Report No. 274a-TUN FILE The Economic Development RETU2N TO of Tunisia REPORTS DESK Volume IIl: Annex-Tourism and Infrastructure WITHIN December 27, 1974 ONE WEEK EMENA Region Country Programs Department II Not ior Public Use Document of the International Bank for Reconstruction and Development International Development Association This report was prepared for official use only by the Bank Group. It may not be published, quoted or cited without Sank Group authornzation. The Bank Croup does noE accept responsibility tor the accuracy or completeness oi the report. CURRENCY EQUIVALENTS Currency Unit = Dinar = 1000 aillimes Wlith effect frorm 1955 US $1.00 - 0.h2 Dinar Diriar 1.00 = US $2.381 With effect from September 28, 196ht UJS $1.00 - 0.52 Dinar Dinar 1.00 - US $1.90 With effect from December 20 1)71 US $1.00 - o.48 Dinar Dinar 1.00 - US $2.08 With effect from February 1973 US $1.00 - 0.44 Dinar Dinar 1.00 - US $2.27 . UNITS. AND WEIGHTS AND MEASURES: MERfIC British/U.S. Equivalents 1 m = 3.28 ft. 1 in ton = 0.981 g. ton = 1.1 US sh. tona 1 m2 10.76 sq. ft. 1. kg = 2.2 lb. 1 km 0.62 mi. 1 litre = 0.22 gal. 1 km2 0.386 sq. mLi. = 0.26 US liq.gallon 1 hectare 2.5 acres 1 m3 = 1.31 cubic yards THE ECONOMIC DEVELOPMENT OF TUNISIA TABLE OF CONTENTS ANNEX III TOURISM AND INFRASTRUCTURE Page No. 16. THE TRANSPORT SECTOR: PROBLEMS AND PROSPECTS A. The Transport Infrastructure ..... ....................... 1 (i) Ports ................................... 1 (ii) Highways ................................. . 1 (iii) Railways ................................. . 1 (iv) Airports ................................... 1 B. Performance ............................................. . 2 (i) Investments ....... ................ . 2 (ii) Supply and Demand . ...... ...... ............ .............. . 3 (iii) Costs and Tariffs ...... ............... 4 (iv) Employment ....... ................ .5 C. Transport Policy ......................................... 5 D. Development Prospects: The Four-Year Plan 1973-76 .... ... 7 17. INLAND TRANSPORT A. General ............. ........................... 11 B. Past Transport Demand and Supply ............ ............. 12 (i) Vehicle Fleet ....................................... 12 (ii) Traffic Increase .................................... 13 (iii) Freight Traffic ..................................... 14 (iv) Passenger Traffic ................................... 15 (v) Urban Transport ..................................... 16 C. Evolution of Inland Transport, 1962-1972 .17 D. Road Transport ........................................... 18 (i) Road Transport Infrastructure ....................... 18 (ii) Road Transport Operation ............................ 19 (iii) Conclusions and Prospe'cts 'Infr'ast'ruc'ture ............ 23 (iv) Conclusions and Prospects: Road Transport Industry . 25 E. Rail Transport ..................... ...................... 28 (i) Railway Investment ................ .................. 28 (ii) Finantial Aspects ................. .................. 28 (iii) Railway Operation ................. .................. 29 (iv) Prospects of Rail Transport .......... .. ............. 30 18. AVIATION AND MARITIME TRANSPORT A. Aviation Transport ....................................... 31 (i) General ............................................. 31 (ii) Organization . ....................................... 31 (iii) Performance ......................................... 31 (iv) Development Prospects ............................... 34 B. Maritime Transport . . ............. 38 (i) General .......... ................................... 38 (ii) Organization ........................................ 38 (iii) Traffic ......... .................................... 39 (iv) Investments ......................................... 40 (v) Cost and Tariffs .................................... 41 (vi) Development Prospects ............................... 42 19. TOURISM A. The Sector ............................................... 43 (i) The Growth of Tourism and its Contribution to the Tunisian Economy ............................... 43 (ii) The Nature of Tourism Demand in Tunisia .... ......... 46 (iii) Tourism Accomodation ............................... 50 (iv) Incentive and Institutional Framework .... ........... 55 B. Development Prospects ...... .............................. 57 (i) Objectives of the Fourth Plan ....................... 57 (ii) Absorptive Capacity ................................. 59 (iii) Hotel Development and Financing ..................... 61 (iv) Demand Prospects - Leisure Activities - Promotion and Marketing .................................. 62 (v) Non-Quantifiable Costs of Tourism ................... 65 C. Spa Facilities in Tunisia ................................ 66 (i) Development of Spa Facilities during the Past Decade. 