In recent years, Tunisia has become a destination, country of transit and refuge for thousands of migrants and refugees from sub-Saharan Africa. And yet, « neither government sources nor non-governmental associations have produced exhaustive data concerning their number », reports Wafa Dhaouadi who is project coordinator at the United Nations Population Fund (UNFPA).

Asylum-seekers hold a sit-in before the UNHCR office in Tunis

According to the UN Department of Economic and Social Affairs (UNDESA), until 2019 there were some 57,000 sub-Saharan migrants (including registered refugees and asylum seekers) living in Tunisia. On 30 June 2021, the UN High Commissioner for Refugees (UNHCR) reported 8,464 refugees and asylum seekers. Whether their objective is to continue studies, find work or flee insecurity, many migrants are in an irregular situation. Their illegal status renders them vulnerable and without any guarantee of access to health care.

Easy entry, difficult exit

« The legal situation for many refugees and migrants living in Tunisia is unclear due to Tunisia’s lack of domestic refugee legislation and its visa-free entry policy for select nationalities, including many from Central and West Africa. Visa-free entry means that many foreigners are able to arrive in the country via regular means, but after three months if they do not find an alternative status they become irregular and begin to accrue fines, which accumulate on a weekly basis », reads the November 2021 study « Hidden hardship of an unnoticed workforce: The economic lives of refugees and migrants in Tunisia » by Mixed Migration in collaboration with the Heinrich Boll Foundation in Tunisia.

Asylum-seekers hold a sit-in before the UNHCR office in Tunis

The study reveals that the majority of migrants in an irregular situation are neither capable of paying the fines accrued, nor able return to their countries of origin. For many, the prospect of finding formal work is an impossibility. They are left with no other option than to work under-the-table, generally in day labor jobs. Without social security or the financial means necessary for private health services, falling ill can be a death-sentence. This precarious situation exacerbates their vulnerability.

Beside the economic hardship they face, many migrants’ illegal status prevents them from seeking public health services, for fear of being denounced by medical personnel and arrested.

Health: a constitutional right

Health depends upon the group of migrants concerned, given that the migratory flow into Tunisia is extremely diverse. In Dhaouadi’s words,

Some migrants suffer from common chronic illnesses that could be medically, legally treated. Without health insurance, however, these individuals risk developing health complications. Others are students who, generally speaking, benefit from a regular situation. Nevertheless, some individuals in this group do not receive their student cards on time, in which case they are not allowed access to school and university health services. There is a third group of individuals which is extremely diverse but which shares a common thread of violence: female migrants. The greatest challenge for these women is access to sexual and reproductive health services.

Many female migrants in this category live in isolation, either confined within their communities or else living completely alone. They lack the necessary information to connect them with health services, explains Dhaouadi. Indeed, such services are free to migrants in public establishments. The right to health is universal, and does not only pertain to Tunisian citizens.

Health is a right for every human being (…),
Article 38 of the Tunisian Constitution.

Migrants are not required to present a residency card to receive treatment in establishments that offer primary health care. For certain medical procedures, explains Dhaouadi, individuals may be asked for ID purely as a means to confirm their age. Few, however, are aware of this right due to the language barrier which hinders communication with care workers.

Stereotypes, racism and the language barrier

« In the south of the country, for example, there is an anglophone community that speaks neither French nor Arabic », Dhaouadi remarks. Saint-Juste Boussou, a member of the Association of Ivorians in Tunisia, echoes this observation:

Many migrants don’t understand Arabic and struggle to make themselves heard by medical staff in public establishments.

Boussou adds that, because of their contempt for the migrant community, some care workers do not make even the slightest communication efforts.

Asylum seekers hold a sit-in before the UNHCR office in Tunis

Kadi is bitterly aware of this obstacle. Working as a housekeeper to support her children, ages four and six, Kadi has come to avoid public health establishments.

Due a skin problem, I had to [seek treatment in a public health establishment] but didn’t receive adequate care. I was tossed around from one department to another. Staff would speak to me in Arabic and simply redirect me, with an incomprehensible wave of the hand, to another office,
Kadi relates.

The refusal to seek care is far from exceptional, Dhaouadi tells us. « Certain stereotypes around migrants persist. During the Covid-19 pandemic, some accused them of being behind the propagation of the virus ». Other forms of discrimination are palpable. « Sometimes, care workers refuse to carry out a thorough examination. The care they provide is sloppy and inattentive. They give us the impression that we are filthy, and carriers of infectious diseases », laments Boussou. Nevertheless, the quality of care available to the migrant population varies:

Quality of care differs from one structure to another and also depends on the level of information available to medical staff. Until 2017, migrants’ access to abortion was not guaranteed. It took the mobilization of civil society to change this. Some health establishments believe that migrants are only guaranteed basic treatment, or that care is only for those suffering from life-threatening conditions,
Dhaouadi says.

Support from NGOs and regional disparities

Quality of care also depends on the extent to which non-governmental bodies in a given region are working on the issue. Dhaouadi reports that, « In the Greater Tunis, significant steps have been taken, especially thanks to the mobilization of civil society, the result of which has been increased awareness around these questions ». She indicates that five different regions benefit from a network of associations who are working on access to health services for migrants. As Boussou points out, the support provided by these non-governmental bodies is « vital » in order for the community to receive proper care. Without such assistance, migrants « run the risk of never benefiting from quality treatment ».

And yet some NGOs are apparently reluctant to advertise the role they play in facilitating irregular migrants’ access to health services. Thus, in spite of our persistence, Doctors of the World and Terre d’asile delayed getting back to us before ultimately refusing to answer our questions.

Asylum seekers hold a sit-in before the UNHCR office in Tunis

Kadi recalls the ordeal endured by her husband, a mason who suffers from back pain. « He experiences agonizing pain that sometimes makes him incapable of going to work. But what can he do? A day off means that much less money, since he is paid by the day. He fears the sort of treatment that I received in hospitals, and we can’t afford treatment in private establishments », she tells us. Like Kadi’s husband, many migrants suffer collateral damage from hard labor. « Many complain of a herniated disk, others of malaria », says Boussou.

Migrants are also among the « key populations » with high prevalence of high STI/HIV. For this reason, they are confronted with the same stigmas that surround Tunisians suffering from these infections. Such marginalization constitutes an extra obstacle which blocks access to adequate medical care.

The migrant population is also plagued by physical, sexual and moral violence that stems as much from within as without. For women, « the community is a support system, and as a result they are afraid to denounce any one of its members. Thus protection and reporting mechanisms regarding violence do not penetrate these groups » Dhaouadi tells Nawaat.

Without a legal framework to regulate the status of migrants and refugees in Tunisia, the latter remain at the mercy of NGO initiatives and the government’s good will. « We are left wondering whether or not the government has a national strategy regarding this issue. Such a strategy would ensure that the government mobilizes resources across multiple sectors, and that it produces thorough data », Dhaouadi explains. Until this sort of plan of action is adopted, associations are the primary structures providing health services to migrants. The risk being that things will continue as they are, with medical care made available through provisional, piecemeal actions without any long-lasting effects for Tunisia’s migrant communities.