29 avril, 2022

Primum Non Nocere

WHO estimates that more than 13 million deaths around the world each year are due to avoidable environmental causes. The climate crisis, which is also a health crisis. There is an urgent need for actions to keep humans and the planet healthy.
Being an ER doctor and having worked during the COVID-19 Pandemic in France and in Tunisia, I was concerned about the enormous quantities of products used by the patients and the health professionals and the management of the medical waste.
It seems to be an emergency to address this issue with the health professionals in order to expose the challenges and advocate for a more environment friendly clinical practice.


The Latin phrase Primum non nocere (First, not to harm) have been introduced into medical ethics in 1864 by the medical ethicist Worthington Hooker.
It gives a maximum and exclusive priority to the negative injunction.
Yet, medical activities are causing an unintended harm.


Health systems are a massive component of the economy and have an important environmental footprint. It is part of the different steps of the materials economy[1].
The health sector consumes enormous quantities of materials, energy and water.
It is also making a major contribution to climate change through the use of the chemicals.


Some very dangerous intoxications of humans and other living beings can directly be caused by medical activities like the mercury pollution. 
Every year, 2,000 tons of mercury end up in the human environment. Mercury is a highly toxic heavy metal. It is impossible to destroy.
Spilled mercury circulates in the environment and gets into the food chain via water, where it concentrates particularly in the bodies of fish[2].
It attacks the heart and the circulatory system and, if it is ingested regularly, can lead to kidney failure, respiratory arrest and death[2].



Direct contact of humans with mercury can result in neurological and behavioral disorders: children exposed to methylmercury while they are in the womb can have impacts to their cognitive thinking, memory, attention, language, fine motor skills, and visual spatial skills[3].
Ingestion of fish and shellfish that contain methylmercury by pregnant women affect unborn infants' growing brains and nervous systems[3]. 




In addition, the health care system produces large amounts of waste, much of which are toxic and is a large source of dioxin emission from medical incinerators.
For example, The Poly Vinyl Chloride or PVC is the utmost used plastic in medical products like IV bags. When it’s burned, it produces a highly toxic dioxin. 



Air pollution plays a role in many of the major health challenges and has been linked to cancer, asthma, stroke and heart disease, diabetes, obesity, and changes linked to dementia[4].
Neither the concentration limits set by governments, nor the World Health Organization’s air quality guidelines, define levels of exposure that are safe for the population[3].


The health care system contributes to at least 4 to 10% of the CO2 footprint.


During the COVID-19 pandemic, there has been an unprecedented increase in health care demand.


(Source FR News)

According to the WHO:
- approximately 87,000 tons[6] of personal protective equipment (PPE) were procured between March 2020- November 2021 and shipped to support countries. This estimate is only about PPE from the UN system and does not include commodities procured outside of the UN initiative, nor waste generated by the public, like disposable medical masks.
-140 million test kits, with a potential to generate 2,600 tons of non-infectious waste (mainly plastic) and 731,000 liters of chemical waste (equivalent to one-third of an Olympic-size swimming pool) have been shipped,
-over 8 billion doses of vaccine have been administered globally producing 144,000 tons of additional waste in the form of syringes, needles, and safety boxes. 
Most of this equipment ended up as waste.


(Source: Inkyfada)

These tens of thousands of tons of extra medical waste weren’t managed adequately because attention and resources were devoted to the COVID-19 pandemic and much less to the safe and sustainable management of COVID-19 related health care waste.
Today, 60% of the health facilities in the least developed countries, are not equipped to handle existing waste loads, let alone the additional COVID-19 load[6].
Underfunded healthcare systems, poor training and lack of awareness of policies and legislations on handling medical waste have led to increased improper handling of waste within hospitals, healthcare facilities and transportation and storage of medical waste. [7]
Many countries do not have national guidelines in place to adhere to the correct disposal of such wastage. In some contexts, hazardous waste is left unprotected under severe weather influences; it can absorb the UV and re-emit it as heat and/or create free radicals[4].



Free radicals cause damage to cells, proteins and DNA and are associated with human diseases, including cancer, atherosclerosis, Alzheimer's disease, Parkinson's disease and many others[8].


Incineration is often the favored disposal method due to the rapid diminishment of up to 90% of waste, as well as production of heat for boilers or for energy production. This type of method – if not applying the right technologies – potentially creates hazardous risks of its own, such as harmful emissions and residuals.


The other used methods are:
-Open dumping Landfill
-Chemical disinfecting
-Indiscriminate waste


These methods also have risks like:
-Airborne contamination
-Land contamination
-Risk of contact in the surrounding communities
-overflow into seas and oceans
-Lasting waste in the environment
-Expenses for electrical usage
-Risk of contact with chemicals,
-possibility of not treating all pathogenic substances leading to contamination after treatment

The lack of effective waste management system, potentially exposes health workers to needle stick injuries, burns and pathogenic microorganisms, while also impacting communities.[9]


There is an urgent need for a climate-smart health care systems.


