20 mars, 2022

Management of the COVID pandemic in Tunisia: What is the solution when there seems to be no solution?

Simon Cordall published an article in The Guardian about the management of the COVID-19 crisis in Tunisia.

I chose to respond to this article and analyze the situation in a more scientific approach.

The article in available through this link:

Tunisia lockdown ends, despite Africa’s worst Covid death rate, Pandemic fatigue and economic woes blamed for lack of action despite rapid rise in number of cases[1]. (Appendix1)



In his article, Simon Cordall addresses the management of the COVID epidemic in Tunisia. The title insists on the mismatch between a catastrophic situation: Tunisia having the worst death rates related to COVID in Africa, and a political decision divergent from common sense given the situation.

The author seems to consider the lockdown as the most important measure for fighting COVID epidemic but insists on its negative impact on the population. The Tunisian government’s decision to end the lockdown was the result of many factors and the author came across some of them in his article.

Cordall tries to have a global view in framing the outcomes of the COVID epidemic in Tunisia, through the adoption of a social determinant framework that he developed via an economic approach.


    He argues that restrictive measures weren’t accepted by the people since the beginning of the epidemic and caused disastrous socio-economic effects on a wide range of the population, with an explosion of unemployment and no access to financial help from the government.

Other elements contributed to worsening the situation in Tunisia: a dysfunctional vaccination program, an individual vaccination hesitancy motivated by propaganda and media appearances of politicians in contradiction with the restrictive national policy and an increasing mistrust in the government.

Insufficient health financing due to cash diverting to security, negatively impacted the public health sector: caused bad working conditions, lack of structures and material and lead to massive migration of health workers.

These anomalies are articulated in a context of political crisis combining bad governance and a lack of coordination between the different institutions.

All these elements contributed to the “Pandemic Fatigue”[1].

In this analysis we will go through the framework used in this article to analyze its limitations. We will try to have a more complete view about the challenges of COVID pandemic in Tunisia and in developing countries and suggest actions.

COVID challenge framework

Social Determinant Framework to COVID response in Tunisia used in Appendix 1


Negative impact of media:

The author discussed how media had a negative impact through a comic program presenting negatively the vaccination. Meanwhile there has been lots of TV shows and radio programs that insisted on the danger of COVID infection and advantages of the protection measures.

Many official media had fear-arousing messages with COVID depicted as national security threat [2]leading to fear and discrimination. These messages failed to have the awaited impact since people that needed to access this kind of information are usually not in the audience [3].Indeed, like Ethnic minorities in the UK[4], Tunisian mainly seek information through social media due to their mistrust in official media channels. Hence, they have been more prone to face disinformation which can exist on social media.

In addition, fear have been proven inefficient in public health education. [5]


At the individual level:

Restrictive measures weren’t applied by individuals:

In the UK[6], many were motivated to comply to governmental policies because they wanted to return to normal life. In Tunisia, the country was globally spared during the first COVID wave, the lockdown has been very short, and the changes in people’s lives have been limited.

In addition, like in the UK, young people felt they weren’t vulnerable to COVID-19. They developed a lower Perceived Susceptibility[7]of having COVID with a reduced perception of seriousness[7]and didn’t comply to the government guidance[4].The Tunisian population being younger, the frequency of non-compliant behavior might appear to be higher.

Moreover, the widespread dissemination of conspiracy theory with a tendency to underestimate the severity and dangerousness of the epidemic and the effectiveness of the COVID-19 guidance in a climate of mistrust, induced demotivation due to watching peers, politician and public figures disregard the rules without being reprimanded.

Vaccination refusal and vaccine hesitancy:

In this context of low perceived seriousness[7][4], the perceived benefits of taking action is also lowered. Vaccination as a health behavior[8]becomes questionable since prior beliefs are important to decide any action[9].

Indeed, in Tunisia and in the UK[4], concerns about COVID vaccine seem to be alike: fear from unknown side effects, doubts about safety, questions about the effectiveness of the vaccines in general and more specifically which are imported from China.


At the setting level:

Weak health system:

The Tunisian health system has been showing a decreasing efficiency since the 90s. It is currently going through a serious and lasting crisis with the COVID epidemic exposing pre-existing failures.

The actual health model was built after the independence and has not changed since though Tunisia's demographic situation has evolved: population tripled since 1960, life expectancy increased… This demographic and epidemiological transitions[10]had consequences to which the health system failed to adapt.

The fragmented and complex health insurance system is inequitable and generates corruption, making access to health care unfair: nearly 2 millions Tunisians have no social health coverage[11]and those affiliated to health protection system don’t access equal services: poor people are entitled to public health structures that are underfunded and poorly managed, while the well-off have can chose the private sector.

