Country profiles

Tunisia

Overview

Tunisia has a land area of 154 530 km². Its population was 9.3 million in 1998. It is characterized by an urban population of 61%. The Tunisian population is young, 33.5% being under 15 (1997) while those more than 65 years of age represent only 7.4% of the population (1997). In 1995, the total adult literacy rate and the adult female literacy rates were estimated at 67% and 55%, respectively. The infant mortality rate was estimated at 29 per 1000 live births in 1997. In 1994, the under-5 mortality rate was 43.1 per 1000 live births. Also in the same year, the maternal mortality rate was calculated to be 6.9 per 10 000 live births. In 1995, the total life expectancy at birth was estimated at 72.9 years of age. The crude birth rate was 21.7 per 1000 population in 1997.

The Tunisian population is projected to exceed 10 000 000 by the year 2006. Administratively, the country is divided into 23 governorates, which are further subdivided into districts (délégations) and subdistricts. This administrative set-up, based on decentralization, is in line with the general government policy to facilitate the people’s access to governmental structures wherever they live and to decentralize and regionalize economic and social developmental activities. The gross national product per capita was US$ 1768 in 1994.

The constitution of Tunisia clearly states that the prosperity of the nation is based on the welfare of the family and on the right of each citizen to work, to health protection and to education. The health strategy based on this policy, has been reinforced and enlarged since 7 November 1987; the Head of State has shown a particular interest in the health sector by examining the important issues of health financing, the mode of practice for physicians, and the operating of hospitals and by carrying out unexpected visits to health facilities in certain less privileged governorates.

The country’s actions and plans aim to:

• allocate a more substantial share of the budget to the less privileged regions in order to reduce regional disparities; health, as a component of development, has profited from this objective and access to health services, an essential element of the health for all strategy, has been improved

• develop agriculture and promote employment; this will have a significant effect on the improvement of health status within the country.

• pay particular attention to public health, as shown in the following trends:

• improving the balance between the regions in the allocation of health resources; personnel, facilities, equipment and budget

• reinforcing the national programmes for maternal and child health and, above all, improving school and university health services, which cover a vulnerable population of about 2 000 000 pupils and students

• seeking a more balanced distribution of financing health costs between the state, the citizens and the social security and insurance agencies

• improve conservation and profitability of the existing infrastructure.

The health infrastructure may be divided into three main sectors: the public, the social security and the private sectors.

The greater part of the population is served by the public sector. The services of government departments, such as the army, the police and the Ministry of Education, are responsible for relatively limited populations.

Since 1990, the pyramid of health infrastructure has had four levels in the governorates: an extensive network of 1471 basic health centres (including maternal and child health centres, dispensaries and health posts) forms its base. At the secondary level are the 102 district hospitals, which provide primary health care and maternity and general inpatient and outpatient care. These two levels of the public health pyramid cover most of the health needs of the local communities. The third level-second-referral level-is made up of 23 regional hospitals. At the top of the pyramid, are 12 teaching hospitals, nine specialized institutes and 15 national specialized centres.

Community involvement in the field of health is carried out within the framework of local health councils (or committees) in each health district. Chaired and organized by the local political and administrative authority, these councils comprise locally elected representatives as well as the officers in charge of health-related sectors. It is also quite common that the community intervenes more directly in setting up a health centre managed directly by the people, in organizing health education, hygiene and first aid campaigns with nongovernmental organizations (for example, the Tunisian Youth Organization, the Red Crescent Society and the Tunisian Organization for Road Safety).

The significance granted to health as a component of development has continually increased since the sixth five-year economic and social development plan (1982-86). Proof of this is the share (in percentage) of the health budget in the overall state budget, which rose to about 9% in 1998. The number of physicians amounted to 4313 in 1990. Paramedical personnel increased from 19 000 in 1985 to about 24 900 in 1990, i.e. a 30% increase.

