The experience of Tunisian public healthcare system toward decentralization to the reduction of health inequalities in low-, middle- income countries

Abstract

From 2014 to 2021, Tunisian government had a firm will to implement a progressive decentralization of welfare state governance, as outlined in its democratic Constitution. The Tunisian public healthcare system was selected as a pilot sector for experimenting with decentralization to reduce disparities in access to and quality of health services across different regions. This paper aimed to formulate an effective strategy for healthcare system decentralization in low- and middle-income countries, drawing on past experiences of its implementation. Country case study resulted the best methodology to achieve that goal. Top heath management, figured out by regional hospitals’ directors, was consulted to describe the technical, managerial and cultural “heritage” collected during the development process of the decentralization reform in public healthcare system in Tunisia. Findings revealed the Tunisian healthcare system decentralization should be, in first instance, the establishment of different decentralization paths according with regional pre-conditions, and then, of common protocols and procedures at national level for overcoming current differences between Tunisian territories. Decentralization process must be tailored to the specific needs of the regional Tunisian contexts to be effective but with a national control on that. Drawing from the Tunisian experience, proposed suggestions were valuable for the definition of an effective national healthcare system decentralization reform strategy more generally in low- and middle- income countries, especially in Middle East and North Africa region’s countries. Due to the common recent democratic history and welfare state approach, these countries could use this “heritage” to apply effective decentralizing reform strategies for reducing territorial inequalities, in this case territorial health inequalities.

Introduction

The process of decentralization in the public sectors involves transferring authority and responsibility of governance from the national level to sub-national, regional or local, levels [1,2,3,4]. Bossert described decentralization as the expansion of “decision space”, with the increase of the number of stakeholders involved in public administration decision-making [5]. Decentralization reforms address power imbalances that hinder effective collaboration between central and territorial government levels in planning, implementing, and controlling administrative and management policies [6, 7]. Vrangbæk extended Bossert’s concept of decentralization to the healthcare sector, identifying variables that characterize the degree of decentralization [8]. The dimensions investigated by Vrangbæk and Bossert influence the model of decentralization, shaping the institutional, organizational, and financial aspects of the reform and, consequently, its impact [6,7,8].

Decentralization in healthcare sector was firstly applied in 80ties as organizational decentralization.

In fact, organizational decentralization was considered as a useful and structured approach to improve efficiency, effectiveness and equity of healthcare systems [9, 10]. The possibility to use the most suitable managerial tools according with the organizational needs of each health organization allowed to address expected goals, enhancing public healthcare system performance [11]. This phenomenon had a wide resonance especially in Europe [12].

Economic sustainability of health care systems that adopted organizational decentralization, could be compromised, when it was not associated with the update and upgrade of financing system. In fact, the increase of access to health services and the improvement of health quality required more resources by welfare State [13, 14]. Financial decentralization [15] emerged as solution to enlarge financing [16, 17], also in situations of budget constraints [16, 17]. Direct consequence of the implementation both of organizational and financial health decentralization was the establishment also of the institutional decentralization, as physiological adaptation of institutional assets to the changed field of action [18].

For these reasons, in the last 40 years healthcare decentralization has spread globally, starting from in high-income countries [12], to arrive in low-middle income countries of all continents in more recent years [11, 19, 20].

Focusing on Africa, healthcare decentralization has been notably diffused in the countries of the sub-Saharan region [21,22,23,24,25] but, to the best of our knowledge, few studies [26, 27] have been conducted in the MENA (Middle East and North Africa) region’s countries yet.

A special attention was paid to the implementation of health decentralization in low- and middle-income countries because a coordinated health governance model between national and local dimensions has not been usually strongly defined [28, 29]. A right degree of decentralization, balancing the national and local powers, in fact, can resolve misalignments between health needs and delivered health responses [5, 6]. On the contrary, risk of corruption can increase, control over health expenditure can be reduced, and regional disparities can be exacerbated [30, 31]. With an optimal degree of decentralization, national level enacts health policies, while territories program autonomously how to achieve national goals satisfying specific population’s health needs. National level also supervises that the same health outputs and outcomes are ensured and uniform among different territories of the country applying same standards nationwide.

It is desirable especially for low- and middle- income countries [32]. These countries usually are not able to rectify any remaining regional disparities post-decentralization due to instable governments and struggling with their ongoing evolutionary process of democracy and economy growing [33, 34].

