See also: Ministry of Public Health (French )   HEALTH CARE IN TUNISIA Introduction Tunisia has a public and private hospital and health infrastructure, which has enabled it to extend health cover to all parts of the country. The Ministry of Public Health watches over the health of the population with the aim of ensuring a harmonious development of their physical and mental faculties as well as their adaptation to the natural and social environment of the country by fighting the causes of deterioration of physical or mental well-being which may affect them individually or collectively. Law 91-63 of July 29, 1991, relative to health organization stipulates in its first article that everyone has the right to health under the best possible conditions. Access to health care and free health care The population's access to health care is governed by the 1998 revision of the terms of setting the categories of beneficiaries of totally free treatment and of reduced rates in public health facilities under the Ministry of Public Health as well as of the terms of granting benefits and the rates to which such treatment is subjected. Regarding free medical assistance in the health structures of the Ministry of Public Health, it covers needy families, which number 160,900, i.e. 7% of the families living below poverty line as well abandoned children and severely handicapped persons. Moreover, reduced rates in the health structures of the Ministry of Public Health are granted to citizens who are not affiliated to one of the social security systems, whose situation does not permit such affiliation, and whose annual income does not exceed: an amount equal to the guaranteed minimum wage in the different trades if the family members do not exceed two. an amount equal to one and a half times the guaranteed minimum wage in the different trades if the family members are between three and five. an amount equal to twice the guaranteed minimum wage in the different trades if the family members are in excess of five persons. The efforts made in te health sector have contributed to improving health indicators as follows: Life expectancy increased from 68.3 years in 1987 to 73.9 years in 2006; Infant mortality dropped from 51.6 ‰ to 19.1‰ over the period 1987-2006; The rate of medical cover increased from 1 physician for 2384 inhabitants in 1990 to 1 physician for 994.3 inhabitants in 2006; The rate of vaccine cover against the six diseases involved in the world vaccine program has extended to over 94% of children age up to one year; The number of basic health centers increased from 1506 in 1990 to 2076 in 2006. The number of hospitals increased from 156 in 1990 to 172 in 2006. Tunisia has been awarded several medals on an international scale for its efforts in the field of health: in 1996, the World Health Organization awarded President Zine El Abidine Ben Ali the "health for all" gold medal; in the same year, the President also received the medal of the World Federation of Blood Donor Organizations; on April 2, 1997, the Red Cross and Red Crescent Society awarded President Zine El Abidine Ben Ali the gold medal of its 7th Conference. The Gross Domestic Product allocated to the health sector is of 1.8% in 2005. The pharmaceutical industry made real progress over the past decade: the cover of national needs in locally produced medicines increased from 7% in 1987 to 43.7% in 1999. Demographic Evolution The Tunisian population increased from 3.8 million in 1956 to 8.8 million in 1994, 9.4 million in 1999, to 10.1 in 2006. Thanks to an avant-garde family planning policy, Tunisia has been able to reduce the natural growth rate. This rate, which was in the order of 2.58% in 1994, was reduced to 1.14% in 1999. Indicators 1956 1966 1975 1984 1994 1996 1997 1998 1999 2000 2004 2006 population (in thousands) 3782.2 4583.2 5511.7 7033.8 8815.4 9089.3 9214.7 9332.9 9455,9 9.5 9.910,872   Natural growth rate (in %) 3.5 3.1 2.7 2.6 1.4 1.3 1.23   1,12 1.14 1.21 1.15 Infant mortality rate (in ‰) 200 120 76,9 51,4 31,8 29,8 28,9 27,8 26,2 25.8   19.1 Gross mortality rate (in ‰) 25 15 10 6.5 5.7   5.6 5.6 5.7 5.6   5.6 Life expectancy(yrs) 47 51.1 58.6 67.1 71.2 71.6 71.9 72 72,1 72.2 73.8 73.9 Population under 15 (in %) 42.5 46.5 43.8 39.7 34.9 34.1 33.4 32.7 30,9 30.4 18.6   Population density (inhabitants/km2) 24.5 27.7 36.2 45.1 56.7   59.3 60.0 60.8 61.5     Evolution of Medical, Juxta-medical and Paramedical Personnel of the Health Sector Year 1990 1995 2000 2004 2006 Physicians 4424 5965 7339 9805 70184 Dentists 809 1038 1319 1889 1858 Pharmacists 1240 1499 1841 2069 2255 Paramedical Personnel 23743 25874 27770 29584 30812 Investment in human resources has enabled the health sector to avail of an ever-increasing quality nursing personnel. This increase has a beneficial effect on health cover throughout the country and on the ratio inhabitants/physician, which increased from 1825 in 1990 to 1320 in 2000. Evolution of the Health Infrastructure Years 1998-2003 Category 1998 1999 2000 2003 2006 General Hospitals 10 10 18 21 172 Specialized Institutes, Centers and Hospitals 12 13 13 06   Regional Hospitals 31 34 32 33   District Hospitals 96 106 106 109   Basic Health Complexes 24 24 24 24   Basic Health Centers 1922 1951 1981 2058 2076 Regional school and university health centers       09   Total       2263   Source : www.santetunisie.rns.tn Public hospitals that do not come under the Ministry of Public Health: 3 Military Hospitals 1 Hospital of the Interior Security Forces in Tunis. Besides this public infrastructure, there is a para-state infrastructure: Para-state infrastructure: Six Polyclinics of the National Social