A growing number of developing countries are currently promoting health system reforms with the aim of attaining ‘ universal health coverage’ (UHC). In Tunisia, several reforms have been undertaken over the last two decades to attain UHC with the goals of ensuring financial protection in health and enhancing access to healthcare. The first of these goals has recently been addressed in a companion paper by Abu-Zaineh et al. (Int J Health Care Financ Econ 13(1):73–93, 2013). The present paper seeks to assess whether these reforms have in fact enhanced access to healthcare. The average treatment effects of two insurance schemes, formal-mandatory (MHI) and state-subsidized (MAS) insurance, on the utilization of outpatient and inpatient healthcare are estimated using propensity score matching. Results support the hypothesis that both schemes (MHI and MAS) increase the utilization of healthcare. However, significant variations in the average effect of these schemes are observed across services and areas. For all the matching methods used and compared with those the excluded from cover, the increase in outpatient and inpatient services for the MHI enrollees was at least 19 and 26 %, respectively, in urban areas, while for MAS beneficiaries this increase was even more pronounced (28 and 75 % in the urban areas compared with 27 and 46 % in the rural areas for outpatient and inpatient services, respectively). One important conclusion that emerges is that the current health insurance schemes, despite improving accessibility to healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for all services. Attaining the latter goal requires a strategy that targets the “trees” not the “forest”.
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Abu-Zaineh, M., Arfa, C., Ventelou, B., Romdhane, H. B., & Moatti, J.-P. (2014). Fairness in healthcare finance and delivery: What about Tunisia? Health Policy and Planning, 29(4), 433–442.
Abu-Zaineh, M., Romdhane, H. B., Ventelou, B., Moatti, J.-P., & Chokri, A. (2013). Appraising financial protection in health: The case of Tunisia. International Journal of Health Care Finance and Economics, 13(1), 73–93.
Abu-Zaineh, M., Mataria, A., Moatti, J.-P., & Ventelou, B. (2011). Measuring and decomposing socioeconomic inequality in health care delivery: A micro-simulation approach with application to the Palestinian conflict-affected fragile setting. Social Science and Medicine, 72(2), 133–141.
Abu-Zaineh, M., Mataria, A., Luchini, S., & Moatti, J.-P. (2009). Equity in health care finance in Palestine: The triple effects revealed. Journal of Health Economics, 28(6), 1071–1080.
Acharya, A., Vellakkal, S., Taylor, F., Masset, E., Satija, A., Burke, M., et al. (2012). Impact of national health insurance for the poor and the informal sector in low-and middle-income countries: a systematic review. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.
Achour, N. (2011). Tunisian health system: Current situation and challenges. United Nations Fund for Population (UNFPA), Tunis.
Arfa, C., & Achouri, H. (2008). Tunisia: Good Practise in expanding health coverage: Lessons reforms in a country in transition. In P. Gottret, G. J. Schieber, & H. R. Waters (Eds.), Good practice in health financing: Lessons from reforms in low and middle-income countries. Washington DC: The World Bank.
Arfa, C., & Elgazzar, H. (2013). UNICO studies series 4 Consolidation and transparency: Transforming Tunisia’s health care for the poor. Washington DC: The World Bank.
Arfa, C., Souidene, A., & Achour, N. (2008). National Health Accounts Report for the years 2004 and 2005. Tunis: National Institute of Public Health, Ministry of Public Health.
Becker, S. O., & Ichino, A. (2002). Estimation of average treatment effects based on propensity scores. The Stata Journal, 2(4), 358–377.
Benyamini, Y. (2008). Self-ratings of health and longevity: A health psychologist’s viewpoint on epidemiological findings. The European Health Psychologist, 10(1), 10–12.
Bonjour, D., Knight, G., & Lissenburgh, S. (2002). Evaluation of New Deal for Young People in Scotland Phase 2. Scottish Executive Central Research Unit. Retrieved May 30, 2012 from http://scotland.gov.uk/Resource/Doc/156692/0042112.pdf.
Bryson, A., Dorsett, R., & Purdon, S. (2002). The Use of Propensity Score Matching in the Evaluation of Active Labour Market Policies. Department for Work and Pensions, Working Paper No. 4.
Burtless, G. (1995). The case for randomized field trials in economic and policy research. Journal of Economic Perspectives, 9(2), 63–84.
