2014

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E c o n o m i c B r i e f
CONTENTS
What policies should be implemented
to address inequalities in health care
Summary p.2
in Tunisia?
1 – General Introduction p.4
Key Messages

2 – Indicators of Health Status
and Use of Health Care
Services p.5
3- Territorial Inequalities in
Health Care Facilities p.9
4- Trend in inequalities in
health spending in Tunisia
between 2000 and 2010 p.27
• Despite the progress achieved, health inequalities remain considerable and relatively little known in
Tunisia. In light of the analysis conducted, there is significant elbow room for reducing these inequalities.
In Tunisia, there are significant inequalities in care consumption between governorates for similar needs
(those related to reproductive health, for example). There are also significant differences in the health status of
the population of these governorates. The life expectancy of 74.5 years in 2009 does not exceed 70 years in
Kasserine and Tataouine, but reaches 77 years in the governorates of Tunis and Sfax. The analysis indicates that:
- The overall inequality in health spending declined from 2000 to 2010. The breakdown of the Gini index
shows that this movement is almost entirely explained by the decrease in inequality in pharmaceuticals
spending, which accounted for 42.2% of health spending in 2010. This trend can be attributed to a
greater availability of pharmacies throughout the national territory.
- The items where inequality has worsened and that had an inertia effect were long-term illnesses (17%
of expenditure), hospital stay and medical surgery (8.6%) and radio and scans (8% of health spending).
Such spending is related to the demographic and epidemiological transition.
- Dental care is characterized by unusually high levels of inequality and lack of access for the
disadvantaged classes.

• The main recommandations in this context are as follow:

5- General Conclusion p.41
- From the supply side: (i) In the public sector, it is necessary to revitalize primary health care by improving
the operation (ii) It is also important to strengthen Level II which seems to be the weak link in the system.
Better coverage of the territory in terms of Level II beds should necessarily go hand-in-hand with the
Bibliography p.42 provision of more specialized physicians for the poorest regions in light of the demographic and
epidemiological transition. (iii) Efforts should be made to ensure that at each level the system performs
its assigned tasks under the best possible conditions. These tasks should be clearly defined. Each
Annexes p.44 hospital institution should have a scheme of work that allows for coherent strategic management. (iv)
The specific incentives that were introduced to encourage physicians to settle in deserted areas should
be evaluated. Public-public and possibly private-public partnerships should be instituted. Also, it is
important to negotiate with corporations an institutional framework to better regulate the opening of
private practices. (v) It is necessary to determine measures that should be implemented to enhance
health care delivery at local or regional level, as part of an overall regional development policy.
- On the demand side: (i) It is important to reduce financial barriers to health care access by better
targeting the poor who benefit from free medical assistance. (ii) Pharmaceuticals are a significant
drain on the budgets of the poorest households and it is necessary to reduce this weight by ensuring
good governance of public pharmacies. (iii) There is a need to ensure a better collective coverage of
Zondo Sakala longterm illness, hospital stay and medical surgery, x-rays and scans. Knowing the profile of households
that incur these expenses will make it possible to better target them, if need be. (iv) Dental care continues
Vice President to be characterized by extremely high inequalities in expenses. Improved coverage of the territory in
z.sakala@afdb.org terms of availability of dental practices and greater public awareness of the importance of dental health
should curb one of the causes of the inequality. Similarly, a special processing of reimbursement for
dental expenses by health insurance, apart from the recurrent expenses, should contribute to reducing
inequalities in dental care access.
- On the institutional side: (i) It is necessary to aim at reducing social and regional inequalities in health care.
Jacob Kolster (ii) There is a need to produce and monitor indicators for assessing the progress of specific categories not
Director ORNA only at the national level but also at the local level. It is important to conduct periodic surveys on the
status of health, health care use, or the failure to seek health care for financial reasons.
j.kolster@afdb.org
+216 7110 2065
This paper was prepared by Salma Zouari, Ines Ayadi and Yassine Jmal, under the supervision of Vincent Castel (ORNA) and Sahar
Rad (ORNA) et Laurence Lannes (OSHD). Overall guidance was received from Jacob Kolster (Director, ORNA). Ahmed Rekik
and Chokri Arfa suggested improvements to the preliminary version of this research. Asma Baklouti, Mariem Ellouze, Rahim Kallel
and Abdessalem Gouider each made an input.

A f r i c a n D e v e l o p m e n t B a n k
 AfDB Economic Brief
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Summary
n Tunisia, there are significant inequalities in care consumption between
I governorates for similar needs (those related to reproductive health,
for example). There are also significant differences in the health status
of the population of these governorates. The life expectancy of 74.5
years in 2009 does not exceed 70 years in Kasserine and Tataouine,
but reaches 77 years in the governorates of Tunis and Sfax.
Three hypotheses were then made:
l Households, whatever the level of their resources and even when they
benefit from social security coverage, have unequal access to care
because of inequities in the provision of health care services in their
immediate environment.
l Despite the importance of social coverage, households assume an
average of 41% of health spending in the form of out-of-pocket
expenditures. Therefore, households have unequal access to care
arising from inequalities in income distribution and illustrated by
unequal health spending.
l Due to the importance of out-of-pocket health care spending, the
regressive (or progressive) nature of care spending and its inelasticity
compared to income, can give them a potentially catastrophic and
impoverishing character that makes unequal access to care even
more acute.
These hypotheses were tested on the basis of available statistical
data. Health policy recommendations have been made.
1- On the assumption that the availability of care provision, whether
public or private, and good coverage of the national territory in health
infrastructure contribute to the decline in inequality in access to care,
we analysed the trend of provision indicators by governorate and the
dispersion of these indicators through the use of cross-sectional data
of the 2010 health map and various longitudinal indicators published
in the Statistical Yearbook of the National Institute of Statistics for the
period 1997-2010. Three aspects were analysed: infrastructure, the
availability of beds and the provision of human resources.
1-1- With regard to infrastructure and bed availability, it turned out
that only the availability of PHCs declined over the last decade. Level
II, which is the reference for Level I, would not be very effective because
it lacks adequate technical equipment and specialized physicians. We
suspect that patients are referred to Level III which takes the place
of Level II, thus causing inefficiencies.
A f r i c a n D e v
Therefore, there is clearly a need to develop a strategy for strengthening
and revitalizing primary health in the country as well as enhancing
Level II.
1-2- Regarding human resource allocations, the inequality between
governorates has decreased, except for physicians whether in the
public or private sector. Although there has been a significant drop
in the number of inhabitants per physician from 2002 to 2010,
the gaps have widened between the better endowed governorates
and the less endowed ones, while the variation coefficients have
increased.
The availability of free medical practitioners is characterized by high
levels of inequality; the relationship between the most endowed and
the least endowed governorates is 14.3. This is followed by dental
practices (ratio of 11.3) and hospital beds (10.7). The most evenly
distributed resources are pharmacies and paramedical staff.
It would be advisable to review the criteria for opening positions of
public health physician at regional level and the institutional framework
governing private practices. Like the practice of pharmacy, the practice
of dentistry and medicine on a free basis should be better regulated.
Similarly, public-private and especially public-public partnerships
(such as agreements between academic physicians and regional
hospitals) that may make disadvantaged areas more attractive as is
being considered for specialists could be a solution. However, the
implementation of such partnerships should be accompanied by
measures to ensure their effectiveness for all stakeholders.
1-3- Lastly, since the status of health care facilities in a governorate
cannot be analysed by reference to a single determinant, all the
components of the sector and the complementarity between different
providers should be taken into account simultaneously. For this purpose,
we have integrated the various determinants of facilities (by category
and overall) in order to arrive at relatively homogeneous groups (called
clusters) and calculated for each governorate, a composite indicator
of care provision that measures its position compared to other
governorates as well as the progress that may be achieved over time.
Among the three components of health care facilities, the geographic
distribution of medical human resources stands out as the most unequal,
with a significant concentration on the coast. Despite an increase in the
density of physicians, regional disparities have widened. Qualitatively,
the inequalities are even more blatant and more than 2/3 of specialists
are found on the coast as regards not only rare specialties but also the
most common such as gynaecology and paediatrics.
2
e l o p m e n t B a n k

Three governorates constantly fall within the most favoured cluster
whatever the aspect considered. They are Tunis, Sousse and Monastir.
Conversely, four governorates always fall within the most disadvantaged
cluster: Jendouba, Kairouan, Kasserine and Sidi Bouzid. Between these
two groups, the various governorates show more or less substantial
deficits depending on the nature of the resources analysed. The scope
of intervention required by each governorate may then be defined.
Government intervention is necessary when there is a build-up of
inequalities. However, the choices related to the health sector and efforts
to better allocate resources to priority areas can only be effective if they
form part of a comprehensive local development strategy in these areas.
The reduction of economic, cultural and social differences between the
governorates can only facilitate and strengthen health reforms.
2- Working from the assumption that inequalities in access to health
are linked to income inequalities, we assessed the inequality of out-of-
pocket household health expenditure and analysed the trends thereof
and training through inequality indicators and their breakdown by
expenditure category. For this purpose, we referred to the individual
data of the national surveys on household budget and consumption in
2000, 2005 and 2010. This data provides information on total health
spending per person per year (SPY) and the various expenditure
categories: routine medical care, special medical care, pharmaceuticals
and medical devices or expenditure sub-categories (medical
consultations; dental care; radio, scanner and medical analysis; medical
stay and surgery; special dental care; special radiology expenditure;
childbirth; long-term diseases; drugs; other pharmaceuticals, etc.).
This approach gave information about:
l Overall inequality in health spending and its trends;
l inequality of SPY in each care spending item and sub-item;
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l the contribution of inequality in each SPY category or sub-category
to total health spending inequality;
l the marginal effect - equalizer or non-equalizer – of the variation of a
particular SPY on total health spending inequality.
2-1- The overall inequality in health spending declined from 2000 to
2010. The breakdown of the Gini index shows that this movement is
almost entirely explained by the decrease in inequality in pharmaceuticals
spending, which accounted for 42.2% of health spending in 2010. This
trend can be attributed to a greater availability of pharmacies throughout
the national territory.
2-2- The items where inequality has worsened and that had an inertia
effect were long-term illnesses (17% of expenditure), hospital stay and
medical surgery (8.6%) and radio and scans (8% of health spending).
Such spending is related to the demographic and epidemiological
transition.
The reduction of the corresponding inequality requires specific
government policies that target the most vulnerable groups. The
collective management of these expenditures still seems insufficient.
Knowing the profile of households that incur these expenditures will
help to better target them.
2-3- Dental care is characterized by unusually high levels of inequality
and lack of access for the disadvantaged classes.
Improved coverage of the territory by dental practices and greater
awareness of people about the importance of oral and dental health
should curb one of the causes of this inequality. Similarly, a specific
treatment for reimbursement made by health insurance that is non-
concurrent with current spending should contribute to the reduction of
inequalities in access to dental care.
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1. General Introduction

ince 1956, the foundations for a universal system of health care is heavily subsidized or free for the beneficiaries of free health coverage
S delivery have been established in Tunisia. For three decades,
the resulting benefits have been improved over time and a social
who are estimated at 27% of the population.

security system has been put in place for employees. However, public
expenditure on the health sector has slowed since the 1990s, and
private practices have gradually substituted public health services that
have experienced some decline in their quality and availability. Household
health spending has risen sharply, sometimes leaving a heavy dent on
the household budget. The most vulnerable segments are not spared
(Arfa, ElGazzar, 2013).
Since January 2011, there is heightened awareness of inequalities in
the health status of the population and health care use. More attention
is paid to issues of equity in access to care and there is more concern
about a more egalitarian distribution of health services throughout the
country.
Indeed, although health infrastructure covers almost the entire
1
country , there are inequalities in availability between the different
regions. The health system is predominantly public, with 87% of bed
capacity in public hospitals and 13% in private clinics. On average,
Tunisia has 123 physicians per 100 000 inhabitants. However,
physician density is much lower in the poorest regions where most
2
of the beneficiaries of free health care are found.
With regard to the financing of the demand for care, the National Health
Insurance Fund (CNAM) covers about 68% of the total population. It
covers both public and private health care services in the country. The
majority of physicians, laboratories, dentists and pharmacists are
contracted with CNAM. There are three branches: the public branch,
the private branch and the reimbursement branch. The public branch
Despite the important size of community coverage of medical care by
insurance or by the State budget, private spending still remains very
high and is increasing. In 2010, health care was financed by public
budgets to the tune of 23.8%, by health insurance resources (CNAM
with 27.7% and private insurance with 7%) and out-of-pocket
household spending that covered 41.2%.
Thus, the health system faces many challenges, and it is important to:
l Reduce regional disparities in the provision of health care services;
l reduce inequalities in household health spending;
l limit the amount of out-of-pocket household spending.
Therefore, it is necessary to better define the situation of health
inequalities and its recent trend, and to identify policies that can help
address the above challenges.
We will begin by recalling some household health status indicators
and the use of health services (Section I). We will then analyse the
inequities in health care provision (Section II). Lastly, we will also
address the spending inequalities and their sources (Section III). In
this respect, we will mainly use data from the 2010 Tunisia Health
Map published by the Ministry of Health as well as data relating to
the health sector published by the National Institute of Statistics (INS)
in the Statistical Yearbook of Tunisia between 1997 and 2010. We
will further use the individual databases of the National Surveys on
Household Budget and Consumption conducted by the INS in 2000,
2005 and 2010.

1
The health system includes: (a) primary health centres or primary health centres and local or district hospitals; (b) regional hospitals; and (c) university teaching
hospitals.
2
Medical density in Tunisia is lower than the European average, which is more than 300 physicians per 100 000 people. It is the highest in the Maghreb
(Algeria and Libya 120, Morocco 60, Mauritania 10) and occupies the ninth place in the EMRO region behind Lebanon (330), Bahrain (300), Qatar (280),
Jordan (260), Egypt (240), Kuwait and Oman (180), Saudi Arabia (160) and ahead of Iran (90), Pakistan (80) , Syrian Arab Republic and Iraq (50 ), Sudan and Yemen
(30) (MH, Tunisia Health Map 2010).

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2. Indicators of Health Status and Use of Health Care Services3

here are few studies and statistics on this issue. However, we because reproductive health concerns the entire population in the
T will refer to data known for their relevance and published regularly
by the INS. The health status will be assessed through life expectancy
same manner.

and the infant mortality rate (IMR). These two indicators are particularly
suited to the health inequalities study (Jusot, 2003). However, they
are published in a systematic way only at the national level. The
mortality rate, which is a poor indicator of health status because it is
sensitive to the structure of the population by age, is however available
at the governorate level. It will only be used to assess the evolution
of its variation coefficient.4 Health service use will be analysed through
the data on reproductive health because of their availability and
1- Health status indicators
Differences in life span may be seen as a synthetic indicator of social
differences affecting health throughout the life cycle (Aïach, 2000).
There has been a remarkable increase in life expectancy at birth in
Tunisia (Figure 1). From only 58 years in 1956, life expectancy has
risen to 74.9 years in 2011. The continuous improvement of this
indicator is applicable to both men and women.

Figure 1: Life expectancy by gender (1990-2011)

78
76
74
72
70
68
66
64
1991

1997

2001

2007

2011
1990

1994
1995
1996

1998
1999
2000

2004
2005
2006

2008
2009
2010
1992
1993

2002
2003

Male Female

The increase in life expectancy is due to a decrease in mortality The mortality rate showed a decreasing trend. From 19.1 per thousand
rates in general, and the sharp decline in infant mortality in in 1960, it dropped to 5.5 per thousand in 2011 (Figure 2). The infant
particular. mortality rate fell from 120 per thousand births in 1966 to 14 per thousand
in 2011 (Figure 2).

3
All the statistics in this section are derived from Tunisian Statistical Yearbooks published by the National Institute of Statistics.
4
For a Y distribution of mortality rates with average  Y, the coefficient of variation, noted CV, is derived from the variance. It is defined as the ratio of the standard
deviation σ to the mean mortality rates:
CV = σ /Y where σ2 = 1/ N ∑(Yi -Y)2
CV is used to compare the dispersions of distributions with different averages. The higher the CV the more dispersed the distribution will be.

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Figure 2: Mortality rate Figure 3: Infant mortality rate

25.0 200
20.0 150
15.0
100
10.0
5.0 50
0.0 0
1968

1988

2008
1990
1964

1972
1976
1980
1984

1992
1996
2000
2001

1960
1964
1968
1972
1976
1980
1984
1988
1992
1996
2000
2004
2008
Infant mortality is an indicator widely used in international comparisons. The life expectancy of 74.5 years in 2009 did not exceed 70 years in
It is an indicator of robust health, revealing a country’s development Kasserine and Tataouine, but reached 77 years in the Tunis or Sfax
level and the quality of its health care system. It depends on several governorates (Map 1). Similarly, the decline in infant mortality has not
factors, including income, maternal educational level and the been equally beneficial to all children regardless of their place of birth
effectiveness of preventive care provided to mother and child (Map 1). In 2009, the infant mortality rate was 17.8 ‰ at the national
(Bouchoucha and Vallin, 2007). The decline in infant mortality rate may level. In the South, it was 21 ‰, while in the Midwest it rose to 23.6 ‰
be attributed to both factors inherent in the health system (modernization (Ministry of Regional Development, 2011). Map 1 shows two groups of
and better coverage of the country) and the evolution of Tunisian society governorates at odds with each other: the first (Tunis, Sousse, Monastir
(improvement in the quality of life and an increase in the living standards and Sfax) recorded the lowest infant mortality rates (IMR), while the
and the educational level of the population). second (Kasserine, Sidi Bouzid and Kairouan) had the highest rates.

