Report No. 651-TUN The Population Program of the Government of Tunisia A Sector Review
Public Disclosure Authorized FILE COPY February 27, 1975 Population and Nutrition Projects Department
Not for Public Use Public Disclosure Authorized Public Disclosure Authorized
Document of the International Bank for Reconstruction and Development
Public Disclosure Authorized International Development Association
This report was prepared for official use only by the Bank Group. It may not be published, quoted or cited without Bank Group authorization. The Bank Group does not accept responsibility for the accuracy or completeness of the report.
THE POPULATION PROGRAM OF THE GOVERNMENT OF TUNISIA
A SECTOR REVIEW
TABLE OF CONTENTS
Page No.
SUMMARY AND RECOMENDATIONS ...... i-vi
PART I
TUNISIA AND ITS POPULATION ...... 1
A. Introduction ...... 1 B. Brief Overview of Population Activities and the National Organization ...... 6 C. Results of the National Family Planning Program 1964-1973 ...... 8
PART II
I. THE NATIONAL OFFICE OF FAMILY PLANNING AND POPULATION 11
A. Organization ...... 11 B. Future Plans ...... 14 C. Recommendations ...... 18
II. DELIVERY OF SERVICES ...... 20
A. Health ...... 20 B. Family Planning ...... 23 C. Recommendations ...... 25
This sector review is based on the findings of two Bank missions to Tunisia. The first visited Tunisia in November/December, 1973 and was comprised of F.J.C.M. Rath (Chief), Dr. N.H. Fisek (Consultant), Joel Montague (Population Council) and A. Shaw (UNESCO), J.W. Kennedy (USAID) and H. Gaenger (UNFPA). Soon after the visit a new President Director General was appointed to the National Office of Family Planning and Population, and he made many changes in the organization, staff and program of the Office. Consequently, a second mission comprised of G. Zaidan (Chief), A. Shaw and Dr. C. Aguillaume (Consultant) was then sent to Tunisia in September, 1974 to review the draft report with the Government. This final version reflects the results of the reorganization which in many instances coincided with the earlier recommendations. Those comments and recommendations that are therefore no longer relevant have been omitted from this version. TABLE OF CONTENTS (Continued) Page No.
III. MANPOWER AND TRAINING ...... 30
A. Physicians ...... 30 B. Paramedical Staff ...... 33 C. Recommendations ...... 35
IV. INFORMATION, EDUCATION AND COMMUNICATIONS ...... 37
A. Organization ...... 37 B. Communication Activities ...... 38 C. Media Research and Evaluation ...... 41 D. Rec ommendations ...... 42
V. EVALUATION AND RESEARCH ...... 44
A. Production of Statistics ...... 44 B. Research Activities ...... 45 C. Recommendations ...... 46
VI. PERSONNEL, SUPPLIES AND TRANSPORTATION ...... 48
ANNEXES
1. Tunisia: Enumerated Population in Censuses, 1891-1966
2. Tunisia: Percentage of Women Married as Reported in the 1956 and 1966 Tunisian Censuses, Classified by Age
3. Tunisia: Family Planning Program Activities and Percent Change, 1964-1973
4. Tunisia: Births Averted According to Method and Year, 1965-1971
5. Tunisia: Relative Contribution of Each Method to the Number of Births Averted, 1965-1971
6. Tunisia: Projection of Births to be Averted by Method and by Governorate for 1975
7. Tunisia: Family Planning Centers, 1972
8. Tunisia: Occupancy Rate and Duration of Stay in Hospitals, 1971
9. Tunisia: Distribution of Maternity Beds in Hospitals
10. Tunisia: Distribution of Hospital Beds and Utilization for Maternity and Gynecological Cases TABLE OF CONTENTS (Continued)
11. Tunisia: Activities of MCH Centers, 1971
12. Tunisia: New Family Planning Acceptors by Health Region, 1973
13. Tunisia: Objectives for the Year 1974 by Governorate and by Method
14. Tunisia: Family Planning Activities by Category of Center, 1972
15. Tunisia: Some Thoughts on Training and Employment of Health Workers
16. Tunisia: The Case for a Multipurpose Organization in the Provision of Family Planning Services
17. Tunisia: Geographical Distribution of Physicians, 1973
18. Tunisia: Tunisian and Foreign Physicians by Speciality, 1972
19. Tunisia: Students in Tunis Medical School by Class, 1964-74
20. Tunisia: Geographical Distribution of Midwives, Nurses and Nurse-Aides, 1972
21. Tunisia: Graduates of Nursing and Midwifery Schools, 1960-74
CHARTS
9490 Tunisia: Organigram of the National Office of Family Planning and Population
9491 Tunisia: Organigram of the Family Planning and Maternal and Child Health Services in a Governorate
SUMMARY AND RECOMMENDATIONS
Foreword: A sector review was undertaken at the request of the Tunisian Government, by two World Bank missions which visited Tunisia in November-December, 1973 and in September, 1974. The missions' main terms of reference were "to write a comprehensive report that will enable the Government to draft a detailed four-year plan of action." The first draft was designed to provide the basis for such a plan of action with the aim of improving family planning services and gaining a greater acceptance of the family planning idea by the general public. Before this draft was completed, the appointment of a new President Director General to the National Office of Family Planning and Population (ONPFP) led to a complete reorganization of the ONPFP. Many of the changes that this reorganization led to coincided with a number of the draft sector review's recommendations. The second Bank Mission visited Tunisia to up-date the review and this final version reflects the progress that has been made during 1974. The main findings and recommenda- tions are as follows:
The Present Situation of the Family Planning Program
1. The official family planning program was started in 1963 with a two-year experimental program, followed by the national program which was launched in 1966. In 1973 a new law was enacted creating the National Office of Family Planning and Population (ONFPF). It functions under (or in rela- tionship with) the Ministry of Health. Apart from the ONPFP there are other bodies working in family planning, notably the Tunisian Family Planning Asso- ciation, the Tunisian National Railroad which has its own clinics, and private practitioners. From 1966 to 1973, family planning program performance was too modest to make an important impact on the fertility level but recent events suggest that the fertility rate is declining. However, it is now estimated that the national family planning program reaches about 7.33% of all eligible women.
Organization
2. a. Relations between the Office, the Ministry of Health and the MCH
Services: A major barrier to the full implementation of the family planning program in 1973 consisted of the Government's failure to precisely define the functions of the ONPFP. The decree establishing the Office gave it responsibility for the planning and execution of the program, but the Office saw its role as being mainly one of planning. The Ministry of Public Health was responsible for the delivery of services mainly through the maternal and child health (MCH) centers, and the Office was to a certain extent distinct from both of them. The appointment of the new President Director General (PDG) has changed this situation. - ii -
The PDG has created excellent working relations with the Minister of Public Health and with the Regional Health Administrators. Through the latter he is in direct touch with the MCH centers; this link will be strengthened by the new infrastructure which the Office is creating by the appointment of a co-ordinating doctor and a regional secret- ary in each Regional Administrator's office. These personnel, who are responsible to the ONPFP, will provide a solid frame- work for family planning operations at the field level. At headquarters' level the system is mainly based on personal relations and this situation should be considered from a long- term point of view.
It is recommended that the relations between the Office, the Ministry of Public Health and the MCH organization be put on a formal footing by the creation of a family planning opera- tion unit within the Ministry of Public Health in which all three organizations would be represented. This would enable the organizations concerned to work together to achieve com- plete coordination of effort, to have a creative interplay of ideas, to improve the program in all its aspects and provide a safeguard against difficulties which might arise because of changes in personnel.
b. Relations with Other Ministries: For nationwide family plan- ning education and information the Office needs the cooperation of other ministries. The Office staff conduct courses for Government servants in ministries such as Agriculture, Labor and Social Affairs and Health, and they in turn pass the message on to their extension workers. The same approach is used with the large national organizations. In this manner a minimum number of people can influence very large numbers since the extension services of the ministries cover the whole country.
Already the Office has set up a technical committee with the Ministry of Education to facilitate the introduction of popula- tion education into the school curricula. Discussions are also taking place with the Ministry of Information to prepare a communication strategy for the use of the media in the family planning program. Through such means the idea of family planning will become more easily acceptable to the public. It is therefore essential that the Office continue to strengthen its efforts to maintain and develop productive relationships with those ministries and non-governmental organizations whose field workers are in a position to adapt the family planning message and use it as part of their own teaching.
Delivery of Services
3. a. Home Visiting: An intensified home visiting service should be established. The integration of family planning into the MCH - iii -
services will help a home visiting service because a woman who might not be prepared to accept a family planning visitor would much more likely welcome someone who comes to advise on the health of herself and her children. This would make family planning motivation and advice much more acceptable.
b. Community Health Workers: Consideration should be given to the idea of recruiting village women as community health workers. They would be selected from the areas where they would eventually work, then given some basic training in first aid, antenatal care and family planning and would thus become more useful members of their own communities. A care- ful system of supervision would need to be organized to help them with their work.
c. Service in the MCH Centers: The attitude of the staff towards the women who visit the MCH centers should be improved so that the women are willing to come there for advice and counselling. No new centers should be established until the existing and projected centers are running efficiently and have created a good image in the surrounding area.
d. Up-grading Paramedical Staff: The process of up-grading the paramedical staff so that they can more effectively carry out family planning activities in the absence of a physician should be continued and intensified. They should be trained to deal with side-effects and thus establish themselves as health work- ers in whom the women can have confidence.
e. The Regional Health Administrator: As the program progresses the work load on the Regional Health Administrator will become increasingly heavy. Already the Office provides a Regional Secretary and a coordinating doctor to help with the work; the progress of this excellent beginning should be followed care- fully to see if it needs strengthening.
f. MCH/FP Teaching Centers: A teaching MCH/FP center should be established in a town which has various kinds of rural commu- nities around it. This would give preservice training to physi- cians, paramedical staff, statisticians and educators in various aspects of teamwork, as well as ensuring the operation of MCH centers and the provision of FP effective services. The courses should give the trainees the ability to work independently and to train others. This would lead to the establishment of a teaching center in each governorate.
4. Manpower and Training
a. Development of Resources
The development of human resources is a key to success in any program, and manpower planning has become a specialized field in - iv -
administrative services. There is some information available about health personnel but it is not sufficient for manpower planning. The Ministry of Public Health should have a unit to undertake this work. The unit would work closely with the Office so that both organizations can forecast and meet their future needs.
b. Distribution
The uneven distribution of health manpower is an obstacle to the development of health and family planning services. In order to achieve a more equitable distribution of physicians, medical students should be trained to practice in MCH centers and dispensaries. One way of doing this would be to institute a 'clerkship' program in the proposed MCH regional training centers.
c. Paramedical Staff
The present up-grading of paramedical staff will be of great help to the family planning program. Careful consideration should be given to the idea, already practiced in many countries, of taking non-professional staff and training them in various aspects of field work to extend the quantity and range of services.
5. Education, Information, and Communications
a. A Dialogue with the People
The Office has a new and progressive policy which will be imple- mented by the Promotion and Education Division. This policy is long term and aims at gradually influencing all the people through information and education to accept the idea of family planning and, by a carefully planned use of motivation elements, persuade them to accept the practice. It is important that the Office consider the implications of a full communications program and ensure that there are sufficient staff and budgetary resources to carry out the work over at least the next three years.
b. Attitude Research
The messages produced will be very much more likely to attain their purpose if the producers understand what their potential audiences are thinking about family planning. The Promotion and Population Divisions should work closely together so that attitude studies are undertaken and the results fedback to the Promotion Division which will use them to ensure that their dialogue with the people is a fruitful one. - v -
c. Evaluation
All communication work must be evaluated so that both the Office and the media producers can determine its level of effectiveness. The basic facilities for evaluation exist in the Population Divi- sion. It is recommended that the evaluation needs of the Promotion and Education Division be programmed on a long-term basis which would allow the Population Division to suggest what would be required in the way of extra staff and budgetary requirements.
d. Production
There is a tentative program for the production of audiovisual aids and television programs. This needs to be amplified and planned in detail for the next three years. When all the educators are in the field in 1977, they will have many needs for materials to make their work more interesting to the people. Production planning should start now so that there is a supply to meet the eventual demand. It is particularly important that the time spent by the women in the waiting rooms of the MCH centers should be made more purposeful by the use of audiovisual aids.
e. Coordination
Consideration should be given to the possibility that the Promotion and Education Division should be the coordinating point for all family planning communication activities.
6. Research and Evaluation
a. Planning
The future research plans of the Population Division are very comprehensive and action-oriented. A detailed three-year plan allocating program items to specific people or institutions and setting target dates for the different stages of each project would be essential if the division is to succeed in achieving the concrete results so urgently needed by the program of the Office.
b. Feedback
Feedback from the field is essential to the progress of all family planning programs, and the Population Division, through the Division of Coordination, should ensure that the material being received is used, that guidelines to field workers are improved to produce relevant types of information, and that eventually all field workers will play a part in the task of understanding the people. - vi -
c. Evaluation of the Program
As programs develop the situations which they face change and it is important that the component parts of the program adapt themselves to these changes. They can only do this if there is a proper system of evaluation. Although acceptance figures are, to a certain extent, a measure of the success of the program -- only if evaluation is carried out all the time can it be determined whether the results could have been better if the approach had been different. The Qffice should consider carefully whether its present structure offers enough possibili- ties for carrying out a useful evaluation of all sectors of its work and thus helping the develppment of the national family planning program. PART I
TUNISIA AND ITS POPULATION SITUATION
A. Introduction
Geographic Background
1.01 Along with Algeria and Morocco, Tunisia forms the "Maghreb" of North Africa. The land area 1/ can be somewhat arbitrarily divided into three major geographic regions: a northern part along the Mediterranean Coast, including a mountain range, a central part from the mountain range southwards to the cities of Tozeur and Gabes, and a southern part consisting of some 45,000 square kilometers of the Tunisian Sahara. The country lies in the subtropical climatic zone of the Western Mediterranean which has hot dry summers and mild winters. Floods or the lack of rainfall in the south and elsewhere have caused periodic crises throughout history.
Political and Cultural Background
1.02 After Independence in 1956, the present Republic was founded. Mr. Habib Bourguiba was elected the Republic's first president, and in the elections of November 1959, all 90 seats in the assembly went to the NeoDestour Party founded by Mr. Bourguiba in 1934. In the general elections of 1964 the name of the party was changed to the Socialist Destour Party. Once again the party won all the seats in the National Assembly under the one-party system; President Bourguiba was since re-elected in every election. The administra- tion of Tunisia rests with the governors in the governorates. The govern- orates are subdivided into delegations, and the delegations are in turn divided into cheikhats, the smallest administrative unit.
1.03 Social change is pervasive throughout Tunisia. At the primary school level there is now almost universal enrollment which has led to consider- able growth in vocational training and secondary education. At the university level there are faculties of arts, law, natural science, medicine, theology and agricultural science. The press, radio and television play important roles in dissemination of information. While traditional values still dominate in the interior and southern parts of the country, in the Sahel and in the major cities new values have been established giving rise to a new life style. The spread of cash crops, the migration of the young to the cities, the reform of land tenure, the growth of political consciousness and the emancipation of women (especially encouraged by the President), brought identification with the state, led to a general awakening, and caused changes in the family structure. The process of social change has been assisted by the fact that Tunisia, unlike its neighbors, is a remarkably cohesive country without large religious or ethnic minorities.
1/ 164,150 km2. -2-
Economic Background
1.04 Before Independence Tunisia's economy was'characterized by a dual system: on the one hand existed traditional forms of agriculture and handi- crafts in which the majority of the population found employment, while on the other hand a modern sector was created by foreign capital and know-how. After Independence, on the basis of a ten-year macro-economic plan, three economic development plans were implemented. At the end of the period 1961-1971, Tunisia's economy showed an average annual growth rate of 4.7%.
1.05 Tunisia marked the beginning of its second decade of planned develop- ment with its Fourth Development Plan (1973-1976). While considerable resources were invested, the growth and employment objectives of the first decade, 1962- 1971 were not fully realized. At the end of 1969 and in the following years the Government decided on a major reorientation of its economic policies. The previous attempt to group farmers into government-organized cooperatives was abandoned; new incentives were given and a greater role for the private sector was foreseen; and emphasis was put on export promotion and a new external market orientation. The Fourth Plan, which is based essentially on the new orientation, was preceded by a thorough reassessment of past planning policies, achievements and shortcomings. The new orientation coincided with strongly favorable agricultural and export developments. In 1971-1972, tourism, petroleum, phosphates, olive oil and workers' remittances made up 63% of the foreign exchange earnings, indicative of the fact that the economy has benefited from recent increases in world commodity prices but is vulnerable to unfavor- able developments in the European demand for tourism and immigrant labor.