“We don’t want to be poisoning people in the name of healing them”. 
(Gary Cohen- Health without Harm)


(Source: ALAMY)


Health professionals must rise up to ensure their safety and that of patients:
There are many actions that can be organized either on the institutional, medical levels or on the individual level that can improve the quality and sustainability of health care:


On the institutional level:
-Working with the stakeholders in order to have the objective to reduce Health care system footprint, which also means big savings from transport, building energy use, water, and purchased goods and services[10]. This can be through strong national policies and regulations, regular monitoring and reporting and increased accountability, behavior change support and workforce development, and increased budgets and financing[6].
-Advocating for the countries to integrate the ongoing negotiations to ban the use of mercury in all kinds of industry and to sign and implement the Minamata convention[11]: Mercury should be forbidden. In Health structures, all products containing mercury need to be replaced with existing safer alternatives.
-Working with accreditation institutions and Advocating to transform the supply chain in order to purchase reusable recyclable or biodegradable devices that are safer for the patients like IV bags without PVC, safer gloves, products used in cleaning and even safer electronics and healthier food, including using eco-friendly packaging and shipping.
-Pressuring The ministry of Health and hospitals to invest in non-burn waste treatment technologies like having more autoclaves and less incinerators and adopting triage and recycling of the Hospitals waste.
-Health professionals can even act in order to transform the design of hospitals to reduce their impact on our environment, advocating for using renewable energies.


On the medical level:
Since 20% of the carbon footprint is made up of energy use in the facilities, some changes in the individual clinical practice will be useful: recognizing which elements of our activity in the health service are adding value to that patient and doing our best to try and strip out wasteful activities.
-Implementing Primary preventive intervention[12] aiming to reduce the need to visit hospitals  which will reduce the aspect of the carbon footprint, through reducing risks or threats to health, reducing demand and consumption of health services[10].
-Implementing secondary and tertiary prevention intervention in all the specialties in medicine across the hole health system, will reduce the demand on health services, making huge savings in the expenses of the health system in a very rapid fashion, it will also contribute to keeping people happy and to saving the environment.
-The implication of patients in their own care management in order to spot dysfunctions earlier, avoiding complications and evitable diseases and expenses.  
There are great examples like the Green nephrology in the UK[10] and the cataract surgery in Aravind Eye Hospital in India[13] that show how some simple interventions can improve quality of care, save money and reduce the health care system footprint.
Clinical leadership[14] in needed to undertake actions, like shifting away from propellant inhalers, changing anesthetic practice, moving to less intensive models of care and working with tools like LCA (Life Cycle Assessment) regulated by the International Organization of Sterilization which enables us to reuse safely medical material and avoid single use disposable items… Many actions can be done within each medical specialty to fight the overmedicalization of health and to rationalize the use of the services.


On the personal level[10]:
-Turning off the computers at night.
-Apply the TLC operation principals: Turn equipment off, lights out and close doors, which diminish energy consumption, improves patients comfort and saves money.
-Putting the waste in the right bin helps manage the medical waste correctly.
-Safe and rational use of PPE and every other medical equipment reduces environmental harm from waste, saves money and reduces potential supply shortages.
- Refuse the prescription of unsafe medical devices like those using mercury in order to completely eliminate its use and supply.
-Whenever possible avoiding prescriptions of drugs in favor of social prescriptions like dietary advices which might reduce the use of pharmaceutical products which production also causes a big part of pollution.


Implementing a sustainable health care system is easy, it saves money, improves health and reduces the CO2 footprint.
The COVID-19 waste challenge and increasing urgency to address environmental sustainability offer an opportunity to strengthen systems to safely and sustainably reduce and manage health care waste.
Health professionals are unwillingly contributing to the environmental problem.
All forms of environmental activism are important: personal commitments, reflection and collective actions, research, collaboration and advocacy, but also disobedience.
Many health professionals around the world chose to be part of resistance movements like the Extinction Rebellion which is a global environmental movement using nonviolent civil disobedience to compel government action to avoid tipping points in the climate system, biodiversity loss, and the risk of social and ecological collapse.


When our patients are exposed to such a clear and avoidable cause of death, illness and disability, it is our duty as health professionals to speak out.


