Journal of Mental Health

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Highlighting successes and challenges of the

mental health system in Tunisia: an overview of
services, facilities, and human resources

Fatma Charfi , Uta Ouali , Jessica Spagnolo , Ahlem Belhadj , Fethi Nacef ,
Olfa Saidi & Wahid Melki

To cite this article: Fatma Charfi , Uta Ouali , Jessica Spagnolo , Ahlem Belhadj , Fethi Nacef ,
Olfa Saidi & Wahid Melki (2021): Highlighting successes and challenges of the mental health
system in Tunisia: an overview of services, facilities, and human resources, Journal of Mental
Health

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Published online: 14 Feb 2021.

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JOURNAL OF MENTAL HEALTH
https://doi.org/10.1080/09638237.2021.1875414

ORIGINAL ARTICLE

Highlighting successes and challenges of the mental health system in Tunisia:

an overview of services, facilities, and human resources
Fatma Charfia,b, Uta Oualib,c , Jessica Spagnolod,e , Ahlem Belhadja,b, Fethi Nacefb,c, Olfa Saidif and
Wahid Melkib,g,h
a
Department of Child Psychiatry, Mongi Slim Hospital, La Marsa, Tunisia; bFaculty of Medicine of Tunis, University of Tunis El Manar, Tunis,
Tunisia; cDepartment of Psychiatry A, Razi Hospital, La Manouba, Tunisia; dD
epartement des sciences de la sant
e communautaire, Facult
e
de m
edecine et des sciences de la sant
e, Universit
e de Sherbrooke, Sherbrooke, Canada; eCentre de recherche Charles-Le-Moyne-Saguenay-
Lac-St-Jean sur les innovations en sant
e, Campus de Longueuil – Universit
e de Sherbrooke, Longueuil, Canada; fWorld Health Organization,
Country office Tunisia; gDepartment of Psychiatry D, Razi Hospital, La Manouba, Tunisia; hTechnical Committee for Mental Health Promotion
in Ministry of Health, Tunisia

ABSTRACT ARTICLE HISTORY

Background: Tunisia is a lower-middle-income country located in North Africa with strengths and Received 26 June 2020
challenges to its mental health system. Revised 5 December 2020
Aims: We present an overview of available services, facilities, and human resources to offer mental Accepted 5 January 2021
health care in Tunisia. Published online 15 January
2021
Methods: We conducted a cross-sectional study, where data for the year 2017 was collected between
May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We com- KEYWORDS
pare this information with data published in the WHO-AIMS report (2008), which presents mental Mental health; mental
health data in Tunisia for the year 2004. health system; resources;
Results: Successes of the mental health system in Tunisia include an increase in the ratios of psychia- LMIC; Tunisia
trists and psychologists, with these ratios being higher than those of other lower-middle-income coun-
tries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health
conditions. Challenges include psychiatrists being over-represented in large cities along the coastline
and in the private sector, and most people receiving treatment in specialized mental health facilities.
Conclusions: The further operationalization of the National Strategy for Mental Health Promotion is
envisioned, through the training of non-specialists in mental health care and incentives offered to psy-
chiatrists to work in the country’s interior and the public sector.

