In recent years, Universal Health Coverage (UHC) has gained a global momentum. First, echoed in the World Health Report 2010 Health System Financing: the Path to Universal Coverage, UHC has been introduced as an integral part of the Sustainable Development Goals (SDGs) which, in September 2015, were adopted by more than 193 countries.
Tunisia, who signed in September 2018 the Universal Health Coverage agreement, is joining this global movement — another step which attests of the country's new constitution that stipulates in Article 38 that “Health is a right for every human being [and] the state shall guarantee preventative health care and treatment for every citizen and provide the means necessary to ensure the safety and quality of health services.”
However, the journey of Tunisia to abide by its constitution and achieve UHC goals is paved with several hurdles that are at the same time difficult to disambiguate and hard to solve. This article will try to shed light on certain aspects of the structural and contextual challenges for reaching UHC.
Contextual Challenges
The demography of Tunisia has undergone an unprecedented change over the past few years with the largest growth seen in the elderly population. In 2015, 11.7% (1.2 million) of the Tunisian population were 60 years of age and older and it is expected to represent more than the quarter of the population by 2050, e.g. 26.5%. This has led in addition to other social determinants of health to an epidemiological transition towards Non-Communicable Diseases. In the recent IHME Global Burden of Disease study in Tunisia, ischemic heart disease, stroke, and Alzheimer's disease are the three leading causes of death and represent more than half of the causes of mortality.
In addition, Tunisia is facing a sustained burden of communicable diseases, primarily tuberculosis and leishmaniasis. Although the incidence rates of these diseases have declined in the last decades, the trend is steadily reaching a plateau. This means that — unless reversed — Tunisia is unlikely to meet the sustainable development goals of eliminating Tuberculosis by 2030. Moreover, the burden associated with tuberculosis for people with HIV/AIDS, multidrug-resistant tuberculosis, and extensively drug-resistant tuberculosis will only become ever-more pressing.
Structural Challenges
The epidemiological transition and growing risk associated with the social determinants of health are putting an immense pressure on healthcare systems which must achieve better care at lower cost. This conundrum is at the heart of the Universal Health Coverage.
The goal of universal health coverage (UHC) is to ensure that every individual and community, irrespective of their gender, race, and socioeconomic status, should receive the health services they need without risking financial hardship. Hence, Universal Health Coverage is not a blueprint of a particular healthcare system but rather a set of characteristics that any healthcare system must attain.
Therefore, to evaluate and guide Tunisia progress towards achieving UHC, an intuitive method would be to analyze the current Tunisian healthcare system using UHC components, namely access, health services, quality, and financing.
First, UHC means “access”, both in terms of availability and proximity of services to all people regardless of gender, race, or socioeconomic status. In Tunisia, despite the progress that was made in terms of developing the healthcare sector since independence in 1956, significant disparities in access and availability of services remain considerably alarming between regions, and increasingly among rich and poor groups within the same region. Recent studies have pointed to the development of a two-tier system of healthcare: one for the rich, who can afford to pay for quality healthcare services from a growing private sector, and one for the poor, who are served by a failing public sector.
Second, UHC means delivering a panoply of “essential health services” ranging from curative, preventive, to palliative care. This would require a transformation of the whole healthcare apparatus to a model often referred to as Integrated Care. This latter pivots the care delivery from one that focuses on hospital-based treatment of distinct clinical episodes to one that prioritizes supporting people to stay healthy or to manage their chronic conditions such as diabetes and hypertension. An integrated care model summons a redistribution of the power-dynamic among healthcare professionals towards primary-care and community-based care. More importantly, it requires a change in the integration of the patient and the caregivers as active players. This structural transition is not fully achieved by the current tier-based structure of the healthcare sector in Tunisia and the changes have been limited to experiments in urban regions.
