Public and private infrastructure projects boost health care standards in Tunisia

Health care has been a national priority for the Tunisian government since the country gained independence from France in 1956. A focus of continued investment, the health care sector has since seen the development of a nation-wide network of public hospitals and health centres, with the country quickly becoming a model in North Africa.

In recent years, the private health care sector has taken the lead in terms of investment, with the construction of a number of new health clinics. This development is set to help the North African country to solidify its position as a regional medical tourism destination. The combination of private sector investment and public sector reforms positions the sector for continued growth.

Governance

The public health system is overseen by the Ministry of Health (MoH), with the support of various public institutions in charge of sector policy and quality control. The National Centre for Drug Control is tasked with quality control and overseeing the pharmaceuticals sector’s regulatory framework. The National Centre of Pharmacovigilance is in charge of the legal aspect of the industry by following up when a drug is found to have adverse effects, and the Directorate of Pharmacy and Medicines (Direction de la Pharmacie et du Médicament, DPM) authorises the release of drugs on the market.

Structure

The health care system includes three levels of care. According to the National Statistics Institute (Institut National de la Statistique, INS), in 2015 the primary level comprised a network of 14 general hospitals and 2123 basic health centres across the country. The secondary level included 108 district hospitals, while the tertiary level was made up of a network of 32 regional hospitals and 21 specialised teaching hospitals known as centres hospitaliers universitaires (CHU).

The public sector remains the main health care provider in Tunisia, accounting for over 80% of the country’s hospital bed capacity, with over 30,000 beds. With numerous projects under way, public health care infrastructure is set to continue to expand in the coming years to accommodate an expected significant rise in demand.

The 2014 constitution declared health a human right under Article 38, making the state responsible for ensuring curative and preventive health services. The government is also now legally required to guarantee social protection and free health care for low-income populations.

Indicators

Significant socio-economic development over the past few decades has also contributed to important demographic and epidemiologic changes to the country’s health profile. Life expectancy at birth increased from 62 years in 1980 to 75 by 2015, according to the World Bank. Fertility rates have also declined considerably, from 5.2 children per woman in 1981 to 2.2 by 2013, according to World Health Organisation (WHO) data, while the maternal mortality ratio fell from 131 deaths per 100,000 live births to 62 between 1991 and 2015.

Deaths by communicable diseases have also decreased significantly thanks to widespread vaccination campaigns and improved access to clean drinking water and sanitation facilities. Immunisation rates for diphtheria-pertussis-tetanus and measles reached 98% in 2014, up from 62% and 43%, respectively, in 1982-83. According to World Bank data, 97.7% and 91.6% of the Tunisian population had access to improved water sources and sanitation facilities, respectively, in 2015.

At the same time, however, as the population’s overall socio-economic status improved, non-communicable diseases (NCDs) have quickly become one of the main health concerns for the country. According to the WHO, NCDs, including diabetes, cardiovascular conditions and cancer, were responsible for an estimated 82% of deaths in 2012. In 2015 one in six Tunisians suffered from diabetes and over 60% of adults over the age of 35 were overweight.

Public Infrastructure

Moving forward, Tunisian authorities are looking to develop additional infrastructure in the country’s south, in a bid to address regional inequalities. In 2016 the MoH was allocated a budget of TD1.8bn (€771.9m), a 9% increase compared to the TD1.6bn (€686m) earmarked for the sector in 2015, with the added funds directed towards upgrading basic health care infrastructure in remote areas.

The health care sector was also prioritised under the Tunisia 2020 strategy, with a TD1.1bn (€471.7m) infrastructure package. Among the upcoming projects under the strategy are a new CHU in Kairouan, two hospitals in Beja and Gabès, as well as eight new regional hospitals in Jelma, El Jem, Makthar, Dahmani, Haffouz, Thala, Sbiba and Manouba. The projects stand in addition to an oncology centre slated for Tunis and a 256-bed hospital in Sfax, a TD120m (€51m) investment under way since March 2016. Funded by China, the project is due to be completed by 2018 at the latest, according to the MoH. A new €60m hospital in Gafsa is also under way, funded under a debt-conversion agreement with France.

Private Sector

Meanwhile, the private sector continues to develop at a steady pace. Fuelled by growing demand for medical services, private clinics have been on the rise since the 1990s, and currently account for close to 20% of the country’s overall bed capacity. According to INS data, the private health care sector is composed of 91 clinics and 7675 private practices, relying on a workforce of some 3101 general physicians and 3614 specialised physicians, roughly 49% of doctors in the country.

“The private sector offers more comfort and quality than the public sector, which suffers particularly from a maintenance issue,” Mourad Kharouf, director-general of Polyclinique Les Jasmins, a private clinic in the capital, told OBG.

Private health care infrastructure in Tunisia is expected to increase significantly in the coming years, as the sector looks to capitalise on rising demand, both domestic and foreign. Private clinics receive support from the government in the form of fiscal incentives, and the government has also been generous with authorisations for new clinics to open. “In Tunis there are about 41 projects in the pipeline and the MoH continues to give out new authorisations,” Kharouf told OBG.

