Moroccan Journal Of Public Health Vol.2, N°1 1(2021), 22-43 ISSN: 2658-8099
Research Article
The devastating impact of covid-19 on the health system in Tunisia
Abdelala BOUNOUH
Independent consultant, Tunisia
Corresponding author: abdelala.bounouh@laposte.net
Article info
Received : June 2021 Accepted : July 2021 Online : July 2021
Keywords Covid-19;
Pandemic;
Health system;
Governance;
Medical staff;
Geographic information system;
Epidemiological status.
.
SUMMARY
Health systems around the world are facing challenges due to the COVID-19 pandemic. This unprecedented global health crisis reveals the shortcomings and dysfunctions of every health system regardless of the degree of development of the country. In Tunisia, the health crisis linked to Covid-19 has exposed the new reality of the Tunisian health system which has to deal with numerous human and material issues and structural and financial difficulties. Based on statistics of the World Health Organization and the Tunisian Ministry of Health, we aim in this study to highlight the effects of COVID-19 on the Tunisian health system 11 months after the outbreak of the pandemic in the country. In this article, we discuss the dynamics of the spread of the virus at the national and regional levels, the shortcomings of the Tunisian health system in the fight against the pandemic, and we evaluate the strategy adopted (where? By whom?) to limit the spread of the virus. Our study has shown that despite the deterioration of the health infrastructure and the economic and political crisis in the country, the main bulwark against the pandemic remains the public hospital.
In addition, the mobilization of health professionals at the beginning of the crisis by the civil society helped reduce the burden on public hospitals. In order to improve the governance of the country's health system, we advocate for the implementation of a Geographic Information System (GIS), able to ensure epidemiological surveillance, determination of primary health care needs, health planning, as well as improving the quality of healthcare
1. Introduction
The global spread of the “ of most health systems around the world. The COVID-19 pandemic weighs heavily on national health systems, especially in low-
income countries and the health system in Tunisia is no exception. Indeed, within a year, the health crisis has affected social, economic and even political life.
Moreover, COVID-19 has uncovered the weaknesses of the health system, particularly, unequal access to
healthcare between the Tunisian regions, the devaluation of health care personnel, the lack of materials, equipment and drugs in hospitals. Thus, the objective of this paper is precisely to reveal the epidemiological situation of COVID-19 in Tunisia, to evaluate the public actions taken in this regard and to draw relevant lessons and conclusions that can be applied to improve the Tunisian health system. In this article we will first present a brief review of the emergence and spread of Covid-19 in the country from March 2020 to mid-March 2021. Then, we will review the healthcare system in the face of this pandemic.
Finally, we will discuss the difficulties of the medical staff, their response to the pandemic, and the lessons learned from this health crisis. Methodologically, our study is based on scientific bibliographic references and articles from the press and electronic journals.
Thus, we considered about fifteen articles, ten of which were published in the local press providing information on the spread of the virus. As for the statistical data, we relied on the statistics provided by the Tunisian Ministry of Health, including the daily bulletins published by 24 Regional Health Directorates at the governorate level and which are published on social networks. The statistics of interest are related to the main epidemiological parameters including the number of daily positive cases, the number of daily deaths, the cumulative incidence per 100 000 inhabitants and the case fatality rate. The data obtained was used to accurately map the spread of the pandemic at the national and regional level. However, this work should be completed by the establishment of a Geographic Information System (GIS), as an information and epidemiological research tool. Indeed, the GIS should improve the governance and optimize the allocation of resources of the Tunisian health
system. Currently, it is important to introduce the uses of GIS in epidemiology in order to ensure epidemiological surveillance, determination of primary health care needs, health planning, as well as the improvement of the quality of healthcare.
Review of the emergence and spread of Covid-19 in Tunisia
The pandemic caused by the SARS-CoV-2 virus has been declared by the World Health Organization (WHO) since January 30, 2020 as a public health emergency of international concern. In Tunisia, the Covid-19 pandemic officially emerged on March 2, 2020. The first case was imported from Italy and was identified as part of the follow-up of travelers from high-risk areas (Ministry of Health, 2020). Four clusters have been identified in four regions of the country (Djerba, La Marsa, Les Berges du Lac, and La Soukra) on March 23, 2020, after a series of horizontal transmission in these areas. As of April 18, 2020, all 24 governorates of the country have been affected by the virus.
Evolution of the epidemiological situation since the emergence of the virus in Tunisia
As of March 26, 2021, a total of 248,037 confirmed positive cases have been recorded. The cumulative incidence of positive cases per 100,000 inhabitants was 2,141.5. The peak of 5,752 cases was recorded on October 17, 2020 ( Table 1). Tunisia had a cumulative incidence rate (CI) of positive cases per 100,000 populations 1.5 times higher than Morocco (2,141.5 versus 1,390.4). The cumulative incidence of positive cases per 100,000 population of Algeria is low (265.9) compared to Tunisia and Morocco and this raises This data variability essentially depends on two parameters: the maximum capacity for detecting Covid19 contaminated cases at the
country level (through the various tests) and the reliability of the statistical test. The number of Covid-19 death the would be greatly underestimated and the toll of the pandemic could be two to three times higher than that officially recorded in many African countries. According to projections by the Seattle Institute for Health Measurement in the United States, the number of Covid-19 deaths in Africa is three to four times higher than reported data (La france, 2021).
Mathematical method adopted by the Center for Systems Science and Engineering (CSSE) of Johns Hopkins
University concerning the “COVID-19 data repository”
and which consisted in calculating the average number of events (cases or deaths) out of 3 or 7 following days which eliminates the fluctuations observed every day and the emphasis on the long-term tren. Regarding the case fatality rate (TL), Tunisia recorded a higher rate than Morocco (3.49% vs. 1.78%). Diagnosis plays a major role in the fight against coronavirus, as it helps to detect new cases and map the extent of the disease (El Kettani, 2020).
