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????I?tr?ducti??

? sant? ! sant? ! b?n?diction des riches ! richesse des pauvres ! qui peut t"acqu?rir ? un prix trop ?lev??

puisqu"il n"y a pas de joie en ce monde sans toi ?

Be? J??S??? V??p??e

?chelle?de?priorit??variable ?conomiques? et? parfois? juridiques.? ? Les? transformations? du? mode? de? vie? et? son? individualisation?? le? recul? de? la? grande? mis?re?? la? g?n?ralisation? de? l?acc?s? aux? connaissances? et? le? d?veloppement? d?un? comportement? sanitaire? pr?ventif? g?n?ralis???? internationale?ou?nationale.? A? l??chelle? internationale?? les? grands? textes? des? droits? de? l?homme??? de? ???T? un?r?le?d?terminant.?? entreprise?d?acculturation.?

?V.? R.? Mass??? ???thique? et? sant?? publique.? ?njeux??valeurs? et? normativit???.? Qu?bec?? Les? Presses? de?

l?Universit??de?Laval???00???p.?7?et?s.? ??Constitution?de?l??MS?du???/07/?9??.? collection?que?sais-je???99?.? ??A? l??chelle? nationale?? la? cons?cration? d?un? droit? ?? la? sant??? inscrit? dans? la? loi? d?sengager Parall?lement?? et? presque? pour? les? m?mes? raisons? qu?on? vient? d??voquer?? les? ce? bouleversement? est? une? remise? en? cause?? partout?dans? le? monde?? des? structures? et? l??ducation la?deuxi?me?ne?devrait?pas?faire?moins

Tunis??l?Manar?.??00???pp????et???.?

?? L?art.? ?9.?? de? l?avant? projet? pr?sent?? par? les? commissions? de? l?assembl?e? nationale? constituante? le?

fondamental?pour?chaque??tre?humain?:?

0?/08/?00???p.???8.?

v?ritablement? autonome? d?assurance? maladie? en? Tunisie? et? par? cons?quent? une? base? conception? qu?on? veut? se? faire? de? cette? solidarit?? nationale.? Ce? travail? se? propose? d?analyser? cette? conception? ?? travers? le? syst?me? d?assurance? maladie? telle? qu?il? a? ?t?? m?me?cadre??ce?travail?sera?situ??dans?son?contexte?historique?(II) et?international?(III).??

I? D?fi?iti?? des ter?es? d??i?itati?? du sujet ?

?a prise e? charge des d?pe?ses de sa?t? par ?a s??idarit? ?ati??a?e? ?? travers? ?!exe?p?e du syst??e tu?isie? d!assura?ce ?a?adie? met? en? jeu? un? certain? nombre? et?du?syst?me?d?assurance?maladie??C?. ?? A/?Prise e? charge des d?pe?ses de sa?t?.? Si? cette? expression? est? de? nos? jours? tr?s? modalit?s?de?prise?en?charge????.? conceptions.? La? premi?re? minimaliste?? signifierai? absence? de? maladie? invalidante? ou?

terme.??xemple?le?Littr??d?finit?la?sant??comme??tat de celui qui est sain? qui se porte bien.?L?origine?du?

terme??tant?le?latin?sanitatem???? est? celle? qui? a? longtemps? pr?valu? au? sein? de? la? communaut?? m?dicale.? C?est? aussi? la? dans?la?d?finition?donn?e?par?l??MS???a sant? est un ?tat de complet bien??tre physique? mental et social et ne consiste pas seulement en une absence de maladie ou infirmit?2??.??n? proclamation? et? de? l?affirmation? laissant? une? part?substantielle? de? subjectivit?? dans? affirm?.? logique ?? et? du? droit?de? la? sant?? qui? est? d?crit? dans? la? deuxi?me? logique??la? premi?re? aspects?de?la?premi?re?logique ?-? L?expression? ??d?penses? de? sant???? d?pend? largement? de? la? conception? et? de? la?

d?finition? donn?e? de? la? sant?.? Plus? cette? d?finition? est? large?? plus? ces? d?penses? seront?

pr?cit?.?

