A national priority since independence, Tunisia’s health care system has been the focus of continued public investment that has seen an extensive network of public hospitals and health centres established nationwide. In recent years, however, the country’s private health care sector has taken the lead in investment, with the construction of new clinics intended to make the country into a regional medical centre.
The development of Tunisia’s health care system has been through several phases since independence. During the 1960s and 1970s, the government prioritised the construction of larger hospitals in the main coastal cities, namely, Tunis, Sousse and Sfax, before re-orienting public spending towards the building of decentralised facilities in remote areas between 1982 and 1986. In the early 1980s, physicians at hospitals received permission to carry out semi-private practices, resulting in the first boom in the development of private clinics.
Tunisia’s public health infrastructure developed through a dynamic two-pronged process: first, the proliferation of dispensaries and district hospitals, which fostered better access to basic health care in underserved areas, and second, the creation of institutes, specialised centres and teaching hospitals (centre hospitalier universitaires, CHU) that led to the development of cutting-edge medical care in Tunisia’s main cities. Following the recent revolution, the new 2014 constitution proclaimed health a human right under Article 38, highlighting the obligation of the state to ensure preventive and curative health services. The government is also now legally required to guarantee social protection and free health care for low-income populations, as well as provide sufficient resources to guarantee quality of service.
The Ministry of Health (Ministére de la Santé, MoS) oversees Tunisia’s public health care system, supported by several public institutions. The National Laboratory for Drug Control is charged with overseeing quality control of medications. The National Centre of Pharmacovigilance is responsible for legal follow-up when a medication is found to have any adverse effects. The Central Pharmacy of Tunisia has held a monopoly on drug imports since 1961, and the Directorate of Pharmacy and Medicines authorises the release of medications on the market and implements national policies related to medication and pharmacies. In 2016 the MoS was allocated a budget of TD1.8bn (€825.5m), representing a 9% increase on the TD1.6bn (€733.8m) granted in 2015. The budget is also focused on upgrading basic health care infrastructure in remote areas.
Tunisia’s health care system includes three levels of care: primary, with a network of 81 clinics and 2091 basic health centres; secondary, with 109 district hospitals; and tertiary, with 33 regional hospitals and 24 modern CHUs, according to MoS figures. As such, the public sector remains by far the primary health care provider in Tunisia, accounting for 87% of hospital bed capacity, with 31,936 beds. Public health infrastructure continues to expand, with numerous projects under way, such as the ongoing construction of a second CHU in Sfax – a TD60m ($27.5m) project being funded by China which was announced in March 2016 by Saïd Aïdi, the minister of health. The Sfax CFU is expected to be completed within the next 18-24 months and have a capacity of 256 beds. Other projects include a new CHU in Kairouan, which is awaiting the completion of a technical study; two planned hospitals in Béja and Gafsa, with the latter being funded under a deal with France to convert €60m of Tunisia’s debt; and a cancer treatment centre in Tunis.
The government is prioritising spending on public health care networks in the south, with a focus on primary and secondary facilities as a means to offset lingering inequalities in access to medical treatment. Public facilities in Tunisia’s three largest cities provide health care that is of high quality by regional standards and is comparable to Europe, while areas in the south do not receive the same quality of care. Currently, the MoS is collaborating with Spain’s Autonomous Service of Public Health of Castilla-La Mancha on implementing a medical information system at all medical centres under the EU-funded Programme to Support Competitiveness of Services (Programme d’Appui á la Compétitivité des Services, PACS).
The past few decades have seen rapid development of the Tunisian economy and major demographic and epidemiologic changes. Average life expectancy rose substantially from 70.3 years in 1990 to 75.6 years by 2013. Fertility rates, meanwhile, have dropped from 5.2 children per woman in 1981 to 2.3 children by 2013, according to World Bank data, along with an important decline in communicable diseases thanks to vaccination campaigns and improved access to clean drinking water and sanitation facilities. As a result, non-communicable diseases (NCDs), including diabetes, vascular diseases and cancer, have become the main health concern for the Tunisian population, accounting for 72% of deaths, according to figures from the World Health Organisation (WHO). As of 2015, one in six Tunisians suffers from diabetes and over 60% of citizens above the age of 35 are overweight, according to WHO.
Over the past decade, Tunisia has made considerable progress in terms of universal health care coverage with the creation of the National Health Insurance Fund (Caisse Nationale d’Assurance Maladie, CNAM) in 2004. The CNAM covers workers from both the public and private sectors, as well as their families, through a system combining fixed fee and ticket modérateur, or health vouchers. Non-insured households are covered under the National Assistance Programme for Families in Need of Free Medical Assistance, which is funded by the state and provides the 28-30% of the population that is uninsured with free, or nearly free, access to health care.