Introduction implementation context. For example, in lower-income set-

tings, with the limited number of mental health specialists,
In low- and middle-income countries (LMICs), there are
the goal would be to further invest in primary and commu-
challenges to mental health service access. LMICs have an
nity care, with the specialists’ role being that of consultant,
important burden from mental disorders (Jacob & Patel,
trainer, and supervisor (Hoeft et al., 2018; Mendenhall et al.,
2014; Lopez et al., 2006; Lund et al., 2012; Rathod et al.,
2017; Thyloth et al., 2016), yet the mental health expend- 2014; Thornicroft et al., 2016). In middle-income settings,
iture per capita in high-income countries (HICs) is more an emphasis on primary and community care is also war-
than 20 times greater than in LMICs (WHO, 2018), which ranted, and with additional options for care, including: out-
may limit the development and implementation of effective patient clinics; community mental health teams; inpatient
mental health services in these countries (WHO, 2013, care in general hospitals; and community-based residential
2018). In addition, if a mental health budget is available in care (Patel et al., 2018; Thornicroft et al., 2016).
LMICs, most funds (an average of 80%) are allocated to Tunisia is a lower-middle-income country (World Bank,
mental health hospitals, often few in number and located 2019) located in North Africa and is included in the 22
within capitals or main cities (Cohen et al., 2014; Patel, countries of the World Health Organization (WHO) Eastern
2007; Saraceno et al., 2007; WHO, 2013, 2018), whereas this Mediterranean Region (EMR). The country is organized
statistic is estimated at 43% in HICs (WHO, 2018). into 24 governorates and has a population of 11,446,300
Evidence suggests that a balanced care model with speci- inhabitants (INS, 2018). The Tunisian health care system,
alized and primary/community-based services is important mainly managed by the Ministry of Health and its 24
for offering effective, quality mental health care across a regional directorates working in the governorates, is com-
continuum (Patel et al., 2018; Thornicroft et al., 2016). prised of a public and a private sector. The public health
These balanced care models can differ depending on the sector has three levels, or lines, of care. The first line

CONTACT Fatma Charfi [email protected] Department of Child Psychiatry, Mongi Slim Hospital, La Marsa 2046, Tunisia
ß 2021 Informa UK Limited, trading as Taylor & Francis Group
2 F. CHARFI ET AL.