?? La? prise? en? charge? des? d?penses? de? sant?? par? la? solidarit?? nationale? r?alise? en? partie? l?objectif?

??importantes?? multiformes? et? difficiles? ?? cerner ?.? Les? d?penses? de? sant?? constituent? par? maladie?tunisienne ?-? Les? modalit?s? de? prise? en? charge? des? d?penses? de? sant?? regroupent? l?ensemble? des? de? sant?.? ??n?ralement? une? d?pense? est? prise? en? charge? par? celui? qui? en? a? besoin.? d?pend? pas? des? capacit?s? financi?res? de? celui? qui? en? a? besoin.? Ce? risque? pose? la? mutualis???soit?socialis? ? ?n?Tunisie??la?prise?en?charge?des?d?penses?de?sant??constitue?un?risque?socialis?? support?? dans? le? cadre? du? r?gime? de? base? ou? des? r?gimes? compl?mentaires.? ?nfin?? sortes?des?d?penses?de?sant?.?

CNAM.?

r?gime?de?la?responsabilit?.????? B/??e c??cept de s??idarit? ?ati??a?e.?C?est?le?concept?fondamental?de?notre?travail.??l? pens?e?juridique?moderne solidarit?? prendrait? le? relais? ?? d?autres? types? de?solidarit?s? devenues? insuffisantes? ou?

d?pass?es? par? l?esprit? du? temps.? La? vie? citadine? et? le? mod?le? de? la? famille? nucl?ique??

aujourd?hui? universalis??? r?duit? sensiblement? le? champ? de? la? solidarit?? familiale?.? induit? par? des? risques? pr?d?termin?s? et? que? ne? peuvent? supporter? individuellement? des? membres ??de?cette?m?me?soci?t?.?? d?crit?dans?le?cadre?de?ce?travail.?V.?? ?me?partie??Titre???chapitre??.? pr?face??.?Moderne???p.????et?s.? ?00???p.???et?particuli?rement?p.???.?? ??Particuli?rement?les?plus?indigents.? ?.?L?art.???de?la?Constitution?de??9?9?

pr?cise? bien? qu?il? s?agit? d?une? solidarit?? ??...) entre les individus? les groupes et les

g?n?rations?.? ?n? mati?re? sanitaire?? la? solidarit?? nationale? en? Tunisie? semble? avoir? une? sociale l??laboration?de?ce?travail.? admis? que? la? solidarit?? nationale? inspire? deux? formes? de? r?alisations.? L?assistance? et? C/?Syst??e d!assura?ce ?a?adie.??l?constitue?l?une?des?branches?les?plus?importantes?de? ??V.?D.?Loschak??op.?cit.?p.????et?s.? secteur? priv?? sanitaire?? depuis? la? r?forme? du? ?? ao?t? ?00?.? L?enjeu? est? de? garantir? ?? ? ?nfin??si?le?syst?me?tunisien?actuel?d?assurance?maladie?g?re?un?r?gime?de?base??le?

nationale?? l?exp?rience? du? droit? compar?? laisse? penser? qu?ils? y? seront? int?gr?s?? car? les?

prise? en? charge? de? l?ensemble? des? d?penses? de? sant??par? un? syst?me? universalis?? d?assurance? maladie? constitue? pour? de? nombreux? pays? l?aboutissement? ultime? du?

II? Hist?rique du syst??e d!assura?ce ?a?adie

est? toujours? influenc?? par? le? mod?le? fran?ais.? Mais? c?est? aussi? l?histoire? d?un? syst?me?