Caliendo, M., & Kopeinig, S. (2008). Some practical guidance for the implementation of propensity score matching. Journal of Economic Surveys, 22(1), 31–72.
De Allegri, M., Sanon, M., & Sauerborn, R. (2006). To enrol or not to enrol? A qualitative investigation of demand for health insurance in rural West Africa. Social Science & Medicine, 62(6), 1520–1527.
Dorsett, R. (2004). The new deal for young people: Effect of the options on the labour market status of young men. London: Policy Studies Institute.
Ensor, T. (2008). Universal Coverage in Developing Countries. In H. Kris (Ed.), International Encyclopedia of Public Health (pp. 441–452). Oxford: Oxford Academic Press.
Giedion, U., Alfonso, E. A., & Díaz, Y. (2013). UNICO studies series 25 the impact of universal coverage schemes in the developing world: A review of the existing evidence. Washington DC: The World Bank.
Gnawali, D. P., Pokhrel, S., Sié, A., Sanon, M., De Allegri, M., Souares, A., et al. (2009). The effect of community-based health insurance on the utilization of modern health care services: Evidence from Burkina Faso. Health Policy, 90(2–3), 214–222.
Galárraga, O., Sosa-Rubí, S. G., Salinas-Rodríguez, A., & Sesma-Vázquez, S. (2010). Health insurance for the poor: Impact on catastrophic and out-of-pocket health expenditures in Mexico. The European Journal of Health Economics, 11(5), 437–447.
Gregg, P., & Wadsworth, J. (1996). How effective are state employment agencies? jobcentre use and job matching in Britain. Oxford Bulletin of Economics and Statistics, 58(3), 443–467.
Hadley, J. (2003). Sicker and poorer-the consequences of being uninsured: A Review of the research on the relationship between health insurance, medical care use, health, work, and income. Medical Care Research and Review, 60(2), 3S–75S.
Hartley, D., Quam, L., & Lurie, N. (1994). Urban and rural differences in health insurance and access to care. The Journal of Rural Health, 10(2), 98–108.
Heckman, J., LaLonde, R., & Smith, J. (1999). The economics and econometrics of active labor market programs. In Ashenfelter, O. and Card, D. (Eds): The Handbook of Labor Economics, Vol III, pp. 1865–2097.
Jütting, J. (2005). Health insurance for the poor in developing countries. New York: Ashgate Publisher.
Koch, S., & Alaba, O. (2010). On health insurance and household decisions: A treatment effect analysis. Social Science & Medicine, 70(2), 175–182.
Leuven, E., Sianesi, B. (2003). PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing and covariate imbalance testing. Retrieved May 30, 2012 from http://ideas.repec.org/c/boc/bocode/s432001.html.
Mensah, J., Oppong, J. R., & Schmidt, C. M. (2010). Ghana’s National Health Insurance Scheme in the context of the health MDGs: An empirical evaluation using propensity score matching. Health Economics, 19(S1), 95–106.
Ministry of Public Health. (2009). Health insurance statistics. Tunis: Tunisia.
Ministry of Social Affairs. (2012). Main social Development Indicators in Tunisia 2012. Tunis: Tunisia.
Ministry of Public Health. (2008). National survey on morbidity and health care utilization: Epidemiological transition and health impact in North Africa (TAHINA). Ministry of Public Health. Tunisia: Tunis.
National Institute of Statistics Tunisia (NIS). (2011). First Results of Employment - National Survey second quarter 2011. Tunis: Tunisia.
National Health Insurance Fund (NHIF). (2012). Statistics of National Health Insurance Fund - January 2012. Tunis: Tunisia.
Nishtar, S. (2010). The mixed health systems syndrome. Bulletin of the World Health Organization, 88(1), 74–75.
Nyman, J. A. (2003). The Theory of Demand for Health Insurance. Stanford: Stanford University Press.
Nyman, J. A. (2004). Is ’Moral Hazard’ inefficient? The policy implications of a new theory. Health Affairs, 23(5), 194–199.
O’Connell, T., Rasanathan, K., & Chopra, M. (2014). What does universal health coverage mean? The Lancet, 383(9913), 277–279.
O’Donnell, O., van Doorslaer, E., Wagstaff, A., & Lindelow, M. (2007). Analyzing health equity using household survey data: A guide to techniques and their implementation. Washington DC: The World Bank.
Pauly, M. V., Zweifel, P., Scheffler, R. M., Preker, A. S., & Bassett, M. M. (2006). Private health insurance in developing countries. Health Affairs, 25(2), 369–379.