However, this overall positive trend hides significant disparities between Lastly, the mortality rate by governorate (indicator sensitive to the age structure
rural and urban areas as well as between socioeconomic groups and of the population) shows contrasting trends and especially an increase in
between the various governorates. We will focus on the regional aspect the variation coefficient, indicating a rise in inter-governorate inequality and
of inequality and health status indicators. greater heterogeneity of living conditions prevailing there (Figure 4).

Figure 4: Coefficient of variation in mortality rates by governorate (1978-2010)

0.25
0.20
0.15
0.10
0.05
0.00
1997 1998 1999 2000 2000 2001 2002 2003 2004 2005 2007 2008 2009 2010

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2- Health care use indicators
In general, health care use is related to health condition and inequality
in health care use primarily reflects unequal needs. Hence it is not
necessarily unfair. It is therefore necessary to analyse the inequalities
observed only when facing the same need. As such, the indicators related
to reproductive health are well suited for such an analysis. They help to
identify women who give birth and analyse inequalities between them.
Tunisian Statistical Yearbooks each year publish statistics on the use
of reproductive health care. We will try to see to what extent the use of
such care is egalitarian.
However, it is important to note that reproductive health care use reflects
women’s perception of health and medicine, and it depends on the
alternative care available to them and their medical environment.
However, it is often subject to social and family control (Gastineau,
2003). Belonging to a family or community group, social habits and the
environment are likely to influence women's choices in this matter.
With reference to the number of deliveries by governorate, we calculated
three indicators: the home delivery rate, the hospital delivery rate and
the clinic delivery rate.5
In 2010, the home delivery rate (or rate of medically unassisted childbirth)
was 7.6%. It varied greatly between governorates. Governorates with
high home delivery rates include Monastir, Nabeul and Mahdia, all of
which have relatively good health infrastructure (Figure 5).

Figure 5: Home delivery rate in 2010 by governorate

50%
40%
30%
20%
10%
0%
Zaghouan
Kasserine
Manouba

Tataouine
Sidi Bouzid
Kairouan
Siliana
Mahdia

Sousse
Nabeul
Monasr
TUNISIA
Medenine

Gaafsa
Ben Arous
Kebili

Ariana
Tozeur
Sfax
Gabes

Jendouba
Beja
Bizerte
Tunis
Le Kef

Clinic delivery rate was 12.3%. With the exception of Monastir, it was private health infrastructure (Figure 6).
generally higher in the major urban centres of the coast which have

Figure 6: Clinic delivery rate in 2010 by governorate

50%
40%
30%
20%
10%
0%
Ben Arous
Sfax
Nabeul
Sousse
Tunis
Ariana
TUNISIA
Bizerte
Médenine

Mahdia
Monas r
Gabes
Kairouan
Beja
Gafsa
Jendouba
Manouba
Sidi Bouzid
Siliana
Touzeur
Kasserine
Kebili
Zaghouan
Tataouine
Le Kef

5
The sum of these three rates is not a unit because some women do not report the place where they gave birth.

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Lastly, hospital delivery is the dominant standard in Tunisia. On are those where the private sector is important (Sfax, Tunisia...)
average, 67.5% of women give birth in hospital. Governorates or where the use of medicine is relatively limited (Sidi Bouzid,
where the propensity to give birth in hospitals is lower (Figure 7) Kasserine…).

Figure 7: Hospital delivery rate in 2010 by governorate

100%
80%
60%
40%
20%
0%
Jendouba
Beja
Tozeur
Kebili
Tataouine
Gabes

Siliana
Bizerte
Gafsa
Ariana
Medenine
Sousse
Mahdia
Kairouan
TUNISIA
Sfax
Nabeul
Tunis
Manouba
Sidi Bouzid
Ben Arous
Kasserine
Monas r
Zaghouan
Le Kef

By comparing the number of antenatal or postnatal visits in the public
sector to the total number of births registered in a year (assisted or
unassisted, in hospital or private clinic), the frequency of these procedures
may be determined. There is an average of three antenatal visits per
delivery. Only Tunis, Sousse, Sfax, Monastir and Mahdia governorates
show a lower frequency rate for these procedures. These governorates
are better off in private infrastructure, and many women consult their
gynaecologist. The number of public postnatal visits is much lower (0.57
in 2010), but it is just as unevenly distributed among the governorates
as the number of antenatal visits (Figures below).

Figure 8: Antenatal visits per delivery Figure 9: Postnatal visits per delivery

1.5
8
6 1.0
4
0.5
2
0 0.0
TUNISIA
Kebili
Gabes
Zaghouan
Kasserine
Ariana
Ben Arous
Sidi Bouzid

Tozeur
Mahdia
Bizerte

Tataouine
Gafsa
Beja
Siliana

Sfax
Monasr
Medenine
Kairouan
Sousse
Tunis
Le Kef
Nabeul
Tozeur
Kebili
Zaghouan
Kasserine
Gabes
Sidi Bouzid
Gafsa

Bizerte
Siliana
Tataouine
Ariana
Beja
Nabeul
Kairouan
Ben Arous
Jendouba
Medenine
TUNISIA
Mahdia
Monasr
Sfax
Sousse
Tunis
Le Kef

Jendouba

More generally, the various governorates do not fall in the same
category for the two indicators, reflecting the importance of community
and social determinants in health care use. It would be interesting to
consider the factors that explain these differences in order to assess
the fairness of the system (Fleurbaey and Schokkaert, 2011). The use
of health care which determines the health status of individuals is
mainly due to the interaction of three determinants:
• Existence of demand related to the expression of a need for health
(disease prevention, disease treatment, reproduction, etc.);
• availability of funding or means of support to make the demand
effective;
• existence of an offer or several offers to meet the need.
When one of the last two elements is absent, access to care becomes
impossible and care will not be provided at the risk of leading to serious
vital and economic consequences. Disease causes a loss of income
and can propel the individual into poverty. As such, these two dimensions
deserve special attention because they have a determinant impact on
access to care. We will devote the following sections to them.

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3. Territorial Inequalities in Health Care Facilities

he availability of a health service whether public or private and
T good coverage of the national territory in health infrastructure
contribute significantly to the reduction of inequality in access to
health care (Gold Zeynep et al., 2009). After an overview of Tunisia’s
health care system, we will analyse the availability of public and private
health resources in the 24 governorates and try to build a composite
indicator of health care facilities that can help to assess inter-regional
inequalities and to monitor their trend.
1- Overview of the health care system in 20106
In Tunisia, the health care delivery system is primarily public although
there is a growing private sector (Arfa, 2007). Nationally, more than
7
86% of hospital beds are in the public sector. The leading care
provider is the Ministry of Health. The public provision of health services
8
is structured in three levels of care. Primary health care is provided
by 2 085 primary health centres (PHC), with 2 923 district hospital
beds (consisting of small facilities with an average of 27 beds per
facility) and maternity centres, which together account for about 15%
of public sector bed capacity. This care level implements preventive
health policy. It handles 60% of public sector medical outpatients and
more than 1.3 million reproductive health visits (perinatal consultations,
contraception, STI, screening for female cancers, etc.). It manages
the health activities of all pupils and students at all levels (pre-school,
primary, secondary, university, vocational training and others).
Level II health care is provided by 33 regional hospitals (RH), which
account for 35% of total bed capacity and medical specialists in the
public sector.
Level III health care consists of a network of 24 hospitals and
academic institutions with an average size of 405 beds. These
hospitals represent approximately 50% of all public sector beds. The
health system further includes the polyclinics of the National Social
Security Fund, hospitals under the Ministry of National Defence and
the facilities of the Ministry of the Interior and Local Development
(Arfa and Elgazzar, 2013).
In Tunisia, access to the various levels is open and not by referral. Hence,
the first line may start at the primary, secondary or tertiary level. The
intense activity of emergency services in hospitals is an example.
The private health care sector has grown significantly: it accounts for
about 14% of total bed capacity and 70% of advanced technology
services. In terms of human resources, it employs 48.3% of physicians
(55.6% of specialists and 42% of general practitioners), 77.5% of dentists
and 81.5% of pharmacists. Private clinics are mostly concentrated in
major coastal urban areas (Arfa and Elgazzar, 2013).
Despite an equalizing trend and geographical accessibility deemed
acceptable for front-line facilities, the distribution of health services
in the country is characterized by a certain inequality that should be
evaluated and corrected.
2- Trend in the distribution of health facilities
To study the trend in the distribution of health facilities in the country,
we will analyse the allocations of the 24 governorates in primary health
centres and hospital beds over the past decade. These two indicators
characterize public health provision.9 We will complete them with
human resource indicators (public sector physicians and paramedical
staff). We will also analyse the availability of private practices,
pharmacies and dental offices in governorates. These three indicators
characterize private health provision.

6
The main source is the 2010 Health Map of Tunisia (Ministry of Health).
7
In 2010, the theoretical public bed capacity is 19 565 beds, while private clinics account for only 3 029 beds.
8
When people need health care, they turn most often to primary health care services, which are the first point of contact with the system. In general, primary health care
has a double function. First, it provides preventive and curative support for common diseases. Then it acts as an interface and when necessary, refers patients to higher
levels; it facilitates their movement within the health system when more specialized care is needed.
9
We will not discuss any issues related to the efficient use of the infrastructure, (World Bank, 2008). Overall, the potential of district hospitals has been under-utilized because
of the weakness of their technical facilities, which limits the scope of diagnostic and therapeutic care management. Regarding regional hospitals, despite generally satisfac-
tory technical facilities, productivity is affected by the lack of specialists, who are more attracted to university hospital careers or private practice. Lastly, UTHs control most of
the heavy equipment in the public sector. Skill levels are high, but the sector suffers from consultation congestion, due to the weakness of the second level, as well as an
increasingly strong tendency for brain drain to private practice that offers significantly higher income levels (WHO, 2010).

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For each indicator, we will refer to the per capita endowment or its
inverse (the number of inhabitants per unit). We will see if, on average,
the indicator improves. In addition, the use of the coefficient of
variation 10 will reveal whether, overall, the distribution of health
resources has become more or less unequal. Comparing the values
of the indicator at the beginning of the last decade and at its end, for
each governorate, will allow description of the trend of the governorate.
The data used are drawn from the Tunisian Statistical Yearbook for
2006-2010 (Serial No. 53).
2-1 Trend in the distribution of public health care facilities
2-1-1. Primary Health Centres (PHCs)
The number of inhabitants by PHC globally reflects a reversal trend from
2003 (Figure 10). It increased from 4 795 in 2003 to 5 051 in 2010. This
trend could mean a more efficient use of PHCs for the benefit of a denser
population. It may also indicate less easy access to these centres. In
the latter case, the PHC facility, as the access point of the population
to the health system, is fulfilling its role of health prevention and curative
treatment of common diseases less than before.
However, the coefficient of variation of the number of inhabitants per
PHC according to the governorate shows a downward trend indicating
a reduction in inter-governorate inequality (Figure 10). The decrease
in inequalities is due primarily to the deterioration of the situation in
governorates such as Monastir, Bizerte, Sfax, Sousse, Nabeul, Ben
Arous, Ariana and Tunis, as shown in Figure 12. These governorates
are relatively well served by Level III and PHCs providing consultations
almost daily.

Figure 10: Inhabitants per PHC (1998-2010) Figure 11: CV inhabitants per PHC (1998-2010)

5100 5100
5000 5000
4900 4900
4800 4800
4700 4700
4600 4600
1998
1999

2001

2005

2007
2008
2009

1998
1999

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

2010

2000

2002
2003
2004

2006

2010
Figure 12: Inhabitants per PHC by governorate

25 000
20 000
15 000
10 000
5 000 2000
0 2010
Tataouine

Siliana
Le Kef

Beja

Mahdia
Sidi Bouzid
Gafsa
Jendouba

Medenine
Gabes

Ensemble

Bizerte
Sfax
Sousse
Nabeul
Manouba
Ben Arous
Ariana
Tunis
Zaghouan

Monasr
Tozeur
Kebili

Kairouan
Kasserine

10
For a Y expenditure distribution with average  Y, the coefficient of variation (CV) is derived from the variance. It is defined as the ratio of the standard deviation
σ to the average of expenses:
CV = σ /Y where σ2 = 1/ N ∑(Yi -Y)2
CV is used to compare the dispersions of distributions with different averages. The higher the CV the more dispersed the distribution will be.

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In this respect, it should be noted that this indicator does not allow
proper assessment of the availability of health services in regions
because it does not take into account the pace of consultations in
the PHC. Indeed, primary health centres differ in their type and the
pace of medical consultation observed there. In 2010, 1040 of the
2085 PHCs provided at most one day of consultation per week. The
2 085 primary health centres are in fact equivalent to 870 full-time
centres.11 In addition, the pace of consultations is not equally distributed
among the PHCs. The proportion of PHCs providing medical
consultation six days per week is only 4.4% in Medenine, 4.8% in
Tataouine, 9.3% in Tozeur, 8% in Mahdia, 8.6% in Kébili, 8.9% in Sidi
Bouzid and 9.6% in Beja. Thus, in these governorates, most of the
population does not have daily access to mobile, community primary
health care services. Accordingly, efforts should focus more towards
improving the frequency of primary health care consultations rather
than the multiplication of small health centres.12
2-1-2. Hospital beds
Unlike the first indicator, the bed equipment rate or number of public
beds per 1000 inhabitants shows a significant increasing trend in the
public provision of care (Figure 13). The number of public beds per 1000
inhabitants increased from 1.74 in 2001 to 1.85 in 2010. Similarly, the
coefficient of variation of the bed rate in governorates decreased (Figure
13). This therefore means reduced inter-governorate inequality.
Despite these positive developments, the public bed equipment rate
varied in 2010 from 0.4 in Ben Arous to 4 in Tunis (Figure 15).

Figure 13: Bed availability rate (1998-2010) Figure 14: CV bed availability rate

1.9 0.60
1.8 0.50
0.40
1.7
0.30
1.6
0.20
1.5 0.10
1.4 0.00
1998
1999

2001

2004

2006
2007
2008

1998
1999

2001

2005

2007
2008
2009
2000

2002
2003

2005

2009

2000

2002
2004

2006

2010
Figure 15: Public hospital beds per 1 000 inhabitants by governorate
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50 2000
0.00
2010
Tunisie entère
Ben Arous
Ariana
Sidi Bouzid

Jendouba
Mahdia
Bizerte
Medenine
Siliana
Gabes
Tataouine
Beja
Sfax

Gafsa

Sousse
Manouba
Nabeul

Zaghouan
Monasr

Tozeur
Le Kef
Kebili

Tunis
Kairouan
Kasserine

11
The 2010 Health Map can be used to calculate for each governorate the number of PHC full-time equivalent and the number of inhabitants per PHC full-time equivalent,
but this statistic is not available for earlier years.
12
Three evaluations of the primary health care system (1997, 2000 and 2004) were carried out by the Ministry of Health as part of the Health Districts National Development
Programme. It is a programme developed since 1994 by the Directorate of Primary Health Care. The overall objective of PNDCS is to make all health units in the country able
to manage the health status of the population through a set of preventive, curative, promotional and rehabilitation activities, and ensure coordination within and between
sectors involving all health stakeholders. The PNDCS has two specific objectives: firstly, improving the (technical and relational) quality and efficiency of care at the primary health
centres (PHC) and the district hospital and secondly, strengthening and involving the population in health management.
The main recommendations were: (i) optimizing health delivery by moving from a logic of coverage with infrastructure (number of hospital beds, number of DHCs) to an
approach of coverage with effective services (number of medical consultation days offered, range of hospital services with appropriate technical facilities); (ii) improving the
dimensions of care quality, for example by adapting opening hours to the rhythm of the patient population.

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Reducing inequality reflects both:
l An improvement in bed equipment in many governorates among the
least well off, notably: Sidi Bouzid, Kasserine, Siliana, Tataouine, Beja,
Kébili, Le Kef, Gafsa, Tozeur...
l a worsening situation in other governorates. The number of beds per
1 000 population decreased in Ariana, Sfax, Monastir, Sousse,
Manouba and Zaghouan. These governorates are experiencing strong
population growth induced in particular by migration. Almost ten years
of stagnation of the bed equipment rate in Tunis or the reduction
thereof in large cities such as Sfax, Monastir, Sousse, Ariana and
Manouba are all the more disturbing trends since these cities are
university teaching hospital centres. The quality of training at the
patient’s bedside may be affected by the increasingly less favourable
conditions in which it takes place. As such, there is the risk of a vicious
circle that reproduces mediocrity. To decongest level III and allow it
to devote more time to training and research missions, level II should
be developed.
Indeed, the bed equipment rate analysed below takes into account beds
at the three levels. It therefore hides disparities within levels. In the absence
of detailed statistics for the study period, it was not possible for us to
appraise the paces of matching developments. However, interviews with
stakeholders led us to conclude that the weak link in the system is level II.
Often this level is ineffective or non-existent and therefore needs to be
strengthened.
Finally, the quest for greater equity in the health system should not result
in levelling from the bottom, or in a substantial carrying forward of
activities from a certain level to a higher one. The system should be able
to ensure that at each of its levels, the tasks assigned are carried out
in the best conditions. These missions should be clearly specified. Each
hospital institution should have a roadmap that allows strategic
management consistent with the whole system.
2-1-3. Public sector physicians
There has been a significant decrease in the number of inhabitants per
physician in the public sector in all governorates with the exception of
Ariana. This decrease reflects an increase in public health care provision.
Overall, the number of inhabitants per physician dropped from 2176 in
2002 to 1569 in 2010 (Figure 16). Until 2008, this trend increased
inequality between governorates. However, since 2008, the inequality
gap is closing but is still significant (Figure 16). The number of inhabitants
per physician in the public sector varied, in 2010, between 493 in Tunis
and 3377 in Kasserine, a ratio of 1 to 6.8.
There is a clear improvement in physician availability in many
governorates (Figure 18). However, at the same time, the situation
has changed very little in governorates like Kasserine, Medenine,
Nabeul and Kébili. Yet these governorates were initially less endowed
with physicians.
Five governorates are better provided with public health physicians
than the country as a whole. The number of inhabitants per physician
there is less than 1569. They are Tunis, Sousse, Monastir, Sfax (which
enjoy level III services) and Tozeur. Conversely, five governorates have
twice less the number of physicians; the number of physicians per
inhabitant is higher than 3 000 in Kairouan, Jendouba, Sidi Bouzid,
Medenine and Kasserine.

