Like many other countries in the global south, Tunisia began adopting neoliberal policy prescriptions in the 1980s. The process was advanced according to the terms of the IMF’s structural adjustment program and disciplined through loan conditionalities. Prioritizing fiscal consolidation, reforms dictated significant budget cuts for public services, amongst other things. These cuts were instituted without accounting for the outsized impact they were to have on marginalized groups, women especially.
Two of the domains where neoliberal reform have most negatively affected Tunisian women are public transportation and healthcare. The deterioration of public transportation, which was induced by austerity, has limited women’s mobility and in doing so, increased their vulnerabilities. Declines in public sector healthcare capacity and the attendant push toward privatization, meanwhile, have led to worsening health and financial outcomes for women.
Public transportation
State withdrawal and struggling public service providers
The underfunding of public transportation in Tunisia has been apparent for some time. It is largely a function of policymakers’ (coerced) embrace of neoliberalism, and revealed in governments’ investing more in road infrastructure than they do in public transportation: Over the past twenty years, in fact, the state has consistently privileged investments in road networks (which favor private car ownership) over investing in the public transportation system.[1] As owning a car is cost prohibitive, one effect of this policy is to restrict mobility for low income groups. More generally, disinvestment has led usage of public transportation to decline markedly. In Greater Tunis, it is estimated that the percentage of the population using public transportation dropped from 68% in 1977 to 28% in 2011.[2]
The effects of austerity are easily observed with TRANSTU, the main public transportation provider in Tunis. At this stage, the state only subsidizes TRANSTU’s school transportation programs, which received 435 million dinars in 2017. Funding for general urban public transport, contrarily, has been squeezed.[3] This provoked TRANSTU’s development of a sizable debt burden. Facing hard financial restraints, the company has not only been prevented from investing to meet rising demand introduced by demographic expansion, but from maintaining its existing fleet. As of 2020, only 650 of TRANSTU’s buses were operational, down from 966 in 2010.[4]
For households, TRANSTU’s declining service capacity has substantially increased the financial cost of mobility. By 2015, the average Tunisian household was spending 360 dinars annually on transport, which represented 9.3% of household expenses. The corresponding figure in 1990 was 7.7%.[5] For low-income families, rising costs hit particularly hard, forcing cuts in daily movement. Due to their lacking access to private vehicles, declines in the availability of public transit options have had acute gendered effects, too.
Women and public transportation: Limited access and unique challenges
While declining public transportation capacity affects both men and women in Tunisia, it impacts women disproportionately. In the first instance, this is because women have comparatively less recourse to private transportation options: A 2016 study from CREDIF (Center for Research, Studies, Documentation and Information on Women) established that only 4.5% of Tunisian women own a vehicle, as compares to 22% of men.[6] As such, though public transportation hardly represents an ideal option—more than a fifth of Tunisia women report experiencing a form of violence (sexual harassment in a plurality of cases) on public transportation—reducing its availability nevertheless implies a loss in welfare for women, and one suffered in low-income neighborhoods most of all.[7] Women in these areas report foregoing higher paid work opportunities located due to the long, multi-leg commutes required to reach more affluent districts.[8]
To reform the public transportation system with an eye on equitability, policymakers must first increase funding for TRANSTU so that it and partner organizations have the capacity to provide connectivity across Tunisia. Thereafter, they must ensure that the length and complexity of commutes do not obstruct people in pursuing their livelihoods. Special attention must be paid to the needs of lower income groups, whose place of residence is typically of greater distance to commercial centers. Furthermore, policymakers should address the variables contributing to women’s experience of sexual harassment on public transportation. This is imperative for a number of reasons. Obviously, it is the right thing to do in and of itself. More than that, though, the prevalence of sexual harassment disincentivizes women from seeking out sources of income and encourages them to strive for car ownership. The former is problematic for obvious reasons. The latter is problematic inasmuch as car ownership is both costly for the individual and ecologically unsustainable for Tunisian society.
Policy Reform Recommendations
Regarding policy fixes, lessons should be learned from the SARS-CoV-2 pandemic. During the time when contagion-related restrictions were imposed, women reported facing significantly less harassment on buses and trains. This suggests that it is overcrowding which mediates the propensity of sexual harassment on public transportation.[9] A pathway to safer, more equitable, and environmentally conscientious mobility can therefore be found in increasing the frequency with which public transportation options run.[10]
Note that there are forms of shared transportation apart from buses and trains in Tunisia, such as taxis, “taxi collectif,” and carpooling. For women, however, these options do not present a viable alternative to public transportation. That’s because they too are frequently host to gender-based violence, and because they evince extremely high rates of accidents. The danger is most pronounced in rural areas, where women working in the agricultural sector have no choice but to use these means of transportation. From 2015 to 2021, commuting agricultural workers were involved in 46 accidents that left 47 dead and 637 injured.[11] The state, in ceding its responsibility for public transportation, is ultimately to blame. It must step back into the breach or risk this continuing to happen.
