In the hallways of Tunisian hospitals, thousands of patients are waiting to receive critical treatments.
For years, Ahmed Hammami and his wife Fatima have struggled to afford treatment for their three boys who suffer from a genetic disorder called beta thalassaemia, a disease that reduces the production of haemoglobin – the protein in red blood cells that carries oxygen throughout the body.
Failure to receive treatment carries a fatal risk.
Adam, one of the couple’s three boys, had a stroke in May after being unable to take the medication that helps regulate iron levels in his body after every blood transfusion. The stroke left him blind in one eye.
“We feel sorry for him [Adam] – he’s only nine but he has to suffer because we have nothing,” Fatima tells The National.
Concern for their children's future has mounted in recent months, as the medicine that they depend on has started gradually disappearing from Tunisia's pharmacies.
“Hydrea [medicine used for cancer treatment and other blood disorders] has been out of stock for two months from the hospital’s pharmacy,” Fatima says as she waits for one of her children’s CT scans at the Bashir Hamza Paediatrics hospital in Tunis.
“Outside, one package costs about 50 dinars [about $17]. We cannot afford the cost of covering it for all our kids.”
Ahmed interjects, holding up his cracked, calloused palms: “Look at my hands. I work in potato fields from dawn to dusk and I cannot even manage to fix my teeth that have fallen over the years, and they expect us to afford such an expensive treatment on our own.
“My wife is tired from running from one hospital to another, at least two days a week as they [the kids] need weekly blood transfusions to survive but now the only treatment we have been relying on is not available anymore.”
The Tunisian National Statistics Institute reported that more than 17 per cent of Tunisians live on the national poverty line compared to 15.2 per cent in 2015. This means that the poorest in the country rely on government subsidies to provide their basic needs, including food and medicines.
Tunisia’s ongoing economic crisis and its public fund deficit has affected all sectors, including health.
A large proportion of Tunisia's population relies on the publicly owned National Health Insurance Fund, or CNAM, to pay for treatment and medication.
The number of patients suffering from chronic diseases that rely on CNAM has increased from 89,801 in 2007 to 1,019,870 in 2021.
The state-owned Tunisian Central Pharmacy is another clear example of this crisis. For months, it has been struggling with a lack of financing that has made it impossible for the pharmacy to pay off its piling debt to external medicine suppliers, making it unable to provide many medicines.
Public hospitals and clinics are witnessing a surge in the number of patients left to pay out of pocket for expensive essential medicines that were previously provided or subsidised by the public healthcare system.
While some can afford the cost, many such as the Hammami family are unable to and must instead wait for the state to begin providing medication again.
The crisis in the healthcare system is not limited to the public sector – it is now spilling over to the private sector, too.
As medication becomes more scarce, even those who can afford to buy it are often having to suspend treatment until medication is available again.
“I had a liver transplant in 2010 and since then I have been taking immunosuppressant medications to avoid organ rejection and other problems, Abdelkader, a taxi driver, tells The National outside Charles Nicolle Public Hospital.
“In recent months, however, some of the essential treatments have disappeared. I can’t even rely on my own money to provide that.”
He adds that this became a problem after the Covid-19 pandemic, as Tunisia’s economic crisis turned critical.
Several other people queuing in front of the Ophthalmology Tunis Hospital tell The National that their surgeries have been pushed back repeatedly due to medical shortages.
Other patients speak about the lack of medication for diabetes, high blood pressure and stroke treatments.
Cancer patients bear the brunt
At the Salah Azaiez cancer treatment centre in Tunis, patients and their families queue in front of a pharmacy.
“We came all the way from Beja [112km from the capital] only to find out that no medication is available, even the basic stuff such as ointment,” Mouna tells The National as she speaks with other patients' families outside the cancer centre.
Mouna’s 90-year-old grandmother, Eljeya, has terminal melanoma. Despite her delicate health, she had to travel to Tunis to receive the medicine she needs to manage her pain. But even basic medication is lacking.
“We were hoping that they would at least clean up the abscess that she now has around her melanoma site but even medical cleaning products are out of stock,” Mouna says.
“It is frustrating for both patients and doctors and at this point all we can do is pray for her [the grandmother] to leave this world as soon as possible to spare her the torture she is going through.”
The Salah Azaiez Cancer Institute is the only medical facility that treats cancer patients in the country. Even the most basic pain management treatments required are only available here.
The centralisation of treatment in the capital is creating a struggle of its own, as doctors continue to leave the country for Europe, frustrated over the lack of facilities and medications needed to carry out their duties.
Depreciation of the dinar and the Tunisian Central Pharmacy debt crisis
The Tunisian Central Pharmacy plays a key role in importing and marketing pharmaceutical products. It is also responsible for setting import prices and the distribution of pharmaceuticals to private pharmacies, hospitals and veterinary facilities.
It is the sole importer of medicines in Tunisia and the main regulator of the country’s pharmaceutical supply system.
In recent years, however, there have been growing problems within the medication supply chain, which has been static for decades and has not evolved to meet the economic challenges that Tunisia has been going through over the past 12 years.
According to a 2021 study conducted by the Tunisian Observatory for Economy, Tunisia lost an estimated 210 million dinars (about €64 million) in 2018 due to the depreciation of the country's currency against the euro.
Eighty per cent of the central pharmacy’s purchases are made in euros. Profitability has also decreased due to a rise in medication costs on the global market.
“The inefficiency of the central pharmacy's system was among other things due to the sharp depreciation of the dinar, which is completely beyond its control, but which has had a major impact on its ability to secure the medicines supply that Tunisia needs,” Tunisia’s Economy Observatory explains says.
Debts increased further as the central pharmacy continued to ask for extensions to its payments deadline, leading suppliers to add late fees.
In 2018, local media started reporting on the worrying medicine shortages and the inability of the central pharmacy’s system to address it.
Tunisians unable to pay for their medication costs started relying more on family members to send it to them from abroad.
Facebook groups and community initiatives focused on helping people find medicines have become more common.
As the failure within the centralised system of medicine distribution persists, Tunisian officials have been trying to find an alternative.
Legislators and the Tunisian Ministry of Health have proposed the creation of a new government body that will aim to limit the central pharmacy's monopoly on the distribution of medicines within the local market.
“We cannot deny that there's a shortage in medications in our country,” Raouf Fkiri, a member of the health committee in the Tunisian Parliament, tells The National.
“The establishment of a national agency for medication and health supplies would help us provide the necessary medicines and supervise the networks of its distribution.
“We would also be able to accelerate the process of giving permits for more distributors, other than the central pharmacy, to be able to support the local market with medical needs.”
However, the creation of this agency could take months as the bill would need to be approved by the parliament and later signed by the Tunisian President.
Although there are many issues within the current subsidies system, MPs are keen to bring it into working order so that it can provide medicines for critical and chronic diseases at cheaper prices.
In February, President Kais Saied carried out an inspection at the headquarters of the Tunisian Pharmaceuticals Industries Company and discovered expired medicines at the company's warehouses.
He said it was “unacceptable” and that those responsible “should be held accountable”.
He blamed the current crisis on “corrupt lobbyists” that want to control the pharmaceuticals market.