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Tunisia: Reform of the health insurance system

ISSA, 18.12.2008 | Feature

A programme to reform the Tunisian health insurance system has been underway since 1996. The reform process was initiated by a Presidential decision but set within a context of public dissatisfaction, with the key players considering the health-care system “exhausted”. Over recent years, the public authorities had concentrated their efforts on extending social security coverage, with coverage of the population increasing from 55 per cent in 1987 to 90 per cent by 2006. Over the period the public authorities have also undertaken to make the health-care system more equitable, to improve the quality of, and access to, health care and to contain the spiralling costs of health care. All of the above was accompanied by an extensive consultation process, which resulted in the drafting of the broad outlines of the reform, enshrined in Law 2004-71 of 2 August, 2004.
The reform process began on 1 July, 2007, with the merger of the sickness benefit programmes of the various social security schemes into a new unified scheme. The new scheme provides the same benefits to all insured persons who, in turn, all pay the same contribution rate to the same fund. The new scheme now makes it possible for insured persons to access private health care, which previously was not the case under mandatory health insurance. The new scheme has also introduced measures to contain costs.

The context and principle reasons for the reform
The inequity of the system
Health insurance was introduced in Tunisia in the 1950s and is made up of a number of private and public schemes. At the outset, the schemes were managed mainly – and then, subsequently, exclusively – by two social security funds providing public- and private-sector coverage, respectively.
The schemes offered persons who were insured under the social security scheme direct and exclusive access to health-care provision under the public health-care structures; insured persons were required to contribute to the costs of their health care with the exception of public-sector workers. The public-sector scheme dispensed with this ruling by allowing its members free access to public or private health care of their choice, by means of an advance payment of costs which were later reimbursed. This inequality in the provision of benefits was compounded by the inequality in contribution rates, which in some schemes (particularly in the agricultural sector) had been set relatively low.

The exclusion of private health care under health insurance coverage
Until the early 1980s, access to private health care was limited to the public sector only; nonetheless, it dominated health-care provision, largely meeting the needs of the population and it was not considered an obstacle for insured persons. Moreover, the crucial role played by private health care in the sector, combined with the numerous national health-care programmes it initiated (for example, systematic vaccination, birth control and health education), had resulted in a remarkable improvement in the country’s health indicators.
However, public-sector provision has proven unable to adapt to the growing needs of a population that has experienced the dual impacts of demographic and epidemiological changes. This has occurred within the institutional context of the extraordinary growth of the private sector over the past two decades. As a result, insured persons are turning increasingly to the private sector to meet their health-care needs, even when this means paying for their own health-care costs.

The proliferation of parallel forms of cover
This situation has prompted insurance companies and mutuals to develop supplementary forms of insurance to cover the wide range of private-sector services offered. However, this has resulted in additional charges, which are mainly being met by employers and which cover the same risks as those covered already by the mandatory schemes.

The rapid growth in health-care expenditure
The increase in health-care expenditure has given cause for concern on two counts. First, it was feared that the rate at which health-care expenditure was growing would lead to a short-term explosion in expenditure levels. Second, there was concern that the growth in expenditure was largely at the expense of disposable household incomes.

Figure 1: Trends in total health expenditure (percentage of GDP)

Figure 2: Trends in health-care expenditure by funding sources (TND millions)

The underlying principles of the reform
In order to achieve the objectives of equity, improved access to health care and containment of health-care costs, the underlying principles of the reform outlined by the government are as follows:
- To unify the mandatory schemes and to ensure sufficient coverage of all risks;
- To maintain the forms of supplementary cover and avoid their duplication;
- To extend health insurance to include private health-care provision while also rationalizing the buyer/provider relationship and safeguarding the coherence of the health-care system with its private and public components; and
- To involve all key players in the health-care system to help control health-care expenditure.

The conception phase
The scale of the reform not only impacts all aspects of the health-care system but also has political and socio-economic implications. As a result, a national health insurance commission, comprising representatives from the funds, supervisory ministries, social partners, and members of the medical and pharmaceutical professional associations, was formed in the early stages of the process to define the orientations of the reform in line with the agreed principles.
Under the strong impetus of the government, the drafting of the reform took years of consultation and negotiations, drawing together diverse views to build a general consensus prior to implementing the reform. Information-seeking missions visited health insurance systems in a number of European countries. And a technical cooperation programme involving experts from French funds was undertaken. All of these initiatives proved important to the team tasked with leading the project. The expertise of specialists from the European Commission, who were tasked by the Tunisian government and the European Union to monitor the programme and support the reform process, also played a contributory role in this initial phase.