consists of a wide network of Primary Health Care Centres operationalization of the strategy, the Technical Committee
(i.e., first-line clinics), Centres for School and University for Mental Health Promotion was created by the Ministry of
Medicine, and Centres for Maternal and Infant Protection. Health in 2015.
The regional hospitals constitute the second line of the pub- In 2017, the WHO EMR invited the Tunisian Ministry of
lic health care sector. They are generally located in the gov- Health to participate in the WHO Mental Health Atlas,
ernorates’ main cities. The third line of care is comprised of which regroups evidence from HICs and LMICs on similar
university facilities, which provide specialized treatment and indicators and targets as the WHO-AIMS (WHO, 2018).
training, as well as conduct research. These institutions are The Ministry of Health and the WHO EMR mandated two
located mainly in cities with universities (Tunis, Sousse, authors of this paper (FC, WM) to collect information on
Monastir, and Sfax) (Ministere de la Sant
e, 2019). mental health services, infrastructure, and human resources
After Tunisia’s independence in 1956, health care focused available in Tunisia for inclusion in the 2017 WHO’s
on eradicating infectious diseases. With their eradication, Mental Health Atlas. Given logistical issues in contacting
Tunisia experienced an epidemiological transition which stakeholders to obtain necessary information (i.e., there is
shifted from communicable to non-communicable diseases, no national information system with data registry), only the
including mental health. Hence, in 1990, the National number of psychiatrists was obtained. This limited portrait
Mental Health Program was adopted, one of the main of mental health care in Tunisia encouraged authors (FC,
objectives being to integrate mental health into the general WM, UO) to fill in the gaps.
health planning strategy (Douki et al., 2005; WHO, 2010a). The overall objective of this article is to provide an over-
In 1992, Law 92–83 was adopted to promote the highest view of available mental health services, facilities, and
respect for the human rights of people with mental health human resources offering mental health care across
conditions, especially those admitted to inpatient care. The Tunisia’s 24 governorates and to compare these data with
Law’s emendation in 2004 was related to the conditions of those published in the 2008 WHO-AIMS report. With this
hospitalization for people with mental disorders (Douki information and comparison, we: explore strengths and
et al., 2005). challenges of Tunisia’s current mental health system; and
In 1999, sectorization, based on the French model, was assess progress that has been made in further integrating
introduced to the Tunisian public mental health care sys- mental health into primary care.
tem, organizing it according to geographical sectors, with
each sector affiliated with one university inpatient depart-
ment of psychiatry (Ben Neticha et al., 2017). Sectorization Material and methods
facilitates timely access to mental health care, especially for Data collection
people living in areas farther away from the north and the
coastline, where most services are located. To facilitate this We conducted a cross-sectional study, where health data for
access, a plan to integrate mental health into Primary the year 2017 was collected by FC and UO between May
Health Care Centres was conceived. Concretely, the univer- 2018 and May 2019. The authors identified key stakeholder
sity psychiatric inpatient units are responsible for organizing groups involved in the health field in Tunisia: members of
training and supervision sessions for primary healthcare the Ministry of Health, as well as representatives of public
professionals and for coordinating referrals and care plan- institutions and professional organizations. FC and UO con-
ning with public- and private-sector psychiatrists (Douki tacted them by telephone to explain the objective of the
et al., 2005). study and to obtain their consent to collect and publish
In 2008, the Ministry of Health in Tunisia and the WHO information about mental health care. Key stakeholders
collected data using the WHO-Assessment Instrument for searched their records and then shared by email data related
Mental Health Systems (AIMS) (WHO & Ministry of to mental health facilities, services, and human resources.
Health Tunisia, 2008), a standardized tool developed to help FC and UO synthesized data according to Questions 5
Ministries of Health identify health system strengths and (workforce) and 7 (service availability) of the WHO’s
challenges (WHO, 2020). Key Tunisian stakeholders con- Mental Health Atlas (WHO, 2018).
tinue to concentrate efforts on mental health initiatives, as
highlighted by the development of the 2013 National
Mental health facilities
Strategy for Mental Health Promotion (Ministry of Health,
2013). One of the strategy’s main objectives is to further We focused on mental health facilities with at least one
promote the integration of mental health within Primary psychiatrist. We obtained information on the mental health
Health Care Centres, notably through the training of pri- hospital (Razi Hospital, the country’s only operating mental
mary care physicians (PCPs), and to facilitate continuity of health hospital) from author FN who is the Medical Staff
mental health services from first- to third-line care President. The information about other public services spe-
(Ministry of Health, 2013). Tunisia is one of the few coun- cializing in mental health care was collected through the
tries of the WHO EMR area to have produced a mental Regional Coordination Unit of the Ministry of Health,
health strategy, and the WHO EMR is one of the WHO which oversees the Regional Health Directorates of the 24
regions with the least number of countries to have produced Tunisian governorates. We present data on the type and
a mental health plan (WHO, 2018). To ensure the number of available public sector mental health care
 JOURNAL OF MENTAL HEALTH 3

facilities and the geographic distribution of mental health collection. These include beds in mental health facilities,
facilities across Tunisia. mental health activities, and human resources.