Focusing on MENA region, Tunisia had properly this issue. After the revolutionary movement “Arabic Spring” (2010–2012), this country has been committed in implementing decentralization according with the strategies of welfare state enforcement promoted by the new democratic Constitution [35, 36]. Public healthcare system was the pivotal economic sector of decentralization application between 2016 and 2021 [37, 38]. Unfortunately, the coup d’etat of President Kais Saied on July 25th, 2021, froze parliamentary activities and the decentralization process, promoting newly the centralization of power in the hands of the Head of State.

However, during the six years Tunisian government promoted and worked on and toward the decentralization of the welfare state, starting with the healthcare system. The several made efforts must be gathered so that they will not be lost. In fact, these efforts represent a heritage in terms of training, organizational, and managerial aspects, and of values that must be preserved and passed on. In this way, when conditions will once again favourable for the implementation of decentralization proposed by the constitution, systems will not have to start from scratch but can, instead, rely on these bases.

Currently, there is no study in the literature that, considering the experiences accumulated by a country in decentralization, preserves the knowledge gained during periods of political stability, generalizes it, and makes it available to other countries in similar conditions. For these reasons, this paper aimed to formulate an effective strategy for healthcare system decentralization in low- and middle-income countries, drawing on past experiences in similar contexts.

Tunisia health care system decentralization

Among MENA countries, between 2016 and 2021 Tunisia was committed to decentralize welfare State according with the policy promoted by the democratic Constitution enacted in 2014 [35, 39]. The latent period between the entry in force of the new Tunisian Constitution and the starting reflection on how to decentralize welfare State was justified by the need to ensure the unity of the nation [37]. After the revolution, centralized government was in fact maintained as necessary step to consolidate the democratic change taking place in Tunisia.

With the progressive affirmation of the democracy, the country has started the decentralization of the public sector, as expected in the Constitution, starting from the public administration and health care sector [37, 40].

Focusing on healthcare sector, Tunisia has a public insurance health system, funded from taxation run by the Caisse Nationale d’Assurance Maladie, which provides care for most of the population. This system is organized in three levels [41]:

• First level composed by a network of 2157 primary health centres, 108 circumscriptions’ hospitals, and 28 basic healthcare groupings.

• Second level of care with 31 regional hospitals.

• Third level with 27 university hospitals and nine specialist health centres.

Between 2017 and 2019, the process of decentralization related to public healthcare system was especially financed by the Italian health cooperation with the project “Future Proche. Local development and decentralized services for sustainability and active citizenship in Tunisia”. This project was co-financed by the Italian Ministry of Foreign Affairs and Tuscany Region. The Future Proche project aimed to promote decentralization and strengthening of governance and local institutions in Tunisia [42]. The Centre of Global Health, the body of Tuscany Region deputed to the international health cooperation, collaborated with local partner to enact two main lines of project’s activities. The first line was focused on structural and technological renovation of some primary care centres and the personnel capacity building with the training of around 150 health professionals working on neonatal resuscitation and chronic diseases management. The second line of activity was of institutions’ building and managerial capacities’ building. Experiences, tools, and techniques were provided to middle (31 general surveillants of regional hospitals) and top management (31 directors of regional hospitals) of Tunisian public healthcare system to jointly develop Tunisian healthcare system decentralization strategy. Top management of Tunisian healthcare system was mainly committed in drafting a reform proposal for decentralization of national public healthcare system supported by the NGO "Pontes, research and interventions", active both in Italy and in Tunisia, and the research group belonging to the University of Florence, in collaboration with the Tunisian Ministry of Health. The same local and academic working group involved likewise health middle management in drafting job description of Tunisian health professionals, starting from nurses, for operatively supporting the decentralisation implementation.

This second line of intervention was of special interest for this study. Output of the second line of intervention was, in fact, a first draft of decentralization strategy to be applied on Tunisian healthcare system. It reported a common and shared idea of the possible future decentralized governance model (system organization, financing system, and evaluation and control system) of Tunisian healthcare system, jointly developed by directors of all Tunisian territories, representing the starting point of the reformative process aimed at reorganizing health planning and service provision by redistribution of decision-making power [39, 43].