?? Certes?? il? existe? un? lien? entre? chaque? branche? de?la? s?curit?? sociale? et? une? politique? publique? qui? y?

politique?sanitaire?du?pays.? de? protection? sociale? comme? la? charit?? ou? les? formes? primitives? de? solidarit?s?.? Deux? milieu? du? XX?me? si?cle.? ?l? s?agit? respectivement? des? mod?les? bismarckien? ???? et? b?v?ridgien????.? plus? ou? mois? important? de? la? solidarit?? nationale.??lles? ?taient? surtout? destin?es? aux? ? L?Allemagne?du?gouvernement?de?Bismarck?est?le?pays?pr?curseur?en?la?mati?re?.? ?rance? en? ?898 ?.? Ces? premiers? syst?mes? modernes? conna?tront? d?autres? extensions? r?volution?industrielle.?

?? Theodor? Lohmann?? juriste?? membre? du? gouvernement? allemand? de? l??poque? est? en? r?alit?? le? v?ritable?

??0nationale? consiste? ?? garantir? le? syst?me? et? ?? apporter? son? concours? technique? et? administratif.?? des? risques? sociaux? par? la? solidarit?? nationale? qui? est? consacr?.? ?l? s?agit? du? model? beveridgien?? du? nom? du? pr?sident? d?une? commission? britannique?? William? Beveridge?? charg?? en? ?9??? par? le? gouvernement? d?analyser? le? syst?me? britannique? des? assurances? son? rapport? en? ?9???? qui? eut? rapidement? un? impact? universel?.? Les? principales? Les? assurances? sociales? ne? sont? plus? seulement? une?r?ponse? et? un? rem?de? aux? risques? unique? de? sant??? financ?? par? l?imp?t? et? la? s?curit?? sociale.? Ce? syst?me? unique? devant? mati?re? ?conomique? et? sociale?? dans? un? cadre? qui? demeure? toutefois? lib?ral.?Ces?

Security Act am?ricain?de??9????d?inspiration?k?yn?sienne????et?surtout?le?syst?me?de?s?curit??sociale?institu??

de?sant??voulu?par?le?rapport?Beveridge????savoir?le??ational ?ealth Service ?N?S?ou? universelle?des?droits?de?l??ommes les? grands? pays? industrialis?s ?? consacreront? d?une? mani?re? ou? d?une? autre? un? mod?le? syst?me? d?assurance? maladie? g?n?reux? et? couvrant? largement? la? population?.? Pour? les? autres? pays?? la? revendication? d?un? mod?le? beveridgien? de? s?curit?? sociale?? en? tant? que? B/? ?istorique? du? syst?me? d?assurance? maladie? en? Tunisie.? L?instauration? des? premiers?

????Toute personne en tant que membre de la soci?t?? a droit ? la s?curit? sociale ???La?s?curit??sociale?

Paris??L.?.D.?.??99???p.??9?et???0.?

travers?la?Social Security Act?de??9??.?V.??.??uteau??op.?cit.??p.?7.?

V.? N.? Kerschen?? ??L?influence? du? rapport? Beveridge?sur? le? plan? fran?ais? de? s?curit?? sociale??.? Revue?

????-? L?assurance? maladie? tunisienne? avant? l?ind?pendance?? constitue? un? syst?me? dont? Ce? sont? les? formes? premi?res? de? solidarit?? qui? pr?valaient? ?? l??poque? mais? ?taient? risques?sanitaires.?? elle? m?me? subdivis?e? en? deux? ?poques? diff?rentes.? La? premi?re? p?riode? concerne? les? tunisienne?de?l?assurance?maladie.? ? Durant?les?premi?res?ann?es?du?protectorat??l?action?m?dico-sociale?de?l??tat??tait? envisag?e?comme?une?id?ologie et un vecteur de mise en valeur du?fait?colonial?.?Le?but? ?tait? de? garantir? au? syst?me? colonial? et? de? lui? p?renniser? une? main? d?#uvre? locale?

?? Les? ?tudes? men?es? sur? l?histoire? de? l?action? m?dico-sociale? en? Tunisie? avant? l?ind?pendance? sont?

pr?coloniale??.?Tunis??STD???97?.?

h?pital? prodiguant? des? soins? selon? les? standards? les? plus? r?cents? de? l??poque.? ?l? existait? ?galement? les?

