions. In addition to corruption and
misconduct in this sector.

To overcome these obstacles and ensure the right of everyone to have access to medicines, it is
necessary to build a national policy to promote the rational use of medicines, based on the
national list of essential medicines, as well as ensure adequate financing for the acquisition of
medicines and combating corruption in the pharmaceutical sector.

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 4- Poor quality of health services:

Because Article 38 of the Constitution stipulates that:

“The state provides the necessary means to ensure the safety and quality of
health services.”

The safety and quality of services are still modest due to the presence of many
shortcomings. Today, citizens complain about the services when it comes to reception, self-
respect, privacy, and the provision of the necessary information and appropriate data to obtain
the sufficient efficiency that the hospital visitor seeks. In addition, the various studies conducted
on hospitalized patients showed a high incidence of hospital sepsis, which reflects the
flagrant weakness of the mechanisms put in place to ensure patient safety.

In addition, the scandal of expired cardiac IUDs, which was reported by the media, has
revealed the absence and ineffectiveness of control mechanisms related to patient safety in the
public and private sectors.

3- Does the Health System Covers All Expenses?

In terms of coverage, the National Health Insurance Fund (CNAM) in Tunisia is designed to
provide universal health coverage for all citizens, regardless of their income or employment
status. Under the CNAM, all Tunisian citizens are required to contribute to the cost of their
health care coverage, with premiums based on their income.

The program covers a wide range of healthcare services, including preventative care,
primary care, hospitalization, and specialist care. It also provides coverage for prescription
drugs, medical equipment, and other necessary healthcare items.

In terms of coverage for family members, the CNAM program provides coverage for spouses
and children of insured individuals. This means that if an individual is insured through the
CNAM, their immediate family members will also be covered under the program.

However, it is important to note that while the CNAM does provide comprehensive coverage
for a wide range of healthcare services, there may be some expenses that are not fully covered.
Patients may be required to pay for certain out-of-pocket expenses, such as co-payments or
deductibles, depending on the specific services they receive. Additionally, some specialized or
elective procedures may not be fully covered by the program.

→ Overall, Tunisians have access to a relatively performing health system that provides
comprehensive coverage for a wide range of health care services. The National Health Insurance
Fund (CNAM) is intended to ensure that all Tunisian citizens have access to affordable health
care services, regardless of their income or employment status. The program covers a wide
range of health care services, including preventative care, primary care, hospitalization, and
specialist care.

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References:

• https://www.who.int/countries/tun/

• https://jamaity.org/2017/01/%D8%A7%D9%84%D8%B5%D8%AD%D8%A9-
%D9%81%D9%8A-%D8%AA%D9%88%D9%86%D8%B3-
%D8%AA%D9%82%D8%B1%D9%8A%D8%B1-
%D8%A7%D9%84%D8%AC%D9%85%D8%B9%D9%8A%D8%A9-
%D8%A7%D9%84%D8%AA%D9%88%D9%86%D8%B3%D9%8A%D8%A9-%D9%84/

• http://www.cnam.nat.tn/

• https://en.wikipedia.org/wiki/Health_in_Tunisia

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