[1] Youtube.com. 2007. The story of stuff. [online] Available at: <https://www.youtube.com/watch?v=9GorqroigqM&t=1276s> [Accessed 6 April 2022].
[2] (www.dw.com), D., 2022. Mercury to be banned | DW | 14.01.2013. [online] DW.COM. Available at: <https://www.dw.com/en/mercury-to-be-banned/a-16519002> [Accessed 27 April 2022].
[3] US EPA. 2022. Health Effects of Exposures to Mercury | US EPA. [online] Available at: <https://www.epa.gov/mercury/health-effects-exposures-mercury> [Accessed 27 April 2022].
[4] Essentracomponents.com. 2019. UV and its effect on plastics: an overview | Global Manufacturer & Distributor of Component Solutions — Essentra Components. [online] Available at: <https://www.essentracomponents.com/en-gb/news/product-resources/uv-and-its-effect-on-plastics-an-overview> [Accessed 27 April 2022].
[5] Holgate, S., 2017. ‘Every breath we take: the lifelong impact of air pollution’ – a call for action. Clinical Medicine, 17(1), pp.8-12.
[6] Who.int. 2022. Tonnes of COVID-19 health care waste expose urgent need to improve waste management systems. [online] Available at: <https://www.who.int/news/item/01-02-2022-tonnes-of-covid-19-health-care-waste-expose-urgent-need-to-improve-waste-management-systems> [Accessed 27 April 2022].
[7] Chisholm, J., Zamani, R., Negm, A., Said, N., Abdel daiem, M., Dibaj, M. and Akrami, M., 2021. Sustainable waste management of medical waste in African developing countries: A narrative review. Waste Management &amp; Research: The Journal for a Sustainable Circular Economy, 39(9), pp.1149-1163.
[8]  livescience.com. 2016. What Are Free Radicals?. [online] Available at: <https://www.livescience.com/54901-free-radicals.html> [Accessed 27 April 2022].
[9] Youtube.com. 2013. Health Care Without Harm. [online] Available at: <https://www.youtube.com/watch?v=iPzoskTpiwQ&t=105s> [Accessed 27 April 2022].
[10]Youtube.com. 2013. Sustainable Specialties. [online] Available at: <https://www.youtube.com/watch?time_continue=95&v=KlT4kP8WSms&feature=emb_logo> [Accessed 27 April 2022].
[11] Mercuryconvention.org. 2021. Convention de Minamata sur le mercure – Texte et Annexes | Minamata Convention on Mercury. [online] Available at: <https://www.mercuryconvention.org/fr/resources/convention-de-minamata-sur-le-mercure-texte-et-annexes> [Accessed 27 April 2022].
[12] Iwh.on.ca. 2022. Primary, secondary and tertiary prevention. [online] Available at: <https://www.iwh.on.ca/what-researchers-mean-by/primary-secondary-and-tertiary-prevention> [Accessed 27 April 2022].
[13] Youtube.com. 2018. Carbon Footprint of Cataract Surgery at Aravind Eye Hospitals High quality and size. [online] Available at: <https://www.youtube.com/watch?v=sdDwu1NEg1I> [Accessed 27 April 2022].
[14] Carevoyance. 2018. Identifying & Understanding Clinical Leadership. [online] Available at: <https://www.carevoyance.com/blog/clinical-leadership> [Accessed 27 April 2022].

09 avril, 2022

Challenge of the waste crisis: the ultimate proof that neoliberalism is bad for the planet

 During the Holocene, humans started the conquest of the Earth. The agricultural and industrial revolutions and the industrial boom at the end of the Second World War[1] were significant events that pushed humanity into the Anthropocene, stimulated by the spread of imperialism and colonization followed by the actual neoliberal neocolonial order.

Technology was supposed to bring social progress. Yet, industrialization and the rise of consumerism generated inequality and pollution of all kinds.

Nowadays, there are calls from experts and activists for a collective action at every level of society in order to achieve planetary health through the implementation of the One Health concept[2]. Researchers defined the planetary boundaries within which humanity can continue to survive. Respecting these boundaries implies deep changes in global governance and limiting growth to minimize negative externalities.[3]

Implementing the planetary boundaries concept[3] implies a boundaryless planet which appears to be very challenging in the actual scattered human population lead by neoliberalism and neocolonialism.

In this article, I expose how the neoliberal system is the culprit in the actual environmental crisis; how pollution is profoundly neocolonialist since the actual management of the crisis makes the most vulnerable bare the load of the rich and I explain why the market shouldn’t have a say in the governance of environmental issues.

The challenge of growth and pollution:

The obligation of growth as a mean of development opened the door to the extensive materials economy[4] which different steps have negative outputs and contribute directly to the anthropogenic pressures on the Earth System causing the imminent transgression of the planetary boundaries[3,5] and the implementation of inequality along the way.

First, extensive natural resources exploitation by the Minority World make a small amount of people use an impressive amount of resources locally and then purloin resources from the Majority World while destroying biomes. Then, the production processes generate a large number of toxic products and chemicals, for which western governments implemented strict policies, making corporations opt for overseas implementation of production units leading to the contamination of populations in 3rd world countries. The distribution mechanism uses exploitative approaches to reduce cost. Finally, Consumption is massively promoted leading to startling aggregates of waste.

Global waste crisis:

Since the 2nd era of globalization, The aim of the neoliberal order was to promote a global free market via ‘structural adjustment’ reforms recommended by institutions such as the IMF and the World Bank[6], giving more space to the material economy to offer cheap products with planned obsolescence to clients immersed in media manipulation that distorts their vision of the world, pushing them to consume more and throw more waste.

The last step of the materials economy is disposal, it’s the more obvious part of the process nowadays. Massive production and consumption lead to colossal amounts of waste which management is challenging in a linear system of production.