Figure 17: CV Inhabitants per public health

Figure 16: Inhabitants per public health physician
physician
3000 0.37
2500 0.36
2000 0.35
1500 0.34
0.33
1000 0.32
500 0.31
0 0.30
1998
1999

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

2010

2002

2003
2004

2005
2006
2007

2008
2009
2010

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Figure 18: Inhabitants per public health physician by governorate

5000
4500
4000
3500
3000
2500
2000
1500 2002
1000
500 2010
0
Sousse

Sfax

Ensemble

Manouba
Mahdia
Tataouine
Ariana
Siliana
Bizerte
Beja
Gafsa

Gabes
Le Kef
Ben Arous
Nabeul

Jendouba
Sidi Bouzid
Medenine
Kairouan

Kasserine
Zaghouan
Tunis

Monas r

Tozeur

Kebili
The overall improvement in the availability of physicians veils significant
deficits in medical specialists (surgery, obstetrics, ophthalmology,
orthopaedics, anaesthesiology ...).
Better coverage of the national territory in level II beds is necessarily
concomitant with better provision of these regions with physicians in
general and specialist physicians in particular.
2-1-4. Public sector paramedical staff
The number of inhabitants per senior technician is a clear indication of
the increase in public health care provision (Figure 19). It went from 341
in 2002 to 308 in 2010. The indicator has improved in all governorates
except Sousse, Monastir and Ariana. The trend of the coefficient of
variation across governorates indicates a gradual reduction of inter-
governorate inequalities (Figure 19).
However, there are still significant inequalities. The number of
inhabitants per public sector paramedical staff varied in 2010 between
150 in Tunis and 720 in Ariana, a ratio of 1 to 4.8. The six governorates
best equipped with paramedical staff are Tunis, Tozeur, Sousse,
Monastir, Gafsa and Kef. The six governorates least equipped are
Zaghouane, Nabeul, Kasserine, Sidi Bouzid, Ben Arous and Ariana,
as shown in Figure 21.

Figure 19: Inhabitants per paramedical staff Figure 20: CV Inhabitants per paramedical staff

0.60
360
0.50
340 0.40
320 0.30
0.20
300
0.10
280 0.00
1998
1999

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

2010

1998
1999

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

2010

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Figure 21: Inhabitants per paramedical staff by governorate

1200
1000
800
600
400 2002
200 2010
0

SIliana
Kebili
Tunis

Sousse

Gafsa
Le Kef

Beja
Ensemble
Tataouine
Sfax
Mahdia
Bizerte

Gabes
Jendouba
Manouba

Medenine

Nabeul

Sidi Bouzid
Ben Arous
Ariana
Kairouan

Kasserine
Zaghouane
Monas r
Tozeur

Once more, better coverage of the territory with level II beds will involve
better provision of these regions with senior health technicians and
nurses.
2.2 Trend in the distribution of private health care facilities
2-2-1. Private practice offices
The number of private practice offices has increased considerably
throughout the past two decades such that the number of inhabitants
per office has on average been divided by 1.66 in 10 years (Figure 22).
Inequalities between governorates declined until 2004, but have since
increased (Figure 22). Between 2004 and 2010, the situation improved
in all governorates except Siliana, Sidi Bouzid and Tataouine.
In 2004, the ratio between the governorate best provided with private
practice offices (Tunis) and the least provided governorate (Siliana)
was 1 to 11.6. In 2010, this ratio rose to 14.3 (Figure 24). This problem
is not specific to Tunisia; the same situation prevails in several
developed countries, including France where it is called “medical
desert” (Potvin Moquet, Jones, 2010; High Council of Public Health,
2009 and Senate 2013).
Thus, in a context where physicians are free to choose their location,
there was a craze for major urban centres and areas where the
purchasing power of the patient base is higher and the quality of life
better. In these areas, even when the number of inhabitants per physician
is already low, this number has continued to decrease. By contrast, in
the hinterland and in the least developed governorates, the propensity
of physicians to settle there was low and the number of inhabitants per
physician remained high and/or was on the increase. To counteract this
spontaneous location of physicians, it is important to negotiate with the
medical corps to revise the institutional framework governing the opening
of private practice offices and/or to grant special incentives to physicians
who settle in priority areas. The Order of 24 December 2009 in part
enshrined the idea by providing for compensation for medical
specialists13 practising in the private sector and contracted with health
facilities in priority areas (defined by the Order of 1 March 1995 issued
by the Prime Minister laying down priority health areas for the granting
of certain benefits). The effects could be assessed.14 In France, a solution
to the “medical desert” phenomenon was the establishment of “medical
home”, that is to say, a structure whose main advantage is that of
bringing together in one place many practitioners and several specialties
with the purpose of saving by pooling and sharing certain costs. However,
these structures instead resulted in the creation of a wider geographical
network of rural and “desert” areas. Proposals have been made to
hamper the freedom of installation of physicians rather than encourage
them to open offices in areas where medical facilities are scarce. In
particular, this means excluding from health insurance physicians who
choose to settle in already saturated areas. As a result, since their patients
are not reimbursed by social security, it would be impossible for a young
physician to build a patient base (Senate, 2013).

13
TND 500 for specialists in surgery and obstetrics and gynaecology, TND 400 for all other specialties.
14
There is concern that physicians may abuse this situation by diverting patients from the hospital to their private practice or by using hospital equipment for private purposes.
Ethical standards and rules of governance should be enacted. Very strict controls must be implemented.

14
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Figure 22: Inhabitants per private practice Figure 23: CV Inhabitants/Private practice
office office

0.70
4 000 0.60
3 000 0.50
0.40
2 000 0.30
1 000 0.20
0.10
0 0.00
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

2010
Figure 24: Number of inhabitants per private practice office by governorate
16000
14000
12000
10000
8000
6000
4000 2001
2000
0 2010
Kebili
Monas r
Tunis

Ariana
Sousse
Ben Arous
Ensemble

Medenine

Bizerte
Nabeul

Manouba
Gabes
Mahdia
Beja
Gafsa

Jendouba
Tozeur
Tataouine
Sidi Bouzid

Siliana
Sfax

Kairouan
Le Kef

Kasserine
Zaghouan

2-2-2. Dental offices per office was divided on average by 1.76 between 2001 and 2009
(Figure 25). Inequalities between governorates have significantly
The number of dental offices has increased significantly over the decreased, as shown by the trend of the variation coefficients
last two decades to the extent that the number of inhabitants (Figure 25).

Figure 25: Inhabitants per dental office Figure 26: CV Inhabitants per dental office

14 000 0.80
12 000
10 000 0.60
8 000
6 000 0.40
4 000
0.20
2 000
0 0.00
1998
1999

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

1999

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

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Figure 27: Number of inhabitants per dental office by governorate

60000
50000
40000
30000
20000 2004
10000
2009
0

Kebili
Tunis
Ariana
Sousse

Ben Arous

Bizerte
Ensemble
Nabeul

Manouba
Mahdia
Medenine
Gafsa

Gabes
Ensemble
Jendouba

Beja
Siliana

Tataouine
Sidi Bouzid

Kasserine
Monas r

Kairouan

Tozeur
Sfax

Zaghouan
Le Kef
Between 2001 and 2009, the situation improved in all governorates
and is particularly striking in Zaghouan, Siliana, Sidi Bouzid and
Kasserine (Figure 27).
In 2004, the ratio between the governorate most provided with dental
offices (Tunis) and the least provided governorate (Zaghouan) was 1 to
30. In 2009, this ratio dropped to 11 (between Tunis and Kebili). So
there are still margins to reduce inequalities in dental office availability.
2-2-3. Pharmacies
Overall, the number of pharmacies has increased faster than the
country’s population, such that the number of inhabitants per pharmacy
has been divided by 1.2 in 10 years (Figure 28). Accordingly, the
inequalities between governorates decreased significantly as shown by
the variation coefficient (Figure 28). The situation improved in all
governorates between 2001 and 2010 (Figure 30).

Figure 28: Inhabitants per pharmacy Figure 29: CV Inhabitants per pharmacy

8 000 0.50
6 000 0.40
0.30
4 000
0.20
2 000
0.10
0 0.00
1998
1999

2001

2005

2007
2008
2009

2001

2005

2007
2008
2009
2000

2002
2003
2004

2006

2010

2000

2002
2003
2004

2006

2010

Figure 30: Inhabitants per pharmacy by governorate

60000
50000
40000
30000
20000 2004
10000 2009
0
Kebili
Tunis
Ariana
Sousse
Sfax
Ben Arous

Bizerte
Ensemble

Manouba
Mahdia
Medenine
Gafsa

Gabes
Ensemble
Jendouba

Beja
Siliana

Sidi Bouzid
Tataouine
Kasserine
Nabeul

Kairouan
Monas r

Tozeur
Zaghouan
Le Kef

16
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The improvement has been very significant in governorates that were
15
less provided with pharmacies. Despite this, in 2010, the governorate
most provided with pharmacies (Tunis) had per capita 2.63 times
more pharmacies than that least provided (Kasserine). It should be
noted that the inequalities in the number of pharmacies nationwide
are much lower than inequalities in private practice offices due to very
strict regulations.
2.3 Summary
The analysis shows a generally favourable trend that however hides
internal distortions (Table 1 below). The availability of PHCs is declining.
Level II, which is the reference for Level I, would not be very effective
because it is poorly resourced. Therefore, there is an important carry
over to Level III, which thus replaces Level II, thereby causing
inefficiencies. Obviously, there is a need to develop a strategy that
strengthens and revitalizes primary health care in the country and
enhances Level II.
Similarly, it has been shown that the trend of all dispersion indicators
is favourable, with the exception of the indicator for physicians,
whether in the public or private sector. Although the number of
physicians per inhabitant witnessed a significant drop between 2002
and 2010 (28.5% for the public health sector and 21% for private
practice), the gaps have widened between the better endowed and
less endowed governorates, and the variation coefficients have
15
The operation of pharmacies is strictly subject to a numerus clausus, which is established on the basis of five areas according to delegations. It is regularly reviewed to adapt
to the new realities of the profession and demographics.
A f r i c a n D
Economic Brief
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2 0 1 4 • w w w . a f d b . o r g
increased. Hence, it is necessary to develop an appropriate strategy
for addressing this challenge. It would be advisable to review the
criteria for opening positions of public health physician at regional
level and the institutional framework governing practices at the private
level. Similarly, public-public partnerships (such as agreements
between academic physicians and regional hospitals) or, failing that,
public-private partnerships likely to make disadvantaged areas more
attractive, could be considered for medical specialists.
The availability of private medical practitioners is characterized by high
levels of inequality; the ratio between the most endowed and the least
endowed governorates is 14.3. They are followed by dental offices (ratio
of 11.3) and hospital beds (10.7). The most fairly distributed resources
are pharmacies and paramedical staff. Like in pharmacy, the private
practice of dentistry and medicine should be better regulated.
Lastly, the status of health care facilities in one governorate cannot be
analysed by reference to a single determinant. As such, all components
of the sector and complementarity between the various providers should
be considered simultaneously. Consequently, it seems worthwhile to
conduct an analysis of health care provision that integrates all the
determinants of the provision so as to end up with relatively homogeneous
groups. It would further be interesting to develop for each governorate
a composite indicator of health care facilities so that a governorate could
gauge its position in relation to other governorates as well as the progress
it may achieve over time.
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Table 1: Level and distribution of major health care provision indicators

Disadvantaged
Indicator Statistics 2002 2010 2010/2002 Appraisal
governorates
Average 4807 5051 +5% Unfavourable Tunis
Inhabitants /PHC CV 0.94 0.89 Favourable Ariana

Max/min 8.63 8.66 Moderate Ben Arous

Average 1.7 1.85 +8.8% Favourable Ben Arous

Hospital beds/
CV 0.49 0.41 Favourable Ariana
1 000 inhabitants
Max/min 47.4 10.7 High Sidi Bouzid

Average 2196 1569 -28.5% Favourable Kasserine

Inhabitants/
Physician (public CV 0.32 0.35 Unfavourable Medenine
sector) 5.27 6.85 Moderate Sidi Bouzid
Max/min

Average 341 308 -8.7% Favourable Ariana

Inhabitants/
Paramedical CV 0.44 0.3 Favourable Ben Arous
staff Sidi Bouzid
Max/min 6.68 4.8 Low

Average 2128 1681 -21% Favourable Siliana

Inhabitants/
Private practice CV 0.5 0.6 Unfavourable Kasserine
(2004-2010) 11.6 14.3 High Sidi Bouzid
Max/min

Average 8847 5774 -34.7% Favourable Tozeur

Inhabitants/
Dental office CV 0.66 0.58 Favourable Kasserine
(2002-2009) Tataouine
Max/min 24 11.3 High

Average 6756 5604 -17% Favourable Tozeur

Inhabitants/
CV 0.39 0.27 Favourable Kasserine
Pharmacy
Max/min 4.4 2.6 Low Tataouine

3- Health care facilities in 2010: cluster analysis 1. Average distance to get to a regional hospital
2. Average distance to get to a general hospital
3.1 Indicators 3. Inhabitants by PHC
4. Proportion of PHCs providing medical consultation 6 days of 6
To analyse the distribution of health care facilities between the 24 governorates 5. Inhabitants per PHC full-time equivalent (FTE)
in Tunisia, we will refer to a broad set of indicators that characterize such 6. Inhabitants per primary care physician
facilities. These are indicators relating to health infrastructure, human resources 7. Frontline bio-medical laboratory unit per 100 000 inhabitants
in public and private health facilities, and equipment. These indicators are 8. Frontline radiology unit per 100 000 inhabitants
drawn from the Tunisia 2010 Health Map published by the Ministry of 9. Frontline dental chairs per 100 000 inhabitants
Health and/or from the Tunisia Statistical Yearbook published by the INS. 10. Inhabitants per day pharmacy
11. Inhabitants per night pharmacy
3-1-1. Health infrastructure indicators 12. Private bio-medical laboratories per 100 000 inhabitants
13. Haemodialysis machines per 100 000 inhabitants (public and
These are indicators on: private)

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3-1-2. Common equipment indicators16 This cluster covers 626 PHCs, 21 district hospitals (341 beds), 13 regional
hospitals (1 315 beds) 22 university hospitals (92% of the overall with 9 032
1. Hospital bed equipment rate (public and private) beds) and 4 590 private medical practices out of 6 273 (general practitioners
2. Public hospital bed equipment rate and specialists). It is characterized by good positioning in terms of access
3. Private bed equipment rate (in clinics) to hospitals and backed by sustained availability of alternative types of
4. General surgery bed equipment rate infrastructure and also by poor positioning in terms of the number of
5. Gynaecology and obstetrics bed equipment rate inhabitants per Primary Health Centre (PHC). Hence, we have:
6. Paediatric bed equipment rate
7. Ophthalmology bed equipment rate l The best location in terms of access to regional hospitals and general
8. ENT bed equipment rate hospitals (except Médenine due to its low density);
9. Orthopaedic bed equipment rate l The largest proportion of PHC providing medical consultation 6 days
10. Cardiology bed equipment rate a week;
11. Anaesthesiology bed equipment rate l The highest number of inhabitants per PHC on average;
12. Psychiatric bed equipment rate l The highest number of inhabitants per PHC in full time equivalent;
l A moderate number of inhabitants per primary care physician;
3-1-3. Human resource indicators l The lowest number of primary biomedical laboratory units for
100 000 inhabitants;
1. Density of physicians (per 100 000 inhabitants) l The lowest number of primary radiology units for 100 000 inhabitants;
2. Density of general practitioners (per 100 000 inhabitants) l The lowest number of primary health care dental chairs for 100 000
3. Density of general practitioners in the public sector (per 100 000 inhabitants;
inhabitants) l The highest number of inhabitants per day-time pharmacy;
4. Density of general practitioners in the private sector (per 100 000 l Moderate number of inhabitants per overnight pharmacy;
inhabitants) l The highest number of medical analysis laboratories for 100 000
5. Density of specialists (per 100 000 inhabitants) inhabitants;
6. Density of public sector specialists (per 100 000 inhabitants) l The highest number of haemodialysis machines for 100 000
7. Density of private sector specialists (per 100 000 inhabitants) inhabitants.
8. Medical density per specialty (all physicians)
9. Density of pharmacists (per 100 000 inhabitants) Besides Médenine, this cluster is composed of university hospital
10. Density of dentists (per 100 000 inhabitants) cities.18 It can be observed that there is a predominance of tertiary
11. Density of nurses, nursing aides and senior technicians (per 100 000 care, including emergency services that are particularly in demand
inhabitants). and are overriding the PHC.19 The question then is not so much
whether or not to increase the density of PHCs but also to understand
3-2 Heath Infrastructure Distribution the motives underlying the people's preference for emergency room
services to PHCs. Should it be blamed on the overly broad primary
Based on health infrastructure indicators in the 24 governorates observed health network or the discrepancy between its temporal accessibility
in 2010 (Tables 15, 16, 17 and 18 in Annex 1), a dynamic clusters analysis17 and the quality of care it provides?20 These two aspects certainly
was conducted in four clusters (Map 3). deserve special consideration and it is appropriate to both standardize
the availability of infrastructure and upgrade the operation of all
3-2-1- The first cluster (Table 13 in Annex 1) includes the Tunis, Ariana, Ben structures at all levels. The certification of hospitals would be entirely
Arous, Manouba, Sousse, Monastir, Sfax and Médenine governorates. appropriate. In this context, an agency for the accreditation and

16
We did not consider indicators for equipment that has a regional scope and serves several governorates, such as the equipment rate for public beds with university status
by major region (north, centre and south); the MRI equipment rate by major region; the scanner equipment rate and the equipment rate for other heavy equipment.
17
The method for classifying dynamic clusters is essentially based on the distribution of a population into homogeneous groups (classes or clusters) using the core concept
associated with each class. It may involve, as in our study, for example, discovering the main governorates with the closest health facilities.