Table 1. Comparison of the covid-19 epidemiological situation in the Maghreb countries (Origin: Worldometers, Coronavirus Carried out on (19/03/2021)).
Items Tunisia Morocco Algeria
Number of inhabitants 11 582 075
(2018)
35 481 848 (2019)
43 820 839 (2020) Total number of covid-19 cases 248 037 493 353 116 543 Cumulative incidence /100 000 inhabitants 2141,5 1 390,4 265,9
Total number of deaths 8 663 8 788 3 071
Fatality rate 3,49% 1,78% 2,63%
Total numer of healings 214 407 481 074 81 065
Total virologic tests performed 1 056 616* 848 474* -
Our analysis of the evolution of the pandemic is based on the data published on Tunisia by the site Worldometer.info/Coronavirus. The average curve over three days, published by the same site, gives us an idea on the progression of the virus (Figure 1).. Thus, one year after the outbreak of the pandemic, we have distinguished three successive waves The first wave was preceded by reassuring epidemiological data between March 2 and June 25, 2020, i.e. 1116 positive cases and about 50 deaths. The positive results recorded during several weeks without the detection of new cases is the result of effective surveillance, monitoring, isolation and general containment policies, but also the restriction of a large part of social and
economic activities in the country. The effective start of the
first wave of the pandemic took place from the end of August 2020 with a 3-day average which gradually increased to reach a peak of 2,645 cases on October 19, 2020. This wave was marked by a continuous increase in the number of Covid-19 positive cases exceeding one thousand per day. It occurred after the lifting of the general lockdown on May 4, 2020 and the opening of air, land and sea borders on June 27, 2020 which was a real turning point. Thus, we observed an outbreak of "imported cases"
with cases of horizontal transmission in the community, which led to an exponential increase in the number of infected individuals (Boukhayatia, 2020). SARS-CoV-2
infection accelerated during September, with more than 6,400 people infected within three weeks. Several factors intervened in the development of this situation, which led to the progression of the pandemic and the appearance of numerous local transmission sites such as the opening of borders, family ceremonies, particularly weddings and funerals, non-compliance with the various health protocols and prevention measures. On October, 9, 2020, the total number of cases in Tunisia reached 26,899 with 409 deaths. One week later, on October, 16, 2020, there were 40,452 cases and 626 deaths, which corresponds to an increase of 50.7% and 53% respectively. These two rates place Tunisia in the first rank of countries in terms of the rate of progression of the disease. Thus, in terms of ranking, Tunisia on that date was the fifth in the world and the second in Africa in terms of the weekly growth rate of the number of new infections by Covid-19, and the third in the world and the first in Africa in terms of the weekly growth rate of deaths (Malouche, 2020).
The second wave occurred just after a slight decline of cases in mid-December 2020 (three-day average of 752 positive cases on 14/12/2020) and continued until the first week of February 2021. This second wave was characterized by an ascending phase with an increase in the number of positive cases in early January 2021. While the monthly average during November was 1332 infections, this average exceeded 2000 positive cases from January.
The three-day average infection curve increased from 950 to 3,376 positive cases between December 15, 2020 January 15, 2021. On January 12, 2021 a four-day general lockdown was declared to limit the spread of Covid-19,
which has reached record levels. This confinement includes a curfew on the tenth anniversary of the revolution (January 14, 2011) in a context of social tensions. It was also decided to suspend classes in schools and universities from January 13 to 24, as all cultural and sporting events were prohibited during the lockdown period. The end of February was marked by a decrease in the number of contaminated people. According to Y. Souteyrand, WHO representative in Tunisia, this was explained by the decrease in the number of detection tests performed per day (from 10 thousand at the beginning of January 2021, to about 4 thousand currently) hence the logical decrease in the number of new cases (WHO, 2021).
The third wave of the virus began at the end of March 2021 and coincided with the spread of the British variant of Covid-19, a strain that is characterized by rapid spread and can cause more severe forms of infection. The three-day average of positive cases will drop from 367 to 1,931 cases between 02/23/2021 and 04/09/2021. In addition, as of April 06, there have been 264,994 confirmed cases of COVID-19 in Tunisia, 9087 deaths and 221,545 recoveries.
According to the same source, 758 patients with Covid-19 were hospitalized, including 382 admitted to intensive care and 114 placed on artificial respirators. The total number of people who received the vaccine against COVID-19 on the 28th day of the national vaccination campaign, reached 130 thousand people. This number of vaccine persons includes health professionals as well as people aged 75 years and over, in accordance with the priorities established in the national vaccination strategy.
Figure 1: Evolution of the number of infected persons per day (March 2020 - April 2021). Blue curve indicates an average over 3 days. Origin: https://www.worldometers.info/coronavirus/country/tunisia/
Table 2. Monthly evolution of the number of contaminated covid-19 (Ministry of Health Source 2021)
High variability in the number of deaths
An important characteristic of infectious diseases, especially those caused by a new pathogen such as SARS- CoV-2, is their severity and their ability to cause death (WHO, 2020). According to data from the Tunisian
Ministry of Health, as of March 30, 2021, the total number of deaths due to Covid-19 was 8,788, of which 217 deaths were recorded in the period between October 9 and 16 (Table 3). This latest weekly record represented 53%
increase over the previous week's tally. The increase in deaths has started since September 2020 (188 deaths) and
Months Contaminated
Number
Average monthly contaminations
Incidence of positif cases /100 000 imhabitants
March 2020 423 13,6 3,61
April 2020 575 19,8 4,91
May 2020 90 2,9 0,76
June 2020 93 3,1 0,79
July 2020 359 12 3,06
August 2020 2268 76 19,37
September 2020 14610 487 124,78
October 2020 41400 1335 353,59
November 2020 36956 1332 315,63
December 2020 42371 1367 361,86
January 2021 69745 2250 595,68
February 2021 17892 639 152,81
March 2021 24392 786 208,32
Total 251174 - 2145,25
far exceeded all the deaths recorded From March, to August 2020 (Figure 2). Over the next five months, the number of deaths recorded monthly exceeded 1000 and reached a peak of more than 2000 deaths during January.