Robyn, P. J., Hill, A., Liu, Y., Souares, A., Savadogo, G., Sié, A., et al. (2012). Econometric analysis to evaluate the effect of community-based health insurance on reducing informal self-care in Burkina Faso. Health Policy and Planning, 27(2), 156–165.
Rosenbaum, P. R., & Rubin, D. B. (1983). The central role of the propensity score in observational studies for causal effects. Biometrika, 70(1), 41–50.
Rosenbaum, P. R., & Rubin, D. B. (1985). The bias due to incomplete matching. Biometrics, 41(1), 103–116.
Rubin, D. B. (1974). Estimating causal effects of treatments in randomised and non-randomised studies. Journal of Educational Psychology, 66(5), 688–701.
Sen, A. (2002). Health: Perception versus observation. British Medical Journal, 324(7342), 860–861.
Sianesi, B. (2004). An evaluation of Swedish system of active labor market programs in the 1990s. The Review of Economics and Statistics, 86(1), 133–155.
Sinha, T., Ranson, M., Chatterjee, M., Acharya, A., & Mills, A. (2006). Barriers faced by the poor in benefiting from community-based insurance services: lessons learnt from SEWA Insurance, Gujarat. Health Policy and Planning, 21(2), 132–142.
Smolderen, K. G., Spertus, J. A., Tang, F., Oetgen, W., Borden, W. B., Ting, H. H., et al. (2013). Treatment differences by health insurance among outpatients with coronary artery disease insights from the national cardiovascular data registry. Journal of the American College of Cardiology, 61(10), 1069–1075.
Subramanian, S. V., Subramanyam, M. A., Selvaraj, S., & Kawachi, I. (2009). Are self-reports of health and morbidities in developing countries misleading? Evidence from India. Social Science & Medicine, 68(2), 260–265.
Thanh, N. X., Lofgren, C., Phuc, H. D., Chuc, N. T., & Lindholm, L. (2010). An assessment of the implementation of the health care funds for the poor policy in rural Vietnam. Health Policy, 98(1), 58–64.
Trujillo, A. J., Portillo, J. E., & Vernon, J. A. (2005). The impact of subsidized health insurance for the poor: Evaluating the Colombian experience using propensity score matching. International Journal of Health Care Finance and Economics, 5(3), 211–239.
Van Doorslaer, E., & Jones, A. M. (2003). Inequalities in self-reported health: Validation of a new approach to measurement. Journal of Health Economics, 22(1), 61–87.
White, M., Lissenburgh, S., & Bryson, A. (1997). The Impact of Public Job Placing Programmes. Policy Studies Institute Report No. 846, London.
Wagstaff, A., & Yu, S. (2007). Do health sector reforms have their intended impacts?: The World Bank’s Health VIII project in Gansu province, China. Journal of Health Economics, 26(3), 505–535.
Wagstaff, A. (2010). Social health insurance reexamined. Health Economics, 19(5), 503–517.
(2006). Republic of Tunisia Health sector Study. Human Development Group Middle East and North Africa Region. Washington DC: World Bank.
World Bank. (2011). Striving for better jobs: The challenge of informality in the middle east and north africa region : Overview. Washington DC: World Bank.
World Health Organization (WHO). (2013). The World Health Report 2013, Research for Universal Health Coverage.
World Health Organization (WHO). (2010). The World Health Report: Health Systems Financing: the path to universal coverage. Geneva: World Health Organization.
We would like to thank The French National Research Agency (ANR) for its financial support to the research project (INEGSANTE-Les Suds-Aujourd’hui II-2010). This work has been completed thanks to the support of the A*MIDEX project (no. ANR-11-IDEX-0001-02) funded by the “Investissements d’Avenir” French Government program, managed by the French National Research Agency (ANR). Thanks are also due to Professor Jean-Paul Moatti, Professor Pedro P. Barros and two anonymous reviewers for helpful comments and suggestions.
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Makhloufi, K., Ventelou, B. & Abu-Zaineh, M. Have health insurance reforms in Tunisia attained their intended objectives?. Int J Health Econ Manag. 15, 29–51 (2015). https://doi.org/10.1007/s10754-014-9157-6
- Universal health coverage
- State-subsidized insurance
- Healthcare utilization
- Propensity score matching
- Developing countries
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- I 13
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