Chapter 1

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