Minority world is creating the biggest percentage of waste: the USA for example, are producing alone, 30% of the world waste. [4]

These different kinds of pollution are responsible for 16% of all deaths worldwide in 2015. Pollution seems to be more proficient than AIDS, tuberculosis, and malaria combined; it kills 15 times more than wars. [5]

In high income countries, where stricter environmental legislation raises the costs for disposal[7] and where recycling is insufficient and cannot be the answer to all kinds of waste, governments and corporations adopted a waste distancing[8] policy:  it is more financially appealing and much easier to operate in the unregulated markets of the global South.

The Global North ends up exporting waste to the Global South in an attempt to hide its industrial inefficiency, to create a physical and mental distance between consumers and their waste in order to keep the consumerism mechanism operational by lowering awareness and avoiding accountability. [8]

Waste distancing policy implies a waste-sink demand that deepen economic inequalities either on a local or global scale: some communities have no choice but to accept the waste of the rich.

The governance of the waste distancing

At the international scale, the neocolonial dynamic normalizes taking advantage of corruption and the lack of environmental policies in low-income countries. These affected populations have a limited social–ecological resilience and have to endure the social impacts of transgressing planetary boundaries[3] without having the competencies to ensure environmental stewardship of hazardous wastes.

The export of waste to developing countries started being a blooming business in the early 1990s.[8] The Basel Convention signed in 1992, sought to control this trade and was followed by regional conventions aiming to control this expanding business sector.

Until 2018, China was the main actor in the waste business field, importing 45% of the world’s plastic waste. In 2018, China started applying restrictions resulting in a waste accumulation in producing countries and the re-routing of hazardous waste toward other markets.[9]

This market on tension resulted in the increase of illegal treatment of hazardous waste in both producing and waste receiving countries coupled with an increase in waste crime reported by Interpole.[9]

At the international level, “Treaties are crucial”[2]because they give civil society organizations the power to make nations accountable. Since the 1990s many cases of illegal waste distancing have been reported and some exporting countries had to take back their hazardous waste.

The Italian Tunisian waste battle[10]:

One of the most recent waste distancing conflicts took place in 2018: an agreement took place between 2 private compagnies in Italy and in Tunisia aiming to export 120 000 tons of Italian toxic waste yearly for a total sum of 5 million euros[11]. The first shipment arrived to the Tunisian coast in July 2020 and was composed of 282 containers filled with 7,900 tons of waste.

At the Tunisian end, the private company was an inactive company created in 2011 that amazingly started working in 2018. It asserted to local authorities that the shipment was made of post-consumer plastic to be recycled. The management of the file didn’t apply the national rules and the specifications were reported to be modified without the approval of the referent national institution: The National Agency for the Protection of the Environment: ANPE.[10]

The Italian company was known to be in the middle of judicial investigations conducted by Salerno's Anti-Mafia Investigation Directorate and seem to have a link with organized crime.[10]

The true nature of the waste wasn’t known but some sources declare it not to be recyclable[12], the Tunisian government declared not being aware of the agreement. Clearly, the entry of the shipment was directly linked to corruption[13] since the former Minister of the Environment, the Tunisian consul in Naples and around 25 other persons have been arrested and charged while the owner of the Tunisian company fled the country.

This case mobilized many environmental NGOs[13] that called for the Italian government to repatriate these containers since the transaction was a clear transgression of the Basel convention, the Bamako convention and the Izmir Protocol of the Barcelona Convention.

The fight was hard, it was even described as a “David versus Goliath battle” in the media[10]: civil society members had to keep on pressuring the Tunisian government for 2 years in order to adapt a firm response.

High level discussions took place between stakeholders from the two countries in order to reach an agreement. Finally, the return of only 213 containers among a total of 282, was validated.

Tunisia's domestic waste is reported to be either incinerated producing toxic dioxin or managed in landfills. CSO’s report[13] reveal that Tunisian domestic solid waste management is a very lucrative sector where opacity and corruption are not only endemic but also institutionalized. Like other developing countries, Tunisia does not have the technology, or working standards to deal with domestic waste properly, not to mention exported one.


Waste is currently the tip of the iceberg, but other types of pollution are just as dangerous. The impacts on human health are disastrous, and we are only just beginning to discover them.

The impact of pollution is suffered by the most vulnerable populations who are more exposed due to their socio-economic situations within countries and by the poorest countries on a global scale. Pollution obeys to the same mechanisms of structural violence and should be qualified as so.

Waste crisis has spurred corruption and crime and generated more inequality and treaties failed to provide an international governance system that would make such practices unappealing. 

This crisis was the result of neoliberal consumerist policies and its management should not be entrusted to the laws of the market.

The externalization of waste from industrialized countries is an avoidance that does not allow them to think about sustainable solutions: the extraction of natural resources in third world countries, the relocation of polluting production units and the outsourcing of waste are only operations to camouflage the problem: rich countries are putting the dirt under the rug.

The implementation of planetary health and the adaptation to the anthropogenic pressures on earth implies the rethinking of actual unequal trading system. We also need to reflect on the role and meaning of borders because they have been shown to be extremely porous when it comes to pollution.


