Chapter 1

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or in the public sector. The Bank is undertaking additional to encourage study activities (in Tunisia and abroad) which studies to determine how to: (1) reduce selectivity in basic closely correspond to the country's development objectives. education, (2) upgrade the professional vocational training Many governments reserve state scholarships to finance spesystem, and (3) create an enabling environment that encour- cializations that have the most economic relevance for the ages the private provision of vocational training. country, while activities considered less important are financed through private resources. Tertiary education There is considerable room for nonprofit private sector expansion in tertiary education in Tunisia, where at present The Government's education and vocational training virtually all (97 percent) of higher education is provided and reform program as well as its broader reform objectives for financed by the state. This contrasts with several Asian counthe civil service and private sector development are causing tries, where private financing covers a larger share of higher the country to rethink the objectives, financing, and study education costs (Malaysia 35 percent, Indonesia 49 percent, emphasis of its tertiary education system. Tunisian higher Korea 77 percent, and the Philippines 86 percent). 3 The education has a strong administrative and legal tradition, Government can promote the private sector's expansion by but a greater emphasis needs to be placed on training civil regulating the quality of education and by using official servants in how to analyze different tax regimes, trade, fis- accreditation policies which the Government is currently cal and monetary policies, and to train lawyers in business- trying to put into place. It can open up opportunities for the related regulations, for example, contract law, bankruptcy development of high standard private institutions (possibly laws, property rights, copyrights, and financial disclosure set up in affiliation with foreign universities) and encourage laws. As the private sector expands, entrepreneurs need greater private sector financing through corporate tax incentraining in business administration. The new advances in tives and fee based cost recovery measures which would teaching methods and the expansion of higher level primary reduce the state's financial burden and promote a better education requires more teacher training. For example, Portugal, Malaysia, and Chile have anywhere from 3 to 4 allocation of public resources. times more students enrolled in business administration, 2 to 3 times more in engineering, and 2.5 to 4 times more in Health care and social security teacher training, architecture, and town planning than in The Government has secured good quality and nearly uni- Tunisia (table 2.7). The Government needs to consider ways versal access to health care through the public provision of health services. Currently 90 percent of the population TABLE 2.7 resides within one hour's walking distance of a health facil- Comparison of enrollment In tertiary education by ity. The ratio of population to doctors is still quite low for a flield of study low-middle income country, but it has improved consider- (Percent.. shawe of total enrollmenvt) ably from 0.17 doctors per thousand people in the 1970s to Field of stud)' Tunisia 1990-92 Malaysia 1989-90 Portugal 1990-91 Chile 1990-91 0.67 per thousand today For nurses, the number has gone from 1.06 to 3.33 per thousand. Public health facilities are Education and available to everyone and are organized at three levels: (1) teacher training Humanities Law 5.0 24.7 12.8 23.0 8.6 1.9 13.1 8.9 8.9 12.1 3.0 4.1 university structures (specialized institutes and tertiary hospitals), (2) regional or 'second line" structures (secondary (Commea e and business administraion) 6.5 Natural sciences 13.4 28.0 20.5 10.6 30.4 18.9 75 32.2 22.9 35 hospitals), and (3) "first line" or provincial structures (dis- trict hospitals and primary health care centers). The health sector priorities in Tunisia combine the concems facing Medicine Engineering Architecture and 10.6 9.4 2.7 13.4 5.6 18.0 5.9 31.1 developing as well OECD countries: * Securing a sustainable system for financing growing torn planning 1.7 826 3210 2.0 health care costs and needs; Total 100.0 100.0 ioo.o io.o * Meeting the demands of a growing population which, Source: UNESCO Educouon Stastetd otarbook 1994. according to the 1994 census, is estimated to be increasing 22 TuNIsiA's GLOBAL INTEGRATION AND SusTAINABLE DVELoPMEN, STRATEGIC CHOICES FOR THE 21sr CENTWW
at around 2 percent a year This rate is lower than the region's The public sector's financing of health care comes partly average (2.8 percent), but is still higher than other low-mid- from general tax revenues to support a national system and dle income countries (1.4 percent) and requires continued partly from public health insurance funds that receive contristrengthening of preventive medical care and family plan- butions from compulsory payroll deductions shared between ning efforts; and employers and employees. The public system is facing diffi- * Adapting services to the changing age structure and geo- culties generating sufficient revenues to cover the operational graphic distribution of the population, as declining fertility and investment costs needed to meet the quality expectations and reduced mortality rates produce an older population of the population and to compete with growing competition with an epidemiological profile with more chronic and from the private sector. Part of the reason for insufficient degenerative diseases that are more expensive to treat. financial resources is because the lump sum