??Abdelm?jid??uelmami??op.?cit.??p.?0.? ???appliqu?es?en??rance plusieurs? ann?es? apr?s? l?ind?pendance.? Tous? comme? la? l?gislation? actuelle?? une? sociaux?du?secteur?priv?.? fonctionnaires?et?employ?s?tunisiens du????f?vrier??908 ???qui?sera?finalement?int?gr?e?dans?un? secteur? ?? partir? de? ?9??

7.? Un? certain? nombre? d?avantages? sociaux? seront? ?galement?

de? l?avantage? social? octroy?.? Cependant?? ?? ce? niveau? ?galement?? l?assurance? maladie? ????T?du???/??/?908?

fonctionnaires? et? employ?s? tunisiens? et? approuvant?les? nouveaux? statuts? de? cet? organisme.? ??T? du?

??/??/?9?9??p.??799.? ??T?du??7/0?/?9????p.???9.?

8?Abdessatar?Mouelhi??ibid.?

?-?L?assurance?maladie?tunisienne?apr?s?l?ind?pendance?se? caract?rise?pour? les? assur?s? ? ?n?ce?qui?concerne?le?secteur?public??la?situation?vis-?-vis?de?l?assurance?maladie?ne? r?gime? optionnel? de? remboursement? des? frais? m?dicaux?? en? contre? partie? d?une? comportant? toujours? une? branche? maladie? assez? g?n?reuse.? Le? volet? maladie? de? cette? r?gime?actuel.?? ? ?n?ce?qui?concerne?le?secteur?priv???et?apr?s?quatre?ann?es?de?maintien?du?r?gime? ????RT?n??7?du???/0?/?97???p.??89.?

TRANSTU?et?de?la?SNT?.?

la?base?de?cette?m?me?loi jour.?? ? Parall?lement???cette?assurance?maladie?int?gr?e?aux?diff?rents?r?gimes?de?s?curit?? sociale?? un? secteur? de? prise? en? charge? des? d?penses? de? sant?? s?est? d?velopp?? r?forme?de??00??le?suivant avancer? les? dits? frais.? Une? autre? partie? d?assur?s?sociaux? tout? aussi? privil?gi?e? et?

non? agricole? ?D.? n?8?-???9? du? ??/?0/?98????? exploitants? et? ind?pendants? agricoles? ?D.? n?8?-???0? du?

???mauvaise? r?partition? g?ographique? et? surtout? des? conditions? d?accueil? et? d?h?tellerie? priv?? sanitaire?? ces? malades? ?tant? soit? des? assur?s? sociaux? que? la? mauvaise? image? du? d?assurance?priv?.? ? Cette?situation??tait?jug?e?d?s?le?milieu?des?ann?es?80?comme??tant?inacceptable??

public? et? priv?? en? mati?re? de? s?curit?? sociale? et? cr?er? une? caisse? propre? ?? l?assurance?

maladie raisons CNRPS?ou?ce?que?la?doctrine?nomme?le corporatisme d"appareils5??enfin?la?r?forme?de? p.7?.? p.?977.? -?la?caisse?nationale?des?pensions?CNP?? p.???9.? ???.?Bouslah??op.?cit.?p.??8?? ??7des?r?gimes?g?r?s entamer?de?v?ritables?r?formes Une? ? d?cennie? plus? tard?? apprenant? sans? doute? les? le?ons? de? ?98??? un? ? conseil? d?assurance? maladie.? Cette? loi? sera? compl?t?e? progressivement? par? son? corpus? juillet??007 III? ?es gra?ds syst??es de prise e? charge des d?pe?ses de sa?t? da?s ?e ???de ? Le?syst?me?tunisien?d?assurance?maladie?s?inspire?des?standards?actuels?en?mati?re? avec? d?autres? grands? syst?mes? existants? dans? le? monde? et? particuli?rement? le? syst?me? fran?ais? ?A??? cela? n?emp?che? pas? le? syst?me? tunisien? de? demeurer? tr?s? diff?rent? des?

