Description
This episode of the Democracy That Delivers podcast focuses on the SAHA Project, a CIPE initiative aimed at improving healthcare governance in Tunisia. Dr. Fatma Habboubi, the project manager, explains how the project, funded by the U.S. Department of State, seeks to enhance the healthcare system through legal and regulatory reforms. These reforms include clarifying the organization of public health facilities, simplifying pharmaceutical pricing, establishing a framework for continuous professional development, and creating a professional order for allied health professionals. The discussion highlights the challenges of navigating complex consensus-building processes and the importance of inclusive and collaborative decision-making to ensure effective and sustainable reforms in Tunisia’s healthcare sector.
Learn more about the SAHA project.
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Transcript
Announcer (00:02):
Democracy that Delivers is brought to you by the Center for International Private Enterprise. Now to your host.
Mischa Benoit-Lavelle (00:10):
How do laws and regulations shape outcomes for patients? What does it mean to improve governance in the healthcare sector? And how can CIPE help diverse stakeholders set aside their differences and come to consensus on reforms in the healthcare sector? My name is Mischa Benoit-Lavelle. I am the senior program manager for North Africa at CIPE. I’m joined by my colleague Dr. Fatma Haboubi, the project manager of the supporting Good Governance in Healthcare Administration or SAHA project. And today we will try to answer some of those questions. But first, a quick word on the SAHA project.
(00:49):
It’s a five-year effort funded by the U.S. Department of State and in partnership with the Tunisian Ministry of Health. CIPE has been implementing the project in Tunisia since 2020. The SAHA project aims to improve the governance of the healthcare sector in Tunisia in three ways. Developing a digital regulatory system for pharmaceuticals, improving training capacity for healthcare professionals, and helping stakeholders to establish an effective and relevant legal and regulatory framework to govern Tunisia’s healthcare system.
(01:22):
To talk about the project’s legal and regulatory reforms today, I’m joined by Dr. Fatma Haboubi. Fatma is a medical doctor with experience in public health, including time with the World Health Organization’s Tunisia office. She worked within the Tunisian Ministry of Health for two years, supporting the country’s COVID-19 crisis units. In addition to her medical degree, Fatma has a master’s in health law from the faculty of Legal, Political and Social Sciences of Tunis. She also has more than 15 years of experience working with civil society. And for the past two years, she’s served as the project manager for the SAHA project, in which role she’s helped us to maintain good relationships with government officials, built support for the reforms that we’re going to talk about today, and also spearheaded our work on training and e-learning. Fatma, welcome.
Fatma Habboubi (02:11):
Thank you, Mischa, for the introduction. And hello, everyone. I’m thrilled to be here actually to connect with all of you through this podcast, and I’m grateful because I see it as an opportunity to explore our experiences and share insights in the strides we’ve been making so far in health policymaking through the SAHA Project in Tunisia. Thank you.
Mischa Benoit-Lavelle (02:36):
Great. So before we dive into our subject matter today, I wanted to take a step back and talk a little bit about your background and what led you to this line of work. So you’re a medical doctor, but you also have this master’s degree in health law, and that’s not the most common combination. I’m interested in what led you to be interested in the governance and legal side of medicine.
Fatma Habboubi (02:58):
I’m often asked this question and each time gives me a chance to reflect on my journey so far and to recall the beginning of my path. So as a doctor, I frequently encountered patients who face significant barriers in their care, which were often due to systemic issues rooted in healthcare governance. One particular patient I remember was struggling to access necessary services, and this is what made me realize how critical governance is in determining patient’s outcomes. And this led me to question where our healthcare fails and why preventive measures and better management resources aren’t more effective in avoiding these situations. These experiences sparked my interest actually in understanding the broader framework that influences best patient care. Also, this is why I pursued the master’s degree in health law, to bridge the gap between clinical practice and the regulatory environment. I wanted to explore how laws and policies actually shape healthcare delivery and impact patient care.
Mischa Benoit-Lavelle (04:09):
I see. So healthcare governance for you is not just something abstract, something you experienced personally and professionally. I think for some of our listeners, it might still be a little abstract. They might be familiar with governance as a broader concept. But what does governance actually mean when we’re talking about the healthcare sector? What is it that we’re talking about?
Fatma Habboubi (04:28):
Yeah. If you’ll be using the word health organization’s definition of health governance, we can find that it is similar to governance in other contexts, encompassing the structures, processes and institutions designed to oversee and manage a country’s healthcare system. So it coordinates interactions between various stakeholders like government bodies and healthcare providers, patients, civil society, and private sector actually.
