How to make sure your healthcare is covered as an expatriate in Tunisia
The Tunisian healthcare system has been modernized over the past 20 years. High-end clinics offer high-quality care and medical equipment for prices equivalent to those in France. However, certain specialties (orthopedics, heart surgery, neurology, oncology) must still be performed abroad. Expatriate health insurance will help you get access to all these healthcare services more easily.
|Healthcare expenditure per capita and per year||€664|
|Annual indexation of health expenses||9%|
|Hospitalization reimbursement rate with the Fund for French Abroad (CFE)||67%|
|Number of insurance companies available||15|
|Annual cost of hospitalization coverage for a 30-year-old||€600|
|Annual cost of hospitalization coverage for a 50-year-old||€1068|
Over the past 20 years, Tunisia has made healthcare one of its priorities, working to ensure free coverage for the most disadvantaged and to become a medical model for Africa. This has been largely successful, with the country now considered a reliable medical destination and even a destination for medical tourism. In 2019, nearly 500,000 foreign patients were hospitalized in Tunisia, and more than two million received outpatient care.
The majority of foreign patients come from neighboring countries, just across the border or in Europe, as healthcare costs are particularly attractive and the types of care available are very diverse. With growing demand from both residents and foreigners, private healthcare has become one of the pillars of the local economy. This is not without its challenges for Tunisia, especially concerning local healthcare coverage and its financing.
Healthcare coverage has been made mandatory since 2004. In 2019, the free medical insurance scheme covered 7.3% of the population, while 17.5% was covered by the low-cost medical assistance, and 58% by the National Social Security Fund.
Recently, Tunisia has focused on improving the quality and delivery of primary care throughout the country, with the development of better infrastructure, albeit infrastructure that is sometimes poorly distributed – particularly in the south and center-west of the country, which have fewer higher-level institutions than, for example, Tunis or Sousse. To overcome some of these shortcomings, the country is developing "e-health" solutions and its private sector.
Developing higher-quality care, building up the private sector (where the number of hospital beds has tripled in 20 years), and increased profitability has increased costs for the public. Various rate increases have taken place over the last six years, and new rate hikes are being considered in the aftermath of the COVID-19 crisis. Expatriate health insurance will cover the leftover costs of certain services that have become more expensive, particularly in the context of hospitalization in the private sector. This is particularly important in a country where only 5% of GDP is devoted to healthcare (Tunisia is ranked among the 15 worst countries in the world for government investment in healthcare), and where the number of physicians per capita is still three times lower than in France.
Tunisia is known as a medical tourism destination for Europeans, particularly for cosmetic surgery or dentistry. These sectors being very lucrative, they unfortunately tends to monopolize the most qualified surgeons at the expense of other specialties.
The Order of Physicians sets the rates in the open-market sector: 35 to 45 TND for a general practitioner, 50 to 70 TND for a specialist, and 50 to 75 TND for a psychiatrist or neurologist.
For dental care, a check-up costs 50 TND; the removal of a wisdom tooth can cost up to 200 TND; and, in a private clinic, a quality dental implant will cost an average of 1,300 to 1,600 TND.
Natural childbirth in the public sector will come to 500 to 700 TND. In the private sector, a Cesarean section can cost from 1,000 to 2,000 TND. If you receive CNAM (National Health Insurance Fund) benefits, this will cover 350 TND in the case of a natural childbirth in an affiliated private clinic.
You will also find affordable medication, about half the price of the same medications in France.
In a country with moderate healthcare costs, expatriate health insurance will primarily cover your hospitalization expenses. Knowing that hospitals may require full payment of medical expenses before patients are discharged, an expatriate health insurance policy will ensure that your hospitalization expenses are paid directly for stays over 24 hours. Finally, this insurance will also cover all or part of your healthcare costs in the private sector, whether for physicians or vision/dental care. Please note that procedures related to cosmetic surgery will not be covered.
Tunisia is not a high health-risk country. There is no mandatory vaccination to travel there. As a preventive measure, though, you are advised to be up to date with the classic DTP, MMR, and anti-tuberculosis vaccinations, and to get vaccinations against hepatitis A, hepatitis B, and possibly typhoid and rabies in the case of long stays in precarious hygiene conditions.
When preparing for your departure, be aware that you will need two hepatitis B vaccinations, one month apart, and plan accordingly. In the case of a hasty departure, there is an alternative accelerated scheme consisting of three doses close together.
Some precautions should also be taken with drinking water: although you can drink tap water in large cities, it is still recommended to drink bottled water. However, this is not necessary for brushing your teeth or cooking.
In the public sector, healthcare is generally free, but of average quality. Healthcare professionals are well trained, but facilities may lack resources.
Any expenses incurred will be reimbursed if you are affiliated with CNAM. The public health facilities in Tunis and Sfax are the best equipped.
Private hospitals and clinics are equipped with modern and efficient medical equipment. Very strict hygiene rules and standards are also applied.
