Tunisia improves right to health through citizen dialogue and participatory juries

Tunisia’s legacy of enshrining the right to healthcare was strengthened through the adoption of Tunisia’s Constitution of 2014.¹ Since ratification, Tunisia has utilized citizen dialogue and democratic participation through the National Health Policy to realize equitable access to healthcare systems. This reform has led to substantial gains in quality healthcare for many citizens, especially vulnerable populations and women.

Tunisia has led the region in healthcare rights, with protections first enshrined in their 1959 constitution and continuously developed through successive reforms. Following the Jasmine Revolution, the 2014 Constitution expanded healthcare rights to encompass the right to water, a healthy environment, and protections for physical inviolability and human dignity. The law further guaranteed all citizens the right to treatment, free of charge for some vulnerable groups and at a low cost for others.² These constitutional additions necessitated innovative reforms to materialize their obligations. The National Health Policy (NHP) emerged amid political, social, economic, and security instabilities of the post-revolution period as a significant shift towards democratic healthcare governance.

The NHP (2011 to present) seeks to reorganize the healthcare system around the needs of citizens through participatory governance. This includes utilizing input from a broad range of stakeholders, including national and civil society organizations, health professionals, and representatives, to identify key challenges and develop solutions to expand access to quality healthcare. Citizen juries have defined problems across a variety of populations, while the government plans for citizen participation in monitoring and evaluation by the completion of the project. These approaches position citizens as active participants in shaping their own healthcare system.

The NHP builds on Tunisia’s strong foundation of near-universal healthcare coverage to improve quality and equity. By 2005, most Tunisians were covered by healthcare insurance: the National Health Insurance Fund, composed mostly of formal sector employees, covered ∼66 percent of the population. The two public medical aid schemes, ‘free healthcare scheme’and ‘reduced-fee plan,’ covered ∼8 percent of the population defined according to the local poverty line for the former and ∼25 percent of the population whose monthly income falls below the minimum wage rate for the latter.³ On this foundation, the NHP centers its values on fairness, solidarity, and equitable access to services, advancing these goals through a multi-phase process which champions transparency, anti-corruption, and meaningful citizen participation.⁴  

Implementation

A multiple phase implementation started in 2012, following the conclusion of the National Health Conference. In the first phase (2012–2014), called the health system diagnosis phase, more than 3,400 participants were involved in various participatory dialogue spaces discussing health system issues and proposing solutions.⁵ The second phase (2016–2021) entitled the “The NHP 2030 development phase” defined the main strategic directions and content of the NHP. This phase featured the first-ever participatory health policy in Tunisia, championing the contributions of civil society and citizen jury participants.⁶ The NHP captured the dialogue of 3,263 participants, including experts, citizens, and health professionals. The third phase, entitled “The NHP implementation phase” (2021–onwards) defines a participatory approach for monitoring and evaluation.⁷ 

Investment

Cost is difficult to analyze from government records, whereas multiple international donors have recorded financial and technical contributions to this project. From 2019-2023, the World Health Organization has granted USD 22.78 million to Tunisia.⁸ In 2025, USD 125.16 million was allocated to Tunisia by the World Bank to support their efforts in 2025.⁹ Agence française de développement (AFD), the European Union, and UNICEF have also contributed with technical support.¹⁰ 

Assessment

As of a 2020 evaluation, the significant advancements towards the right to health have been recorded. The life expectancy at birth was 75.3 years (72.7 for males and 77.5 for females) compared to 71.5 years in 1995 (69.5 years for males and 73.3 years for females).¹¹ However, the life expectancy may have been skewed by COVID-19, as in 2019, the average life expectancy was 76.3. This is the third-highest expectancy rate in Africa and above the world average of 72 years.¹² The same evaluation demonstrated that national programs eradicated deadly infectious diseases such as malaria, schistosomiasis, ophthalmia, tuberculosis, infectious diarrhea, polio, neonatal tetanus, and diphtheria.¹³  

Specific gains have been made for women and vulnerable populations. Under five mortality rates declined from 15.7 per 1,000 live births in 2013 to 13.3 per 1,000 live births in 2020, but a large gap remains in rural and urban areas.¹⁴ In 2019, 84.1% of women between 15 and 49 years received four or more checkups by qualified health workers during their most recent pregnancies.¹⁵ Additionally, more than 99% of women between 15 and 49 were assisted by qualified health staff during live births.¹⁶ Out-of-pocket (OOP) spending by households, which disproportionately affect homes in poverty, accounted for 37.9% of current health expenditures in 2019 compared to 42.5% in 2005. This decrease is likely due to the health system’s coverage.¹⁷ 

Furthermore, Tunisia has invested in infrastructure to support its commitment to quality healthcare. In 2017, Tunisia maintained an exemplary ratio of doctors to citizens 130 doctors per 100,000 inhabitants. Tunisia’s greatest asset in healthcare are the 14,896 doctors employed in the sector, of which 6,491 are general practitioners and 8,405 are specialists.¹⁸ In 2019, there were 70 projects to renovate and create clinics, with the intention to expand the capacity of current private sector facilities by 10,000 beds and supply critical technology such as MRI machines and scanners.¹⁹ 

The NHP has not addressed all barriers to the right to healthcare. Despite the existence of two insurance schemes, nearly one million people are not covered (8-10 percent) of the population.²⁰ This population is at risk of experiencing financial distress due to high out-of-pocket costs, especially for those who are vulnerable or in poverty. Bribery, corruption, and nepotism in the healthcare disproportionately impact on vulnerable groups seeking appointments, treatment, and medicine.²¹ Further economic disparities are pronounced in healthcare with an imbalance of doctors in private (5,407) compared to public sector (2,318).²² Additionally, strikes have led to the exodus of over 4,000 doctors between 2017–2019.²³

Democratic dialogue has proven to be an effective way to improve healthcare outcomes in Tunisia. However, the system must overcome substantial barriers to guarantee accessible and equitable healthcare for all. The NHP activities are scheduled to conclude in 2030, leaving time to create impactful solutions to the current constraints. Further processes to refine the healthcare system with citizen dialogue must shape access to healthcare for the most excluded groups with specific attention to regional and economic differences.

Photo Caption © “Health worker administers the COVID-19 vaccine to USAID staff in Tunisia.” Photo by USAID/Tunisia

Tags

• Building Solidarity
• Healthcare
• Low-Income Groups
• Middle East & North Africa
• Middle-Income Country
• Political & Civic Participation
• Tunisia
• Universal