This leads to an unjust and inefficient health system, unable to respond to the pandemic, thus putting greater pressure on decision-makers to choose restrictive measures with negative social and economic consequences.

In addition, Tunisia has experienced great political instability, with a record of 5 health ministers during the year 2020. As a result, political responses were often reactive and neither  met the needs, nor had prospects of lasting solutions.

Furthermore, there is a great deal of corruption that forbids improvements of the public health system and favors the development of the private sector with a market driven approach. 

More generally, this crisis exposes the misdeeds of capitalism by accentuating global inequalities and more specifically in health.[12].

 Human resources issues in the public health sector:

Migration of medical practitioners abroad has been raised repeatedly since the 2011’s Revolution as the main cause of destruction of the health system[11].

This brain drain is a fact, a study[13]showed that 69% of young doctors intended to emigrate, but only 28% wanted a permanent emigration.

This massive departure was justified by the unfavorable working conditions, the low remuneration, the unstable political climate and the decline of purchasing power[14].

In addition, Structural Adjustment Programs made the government adopt unclear health policy aiming to have doctors at lower cost with vulnerable contracts but also offering voluntary departure programs, early retirement or even part-time work incentives for doctors and health workers[15].

On the other hand, European countries have a migration policy that promote qualified migration. Qualified migrants are paid less than Europeans for the same work, are poorly unionized and are assigned to positions where the workload is heavier. However, people migrate because there is still an improvement in their socio-economic status and better respect to their human rights.

At the national level, politician continue to create and benefit from this social conflict between health professionals and population because they are unable to put in place structural solutions.

Weak vaccination program:

Tunisia put in place a national vaccination program that is facing many challenges. The implementation of the vaccination strategy has experienced several flaws like queue-jumping, pushing organization like IWatch to put in place a defects’ reporting system. [16]. These weaknesses amplified population’s frustration and mistrust in the authorities.

Due to limited availability of vaccines, the health authorities gave licenses to vaccines which efficiency have been questioned by some health experts (China vaccines). These vaccines with bad reputation had a poor acceptance by the population. 

Tunisia enrolled in the UN vaccination program: COVAX that is actually unable to provide vaccines because of lack of funds[17]and unavailability of vaccines[18].

To make the situation more complex, the underdeveloped countries which are involved in the COVAX initiative have initially signed an agreement obliging them not to take unilateral initiatives to obtain vaccines. Tunisia was therefore in a deadlock situation and lost precious time before changing the policies when COVAX realized its dysfunction.


Socio-economic problems ignited the Tunisian revolution, in 2011.  The different governments couldn’t overcome these economic challenges. The figures of unemployment available in world bank publications are slightly different from the article and show that this is lasting issue in Tunisia. Unemployment was at 18.3% in 2011 and diminished a bit afterward due to massive illegal migration during political instability to stabilize afterward, around 16%[19].

Unemployment often implies a deprivation of social protection since many young unemployed people usually work in the black market or are day laborer making them not eligible to the state help provided during the COVID crisis despite their loss of income due to restrictive measures.

At the structural level:

Low health budget in health care 

The lack of budget in health isn’t a recent fact due to “cash diverted to strengthen domestic security” as Cordall mentioned: health expenditure per capita knew its highest rate in 2014 ($293), fluctuated then, not significantly and stagnated around $252[20] .

However Per capita health expenditure in developed countries, according to OECD data, ranges from $794 in Mexico to $ 6,714 in the United States [21].

Health budget has always been scares and the actual economic crisis didn’t improve things.

In addition, Security has mainly been financed by international Aids during the last 10 years[22].

Governments have requested multiple loans and the IMF[15]recently granted loan to Tunisia meeting the Structural Adjustment Program[23]conditions.

To reduce the civil service wage bill in accordance to the SAP, the government will apply cuts in the health sector[24].  This choice will have negative impact on a very vulnerable health system.


Lockdown and unintended suffering: 

People experiencing poverty due to neo-material factors like insufficient public resources and infrastructure, had to endure unintended suffering due to lockdown. Indeed, curfews and quarantines weren’t successful measures[2]since they don’t take into account nonmedical determinants.

The choice of ending lockdown wasn’t purely negative: in a fairly volatile social context with strikes against the lockdown and geopolitical events, the risks of violence escalation by the police was very high. The government had also to be more flexible since it couldn’t assist people economically during lockdown. But these choices resulted in a high circulation of the virus with a high death rate pushing toward lockdowns in target areas for now.