[1] Strasser, S., 1999. Waste and Want: A Social History of Trash. New York: Metropolitan Books, pp.13-14.

[2] Schuftan, C., Legge, D., Sanders, D. and Nadimpally, S., 2014. A manifesto for planetary health. The Lancet, 383(9927), pp.1459-1460. 

[3]  Rockström, J., Steffen, W., Noone, K., Persson, Å., Chapin, F., Lambin, E., Lenton, T., et al., 2009. Planetary Boundaries: Exploring the Safe Operating Space for Humanity. Ecology and Society, 14(2).

[4] Youtube.com. 2007. The story of stuff. [online] Available at: <https://www.youtube.com/watch?v=9GorqroigqM&t=1276s> [Accessed 6 April 2022].

[5]   Landrigan, P., Fuller, R., Acosta, N., Adeyi, O., Arnold, R. and Basu, N. et al., 2018. he Lancet Commission on pollution and health. The Lancet, 391(10119), pp.462-512.

[6] McMichael, P., 2000. For an overview of the globalization project and its impact on developing countries. Development and Social Change: A Global Perspective.

[7] Müller, S., 2019. Hidden Externalities: The Globalization of Hazardous Waste. Business History Review, 93(1), pp.51-74.

[8] Clapp, J., 2002. Distancing of Waste: Overconsumption in a Global Economy in Confronting Consumption. MIT Press. 

[9]  2020. INTERPOL STRATEGIC ANALYSIS REPORT: Emerging criminal trends in the global plastic waste market since January 2018. INTERPOL.

[10] France 24. 2022. Tunisian NGOs triumph in David-vs-Goliath toxic waste battle with Italy. [online] Available at: <https://www.france24.com/en/africa/20220221-tunisian-ngos-triumph-in-david-vs-goliath-toxic-waste-battle-with-italy> [Accessed 6 April 2022].

[11] Heinrich-Böll-Stiftung. 2022. L'environnementalisme post-décentralisation | Heinrich-Böll-Stiftung | Tunisia - Tunis. [online] Available at: <https://tn.boell.org/fr/2021/04/29/lenvironnementalisme-post-decentralisation#_edn6> [Accessed 6 April 2022].

[12] GAIA. 2022. Italy and the EU must take back waste dumped in Tunisia Now. [online] Available at: <https://www.no-burn.org/italy-must-take-back-waste-dumped-in-tunisia/> [Accessed 6 April 2022].

[13] 2022. Déchets italiens : derrière le scandale environnemental, une vaste affaire de corruption. [online] Available at: <https://inkyfada.com/fr/2021/02/11/enquete-dechet-corruption-italie-tunisie/> [Accessed 6 April 2022].

20 mars, 2022

Analysis of the Tunisian health system structure and financing and recommandations to achieve Universal Health Coverage

Tunisian context:

•Tunisia is classified by the WB as a low-middle income country.
•Total population in 2020: 11 818 618 (1)
•GDP in 2020 was 39.236 billion US dollars (2)
•GDP annual growth in 2020 is -8.6% (3)
•National debt in relation to gross domestic product (GDP) in 2021 is 91.19% (4)

Historical evolution of the health system in Tunisia:

        The history of the health system in Tunisia dates back to Carthage. This period had known 55 Carthaginian doctors, including a few women.

The 8th century saw the Kairouanese school of medicine, with Ibn Al Jazzar (5) who wrote several works of central medicine a great social predisposition unusual at the time, in particular with his work of medicine intended for the poor.

In the 14th century, Tunisia knew the "Al-TabibAl-Skolli" which was a line of Tunisian doctors who taught medicine at the Zeitounaand practiced in "Moristan" founded by the King of Tunis AbouFares AbdelAzizfor the benefit of the poor. 
Among the “Tabibs As-Skoly” some wrote the best medical and pharmacy treatises of their time.

Then, in a more recent history, in the 16th century, we retain the fight against maraboutismvia the creation of health structures such as the Aziza Othmena hospital, the first example of a psychiatric hospital in the Tunisian context, initially housed in the rue des Tunisians "AZZAFINS" (musicians), where the patients received upon their discharge, sums of money to compensate for their time of inactivity due to hospitalization and where musicians played music to brighten the minds of the sick.

The Tunisian health system experienced during colonization, the introduction of new Western medical concepts, with a new way of doing medicine as well as the creation of new health structures mainly for the colonizers and the Pastor reaserchInstitute.Therehas been a « transplantation of the hospital-basedhealthcare system to developingcountries and the lackof emphasison prevention» (6)

During this period the democratization of access to health was not on the agenda since the colonial context did not lend itself to it. Thus, health structures had only been developed in regions of economic interest to colonizers.

After the 2nd World War, the dynamic of national liberation allowed the development of national health systems with the provision of public services and the establishment of national programs.

This patriotic ardor was accompanied by a political desire for equality which allowed the construction of the Tunisian health system with the development of several small local health structures and the development of many regional and district hospitals as well as the design and establishment of national prevention and reproductive health programs.