66 (ii) Forecasts for the Fourth Plan 1973-1976 .... ......... 67 20. EDUCATION A. Introduction ............................................. 68 B. The School System............ .......... 68 C. The 1959 Targets .............3.........., 7 D. An Appraisal of the System ............................... 74 (i) Primary Education .......I......... .................. 74 (ii) Secondary Education ............... .. ................ 75 (iii) Vocational Tralning ....................... 78 (iv) Higher Education ............. I ...................... 85 (v) Adult Education and Literacy ...... .................. 86 (vi) Private Education .................... 87 (vil) Pre-school Education ...n. ..........................n.. 87 -3- E. Cost and Efficiency of Education ......................... 88 F. The Fourth Plan 1973-1976 ................................ 92 G. Elements of a New Orientation ..... ....................... 94 21. SOME OBSERVATIONS ON HEALTH, NUTRITION AND FAMILY PLANNING A. Introduction ................... 98 B. Health .............. 98 C. Nutrition ................................................ 102 D. Family Planning .......................................... 103 ANNEX III LIST OF MAPS Map No. 10001 TransportationNetwork....... 10697 Tourism Areas... 3151 Proportional Distribution of the Population by Province 3153R1 Maternity Facilities and M.C.H. Network .................. LIST OF GRAPHS Graph No. 20.1 Growth in Enrollments, 1956-1976 .. .. 69 20.2 Educational Pyramid, 1958 and 1972 . . 70 20.3 Organization of the Office of Vocational Training and Employment..... 80 20.4 Agricultural Formation System . . . .83 I 16. THE TRANSPORT SECTOR: STRUCTURE, PROBLEMS AND PROSPECTS A. The Transport Infrastructure 16.1 On becoming independent in 1956, Tunisia inherited a relatively well developed transport system. Few additions were made until 1968-1969, when major improvements to ports, railways, highways and airports were undertaken in the light of the recommendations of a transport survey carried out in 1968 with the assistance of the United Nations Development Programme (UNDP). (i) Ports 16.2 With about 1200 km of coast, the country has four major commercial ports (Tunis-La Goulette, Bizerte, Sousse, and Sfax). A fifth port is under construction at Gabes for exports of phosphates and chemicals. Owing to recent improvements, which IBRD helped to finance, the present capacity of the Tunisian ports is adequate for the next five to ten years, except for the port of Sfax, which is approaching capacity. However, some redistribution of traffic between Sfax and Gabes might provide medium-term relief. (ii) Highways 16.3 There are about 16,000 km of roads, two thirds of which are sur- faced. The road network is most developed in the north, where the bulk of eco- nomic activity is concentrated. Although the road network is generally ade- quate, the most heavily travelled highways need major improvements, and there is a need for more feeder roads to stimulate agricultural production. Under the first highway project, partly financed by IBRD in 1971, the maintenance shortcomings were remedied on a number of road sections. However, recent traffic surveys show that traffic is growing faster than expected and there is a need for further major improvements, particularly in access roads to large cities. In the long run, new traffic patterns are likely to arise as the result of a more balanced regional development policy. (iii) Railways 16.4 The railway network consists of 479 route-km of standard gauge in the north and about 1520 route-km of narrow gauge linking Tunis and Gabes and serving the phosphate and iron mines of the interior. The two systems meet in Tunis. Because emphasis has been chiefly on the renewal of old equipment and the acquisition of new roLling stock, the condition of the track is poor, and major improvements are required. In 1969 the Societe Nationale des Chemins de Fer Tunisiens (SNCFT), the l,overnment agency which owns and operates the railways, began to carry out a rehabilitation program which is still under way, and which IBRD is helping to finance. (iv) Airports 16.5 There are three international airports (Tunis-Carthage, Sousse- Monastir and Djerba-Mellita), to serve the tourism demand. The domestic air- ports, with the exception of those at Sfax and Gabes, are not equipped for -2- use by commercial aircraft. The three international airports have recently been expanded to accommodate jet services (Boeing 707 type). However, the aircraft parking and ground facilities of Tunis-Carthage Airport will have to be expanded further to meet the 1975-76 demand. There is also a need for im- provement of existing domestic airports, particularly in the south, to restore domestic services. B. Performance (i) Investments 16.6 From 1962 to 1971 total investment