Tunisia: Barriers to Covid-19 vaccines expose stark disparities in access to health

The Tunisian authorities’ response to the Covid-19 pandemic, particularly their management of the country’s vaccine rollout program, has exposed the entrenched inequality in the country’s healthcare system, Amnesty International said today. 

With the World Health Organization (WHO) warning that new Covid variants may unleash another wave of infections, only 54% of Tunisia’s population have received two doses and only 10% a third. Of those third doses, those living in urban areas received up to 60%, while in many rural regions, vaccination rates for the third shot were as low as 4,5%. 

In a new briefing, Covid-19 vaccines and access to health in rural Tunisia, the organization sets out the significant disparities in vaccination coverage between urban areas along the coast and rural regions of the country. To identify the structural barriers that prevent people in marginalized regions from gaining fair access to vaccines, Amnesty International conducted field research in Ghardimaou, a deprived region located in a mountainous area beside the Tunisian-Algerian border.  

“Today, on the first day of World Immunization Week, we remind the Tunisian authorities of the importance of granting equal access to vaccines and prioritizing the most marginalized. It’s unacceptable in today’s Tunisia that during a pandemic, the rural regions are yet again forgotten and receive less than half the vaccines that urban regions have,” said Amna Guellali, Amnesty International’s Deputy Director for the Middle East and North Africa. 

“Tunisian health officials must ensure that everyone can enjoy their right to health without consideration of their location or socio-economic status. They must urgently address these flagrant disparities and prioritize strategies to improve health infrastructures in rural areas, especially given that new Covid variants might lead to a new wave of infections and further loss of life.”

Since December 2020, Tunisia has officially recorded at least a million cases of Covid-19, along with 28,509 deaths. According to the Health Ministry, although more than 6.3 million individuals have received two doses of a Covid-19 vaccine, only 1.18 million have received a third booster dose.

Historically, Tunisia’s healthcare system has proved fragile and unevenly distributed, with access to services in rural regions often limited. Rural areas also suffer from disproportionately high levels of poverty and unemployment. This inequality is also reflected in Tunisia’s national vaccination campaign; official data published since June 2021 shows significant disparities in vaccination coverage between rural and urban governorates.   

Amnesty International’s analysis of national vaccination data shows that as of 17 April 2022, less than 40% of the local population was fully vaccinated in the interior and predominately rural governorates of Tataouine (38.20%) and Kairouan (37.79%), while more than 60% of the population is fully vaccinated in some urban and coastal governorates such as Tunis (65.25%) and Ben Arous (62.57%). Regional vaccine inequalities were also more extreme at district level. Several urban districts had rates exceeding 90% whereas rural and interior districts had significantly lower rates around 20%, such as the districts of Beni Khedache (20.52%) and Balta-Bouaouene (15.64%).

Tunisian health officials must ensure that everyone can enjoy their right to health without consideration of their location or socio-economic status.

Amna Guellali, Amnesty International

As the Ministry of Health started offering third Covid-19 vaccine booster shots since September 2021, about 10% of the population (1.18 million people) received their third vaccine dose so far. In the delegation of Ghardimaou, about 4.54% of the local population received a third booster shot while other districts in urban areas received up to 57 % of third doses.

Amnesty International found that Tunisia’s vaccination strategy prioritized particular groups based on their age or area of employment, while socio-economic factors and the historic lack of access to healthcare in rural regions were not taken into consideration.

Ghardimaou residents denied equal access to vaccines

In Ghardimaou, Amnesty International reviewed official decrees, documents and statements on the national vaccination campaign, and interviewed 33 rural residents, three local healthcare professionals, and four representatives of local civil society organizations.

The organization identified at least four structural barriers that have prevented residents of Ghardimaou, and those in a similar situation, from accessing vaccines. As a consequence, only 45.88% of the local population is fully vaccinated, compared to more than 54% nationwide, with some urban districts approaching 100%. 

Access to public health facilities and vaccination centres is limited as affordable, reliable public transport to such facilities remains out of reach to many residents. In some cases, locals need to travel many miles due to the scarcity of local facilities. In the Jendouba region, where Ghardimaou is located, there are only seven doctors per 10,000 residents, compared to a national average of 13.2. 

There is also a lack of access to information about Covid-19 vaccines as the authorities have focused their communication campaigns on Tunis and other major cities, while depriving areas like Ghardimaou. The authorities did not develop an offline communication strategy, which could have effectively targeted rural audiences. 

Thirdly, a lack of access to education and technology represents a significant obstacle to vaccine registration in rural areas, where information on registration has mainly been shared online. In Ghardimaou, only 21% of residents interviewed had registered on Evax, an online platform where people can register for vaccination appointments. 

“On the radio, I heard that everyone could register to get a vaccine by using a mobile phone or a computer. I do have a mobile phone, but I have no idea how to register. This is complicated for me since I never went to school,” a 54-year-old woman from the district of Messiwa, Ghardimaou, told Amnesty International.

Finally, the authorities adopted a non-participatory, non-inclusive approach to rural communities when planning the national vaccination campaign, which led to scepticism against vaccines. The national vaccination campaign remained highly centralized, with the authorities failing to take into account the needs of residents in rural areas or to offer them adequate resources for their vaccination drive. 

“The case study of Ghardimaou shows us that Tunisian authorities can take a number of immediate measures to reverse historic neglect and prioritize the vaccination of rural people by investing in overlooked health centres, building effective partnerships with community leaders and local organizations, and expanding the number of vaccination sites in rural areas,” said Amna Guellali. 

In a right of response letter sent to Amnesty International on 25 July, Tunisian authorities asserted that their vaccination strategy was implemented “in concertation with local authorities” and involved the mobilisation of public and private resources, in order to ensure fair access to vaccines.