“The people have a right and duty to participate individually and collectively in the planning and implementation of their health care.” –Alma-Ata Declaration, 1978
Over the past decades, and following three reforms of the Tunisian health system (primary health care, management of health facilities, and health insurance) significant achievements have contributed to the improvement of global health indicators. However, the accumulation of problems not addressed have hampered the proper functioning of the system. In addition, global indicators have sometimes hidden striking regional differences as recently highlighted by the MICS (Multiple Indicator Cluster Survey). Many people think that these failures of the welfare system were among the lead causes that fueled the discontent of the population and led to the revolution of 14 January 2011.
The many transformations that Tunisia has experienced since, as well as the effervescence of the anti-power civil society movement, were indicative of the need to engage in a range of reforms that will take shape in the years to come. The Ministry of Health has understood and supports an extensive societal dialogue program to be established during this period of democratic transition. Such a program would provide a solid foundation for a comprehensive reform of the Tunisian health system.
This process is structured in three phases spread out over the course of three years (2013-2015): situation assessment, regional and national deliberations to build a consensus around health system reforms, and progressive implementation and evaluation. This process is supported by the World Health Organization, through the European Union and Luxembourg Universal Health Coverage Partnership.
Wide consultations were organized to assess the situation. More than a dozen workshops and 20 focus groups were conducted in 2013 across Tunisia, bringing together in total more than 600 actors of the Tunisian society – individuals and institutions, civil society and professional groups, experts and policy-makers – with the objective of understanding key hurdles to universal health coverage, sanitary democracy, and to foster a health-enabling environment. “We asked citizens questions regarding their last visit to the doctor, waiting time, and quality of experience but also their perception on health and factors affecting their health” explains Dr. Ann Lise Guisset, the Health Systems Advisor of the World Health Organization. The goal of these focus groups was to complement already existing data and evaluation studies with concrete stories from citizens and professionals to focus the reforms on people. “It is not just about numbers, but about people’s lives,” adds Dr. Guisset.
During the focus groups, some dramatic stories of delayed diagnosis or discontinued treatment were exposed; the challenges faced by doctors in remote regions were also taken into account. “If you’re a doctor and you have dozens of sick people in your waiting room, you’re only going to spend a little bit of time on each patient,” says Ben Jemaa, spokesman for the societal dialogue and President of the civil society organization 20 millions de consommateurs. “A number of people we met expressed anxiety and mental disorders caused by financial hardship and uncertainty about the future,” reports Ben Jemaa. But on those occasions, people also expressed their hopes, talked about their privileged relationships with a nurse or a doctor, and highlighted remarkable initiatives.
This year, national and international experts will be consulted to reflect on the comprehensive information collect and to suggest alternative reforms. These will then be proposed for selection (or prioritization) during regional and national deliberations.
The role of the media to inform and prepare citizens for such deliberations is central. “It’s important to count the media as our ally so they can provide correct statistics and stir a constructive national conversation on access to health,” says Dr. Guisset. For this purpose, a “day of sensitization and partnership” was conducted for the Tunisian press, teaching print, broadcast and web journalists about themes of health, the right to health and the concept of universal health coverage. Indeed, “we are faced with a confidence crisis,” explains Dr. Guisset to justify the communication strategy. According to Dr. Guisset, adequate and efficient policies can only be accepted and properly implemented if all groups of society have been involved in their formulation and understand how priorities were set and choices were made. This inclusive process is meant to be restorative of a national confidence level by ensuring that all voices are heard and that individuals do not feel powerless.
Once the recommendations have been formulated and made available publicly on the partnership website, and once the new government has been elected by the end of 2014, Dr. Guisset and Mr. Ben Jemaa count on immediate action from the Ministry of Health to make sure that those are implemented so that each individual in Tunisia receives proper and timely treatment.