The country even reached its record of 100 deaths in 24 hours on January 21, 2021.
The case fatality rate is the proportion of deaths related to a particular disease or condition out of the total number of cases affected by the disease. It is used to measure the virulence of a disease, to identify populations at risk, and to
assess the quality of health care (WHO, 2020). The monthly evolution of the case fatality rate in Tunisia during the studied period (from March 2020 to March 2021) was characterized by a great variability (Table 3). Indeed, during the first three months of the virus spreading, we observed a constant increase of the case fatality rate from 2.84% to 7.78%. Subsequently, we noticed a decrease in the case-fatality rate to less than 1% during July 2020 (Ministry of Health, 2020).
Table 3. Monthly variation in the number of infected persons, deaths, and case fatality rate between March 2020 and March 2021
Month Number of cases Number of Deaths
Fatality rate (%)
March 2020 423 12 2,84
April 2020 575 29 5,04
May 2020 90 07 7,78
June 2020 93 02 2,15
July 2020 359 01 0,28
August 2020 2 268 26 1,15
September 2020 14 610 188 1,29
October 2020 41 400 1 052 2,54
November 2020 36 956 1 943 5,26
December 2020 42 371 1 416 3,34
January 2021 69 745 2 078 2,98
February 2021 17 892 1 247 6,97
March 2021 24 392 759 3,11
Total 251 174 8 760 3,48
Between October 2020 and March 2021, the case-fatality rate increased by 5%. Among the hypotheses that can explain these high case fatality rates, we can mention the limited screening capacity. Indeed, the greater the number
of tests, the greater the number of cases, therefore, the case-fatality rate will be lower. During the studied period, Morocco recorded almost the same number of covid-19 deaths as Tunisia (8,788 versus 8,663), but the case fatality
rate was not the same (1.7% in Morocco versus 3.4% in Tunisia). This situation can be explained by the fact that in mid-March 2021, Morocco performed five times more tests
to detect infected persons than Tunisia (5.8 million tests versus 1 million) (El Kettani, 2021).
Figure 2: Evolution of the number of daily deaths (March 2020 - April 2021)
The pace of progression of the pandemic of Covid-19 in Tunisia has not stopped increasing since the beginning of September. The rates of progression of COVID-19 deaths and infections have ranged between 40% to 50% since the end of September. The mortality curve of Covid-19 confirmed cases has practically the same profile as the confirmed contaminations curve, which implies a strong correlation between the numbers of contaminated and the number of deaths. The WHO representative in Tunisia, Yves Souteyrand, said that, given the number of inhabitants, Tunisia is among the countries most affected by COVID-19 in Africa, with the second highest mortality rate (TAP, 2021) . According to a recent study conducted by the National Institute of Statistics ( NIS), mortality have been significantly impacted by the Covid-19 pandemic in 2020. The excess deaths from March 2020 to February 2021 were estimated at nearly 4,850. Although the increase in the total number of deaths has not changed and has the same shape of previous years, the recent trajectory of mortality has been marked by an exceptional acceleration of deaths at the end of the year, especially among the elderly (NIS, 2020).
The year 2020 presented an atypical profile with a slight in the death rate at the beginning of the year, followed by a strong over-mortality in the last quarter estimated at nearly 4,000 excess deaths, culminating in October when the excess death rate reached 1,850 deaths (INS, 2020). At the end of December 2020, "about 50 doctors and 300 paramedical staff died from COVID-19 infection after being infected by their patients," said the president of the National Council of the Tunisian Medical Association. On the other hand, the Ministry of Education announced that the number of infections in the educational environment has augmented between September 15, 2020 and February 11, 2021 and has reached 7,525 cases including 3,520 teachers, 3,123 students, 656 administrative staff and 226 among the staff. The number of recoveries from COVID- 19 in the education sector reached 6266 (TAP, 2020).
Predominant outbreak of infected cases on the eastern coast of Tunisia
In total, between March 2020 and mid-January 2021, 117,459 people have tested positive for the virus. The regions of Greater Tunis, the North-East, Centre-East and
South-East located on the coast were the most affected and represented 79% of all infected. Nearly 70% of the population and 92% of all industrial enterprises are located in the four coastal regions where we find the country’s largest cities namely Tunis, Sousse, Sfax and Gabes, which constitute the mainstay of economic activity (more than 85% of the country's Gross Domestic Product). The Center-East (2.5 million inhabitants) with Sfax and Sousse recorded the largest number of positive cases (35%), followed by the region of Greater Tunis (2.6 million inhabitants) with the capital and its affiliated cities (Ariana, La Manouba and Ben Arous) which recorded the second highest number of cases with (20% of infections). The Greater Tunis and the Center-East, which account for half of the infected people and host more than half of the total population of the country, are characterized by high population density (more than 1500 inhabitants / km2) and high urbanization rates (more than 70%). The North-West, Central-West and South-West regions, which recorded 32,470 positive cases (21.6% of the total of cases) during the same period, are home to almost 30% of the country's
total population and are characterized by relatively low population densities and urbanization rates compared to the coastal regions. In general, the map of the spread of the Covid-19 pandemic reproduces exactly these disparities, but poverty and enclosure seem to be a barrier to COVID- 19 : the most deprived areas are, at this point, the least affected (Dahmani, 2020). Urbanization, high population density, and travel are factors that contribute to the spread of infectious diseases transmitted from person to person, due to close contacts. In addition to urban density, the risk of transmission is higher in areas where the number of rooms is insufficient for family members and this is observed mainly in large cities where the risk of spreading the virus is greater. In fact, within large cities, old residential areas such as the “medina” and precarious housing areas are among the areas at risk whether in terms of population density or over-occupation of housing. 2014 census data revealed that 27.6% of dwellings comprise less than 2 rooms and during the quarantine it becomes extremely difficult for a household of 4 members to live in it (Mahjoub, 2020).
