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expenditure on health. According to the World Bank (2013), FMAP is funded and managed entirely by
the public sector, which has shown a lot of inefficiency issues and is relatively weak in targeting the
poorest sections of the population. The institutional framework and targeting will have to be reformed
in order to achieve truly guaranteed free health care for the poor.
In 2010, 45.8 per cent of the total health expenditure were “out of pocket” expenses, hinting towards
high amounts of money spent by the poorest and uncovered parts of the population for health services
in the private sector. This went in hand with a reduction of public sector spending on healthcare from
around 45 per cent in 1970s to around 26 per cent in 2008, and an expansion of the private health
sector.
Health inequities are visible across many health outcomes or health access indicators, when
comparing the poorest with the richest quintiles of the population. For example, under-5 mortality
rates are much higher amongst the poorest part of the population (32 deaths per 1,000 live births),
compared to those in the richest (16 deaths per 1,000 births) (MICS, 2011-12); and the percentage of
pregnant women aged 15-49 that had at least 4 antenatal visits was 96.3% for the richest quintile, but
only 73.2% for the poorest. Likewise, 89.1 per cent of women of the same age amongst the richest
wealth quintile being were assisted by a medical professional while giving birth, whereas only 62.8
per cent of women in the poorest quintile of the population benefitted from this service (MICS, 2011-
12). Further reforms and policies are needed to reduce the socio-economic disparities and secure free
access to the poorest and most vulnerable parts of the population.
Figure 40: Health expenditures development in Tunisia between 2000 and 2016
Source: World Development Indicators
Pro-poor initiatives for access to health services
0
200
400
600
800
1.000
1.200
1.400
2000 2005 2010 2011 2012 2013 2014 2015 2016
Expenditure in million current US$
Health Financing - Expenditure between 2000 - 2016
Government schemes
Compulsory contributory health insurance schemes
Voluntary health care payment schemes
Household out-of-pocket payment
Voluntary health insurance schemes