?? La? r?forme? de? l?assurance? maladie? en? ?00?? est? ?? la? fois? une? r?forme? structurelle? et? une? r?forme? de?

?? ?ouvernement? ?minist?re? des? affaires? sociales? et? minist?re? de? la? sant?? publique??? patronat?? travailleur??

??8A/?Le?syst?me?fran?ais sociale.? ?l? fait? intervenir? des? organismes? paritaires? compos?s? des? repr?sentants? des? employeurs?et?des?salari?s constitu?e? de? trois? principaux? r?gimes.? Un? r?gime? g?n?ral? pour? la? majeur? partie? de? la? pour? les? ind?pendants? ?RS??? qui? couvre? les? artisans?? commer?ants?? industriels? et?

La? r?forme? de? ?99?

?? introduit? en? droit? fran?ais? une? nouvelle? ?chelle? de? syst?me?de?protection?sociale ?99?? relatives? ?? la? ma?trise? m?dicalis?e? des? d?penses? de? soins?? ?? l?organisation? de? la? ?999? ?ou? loi? Aubry?? institue? la? Couverture? maladie?universelle? ?CMU? de? base?? et? la?

la? prise? en? charge? de? ses? soins? ?maladie? et? maternit??? quelle? que? soit? son? activit?.? La?

?? La? litt?rature? relative? au? syst?me? fran?ais? d?assurance? maladie? est? extr?mement? riche?? nous? citerons?

sociale??.? Paris?? Dalloz?? ?0???? particuli?rement? les? p.???? et? s.??? M.? ?lbaum? ?? ?conomie? politique? de? la?

?rance.? sociaux? cotisation? ?environ? ?8%??? des? ressources? fiscales? ?environs? ?0%?? ainsi? que? d?autres? ressources maladie??? ??NDAM?.? La? r?forme? tunisienne? de? ?00?? comporte? un? certain? nombre? de? s?agit? en? premier? lieu? de? l?instauration?? certes? plus? limit???? d?un? parcours? de? soins? et? fran?ais.? Le? syst?me? britannique? actuel? est? l?h?ritier? direct? du? rapport? Beveridge?? particuli?rement? en? ce? qui? concerne? les? grands? principes? de? la? s?curit?? sociale? :? universalit??? g?n?ralit??? unicit??? uniformit?? des? prestations? en? esp?ces.? L?ensemble? du? syst?me? de? l?assurance? maladie? est? g?r?? uniquement? par?l??tat?? sans? intervention? des? ?A? cet? ?gard?? le? financement? du? syst?me? britannique?se? fait? essentiellement? par? seconde? en? ?00?? qui? cr?a? des? r?seaux? publics? de? soins?et? instaurant? un? partenariat?

?? Toutefois?? les? diff?rences? d?passent? et? de? loin? les? points? de? ressemblance? particuli?rement? en? ce? qui?

maladie.???? l??tranger.? Cette? m?me? r?forme? instaure? par? ailleurs? plus? de? souplesse? dans? la? gestion?

Aux? ?tats-Unis

??? l?assurance? maladie? d?pend? surtout? d?assureurs? priv?s.? Les? pouvoirs? publics? garantissent? les? soins? aux? personnes? ?g?es? ?Medicare?? ou? d?munies? qu?un?cinqui?me?des?non-assur?s la?plus?ch?re?au?monde ???tous?syst?mes?confondus.?? des? Repr?sentants? en? mars? ?0??.? ?lle? contraint? tous? les? Am?ricains? ?? souscrire? une?

?? ?.-?.? Dupeyroux?? op.? cit.?? p.? 7?.? Pour?une? description? plus?d?taill?e? des? r?formes? r?centes? du? syst?me?