Moreover, the types of care offered are very diversified: dental care, general and specialized surgery, oncology, ophthalmology, thalassotherapy, thermalism, cosmetic surgery, etc.
Staff tends to be friendly and have degrees from European and American universities.
However, this system is weaker in terms of post-operative care and rehabilitation centers.
Many physicians in the cities speak French or English. So you have a wide choice there.
First of all, you have the consular physicians. Contact the consulates located in in the major cities for more information.
They will have lists of trusted physicians, hospitals, and clinics for expatriates. These lists are also available on specialized websites for expatriates.
If you are a member of the CFE (Fund for French Abroad) who needs to be hospitalized, there are hospitals and clinics approved by the CFE that will not require members to pay up front.
The list will be provided to you at the time of hospitalization. The CFE no longer provides these lists in advance. Unfortunately, that’s the way it is.
Almost all expatriate insurers also offer access to a teleconsultation platform with general practitioners and specialists as well as a second medical opinion service.
Tunisia has signed several bilateral social-welfare agreements with EU countries (Germany, Belgium, France, the Netherlands, etc.). These agreements help residents transition from one country to another, and involve all branches of insurance: sickness & maternity, old age, life & disability, work accidents & occupational illness, and family benefits.
Thus, a beneficiary of a social-welfare system in one of these countries will benefit without delay from the Tunisian Social Security system. To benefit from this, you must have a certificate of ongoing insurance coverage filled out before your departure.
CAUTION: Many retirees spend a large part of the year in Tunisia without notifying their social-welfare system on the pretext that they are still living in their country of origin. This is a mistake that can cost them dearly. Generally, social-welfare systems only cover expenses abroad if they occur unexpectedly during a temporary stay. Your home country’s social-welfare system may therefore refuse to cover hospitalization for a medical condition that is not unexpected, or may ask for proof of a temporary stay, such as airline tickets.
Taking out expatriate health insurance or joining the Caisse des Français de l'Etranger (CFE) can help you avoid problems.
Plus, not being considered a resident of your home country can have a financial advantage (as it does in France): exemption from certain taxes and social-welfare contributions.
CFE membership is available to all EU and Swiss citizens. CFE health insurance reimburses all your expenses: medical, surgical, hospital, dental, vision, lab tests, and more – within the limits applied in the CFE’s “zone 1” coverage.
The CFE will therefore cover your healthcare expenses incurred in Tunisia as a first basis for reimbursement. For example, for your pharmacy bills, they’ll reimburse 65% of the invoice (the regulation on generic drugs does not apply), or 50% of your blood-test bills. You’ll need a complementary health insurance if you want to be 100% covered.
A special feature of CFE coverage in Tunisia is that 100% hospitalization coverage has been set up for policyholders who have not taken out complementary insurance. This coverage is provided through VYV assistance, CFE's partner for the direct payment of hospitalization expenses. To benefit from this 100% coverage, you must first contact the assistance provider and then go to the hospital designated by them. There is no possibility of selecting the place of treatment yourself, or even of knowing the list of hospitals beforehand.
This option may seem interesting, but experience has shown that it isn’t always reliable, since the CFE can stop their coverage at any time. This has happened twice in the past eight years. Legally, the CFE is not obligated to maintain this service, and it is possible that the day you need it, it will no longer exist.
It’s up to you to determine what your needs are and whether you opt for CFE coverage alone or with complementary coverage, or expatriate health insurance alone (called "at 1st euro"). These expatriate health insurance plans provide you with 100% hospitalization coverage in the hospital of your choice, and additional reimbursements for your routine expenses. They’re especially ideal for those who want a good reimbursement of vision and dental expenses or expensive exams.
The Tunisian social-welfare system provides health services, welfare provisions (incapacity, invalidity, and death benefits), and family and unemployment benefits for salaried workers and the self-employed. It’s composed of several schemes (determined by occupational category) and managed by two main organizations:
- The Caisse Nationale de Sécurité Sociale (CNSS, the Tunisian National Social Security Fund), which handles old age, disability, survivor, death, unemployment, and family benefits. Employers must register their employees within one month of hiring them, and then they will receive a card. Always verify that that this process has been started in time.
- The Caisse Nationale d'Assurance Maladie (CNAM, the Tunisian National Health Insurance Fund), which manages health and maternity insurance, work accidents and occupational illness. Membership in the CNAM is compulsory for all Tunisian citizens and residents and allows them to benefit from free services in public health establishments.
The CNAM gives you access to outpatient consultations in public hospitals and establishments, as well as the six polyclinics of the CNSS. Health insurance coverage applies to both the public and private sectors, with health expenses reimbursed according to the same maximum limits and fixed reference rates in both sectors. The choice of the health insurance sector is determined at the time of subscription and is for the whole year:
- Public sector (blue card): Hospitalization and outpatient coverage in all public healthcare sites, plus approved or CNSS polyclinics. The policyholder only needs to pay the co-pay. The total amount of out-of-pocket expenses is limited to the equivalent of one and a half times the policyholder’s salary per year.