Table 4. Population, Density, Urbanization Rate, and Number of Infected Cases by Region
Regions Population
(thousands) 2014
Population Percentage
Density Inhabitants/Km2
Urbanization rate
Number of case (Mid-january 2021)
Great Tunis 2644 24,1 1552,7 88,8% 29 300
North-East 1533 14 167,5 59,0% 21 331
Center-East 2590 23,5 267,3 72,3% 51 439
South-East 1003 9,2 35,2 66,9% 15 389
Coastal regions 7770 70,7 505,675 71,75% 117 459
North-West 1170 10,7 76,8 43,4% 12 181
Center-West 1439 13,1 66,3 35,3% 7 855
South-West 602 5,5 23,1 62,1% 12 434
Interior regions 3211 29,3 55,4 46,93% 32 470
Total 10981 100 312,7 61,1% 149 929
Figure 3: Distribution of contamination cases at the governorate level (March 2020-February 2021)
The epidemiological situation during the study period at the governorate level showed a large number of positive cases in Sfax (more than 24 000 cases) followed by Sousse, Tunis and Nabeul (more than 16 000 each). As for deaths, these same governorates occupy the first positions. The majority of governorates located in the interior of the country, showed lower statistics than the coastal governorates. This is the case for Jendouba and Siliana where the number of positive cases was less than 4,000 and the number of deaths was less than 200. In terms of lethality, Tunis shows a 5% lethality rate, while Tataouine
and Jendouba, with less than 200 deaths , had a higher rate than that of Tunis (over 6%). This situation can be explained by the fact that the number of infected people was underestimated and that there was a limited testing capacity to give a number close to reality. With regard to recovery cases, the latest statistics of the Ministry of Health indicated that as of April 14, 2021, there were 229,754 recoveries out of 276,727 positive case with a recovery rate of 83%. At the governorate level and until the end of March 2021 recovery rates were above 90% for Nabeul, Sfax, Tozeur and Jendouba.
Table 5. Positive cases, deaths, case fatality and recoveries in selected governorates affected by Covid-19 in the coastal and inland areas (End of March 2021)
Governorat es
Number of positive cases Number of deaths
Lethality rate
Number of healings
Tunis* 16 753 870 5,19 14 389
Nabeul 16 428 510 3,10 15 665
Sousse 17 794 605 3,40 15 539
Sfax 24 866 692 2,78 22 881
Gabès** 9 469 292 3,08 9 248
Jendouba 2944 178 6,04 2814
Siliana 3460 144 4,16 -
Sidi Bouzid 5504 201 3,65 4767
Tozeur 5081 101 1,98 4973
Tataouine 2785 171 6,14 -
Tunisian health system difficulties in the face of the pandemic
Tunisian authorities, since their independence in 1956, have attached great importance to health and education.
Indeed, the health sector was among the priorities and the country currently has a strong public health infrastructure network with 166 hospitals, more than 2,100 health centers, and more than 20,000 hospital beds according to official statistics in 2018. However, since the beginning of the 1990s, with the advent of the private sector, public health services have been deteriorated and do not fully meet the needs of citizens. The health crisis related to Covid-19 has revealed the new reality of the Tunisian health system that has to deal with many human and material hazards and structural and financial difficulties.
(Ministry of Health, 2019).
The crisis of Covid-19 has unmasked the weaknesses of the Tunisian health system and has allowed to raise the ills that the health sector suffer from. This problems including but not limited to lack of resuscitation beds, lack of virology
laboratories, lack of sources of oxygen in medical services, deterioration of the infrastructure, lake of drugs and acute shortage of medical equipment. On another level, the financial deficit of public health institutions, the deterioration of social funds and finally the extremely difficult working conditions of the nursing staff due to the lack of human resources in hospitals worsen the situation.
On the other hand, the pandemic has shown that in the presence of a health crisis, the only bulwark against it remains the public hospital.
The financial crisis of the Tunisian health system is explained primarily by a series of unpaid debts of which hospitals, the first line of care, are the main victims.
According to estimates, the debts amount to nearly 500 million dinars, equivalent to 156 million euros, on the Central Pharmacy of Tunisia alone. In addition, there are several million dinars of debts to service providers and private suppliers. Recently the hospital "La Rabta" in Tunis threatened to close because of the deterioration of its financial situation (about 40 million dinars of dept). Today, the debts of public hospitals and university hospital centers
(CHU) , are so important , they threaten, their functioning and endanger the right of Tunisians to access the necessary
care. ( Jelassi, K 2020).
Figure 4: Distribution of the number of deaths at the governorate level (March 2020 - February 2021)
Tunisian health system difficulties in the face of the pandemic
Tunisian authorities, since their independence in 1956, have attached great importance to health and education.
Indeed, the health sector was among the priorities and the country currently has a strong public health infrastructure network with 166 hospitals, more than 2,100 health centers, and more than 20,000 hospital beds according to official statistics in 2018. However, since the beginning of the 1990s, with the advent of the private sector, public health services have been deteriorated and do not fully
meet the needs of citizens. The health crisis related to Covid-19 has revealed the new reality of the Tunisian health system that has to deal with many human and material hazards and structural and financial difficulties.
(Ministry of Health, 2019).
The crisis of Covid-19 has unmasked the weaknesses of the Tunisian health system and has allowed to raise the ills that the health sector suffer from. This problems including but not limited to lack of resuscitation beds, lack of virology laboratories, lack of sources of oxygen in medical services, deterioration of the infrastructure, lake of drugs and acute
shortage of medical equipment. On another level, the financial deficit of public health institutions, the deterioration of social funds and finally the extremely difficult working conditions of the nursing staff due to the lack of human resources in hospitals worsen the situation.
