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

Tunisia
in the Ministry of Health, which is an important element for structuring the health information
system, and re-structuring the National Centre for Biomedical Maintenance which is now an expert
unit serving the Ministry of Health.
2.4 Resources allocated to the health system
Financial resources
The trend in overall health expenditures is characterized by a steady increase, from about 574
million Tunisian dinars (TND) in 1990 to approximately 1670 in 2002 and 1821 in 2003.
In the early 1990s, overall health expenditures represented about 4.5% of the GDP, and then
starting from 1994, a markedly more rapid progression than that of the GDP brought it to an
average level of about 5.6% (2002). Per capita expenditure in current dinars rose from about 70 in
1990 to about 105.5 in 1995, 150.5 in 2000 and 180.0 in 2003.
Within this overall trend, important changes have affected the structure of health care
financing. They concern mainly the respective roles of out-of-pocket payment by the state’s
beneficiaries and the social security funds. As from 1990, there has been a steady decline in the
share financed by the state to reach about 23.9 in 2003, resulting in an average annual growth rate
of 8.2% (1995–2000), lower than that of the total expenditure.
The share of the social security funds has steadily increased from about 15% in 1990 up to
about 20% in 2000 (22.5% in 2003), increasing at an average annual rate of 12.5%.
The gradual adjustment of the contributions of these two major funds has started from the
beginning of 2000 with the revaluation of the lump sum contribution made by the funds to the
public health budget for health care provided to their affiliates in public facilities, along with the
reform of hospital management. However, a much more substantial change has taken place with the
introduction of single-act billing in public health facilities. This will expand with the extension of
this mechanism to regional hospitals.
Other approaches of the social security funds have also contributed to increasing their share in
the health care financing:
Specific agreements for the coverage of some diseases increased from about TND 2 million in 1990 to
TND 19 million in 2000.
The coverage of some health care categories (haemodialysis, devices, care abroad, spa treatment)
increased during the same period from TND 23 to 61 million.
Other direct actions, notably health care in the CNSS private general hospitals and reimbursements
made by the CNRPS, increased from TND 12 to 32 million and from TND 9 to 24 million,
respectively, between 1990 and 2000.
The contributions of mutual insurance companies, private insurance companies and enterprise
services have also increased rapidly, at an average annual rate of 13%. However, they remain
marginal compared with total expenditure.
Out-of-pocket household expenditure has increased at a rate that is slightly more rapid than
total expenditure, estimated at an average of 10.3% per annum. However, the increase of out-of-
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