In 2021, the attempt to implement Tunisian democratization process with the decentralization of the public healthcare system failed. On July 25th, 2021, President Kais Saied froze parliamentary activities, marking the beginning of a new transitional phase in Tunisian history. The coup was immediately characterized by a strong new centralization of power in the hands of the Head of State and initiated a mechanism to transform the State’s identity towards a more presidential system. At the same time, the socio-economic impact of the COVID-19 pandemic exacerbated existing vulnerabilities and inequalities with the triggering frustration and distrust among Tunisians towards institutions, ruling elites, and political parties [44].

Nevertheless, Tunisia remains one of the most successful social experiment in the tumultuous transnational path of the Arab Spring as a symbol of hope in the MENA region for about a decade. Tunisia efforded for welfare state decentralisation to overcome inequalities among regions, especially in public healthcare system. So, ideas offered by the Future Proche project may be taken into account as possible future restarting point, considered as cultural “heritage” not only for and within Tunisia. This experience, in fact, could be exploited also in MENA countries and, more generally, in low- and middle- income countries.

Materials and methodology

Case study

The country case study was identified as the most effective methodology for addressing the paper scope [45, 46]. This methodology facilitated the in-depth understanding of a phenomenon within intervention context [45, 47], especially when the object of analysis is complex as a decentralisation process of an healthcare system. Furthermore, one of the methodology’s main features lies in its capacity to investigate phenomena from a practical point of view, thus filling one of the most debated points in corporate literature, namely the gap between theory and practice [48]. At the end, case study enables the generalization of findings, extending their relevance to similar situations [49].

As before mentioned, Tunisia emerged as a significant case study in MENA region because this nation began the decentralization reform after the technical period of the new Constitution enactment. Among 2016 and 2021, here there was a strong political will to decentralize the governance of the welfare State, starting from the public healthcare system. Among all main goals of health care decentralization, the will of Tunisian government was to focus on addressing the reduction of regional disparities along coast, inland, and south ( [50] Fig. 1). In fact, decentralization was identified as an effective mean to promote health equity nationwide because of that sustained the synergy and collaboration between the national governance level and the regional ones operationalizing democratic Constitution [50].

Fig. 1

Main regions of Tunisia: Coast (blue), Inland (green) and South (red)

Data collection

The county case study was structured through documentary analysis of primary and secondary sources. Primary sources were questionnaires submitted to all 31 directors of Tunisian regional hospitals as represents of local top management. This sample was chosen especially to overcome Tunisia’s regional diversity. The perspective of local health top management was considered the most effective for summarizing technical, managerial and cultural heritage collected during the development process of the decentralization reform of public healthcare system in Tunisia. On the other side, they perfectly knew remained critical issues that should be overcame in future. In fact, they have had a privileged and complete vision on the application path of decentralization reform in Tunisian healthcare system [51]. Moreover, directors of regional hospitals were the best evaluators among all stakeholders involved in the decentralization process for their role in monitoring and controlling the progress or regression of public healthcare systems [52]. Secondary sources were acquired by final reports of the Future Proche project that reported the first draft of decentralization strategy proposing the possible future decentralized governance model (system organization, financing system, and evaluation and control system) of Tunisian healthcare system. Moreover, the state-of-art was also analysed though the integration of information obtained from both official national and international reports on Tunisian healthcare system to have a complete overview on it [41].

Questionnaire per SWOT analysis

Questionnaire was developed by the research group and validated by an experts panel using the Delphi method [53]. The panel was composed by five experts: a represent of NGOs “Pontes, research and intervention” (H.A.), an Italian top manager in healthcare sector (F.T.), a general director of an Italian local health Authority (M.B.), an administrative (M.D.L.) and a medical (M.J.C) experts of international health cooperation.

The questionnaire was structured in five sub-paragraphs (Annex 1):

• 1. Personal and professional data.

• 2. Decentralization.

• 3. Institutional decentralization.

• 4. Organizational decentralization.

• 5. Financial decentralization.

In each subsection, directors had to choose among a list of possible responses for filling a weighted SWOT analysis on different aspects of decentralization [54, 55]. The rationale was to fill SWOT analysis in relation with the impact of the done work on the development of decentralization strategy in terms of reduction of health inequalities among Tunisian territories. In this way, it was possible to highlight achieved results, identify collected “heritage”, and prioritize future next steps.