On the other hand, the pandemic has shown that in the presence of a health crisis, the only bulwark against it remains the public hospital.
The financial crisis of the Tunisian health system is explained primarily by a series of unpaid debts of which hospitals, the first line of care, are the main victims.
According to estimates, the debts amount to nearly 500 million dinars, equivalent to 156 million euros, on the Central Pharmacy of Tunisia alone. In addition, there are several million dinars of debts to service providers and private suppliers. Recently the hospital "La Rabta" in Tunis threatened to close because of the deterioration of its financial situation (about 40 million dinars of dept). Today, the debts of public hospitals and university hospital centers (CHU) , are so important , they threaten, their functioning and endanger the right of Tunisians to access the necessary care. ( Jelassi, K 2020).
The public hospital is the main bulwark against the pandemic
Tunisia is characterized by the predominance of public and semi-private sector structures consisting of institutions
directly subordinate to the Ministry of Health and other ministries and semi-private institutions. The public health service is organized at four levels. The first level comprises the Basic Health Centers, which are a gateway to the public sector and form a decentralized network that covers basic preventive and curative healthcare needs. These centers are located in poor areas where the majority of population suffers from poverty and inadequate public infrastructures.
In case of serious health problems, the residents resort to costly private health care structures without hope of reimbursement. There are 110 local hospitals, including rural maternity hospitals, with 2,613 beds, covering a large part of the national territory, but they do not have adequate technical facilities or sufficient operating budget . The general practitioners of public health most of the interior regions do not have a number of doctors (Belhadj et al, 2016). The second level relates to regional hospitals (35 hospitals with 8,139 beds) which are located in the main cities of governorates and in some highly populated regions and constitute the first level of reference for specialized care. Some regional hospitals in the governorate capitals have an insufficient number of beds per inhabitant and do not have the necessary specialty services. The key and most prevalent problems is the lack of specialized physicians in these hospitals especially specialties such as obstetrics, surgery, anesthesia/resuscitation, radiology, and pediatrics (Ministry of Health, 2019).
Table 6. Public and private sector health facilities in Tunisia in 2018 Public Structures
(2018)
Semi-privat structures (2018)
Privat Structures (2018) 24 University Hospitals
Specialized Centers 110 District Hospitals 35 Regional Hospitals 2161 Basic health centers
06 Polyclinics of the CNSS 03 Military hospitals
01 Polyclinics of the CNSS (06)
102 Clinics
115 Dialysis centers Free practice offices
The third level of care is represented by 24 University Hospital Centers and specialized Institutes centers located in the coastal cities; Tunis, Sousse, Monastir, Sfax (Table 6). This level, which includes 70% of public sector specialists, has a capacity of 10,103 beds which represents 47.3% of the country’s total capacity. These University Hospital Centers also contain technical platforms and a large part of the secor’s sophisticated equipment. The new University Hospital Center (UHC) located on the outskirts of Sfax, built by the Chinese with a capacity of 250 beds, offers a range of services including outpatient consultations, a resuscitation service, an emergency department, a medical-surgical complex with a capacity of 156 beds, and a psychiatric service with a capacity of 80 beds. This hospital was dedicated to the fight against the Covid-19 pandemic before operating as a military hospital.
Deficiencies in Basic Health Centers ( BHCs), ward hospitals, and regional hospitals cause significant crowding of UHCs, which are finding it increasingly difficult to fulfill their roles of high-level care, education, and research (Ministry of Health, 2019). The parapublic sector includes six polyclinics from the National Fund for Social Security, 3 military hospitals managed by the Ministry of Defense,
and a hospital of the internal security forces in Tunis (WHO, 2010).
Decline and marginalization of front-line public structures The COVID-19 pandemic has highlighted the dysfunctions of public health in the country and has reinforced regional inequalities in the health sector. Between the developed coastline and the disadvantaged areas of the center and south, the disparities in the medical system are very evident. The resources made available to front-line health structures; in particular District Hospitals (DH) and BHC, which cover a large part of the national territory, are limited. About 1,000 rural BHC (frequented by around a million patients) provide only one medical consultation per week and are open only a few hours a day. There is an acute shortage of medicines in these facilities, especially for the one million chronically ill patients who consult public health settings, a weakness in communication facilities that can even affect preventive programs, and a fragmented information. The various officials of the Ministry of Health develop strategies, programs, and plans that do not take into account the deteriorating reality of these sittings and only marginally involve front-line professionals (Achouri et al., 2020).
Table 7. Evolution of health structures in the public sector in Tunisia ((a) Number of units; (b) Number of beds; Source:
Ministry of Health, 1989,2008,2018).
Structure 1989 2008 2018 Rate of growth
Number of beds between 1989 and 2018
Basic Health Center (BHC) 2008 (a) 2067 (a) 2161(a) -
District Hospital 98 (a)
2664(b)
118(a) 2613(b)
110(a) 2613(b)
-0,06%
Regional Hospital 24(a)
5090(b)
34(a) 5479(b)
35(a) 8139(b)
1,6%
University Hospital and Specialized Centers 22(a) 7723 (b)
22(a) 8590(b)
24(a) 10103(b)
0,9%
Until March 26, only the laboratory at Charles Nicolle Hospital was performing tests. The maximum number of tests performed in one day (March 25) was 309. Since then,
the Pasteur Institute of Tunis and the military hospital have also become diagnostic centers and conducted 724 tests in March 2020 (Mzalouat, 2020). Finally, Covid-19 revealed
already known inequalities and the authorities have set up public testing laboratories interior in cities of the country.