Post-colonial Tunisia had adopted, like all southern countries, the biomedical model preached by Western countries in the 19th century and reinvigorated with scientific discoveries and technological innovations post WWII.

As in otherafricancountries, Primaryhealthcare wasfavoredby the spread of national, anti- imperialist, and leftistmovements. (6)

In the first years of independence, the health system therefore focused on disease management and epidemic control. A social system has been implemented and the health system was directly conceptualized as a 2ndgeneration health system insisting on the the promotion of primaryhealthcare as a route to achievingaffordableuniversalcoverage, usingmainlysmallproximal structures; in orderto  ensurea minimum levelfor all of healthservices. There has alsobeen a focus on education(7).

In 1987, a putchhas been doneby Ben Ali (second president) andsincethentherehas been a change in the approach.

Politicalwillcontinuedworkingon adequatesupplyof safewater and basic sanitationbut therehas been a change in the social securitysystem thatopenedthe doorsto corruption, makingfundingsno more earmarked. In addition, therehas been a greatpromotion of privatesectorwiththe implementationof severalprivatepractices and privateclinicsin the country.

In 2011, therehas been a revolutionwithan importance politicalchanges and a climateof instability. Thehealthsystem continuedto bea societalbased  mixed type witha strongtendencytowarda marketdrivenapproach.

Corruption and badgovernancehavenegativelyimpactedthe healthsystem.


Since the independance, Tunisia's demographic situation has changed with an increase in life expectancy (went from 42 years in 1960 to 76.7 years in 2019) (8) and an increase in the population which rose from 4.178 million in 1960 to 10.694 million in 2019 (9).

During this period, public health facilities did not see any noticeable improvement. This stagnation has been accompanied by serious operational problems, affecting the availability, quality and safety of services.

By keeping a vertical and centralized management mode, no autonomy was possible for public health establishments created in the mid-1990s.

At the same time, the private sector has been strongly encouraged. Private clinics were establishing themselves in increasing numbers in advantaged areas which were still urban and coastal areas.

This same health policy continued after the revolution of 2011; the growing deterioration of public structures goes hand in hand with the increase in the number of beds in the private sector, which has even more than doubled since 2011, while still remaining outside disadvantaged areas.

Following the independency many fact had an impact on tunisian demography:

The abolition of polygamy, whichtookplace sinceindependence(1956) associated with a family planning policy and progress in the health system lead to a demographic and an epidemiological transitions.

The demographic transition in Tunisia:

•A growth in the country's total population: from 3,780 in 1956 to 11 818  million in 2020 (nearly4 times).(10) 
•A change in the age structure of the population: the number of over 60 years was 6.7% in 1984 to 12.96% in 2019 (11)
•The decline in infant mortality has resulted in an increase in life expectancy at birth, which went from 37 years at the end of the 1940s to 52 years at the end of the 1960s and to 74.5 years in 2009(10) and 76.699 in 2019 (12)
Epidemiologic transition in Tunisia:
•Decline/ eradicationof "traditional" transmissible diseases(malaria, bilharzia, trachoma, tuberculosis, infectiousdiarrhea...) and thoseof infancy(polio, tetanus, neonatal, diphtheria...). 
•In 2002, non-communicable diseasesconstituted79.7% of deathsand 70.8% of the diseaseburden(10)
•Emergence of non-communicable diseasesof chronicand degenerativetype, witha multifactorialetiologyand at a high costof treatment. 
•An upsurge in road accidents with their consequences in terms of mortality and morbidity

Basic indicators in 2018: 

-Total expenditureon healthfor Tunisiawas2,909 million US dollars. Expenditureon healthof Tunisiaincreasedfrom1,701 million US dollars in 2004 to 2,909 million US dollars in 2018 growingat an averageannualrate of 4.10%. (13)

-THE (Total Health Expenditure) was 7.292% as a share of the GDP. (14)

-Domestic general government expenditure on health as a share of current health expenditure is 57.4% including voluntaryhealthinsurancefor privateworkersand obligatorysocial healthinsurancefor public sectorworkers(15)

-Health expenditure per capita is 252 dollars (15)

-Governmental health expenditure per capita is 144 dollars (15) 

Financing of the health system is based on 4 types of funds (2014)(16)

1-Social insurance:

When considering total health spending by the public sector(defined as spending by the State and by compulsory social insurance schemes), there is a noticeable decrease in public spending, replaced by an increase in the portion of private spending. 

2-Out of Pocket paiement:

•The OOP isthe mostimportant formof financingthe healthsystem in Tunisiaand constitute39.4% of the THE in 2014 (16)
•Itismade of direct full paiement, Co-paiement and User feesand doesnot takeintoconsiderationinformalpaiement.
•Thisveryhigh levelof expenditureleads to foregoinghealthcareand sometimesleads to insurmountabledebt. As a result, each year more than100 thousand people fall into poverty due to catastrophic health expenses.


Public Fundingfromthe Ministry of Healthisthe main public fundingand constitues 24.1% of the THE in 2014 (16) It is a global operating budget.