(04:56):
So in practical terms, health governance involves management of healthcare facilities, community involvement in healthcare decisions, resource distributions, and setting and enforcing performance standards. It’s fundamentally about the system in place that guide, control, and ensure accountability within healthcare organizations to meet the health needs of the population, which is about providing accessible, equitable, efficient, and high-quality healthcare services to all. And here the SAHA project embodies these principles and aims to enhance healthcare governance in Tunisia by fostering transparency and accountabilities.
Mischa Benoit-Lavelle (05:41):
Well, working on the interaction between government, private sector and civil society and citizenry as a whole, that certainly sounds like something that CIPE has a lot of experience with and making sure that government services are delivering for people is central to CIPE’s mission. It’s also central to the SAHA project, and I know as I mentioned at the beginning, we’re working on improving the governance of the healthcare sector in a few different ways, but today we’re talking about the legal and regulatory reform component of it. So tell me a little bit about the reforms under the project. What are they, and how are we hoping that they will benefit people?
Fatma Habboubi (06:19):
Yeah. So under the SAHA project, we can say that we have four pivotal reforms that have been prioritized collaboratively with key stakeholders in the field, and they are aiming to enhance the healthcare landscape. So the first one is about clarifying and improving the organization of public health facilities. The second reform is about simplifying and rationalizing pharmaceutical pricing. The third reform is about developing the legal framework for continuing professional development. And the fourth reform is about establishing a professional order for allied health professionals.
(06:56):
So the first reform is about the organization of public health facilities, and it involves the update of existing regulations. This includes clarifying the roles and composition of boards of directors within these institutions by implementing merit-based procedures for appointing general directors and clearly defining their responsibilities and powers. The reform aims to foster greater accountability and efficiency in delivering the healthcare, which is the mission of these institutions. And the second reform that aims at simplifying pharmaceutical pricing through the consolidation of drug pricing under a unified committee, because now it’s fragmented between three different entities. So the aim is through this streamlined approach is not only to improve the market access, but also to ensure transparency in drug prices and reimbursement rates, thereby making essential medications more affordable and accessible to all people.
(08:00):
The third reform, which is about establishing the continuing professional development, a framework aims to ensure that healthcare professionals enhance their skills. Here guidelines or regulations for these activities will be put in place, particularly focusing on practitioners involved in direct patient care. And the last but not least, reform is about the creation of the professional order for allied health professionals, including nurses, aims to elevate standards and accountability for non-doctor healthcare professionals. And here this initiative defines the structure and relationships within the professional order, linking it closely with a national council and governmental entities for improved coordination, and it aims to strengthen the entire healthcare system by integrating these crucial professionals more effectively in it. So these were our four reforms project we are working on under the SAHA project.
Mischa Benoit-Lavelle (09:01):
Wow. Well, I can definitely see how those are ambitious and far-reaching reforms. I really appreciate that. Very concise rundown of these pretty complex issues that are at stake. But I could see how improving the governance of these structures, healthcare facilities that serve so many Tunisians, that’s something that would be really impactful on how efficiently those institutions are run, drug pricing. Obviously if there’s any way that that could be made more efficient and faster, that could also have a big impact. But there’s a lot of potential reforms out there. The healthcare system is vast, the number of laws and regulations that affected are also vast. What was the process that led to selecting these four? How did we get here?
Fatma Habboubi (09:40):
Yeah, as you said, there are a lot of reforms that need to take place, Mischa, but time and resources are limited and we had to prioritize and select some of them to shape and design under the SAHA project. And here what we can say, which was innovative somehow for the SAHA project is that it was a collaborative and inclusive process with shared decision-making at its core. It was driven by stakeholders themselves. And it was organized in partnership with our civil society ALIA, another association for citizenship and equitable development that is called BEDER, which by the way demonstrated remarkable accomplishment in co-facilitating this process by assisting stakeholders in transforming identified issues into concrete reform proposals and legal texts. So the process began in July 2021 and involved engaging over, we can say 375 stakeholders across Tunisia, ensuring diverse regional perspectives were included. It also involved conducting assessment-based and inclusive consultations, civil society organization round tables and citizen juries.
