Since gaining independence in the 1950s, Tunisia has prioritised the development of its health care system and has introduced basic services to a large share of its population. Nevertheless, the system is currently in need of pressing reforms to improve the quality of its services, particularly in the public sector. To this end, a reform announced by the government in March 2019 is set to overhaul the system and strengthen Tunisia’s position as a medical centre for Africa.
Structure & Oversight
The health system comprises the public, private and public-private sectors structured around three levels of care: primary, secondary and tertiary. The public sector is the primary health care provider, accounting for 79% of total hospital capacity in 2017. The Ministry of Health (MoH) oversees the sector and implements health policies, while the Central Pharmacy of Tunisia (Pharmacie Centrale de Tunisie, PCT) is the exclusive importer of drugs, and the sole distributor of drugs in the public sector.
According to the MoH, as of August 2019 the public sector comprised a total of 2263 health centres, of which there were 2058 basic health centres, 109 district hospitals, 33 regional hospitals, 24 basic health groups, 21 public health establishments, nine regional health education centres, six specialised centres and three military hospitals. In the private sector there was a total of 3351 centres, of which there were 1536 pharmacies, 1260 dental offices, 224 laboratories, 117 radiology centres, 100 haemodialysis centres, 75 clinics and 39 medical imaging centres. Regarding the public-private sector, there were six polyclinics (belonging to the National Social Security Fund) and six haemodialysis centres. Total hospital bed capacity stood at 26,715 in 2017 compared to 25,830 in 2016.
According to the most recent World Bank data, life expectancy at birth was 76 years in 2017, compared to 75 in 2007 and 62 in 1980. Tunisia has the third-highest life expectancy rate in Africa, after Morocco and Algeria. At the broader level, Tunisia’s score is above the world average of 72 years but below the OECD average of 80 years.
The infant mortality rate per 1000 live births improved from 17.5 in 2007 to 11.2 in 2017, putting Tunisia above the OECD average of 5.7. The maternal mortality rate per 100,000 live births also decreased, from 74 in 2005 to 62 in 2015, although some regions remain disproportionately affected. According to Rafla Tej Dallegi, the president and CEO of the National Office for Family and Population, the maternal mortality rate per 100,000 live births dropped to 30 by end-2018.
National health policies have emphasised the need to improve the quality and provision of primary health care throughout the country, as well as supporting the decentralisation of the system and providing care at the local level. Investment in training, equipment and primary health centres are supporting this decentralisation shift. Tunisia also delivers preventative health care services to school and university students.
However, poor governance and corruption have weighed on the sector in recent years. A 2017 report by the Tunisian Association Defending the Right to Health (l’Association Tunisienne de Défense du Droit à la Santé, ATDDS) denounced governance issues in Tunisian hospitals and recommended a reform of the national health system.“Tunisia’s health care system has had to grapple with weak governance and a lack of oversight since the revolution,” Boubaker Zakhama, chairman of the National Federation of Health, told OBG. In 2019 the Bloomberg Healthiest Country Index, which assessed the health systems of 169 countries according to diverse variables such as life expectancy, access to clean water and eating habits, ranked Tunisia as the second-most-efficient health system in Africa, losing its top position from 2018 to South Africa.
Although health infrastructure is available throughout the country, regional disparities remain, notably in the south and central west. While primary health establishments are relatively spread across the territory, tertiary-level institutions are usually concentrated in big coastal cities, such as Tunis and Sousse. To help tackle this issue, Tunisia is adopting e-heath solutions to broaden access to care. In a bid to support the development of e-health in Tunisia, in February 2019 the French Development Agency signed a loan agreement of €27.3m with the MoH. The agreement targets the implementation of a digital information system including electronic medical records, digital archives and digital medicines distribution. It also plans to implement telemedicine in five hospitals before introducing the technology to other hospitals around the country. In other news, Abderraouf Chérif, the then-minister of health announced in February 2019 the digitalisation of 22 university hospitals to be carried out in 2019-20.