Health care
Speeding towards privatization
Like its public transportation system, Tunisia’s public healthcare system has been negatively affected by the imposition of austerity. In the case of healthcare, austerity led to a widening footprint for private providers and higher out-of-pocket expenditures for households.
Though preceding the democratic transition, the harsh decline in public spending on healthcare continued throughout the post-Ben Ali era. Between 2013 and 2018, government health spending per capita fell from $165 to $110, while as a percentage of GDP, government spending sank to a decade low of 5.9% during the years in question. Expectantly, this resulted in out-of-pocket expenditures for households hitting an all-time high in 2018.
A brief uptick in government healthcare spending was prompted by the SARS-CoV-2 pandemic.[12] It receded, however, after the emergency-stage of the policy response passed. Thereafter, the trend of shifting the expenditure burden onto households continued.
In terms of service provision, some of the vacuum created by the state’s retreat from the healthcare sector has been filled by private institutions. Whereas the number of state-run healthcare facilities has declined over the past decade in net terms, the number of private facilities has increased by 23%.[13] Similarly, the volume of heavy equipment like X-Rays and MRIs possessed by the private sector has grown at such a rate as to now total three times the holdings of the public sector.[14]
Given that recourse to private healthcare facilities is contingent upon one having either the insurance coverage or personal funds required to pay for services, the divergent trajectories of Tunisia’s public and private healthcare systems in recent times have been of enormous social consequence. Leaving the less well-off with worse care while extracting a greater share of income from lower and middle-income earners, changes on the provider side of things have accentuated inequalities in Tunisian society considerably. Unsurprisingly, these changes have also had gendered and geographic dimensions.
Gender and SR healthcare: challenges at all stages, from health coverage to treatment
The gendered and geographic effects of Tunisia’s changing healthcare system are easily observed when it comes to sexual and reproductive care.
To begin, there is the matter of healthcare insurance coverage: Only 12.7% of women have insurance in their own name, compared to 28% of men.[15] This renders access to treatment externally dependent, creating a fundamental vulnerability for many women. In rural areas, gendered-based disparities are even wider. Only 33% of women working in the agriculture sector benefit from social protection of any kind, health insurance included, while a mere 10% report qualifying for free healthcare. Insofar as women in the sector also face a wage gap—their wages often but a half of those of men doing the same tasks—while being more exposed to work-related accidents,[16] the weak prevalence of coverage creates enormous health risks.
As pertains specifically to sexual and reproductive health, there are austerity-induced absences in preventative care access to consider as well. With government spending on healthcare receding, existing preventative programs have not been sufficiently maintained. The effects of this are apparent in statistics like contraceptives use, which dropped by 7% for women aged 15 to 49 between 2012 and 2018.[17] Such a decline cannot be explained by lessening demand for contraceptives: After all, during the same years, the percentage of married women aged 15 to 49 reporting an unmet need for contraceptives increased by 12%.[18] Predictably, it is rural women who have been hurt most by the state’s divestment on preventative care. The mobile healthcare teams once deployed by the public healthcare system to service the sexual and reproductive health needs of women in the countryside were disbanded in the 1990s. Ever since, access to contraception has become increasingly limited to those able to afford the travel and accommodation costs associated with seeking care in urban centers.[19]
The declining reach of the public health care system has also pushed women in need of natal care toward the more expensive options provided in the private sector. The last decade has seen a significant increase in the number of women giving birth in private health institutions, up to 10% in certain urban areas.[20] This may reflect a preference for private care as much as the inaccessibility of public care. Regardless, the change contains pronounced social biases. This is because access to private childbirth services is contingent upon income: 64% of households earning more than 2000 dinars per month report being able to afford private care, compared to only 8% of households with monthly incomes between 500 and 800 dinars.[21] As private health services grow their share of the healthcare market, the possibility of low income families being locked out of natal care becomes very real.
Policy Reform Recommendations
To remedy these issues and reverse trends presenting such obvious social and gendered biases, policymakers need to take a number of steps. First, they must pour funding into Tunisia’s public healthcare and social protection systems. In the case of the former, they should emphasize the building of capacity for delivering preventative services. Jointly, this investment will not only ensure equitable access to medical care, but also help cut long-term costs for both households and the state. Clearly, they must revitalize now dormant sexual and reproductive health preventive (SRH) programs as well. All Tunisians must be able to access quality care, regardless of income or geographic location. Given existing disparities in access to care–disparities which break according to location and socioeconomic status–implementing this reform will be particularly crucial.