- Private sector (yellow card): You must register with a family physician, who must be consulted before visiting any specialist. Some specializations – such as gynecology, ophthalmology, dental care, or pediatrics – do not require a pre-visit referral. The state health insurance fund will pay the costs directly (within the limits of the established rates), except for the co-payment and for dental care. Hospitalization is paid for directly in public establishments and in those that have signed a CNAM agreement. ATTENTION: Outpatient reimbursements are limited to 200 TND per year (per insured person) in the public sector.
- Reimbursement system (green card): Access to any healthcare facility, private or public. The insured person pays the full amount of the conventional rates and is then reimbursed according to reference rates, within the annual limit of 200 TND (per insured person) for outpatient care in the private sector. Reimbursement must be requested within 60 days of billing.
Regardless of the scheme chosen, hospitalization coverage is identical in all three systems. You can change your scheme at the end of each year by submitting request to the CNAM with three months' notice.
You are entitled to CNAM health and maternity insurance if you have worked for at least 50 days during the last two calendar quarters, or if you have worked for at least 80 days during the last four quarters.
Spouses, children under 25 years of age who are still students, and family members 60 years of age or older who are dependent on you for housing, food, and clothing will be covered as dependents, if they do not have other healthcare coverage.
Tunisian health insurance offers sufficient benefits within the public healthcare system, but it doesn’t reimburse outpatient expenses in the private sector, or small portions of them. You’ll need expatriate health insurance to cover medical expenses in the private sector, as well as any surpluss expenses in the public sector.
The local mandatory health insurance offers satisfactory reimbursements within the public healthcare system. However, it doesn’t offer sufficient reimbursements for care provided in the private sector. Also, the maximum reimbursement limits of the health insurance system can be quickly reached.
An expatriate health insurance for Tunisia will cover your local healthcare expenses, and offers a wider choice of physicians and healthcare facilities. It will ensure you’re properly reimbursed when you consult with a physician in the private sector, or if you need to be hospitalized in a private hospital or clinic.
Expat health insurance also offers the following benefits:
- The possibility of being treated in other countries (either to have access to better facilities, or as needed during a business trip or vacation),
- Teleconsultation and second medical opinion services,
- Easy repatriation in case of need, and
- The possibility of being assisted in all your legal and medical procedures.
As medical expenses are affordable in Tunisia, even in the private sector, an a more basic plan, perhaps with a few extra benefits, might be enough to suit your needs.
However, consider whether you want to choose an insurance policy that will also cover you if you wish to be treated in another country – for example, your country of origin, or a country better equipped in terms of highly specialized care. This can be useful for certain pathologies or to move you closer to your family.
Your insurance plan can be extended to include other benefits depending on your situation: repatriation assistance, legal assistance, daily indemnity, death and disability benefits, etc. – all of which could also be very useful.
If a serious medical procedure is needed, repatriation assistance will allow for medical evacuation to your home country, Tunis, or another neighboring country.
Our advisers will be able to guide you according to your needs and budget.
If you are a member of the CNSS/CNAM system, depending on the type of care you have chosen, direct payment can be made for you – you will just have to make the co-payment, in the public sector or in an approved establishment. All of these options allow for direct coverage in the event of hospitalization, within the limits of the locally defined rates.
With expatriate health insurance: in the event of hospitalization of more than 24 hours, the insurer will arrange for direct payment to the hospital/clinic. Routine medical and vision/dental expenses must be paid up front by you.
Requests for reimbursement can easily be made online (no more snail mail); the insurance providers all have online customer portals, and sometimes mobile applications, to manage your reimbursements.
In general, invoices of up to €1,000 can be sent digitally. Invoices over €1,000 (rarer) will still have to be sent by postal mail.
Signing up for expat health insurance is more complex than for traditional health insurance, so it is advisable to apply at least 30 days before your departure or the desired start date of your contract.
It’s possible to purchase health insurance from Tunisia; however, we recommend you do it before you leave to benefit from the coverage right away when you get there, and to have a more extensive choice of plans.
Our website helps you request an online price quote and compare coverage. An adviser can then help you with the entire sign-up process.
Even if the local social-welfare system meets most of your healthcare needs, a medical evacuation may one day be necessary, either to another country or to Tunis if you live in another region.
Repatriation assistance is then useful; it also offers additional benefits, such as having a relative brought to you or a second medical opinion – highly appreciated in the case of a serious incident.
Remember that neither your embassy nor consulate are responsible for your repatriation in case of local medical problems.
This covers all material and immaterial damages that you, or a family member, could cause to a third party.
Third-party liability insurance will not apply when driving a motor vehicle – check with your auto insurance provider for this coverage.
While the government provides basic coverage, it is very minimal. You need to arrange your own coverage to protect your spouse and children.
It is recommended that you take out private insurance or one of the CFE options to fill in gaps in coverage.