Subsequently, RT-PCR iscreening tests were performed in private laboratories, in order to mnimize the pressure on the public sector. Indeed, the Technical Commission of Medical Biology of the Ministry of Health has granted permission to about fifty private biological analysis laboratories to diagnose the COVID-19. These laboratories are spread over several regions of Tunisia including Greater Tunis, Kasserine, Sfax, Jendouba, Sousse, Monastir, Jerba, Nabeul, Bizerte, Kairouan, Beja, Kef, and Gabes.
The number of resuscitation beds in all public hospitals remains insufficient, which is a major barrier to patient care represents in times of crisis. Indeed, there are deep regional disparities in the distribution of resuscitation and oxygen beds for patients with Covid-19. A year after the emergence of the pandemic in Tunisia, the interior regions have, so far, recorded a stark shortage of resuscitation beds for Covid-19 patients. In the governorates of Beja, Le Kef,
Siliana, Jendouba, Kairouan, Tozeur and Tataouine there are at most 5 resuscitation beds, or less, in each region. On the other hand, the governorates of Greater Tunis, Sousse, Monastir, Mahdia and Sfax had more than 60% of the total 307 resuscitation beds for Covid-19 as of January 16, 2020.
At the beginning of the pandemic, only one hospital (Abderrahmen Mami Pneumo Phthisiology Hospital at Ariana) was allowed to receive COVID-19 patients (Ministry of Health, 2020).
Lack of cooperation and inappropriate practices of the private sector
The development of private hospitalization in the framework of clinics has progressed significantly the system of the former regime of President Ben Ali has encouraged businessmen to invest in the health sector, notably by building private clinics. The number of clinics increased from 81 in 2011 to 102 in 2018 with the number of beds doubling (from 3,326 to 6,370 beds) mainly in Greater Tunis and Sfax ( Table 8).
Table 8. Distribution of private clinics by region in 2018 ( Origin : Minstry of Health, 2018)
Region Number Bed capacities
Great Tunisia 41 2 938
North-East 11 714
North-West 05 183
Center-East 29 1 659
Center-West 03 167
South-East 11 650
South-West 2 59
Total 102 6 370
Thus, the private sector, which complements the public sector, is positioned as the second line of care and has the vast majority of advanced equipment that are mostly available in areas that are already well equipped, thus
aggravating the disparities between regions ( Table 9). In 2014, 80% of Magnetic Resonance Imaging devices, and 76% of scanners and Magnetic Resonance Imaging devices were owned by the private sector. The health crisis has not
only unmasked the fragility of the health infrastructure in the public sector, but it has also highlighted certain inappropriate practices observed by clinics, including situations of exaggerated financial exploitation and even illegal and inhumane practices. While some hospitals are saturated, private clinics are charging exorbitant fees for resuscitation beds and those equipped with oxygen. At the beginning of the first wave of the pandemic, the Tunisian General Labor Union (TGLU) pointed out the lack of cooperation between public and private sectors and called
on the government in early November 2020 to "increase control over private clinics hosting patients with Covid-19.
Several political parties and national organizations had called for the private health sector to support national efforts to fight against COVID-19. To clarify this situation, the head of the private clinics Chamber said that the health crisis has had "significant repercussions on private clinics whose revenues decreased by 80% due to the postponement of several surgeries and the absence of foreign patients" (Jelassi, 2020).
Table 9. Evolution of private sector health structures between 1990 and 2018. (Origin: Ministry of Health 2011, 2018)
Structures 1990 2011 2018
Offices 1055 1902 2127
Analysis laboratories - 324 544
Hemodialysis centers 18 99 115
Private clinics 33 81 102
Scarcity of medical specialists in the interior regions The geographical distribution of medical human resources is the most uneven and is mostly concentrated in coastal regions (Table 10). Although the number of medical facilities has increased, regional disparities have also increased. In terms of quality, the inequalities are even more obvious and more than two-thirds of the specialists work in coastal areas. This concerns not only rare specialties, but also most common ones, such as gynecology and pediatrics. This regional distribution reflects the geographical division which shows a flagrant
regional imbalance in favor of the coast, at the expense of the North-West and the Center-West of Tunisia. In fact, 44% of specialists are located in the cities of Greater Tunis, particularly Tunis, Ben Arous, Manouba and Ariana. The proportion of specialists in the interior regions is very low and this is the case of the South-West region which has less than 2% of specialists. It is the difficult living conditions associated with the inadequacies of the health infrastructure and the income level of the population that explain the shortage of specialists in the hospitals of the interior regions of the country (Ministère de la santé ,2018).
Table 10. Distribution of the number of public and private sector physicians at the regional level (2018), Origin: Ministry of Health, 2018.
Regions Generalists Specialists Total
Great Tunisia 2 081 3 654 5 735
North-East 844 765 1 609
South-East 512 398 910
Center-East 1 882 2 623 4 505
Coastal regions 5 319 7 440 12 759
North-West 600 314 914
Center-West 613 308 921
South-West 387 155 542
Interior regions 1 600 777 2 377
Total 6 919 8 217 15 136
The former Minister of Health has reported an increased shortage of human resources in hospitals including medical specialists and health technicians in the interior of the country. Highlighted the issue of regional imbalance and she said in an interview that the situation is also worrying, even in hospitals in Tunis. The issue is not specific to hospital structures in the interior of the country, but rather a general problem, as even hospitals in the capital suffer from this imbalance. Indeed, for nearly six years, no medical staff has been recruited (Jelassi, 2019). The lack of doctors in these regions and even in the capital is explained in particular by the migration of Tunisian doctors which has increased in recent years, leaving the public health sector in a critical situation . Indeed, Tunisia has gained a good reputation in the field of medical skills over the past decades. On the other hand, the university hospitals have a large number of medical specialists. But the organization of the work of the hospital services is hard due to the unavailability of doctors because of the authorization granted to them to carry out a complementary private activity (APC) to retain them in the public sector. By trying
to oblige young doctors to practice for a year in the interior regions of country as part of their military service, the public authorities have only aggravated the situation and the phenomenon departure abroad. Specialists are increasingly avoiding public hospitals and choosing private practice which becomes more and more saturated. Thus, every year, there are only 50 general practitioners who settle in the private sector, as opposed to 350 specialists, according to the Doctor Bellamine, President of the Tunisian Society of Family Medicine. As a result, the saturation of the private sector with specialists encourages the emigration to France or Germany by young doctors (Bobin, 2017).
