Tunisia: two-speed medicine

The state must end its neglect policy, pay particular attention to the medical record and ensure that the right to quality care is a reality and not just a political slogan written in a constitution. If it does nothing about it, it will confirm what many believe, that we are indeed in a populist state run by notorious incompetents. (Kaïs Saïed at Rabta hospital: he talks, he talks, but what does he do?)

Of Raouf Chatty *

There are two health systems in Tunisia: one for the rich, those who have a lot of money or who can afford it (that would be at most 30% of the total population), and another for the poor (the remaining 70%, including the middle classes). .

The former can be treated in private clinics and bear the excessively burdensome costs of these establishments with hotel reception standards, managed as profitable activities, the latter go to public hospitals, most of which are dilapidated and where they will suffer all the miseries, without guarantee adequate treatment.

We are therefore in Tunisia facing a two-speed medicine. Strange when we know that the current Constitution, promulgated in July 2022 by President Kaïs Saïed, like that of January 2014, nevertheless solemnly establishes that health is a fundamental right.

Health has become a commercial product

In reality, it is nothing. Health has become a commodity. At a time when public health facilities are becoming increasingly poor, their miserable situation reminiscent of the health of the early post-independence years, private health facilities are springing up like mushrooms and achieving very substantial turnovers. It is that the sector, when it is well managed, remains profitable. This is unfortunately not the case with public hospitals which are all in deficit due to poor governance.

Recently, the President of the Republic paid an unexpected visit to the Rabta University Hospital in Tunis, built in the 1930s. He saw firsthand the extent of the multidimensional difficulties facing the public hospital. A simple political communication operation in view of the legislative elections on December 17 to demonstrate the interest of the state in public health.

The president knows better than anyone else the public health situation in Tunisia. It was not he who, in the midst of the Covid-19 pandemic and its catastrophic management, with over 22,000 deaths in two years, had dismissed, in 2021, the former head of the government and the former Minister of Health and had done loading the file itself.

He is also aware of the complexity of this sector, which is very poorly managed and involves huge interests. Furthermore, the stagnation of the construction project of the Medical City of Kairouan, which began in 2017 and which he believed he could fulfill his mandate, but which still suffers despite his promises, testifies to the public health crisis in Tunisia.

What keeps young doctors away

If we often congratulate ourselves on the excellent academic and professional level of our doctors, we cannot ignore the fact that things have gotten considerably worse in public hospitals where doctors and patients lack everything.

The former, in particular young doctors, interns and residents, work in inhumane conditions and are subject to forced labor. They are under the hammer of their department heads and the anvil of the paramedics who dictate the law in hospitals, thanks to their seniority in hospital-university services and the hegemony of the trade unions.

More than once, we have seen young doctors being violently attacked in hospitals. Worse still, a young resident doctor had died two years ago, falling into the cage of a Jendouba hospital elevator, a case that, in his time, had moved the entire nation but which is now completely forgotten.

Should we therefore be surprised that young doctors today are fleeing Tunisia en masse to work in France, Germany and elsewhere?

This situation is very serious and must be said clearly: today we are in a country where we are rapidly moving towards unbridled liberalism in all fields, including health and education, and the hasty disengagement of the state, due to lack of means, has consequences whose gravity we now measure. And for good reason: health has become a commercial commodity like any other, and private clinics are mushrooming, especially in big cities, while the medical wasteland is spreading to the rest of the country. The Minister of Health has just inaugurated a few days ago with great fanfare one of these clinics in the southern suburbs of the capital, which is nevertheless well supplied with them. The construction of the new factory cost millions of dinars and the purchase of its ultra-modern equipment another few millions. Definitely financed with bank loans.

Private clinics and marketing

These private clinics that keep opening their doors could eventually attract thousands of foreign patients. And this is one more reason for public authorities to keep an eye on this sector.

The very high cost of these investments should not obscure the fact that many patients complain about the excessively high prices charged by many private clinics and health centers. Patients do not understand much about the pricing systems and rates that professionals demand. In a panic when they go to the clinics, legitimately worried about their health, they become real prisoners.

Many patients argue that, as a general rule, private clinics require hospitalization guarantee checks in the order of thousands of dinars. Patients often sign documents in which they commit to points that affect their health without being adequately informed about the consequences of their commitment. In short, they become hostages of the clinics. Furthermore, they can be authorized to leave only after the hospital bill has been paid if the accumulation of figures and their integration do not respond to clear logic. In short, many clinics act freely without worrying about the interests of their patients, assimilated to the simple “customers”.

The state must come out of its complacent lethargy in the face of abuses of all kinds complained by patients. He must take the bull by the horns, without complacency and vigorously face corporatism which, in the health field, can be fatal. And the word is not strong, especially if we think of the many victims of medical errors. Among the issues that deserve immediate attention are: the state of public and private health, the state of paramedical care, access to medical studies, the state of doctors, the problem of emigration of young doctors, the catastrophic situation of the coffers social, and in particular of the National Health Insurance Fund (Cnam), which is heavily in deficit.

The state must end its neglect policy, pay particular attention to the medical record and ensure that the right to quality care is a reality and not just a political slogan written in a constitution. If it does nothing about it, it will confirm what many believe, that we are indeed in a populist state run by notorious incompetents.

* Former ambassador.

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