1.06 In 1972, the total work force was estimated at about 1.5 million, of which about 53% were employed in agriculture. Of the 1.5 million, only 900,000 were fully employed, the remainder being either underemployed (460,000) or unemployed (130,000). On the average each member of the labor force has more than three persons to support and, if the unemployed and underemployed are excluded, the number supported by each member of the labor force is five. The objectives of the Fourth Plan (1973-1976) are employment creation, a more equitable income distribution and a raising of the standard of living. But even the 6.6% economic growth target will be insufficient to solve the un- employment problem. Sufficient foreign and domestic capital are likely to be available to achieve a higher rate of growth if they could be put to effective use. -3-
Demographic Background
1.07 Population Censuses: The first demographic information on Tunisians was collected in the census of 1921, yielding a total of 1.9 million Tunisians, 156 thousand Europeans (of which only one-third was French) and some 67 thousand inhabitants of other than Tunisian or European stock. By 1936 the Tunisian population had grown to 2.3 million, the total population being 2.6 million. The censuses between 1921 and 1936 suffered from incomplete coverage, under- enumeration (especially of Tunisian women and young children) and other errors. Data on the European population were more reliable, but represented, for example, in the 1936 census, only 11% of the total population.
1.08 The censuses of 1946 and 1956 both also suffered from shortcomings. The official 1946 census documents have been lost while the 1956 census was influenced by important administrative changes under way. Results of the 1956 census were based exclusively on a 10% sample. In addition to differ- ences in quality, comparison between censuses is difficult because at one time the population "de jure", at another time the population "de facto", was considered. The most recent and reliable census was taken in 1966. However, no post-censal survey was made so that under-enumeration could not immediately be estimated. The total enumerated population in 1966 was 4.5 million, an increase of 750,000 persons or 20% since the 1956 census. (Annex 1)
Total Tunisian Census Population Population Average Annual Growth Rate (Tunisian Population Onl1
1921 2,093,139 1,874,256 1926 2,159,708 1,917,930 .5 1931 2,410,692 2,142,102 2.2 1936 2,608,313 2,324,972 2.1 1946 3,230,952 2,903,949 2.0 1956 3,783,169 3,441,696 1.9 1966 4,533,351 4,466,517 2.6
Source: La Situation Demographique a la fin de 1969, Revue Tunisienne d'Economie et de Statistique, Institut National de la Statistique, No. 2, 1972.
Between 1956 and 1966 Tunisia experienced an increase in the growth rate of population as a result of a decrease in the death rate and a sustained high birth rate.
1.09 The National Demographic Survey: The inadequacy of vital statistics and the urge for a fuller understanding of population growth (the National Family Planning Program got underway in 1966) led to a national demographic survey in 1967. The survey sample was comprised of 25,000 households selected from four strata. Data were collected from this sample through three repetitive visits to selected households between June 1967 and June 1969. Among other information the survey yielded new estimates of crude birth and death rates, and consequently an estimate of under-registration. Detailed information was obtained on present and total fertility by socio-economic and cultural charac- teristics of 35,000 women; furthermore, information was obtained on infant mortality, differential mortality, and internal migration. Unfortunately, the final results of the National Demographic Survey have not yet been pub- lished.
The Present Population and Its Composition
1.10 The census of 1966 yielded a total population figure of 4,533,351 of which 2,314,419 were males and 2,218,932 were females. The resulting male/ female ratio suggests an under-enumeration of females (often found in Muslim countries), rather than a higher mortality of females. At the beginning of 1974 the total population was estimated at 5.6 million and the population den- sity was about 34 inhabitants per square kilometer.
1.11 The urban population comprises just over 40% of the total. Some 18% of the population lives in the capital of Tunis; other major concentra- tions are found in Sfax with over 200,000 inhabitants and in Sousse with almost 100,000. Half of Tunisia's population lives in the four coastal governorates in the North and North East: Bizerte, Tunis, Sousse and Sfax. These areas, and especially their capitals, attract people migrating from the central and southern governorates.
1.12 Sustained high fertility and a decreasing mortality have led to a young age structure of the population -- over 56% are less than 20 years old and only a mere 3.6% are over 65 years of age.
1.13 With a working age population comprising over half of the total population, labor force participation is relatively low -- 83.5% for males and 26.3% for females. 1/ Between 1956 and 1972 the percentage of the labor force employed in the primary sector (agriculture, fishing, mining and quarrying), dropped from 75% to just under 60%, while the percentage of employment in the secondary sector (manufacturing, construction and public works), increased from 9.4 to 16.6%.
1.14 The ethnic and religious composition of the population is very homogeneous -- 99% of the Tunisian population is of the same language, religion, and ethnic group. There are small Berber and Jewish groups and a small foreign population -- both Muslim and Christian.
Crude Birth Rates and Death Rates
1.15 Under-registration and also late registration (often several years after birth took place) made reliable estimates of crude birth rates (CBRs) very difficult prior to 1961. For that year the adjusted CBR was estimated
1/ 1966 figures. - 5 -
to be 49.6. From 1964 on a downward trend set in; the CBR declined from 50.4 to 42.8 in 1969, and some estimates set the CBR for 1972 at 38 per thousand. This decline, however, is not exclusively due to the actions of the national family planning program. Changes in the age-structure and a decline in nup- tiality (especially among girls in the 15-19 age group) also were contributing factors. There are marked regional differences in birth rates, with the lowest level found in the Tunis Governorate followed by the coastal governorates of Bizerte, Sousse and Sfax. These are the more developed regions.
1.16 Deaths in developing countries are always less accurately registered than births, and Tunisia is no exception. Even today the under-registration of deaths is estimated to be almost one-third. Time series of death rates, therefore, are unreliable, although the system has improved considerably. At present the actual level of mortality is probably about 14-16 per thousand, but there is no way to tell what the mortality level was thirty or forty years ago.
Nuptiality and Fertility
1.17 In 1964 the minimum legal age at marriage was changed to 17 years for girls and 20 years for boys. A comparison between the proportion of married women by age in the 1956 and 1966 censuses shows that the changed legislation had an important effect on the marriage patterns, especially for the 15-19 and the 20-24 age groups. (Annex 2)
1.18 At the same time the upgrading of the status of women in Tunisia, so vigorously promoted by the President, had its effect on the mean age of marriage. Consequently, the drop in the crude birth rate in the years following 1964 must, therefore, in part be ascribed to this change in the structure of nuptiality.
1.19 The 1966 census also showed important regional differences in the mean age at marriage. In the four most urbanized Governorates of Tunis, Bizerte, Sousse and Sfax the mean age at marriage was between 21.5 and 21.9 years, while the lowest mean age was between 19.0 and 19.4 years and was ob- served in the central Governorate of Kasserine.
1.20 This change in the minimum marriage age is reflected in the first two age groups in the following estimated age specific fertility rates for 1960, 1965 and 1971: 1/
1/ Marcoux, Alain: "La Croissance de la Population de la Tunisie, Passe Recent et Perspectives" in: Population, Numero Special, March 1971. - 6 -
Age Specific Fertility Rates - 1960, 1965 and 1971 (rates per 1,000 women)
Age Group 1960 1965 1971
15-19 70 88 56 20-24 306 279 261 25-29 338 333 327 30-34 299 297 294 35-39 209 225 207 40-44 106 105 103 45-49 30 30 28
1.21 The implicit gross reproduction rate did not change between 1960 and 1965 (staying at 3.31) but dropped to 3.11 in 1971. This is a much smaller decline in fertility than that suggested by the drop in the crude birth rate, for which explanations have been given above.
International Migration
1.22 Problems presented by the claim of ever more youngsters for a place in the labor market and the inability of the Government to satisfy this demand together with the increasing shortage of unskilled and semi-skilled labor in the West European countries led to emigration of laborers mostly male and under 45 years of age. This movement, starting modestly in the late fifties, represented in the late sixties some 20 to 30 thousand persons per year. The population projections for 1971-2001 adopted by the Government assume this movement to continue at a pace of 20,000 persons per year.
B. Brief Overview of Population Activities and the National Organization
The Program Under the Ministry of Public Health
1.23 Immediately after Independence in 1956, Tunisia passed a series of laws which contributed to the emancipation of women. However, these laws were not passed with demographic considerations in mind. The implications of Tunisia's population growth for economic development were highlighted by President Bourguiba in his first major speech on the subject on March 12, 1962 when he stated:
"With our rapidly growing population, the rising generations are exerting pressure on us. If we are not careful now, in ten or twenty years' time there will be a marked disproportion between the national income and the number of people we have to feed. A race against the clock is going on between our economic development and the demographic increase. Unless we take, as of today, the necessary measures, the country in a few decades will experience convulsions." - 7 -
1.24 In mid-1963 a two-year experimental program was agreed upon by the Ministry of Public Health with financial assistance from the Ford Foundation, technical help from the Population Council, and with the Government providing 165,000 dinars. The program, which was to be integrated into the maternal and child health centers, became operational in June 1964. For the next seven years there were various changes of administration and policy.
1.25 On July 1, 1965, Article 214 of the Penal Code was abrogated and replaced by a law providing penalties for criminal abortion but allowing "social abortions" during the first three months of pregnancy in cases where the couple had at least five living children. This was only one of the many types of legislation passed which were supportive of family planning.
1.26 During these early years the program experienced the usual successes and set-backs which are undergone by nearly all family planning programs. Then, in 1971 the National Institute of Family Planning and Maternal and Child Health was created by law and placed under the guidance of the Ministry of Public Health but with its own budget. This was only another step in the development of the program.
1.27 Apart from the Ford Foundation and the Population Council, USAID had been the major foreign donor to the Tunisian program since 1968. In April 1971 the Tunisian Government and the International Development Associa- tion (IDA) signed a credit agreement, providing US$4.8 million to help further Tunisia's family planning program. The project consisted of the establishment of four maternity hospitals, two rural maternity centers and 29 MCH centers where specially-trained personnel were to provide the full range of family planning services, and the extension of a paramedical school in Tunis, includ- ing a postgraduate section. The provision of family planning services in close association with health services for mothers and children was felt to be important to the success of the program. Another aspect of the project was the financing of technical assistance in management, in personnel train- ing, and in reviewing program effectiveness.
1.28 By Decree No. 71-381 dated October 21, 1971 a National Council of Family Planning was created. The Minister of Health was to be President and it had as members representatives from the Institute of Family Planning and Maternal and Child Health, the National Institute of Child Health, several ministries and agencies, plus nine members from private and other groups and associations.
1.29 An analysis of the Institute program made by SERETES, a French management consultant firm -- provided for under the IDA credit population project -- noted that family planning services are in the process of being offered in 178 rural dispensaries, 68 community dispensaries, 79 MCH centers, 23 auxiliary hospitals, and 19 principal and regional hospitals. SERETES also noted that a reorganization of the mobile teams would be useful as approximately 200 centers out of 324 accomplished only 8 to 9% of the total family planning activities. - 8 -
1.30 The role of the Institute remained somewhat unclear. For example, a document of service of March 23, 1972 included a certain ambiguity: the activities of most MCH centers and certain maternities were to be programmed, realized and evaluated by the Institute, although regional family planning and MCH personnel would work under the control and authority of the Regional Health Administrators assisted by Regional Secretaries and Educators.
C. Results of the National Family Planning Program 1964-1973
1.31 As mentioned before, the national program entered its experimental phase in June 1964 for a two-year period. During this time the number of family planning acceptors was very encouraging indeed. By the end of the experimental period, some 20,000 women had accepted an effective method of family planning (IUD or contraceptive pill), some nine hundred women had accepted sterilization and over one thousand social abortions had been performed.
1.32 However the initial momentum of the program was not maintained in the years to follow. (Annex 3) IUD primary insertions which totalled over 12,000 in 1966 declined in the following years to a low of 8,700 in 1969 and it was not until 1971 that the level of 1966 was reached again; in the mean- time the number of eligible women had increased by about one hundred thousand. Initially the program relied mainly on IUDs; in 1967 about 600 new pill accep- tors were reported, but that figure jumped to around 4,800 for 1968 and to more than 7,800 for 1969. By 1970 the total number of new pill acceptors (9,950) had surpassed the number of primary IUD insertions (9,640) for that year. The number of pill acceptors continued to increase steadily, although over the last year a recession was noted for which the reasons are not too clear.
1.33 Figures of acceptance and use of family planning methods for 1972 are as follows:
Primary IUD insertions 13,241 New pill acceptors 13,012 Monthly average pill users 8,403 Monthly average condom users 2,321 Tubal ligations 2,458 Induced abortions (social) 4,621
A study made in the World Bank 1/ showed that between 1965 and 1971 some 51,000 births were averted. More births were averted in 1970 than in any other year (over 12,000) but the program showed a recession in 1971 when about 20% fewer births were averted than the previous year. (Annex 4)
1/ Cuca, Roberto: "Evaluation of Family Planning Programs using Service Statistics," International Bank for Reconstruction and Development, Working Paper No. 137, November 1972. - 9 -
1.34 In the relative contribution by method, the IUD stands out with 65% of the total of averted births, social abortion comes in second place account- ing for 15%, and in third place tubal ligation with 8%. The contraceptive pill contributed only 7% during this period. However, looking at the data year by year, since 1967 one notes a clear tendency of diminishing influence of the IUD in favor of the pill. Whereas in that year almost four-fifths of the total births averted were due to the use of the IUD, the contraceptive pill had hardly any influence on the prevention of births (only 1%); by 1971, 15% of all prevented births were due to the use of the pill while the relative influence of the IUD had diminished to 55%. (Annex 5)
1.35 An evaluation of the program during the first five years 1/ indicated that only one-third of the drop in the birth rate during that period could be attributed to the program while other factors were a change in the age structure (the Second World War cohort entering the peak reproductive ages) and the change in nuptiality due to a law raising the minimum age of marriage for girls to 17 and for boys to 20, which had the effect of lowering drastically the fertility of the 15-19 age group.
1.36 Some conclusions that can be drawn from the series of service statistics of the Tunisian program are:
a. The Tunisian program has probably shown the same experience as other beginning programs in the sense that an initially enthus- iastic group of people who were ready to adopt family planning, but did not have easy access to the means of controlling con- ception, entered the program as soon as it was established. Once these women were in the program a threshold was reached and the recruiting of new acceptors became more difficult; hence the drop in overall performance of the program.
b. There have been no reliable follow-up studies which would indicate the ability of the program to retain the recruited women as regu- lar users of family planning. However, taking the data on new pill acceptors, the conclusion must be that there has been an enormous dropout. For example, the number of regular users of oral contra- ceptives in December 1970 was 7,342 and during 1971 about 11,800 new pill acceptors were registered; nevertheless by December 1971 the number of regular pill users had only increased by about 1,300. Of course, not all these women would return to the program's outlets to receive contraceptive supplies but the numerical dif- ference is too large to assume that the majority of newly recruited pill acceptors were privately continuing contraceptive practice. Observations in the field, moreover, suggest that little or no attention is paid to the follow-up of newly recruited acceptors.