A delicate situation for medical personnel faced with the health crisis
Since the beginning of the pandemic, health professionals in the public sector have been committed to facing the pandemic and dealing with an unprecedented crisis despite the lack of Personnel Protective Equipments, diagnostic tools and management of diagnosed cases. Indeed,
practitioners in public structures continue to work in precarious conditions with a lack of technical means and equipment (ambulances, radio, etc.), as well as the necessary equipment for diagnosis (stethoscope, blood pressure monitor, etc.) and sometimes even emergency drugs. In addition, medical staff are subjected to verbal and physical aggression from patients and their relatives. Often, the number of staff in different departments is not enough for the workload. The workforces in the various services are often insufficient for the workload. The increase in physical and verbal attacks as well as acts of destruction of public property and medical equipment in hospitals is a recurring problem that does not seem to have a solution.
The disastrous management of the Covid-19 pandemic leads citizens to further attack the medical and paramedical corps working in particular in hospitals (Khdimallah, M 2020).
Repulsive working conditions in the public sector The lack of equipment, basic supplies (syringes, dressings, and medicines) and the lack of complementary specialties do not help the specialized doctor to exercise his heavy medical responsibility in adequate conditions (Table 11).
Professionals are regularly face sensitive and complicated situations; they are increasingly being questioned in the context of dilapidated public health structures such as the growing number of demonstrations against specialist doctors following the death of their patients. The medical profession is worried by the weakness of the hospital infrastructure and the lack of equipments in the interior regions to deal with the spread of the virus. For example, the Kasserine regional hospital in the Center-West has only two intensive care beds, and the nursing staff lack means of protection (Dahmani, 2020).
Table 11. Major factors that hinder work in the public health sector
Conditions Factors
Working conditions • The arduousness of permanence (48 hours of work) with the low staffing levels,
• Delays in the payment of temporary workers recruited to fight against Covid-19
• The inequitable distribution of the workload
• The deterioration of the hospitals' infrastructure
• Lack of reform of medical studies
• The distribution of resources, especially human resources, is dealt with rigorously.
Material and financial conditions
• Low wages and low purchasing power
• The non-payment of interns' shifts
• The freeze on recruitment in the public sector
• Dissatisfaction with professional prospects
• The absence of a clear vision for the sector
• The dysfunction of public health structures General situation of the
country
• The deterioration of the economic situation: a continuing economic crisis
• The unstable political climate
Moving to the private sector offers better working conditions and better wages, especially in the coastal
regions. Free practice in large cities becomes the preferred choice for the qualified physicians who theoretically benefits from better conditions to treat his patients. Thus,
patients in the public sector find in this private network of professionals a substitute for the dysfunction of public health structures which are not able to honor all the medical prescriptions prescribed. The concentration of doctors in the regions of Greater Tunis, the Center East and Sfax, regardless of their qualifications, professional status and gender, shows that the productive combination of effective care is a determining factor. The country has also allowed public health specialists to engage in a private, paid activity in hospitals in the interior regions of the country. Both forms of activity are well organized and limited in time to twice a week. In fact, the majority of doctors with this status, who work in the public and private sectors, devote more of their working time to the private sector. As a result, the private sector reputed to be innovative and responsive, attracts wealthy local and foreign customers and attracts the best executives.
However, some complaints are reported against pricing abuse sometimes leading to a lack of patient confidence.
As for the public sector, handicapped by red tape and routine, it cannot cope with the influx of patients from the poor and middle classes. Thus, doctors specializing in public health are authorized to exercise a paid private activity in hospitals in the interior regions of the country.
These activities are well regulated and limited in time to two afternoons per week. In fact, the majority of doctors under this status, straddling the public and private sectors, devote more of their working time to the private sector (Jdidi, et al., 2017)
Poor governance of public health
Corruption in health care is a phenomenon that has grown and can no longer be ignored. The citizen's perception of the health care system is severely affected by the corruption that the sector suffer from. According to a survey conducted in 2015 by the Tunisian Association of
Public Comptrollers (TAPC), 66% of respondents consider the sector to be very affected by corruption. The lack of common agreed protocols for the treatment of diseases and the lack of monitoring of drugs from acquisition to distribution to patients are factors that favors corruption in the sector. In recent years the public health sector in Tunisia has become synonymous with mismanagement and corruption. The structures of health institutions are now dilapidated, unmanageable, lacking the minimum organization. With the economic and health crisis, it has become the den of corruption and bribery. For example, R.
Zarrouk, president of the Association of Cancer Patients of Tunisia (ACPT) said that "There is trafficking in medical records of cancer patients ", which is now a source of income for some parties at the level of health institutions.
The president of the ACPT believes that there is no social justice in the health sector, "witnessing the suffering experienced by patients belonging to the social category to get a medical appointment or to obtain a medication. She added that "Cancer patients in Tunisia are facing a slow death because of the very long waiting times for medical appointments, loss of medical records, and the lack of a real strategy to fight against cancer (The Expert, 2019).
In a recent survey conducted by the Tunisian Organization of Young Doctors (OTJM) among 235 professionals in the country, 48% confirmed drug thefts by health care staff.
Corruption is related to health care providers concerns the following aspects: theft of drugs and medical supplies, informal payments, referral of patients to the private sector, counterfeiting and selling medical certificates of the drug, the game of stickers stuck on prescriptions without delivery of drugs, the use of public infrastructure by the medical profession to make money. On several occasions, trafficking and theft of medicines have been reported in public hospitals and investigations have been initiated to identify the perpetrators (Haouari I., 2019).
