First published in ITIJ 108, January 2010
Robin Gauldie has the details of how a tourist in need of medical help could be pleasantly surprised by the services on offer in Tunisia
When my girlfriend fell ill late at night with sudden, agonising stomach cramps on a recent holiday in Tunisia, our hotel conjured up a courteous, competent local doctor in a matter of minutes. His diagnosis was swift, and professional: no hospital treatment required. Had it been necessary, there was an international-standard private clinic just minutes away.
This level of competence and efficiency is one of Tunisia’s less obvious selling points. More obvious sales angles include Mediterranean beaches, a clement climate, and cultural attractions that range from the ruins of ancient civilisations to bustling bazaars and age-old mosques. But a high-quality health infrastructure is become a more important element in Tunisia’s overall tourism marketing strategy.
A growing market
Overall, this is a reassuringly safe destination for the holidaymaker. There is little violent crime, and levels of petty theft are relatively low. Erring on the side of caution, the UK Foreign and Commonwealth Office notes a ‘general threat’ from terrorism, but there have been no major acts of terror since the bombing of a synagogue on the holiday island of Djerba in 2002, which killed 19 people, including a number of German tourists. Tuberculosis is present, as is HIV, but the HIV prevalence rate is half that in the UK, according to the World Health Organization. Road safety is a matter of somewhat greater concern. Roads are generally good, except in the deep desert hinterland, but poor driving standards and a general disregard for safe speed limits contribute to 11,000 accidents and around 1,500 deaths a year.
The country has built a successful tourism industry by offering Europeans guaranteed sunshine with a whiff of the exotic, only a short-haul hop away from home, and at a very attractive price compared with rival destinations around the shores of the Mediterranean.
Overall visitor numbers have trended steadily upwards in recent years, from 6,378,500 in 2005 to 7,049,700 in 2008, though the numbers available for the first 10 months of 2009 indicate a downward blip last year as a result of the world economic crisis. France is Tunisia’s largest tourism market, with French visitors spending 9,157,000 nights in 2008, followed by Germany (6,099,000 nights); Italy (3,007,000) and Britons (2,528,000).
Tourism is Tunisia’s biggest foreign currency earner, and also employs up to 17 per cent of the workforce.
For at least one of these key European markets, price has become an even more important factor since the start of the global economic crisis. The Sterling’s poor performance against the Euro and the US dollar sent British holidaymakers in search of destinations with softer currencies, but still close to home. In 2009, many Britons hoping for bargain shopping, eating and drinking in some destinations just outside the Eurozone – notably Turkey and Egypt – were disappointed to find that price hikes by greedy local entrepreneurs wiped out any exchange rate advantages that the pound might have had over local currencies.
There is little violent crime, and levels of petty theft are relatively low
Not so in Tunisia, where the cost of most holiday extras reminds British holidaymakers of the good old days when the pound sterling bought more abroad than at home. Perhaps surprisingly in a predominantly Muslim country, even alcoholic drinks are significantly cheaper than in the UK or in most holiday destinations within the European Union. Alcohol isn’t as ubiquitously available as it is in many non-Muslim countries, but it is not demonised. Tunisia produces not only its own beer and spirits, but some perfectly drinkable wines.
Other peccadillos are given the nod, too. Gambling is legal, with casinos in key tourism hot spots such as Hammamet, Djerba and Port el Kantaoui. This certainly isn’t Las Vegas (still less, Bangkok) – but it is a tolerant, relaxed Muslim country where visitors from more restrictive Muslin nations can come to unwind without fear of religious censure.
Their numbers are set to increase. In 2005, Tunisia started a programme of incentives to encourage foreign companies to invest in developments in its established tourism areas. The result has been a flood of investment from the Middle East and Turkey into a wide array of major infrastructure projects, a new marina at Bizerte, and a huge ‘cultural city’ near the Tunis waterfront. Century City, built on 1000 hectares, represents a US$25-billion investment and when complete will be twice the size of London’s Canary Wharf, comprising housing for half a million people, office space for 2,500 companies, and 14 luxury hotels and resorts.
Other projects a new 20,000 bed tourism resort at El Ghedhabna, intended to be the second biggest resort in Tunisia after Hamamet. However, much of the investment for these ambitious projects comes from Dubai, which is the largest foreign investor in Tunisia, and it is not yet clear what impact the emirate’s current financial woes may have on their progress.
In May 2009 the government announced the world’s third-largest spa resort at Monastir. Spa treatments and thalassotherapy (using salt water and natural marine products) have already become big business, with more than 150,000 European visitors to Tunisia’s thalassotherapy centres in 2007, making it the second favourite destination for such treatments (after France).
The first phase of a new international airport at Enfidha, midway between Tunis and Monastir and built by the Turkish developer Teke Apfen Ventures, opened in November 2009 and can handle up to four million passengers annually. When complete, it will be the largest airport in Africa, and a new ‘open skies’ strategy for Tunisian aviation means it could be receiving low-cost flights from Europe and the Middle East and ushering in a new boom era for tourism.
For now, however, the bulk of Tunisia’s most lucrative holiday business remains very firmly in the hands of just a few major European tour operators. Chief among them are the multinational conglomerates Thomson/TUI and Thomas Cook, which between them control the lions’ share of package holiday markets in Britain and Germany, two of Tunisia’s four big markets. As a result, many British, German and other European travellers to Tunisia are likely to buy their holiday insurance from one of the giant tour operators as part of their holiday package, leaving slim pickings for independent travel insurance providers.
