By 2020, Tunisia’s health sector had all the components of a crisis, and any discussion about it had come to revolve around certain themes expressing much disappointment and many blatant contradictions. The disparity between a public sector weighed down by problems and structural and functional incapacity escalating daily and a private sector reaping significant profits and enormous investments and attracting increasing numbers of patients, including those belonging to the middle and poor classes despite the unaffordability of treatment, had become clear. The country had also witnessed a continuous decline in the most important indicators concerning health services and their quality relative to the 1970s and 1980s and to some other Arab and African states.
The most dangerous feature of the crisis may be the habituation to news of gross and frequent medical errors, rampant unionism in the hospitals, assaults by citizens on medical and paramedical staff, a lack of specialist doctors in the interior regions, and the emigration of doctors.
While the long-suffering health sector was languishing under these burdens and adversities, COVID-19 descended upon our country, and the state and Tunisian people began looking to it to address the pandemic despite its weakness. Only then did everyone remember the public hospital and the shortcomings in it. The conversation began revolving around the number of intensive care beds and specialist doctors, equipment shortages began dominating the headlines, and all the discourse about austerity, reducing spending, and the state’s poor financial capacities vanished. Is this belated awareness of this sector’s importance a true awakening or merely a transient fear of death approaching from the East?
Whatever the case, this crisis enabled the public hospitals to obtain in a brief time equipment that they had been struggling for many years to obtain a fraction of. Burning questions about the health sector’s status and the means of reforming it became the main topic of political dialogues and communal discussions in the public and private spheres. The crisis was also an opportunity for Tunisians, like other peoples of the world, to discover that public hospitals are the first and last refuge, that developing and maintaining them is a matter of life and death, and that however much the private hospital sector has developed, it remains unable to achieve national health security.
Despite the great difficulties and challenges posed by the COVID-19 crisis, most people concerned with the health sector now see it as a glimmer of hope and a golden opportunity to rescue the sector from its dilapidation. This is because it has caused urgent reforms and a radical change in the way that the requirements for improving the health system are handled.
Rearranging Priorities: Health First and Foremost
COVID-19’s first “benefit” is that it has made all the political actors in government and opposition, and all groups across the ideological and social spectrum, rethink the priorities of the state and society. It drew attention to the need to end the mad surge of austerity policies in expenditure on public utilities, particularly health, which conceal the state’s intent to withdraw gradually from this strategic sector. The crisis demonstrated that society’s physical and psychological health is the top priority and the mainstay of all development, that any talk about austerity in this area is an indirect waste of the state and society’s capacities and disregards national security, and that any investment in it leads to certain, stable profit, albeit delayed and not readily visible. After years of austerity policies in public health expenditure, diseases – especially chronic and noncommunicable ones such as diabetes, heart and artery diseases, and cancer – have escalated. Hence, the national community – i.e. both state and citizens – now bears enormous treatment costs, not to mention the indirect cost of weak healthcare that consist of poor profitability and productivity, increased cases of physical disability, the exhaustion of social funds via disability pensions, and, in particular, the loss of citizens’ trust in the state and their feeling that it has abandoned them, among other serious repercussions on social cohesion and the unity of the state.
Perhaps COVID-19 came at the opportune time. Perhaps it was necessary for a course correction and for us to think about assigning the public health sector the place it deserves and that adopting a deeper approach is not based on the market logic of loss and profit but the basic notion that while health is expensive, illness costs much more.
The Geography of Health: Inequality Before Disease
It is not necessary to see precise data on the distribution of health institutions to perceive the vast disparity among the country’s regions and the concentration of the university-affiliated public health institutions in three areas, namely Tunis, the coastal region, and Sfax. The remaining governorates, particularly the interior governorates in the north, center, and south, lack health facilities possessing the minimum level of equipment and necessary human resources, particularly specialist doctors. People of these governorates are forced to travel distances sometimes exceeding 300 kilometers to reach the nearest health institution capable of treating them. This is because as much as Tunisia succeeded in establishing local hospitals and primary healthcare centers in most of the country’s cities and villages over four decades, it failed to develop the level and quality of the medical services that they provide, on one hand, and to ensure a fair and objective distribution of the major health institutions among the various governorates, on the other. This imbalance became clearly apparent following the COVID-19 crisis and Tunisians’ very clear discovery – via numbers this time – that most governorates are living below the health poverty line and the health facilities in them usually cannot provide certain basic services for one reason or another.