in the transport sector amounted to D 127 million and accounted for about 10 percent of total gross invest- ment over the same period. Of this total, public investment by the Govern- ment and its enterprises accounted for D 114 million, and private investment for D 13.0 million. Table 16.1: TRANSPORT INVESTMENT 1962-71 D Million % Government 29.3 23.0 Enterprises Public 84.8 66.7 Private 13.0 10.3 Subtotal 97.8 77.0 Grand Total 127.1 100.0 Although there are no general rules to determine what share of GDP or of total investment should go to transport, it appears that, at least until 1969-1970, investment in transport in Tunisia was relatively much less than in other countries at a similar stage of development, although this was partly due to the relatively extensive transport system already existing in 1962. 16.7 Until the end of the 1960s investment was allocated among the various branches of transport on an ad hoc basis as and when the need arose. Priority was given to road transport (equipment), which consistently received more than the planned allocations. The share of transport in gross investment rose to about 14 percent in. 1970 and 21 percent in 1971. Investment in inland trans- port, including automotive equipment, accounted for 65.5 percent of total in- vestment, the remainder being divided between air transport (16.5 percent) and maritime transport (18 percent). Except for ports, the emphasis was on equipment which, over the 1962-69 period, accounted for 60 percent of total investment. This was particularly true of maritime and air transport, in which Tunisia wanted to take a larger share of the traffic. The distribution of investment changed after 1968-69, following the recommendation of the transport survey, and large infrastructure projects (airport, railway and road rehabilitation) became preponderant. -3- 16.8 Capital-output ratios 1/ in the transport : 0 SERVICE FOR TRAINING TECHNICIANS O SERVICE FOR THE PROMOTION z OF TECHNICAL TRAINING - -- m °m SERVICE OF TESTING > SERVICE OF PROFESSIONAL TRAINING < SERVICE OF PRODUCTION TRAINING IZ H H I-……O~~~~~~~~~~~~~~~C >0 _ _2I Tl I _ T SERVICE FOR APPRENTICESHIP I i Z SERVICE FOR METHODS AND PROGRAMS i< z O cn > 205 M r- SERVICE FOR TECHNIQUES >0 O E_ Im~~~~~~~~~~~~~~~~~~~~~; U) m Z t m Z O~~~~~~~~~~~~~~~~~~~c > > < O N SERVICE FOR AUDIOVISUAL & E 2 m m -> m~~~ H1 0 0~~~ z -n SERVICE FOR WORKING EDCATON 00 m O | & IMMIGRATION~~~~~~~~~~Cm < 1 O Zmn SERVICE FOR TRAINING OF WO> rn> -- M O r o | OF EMPLOYMENT MARKEI- l 5 o | m m~~~-T ,Z m zm 0~~~~~~~~~~~~~~~~~~~~ SERVICEF FOR TRAIININGF F RMCOM 0 H2 0 00 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _m 0 2z z >~~~~~~~~~~~~~~ >OH 2 0 2~~~~~~~ 0 2~~~~~~~~~ _ E) zo |EERIC OFIPLANCILSRING MAUA >AOn- m I cn z :0 > > 0, > ~~~~~~~r < 0~~~ 0 > 2 m H INSPECTION FOR TECHNIQUE &, PEDAGOGY < z INSPECTI,ON FOR PLACEMENT t mcn 2 INSPECTION FOR ADMIN. & FINANCE a 20 < z4 m SERVICE FOR THEORANIZATION SERVICE FOR STATISATICSm 01 SERV~~~~~ICEFOF THE INSPECION T OF WORK SRIEOF EPLANMNIN MANUAL LABO 0~~~ - 81 - Table 20.8: OTHER VOCATIONAL TRAINING IN 1972 Centers/Firms Students Primary schools (5th and 6th grades) 549 In-plant Apprenticeship: Construction 1,602 Metals 3,175 Other 3,060 Other Courses: Evening 380 Correspondence 560 Total 9,326 Source: Ministere des Affaires Sociales, OFPE, February 1972. Table 20.9: VOCATIONAL TRAINING, UNDER MINISTRY OF SOCIAL AFFAIRS (number of students) Organization 1971 1971 1972 Office National de la Peche 274 429 Union Nationale des Travailleurs Tunisiens 760 800 Union Nationale des Agriculteurs 3,153 2,837 Inst. Orient 382 356 Ecole de Montfleury 30 29 Centre de Formation d'Assistants en Gestion 67 142 Beaux-Arts 210 207 Service Social /1 197 113 Institut National de Nutrition 69 136 Croissant Rouge 27 42 Institut National des Sports 211 247 Ecole Normale des Maitres d'Etudes :Primaires 153 154 Ecole Nationale des Cadres et de la Jeunesse 88 81 Ecole Nationale d'Administration 531 530 Union Nationale des Femmes Tunisiennes 1,500 1,500 Office des Cereales 15 15 Total 7,667 7,618 /1 This is inside the Ministry of Social Affairs. Source: Ministere du Plan, 1973. - 82 - 20.27 (2) Agriculture. The agricultural sector was severely affected by the withdrawal of expatriate technicians in the late 1950s and early 1960s. Before Independence, only one Tunisian had graduated from the Faculte d'Agronomie. Agricultural training has usually been the responsibility of the Ministry of Agriculture except for a short period in the late 1960s, when it was transferred to the Ministry of Education. The courses range from the training of special- ized workers to preparation for university degrees. 