Medical care in Tunisia is adequate for routine problems but specialised treatment may not be available, notes the travel health information web site www.MDtravelhealth.com.
Ambulance service is provided by Service d’Aide Medical Urgente and by several private ambulance firms, and the US Embassy lists five emergency medical facilities in Tunis, including the Military Hospital.
Medical care in Tunisia is adequate for routine problems but specialised treatment may not be available
Most expatriates use the increasing number of private polyclinics, which function as simple hospitals. Most of these are likely to require payment in cash, regardless of whether the payor has travel health insurance, so in some cases insurers may need to facilitate this for their clients.
Serious medical problems may call for air evacuation to a country with state-of-the-art facilities. In practice, this is likely to mean France, which is less than an hour’s flying time from Tunis.
Medical evacuation services within Tunisia are provided by charter company Tunisavia, which is part owned by national carrier Tunis Air and which has recently added two new Dauphin 365N3 helicopters to its fleet.
Tunisia’s record of investment in its health infrastructure is not unimpressive, with public spending accounting for 75 per cent of total healthcare expenditure.
Out of a population of 10,315,000, 65 per cent live in the country’s major towns and cities (with more than 2.3 million living in Tunis, the capital and the biggest city) and 95 per cent have access to local health services. Total public expenditure on health is around $488 per capita, equivalent to 5.3 per cent of GDP, according to the World Health Organization. Life expectancy is 70 years for men and 75 for women, indicative of an adequate level of nutrition and healthcare.
Public health expenditure as a percentage of the state budget has declined in recent years, shrinking from eight per cent in 2003 to 6.8 per cent of the budget in 2007, the last year for which official statistics are available. Over the same time, the number of hospitals increased from 168 to 172, with 17,998 beds available in 2007.
The number of inhabitants per surgeon decreased slightly over that time period, from 1,038 in 2003 to 968 in 2007, but the number of people per doctor increased significantly, from 8189 in 2003 to 10,554 in 2007.
(Source: Tunisian Ministry of Public Health).
In 2007 a new health insurance system came into effect, with the number of insured persons reaching 3,220,622 and health coverage expenses increasing to 634.6 million dinars (21.2 per cent of the total volume of social security expenses.
The insurance sector has undergone significant change over the past year, with the part-privatisation of Tunisia’s state-owned largest insurance company, Societe Tunisienne d’Assurances et de Reassurances (STAR). French company Groupama has bought 35 per cent of STAR’s capital.
The in June 2009, work began on an ambitious offshore financial centre, Tunis Financial Harbour, with one of its four specialised ‘business clusters’ to be set aside for the insurance sector.
“Tunisia is one of the region’s most competitive and economies, enjoying sustained stability and a strong record of GDP growth, a prosperous industrial sector, a diversified services sector, modern infrastructure and skilled human capital,” said Esam ahani, chairman of Gulf Finance House, the Bahrain company behind the €2-billion project.
Meanwhile, the number of private clinics has increased four-fold in the last 20 years, giving Tunisia more than 80 private clinics with a total of more than 2,500 beds. And the boom in the number of visitors coming here for elective surgery and other forms of health tourism has soared phenomenally, from around 2,000 in 2004 to more than 150,000, according to Tunisia’s National Syndicate of Private Clinics.
Tunisia’s president Zine el Abidine Ben Ali nurtures hopes of turning his country into an international hub for medical tourism. In 2009, Ben Ali announced an ambitious array of measures to promote medical tourism. These follow on from earlier measures, including 2001 decree authorising the building of private hospitals solely for non-residents and legislation exempting non-residents from paying value added tax on hospital care and medical services.
The draft action plan, still under discussion at cabinet level, will include the creation of a government body to promote Tunisia’s healthcare sector and will lead to the creation of a dedicated medical resort and designated medical tourism zones around the country.
Serious medical problems may call for air evacuation to a country with state-of-the-art facilities. In practice, this is likely to mean France, which is less than an hour’s flying time from Tunisia
Tokushukai Medical Corporation, the world’s third-largest private hospital group, is scheduled to begin construction this year of a new, 400-bed private hospital in Tunis, costing some 65 million Tunisian dinars.
Tunisia’s main target market for elective medical tourism is the Middle East,
although it could also become an attractive destination for some European markets. The country is now second only to France in the number of hotels offering thalassotherapy health and wellness facilities, and according to the authoritative Euromonitor International Travel and Tourism in Tunisia report, health tourism is the most lucrative tourism niche in Tunisia, while the country is ranked as by far the leading medical and health tourism destination in North Africa.
Overall, its relatively small size, adequate levels of public health and hygiene, low levels of serious endemic disease and good infrastructure mean Tunisia, as a destination, presents few major issues for travel insurers. High levels of investment in private health facilities are likely to mean that in future fewer clients will require medical evacuation to Europe, so it could be worth insurance companies’ time to form good relationships with the state-of-the-art clinics that are currently under construction. One area that may require closer attention from those selling travel insurance, however, is the growth in adventure tourism; clearly, travellers heading off-road into the deep desert require a higher level of cover than those on a simple beach holiday. Business travellers heading for Tunisia’s deep-desert oil facilities may also require a higher level of cover, and could present a lucrative segment for international private medical insurance providers.