Security Fund (CNSS) providing outpatients health care of a general nature, specialized treatment and diagnostic services for social security affiliates. Public Health Infrastructure The public sector remains the main provider of health care particularly preventive and hospital care. It is based on three complementary resort levels: the first level is comprised of 2058 basic health care centers and 109 district hospitals; the second level is covered by 33 regional hospitals located in most cases at the level of the administrative center of each governorate in 2003; the third level is composed of 18 university hospitals with a total of 196 sections and 40 specialized medical fields. Private Health Infrastructure It is comprised of an outpatient network of general or specialized medicine, paramedical treatment and hospitalization facilities. This infrastructure consists of: 70 multidisciplinary or monodisciplinary clinics; 1260 dental practice; A capacity of 16142 beds as against 16 013 beds in the public sector; 3293 medical practice of which 50.9% are specialized; 1394 pharmacies: 1259-day pharmacies and 141 night pharmacies; 156 medical analysis laboratories: 147 medical biology laboratories and 9 anatomy biology laboratories; 56 hospital transport services; 100 homo-dialysis centers; 567 paramedical free practice. Tunisia considers the health sector as among its highest priorities in light of the prominent role it has been playing in the country's development process and in warranting its social well-being. This is why, since the Change of November 7, 1987, the health sector has undergone a net development allowing a much better accessibility to both the public and private health structures, as well as an improvement of health indicators. Improvement of health indicators : - A life expectancy at birth, which has evolved from 67.4 years, in 1984, to 74.2 years in 2007. - A children mortality rate of 17‰, in 2006, as against 51.4‰ in 1984. - A maternal mortality rate of the order of 36.4 for 100 thousand living births, in 2007, as against 69 for 100 thousand living births in 1994. - A decrease of the synthetic fecundity index from 4.06, in 1987, to stand respectively at 2.02, in 2006 and at 1,7 in 2007. - A rate of use of contraceptive means by women in procreative age of 66%, in 2007, as against 49.8% in 1988. - An increase in the health cover for pregnant women through a prenatal medical consulting from 72%, in 1987, to reach 96%, in 2007. - A rate of post-natal health cover in the hospital sector which reached 96% in 2007. - An improvement of the health cover, of one doctor for 930 inhabitants in 2007, as against one doctor for 2110 inhabitants in 1987. - Substantial advances have been achieved in the control of transmittable diseases through the eradication of several diseases which were endemic, such as Cholera and Bilharzias. - 95% of the population has access to a health structure that is less than 5km away. Evolution of health structures within both the public and private sectors In order to improve geographic accessibility to all social categories, and regions, the infrastructure has developed as follows: In order to promote the export of health services, a decree was promulgated, in 2001, which allows for the creation of private health structures exclusively reserved for non-resident persons. It has been followed by a law exempting non-resident patients from paying the value added tax (VAT) in 2005. Furthermore, a set of pioneering measures have been decided by the Head of State on 5th September, 2008 for the promotion of exporting health services. Promotion of preventive services and programs As regards preventive care, efforts have been pursued to promote healthcare services and to expand the range of preventive programs, particularly in the field of hygiene, environment protection, school and university medicine, and basic healthcare. Preventive programs include: - The National Program for the Fight Against Aids - The National Program for Mental Health - The National Program for Mother and Child Health - The National Program for the Fight Against Cancer On the other hand, to reduce mother mortality and develop the concept of reproductive health, in light of the progress achieved in medical sciences at the national and international levels, action has been focused on : - Implementing, since 2001, a strategy for decreasing the rate of mother mortality; - Launching a plan of action to promote rural women's health; Other achievements have been made. These include : - Establishing a national center of pharmaco-vigilance; - Establishing a legal framework for the prevention against the dangers of smoking; - Creating a national agency for the health and environmental control of products - Creating a national anti-doping center - Developing a national plan for the fight against cancer - Establishing a national observatory for emergent diseases. Improvement of the performances of public health structures In order to bring services close to citizens and to improve the regional balance and the efficiency of public health structures, several projects have been implemented such as: - The project 'population and family health' during the 8th Economic and Social Development Plan (1992-1996). The first level of care benefited from a particular attention by implementing a specific project ('population and family health') characterized by the improvement of the countries coverage of basic health centres, reinforcement of the technical platform of district hospitals and nearby maternities (laboratory services, radiology, dental medicine) and the implementation of a mothers and infants health