At the end of the year, we lost 1,500 doctors trained in our universities in two years. According to statistics, 80% of Tunisian doctors working abroad left after the revolution.
More than 4,000 doctors have emigrated to Europe over the past five years, particularly to France and Germany.
According to estimates by the Council of the Order, these are no longer only young people who are leaving, but also senior citizens. According to the database of statistics of the National Institute of Statistics and Economic Studies, the number of Tunisian doctors working in France exceeded 3800 practitioners in 2012 (Kouni, 2019). In the framework of his MD thesis, Ibrahim Ben Slama tried to study the intentions and motives of emigration among young family physicians. The main results of this study showed that 69% of these young doctors intend to emigrate, 27% have not yet decided, while only 4% intend to stay in Tunisia. The main destination was Germany, followed by France. Most planned to specialize abroad and only 28% of respondents had a strong intention to emigrate permanently (Rafrafi, 2021).
SWOT Analysis of the Tunisian Health System in the Face of cCovid-19
SWOT analysis organizes and synthesizes information to simplify the understanding of an organization within its environment. This analysis aims to conduct an internal assessment to understand the organization's competencies, strengths, and weaknesses; it also aims to conduct an external assessment of the environment to identify threats and opportunities. From the internal point of view, this diagnosis takes the form of an inventory of strengths (assets) and weaknesses (handicaps) in terms of human resources (skills), technical and financial resources (sources of funding), the main difficulty being, of course, to have reliable information for this analysis to be relevant from an external point of view, the diagnosis consists of
identifying opportunities and threats that depend on several factors, including societal, economic, and political developments, which are considerably important for the analysis of the environment in general (Iraqi, 2019).
Regarding the health system in Tunisia, we based our analysis on the results of the SWOT analysis conducted by the National Institute of Strategic Studies (INTES) and those conducted by The Maghreb Network for the Pedagogy-Research-Publication in Health Sciences (PRPHS) ,in the framework of the "performance evaluation of the Maghrebian response strategies against COVID-19”, in order to draw a picture synthesizing the main positive and negative aspects of the strategy to fight against Covid- 19.
- Several strong points in the strategy have helped to reduce the spread of the virus including the creation of a Plan of Prevention, Response and Reply, the implementation of about sixty circuits Covid-19 in health facilities through the mobilization of health staff called for the occasion "army of white coats" and the timely introduction of preventive measures such as containment and prohibition of movement between the governorates.
The communication component has facilitated awareness with mass messages on cell phones, street posters, publications in the press and social media, and websites.
The use of digital technology has enabled the creation of several digital applications thanks to the commitment of university structures and civil society. Finally, we note the generalization of thermal control at the borders and in all institutions and public and private companies throughout the country.
- Gaps in the strategy include poor engagement of frontline units (FTUs) and private sector pharmacies, as well as lack of coordination between the public and private sectors. The degradation of the infrastructure in the hospital units due to the insufficiency of material and financial resources, has
favored the flight of health personnel to the private sector and abroad. On another level the slackness recorded at the level of the measures barriers to be respected and the non- compliance of the rules of sanitary prevention applied to some of Tunisians community favored the propagation of the virus.
- The strategy adopted to fight the pandemic has revealed several opportunities including the restoration of confidence in professionals in the public sector and the obligation to upgrade the health sector. On the other hand, the authorities have found an opportunity to engage in communication information, international cooperation, intersectoral collaboration and the acceleration of digitalization. Several Tunisian companies have taken advantage of the health crisis to increase their manufacturing and export capacities of materials (masks, hydro-alcoholic gel), devices for medical use and drugs.
On another level, the pandemic has enabled the mobilization of civil society in the field and has shown the importance of public-private partnerships.
- Among the threats that can make the strategy fail, we will mention in the first place the weak commitment of the population going underestimation through from underestimation through unconsciousness, indifference,
irresponsibility, lack of confidence in official structures, negative attitudes towards vaccines. Indeed According to a study by Honoris United University and Eshmoun Clinique Research carried out by Erhmod Consulting and published in early February 20211, only 41% of Tunisians say they are ready to be vaccinated against COVID-19 (IlBoursa, 2021). On another level, the chronic budget deficits of hospitals, the disruption of supplies due to the dependence on foreign suppliers, the shortcomings in the capacity of resuscitation beds and finally the delays in the arrival of vaccines and the nationwide vaccination campaign constitute a real danger to the success of the strategy.
Conclusion
Tunisia has benefited from its experience in managing previous pandemics that have hit the country (H5N1, H1N1, SARS-CoV-1, etc.). However, the Covid-19 pandemic has clearly demonstrated the dysfunctions of the health system in Tunisia, hence the urgency to draw conclusions in order to engage the country in the first lines of a solid, comprehensive and sustainable health policy.
Thus, the health reform must begin with a decentralization of the sector giving a real autonomy to the health regions.
In addition, it is essential to raise the level of skills of the public health sector and it is therefore imperative to review
the training and management of human resources.
Similarly, support for the public sector is more necessary than ever, as it has proven, during this period of crisis, the availability and competence of its personnel. Since the beginning of the pandemic, all members of the health care personnel have been mobilized to face the health crisis, despite inappropriate working conditions, a continuous deterioration of the material and financial situation, the lack of means of protection, and the lack of diagnostic tools and of management of the cases diagnosed as positive.
Conflicts of Interest:
There is no conflict of interests
Source of funding support:
Preparation of this article did not receive any funding.
Author’s information: Abdelala BOUNOUH is a doctor in Geography and Planning, Urbanism option, obtained at the University of Toulouse le Mirail and taught at the Higher Institute of Technologies of the Environment, Urban Planning and Building (University of Carthage) In
as a teacher-researcher, he has participated in several national and international conferences and seminars and currently works as an independent consultant and geographer
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