Implementation
The content of the reform
The reform process was initiated by the enactment of Law No 2004-71 of 2 August, 2004, on the creation of a new health insurance scheme. The principle measures announced in this Law included:
- The introduction of a single and unified mandatory scheme for all insured persons, which would be managed by the national health insurance fund (Caisse Nationale d’Assurance Maladie (CNAM)) also established under the same Law;
- The setting of a single contribution rate for all economically active insured persons (6.75 per cent, of which 4 per cent are employer contributions) and a 4 per cent contribution rate for beneficiaries in receipt of a pension;
- The definition of a “basket” of health-care services;
- The opening up of mandatory health insurance to private-sector providers within a convention framework that sets out their relationship with the CNAM;
- Maintaining optional supplementary cover, but limiting the scope of intervention to benefits and, with regard to health-care costs, requiring the insured person to meet his or her own costs;
- Establishing a national health insurance commission, comprising key players within the health insurance system whose mandate is to periodically evaluate the new scheme and to propose any necessary corrective measures.
Consequently, this Law has established the major framework for the new health insurance scheme; details regarding the practical application of the Law are laid down in the texts, as are subject matters for consultation with the parties concerned.

The preliminaries
The introduction of this new health insurance scheme has necessitated preliminary work in three parallel areas:
a. The completion of the regulatory mechanism
This activity had been largely undertaken in close consultation with all key players, namely the Ministry of Public Health, social partners, and health-care providers including trade union representatives. The aim is to finalize the texts on the application of the new Law, and, in particular, the texts relating to medical supervision, ministerial contractual arrangements, the national health insurance commission, the terms and rates for the provision of health care and the incremental increases in contribution rates.
This work has paved the way for establishing the mechanisms and practical application of the new scheme. Specifically, this consists of offering persons insured under the social security scheme the option of choosing between three types of cover according to the different rules governing the following: access to health care (public or private providers), methods of payment (per treatment or course of treatment), types of cover (advance payment of costs or direct payment from insurers), and the level of cover for health-care costs (level of provision of cover, ceiling for reimbursements, reference price for medication etc). These options are only available for ambulatory health care. The same rules apply for hospitalization, irrespective of the option chosen by the insured person.
b. Setting up the CNAM
Once the CNAM has been set up centrally and regionally, it will take responsibility for managing the schemes that were previously managed by the pre-existing funds and for ensuring continuity until the new scheme comes into force. The merging of the funds’ sickness insurance programmes with the CNAM will also involve the transfer of personnel, logistics (premises, equipment, vehicles etc) and the installation of the CNAM’s information technology (IT) system.
c. Concluding the conventions with health-care providers
The negotiation of conventions with trade union organizations that represent private health-care providers has necessitated several rounds of discussions and, at times, government arbitration, particularly on the question of rates.
The agreement on the principal conventions with medical practitioners, dentists, biologists, pharmacists, and clinics is considered an essential prerequisite to the introduction of the new scheme and was only concluded several months after the introduction of the new scheme.

The introduction of the new scheme
The new health insurance scheme is being phased in gradually. The first phase commenced on 1 July, 2007, and concerned:
- The increase in contributions: The rates of the various schemes will increase annually over a period of 2 to 5 years and will eventually harmonize around a single rate.
- The categories of insured persons: The new scheme will apply to all schemes with the exception of schemes for students and workers with low incomes, who will continue to receive the same benefits as previously. These schemes will be reviewed at a later date.
- Benefits: The opening up of private health-care provision has been programmed in two stages. The first stage concerns care for pregnancy and child birth, some chronic illnesses (according to the schedule in law), and a list of surgical operations. Insured persons can choose either to be reimbursed or to receive a direct payment from the insurers, conditional upon the pre-established rules.
This first phase, which took only 12 months to complete, has enabled the three key players (the fund, beneficiaries and health-care providers) to familiarize themselves with the measures of the new scheme. During this period, two large-scale operations were also completed: the first operation concerned the choice of options for insured persons (the choice between the “public option”, the “private option”, or the “system of reimbursements”); the second operation concerned the publication and distribution of health-care programmes.
The second phase of the implementation of the new health insurance scheme, with all its component parts, began on 1 July, 2008.
In addition, a number of training sessions were held for CNAM personnel and contracted health-care providers prior to and during each stage of the reform process. An extensive media campaign was also undertaken informing end users of the details of the new scheme and its new rules. It is anticipated that the campaign will continue in the months and years to come.
At the present time, the public authorities are prioritizing the modernization of the health-care system by putting even greater emphasis on new technologies and, in particular, technologies that will facilitate data exchange procedures between the CNAM and its partners.