In addition, policymakers must scale up the recruitment of healthcare workers, specialists especially, and make certain that these workers are distributed equitably across the country. Presently, the concentration of healthcare resources in urban centers is rather extreme. Finally, investments in equipment for the public healthcare system, diagnostic tools like X-rays and MRIs most of all, must be undertaken. This is necessary to close the service gap between private and public providers, a critical step in rebuilding a socially equitable healthcare system.
Conclusion
Gendered biases in accessing public services in Tunisia at once derive from entrenched inequalities and make those inequalities worse. As this policy brief highlights, austerity has led to the systematic underfunding of Tunisian public services, transportation and healthcare included. Resulting declines in service capacity have disproportionately impacted vulnerable groups, women foremost amongst them. Amongst other things, women are suffering from reduced mobility, lack of access to healthcare, and increasing expenditures. With female-headed households already 34% more likely to experience extreme poverty than male-headed ones, the effects of these changes have been pronounced.[22]
For Tunisian women to have a chance at a better life, the country’s policymakers must opt out of the austerity paradigm. The path to social justice lies in prioritizing investments in public services, with special attention granted to the needs of women and other vulnerable groups.
[1] République tunisienne Politique nationale de la mobilité urbaine, “Rapport de synthèse de la démarche PNMU en Tunisie”, Report (2020): 16
[2] Gina Porter, Emma Murphy, Saerom Han, Hichem Mansour, Hanen Keskes, Claire Dungey, Sam Clark, and Kim van der Weijd, “Improving young women’s access to safe mobility in a low-income area of Tunis: Challenges and opportunities pre- and post-Covid”, Transportation Research Procedia 60 (September 2021): 2
[3] World Bank, “Note de stratégie sectorielle relative au secteur des transports urbains”, Report (2019): 13
[4] Bedirhem Erdem Mutlu, “Freedom, justice, and dignity in movement: Mobility regimes in the Grand Tunis”, Arab Reform Initiative (July 2022)
[5] Ibid
[6] Stéphanie Pouessel, “Femmes et transport en Tunisie: l’insécurité du quotidien. l’épreuve genrée des déplacements du quotidien en contexte urbain et rural”, Aswaat Nissa (2024): 19
[7]Porter et al. (2021): 3
[8] Ibid: 4
[9] Ibid: 6
[10] On ecological sustainability, note that many women report wanting to purchase a car in order to avoid the sexual harassment that is so rampant on public transportation. 44.8% of women, in fact, express a preference for owning a car due to the burdens and dangers that public transportation presents. In the face of climate change, though, the reality is more and more car ownership is not viable
[11] Stéphanie Pouessel (2024): 58
[12] World bank: Domestic general government health expenditure per capita (current US$) – Tunisia (Accessed October 10,2024)
[13] Sahar Mechmech and Houssem Chammem, “Austerity, A Chronic Condition of Public Health”, Al Bawsala (2022): 13
[14] IBID: 18
[15] Jawhar Mzid, “Youth health services in Tunisia” Report: International Alert (2023): 21
[16] Alessandra Bajec, “Tunisia: COVID-19 Increases Vulnerability of Rural Women”, Arab Reform Initiative (November 2020)
[17] World bank Gender Data: Contraceptive prevalence, % of women ages 15-49 (Accessed October 10,2024)
[18] World Bank Gender Data: Unmet need for contraception, % of married women ages 15-49 (Accessed October 10,2024)
[19] Irene Maffi, “Governing Reproduction in Post-revolutionary Tunisia:Contraception, Abortion and Infertility”, Medical Anthropology 41 (2022): 4
[20] Jawhar Mzid (2023): 67The disparities are even more pronounced at the regional level. In El Mourouj (Greater Tunis), 43.8% of women gave birth in private institutions, whereas in more marginalized regions like northern Tataouine and Kasserine, the rates were significantly lower at 10.7% and 21.5%, respectively. This geographic divide underscores the unequal access to healthcare, where women in disadvantaged areas face additional barriers to receiving quality natal care, further entrenching the cycle of inequality across the country.
[21] Ibid
[22] MENAFem, “Impact of structural adjustment and austerity measures imposed by Bretton Woods Institutions on Women’s welfare and social safety nets”, Blog: MENAFEM (July 2024).