19
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certification of health services was established by Decree No. 2012-
1709 of 06/09/2012.
3-2-2- The second cluster (Table 14 in Annex 1) includes the Bizerte,
Nabeul and Kebili governorates. This cluster is characterized by a
very average positioning with respect to all criteria relating to public
infrastructure (hospitals, PHC ...) or private facilities (pharmacies,
dental offices, laboratories, etc.). It includes 273 PHC, 9 CH and 6
RH (2 135 beds i.e. 11% of the overall nominal capacity), 709 private
practices, 286 pharmacies, 221 dental offices...
3-2-3- The third cluster (Table 15 in Annex 1) includes the Béja, Gabès,
Gafsa, Le Kef, Mahdia, Siliana, Tataouine, Tozeur and Zaghouan
governorates.
These nine governorates have a rather low hospital access rate (due
to low population density) and limited availability of various types
of infrastructure, especially those that are private-owned. This
shortcoming is partly offset by proper positioning in terms of the number
of inhabitants per PHC and per primary care physician.
Yet these governorates have 46 district hospitals out of a total of 109,
10 regional hospitals (about 33 throughout Tunisia) and two university
hospitals (in Mahdia and Zaghouan), with a nominal capacity of 4 133
beds (21 % of national capacity).
However, while a hospital should have at least one surgical ward and
an intensive care unit, with the technical equipment needed to support
different types of emergencies, district hospitals currently perform only
a single real hospital function: carrying out eutocic deliveries. Regional
hospitals that are supposed to provide Level II care, lack specialists (the
cluster is very poorly staffed with specialist physicians) and equipment.
Furthermore, quality certification will help bring these structures up to
standard. Lastly, it would be appropriate to develop specific incentives
to induce private stakeholders to settle in these governorates.
3-2-4- The fourth cluster (Table 16 in Annex 1) includes the Jendouba,
Kairouan, Kasserine and Sidi Bouzid governorates. This cluster is
characterized by even low rate of access to hospitals and available
basic infrastructure (with 27 CH, 470 PHC and only 4 RH). Furthermore,
the most reduced availability of private facilities can be observed (350
private practices). The shortfall of private health services is probably
due to the low standard of living in these governorates and the lack of
effective demand for health services.
Hence, this fourth cluster comprises all priority governorates in terms
of infrastructure wherein an intervention to enhance public health
coverage would allow coverage similar to the rest of the country, and
seems to be a necessary step to boost private coverage through the
ripple effect. In this regard, it would be wise to develop specific incentives
to induce private stakeholders to settle in these governorates.
The table below summarizes the specificities of each cluster with respect
to health infrastructure.

18
Tunis, Sousse, Monastir and Sfax.
19
In a study on the reasons for recourse to the emergency services of major hospitals in Greater Tunis (Ben Gobrane et al., 2012), the major reasons given by
patients are quick and easy access to emergency services, the availability of equipment as compared to PHCs and, for the populations, inappropriate working hours
of primary care facilities that work only in the morning. Hence, recourse to emergency services is partly due to the shortcomings of primary care medicine.
20
In most of these structures, consultations are carried out only in the morning. In rural areas, the length of consultations is notoriously reduced given the
number of consultations conducted. In urban areas, opening hours do not match the time users are available for consultation. The result is threefold: either
unwarranted recourse to hospital emergency services at different levels, or delay in recourse or forced and costly recourse to private primary care facilities.

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Table 2: Distribution of health infrastructure by clusters

Characteristics of Allocations
Governorates
Other front-line Private medical
Hospitals PHC
structures structures

Tunis, Ariana, Ben Arous, Manouba, Sousse,

Cluster 1 Monastir, Sfax and Medenine.
+ - - +

Cluster 2 Bizerte, Kebili et Nabeul +/- +/- +/- +/-

Beja, Gabes, Gafsa, Le Kef, Mahdia, Siliana,

Cluster 3 Tataouine, Tozeur et Zaghouan
- + + +/-

Jendouba, Kairouan, Kasserine and

Cluster 4 Sidi Bouzid
+/- +/- +/- -

The analysis below focused on hospital availability in terms of average located. Moreover, the quality of private technical equipment in Tunis
distance access to a hospital, but did not provide information on the and the concentration of specialists observed there have fostered the
availability of the said hospitals. Furthermore, to better clarify this aspect, export of health services. Standardization and certification procedures
we will consider some indicators of bed availability rates. would allow a greater development of this sector.

3-3 Bed Availability Rate
Based on the bed availability rate in the 24 governorates observed in 2010
(Table 19, 20, 21 and 22 in the annex), a dynamic cluster analysis was
conducted in four clusters (Listing 2: Map 4).
3-3-1- The first cluster (Table 17 in Annex 1) includes the Tunis,
Sousse, Monastir, Tozeur and Manouba governorates. This cluster is
characterized by:
• The best positioning in terms of bed availability rates and hospital
bed availability rates (public beds). This positioning is observed for
all specialties except ORL and psychiatry; and
• The second positioning in terms of clinic beds (private rooms) as
well as public beds in ORL and psychiatry.
In this cluster, Tunis, Monastir and Sousse are three university hospitals
with a total of 6 664 beds (34% of the national capacity), including 2
961 by specialty. These UH are regional in scope and assigned to the
North and Centre, and even national for certain specialties. They service
a much larger population than that of the governorate in which they are
3-3-2- The second cluster (Table 18 in Annex 1) includes the Sfax,
Mahdia, Le Kef and Médenine governorates. This cluster is characterized
by its leadership in private infrastructure. It ranks first in terms of bed
availability rates in clinics. However, the number of its public beds is
relatively small (3 567 out of 19 565 beds, i.e. 18%). Overall, it ranks
third in terms of hospital beds as well as specialties in general surgery,
orthopaedics, ORL, ophthalmology, paediatrics and anaesthesiology.
However, this cluster has the highest number of beds in psychiatric
wards and ranks immediately after the first cluster with respect to
specialized beds in gynaecology and cardiology wards.
In this cluster, Sfax is a university hospital city. Its two university hospital
centres21, which are adjacent to each other, suffer various shortcomings.
They are congested and overwhelmed by a workload exceeding their
nominal capacity and thereby leading to long waiting periods. They
service not only the Sfax governorate but also the southern population
of more than 4 million inhabitants, which implies overuse of equipment.
Because of such anomalies, these UH increasingly face difficulty in
meeting academic training, specialization, high-level care and medical
research needs in good condition. For over a decade, a new UH has
been programmed for Sfax but has not yet been implemented.

21
The Habib Bourguiba Hospital (506 beds) is home to the surgical specialty services; the Hedi Chaker Hospital (889 beds), which is older, provides medical pathology ser-
vices.

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However, Sfax is characterized by a significant private health sector,
with clinics (mono-disciplinary or polyclinic), radiology centres, medical
laboratories and pharmacies. It serves as a medical platform for the
South and for the export of health services primarily for Libyans.
3-3-3- The third cluster (Table 19 in Annex 1) comprises the Béja, Gafsa,
Kébili and Tataouine governorates. This cluster is relatively very well
equipped in terms of public beds but is poorly equipped with respect to
private beds. It ranks second with respect to public infrastructure (1 831
hospital beds in Levels 1 and 2). The significance of the public sector is
highlighted by the specialized beds availability rate in ORL, surgery,
orthopaedics, ophthalmology, paediatrics and anaesthesiology. However,
there is a shortfall of equipment for gynaecology, cardiology and psychiatry.
In addition, this cluster is characterized by a relatively underdeveloped
private sector. It is the most underprivileged group in terms of
clinic beds. The establishment of clinics is governed by clinical
specifications22, considered stringent as compared to that of public
structures (e.g. it is required to have a nurse for two intensive care
beds, whereas there are no set standards for the public sector). The
previous investment code provided for some tax incentives 23 for
equipment.
3-3-4- Cluster 4 (Table 20 in Annex 1) comprises the less affluent
governorates in terms of beds: Ariana, Ben Arous, Zaghouan, Bizerte,
Nabeul, Jendouba, Kairouan, Kasserine, Sidi Bouzid and Gabes. There
have, on average, the lowest public bed availability rates and, to a lesser
extent, low private bed availability rates. This is true for almost all specialties.
However, the Northern governorates (Ariana, Ben Arous, Zaghouan,
Bizerte and Nabeul) seem to be of lower priority due to their proximity to
Tunis and the importance of the private sector. In the other governorates
(Jendouba, Kairouan, Kasserine, Sidi Bouzid and Gabes), not only is the
per capita bed ratio low, but a significant proportion of the beds are district
hospital beds, and district hospitals are often poorly equipped and poorly
staffed with specialists. The lack of equipment and resources in DHs has
transformed these centres into intermediate facilities incapable of resolving
the problems they encounter, thereby causing users to bypass this level
and resort to the private sector or the secondary and tertiary levels, usually
in other governorates. Table 3 below summarizes the distribution of beds
between the public and private facilities for each cluster.

Table 3: Bed distribution by cluster

Governorates Public Beds Private Beds

Cluster 1 Tunis, Sousse, Monastir, Manouba and Tozeur + +/-

Cluster 2 Sfax, Mahdia, Le Kef and Medenine +/- +

Cluster 3 Beja, Gafsa, Kebili et Tataouine +/- -

Ariana, Ben Arous, Zaghouan, Bizerte, Nabeul,

Cluster 4 Jendouba, Siliana, Kairouan, Kasserine, Sidi Bouzid - +/-
and Gabes

22
Decree No. 93-1915 of 31 August 1993 to determine structures and specialties, and standards in terms of capacity, equipment and staffing of private health
institutions, as supplemented and amended by Decree No. 99-2833 of 21 December 1999 and Decree No. 2001-1082 of 14 May 2001.
23
Decree No. 94-1056 of 9 May 1994, establishing a list of equipment needed for health and hospital institutions that may qualify for the tax incentives under
Section 49 of the Investment Incentives Code and the conditions for granting these benefits, as amended and supplemented by Decree No. 98-967 of 27 April 1998
and Decree No. 2006-382 of 6 February 2006.

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3-4 Human Resources
Based on human resource indicators from the 24 governorates, reported
in 2010 (Tables 23, 24, 25 and 26 in Annex 1), a dynamic cluster analysis
was conducted in four clusters (Listing 3: Map 5).
Tataouine and Tozeur (Table 24 in Annex 1). In the public hospitals o
f the 10 governorates, there are only 1 134 physicians (general
practitioners and specialists), i.e. 17% of public health physicians. The
private sector has only 601 physicians (308 general practitioners and
221 specialists) and relatively few dentists.

3-4-1- The first cluster (Table 21 in Annex 1) comprises the Tunis, Ariana,
Sousse, Monastir, and Sfax Governorates. Overall, these five
governorates have the highest rates of human resource allocation both
in the public sector (3957 to 6723 physicians, i.e. 59% of all physicians
in the public sector) and the private sector (47% of physicians in the
private sector practice in these five governorates), regardless of the
area of specialization. 56% of private dentists and 43% of pharmacies
are located in the governorates of this cluster.
3-4-3- Ben Arous, Bizerte, Gabes, Mahdia, Manouba, Médenine,
Nabeul and Zaghouan constitute an intermediate group with moderate
human resource allocation for almost all categories. 25% of doctors
and 27% of paramedical personnel in the public and private sector
have settled in these 8 governorates (Table 22 in Annex 1).
3-4-4- Béja (Table 23 in Annex 1) is a governorate hinged between the
second cluster and the cluster of human resource-deficient governorates.

3-4-2- The cluster of human resource-deficient governorates comprises The table below compares the distribution of human resources in both
Gafsa, Jendouba Kairouan, Kasserine, Kebili, Le Kef, Sidi Bouzid, Siliana, sectors for the 4 clusters.

Table 4: Distribution of health workers by cluster and by sector

Governorates Public Beds Private Beds

Cluster 1 Tunis, Ariana, Sousse, Monastir, Sfax + +

Ben Arous, Bizerte, Gabes, Mahdia, Manouba,

Cluster 2 Medenine, Nabeul and Zaghouan
+/- +/-

Cluster 3 Beja +/- +/-

Gafsa, Jendouba, Kairouan, Kasserine, Kebili,

Cluster 4 Le Kef, Sidi Bouzid, Siliana, Tataouine and Tozeur
- -

Overall, among the three types of indicators of health care provision, of health care provision. Hence, it is important to summarize
the geographic distribution of health human resources turns out to be infrastructure, equipment and human resource indicators into a single
the most unequal and reveals a significant concentration on the coast. indicator.
Despite an increase in physician density, regional disparities have
widened. Qualitatively, the inequalities are even more egregious and 4- Profile of governorates and composite indicator
more than 2/3 of the specialists are concentrated in the coast, not only of health care facilities by governorate.
for rare specialties but also for the most common ones such as
gynaecology and paediatrics. 4-1 Profile of governorates

Such regional breakdown reflects the geographic dichotomy that shows The ranking of the various governorates into homogenous groups with
a clear regional imbalance in favour of the coast to the detriment of the respect to their medical infrastructure, their availability in terms of beds
North West and Central West of Tunisia. It is important to consider the and human resources, help to develop a profile for each governorate
impact of this inequality in human resource allocation on the inequality according to the groups to which it belongs (see Table below).

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Table 5: Assignment of governorates to clusters (Rji)

Governorates Human Resources Infrastructure Equipements

MONASTIR 1 1 1

SOUSSE 1 1 1

TUNIS 1 1 1

SFAX 1 1 2

MANOUBA 2 1 1

ARIANA 1 1 4

MEDENINE 2 1 2

BEN AROUS 2 1 4

TOZEUR 4 3 1

MAHDIA 2 3 2

BIZERTE 2 2 4

NABEUL 2 2 4

GABES 2 3 4

KEBILI 4 2 3

LE KEF 4 3 2

ZAGHOUAN 2 3 4

BEJA 3 3 3

GAFSA 4 3 3

TATAOUINE 4 3 3

SILIANA 4 3 4

JENDOUBA 4 4 4

KAIROUAN 4 4 4

KASSERINE 4 4 4

SIDI BOUZID 4 4 4

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The table shows that three governorates still belong to the most
advantaged cluster irrespective of the criterion applied. They are Tunis,
Sousse and Monastir. By contrast, four governorates still belong to the
most disadvantaged cluster. They are Jendouba, Kairouan, Kasserine
and Sidi Bouzid (Map 6).
This indicator is the average of the three scores awarded to each
governorate.
If rji is the ranking of the cluster to which governorate j belongs with
respect to resource i, score sji may be defined as the inverse of rji

Between these two groups, the other governorates have more or less
significant shortfalls depending on the type of resources being analysed.
The table defines the scope of intervention required by each governorate.
Hence, Sfax, for example, requires greater bed availability rates in order
to measure up to Tunis, Sousse and Monastir.
sji = 1/rji given that rji = 1, 2, 3, 4
Thus, the score of governorate j for resource i (sji) is considered a unit
score where the governorate belongs to the higher class. The score
decreases as the governorate moves away from this class.

4-2 Composite indicator of health care provision The composite indicator of a governorate’s health care provision is equal
to the arithmetic average of its scores. Ij = ∑ (sji)/3
Each governorate, depending on its profile, may be assigned a
composite indicator of health care provision. The outcomes are presented in the table below.

Table 4: Score by resource and composite indicator of health care facilities by governorate.

