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FACULTY OF MEDICINE OF TUNIS
Health Insurance and
Medical Training in Tunisia
Dr Ahmed BANASR
March the 26th, 2012
Health Medical
Insurance Doctors
Training
Health system care
Introduction
• A context of public dissatisfaction,
• Key players considering the health-care
system “exhausted”.
• Decision to reform separately :
• Health insurance
• Medical training
• Health insurance reform
• Medical training reform
• Family medicine
• Solution outlines
Health insurance reform
The context and principle reasons for
the reform
• The inequity of the system
• The exclusion of private health care under
health insurance coverage
• The proliferation of parallel forms of cover
• The rapid growth in health-care expenditure
Stages of reform
• A programme to reform the Tunisian health insurance
system has been underway since 1996.
• The public authorities have
• Concentrated their efforts on extending social security
coverage (55 % in 1987 90 % by 2006).
• 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.
• 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
Stages of reform
• 2005-2007: Publication of decrees and
orders in a manner negotiated with all
partners of public and private sectors ;
– Uniform contribution rate of 6.75%
– Pricing, list of drugs and acts, coverage, acts
contracted, repositories, ...
– Limit on certain benefits ...
• Gradual accession of doctors, pharmacists,
dentists, clinical
Principles of Reform
• Provide insured freedom to seek care at their
option either in the public sector or private
sector
• Require all policy holders to adhere to a system
of health protection called basic plan, covering a
range of outpatient and inpatient care defined
• Leave to policy holders who want the
opportunity to join a scheme complementary
coverage said , intended to cover care not
covered by the general scheme
A General Rule
A Single Chain of Care
1.Public sector :
The public care provides support care benefits provided
by the public health structures against the payment of user
fees
2. Private sector:
- This sector is based on the principle of coordinated course of
care or third party payer.
- It requires, with certain exceptions
(gynecologist, pediatrician ...) a passage by the family doctor.
- The insured must, in this case, choose a family
doctor arrangement with the CNAM + + +
A General Rule
A Single Chain of care
3. Reimbursement scheme :
- The third sector care allows the insured to receive care on
an outpatient basis to the various providers of public and
private care contracted against the payment of expenses of
total care.
- The insured is reimbursed, a posteriori, within an annual
limit
N.B : Possibility of change course at the request of the
insured after one year
Joint Services
• Hospitalizations in all medical specialties within public
health facilities and public facilities under agreement
• Hospitalization in private facilities under agreement in
a limited number of specialties.
• CNAM provides an opening to the private everything
concerning oncological operations.
• Care benefits currently supported in the private and
public (dialysis, prosthetics, orthotics, organ
transplantation and lithotripsy).
• APCI: list of 24 chronic conditions (hypertension,
diabetes, cancer, ..) with full support (prior approval)
Expenses of the CNAM (2009)
• Total: 1138 Million Tunisian Dinars
– Public sector = 60%
– Private sector = 40%
• Chronic Diseases: TD 440 million or 39%
Population covered by Health
Insurance (2008)
• Coverage rate = 68% CNAM
– Public sector: 49.5%
– Private sector: 8.2%
– Reimbursement: 10.3%
• Coverage rate of free medical aid
(AMG1 and 2) = 20%
• Not having any coverage = 12%
The Medical training reform
The context and principle reasons
for the Medical training reform
• A degree in general medicine more non-
compliant with international standard
• Practical training devalued as compared to
the theory
• Research undervalued
• Teachers demotivated by the academic
responsibilities
The context and principle reasons
for the Medical training reform
• Lack of an objective evaluation
• Undeveloped communication (website,
mailing)
• International relations are Limited
• The students not implicated
CURSUS ACTUEL
F PCEM
O
T R 1 FORMATION
F R M
A O A 2 SCIENTIFIQUE
T DE BASE
C N I DCEM
C
U O
1
N
L C 2 FORMATION
T O G
M E
3 CLINIQUE
E N
M E
DE BASE
U R
Internat
N A
L 1
E
2
C CONCOURS DE RESIDANAT
F
O
A
L
L
C SPECIALITE
U MG
E
G
L 4-5ans
T
E
E
S COLLEGE DES SPECIALITES
Main Areas of Reform
CURSUS PROPOSE
F PCEM
O
T R 1 FORMATION
F R M
A O A 2 SCIENTIFIQUE
T DE BASE
C N I DCEM
C
U O
1
N
L C 2 FORMATION
T O G
M E
3 CLINIQUE
E N
M E CONCOURS DE RESIDANAT DE BASE
U R 4
N A
L
E
TCEM
C
O
F MG/MF FORMATION
L
A
2ans SPECIALISEE SPECIALITE
C
L
E
U 4-5ans
L
G
T
E
E
S 2eme Cycle des études
COLLEGE de MF COLLEGE DES SPECIALITES
médicales
Undergraduate medical studies
• Two years of medical education taken by all
students.