Over the decades Tunisia saw the decline and, at times, eradication of numerous communicable diseases, largely thanks to an efficient prevention strategy and a compulsory vaccination policy. For instance, as a result of a programme ongoing since 1959 aimed at fighting tuberculosis, the country has made significant progress in the eradication of this disease, the incidence of which dropped from 48.8 per 100,000 people in 1976 to 21.4 in 2000, according to the MoH. However, Tunisia experienced a significant upsurge of the disease during the last decade, as the rate of incidence increased from an average of 26 per 100,000 people between 2000 and 2010 to 38 in 2016. The government took measures to counter this outbreak by launching a strategy covering the 2017-21 period to fight the disease. During the first year of the plan’s implementation, the rate of incidence per 100,000 people dropped to 29, according to the MoH.
Changing lifestyles, informal settlements and an ageing population have contributed to a rise in the incidence of non-communicable diseases over the past two decades, a challenge for a health system that has been historically focused on fighting communicable diseases. According to the ATDDS report, non-communicable diseases caused 82% of deaths in 2017 compared to 63% globally, with cardiovascular disease the top cause of death. It was also estimated that 2m Tunisians suffered from hypertension, 1m from diabetes and that there are 15,000 new cases of cancer each year.
To tackle the growing incidence of non-communicable diseases, Tunisia designed the National Strategy for Non-Communicable Diseases 2018-25, which is focused on prevention through the promotion of health and physical activity. Among other objectives, the campaign is targeting the reduction of smoking and salt intake.
The public health sector was brought under both local and international scrutiny in March 2019 following the sudden death of 15 newborns at the Rabta hospital in Tunis, which led to the resignation of Chérif as the minister of health.
In light of recent events, a series of investments aimed at improving the public health care sector were announced between March and April 2019. Sonia Ben Cheikh, the acting minister of health, promised to invest TD80m ($27.8m) for the modernisation of computer systems in Tunisian hospitals, with the broader objective of boosting telemedicine. Additionally, an investment of TD15m ($5.2m) is earmarked to equip all health care infrastructures with computers over the 2020-21 period. Moreover, the National Pension and Social Welfare Fund is set to receive an investment of TD100m ($34.7m), while the government promised to pay the TD200m ($69.5m) worth of debt owed by hospitals to the PCT and invest a total of TD107m ($37.2m) in hospital equipment. Lastly, the government also announced that public hospitals will recruit 2000 additional employees by the end of 2019.
The private health sector grew considerably over the last two decades, with the number of private hospital beds increasing from 2100 in 2001 to 6000 in 2019. “This number is expected to reach 10,000 by 2024,” Zakhama told OBG. “There are at least 70 clinic projects under way, each at various stages of completion.” Compared to the public sector, the private sector offers the bulk of heavy equipment, including scanners and MRI machines. “Two-thirds of heavy equipment in the industry are provided by the private sector,” Zakhama said.
Medical Staff & Insurance
One of the biggest assets of Tunisia’s health system is its qualified medical staff. In 2017 there were 14,896 doctors – of which 6491 were general practitioners and 8405 were specialists – with a ratio of 130 doctors per 100,000 inhabitants. However, the spread of medical practitioners remains imbalanced: in 2017 the Tunis governorate had the highest medical density, at 334 doctors for every 100,000 inhabitants, while Sidi Bouzid, which is located in the centre of the country, had 51 doctors for every 100,000 inhabitants.
In addition to the regional disparity, recurring strikes, coupled with a lack of equipment and medicine, have also weighed on the availability of medical personnel. In a local media report published in March 2019, Youssef Chahed, the head of government, estimated that 4000 doctors left the country over the 2017-19 period to seek work abroad. Furthermore, the ATDDS reported an increasing number of doctors emigrating in recent years, with half of all newly registered doctors in 2018 having left the country. Moreover, there is a lack of medical specialists in regional hospitals and more generally in the public sector overall: in 2017 the private sector accounted for 60% of all specialists.
