Appraising financial protection in health: the case of Tunisia

Abstract

Despite the remarkable progress in expanding the coverage of social protection mechanisms in health, the Tunisian healthcare system is still largely funded through direct out-of-pocket payments. This paper seeks to assess financial protection in health in the particular policy and epidemiological transition of Tunisia using nationally representative survey data on healthcare expenditure, utilization and morbidity. The extent to which the healthcare system protects people against the financial repercussions of ill-health is assessed using the catastrophic and impoverishing payment approaches. The characteristics associated with the likelihood of vulnerability to catastrophic health expenditure (CHE) are examined using multivariate logistic regression technique. Results revealed that non-negligible proportions of the Tunisian population (ranging from 4.5 % at the conservative 40 % threshold of discretionary nonfood expenditure to 12 % at the 10 % threshold of total expenditure) incurred CHE. In terms of impoverishment, results showed that health expenditure can be held responsible for about 18 % of the rise in the poverty gap. These results appeared to be relatively higher when compared with those obtained for other countries with similar level of development. Nonetheless, although households belonging to richer quintiles reported more illness episodes and received more treatment than the poor households, the latter households were more likely to incur CHE at any threshold. Amongst the correlates of CHE, health insurance coverage was significantly related to CHE regardless of the threshold used. Some implications and policy recommendations, which might also be useful for other similar countries, are advanced to enhance the financial protection capacity of the Tunisian healthcare system.

The impact of out‐of‐pocket health expenditure on household impoverishment: Evidence from Morocco

“…Other studies have used the Wagstaff and Doorslaer approach, treating direct payments on healthcare as catastrophic when they exceed a certain percentage of household income. Abu‐Zaineh et al compare the results of the two approaches in a Tunisia study. The authors note that the incidence of catastrophic expenditure differs significantly according to the thresholds used.…”

How do supply‐side factors influence informal payments for healthcare? The case of HIV patients in Cameroon

“…Direct out‐of‐pocket payments for healthcare continue to be a major source of health financing in low‐income and middle‐income countries (WHO, ; Abu‐Zaineh et al ., ). Some of these payments take the form of informal charges that are borne by the patients to access the needed healthcare services (Lewis, , ; Ensor, ; Gaal et al ., ; Stepurko et al ., ; Mokhtari and Ashtari, ; Chereches et al ., ).…”

Health Insecurity and Social Protection: Pathways, Gaps, and Their Implications on Health Outcomes and Poverty

“…Many such mechanisms aim at removing financial barriers preventing access to uptake of existing healthcare services or providing incentives for their uptake and protecting poor people from the impoverishing effects of medical expenditures. 2,[8][9][10][11] Specifically, SPH consists of a menu of policies that addresses health, poverty and vulnerability, through user fee removal, fee waivers, social assistance in healthcare, social health insurance and other similar schemes such as result-based financing mechanisms aimed at increasing access to healthcare among disenfranchised communities. [8][9][10][11] Recently, SPH has been reformulated as an essential characteristic of universal health coverage and has attracted greater attention.…”

“…10 The proposed sustainable development goals (SDGs) 1 and 3 will concentrate on full implementation of nationally appropriate social protection measures, with a focus on coverage of the poor, in particular the most marginalised and people in vulnerable situations. 11,[14][15][16][17] Similarly, international development agencies 1,2 and organisations within the UN family have adopted and adapted social protection strategies and policies within the health sector. Furthermore, a growing number of national governments in low-income countries are developing and adapting national social protection strategies in their national (health) plans.…”

“…Furthermore, a growing number of national governments in low-income countries are developing and adapting national social protection strategies in their national (health) plans. 11 There is also a rising interest in social protection among health system researchers, medical research institutes and higher education organisations. 7,18 However, despite global and local interests and adoption of social protection interventions in LMICs, the implementation, uptake, equity and effectiveness of current social protection interventions are limited by various factors.…”