Executive summary:
The right to health is guaranteed by the Tunisian constitution. However, human capital plays a vital role in ensuring that citizens have access to good quality health care. The exodus of Tunisian doctors has been causing a drastic decline in the quality of healthcare for several years. Doctors, mainly young graduates, leave because they aspire for a better salary, a better quality of life, and a better working environment. Several leave the country after completing their training at public universities in response to a growing demand for doctors in destination countries. This leads to a decrease in access to healthcare, particularly in the interior regions. Without a policy to address this phenomenon, the healthcare structures will deteriorate and unequal access to care will increase which would only favor a wealthy minority. Furthermore, this would also decrease the attractiveness of medical studies and further exacerbate this vicious circle. Therefore, it is imperative to address the national level factors which are causing this migratory flow of doctors.
Introduction:
“The state shall guarantee preventative health care and treatment for every citizen and provide the means necessary to ensure the safety and quality of health services.” (Article 38 of the Tunisian Constitution)[1]
The health sector is essential for the protection of human dignity and the well-being of people. Without good health, we cannot enjoy any other rights, especially education and employment, and we cannot contribute to the development of our country or community[2]. This fundamental and constitutional right faces a difficult reality: in addition to institutional and structural challenges, the growing shortage of “human capital” remains one of the main problems to be addressed in order to guarantee health coverage for all citizens. For years, human capital has deserted the public sector for the private sector, and left Tunisia to high-income countries. This has negatively affected equal access to healthcare and has aggravated growing socio-economic inequalities.
The desire amongst young doctors to emigrate has increased due to several factors including political instability (13 ministers of health since 2011[3]), the non-responsiveness of the various governments to the problems of the public health sector, in particular the deterioration of working conditions in hospitals, and the considerable increase in violence against health professionals (400 cases of violence and abuse in all hospitals during 2017[4]),
The exodus of doctors: A “hemorrhage” threatening the health sector
The alarming figures of the brain drain
The exodus of Tunisian doctors is a phenomenon that has been occurring at an increasingly frantic pace since the revolution. According to the Office of Tunisians Abroad, the number of doctors abroad (mainly in Europe) reached 563 doctors in 2000[5]. This figure has almost doubled, reaching 1000 doctors abroad in 2017[6].
Since 2017, 800 doctors have left Tunisia each year, mainly young doctors, against an average of 800 qualified doctors each year[7]. These doctors leave Tunisia, after having obtained their doctorate in medicine, to join two preferred destinations: France or Germany[8]. The latter attracts increasingly young doctors, in particular those trained to provide primary line care[9].
The emigration of Tunisian doctors has led to a decrease in health coverage, which is already lacking for 25% of the Tunisian population[10]. Although the number of doctors per 10,000 inhabitants reached 13.1 in 2018[11], close to the world average, this distribution is very disparate between regions. For example, in 2018, the governorate of Tunis had 15 times more doctors than that of Sidi Bouzid according to the National Council of the Order of Doctors[12].
| Tunis | Sidi Bouzid | |
| Number of doctors | 3639 | 241 |
| Population | 1071375 | 449026 |
This disparity associated with an inequality in the distribution of economic and social resources leads to an increased deterioration in the health of citizens in interior regions.
The absence of a political will to stop the exodus of doctors will lead to a chain reaction; the loss of doctors from the public sector will lead to a considerable reduction in the number of professors in Medicine. This reduction will jeopardize the training of new generations of physicians which will lead to both an aggravation of the shortage of physicians. It will also decrease the attractiveness of studying medicine which in turn would lead to a further reduction in the number of physicians.
Moreover, this migratory flow of doctors leads to a phenomenon of “brain waste” or loss of skills. Tunisia is losing its “gray matter” at an infernal rate day by day. Specialists trained thanks to the Tunisian taxpayer, escape in a simple gesture and sometimes accept professional positions lower than their academic degrees (“FFI” status: Acting as an intern in France occupied by proven specialists).
A structural crisis and irrational measures:
Tunisia is losing its “intelligentsia” on a daily basis while there is silence from the rulers [13]. Currently, a clear and far-sighted political strategy to tackle doctors’ migratory flow to high-income countries seems almost absent.