Governorates Human Resources Infrastructure Equipements Total

MONASTIR 1.00 1.00 1.00 1.00

SOUSSE 1.00 1.00 1.00 1.00

TUNIS 1.00 1.00 1.00 1.00

SFAX 1.00 1.00 0.50 0.83

MANOUBA 0.50 1.00 1.00 0.83

ARIANA 1.00 1.00 0.25 0.75

MEDENINE 0.50 1.00 0.50 0.67

BEN AROUS 0.50 1.00 0.25 0.58

TOZEUR 0.25 0.33 1.00 0.53

MAHDIA 0.50 0.33 0.50 0.44

BIZERTE 0.50 0.50 0.25 0.42

NABEUL 0.50 0.50 0.25 0.42

GABES 0.50 0.33 0.25 0.36

KEBILI 0.25 0.50 0.33 0.36

LE KEF 0.25 0.33 0.50 0.36

ZAGHOUAN 0.50 0.33 0.25 0.36

BEJA 0.33 0.33 0.33 0.33

GAFSA 0.25 0.33 0.33 0.31

TATAOUINE 0.25 0.33 0.33 0.31

SILIANA 0.25 0.33 0.25 0.28

JENDOUBA 0.25 0.25 0.25 0.25

KAIROUAN 0.25 0.25 0.25 0.25

KASSERINE 0.25 0.25 0.25 0.25

SIDI BOUZID 0.25 0.25 0.25 0.25

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The analysis is based primarily on quantitative indicators. However,
qualitative aspects are still essential. The same is true for those relating
to the efficiency of structures. It is obvious that it is equally important
to improve the functioning of the existing infrastructure to make the
most out of them, as it is to further increase the density of infrastructure
(World Bank, 2008).
To this end, a certification of existing structures should be considered
(at least the most important). The missions and responsibilities of each
level of care should be laid down, and resources should be allocated
accordingly. Establishment projects should be stopped for each
structure.
The analysis revealed that, despite the reduction in public budgets
allocated to health, there is reduced inequality in the allocation of
infrastructure to the various regions. This decrease in inequality is partly
due to the concentration of government efforts on the most resource-
deprived areas. However, it stems mostly from a reduction of resources
allocated to the major urban centres with high population growth
dynamics. This movement is synonymous with a decline in access to
health care for vulnerable populations in these regions. It is also
symptomatic of reduced resources allocated to structures responsible
for the training of future doctors and paramedical personnel.
The dwindling resources allocated to the public sector and the ensuing
reduced access to care would be offset by an increase in private
sector resources and a greater availability of its services. In fact, there
is an interesting private sector dynamics in its three components:
private medical practices, dental offices and pharmacies. However,
A f r i c a n D e v
while it is true that the choice of the location of pharmacies, given
that it is highly regulated, resulted in a fairly equal space coverage by
pharmacies, it is worth noting also that such was not the case for
dental practices and especially for private medical practices which,
instead of correcting the deficiencies resulting from the lack of public
health services, exacerbate existing inequalities. It is then clear that
in the absence of a regulatory framework for the opening of private
medical practices, it is important to introduce special incentives for
young doctors to settle in priority governorates, despite the absence
of an adequately solvent demand. It may include conventional
cooperation between regional hospitals and specialists in private
practice for the missing specialties.
However, the choices relating to the health sector and the efforts to
better allocate resources to priority areas can be effective only if they
form part of a comprehensive local development strategy for these
areas. The reduction of economic, cultural and social gaps between
the governorates can only facilitate and strengthen the health reforms.
To better support our recommendations, we would have liked to test a
panel model which explains the population’s health status by governorate
(life expectancy and infant mortality rate) and by the prevailing health
status in each governorate. We were not able to do so because health
indicators are not published at the governorate level. Such work would
be very informative and could be conducted later.
Reduction of health inequalities may be achieved only by understanding
the determinants, setting the corresponding objective, informing health
care professionals and monitoring the achievements.
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4. Trend in inequalities in health spending in Tunisia between 2000 and 2010

n recent years, the State’s effort in favour of health has been on the
I decline. Public health expenditures accounted for 2.7% of GDP in
1995 and for only 2.3% in 2011. By contrast, private spending by
households rose sharply. In 2010, household spending amounted to
51% of total health expenditures, with approximately 80% being out-
of-pocket payments and 20% corresponding to health insurance
premiums. In fact, out-of-pocket payments made by households for
health purposes account for 41.2% of national health expenditures
(Arfa et al., 2013).
The importance of out-of-pocket health expenditure in national health
accounts (Arfa et al., 2007 and 2008) implies that the search for
greater equity in health should entail efforts to achieve more equitable
distribution of the out-of-pocket spending of households. Therefore,
it is important to evaluate the inequality of out-of-pocket health
expenditures of households and to analyse their trends using inequality
indicators.
To that end, we will refer to data from the national surveys on budget
and household consumption of 2000, 2005 and 2010. These surveys
were conducted on a representative sample of households across
the country.24 They provide information on individual consumption of
goods and services, and therefore make it possible to study the trends
in the living standards of households through their expenditures.
These data provide information on expenditures per person per year
(SPY) and their structure by various expenditure items, especially
those related to health. The data also facilitates the assessment of
the degree of inequality of these expenditures and the analysis of
their trends. Various health spending items were covered in the
consumer surveys (see nomenclature in Annex 1: Health indicators
by cluster 2). They correspond to disbursements made by households.
The analysis of the contribution of the various out-of-pocket health
expenditure items to the total health expenditure inequality and the
trends of this contribution between 2000 and 2010 should help to
better understand some of the causes of the inequality in out-of-
pocket health spending and to possibly identify policies that should
be implemented to reduce this inequality. In this regard, we will use
the breakdown of the inequality index by source25 (or component).
This technique indicates which expenditure categories contributed
most to the formation of inequality. Any policy aimed at reducing
health care inequalities should primarily target these categories
(Wagstaff and Van Doorslaer, 2000).
Traditionally, inequalities in expenditures are captured through the
Lorenz curve and the Gini index that analyse the distribution of health
expenditures in themselves. However, despite its merits, this approach
presents only a partial picture of the inequalities in health expenditures.
A more comprehensive picture may be obtained through the
concentration curve and index, which analyse the distribution of health
expenditures in relation to the distribution of the population’s living
standards ranked from the poorest to the richest.
We will start off by focusing on the Gini index, considered as an indicator
of inequality in health spending, to see how its breakdown by source
can provide information on the formation and trend of inequality. Next,
we will follow the same approach for the concentration index.26 Lastly,
we will analyse the inequality in health spending and its trend in light of
the available data.
For estimates of the Gini and concentration indices, we use the STATA
12 and DASP27 version 2.2 software, which enable us to calculate and
break down the various indices.

24
For the three surveys, the initial sample is drawn from a stratified random sampling conducted in two stages in each governorate. The sample frame consisted of
the data files of the general population census (1994 and 2004 respectively). Regarding the 2000 survey, 12 960 households were sampled and 12 249 responded
(representing a response rate of 95%). Concerning the 2005 survey, 13 392 households were sampled and 12 317 responded (that is, a response rate of 92%). As
for the 2010 survey, of the 13 392 households initially sampled, 11 291 responded (representing a response rate of 85%).
25
The breakdown of inequality indices was introduced in health economics by Wagstaff et al. (2003).
26
The literature on inequalities shows that there is a range of relevant inequality indicators, including the Theil indicator and the log deviation. In addition, other break-
down techniques, such as groups, are interesting and very informative. In subsequent research, we plan to break down the inequalities in health
expenditures using various geographic (environment, region, governorate) and socioeconomic (occupational status of the household head, household size, vulne-
rability. etc.) criteria, and to identify the relative importance of intra-group and inter-group inequalities and their trend.
27
Distributive Analysis Stata Package, developed by Araar and Duclos (2007). PEP, World Bank, UNDP and Laval University. http://dasp.ecn.ulaval.ca/

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1- Lorenz curve and the Gini index
To describe the distribution of health expenditures as well as the
degree and origins of their inequality, we start by adopting the Lorenz
classification method and then the method that consists in calculating
acceptable inequality indicators.
1.1. Lorenz Curve
Inequality in the distribution of a variable (health expenditure, for
example) may be highlighted using the Lorenz curve (Figure 31) which
matches the proportion of the population classified by increasing order
of health expenditures with the share of total health expenditures
incurred by that population.
Figure 31: Lorenz Curve for health spending
In the case of two distributions X and Y, X dominates Y if the Lorenz
curve relating to distribution “X” constantly lies above the curve relating
to distribution “Y”. Distribution “X” is then more egalitarian than “Y”.
Nevertheless, when two curves intersect, comparison of the inequality
trend becomes impossible. Therefore, the digital indicators for evaluating
inequality must be calculated as the Gini coefficient.
1.2. GINI coefficient
The Gini coefficient seems to be the most popular of the various
inequality indices. It is derived from the Lorenz curve (concentration
curve) in that it is the ratio of the area between this curve and the first
diagonal line and the half-square in which the curve lies. The Gini
index lies within the range [0, 1]. The more it tends towards 1, the
more unequal is the distribution of expenditures. On the other hand,
when the indicator declines, the distribution of expenditure becomes
more egalitarian.
A f r i c a n D e v
1.3. Breakdown of the Gini index by expenditure categories
Analytically, the Gini index has several expressions. Lerman and Yitshaki
(1985) showed that:
G = 2 cov (Y ; F(Y)) / Y
 (Equation 1)
Y being the expenditure vector Y : (Y1, Y2, .... Yn) and F(Y) representing
the cumulative distribution considered as random variable uniformly distributed
between [0, 1].
The breakdown adopted makes it possible to analyse the contributions
to total inequality of the various expenditure categories (consultations,
radiological procedures, drug purchases, etc.). It also facilitates the
measurement of their specific inequality contribution to the total
inequality (Lerman and Yitshaki 1985).
Let Y= (Y1, Y2, .... Yn) be the distribution of total health expenditures and
Yik the expenditure of the person i in item or category k where k=1....K.
Y1,Y2,...,Yk are therefore the expenditure components and Y = ∑ Yk
(Equation 2)
Given the properties of the covariance, we have:
G = 2 ∑cov (Yk ; F(Y)) / Y
 (Equation 3)
where cov (Yk ; F(Y)) represents the covariance of the expenditure in
item k with the cumulative distribution of total expenditure.
When cov (Yk , F(Yk)) Yk, is multiplied and divided by cov(Yk ;F(Yk ))
and by Yk, we obtain the rule of breakdown according to the source
(or component), that is:
G = ∑ [ [cov (Yk ; F(Y)) / cov (Yk ; F(Yk))] * [2cov (Yk ; F(Yk)/ Y
 k] * (Yk /Y) ]
(Equation 4)
Let’s note:
- the Gini correlation between the component k and the total
expenditure:
Rk = cov (Yk ; F(Y)) / cov (Yk ; F(Yk)) (Equation 5)
- the Gini coefficient related to the component k: G k = 2cov
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(Yk ; F(Yk) / Yk (Equation 6) living, ranked from the poorest to the richest (horizontal axis). In other
words, it links the share of health expenditures to the quintiles of total
- the proportion of the component k in the total expenditure : expenditures (or other variable indicating the standard of living).28

Sk = Y
 k /Y (Equation 7) Figure 32: Concentration curve for health
spending in 2010
Then G = ∑ Rk Gk Sk (Equation 8)

The relative contribution of an expenditure source k to the total

Cumulative distribution of Heath expenditure

inequality is:

Pk = Rk Gk Sk / G. (Equation 9)

The sum of the relative contributions of various sources (components)

is equal to the unit. The breakdown of the Gini index also helps to
determine the marginal effect of variation in each expenditure category
k on total expenditure inequality. Let ek be a scalar slightly superior
to the unit, an increase in expenditures derived from the source k
results in the passage to vector ekYk and will involve a variation of
G. The variation in the value of G brought about by this change at
the margin of the expenditure category is obtained from the partial
derivative of G in relation to ek. We show that:
∂G/ ∂ek = Sk (Rk Gk - G) (Equation 10)
∂G/ ∂ek ek is the marginal contribution of source k to total inequality.
The relative marginal effect is obtained by dividing the above expression by
G, that is to say:
(∂G/ ∂ek)/ G = ( Rk Gk Sk / G ) - Sk (Equation 11)
It is clear that the sum of the relative marginal effects is nil, multiplying
all the sources of income by e leaves Gini’s global index unchanged.
2. Concentration curve and index
Population in order of increasing Heath expenditure
2.2. Concentration index
The concentration index (Kakwani, 1980), which derives directly from
the concentration curve, quantifies the degree of socioeconomic
inequality related to the variable being examined (health expenditure).
The concentration index is equal to twice the area between the
concentration curve and the first bisector. If there is no socioeconomic
inequality, the concentration curve is confounded with the bisector
and the concentration index is equal to zero. By convention, the
concentration index is negative when the concentration curve lies
above the first bisector. In this case, health expenditures are highly
concentrated among the poor. Conversely, the concentration index
is positive when the concentration curve lies below the first bisector.
Consequently, it is important not to focus on the inequality of health
expenditures as reflected by the Gini index for these expenditures,
but instead on the inequality of health expenditures as revealed by
the concentration index.

2.1. Concentration Curve 2.3. Breakdown of the concentration index by

expenditure categories
The concentration curve (Figure 32) represents the cumulative
percentage of health expenditures (vertical axis) associated with the According to Kakwani (1980), the expenditure concentration index
percentage of the population classified by increasing standards of X is:

28
The Gini curve appears as a special case of the concentration curve. For the Lorenz curve, the vertical axis and the horizontal axis refer to the same variable. For
the concentration curve, the variables are different.

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C = 2 cov (X ; F(Y)) / Y
 (Equation 12)
X being the health spending vector and Y the vector of total
expenditure: (Y1, Y2, .... Yn) and F (Y) representing the cumulated
distribution considered as a random variable evenly distributed
between [0 and 1].
The Gini index appears as a special case of the concentration index
where X=Y.
That is, X1,X2,...,Xk the expenditure components with X = ∑ Xk (Equation 13)
The concentration index C may be written as follows (O’Donnell et al.,
2008):
C = ∑ Sk Ck (Equation 14)
Where Sk = Xk /X represents the specific budget coefficient relating
to expenditure item k or the expenditure elasticity Xk in relation to total
expenditure X.
Ck is the concentration index specific to the category k
The contribution of category k to total inequality is:
Pk = SkCk/C (Equation 15)
This leads to: ∑ Sk Ck /C = 1
The sum of the relative contributions of various sources (components)
is equal to the unit. The breakdown of the concentration index also
helps to determine the contribution of variation in each expenditure
category k to total expenditure inequality.
Thus, the breakdown of the Gini index as proposed by Lerman and
Yitshaki (1985) and that of the concentration index as presented by
Kakwani (2000) makes it possible to measure the contribution of an
expenditure category to the total inequality. The breakdown also helps
to gauge the impact of a marginal increase in a particular expenditure
category on total inequality. We will use these breakdown techniques
to analyse how the various items of health expenditure have
contributed to the inequality in private expenditures on health in
Tunisia.
A f r i c a n D e v
3. Kakwani index
The comparison of the health expenditures concentration curve with
the Gini curve of total expenditures gives an indication of the progressivity
of the variables being studied, which, in our case, are health expenditures.
If health expenditures are proportional to the standard of living, then the
inequality in health expenditures is similar to that of living standards,
and the concentration curve of health expenditures is confounded with
that of living standards (or Lorenz curve). When the poor spend
proportionately less on their health, their share of health spending is
lower than their share in the total expenditures. In this case, the Lorenz
curve dominates (or is above) the concentration curve. The opposite
phenomenon is observed when the system is regressive.
The Kakwani index is equal to twice the area between the Gini curve
and the concentration curve. It is equal to the difference between the
health spending concentration index and the Gini index of total
expenditures.
I=C–G
The value of I lies between -2 and 1. A negative value means that
health spending is regressive; the Gini curve is below the concentration
curve. A positive value implies the progressivity of health spending;
the Gini curve is above the concentration curve. There is uncertainty
when the curves intersect. In which case, it becomes necessary, in
addition to the graphical analysis, to use the Kakwani index to
distinguish between these cases.
Figure 33: Concentration curves for the health
SPY and total SPY in 2010
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4. Trend in and sources of inequality of health SPY: Table 8: Trend in the concentration index and
2000-2005-2010 Kakwani index

4.1. Overall inequality trends Years 2000 2005 2010

Gini indices show that inequalities in health expenditures are much

C 0.444437 0.448276 0.410342
greater than inequalities in total household expenditures (Table 7). In
2010, the Gini curve of health spending revealed a high concentration
G 0.408558 0.414008 0.384674
of health expenditures (Figure 31). Twenty per cent (20%) of the
population accounts for over 75% of health spending. The high levels
I 0.035879 0.034268 0.025668
of inequality stem from unequal health status of the population, given
that health expenditures are closely linked to the need for care, which
is expressed only by those in poor health. The concentration index shows that inequality in health spending
increased between 2000 and 2005, but dropped sharply between
Table 7: Trend in Gini index for total SPY and the
2005 and 2010 (Table 5). Despite this decline, inequality in health
health SPY29
spending continues to be higher than inequality in total expenditures

Years 2000 2005 2010 (Figure 33).

Total SPY 0.408558 0.414008 0.384674 The Kakwani index is positive. Health expenditures are progressive
(Figure 34). The Kakwani index declined between 2000 and 2010,
Health SPY
0.744939 0.715508 0.711574 the progressivity of health spending was constrained.
santé

Therefore, it is important to consider not the inequality in health The scope of the inequalities in health care spending explains why
spending as reflected by the Gini index for these expenses, but the they should be paid close attention and the need to identify ways and
inequality in health spending as shown by the concentration index. means of reducing these inequalities.

