1991: Implementation of the Free Healthcare Assistance programme (Assistance Médicale Gratuite – AMG) [Law No. 1-63 of 29 July 1991]

The Free Healthcare Assistance programme (AMG) was first established by Law No. 1-63 of 29 July 1991. Its funding is ensured by central government transfers to the Ministry of Health to cover the cost of granted health care. The AMG has two components: AMG 1 and AMG 2. Under the AMG 1 programme, free healthcare is provided in public health structures for poor households who are already enrolled in the PNAFN. Free healthcare is granted for five years to a limited number of households, and eligibility is based on regional quotas. The AMG 2 programme targets households who are deemed vulnerable but not considered poor enough to be provided with free healthcare services. AMG 2 provides subsidies for healthcare services to eligible households, including co-payments for hospital visits. The total number of recipients of free or subsidised healthcare services is limited to a national quota set up by the central government. The quota is indexed on out to date data and econometric projections the accuracy of which is debatable. The impact of the PNAFN (including the AMG 1) and AMG 2 programmes is estimated at 267,000 beneficiaries of PNAFN in 2020 (or 7.8% of the Tunisian population), and 607,697 beneficiaries of the reduced rate medical assistance programme (AMG 2) in 2017 [ERF 2022b]).

Nevertheless, access to healthcare remains uneven between beneficiaries because of geographical disparities, whereby urban centres not only have a higher number of health practitioners, but also enjoy a higher quality of care. Moreover, since healthcare services in rural areas are absent or insufficient, eligible households to the AMG programme often have to travel to urban areas to access proper healthcare services, resulting in additional costs. As highlighted by an ESCWA study, it is likely that beneficiaries of AMG would still make out-of-pocket payments for primary care and medicines to compensate for long queues, inadequate quality, or a lack of medications, particularly outside of the capital and the main cities (ESCWA 2016, 24).