Have health insurance reforms in Tunisia attained their intended objectives?

Abstract

A growing number of developing countries are currently promoting health system reforms with the aim of attaining ' universal health coverage' (UHC). In Tunisia, several reforms have been undertaken over the last two decades to attain UHC with the goals of ensuring financial protection in health and enhancing access to healthcare. The first of these goals has recently been addressed in a companion paper by Abu-Zaineh et al. (Int J Health Care Financ Econ 13(1):73-93, 2013). The present paper seeks to assess whether these reforms have in fact enhanced access to healthcare. The average treatment effects of two insurance schemes, formal-mandatory (MHI) and state-subsidized (MAS) insurance, on the utilization of outpatient and inpatient healthcare are estimated using propensity score matching. Results support the hypothesis that both schemes (MHI and MAS) increase the utilization of healthcare. However, significant variations in the average effect of these schemes are observed across services and areas. For all the matching methods used and compared with those the excluded from cover, the increase in outpatient and inpatient services for the MHI enrollees was at least 19 and 26 %, respectively, in urban areas, while for MAS beneficiaries this increase was even more pronounced (28 and 75 % in the urban areas compared with 27 and 46 % in the rural areas for outpatient and inpatient services, respectively). One important conclusion that emerges is that the current health insurance schemes, despite improving accessibility to healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for all services. Attaining the latter goal requires a strategy that targets the "trees" not the "forest".

Universal health insurance in Africa: a narrative review of the literature on institutional models

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Can a Circular Payment Card Format Effectively Elicit Preferences? Evidence From a Survey on a Mandatory Health Insurance Scheme in Tunisia

“…The second part describes the current formal "public single-provider scheme" -run by the "Caisse Nationale d'Assurance Maladie" (CNAM). This scheme covers healthcare services that are only provided by public sector facilities, with a cap on annual copayments [51]. Respondents are then asked to reveal their willingness-to-join and their quarterly WTP for this Voluntary pre-payment Health Insurance Scheme (VHIS).…”

Public–private differentials in health care delivery: the case of cesarean deliveries in Algeria

“…The relatively high share of household direct expenditures on health care can also be explained by the small share of medical costs covered by the social security, especially for private sector health services. Although in the case of Algeria no empirical evidence has been made available to date on the effect of health care expenditure on household welfare, reported evidence from neighboring countries with similar socio-economic characteristics alert on the relatively high financial burden and the risk of catastrophic and impoverishing health expenditures associated with ill-health (Abu-Zaineh et al, 2013;Makhloufi et al, 2015). From a macroeconomic perspective, Bousmah et al (2016) show that the increasing share of private health spending in total health spending in the Middle-East and North-Africa region is negatively associated with health outcomes when institutional quality is weak.…”