title: Fairness in healthcare finance and delivery: what about Tunisia?
abstract: Anecdotal evidence on hidden inequity in health care in North African countries abounds. Yet firm empirical evidence has been harder to come by. This article fills the gap. It presents the first analysis of equity in the healthcare system using the particular case of Tunisia. Analyses are based on an unusually rich source of data taken from the Tunisian HealthCare Utilization and Morbidity Survey. Payments for health care are derived from the total amount of healthcare spending which was incurred by households over the last year. Utilization of health care is measured by the number of physical units of two types of services: outpatient and inpatient. The measurement of need for health care is apprehended through a rich set of ill-health indicators and demographics. Findings are presented and compared at both the aggregate level, using the general summary index approach, and the disaggregate level, using the distribution-free stochastic dominance approach. The overall picture is that direct out-of-pocket payments, which constitute a sizeable share in the current financing mix, emerge to be a progressive means of financing health care overall. Interestingly, however, when statistical testing is applied at the disaggregate level progressivity is retained over the top half of the distribution. Further analyses of the distributions of need for--and utilization of--two types of health care--outpatient and inpatient--reveal that the observed progressivity is rather an outcome of the heavy use, but not need, for health care at the higher income levels. Several policy relevant factors are discussed, and some recommendations are advanced for future reforms of the health care in Tunisia.
authors.affiliation: INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Economics & Social Sciences, Health and Medical Information Processing (SESSTIM-UMR) 912, Marseille, France National Institute of Labor and Social Studies (INTES), University of Carthage, Tunis, Tunisia National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP) and INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Marseille, France Cardiovascular Diseases Research Laboratory, Faculty of Medicine, Tunis, Tunisia mohammad.abu-zaineh@inserm.fr.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Abu-Zaineh
authors.affiliation: INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Economics & Social Sciences, Health and Medical Information Processing (SESSTIM-UMR) 912, Marseille, France National Institute of Labor and Social Studies (INTES), University of Carthage, Tunis, Tunisia National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP) and INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Marseille, France Cardiovascular Diseases Research Laboratory, Faculty of Medicine, Tunis, Tunisia.
authors.forename: Chokri
authors.initials: C
authors.lastname: Arfa
authors.affiliation: INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Economics & Social Sciences, Health and Medical Information Processing (SESSTIM-UMR) 912, Marseille, France National Institute of Labor and Social Studies (INTES), University of Carthage, Tunis, Tunisia National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP) and INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Marseille, France Cardiovascular Diseases Research Laboratory, Faculty of Medicine, Tunis, Tunisia.
authors.forename: Bruno
authors.initials: B
authors.lastname: Ventelou
authors.affiliation: INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Economics & Social Sciences, Health and Medical Information Processing (SESSTIM-UMR) 912, Marseille, France National Institute of Labor and Social Studies (INTES), University of Carthage, Tunis, Tunisia National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP) and INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Marseille, France Cardiovascular Diseases Research Laboratory, Faculty of Medicine, Tunis, Tunisia.
authors.forename: Habiba
authors.initials: H
authors.lastname: Ben Romdhane
authors.affiliation: INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Economics & Social Sciences, Health and Medical Information Processing (SESSTIM-UMR) 912, Marseille, France National Institute of Labor and Social Studies (INTES), University of Carthage, Tunis, Tunisia National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP) and INSERM-IRD-University of Aix-Marseille, Aix-Marseille School of Economics (AMSE), Marseille, France Cardiovascular Diseases Research Laboratory, Faculty of Medicine, Tunis, Tunisia.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Moatti
mesh_terms: D017047:Cost Sharing; D003695:Delivery of Health Care / Q000191:economics*; D005191:Family Characteristics; D005380:Financing, Government / Q000191:economics*; D005382:Financing, Personal / Q000191:economics*; D006296:Health Services / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics; D054625:Healthcare Disparities / Q000191:economics*; D061889:Healthcare Financing; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D012959:Socioeconomic Factors; D014416:Tunisia
keywords: Healthcare finance; Tunisia; healthcare delivery; horizontal equity; progressivity