Habib Toumi, CEO of the Tunisian National Social Security Fund (CNSS), discusses implementing universal healthcare coverage, restoring the financial equilibrium of the fund, and managing the continuous improvement of services provided in the CNSS policlinics.
Can you describe the operational characteristics of the Tunisian National Social Security Fund (CNSS)?
“Concerning the sanitary aspect, the CNSS manages six policlinics in the country as well as an orthopedic equipment center.”
The CNSS manages the private sector’s social security regimes. The public sector’s social security regime is under the responsibility of another body: The National Pension and Social Welfare Fund (CNRPS). The government appoints its chief executive officer who also manages the administrative board. Twelve members sit at this board which equally represents the stakeholders of the social security regime in Tunisia. There are four representatives of the workforce’s union (UGTT), four members of the administration, including the chief executive officer and four members of the employers’ union (UTICA). This composition ensures the impartiality of decisions made by the CNSS’ board. The decisions can be taken unanimously or by majority.
Tunisia’s social security regime in the private sector is a contributive model with 9 affiliation models.
– The non-agricultural employees, which accounts for 70 percent of members
– Agricultural employees’ regime
– Improved agricultural employee improve regime
– Self-employed regime
– Fishermen’s regime,
– International workers’ regime
– Student regime.
– Regime for artists, creators and intellectuals
– Domestic workers’ regime
What services do you offer to your affiliates and how do you finance them?
The CNSS ensures the collection of employer and employee contributions. The majority of these contributions are spent on pension funding. That said, we also fund a portion of health-related spending.
In this regard, part of the recovered contributions is transferred to the national health insurance fund (CNAM created in 2007) to finance the care benefits to the insured persons.
CNAM manages the health insurance branch for the benefit of public and private sector workers under Law 71-2004 of 2 August 2004 through:
– A compulsory basic health insurance scheme: granting of cash benefits (sickness and nursing allowances) and taking charge of various medical procedures and medicines.
– A system for compensation for injuries resulting from industrial accidents and occupational diseases, temporary allowance and annuity, according to the disability rate.
To benefit from the care, the insured persons have the choice between 3 paths namely: the public sector (care in public hospitals only), reimbursement system or private sector-family doctor.
The social mission of the CNSS extends to the social and health aspects. Indeed, the CNSS offers loans to its affiliates for the purchase of a housing or a vehicle on advantageous terms. This action improves the quality of life of Tunisians. The fund provides temporary assistance to employees in the event of loss of employment for economic reasons. Grants are made to associations for the rehabilitation of the handicapped.
Concerning the sanitary aspect, the CNSS manages six policlinics in the country as well as an orthopedic equipment center. Polyclinics are multidisciplinary and cover ambulatory care, day hospitals, medical analyzes and the provision of medicines to patients, among others. Access to health care in these policlinics is possible through a co-payment that comes close to free admission and we have recorded no fewer than 1.2 million consultations last year in these six policlinics.
The orthopedic fitting center makes it possible to provide prostheses to the Tunisians who need it at an affordable price. It must be highlighted all devices produced for the orthopedic fitting center are produced in Tunisia.
In August 2017 you were appointed CEO of the CNSS. What objectives were set to you at the beginning of your mandate?
The government has set a number of areas of focus. Firstly, I must manage the CNSS and ensure that it operates within the framework of the recommendations on good governance prescribed by the OECD. In this context, I ensure that computer systems and new technologies are put in place for social security, as well as the decentralization of decision-making systems that will make the system faster in the provision of services to all insured persons.
Secondly, I am responsible for restoring the financial equilibrium of the CNSS, in particular by implementing effective contribution recollection procedures. My action is played out in a difficult context for social security since the regime in place is chronically in deficit. The deficit remains manageable on the condition that it quickly finds the means to recover the contributions due and to face a decrease in the ratio contributor-beneficiary that results from a reversal of the age pyramid. Despite a deduction at the source of employer and employee contributions, we face a problem of tax evasion. The means to be put in place are still under discussion, and the services provided might be reformed according to the contribution.
Only seven percent of our expenses are administrative. The remaining 93 percent relate directly to social benefits, but in the interests of transparency, and because we are a public institution, we have a duty to conduct an internal investigation and find a way to make savings ourselves. A thorough and rigorous analysis of our cost centers should allow for structural reforms to prevent the CNSS debt from widening. That’s why I set up a commission to investigate our items of expenditure.
Third, I must achieve universal coverage. Unfortunately, the informal sector in Tunisia is a real scourge that escapes any form of control or service. We are doing our utmost to extend the services of CNSS to all Tunisians. We have regional and local branches that provide a local service to the greatest number.
Finally, I am responsible for the upgrade in services provided by the policlinics of the CNSS across Tunisia to ensure the care offered to patients is of the up-most quality.
When will you attain financial equilibrium?
At the time of CNSS’ creation, expenses of one beneficiary were covered with the contributions of ten affiliates. Nowadays, we cover the expenses of one beneficiary with the contributions of less than three contributors. On top of this, the CNSS also covers for the pension’s inflation adjustment. In the wake of this situation, reforming the system appears mandatory. Nonetheless I would like to assure Tunisians the CNSS will continue to cater to the needs of its affiliates. The government takes responsibility for its citizens and therefore the Tunisian Social Security Fund will continue to provide services to its affiliates.