Developing the Legal System and Plugging Legislative Gaps: Today, Not Tomorrow
The legal system regulating Tunisia’s health sector continues to suffer from several defects in several areas, particularly the legal framework guaranteeing patients’ rights and treatment quality and governing medical liability. This significant gap has had serious consequences. On one hand, it has created an ambiguous legal situation in which the patient, the medical professionals, and even the competent legal personnel barely comprehend the rights afforded to patients and the rules governing medical liability should a medical accident occur. Although both the administrative judiciary and the regular judiciary have tried to fill this legislative gap by occasionally producing and developing rules of jurisprudence, these attempts have failed to clarify the rights and duties of each side and rebuild the trust between doctor and patient. They may have even indirectly helped produce a relationship based on apprehension and distrust among medical professionals afraid of prosecutions and judicial interpretations in the absence of clear legal rules, on one hand, and patients fearing medical errors and the length and complexity of litigation procedures, on the other. This ambiguity and mutual fear have resulted in a tendency for doctors to practice defensive medicine, which raises treatment costs. From another angle, this legislative and institutional gap has led to the absence of institutions and bodies concerned with patient safety and providing the necessary prevention and monitoring mechanisms to ensure the quality of health service and limit treatment risks.
Although the Ministry of Health began drafting the bill for the organic law on patients’ rights and medical liability in early 2013, several difficulties, most importantly the absence of a political will, have so far prevented the law’s issuance.
Reforming Health Facilities and Their Governance: Stopping the Bleeding
The national projects and programs for improving the health sector (most importantly the Hospital Restructuring Support Project that Tunisia implemented with World Bank support between 1992 and 1999) achieved significant results and caused a qualitative leap in the regulation and administration of public health facilities. Nevertheless, all the follow-up and evaluation reports by the Ministry of Health and oversight reports by the Court of Audit have underscored deep structural problems in these institutions and presented several recommendations for overcoming them as soon as possible, the most important being:
Support decentralized decision-making and management in public health institutions by bolstering their independence to encompass management of investments and personnel, and establish coordination and planning mechanisms on the national level.
Develop the information system in health institutions to encompass all aspects of the administration of these institutions and the medical services they provide.
Radically review the mechanisms of funding hospital expenditure, find urgent solutions for the public health institutions’ indebtedness, and enable them to access their arrears in the National Health Insurance Fund.
Improve strategic and forward-looking management in the public health facilities by adopting clear and precise goals, following-up their implementation, evaluating them completely objectively, and making the necessary decisions based on the results achieved.
Develop a national plan for improving the quality of health services by establishing a culture of quality and evaluation at all levels of the health system, with a focus on improving human resources via an integrated program for awareness-raising, sensitization, and training and establishing evaluation controls that encompass facilities, equipment, human resources, and administration systems.
Despite their importance, all these plans and recommendations remained ink on paper. They did not gain the support of any political actor, and the civil society organizations failed in turning them into a public issue and defending them. Here is where the COVID-19 pandemic succeeded superbly, removing the plans and recommendations from the drawers and placing them atop the desks of the highest state officials and at the forefront of public affairs.