Mental health workforce Statistical analysis

We included mental health professionals listed in Question The ratios were calculated as the number of available
5 of WHO’s Mental Health Atlas (WHO, 2018), except resources relative to the total population (INS, 2018),
nurses and other specialist doctors. We obtained data on adjusted for 100,000 inhabitants.
public sector psychiatrists from the Ministry of Health (i.e., To facilitate comparison with the WHO-AIMS report
the Technical Committee for Mental Health Promotion) (2008) and our results, we generated percentages from our
(WM)) and from the National Medical Council, which regu- results as follows: number of available beds for each type of
lates the professional practice of public and private sector facility, divided by the total number of mental health beds
physicians, as well as implements, promotes, and monitors in Tunisia. To present comparisons about the mental health
ethical standards. Data was validated by the different public hospital’s activities and psychiatric inpatient activities in
health care institutions. general hospitals, we added detailed data for both adult and
Data on the number of private sector psychiatrists was child psychiatry, generating a total sum which we then div-
obtained from the National Medical Council. Data on the ided by the total population.
number of psychologists and their sector of employment
(public or private) was obtained through the Tunisian Ethical considerations
Association of Psychologists. Through the National Union
of Speech Therapists and the National Union of Ethical approval was obtained from Razi Hospital (RPA3/
Occupational Therapists, we obtained data on the number 2018), the affiliation of three of the study’s authors. The
of speech therapists and occupational therapists. The num- data received had already been anonymized.
ber of social workers was obtained from the Representative
of Social Workers, affiliated with the Ministry of Social
Results
Affairs, who coordinates all public sector social workers
working in health care institutions. Mental health facilities
We present data according to health profession and place
In Tunisia’s public sector, the following structures offer spe-
of work. To highlight regional differences, we calculated the
cialized psychiatric in- and outpatient services: the only
geographical distribution of psychiatrists.
operating mental health hospital in the country (Razi
Hospital); psychiatry departments in general hospitals; and
Activities related to the provision of mental health care psychiatric outpatient clinics in several healthcare settings.
Most of these structures are considered second- or third-
We collected data on the number of activities related to the line care (i.e., specialized services).
provision of mental health care, which we defined as care Razi Hospital, in the Greater Tunis area (La Manouba),
offered to people in need of mental health services and who has a total number of seven adult in- and outpatient depart-
present for consultation in mental health facilities (defin- ments, one adult outpatient and emergency department, one
ition above). Following Question 7 of WHO’s Mental forensic psychiatry department, and one in- and outpatient
Health Atlas (WHO, 2018), we collected information about department of child psychiatry.
number of beds and admissions for inpatient services, as The total number of psychiatry departments providing
well as visits in mental health facilities between 1 January in- and outpatient services within general hospitals is 11.
2017 to 31 December 2017. This information was obtained These structures consist of multidisciplinary teams of mental
from the General Director of Public Healthcare Facilities, health professionals. Among these psychiatry departments,
responsible for the management of all public sector hospitals one is part of the Military Hospital of Tunis, reserved for
and for information about activities provided by hospitals. veterans and their relatives. Other general hospitals only
For mental health services provided out of hospitals (i.e., have specialized outpatient clinics where one psych-
School and University Medicine, the National Office for the iatrist works.
Family and the Population), we collected data from child Tunisia has one residential long-term care inpatient facil-
psychiatrists. We were unable to obtain information on ity. Mental health facility details are presented in Table 1.
activities related to the provision of mental health care in There are no recorded community mental health centers
the private sector because there is no system for collecting and no outreach mental health services in Tunisia. In the
data from physicians working within this sector. We present private sector, there are no inpatient facilities specialized in
number of beds, admissions, and mental health mental health care. Private sector psychiatrists offer consul-
consultations. tations mostly in outpatient services.
For data comparison between our findings and those of Most specialized public and private sector mental health
the WHO-AIMS report (2008), we compared only data facilities are in the Greater Tunis area and in larger cities
from the report that we were able to obtain during our along the coastline. Mental health services are lacking in the
4 F. CHARFI ET AL.

Table 1. Type and number of available mental health care facilities with at least one psychiatrist in the public sector.
Adult Adult Child Child Forensic
Mental health care facility outpatient inpatient outpatient inpatient inpatient
(line of care) services services services services department
Mental health hospital (3rd) 8 7 1 1 1
Psychiatry departments in general university 11
9
4 1 –
hospitals (3rd)
Psychiatry departments in regional hospitals (2nd) 1 1 – – –
Specialized outpatient clinics in regional hospitals (2nd) 8 – 2 – –
School and university medicine (1st) – – 5 – –
National Office of Family and Population – – 1 – –
(line of care not available)
Residential long-term care facility – 1 – – –
(line of care not available)
Total 28 18 13 2 1

Includes services offered at the Military Hospital.