provided by the The Government is the main provider and financier of CNSS to the public health care system covers only an estihealth care. The private sector's role is growing, even mated 40-50 percent of the cost of services provided by pubthough the Government provides nearly half the popula- lic health care providers to the CNSS affiliates (a tion with free or highly subsidized care. In addition, the Government study is underway to determine this share more public insurance funds and the Social Security Fund precisely). The public health system is also providing free or (CNSS) do not compensate private health care providers highly subsidized care to a larger share of the population than (Social Protection System Study, 1993). Nevertheless, the is warranted based on income levels. The government needs private sector's role is growing, particularly for ambulatory to: (1) increase CNSS payments to health care providers health services (table 2.8a). Government budgetary expen- commensurate with the use of its affiliates; (2) limit the covditures on health care as a share of GDP have remained vir- erage of free assistance to the really needy and raise health tually constant at 2.2 percent since the 1980s, but health care service fees for those who can pay, as a means of encourcare costs have gone up considerably, and these increases aging people to affiliate with and contribute to the Social have had to be picked up by households (table 2.8b). The Security System; and (3) link pension and health insurance increase in household expenditures is also a reflection of benefits more closely to contributions. higher private sector participation. The Tunisian authorities have a commitment to equity in health care, yet resources are scarce and the system is suf- TABLE 2.AA fering from growing demand, insufficient funds, and con- Main providers of health care straints in maintaining quality. Mobilizing private resources (Percentae of services provided, 1 992) in addition to public funds and encouraging the private pro- Provider Hospital services Ambulatory haltkh services vision of services are necessary to increase and maintain the quality of services available. A greater role for the private Ministry of Health Social security 90 0 50 3 sector can be realized only if the government actively reduces its widespread provision of free or highly subsidized Private sector No access 10 0 47 0 care, and more explicitly targets its provision of subsidized Total 100 100 services. A variety of options could be considered: increas- TABLE 2.8B ing user selected fees; privatizing certain services; and increasing the regulatory role of the state. A combination of Health expenditures state supervision with private provision of services would (Percentage of total expenditures) diversify the supply of health services, maintain quality, and Source of ependiture 1980 1992 promote the efficient use of resources. Govemment budget Social securh) 51 I I 36 48 The environment: Households Enterpise practices 37 I 48 I sustainability Tota 100 100 a. The expenditure share ofthe social security funds covers its own ambulatory but only part of the services provided by the pubic sector (MOH). Source: Minstry of Health and World Bank estimates, Growth and dinics Environmental protection has long been of general concern 1994. to the government, but it is only in recent years that envi- ROLE OF THE STATE IN THP ECONOMY 23
Page 1: Public Disclosure Authorized Public
Page 4 and 5: Copyright i 1996 The International
Page 6 and 7: Education policies 20 Basic educati
Page 8 and 9: 2.4 Demand for telephone connection
Page 10 and 11: Acknowledgments The report is a pro
Page 12 and 13: STIL Soci&e Tunisienne d'Industrial
Page 15 and 16: Executive summary Elements of Tunis
Page 17 and 18: ments and controlling the expansion
Page 19 and 20: Progress in strengthening market fo
Page 21 and 22: investment banking, restructure som
Page 23 and 24: Chapter 1 Macroeconomic policy The
Page 25 and 26: Box .I Monetary policy Instruments,
Page 27 and 28: TALE 1.3 Main monetary Indicators 1
Page 29 and 30: national markets and ensure the sus
Page 31 and 32: domestic production, and inducing a
Page 33 and 34: was actually higher than that for t
Page 35: public banks and enterprises reveal
Page 38 and 39: (10 percent), and Malaysia (12 perc
Page 40 and 41: Infrastructure services: Provision
Page 42 and 43: on a pilot basis and is studying th
Page 46 and 47: onmental issues and their relation
Page 48 and 49: several industrial zones. Despite t
Page 50 and 51: vocational education more relevant
Page 52 and 53: also showed high effective rates of
Page 54 and 55: try an opportunity to accelerate a
Page 56 and 57: BOX 3.2 Free trade zones: Maximizin
Page 58 and 59: largest share of total employment (
Page 60 and 61: encouraging results and provides us
Page 62 and 63: ill market and to modernize the leg
Page 64 and 65: price/earnings ratio of about 25 in
Page 66 and 67: achieve their intended objectives i
Page 68 and 69: TABLE 4.2 crisis brought about an 7
Page 70 and 71: costly process of adjustment, the a
Page 72 and 73: ented economy The growth of exports
Page 74 and 75: as a whole, but the related transit
Page 76 and 77: Land degradation and water scarcity
Page 78 and 79: TABLE 5.1 Poky otfecdt Short term M
Page 80 and 81: TABLE 5.2 Complementary reforms (co
Page 82 and 83: IMF (International Monetasy Fund).
Page 84 and 85: Statistical Annex TABLE SA. I Exter
Page 86 and 87: TABLE SA.3 Public sector accounts,
Page 88 and 89: TABLE Sk6 GNP, output, and governme
Page 90 and 91: TABLE SA.8 Money, credit, prices, a
Page 92 and 93: TABLE SA IO Key economic variables,
Page 96:
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Chapter 1

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