Figure 34: Budget coefficient of health spending by decile of total expenditures in 2010

7%
6%
5%
4%
3%
2%
1%
0%
d1 d2 d3 d4 d5 d6 d7 d8 d9 d10

29
The Gini index for total SPY 2000 is equal to that published in the report of the 2000 consumption survey (p.27). The 2000 and 2005 indices differ from those published in
2012 in the poverty report (p. 23). However, the 2010 index does not differ from the latter.

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4.2. Contribution of expenditure items to total inequality
in health spending
In the national budget and household consumption surveys of 2000,
2005 and 2010, health expenditures are classified into four categories:
• Routine medical care which includes medical consultations,
dental care, paramedical services (x-rays, analyses and nursing
services) in both public and private institutions. This item also
includes the use of traditional medicine (healers and medicinal
plants);
• Special medical care which includes stays in the hospital
or clinic, surgical procedures, special dental surgery procedures,
special radiology services (scans and MRI), child delivery, medical
treatment abroad, long-term care (long-term consultations and
medication) and cosmetic surgery (since 2010);
• Pharmaceuticals (drugs) and such other pharmaceuticals as baby
products (talc, soap, etc.), adhesive bandages, etc.;
• Medical devices, including optical glasses, blood pressure
measuring devices, hearing aids, etc.
Therefore, one may wonder to what extent each of these items
contributed to changes in health spending inequalities. To answer this
question, we will proceed to break down the health inequalities by
category (Table 9).

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Table 9: Breakdown of health spending inequality by expenditure category

Kakwani
Year Item Yk in D Sk Gini Index Concentration Index
Index

Marginal
Gk RkSkGk/G Gk SkCk/C Ck-G
effect

Routine medical
15.471 21.8% 0.877% 22.6% 0.008 0.471 23.14% 0.062442
care

Special medical
27.974 39.4% 0.872 40.6% 0.012 0.456 40.78% 0.050442
care

2000 Pharmaceuticals 26.351 37.2% 0.799 35.3% -0.019 0.408 34.10% -0.000558

Medical
1.130 1.6% 0.984 1v5% -0.001 0.550 1.97% 0.141442
equipment

Total 70.927 100% 0.745 100.0% 0.0000 0.444 100.0% 0.035442

Routine medical
30.287 27.1% 0.846 28.6% 0.015 0.486 29.45% 0.071992
care

Special medical
32.054 28.7% 0.888 30.4% 0.017 0.453 29.01% 0.038992
care

2005 Pharmaceuticals 47.510 42.6% 0.740 39.5% -0.031 0.417 39.57% 0.002992

Medical
1.742 1.6% 0.977 1.5% -0.001 0.565 1.97% 0.150992
equipment

Total 111.672 100% 0.716 100.0% 0.0000 0.448 100.0% 0.033992

Routine medical
39.062 27.1% 0.843 28.6% 0.015 0.433 26.04% 0.048326
care

Special medical
42.067 29.2% 0.903 32.1% 0.029 0.493 39.99% 0.108326
care

2010 Pharmaceuticals 60.790 42.2% 0.724 37.8% -0.044 0.331 31.91% -0.053674

Medical
2.210 1.5% 0.986 1.5% -0.000 0.625 2.06% 0.240326
equipment

Total 144.251 100% 0.730 100.0% 0.0000 0.410 100.0% 0.025326

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Inequality of the SPY for routine medical care (G = 0.843 and C =
0.433 in 2010) was higher than the overall inequality in health
expenditures (G = 0.730 and C = 0.410 in 2010). However, on
account of their average share in these expenditures (the Sk stood at
27.1% in 2010), their relative contribution to inequality was average
(28.6% in 2010). From 2000 to 2010, the relative marginal effect of
spending on routine medical care was positive throughout the period,
meaning that this source of inequality instead had an inertia effect on
inequalities in health spending. The Kakwani index was positive and
routine health care expenditures were progressive. Indeed, in 2010,
the budget coefficient of these expenses decreased for the 9th and
10 deciles (Figure 35).
were progressive as evidenced by the Kakwani index and budgetary
coefficients by decile of total SPY (Figure 35).
Of all health expenditures, pharmaceutical expenditures were the most
substantial and the least unequal component (Table 6). In 2010, they
accounted for 42.2% of total health expenditures, while their contribution
to the formation of inequality stood at 37.8%, according to the Gini index,
and at 42.2%, according to the concentration index. From 2000 to 2010,
the Gini index specific to pharmaceutical expenditures declined from
0.799 to 0.724.30 The marginal effect of the growth of these expenditures
on inequality was negative throughout the period analysed, reflecting an
equalizing impact. In 2010, pharmaceutical expenditures were regressive
from the fifth decile (Figure 35) and the Kakwani index was negative.

The inequality of the SPY for special medical care was on the uptrend
(GK2000 = 0.872; Gk2010 = 0.903 and = 0.459 CK2000; Ck2010 =
0.493). Throughout the period, their relative marginal effect remained
positive. This development shows that spending on special medical
care is a source of inequality and its increase helped to worsen the
inequality in overall care expenditures, given that these expenditures
Expenditures on medical equipment were the smallest component
of health expenditures (Table 6), yet they were the most unequal
(Gk201=0.986 and Ck2010=0.625). In 2010, they accounted for
1.5%, while their contribution to the formation of inequality stood at
1.5%, according to the Gini index. These expenditures were highly
progressive and had the highest Kakwani index.

Figure 35: Budget coefficients of health spending by decile of total SPY, by category, in 201031

0.03 Rou ne medical

0.025 care
0.02 Special medical
0.015 care
0.01
Pharmaceu cals
0.005
0
Medical equipement
d2 d3 d4 d5 d6 d7 d8 d9 d10

30
The concentration index went from 0.408 to 0.331
31
Our calculations from the pooled budget data on the 2010 survey published on site of the National Institute of Statistics (INS) http://www.ins.nat.tn/indexfr.php

34
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4.3. Contribution of routine medical care to the total
inequality
Routine care expenses include medical consultations, dental care,
radiology and biological procedures in both public and private sector
facilities, and the use of traditional medicine (Table 7).
Between 2000 and 2010, the decline in inequalities in routine medical
care expenses was driven by the decline in inequalities in medical
consultations (Gk2000 = 0.877; Gk2010 = 0.849 and Gk2010 = 0.443; Ck2010
= 0.433). In 2010, the specific budget coefficient of these expenditures
decreased for the 9th and 10th deciles (Figure 36). The Kakwani index
was positive but very small.
The decline in inequalities in spending on medical consultations may be
attributed to the greater availability of physicians (reflected in the
reduction in the ratio of the number of inhabitants per physicians). The
decline is observable despite an increase in inequality in the availability
of physicians nationwide. This suggests that when patients do not have
easy access to medical services and physicians, they tend to move
towards the latter.
Spending on radiological and biological procedures continued to be
highly unequal (G2010 = 0.947 and C2010 = 0.464). The same is true for
dental care, which is generally not considered a priority by the poor
Figure 36: Budget coefficients of routine health spending by deciles of total SPY,
and by sub-item, in 201033
0.015
0.01
0.005
0 Medical analyses
d1 d2 d3 d4 d5 d6 d7 d8 d9 d10
32
For these types of care, there is balance and the demand nil.
33
Our calculations from the pooled budget data on the 2010 survey published on site of the National Institute of Statistics (INS) http://www.ins.nat.tn/indexfr.php
A f r i c a n D
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(G2010 = 0.993 and C2010 = 0.600). This situation reflects the difficulty that
poor people have in accessing health care other than the one provided
free of charge. The often exorbitant cost of these procedures and care
would lead to high elasticity and discourage low-income patients from
using the services.32 In actual fact, the expenses entailed amount to a
high proportion of their income. The budget coefficient for these
expenses increases exponentially with income (Figure 36). The Kakwani
index is very high, compared to other items of expenditure. There is
therefore considerable elbow room for improving the access of poor
people to such care.
The trends are similar to those recounted in the literature.
Socioeconomic status is identified as a key determinant of health
expenditure. Similarly, people of higher socio-economic status generally
use more health care services, especially the specialized services, than
other people (Allin et al. 2006). In contrast, when people of lower socio-
economic status are not entitled to free care, they are more likely, than
other people, to forgo health expenditures.
For De Looper and Lafortune (2009), despite having higher rates of
illness, disease and death, poorer or less educated persons often have
difficulties in accessing appropriate specialists and preventive health
services. They make less use of these goods and services, some of
which are very expensive compared to their income. We would expect
the same to be true for special medical expenses.
Medical consulta ons
Dental
X-Rays, Scans and
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Table 10: Breakdown of inequality in routine health spending by expenditure sub-category

Kakwani
Year Item Yk in D Sk Gini Index Concentration Index
Index

Marginal
Gk RkSkGk/G Gk SkCk/C Ck-G
Effect

Medical
11.571 16.3% 0.877 16.3% 0.0000 0.443 16.26% 0.03444
consultations

Dental care 0.806 1.14% 0.996 1.3% 0.0016 0.607 1.55% 0.19844

X-rays, scans
2000 and medical 3.037 4.28% 0.98 4.9% -0.0062 0.544 5.24% 0.13544
analyses

Traditional
0.056 0.08% 0.99 0.08% -0.0000 0.525 0.09% 0.11644
medicine

ROUNTINE
MEDICAL 15.471 21.8% 0.877 22.6% 0.008 0.471 23.14% 0.06244
CARE

Medical
21.177 19.0% 0.849 19.5% 0.005 0.600 19.66% 0.18599
consultations

Dental care 1.506 1.3% 0.995 1.6% 0.003 0.464 2.02% 0.04999

X-rays, scans
2005 and medical 7.515 6.7% 0.954 7.4% 0.007 0.822 7.66% 0.40799
analyses

Traditional
0.089 0.08% 0.999 0.09% 0.000 0.578 0.10% 0.16399
medicine

ROUNTINE
MEDICAL 30.287 27.1% 0.846 28.6% 0.015 0.486 29.45% 0.07199
CARE

Medical
25.749 17.9% 0.849 18.2% 0.003 0.406 16.08% 0.02133
consultations

Dental care 1.640 1.1% 0.993 1.2% 0.001 0.600 1.65% 0.21533

X-rays, scans
2010 and medical 11.515 8.0% 0.947 8.9% 0.009 0.464 8.23% 0.07933
analyses

Traditional
0.157 0.1% 0.999 0.1% 0.000 0.822 0.07% 0.43733
medicine

ROUNTINE
MEDICAL 39.062 27.1% 0.843 28.6% 0.015 0.433 26.04% 0.04833
CARE

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4.4. Contribution of special medical expenditures
Les dépenses de soins exceptionnels regroupent les maladies de
longue durée, les dépenses de séjour et chirurgie médicale, les soins
dentaires exceptionnels, les dépenses exceptionnelles de radiologie et
les accouchements (Tableau 11).
Increasing inequalities in special health care services are observed in all
expenditure items with the exception of special expenditures for
radiological services (MRI and scans). Whenever radiological services
are called for, the special expenditures for the services are most often
waived in hospitals or covered by health insurance, and the patients
themselves seldom have to make any payments.

Table 11: Breakdown of inequality in special care spending by expenditure sub-category

Concentration Kakwani
Gini index
Year Item Yk in D Sk index index
Marginal
Gk RkSkGk/G Gk SkCk/C Ck-G
effects
Hospital stay and medical 8.703 12.3% 0.94 13.5% 0.0123 0.509 14.05% 0.1004
surgery
Special dental care 0.710 1.0% 0.99 11.7% 0.0017 0.768 1.73% 0.3594

Special radiology expenses 0.671 0.9% 0.99 1% 0.0008 0.503 1.07% 0.0944

2000 Child Delivery 1.110 1.6% 0.98 1.4% -0.0017 0.341 1.20% -0.0676

Treatment abroad 0.215 0.3% 0.99 0.4% 0.0008 0.769 0.53% 0.3604

Long-term illnesses 16.565 23.4% 0.90 23.1% -0.0024 0.423 22.20% 0.0144

SPECIAL MEDICAL CARE 27.974 39.4% 0.872 40.6% 0.012 0.459 40.78% 0.0504

Hospital stay and medical 11.244 10.1% 0.96 11.3% 0.0125 0.470 10.56% 0.0560
surgery
Special dental care 0.837 0.7% 0.99 0.7% 0.00015 0.575 0.96% 0.1610

Special radiology expenses 1.474 1.3% 0.98 1.4% 0.0005 0.430 1.27% 0.0160

Child Delivery 1.793 1.6% 0.98 1.7% 0.00045 0.448 1.61% 0.0340
2005
Treatment abroad 0.034 0.03% 0.99 0.04% 0.0001 0.750 0.05% 0.3360

Long-term illnesses 16.673 14.9% 0.93 15.2% 0.0034 0.437 14.57% 0.0230

SPECIAL MEDICAL CARE 32.054 28.7% 0.888 30.4% 0.017 0.453 29.01% 0.0390

Hospital stay and medical 12.472 8.6% 0.977 10.3% 0.0174 0.515 12.42% 0.1303
surgery

Special dental care 1.156 0.8% 0.996 0.8% 0.0006 0.665 1.42% 0.2803

Special radiology expenses 2.101 1.5% 0.981 1.5% 0.0004 0.396 1.55% 0.0113

Child Delivery 1.870 1.3% 0.987 1.3% 0.0004 0.444 0.98% 0.0593
2010
Treatment abroad 0.000 0.0% 0.999 0.0% -0.000 0.392 0.00% 0.0073

Long-term illnesses 24.464 17.0% 0.933 18.0% -0.0101 0.485 23.61% 0.1003

SPECIAL MEDICAL CARE 0.009 0.0% 0.999 0.0% 0.000 0.411 12.42% 0.0263

SOINS MEDICAUX
42.067 29.2% 0.903 32.1% 0.029 0.493 39.99% 0.1083
EXCEPTIONNELS

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Long-term illnesses had the most substantial marginal effect, accounting coefficients were strongly on the uptrend, reflecting the magnitude of the
for 17% of total health expenditures in 2010, including expenses inequalities (Figure 37). The highest Kakwani index observed was for
for hospital stay and medical surgery. The corresponding budget special dental care and treatment abroad in 2000 and 2005.

Figure 37: Budget coefficients of special health spending by deciles of total SPY
and by sub-item, in 201034

0.014
0.012 Hospital Stay and Surgery
0.01
Special Dental Care
0.008
0.006 Special Radiology
0.004 Expenditures
0.002 Child Delivery
0
d1 d2 d3 d4 d5 d6 d7 d8 d9 d10 Long-term Illnesses

This trend reflects the demographic and epidemiological transitions35
experienced by the country. The health indicators in Tunisia show
an overall decline in the incidence of infectious diseases and a
simultaneous increase in the incidence of non-communicable diseases
and chronic diseases among aging populations. Analysis of mortality
data36 shows that the main causes of death are diseases of the
circulatory system, metabolic diseases and cancer. These diseases may
be avoided through primary (healthier lifestyles) or secondary prevention
(screening, early diagnosis). Their prevention and, above all, treatment
call for increased spending by households and the community.
inequality in pharmaceutical expenditures and the weight of these
expenditures on the poorest populations, although they are entitled to
free or virtually free care and medicines.37
The Kakwani indices were negative or extremely low.
The decline in inequality in pharmaceutical expenditures was due to the
decrease in inequality relating to these two types of expenditures. Their
contribution to inequality diminished and their marginal effect was
negative, pointing to an equalizing effect.

4.5. Contribution of pharmaceutical expenditures
The pharmaceutical expenditures include expenses relating to purchase
of drugs and those relating to the purchase of pharmaceutical products
(Table 9). In 2010, the corresponding budget coefficients were on the
downtrend depending on the deciles (Figure 38), reflecting the low
The decline in inequality of pharmaceutical expenditures may be
attributed to the increasingly equal availability of pharmacies nationwide.
Faced with the difficulty of accessing physicians, patients - especially
the poorer ones and those of the middle class - often resign themselves
to self-medication. This is also true for patients who live in areas that are
under-served in terms of health infrastructure and doctors.

34
Our calculations from the pooled budget data on the 2010 survey published on site of the National Institute of Statistics (INS) http://www.ins.nat.tn/indexfr.php
35
The infant mortality rate dropped from 51.4 ‰ in 1984 to 16 ‰ in 2011. Life expectancy at birth was 74.9 years in 2011 (source: National Institute of Statistics - INS).
36
National Statistics on Medical Causes of Death. Tunis 2009). Research Unit on Aging and Medical Causes of Death – National Public Health Institute.
37
It would appear patients entitled to free drugs are sometimes forced to buy their drugs from private pharmacies due to shortages in hospital pharmacies or Primary Health
Centres (PHCs). These shortages are caused by governance problems and would be resolved.

