Medical tourism in Tunisia flourishes as tourist numbers reach record highs

Tunisia has over 1200 km of coastline to the north and east, and is bordered by desert and oasis to the west, allowing it to enjoy a mild Mediterranean climate. With over 30,000 archaeological sites around the country, it offers a wide array of tourism options.

Since suffering two terrorist attacks in 2015, in March at the Bardo Museum in Tunis and in June at a resort in Sousse, the country has worked to slowly re-establish itself as a safe and attractive holiday destination. Indeed, following a robust performance in 2018, in which visitor numbers reached an all-time high, the sector is poised to continue growing. Furthermore, niche segments such as medical tourism are attracting new source markets to the country.

Economic Contribution

Tourism plays an important role in the Tunisian economy, providing a much-needed infusion of foreign currency. It is a strong contributor to the domestic market and accounts for around 8% of GDP. In addition, it provides employment for an estimated 400,000 people, of which approximately 85,000 are directly employed. However, it should be noted that there is a strong seasonal bias in employment levels.

According to the National Office of Tunisian Tourism (Office National du Tourisme Tunisien, ONTT), in 2018 the sector not only returned to levels seen prior to 2015 for the first time, but exceeded them, with revenue hitting TD4.1bn ($1.4bn), some 14% above 2014’s numbers and 45% over 2017’s relatively weak performance. The Tunisian Federation of Hoteliers (Fédération Tunisienne de l’Hôtellerie, FTH) suggests that revenue is much higher than indicated by the ONTT. The FTH says that the ONTT’s calculations omit local currency spending. As roughly 65% of tourists entering Tunisia conduct their transactions in Tunisian dinar, this is a substantial omission. The numbers include visiting residents of North Africa, spending from Tunisian residents living abroad, income from medical tourism, and revenue from air and sea transport. The FTH believes that revenue generated by the tourism sector in 2018 was actually closer to TD7.2bn ($2.5bn), and puts the sector’s GDP contribution at between 13% and 17%.

In Figures

Arrivals to Tunisia continued apace throughout 2018, with data from the ONTT indicating that foreign arrivals increased by 18% to reach 8.3m. Visitor numbers from Algeria rose by 9% to 2.7m, representing 39% of all arrivals. This was followed by Libya, at around 22%. European tourists have also been regaining confidence to travel to the country: visitors from Germany increased by 52%; Belgium by 93%; France by 37%; and incoming visitors from the UK were up four-fold. Although the trend among Europeans is encouraging, there remains considerable potential for growth, and visitor numbers are still a substantial 14% lower than 2014 levels and 37% below pre-Arab Spring levels. The increase in tourist arrivals translated into a greater number of overnight stays, with total non-resident hotel bookings increasing by 30%. Once more, a notable increase was seen among Europeans: German stays were up 47%; stays by Belgian tourists rose 163%; UK stays by 822%; and French by 48%. big tour operators like the UK’s Thomas Cook and Anglo-German company TUI contributed strongly to the turnaround in visitor numbers. In hand with the surge in European tourism, in 2018 the number of visitors travelling to the country by air increased by 37% to account for 45% of all arrivals, while 54% travelled into the country by road and 1% by sea.

Looking forward, René Trabelsi, the minister of tourism and handicrafts, announced that Tunisia’s goal is to attract over 9m holidaymakers in 2019, which would represent an 8% increase over 2018, with this increasing to 10m in 2020. Visitors from Europe are expected to rise by at least 30% in 2019 based on predictions announced earlier in the year. The country hopes to attract 1m French tourists, 640,000 Russian tourists and 390,000 German tourists in 2019. This is partially due to Tunisia’s participation in a number of international tourism exhibitions, which is aimed at further bolstering tour operator numbers. The country also hopes to attract the attention of Tunisians living abroad, who accounted for 1.3m tourists in 2018, as well as that of residents in other North African countries.

Early data for 2019 suggests that the target for 2019 may well be achievable, with arrivals for the first quarter up 17.4% year-on-year (y-o-y). In addition, the sector’s revenue increased by 35% to TD787.8m ($273.6m) for the quarter, bolstered by the higher arrivals from Europe, which were up 22.3% y-o-y.

Open Skies

In an effort to attract a greater number of tourists, in December 2017 Tunisian officials finalised an open skies agreement with the EU. The deal was expected to open Tunisia’s airspace to competition from low-cost European airlines, thereby boosting tourism numbers and increasing revenue in the sector. A similar deal that was signed between Morocco and the EU in 2006 preceded the doubling of its foreign arrivals. Indeed, tourism officials in the country estimate that a Tunisia-EU open skies agreement could boost GDP by 2.7% and increase arrivals by 800,000 over five years.