Definitions of each reform’s applications (institutional, organizational and financial − 6) were given within the questionnaire in order to reduce possible personal interpretations, which could compromise the validity of the acquired information.

Questionnaire was sent to all directors of the 31 Tunisian regional hospitals by email as Google form link (arranged in advance in French language in collaboration with a mother language Tunisian cultural mediator). The time window for filling the questionnaire was two weeks, starting from sending day.

In this period, a cultural mediator belonging to NGO “Pontes, research and interventions” was available for directors via mail in case of filling doubts, who worked as linking bridge between directors and researchers’ group.

Each participant was required to sign a privacy policy document to consent the management of their personal data in compliance with the European (Regulation (EU) n. 679/2016, Regulation (EU) n. 536/2014) and national regulation (Italian Law 2019/2017). The request for the approval of the research by the ethic committee or the institutional review board was not required because of the absence of health sensible data related to medical treatment and for research involving human participants [56, 57].

Questionnaire data were statistically analysed to describe in the best way the “heritage”, in terms of knowledge, relationships/networking, competences and skills/abilities, collected during the 5-working years for the decentralization reform’s building. Data were especially studied in accordance with the territories in which managers operated: coast, inland and south (Fig. 1). In fact, historically data on Tunisia have been segmented according with these three regions characterized by substantial geographic, demographic, and economic differences and associated inequalities, especially in the access to and quality of provided health care services [50].

Results

Sample

The sample consisted of 25 out of 31 directors of regional hospitals in Tunisia, representing 81% of the population surveyed and 100% of governatores overseeing regional hospitals (21 out of 24). The directors represented a broad geographic distribution: 11 directors came from 9 coastal governorates (Bizerte, Ariana, Ben Arous, Nabeul [2], Zaghouan, Sousse, Monastir, Mahdia, Sfax [2]); 7 directors were from 6 inland governorates (Béja [2], Siliana, Kairouan, Kasserine, Sidi Bouzid, Jendouba); and another 7 were from 6 southern governorates (Gabès, Médenine [2], Gafsa, Tozeur, Tataouine, Kébili). So, the sample strongly represented Tunisia’s healthcare system, as directors were drawn from 21 of the 24 governorates with regional hospitals.

Among the 25 general managers, 56% hold a bachelor’s degree, 36% have a diploma from the National School of Public Administration, and 8% possess a PhD. The directors’ training was not solely medical but included economic and legal contexts. Only 24% of respondents had international study experience, which was instrumental in broadening their understanding of other welfare systems.

72% of the directors had prior professional experience. In terms of tenure, 36% had been working at their current hospital for less than a year, 40% for 2–5 years, and 24% for more than 5 years. Of these directors, 86% managed standard regional hospitals, while the remaining 14% oversaw regional hospitals which should be converted in university hospitals (located in Kairouan, Mahdia, and Nabeul) in the near future.

Furthermore, 52% of the sample actively participated in the Future Proche project.

Decentralization reform

Data highlighed that Tunisian top management largely agreed that decentralization, in all its forms—institutional, organizational, financial (76%)—could significantly reduce health inequalities while fostering the development of the healthcare system (92%).

Key strengths included the specialization of regions to better address local needs (80%) and the establishment of a national evaluation and control system (80%). However, significant challenges remained to reduce disparities between regions and health districts, both internal and external. Internally, there was a pressing need to train the managerial class (80%) to comprehend the goals of decentralization, so that they could be committed in decentralization implementation (76%). This effort would be supported by granting managers greater authority, coupled with increased responsibility (76%).

Externally, decentralization faced obstacles such as a lack of synergy between stakeholders (88%), poor resources (76%), and an insufficient provision of primary healthcare services (80%) (see Table 1).

Table 1 SWOT decentralization

Institutional decentralization

Institutional decentralization involves delegating decision-making authority on healthcare system from the policy level to managerial levels, empowering local technical experts to consistently address the healthcare needs of the population, regardless of positive or negative political changes.

The primary benefits of institutional decentralization in reducing health inequalities included valuing local needs (88%) and public opinion (80%) in decision-making. However, significant challenges remained, particularly the insufficient training of local health authorities in effectively managing the new responsibilities associated with decentralization (technical knowledge – 84%).