38
A f r i c a n D e v e l o p m e n t B a n k
 Economic Brief
AfDB
2 0 1 4 • w w w . a f d b . o r g

Figure 38: Budgetary coefficients for pharmaceuticals by deciles of total SPY,

and by sub-items, in 201038

0.025
0.02
0.015 Drugs
0.01
Other Pharmaceu cals
0.005
0
d1 d2 d3 d4 d5 d6 d7 d8 d9 d10

Table 12: Breakdown of inequality in spending on pharmaceuticals by expenditure sub-category

Concentration Kakwani
Gini Index
Index Index
Year Item Yk in D Sk
Marginal
Gk RkSkGk/G Gk SkCk/C Ck-G
Effect

Medicines 24.448 34.4% 0.813 33.1% -0.013304 0.404 31.31% -0.004558

Other
2000 1.904 2.7% 0.963 2.1% -0.005545 0.462 2.79% 0.053442
pharmaceuticals

PHARMACEUTICALS 26.351 37.2% 0.799 35.3% -0.019 0.408 34.10% -0.000558

Medicines 39.783 35.6% 0.782 34.7% -0.008982 0.435 34.59% 0.020992

Other
2005 7.728 6.9% 0.857 4.7% -0.02157 0.322 4.98% -0.092008
pharmaceuticals

PHARMACEUTICALS 47.510 42.6% 0.740 39.5% -0.031 0.417 39.57% 0.002992

Medicines 47.795 33.1% 0.792 32.3% -0.008436 0.366 28.69% -0.018674

Other
2010 12.995 9.1% 0.788 5.5% -0.035153 0.202 3.23% 0.182674
pharmaceuticals

PHARMACEUTICALS 60.790 42.2% 0.724 37.8% -0.044 0.331 31.91% -0.053674

38
Our calculations from the pooled budget data on the 2010 survey published on site of the National Institute of Statistics (INS) http://www.ins.nat.tn/indexfr.php

39
A f r i c a n D e v e l o p m e n t B a n k
 AfDB Economic Brief
2 0 1 4 • w w w . a f d b . o r g
The analysis focused on the trends in the inequality in health spending
in Tunisia and the contribution of the various items of expenditure to the
formation of this inequality. The analysis is based on data on total health
spending per person per year (SPY), as established by the national
budget and household consumption surveys for 2000, 2005 and 2010.
The trends and sources of inequality are captured mainly through the
calculation and breakdown of the Gini index and the concentration index
by expenditure category. This approach is likely to furnish us with
information on:
• The overall inequality in health spending and its trends;
• the inequality of the SPY in each health care expenditure item
and sub-item;
• the contribution of the inequality of each SPY to the total inequality;
• the marginal effect (equalizer or non-equalizer) of the variation of
a particular SPY on the total inequality in health expenditure.
The outcomes showed that overall inequality declined from 2000
to 2010. The breakdown of inequality indicators reveals that this
trend was almost exclusively due to a decrease in inequality in
pharmaceutical expenditures, which accounted for 42.2% of health
A f r i c a n D e v
spending in 2010. Medical consultations (16.3% of health spending)
and medical devices (1.5% of health spending) also had equalizer
effects. These changes may be attributed to the increased availability of
physicians and the improved national coverage in terms of pharmacies.
The items where inequality has worsened and produced an inertia effect
were long-term illness (17% of spending), the spending on hospital stay
and medical surgery (8.6%) and paramedical or x-ray, scanner and
biology services (8% of health spending). These expenses are related to
the demographic and epidemiological transition. To reduce the
corresponding inequality, government authorities need to adopt specific
policies targeting the most vulnerable groups among the young and the
elderly.
Dental care continues to be characterized by unusually high levels of
inequality and lack of access suffered by disadvantaged classes.
Improved coverage of the territory by dental practices and increased
public awareness of the importance of oral health should curb one of the
causes of this inequality. Similarly, special processing of their dental
expenditure refund by health insurance, with no competition with
recurrent expenditures, should contribute to reducing inequalities in
dental care access.
40
e l o p m e n t B a n k

5. General Conclusion
espite the progress achieved, health inequalities remain
D considerable and relatively little known in Tunisia. In light of the
analysis conducted, there is significant elbow room for reducing these
inequalities.
1- From the supply side:
1-1- In the public sector, it is necessary to revitalize primary health
care by improving the operation
1-2- It is also important to strengthen Level II which seems
to be the weak link in the system. Better coverage of the territory in
terms of Level II beds should necessarily go hand-in-hand with the
provision of more specialized physicians for the poorest regions in
light of the demographic and epidemiological transition.
1-3- Efforts should be made to ensure that at each level the system
performs its assigned tasks under the best possible conditions.
These tasks should be clearly defined. Each hospital institution should
have a scheme of work that allows for coherent strategic
management.
1-4- The specific incentives that were introduced to encourage
physicians to settle in deserted areas should be evaluated. Public-
public and possibly private-public partnerships should be instituted.
Also, it is important to negotiate with corporations an institutional
framework to better regulate the opening of private practices.
1-5- It is necessary to determine measures that should be
implemented to enhance health care delivery at local or regional level,
as part of an overall regional development policy.
A f r i c a n D
Economic Brief
AfDB
2 0 1 4 • w w w . a f d b . o r g
2- On the demand side:
2-1- It is important to reduce financial barriers to health care access by
better targeting the poor who benefit from free medical assistance.
2-2- Pharmaceuticals are a significant drain on the budgets of the
poorest households and it is necessary to reduce this weight by
ensuring good governance of public pharmacies.
2-2- There is a need to ensure a better collective coverage of long-
term illness, hospital stay and medical surgery, x-rays and scans.
Knowing the profile of households that incur these expenses will make
it possible to better target them, if need be.
2-3- Dental care continues to be characterized by extremely high
inequalities in expenses. Improved coverage of the territory in terms of
availability of dental practices and greater public awareness of the
importance of dental health should curb one of the causes of the
inequality. Similarly, a special processing of reimbursement for dental
expenses by health insurance, apart from the recurrent expenses,
should contribute to reducing inequalities in dental care access.
3- On the institutional side:
3-1- It is necessary to aim at reducing social and regional inequalities
in health care.
3-2- There is a need to produce and monitor indicators for assessing the
progress of specific categories not only at the national level but also at the
local level. It is important to conduct periodic surveys on the status of health,
health care use, or the failure to seek health care for financial reasons.
41
e v e l o p m e n t B a n k
AfDB Economic Brief

2 0 1 4 • w w w . a f d b . o r g

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43
A f r i c a n D e v e l o p m e n t B a n k
 Governorate Average Average Inhabit. Proportion Inhabit. Inhabit. Frontline Frontline Frontline Inhab. Inhab. Medical Haemodialy-
distance distance per of PHC /PHC FTE per medical radiology dental /daytime /Night- Laboratory sis machines
from a from a Primary offering (Full-Time primary laboratory unit per chairs phar- time per 100000 per 100 000
Regional General Centre medical Equivalent) care unit per 100000 100000 macy phar- inhab. inhab. (Total,
Hospital Hospital (PHC) consulta- physi- 100000 inhabit. per macy public and
(RH) (GH) tion 6 days cian inhabit. inhab. private)
per week

ARIANA 14 22 19920 0.76 22299 5242 0.6 0.2 1.61 6385 45273 4 23.7

A
f
r
BEN
8 17 11786 0.551 18529 6144 0.52 0.52 1.39 5203 41250 3.8 24.6

i
AROUS

c
a
n
MANOUBA 20 9218 0.3 14847 7090 0.54 0.54 1.9 7229 36870 1.9 19

D
e
v
e
MEDENINE 20 219 4035 0.044 15030 9498 1.54 0.88 1.54 5845 50656 0.8 27.6

l
45
o
p
m
MONASTIR 14 19 5368 0.25 8425 4816 2.33 2.52 4.66 5923 17769 2.3 19.4

e
n
t
SFAX 28 37 6006 0.226 13144 5677 0.86 0.86 1.5 5575 46550 5.6 23.9
Annex 1: Indicators of Health care Facilities by Cluster

B
a
n
k
SOUSSE 20 22 6180 0.263 10640 6118 1.14 1.14 2.94 5883 33989 3.6 18.3
Table 13: Health infrastructure indicators: Cluster 1.1
2 0 1 4
•

TUNIS 2 20414 1 20414 5588 0.2 0.2 0.7 3877 45468 6.9 30.1
Economic Brief

Rank of
cluster
depending 1 1 4 1 4 2 1 1 1 1 3 1 1
on the
criteria
AfDB
w w w . a f d b . o r g
 2 0 1 4
•
AfDB
Economic Brief

w w w . a f d b . o r g

Governorate Average Average Inhabit. Proportion Inhabit. Inhabit. Frontline Frontline Frontline Inhab. Inhab. Medical Haemodialysis
distance distance per of PHC /PHC FTE per medical la- radiology dental /daytime /Night- Laboratory machines per

A
f
from a from a Primary offering me- (Full-Time primary boratory unit per chairs pharmacy time phar- per 100000 100 000 inhab.

r
Regional General Centre dical Equivalent) care unit per 100000 100000 macy inhab. (Total, public

i
Hospital Hospital (PHC) consultation physician 100000 inhabit. per and

c
(RH) (GH) 6 days per inhabit. inhab. private)

a
week

n
D
e
BIZERTE 23 86 6073 14% 14197 7699 2.01 2.01 2.74 6833 36440 1.8 24.2

v
e
l
46
o
p
KEBILI 40 299 1784 9% 4687 4432 1.99 1.99 1.99 10047 30140 1.3 19.2

m
e
n
t
NABEUL 24 84 6022 14% 14858 7682 1.46 1.46 2.79 5791 31367 2.5 18.5

B
a
n
Ranking 2 3 3 3 2 3 2 2 3 2 1 2 3

k
Table 14: Health infrastructure indicators, Cluster 1.2
 Governorate Average Average Inhab. Proportion Inhab. Inhab. Frontline Frontline Frontline Inhab. Inhab. Medical La- Haemodialysis
distance distance per of PHC /PHC FTE per medical radiology dental /daytime /Night- boratory per machines per
from a from a Primary offering (Full-Time primary laboratory unit per chairs pharmacy time 100000 100 000
Regional General Centre medical Equivalent) care unit per 100000 100000 pharmacy inhab. inhab. (Total,
Hospital Hospital (PHC) consultation physician 100000 inhab. per public and
(RH) (GH) 6 days per inhab. inhab. private)
week

A
BEJA 22 127 3257 10% 11067 5777 1.96 1.96 2.61 9279 38275 1 14.4

f
r
i
c
GABES 32 168 3929 25% 9726 6821 2.49 2.21 3.04 6694 36150 1.7 16.3

a
n
GAFSA 36 226 3635 20% 9316 6379 2.66 3.25 2.66 9138 42263 0.6 24.8

D
e
v
e
LE KEF 44 206 2759 19% 7998 5832 3.51 2.73 3.51 8848 36657 0.8 21

l
47
o
p
m
MAHDIA 44 44 3538 8% 7979 4833 2.78 2.52 2.78 9007 30485 1 19.4

e
n
t
SILIANA 40 143 2629 18% 8116 4500 3.85 3.85 3.42 11700 29250 0.4 16.7

B
a
n
TATAOUINE 59 307 2358 5% 8141 4177 4.1 3.42 4.1 7310 29240 0.7 25.3

k
Table 15: Health infrastructure indicators, Cluster 1.3
2 0 1 4

TOZEUR 42 333 4709 6% 8295 3996 5.8 3.86 4.83 7962 34500 0 30.9
•

ZAGHOUAN 29 69 3480 20% 7809 4736 2.93 2.35 2.93 8974 28417 1.2 28.2
Economic Brief

Ranking 3 4 1 3 1 1 4 4 4 3 2 3 2
AfDB
w w w . a f d b . o r g
 2 0 1 4
•
AfDB

Governorate Average Average Inhab. Proportion Inhab. Inhab. Frontline Frontline Frontline Inhab. Inhab. Medical La- Haemodialysis
distance distance per of PHC /PHC FTE per medical radiology dental /daytime /Night- boratory machines per
Economic Brief

from a from a Primary offering (Full-Time primary laboratory unit per chairs pharmacy time per 100000 100 000
w w w . a f d b . o r g

Regional General Centre medical Equivalent) care unit per 100000 100000 pharmacy inhab. inhab. (Total,

A
Hospital Hospital (PHC) consultation physician 100000 inhab. per public and

f
(RH) (GH) 6 days per inhab. inhab. private)

r
week

i
c
a
n
D
JENDOUBA 36 157 3712 11% 12432 8637 1.42 1.65 1.89 10076 70533 0.5 15.8

e
v
e
l
48
KAIROUAN 46 98 4305 17% 13596 8354 1.97 1.97 1.97 9995 43054 0.5 8.8

o
p
m
e
KASSERINE 50 257 4238 16% 12530 5720 2.78 2.08 2.31 11376 54038 0.2 11.6

n
t
B
SIDI

a
44 157 3327 9% 13130 3438 2.67 2091 2.91 11458 41250 0.2 13.6
BOUZID

n
k
Table 16: Health infrastructure indicators, Cluster 1.4

Ranking 4 2 2 2 3 4 3 2 4 4 4 4 4
 Governorate Beds per Hospital Clinic General Gyneco Paediatrics Ophthal- ENR beds Ortho- Cardio- Anaesthe- Psychiatric
10 000 beds / beds / surgery beds/ beds/ mology /10000 paedics logy bed sia and in- beds/10000
inhab 10 000 10 000 beds / 10000 10000 beds inhab. beds per per tensive inhab.
(pub + inhab. inhab 10 000 WCBA children /10000 10000 10000 care beds
private) inhab. below 15 inhab. inhab. Inhab. /10000

A
years inhab.

f
r
i
c
a
n
MANOUBA 26 26 0 0 0 0 0 0 3.25 0 0.79 16.41

D
e
v
e
MONASTIR 23.9 22.5 1.4 2.93 8.31 8,81 0.66 0.74 0.54 1.47 0.66 0.62

l
49
o
p
m
SOUSSE 26.6 23.9 2.8 1.63 8.13 7,28 0.98 0.67 0.98 1.18 0.75 0.49

e
n
t
TOZEUR 30.9 30.9 0 4.83 10.03 11.41 1.93 0.97 0 0.97 0.97 0

B
a
n
Table 17: Bed availability indicators, Cluster 2.1

TUNIS 52.7 40.4 12.3 5.03 15.69 21.6 1.96 0.66 1.73 2.22 0.99 0

k
2 0 1 4

Ranking 1 1 1 1 1 1 1 2 1 1 1 1
•
Economic Brief
AfDB
w w w . a f d b . o r g
 2 0 1 4
•
AfDB
Economic Brief

w w w . a f d b . o r g

Governorate Beds per Hospital Clinic General Gyneco Paediatrics Ophthal- ENR beds Ortho- Cardio- Anaes- Psychiatric

A
10 000 beds / beds / surgery beds/ beds/ mology /10000 paedics logy bed thesia beds/10000

f
inhab 10 000 10 000 beds / 10000 10000 beds inhab. beds per per and inhab.

r
(pub + inhab. inhab. 10 000 WCBA children /10000 10000 10000 intensive

i
private) inhab. below 15 inhab. inhab. Inhab. care

c
years beds

a
/10000

n
inhab.

D
e
v
e
LE KEF 21.7 21.2 0.6 2.73 8.32 7.04 0.58 0.58 0.58 0.17 0.31 0.58

l
50
o
p
m
MAHDIA 16.5 14.9 1.6 1.94 6.97 4.94 0.25 0.5 0.81 0.86 0.25 0.63

e
n
t
MEDENINE 20.9 16.6 4.3 2.68 7.99 8.89 0.72 0.61 0.77 0.66 0.53 0.13

B
a
n
Table 18: Bed availability indicators, Cluster 2.2

Ranking 2 3 2 3 2 3 3 3 3 2 3 2

k
 Governorate Beds per Hospital Clinic General Gyneco Paedia- Ophthal- ENR beds Ortho- Cardio- Anaes- Psychiatric
10 000 beds / beds / surgery beds/ trics mology /10000 paedics logy bed thesia beds/10000
inhab 10 000 10 000 beds / 10000 beds/ beds inhab. beds per per and i inhab.

