The role of contractual arrangements in improving health sector ...

The role of contractual arrangements in improving health sector performance
large sums of money to almost 60% of patients requiring cardiac surgery in order to send
them abroad.
Currently, the relationships between the health insurance organization (Social
Security Fund) and health care providers (both public and private) are managed and
regulated through contracting, which also helps achieve consensus on the often
conflicting interests of the fund and the providers. Several specialized services were not
provided for in the initial agreements made between the Social Security Fund and the
Ministry of Public Health. Most of these health care services are the subject of
agreements and memoranda of understanding with the Ministry, to which some private
specialized care institutions and the military hospital have been included. There is no act
or decree allowing the socially insured to receive health care in private health facilities.
The agreements have proved useful as they enable the private facilities to be brought into
the process of contracting of health services.
There are two types of health coverage schemes operational in Tunisia, health cards
and reimbursement schemes. Irrespective of the scheme, the affiliate members are
entitled to all health care services provided in the terms of agreement. The wide range of
services include highly sophisticated techniques such as lithotripsy, transplants (bone
marrow, renal and heart), other cardiovascular interventions, thermal treatments,
haemodialysis, and all forms of scanning procedures.
In order to participate in the contractual arrangement, private institutions are
obliged to accept the following conditions: a) reimbursement is made on the basis of a
flat rate determined at the level of the Ministry of Public Health; b) private facilities
cannot increase the agreed rates or charge co-payment; c) for cardiovascular
interventions, a justification for the procedure is required from the private institutions;
and d) private facilities are subject to medical inspection, provided for in the agreements,
which is also a requirement for public facilities.
Overall capacity for contracting health services
Contracting out of health services occurs more frequently than presumed. There is a
wide range of services contracted out that varies from non-clinical services to primary
care and hospital services. Table 2 shows a comparison of the overall capacity of the
public sector in general and ministries of health in particular to contract out health
services. The rationales for contracting out by ministries of health are to: improve
efficiency; enhance access and coverage; improve quality of care; address shortage of
public hospitals; and provide services targeted at culturally sensitive problems such as
HIV/AIDS through building partnership between public and private sectors.
Most countries, with the exception of the Syrian Arab Republic, have a policy that
promotes enhanced involvement of private sector. Afghanistan has the most explicit
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