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

Tunisia
balances: proper specialty mix; consistency of the structure of the personnel (medical, paramedical,
technical and administrative); balance in the geographical distribution; and matching competencies
and functions. The system of basic and continuing education makes a crucial contribution towards
reaching these balances; the same holds for the organization of remunerations and incentives.
These concerns for appropriate education and efficient management of human resources
(Table 1) are strongly emphasized, as mentioned earlier, in the national programmes for the health
sector reform. They contribute, along with the relevant quantitative indicators, to reflect the efforts
made and actions undertaken for strengthening and promoting health personnel.
Table 1. Human resources in the Tunisian health system, 2002
Category Private sector Public sector Total
Physicians 3297 4147 7444
Dentists 940 375 1315
Pharmacists 1614 337 1951
Paramedical personnel 726 27 392 28 118
The overall indicators underline the steady and substantial improvement of medical
∗
supervision. The population per physicianTP PT decreased steadily from about 1900 in 1990 to 1100 in
2000; so, for 1000 population, we had 0.5 physicians in 1990 and 0.9 physicians in 2000. This
improvement is found both in the public and private sectors. The population per public sector
physician decreased from about 3100 in 1990 to approximately 2100 in 2000. For private practice
physicians, this ratio decreased from about 4750 to approximately 2300 during the same period.
Paramedical supervision remains exclusively limited to the public sector, with a population per
paramedic of about 340. Indeed, the private sector has only 726 staff belonging to this category of
human resources, compared with 27 147 in the public sector (June 2000). Conversely, the number
of dentists and pharmacists has substantially increased in the private sector, from 684 and 1087 in
1992 to 928 and 1508 in 2000, respectively, i.e. an average annual growth of 3.9% and 4.2%
respectively.
2.5 Performance indicators of the health system
The assessment of the performance of a health system aims at evaluating the actions
undertaken within the framework of health policies, i.e. to which extent the objectives set in these
policies have been achieved.
This concerns mainly the degree of improvement in the population’s health status and the
conditions of such improvement, particularly in organizational and financial terms. It involves
addressing not only the costs of health care services, but also the responsiveness of the health
system and its capacity to meet patient demands, and to anticipate changes in demand resulting
from demographic and socioeconomic factors or even those caused by major unexpected events. It
also involves assessing the accessibility of health care by all the segments of the population, i.e. the
equity of the health system.
∗ Including dentists; if dentists are excluded, the population/physician ratio is 1284 (Source DEP/MSP)
234