(10:59):
Here citizen juries refers to randomly selected members of the public who convened to discuss and recommend actions or policies related to healthcare in our case. And all these discussions, round tables and so on were organized with careful consideration given to gender, regional, age and academic balance. Then the process involved forming four reform groups, what we call reform groups. These are one reform group for each of the reform projects.
(11:27):
It consists of stakeholders from sectors such as ministry of health, the health governance experts, civil society and the private sector. And a group ensured that the reforms reflected the perspectives of those directly affected by it. It was an interesting dynamic in there. Then comes the drafting itself of the legal text. It was in collaboration with legal experts who were hired by CIPE for the legally sound aspect of the reform proposed by the SAHA project, and it involved let’s say nine reform group meetings per reform project over a span of 15 months. So it was really, as we say, a sprint for change. And it was really interesting because it involved overcoming challenges through months of dialogue to build consensus on the reform objectives. So this collaborative effort culminated today in the drafting of four laws and decrees, marking a significant milestone in establishing, as I said, in establishing public-private dialogue for legal and regulatory reforms, which is a specific kind of policies here within Tunisia’s healthcare sector.
Mischa Benoit-Lavelle (12:39):
It sounds like quite a balancing act. I’m wondering if you could maybe tell us a little bit more about some of the challenges of that process. You’ve just mentioned some, but how did we identify the challenges, the issues that we’re going to face and mitigate that?
Fatma Habboubi (12:54):
Yeah, so it was full of learned lessons, let’s say, but it was an interesting journey. So embarking on these healthcare reforms has been challenging but yet rewarding. And we’ve encountered several hurdles, as you said, along the way. And one of which I can share also was about navigating complex consensus-building processes. So here, balancing diverse objectives and expectations from various stakeholders was crucial. For example, for politicians, they sought policy justification and public support. Then for administrators, they focus on operational efficiency. And healthcare professionals, prioritize working conditions. While patients emphasize quality care and respectful treatment.
(13:41):
So achieving consensus among these perspectives required careful negotiation and compromise. And here the key word is about building trust among the stakeholder, and especially between government entities and the private sector. It was significant challenge, initially marked by considerable mistrust. We addressed these through transparent dialogues and sustained communication, regular one-on-one meetings with government officials and open discussions helped align stakeholders with our reform goals and reduce conflicts and foster mutual understanding of the solution we were looking for through these reforms.
(14:23):
Then the other challenge is about breaking the institutional status quo and overcoming resistance to change. As any change we can undertake, it was an additional obstacle for us. So confronting entrenched administrative traditions and reluctance to adopt new methods required thorough analysis and streamlining of existing processes. So we developed a coherent plan for sustainable reforms, engaging stakeholders early in it, in designing the solution and providing necessary training.
Mischa Benoit-Lavelle (14:58):
Managing change is always really, really difficult. And I can imagine with all of those interests and differing incentives, all the more so in this case. I wanted to follow up on one point you mentioned earlier about representation and representativity because as you know, one of CIPE’s core values is inclusion. And you mentioned for example, in some of the round tables in the dialogue process, making sure that there is gender and age and demographic balance. There’s also an issue of balance of the right stakeholders, the people who have decision-making influence. So how did you navigate all of that and make sure that the process really was inclusive?
Fatma Habboubi (15:33):
So here it’s important to say that we didn’t do inclusion for the sake of inclusion. So representation of stakeholders was something we focused on. We aim it for consistent and stable representation, but we recognize the importance of engaging underrepresented voices. We wanted inclusion to be effective. We wanted to be effective representation of the broader possible range of perspectives. So we’ve expanded our methods to include, for example, surveys, [inaudible 00:16:06] groups, round tables to capture the broader assay range of perspectives. These were some tools we have used. Also, facilitating balanced discussions between institutional directives and personal insights helped in reconciling diverse perspectives. And finally, we understood that achieving perfect representativeness is challenging for sure. In summary, while the path has been fraught with challenges, our approach has been to foster open communication, build a trust, and actively engage all stakeholders.
Mischa Benoit-Lavelle (16:40):
Let’s take another step back and zoom out. At the beginning of this podcast, I asked you about your background and what led you here. Let’s project into the future a little bit, and it should acknowledge that this is a difficult time for Tunisia’s healthcare system. As many countries in the world faced a lot of challenges from the COVID pandemic, and that left some lingering issues in a lot of contexts in the world. But if we try to challenge ourselves to think optimistically about the future, what for you, what’s your vision of 10 years from now, 20 years from now, however long it takes of a better future for Tunisian healthcare? What would that look like?