Faced with a continuously decreasing number of doctors and a growing migratory flow, the adopted policy is to discourage recruitment in the public sector and encourage resignations[14]. This is part of a policy to reduce the Ministry of Health wage bill as part of an IMF recommended budget cut from 6.6% in 2011 to 5% in 2021[15]. To implement the IMF recommended austerity measures, in 2018, the Government of National Unity encouraged civil servants, including public sector doctors, to take voluntary early retirement in return for 24 to 26 months of severance payment [16].
In addition, the exodus of health professionals from Tunisia has increased due to the adoption of a free market strategy by high-income countries in the recruitment of doctors from low-income countries. This practice is contrary to the World Health Organisation (WHO) code of recruitment of health professionals [17] but Tunisia has not registered any complaints.
One of the few measures taken by the Tunisian government to address doctors leaving the public sector was the establishment of a year of compulsory work at a public hospital for all Tunisian medical specialists[18]. This measure, imposed five years earlier, was designed to reduce inter-regional disparities. However, given the increase in migration figures this policy has been far from effective. Confronted with a lack of material resources and a stagnation in their professional development, medical specialists only perceive this year as a temporary obligation. This strategy, which is part of the retention of health professionals against their will, goes against the principle of freedom of movement for employees[19], without constituting a sustainable alternative. This type of compulsory measure has proven to be ineffective in the medium and long terms.
Moreover, as the migratory flow has affected certain specialties, such as anaesthesia and resuscitation in particular, the academic authorities have increased the number of positions granted to these specialties in the residency competition. This measure is based on the assumption that it is possible to replace the number of emigrated doctors. However, the absence of a simultaneous strategy to fight against the exodus of doctors, falsifies the assumption when this measure leads to an increase in the flow of doctors to the private sector and abroad.
2020 highlighted the imbalance of “push” factors, which probably outweigh the “pull” factors, that contribute to the exodus of doctors’ phenomenon. During the Covid-19 pandemic, many countries publicly praised the work of health professionals and in particular Tunisian doctors. Having benefited from the work of Tunisian doctors during this crisis, France streamlined administrative procedures for providing foreign doctors with French nationality. This measure made it even more difficult for doctors to return to Tunisia. In contrast, the Tunisian Ministry of Health recruited an additional 160 doctors to support the fight against Covid-19. However, after eight months, they have received the equivalent of only three months’ salary. 60 have resigned and the remaining 100 were not entitled to a third renewal of their contracts despite the worsening epidemiological situation in Tunisia.
Alternatives and measures to be adopted
Financial incentives
In order to reduce the exodus of doctors’ phenomenon, the Government should address the financial factor by increasing salaries of public healthcare physicians. Wage increases that ensure the financial security of public sector doctors and thus retain their services rather than prepare them to settle in the private sector or to leave the country can be implemented. In order to achieve this, it would be possible to make salary increases proportional to the length of employment that the doctor in question is ready to undertake. This would encourage doctors to extend their term of public service and also guarantee their right of movement once the agreed period is over. This type of commitment, developed in collaboration with health professionals rather than against their will, would consequently be felt as mutual participation and would improve health workers’ professionalism and involvement in the field.
Alternatives to financial incentives are possible, in particular the proposals for additional vacation days, also helping to improve health professionals’ quality of life and work-life balance. This should be done in conjunction with other measures to avoid altering the quality of care provided to citizens.
The main dilemma we are faced with when thinking about the alternatives to adopt to fight against the migratory flow of health professionals is the balance between the right to professional mobility and the fight against the exodus of doctors.
Rethinking the financing of the public health sector
In order to offer financial incentives, rethinking the financing of the public health sector is necessary. Various possibilities are available to the state such as increasing taxation on industries that harm health, the private sector (in proportion to the number of doctors recruited), strengthening the role of local authorities via their allotted health budget, etc. A well-developed strategy aiming to increase the budget allocated to health and the salaries of health professionals should be designed in order to offer a better quality of life to these professionals thus encouraging them to stay longer on Tunisian territory. Indeed, improving quality of life seems to be the main reason for migration intentions among young family physicians[20].
