Ten years after the revolution in Tunisia that ended the rule of Zine El Abidine Ben Ali, it is clear from the resurgence of street protests that while Tunisia has been praised for its progress on personal liberties and freedom of speech, the fulfilment of much-needed socio-economic rights still lags behind.

The right to health, affirmed in the constitution of 2014, is a prime example of this. The pandemic demonstrated the deepening inequalities in access to healthcare and social security services in the country.

There is an absence of strategy and resources, marked by the sparse funding provided to the ministry of health, which constitutes less than 6% of the state’s budget.

Apart from some aid distribution at the onset of the crisis, handed out in a rather chaotic manner to the families most in need, the authorities' response has been primarily security-centred. This was clear in the repression of the January riots, which involved young people in working-class neighbourhoods and marginalised areas.

There is still no long-term strategy to reform the healthcare sector and its blatant regional disparities. Tunisians are suffering from a high level of mortality, with over 11.000 deaths since the start of the pandemic. Shortages of ICU beds, confirmed by statements from the Ministry of Health, have been recorded along with irregularities in the slow and inequitable roll out of COVID-19 vaccinations.

The privileges of coastal cities

The long-existing disparities between Tunisia’s more privileged coastal cities and the less developed border regions, or between affluent areas and the many working-class neighbourhoods of the bigger cities, have never been really addressed.

Until October 2020, Kasserine, a neglected city of half a million inhabitants near Algeria, had no laboratories for COVID testing.

The shortage of medical specialists and resuscitation beds predates the pandemic. In 2019, according to the ministry of health, Kasserine had only 11 obstetrician-gynaecologists as opposed to 54 in a comparable population in the coastal governorate of Monastir.

The coastal city of Sousse has 338 medical specialists working in the public sector, while Tataouine in south-eastern Tunisia only has one. Access to medication in the latter city is also compromised, with a majority of people (70%) saying that they can never find prescribed medications.

International Alert, the peacebuilding organisation we serve, works with young people from working-class neighbourhoods to address the marginalisation they are confronted with. We have seen time and again how these young people are overlooked in discussions around health, and regarded as non-priority, for not being at risk of chronic diseases and presumed to be in good health.

We recently supported 25 young people under 30 to create an evaluation system, allowing these undercover or ‘mystery’ patients to become healthcare regulators, in order to test whether it would drive improvements in standards and equality of access. It was piloted in three traditionally under-resourced areas: a working-class neighbourhood in Greater Tunis, a municipality in Kasserine and another in Tataouine.

The work represents a model for politicians, as it could be readily applied in other underserved Tunisian territories such as Al Kabarya or Ettadhamon, or in countries facing similar challenges to deliver healthcare consistently and equitably, such as Lebanon.

Diagnosing what’s lacking

The experience of being ‘regulated’ by young patients gave professionals an incentive to reflect and change the service they were offering, in order to meet the expectations of those who had developed the evaluation system.

“When we came back to re-evaluate some of the services, many of the doctors were keen on introducing improvements and asked that we delay our re-evaluations until they made the necessary improvements,” recalls Ines Aloui, who enjoyed the experience of sharing and performing an evaluation in Kasserine.

In those discussions, a grace period was given to the health facility, during which it could work on improving its services before a re-assessment would take place. Almost 100 assessments of different healthcare services were conducted between 2019 and 2020, with the facilities often eager to try to improve their results.

Mabrouk Dhakar, part of a regional health delegation in Tataouine, said: “the importance of this initiative lies in its ability to provide us with a diagnosis of what is lacking in public healthcare facilities.”

This citizen diagnostic experience has not only given young people in marginalised areas the platform for the production of accurate, objective and timely appraisals of healthcare facilities in their areas. It has also put them in a different relation of power when engaging with local authorities. Usually seen as perpetrators of delinquency and crime in their neighbourhoods, they have proven again their ability to be ‘reinvented’ as informed collaborators involved in the discussion around the improvement of public services.

It doesn’t have to be bureaucrats and politicians holding all the power to inform the public about the implementation and impact of policies. The success of this project can be a model for meeting the needs and expectations of marginalised groups such as disabled patients, migrant groups, sexual minorities, and others facing barriers. Inclusive politics and mechanisms for participatory democracy are the treatments Tunisia needs for its democratic transition to be realised.