Healthcare System Reform: A Balanced Approach Between Public and Private Sectors
In the face of 40% of healthcare expenses being paid directly by patients and chronic delays by the National Health Insurance Fund (CNAM), there is a need to create a balanced system between public and private sectors to ensure equitable access to care. To discuss this, the Tunisian-French Chamber of Commerce and Industry brought together healthcare professionals on February 5, 2026, at the Berges du Lac.
Challenges in the Current System
According to Molka El Moudir, Vice-President of the SPOT, Tunisian families spend almost 60% of their healthcare budget on medications. Pharmacies face significant difficulties due to delayed payments from the CNAM, sometimes up to 180 days in 2025, and are forced to borrow from banks, threatening the availability of care. To address this, she proposes a hybrid model to complement the public system, with clear rules on responsibilities and payment deadlines. A pilot phase would reduce patients' out-of-pocket expenses and reposition pharmacists as advisors rather than lenders.
Solutions and Recommendations
Dr. Samir Cherourou, spokesperson for the National Order of Physicians, highlighted several challenges, including the migration of young doctors, demographic aging, and 40% of out-of-pocket expenses. He also pointed out the weaknesses of the CNAM, which receives 6.75% of revenues and 5.5% of the state budget but does not benefit from funds transferred by other funds, leaving a third of the population without coverage. His solutions include:
- Universal solidarity insurance
- Health complements
- Public-Private Partnerships (PPPs) to combat medical deserts
- Good governance and social dialogue to better manage existing funds
Hafedh Lamouri, an expert in labor and social security law, noted that the CNAM appears to have a budget surplus of 900 million dinars, but is actually deficitary. Untransferred contributions from the CNSS and CNRPS are blocking the system, leaving 2 million people without coverage, including 650,000 unemployed individuals, and 75% of beneficiaries with very low pensions (less than 5,000 dinars per year). To address this, he proposes:
- Unifying retirement funds through direct collection
- Channeling parafiscal taxes to the CNAM
- Strengthening prevention and increasing ceilings for 24 long-term conditions to ensure actuarial balance over 30 years
Mondher Khabcheche, President of the Ftusa, noted that the sector has 24 companies, including 15 in healthcare, with a turnover of 8,800 million dinars. However, the healthcare branch is deficitary, coverage is low (group/individual), doctors are leaving the country, and the age pyramid is inverted (2.3 active individuals per retiree). He suggests:
- Tax niches (deductions like life insurance)
- Interconnecting retirement and health
- Developing PPPs and prevention, aiming for private coverage like in Chile (20%) or France (13%)
Conclusion
The panelists agree on the importance of prioritizing the public sector for chronic diseases and vulnerable populations, while developing a hybrid model with a pilot phase and clear rules. They also emphasize the need for reforms to ensure universal coverage, improve governance, strengthen prevention, and always place the patient at the center of the system.