However, the accord has yet to take effect, with both sides working to ratify the deal. Brexit is believed to be causing delays on the part of the EU, while local media in Tunisia reports that the delay is due to challenges that the agreement may present to local air carriers. “The modernisation of infrastructure – that is, airline, road and port – is key to developing the tourism sector,” Tarak Cherif, president of the Tunisian Confederation of Citizen Enterprises, told OBG. “In particular, the open skies agreement would give Tunisia exposure to the dynamic last-minute holiday market, which it is currently excluded from by a lack of connectivity,” he said.

Services

Beyond infrastructure and maintaining a high level of security, one of the biggest challenges facing Tunisia is its reputation as a mass-market destination. The country is trying to address this through diversification in its hotel options and by improving the level of services offered in the country. To this effect, in 2017 the government established a hospitality training agency. Thus far the agency has been successful, with eight centres now open, offering 2300 training positions across a range of competencies. It is also establishing partnerships with schools in France, Belgium and Switzerland, in order to ensure that both its teachers and trainees remain abreast of the latest approaches and developments within the international industry.

In 2017 the Ministry of Tourism and Handicrafts launched a new label, Quality Tourism Tunisia, to establish a quality-promotion mechanism in the sector. It was the culmination of a two-year, €1.4m collaboration between Tunisia, the EU, France and Austria. Travel agencies, hotels, guest houses, restaurants and other sites of interest are eligible to apply. If successful in obtaining the label, assistance will be provided to help recipients further improve their services, profitability and brand image.

Hotel Infrastructure

The World Economic Forum’s “Travel and Tourism Competitiveness Report 2017” evaluated Tunisia’s tourism infrastructure and ranked it fourth in Africa and first in North Africa. This placement was based on four indicators: the number of hotel rooms, the quality of tourism infrastructure, the presence of large international car rental companies and the number of cashpoints in the country. Indeed, following several lacklustre years in the industry, international hotels are once again investing in the country.

According to the “2018 Pipeline Report” published by W Hospitality Group, it is the sixth-most-attractive country in Africa for hotel investors. The report lists 21 hotels as being under construction, which will add a total of 4279 rooms. A number of luxury hotels are also set to open. The Four Seasons opened its doors in early 2018. This is expected to be followed by Mövenpick, Avani and Anantara hotels by the end of 2019. Meanwhile, a Ritz-Carlton at Carthage is reported to be in the pipeline. These hotels are geared towards attracting new high-end clientele from throughout Asia and the Gulf region.

New Markets

Prior to the Arab Spring and the 2015 terror attacks, Europeans represented 49% of tourists and 83% of hotel stays. With visitor numbers plummeting in 2011 to an all-time low in 2016, Tunisia has looked to new markets to attract more tourists. Its biggest success has been seen in Algerian visitors, which have increased from around 1m, or 13.5% of tourists in 2010, to over 2.7m, or 33% of the total, in 2018. This growth was facilitated by improved procedures and amenities at the border, and a number of marketing campaigns promoting Tunisia as a holiday destination in Algeria. These include a 2018 deal between a private Algerian operator and Tunisian Post that allows Algerians to obtain a bank credit card, as well as offering its cardholders a 20% discount at numerous medical clinics.

Algerians do not spend as much as their European counterparts, preferring holiday rentals to hotels and restaurants, and often arrive with their own method of transportation. Despite representing 33% of visitors in 2018, Algerians accounted for a modest 9.4% of overnight hotel stays. Nevertheless, this market remains a key contributor to the success of Tunisia’s tourism sector – a role it is unlikely to cede in the near future. It is expected that the number of Algerian tourists could reach 3.2m in 2019.

Russians have also been holidaying in Tunisia in increasing numbers. In 2018 that figure reached 630,000, or almost 8% of the total, firmly establishing Russia as a key player in Tunisia’s tourism landscape. At the 26th annual Moscow International Travel and Tourism Convention held in March 2019, Trabelsi indicated that they anticipate somewhere between 650,000 and 750,000 Russian tourists in 2019, with potential for up to 1m in 2020 following the engagement of Russian tour operators. Russian tourists spend similarly to Europeans, preferring coastal resorts such as Hammamet, Monastir, Djerba, Sousse or Nabeul, and generally stay at four- or fivestar, all-inclusive hotels. ONTT data suggests that, at 6.1m overnight visits, Russian tourists were the biggest source of hotel stays in 2018.

Tunisia also continues to focus on China, one of the tourism industry’s fastest-growing foreign markets. Following the cancellation of visa requirements for Chinese tourists in 2017, Tunisia has seen a surge of interest from the country, with visitor numbers jumping from 7400 in 2016 to 27,900 in 2018. In October 2018 the then-minister of tourism and handicrafts told local press that Tunisia has been making trips from China more convenient and enjoyable, by “upgrading payment methods, setting up Chinese logos, launching direct flights as well as running Chinese restaurants”. It appears that this strategy is beginning to work, and data from online Chinese travel agency Ctrip states that during China’s 2018 week-long national day holiday in October, Tunisia figured in the top-10 preferred destinations.