4-Private healthinsurance:

There is a very low enrollement in private insurances in Tunisia.

Private health insurance and some fundings from other ministries like social affairs had a share of current health expenditure of 1.3% in 2014 (16)

Social insurance: Different types of coverage

•Twomodes of financingcoexist: a Bismarckiansystem compulsoryhealthinsuranceand a Beveridgiensystem targetingthe poorand low-incomepopulation. Historically, the latter wasthe predominantmode and has been graduallyreplacedby the former, since1995. (17)
•Most of the Tunisianpopulation benefitsfromhealthcoverage, accordingto variable modalities: compulsorysocial securityschemes, free medicalassistance (free of charge or withreducedrates). 
•Additionalinsurances(group and mutualinsurance) have been developedto compensatefor the inadequaciesof the healthinsuranceof social securityfunds.

There are 2 Funds as a social insurance: (18)

-The National Social Security Fund (CNSS) which is responsible for elderly, invalidity, survivors, supplementary retirement, death and unemployment insurance and provides family benefits,

-The National Health Insurance Fund (CNAM) which manages health, maternity, industrial accidents and occupational diseases insurance.

Protection against the financial risk of illness was strengthened with the creation of the CNAM during the 90s, which was to support both public and private sector services. 

However, it is the private sector that benefits the most. 

Health insurance is compulsory for workers in the public sector and it is voluntary for workers in the private sector.(19)

The contribution of the CNAM as a share of current health expenditure was 34.6% in 2014 (16)

The state guarantees free or subsidized healthcare to the lowest income groups under two public medical assistance schemes: (10)

•Free care: This categoryisdefinedaccordingto the povertyline and ismade up of the targetfamiliesof a permanent assistance program.
•Beneficiariesof reducedrates: The grantingof reducedrate cardsisgrantedon the basis of annualfamilyincome, takingintoaccountthe size of the family.
•Thecoveragerate is100% for civil servants (CNRPS) and reaches95% of eligibleworkersin the privatesector.
•Arecentstudypublishedin 2019 shows that17.2% of the Tunisianpopulation (estimatedat 11,295,787 people in 2016) do not have anysocial coverageagainstthe disease.
•There are marked inequalities in access to healthcare: the latest studies report that17% (nearly2 million Tunisians) are neither covered by the National HealthInsuranceFund(CNAM) nor by Free MedicalAssistance (AMG) and therefore do not have any social health coverage.

The fragmented, complex health insurance system is inequitable and generates corruption.

“Access to health services differs depending on the protection regime: beneficiaries of free healthcare and reduced rates are entitled only to public health structures, while social insured have the choice between three channels giving them access either to public providers or those in the private sector. »

beneficiaries of free healthcare cannot access healthcare in the private sector and sometimes have difficulty obtaining or renewing cards.


A variety of provider payment methods is used by the different payers of care (17)

MOH pays regional and university hospitals on the basis of a global operating annual budget.

The social security which covers public employees pays for care in regional and university hospitals on the basis of a simple case-based fee system but within the context of a global budget. 

Individuals and many private insurance companies, pay on a fee-for-service basis. 

Provider payment mechanisms in the health sector tend to be dominated by fee-for-service, salary, and global budgets.

Financial flow and Health expenditure(10)

The private sector is rather flourishing but very unevenly distributed over the territory. It remainsfinanciallyinaccessible for the vastmajorityof Tunisians.

The public sector provides the majority of health services: two-thirds of consultations and 90% of hospitalizations but has less funds than the private sector.

And has a limited service package because of rationing and shortages due to budgetary constraints, linked to the inadequate use of resources and the insufficient and capped contribution of the CNAM.

Without forgetting that the funds of the CNAM are often used to makeup the deficit of the social funds and are thus deviated from their real objective.

The public sectoristhe unique provider of Preventiveand promotionalactivities.

These activities are marginalized in a public sector which has become very hospital-centered and oriented towards curative care. 

According to national health accounts, even the budget allocated to prevention in Tunisia is very marginal.

OOP expenditure are mainly directed to the private sector and is distributed as follows:

Pharmacy: 34.81%

Privateclinics: 28.04%

MD and dentists: 13.52%

Otherproviders: 14.51%

Labs and radiology: 9.13%

It is also interesting to note that there is no data about the informal paiements knowing that these tend to be more frequent in a corrupted system.


A progressive health system (20)

Kakwani index is positive in Tunisia indicating a progressive healthcare financing system. The rich pay more than the poor for their health services and the country established free healthcare services for people below the poverty line and reduced wages for people earning the minimum wage(20)

Equity in health financing

•When it comes to fairness in financial contribution, Tunisia is ranked between108 and 111 from a total of 191 countries according to the WHO report. (7)
•There is a very high level of OOP expenditure that leads to foregoing healthcare and sometimes leads to insurmountable debt. As a result, each year more than100 thousand people fall into poverty due to catastrophic health expenses in Tunisia.

