Out-of-pocket health spending and equity implications in Tunisia

Using data from 2000, 2005 and 2010 national household budget and consumption surveys, this paper examines the scope of catastrophic out-of-pocket (OOP) health expenditures in Tunisia and their distribution. It analyses their evolution since 2000 in relation to policy reforms in Tunisia especially since a new national health insurance fund (Caisse Nationale d’Assurance Maladie (CNAM)) became effective in 2007. The paper assesses the catastrophic dimension of OOP payments by calculating their incidence and their intensity at several thresholds and by analyzing their distribution throughout concentration indices. Estimating a probit model, the paper explores the determinants of catastrophic payments and identifies the characteristics of households coping with higher risk of catastrophic health expenditures. Finally, questioning whether the catastrophic payments have impoverishing effects on households, the paper estimates the percentage of households who move below the poverty line when accounting for OOP health payments. The paper concludes that the lasting importance of health OOP expenditures in Tunisia, their catastrophic dimension and their impoverishing effect make it necessary to look for a better allocation of the existing resources through more efficient financing mechanisms and better institutional arrangements.