The private sector is also leading the drive towards innovation, with the launch of new start-ups. One local start-up is AlloTabib.net, a platform linking patients to suitable, nearby and available doctors. According to the app’s founder, Rebai Hamida, around 312 doctors and more than 1200 patients had signed up for the service by June 2016. The company’s five-year plan foresees the firm managing data for 100% of the country’s hospitals and 70% of clinics. Thanks to the platform, patients can see doctors’ schedules, qualifications and patient reviews, and from there choose the most suitable practitioner and make an appointment.

Human Resources

With demand for health care services on the rise, the private and – to a lesser extent – public sectors are increasingly facing shortages of medical staff. According to MoH figures, the health care sector employs over 58,000 people, with the public system accounting for about 86% of that figure. In terms of doctors, 51% are part of the public system, with the private sector making up the remaining 49%. “There is direct competition between the public and the private sector over staff, though the public sector is able to attract more human capital as it can give certain guarantees such as job stability,” Kharouf told OBG.

Though the public sector is able to more easily attract human capital thanks to MoH recruitment campaigns, assigning staff to remote areas of the country continues to pose challenges. “When it comes to assigning medical staff, the disparities in Tunisia are between the east and the west, rather than the north and the south,” Amor Toumi, a health consultant and former director of the DPM, told OBG. “It remains extremely difficult to allocate staff to parts of the western region of the country.”

Under the current system, medical staff pass a national exam and get assigned accordingly. However, Toumi believes the regionalisation of staff recruitment would be a more effective way to ensure basic medical coverage in each region. According to Toumi, this would ensure local talent remains in the region and would therefore contribute to quality improvements in some of the more remote and inaccessible areas of the country.

The staffing shortage is particularly acute for specialist doctors and paramedical staff, though it extends as far as administrative positions. The situation is also made worse by a degree of brain drain, with some Tunisian health professionals choosing to leave the country to look for career opportunities in Europe, particularly in France.

Medical Tourism

The private sector continues to lead the national effort around boosting Tunisia’s medical tourism sector. According to Mohamed Salah Ben Ammar, the former minister of health, in 2013 Tunisia received 155,000 medical tourists. Patients seeking medical treatment in Tunisia come primarily from four key markets.

The largest is neighbouring Libya, whose citizens have been seeking medical treatment in Tunisia for decades. While the ongoing unrest in Libya has caused a decline in the number of Libyan patients seeking private health services in Tunisia since 2015, Libyans still make up an important market. The future of this source market depends on political developments. “Nowadays relying entirely on Libyan patients to keep a clinic up and running is a risk given the instability in Libya and the real possibility of the borders closing one day to the next,” Kharouf told OBG. “Some clinics, especially the ones closer to the border, served a clientele that was 95% Libyan, and they are currently experiencing financial difficulties. However, Libyan medical tourism remains interesting enough to continue to attract attention, as they come over to solicit all types of treatment.”

The second-largest source market is Algeria, whose citizens primarily seek specialised types of medical treatment in Tunisia, in particular ophthalmology and fertility treatments. The wider African market is slowly beginning to expand. “Currently, the main client base from Africa is composed primarily of local civil servants and their families, as well as the wealthiest class,” Kharouf said. “In this, we are in direct competition with Turkey and Morocco, and Tunisia is now beginning to slowly court the West African francophone market.”

Though smaller, the European market – in particular the French and Italian markets – is also significant. European medical tourists primarily come for plastic surgery procedures and other treatments not covered by the European insurance system. “Plastic surgery is a highly competitive market, which is positive as it attracts medical tourists, but also negative as certain clinics will sacrifice quality for profit,” Kharouf told OBG.

Thermal Therapy

Tunisia is also known as a hydrotherapy destination, a practice dating back to Roman times. According to the National Office of Thermalism and Hydrotherapy (Office National du Thermalisme et de l’Hydrothérapie, ONTH), Tunisia has more than 1000 thermal springs known to possess specific chemical compositions with therapeutic qualities that help treat medical conditions such as arthritis and rheumatism. Thermal therapy stations began to flourish in the region in the 1960s, with centres operating around hot water springs in Korbous, Hammam Bourguiba and other towns.

Today the country boasts four important thermal stations and over 40 hammams offering different treatments, with some centres attracting more than 14,000 annual visitors, according to local media. The country has ambitious targets for the development of the tourism subsector. According to the ONTH, authorities are working to establish 54 new hydrotherapy centres by 2020, raising the total number of facilities in the country to 100. The measures are expected to attract 375,000 spa visitors by 2020, with revenues of around TD200m (€85.8m).

Outlook

Tunisia’s achievements since independence in terms of the progress made in improving health indicators and reducing the threat of communicable diseases is remarkable. Nonetheless, the country is now faced with lingering challenges such as profoundly unequal service provision in urban and rural areas and a rapidly changing health profile. Curbing the rising national health burden from NCDs, for example, will require greater emphasis on preventive care and ensuring regional gaps are bridged. Overcoming these challenges will be key to ensure Tunisia remains a health care model for the region and a preferred medical tourism destination.