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A new governance model to reach the right to health? The Tunisian societal dialogue

By Fahdi Dkhimi
on October 24, 2014

Fahdi wrote this blog together with Vincent De Brouwere.


In many Arab countries, memories of the so called “Arab spring” are still very vivid. However, four years after large swathes of the Tunisian population took to the streets to claim more freedom and improved social justice, a new societal model is still to emerge. Substantial changes in decision making processes still need to happen in order to accommodate the new aspirations towards a more participatory, equitable and evidence-informed decision making process which is in turn expected to lead to a more inclusive and accountable government.

In most of the Arab countries, such a transformation of the policymaking process will be anything but easy. To use a medical metaphor, the delivery will be long and complicated, and “success” is certainly not inevitable. However, a few ongoing initiatives are worth an in-depth look. One of them is certainly the large-scale consultative process – the “societal dialogue” – currently taking place in Tunisia. This dialogue aims to tackle some of the above mentioned governance issues through a high level of citizen involvement in the decision making process. The first phase of this dialogue ended beginning of September 2014, in Tunis, during the national health conference. Its objective was to identify, in a participatory manner, the potential contribution of the health system to the realization of the right to health, recently enshrined in the new Tunisian constitution.

What was the starting point of the whole consultation?

A steering committee composed of 75 representatives of the entire health system and beyond – supported by a technical committee in charge of the coordination of the process – adopted and piloted a national consultation in 2012 comprising the following steps.

First, from June 2013 to March 2014, this steering committee conducted an in-depth assessment of the Tunisian health system, based on a broad literature review, complemented by thematic workshops, expert panels and focus groups with citizens, experts and health professionals. This assessment engaged more than 800 individuals.

Then, in April-May 2014, two health “rendez-vous” were organized in each of the 24 Tunisian administrative regions: one with health professionals, another one with a more or less representative group of citizens. All in all, 3,424 people had the chance to discuss and add to the findings of the above mentioned evaluation, and express their opinion on the values that should shape the Tunisian health system.

A third step, in June 2014, gathered 92 citizens and health professionals (selected through a lucky draw during the “rendez-vous”) together with 15 national and international experts. The people from this group aimed to make a synthesis of the assessment and the large consultation conducted in the administrative regions. They came up with some conclusions which were shared during the last step of the process: the national health conference, which took place from September 2nd to September 4th.

We were fortunate to take part in the national conference. This conference brought a real ‘marathon dialogue’ on strategies to align the Tunisian health system with the aspirations of the citizens to a successful conclusion. The event produced the Tunisian white paper for the health sector.

The truly participatory “feel” of the process really struck us. We were impressed by the constant concern of the organizers to give voice to a, till recently, rather “symbolic” figure in the political system: the citizen. They also sent out feedback to the outside world through a website which aims to raise awareness about the health system and the ongoing societal dialogue (see especially the section “Le saviez-vous?”, literally “Did you know that…”). Here we could feel the vigour and enthusiasm of a brand new democracy.

Of course, there were implementation gaps. For example, one of the key questions is to know whether the organizers have managed to assure randomness in the selection process of participants, as intended.

The weak institutionalization of the process is also a great concern today, especially with the rather low level of ownership from both the technocrats from the Ministry of Health – who felt left out of the consultation – and the political parties which didn’t integrate the recommendations of the national conference into their electoral promises – the first democratic elections in Tunisia will take place this weekend (26 October), by the way. But let’s not deny one fact: this was a real attempt to address, within the health system, some of the concerns expressed by the citizens in the streets four years ago. This is evidenced by some key figures e.g. the 120 hours of dialogue recorded/taped in the process. More, it’s probably one of the few key attempts so far, while most of the Arab countries still fail to deliver a new social contract that satisfies the majority of their citizens.

About a year ago, the Moroccan Ministry of Health also organized a national health conference (a new trend in Arab countries?). Goals were similar but the process was different – the Ministry of health took the lead in the Moroccan process.

Two ways, two models to translate social aspirations into political practices? Before we can make such a claim, it’s important to first document these two processes in-depth and identify differences and commonalities. Only then we’ll be able to explore and assess the results of these “models” in their respective contexts. What kind of results? Well, as Rashad’s rightly stated in a Lancet special theme issue on health in the Arab World, last January: “The legitimate aspirations of the Arab population are suffocated by deeply polarized societies and a very narrow interpretation of social justice.” In other words, can these two processes address this gap and make significant steps towards the realization of the right to health?

Let’s wait and see, but what an interesting topic!

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