20.28 Formal agricultural education and training begins at the college moyen level. Three-year courses to train field officers (agents techniques) are given in eight of these colleges to pupils who have completed their pri- mary education and are not less than 14 years of age. Upon leaving, some 60 percent of the pupils pass into a vocational training school from which they emerge two years later as junior technical assistants (adjoints tech- niques) or as instructors in government service: a further 25 percent secure direct employment on farms or in other agricultural undertakings. For the re- maining 15 percent, three agricultural schools provide second-cycle secondary education leading to employment as senior technical assistants, agricultural teachers, and farm managers. The course is of three years, and receives equal intakes from the first cycle of general secondary education and from the agricultural colleges moyens; during the first year the former group re- ceives agricultural subjects and the latter a general scientific training. During the second and third years, common courses are followed in one of three main streams: scientific, technical, and instructor training. 20.29 Some 75 percent of those who obtain the secondary agricultural studies diploma find immediate employment in government or the private sector. The remaining 25 percent enter the Ecole Nationale Superieure d'Agriculture de Tunis (ENSAT), where they are joined by entrants who have completed the second cycle of general secondary education. The courses, of four and six years, lead to diplomas in agricultural and agronomic engineering respectively. 20.30 An entirely different path leads from the primary school to the Agricultural Vocational Training Centers. Recruiting pupils of 14 or 15 years of age, the centers offer two-year courses leading to certificates marking the completion of elementary agricultural studies or of agricultural appren- tice training. The curriculum includes general education and farm economics, together with technical subjects, selected according to the areas served, which include irrigation, sheep farming, fruit farming, cattle rearing, forestry, commercial grasses, horticulture, agricultural machinery, fishing, and rural feminine crafts. In addition to these full-time courses, producing practical farmers with a sound knowledge of modern methods and techniques, the centers also provide one-week to three-mwnth upgrading courses for farm workers wishing to keep abreast of recent developments or to qualify for promotion. 20.31 Table 20.11 shows the number of graduates, planned and actual, during the 1962-71 period. The number of specialized workers almost doubled over the period and the number of university graduates increased 3.6 times. How- ever, the results range from 50 to 59 percent of the targets set in 1962. The 43 separate facilities under the Ministry have an unused capacity varying between 56 percent and 84 percent. Graph. 20.-I TUNISIA: SYSTEM OF AGRICULTURAL EDUCATION AGRICULTURAL TRAINING CENTER 1 2 G ~~~~~~~~OUTPUT:- ®i) SSKILLED FARMER ®i) JUNIOR TECHNICAL ASSISTANT ADMINISTRATION; - SENIOR TECHNICAL ASSISTANT Oi AGRICULTURAL ENGINEER MINISTRY OF NATIONAL EDUCATION AGRICULTURAL AGRONOMIC ENGINEER - MINISTRY OF AGRICULTURE "COLLEGE MOYEN" AGRONOMIC ENGINEER AGRICULTURAL SECONDARY SCHOOL HIGHER NATIONAL SCHOOL (2nd CYCLE) OF AGRICULTURE r---j r--j rf, r-I r-, r--i Ii- 234 L-. L 5i -'6L-- l 1 2 r-- 3 t-- 4 t--i 5 - t-- L _ . L _- L -. _ L -_J L _ . L _ . I PRIMARY I SECONDARY I HIGHER _ EDUCATION EDUCATION EDUCATION World Bank - 8446 - 84 - 20.32 In general, the capacity of the system of vocational training appears fairly adequate, but the quality of the graduate of the non-agricultural training centers is not very high. Gaps exist in particular in training for special trade skills, and in the supervisory and higher technical grades in manufacturing, tourism and building and construction. In the training of primary school leavers and dropouts, formal education is emphasized at the expense of practical training. There is a lack of interest on the part of potential employers. In the agricultural schools, the problem is rather the misuse or misdirection of the graduates and their limited suitability for field work. This is partly due to the method of selection, with its urban basis and its the lack of emplhasis on rural background and vocational motivation. Table 20.10: STUDENTS A3ND SCHOOLS IN AGRICULTURAL EDUCATION, 1972 Percentage Centers Capacity Students Graduated of Year Capacity (A) Vocational Training (stagiaires) 17 .. 4,500 4,500 Adult Training (Ouvriers specialises) 15 2,760 2,005 1,200 73 Total 32 6,505 5,700 (B) Lycees (Agents techniques) 8 1,680 1,418 350 84 Technical Institutes (Adjoints techniques) 3 780 433 110 56 Total 11 2,460 1,851 460 (C) higher Education (Faculte d'agronomie, ingenieurs) 1 330 226 45 /a 68 Total A, B, C 44 .. 