The eight years leading to 2013 saw annual health care spending double to reach TD5bn (€2.3bn), equivalent to 7.1% of GDP, according to MoS figures. Of this total, 37% of costs were assumed by Tunisian households, 35% by CNAM and 28% directly by the government. Public spending on health accounts for 4.4% of GDP, according to MoS figures, which is slightly lower than comparable economies at around 5%.
While only accounting for around 20% of total capacity, the private sector generates 54% of total health care spending, which can be broken down further into 91% of households’ health spending, 62% of CNAM health expenditures and 25% of government health spending. The high level of contribution by Tunisian households is mainly due to public health care investments having increased at a lower rate than demand since the late 1990s, which has pushed more Tunisians towards private facilities, leading in turn to increased fees. According to the OECD, some 40% of total health care expenditure in the country is accounted for by patients paying out of pocket.
Private medicine has always existed in Tunisia, but private clinics are a more recent development. With the exception of the Clinique Saint Augustin which was established in 1933, most private institutions were only founded in the 1990s, following a series of tax incentives for private medical institutions that were approved in 1992. Around a decade later, in 2001, the government passed Law No 2001-13, which facilitates the creation of private clinics by no longer requiring them to receive prior authorisation from the MoS; instead, investors are expected to adhere to set of regulatory standards. Tunisia’s private health care sector is primarily composed of doctors and paramedical practices, as well as private clinics, relying on a workforce of 3101 general physicians and 3614 specialised physicians – equivalent to 49% of doctors in the country, according to MoS figures. There are around 81 private clinics and medical centres, according to MoS figures.
The private sector is seeking to capitalise on the high quality of medical training in the country, Tunisia’s location as a gateway to Africa and its competitive health care prices in order to play an increasing role in health care service exports – a new revenue stream for the country. As such, the construction of private clinics should accelerate, with 75 new clinics expected to be built by 2025. Taoufik Haj Hissine, director-general of the new Clinique Pasteur in Tunis, told OBG, “With the current development of private infrastructure, private health care capacities should double to reach 10,000 beds within three years.”
Foreigners already account for a large proportion of private institutions’ clientele, which has prompted clinics to further diversify their offerings to a wider range of medical services, including dentistry, optics, orthopaedics and cosmetic operations. According to Hissine, “Foreigners represent 30% of our customer base, half of whom are Libyan, followed by Algerians, sub-Saharan Africans and Europeans.”
While the vast majority of investments in health care facilities have thus far been from Tunisian shareholders, the sector is now witnessing rising interest among foreign investors willing to take a share in the development of Tunisia’s health care. In 2014 UAE-based private equity Abraaj Group bought two clinics in Tunisia, Clinic Taoufik and Clinic La Soukra, with its partners the European Bank for Reconstruction and Development, Germany’s DEG and France’s Proparco. The acquisition led to the establishment of the North Africa Hospitals Holdings Group, which will improve quality standards and human capital through training programmes and accreditation processes. Other private initiatives are under study, such as the $34m Tunis Mediterranean Hospital, which is slated to be a modern hospital that utilises a holistic approach to health care, digital records and high-tech equipment. A €25m cancer treatment and research centre in Gabés is also being planned under an EU-Tunisian partnership; however, the project has slowed due to disagreements with the MoH and bureaucratic obstacles.
Over 58,000 people work in health care, of which 86% work for the public sector, according to MoS figures. In terms of doctors, 51% work for the public sector and 49% for the private sector. Public hospitals are facing an increasing shortage of specialised doctors and paramedical staff due to the reluctance of professionals to work for the public sector, especially in remote areas. The situation is only slightly better in the private sector. Hissine said, “Even though wages for paramedical staff are generally higher in the private sector, private clinics still struggle to find qualified workers, hence the necessity to train more paramedical staff every year.”
In a bid to improve quality care in Tunisia, the government created the National Health Accreditation Authority (Instance Nationale d’Accréditation en Santé, INAS) in 2012. The INAS is tasked with promoting the quality and safety of health care services in compliance with the standards of the International Society for Quality in Healthcare. The authority is also in charge of implementing regulations, criteria and procedures for professional practice, granting accreditation to health care institutions, assessing the economic impacts of health care and diagnostic services, and coordinating between national and international accreditation agencies. INAS is also working with the EU on the €2m Assistance Programme for Disadvantaged Areas. This projects aims at improving access to health care in 13 Tunisian governorates. The supporting PACS project was launched in 2015 and is aimed at improving management and follow-up at 30 medical facilities.
As a whole, Tunisia’s health care system can rely its solid foundation, blossoming private sector and qualified workforce. However, according to WHO, health system reform is needed in order to implement an integrated approach that is focused on primary care, prevention and provision of palliative care in order to better respond to the increase in NCDs. In addition, the government is focusing on policies aimed at identifying medium- to long-term reform measures that will reduce health inequalities and improve the system’s responses to the evolving demographic and epidemiologic situation. The major challenge to overcome remains the lingering disparities between Tunisia’s northern and southern regions. The government’s development plans for the next decade must clearly prioritise these reforms.
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