Conference Paper
Unpacking PHC’s Financial Protection Effects: From the Lived Experience of Patients to the Promise of Systemic Equity in Tunisia
No.
ERF32AC_39
Publisher
ERF
Date
May, 2026
Primary Health Care first entry is widely recognized for improving population health outcomes, although its potential contribution to financial risk protection remains insufficiently explored. This study investigates the extent to which PHC-first entry strengthens financial protection within the Tunisian health system. A dual-level approach was applied. At the patient level, a quasi-experimental analysis estimated the causal impact of PHC-first entry on out-of-pocket expenditure using representative survey data for diabetes (n = 1624) and hypertension patients (n = 1749). At the population level, Structural Equation Modelling assessed the direct and indirect effects of PHC-first entry, referral adherence, and service utilization on financial protection using the 2021 household expenditure survey (n = 59,042). The quasi-experimental analysis showed that PHC-first entry reduced OOPE by 14–19%, although not all patients followed the PHC pathway, limiting its full protective effect. Referral adherence yielded stronger reductions (17–26%) and significantly lowered catastrophic spending. SEM confirmed that PHC enhances financial protection through both direct (54%) and indirect (46%) pathways, with protection maximized when referral protocols are followed rather than bypassed. In Tunisia, PHC serves as a financial protection lever when it functions as the first point of entry and is not bypassed. Its protective potential is significantly enhanced when referral protocols are enforced, insurance coverage is aligned with mandatory PHC-first pathways, and PHC capacity is strengthened through digital platforms and coordinated care. Under these conditions, household-level reductions in OOPE can be scaled into broader gains in equity, financial protection, and overall health system resilience.