1/ Lapham, Robert J. : "Family Planning and Fertility in Tunisia," in Demography, Volume 7, No. 2, May 1970. - 10 -
c. Each year, service statistics show great seasonal differences which for IUDs nevertheless seem to indicate a certain pattern: the number of IUD acceptors reaches a peak in the first three months of the year while the number is lowest in November or December. On the other hand, the data on pill acceptors do not show a regular pattern. Quite to the contrary, in some years the end of the year is marked by a very low level of IUD acceptors while the number of new pill acceptors is one of the highest.
d. Over the period that the program was carried out on a national scale, that is to say between the years 1966 and 1973, the performance was too modest to make an important impact on the fertility level and pattern of the country. Now with the new direction of the ONPFP the birth rate shows a noticeable decline. Even though it is now estimated that at present the national family planning program does not reach more than some 7.33% of the eligible women. Male participation in the program can be discounted since the number of vasectomies and the number of regular condom users are too insignificant to have a demographic impact. e. Some partial studies on the characteristics of acceptors suggest that the mean age of the acceptors was, at least in the early years of the program, relatively high, suggesting that the acceptor had already four children or more before turning to fertility control methods. A study carried out among IUD acceptors in Tunis and Le Kef between July 1966 and December 1967 indicates that 78% had four children or more (60% had five children or more); 71% were over 30 years of age and 74% had had a pregnancy in the preceding twelve months. - 11 -
Part II
I. THE NATIONAL OFFICE OF FAMILY PLANNING AND POPULATION
A. Organization
1.01 On March 23, 1973 a law was enacted, creating the National Office 1/ of Family Planning and Population (ONPFP) replacing the National Institute of Family Planning and Maternal and Child Health. The Office has financial autonomy but unlike the previous family planning organizations, it has a commercial character which allows for greater financial flexibility. Its mission is to (a) undertake research, (b) establish and execute programs to preserve the equilibrium and health of families, (c) provide assistance and information to public health facilities of all kinds, and (d) undertake training and population education programs. The "Office" functions under authority of the following groups:
(a) A High Council of Population: The Council outlines the broad lines of activities and programs of the "Office," as well as those of the Regional Population Councils (in each governorate). Its President is the Prime Minister and its Vice-President is the Minister of Public Health. All interested ministries and national organizations are represented in the High Council.
(b) The Ministry of Public Health: The Office functions under the aegis of the Ministry of Public Health. Virtually all field service personnel working with the Office are Ministry of Public Health employees who receive instruction from the Ministry.
(c) An Administrative Council: The Administrative Council consists of the President Director General (PDG) of the Office and eight members assigned by the Ministry of Public Health under whose supervision it functions. The Administrative Council gives general guidance to the day-to-day operations of the Office.
1.02 The Office is directed by the President Director General who is nominated by the Minister of Public Health and appointed by decree. He is vested with broad powers to act in the name of the Office, including the appointment of an Assistant Director General and delegation of partial powers to him. While this post has never been filled, a Management Counsellor, who is attached to the PDG's office, has been appointed. The divisions and sections directly responsible to the PDG are as follows (also see Chart 9490):
1/ In Tunisia the term "Office" is often used to designate autonomous state-run organizations which are entrusted by legislation with a mission of orientation and coordination and provision of technical services in the field of socio-economic activities. - 12 -
(a) Medical Division: There is a permanent medical director in charge and a part-time doctor to assist. There are also four supervisory midwives. An administrator will be appointed. The Division is in charge of all matters relating to the delivery of services either directly or through the Ministry of Public Health through the Regional Administrators.
(b) Population Division: The division is responsible for research, evaluation and statistics as a support to the whole program. It is undertaking a series of research projects which will be of direct use to the operational divisions.
(c) Promotion and Education Division: This division is responsible for all activities related to information, education and motiva- tion. This is done by:
(i) Organizing in-service training courses in family planning for the staff of other ministries and field workers, and holding seminars and organizing population days in the regions;
(ii) Working in cooperation with the press, radio and television to put across the family planning message;
(iii) Eventually organizing the work of regional educators when they have been trained (in the meantime, two mobile education teams make field trips from Tunis);
(iv) Producing audiovisual aid materials to support the program; and
(v) Being responsible for cooperation with other ministries.
(d) Cooperation Division: This has no division chief but two heads of service: bilateral cooperation and multilateral cooperation.
(e) Division of Accounting and Budget: Responsible also for commer- cial activities such as exploitation of the printing shop.
(f) Administrative Division: This is concerned with personnel and supplies. It controls all transport as well as the purchase and distribution of medical supplies.
(g) Control and Coordination Section: This is a key section. It ensures that all the work of the Office is coordinated and it organizes the monthly meetings of the regional secretaries who come in from the Governorates to discuss their work and receive directives. This section receives all reports from the field-- from the regional secretaries and midwives--and ensures that appropriate action is taken to meet their requests or suggestions at headquarters. - 13 -
(h) Documentation Section: This section assembles all documents concerning family-planning in Tunisia together with documents on the same subject from abroad. These documents are then studied to ascertain whether they contain material that might be of use to the Tunisian program. All the divisions are serviced by this section. The section also publishes the official family planning bulletin.
1.03 Organization in the Field: The Regional Health Administrators of the Ministry of Health represent the Office in the field and thus enable the Office to take action within an operational framework. For this representa- tion the Administrators receive a supplementary salary as well as extra funds for family planning activities. The Office appoints and pays a Regional Secretary who is attached to the Regional Health Administrator and he carries out administrative work concerned with the program. Present plans provide for a family planning educator to be attached to each administrator.
1.04 In each region a Tunisian doctor is appointed by the Office as coordinator of family planning activities and for this he receives a supple- mentary salary. He submits a work plan to the Office and reports on its progress. Part of his job is to stimulate interest in family planning at official levels within the Governorate. The doctor is assisted by a super- visory midwife.
1.05 At the end of 1974 the basic question that affected the future of the Office was that of precisely determining its authority and responsibility. At that time, the Office saw its main role as being one of planning, evaluation and research with some responsibilitity for motivation, training and coordina- tion. Now, with the new PDG and the subsequent reorganization, the Office has come much nearer to the intent of the decree under which it was formed and is much more responsible for "the planning and execution of the program."
Reorganization of the Office
1.06 The last reorganization took place early in 1974 and it has been a very thorough one and in some areas finishing touches are still being added. The drastic simplification of the organizational structure of the Office is a great improvement over the rather complex former one and gives scope for proper coordination between the divisions by encouraging an inter- play of ideas and programs. The latest Bank mission was happy to note that many of the systems which were inhibiting work last year have been replaced by an approach which could be much more flexible and conducive to productive work. This was particularly notable in connection with the delegation of authority, through the division chiefs, to the staff. This has led to more job satisfaction, and a reorganization of the system, which has led to better management of the supplies and transport section. Another important innova- tion concerns staff travel which is now much more frequently undertaken.
1.07 A start has been made, through the Promotion and Education Division, to build up relations with other ministries whose activities could have an effect on population and family planning. The organigram of the Office (Chart - 14 -
9490) is an internal one and does not show links with the outside organizations, nor at what level the links exist, nor the organizations concerned. Such additional information would be useful to back up the present personal contact approach since it would show not only which ministries are involved but also organizations such as the Trade Unions of Tunisian Workers and the Union of Tunisian Women, etc., which receive subventions from the Office.
1.08 The relationship with the Maternal and Child Health sector which disappeared from the mandate of the national organization in charge of family planning after the office was created, shows signs of becoming a workable one. The MCH centers come under the Regional Health Administrators, who represent the Office as well as the Ministry of Health in the regions. In principle, any new approaches or initiatives could be introduced into the MCHs, through this network, since the Institute of Child Care--which is officially in charge of MCH services and said to be mainly technical--does not appear to play a major role.
1.09 Thus, as far as action in the field is concerned, much depends on the relationship whch exists between each of the Regional Health Administ- rators and the Office. At present, this seems to work well as the PDG has taken a great deal of trouble to create good relationships by personal visits to the regions, meetings in Tunis and policy instructions to his staff. The cornerstone of the whole system is the excellent understanding that exists between the Minister of Health and the PDG.
B. Future Plans
1.10 During the course of 1973 the OffCiE elaborated a draft Four-Year Plan for the period 1973-1976. With the appointment of the new PDG at the beginning of 1974 the Office was entirely reorganized and a series of new plans were started. These plans take into account all the previous work and ideas of the Office; they introduce new approaches and translate the results into short-term and long-term objectives. They cover not only the program of the Office for 1974 and a draft Three-Year Plan for 1974-1976, but they also deal with internal matters and procedures that would make the implemen- tation of the program plans possible to achieve. Some of these plans are already in action, some are being tested and others are being finalized after a trial period.
1.11 The Three-Year Plan contains an important program of action. It sets a target of 78,750 averted births. Of this number 22,500 are to be averted in 1974 and the figures for the first three months of the year suggest that this target will be achieved. Strongly stressed is the need for an intensification of action in the rural areas to be accompanied by greater efforts to reduce infant mortality rates. In support of the rural effort, studies will be made of the MCH centers, the areas surrounding them and of the characteristics of the people in each area in order to obtain a better understanding of the human situation. At the same time, long-term plans are - 15 -
outlined for an intensification of information and education activities so that family planning will gradually be accepted as a normal health service, thus making dramatic special campaigns unnecessary. This is part of the overall aim of integrating family planning into the basic health services.
1.12 The following paragraphs were written about the Four-Year Plan and are included since the demographic comments are still valid. However, where they are no longer applicable they have been up-dated with the help of the Population Division of the Office.
The Demographic Objectives of the Four-Year Plan
1.13 Some preliminary remarks should be made here. In the first place population projections are not predictions; they are models of future popula- tion change which are constructed with the best available data at a given time. As more and better data become available over time, the projections should be reviewed and adjusted. Population projections should, therefore, be subject to constant revision. Secondly, projections usually refer to a fairly long span of time, but short-term planning considers the years imme- diately following the initial year of the projections when the differences between variants, assuming different sets of parameters, are relatively small. However, these small differences should be taken very seriously because of their possible wide impact in the long run. Consequently, the number of couple years of protection (CYPs) or the number of new acceptors which are required to meet certain demographic goals cannot be distributed at random over several years or redistributed, e.g., to make up for the number of new acceptors not achieved in a previous year. Such a redistribution would invalidate the accepted projection. Thirdly, the assumptions underlying population projections must be reasonable, although they are in fact specula- tive; for example, no zero population growth can be expected shortly after a fertility level equal to replacement has been reached.
1.14 The National Institute of Statistics made population projections for the period 1971-2001 with two variants each assuming a different decline in fertility and a third variant assuming constant fertility. Variant A shows a linear decline of fertility by 63%. The Variant B projection assumes an even quicker decline in fertility over the 1971-1981 period, but would by 2001 have the same fertility level as that of Variant A. The Economic Development Plan 1973-1976 adopts the Variant A projection. This would mean a total population of 9,770,000 by the year 2001 and a level of fertility equal to that of Italy in 1970 (a gross reproduction rate of 1.14).
1.15 In fact, in the Variant A projection retained by the Government, the NRR by the year 2001 will be about one. This is quite similar to "Projection 3" in the series of five projections made by Tomas Freika of the Population Council, Inc., New York, although Freika used somewhat different fertility and mortality assumptions. Freika calculated that the Tunisian population would stabilize at around 15 million by 2070 if a NRR = 1 were attained at the start of the next century. - 16 -
1.16 A far more important factor is, of course, whether a population movement as assumed in this projection is likely to occur. The first years of the Plan will in this respect be decisive. The data which are supplied in the description of the demographic objectives in the draft Four-Year Plan as well as in the 1973 and 1974 work plans are not completely satisfactory for a feasibility examination of the objective adopted. It would be more helpful for planners if the projections and their underlying assumptions were presented, plus the calculations of births to be averted from which then the number of new acceptors to be recruited would be derived. The citation of several parameters without presenting the basic calculations makes little sense for the purposes of discussing demographic goals. The further assumptions on couple years of protection (CYP) to avert one birth and the number of abortions needed to avert one birth must be questioned. The former because the assumption is that four "protected women" or four CYPs avert one birth while a general fertility rate of around 160 is given, which would rather suggest that over six CYPs are required to have that effect in Tunisia. The latter, because one abortion avoids probably less than .6 birth, if one assumes abortions to take place on an average after two months of pregnancy and allowing for one-month postpartum amenorrhea, thus resulting in only three cycle months (13 in one calendar year) of "protection".
1.17 The distribution of births to be averted by contraceptive or birth control methods deserves a closer look. More relevant information is given in the 1974 work plan. New acceptors for IUDs and contraceptive pills are calculated by assuming a linear increase; tubal ligations are targeted at 14,080 in the course of 1974 and in the same year 10,000 abortions are foreseen. Targets for 1975 are shown in Annex 6.
1.18 At the end of 1973, the mission considered that the very great empnasis placed on the tubal ligation method of family planning and the hopes placed in the effects of abortions on the population suggested a possible danger for the program. The draft report said: "The IUD and the pill are really family planning methods; tubal ligations and abortion are a method of 'birth control' not of family planning." It is true that in a country where health services are still being developed and still do not reach large sections of the rural people, tubal ligation is a more practical approach in areas where the women are far from medical aid since it avoids the difficulties which occur when there are side effects from the IUD and the pill. In the new program tubal ligations still have their importance but the stress is much more on education and information than on campaigning for one contraceptive method against another.
Regional Targets
1.19 The work plans of 1974 and the Three-Year Plan give targets for averted births by Governorate. These regional targets will certainly be very helpful in achieving national targets and for follow-up and guidance of regional programs. The number of acceptors by Governorate indicated for the second quarter of 1974 shows very dramatic differences between the number - 17 -
of acceptors of all four methods (pill, IUD, abortion and tubal ligation). Some of these differences are doubtlessly due to service availability but other factors of great interest to the program planners will undoubtedly emerge. Once the service factor has been equalized these quarterly charts will provide a good measurement of effectiveness by area.
Plans and Objectives: Two basic documents provide insight into the present plans and objectives of the Office. These are:
(a) Programme de Planning Familial en Tunisie (Plan Triennal 1974-1976, DRAFT). (b) Republique Tunisienne, Office Na (b) Republique Tunisienne, Office National du Planning Familial et de la Population, Programme de Travail, 1974.
1.20 The draft Three-Year Program translates demographic objectives into a family planning action and defines what has to be done to achieve those aims. It is based mainly on logistic and economic factors. It also includes a review of the projects presented to bilateral and multilateral aid, notably the six presented to the UNFPA.
1.21 The Program stresses the problems presented to the Government, particularly in the field of education and employment if population growth is not slowed down and states that only an effort of mass education and information will influence the Tunisian attitude toward family size. An important extension of family planning work in the rural sector is foreseen and there will be a building up of hospital facilities and an integration of family planning into the MCH services in the urban areas. If the objectives of the national plan are to be achieved the demand for services will have to increase and at the same time the delivery of services will have to be ready to meet the demand. The direct linking of these two activities is to be welcomed.
1.22 The demographic objectives are translated into births to be averted by method and by year and include target figures for each Governorate. The document is not explicit as to how these objectives are to be attained since there are no detailed work plans but the elaborations of each section which are being prepared at the Office suggest that the basic preparatory work is being done.
1.23 The Three-Year Plan, among other activities, contains the following:
(a) the opening of a family planning center in each region; - 18 -
(b) the implementation of six projects funded by the UNFPA and carried out with the help of FAO, UNESCO, UNICEF, ILO and WHO; 1/
(c) training seminars for Regional Health Administrators, the co-ordinating doctors and midwives (the mission noted that these have already been carried out, this is a great step forward in the process of gaining the support of Ministry of Health staff); and
(d) continued USAID support for all sections of the program; a project with Belgium which will provide five doctors and clinical equipment in the regions of Gafsa, Tozeur and Sidi Bouzid; a training program as well as a project at Beja with WHO and the continuation of Population Council assistance to research projects.
1.24 The preparatory and implementation work for these projects, being additional to the regular program, will be a challenge to the new organi- zation of the Office. Although most of the UNFPA-funded projects will be carried out by the ministries, there will be a very important coordination job to be done to ensure that project execution is integrated into the national program. The mission noted with pleasure that the newly structured Office would seem to be well prepared to carry through this heavy program successfully.
1.25 The 1974 Program shows that the Office is well aware of the magnitude of the task. It states that the program is based on two vital elements: The delivery of services is to be developed but, in this context, the word "services" is used in a broader sense than hitherto so that it includes not only medical but social education, information and the pro- motion of family planning. These are to be linked and to be carried out as an integrated program. The second is the creation of new service develop- ment structures by making a sufficient investment in personnel and materials so that the work of the next few years can be accomplished.
C. Recommendations
1.26 As far as overall policy is concerned the Office is operational in two ways. Firstly through the Minister of Public Health who, if he agrees to the new approaches suggested by the Office, supports them by
1/ The projects will be implemented by the appropriate ministries and will cover the introduction of family planning education in the training of agricultural extension workers, the introduction of population education into the school curriculum, an inter-sectoral family planning program, a program of population information/education for industrial workers, the creation of three clinics at Le Kef, Nabeul and Bizerte and an incentive scheme for people who are helping the family planning program. - 19 -
issuing instructions to the Ministry's staff. Secondly, through the Regional Health Administrators. Both of these systems are influenced by personal relationships which are very good at present and will doubtlessly continue to be so as long as the people concerned stay where they are. But from a long-term point of view it may well be that personal relationships may not prove to be a foundation which is sufficiently strong to survive changes in personnel and this could cause a setback to the whole program. Since one of the expressed aims of the Office is to integrate family planning into the health services, consideration could be given to formalizing, gradually, the existing system by creating a small high-level action unit within the Ministry which would include the PDG of the Office and a representative from both the medical and administrative sections.
