The summer of 2026 has placed Tunisia’s National Health Insurance Fund (CNAM) at the center of two successive ultimatums. The first expired on July 1, while the second runs until August 31.
Between the two lies a question few have asked: how has an institution whose latest published accounts show an annual surplus of more than TND 1 billion come to threaten the country’s healthcare supply chain over unpaid debts that, on paper, its own balance sheet appears capable of covering?
Two ultimatums in two months
The first dispute concerns medicines. In a statement issued on June 24, 2026, the Tunisian Pharmacists’ Union (SPOT) threatened to suspend the third-party payment system for insured patients starting July 1, citing a deep crisis of confidence with CNAM caused by mounting payment delays and unfulfilled commitments.
SPOT President Zoubeir Guiga estimated the outstanding debt at around TND 80 million, with payments overdue by three to four months. He stressed that pharmacies could no longer continue acting as “intermediate financiers” of Tunisia’s healthcare system.
The dispute is particularly significant because a settlement agreement had been reached on January 14, 2026, following direct intervention by President Kais Saied.
The agreement provided for the repayment of 2025 arrears over six months. However, former union president Naoufel Amira has since described the agreement as “stillborn.”
On June 30, the National Order of Pharmacists established a permanent crisis committee bringing together pharmacies, medical laboratories and pharmaceutical wholesalers. Tensions have since eased, with the third-party payment system remaining in place while a meeting between CNAM and healthcare representatives, chaired by the Minister of Social Affairs, is scheduled for mid-July.
The second dispute concerns medical equipment. On July 7, the National Chamber of Medical Devices, affiliated with UTICA, gave authorities until August 31, 2026, to settle debts owed to more than 600 companies by public hospitals and, to a lesser extent, CNAM.
Its president, Lotfi Ben Yedder, described an unprecedented liquidity crisis, with some unpaid invoices dating back to 2020. He said several companies had halted imports since January to focus solely on debt collection, while others were struggling to pay employee salaries.
If payments are not made, the sector says it will invoke “force majeure” and suspend both equipment deliveries and maintenance services.
Speaking on Diwan FM on July 12, Ben Yedder confirmed that discussions had begun with the Ministry of Health, which promised financing during July and August, although no amounts were disclosed.
The paradox of CNAM’s accounts
What do CNAM’s financial statements reveal?
The latest publicly available figures appear in the report on public enterprises attached to Tunisia’s 2024 Finance Bill and cover only the 2022 fiscal year, which remains provisional.
They depict an institution that is far from insolvent.
Operating revenue rose from TND 3.53 billion in 2020 to TND 4.13 billion in 2022.
Operating profit remained positive throughout the three-year period, reaching TND 815.7 million in 2020, TND 1.03 billion in 2021, and TND 1.02 billion in 2022.
Net profit exceeded TND 1 billion in both 2021 and 2022, after standing at TND 816.1 million in 2020.
Shareholders’ equity reached TND 6.19 billion.
Cash holdings also improved, rising from TND 29.1 million at the end of 2021 to TND 75.5 million at the end of 2022, most of it deposited with Tunisia’s Treasury following the centralization of public-sector funds.
Strikingly, the TND 80 million claimed by pharmacists is roughly equivalent to CNAM’s last reported cash balance.
Measured against those figures, the crisis threatening access to medicines for 3.5 million insured Tunisians appears to revolve around an amount roughly equal to the fund’s available cash at the Treasury.
A surplus that exists only on paper
The same report explains the apparent contradiction. At the end of 2022, CNAM held total assets of TND 10.72 billion.
Of this amount, TND 8.79 billion, 82% of total assets, consisted of receivables owed by Tunisia’s National Social Security Fund (CNSS) and the National Pension and Social Security Fund (CNRPS), which collect health insurance contributions on CNAM’s behalf.
Those receivables had risen sharply from TND 5.78 billion just two years earlier.
Every year, these unpaid transfers increase by roughly TND 1.5 billion, more than CNAM’s annual accounting surplus.
In other words, the surplus exists under accrual accounting but not in actual cash. It is recorded as money owed by two social security institutions that are themselves running deficits.
As a result, CNAM’s own debts to healthcare providers rose automatically from TND 1.62 billion to TND 2.34 billion in just two years, an increase of 44%.
The Ministry of Finance itself attributes this increase to “the weak transfers from the two social security funds regarding health insurance contributions owed to CNAM.”
Pharmacists and medical equipment suppliers, therefore, are not creditors of a poor health insurance fund; they are the final creditors in a chain of unpaid obligations that begins with CNSS and CNRPS, a situation the government is fully aware of and has documented.
Negotiating without transparency
Another issue remains unresolved. The financial data cited above are now four years old. CNAM’s financial statements for 2023, 2024 and 2025 have not been made public.
The institution does not publish its own financial reports and the only available source, the annual report attached to the Finance Bill, is released once a year with a delay of two to three fiscal years. Even then, the Ministry of Finance notes that the figures have not yet been formally approved by CNAM’s board of directors.
Members of Parliament who approved the 2026 Finance Law, which pharmacists had hoped would include exceptional funding for CNAM, did so without access to any financial statements more recent than 2022.
Likewise, healthcare professionals currently negotiating repayment schedules are doing so with a debtor whose current financial position cannot be independently verified.
If the broad financial picture from 2022 still holds, then the current deadlock is not an accounting problem but a policy decision.
The central question this summer is therefore whether it is CNAM, or the Tunisian state, which now centralizes its cash holdings, that is choosing not to make the payments.