Globalization as ‘a key source of pathogenicity’[2]

The government tries to implement institutional biosecuritization[2]through PCR tests for Tunisian diaspora and tourists, but is unable to close the borders like other neighbor countries with natural resources did, since the tourism is one of the main resources of the country.

To face the economic crisis, they chose to ask for loans which would help in short terms but would have negative outcomes in a longer term. What Simmons was arguing about low SES people being prone to prioritize immediate rewards than long-range goals[25] seem to be also applicable to poor governments.

Governance and Communication:

Management of COVID epidemic was chaotic, many inconsistencies have been observed since multiple unilateral ministerial decisions weren’t synergetic.

There was no global strategy and official communication was a real cacophony which deepened mistrust in the government.


At the heart of the COVID crisis in Tunisia, there are social and political determinants that challenge rapid solutions like lockdown which had been proven inefficient during Ebola and caused more suffering in poor countries[2].

The experience of inequality during COVID epidemic wasn’t homogeneous in Tunisia as presented in the article. An intersectional approach would have been more appropriate to analyze the situation: (1)health facilities are not fairly distributed over the territory; living in certain areas exposes to a greater risk of mortality, (2)elder people are socially vulnerable and more prone to develop serious illnesses, (3)people with low SES[3]and migrants were more affected because of the increase of inequality in income and in access to health. 

Agency is very limited in this context as shows the photos in the article: people are stuck in a full metro or going on a strike but still wearing masks. They try to apply recommendations, but they lack the means to do so because of the increased impact of ne-material poverty during the epidemic. 

Pandemic fatigue is a planetary phenomenon during COVID crisis, but it is more intense in countries with preexisting socio-economic problems. 

Vaccination seems to be the only viable option. COVAX initiative had a very positive grounding : trying to avoid a market-driven approach; but didn’t succeed because of the North-South historical relations and competition between developed countries to get access to the vaccine.

COVAX system put the underdeveloped countries in a critical situation and caused unintended social suffering by not allowing them to purchase vaccines when enrolling in this sadly dysfunctional mechanism[17]; which negatively impacted the management of the epidemic in the third world. 

Unfortunately, developed countries had a nationalist approach and some already started throwing expired COVID vaccines while developing countries struggle to find them on the market. 

Vaccination can only be successful when it is global, the only way out is an international cooperation to shorten the pandemic.



[1]Pandemic fatigue Reinvigorating the public to prevent COVID-19 Policy framework for supporting pandemic prevention and management. [Internet]. Apps.who.int. 2021 [cited 30 June 2021]. Available from: https://apps.who.int/iris/bitstream/handle/10665/335820/WHO-EURO-2020-1160-40906-55390-eng.pdf

[2]Biehl J. Theorizing global health. Medicine Anthropology Theory. 2016;3(2):127–142.

[3]C. J. Personal Influence: The Part Played by People in the Flow of Mass Communications. By Elihu Katz and Paul F. Lazarsfeld. (Glencoe, Ill.: The Free Press. 1955. Pp. xx, 400. $6.00.) - New York State Library. Checklist of books and pamphlets in the social sciences including anthropology, economics, philosophy, political science, psychology, welfare, but not including education, history and law. (Albany: New York State Library. 1955. Pp. viii, 142.). American Political Science Review. 1956;50(3):918-918.

[4]Coronavirus and compliance with government guidance, UK - Office for National Statistics [Internet]. Ons.gov.uk. 2021 [cited 30 June 2021]. Available from: 


[5]Studies Related to What People Know, Believe, and Do about Health. Health Education Monographs. 1963;1(1_suppl):3-22.

[6]Coronavirus and compliance with government guidance, UK - Office for National Statistics [Internet]. Ons.gov.uk. 2021 [cited 30 June 2021]. Available from: 


[7]Robbins, Paul, Some Explorations Into the Nature of Anxieties Relating to Illness, United States Department of Health, Education and Welfare, Public Health Service, Genetic Psychology Monographs. 1962;66:91–141,

[8]Kasl S, Cobb S. Health Behavior, Illness Behavior, and Sick-Role Behavior. Archives of Environmental Health: An International Journal. 1966;12(4):531-541.

[9]Leventhal, Howard, et al. Epidemic Impact on the General Population in Two Cities, in The Impact of Asian Influenza on Community Life: A Study In Five Cities, United States Department of Health, Education and Welfare, Public Health Service. 1960. Report No.: 766

[10]Wilkinson R, Pickett K. Spirit level. London: Penguin Books Ltd; 2011.