1.27 Last year it was difficult to understand exactly how the MOH centers fitted into the overall family planning service delivery system. Now the situation is clearer. Officially the MCH services come under the Institute for Child Care but this is considered to be a technical body and the MCH centers are under the effective control of the Regional Health Administrator in the Governorates through the doctors and midwives. Thus MOH services come within the sphere of action of the Office through its link with the Regional Health Administrators. To a certain extent the Office sees itself as being in charge of the MCH centers in fact, if not on paper. This system seems to work well at the moment but it needs to be strengthened through a more formal arrangement. A more durable arrangement might be arrived at if the MCH services were to be represented in the action unit at the Ministry of Health suggested above. The Ministry of Health, the Office and the MCH services would thus become a joint task force capable of taking concerted action not only now but in the future.
1.28 The Office has started to create vital links with the other ministries which are in a position to help with the national family planning program. Although this is a sensitive area a start has been made with the Ministries of Information and Education and working parties have been set up to create a cooperative effort. It is important that such arrangements do not break down through lack of initiative or because of the difficulties involved and that new ministries and organizations are brought into the joint plan of action.
1.29 In the past, the development of the national family planning program has been hindered by changes of direction particularly at the higher levels. Every effort should be made to retain the services of the present team who have helped create the program under the leadership of the PDG. - 20 -
II. DELIVERY OF SERVICES
2.01 At a time when the country was desperately short of personnel and facilities the Ministry of Public Health made efforts to provide medical services to the entire population and simultaneously mounted a comprehensive program in the field of public health. Shortly thereafter, Ministry person- nel, already overloaded with clinical work, became involved in a totally new and far more difficult and delicate program than had ever been undertaken before -- that of family planning.
2.02 As long as the program was small and experimental there were no major problems so far as the organization and administration of the program were concerned. However, with the development of a nationwide family planning effort, physicians and paramedicals delivering services had to make the choice between providing clinical services to meet a very real demand and public health services such as family planning. The decision of the medical workers in favor of curative services is quite understandable given the fact that many field workers had not at that time (and still have not) all received family planning training. There was also a significant language problem experienced by the many foreign doctors in rural areas in discussing family planning with the local women.
2.03 Even more importantly, in terms of medical organization, there has been a tendency in the past to treat family planning in the same manner as any other campaign in public health, for instance, the malaria campaign, and thus seek short-term advantages, represented by new acceptors. Family plan- ning cannot be treated in this fashion. Contraceptive clients are not sick or threatened by an epidemic. The whole concept of family planning is a long-term one. This is now understood and the basis of the current program emphasizes educating and informing the people while at the same time a service organization is being created which will respond to the resulting growing demand from the public.
A. Health
Infrastructure
2.04 The Ministry of Public Health is the authority responsible for providing family planning services to the public. This is done mainly through the National Office of Family Planning and Population.
2.05 In addition to the Ministry's own hospitals, dispensaries and MCH centers there are family planning clinics belonging to the Tunisian Family Planning Association (a private association whichexisted before the creation of the National Office of Family Planning and Population) to the National Tunisian Railroads, to the Social Security and to other organiza- tions such as the Union of Tunisian Women and the Neo-Destour political party. Doctors with private practices also give family planning advice to their patients but provide no figures to the statistical service. - 21 -
2.06 There are 327 centers in Tunisia providing family planning services to the public. The distribution of these 327 centers by gover- norate is given in Annex 7.
Gynecological and Obstetrical Services in Hospitals
2.07 There are 89 hospitals which have a total of 12,571 beds (24 beds per 10,000 population). In 1971, twenty hospitals out of the 89 had obstetric and gynecological wards run by obstetrician-gynecologists; 10.5 percent of the hospital beds were reserved for obstetric and gynecological patients (2.5 beds per 10,000 population). The family planning activities in hospitals, where there is no resident gynecologist-obstetrician, are run by the gynecologist-obstetricians of the mobile teams.
2.08 The number of hospital beds, occupancy rate, and the average duration of stay of the patients in different types of hospitals for 1971 are given in Annex 8.
2.09 The utilization rate of beds is low in hospitals and maternity wards in rural regions for both general medicine and gynecological cases. This is due to socio-economic reasons and a conservative mentality, heightened by the lack of communications. The authorities are concerned by this fact and consider that it would be better to have more mobile teams delivering services in each delegation rather than delivery of services from a single large hospital; at the same time they intend to open small MCH centers as soon as possible.
2.10 The distribution of hospital beds throughout the country varies greatly from one governorate to another. The hospital beds/population ratio was 45.1 per 10,000 in Tunis and 6.6 per 10,000 in Kasserine in 1971. In that year, 30.6 percent of the deliveries took place in health facilities in Tunisia. The number of maternity and hospital beds, bed occupancy rates and percentage of deliveries in hospitals are given in Annexes 9 and 10. Annex 10 indicates wide regional variations. For example, beds for gyneco- logical and obstetrical cases were over-utilized in Le Kef and Kasserine, while the utilization rates of beds for gynecological and obstetrical cases in Gafsa, Sousse and Nabeul were lower than in other governorates. The preference of pregnant women for the place of delivery also differed from governorate to governorate. Whereas, 55 percent of deliveries in Tunis took place in hospitals, in Kasserine only 7 percent of deliveries occurred in hospitals.
2.11 Officially, all clinics and departments of the Ministry of Public Health are licensed to provide family planning services. Figures for 1971 are as follows: - 22 -
Number Total admissions to hospitals 298,338 Admissions to Ob./Gyn. clinics 93,003 Deliveries in hospitals 56,018 Tubal ligations 2,459 Induced abortions (social reason) 4,621 Abortions (other reasons) 12,586 Total out-patient consultations in hospitals 2,969,675 Out-patient consultations in Ob./Gyn. department 72,401 Out-patient consultations for abortion and tubal ligation 5,479 Total births in Tunisia 182,749 Married women between the ages 20-49 754,860
Maternal and Child Health Centers
2.12 MCH centers, dispensaries and rural centers served by the mobile teams are the main sources for the provision of family planning services. While the MCH centers provide for antenatal and postnatal care and family planning, they principally function for the care of sick children. Since the patient load is sometimes very heavy in the centers, the care of sick children absorbs most of the staff's time.
2.13 The permanent staff of the centers are midwives and nurse-aides. According to the demand and their availability, pediatricians work in the centers anywhere from one to five half-days a week and only care for sick children. The number of children seen by a pediatrician within three to four hours may reach 100-150. An obstetrician-gynecologist usually visits a center one half-day a week, but in some centers these visits may be more frequent. He gives family planning advice to women who have requested it or who have been persuaded to see him by the paramedical staff.
2.14 The midwife in the center is responsible for antenatal and post- natal care, health education of mother and child, and family planning. In addition to her professional activities, she has administrative responsibil- ities and may also be asked by the physician to assist in the examination of patients. Administrative tasks of the midwives, such as record-keeping and preparing statistical reports, absorb many working hours. There are no visits by patients in most of the centers during the afternoons when midwives do their administrative tasks and nurse-aides clean the building or, very rarely, make home visits. The number of home visits ranged from 836 to 3,602 for the whole of Tunisia between 1965 and 1969. Figures for 1970 and later are not available. The regular follow-up of normal children and pregnant women is very rare. It is, in fact, difficult to follow up women who have just given birth even if there is sufficient staff. This may be partly due to local custom or it may be that women live too far away from the clinic. Many mothers will pay one visit in an emergency but will not return again as requested. - 23 -
2.15 The activities of the MCH centers, excluding family planning services, in 1971, are shown in Annex 11.
B. Family Planning
Organization
2.16 The mobile family planning teams, which consist of an obstetrician- gynecologist and/or a midwife, trained in family planning, and a nurse-aide, are the major force in the provision of family planning services. These teams visit MCH centers, dispensaries and rural hospitals in their area according to a fixed schedule. They usually work in one center for one to two half-days a week to consult with women who seek contraceptive advice, to follow-up women who are already practicing contraception and to examine women with gynecological and other disorders. Because a significant number of women who practice contraception are inclined to believe that any illness they may have might be due to the method of contraception they are using, much of the working time of the teams is spent in examining and treating patients in this third category.
2.17 The teams use the physical facilities of the centers, dispensaries and rural hospitals. The permanent staff of these establishments distribute condoms and certain pharmaceutical products prescribed by the head of the team. The staff prepares people for consultations on family planning and sometimes carries out MCH work in rural areas.
2.18 There are 20 mobile teams in Tunisia at the moment and new teams will be formed as soon as the extra vehicles arrive. The National Family Planning Office has just launched an experiment which consists in giving midwives supplementary training in MCH/FP which will enable them to carry out IUD insertions and prescribe the pill in certain regions which are visited by a gynecologist. In the medical profession there are two lines of thought on this subject: One does not recognize the right of midwives to carry out family planning responsibilities such as IUD insertion and pill prescription; the other would allow a wider delegation of work to the mid- wife by giving them and other paramedicals more comprehensive training. The Office and the National School of Public Health have already started to introduce this additional training into their third-year program for midwives while waiting for a complete revision of the curriculum. However, the medical corps is still very powerful and not yet completely ready to allow this delegation of responsibility which does not conform to classical medical practice. It considers that only doctors have the right to prescribe methods of contraception or give health care to infants.
2.19 A similar situation exists in the development of MCH services. In this case, a plan was developed by the Tunisian Government and the World Health Organization to train midwives and assign them to centers to run healthy infant care clinics. However, when some of the trained midwives began to give routine examinations to healthy infants, to immunize them, and to advise - 24 -
mothers on how to feed them, the medical profession objected. The Govern- ment has now accepted its view. Since there are not enough pediatricians in MCH centers even to meet the demand for curative care, the healthy infant care programs cannot develop in Tunisia unless the attitude of the medical profession changes.
Family Planning Practice
2.20 The only nationwide study on knowledge, attitude and practice (KAP) of family planning was carried out in 1964. It showed that 15.4 percent of married women had knowledge of some form of contraception.
2.21 The percentage of women of fertile age and protected by family planning was estimated at 6.10% in 1971; 6.63% in 1972; and 7.40% in 1973. Acceptors by method in each governorate for 1973 and objectives for 1974 are listed in Annexes 12 and 13.
2.22 The Ministry of Public Health's system provides a variety of contraceptive methods (IUD, pill, condom and contraceptive cream). Legal abortion and methods of sterilization are accessible to all those who want them.
2.23 In 1966, when the program was launched, the Ministry of Public Health emphasized the IUD method and carried out the program as a mass campaign. The people were not sufficiently informed on possible side-effects and women in the rural areas could not find anyone to consult within an easily reachable distance when needed. This hasty action and insufficient motivation created a resistance to the IUD in the following years.
2.24 The demand for tubectomy has increased considerably since facilities were made available in all the regions. At the same time the number of legal abortions has also increased. It is certain that a well-planned program of information and education will be necessary to guard against a possible resistance to these methods and to promote family planning by explaining such drawbacks as psychological and secondary effects from the IUD and the pill.
2.25 The family planning activities in the different categories of centers for 1972 are shown in Annex 14; the acceptors were recruited by itinerant teams in MCH centers, dispensaries, rural hospitals, and other health facilities. On the basis of service statistics and allowing for dropouts, the number of eligible couples practicing contraception in 1972 was estimated at about 5.5 percent. The average numbers of IUD insertions and new pill acceptors per team for the same year were 44 and 53 respectively. Since the estimated expenditure for a team in one month is approximately 600TD, the cost of one new acceptor to the Tunisian Government is 6.18TD (equivalent to about US$15). However, since the thrust which was given to family planning recently, recruit- ment has increased considerably in the larger towns thanks to an intensified information effort and the supplemental family planning training given to the midwives. - 25 -
2.26 The control of some communicable diseases and the improvement of hospital services are the only health services which are mentioned in the draft Four-Year Plan. The maternal and child health services mentioned are only in connection with the population project, carried out under an agreement between the Tunisian Government and IDA. Neither the Plan nor the 1973 or 1974 Work Plans discuss the measures accepted in the Plan for the development of the MCH and family planning services in the MCH centers which will be built.
Postpartum Program
2.27 The postpartum program in Tunisia began in 1969. In 1970, among the women who gave childbirth or had an abortion in a hospital, 20,856 or roughly one-third, received information on IUD and other methods of contraception. Of these, 3,905 came to a hospital for consultation and 3,845 of them accepted a method of contraception. The number of acceptors was 6 percent of the women who delivered or had an abortion in a hospital. The proportions for 1971 and 1972 are similar to those of 1970. These results are unsatisfying and the situation has been reviewed.
2.28 The draft Four-Year Plan and the 1973 Work Plan propose to start a new program for women who have just given birth. In practice, in 1974, this program had already begun. The number of women, who will come for consultation after childbirth or abortion is estimated to increase from 10,500 in 1974 to 24,000 in 1976. If the rate of acceptance among the women who return to the hospital for consultation remains as it was in 1970, it means that 10,290 women will accept family planning through the postpartum programs in 1974. But it should be remembered that only about one-third of the women who give birth do so in a hospital or center and that only about 6% of these women return to the hospital for consultation.
C. Recommendations
2.29 Any recommendations made in order to improve family planning servi- ces in Tunisia require an examination of the reasons for slow progress in family planning acceptance. Apart from the influence of traditions and beliefs, the major reason is the missing link between the public and the centers where the family planning services are offered. The operational philosophy of the centers is similar to the philosophy of ambulatory patient-care clinics. Persons feeling ill need no motivation to visit the clinics. The situation is different in preventive services. Both in developed and developing countries the majority of persons do not go to the centers for prevention of diseases, unless they are educated to do so. Therefore an intensified home-visiting program should be established to educate and motivate people to go to the centers for preventive services. Some of these services may even be delivered in the homes. Family planning services have to be organized like preventive services, not like the ambulatory patient-care. It should be noted that home visiting is the least developed part of the family planning services in Tunisia. - 26 -
2.30 Home Visits and Community Health Workers: The maintenance of close and frequent contacts between family planning workers and married women within the reproductive ages is one of the necessary conditions for the successful implementation of family planning programs. This close contact could best be achieved by developing maternal and child health services and by carrying out educational and clinical activities in family planning together with MCH services. If MCH activities including education are run properly, a pregnant woman may be seen at least three or four times before childbirth, immediately after delivery and at least six or seven times during the infancy period of her child; then less frequently, but at least twice before her child reaches six years of age. Mothers and children may be followed up either at home or in the centers. If a health worker visits homes solely to provide family planning education, those women who have declined the practice of contraception may not admit the health worker to their houses. The health workers themselves may find it futile to visit women who have already refused to accept contraception. Consequently, the rule of close and frequent contact for family planning education cannot be applied. The integration of MCH and family planning services provides a reason for frequent visits.
2.31 Home visits -are an established practice in countries where the health services are well developed. The professional background of the community health workers changes from country to country. In China, the health workers in rural areas are peasants trained in health care. Turkey started a program to train and employ rural midwives after the Second World War. The Republic of South Korea employs health workers who have completed a nine-month course; these workers visit homes in order to motivate women and follow up the acceptors.
2.32 Countries which are short in health manpower should adopt the same principle. The level of basic education of the recruited persons, duration of their training and their function have to be decided according to the existing conditions in each country. The principal rule to be observed in the employment of sub-professionals is the need for continuous supervision and on-the-job training of these workers.
2.33 Home visiting to improve family planning activities was already tested in Tunisia. The results were very promising. In Kelibia between 1966 and 1970, a Swedish team employed young girls to improve childcare and family planning services. The number of family planning acceptors increased parallel to the number of consultations for promoting the health of normal children. Some of the basic points for a project aiming at the training and employment of health workers are given in Annex 15. The basis of the project is that community health workers should be recruited from the communities where they will work after being trained and the training should include first aid, antenatal care and other basic disciplines as well as family planning.
2.34 The second reason for slow progress in family planning is the quality of services. Sick persons may wait for hours in the centers. Even if they are mistreated they do not leave the center until seen by a physician. In the case of preventive services, including family planning services, healthy - 27 -
persons give up seeking services if not satisfied or perhaps do not even go to the centers if they have heard complaints from their neighbors. The reception in the centers must be humanized so that the women can overcome their fears and shyness, and feel at ease; they will then be able to positively influence other women by their convincing reports.