A
(pub + inhab. inhab. 10 000 WCBA 10000 /10000 10000 10000 ntensive

f
private) inhab. children inhab. inhab. Inhab. care

r
below 15 beds

i
years /10000

c
inhab.

a
n
D
e
BEJA 17.9 17.9 0 2.45 9.1 6.03 0.65 0.65 0.98 0 0.33 0

v
e
l
51
o
GAFSA 23.2 22 1.2 2.96 5.95 6.66 1.33 0.33 0.86 0.8 0.18 0

p
m
e
n
KEBILI 19.8 18.5 1.3 3.98 7.11 8.4 0.53 0.8 0 0 0.53 0

t
B
TATAOUINE 17.7 17.7 0 2.05 6.52 8.33 0.68 0.68 0.82 0 0.68 0

a
n
Table 19: Bed availability indicators, Cluster 2.3

k
Ranking 3 2 4 2 3 2 2 1 2 4 2 4
2 0 1 4
•
Economic Brief
AfDB
w w w . a f d b . o r g
 Governorate Beds per Hospital Clinic General Gyneco Paedia- Ophthal- ENR beds Ortho- Cardio- Anaes- Psychiatric
10 000 beds / beds / surgery beds/ trics mology /10000 paedics logy bed thesia beds/10000

2 0 1 4
inhab 10 000 10 000 beds / 10000 beds/ beds inhab. beds per per and inhab.
•
AfDB
(pub + inhab. inhab. 10 000 WCBA 10000 /10000 10000 10000 intensive
private) inhab. children inhab. inhab. Inhab. care
below 15 beds
years /10000
inhab.
Economic Brief

ARIANA 12.6 8.3 4.3 0 3.89 0 0 0 0 0.6 0.7 0

w w w . a f d b . o r g

A
f
BEN AROUS 5.5 3.8 1.7 0.45 2.06 0 0 0 0 0 0.21 0

r
i
c
a
BIZERTE 17 16.5 0.5 2.47 6.83 8.47 0.37 0.37 0.55 0.73 0.11 0

n
D
GABES 19.1 17 2.1 1.66 7.91 5.17 0.97 0.55 0 0.41 0.83 0

e
v
e
JENDOUBA 15.8 14.3 1.5 1.77 3.31 2.58 0.35 0.35 0 0.71 0 0.57

l
52
o
p
KAIROUAN 12.8 12.1 0.6 1.14 3.77 3.97 0.36 0.36 0.54 0.54 0.27 0.71

m
e
n
t
KASSERINE 12.8 12.3 0.6 1.16 4.89 4.08 0.46 0.46 0.65 0 0.23 0

B
a
NABEUL 14.9 12.7 2.2 1.46 6.74 3.94 0.27 0.27 0.8 0.4 0.27 0

n
Table 20: Bed availability indicators, Cluster 2.4

k
SIDI
10.7 10.7 0 1.45 4.57 3.69 0.39 0.29 0 0.48 0.15 0
BOUZID

SILIANA 16.7 16.7 0 1.79 4.84 3.95 0.43 0.43 0 0.77 0 0

ZAGHOUAN 27.9 27.9 0 1.47 5.22 4.49 0 0 0 0 0 0

Ranking 4 4 3 4 4 4 4 4 4 3 4 3
 Governorate General pract Specialists/ Physicians/ General pract. Specialists/ Physicians/ Physicians / General pract Specialists/
100000 inhab. 100000 100000 100000 inhab. 100000 inhab 100000 100000 inhab. 100000 inhab. 100000
(public) inhab. inhab. (public (private) (private). inhab. (pri- (total) (total) inhab. (total).
(public sector) sector) vate)

ARIANA 29.9 18.1 48.0 34.9 49.4 84.3 132.3 64.9 67.5

MONASTIR 41.1 33.8 74.9 28.1 21.5 49.7 124.6 69.3 55.3

SFAX 33.8 34.2 68.0 46.7 60.5 107.2 175.2 80.6 94.6

SOUSSSE 60.5 49.2 109.7 37.6 44.6 82.2 191.9 98.1 93.8

TUNIS 100.6 102.2 202.7 58.3 106.9 165.2 367.9 158.9 209.0

A
f
Ranking 1 1 1 1 1 1 1 1 1

r
i
c
Governorate General Gyneco-obstetri- Podiatrists Ophthalmolo- Surgeons/ Cardiologists Anaesthetists/ Psychiatrists/

a
surgeons cians /100000 /10000 gists/ 100000 inhab. /100000 100000 inhab. 100000 inhab.

n
/100000 women of childbea- children 100000 inhab. inhab.
inhab. ring age

D
(15-49 years)

e
ARIANA 2.4 2,83 7.6 3.8 2.4 6 2 0

v
e
MONASTIR 3.3 2,3 6.6 3.3 2.1 2.5 2.7 1.62

l
53
4.5 2,84 6.6 5.7 4.4 3.7 4.1 1.61

o
SFAX

p
SOUSSSE 3.3 3,78 8.2 5.4 3.6 3.9 3.9 1.07

m
TUNIS 10.3 6.85 17.4 13.6 7.6 11.3 10.3 0.5

e
n
Ranking 1 1 1 1 1 1 1 1

t
B
Governorate Pharmacists / Pharmacists/ Pharmacists/ Dentists /100000 Dentists /100000 Dentists Paramedical Paramedical Paramedical

a
100000 inhab. 100000 100000 inhab. inhab. private inhab. public /100000 inhab. staff/100 000 staff/100 000 staff/100 000
private inhab. public total total inhab. public inhab. private inhab. total

n
Table 21: Human resource indicators: Cluster 3.1

k
ARIANA 17.5 2.2 19.7 21.3 4.8 26.1 139.2 24.1 163.3
2 0 1 4

MONASTIR 22.3 8.7 31.0 18.0 16.9 34.9 400.9 9.7 410.6
•

SFAX 20.1 3.2 23.3 25.5 2.4 27.8 315.4 22.3 337.7

SOUSSSE 19.8 10.5 30.2 27.0 8.3 35.3 436.3 10.3 446.6
Economic Brief

TUNIS 28.1 12.8 40.9 35.8 7.4 43.2 666.5 42.6 709.1

ARIANA 21.5 7.5 29.0 25.5 8.0 33.5 391.6 21.8 413.4

Ranking 1 1 1 1 1 1 1 1 1
AfDB
w w w . a f d b . o r g
 2 0 1 4
Governorate General pract Specialists/ Physicians/ General pract. Specialists/ Physicians/ Physicians/ General pract Specialists/
•
AfDB
100000 inhab. 100000 100000 100000 inhab. 100000 inhab 100000 100000 100000 inhab. 100000
(public) inhab. inhab. (public (private) (private). inhab. inhab. (total) (total) inhab. (total).
(public sector) sector) (private)

BEN AROUS 25.8 9.5 35.3 38.3 30.0 68.2 103.5 64.1 39.5

BIZERTE 29.6 15.4 45.0 25.8 22.5 48.3 93.3 55.4 37.9
Economic Brief

GABES 29.0 11.9 40.9 16.6 20.2 36.8 77.7 45.6 32.1
w w w . a f d b . o r g

A
MAHDIA 36.1 15.6 51.7 23.2 11.4 34.6 86.3 59.3 27.0

f
r
MANOUBA 31.7 20.1 51.8 27.9 9.0 36.9 88.7 59.7 29.0

i
c
MEDENINE 21.7 8.3 30.1 26.1 24.6 50.7 80.7 47.8 32.9

a
n
NABEUL 22.6 11.6 34.1 27.9 27.1 55.0 89.1 50.5 38.7

45.2 17.6 62.8 18.8 7.0 25.8 88.6 63.9 24.6

D
ZAGHOUAN

e
Ranking 4 2 3 2 2 2 2 2 2

v
e
l
54
o
Governorate General Gyneco-obstetri- Podiatrists Ophthalmolo- Surgeons/ Cardiologists Anaesthetists/ Psychiatrists/

p
surgeons cians /100000 /10000 gists/ 100000 inhab. /100000 100000 inhab. 100000 inhab.

m
/100000 women of childbearing children 100000 inhab. inhab.

e
inhab. age (15-49 years)

n
t
BEN AROUS 1.6 2.36 5.7 4.2 2.6 1.6 0.7 0.17

B
BIZERTE 2 1.82 5.7 3.3 2 2.4 0.9 0.18

a
n
GABES 2.5 1.12 2.8 2.5 2.2 1.4 0.8 0.55
Table 22: Human resource indicators. Cluster 3.2

k
MAHDIA 1.8 1.5 3.3 2 1 0.5 1 1.21

MANOUBA 0 1.04 4.6 1.1 1.4 0.5 0.3 13.29

MEDENINE 3.5 1.55 3.1 3.1 2 2 0.7 0

NABEUL 2.7 2.17 4.4 3.7 1.9 2.1 1.2 0.53

ZAGHOUAN 2.3 1.25 2.9 2.3 1.8 1.2 0 1.17

Ranking 2 2 2 2 2 3 2 2
 Governorate Pharmacists / Pharmacists/ Pharmacists/ Dentists /100000 Dentists /100000 Dentists Paramedical Paramedical

A
100000 inhab. 100000 inhab. 100000 inhab. inhab. private inhab. public /100000 inhab. staff/100 000 staff/100 000

f
private public total total inhab. public inhab. private

r
i
c
a
BEN AROUS 24.8 1.4 26.1 21.1 2.8 23.9 175.2 13.5

n
BIZERTE 20.7 1.6 22.3 17.6 3.3 20.9 294.4 12.4

D
e
GABES 18.0 2.5 20.5 11.9 3.6 15.5 283.0 10.2

v
e
MAHDIA 12.6 3.3 15.9 11.9 3.3 15.1 302.0 11.1

l
55
o
MANOUBA 16.5 3.8 20.3 9.0 3.8 12.7 272.3 10.8

p
m
MEDENINE 21.5 2.4 23.9 12.7 2.9 15.6 266.1 5.7

e
n
NABEUL 20.5 2.5 23.0 14.9 4.5 19.4 221.7 14.2

t
ZAGHOUAN 15.8 1.8 17.6 8.2 5.3 13.5 261.6 1.2

B
a
BEN AROUS 18.8 2.4 21.2 13.4 3.7 17.1 259.5 9.9

n
Table 22: Human resource indicators. Cluster 3.2

k
Ranking 2 2 2 2 3 2 4 2
2 0 1 4
•
Economic Brief
AfDB
w w w . a f d b . o r g
 2 0 1 4
•
AfDB

Governorate General Specialists/ Physicians/ General pract. Specialists/ Physicians/ Physicians / General pract Specialists/
pract./ 100000 100000 100000 inhab. 100000 inhab. 100000 100000 inhab. 100000 inhab. 100000
100000 inhab. (pu- inhab. (public (private) (private sec- inhab. (total) (total) inhab. (total)
Economic Brief

w w w . a f d b . o r g

inhab. (public) blic sector). sector) tor). (private

sector)

A
f
r
BEJA 31.7 13.1 44.7 13.1 16.3 29.4 74.1 44.7 29.4

i
c
Ranking 3 3 2 3 3 3 3 3 3

a
n
Governorate General Gyneco-obstetricians Podiatrists Ophthalmolo- Surgeons/ Cardiologists/ Anaesthetists/ Psychiatrists/

D
surgeons /100000 women of /10000 gists/ 100000 inhab. 100000 100000 inhab. 100000 inhab.

e
/100000 childbearing age children 100000 inhab. inhab.

v
inhab (15-49 years)

e
l
56
o
BEJA 1.3 1.42 2.9 2.6 2 1.6 0 0.33

p
m
Ranking 4 3 3 3 3 2 4 4

e
n
t
Governorate Pharmacists / Pharmacists/ Pharmacists/ Dentists Dentists Dentists Paramedical Paramedical Paramédical

B
100000 inhab. 100000 inhab. 100000 inhab. /100000 inhab. /100000 /100000 staff/100 000 staff/100 000 /100 000

a
private public total private inhab. public inhab. total inhab. public inhab. private hab. total

n
Table 23: Human resource indicators. Cluster 3.3

k
BEJA 12.7 2.0 14.7 9.8 3.9 13.7 329.5 4.6 334.1

Ranking 3 3 3 4 3 2 3 2
 Gouvernorat General Specialists Physicians/ General Specialists/ Physicians/ General PR Specialists Physicians/
pract./ 100000 100000 100000 practitioners 100000 inhab. 100000 actioners/ /100000 100000
inhab. (public) inhab. (pu- inhab. (pu- /100000 inhab. (private) inhab. (pri- 100000 inhab. (total) inhab. (total)
blic) blic) (private) vate) inhab. (total)

GAFSA 35.5 8.6 44.1 15.1 11.2 26.3 50.6 19.8 70.4

JENDOUBA 23.9 8.3 32.1 12.1 7.3 19.4 35.9 15.6 51.5

KAIROUAN 24.3 8.9 33.2 14.7 9.3 23.9 38.9 18.2 57.2

KASSERINE 25.9 3.7 29.6 9.7 6.0 15.7 35.6 9.7 45.3

KEBILI 37.2 5.3 42.5 12.6 8.0 20.6 49.8 13.3 63.0

A
f
LE KEF 32.3 7.8 40.1 13.6 10.5 24.2 46.0 18.3 64.3

r
i
SIDI
24.7 5.6 30.3 11.9 4.1 16.0 36.6 9.7 46.3

c
BOUZID

a
SILIANA 37.2 8.5 45.7 9.8 1.7 11.5 47.0 10.3 57.3

n
TATAOUINE 45.8 2.1 47.9 10.3 6.2 16.4 56.1 8.2 64.3

D
TOZEUR 52.2 11.6 63.8 12.6 4.8 17.4 64.7 16.4 81.2

e
v
Ranking 2 4 4 4 4 4 4 4 4

e
l
57
o
Gouvernorat Chirurgiens Gynéco-obstétri- Pédiatres/ Ophtalm./ Chirurgiens/ Cardialogues/ Anesthésistes/ Psychiatre/

p
Généralistes ciens /100 000 10000 100000 hab. 100000 hab 100000 hab 100000 hab 100000 hab
/100000 hab femmes en âge de enfants

m
procréer

e
(15 – 49 ans)

n
t
GAFSA 1.8 1.09 1.5 1.8 0.9 1.2 0.3 0.3

JENDOUBA 1.7 0.91 2.1 0.9 0.9 0.9 0.2 0.71

B
a
KAIROUAN 1.8 0.82 2.1 1.4 0.7 1.1 0.9 0.82

n
Table 24: Human resource indicators. Cluster 3.4

k
KASSERINE 0.7 0.49 1.6 0.7 0.7 0.2 0.2 0.19

KEBILI 0.7 0.67 0.7 1.3 2 0.7 0.7 0

2 0 1 4

LE KEF 2.3 0.97 2.3 1.2 1.6 0.4 0 0.39

•

SIDI
0.7 0.5 1.7 1 0.2 0.5 0 0.5
BOUZID
SILIANA 1.3 0.3 1.7 1.3 0.9 0.9 0 0
Economic Brief

TATAOUINE 0.7 0.43 2.1 1.4 0.7 0.7 0 0

TOZEUR 1.9 0.67 3.9 1.9 1.9 1 0 0.97

Ranking 3 4 4 4 4 4 3 3
AfDB
w w w . a f d b . o r g
 2 0 1 4
•
AfDB
Economic Brief

Gouvernorat Pharmacists/ Pharmacists / Pharmacists/ Dentists/100000 Dentists/100000 Dentists/100000 Paramedical

w w w . a f d b . o r g

100000 inhab. 100000 inhab. 10 000 inhab. inhab. private inhab. public inhab. total staff/100 000

A
private public total inhab. public

f
r
i
GAFSA 15.1 7.1 3.8 10.9 397.5 5.9 403.4

c
a
JENDOUBA 11.3 8.0 2.6 10.6 273.6 1.7 275.3

n
KAIROUAN 12.3 9.5 2.9 12.3 270.3 2.0 272.3

D
e
KASSERINE 12.5 5.1 2.8 7.9 215.1 0.7 215.8

v
e
l
58
KEBILI 15.9 8.6 4.0 12.6 382.2 4.6 386.9

o
p
LE KEF 14.0 6.2 4.3 10.5 385.4 9.0 394.4

m
SIDI BOUZID 10.9 6.8 3.2 9.9 199.8 2.7 202.4

e
n
15.8 7.3 5.1 12.4 287.6 1.7 289.3

t
SILIANA

B
TATAOUINE 19.2 4.8 3.4 8.2 318.1 1.4 319.4

a
n
TOZEUR 17.4 7.7 5.8 13.5 492.8 4.8 497.6
Table 24: Human resource indicators. Cluster 3.4

k
Ranking 4 4 3 4 3 4 3
 Economic Brief
AfDB
2 0 1 4 • w w w . a f d b . o r g

Annex 2: Health Expenditure Nomenclature 2000 in 2005

(source : www.ins.nat.tn )

41 ROUTINE MEDICAL CARE 423 MRI SCAN

4231 Mri scan in a public institution
411 MEDICAL CONSULTATIONS 4232 Mri scan in a private institution
4111 Consultations by public institutions 4239 Mri scan in a with no indication
4112 Consultations by private institutions
424 CHILD DELIVERY
4119 Consultation with no indication
4241 Child delivery in a public institution
4242 Child delivery in a private institution
412 DENTAL CARE 4249 Child delivery with no indication
4121 Dental care in public institutions
4122 Dental care in private institutions 425 MEDICAL TREATMENT ABROAD
4129 Dental care with no indication
426 LONG-TERM CARE
413 X-RAY AND ANALYSES 4261 Consultations for long-term illnesses
4131 X-ray and medical analyses in public institutions 4262 Drugs for long-term illness
4263 Non-classified expenditure on long-term illnesses
4132 X-ray and medical analyses in private institutions
4139 X-ray and medical analyses with no indication
43 PHARMACEUTICALS
416 TRADITIONAL HEALER 431 DRUGS, NURSING
4161 Traditional healer 4321 Baby products
4322 Other pharmaceuticals
42 SPECIAL MEDICAL CARE
432 AUTRES PRODUITS PHARMACEUTIQUES
421 STAY AND SURGERY 4321 Produits pour bebe
4211 Stay and surgery in a public institution 4322 Autre produit pharmaceutique
4212 Stay and surgery in a private institution
4219 Stay and surgery with no indication 44 MEDICAL EQUIPMENT

441 MEDICAL EQUIPMENT

422 SPECIAL DENTAL SURGERY
4411 Medical eyeglasses
4221 Special dental care in a public institution
4222 Special dental care in a private institution 4412 Hearing aids
4229 Special dental care with no indications 4419 Other medical equipment

59
A f r i c a n D e v e l o p m e n t B a n k
 © 2010 - AfDB - Design, External Relations and Communication Unit/YAL

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