8,582 6,200 /a Excludes 36 who graduated abroad. Source: llinistere de l'Agriculture, Plan Ouadriennal: Formation des Cadres, Tunis, 1973. - 85 - Table 20.11: PLANNED AND ACTUAL OUTPUT OF AGRICULTURAL EDUCATION Achieved/ Available Planned Achieved planned Output/ in 1962 1962-71 1962-71 (%) Year Ouvriers Specialises 10,600 47,500 27,862 59 2,786 Agents techniques - 5,417 2,838 52 284 Adjoints techniques 19 1,425 722 51 72 Ingenieurs 164 1,204 606 50 50 Source: Ministere de l'Agriculture, Plan Quadrennial: Formation des Cadres, Tunis 1973. (iv) Higher Education 20.33 In 1961/1962, the University of Tunis and other schools of higher education had 2,234 students. By 1971/1972 enrollment had reached 10,849. Higher education is open to all holders of the secondary school "baccalaureate'", and only 6 percent of these fail to enroll. This requirement is often waived; 37 percent of first-year students in 1970/1971 did not have the baccalaureate. Some institutions for example, the Faculty of Theology and the Normal School of Assistant Teachers, do not require the baccalaureate. The distribution of students is given in Table 20.12. The supply of higher education places in Tunisia increased suficiently to reduce the percentage of students studying abroad from 45 percent in 1960 to 30 percent in 1971. Table 20.12: STUDENTS AND FACULTY IN HIGHER EDUCATION, 1971/72 Students/ Students Faculty Faculty Ecole Nationale d'Ingenieurs 266 74 4 Institut Superieur de Gestion 133 24 6 Institut des Htes Etudes Commerciales 108 10 11 Ecole Normale des Professeurs Adjoints 871 68 13 Faculte des Sciences 2,299 174 13 Faculte de Medecine 798 47 17 Faculte des Lettres 3,320 102 33 Faculte de Droit 1,948 48 41 Faculte de Theologie et des Sciences Religieuses 867 18 48 Total 10,610 565 19 Source: Ministere de l'Education Nationale. - 86 - 20.34 The quantitative objectives of the Perspectives and the three devel- opment plans were achieved. The goal was to have between 12,000 and 15,000 students in higher studies at home and abroad in 1971, and the actual figure was 14,073. The number actually graduated was 8,000, of whom 5,200 were from the University of Tunis. The demand for graduates was estimated at 11,000, of whom about 6,000 were needed for teaching, mainly at the secondary level. But, during the decade, only 2,000 were trained as teachers and of these it is estimated that half are not teaching but are working either in education administration or outside education. 20.35 Unemployed university graduates appeared for the first time in the fall of 1971 and in 1972 the number was larger. Because they were comparatively few in number, a considerable proportion was easily absorbed by jobs created in government for the purpose. However, even under optimistic assumptions about the rate of growth of GDP and the number of new jobs, the planned rate of expansion of the faculties for the next decade will probably mean that more graduates will be unemployed. These graduates, unlike "blue collar" workers, will not find a ready demand for their skills in Europe, which faces a similar disequilibrium except in a few fields, such as medicine, statistics, management and accounting. Some graduates could, however, find jobs in other Arab coun- tries. A number could also go into primary and secondary teaching, after suitable training. While more years of schooling are often regarded as a net social benefit, these benefits will have to be carefully compared with the net benefits from alternative investments, the social and political problems of unemployed graduates, and the mounting financial burden of university education. The Government has now undertaken the definition of a specific policy for the training of manpower for higher education and of a clear strategy of career guidance. (v) Adult Education and Literacy 20.36 To reduce the proportion of illiterates has been one of the Govern- ment's principal objectives but a nationally organized and financed program was not undertaken until 1965, at the same time as UNESCO began its campaign to promote functional literacy. Thus, the Tunisian program, supplemented by UNESCO, provided information useful for low-income adults as well as teaching the simple cognitive skills. The number of participants reached a peak of 41,000 in 1968/1969 and by 1971 had declined to 26,000. The program seems to have had less than the expected impact on the cognitive achievement or attitudes of the participants. An evaluation of the better program centers showed that four years attendance was necessary to achieve the proficiency of a sixth-grade primary student in Arabic reading comprehension. Adults with less than four years did worse than fourth-grade students, which meant they could not read and understand a national newspaper. The adults who did best came from the city, had had previous education, and had parents