2.35 The third reason is the lack of moral and technical support of the staff working in the centers and in the communities. One feels that, in the past, more emphasis was given to improving the work at the central level than at the community level. The staff in the centers, from physicians to nurse-aides, have to be trained, supervised continuously, and encouraged so that they will be proud of and satisfied with, their work.
A Recommended Model for Family Planning Services
2.36 The number of existing and projected hospitals, dispensaries and MCH centers, including the centers which will be built with the IDA Credit, is sufficient to carry out family planning programs successfully for the time being. Therefore, no more centers should be established before the existing and projected centers are operating efficiently and effectively.
2.37 The new policy of the Office recognizes that the basic principle of organizing family planning services should be their integration with the MCH system. This is the most effective and efficient way to deliver family planning services. (A case for multipurpose organization of services is given in Annex 16.) The recommended organizational model for the MCH/FP regional system is shown in Chart 2. The following manpower and training procedures relate to the implementation of this model.
2.38 The midwives and auxiliary nurse-midwives who are trained in antenatal and postnatal care, childcare and family planning services should be in charge of examining pregnant women, following up the development of the children, immunizing children and pregnant women, teaching pregnant women how to care for themselves, teaching mothers how to feed and care for their children, educating pregnant women in family planning before and after childbirth, and dispensing condoms and other nonmedical contraceptives. Pregnant women or children who have any symptoms of disease should be referred to a physician.
2.39 In the case of IUD insertion and the prescribing of oral pills, two alternatives may be considered. If an obstetrician-gynecologist or a general practitioner trained in family planning is available, the IUD insertion and prescribing of oral pills should be done by the physician. A physician who visits the unit once or twice a week can provide sufficient family planning services. If a physician is not available, the women should not be deprived of family planning services; a midwife or even an auxiliary nurse-midwife may successfully be trained to insert IUDs and prescribe oral pills as efficiently as a physician.
2.40 The use of midwives and nurses in MCH and family planning services even in the treatment of minor illness is a routine practice in many - 28 -
developed and developing countries. For example, public health nurses who have had courses in diagnosis and treatment of minor diseases and injuries are sent by the Canadian Government to small communities in isolated rural areas where they practice. The situation in the recommended model for Tunisia is more favorable because a physician will visit the centers regularly, and midwives and auxiliary nurse-midwives will improve their knowledge and skills by discussing the problems with a physician, most probably with a pediatrician or obstetrician-gynecologist.
2.41 Tunisian midwives and auxiliary nurse-midwives should be fully trained in treating side-effects, removing IUDs or advising women to dis- continue taking pills if severe side reactions occur. This training is indispensable to the success of family planning programs. Women who have side-effects are in need of immediate consultation. They cannot wait for as long as perhaps a week for the visit of an itinerant physician and their continuous complaints may discourage many women. If women know that there is someone in their community to help them if side reactions occur, they will accept contraception more easily than women in places where such a person is not available.
2.42 Supervision of community health workers may be done by a public health nurse with special training in MCH and family planning education.
2.43 Supervisor nurse-midwives should be selected from midwives already having experience in running a MCH and FP unit successfully. Their main function should be to train midwives and auxiliary nurse-midwives, and super- vise them on the job.
2.44 The function of itinerant physicians should be to examine the women and children referred to them by midwives, auxiliary nurse-midwives and community workers and also train these workers on-the-job by discussing problems and answering their questions.
2.45 The Regional Hospital Administrator who, in fact, is a regional health director has a wide variety of work. He usually has a very limited number of technical staff, especially for preventive work. If MCH/FP services develop as they are recommended, his workload will increase even more. It is necessary to establish in his office a position for a MCH/FP officer. This officer should be a physician preferably trained in public health. The post of coordinating doctor, recently established by the Office, could develop into such a position.
2.46 Other positions in the organigram (Chart 9491), such as educators and statistical clerks, are inseparable elements of the family planning team which serves the whole governorate.
Implementation of the Model
2.47 The first step in the implementation of the model is the establish- ment of a teaching MCH/FP center. The place for the teaching MCH/FP center should be a town having both agglomerated and scattered rural communities - 29 -
around it. The population to be served in this center should be around 15,000. This is the average size of population per center (MCH centers, dispensaries, rural hospitals) in Tunisia at present.
2.48 This teaching MCH/FP center should be used to give pre-service training to physicians, midwives, nurses, auxiliary nurse-midwives, statistical clerks and educators on aspects of teamwork and of operating MCH centers and FP services effectively and efficiently. The staff of this center should be selected carefully and trained properly. It may take at least six months to develop the services to a satisfactory level in order to accept trainees.
2.49 The trainees should have had courses on the technical aspects of their functions in MCH and FP services prior to receiving instruction at the teaching MCH/FP center. At the center they would work as staff members under the supervision of the teaching staff. The courses should be sufficient to give them the ability to work independently and to train others. Community health workers may be trained in the teaching MCH/FP center after the trained staff have started work.
2.50 The second step is the establishment of one teaching MCH/FP center in each governorate. These centers will be similar to those mentioned above.
2.51 The third step will be to train staff for other centers (MCH, dis- pensaries, and rural hospitals) in the governorates. The teaching MCH/FP center in each governorate should be responsible for pre-service and in-service training for the staff members of each center in that govenorate. - 30 -
III. MANPOWER AND TRAINING
A. Physicians
3.01 While Tunisia has made enormous progress in the development of its health system, many problems remain which in general handicap the efforts of the Ministry of Public Health.
3.02 The shortage of physicians is an acute problem in Tunisia; the physician/population ratio is 1 to 6,375 in spite of the number of foreign physicians. The unequal distribution of physicians aggravates the situation for many governorates, and especially for the rural population; in 1973 the physician/population ratio was 1 to 2,529 in the Governorate of Tunis and 1 to 23,090 in the Governorate of Kasserine. (Annex 17) The employment of foreign physicians helps to alleviate the situation to a certain extent; these physicians are appointed to posts in less developed governorates and in small towns where Tunisian physicians do not wish to work. The latter mostly prefer to work in large cities and more developed parts of the country. They also prefer either to practice privately or work part-time in health services.
3.03 In 1962 there were no more than 460 doctors in Tunisia, many having left Tunisia at the time of Independence. By 1966 there were 576 doctors -- 28 more than ten years before -- but the population had grown by an additional 750,000 in the same period, and probably 50% of the doctors were still in the nation's capital. In 1968 when the number of doctors had dropped to a total of 558, about 362 were foreigners -- primarily Bulgarians and Czechs on short-term contracts.
3.04 The Tunisian Government has made serious efforts to rectify the manpower shortage. First, a decree in 1962 stated in effect that all doctors, surgeons, specialists and dentists attached to hospitals had to work full- time (40 hours per week) for the hospital although the law did not prohibit a doctor from seeing and treating his private patients at the hospital, with- in certain limits. Second, legislation was passed creating programs for the training of Tunisian medical and paramedical personnel, and arrangements were made for a more equitable distribution of doctors in the country. This law was modified by a decree in 1969 which gave doctors the right -- with certain reservations -- to choose between full-time and part-time public service or private practice.
3.05 As of December, 1973, 847 physicians were practicing in Tunisia. Only 47.8 percent of these were Tunisians. The median age of Tunisian phy- sicians who work in health services is 37.4 years. The majority of Tunisian physicians are men; only 4.8 percent are women.
3.06 In 1972, a great majority of foreign physicians were Bulgarian (154), French (124), Czechoslovakian (41), Russian (27) or Polish (23). Recently, a group of Chinese physicians started to work in the hospitals of Jendouba and Mahdia. - 31 -
3.07 Most foreign physicians are employed full-time in the public sector, while 25.7 percent of Tunisian physicians are in private practice and 35.3 percent are working fulltime in the public sector. Others are employed either part-time or on a contract basis.
3.08 One of the characteristics of medical manpower in Tunisia is the high percentage of physicians who are specialists -- 81.5 percent of Tunisian physicians and 71.2 percent of foreign physicians. The number of physicians by specialty is given in Annex 18.
Medical Education
3.09 The first medical school in Tunisia was established in 1964 and the students of the first class completed their internship in 1971. More than 1,900 students have been admitted to the medical school since 1964 and 264 students have graduated. At present, there are 1,056 medical students and 84 interns in the schools. The number of students in each class between 1964-65 and 1973-74 academic years are given in Annex 19.
3.10 The dropout rate in the medical school is quite high. Only 36.7 percent of the students admitted to the school between 1964 and 1969 gradu- ated. Since the number of students who are admitted to the medical school has increased more than five times during the last three years, the percent- age of dropouts may increase in coming years.
3.11 The Tunisian Government decided to establish two new medical schools, one at Sfax and the other at Sousse. These two faculties will open in time for the beginning of the 1974 scholastic year.
3.12 Completion of medical studies in Tunisia requires eight years. There is a first year of preparation, then five years of study at one of the faculties of medicine. After receiving their diplomas, graduates must work for two years as interns before they are allowed to practice on their own. During this two-year period they take a six-month course in general medicine and then another course in social and preventive medicine. The latter can be taken in a dispensary, a MCH center, a factory or in a school. The course occupies sixty hours and includes topics such as the health organization in Tunisia, MCH services, health education and demography (fertility and mortal-, ity). This course is still rather weak as there is not, as yet, a suffi- ciently strong framework.
3.13 Subjects related to family planning and population problems are taught in courses on gynecology and family planning and in social and preven- tive medicine. A special course in gynecology and family planning is given in the fourth year for a duration of six months. Human reproduction, the pharmacology of contraceptives and clinical aspects of family planning are included in the program of this course.
3.14 Students who complete the internship program may be appointed as residents to a university hospital or as assistants to a principal hospital of the Ministry of Public Health. Usually every graduate will find a place - 32 -
in a hospital as a resident or assistant. Very few of them prefer to be general practitioners. Physicians who complete their residency or assistant's program successfully may be appointed to regional hospitals as a chief of a service.
3.15 Medical education is free in Tunisia, and formerly after graduation students were not obligated to do a term of official work as a contribution to the Government which had financed their studies. However, following the lead of other countries that send physicians to rural areas to posts which are difficult to fill, Tunisia instituted a National Civil Service in 1971. The mission was pleased to find that every young doctor must, after three months of military service, spend nine months in the civil service as a doctor, most frequently in districts where there exists no medical personnel, but with the possibility of taking a Government contract afterwards.
3.16 The target for medical manpower which has been accepted by the Tunisian Government in the draft Quadrennial Plan projects seven physicians per 4,000 population in 1980 and seven physicians per 2,000 population in 1990. Given the number of students in training at the medical school (see Annex 19) and considering that the two Medical Faculties at Sousse and Sfax will be productive eight years hence, it seems that these targets could be achieved.
3.17 The manpower program for family planning estimates that for a total of 342,000 family planning consultations in 1973, some 28 physicians and 110 paramedicals should have been employed. For 1976, 43 physicians and 167 paramedicals would be required to attend the estimated total of 567,000 con- sultations.
3.18 The training activities foreseen for the plan period are as follows:
a. Short courses to train public health officers and chiefs of rural hospitals in family planning;
b. Two-or-three-day courses in regional hospitals for obstetrician-gynecologists to teach them the suction method of abortion; and
c. Three-month courses for midwives to teach them IUD insertion and how to advise women on the use of other methods of contra- ception, including pills.
3.19 International cooperation for manpower training is quite extensive. The IDA population project includes the expansion of the Avicenne Paramedical Training School to increase the capacity of training in midwifery. WHO, UNICEF, UNFPA and USAID support projects to improve the training of medical and paramedical personnel.
3.20 The assistance of USAID includes 23 long-term and 10 short-term fellowships for the period 1973-1977. Tunisian participants will be trained in public health, health administration, health education, and nursing and clinical aspects of family planning. - 33 -
B. Paramedical Staff
3.21 As with the doctors, the same diminution in staff took place in the paramedical group, which had a total of 1,917 personnel in 1955. In 1960, only 600 paramedical workers remained. The number of midwives -- a critical group in the later development of family planning services -- was 138 in 1956 and dropped to 112 in 1960. At present, it is less than 200 and less than one-third of the total number of physicians in the country.
3.22 The number of midwives, nurses and nurse-aides in Tunisia in 1972 was 150, 2,003 and 3,222 respectively. The distribution throughout the governorates is given in Annex 20. The number has increased since last year.
3.23 In 1973, 40% of the midwives worked in Tunis. For the new 1974 training intake this imbalance has been taken into account. Each governorate has assessed its needs and has been asked to find a suitable number of candi- dates who, when trained, will return to their own areas.
3.24 Undergraduate Training: The first nursing school in Tunisia was established in the Aziza Othmana Hospital in 1924, but did not function con- tinuously until 1945. After 1945, and especially after 1950, nursing educa- tion received more emphasis. In 1950, two more schools of nursing were established. Training of nurse-aides was started in nursing schools in 1957. During the following years training in midwifery and graduate training in different specialized branches of nursing was started. At present there are ten schools for paramedicals. Three schools for midwifery and basic nursing education are located in Tunis, Sfax and Sousse. Nurse-aides are also trained in the above mentioned schools and there are five more schools in different cities, i.e., Menzel Bourguiba, Le Kef, Gabes, Kairouan and Gafsa, where only nurse-aides are trained. In addition to these schools, there is a school for hygienists in Nabeul where sanitary inspectors and male nurses for the con- trol of communicable diseases are trained.
3.25 Nursing and midwifery education is also free in Tunisia. The students are given either free board and housing or 15 TD stipends per month. The level of basic education required for admission to the schools and the duration of education for midwives, nurses and nurse-aides is as follows:
Level of Basic Duration of Profession Education Education
Midwives 12 years 3 years
Nurses 11 years 2 years
Nurse-aides 9 years plus entrance examination 2 years
3.26 Graduate Training: A two-year graduate training course in nursing is given in psychiatric, pediatric, anesthesia and reanimation nursing. - 34 -
Nurses must have at least three years' work experience in order to be ad- mitted to the school for graduate training. Public health nursing is not a recognized field of specialization for nurses in Tunisia. A graduate program for training nursing instructors was started recently.
3.27 A new training structure has been approved since the last mission. In the public health schools the midwives, as mentioned above, receive train- ing in family planning. This theoretical and practical teaching, as well as other aspects of mother and child care, will be strengthened starting with the school year 1974-1975. This will create a corps of paramedicals with satisfactory training in family planning. This is part of the policy of integrating family planning into the health services.
3.28 Number of Students and Graduates: The total numbers of midwives, nurses and nurse-aides graduated since 1960 are 201, 1,735 and 3,693 respec- tively. An expected 61 midwives, 109 nurses and 230 nurse-aides will graduate in 1974. The number of graduates in midwifery has increased during recent years, but the number is still too limited to meet the needs (Annex 21).
3.29 The decrease in the number of student nurse-aides and the increase in the number of student nurses in the first year are the result of a new policy which intends to replace gradually nurse-aides by nurses. The training of obstetrical nurse-aides has been stopped and replaced by a two-month training course in family planning and MCH. In 1975 a new policy will be adopted. This will widen the course of instruction of nurse-aides so that midwives can be released from certain duties and thus be enabled to carry out more impor- tant and useful jobs.
3.30 A two-year evening course for nurse-aides in order to prepare them for the examination leading to a Diploma in Nursing is given in Tunis. Nurse- aides who live in other cities may take courses by correspondence.
Pre-Service and In-Service Training
3.31 Pre-service and in-service training courses have been organized by the National Office of Family Planning and Population. The following courses were given in 1973:
No. of Participants Subject Duration Courses Participants
Nurse-aides Obstetrical 3-1/2 months 5 47 nurse-aides Nurse-aides Family Planning 3 weeks 1 10 Midwives Family Planning 6 weeks 1 14 Midwives Supervision 12 months 1 14
3.32 The Training Program for 1974: The courses for in-service training of staff in 1974 are as follows: - 35 -
No. of No. of Participants Subject Duration Courses Participants
Nurse-aides Midwifery 3-1/2 months 2 22 Nurse-aides Family Planning 1 month 8 88 Midwives Family Planning 6 weeks 3 35 Midwives Supervision 6 months 1 5 Ob/Gyn (foreigner) Family Planning 1 week - 20 General Practitioners (Tunisia) Family Planning 2 weeks 6 60
3.33 The courses which will be given to the nurse-aides are a continua- tion of the program which started in 1973. The decision of the Tunisian Government to train nurse-aides in obstetrics is a very important measure which is needed to meet the manpower needs of MCH and family planning services. This training will not only help to increase the number of midwives but also to facilitate the distribution of midwives throughout the country since the nurse-aides who work in centers where there are no midwives will pursue the obstetrical courses. The courses for foreign obstetrician-gynecologists are given as pre-service training when the foreign physicians join the service.