Third, UHC focuses on ensuring “quality”. Evidence suggests that strengthening healthcare quality shall not be considered an endpoint in and of itself but rather a continuous process for achieving efficiency, safety, and responsiveness of health services, as well as support achieving UHC. Quality can only be realized if quality-enhancing mechanisms are to be successfully implemented. In that regard, one of the promising mechanisms is to coordinate quality through accreditation bodies. In the current debate, accreditation is considered among the most important strategies for low and middle-income countries to improve quality of care. In Tunisia, the government established the National Health Accreditation Authority (Instance Nationale d'Accréditation en Santé, INASanté) in 2012. The INASanté is tasked with promoting the quality and safety of health care services. It is also given a wide set of tasks ranging from setting regulations and procedure for the practice of medicine and healthcare provision (guiding), to granting accreditation (regulation), to assessing the economic impacts of health care and diagnostic services (evaluation and monitoring). However, INASanté is one piece of the puzzle and it is not clear whether INASanté will be able to enforce its regulations and maintain its status as an independent body. Quality cannot be achieved unless careful considerations to organisational and cultural change to enable and empower those who work in the frontline to improve quality locally. A lack of a well-defined culture around quality and the ways of measuring and evaluating it will lead to confusion among healthcare players — e.g. hospitals, insurers, policymakers — about which standards and protocols to adopt, which measures or indicators to report, and which incentives to align with. It can lead to an inadequate strategy, a widening in health disparities and an overall catastrophic result on health delivery.
Lastly, UHC focuses on health financing and financial protection by lowering out of pocket spending and the risk of catastrophic health expenditure. Hitherto an important part in health strategy, health financing had been largely overlooked as a tool or an impediment to achieving healthcare goals. In the UHC era, health financing has risen to first-class citizen and an essential facet in achieving healthcare goals. Evidence suggests that health financing is not solely linked to the affordability of healthcare services but it has a causal and direct impact on the quality and accessibility. An adequate financing could encourage the efficient use of health services. On the other hand, if poorly designed, it could have a significant impact on healthcare by limiting access to the right care at the right time for the right citizen. This, in turn, could increase spending and utilization of high-cost services. From a design perspective, healthcare financing shall be considered in its broader sense as the orchestration of the three streams: (1) revenue stream through taxation, earmarked, or other mechanisms, (2) risk pooling stream for redistribution, and (3) service purchasing stream. These streams can be designed separately; however, it is their overall configuration that shall be the primary key to evaluate the success of any health financing model. More often, the key metric for success is access to healthcare without financial hardship. This is measured in the Sustainable Development Goals (SDG 3.8.2) as the proportion of the population with large household expenditure on health as a share — either 10% or 25% — of total household expenditure or income. Little evidence exists on whether Tunisia could match this target and inject the substantial investment in health required to achieve UHC. Any strategy should balance financial sustainability with a clear definition of health provision that must adhere to the principles of equity, access, and quality of healthcare services for all, including minorities and the most vulnerable populations. At the moment, Tunisia has an excessively high proportion of out-of-pocket spending (OOP) of over 40% of total healthcare expenditure which is a catastrophic and impoverishing level that makes unequal access to care even more acute. Each year, nearly 5 per cent of households faced catastrophic expenditure levels and 2 per cent were pushed every year into poverty due to healthcare spending.
Conclusion
Tunisia is facing multiple compounded health challenges which require a consolidated and sophisticated orchestration to achieve Universal Health Coverage. Achieving UHC for all is distinctly far more complex and, without a concerted effort of all players in the country and in collaboration with global actors, elusive. There is no single UHC recipe and any potential solution must take into account the context of the healthcare environment in the country and the economic turbulence following the 2011 uprising. Also, UHC cannot be attained unless the country invests in research, information systems, transparency and continuous improvement of health services. Otherwise, investment will be poised to be reactive, inadequate and inefficient.
Needless to say, UHC is the most prominent item on the global health agenda. It is the main -if not the sole- contender. Tunisia must seize the opportunity to propel itself and join other countries in successfully transitioning its healthcare system to adhere to the international standards and quality in compliance with the inspiration of its citizens and its constitution.