In terms of health insurance, which has been compulsory in Tunisia since 2004, around 82% of the population is covered, according to the Centre for Research and Social Studies in May 2019. Some 58% were covered by the National Social Security Fund, 17.5% were under the Reduced-Price Medical Assistance scheme and 7.3% were under the Free Medical Assistance scheme. This left 17.2% of Tunisians without health insurance.
With a strategic geographic position, and a relatively affordable health care system, Tunisia has long been regarded as a reliable medical destination in the region. Every year about 500,000 foreign patients seek inpatient care at Tunisian hospitals and around 2m-2.5m foreign patients utilise outpatient care. The bulk of foreign patients come from its bordering neighbours, Libya and Algeria, but a sizeable number also come from sub-Saharan Africa. Zakhama believes that Tunisia’s outpatient care could see potential growth in the future; however, certain barriers must first be addressed. “One of the main challenges to the development of this segment is our air fleet, as we do not cover all African countries. We cannot compare our fleet to Morocco’s, for example, which has far more connections to Africa than Tunisia has,” he told OBG. While this segment is expected to help support sector growth, it has also led the country to financial difficulties. According to Zakhama, care provided to Libyans has accumulated a debt of TD240m ($83.4m).
The pharmaceutical industry has been growing since the 1990s, when a number of incentives and a favourable legal framework were put in place. The size of the market is estimated at TD2.4bn ($833.6m), of which 75% is generated by the private sector and 25% by hospitals. The sector still has room for development, given that local production covered about 60% of domestic needs in 2018. In June 2019 Ben Cheikh announced that Tunisia aims to cover 70% of its pharmaceutical needs by 2020.
Although five multinational companies left the Tunisian market in 2018 due to operational challenges, Tunisia remains a regional centre for manufacturing and foreign firms are still active. In 2019, 18 international companies were members of the Association of Innovative Pharmaceutical Research Companies and had a direct presence in the country.
Between 2012 and 2017 medicine exports rose from TD60bn ($20.8bn) to TD116bn ($40.3bn). Tunisia’s main pharmaceutical export markets are Libya, Senegal and Côte d’Ivoire. While rising export numbers point to a growing industry, Sofiene Zerelli, national sales manager at global pharmaceutical company AstraZeneca, noted that the pharmaceuticals market overall has been experiencing headwinds. “The market has been slowing down in recent years because of a decline in the purchasing power of Tunisians,” Zerelli told OBG.
In December 2018 Tunisia faced a shortage of drugs, many of which were vital. According to the then-minister of health, 20% of drugs were unavailable at that time. This was due in large part to Treasury issues encountered by the PCT, as a result of payment delays from the National Health Insurance Fund and public hospitals.
In spite of these challenges, a number of pharmaceutical projects are under way. In April 2018 the Tunisian multinational laboratory, MédiS, inaugurated a TD50m ($17.4m), 3700-sq-metre production unit dedicated to anti-cancer medicine in Aïn Kmicha, located in the north-eastern part of the country. The intake of dietary supplements has also increased in popularity in recent years. In June 2018 Aleonat, a pharmaceutical laboratory in Sfax specialising in the production of dietary supplements, received an undisclosed amount of funding from the Tunisian American Enterprise Fund in June 2018, backed by the US Agency for International Development. The investment is expected to go towards plans to expand capacity at Aleonat’s existing plant, launch new products and recruit new talent.
In addition to the pharmaceuticals market, some experts forecast growth of the biosimilars and clinical-research segments will support the development of the health sector. “An opportunity for our local industry lies in the manufacturing of biosimilar medicines,” Chokri Jeribi, director of local firm Jeribi Consulting Pharma, told OBG. “Moreover, clinical research is on the rise and could bring a return on investment 20 times higher than drug exports.”
With a growing demand for services from both nationals and foreigners, the health sector remains a crucial pillar of Tunisia’s economy. The country’s low health care costs is a key competitive advantage, attracting patients from Africa and Europe. However, many challenges need to be addressed before the sector can realise its full potential. To this end, the raft of investments is expected to improve the quality and provision of care. The pharmaceutical industry also presents significant prospects for the sector, notably in dietary supplements, biosimilars and clinical research.