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

Tunisia
With regard to the Funds, current trends indicate that the agreements are responsible for
higher costs, which is likely to create a fiscal imbalance of the Funds. The cost of contractual
arrangements may become unbearable for the following reasons:
Patients benefitting from two or three different types of coverage.
The extension of private facilities that are joining in the agreements.
Table 11 shows the upward trend in the agreement costs for the two Funds over five
years (1996–2001).
Table 11. Trend of CNSS and CNRPS expenditures on health care provided under
agreements between 1996 and 2001T (in million dinars)
CNSS CNRPS
1996 2001 1996 2001
Ben Exp Ben Exp Ben Exp Ben Exp
Lithotripsy 709 0.280 1118 0.432 464 0.163 706 0.268
Scanning 3255 0.234 12183 0.882 2962 0.211 7034 0.508
MRI 2042 0.613 4570 1.377 885 0.279 2995 0.889
For lithotripsy, the CNSS and CNRPS expenditures have increased by 50%. For
scanning procedures, they have increased by 3.8 and 2.4, respectively.
On their part, the Funds will have to ask for an increase in the contribution rate, which
is likely to further increase the households’ contributions to health financing and to cause
problems for private employers (increase in production costs). Indeed, in 1987 the Funds
contributed to 13.5% in 1987 of the total expenditure before the agreements, and about 21.1%
in 2002.
The increase in the costs of contractual arrangements stems from the fact that they are
involved only in care requiring advanced technological equipment. Such equipment enables
rapid and effective diagnosis of disease, hence the significant increase in the number of
beneficiaries.
It has been observed that the agreement system, based on flat rates, has prompted the
actors––health care providers––to adopt the principle of costing so as to be able to adjust
themselves to the new context of contractual arrangements aiming at payment of the true costs
of health care. The Ministry of Public Health has adopted, since 1999, the principle of health
care costing which is conducted yearly by the directorate responsible for supervising
hospitals. The objectives of the routine costing exercise are to:
measure the performance of the various activities.
establish the basis for charging the services provided.
explain and account for the results of each exercise.
facilitate budgeting and budget control.
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