Health: A Strategic Sector and Driver of Economic Development
For many decades, the Tunisian state has consistently dealt with the health sector as an obligation it must shoulder for compelling political and social reasons and a heavy financial burden to try to reduce as much as possible. This conception has been overtaken by events and rendered irrelevant by the vast investment opportunities that the sector provides today and the availability of large capacities that could be exploited to create a new economy based on producing and exporting health services and medical products. For Tunisia, despite all the aforementioned shortcomings, has three major comparative advantages in this area:
The presence of education and training institutions from which thousands of highly competent doctors and medical professionals have graduated – personnel who are continually drawn to work in Gulf countries and Western Europe. A national plan could be developed to improve these institutions’ training capabilities, increase their capacity, and turn them into regional hotspots for medical education and training in all health professions that enable a large number of Tunisian students to pursue study in these promising, high-employability sectors. These institutions could also be made to draw a significant number of African, Arab, and even European medical students, bringing significant income and direct and indirect investments that could transform the country into a regional center for medical studies and research.
The development of medical tourism and cosmetic medicine. Today, Tunisia is one of the countries emerging in this area. However, the success achieved so far is based on the individual efforts and initiatives of private sector institutions, while the contribution from the state and its institutions has been modest. The experience accumulated in this area could be drawn upon to implement a national health program. Under such a program, Tunisia would become Africa’s hospital and a health resort for wealthy people from Europe and around the world thanks to its distinguished medical cadre and its ability to offer these services at very competitive prices. This would require striving to raise the quality of the health services offered in public and private health facilities and providing the necessary legal and financial facilitations to the institutions wanting to operate in this area by creating the necessary funding and support mechanisms.
Tunisia’s involvement in pharmaceutical industries. This involvement began in 1970 with the establishment of the Society of Pharmaceutical Industries of Tunisia (SIPHAT), which allowed the country to create a solid core for a national industry in this area. The industry steadily developed until, by 2016, there were 74 companies operating in it, providing more than 86,000 jobs. Although this sector witnessed significant growth (approximately 12%) between 2000 and 2016, the margin for potential growth and development is much larger for several reasons. Firstly, Tunisian pharmaceutical industries possess significant competitive power, particularly when it comes to quality and production costs. Secondly, they are close to promising African and Arab markets. Thirdly, there should be a rise in the global demand for medicines, vaccines, serums, and medical supplies because of the growth in health sector spending and the health policy reviews that the World Bank and World Health Organization anticipate in most countries.
In conclusion, the COVID-19 pandemic has once again confirmed, to everyone concerned with the health sector and to Tunisians in general, the extent of the bizarre paradox between the sector’s vast capabilities and huge growth potential on one hand, and its harsh situation despite the country’s dire need for it and its development on the other. Blame for this paradox rests primarily with a political will that has been and remains oblivious, absent, or occupied with matters that do not benefit the people.
The question today is, will Tunisia manage to exploit this historical opportunity born from the crisis? Or will successive governments continue rubbing salt in the wound and wasting opportunities?
Keywords: Tunisia, COVID-19, Health, Public health, Health sector, Patients’ rights, Medical liability
 The Ministry of Health’s budget constituted 5% of the total state budget in 2018. The state’s grant for funding the public health institutions’ operating budget shrunk from 68% in 1992 to 3% in 2003, and its amount fell by approximately 90%.
 Ministry of Health study titled “Santé Tunisie en chiffres 2018”.
 According to statistics from the Ministry of Health, 46.5% of primary health centers operate one day per week and provide initial medical examinations and the minimum level of health services.
 In defensive medicine, doctors resort to carrying out many examinations and tests and provide patients with the treatment with the least complications, rather than the ideal treatment for their cases, for fear of legal prosecution due to the unclear rules governing medical liability. For more information, see Dominique Demers, La médecine défensive: fondement, principes responsabilité médicale et solutions.
 Mahdi Elleuch, “Huquq Marda Tahta Rahmat al-Lubiyat al-Qita'iyya fi Tunis”, I'adat Mashru' Qanun Huquq al-Marda wa-l-Mas'uliyya al-Tibbiyya li-Lajnat al-Sihha”, The Legal Agenda, 22 January 2020.
 This data is from a press interview with the general director of manufacturing industries in the Ministry of Industry and Small and Medium Businesses by Assabah, 11 October 2016.