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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.

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Notes

  1. It is worth noting that we have also conducted the multivariate analysis for the other thresholds/cut-off levels. However, given that our results exhibited broadly similar patterns in that the coefficients of the key covariates were found to be significant, though at different levels and slightly different magnitudes. Therefore, we have opted to present results for the most commonly used thresholds: the 10 and 40 % of total and discretionary expenditure, respectively. Results on the other thresholds are available upon request.

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Acknowledgments

We would like to thank The French National Research Agency (ANR) for its financial support to the research project (INEGSANTE-Les Suds-Aujourd’hui II-2010). Thanks are also due to the Tunisian National Institute of Public Health (INSP-Tunis) and to TAHINA Team. We are grateful to Professor Pedro P. Barros and two anonymous referees for helpful comments and suggestions. The authors are also grateful to Dr. Yves Arrighi for reading and commenting on the paper.

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Correspondence to Mohammad Abu-Zaineh.

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Abu-Zaineh, M., Romdhane, H.B., Ventelou, B. et al. Appraising financial protection in health: the case of Tunisia. Int J Health Care Finance Econ 13, 73–93 (2013). https://doi.org/10.1007/s10754-013-9123-8

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  • DOI: https://doi.org/10.1007/s10754-013-9123-8

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