[ TUNISIA Health Information System characteristics Paris, 1-5 October 2012

1. [TUNISIAHealth Information System characteristicsParis, 1-5 October 2012 Moncef Bouslama (MS) Souad Benneji (INS)

2. Plan of the presentation • The National Statistics Council • The Health system • The Health Information system characteristics • Conclusions &perspectives

3. National Statistics System The NSS comprises: • The statistics system in Tunisia • The National Statistics Institute • Other specialized public statistics structures • Statistics training institutions.

4. Legal texts related to the statistical activity in Tunisia (1) • Law no. 99-32 of 13 April 1999 relating to the national statistics system. • Decree no. 99-2797 of 13 December 1999 setting out the composition, organization and working methods of the National Statistics Council. • Decree no. 99-2798 of 13 December 1999 setting out the methods and conditions of payment of the contribution made by the users of statistical information.

5. Legal texts related to the statistical activity in Tunisia (2) Decree no. 99-2799 of 13 December 1999 setting out the conditions and procedures whereby the public statistics structures conduct censuses and statistical surveys concerning  people not belonging to these structures.

6. Legal texts related to the statistical activity in Tunisia (3) The legislation has been reinforced and the law of Statistics initiated at 1999 outline scientific independency to statistics board, impartiality and transparency and the right to information access But these legislation is limited by an other text of law as the role of the National Statistic Institute which must submit results of statistics operation (surveys, census, ) to the tutelary ministry Thus some figures are censored and not published or published with big delays.

7. The Health System characteristics

8. TUNISIA HEALTH SYSTEM • The health care system in Tunisia is made of three subsectors :Public, Semi-public and Private. • The Ministry of Health (MH) is responsible for formulating policies, strategies, plans, programs and technical and administrative standards on health matters in order to guarantee the people's constitutional right to health.

9. TUNISIA HEALTH SYSTEM • Health policy is based on primary health careand has been endorsed at the highest official level. The Constitution strengthens the fact that the prosperity of the nation is based on the welfare of the family and on the right of each citizen for work, for health protection and for education.   • In order to reach the entire population, the services of the MH are decentralized and located in the 24 regions into which the country is divided for administrative and political purposes.

10. Each governorate is also divided in health district covering one ore two delegations (territorial entity). 24 GOVERNORATES

11. HEALTH ORGANISATION • The Health care system is organized according to pyramid structure : • ·At the first base level, • more than 2090 Primary Health Care Centres are equally spread throughout the whole territory, even in the poorest areas, " • About 109 district hospitals based in the main chef-lieu of commune : services provided by these hospitals comprise general medical and maternal care in addition to diagnostic investigations. These two levels should cover most of the needs of the local communities  

12. HEALTH ORGANISATION • The second level ( second referral level ) comprise 33 regional hospitals located in the main city of each governorate. Their activity comprise the above specialities with pediatrics and surgery and they are in process of progressively developing most other specialities. • 22 teaching hospitals or specialized institutes divided in four geographic poles :Tunis, Sousse, Sfax and Monastir. These structures host very performing technical platforms and specialized services covering all the specialities and giving space to most avant-guard medicine. They constitute the head of the pyramid and the third level.

13. PRIVATE SECTOR • Clinics : 116 ( 2737 beds = 13 % of total), • DialysisCenters : 99 (986 machines) • Physicians: 6 300 • Pharmacists: 1 900 • Dentists: 1 800 • Nurses: 1 262 • Thalasso centers :33

14. health sector Challenges

15. health sector Challenges • Urbanization and pressure on social services • Ageing of the population • health personnel Employment • Increasing medical demography and problems of insertion of new graduates • Maintenance of the sanitary infrastructure • To be with the tuning fork of technical progress and innovations • Private sector and public sector Complementarities • Financinggrowinghealthexpenditure • Healthinsurancereform • WeakHealth information system

16. Training Weaknesses • Severalstudiesunderlined the need of establishing a National School of Health whichaims to train healthprofessional in the areas of Health Economics, Health statistics, epidemiology, best practices in research and use of basedevidence practice in medicine and Health • A training on leadership and management in Health canimproveskill of the health managers and willbe have a beneficial impact on healthoutcomes •  The training of trainerscanbe a solution to create a core of professionals and teachers.