interior and southern regions of the country. In addition, Comparison between our 2017 findings and the WHO-
five governorates (Kebili, Medenine, Tataouine, Kasserine, AIMS data
and Gafsa) have no public sector specialized mental health
We compared our findings with some data presented in the
services for either inpatients or outpatients. The distribution
WHO-AIMS report (2008), collected across Tunisia in 2004.
of mental health facilities is illustrated in Figure 1.
With this comparison, we highlight the evolution in human
resources and activities related to the provision of mental
Mental health workforce in the public and health care. Results are presented in Table 4.
private sectors
In 2017, Tunisia had: 322 psychiatrists (277 adult psychia- Discussion
trists and 45 child psychiatrists); 190 psychologists; 342
This paper highlights the mental health services, facili-
speech therapists; 90 occupational therapists working in
ties, and human resources available across Tunisia in
health facilities and 27 social workers working in mental
2017. To our knowledge, it is the first research study on
health facilities, specifically. Hence, per 100,000 inhabitants, the topic and the first overview since the WHO-AIMS
there are, respectively: 2.81 adult and child psychiatrists; reported similar information for 2004. Our paper there-
1.66 psychologists; 2.98 speech therapists; 0.78 occupational fore fills an important gap in the literature by providing
therapists; and 0.23 social workers. an up-to-date portrait of the mental health care infra-
A detailed description of the mental health workforce is structure in Tunisia. We compared our findings with
presented in Table 2. The geographical distribution of psy- those of the WHO-AIMS report (2008). In addition, we
chiatrists is presented in Figure 2. can situate the results for Tunisia in comparison to other
middle-income countries (including lower-middle-
Activities related to the provision of mental health care income countries and upper-middle-income countries)
and WHO EMR countries that participated in the 2017
In 2017, the total number of mental health beds was 953, a WHO’s Mental Health Atlas (WHO, 2018), useful given
ratio of 8.32 per 100,000 inhabitants. In the mental health that our data also covers the year 2017. These compari-
hospital, adult and youth services, as well as the forensic sons can help us to glean strengths and challenges of the
unit, had 516 mental health beds altogether, a ratio of 4.50 Tunisian mental health system and to explore progress
per 100,000 inhabitants. Adult and child psychiatry depart- made in further integrating mental health into primary
ments in general hospitals had 325 beds, a ratio of 2.83 per and community-based settings (WHO, 2013, 2018). This
100,000 inhabitants. paper will be instrumental in helping to shape Tunisian
Inpatient services are mostly provided to people with policies to increase mental health capacity in primary
severe mental illness (e.g. psychoses and bipolar disorder) and community-based settings. It can also be the basis of
and mainly offer pharmacotherapy. No inpatient services new mental health programs and mental health plans.
are specialized according to mental disorders. Strengths of the mental health system, specifically those
Each psychiatric inpatient department receives patients related to available human resources in Tunisia, should be
from one specific geographic sector. In 2017, the overall rate noted. First, our findings highlight that Tunisia has 2.81
of visits in outpatient mental health care facilities was psychiatrists and 1.66 psychologists per 100,000 inhabitants.
2664.31 per 100,000 inhabitants. Outpatient psychiatric These mental health professionals are important in a bal-
activity includes pharmacotherapy and psychological treat- anced care model: they can ensure the training and supervi-
ments for common and severe mental disorders. sion of non-specialists in mental health care, hence building
Table 3 presents details on activities offered in the public the capacity of proximity mental health services for a wider
sector related to the provision of mental health care for population, and they can support continuity of mental
adults and youth. health services for more complex cases through
 JOURNAL OF MENTAL HEALTH 5

Figure 1. Geographic distribution of mental health facilities with at least one psychiatrist in the public sector.