C. Recommendations
3. 34 Health Manpower Planning: The development of human resources is always a key to success in the implementation of any program. It requires detailed information about the characteristics, functions and expectations of personnel at all levels. In Tunisia, some of the necessary information about the health personnel is available, but it is not sufficient to use in planning manpower production and improving the services. The development of health manpower also requires a carefully designed long-range program which is linked with the development of health services.
3.35 Manpower planning has become a specialized field in administrative services. The Ministry of Health should have a manpower planning unit. A physician or administrator should be trained in manpower planning within the framework of the family planning project.
3.36 Measures for Improving the Distribution of Health Manpower: The uneven distribution of health manpower is a great obstacle to the development of health and family planning services in Tunisia. In order to achieve a more equitable distribution of Tunisian physicians, medical students should be trained to practice in MCH centers and dispensaries. One way of achieving this goal would be to institute a clerkship program in centers which are especially organized for teaching. A crowded center which gives low-grade service to the people is not the proper place for teaching and motivating students in community practice.
3. 37 Last year's mission recommended that all doctors, on the completion of their training, should be obliged to work for one or two years in a rural area. This policy has already been introduced and, at the moment, young - 36 -
doctors must complete nine months of rural practice in areas where there are no medical services. A new law, at present in draft form, will increase this period to one year by suppressing military service for doctors. This will give the doctors experience and provide medical service for people who otherwise would have to do without it. Careful consideration should be given to the long-term impact of this policy and the possibility of extending the length of rural service.
3.38 Changes in Job Assignments for Paramedicals: The new trend in medical practice throughout the world is to give responsibility to para- medicals and sub-professionals in medical practice. The new Medical Assist- ant Program in the United States exemplifies this trend. These medical assistants are undertaking many complicated tasks performed by physicians previously and they also work independently in isolated communities. The level of their education is not higher than the midwives in Tunisia. Similar projects are carried out in other countries employing persons with a very low basic education in health services. The rural health project of China is an example of a health project which is carried out successfully employ- ing sub-professionals. Possibilities of increasing the use of paramedical personnel and of using non-medical personnel should be reviewed periodically.
3.39 As described earlier, the responsibilities of midwives, nurses and nurse-midwives, in maternal and child health and family planning services should be extended and formalized and in-service training should be adopted accordingly. - 37 -
IV. INFORMATION, EDUCATION AND COMMUNICATIONS
4.01 The President of Tunisia has taken the lead in popularizing family planning. In speeches made in the capital, as well as during his frequent travels, he talks of population problems and family planning from many angles. He emphasizes the crucial role that population control has to play in the economic and social development of the country, and his new annual prize for the Governorate that is most successful in family planning work has created great interest and enthusiasm. The Minister of Health frequently pays visits to the regions and encourages the Regional Health Administrators to accel- erate the delivery of family planning services. The mass media support these efforts with a steady flow of articles, radio programs and television cover- age. Thus it is probably true to say that most adults in Tunisia know that family planning exists. Yet even after eight years, the idea is not accept- able to a great many people.
A. Organization
4.02 The responsibility for information, education and communication activities lies with the Promotion and Education Division, although a large part of the communication work will be carried out by the field workers of other ministries and national organizations. The Promotion and Education Division has three services: (a) Training, (b) Promotion, and (c) Education.
Training
4.03 The Training Service gives courses in family planning motivation as part of the training schemes of other ministries such as agriculture, labor, and social welfare. It organizes seminars in various parts of the country and introduces family planning and population topics into meetings organized by other bodies. The Training Section also has the responsibility for creating effective working relationships with the staff of other ministries who will spread the family planning message through the extension networks of agriculture, labor, social welfare, etc. This is being done in the field of population education by means of a joint working committee of the Office and the Ministry of Education. Given the pressures on people's time, inter- ministerial cooperation is not easy to achieve but the results could be of great importance to the whole program.
Promotion
4.04 The Promotion Service supplies the mass media with materials for public information about family planning and is concerned with what use they make of them as well as with the programs that the Ministry of Information produces on its own. The Promotion Service also organizes exhibitions all over Tunisia and controls the media production services, notably the printing press which publishes booklets, folders and family planning speeches. There are basic facilities and qualified staff for film and film slide production - 38 -
but, as yet they have not been much used. The Ministry of Information will provide the section with a producer and a TV camera -- the section already has a cameraman -- and it will make TV programs. Later, the programs will be filmed and used throughout the country by the regional educators.
Education
4.05 The Education Service spreads family planning information/education/ motivation throughout the country. A team of educators is being trained; by 1976 there will be one in each governorate. The educators will work out of the regional family planning offices and will be responsible both to the Office and to the Regional Health Administrator. Until the educators take up their posts, education is being carried out by two mobile teams working out of the Office headquarters. Each team visits a region for one or two weeks and, after having worked out a program with the administrator, it gives motivation training to the family planning field staff and to groups of people whose efforts could help the program.
B. Communication Activities
The Role of Communications and Mass Media
4.06 The media frequently transmit the family planning message and the Ministry of Information's radio service does this regularly in its Sunday prime time program for women. Television also has programs which refer to family planning but there is a difference of opinion among authorities as to how explicit such programs can be without offending the public. The view- ing audience is a large one because the Government encourages- importation of receiving sets. The press gives excellent coverage, but illiteracy limits its field of influence.
4.07 The latest Bank mission noted that the Government and the Office are now giving greater importance to the role of communications in the na- tional family planning program and to the long-term effects that can be achieved by a planned use of all means of education and information. This policy has evolved in conformity with a new approach to the subject of family planning and its relationship to the Tunisian people. Health, nutrition and mother and child care form the basis of, and will develop into, family welfare which will include family planning. There will be no major campaigns or shock tactics but instead the whole idea will be carefully considered and gradually built up through education and information. The central theme will be the importance of the family as the key factor in Tunisia's social development.
4.08 By putting everything relating to education and information under the Promotion and Education Division, it is now possible to draw up a long- term and detailed plan. Such a plan would be based on broad lines, would cover all channels of communication, set target dates for the various activi- ties and allocate responsibilities for carrying out the work. Broad lines - 39 -
are suggested since there is great awareness that the communication design must be flexible enough to adapt to changing circumstances. In an area where there are no delivery services the stress would be on family welfare only. In another area where services exist but the response is poor the trend could be towards the family planning elements of family welfare. In such an area there might be need for a local study of attitudes to discover the causes of resistance. The use of the mass media would have to be carefully evaluated as the program develops to ensure that the messages produced are in keeping with the situation as it exists at any given moment. The Promotion and Education Division can now watch all aspects of the communication program.
4.09 Once the impact of the mass media has been carried out the effec- tiveness of the work can be judged and future programs reshaped to improve their communication value. The mass media have an important role to play in keeping up general awareness and, even if the volume of production has to be changed to avoid over, or under, saturation, the need will still be there. This suggests a very close relationship between the Promotion and Education Division and the Ministry of Information.
Functions of the Educators
4.10 Apart from the mass media, the communication work in the field will be carried out by the educators. Their job will be to teach communications techniques to the paramedical staff, to train and encourage the field workers of other ministries and national organizations and, in general, stimulate interest in family planning in their region. They will need to be innovative in their work, find new approaches and pinpoint new sectors in need of family planning education. It will be very important that the monthly reports, already foreseen as part of their work, contain information that will be useful for program guidance at the Office. This feedback provided by the educators will be of paramount importance to the planners. The duties and responsibilities of the educators should be carefully defined in a job des- cription which will have to be agreed to with the Regional Health Administ- rators. The educators will work out of the new Regional Family Planning Centers which are being created and in each center there will be an education room. Each educator will have a film projector and materials for making simple visual aids.
Use of Audiovisual Aids
4.11 There were some indications that the educators and the extension workers in general are finding their audiences increasingly restive when subjected to the family planning message. At the same time, it is possible that the fieldworkers themselves, faced with an indifferent audience, are finding it more and more difficult to repeat the same message with enthusiasm.
4.12 Picture and sound would help to make the motivation work more effec- tive. The new program envisages greater use of audiovisual aids especially through the use of television programs/films; facilities for their use in the governorates has been arranged. It is probable that there will be a need for more materials than are as yet planned. Each educator should have a library which would probably consist of the following materials: - 40 -
a. Six fifteen-minute films in black and white, with sound, of a general family welfare character made in different regions in Tunisia.
b. Six films made in other Arab countries which in one way or another touch on family welfare/planning and dubbed into the Arabic best understood by the people.
c. Six technical films about contraceptive techniques, human reproduction, etc. These could come from any source as the narration would be given by the educator and the films would be educational and not motivational.
d. A series of sets of color film slides on family welfare and, for variety, on subjects of general Tunisian interest. These could be very useful in MCH centers.
e. Tapes could be prepared with programs which would include music, talks on family welfare/planning, and interviews with women who have adopted family planning. These also would be very useful in MCH clinics.
4.13 Because they entertain these materials would form the basis of a new audiovisual approach which would aim at attracting the attention of the audience. Other aids such as the flannelgraph, which is very effective especially with small groups, could be introduced. Illustrated printed materials would also have a part to play.
4.14 An experiment carried out at the Belle Vue Clinic waiting room where a mix of audiovisual aids was used to give information to the patients was a great success. Once the audiovisual material is available in each governorate the educator would approach the local MCH center and discuss with the staff the possibilities of using sound and picture to carry the message to the waiting women. It would be impossible to make an overall and standard plan for the use of audiovisual aids in all MCH centers as each one has its own individual characteristics. Nevertheless, the program could benefit from the use of what is at present wasted time; if the education program went for- ward hand in hand with a scheme for improving the reception at the clinics, the MCH centers could become important communication centers.
Personnel and Budget
4.15 The new and much more flexible approach to communications envisaged by the Office whereby specific kinds of media will be used for clearly defined but quite varied situations will require a wider variety of visual aids. Each will have to be made with certain types of audiences in mind -- urban, semi- urban, large rural agglomerations, country towns, scattered hamlets or con- servative groups, young people, men, returned emigrants, displaced youth, etc. Whether the Population and Education Divisions will have adequate staff and funds to plan and execute a highly-developed program is not clear. An elaboration of even a three-year plan (and in the case of audiovisual aid - 41 -
production this will only be a minimum period of what will be a much longer- term use) will require much time from photographers, film makers, graphic artists, sound program producers, printers, etc. The Three-Year Plan does not give budgetary allocations by division although it is noted that UNICEF will give some funds for audiovisual exhibition equipment. It would seem advisable that the Office give full consideration to the staff and budgetary implications of a planned communication strategy.
C. Media Research and Evaluation
4.16 The people of Tunisia have not yet accepted "en masse" the practice of family planning even though knowledge is widespread and services are within reach of many. Motivation of people towards a new practice is diffi- cult unless it is known what they think about it. Therefore, all communi- cation design must begin with research into attitudes. This does not mean long-term sociological studies but rather action-oriented research applied to identify people/problem areas. The results are then used as the basis for devising communication messages that will be effective.
4.17 New studies planned by the Population Division include some that will provide essential information as to what the Tunisian people are think- ing about family planning; since cooperation between the divisions in the Office is now assured, the Promotion and Education Division will be able to work with the Population Division to find the answers to many questions which will guide them in their education/information work. For example, it is accepted that the men, on the whole, are opposed to family planning. What are the reasons? Is it due to their personal interpretation of religious tenets? Is it the economic factor -- how much land; how many beasts, how many children needed to help? Or do they see it as undermining the masculine prerogative? The men appear to know very little about human reproduction and have been resentful when educators have tried to explain it. Does this behavior cover another sort of resistance? The women, on the whole, seem more ready to accept the idea that family planning is possible and might provide a relief from unspaced pregnancies and the problems of large families. But they are still slow to take action. Is this due to fear caused by swiftly spread stories about side effects or is it a fear of losing existing children through sickness and having none to replace them? And if each reason is part of a larger resistance what does this consist of and which is the more impor- tant of the two fears? If the real attitudes of both men and women were known a much more effective education/information pattern could be designed.
4.18 There has been very little evaluation of the effects of the many communication activities that have taken place in the past. While it can be said that no planned communication effort is likely to be entirely wasted, it would also be true to say that communication activities can only be truly effective if their effects are evaluated. This not only measures the effective- ness of the message but leads to decisions as to which of the media is making the greatest impact. Such judgments are most important as a means of assessing cost effectiveness. - 42 -
4.19 A rough and ready method of evaluation will be provided by the educators and the more they are taught about the techniques of evaluation during their training period, the more useful their feedback will be. They should be able to go beyond the first polite answer to a question and find out what the audience thought about the slide/film/radio program/home visitor's message. From time to time, a spot evaluation of the different kinds of communication could be made, e.g., the first television programs produced by the Office.
4.20 This work could be carried out between the Promotion and Education Division and the Population Division. Evaluation is an activity that is not always easy to put into practice in a family planning program. Producers find it difficult to accept an evaluation from outside and sometimes the results are rather unreliable if undertaken by the production unit. With the resources at its disposal, the Office should be able to find an answer to this problem.
D. Recommendations
4.21 The Office has adopted a new and progressive policy in the field of communications and all the elements for a strategic approach are present. Between them, the divisions can carry out research into people's attitudes toward family planning, translate the results into effective messages, produce audiovisual materials that will carry the message to the people, pre-test the productions, disseminate the materials throughout the country and evaluate the results produced through feedback. It would seem essential at this point for the Office to consider whether its personnal and budgetary resources are sufficient for the implementation of a full communication program.
4.22 Research into people's attitudes towards family planning must form the basis of all communication work. It will be necessary for the Popula- tion and Education Divisions to work closely together so that certain research studies are designed to give the media the material they need on which to base their messages.
4.23 The degree of effectiveness of all communications needs constant evaluation. It is suggested that the Office prepare a program for continuous evaluation either from within the Promotion and Education Division or by the Population Division. The yardstick given by the numbers of acceptors does not tell us why they became acceptors or whether there might not have been more if other approaches had been used.
4.24 The mission welcomed the growing liaison between the Office and the Ministry of Information. It is to be hoped that there will be an evalu- ation of radio and television programs to ascertain to what extent they are motivating the people. Fellowships for radio/press/television staff to visit programs in other countries would be helpful. It would also be helpful if - 43 -
study tours were to be arranged for officials responsible for media produc- tion -- press, radio and television -- so that they could find out what is happening in other countries and thus have a better understanding of the use of media in family planning programs.
4.25 A more comprehensive program of audiovisual aids production should be planned and started now. The full complement of educators will be in the field in 1977 and planning, financing and production will take at least two years before there is enough material to meet the demands of each educator who should have a library of films and slides.
4.26 After the educators have been in the regions for about a year, it should, with the help of the cooperating doctors, be possible to pinpoint those areas or groups of people where the message is most needed.
4.27 The educators should establish plans for using audiovisual aids of one kind or another in the MCH centers and should train the MCH staff to use them. Every MCH center in the country should have some form of education/ information entertainment in action by 1977. The postpartum program will also have special visual aid needs.
4.28 The projects supported by the UNFPA have communication elements in them and so will other projects related to the Office. It would seem sensi- ble that the Promotion and Education Division should gradually become the coordinating point for all family planning communication activities. - 44 -
V. EVALUATION AND RESEARCH
5.01 The 1973 Bank mission stated that the Office needed a good evalua- tion and research program to back up the efforts to reduce the country's fertility level. Such a backstopping is not only desirable for the develop- ment of a sound set of basic demographic parameters against which eventual family planning targets must be measured, but it is also an indispensable tool for the feedback of program operations.
5.02 The Tunisian National Program has had an evaluation unit since the start of its operations. Its main function was the production of monthly service statistics and with admirable regularity the successive organizations in charge of the program have turned out htese service statistics; occasion- ally papers on program performance have also been produced. The Office has for several years received technical assistance from the Population Council, Inc., which for three years seconded a demographer to the Office. Another Council adviser is now working on a Study of Continuation Rates of Pill and IUD Acceptors.
