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

Tunisia
A dependent child: must be a minor or an orphan under 20 years of age or disabled without any paid
activity (without age limit) or a girl without any income and unmarried (without age limit).
A socially insured person’s ascendant beneficiary: must be dependent upon the socially insured
person.
Conditions of contractual arrangements
The agreements are governed by criteria for coverage required to be fulfilled by the recipient
(beneficiary) and by conditions to be met by the signatory health facilities, particularly private ones.
The criteria for coverage vary according to the CNSS or the CNRPS.
In order to conclude an agreement with the Ministry of Social Affairs and Solidarity, private
institutions are obliged to accept the following conditions.
Reimbursement is made on the basis of a flat rate determined at the level of the Ministry of Public
Health.
Private facilities are committed not to increase these rates and to require no payment from the patient
covered under the agreements.
For cardiovascular interventions, a definition of requirements has recently been established
concerning only private institutions.
The public or private facilities are subject to a medical inspection, provided for in the agreements. The
inspection concerns the hospitalization and treatment conditions of the CNSS insured patients.
In order for an affiliate who applies for coverage to receive health care under the contractual
arrangements, the following conditions should be met.
Prior approval of the social security fund medical committee is mandatory, except for emergencies.
A request from the hospital is required and should be in accordance with the form developed by the
social security funds. It should be accompanied by a medical report describing the patient’s
health condition and his/her need for care. For every agreement, the social security funds have
devised an application form for prior approval.
Resources involved in implementation
Contributions of the social security funds
The agreements are divided into two categories: the first category concerns the funds’
contribution to the financing of the public institutions providing health care to their affiliate
members. Three forms of financing are currently applied: strengthening of public health institutions,
contribution to the budgets of the regional hospitals and the system of billing.
The second category concerns the coverage of health care services provided by parties under
contract with the social security funds, the Ministry of Public Health, the Military Hospital and the
private health institutions.
Tables 3 and 4 show the trend of social security fund contributions to the Ministry of Public
Health during the period 1995–2004.
Table 3. Trend of social security fund contributions to the financing of public health facilities
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