17. HEALTH INFORMATION SYSTEM Population data Census civil registration – Demographic surveillance Houshold survey Health statistics Registers Data on activities/ Survey within the hospitals Information on the Health system (infrastructures, Equiupmentss, Human and financial ressources) HIS HMN Ministry of health National Statistic Institute

18. The Health Information System characteristics

19. Health Information System Weakness • Weakness of HIS which suffer from desintegration and lack of leadership . • Too many evaluations has been done, the last one based on Health Metrics approach, but for several reason the step of establishing a strategic plan for improving the HIS has not been achieved • The system is heavy centralised and we notice lack of trained personnl at regional, local levels bouslama moncef

20. Health Information System • The data still be mostly gathered manually at local and district levels. The regional level has been endowed by computer but still continue to suffer from undertrained personnel in health statistics, collection of data, verification, analysis, interpretation, use and dissimenation of results • Cause of morbidity is not systematically gathered until we sensitize physican at the regional and universitary hospitals • It has a negative impact on data availability, accuracy

21. Health Information System • Cause of death certificate established in 1999 continue to suffer of non exhaustivity . The centralisation of the data collection has inhibite the regional level to improve the quality of the data collected . • Physician continue to consider this task as an addin to their work and must be delegated for other personnel to be recruited • The differents report on Cause of death are mostly based on proportional mortality • It has a negative impact on data availability, accuracy

22. Conducting surveys • A maternalmortalitysurvey has been conducted in 2009 based on death of year 2008. • The results has been published and a strategy has been done to struggle maternalmortality • The last years (2) severalmunicipalitiesdismissed of their crucial role in allowingbetterdeclaration of cause of deathunder the pression of colateraleffects of the revolution

23. Conducting surveys • MICS 4 has been conducted in 2011 and the data are in the phase of analysis • Poverty estimation done by the NIS has encountred a lot of critics and nowthereis a team workincluding World bank, AfricanDevelopment Bank and Reshearcher to consider the methodologies in determiningpoverty • Ministry of Social Affairsisalsoverifing the eligibility of families to assistance and to health free insurancecoverage

24. Conducting surveys • The householdconsumptionsurveyconductedeach five years have a module on health not yetfullyexploited and weexpectbetter analyse of the information on : • Social coverage • Medical care • Chronicaldisease • Pregnancy & maternity • Healthexpenditure

25. CONCLUSIONS AND PERSPECTIVES

26. HIS strategic focus for the next years • Which HIS areas will be the focus of the country strategic plan for the next years? • Clarify information gaps and reorganize data collection • Publishing and dissemination of health information • Following up of the implementation of Statistics plan in the country • Improvement local and regional capacities in health information system • Promotion of routine statistics based on administrative source

27. The Tunisian revolution show the gap between the promises and the reality, between official statistics and reality In the past years Statistics were orchestrated by the Government to answer mainly to government agenda and to demonstrate the success of its policy and its development model. Statistics are used to meet mostly to state needs

28. Statistics use New orientations for statistics are to meet the needs of society. The provisional Government had enact, in May 26, 2011, a decree law guaranteeing the right of access to administrative documentsother than those of some institutions (army, police, justice…). This legislation, developed according to international standards, was not sufficiently publicized and explained to the public. We must also follow the application of the law in the field

29. New role of the NIS We notice also a new role of the NIS which conduct monthly media conferences to present survey result on statistics figures : Unemployment, poverty, inflation, etc… Raw data of main survey are published on the Web site of the NIS www.ins.nat.tn

30. About health in Tunisia • http://www.santetunisie.rns.tn/msp/msp.htm • http://www.santetunisie.rns.tn/msp/images/CSfinale2010.pdf • Last informations published

31. TOUT LE MONDE COMPTEBetter information. BetterdecisionBetterHealth. EVERY ONE COUNT

32. THANK YOU FOR YOUR ATTENTION • Merci pour votre attention