???.-?.?Dupeyroux?op.?cit.?p.?7??et?s.??

repr?sente? ??? %? du? P?B? am?ricain.? Toutes? ces? sources? et? donn?es? chiffr?es? sont? cit?s? par? les? auteurs?

pr?c?demment?cit?s.?

?? V.? ??La? r?forme? ?bama?:? une? meilleure? couverture? du? risque? maladie? pour? les? am?ricains??.? Rapport?

d?une? importante? manne? financi?re? provenant? de? l?exploitation? des? richesses? hydrocarbures.? La? s?curit?? sociale? et? plus? particuli?rement? le? financement? de? la? sant?? constitue? un? des? proc?d?s? de? redistribution? de? cette? richesse? p?troli?re? et? gazi?re.? s?exprime? en? Alg?rie? par? l?instauration? depuis? ?97?? d?une? gratuit?? des? soins? dans? les? auteurs sources? de? gaspillages.? La? persistance? de? la? manne??nerg?tique? fige? ce? pays? dans?

Quant? au? Maroc?? il? a? entam?? d?s? ?00?

?? sa? propre? r?forme? de? son? syst?me? ?00?.? La? sp?cificit?? du? cas? marocain? est? que? l?assurance? maladie? ?Assurance? maladie? aux? plus? d?munis? ?R?gime? d?assistance? m?dical? ou? RAM?D?? ? sont? int?gr?s? dans? un? syst?me? unique ?.? Cependant? le? principal? probl?me? que? doit? faire? face? ce? pays? est? la? ??-Z.??ufriha??op.?cit.??p.???7.?

?? Dahir? n??-0?-?9?? du? 0?/?0/?00?? portant? promulgation? de? la? loi? n???-00? portant? code? de? couverture?

des? salari?s.?Auparavant??seul? les?fonctionnaires? et? certains? salari?s? du?priv??b?n?ficiaient? d?un? syst?me?

d?assurance?maladie?obligatoire.? ?00?.?? ?/?? seulement? de? la? population???? le? RAM?D? ?tant? par? ailleurs? toujours? au? stade? exp?rimental?en??0??.?

IV? I?t?r?t du sujet et pr?b???atique

Aborder? la? question? de? la? solidarit?? nationale? ?? travers? le? syst?me? d?assurance? le? cadre? stricte? de? la? r?flexion? juridique.? Ce? travail? met? en? jeux? un? certain? nombre? ? ?l?s?agit?d?une?question?de?soci?t??que?les??v?nements?de??0???ont?remise?sur?le? ? La?solidarit??nationale?en?mati?re?de?prise?en?charge?des?d?penses?de?sant?? nombre? d?indicateurs? qu?il? serait? int?ressant? de? pr?senter.? Ces? d?penses? constituent? en? confondue??????9% ?007.? Depuis? cette? ann?e?? c?est? en? revanche? les? d?penses? de? l?assurance? maladie? qui? ??ao?t??00? par?la?solidarit??nationale de??00??n?a?pas?v?ritablement?boulevers?

Union??dition???99?.?

???bid.? ??Les?services?d?urgence?par?exemple.? ???nationale comme? ??principe??.? Dans? le? premier? cas? la? solidarit?? nationale? traduit?la relation d"interd?pendance entre tous les membres de la soci?t?? C"est dans un m?canisme qu"elle s"incarne : le m?canisme de la prise en charge socialis?e?.?L?ensemble?des?dispositions?en? solidarit??nationale?s??rige?en?? principe?r?gle ??ayant?vocation ? surplomber un certain nombre de r?gles particuli?res et ? en gouverner l"interpr?tation? ?l peut ?galement ? ce titre incarner des valeurs exprim?es dans le syst?me juridique? qui auront plus de force que le principe?r?gle s"?l?ve dans la hi?rarchie des normes3.??n?d?autre?terme??la?solidarit?? devient? non? seulement? fondement? principal? de? l?assurance? maladie? mais? aussi? source? de?la?loi??00?-7??du???ao?t??00? principe. La? probl?matique? principale? de? la? r?flexion? dans? le? cadre? tunisien? est? par? charge?des?d?penses?de?sant??(??re Partie).??