Recommendations for sustaining or achieving Universal Health Coverage

•It seems compulsory to consider restructuring the debt of the country in order to have a stronger state' input into the health system..
The fight against corruption has to be done to eliminate malfunctioning and let the system evolve.
•It is necessary to put in place a comprehensive health reform with a health financing reform which should aim to increase the resources devoted to health and reduce the share of direct house hold expenditure. 
This financial reform should also include the CNAM to implement a system of universal health coverage. 
It is essential to extend health risk coverage to those currently not covered and to abolish the different classifications in order to adopt a single universal health coverage.
•Benchmark of good practices that could limit over-medicalization due to the commercial dimension that underpins private sector development.

1.Population, total - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited21 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.POP.TOTL?locations=TN
2.GDP (currentUS$) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited22 October2021]. Availablefromhttps://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=TN
3.GDP growth(annual%) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited22 October2021]. Availablefromhttps://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=TN
4.Tunisia - national debtin relation to grossdomesticproduct(GDP) 2016-2026 | Statista[Internet]. Statista. 2021 [cited22 October2021]. Availablefromhttps://www.statista.com/statistics/524541/national-debt-of-tunisia-in-relation-to-gross-domestic-product-gdp/
5.tasci u. Ibn al Jazzaridentifiedcontagiousdiseases1,000 yearsago[Internet]. TRTWORLD. 2020 [cited21 October2021]. Availablefromhttps://www.trtworld.com/magazine/ibn-al-jazzar-identified-contagious-diseases-1-000-years-ago-35581
6.Cueto M. The ORIGINS of PrimaryHealthCare and SELECTIVE PrimaryHealthCare. American Journal of Public Health. 2004;94(11):1864-1874.
7.The World healthreport 2000 Healthsystemsimprovingperformance. Geneva; 2000
8. Life expectancyat birth, total (years) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited21 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=TN
9.Population, total - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited21 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.POP.TOTL?locations=TN
10.Achour N. LE SYSTEME DE SANTE TUNISIEN : « ETAT DES LIEUX ET DEFIS » [Internet]. Fphm.rnu.tn. 2011 [cited22 October2021]. Availablefromhttp://www.fphm.rnu.tn/sites/default/files/Annexe%202%20Le%20système%20de%20santé%20tunisien%202011%20Noureddine%20Achour.pdf
11. Tunisie - Pyramide des âges 2020 [Internet]. countryeconomy.com. 2021 [cited22 October2021]. Availablefromhttps://fr.countryeconomy.com/demographie/structure-population/tunisie
12.Lifeexpectancyat birth, total (years) - Tunisia| Data [Internet]. Data.worldbank.org. 2021 [cited22 October2021]. Availablefromhttps://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=TN`
13.TunisiaExpenditureon health, 2000-2018 - knoema.com[Internet]. Knoema. 2021 [cited22 October2021]. Availablefromhttps://knoema.com/atlas/Tunisia/topics/Health/Health-Expenditure/Expenditure-on-health
14.Currenthealthexpenditure(% of GDP) - Tunisia| Data [Internet]. Donnees.banquemondiale.org. 2021 [cited21 October2021]. Availablefromhttps://donnees.banquemondiale.org/indicateur/SH.XPD.CHEX.GD.ZS?locations=TN
15.Tunisie General governmentexpenditureon healthas a shareof currenthealthexpenditure, 1960-2020 - knoema.com[Internet]. Knoema. 2021 [cited21 October2021]. Availablefrom: https://knoema.fr/atlas/Tunisie/topics/Santé/Dépense-de-santé/General-government-expenditure-on-health-as-a-share-of-current-health-expenditure
16.Ben Abdelaziz A, HAJ AMOR S, AyadiI, KhelilM, ZoghlamiC, Ben Abdelfattah S. Article medicaleTunisie, Article medicaleFinancement des soins de santé - Dépenses de santé - Participation aux coûts- Financement du gouvernement - Financement individuel - Soutien financier à la planification et au développement de la santé - Assurance maladie - Couverture d'assurance - [Internet].Latunisiemedicale.com. 2018 [cited21 October2021]. Availablefromhttps://www.latunisiemedicale.com/m/article-medicale-tunisie_3467_fr
17.Republicof TunisiaHealthsectorstudy[Internet]. Documents1.worldbank.org. 2006 [cited22 October2021]. Availablefromhttps://documents1.worldbank.org/curated/en/201241468312891649/pdf/410180ENGLISH010Sector0Study10Final.pdf
18.La sécurité sociale des salariés en Tunisie [Internet]. Cleiss.fr. 2020 [cited21 October2021]. Availablefromhttps://www.cleiss.fr/docs/regimes/regime_tunisie_salaries.html
19. Les cotisations en Tunisie [Internet]. Cleiss.fr. 2020 [cited21 October2021]. Availablefromhttps://www.cleiss.fr/docs/cotisations/tunisie.html
20.RostampourM, NosratnejadS. A SystematicReviewof Equityin Healthcare Financingin Low- and Middle-IncomeCountries. Value in HealthRegionalIssues. 2020;21:133-140.