Tunisian doctors sound alarm on health system collapse

TUNIS, Tunisia — Ons Zouiten, a dentist, decided to leave Tunisia for Paris in 2008 to upgrade his credentials to include dental implants and periodontal plastic surgery. His wife, Iman, joined him in 2011, and they settled permanently in Paris. Zouiten told Al-Monitor that he had moved to Europe because he could not pursue further training or studies in Tunisia because of the lack of financial and facility resources at local faculties of medicine.

“When I first traveled, I did not think it would be permanent and that I would settle in France,” Zouiten said, speaking by phone. “I wanted to go back to Tunisia, but when I completed my studies, I noticed a huge difference between work conditions in Paris and Tunisia in terms of salary, as doctors in Tunisia earn less and can barely make ends meet between the clinic’s rent and medical appliances, especially in the country's central provinces. I had a more promising professional and family outlook in France, and I decided to stay. I still visit Tunisia regularly to provide professional training to dentists in dental implants.”

Zouiten is just one out of thousands of cases of Tunisian doctors who, given the lack of opportunities in Tunisia, have pursued better professional opportunities and financial security in Europe, the United States, Canada and the Gulf. After the toppling of Tunisian President Zine El Abidine Ben Ali in the 2011 revolution, health services, including public hospitals, suffered like other sectors amid the social and economic upheaval.

Health sector employees have recently warned of an imminent crisis. Khaled al-Nabli, the head of the private clinic syndicate, said in a Feb. 12 press release that the health care system could collapse and that within the next 15 years, Tunisians will have to leave the country to obtain medical treatment.

Mounir Youssef Maqni, the president of the National Council of Doctors, told Al-Monitor, “The number of Tunisian doctors leaving the country has been high in the past five years. Countries like Germany, Saudi Arabia and Canada are luring them away by offering them incentives and competitive salaries.”

Maqni further stated, “There isn’t an official count of doctors who migrated, so the syndicate has relied on the increasing number of good-conduct letters that Tunisian authorities granted to Tunisian doctors so they can be employed in the preferred countries. In the past five years, the number of letters has soared. In 2013, 58 letters were issued, and 926 doctors were accepted into the syndicate. In 2017, 453 letters were sent out, and 1,000 doctors joined the syndicate. In the past five years, the migration of doctors increased from 6% to 45%.”

“The syndicate is sounding the alarm,” Maqni said. “In the case of migration persisting at this rate, the Ministry of Health and the country will suffer from a huge shortage of medical staff in the coming 10 years. The [care-provisioning] structure of public and private hospitals will be threatened, and we will be forced to bring in foreign doctors as the number of newly graduated doctors joining the syndicate each year is estimated at between 800 and 1,000.”

The Tunisian Organization of Young Doctors, an independent organization defending the rights of young doctors in Tunisia, on Feb. 6 announced a public strike for Feb. 9 to protest work conditions — described as horrible by interns, residents and medical students, who complained that the Ministry of Health is not responding to their demands: codify rights for medical students, residents and doctors working at university hospitals, improve work conditions for doctors in marginalized areas and reduce all doctors' work hours.

Minister of Health Imad al-Hamami on Feb. 6 described the upcoming strike as “overblown.” He claimed that the ministry had already fulfilled the demands within the framework of what he called, without elaboration, “intervention policies.”

Jad al-Hanshari, the director of the Tunisian Organization of Young Doctors, told Al-Monitor that his organization's members feel desperate and suffocated, which is driving them to consider migrating.

“The government health sector is deteriorating and draining the capacities of doctors in university hospitals,” Hanshari said. “Most of them are thinking of leaving to Europe or Canada as soon as they complete their medical degree to continue their research and specialization and to find better opportunities and learn scientific skills based on medical discoveries that are not available in their country.”

Hanshari remarked that financial incentives are not the only factor encouraging Tunisian doctors to migrate. They also feel that their worth in Tunisian society has dropped, with verbal and physical attacks against them by patients and patients' families on the rise. Hanshari said the involvement of some Tunisian media outlets in demonizing doctors by hyping individual medical errors and generalizing them have distorted the image of doctors.

Hanshari claims that government-run hospitals in Tunisia are in catastrophic shape, lacking the most basic medical equipment and medicines. This means doctors cannot properly do their jobs.

Nabiha al-Boursali Falfoul, the general director of the Ministry of Health, told Al-Monitor, “The ministry is concerned about the ongoing migration of doctors and the impact on the country’s health system.” She also said, however, that the ministry will put a structural reform program in place over the next four years to improve the sector in general and the work of doctors in particular by creating new job opportunities and increasing the number of specialists graduating medical school from the current 500 a year to 900. In addition, young doctors will be required to work in private hospitals rather than going into private practice.

She added, “Financial incentives will be given to specialized doctors who work in central regions and will reach $400 [a month]. A program encouraging scientific research in the medical field will be implemented to curb the migration of young doctors seeking to develop their skills and medical specializations outside Tunisia.”

According to Boursali, there are around 6,000 doctors in the public sector distributed among governmental health facilities at a ratio of 13 doctors for every 10,000 residents. In 2017, the number of new doctors appointed in the sector was 390, while on average 1,000 doctors migrate per year.

Boursali stated, “Mid-senior doctors migrate to the Gulf particularly because salaries are higher, reaching 40,000 dinars per month [$17,000], which is 10 times what a doctor earns in Tunisia. Doctors in Tunisia working in the public sector earn between $700 and $1,500 a month.”