Universit??de?Montpellier???99?.??

?? V.? L.-?.? Camaji?? ??La? personne? dans? la? protection?sociale?:? Recherche? sur? la? nature? des? droits? des?

Nanterre.?Dalloz???00???p.??08.???

???p.?cit.?p.???0.?

?????l est institu? un r?gime d"assurance maladie? au profit des assur?s sociaux et de leurs ayants droit? fond?

sur les principes de la solidarit? et l"?galit? des droits??.?Cette?m?me?cons?cration?se?retrouve?dans?la?loi?

fran?aise?du???/08/?00??relative???l?assurance?maladie????a ?ation affirme son attachement au caract?re

universel? obligatoire et solidaire de l"assurance maladie ?.?? demeure?fortement?limit?e??(2??e Partie).????

PR??I?R? PARTI?

?A R?F??DATI?? DU

SYST??? TU?ISI??

D!ASSURA?C? ?A?ADI? ? U??

S??IDARIT? ?ATI??A??

R???UV????

?conomiques r?gimes? l?gaux? de? s?curit?? sociale? institu?s? par? la? loi? de? ?9?0? notamment?-? a? le? plus? aussi?les?professionnels?de?la?sant??et?les? usagers?invoquaient?des?insuffisances?et?des? imperfections s?curit??sociale.?

?? Citons? ?? titre? d?exemple? la? crise? de? ?9?9? ayant? mis? fin? ?? l?exp?rience? de? l??conomie? planifi?e? ou?

une? r?formes? globale? du? cadre? financier?? fiscal? et?administratif? de? l??tat? et? le? lancement? des? premi?res?

par?cet??v?nement.?

Bouslah??op.?cit.?p.???9.

de?l?assurance?maladie?de??00?.?????? ??8A? cet? ?gard?? on? pourrait? se? poser? la? question? sur? les? raisons? qui? ont? men?? les? pouvoirs? publics? ?? adopter??? certes? avec? difficult?? comme? on? le? verra? plus? loin?? cette? r?forme?en??00? ?n? r?alit?? plusieurs? facteurs? se? sont? accumul?s? au?d?but? des? ann?es? ?000? qui? ?tat? de? sant?? globalement? satisfaisant? de? la? population? tunisienne?.? Au? passif? de? ce? autre? m?decine? destin?es? pour? les? cat?gories? sociales?les? moins? favoris?es?.? Pour? les? totalit?? des? usagers? comme? ?tant? d?plorables.? D?o??une? r?orientation? n?cessaire? de? la? solidarit?? nationale? non? plus? vers? la? r?alisation? du? minimum? acceptable? de? protection? sanitaire? de? la? population? ?d?j?? r?alis???? mais? vers? un? acc?s? ?quitable? ?? ce? minimum? Le? deuxi?me? facteur? qui? pourrait? expliquer? cette? r?forme? est? justement? la?

?? ?n? ?liminant? bien? s?r? des? raisons? conjoncturelles?? telle? que? le? fait? que? l?ann?e? ?00?? ?? ?t?? une? ann?e?

promesse?des?autorit?s?de?l??poque.?? pr?cit???p.77.?? ibid.?? ?nfin?? troisi?me? facteur?? sans? doute? le? plus? d?terminant? est? la? pression? internationale.? D?abord? une? pression? ? directe? de? certains? organismes?? notamment? les?

pression? indirecte? par? le? fait? que? le? r?gime? ant?rieur? ?? la? loi? de? ?00?? se? trouvait? en?

d?phasage? total? avec? les? grands? standards? internationaux? de? l?assurance? maladie?.? La? une?bonne?partie?de?ces?standards.? ???r?orientation?ayant?pour?principale?quotesdbs_dbs1.pdfusesText_1

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