The official reaction to the deaths of 15 infants at the Wassila Bourguiba Hospital in Tunis on 8 March 2019 was the following: a series of dismissals and new appointments at the Ministry of Health, press conferences and participatory dialogue sessions between various health sector stakeholders, a hastily drafted government program to “save the health sector”, and promises to disclose the truth within 10 days. These “urgent” measures were a smokescreen used to obscure the depth of the public health crisis caused by the accumulation of government policies which targeted most public sectors.

Public reaction and mobilization of media and civil society organizations in the wake of the infant deaths has faded into oblivion. Such a fate was in line with the government’s usual bet that such issues are short-lived and will eventually die down the same way other issues have ceased to occupy public opinion. As a result, several issues about the reality of public health in Tunisia that were raised during the two weeks following the incident have been shelved. It is an outcome that did not stray too far from the policy of a state that has mastered sweeping problems under the rug.

 

Marginalizing Public Health: A State’s Policy

In the past five years, the Ministry of Health’s budget increased by 30.9%, amounting to DT2,055.3 million in 2019. This rise however does not reflect the real situation in this vital sector. A detailed budget report of this ministry reveals the extent of the government’s policy of reducing its intervention and support for public health. The budgets allocated to the Ministry of Health represent 5.1% of the total state general budget of 2019, of which 87% is allocated to disposition and administration expenditures, while those set for development do not exceed DT269 million (only 13% of the ministry’s budget). Public funding of health development allocations has decreased by 27% compared to 2017, and the government's austerity policy in this regard directly impacts the health and life of Tunisians. The accumulation of debt by public hospitals, amounting to DT700 million during 2019 (almost three times the development allocations), has taken a toll on health infrastructure development and the public health system’s capacity to provide decent services to citizens. Over the past decade, public health facilities were not developed to account for  a population increase of nearly 1 million according to figures by the National Institute of Statistics. A mere three public hospitals were established, bringing the total number to 14 hospitals for a population of more than 11.5 million . Meanwhile, all 21 health centers and institutions have not undergone any development, and instead the number of regional and local hospitals has dropped from 33 to 32 and 109 to 108 respectively between 2008 and 2016. 

 

Impoverishing the Public Health Sector: Depletion of Skills

The consequences of the government’s “austerity” policy in the public health sector were not limited to the infrastructure but extended to human resources, especially doctors. The state's choice to tighten its expenditures in this area has led to a real depletion of human resources in the public health system. In parallel with the increase in the number of Tunisian doctors (14,892 physicians in 2017 according to the National Institute of Statistics), with a growth rate of 22.5% during the past decade, the development in the number of doctors in public health facilities during the same period did not exceed 14% overall. According to the same source, from 2011 onwards the statistics have been alarming as the number of doctors in public hospitals continues to decrease, as shown in 2017 when the number of doctors decreased from 6,971 to 6,753.

Figures on the loss in human resources from the National Institute of Statistics and the Ministry of Health have also set off alarm bells.To combat the growing danger of this loss, and in the context of its plan to reduce wages and the deficit in the state's budgets, the government has suspended public service secondment since 2016 in almost all sectors, except in the ministries of defense and interior. This decision has pushed young doctors to turn their backs on the public health sector and pursue their careers elsewhere. This resulted in annual waves of migration out of the country of about 600 young doctors and medical students in 2018, with this number expected to reach 2,700 by the year 2022 as publicly stressed by President of the National Council of Doctors Youssef Maqni . According to the Ministry of Health, those who could not leave the country were solicited by private clinics. In 2017, these clinics  employed 55% of the total number of physicians nationwide. The final outcome was an increase in the population to physician ratio [in the private sector] in just three years, from 772 in 2013 to 808 inhabitants per doctor in 2016, and mounting pressure on public health facilities with only 6 doctors per 10,000 inhabitants.

 

Health: Another Aspect of Social and Developmental Grievance

In the western region, the barrenstrip of the most impoverished cities and villages has for decades come last on the list of developmental and human indicators. In this area, the  public health sector situation is another victim to the injustice inflicted on Tunisian citizens. Such areas have always been absent from the image of Tunisia that decision makers want portrayed in the media and on postcards, and have continuously been neglected and absent from both development plans and public and private investment programs.