Table 2. Number of human resources for mental health care in the public and private sectors.
Adult Child Speech Occupational Social
Psychiatrists Psychiatrists Psychologists therapists therapists workers
Mental health hospital 39 4 21 3 7 3
Psychiatric departments (in- and outpatient) 46 17 12 4 5 12
within public general hospitals
Outpatient services 18 2 80 81 14 12
within public general hospitals
Other public services (managed by the Ministry 0 6 44 34 2 32




of Health)
Other public services (managed by other 0 0 359
77

11

2269


ministries than those of health)
Private sector 174 16 33 220 62 0
Total number of human resources for mental 277 (2.42) 45 (0.39) 549 (1.66)


419 (2.98 )


101 (0.78 )


2328 (0.23)



health (Ratio/100,000 inhabitants)

Distributed as follows: Ministry of Social Affairs ¼ 120; Child Protection Officers ¼ 9; Ministry of Women, Child and Elderly ¼ 15; University (general campus)
¼ 37; University student residences ¼ 18; Ministry of Education (primary and secondary schools) ¼ 52; Military Health Care Services ¼ 35; Prisons and
Rehabilitation Centres ¼ 39; Ministry of Employment and Vocational Training ¼ 25; Others ministries (interior, physical education, and youth) ¼ 9. The number
of psychologists working in NGOs was not available.


Ministry of Social Affairs (social services for social workers and centers where speech therapists and occupational therapists work). This number was not
included in calculating the ratio of social workers per 100,000 inhabitants.



We only considered the rate of mental health workers in the health sector and we excluded those who work in other sectors.




This number was not included in calculating the ratio of social workers per 100,000 inhabitants.

collaborations (Hoeft et al., 2018; Kates et al., 2018). Our inhabitants. In addition, Tunisia had rates of psychiatrists
findings show an increase in the ratio of psychiatrists since comparable to countries listed as upper-middle-income
the WHO-AIMS report (2008). Moreover, when compared countries (UMICs). Our findings also highlight an increase
to the 2017 WHO Mental Health Atlas (WHO, 2018), in psychologists since the WHO-AIMS report (2008), most
Tunisia reported more psychiatrists than the global median of whom work in the public sector. This increase is due to
of 1.3 per 100,000 inhabitants, the median of 1.2 per widespread public sector recruitment (e.g. at health facilities
100,000 inhabitants for countries of the WHO EMR, and and academic institutions) and to rising awareness of mental
the lower-middle-income country median of 0.5 per 100,000 health needs since the Tunisian Revolution (Ouanes et al.,
6 F. CHARFI ET AL.

Figure 2. Geographic distribution of psychiatrists in Tunisia in both the public and private sectors.

Table 3. Number of activities related to the provision of mental health care in the public sector.
Type of mental health care Beds Admissions Consultations
Adult mental health care
Third line
Mental health hospital (without forensic and child psychiatry) 449 6163 129,641
Forensic inpatient departments (in mental health hospital) 56 56
692
Psychiatric departments in general hospitals 293 3369 103,385
Second line
Psychiatric departments and specialized outpatient clinics in general 12 180 36,942
hospitals


Line of care not available
Residential long-term psychiatric care facility 112 92


–
Total number activities in adult mental health (Ratio/100,000 inhabitants) 922 (8.05) 9736 (85.82) 270,660 (2364.60)
Youth mental health care
Third line
Mental health hospital 11 97 10,615
Child psychiatric departments in general hospitals 20 163 15,662
Second line
Specialized outpatient clinics in general hospital – – 1427
First line
Outpatient clinics specialized in school and university medicine



– – 5887
Line of care not available
Outpatient clinics at National Office of Family and Population)



– – 714
Total number of activities in youth mental health (Ratio/100,000 inhabitants) 31 (0.27) 260 (2.27) 34,305 (299.70)

20 of whom were admitted in 2017.

8 outpatient clinics, 1 in- and outpatient department.


4 of whom were admitted in 2017.




Includes only activities provided by child psychiatrists.