Another highlighted issue was the limited autonomy of hospitals (80%). This concern aligned with broader discussions of decentralization, which noted the excessive specialization of certain hospitals (76%).

While institutional decentralization was seen as an opportunity to collaborate on reform at the national level (80%), critical discussions were focused on the persistence of significant health inequalities across different regions (80%) (see Table 2).

Organizational decentralization

Organizational decentralization in the healthcare system involves granting territorial health organizations a certain degree of managerial autonomy from the national health government.

Tunisian top management identified organizational decentralization as one of the key interventions positively impacting the country’s healthcare system. This approach enabled territories to autonomously define their strategic objectives (80%) and, accordingly, manage allocated resources (84%). It also facilitated achieving shared outcomes, such as implementing standardized management controls at the national level (92%) and meeting budgetary objectives (72%).

On the other side, organizational decentralization has not yet fully extended to personnel (72%) and investment (64%), management, which remained under central level control. Moreover, while some managerial skills have already been developed by personnel (72%), the lack of a dedicated administrative structure (84%) hindered the effective provision of services (84%).

Top management supported defining an optimal degree of decentralization to balance powers between national and local levels, particularly in terms of financing (80%), to reduce health inequalities among Tunisian territories. Additionally, separating the political and technical aspects of health governance (72%) has ensured continuity and coherence in the administration of Tunisia’s health system, making it less vulnerable to frequent political changes.

Table 2 SWOT institutional decentralization

Table 3 SWOT organizational decentralization

Financial decentralization

Financial decentralization entails the independent allocation, management, and utilization of resources within Tunisia’s public healthcare system at the local level.

The entire top management unanimously recognized financial decentralization as the key solution to improving the efficiency of the Tunisian public healthcare system (100%). Financial decentralization, in fact, allowed to allocate resources according to the real needs of the territories (96%). But, the system still lacked the necessary technologies (100%), expertise (84%), and legal frameworks and procedures (100%) to fully implement it.

So top management strongly advocated for the introduction of standardized accounting and management control models (84%) as well as expense monitoring systems (72%) at the national level.

An additional noteworthy recommendation was the creation of dedicated funds for vulnerable populations (72%), reflecting a shared commitment to addressing current inequalities in access to healthcare services in Tunisia (72%).

Table 4 SWOT financial decentralization

Opinion by difference regions on healthcare decentralization (Figs. 2, 3, 4 and 5)

Coast

Representatives from the coastal regions viewed decentralization in all its forms as an opportunity to consolidate and strengthen their local healthcare systems (91%). By gaining greater autonomy, the coastal regions aimed to tailor healthcare services for better addressing the specific needs of local population (100%). However, there was concern about the potential reduction in hospital autonomy (91%) and the lack of subsidies for economically disadvantaged individuals (91%).

Fig. 2

SWOT decentralization for areas

Fig. 3

SWOT institutional organization for areas

Fig. 4

SWOT organization decentralization for areas

Fig. 5

SWOT financial decentralization for areas

While the coastal regions were prepared to implement the healthcare reorganization proposed by decentralization at local level (91%), the absence of a strong governance model—both centrally and locally—posed significant challenges (91%).

Without effective coordination among stakeholders, the decentralization process risked being paralyzed (91%).

In response, the top management of coastal region expressed a clear preference for a high degree of financial decentralization for the benefits in terms of efficiency (100%), along with autonomous management of human resources (82%) and investments (82%). Nevertheless, they recognized that strong regional inequalities (91%), if not effectively addressed, could hindered the ability of all regions to meet ministerial objectives (91%). Consequently, they strongly supported the introduction of a common national evaluation and control mechanisms as well as the implementation of standard staff training program (91%).

Inland

Top management from inland areas recognized decentralization as an opportunity to enlarge of Tunisian healthcare governance, extending responsibility and power to local level (86%) by networking (86%). For representatives from inland governorates, the key priorities for effectively implementing decentralization were:

• Involving local health facilities in the discussion on health decentralization (86%) and its implementation.

• Ensuring autonomy in resource management to optimize their effective allocation (86%).

• Establishing a rigorous evaluation and control system to improve efficiency at national level (100%).

Directors emphasized the strengthening of administrative framework within the healthcare system in Tunisia’s inland regions to ensure the availability of resources (86%), competencies, and skills needed to tackle challenges especially related to primary healthcare delivery (86%) that currently were missing.