The establishment of health villages, especially in medical “deserts”, could provide doctors who work there with an atmosphere and the infrastructure to encourage their long term settlement. This would ensure access to healthcare for citizens but also offer job opportunities to citizens, making their access to healthcare more affordable.
Non-financial incentives
Insecurity in healthcare facilities appears to be a major factor that motivates doctors to emigrate. Ensuring the sustainable safety of health professionals and citizens would help to reduce these migratory flows.
The one year compulsory placement in a military health facility should be made more attractive by ensuring the right of participating doctors to an evolving professional career. The placement should start immediately after the end of the academic medical course in order to shorten the period of forced unemployment imposed on newly graduated doctors. Doctors who have completed their academic studies are currently forced to wait for their end-of-speciality examination and until the Ministry of Defense calls them months after the end of their academic medical course. These months of unemployment are seen as frustrating by most young doctors, causing them to leave the country and depriving the regions of the skills of these doctors for months. In addition, before doctors begin their compulsory placement in a particular health structure, they should be given the promise of recruitment and a clear career plan.
Encourage the return of Tunisian doctors
Doctors who have migrated to high-income countries should be actively encouraged to return to Tunisia. Their return would contribute to increasing the number of doctors per Tunisian citizen but also to improving the quality of care through the skills that they have acquired abroad. This could be incentivised by recognizing their years of experience abroad and offering them advanced positions in university hospitals. Administrative procedures that fast track their reintegration into the public sector should also be implemented.
In order to guarantee quality care accessible to all Tunisian citizens, we should consider alternative services based on non-medical professionals. These alternatives, undertaken in other countries such as Brazil or Bangladesh[21], do not aim to replace doctors but to provide health care as much as possible. Accelerated and short training would make it possible to provide primary care while making it possible to reduce inter-regional disparities and relieve the tertiary structures centralized on Tunisian territory. This could be applicable mainly for maternal and child health (Family health workers experience in Brazil in the 1990s) but also for ophthalmology such as in Ghana.
It is essential to ensure pressure on recruiting countries to uphold their ethical responsibilities towards the world community by respecting the WHO code for the international recruitment of health personnel. In particular, by reducing the “active” recruitment of health professionals from low- and intermediate-income countries such as Tunisia.
Recommendations
Faced with an exponential increase in the exodus of doctors, the failure to take urgent short and long-term measures would lead to a drastic reduction in the health coverage offered to Tunisian citizens, a fundamental right guaranteed by the constitution.
In order to fight against this phenomenon, the following policy recommendations should be implemented.
- Use financial incentives (salary increase and bonus proportional to the duration of the engagement) and non-financial incentives (establishment of health villages and address insecurity in healthcare structures) in order to make the public health sector in Tunisia more attractive to doctors. (Ministry of Health, Ministry of the Interior, deputies of the health committee)
- Members of the health committee must increase the budget allocated to health by increasing taxation on industries that are harmful to health and the private sector (in proportion to the number of doctors recruited).
- Reform the compulsory placement year by starting it immediately after the end of the academic course and providing clear career plans for newly qualified doctors with promises of recruitment in specific health structures (Ministry of Health, Ministry of Defense, deputies of the health committee)
