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

Tunisia
The National Pension and Social Security Fund (CNRPS)
The social security scheme managed by the CNRPS is based on two mutually exclusive
schemes, the direct health care provision scheme (health card) and the reimbursement scheme.
Regardless of scheme, the affiliate member is entitled to direct care services mentioned in the
introduction. Most of these services have been the subject of memoranda of agreement with the
Ministry of Public Health, to which some specialized health care facilities adhere.
For the period 1987–2001, the CNRPS spent 169.5 million dinars for all the health care
provided by parties under contract: 68% was for coverage of haemodialysis sessions.
Haemodialysis expenses increased at an average annual rate of 15.9% (Table 7).
Cardiovascular surgery interventions accounted for 18.7% of the total expenditures by the
CRPS on health care provided under agreements. During the period 1988–2001, cardiovascular
surgery expenses increased at an average annual rate of 28.8%.
Moreover, there has been a significant increase in the number of persons benefiting from the
health care provided under the agreements. The number of beneficiaries for cardiovascular
interventions has increased from 75 to 1373 (1988–2001). For the scanner, this number has reached
7034 in 2001 compared to 141 in 1990.
According to Table 7, the policy of reducing the need for health care abroad, which was the
reason for CNSS adopting contractual arrangements, has been successful. In 14 years, the number
of beneficiaries receiving health care abroad had been reduced about sixfold. CNRPS expenditures
have been reduced by 3.1 million dinars, without adjusting for international inflation and with
coverage maintained at a high level.
Since 1987, the largest share of expenditures on health care has been for haemodialysis
sessions. Haemodialysis expenditures exceed 60% of total expenditures for the period 1987–2001.
In 1987, the share haemoialysis expenditures 83%, decreasing to 62% in 2001 (Figure 2).
In 2001, 62% of CNRPS expenditures under agreements were for haemodialysis sessions,
21% for cardiovascular interventions and 13% for remaining items and procedures (thermal
treatment, bone marrow and kidney transplants, scanner, MRI, lithotripsy and the Military
Hospital).
245