2014). Tunisia’s median of psychologists is above the global inhabitants) (WHO, 2018). Increasing psychiatrist and
median (0.88 per 100,000 inhabitants), the median for coun- psychologist availability in Tunisia may have helped to
tries of the WHO EMR (0.7 per 100.000), and the median address the mental health needs of the wider population
of lower-middle-income countries (0.26 per 100,000 inhabi- during the COVID-19 pandemic: 240 professionals quickly
tants), as listed in the WHO Mental Health Atlas (2018). It volunteered at the pandemic’s start to provide free psycho-
is also close to the median of UMICs (1.89 per 100,000 logical support via telephone (Zgueb et al., 2020).
 JOURNAL OF MENTAL HEALTH 7

Table 4. Comparison between our 2017 findings and the WHO-AIMS data. community-based services, regardless of evidence-based rec-
2004 2017 ommendations (WHO, 2013). For example, PCPs, the most
Mental health facilities (WHO-AIMS) (our study)
often consulted healthcare professionals within primary or
Beds in mental health facilities
Mental hospital (Razi Hospital) 46% 48.2%
community-based settings for matters related to mental
Psychiatric inpatient services in general hospitals 29% 34.1% health, reported gaps in clinical capacity for mental health
Forensic units 6% 5.8% treatment (Ben Thabet et al., 2018; Spagnolo et al., 2018).
Other residential facilities 19% 11.7%
Patient consultations in mental health facilities (Ratio/100,000 inhabitants)
These gaps can help explain why PCPs may feel confident
Outpatient facilities 994 2664.31 in their capacity to refer people presenting with mental
Mental health hospital (admissions) 46 54.69 health problems to specialized services (Spagnolo et al.,
Psychiatric inpatient units in general hospitals 33 33.23
Forensic units 0.5 0.49 2018). Regardless, this referral highlights that PCPs may
Day treatment facilities (day hospitals) 0.7 0 have detected a mental health problem, a first step in receiv-
Human Resources (Ratio/100,000 inhabitants) ing treatment. Mental health care provision might also be
Psychiatrists (public and private sectors) 1.5 2.81
Psychologists 0.3 1.66 encouraged by enabling more people with mental health
Social workers 0.2 0.23
problems to seek care. For instance, patients’ help-seeking
Occupational therapists 0.1 0.78 behaviours may be facilitated by reducing mental health