- Reduce the current impact of the exodus of doctors on access to care, especially in the regions, by increasing the training of non-doctor family health professionals. (Ministry of Higher Education, Colleagues in medical specialties)
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Available in: http://kapitalis.com/tunisie/2018/03/22/tunisie-le-projet-de-loi-de-protection-des-professionnels-de-la-sante-enfin-pret/ (Accessed January 20, 2021, 10:57) [5] OCED, “Contribution of migrant doctors and nurses to tackling COVID-19 crisis in OECD countries”, May 13, 2020, available on: https://www.oecd.org/coronavirus/policy-responses/contribution-of-migrant-doctors-and-nurses-to-tackling-covid-19-crisis-in-oecd-countries-2f7bace2/ (Consulted on January 20, 2021, 09:47) [6]Samet (K.), “La fuite des cerveaux en Tunisie. Évolution et effets sur l’économie tunisienne”, Hommes et Migration, July 1, 2014, available on: https://journals.openedition.org/hommesmigrations/pdf/2891, posted on July 1, 2017, p . 123 (Consulted on January 20, 2021, 09:51) [7] IACE, “La Tunisie et les directives Européennes: Convergence Vs Protectionnisme”, 6th edition of Tunis Forum, available on: http://www.iace.tn/wp-content/uploads/2019/03/tf-doc.pdf (Consulted on January 20, 2021, 09:54) [8] BEN NESSIR (C.), “Manque cruel de médecins”, published on: La Presse de Tunisie, September 18, 2020, available on: https://lapresse.tn/73706/manque-cruel-de-medecins/ (Consulted on January 20, 2021, 09:57) [9] Harzi (M.), “The elderly are attracted by France and the youth to Germany / 800 doctors are ‘fleeing’ … annually!” Published in: – Al-Sabah News, available at: https://bit.ly/2XX11NW (Accessed on January 20, 2021, 10:04) [10] Boughzala (W.), Hariz (A.), Badri (T.), Ben Hassinen (L.), Azzabi (S.), Khalfallah (N.)., “Family medicine: attractiveness, constraints and prospects as perceived by residents of the specialty”, published on Tunis Med, July 1st, 2019, ;97:904-9, available on: https://pubmed.ncbi.nlm.nih.gov/31872402/ (Consulted on January 20, 2021, 10:12) [11] Oxfam & Developpement Finance International, Indice de l’engagement à la réduction des inégalités. July 2017, https://www-cdn.oxfam.org/s3fs-public/file_attachments/rr-commitment-reduce-inequality-index-170717-summ-fr.pdf (Consulted on January 20, 2021, 10:14) [12] . Ministry of Health and Planning Studies Department, “Démographies médicales, des dentistes, pharmaciens, et du personnel soignant, les chiffres clés année 2018, published in January 2020, http://www.santetunisie.tn/images/depamel/Dmographie-2019-version-final3.pdf (Consulted on January 20, 2021, 10:18) [13] FMI, “Déclaration du FMI sur la Tunisie”, August 3, 2017, https://www.imf.org/fr/News/Articles/2017/08/03/pr17319-imf-statement-on-tunisia (Consulted on January 20, 2021, 10:21) [14] Law n ° 2018-5 of 23 January 2018, relating to the voluntary departure of public officials (1), available at: http://www.legislation.tn/sites/default/files/news/tf201851.pdf (Consulted on January 20, 2021, 10:24) [15] S. (M.), “Tunisie: Départ volontaire à la retraite anticipée, 6.000 demandes déposées”, published on: Tunisie Numérique, available on: https://www.tunisienumerique.com/tunisie-depart-volontaire-a-la-retraite-anticipee-6-000-demandes-deposees/ (Consulted on January 20, 2021, 10:31) [16] . Le Temps, “Un programme de départ volontaire négocié sans limite d’âge”, available on: http://www.letemps.com.tn/article/105124/un-programme-de-d%C3%A9part-volontaire-n%C3%A9goci%C3%A9-sans-limite-d%E2%80%99%C3%A2ge (Consulted on January 20, 2021, 10:32) [17] French Ministry of Interior, “Reconnaissance de l’engagement des ressortissants étrangers pendant l’état d’urgence de la COVID-19”, December 7, 2020, available on: https://www.immigration.interieur.gouv.fr/Accueil-et-accompagnement/La-nationalite-francaise/Reconnaissance-de-l-engagement-des-ressortissants-etrangers-pendant-l-etat-d-urgence-de-la-COVID-19 (Consulted on January 20, 2021, 10:41) [18] Chemli (A.), “100 médecins contractuels remerciés sans être payés”, Le Quotidien, January 5, 2021. [19] . WHO Global Code of Practice for the International Recruitment of Health Personnel, 21 May 2010, available at: https://www.who.int/hrh/migration/code/code_fr.pdf?ua=1 (Consulted on January 20, 2021, 10:49) [20] OCED, “Contribution of migrant doctors and nurses to tackling COVID-19 crisis in OECD countries’ ‘, already cited. [21] OMS, “Rapport sur la santé dans le monde, Les enjeux d’un monde en évolution, 2008” https://www.who.int/whr/2008/08_chap1_fr.pdf?ua=1 (Consulted February 8, 2021, at 16:57)
