80
The structure of Tunisia’s health services and health coverage system
Over the past 50 years, Tunisia has shown a significant effort in building and maintaining a national
healthcare system that is accessible for all. After its independence in 1956, Tunisia created a free for
all healthcare system which was at the time funded solely by the public sector. In 1982, a new policy
implemented health centres which improved access to services, extended the existing services and led
to the development of a private health sector. Today, Tunisia’s health care system is based both on the
public sector as well as a continuously growing private sector (Chahed et al, 2014). There is a large
imbalance between the two sectors both in coverage and in financing: Whereas the public sector deals
with 80 per cent of the whole population and makes up only 20% of the total health expenditure, the
private sector deals with only a 20 per cent of the population and benefits from a 60 per cent of total
expenditures (Chahed et al, 2014).
Tunisia also established its main health insurance mechanism, the National Fund of Health Insurance
(NFHI) in 2006 to improve coverage of health care services across the country. The mandated social
insurance scheme is still in effect today, which included public and private sector workers and is
financed both by employees and employers. Initially, the scheme covered the 68 per cent of the
population (in 2006) but was later extended for more coverage through the private sector and resulted
in nearly 90 per cent of the population having access to health services by 2014. Although insurance
schemes have shown significant progress over the past years, a few gaps remain. Between 8 – 10 per
cent (almost 1 million people) of the population is still not covered by health insurance, and the
inefficiency of specific public aid schemes are still causing a strain to the government’s budget (Chahed
et al., 2014).
The results of this progress in the Tunisian healthcare system can be seen in a number of indicators.
Since 2006, 95 per cent of the population has access to a health care facility within 5 km of their homes
(WHO, 2006). Coverage of immunisations against DTP and measles is also very high at 95 per cent for
children just below 2 years old (DHS Comparative Report 46, 2017). Immunisation coverage of
children of 1 year has been at 96-98% for most diseases since 2013, which has eliminated polio
diseases and neonatal tetanus in the country. The progress in neonatal tetanus coverage is in fact
impressive as it increased from only 40% of children in 1990 to 96% in 2013 (WHO, 2015b).
Furthermore, the percentage of mothers that receive antenatal care (ANC) and the proportion of births
attended by a skilled professional maintain a very high level in the past few years: During 2012, 98 per
cent of pregnant women received ANC at least once, and 98.6 per cent of births were attended by a
professional health worker (World Bank, 2017; see als .
This progress in access is reflected in improved health indicators. For example, fertility rates now show
a relatively “stable” population at 2.1 births per woman (MICS, 2011-12). According to the World Bank
(2017) in the period 2006-2015 the infant mortality rate fell from 18.5 to 12.1 per 1,000 live births,
and the mortality rate among children under 5 years old decreased from 21.7 deaths to 14 per 1,000
live births. Likewise, maternal mortality shows a downwards trend, falling from 74 to 64 deaths per
100,000 live births in between 2005-2015 (Maternal Mortality Estimation Inter-Agency Group 2016).
Furthermore, life expectancy of Tunisian citizens has increased dramatically from 42 in 1960 to 75.7
years in 2016, which is the highest reported in the North African region and globally higher than
average (World Bank, 2018). Lastly, Tunisia shows very low HIV/AIDS prevalence at 0.1% among
adults of ages 15-49 and has officially eliminated malaria (WHO, 2015b).
Although Tunisia has shown very high health indicators and improved access relative to other low and
middle-income countries, the country has not yet achieved universal health coverage (UHC) – one of
the SDGs that it had committed itself to reach until 2030. One of the main problems that appear in the
structure of Tunisia’s health care system is the unbalanced development between public and private
sector. The growing private sector has caused large out-of-pocket household expenses, which is
particularly damaging for the 10 per cent of the population, which is not covered with insurance.