Lastly, Tunisia continues its efforts to increase ties with the Gulf. Notably, in 2018 it revised visa requirements for residents of the GCC, enabling them to acquire visas on arrival. With the recent spate of luxury hotel openings and the launch of a digital platform in the region, there was a 10% increase in tourist arrivals from the Gulf in 2018.

Medical Tourism

Tunisia boasts a well-developed medical tourism industry. This results in part from its proximity to and shared language with many European and Arab markets, as well as its reputation for highly competent medical staff. The country is an established destination for Europeans seeking cosmetic surgery, and other procedures such as gastric bypass are growing in popularity. “Lots of French patients are already coming to Tunisia for bariatric surgery, as it is much more accessible here than in France,” Imed Hadj Hassine, deputy director-general of Tunisian medical clinic Clinique Pasteur, told OBG, citing French regulations that require patients to try other weight-loss strategies before they are eligible for surgery. Other important source markets include Libya and Algeria, both of which have health systems that fund patients’ treatment abroad. Of particular importance is Libya, where years of civil crisis have damaged health infrastructure.

A recent report by the Global Wellness Institute (GWI), a national industry body, shows that in 2017 Tunisia welcomed 577,300 wellness tourists, who spent a total of $313.8m. The report found that tourists in the MENA region spend 44% more on average during a wellness trip than on a normal holiday. The GWI also notes that hot springs and mineral-rich seawater treatments are popular among with wellness travellers. Tunisia is a top destination for seawater-based thalassotherapy and benefits from a dedicated legislative framework that upholds high standards. According to the GWI, plans are currently under way to privatise thermal centres and build some 54 new facilities in Tunisia by 2020 in order to capitalise on the burgeoning market.

“Africa is the most promising region in terms of promoting development of medical tourism in Tunisia, with cardiac surgery showing strong potential,” Hassine told OBG. Meanwhile, he notes that increasing levels of international accreditation at Tunisian health facilities will also help to boost European arrivals in coming years, with particular promise shown by orthopaedic medicine.

Heritage

Tunisia is home to seven UNESCO World Heritage sites of archaeological merit and boasts over 30,000 historic sites of interest. However, poor governance, unclear strategy and lack of investment means that only 60 sites are open to the public, and many of these are in poor repair.

The government has been making an effort to increase interest in cultural tourism, and the Ministry of Tourism and Handicrafts recently inked agreements with Russian tour operators to boost promotion of tours in Saharan oases such as Tozeur. They also agreed on the continued operation of charter flights to the Monastir and Enfidha airports, with increased focus on desert excursions from these beach resorts. Heritage tourism represents a considerable opportunity, especially as it aims to increase Chinese visitors to 50,000 by 2020.

In nearby Morocco, a country that offers a similar climate and holiday experience, visa requirements were similarly abolished in 2016. However, in comparison to Tunisia’s 27,900 Chinese visitors in 2018, Morocco welcomed over 180,000; its extensive cultural tourism offerings appear key to this difference. Mohamed Basly, president of the China-Tunisia Cooperation Council, told local media that in order to better meet Chinese tourist demands, Tunisia needs to improve its infrastructure and increasingly highlight its many cultural and historic sites. These sentiments were echoed by Mohamed Essayem, regional tourism commissary in Kébili-Douz, an area in the south of Tunisia which hosts ecological, cultural, sporting and adventure holiday circuits, and welcomed almost 166,000 tourists in 2018. “In order to further boost tourism in the region, investment is needed to bring tourist offerings up to standard, while regular flights with the capital need to be reinstated to facilitate access to the south,” Essayem told OBG. According to industry observers, in order for Tunisia’s cultural sites to meet tourists’ expectations, deep reforms are needed. These include restructuring institutions charged with overseeing cultural patrimony, retraining personnel and revising sources of financing. In the longer term, improving the education provided to Tunisians regarding the country’s rich historical heritage will motivate them to make the most of its resources and create systems of their own to protect the country in the future.

Outlook

With heightened security measures raising tourist confidence and the weak dinar making holidays in Tunisia increasingly attractive, the tourism sector is seeing a renaissance. However, in order for this growth to be sustainable, investment is needed to modernise and improve supporting infrastructure. Furthermore, most historic or cultural sites require a significant influx of restoration funds and better general management in order to attract greater numbers of international tourists.

Nevertheless, as Tunisia continues to build on its quickly diversifying tourist base, and with Europeans returning in droves to take advantage of the country’s sunshine and beaches, the outlook for the sector is bright. Government commitment is strong, and with better organisation and investment, the tourism sector has ample potential to become a significant driver of sustainable development in the region.