MENTAL HEALTH

The mental health facilities and human resources are largely centralized and institution-based in Tunisia. There is a concentration of psychiatrists in the capital city, which has about two-thirds of the specialists. A 1992 ministerial decree established a technical committee for mental health.

The chief components of mental health care are the psychiatric hospitals. The total number of psychiatric beds in the country is 902. These are distributed as follows:

Razi Hospital-640 beds

Military Hospital, Tunis-48 beds

Fattima Bourghiba Hospital, Monastir-25 beds

Aedi Shaker Hospital, Sfax-189 beds

There is a total lack of facilities in the interior of the country, particularly in the governorates of the west, the centre and the north, except in Kavioun where there is a psychiatrist to provide services for 450 000 population.

specialized health care for children and adolescents are almost non-existent, with the exception of the day hospital of Habib Thameur, in Tunis, the consultancy in Sfax, at Monastir Hospital and the school centres in Tunis and Sousse.

There are other institutions in which mentally ill persons are housed and receive care. These institutions include asylums for the elderly (under the auspices of the Ministry of Social Welfare), homes for the handicapped without families, private hospitals and traditional healers’ wards. There are also non-governmental organizations, which participate in the care of the mentally ill and for the retarded (e.g., the League for the Care of the Mentally Retarded).

The prevailing conditions and the quality of care in the institutions in Razi, Sfax and Monastir have the problems of centralized and long-stay institutions everywhere. There is a need for these institutions to review their facilities using WHO’s quality assurance guidelines.

There are 81 psychiatrists in the country. Of these, 19 are in the health department, 20 in academic departments and 42 in private sectors. There are 10 psychologists in the country and no social workers. There are 310 psychiatric nurses, of whom 40 have received specialized training in psychiatry.

There are four medical colleges and the undergraduate medical students receive limited training in mental health amounting to 28 hours. There is a need to upgrade the amount and type of training to enhance the knowledge, skills and attitudes of the fresh medical graduates. In Tunis, the problem-oriented training has been introduced.

The draft programme was developed in Tunisia against the background of rapid social change and urbanization with a resultant greater recognition of the need for mental health care for the general population. The focus of the national mental health programme is to provide appropriate care for psychiatric patients and to prevent mental disorders, especially those caused as a result of industrialization and modernization. The programme aims at integration of mental health with general health and primary health care, intersectoral coordination, training of personnel and information, education and communication to the general population.

A ministerial decree issued in May 1992 established a technical committee for mental health. The committee consists of leading psychiatrists, representatives of other ministries. There are five sub-committees, on training, on health education and information, on the treatment of the mentally ill and care for groups at high risk, on juridical issues, and for coordination among social sectors.

The subcommittees have initiated several activities, such as training of personnel, preparation of a manual for physicians at the primary health care level, visits of specialists to outpatient departments on a periodic basis, review of the drug lists at the primary health care level, radio and television programmes and research.

There is very good primary health care in the country. These facilities and staff are providing good general health care. There has been increased importance given to this sector of health care in the health planning during the past decade. Currently, no systematic effort to integrate mental health care with primary health care has been made. The only activities have been the preparation of a doctors’ manual, training for 60 health workers, 120 nurses and about 500 general physicians. There is no system of follow-up of the training and evaluation of the mental health care provided by the trained persons.

The school health programme in the country is very well developed, consisting of about 500 public health physicians and 700 nurses. This has could include mental health components. Currently, only one centre carries out mental health work.

Currently, a general population epidemiological survey of depression and schizophrenia in the Ariana area is in progress. Similarly, other studies about the prevalence of mental illness in those housed in the homes of the elderly and divorce have been completed.

There are a number of current limitations. The most important ones are limited number of trained human resources and their unequal distribution, overuse of the tertiary level facilities and lack of secondary level care, lack of recording and reporting of data, no programme evaluation, lack of ongoing relationship with the primary health care level and lack of coordination.

The new priorities identified for future work are development of a national network of mental health facilities, enhancing community participation, decentralizing the role of mental health professionals, intersectoral coordination and integration of the mental health programme with primary health care.