Appraising financial protection in health: the case of Tunisia

  • Mohammad Abu-Zaineh
  • Habiba Ben Romdhane
  • Bruno Ventelou
  • Jean-Paul Moatti
  • Arfa Chokri


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.


Poverty Line Health Expenditure Benefit Package Healthcare Payment Total Health Expenditure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



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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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Mohammad Abu-Zaineh
    • 1
    • 2
  • Habiba Ben Romdhane
    • 3
  • Bruno Ventelou
    • 1
    • 4
  • Jean-Paul Moatti
    • 1
    • 2
  • Arfa Chokri
    • 5
  1. 1.INSERM-IRD-UMR 912 (SESSIM)MarseilleFrance
  2. 2.Aix-Marseille University, Aix-Marseille School of Economics (AMSE)MarseilleFrance
  3. 3.Cardiovascular Diseases Research Laboratory, Faculty of MedicineTunisTunisia
  4. 4.French National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP), Aix-Marseille School of Economics (AMSE)MarseilleFrance
  5. 5.National Institute of Labour and Social Studies (INTES)-University of Carthage-TunisTunisTunisia

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