national program granting special care to the integration of services, reinforcement of family planning activities, improvement of work conditions thus enabling them to become a privileged place for the continuous training of health executives in the field of mothers and infants health and family planning. - The project 'support of the hospital management reform' that targeted in &1992 university hospitals. Indeed, and in order to reshape the institutional and financial structure of the public hospital sector, university hospitals benefited during the 8th Plan from a specific action the 'support of the hospital management reform' project. This reform concerned 19 hospitals, institutes and specialized centres. - Enacting an upgrading program for regional hospitals as from 1999, enabled the improvement of work conditions and the taking in charge of patients by reinforcing these structures as far as specialized human resources are concerned and by means of necessary diagnosis and treatment, as well as management modernization. - Development of medical emergency within the framework of the national policy set as from 1998. This strategy is composed of three specific parts: medical emergency services (SAMU) in Sfax, Gafsa and Gabès and the establishment of several mobile services (SMUR) in the EPS (public health establishments) of La Marsa, Habib Bourguiba in Sfax, and in the regional hospitals of Ben Arous, Nabeul, Kairouan, Kasserine and Mahdia, taking in charge of patients in emergency units and basic and continuous training. - Generalizing Haemodialysis units in some regional and local hospitals at the level of important delegations. - Development of inter-regional poles in some specialties such as mothers and infants' health at the level of the governorate of Béja, Kasserine, Monastir and Kairouan, and psychiatry in the governorate of Jendouba, Gabès and Gafsa. - Establishment of an upgrading strategy in the public sector and identification of a set of pilot sites that will be concerned with this program. Development of Modern medicine In order to allow, on the one hand, the Tunisian medical system to enjoy the same level as that of developed countries, and with the objective to reducing the number of Tunisian patients going abroad for treatment (presently less than 100 patients per year, as against 1,152 in 1987) and, on the other hand, so as to allow Tunisia to become an export pole for health services, several actions have been undertaken such as: The creation of different structures and services: - The National Center for the Promotion of Organ Transplants - The National Center for the Transplant of bone marrow - The Center for Emergency Medicine, Trauma and burns at Ben Arous - The Center for Neonatology at Monastir - The National Center for blood transfusion - The National Laboratory for the Control of Medicine - The Service for Thoracic Surgery at Ariana Hospital - The Service for Cardiovascular Surgery at La Rabta Hospital - The Neonatology Services of Tunis, Sousse and Sfax - The Carcinology Services at Sousse and Sfax - The Service for Hereditary and Genetic Diseases at the Charles Nicolle Hospital. The development of organ transplant activities as an evolving process (Cornea, kidneys, heart, liver, bone marrow, body parts…) The introduction of new medical technologies and of state-of-the-art techniques thanks to national medical expertise and an efficient cooperation with foreign medical teams, which has made possible a better management of health problems, particularly those pertaining to the digestive system, to ophthalmology, to neurology, to neurosurgery, to urology and to nephrology, as well as the covering of expenses for cancers, acupuncture expertise, surgery through coelioscopy and medical paediatric reanimation, the treatment of pain and cardiovascular diseases. The development of the local production of medicines on both the quantitative and qualitative levels, which has made it possible to cover 45% of the country's needs in medicines, as against only 7% in 1987. The development of technical means, as well human resources in the field of safe blood transfusion and derivatives. Reform of the financing system of the health sector In this framework, it is possible to mention: - The increase, as from 1995, in the participation of social security funds to the budget of the Ministry of Public Health, - The payment by the social security funds of the health costs pertaining to some diseases and some medical explorations (since 1996) that are provided to their affiliates in the private sector within the framework of bilateral agreement protocols, - The covering by the social security funds of the health costs of their affiliates in the public sector within the framework of a billing process that had been first put in place in University Hospitals (since 1996), and then in regional Hospitals (since 1999). - The revision of the conditions for delivering health care cards and for benefiting from reduced tariffs and from free health care in the public health structures in 1998. - Implementation of a new system for health insurance. - The increase in the budget of the Ministry of Public Health (from 187.9 MD in 1987 to 1,213.2 MD in 2008). Tunisia has managed to achieve many concrete results concerning, in particular, the improvement of the well-being of the Tunisian citizen as witnessed by the Gold Medal awarded by the World Health Organization, to President Zine El Abidine Ben Ali. It is also worth noting that Tunisia is one among few countries, which have achieved the objective of the program known as "Good Health for All before the Year 2000", as recommended by the WHO.