The Tunisian healthcare sector faces challenges that predate the outbreak of the COVID-19 pandemic, which has underscored regional disparities and the depletion of the public healthcare sector.
Regional marginalization is the main feature of post-colonial Tunisia, where interior regions and border governorates suffer from a myriad of socio-economic problems that are exacerbated in comparison to the capital and coastal governorates. Rates of school dropouts, poverty, and unemployment in the interior governorates are often twice as high as in coastal regions.
Access to healthcare is no exception. Based on official 2018 numbers, the governorate of Sousse has 391 specialists in the public sector, while the border governorate of Tataouine has nine. Given International Alert Tunisia’s longstanding experience of working on bottom-up mechanisms of participatory democracy and the inclusion of youth, an innovative project has been developed to respond to marginalized youth’s exclusion on decisions relating to access to health.
Youth-friendly healthcare services
Alert’s innovative project Youth-friendly healthcare services is informed by the aforementioned realities and by the engagement Alert has maintained with youth networks in the three regions of Kasserine (on the Tunisian-Algerian border), Tataouine (on the Tunisian-Libyan border), and Douar Hicher, a marginalized neighborhood in Greater Tunis. Alert has set up three youth networks, where its young men and women take part in informing and implementing the different project lines.
The importance of this project stems from its approach ‘from the youth, to the youth’. Through an interactive mobile app, young people are able to assess seven different kinds of healthcare facilities (hospitals, primary healthcare centres, reproductive health centres, clinics, pharmacies, laboratories and gyms), identified by them as locations they frequent for health services. The assessment measures and criteria are based on a series of in-depth focus group meetings with youth from the three regions. Each meeting incrementally builds on the preceding one, aiming at arriving at a consensus on the measures and indicators.
The data collected through all these meetings was further developed by medical specialists to ensure that all measures and criteria correspond to the mandate of the different healthcare facilities, but also by tech specialists to convert them into an accessible user-friendly app. At a later stage, Alert’s youth networks from the three regions came together for a test run of the app, where they took off to the field in the governorate of Sousse and came back with feedback on improving it. Sousse was selected as a middle ground, so that youth can use the app in an area where no group has advantage over the other.
Feedback from the field and peacebuilding implications
After the first round of assessments, many healthcare facilities not identified as ‘youth-friendly’ contacted our youth networks to request a reassessment after introducing changes related to the recommendations made by the youth networks. In the midst of discussions, members of the youth networks noted the fact they can now engage objectively with relevant healthcare authorities on the quality of services, a discussion from which they have long been excluded. Additionally, healthcare facilities were encouraged by the recognition through the sign to improve their services, creating an environment of positive competition. If a clinic is not awarded the sign, but another on the same street or in the same neighbourhood is, the clinic will be motivated to prove the same quality of serviceWe also noted that many of the public healthcare services can introduce changes that do not require more budget to yield a positive result.
This pilot project, like other pilot field projects, benefitted from a wide range of recommendations for improvement by the implementing parties and demands for expansion by the youth networks and healthcare facilities alike. With social movements erupting in marginalised areas and irregular migration reaching its peak last July after the declaration of deconfinement, with the highest numbers of youth leaving for Europe, social stability in many marginalised regions seems volatile. The outbreak of COVID-19 affects vulnerable communities the most, but also presents an opportunity to push forward much needed debates on access to healthcare, the quality of public healthcare services and public spending on health. This pilot project not only serves to improve relations between youth and local authorities, but also provide objective and concrete recommendations that can inform policy reform.