Economic Brief

AfDB 2014 www.afdb.org Economic Brief What policies should be implemented CONTENTS to address inequalities in health care in Tunisia? Summary p.2 1 – General Introduction p.4 Key Messages 2 – Indicators of Health Status • Despite the progress achieved, health inequalities remain considerable and relatively little known in Tunisia. In light of the analysis conducted, there is significant elbow room for reducing these inequalities. and Use of Health Care In Tunisia, there are significant inequalities in care consumption between governorates for similar needs Services p.5 (those related to reproductive health, for example). There are also significant differences in the health status of the population of these governorates. The life expectancy of 74.5 years in 2009 does not exceed 70 years in Kasserine and Tataouine, but reaches 77 years in the governorates of Tunis and Sfax. The analysis indicates that: 3- T erritorial Inequalities in - The overall inequality in health spending declined from 2000 to 2010. The breakdown of the Gini index Health Care Facilities p.9 shows that this movement is almost entirely explained by the decrease in inequality in pharmaceuticals spending, which accounted for 42.2% of health spending in 2010. This trend can be attributed to a greater availability of pharmacies throughout the national territory. 4- Trend in inequalities in - The items where inequality has worsened and that had an inertia effect were long-term illnesses (17% of expenditure), hospital stay and medical surgery (8.6%) and radio and scans (8% of health spending). health spending in Tunisia Such spending is related to the demographic and epidemiological transition. between 2000 and 201 0 p.27 - Dental care is characterized by unusually high levels of inequality and lack of access for the disadvantaged classes. • The main recommandations in this context are as follow: 5- General Conclusion p.4 1 - From the supply side: (i) In the public sector, it is necessary to revitalize primary health care by improving the operation (ii) It is also important to strengthen Level II which seems to be the weak link in the system. Better coverage of the territory in terms of Level II beds should necessarily go hand-in-hand with the Bibliography p.42 provision of more specialized physicians for the poorest regions in light of the demographic and epidemiological transition. (iii) Efforts should be made to ensure that at each level the system performs its assigned tasks under the best possible conditions. These tasks should be clearly defined. Each Annexes p.44 hospital institution should have a scheme of work that allows for coherent strategic management. (iv) The specific incentives that were introduced to encourage physicians to settle in deserted areas should be evaluated. Public-public and possibly private-public partnerships should be instituted. Also, it is important to negotiate with corporations an institutional framework to better regulate the opening of private practices. (v) It is necessary to determine measures that should be implemented to enhance health care delivery at local or regional level, as part of an overall regional development policy. - On the demand side: (i) It is important to reduce financial barriers to health care access by better targeting the poor who benefit from free medical assistance. (ii) Pharmaceuticals are a significant drain on the budgets of the poorest households and it is necessary to reduce this weight by ensuring good governance of public pharmacies. (iii) There is a need to ensure a better collective coverage of Zondo Sakala longterm illness, hospital stay and medical surgery, x-rays and scans. Knowing the profile of households that incur these expenses will make it possible to better target them, if need be. (iv) Dental care continues Vice President to be characterized by extremely high inequalities in expenses. Improved coverage of the territory in [email protected] terms of availability of dental practices and greater public awareness of the importance of dental health should curb one of the causes of the inequality. Similarly, a special processing of reimbursement for dental expenses by health insurance, apart from the recurrent expenses, should contribute to reducing inequalities in dental care access. - On the institutional side: (i) It is necessary to aim at reducing social and regional inequalities in health care. Jacob Kolster (ii) There is a need to produce and monitor indicators for assessing the progress of specific categories not Director ORNA only at the national level but also at the local level. It is important to conduct periodic surveys on the [email protected] status of health, health care use, or the failure to seek health care for financial reasons. +216 7110 2065 This paper was prepared by Salma Zouari, Ines Ayadi and Yassine Jmal, under the supervision of Vincent Castel (ORNA) and Sahar Rad (ORNA) et Laurence Lannes (OSHD). Overall guidance was received from Jacob Kolster (Director, ORNA). Ahmed Rekik and Chokri Arfa suggested improvements to the preliminary version of this research. Asma Baklouti, Mariem