A. Production of Statistics
5.03 The statistics are based on information collected on standard forms which are filled out by the assistant nurse or assistant midwife in the MCH centers, hospitals and other health facilities where family planning services are offered. The assistant nurse (or midwife) fills out individual cards for each new visitor, which contains her bio-data, address, medical data and data on husband's profession. Each visitor is also entered in an Activity Register, which refers to individual cards and the treatment given. If the woman accepts an IUD, tubal ligation or abortion, another form is filled out. It is an arguable point whether this work places too great a burden on the staff of the clinics or not. When the program starts to make the real impact, which it is likely to do, the clerical work might become burdensome and at that point the temptation might be to get it done but not necessarily in the proper manner. This is a situation which will need reviewing.
5.04 The service statistics are collected once a month by the Regional Family Planning Secretariat and sent to the Central Office in Tunis. This system in general has worked well and quarterly results are published without much delay.
5.05 There is every indication that the results shown by the quarterly tables and the conclusions to be drawn from them are being fed back into the program and that, in the future, the conclusions will be more fully amplified for the benefit of all the divisions. - 45 -
5.06 Feedback is required for all levels of responsibility. Therefore, all fieldworkers will regularly receive statistical information accompanied by interpretative comments, indicating trends in performance. Results of each three-month period should be compared with previous quarters. Indica- tions of success mean encouragement for those involved and comparison of per- formance between regions may create a healthy competition among fieldworkers.
5.07 Although socio-economic and demographic data of acceptors have been collected occasionally, they have not been fully exploited. Studies based on a sample of individual cards are now under way. These kinds of studies may produce information on the characteristics of the program population as to age, education, socio-economic background, and parity at the moment of entering the program. This information should indicate whether there is a concentration of acceptors e.g., in a certain age-group or at a certain socio-economic level. On the basis of these results special recruitment target groups can be estab- lished.
B. Research Activities
5.08 The draft Three-Year Plan does not include evaluation and research but the 1974 program does. Research activities mentioned in the Plan are as follows:
(a) a national fertility survey and a knowledge, attitude and practice (KAP) study to be carried out over a two-year period, (the KAP study is meant to yield a better orientation to the information, education and communications activities);
(b) a survey on the continuation of contraceptive practice which is nearly complete (see Part II, para. 1.11);
(c) an evaluation of motivation and education campaigns;
(d) a training program to improve the collection of data;
(e) the cost effectiveness of the national family planning program;
(f) studies of attitudes toward abortion and tubectomy;
(g) the Tunisian people's attitudes toward family planning; It is specified that this will be more comprehensive than KAP studies;
(h) a survey of demographic research in Tunisia;
(i) a study on the effect of the Promotion and Education Program which is being carried out by means of meetings and personal contacts in two regions; - 46 -
(j) a law and population study (part of an international series of studies which aims at making suggestions to the legislature); and
(k) the measurement of the impact of the program on fecundity which is also part of a world-wide survey.
5.09 In addtion to these there will be the important "Study of the MCH/ Family Planning Centers" which will survey the work in the centers (which have been chosen), the attitudes of the people using them and the effect on the surrounding area. The results, it is hoped, will help the work being done by the centers, improve the quality of the services rendered and throw light on the psycho-social characteristics of the people using them. It will also produce indications as to why people do not go to the clinics. The study will be done on a sample basis.
5.10 The 1973 Work Plan envisaged a series of studies to be carried out with the help of the Family and Community Studies Center of the University of Chicago. This undertaking has been postponed and discussions will resume towards the end of 1975.
5.11 The Population Division Work Plan is comprehensive and could have great practical effects on the future program. The Division has as permanent staff three demographers (a sociologist, an economist, and a medical economist) plus a social-psychologist, together with two assistant statisticians. The reorganization of the Office has meant that it can also take on consultants and contract out to organizations such as the Center for Economic and Scientific Research.
C. Recommendations
5.12 The Population Division is staffed by capable personnel. The thorough and practical program envisaged is, at the same time, a large under- taking for what is a relatively small division. Careful planning, allocation of studies to specified people or organizations, and target dates will be essential if the program is to be achieved within a reasonable time. In the past it was a question of preparing an action-oriented research program. Now that this has been done the question is how to achieve it. It will mean determining priorities, and, in carrying out this task, it is hoped that the immediate and long-term needs of the program will be given priority (thus following the policy of the Office) and that the more peripheral studies will be contracted out.
5.13 The available research expertise in other national institutions (e.g., CERES, the National Statistical Institute, etc.) will be explored to the maximum. The population strategy of the country will need information about many areas which obviously lie beyond the scope of the Population Divi- sion. The Office should stimulate other institutions to undertake research - 47 -
in these broader fields. Furthermore, through stimulation and possible sub- vention of research outside the Office, more interest in population research will be awakened in these institutions.
5.14 The ONPFP's Bulletin is carrying information back to the field and the monthly meetings of the Regional Secretaries give an opportunity for briefings on research results. As a result of studies undertaken and feed- back from the field, the Minister of Health has put out a circular asking for better treatment of clients when they arrive at the clinics. If the present research and evaluation policy is continued there will be other immediate benefits to the program.
5.15 There is the need for training more demographers and population specialists. Assigning research projects to educational institutions pro- vides the students with an opportunity to gain experience in these fields. Fellowships in demography and related disciplines for training outside the country should be actively sought by the Office and made available to suit- able candidates of the schools of economics, sociology, and social work and to the staff of medical and paramedical training institutes.
5.16 The second Bank mission was pleased to find that research and evaluation have been given a new and practical impetus since December 1973. - 48 -
VI. PERSONNEL, SUPPLIES AND TRANSPORTATION
6.01 The Administration Division has two sections: (a) Personnel and (b) Services. The Services Section deals with procurement and distribution of supplies and transportation. Both sections have been completely reor- ganized since 1973 but it was in the Services Section that the draft sector review needed to be completely updated since all its recommendations are now in practice.
Personnel
6.02 This section was not reported on in the draft sector review. The staff of the Office is comprised of four administrative categories:
(a) regular staff who are integrated into the public service;
(b) medical staff who fill posts provided permanently by the Ministry of Public Health and funded by the Ministry;
(c) contract staff who are not integrated; and,
(d) consultants who are taken on according to needs.
The Office feels that it now has sufficient staff and that the present system is flexible enough to meet any demands required by the program in the future.
Supplies and Transportation
6.03 The reorganization of the Office has been accompanied by more delega- tion of authority which makes it possible for the Supply and Transportation Section to purchase supplies. No longer does every minor purchase order need to cross the PDG's desk as in the past.
6.04 Since the relations with the Regional Health Administrators have improved and there is now in each region a coordinating doctor and a Regional Secretary working for the Office, supplies to the field have been regularized.
6.05 The list of medicines and drugs in the Office inventory has been reduced, thus making procurement and distribution much simpler. The draft review suggested that all medical supplies would be better placed under the Central Pharmacy to avoid the need for a separate system to deal with the Office supply work. The present system is considered to be more easily controlled and flexible and therefore, more responsive to the changing demands of the program.
Repair of Equipment and Vehicles
6.06 There was a serious problem related to the repair of medical equip- ment utilized in the family planning program. The repair shop of the Ministry of Health was not equipped to handle repairs for the Office in an expeditious manner. This situation is now being dealt with. - 49 -
6.07 An inventory of all vehicles has been made and they have been graded; all those which could be usefully repaired have had the work done and the others have been scrapped. The transport needs have been assessed and new vehicles have been purchased which, together with those being provided by UNICEF would provide sufficient transport for future needs. A system has been introduced whereby office staff will give reasonable warning of their transport needs.
6.08 A transportation officer has been appointed, together with a permanent mechanic, and at present, a workshop, a garage and a car park are under construction.
ANNEX 1
Tunisia: Enumerated Population in Censuses, 1891 - 1966
Census Total Other Year Population Tunisian French European Other
18911/ 9,973 18961/ 16,207 - 19011/ 24,201 - 19067/ 128,895 - 34,610 94,285 - 19112/ 148,476 - 46,044 102,432 - 1921 2,093,939 1,874,981 54,476 101,639 62,843 1926 2,159,708 1,919,151 71,000 102,281 67,276 1931 2,410,692 2,143,010 91,427 103,966 72,289 1936 2,608,313 2,325,235 108,068 105,137 69,873 1946 3,230,952 1956 3,783,169 1966 4,533,351
1/ French population enumerated only.
2/ European population enumerated only.
Sources: 1. Picouet, Michel: Les Sources de la Demographic Tunisienne A 1'Epoque Contemporaine, Institut National de la Statistique, Tunis 1972.
2. U.N. Demographic Yearbook, 1970, Table 7; New York 1972. ANNEX 2
Tunisia: Percentage of Women Married as Reported in the 1956 and 1966 Tunisian Censuses, Classified by Age
Percentage of Women Married Percentage of Ae 1956 1966 Change
15-19 39.8 18.5 -21.3
20-24 76.8 71.1 - 5.7
25-29 89.1 88.5 - 0.6
30-34 90.6 92.4 + 1.8
35-39 88.0 91.8 + 3.8
40-44 82.9 87.9 + 5.0
45-49 72.2 81.8 + 9.6
50-54 62.3 70.4 + 8.1
Source: Lapham, Robert J., "Family Planning and Fertility in Tunisia," Demography, Volume 7, Number 2, May 1970. Tunisia: Family Planning Program Activities and Percentage of Change 1964-1973
Year First IUD New Pill % Pill 7 Condom 0 Tubal Social Insertion Change Acceptors Change Users Change Users Change Ligations Change Abortions Change
1964 1,154 - - - 25 - - - 293 - -
1965 12,832 - 343 - 143 - 538 - 384 - 342 -
1966 12,077 -6 350 +2 208 +45 423 -27 766 +99 1,396 +294
1967 9,657 -20 591 +69 290 +39 402 - 5 742 - 3 1,331 - 5 1968 9,304 - 4 4,780 +709 1,779 +513 943 +135 1,627 +119 2,246 + 69 1969 8,696 7 - 7,867 + 65 4,181 +135 1,558 + 65 2,513 + 54 2,860 + 27
1970 9,638 +11 9,959 + 27 6,285 + 50 2,254 + 45 2,539 + 1 2,705 - 6 1971 12,381 +28 11,778 + 18 7,612 + 21 2,237 - 1 2,280 - 10 3,197 + 18
1972 13,250 + 7 12,026 + 2 8,248 + 8 2,228 + 2 2,459 + 8 4,621 + 45 1973 16,790 +27 11,194 - 7 8,199 - 1 2,125 - 7 4,964 +102 6,547 + 42
Source: Statistical Service, National Family Planning Program. ANNEX 4
Tunisia: Births Averted According to Method and Year, 1965-1971
Tubal Year IUD Pill Condom Jelly Litigation Abortion Total
1965 205 8 33 17 34 - 297
1966 2,878 53 160 56 128 755 4,030 1967 5,120 56 119 35 284 898 6,512
1968 6,102 107 138 32 442 1,103 7,924 1969 6,526 747 349 65 734 2,000 10,421
1970 6,889 1,396 510 88 1,237 2,015 12,135
1971 5,394 1,h43 512 76 1,234 1,114 9,773
Total 33,114 3,810 1,821 369 4,093 7,885 51,092
Source: Cuca, Roberto, Evaluation of Family Planning Programs Using Service Statistics, International Bank for Reconstruction and Development, Working Paper No. 137, November 1972. ANNEX 5
Tunisia: Contribution of Each Method to the Number of Births Averted, 1965-1971 (in percentage)
Tubal Year IUD Pill Condom Jelly Litigation Abortion Total
1965 69 03 11 06 11 - 100
1966 72 01 Oh 01 03 19 100
1967 79 01 02 00 Oh 14 100
1968 77 01 02 00 06 14 100
1969 63 07 03 01 07 19 100
1970 57 11 0 01 10 17 100
1971 55 15 05 01 13 11 100
Average 65 07 oh 01 08 15 100
Source: Cuca, Roberto, Evaluation of Family Planning Programs Using Service Statistics International Bank for Reconstruction and Development, Working Paper No. 137, November 1972. Tunisia: Projection of Births To Be Averted By Method And By Governorate For 1975
Secondary Social Total Births Governorate IUD Pill Methods TubectorV Abortion to be Averted
Tunis 2,864 515 289 1,652 3,000 8,302 Bizerte 710 132 100 1,077 600 2,619 B6j 44 177 15 1,159 353 2,148 Jendouba 509 99 35 847 150 1,640 Le Kef 748 90 13 565 225 1,641 Kasserine 112 29 18 23 75 257 Gafsa 254 123 64 11,112 330 883 M6denine 131 74 68 152 150 555 Gab6s 227 281 26 70 225 829 Sfax 1,085 145 418 737 750 3,135 Kairouan 245 39 36 237 202 759 Sousse 1,076 215 129 825 1,o65 3,310 Nabeul 650 81 184 268 375 1,558
Total of Births to Be Averted 9,037 2,000 1,375 7,724 7,500 27,636
1/ Projection based on the mean average.