of higher socio-economic status. Finally, 34 percent showed a decline in read- ing ability two years after completing the course, while 48 percent showed a gain. Students with previous education were more retentive than those with- out. Eighteen percent were unchanged. The program was costly since only 50 percent of each grade was permitted to proceed to the next. The costs per graduate of the 4-year course were as high as D 1,600. Since 1970 the program has been affected by a budget reduction and the number of participants has - 87 - diminished. The 1966 census indicated a literacy rate of 55 percent of the population, on the basis of the number of people who had completed 4 years of primary school. (vi) Private Education 20.37 Private education performed an important function in Tunisia before Independence. In 1972, the totatl number of private students was less than 3 percent of the number enrolled in public schools. There are two main kinds of private schools: schools staffed by French teachers and subsidized by the French Government, mainly attended by children of the elite, and schools at- tended by students of the middle and upper income groups who drop or are pushed out of the public secondary system. The former concentrate on academic subjects, while the latter provide a mixture of academic and commercial courses. With the reduction in 1970 in the percentage of primary students admitted to public secondary schools, the number of private students has increased at both primary and secondary levels. New "non-elite" private schools have opened across the country, 17 in 1972 alone. The number of students receiving private education was 21,000 in 1972, 20 percent more than in 1971. (vii) Pre-School Education 20.38 Most pre-school education is in private institutions, some of which are subsidized by the French Government. In the middle 1960s, however, the Ministry of Social Affairs began to organize kindergartens, supported by local contributions, in which 4-6 year olds engage in supervised play and receive nutritious meals. Low-income students either pay half fees or nothing, according to the local contribution. - 88 - Table 20.13: STUDENTS AND SCHOOLS IN PRIVATE EDUCATION 1971/72 1972/73 Students /1 Primary 8,475 9,404 Secondary - Professional 2,056 2,596 - Academic 5,248 8,127 - Pre-professional 1,189 1,189 Total 16,968 21,316 Schools Primary 36 39 Secondary 55 69 Total 91 108 /1 These include students at the French mission schools: 1971/72 1972/73 Primary 1,599 1,678 Secondary 2,262 2,655 Source: Ministere de l'Education Nationale. E. Cost and Efficiency of Education 20.39 Two studies 1/ on educational costs in Tunisia carried out in the past few years reached the conclusion that real costs per secondary and university student were high and rapidly rising. The costs per student for the three levels of the education system are given in Table 20.14 below. Secondary education is at least seven times as expensive as primary. Agricul- tural education costs 17 times as much as primary, and higher education 41 times as much, per student. A major component of these high costs is the high salaries of foreign teachers, who constitute nearly half of the. staff at the secondary and higher levels. Scholarships average D 75 per holder for secondary and D 406 for higher education. 1/ Bsais, A & C Morrison: Les Couts de l'Education en Tunisie, in Cahiers du CERES, No. 3, June 1970. Tibi, Claude: Economic Development and Financial Aspects of Education Policy: The Tunisian Case, The Inter- national Institute for Education Policy, Paris, 1972. - 89 - Table 20.14: UNIT COSTS OF EDUCATION IN 1971 (current prices in dinars) Current Capital Total Index Primary /a 23 /b 1 24 100 Secondary /c 156 25 181 754 Vocational 7d (Indust.) 202 6 208 867 Vocational (Agric.) 416 /e - 416 1,733 Higher 762 If 224 986 4,108 /a Note de Synthese preparatory to Plan. T Of which D 1.40 was spent on food, clothing and scholarships. Ic For 1970, and includes acadlemic and professional. Id For 15,000 students. /e 1969. 7T Of which D 406 went for food, tuition and scholarships. 20.40 The real cost of producing one graduate consists of the total cost of his education plus a share of the cost of the education of those students who did not graduate. This fails, of course, to take account of the benefits that may have accrued to the students who did not graduate, although these benefits are small for secondary students who do not reach "Brevet" certifi- cate stage and are almost insignificant for primary students. The costs per graduate at each level of the education structure, when the costs of dropouts and repeaters are included, are shown in Table 20.15. The cost per primary graduate was D 394 in 1971. The cumulative cost of obtaining one secondary graduate (i.e., primary plus secondary) was D 4,792 and one university grad- uate D 19,582. - 90 - Table 20.15: COST PER GRADUATE IN 1971 (current prices in dinars) Number Of Non- Certi- Mean Total Mean ficate Years Cost Years Students Schooling Of Non- Required Per Non- Certi- To Obtain Cost/ Certi- Certi- ficate Cost/ Cost/ Certi- Grad- ficate ficate Students Graduate Student ficate uate holder Students (1)x(4)x(5) (3)+(6) (1) (2) (3) (4) (5) (6) (7) 1. EACH LEVEL Primary 24 8 192 2.1 4 202 394 Secondary 181 9 1,629 5.2 3 2,769 4,398 Vocational (Indus.) 