The  report from the Tunisian Forum on Economic and Social Rights in 2017, entitled “On Economic, Social, and Cultural Rights, Seven Years After the Revolution”, reveals the preliminary outline of the health map in what has become known in Tunisia as the “shadow” areas. The section of the report prepared by Dr. Moncef Ben Haj Yahia of the Tunisian Association Defending the Right to Health states that infant mortality rates in rural areas is 6.42/1000. This is almost three times the maximum rate of 2.21/1000 reported in  urban areas, as reported by a joint investigation between the National Institute of Statistics and the United Nations Children's Fund. Maternal mortality rates in North West Tunisia is catastrophic (76/1000 compared to the North East where the rate is 9.7/1000). These shocking figures are borne out by the statistics on the distribution of public health facilities and medical personnel across the country's barren strip areas. This uneven distribution clearly explains how death is faster and more common among citizens of the West Strip area. Eastern provinces that include the cities of Greater Tunis occupy 74% of the capacity of hospitals in the public sector, amounting to around 20,500 beds in 2017 according to the Ministry of Health’s data. As for the rest of the country, close to 5,360 beds are distributed among 10 governorates. Regional discrimination is not only apparent in health facilities but also in the distribution of doctors and medical cadres where 78% thereof are located in Tunis and the country's coastal strip. Things do not look much better for the remaining 2,060 basic health centers that aim to provide health coverage in rural areas. The final report on the current state of basic health centers prepared in 2017 by the Mourakiboun Association, in cooperation with the National Democratic Institute of America, revealed that 41% of the buildings were in poor or very poor condition, 47% of these facilities were connected to bad roads, 39% lack means of communication, and 53% are located in an unsafe and polluted environment. Finally, in addition to the fact that one third of the basic health centers do not have refrigerators to store medicine, only 18% of them provide medical services to citizens throughout the week.

 

International Monetary Fund Recommendations to Blame

The Tunisian government's austerity policy was not the result of a national choice of prioritizing and taking into consideration the sectorial specificities of its various public facilities. Under the pressure of the mounting economic crisis, the government was quick to sign the “Extended Fund Facility” loan agreement with the International Monetary Fund (IMF) on 15 April 2016, worth US$2.8 billion. The loan will be disbursed in installments up until the beginning of 2020. This agreement, entitled “Accelerating the Pace of Economic Reforms in Tunisia to Reduce Weaknesses, Speed up Growth, and Support the Provision of Jobs in a Sustainable Manner”, according to the IMF statement, carried a number of commitments that the Tunisian government should implement within the subsequent four years. This includes an annex that underlies the aspects of an integrated strategy to restructure public service under the justification of reducing public wages and expenses. The government has been implementing this plan diligently since 2017 by freezing any secondments in all public sectors, halting compensation for pensioners or those leaving their service voluntarily, and tightening public investment and support expenditures of various government departments, especially health and education ministries which are the second largest after interior and defense. Full government compliance with the IMF conditions on public spending was coupled with an open-door policy to the private sector for investment that would fill the void left by public institutions, including the health sector. This happened in accordance with the terms of the aforementioned loan agreement that stipulates strengthening partnership between public and private sectors and issuing a new investment magazine. The government's excessive generosity was evident in a period of two years. The number of private clinics and their capacity increased by about 10% between 2016 and 2017. In addition, these clinics recruited 412 new doctors during 2017, according to the Ministry of Health.

Negligence of the public health sector is most evident in the plan the Tunisian government announced on 30 November 2016, during the International Symposium on Investment and Economic Support, Tunis 2020. Under this plan, the private sector will take up 64% of future investment projects in the health sector worth US$4 billion over the coming years. The state, meanwhile, will have 5 projects related to the improvement of regional hospitals and the provision of some equipment in a number of public health centers.

On paper, the Tunisian revolution established health as a constitutional right, as stipulated in Article 38 of the Constitution which states: “The state shall guarantee preventative health care and treatment for every citizen and provide the means necessary to ensure the safety and quality of health services”. This text, just like other texts that addressed the right to housing, education, the physical sanctity of citizens, and the rights to dissent and free expression, has quickly collapsed before the language of figures, indicators, and the practices of the authority and its calculations. We find ourselves wondering as  Egyptian writer Alaa al-Aswany did in his novel “Jumhuriyat kaʾanna” [The So-Called Republic]: “Will each one of us discover at one point that we lived in the Republic of “as if” where everything seems to be real when in the end it was all an illusion?”

 

This article is an edited translation from Arabic. 

 

Keywords: Tunisia, Health facilities, Health sector, Public health,