Fatma Habboubi (17:19):
Yeah, so I like it when you say, Mischa, optimistically, think optimistically about the future. So when we think about success for the Tunisian healthcare system, we envision a future where every citizen regardless of their background or location, has equal access to high-quality healthcare services. This vision is characterized by several key attitudes and attributes. Firstly, we see well-organized and efficient public health facilities at the heart of healthcare system delivery, and these institutions will operate under clear governance guidelines with effective and accountable boards and merit-based leadership. And this ensures that the right individuals driven by their expertise and commitment are in charge, and they’re fostering a culture of responsive and responsible governance, let’s say.
(18:15):
Then in this best scenario, the process of accessing medications will be streamlined and transparent. This will not only make essential medications timely and affordable, but also create a sustainable market that benefits both consumers and providers. Then the success also means the healthcare system where continuous professional development is a cornerstone, healthcare professionals will be engaged in ongoing learning, upholding high standards of care through inclusive, continuous professional development activities. And then we foresee a robust structure for allied health professionals through a well-defined professional order. This will offer a structured representation, improve the quality of services, and advocate effectively for the needs of these members. So such a system will ensure that all healthcare roles from nurses to technicians are recognized and supported, contributing to the overall excellence of patient care.
Mischa Benoit-Lavelle (19:19):
Yeah, these are tangible steps, it sounds like. It’s easy to talk in grand, optimistic, idealistic terms, but these are very tangible pathways to a better future for Tunisian patients. We’re still on that pathway, right? The SAHA project is still ongoing, and obviously the path leaving continue after the SAHA project. But what’s next in terms of the project and in particular, in terms of these reforms? As I understand it, they’re not yet actually codified into law yet. Right? So where do things stand and what’s next for the laws and regulations under the project?
Fatma Habboubi (19:53):
Yeah, they are not yet officially identified as laws. They are still projects for now. We just designed the projects. And as we look ahead, the next step for SAHA project regarding these legal and regulatory reforms is to sustain the momentum, let’s say built during all these periods. One of the primary objectives we had in mind is to help such local civil partner, BEDER organization and stakeholders to advocate for the adoption and implementation of the proposed legal and regulatory reforms.
(20:28):
In this phase, BEDER will play a pivotal role engaging with policymakers and stakeholders to ensure these reforms are officially approved by the Parliament and put into action after that. Then to support this effort, the reform groups, because the reform groups here are very interesting entities, there is a trust. We have built trust background, and it will be really interesting to invest more in the future and to sustain more these entities. So we have to think about transforming them into sustainable reform coalitions.
(21:07):
These coalitions will monitor the progress of the reforms, ensuring effective implementation and continued alignment with the needs of the public engagement, the population. So here, by institutionalizing this group, a robust mechanism for accountability and sustained reform can be created. Another mechanism we have already developed it and expanding launch is the online reform tracker. So it’s a tool to provide a transparent and accessible platform for the public and stakeholders to track the progress of the SAHA reforms.
(21:47):
It will serve as a powerful resource for maintaining public engagement and accountability, showing clearly how each step of the reform process is unfolding. Another key step would involve helping our local partner advocating for an enabling institutional environment to encourage community participation. So the voices of the community are considered essential in shaping the healthcare system that truly serves everyone, and therefore efforts will be made to support BEDER in building a network of healthcare-focused civil society organizations. And by fostering collaboration and coordination among these groups, a united front you can say can be created to effectively advocate for and support ongoing reforms and future reforms also.
Mischa Benoit-Lavelle (22:41):
Well, clearly we’re at a very critical time for the project and for these reforms, building support and getting them passed into law, and then implementation, as you mentioned, that’s at least half the battle. So clearly a lot to look forward to in the coming months. Thank you again, Fatma for joining, for taking the time out of your, I know, very busy day to engage in this really interesting discussion and share your insights with our listeners.
Fatma Habboubi (23:08):
Thank you, Mischa. It was my pleasure, let’s say to discuss the SAHA project and the exciting growth ahead.
Mischa Benoit-Lavelle (23:15):
And thank you all as well for tuning in to listen. If you want to find out more about the SAHA project, search for SAHA project on LinkedIn, Facebook, and Twitter. You can get all the latest updates about everything you heard today, a link to the reform tracker as soon as that is ready. You can follow along the progress of these reforms yourself. Thank you all again.
Announcer (23:38):
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Published Date: September 04, 2024