• This common curriculum would consist of 50
percent basic science with an emphasis on
competencies that would be useful to every
physician.
Undergraduate medical studies
• One-third of the time would be devoted to an
introduction to clinical care of individual
patients.
• One-sixth of the time would be used to cover
key aspects of the health of populations and
the organization and delivery of care.
• It is important for all physicians, regardless of
prospective careers, to understand how each
element fits into a health care system
Practical training
Second Cycle of Medical Studies
Internships
TP, TD
A third Cycle fo Medical studies
• One year of rotating intership
• Specialisation
Or
• Family Medicine
Family medicine
Family Medicine
• The family physician is the gateway to the
health system,
• He is responsible for continuing care and
comprehensive care of individuals in the
context of
– their environment,
– their families
– their cultures.
• He provides palliative care deals with disease
prevention and health promotion
Family Medicine
• The reform of health insurance :
– Making a family doctor axial element in
controlling health costs.
– Programmed to obtain a better preparation of
the GP's role as family doctor.
• A recall in 2008, an interagency group in
collaboration with the Faculty World Health
Organization (WHO) was created to promote
family medicine in Tunisia and had established
a framework for its development..
Family Medicine
• Initially, the idea was to rely on international
standards that require medical studies around
8 years of training.
• The reform had to add one year.
• It should also review the medical school for
more efficiency
Family Medicine
• The future family physicians must be trained
in the third cycle of university and continuing
education
• Different fields and skills to be acquired by a
family doctor.
• This training include, in addition to two cycles
of medical education, a third cycle of two
years of specialization in family medicine
Family Medicine
• The training of future family physicians should
be in offices and in private clinics
• Must learn how to think for young doctors to
a patient, how to treat every day.
• Training of family physicians is not only
objective medical procedure, but the medical
service must go beyond the doctor-patient
relationship to include family and community
Solution outlines
Solutions
• In Tunisia there were two major projects : the
reform of medical education and reform of
health insurance.
• Now we need a third site, namely the reform
of the health system that must meet its
objectives
Improve health coverage
• Implement universal health coverage (CMU).
• CMU does not mean the free care for all, but the
possibility for a patient to opt for care in the
public or private sector, at its discretion.
• In this context, the repayment of the patient will
based on a repayment schedule, applied equally
to public sector and the private sector.
• The rate of reimbursement would be based
on actual cost of benefits granted by the public
sector
Improve Medical education
• Arrange an education, centering on the
student, with programs that take
account the profile of the position.
• Select indicators for monitoring
the training short, medium and
long term partnership with the trainer and the
employer.
• This education must be level of international
standards and courses must be consistent
with real life subsequent professional
Improve attractiveness
• Improve attractiveness in the hospital sector, by acting
on salaries, contracts and working conditions.
• In particular, it is recommended to :
• Open new academic positions
• Enhance the status of university by :
• Creating other issues
• Encouraging exchanges between scholars in the medical sector and other
sectors non-medical.
• This will :
• improve the learning conditions of students and trainees,
• encourage medical research in Tunisia
Improve Family medicine
• Family medicine :
– a strategic importance to the health of Tunisians,
– this discipline must occupy primordial place in the
country's health system.
• Redefining family medicine,
• Marking its fields of action,
• Lighten reports with the CNAM
CONCLUSION
• Initiate a national consultation on funding the
real needs of Health in Tunisia, and
the responses to it.
• Assess the financing needs of health
coverage.
CONCLUSION
• Restructuring of the health map (territorial
coverage units care)
• Improve the remuneration of medical and
paramedical personnel
• Improve conditions of care (care early through
improved proximity).
• Finally, the computerization of the entire
system health is likely to ensure better cost
control
