Abstract

Tunisia embarked on a process of population consultation in 2013, the first phase of which is often presented as an example, including in the paper in this issue by Rohrer, Rajan and Schmets (2017). The present commentary aims to provide an update on the development and challenges encountered in recent years and also explore their causes and possible ways to move ahead.

Tunisia embarked on a process of population consultation in 2013 – the “dialogue societal en santé” – with the explicit goal to promote the involvement of citizens as a key instrument for the development of the national health policy.

This was foreseen, from the start, as a long-term cycle, consisting of three complementary phases (which could later on be repeated), all expected to rely on a high level of citizens’ participation:

  • the first phase is dedicated to the establishment of a common vision and key priorities for health policy based on a mutually agreed upon analysis of the current situation;
  • the second phase is dedicated to the operationalization based on the participatory, consensual selection of the best options to move ahead with the reforms; and
  • the third phase consists of monitoring and reporting of achievements and challenges in the implementation and in the consensual determination of corrective measures.

The first phase started in 2013 and relied on the intense regional consultation of thousands of citizens and health professionals to considerably enrich the situation analysis, which would have otherwise, as often, solely consisted of experts’ work on existing literature and official data. Even better, each regional assembly elected its representatives, responsible for collectively validating the situation analysis and establishing a common vision and key priorities, to be then compiled as the premises of a strategic vision for the long-term development of the health sector. This process culminated in September 2014, with a time of high-level political appropriation, during a National Conference, which presented the White Book for better health in Tunisia – the “Livre Blanc” and endorsed a declaration on the “Realization of the right to health in Tunisia.”

Phase I was rich, innovative and rightfully promoted as an example of what could be done to better involve citizens in health policy. But where did it go from that point?

Since 2014, the launch of the second phase suffered numerous delays, reasons for which can be found in not only the specific Tunisian political context but also in the inherent nature of phase II.

Starting with the latter, phase II, dedicated to the selection of options of health policy for each of the priorities identified in phase I, is immensely more technical than phase I. To lead to a properly informed, collective and consensual selection of options, time is required first to formulate these options, and then to word them concretely enough – they are often very complex – so that everyone can express their opinion. The timing and nature of population consultation is therefore very different. In phase I, the situation analysis involved everyone massively from the start. In phase II, facilitators of the process have to manage citizens’ expectations (high since phase I), keep them informed of the progress of the technical work on options being developed, identify everyone’s skills to be able to involve them at crucial times, etc. Determining this modus operandi certainly took time in Tunisia, and it is actually still in the process, as the main objective is to go on with a genuinely sincere citizens’ participation.

The political situation, characterized with frequent changes in the composition of the government and of the ministerial teams, including at the ministry of health, also played a role. In periods of profound political and socio-economic changes such as the one currently experienced in Tunisia, those in charge are often asked to deliver drastic improvements in a short period of time, and social services including health, often crystalize the dissatisfaction of the population, practitioners and the government alike. In such times, citizens’ participation may be (wrongly) perceived as a threat, providing a stage for political destabilization and generating even more delays, and the temptation is high for a government, of course, to take into account existing priorities, but to move ahead in the determination of a way forward without further consultation.

What To Do To Move Ahead Then?

First and foremost, advocacy work is currently conducted to convince the decision-makers that the time initially dedicated to dialogue is never wasted and that it may actually later spare a lot of the headache of a conflict emerging during implementation. In fact, dialogue may even speed things up during the development of reforms by creating an appeased atmosphere. This is a lesson of phase I: regional meetings gathered people who were initially conflicting with each other and they reached consensus in record time. First, progresses are currently happening in this direction in Tunisia, with the forthcoming approval of a roadmap for phase II of the “Dialogue societal.

Secondly, and however pleasant it is to be perceived as an example, it is certainly time for Tunisia to look around at other international experiences in terms of citizen participation and the article by Rohrer, Rajan and Schmets (2017). is certainly inspirational. The case of National Health Assemblies in Thailand brings, for instance, a lot of good ideas on how to address the challenges just described.

To conclude, population consultation is still alive and kicking in Tunisia, benefiting from a renewed political interest and looking for innovative ideas to move ahead.

About the Author

Benoit Mathivet, MSc, Health Policy Adviser, World Health Organization, Tunis, Tunisia

Correspondence may be directed to: Benoit Mathivet, World Health Organization, Rue du Développement, Cité El Kadhra, Tunis, Tunisia; E-mail: mathivetb@who.int

References

Comité technique du dialogue sociétal. 2014. Livre Blanc pour une meilleure santé en Tunisie : faisons le chemin ensemble. Retrieved May 26, 2017. <http://www.hiwarsaha.tn/upload/1409228805.pdf>.

Rohrer, K., D. Rajan and G. Schmets. 2017. “Population Consultation: A Powerful Means to Ensure that Health Strategies are Oriented Towards Universal Health Coverage.” World Health & Population 17(2): 5–15. doi:10.12927/whp.2017.25157.