From a budgetary perspective, public health institutions operate under a hybrid financial model. Their resources combine internally generated revenues, estimated at 925 million CFA francs (MDT), derived from their operational activity, with operating subsidies amounting to 587 MDT. These subsidies are frequently allocated to cover a portion of operational costs or specific investment projects. The state remains an indispensable guarantor of the financial survival of public hospitals.
Simultaneously, this heavy reliance on public finances exposes healthcare facilities to budgetary trade-offs and payment delays, which significantly strain their cash flow and their ability to meet obligations to suppliers of medicines, equipment, and services.
The share of autonomous revenues—stemming from billing for medical procedures, agreements with the National Health Insurance Fund (CNAM), and paid services—demonstrates that hospitals generate substantial economic activity. In reality, however, the system frequently faces chronic difficulties in collecting receivables, particularly from the CNAM or from patients with unpaid bills. This gap between "accounting revenue" and "actual cash flow" fuels the vicious cycle of hospital debt.
The tariff grids applied in the public sector, particularly for social security beneficiaries and basic care, have not evolved at the same pace as the rising costs of technologies, imported consumables, and hospital pharmacy supplies. This creates a structural mismatch between the actual costs of delivering care and the revenues generated.
The budgetary cost of public healthcare raises the question of the long-term sustainability of free or near-free care for vulnerable populations without a fair and fluid compensation mechanism. It is likely time to revise these tariffs upward. Such an adjustment is essential for the financial sustainability of these institutions.