Source: National Office of Family Planning and Population. C7 ANNEX 7
Tunisia: Family Planning Centers, 1972
Governorate Population Area Number of Population Area Served 2 (in thousands) (Km2) Centers per Center by Center (Km2
Tunis 1,181 5,579 h2 28,119 132.8
Bizerte 325 3,604 28 11,607 128.7
B6jA 304 5,341 22 13,818 242.8
Jendouba 280 3,031 17 16,471 178.3
Le Kef 343 8,063 20 17,150 403.2
Kasserine 231 9,130 10 23,100 913.0
Gafsa 375 18,400 13 28,845 1,415.4
M6denine 269 56,354 19 14,158 2,966.0
Gab6s 228 29,150 32 7,125 910.9
Sfax 497 8,834 38 13,079 232.5
Kairouan 303 6,978 27 11,222 258.4
Sousse 607 6,138 36 16,861 170.5
Nabeul 338 3,008 23 14,696 130.8
Total 5,281 163,610 327 16,150 500.3
Source: Internal Document Population Division. ANNEX 8
Tunisia: Occupancy Rate and Duration of Stay in Hospitals, 1971
No. of Occupancy Rate Duration of Stay No. of Hospital (Percentage) (days) Type of Hospital Hospitals Beds General Ob/b General Ob/Gyn
Institutes 4 1,095 85.1 - 26.8 -
Specialized Hospitals 5 1,497 95.3 - 66.1 -
Principal Hospitals 7 4,755 75.9 72.2 10.9 2.9
Regional Hospitals 12 2,876 76.1 87.0 8.6 3.8
Rural Hospitals 54 2,272 56.9 38.0 7.0 2.9
Maternity Homes 7 76 26.6 26.6 3.1 3.1
Total 89 12,571 75.4 65.1 11.6 3.2
Source: Statistiques 1971, R6publique Tunisienne, Ninist6re de la Sant6 Publique, Service Central des Statistiques Sanitaires. ANNEX 9 Tunisia: Distribution of Maternity Beds Page 1 of 2 in Hospitals
General Hospitals Regional Hospitals
Establishments No. of Beds Establishments' No. of Beds
Charles Nicolle 120 Bizerte 38 B6jA 78 Habib Thameur 106 Jendouba 3) Le Kef 46 Aziza Othmana 95 Kasserine a Gafsa 16 Menzel Bourguiba 71 M6denine 12 Gabes 20 Sousse (general hospital) 72 Kairouan 33 Mahdia 16 Sfax (general hospital) 75 Monastir 21 Nabeul 4C
539 362 District Hospitals
Charles Nicolle M&denine La Marsa 25 Djerba 12 Tataouine 16 Ernest Conseil ?6bourba 4 Gab4s K6bili 8 Habib Thameur Zaghouan 8 Sfax Pt. du fahs 3 Mahres 6 Kerkeuuah 2 Djebeniana 6 Bizerte Ras Djebel 7 Mateur 16 Sousse EnfifidLa 7
Mesjez El Bab 8 Monastei Gaafour 5 Ksar hellal 13 Teboursouk .7 Moknine 12 Bouarado 6 Djemnel 9
Jendouba Bou Salem 12 Nabeul Tabarka 8 Grombalia 8 Ghardimaou 7 Menzel Temime 20 Ain Drahem 15 Beni Ilalled 7 Menzel Bon Zelfa 7 Kelibia 10 Le Kef Maktar 5 Gafsa 'oseur 15 Matlaoni 8 Redejef 15 Gammouda 15 Moulares 5 ANNEX 9 Page 2 of 2
Tunisia: Distribution of Maternity Beds in Independent Hospitals
Hospitals No. of Beds
Nefza 5
Testour 15
El Djeum 15
Hammamet 10
Solimian 7
Korba 18
Kalaa K6bira 5
75
Total Number of Beds = 1,313
Source: Dr. Rejeb-Ministry of Health, attached to the Office. ANNEX 10
Tunisia: Distribution of Hospital Beds and Utilization for Maternity and Gynecological Cases
Number of Rate of Rate of Number of Percentages Beds per Bed Occupancy Bed Occupancy Births of 10,000 for General for Ob/Gyn Registered Births in Governorate Population Inhabitants Medicine (W) (%) in Hospitals Hospitals
Tunis 1,104 45.1 82.8 73.2 19,382 55.0 Bizerte 333 32.2 67.7 64.4 3,830 36.0 B&jA 307 16.0 62.2 61.5 2,h11 26.0 Jendouba 283 15.3 75.3 58.o 2,513 28.8 Le Kef 349 18.5 76.9 138.2 1,346 11.8 Kasserine 347 6.6 55.5 125.5 503 7.0 Gafsa 378 13.3 56.3 38.8 2,544 16.7 M6denine 272 14.0 63.4 85.0 1,398 12.1 Gabes 235 17.6 64.9 66.5 1,795 18.2 Sfax 484 19.6 79.2 62.9 5,109 32.5 Kairouan 324 14.9 78.0 98.0 1,332 10.7 Sousse 590 22.7 78.7 47.1 8,768 40.6 Nabeul 335 21.2 63.8 46.9 5,087 41.7
Total 5,241 24.0 75.4 65.1 56,018 30.6
Source: Central Statistical Service of the Ministry of Public Health, 1971. ANNEX 11
Tunisia: Activities of MCH Centers, 1971
Prenatal Postnatal Child Care (sick and healthX children) Governorate Examinations Examinations 0-1 years 1-6 years New Cases
Tunis 17,408 1,126 120,038 183,645 27,167
Bizerte 4,134 123 24,419 35,840 10,038
BAjA 1,261 14 12,093 18,782 4,216
Jendouba 583 25 8,584 25,815 5,402 i,e Kef 4,30 1,163 8,762 12,188 2,760
Kasserine 260 74 11,488 14,982 3,957
Gafsa 2,964 1,374 14,404 15,922 7,307
MC-denine 1,177 121 9,664" 8,163 383
Gabes 1,728 25 20,321 18,594 7,145
Sfax 4,488 680 25,928 33,685 7,322
Kairouan 835 23 8,227 13,259 3,198
Sousse 7,825 505 26,810 24,358 7,491
Nabeul 6,597 438 22,642 41,752 7,491
Total 53,563 5,691 313,160 446,995 93,878
Source: Central Statistical Service of the Ministry of Public Health, 1971. ANNEX 12
Tunisia: New Family Planning Acceptors by Health Region, 1973
New IUD New Pill Tubal Social Governorate Insertions Acceptors Condoms Jelly Ligations Abortions
Tunis (North) 324 135 224 136 31 231
Tunis (South) 28 23 35 2 - -
Bizerte 74 35 92 22 14 32
Menzel Bourguiba 37 37 43 1 8 15
BejA 87 44 16 15 19 30
Jendouba 34 17 25 31 137 25
Le Kef 139 64 23 9 9 27
Kasserine 2 33 19 15 3 8
Gafsa 12 47 69 12 2 6
M&denine 12 68 78 15 7 2
Gabes 4 82 36 16 - 2
Sfax 99 55 570 59 18 41 Kairouan 34 20 44 31 4 15
Sousse 71 68 79 9 11 17
Monastir 18 37 62 22 4 6
Mahdia 10 7 40 9 8 2
Nabeul 100 28 191 70 15 24
Total 1,085 800 1,646 474 290 483
Source: Service Statistics, National Office for Family Planning and Population. ANNEX 13
Tunisia: Objectives for the Year 1974,by Governorate and by Method
Tubectomy Minimum Medium Maximum Governorate IUD Pill Social Abortion Assumption Assumption Assumtion
Tunis South 3,300 3,000 4,000 820 1,776 2,000
Tunis North 800 150 ------
Bizerte 1,400 500 800 1,240 2,484 3,000
B&jA 600 1,200 470 740 1,0h 1,800
Jendouba 850 600 200 620 1,732 1,500
Le Kef 1,240 400 300 820 1,048 2,000
Kasserine 300 100 100 80 48 200
Gafsa 560 450 -- 100 188 250
Sidi-Bouzid 130 100 440 ------
4'denine 330 250 200 120 240 300
Babes 570 1,700 300 310 216 750
Sfax 2,780 800 1,000 1,030 1,808 2,500
Kairouan 570 200 270 410 824 1,000
Mahdia 570 200 200 430 632 1,040
Sousse 600 650 850 2,350 1,008 5,700
Monastir 1,200 300 370 640 616 1,560
Nabeul 1,100 400 500 1,030 416 2,500
Total 17,000 11,000 10,000 10,740 14,080 26,100
Minimum Assumption: to attain the 1974 objectives and make up for the delays of 1973. Medium Assumption: extrapolation of the results of the first quarter of 1974. Maximum Assumption: to reach the targets agreed with the Ministry of Public Health.
Source: National Office of Family Planning. Tunisia, Family Planning Activities by Category of Center, 1972
Category New IUD Insertions New Pill Acceptors Tubectomies Social Abortions Consultations of Center No. No. No. No. No.
Principal and 2,788 21 1,334 10 2,250 92 3,455 75 11,589 27 Regional Hospitals
Auxiliary and 930 7 1,753 14 49 2 32 1 4,204 10 District Hospitals
MCH Centers 5,255 h0 5,732 45 6 - 232 5 15,208 35
Communal 846 7 1,334 10 - - - - 3,531 8 Dispensaries
Rural Dispensaries 1,101 8 1,719 13 6 - 3 - 4,011 9 and Mobile Teams
Others 2,207 17 1,005 8 146 6 881 19 4,847 11
Total 13,127 100 12,877 100 2,457 100 4,603 100 43,390 100
Source: Internal Document of the Office.
fr'; ANNEX 15 Page 1
Tunisia: Some Thoughts on Training and Employment of Health Workers
(a) Community health workers should be recruited from the community where they will work after being trained.
(b) They should be trained in giving advice for antenatal and postnatal care, childcare and feeding, as well as in the need for family planning, and in the methods of contraception and first aid. They may also be trained in home economics. In this case their service becomes more appreciated by the public and they are most influential in convincing women.
(c) The training may be given in nearby centers. The number and duration of the courses may be decided according to the local condition.
(d) Community health workers should be a member of a health team and supervised closely.
(e) On-the-job training is essential in order to increase the quality of their service.
(f) Community health workers should be part-time workers so that they can carry out their own housework and the home visits efficiently.
(g) The monthly salaries could be between 15 to 20 TD for two hours work per day.
(h) The supervision and evaluation of the work of a community health worker may be done by checking the records of the center. If the pregnant women and children come to the center regularly and follow the health worker's advice, this indicates that the community health worker is doing her job satisfactorily.
(i) Monthly instruction and on-the-job training meetings could be given to the community health workers.
(j) It would be necessary to nominate inspectors who could visit community health workers on the spot to check their work. ANNEX 16 Page 1 of 2
Tunisia: The Case for a Multipurpose Organization in the Provision of Family Planning Services
This report argues that the creation of multipurpose health units serving populations of an appropriate size and connected to hospitals is the most efficient and effective system for fertility control. This view is based on the following observations:
(a) Unipurpose models which have proved to be very successful in the control of health hazards are not appropriate for the control of fertility because the latter requires a continuing relationship between the staff and the public. This relationship between staff and public becomes weaker as the size of the population served increases. Since unipurpose workers have to be assigned larger populations than multipurpose workers in order for them to utilize their full working capacity, they cannot develop the desired staff/public relations.
(b) Nurse midwives or auxiliary nurse-midwives (ANM) who are paid by the government and who serve in a district which has a population of the appropriate size are the best family planning workers. They gain the full confidence of the people because they are in close and continuous contact with all the members of the families with whom they work and because they are also frequently regarded as community leaders in the villages where they reside.
(c) The most effective method for educating women as well as men in family planning is continuous face-to-face education. Frequent house visits give ANMs the opportunity to practice this type of motivation more than other workers.
(d) The antenatal and postpartum periods are the most effective times for pursuing family planning education. ANMs are in close contact with women during these periods. Infant care, which is part of their responsibilities, also allows them the opportunity to extend educational activities over a longer period of time to women who have delayed accepting and practicing contraception.
(e) One of the basic rules in adult education is to link the subject to education with the needs of the person. The ANMs are regarded as authorities in health matters by most of the public, especially in rural areas. Therefore they can easily link contraception with the health of the mother and her child. ANNEX 16 Page 2 of 2
(f) Women in conservative societies because of cultural values, may not like it to be known that they are visited by family planning workers. Therefore, they will prefer to get advice in family planning from multipurpose workers.
(g) It is a known fact that the distance between the house of the patient and the surgeries or health centers has a great effect on the frequency of patient calls, especially in rural areas. Consequently, the service should be made available to people as near as possible to their homes, or even within their homes if necessary. This is especially true for family planning services. The distance problem is,one of the main reasons that clinics established in towns and cities have failed to serve rural population properly. Mobile teams have been created to overcome this difficulty. However, the efficient use of mobile teams requires the presence of resident workers in the communities, such as ANMs.
(h) High levels of performance from ANMs depends on their being members of a health team, on the close supervision of their activities, on their being trained on the job continuously, and on their being supported morally as well as technically. Considering the above, the establishment of a team composed of ANMs, supervising nurses and physicians -- or at least a medical assistant -- will help to bring the services to a satisfactory level.
(i) Patient care should be an integrated part of maternal and child health services in developing countries not only to increase the health level and survival chances of mothers and children but also to maintain and increase the prestige of the ANM and her team which is essential for the success of family planning programs.
(j) The efficiency of community health units will be increased considerably when they are affiliated with a hospital. In addition to the betterment of patient care, this alliance also makes the performance of abortions and sterilizations possible under improved conditions. The availability of the facilities for abortion and sterilization promotes the success of family planning programs even in countries where abortion and sterilization are not used as routine methods of fertility control. AMEX 17
Tunisia: Geographical Distribution of Physicians, 1973
Physicians 1/ Public Sector Physician/ Governorate Population- In Private Part- Full- Number of Physicians Population (in thousands) Practice time time Tunisian Foreign Total Ratio
Tunis 1,181 68 118 265 297 154 451 2,529
Bizerte 325 h h 40 9 39 48 7,104 Béjà 304 1 2 18 h 17 21 14,857
Jendouba 280 2 - 19 3 18 21 9,198
Le Kef 343 3 1 25 6 23 29 12,241
Kasserine 231 - 1 10 1 10 11 23,090 Gafsa 375 h - 29 3 30 33 11,818
Medenine 269 3 2 15 5 15 20 13,850
Gabes 228 - h 15 h 15 19 12,63 Sfax 497 10 1h 47 2h 37 61 8,081
Kairouan 303 1 - 17 3 15 18 18,44 Sousse 607 6 10 60 30 46 76 7,894
Nabeul 338 1 2 35 16 22 38 9,052
Total 5,281 103 158 585 405 441 846 6,335
1/ As of January 1971.
Sources: 1. Profils Démographiques, Socio-Economiques et Sanitaires Regionaux - République Tunisienne, Ministère de la SantePublique, INPF et PM (p.>).
2. Recensement du Personnel de Santé, 31.12.1972, Ré'publique Tunisienne, Ministère de la Santé Publique, Service Central des Statistiques (pp.5, 8 and 10). ANNEX 18
Tunisia: Tunisian and Foreign Physicians by Speciality, 1972-'
Tunisians Foreign Total Speciality Male Female Total Male Female Total Male Female Total
General Practice 64 1 65 75 38 113 139 39 178
Obstetrics and Gynecology 31 3 34 23 13 36 54 16 70
Pediatrics 33 6 39 15 25 0 48 31 79
Public Health2-/ 17 1 18 19 19 38 36 20 56
Others 189 6 195 131 34 165 320 40 360
Total 334 17 351 263 129 392 597 146 743
1/ Working for the Ministry of Health.
2/ Breakdown: 9-Health Administration, 14-Preventive Medicine and Epidemiology, _-Occupational Health, 25-School Health, and 3-Nutrition.
Source: Recensement du Personnel de Sante au 31.12.1972, Republique Tunisienne, Minist'erede la Sante* Publique, Service Central des Statistiques (p.17). ANNEX 19
Tunisia: Students in Tunis Medical School by Class, 1964-74
Undergraduate Classes Interns Academic Year 1st 2nd 3rd 4th 5th 1st 2nd
1964-65 59
1965-66 85 48 1966-67 81 64 39
1967-68 94 64 41 33
1968-69 156 75 54 40 24
1969-70 187 123 59 48 34 24
1970-71 259 138 96 44 34 32 24
1971-72 333 218 111 72 30 34 32
1972-73 334 297 179 85 55 30 34
1973-74 329 273 250 138 66 54 30
Source: Guide d' Etudiant, Ann6e 1970-71, Faculte de Medicine, Universite de Tunis (p.94) and Archive of the School for the last four years. ANNEX 20
Tunisia: Geographical Distribution of Midwives, Nurses and Nurse-Aides, 1972
Population Per Governorate Population Midwives Nurses Nurse-Aides Associate 1/ (in thousands) Professionals-
Tunis 1,181 58 952 1,299 512 Bizerte 325 10 118 165 1,109 B6ja 304 7 42 158 1,469 Jendouba 280 5 37 124 1,687 Le Kef 343 6 21 164 1,796 Kasserine 231 2 42 83 1,819 Gafsa 375 5 58 127 1,974 M6denine 269 6 64 85 1,736 Gabbs 228 5 85 126 1,056 Sfax 497 9 181 223 1,203 Kairouan 303 3 29 70 2,971 Sousse 607 21 279 415 849 Nabeul 338 13 95 183 1,162
Total 5,281 150 2,003 3,222 983
Population per Associate Professionals 35,207 2,637 1,639 -
Associate Professionals per Physician 0.18 2.36 3.80
1/ Base population is the estimated population for January 1972.
Source: Recensement du Personnel de Sant6 on 31.12.1973, R4publique Tunisienne, Ministere de la Sante Publique, Service Central des Statistiques (pp.25-26 ). ANNEX 21
Tunisia: Graduates of Nursing and Midwifery Schools, 1960-74
Year Midwives Nurses Nurse-Aides Total
1960 17 52 61 130 1961 18 55 203 276 1962 8 68 293 369 1963 8 77 278 363 1964 11 70 89 170 1965 7 112 240 359 1966 10 119 303 432 1967 131/ 129 350 492 1968 8i 110 262 380 1969 121' 78 125 215 1970 6 131 257 394 1971 22 205 612 839 1972 21 271 372 664 1973 43 258 248 549
Total 201 1,735 3,693 5,632
197)4Y 61 109 230 400
1/ Nurse/midwives.
2/ Estimated.
Source: National Office of Family Planning.
TUNISIA: ORGANIGRAM OF THE NATIONAL OFFICE OF FAMILY PLANNING AND POPULATION
The President Director General
Control and Coordination Documentation Center Center
IAdministration of the IDA Project
Administrative Division AccoutingPromotion1 Population Division and Personnel accountingCooperation Medical and Budget I DEducation Research Supplies Division Division Evaluation Division IIDivision Transport E I Statistics
World Bank-9490
TUNISIA: ORGANIGRAM OF THE FAMILY PLANNING AND MATERNAL AND CHILD HEALTH SERVICES IN A GOVERNORATE
Regional Hospital Administrator
Regional Secretary and Coordinating Doctor
. Regional Chief of MCH anc, FP Services
Ob/Gyn. Supervisor Educator Administration Statistician -Pediatcan Midwife a Midwife * (to be posted)
Staff in the Center Medical Secretary Auxiliary Nurse andSupersor Mobile Team and Midwives Statistical Clerk I
Community Workers 11 d
Permanent Staff
L - - - j Itinerant Staff L ... 1World Bank-9491