208 4 832 2.7 2 1,123 1,955 Vocational (Agric.) 416 7 2,912 3.0 3 3,744 6,656 Higher 986 6 5,916 3.0 3 8,874 14,790 2. CUMULATIVE Primary + Secondary . . 1,829 . . 4,792 Primary + Voc. (Ag.) . . 3,104 . . . 7,050 Primary + Sec. + Higher . . 7,745 . . 19,582 Source: Ministere de l'Education Nationale. 20.41 Private studies 1/ made to measure the achievement of students as a function of school inputs, family background and personality show that the fact that some students score higher than others is probably due more to family background and personality rather than to the quality or quantity of school inputs. As regards measurement of non-cognitive educational achievement, the studies show that primary schooling has little effect in developing "modern attitudes" as measured on the Inkles modernity scale, but secondary schooling has a significant effect. These results appear consistent with those of recent 1/ Carnoy, Martin, Hans Thias and Richard Sack, "Middle Level Manpower, The Links Between Socioeconomic Origin, Schooling and Job History in Tunisia," Tone and Simmons, 1973. Simmons, John, "The Income Benefits from Formal and Informal Education, Estimates for a Socioeconomic Model," Development Research Center, Harvard University, Cambridge, Mass., 1972. Erkut, Sumru, "A Theoretical and Empirical Study of Modernity as a Concomitant of Industrialization," Department of Social Phsychology, PhD Dissertation, Harvard University, Cambridge, Mass., Nov. 1972. -- 91 - educational research in other countries, and the questions they raise demons- trate the need to pursue the study of this problem. 20.42 Several studies have o3ought to determine the importance of schooling for lifetime earnings. Earnings are regarded as a function of schooling, ability, work experience, and parental socio-economic status. A national survey (Carnoy, Thias, Sack 1972) 1/ found that the predicted lifetime earnings of a worker with no education al: all were just as high as those of a worker with full primary and two grades of post-primary schooling. The more school- ing workers had after the second secondary year, the higher their earnings. But the older the workers in this group, the less important schooling below a certain level was in determin:Lng their earnings. For example, for schooling to be significant for workers above 40, they had to have had one year of university training. Contrary to expectations, workers aged 21-40 with voca- tional training were found to earn less than workers who had general education. Furthermore, training on the job was highly significant in determining earn- ings. 20.43 Equity in the education sector implies a proper distribution of benefits and costs, over the long term, between the different social groups. Unfortunately, the basic data available for Tunisia is limited and the inter- generational social mobility dat:a required to answer these questions is quite incomplete. In 1970 the Ministry of Education classified students at the three levels of education according to social situation. The results are presented in Table 20.16. Since this classification could not be made for the primary- school group, it was assumed that the classification for the primary group corresponds to that for the population as a whole. In fact, this "estimate by residue" is far from objective, since most primary-school children come from the lowest income groups oi- the population. Even on this assumption, the proportion of students with fathers of high socio-economic status (SES) getting some higher education is 8.8 times as high as the proportion of high- SES students in the population. The lowest income group has only 27 percent of the places at the university level that would be expected if education were distributed absolutely equitably. Table 20.16 shows that in 1970 children in the upper income groups were clearly getting the lion's share of higher educa- tion. Account must, of course, be taken of the quite undemocratic nature of primary education at the time of Independence. 