Managerial autonomy was highlighted as a critical factor in driving the reorganization of healthcare services (100%). In fact, they were absolutely not confident with the full implementation of decentralization (100%) due to bureaucracy (86%), ineffectiveness of applied control (86%) and the fragility of the IT system (86%).

Moroever, the reduced autonomy of hospital was seen as a critical issue (100%), stopping the ongoing enforcement of the healthcare system of this region that was here located.

However, unlike other regions, inland leadership expressed limited trust in the opportunities presented by financial decentralization, citing risks associated with weaknesses in the local tax system (86%).

South

Meanwhile, top management in the southern regions fully sustained the decentralization implementation (100%) but they remained cautious. Challenges were liked to the fragility of the healthcare system, which was unable to meet even the basic level of assistance (43%) and showed substantial health inequalities (100%).

But the local-level debate on healthcare decentralization sought to finally address the recognition of their specific needs in defining national health strategies (100%), advocating for greater responsibility and autonomy at the local level (100%).

The primary issue to address was the chronic shortage of technical knowledge (86%), which could potentially be resolved by adopting standardized accounting and management control models (86%) at national level. Additionally, shortcomings in the Tunisian health insurance system resonated more strongly in the southern regions than in other areas of the country (43%) for the lower income of this region.

Also the top management in the south expressed limited confidence in the opportunities offered by financial decentralization, highlighting concerns about the lack of spending control culture (86%) and related tools (100%) that limited to address the auspicated greater efficiency (100%).

Furthermore, this group emphasized the role of central authorities in coordinating collaboration between regions to foster positive synergies and improve overall system performance (86%).

Discussion

The data revealed that Tunisia’s healthcare top management expressed consistent and strong approval for the tangible and effective contributions of healthcare system’s decentralization in reducing health inequalities across the country [36, 38]. However, differing perspectives on the various aspects of decentralization emerged, analyzing responses by regional background [37, 50]. These variations were influenced by distinct geographical, socio-demographic, and economic contexts [43, 51].

Despite these differences, representatives from all regions agreed on the following measures as essential for implementing decentralization aimed at reducing territorial health inequalities:

• Empowering local health authorities to determine their own health strategies [34]. This alignment would help tailor healthcare services to meet the specific health needs of each population more equitably.

• Revising administrative, managerial, organizational, and operational procedures based on principles of efficiency and effectiveness [10]. Such reforms would enhance performance, quality, safety, and economic sustainability within each regional healthcare system in Tunisia.

• Emphasizing the need for a differentiated approach to implementing health decentralization, taking into account the unique needs of each locality [26, 27]. Establishing a robust national oversight system. This system would standardize healthcare service accreditation across all regions, preventing the reemergence of conditions fostering inequality [6, 8].

These findings confirm that all three regions support decentralization and share the same goals. These measures could serve as starting points to standardize managerial approaches across Tunisia’s healthcare system for overcoming, in first instance, cultural differences among coast, inland and south in Tunisia. This is the heritage that reflect the progress made during the five years of active efforts by Tunsian healthcare top management to establish healthcare system decentralization, as mandated by their Constitution [35, 39].

Conclusions

Tunisian health top management perspective empathized the importance to implement, in first instance, differentiated decentralisation for reducing health inequalities among regions and then, a common control system at national level for ensuring the same standard of efficiency and effectiveness.

Drawing from the Tunisian experience, this “heritage” is valuable as starting point for the definition of future effective national healthcare system decentralization strategy not only in Tunisia but more generally in low- and middle-income countries, especially in MENA region’s countries. These countries have in fact, similar territorial conditions. The exploitation of offered suggestions allow to accellerate decentralization’ planning phase, previously knowing critical issue, programming phase already having possible solution and, at the end, implementation phase borrowing experimented approaches and tools.

Following President Kais Saied’s coup, all managers in senior roles within the Tunisian public healthcare system were replaced. New top management had their responsibility and autonomy significantly restricted. Future development of the research could involve contacting the new Tunisian healthcare management to gather their opinions on the possible future decentralization of the public healthcare system, especially regarding the reduction of health inequalities. Moreover, a research limit was the lack involvement of middle management. Hopefully possible development could include in the target group also middle management of Tunisian healthcare system.