Maternal Health, Family Planning Unqualified Success in Tunisia

By Richard H. Curtiss

A visit to the office of Dr. Mohamed Moncef Boukhris, director general of Tunisia's National Office of Family and Population, known as ONFP from its initials in French, is an optimist's delight. Like Tunisia itself, ONFP is a place where the best-laid plans actually come true.

The statistics alone are worth the visit. They are unique in Africa and the Arab world as well. When Tunisia became independent from France in 1956, its infant mortality rate was 4 percent. Now it is 2.5 percent. In the same period, its overall death rate has been reduced by 80 percent.

Does that mean Tunisia's population is soaring out of control? Not at all. In 1956, the country's fertility rate was 7 children per woman. Now it is 3.4 children per woman, and the Tunisian government is aiming to stabilize the fertility rate at 2 children per woman by the year 2026. The result of these changes is that while the population was growing at the rate of 3 percent per year in 1956, at present it is growing at the rate of only 1.9 percent annually, and that growth rate is falling steadily. Getting control of the population growth rate means not only remarkable improvements in the education and health care available to all Tunisians, but also perceptible improvements in Tunisia's standard of living and the economy as a whole.

A major factor in all of these statistics from Tunisia's first 37 years of independence is the spread of family planning from urban centers to the most remote Tunisian villages. At present, 52 percent of married women in Tunisia practice some form of family planning, compared to fewer than 20 percent at the time of independence. The government hopes to increase the number of married women practicing family planning to 60 percent by the end of 1993.

In the Arab world, only Morocco, Algeria and Egypt even approach these figures, according to Dr. Boukhris. He cites two reasons for Tunisia's success. One is that the government lets the private sector do part of the job, subsidizing the contraceptives made available to their patients by private physicians and clinics. The other is the Tunisian government's determination to take its programs to the remotest corners of the country.

"Our problem is the difference between urban and rural areas," says Dr. Boukhris. "But we are going into all regions on instructions from President Zine El Abidine Ben Ali to reach the sectors of the population that most need our services."

The ONFP has set up 48 model clinics in various parts of the country and has 10 mobile clinics from which a midwife can not only advise and counsel village women, but also actually insert an intrauterine device (IUD), the most widely used contraceptive technique, if so requested. The result, Dr. Boukhris says, is that in some remote areas the villagers joke that the only government officials they ever meet personally are police and family planning personnel.

Free Government Services

All government family planning services are available to Tunisians free of charge. Tunisia is one of the few Islamic countries where women do not need permission from their husbands to avail themselves of such services. Tunisia also is the only Arab country that permits abortion on demand by a woman without reference to her husband or other member of her family.

In practice, abortion is extremely common throughout the Arab world, even where it is not legal except in cases where the life of the mother depends upon it. Sadly, in countries where family planning services are not so widely available as in Tunisia, abortion sometimes becomes a principal means of contraception, at great cost to the health of the women concerned.

Even the most conservative Muslims in Tunisia, therefore, are supportive of the Tunisian government's family planning programs, which they recognize as a major benefit to maternal and child health. Their reservations, Dr. Boukhris says, center largely upon such irreversible contraceptive measures as tubal ligation, rather than the reversible measures in widespread use which enable couples to space children rather than permanently terminate fertility.

The fact that Tunisian programs have produced such an unqualified success story, Dr. Boukhris says, is due to enlightened legislation and hard work by the government on many social, educational and political fronts. From the time their country became independent, Tunisians recognized that their natural resources were limited and that the country must make the best possible use of its human resources. Education now is compulsory to the age of 16.

Tunisia traditionally has been open to debate and the clash of differing ideas, and was the first Arab country to codify completely equal rights for women and put them into practice. "Fortunately, we had political thinkers and leaders who emphasized improving the welfare of women," Dr. Boukhris explains. "Now we have made those advances irreversible."

Even the rise of more conservative thinking elsewhere in the Islamic world has not engendered local opposition to Tunisia's government programs. "Fundamentalists say that our religion permits family planning, but they question whether our economy requires it," Dr. Boukhris explains. However, ONFP clinics in some of the most conservative areas of the country are widely used.

"Conservative women come in great numbers to our clinics, and since all people in Tunisia consider our programs health programs for women, they do not oppose them," he says.

Dr. Boukhris lists a number of other factors that have been essential to the success of Tunisia's family and population program:

"First, we had the political will and a very clear strategy based upon passage of legislation regarding women, health and family measures, including the use of contraceptives.

"Second, we could have done nothing without successful educational programs for girls. More than 87 percent of our girls presently are attending school, and now we are seeing the results.

"Third is the establishment of respect for the rights of women, and establishment of organized and visible programs in family planning that reach vertically through all levels of society and horizontally to all regions. We also concluded that just modernizing and improving general health systems is insufficient. We have chosen to give a high priority to family planning within that system.

"Finally, an extremely important element is the strong political support given to our programs by the Tunisian government. We expect all members of the government to utilize all methods of communication to explain that family planning is a right and that it contributes immeasurably to raising national standards of health and prosperity."

Another factor that Dr. Boukhris is perhaps too modest to mention is the importance of enlightened direction by qualified government officials who believe in and practice what they preach. Dr. Boukhris, a gynecologist who has written a book in French entitled La Population en Tunisie: Realites et Perspectives, and a study in English entitled Family Health and Population Policy in Tunisia, obviously is qualified.

On the personal level, Dr. Boukhris, who has held his present position for three years, also practices what he preaches. He is married and he and his wife have two children.