[11]Rapport Sur Le Droit A La Santé En Tunisie Par L’Association Tunisienne de la Défense de Droit à la Santé [Internet]. Ftdes.net. 2021 [cited 30 June 2021]. Available from: https://ftdes.net/rapports/ATDDS.pdf

[12].Stevano S, Franz T, Dafermos Y, Van Waeyenberge E. COVID-19 and crises of capitalism: intensifying inequalities and global responses. Canadian Journal of Development Studies / Revue canadienne d'études du développement. 2021;42(1-2):1-17.

[13] Médecine de famille: 4% seulement des médecins ont l’intention de rester en Tunisie | La Presse de Tunisie [Internet]. La Presse de Tunisie. 2021 [cited 30 June 2021]. Available from: https://lapresse.tn/85874/medecine-de-famille-4-seulement-des-medecins-ont-lintention-de-rester-en-tunisie/

[14]Les intentions et motifs d'émigration des jeunes médecins de famille, objet d'une thèse de doctorat en médecine [Internet]. Leaders. 2021 [cited 30 June 2021]. Available from: https://www.leaders.com.tn/article/31499-les-intentions-et-motifs-d-emigration-des-jeunes-medecins-de-famille-etude-realisee-dans-le-cadre-d-une-these-en-medecine

[15]Le FMI se dit prêt à accompagner la Tunisie dans ses réformes économiques [Internet]. Le Monde.fr. 2021 [cited 30 June 2021]. Available from: https://www.lemonde.fr/afrique/article/2021/05/07/le-fmi-se-dit-pret-a-accompagner-la-tunisie-dans-ses-reformes-economiques_6079444_3212.html

[16] I-Watch : défaillances au niveau de la mise en œuvre de la campagne de vaccination [Internet]. L'Economiste Maghrébin. 2021 [cited 30 June 2021]. Available from: https://www.leconomistemaghrebin.com/2021/04/24/i-watch-defaillances-au-niveau-de-la-mise-en-oeuvre-de-la-campagne-de-vaccination/

[17]Why Covax, the fund to vaccinate the world, is struggling [Internet]. Vox. 2021 [cited 30 June 2021]. Available from: https://www.vox.com/future-perfect/22440986/covax-challenges-covid-19-vaccines-global-inequity?fbclid=IwAR2ApNzW1nPy4HSJbyJ9DLFQ6P7e4W-zL_WlKiJNZlB544syE5SRAG6HYbY

[18]Merelli A. The best explanation yet of why Covax is failing Africa [Internet]. Quartz. 2021 [cited 30 June 2021]. Available from: https://qz.com/africa/2026391/strive-masiyiwa-on-why-covax-is-failing-africa/?fbclid=IwAR2U9y-505AuQ-gylniVB01A8lNTNP1c22TOJNnfZAVmUKlB-D65bHVbsLM

[19]Unemployment, total (% of total labor force) (modeled ILO estimate) - Tunisia | Data [Internet]. Data.worldbank.org. 2021 [cited 30 June 2021]. Available from: https://data.worldbank.org/indicator/SL.UEM.TOTL.ZS?locations=TN&most_recent_value_desc=false

[20] Current health expenditure (% of GDP) - Tunisia | Data [Internet]. Donnees.banquemondiale.org. 2021 [cited 30 June 2021]. Available from: https://donnees.banquemondiale.org/indicateur/SH.XPD.CHEX.GD.ZS?locations=TN

[21]CHAMBARETAUD S. Le financement des systèmes de santé dans les pays développés: analyse comparative [Internet]. Realites-cardiologiques.com. 2021 [cited 30 June 2021]. Available from: http://www.realites-cardiologiques.com/wp-content/uploads/sites/2/2010/11/022

[22]Comment aider la Tunisie à sortir des listes noire et grise de l’Union Européenne et du GAFI ? | goPortfolio [Internet]. Unite.un.org. 2021 [cited 30 June 2021]. Available from: https://unite.un.org/goportfolio/fr/news/comment-aider-la-tunisie-à-sortir-des-listes-noire-et-grise-de-l’union-européenne-et-du-gafi

[23]Van Waeyenberge, E. (2006) 'From Washington to post-Washington Consensus: Illusions of Development (Links to an external site.).' In: Fine, Ben and Jomo, K.S., (eds.), The New Development Economics: After the Washington Consensus. London: Zed Books. 

[24]Molina C, Kim J, Millen J, Irwin A, Gershman J. Dying for Growth: Global Inequality and the Health of the Poor. Journal of Public Health Policy. 2001;22(2):235.

[25]Simmons O. Implications of Social Class for Public Health. Human Organization. 1957;16(3):7-10.


[1]Link: https://www.theguardian.com/global-development/2021/may/19/tunisia-lockdown-ends-despite-africas-worst-covid-death-rate

[2]Andrew Lakoff and Stephen Collier (2008, 16)

[3]Socio-economic status

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