Ellouze, Rahim Kallel and Abdessalem Gouider each made an input. African Development Bank AfDB Economic Brief 2014 • www.afdb.org Summary Therefore, there is clearly a need to develop a strategy for strengthening and revitalizing primary health in the country as well as enhancing Level II. n Tunisia, there are significant inequalities in care consumption between Igovernorates for similar needs (those related to reproductive health, 1-2- Regarding human resource allocations, the inequality between for example). There are also significant differences in the health status governorates has decreased, except for physicians whether in the of the population of these governorates. The life expectancy of 74.5 public or private sector. Although there has been a significant drop years in 2009 does not exceed 70 years in Kasserine and Tataouine, in the number of inhabitants per physician from 2002 to 2010, but reaches 77 years in the governorates of Tunis and Sfax. the gaps have widened between the better endowed governorates and the less endowed ones, while the variation coefficients have Three hypotheses were then made: increased. l Households, whatever the level of their resources and even when they The availability of free medical practitioners is characterized by high benefit from social security coverage, have unequal access to care levels of inequality; the relationship between the most endowed and because of inequities in the provision of health care services in their the least endowed governorates is 14.3. This is followed by dental immediate environment. practices (ratio of 11.3) and hospital beds (10.7). The most evenly l Despite the importance of social coverage, households assume an distributed resources are pharmacies and paramedical staff. average of 41% of health spending in the form of out-of-pocket expenditures. Therefore, households have unequal access to care It would be advisable to review the criteria for opening positions of arising from inequalities in income distribution and illustrated by public health physician at regional level and the institutional framework unequal health spending. governing private practices. Like the practice of pharmacy, the practice l Due to the importance of out-of-pocket health care spending, the of dentistry and medicine on a free basis should be better regulated. regressive (or progressive) nature of care spending and its inelasticity Similarly, public-private and especially public-public partnerships compared to income, can give them a potentially catastrophic and (such as agreements between academic physicians and regional impoverishing character that makes unequal access to care even hospitals) that may make disadvantaged areas more attractive as is more acute. being considered for specialists could be a solution. However, the implementation of such partnerships should be accompanied by These hypotheses were tested on the basis of available statistical measures to ensure their effectiveness for all stakeholders. data. Health policy recommendations have been made. 1-3- Lastly, since the status of health care facilities in a governorate 1- On the assumption that the availability of care provision, whether cannot be analysed by reference to a single determinant, all the public or private, and good coverage of the national territory in health components of the sector and the complementarity between different infrastructure contribute to the decline in inequality in access to care, providers should be taken into account simultaneously. For this purpose, we analysed the trend of provision indicators by governorate and the we have integrated the various determinants of facilities (by category dispersion of these indicators through the use of cross-sectional data and overall) in order to arrive at relatively homogeneous groups (called of the 2010 health map and various longitudinal indicators published clusters) and calculated for each governorate, a composite indicator in the Statistical Yearbook of the National Institute of Statistics for the of care provision that measures its position compared to other period 1997-2010. Three aspects were analysed: infrastructure, the governorates as well as the progress that may be achieved over time. availability of beds and the provision of human resources. Among the three components of health care facilities, the geographic 1-1- With regard to infrastructure and bed availability, it turned out distribution of medical human resources stands out as the most unequal, that only the availability of PHCs declined over the last decade. Level with a significant concentration on the coast. Despite an increase in the II, which is the reference for Level I, would not be very effective because density of physicians, regional disparities have widened. Qualitatively, it lacks adequate technical equipment and specialized physicians. We the inequalities are even more blatant and more than 2/3 of specialists suspect that patients are referred to Level III which takes the place are found on the coast as regards not only rare specialties but also the of Level II, thus causing inefficiencies.

Load more