This ratio represents social workers working within mental health facilities.
stigma within healthcare organizations and increasing soci-
etal awareness of the importance of accessing mental health
services (Khiari et al., 2019).
Child psychiatry is a success story in Tunisia. As shown Challenges to the Tunisian mental health system are also
in the WHO Mental Health Atlas (2018), child psychiatrists worth noting. Despite the promising median of psychiatrists
are rare resources in all countries except those listed as by population found by our study, they are inequitably dis-
high-income. For example, lower-middle-income countries tributed across the country. As highlighted in Figure 1,
report an average of 0.02 child psychiatrists per 100,000 most psychiatrists work in and around the capital city of
inhabitants and UMICs, 0.09 per 100,000 inhabitants. Tunis, in the north of the country, and along the coastline.
Tunisia, however, has 0.39 child psychiatrists per 100,000 This uneven distribution, a finding also shared in the
inhabitants, most of whom work in the public sector. The WHO-AIMS report (2008), is still the reality in many
creation of a child psychiatry residency in 1994 can explain LMICs (WHO, 2018), confirming the need to further inte-
the country’s success in this field. Child psychiatry has grate mental health services into primary care and commu-
become a popular and rapidly developing specialty. nity-based settings.
Interestingly, an awareness of youth mental health may have With these successes and challenges, we enumerate solu-
led to an increase in demand for care and an increase in tions for mental health care in Tunisia. First, as highlighted
available facilities (Charfi et al., 2015). by our findings, most mental health services are offered by
There has been an increase in the rate of people treated specialized facilities. Initiatives have been implemented to
in mental health facilities (i.e. specialized care) since the further integrate mental health into primary care and com-
WHO-AIMS report (2008). Specifically, the number of con- munity-based settings. Mental health training has been
sultations for mental health services in mental health facili- offered to healthcare professionals. For example, in 2011,
ties and the number of admissions at the mental health the Ministry of Health passed a decree for the inclusion of a
hospital have increased between 2004 and 2017 (e.g. 994 to mandatory mental health internship in post-graduate med-
2664.31/100,000 inhabitants for consultations and 46 to ical school for future family physicians, previously optional
54.7/100,000 inhabitants for admissions at the mental health (Ministere de la sant
e publique, 2011). In 2016, PCPs of the
hospital). This increase may be due to more human resour- public sector working in the Greater Tunis area were offered
ces (psychiatrists and psychologists) available in mental a training based on the Mental Health Gap Action
health hospital settings and an increase in mental health Programme (mhGAP) Intervention Guide (IG) (Spagnolo
awareness since the Tunisian Revolution. This reality may et al., 2020), developed by the WHO to further build the
also reflect the limited number of mental health beds in set- mental health capacity of non-specialists (WHO, 2010b,
tings outside specialized mental health facilities: despite the 2016). Lessons learned from the mhGAP-based training
Ministerial vision supporting deinstitutionalization, the were used to inform the scale-up of a mental health training
number of mental health beds in Tunisia (8/100,000 inhabi- program offered to PCPs across the 24 governorates of
tants) and mental health admissions (85.8/100,000 inhabi- Tunisia, which began in January 2020. With these initiatives,
tants) for adult care remains lower than that of UMICs we hope that healthcare professionals working in primary
(24.3 and 117.2 per 100.000), as listed in the WHO Mental and/or community-based settings will further engage in
Health Atlas (2018). In addition, this finding may highlight mental health care delivery.
the higher rates of detecting mental health problems in pri- Second, our findings highlight that most psychiatrists
mary and community-based settings, which can produce work in the private sector in Tunisia. One possible explan-
referrals from those settings to mental health facilities. ation for this might be that there is very little financial
There is very low mental health funding in LMICs, includ- incentive to work in the public sector. This challenge may
ing in Tunisia, with the bulk of financial resources allocated reinforce social and health inequities through the encourage-
to mental health hospitals and less to primary care and ment of a two-tiered system (Carbonell et al., 2020) and
8 F. CHARFI ET AL.

hinder public sector task-sharing initiatives. In addition, Sofiane Manai, and Zeineb Boughdiri (Direction of Public Healthcare
most public sector psychiatrists work in the north of the Facilities at the Ministry of Health); Sihem Bellalouna (Regional
Coordination Unit at the Ministry of Health); Lobna Ghrab (Social
country or along the coastline, therefore challenging equit- Worker, Ministry of Social Affairs, attached to the Ministry of Health);
able access to care (INS, 2014). There is little incentive for Ahlem Gzara (Direction of School and University Medicine); Hela
psychiatrists to work in Tunisia’s interior, as infrastructure Ouennich (National Office of Family and Population), Mohamed
is not as developed. Since the 2011 Revolution, developing Turki (National Medical Council), Aslem Lazaar Selimi (Tunisian
the interior’s infrastructure has been a priority. There have Association of Psychologists), Samia Chaabene (National Union of
Speech Therapists), Amel Salem Mouhli (National Union of
also been increases in the salaries of public sector healthcare Occupational Therapists). The authors also wish to thank Matthew
professionals; however, these are still inferior to those in the Rettino for his editing services and Slim Achour for drafting
private sector. the figures.
Lastly, for lack of an available information system in
Tunisia, this study was done through telephone and email
consultations with key stakeholder groups. We suggest the Disclosure statement
development and implementation of a national information No potential conflict of interest was reported by the author(s).
system with a data registry, including information on serv-
ices, facilities, human resources, and consultations for men-
tal health conditions. This information system would be
ORCID
invaluable in ensuring the monitoring and planning of care Uta Ouali http://orcid.org/0000-0001-6916-2110
to meet each region’s mental health needs, especially in the Jessica Spagnolo http://orcid.org/0000-0002-1125-3121
context of a per- and post-COVID-19 pandemic society,
where mental health issues and consultations are expected References
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