1/ Carnoy, Martin, Hans, Thias and Richard Sach, "Middle Level Manpower, The Links Between Socioeconomic Origin, Schooling and Job History in Tunisia," Stone and Simmons, 1973. - 92 - Table 20.16: SOCIO-ECONOMIC STATUS OF STUDENTS' FATHERS (1970) (percentage) Socio-economic Primary Secondary Higher Ratio Status (1) (2) (3) (3)/(1) High 1 1.2 5.9 10.5 8.8 2 26.5 40.0 26.2 1.0 3 12.7 20.8 17.6 1.4 Low 4 43.5 17.3 11.9 0.27 Other 16.1 16.0 33.0 2.0 Total 100.0 100.0 100.0 Number of Students (000) 113.9 7.8 0.6 Status: High 1: Highest white collar, professions, heads of firms and employees Category A. 2: Employees Categories B and C, office staff and skilled workers. " 3: Foremen, semiskilled or unskilled industrial workers. Low 4: Agricultural laborer and non-industrial unskilled workers. Other : Retired, without occupation, and father dead. Source: Ministere de l'Education Nationale, Bureau de Planification. F. The Fourth Economic and Social Development Plan, 1973-76 20.44 The preparatory documentation for the Fourth Plan, 1/ and the Plan itself, stress the absolute necessity of bringing the output of the education system into line with the needs of the economy. The Fourth Plan does not claim to solve all the problems posed by the structural imbalance of educa- tion. A committee has been set up to carry out a far-reaching reform of education during the Plan period. Alongside this work, the tasks of short- term education planning will be continued. 20.45 At the present stage, the policy and objectives defined by the Fourth Plan can be summarized as follows: (i) Primary education The starting point adopted for the development of primary education is the basic decision to create structures to 1/ Commission Nationale Sectorielle de l'Education et de la Recherche Scientifique, "Rapport de synthese sur l'education pour la decennie 1961-1972," July 1972; Ministere de l'Education Nationale, Note de Synthese du Plan Quadriennal 1973-76: "Les objectifs quantitatifs et qualitatifs du systeme scolaire et universitaire," May 1973. - 93 - accommodate all school--age children that wish to enroll: the right of every child to primary education is assured without going so far as to make schooling compulsory. Primary en- rollment is expected to increase from 884,000 in 1972/73 to 1 million in 1976/77, an annual growth of 3.3 percent; with this rate, which compares with 8.5 percent in the 1960s, it will be possible to cope with the population growth while continuing to improve the percentage of school-age children receiving schooling. The qualitative objectives of the Plan are, essentially: to improve the internal productivity of education by revising timetables and strengthening teacher-training, and to guide students toward scientific and technical careers through appropriate curricula adjust- ments. (ii) Secondary education Secondary school enrollment is expected to grow by 4 percent a year, from 172,000 in 1972/73 to 200,000 in 1976/77. Most of this increase will be in the technical, mathematics, science and vocational tracks. In order to steer a higher percentage of pupils toward these, it is proposed to strengthen the mathematics, sciences and technical courses, to increase the number of teachers in these subjects, and to prepare the necessary structures to handle the growing technical and vocational enrollment. (iii) Higher Education Having regard to the foreseeable number of secondary-school graduates (bacheliers), student enrollment is expected to increase from 10,650 in 1972/73 to 22,700 in 1976/77, i.e. at a rate of 22 percent a year. In addition to this sub- stantial growth, the Fourth Plan identifies the other two problems that higher education will have to face: the im- balances between the sciLentific and technical disciplines on the one hand and literature and the arts on the other, which will tend to widen, and the low output of the studies. The measures to change t:he enrollment structure at the secondary level should make it possible to guide students towards the scientific amd technial disciplines and progre- ssively to redress the balance of higher education to fit needs. Thus, the Plan calls for an increase of 226 percent in enrollment in the Faculty of Sciences and the scientific sections of the Ecole Normale Superieure, doubling of the enroll- ment in the Faculty of Medicine (from 1,000 to 2,250 in 4 years), and an increase in enrollment in the National Engineering Schools from 340 in 1972/73 to 2,120 in 1976/77. - 94 - Table 20.17: PROJECTED STUDENT ENROLLMENTS, FOURTH PLAN, 1973-76 (000 students) Percent 1972 1973 1974 1975 1976 Growth 1972-1976 Total Primary 883 918 950 975 999 13.2 Total Secondary 172 182 191 199 200 16.4 - of which Professional 18 27 34 41 41 124.4 Total Higher 11 12 14 18 23 109.0 Source: Ministere de l'Education Nationale and Ministere du Plan. 20.46 For teachers, the Fourth Plan gives detailed projections only for the secondary level. It appears that a sufficient number of teachers can be trained to cope with the increase in school population at the primary level. In higher education, the large increase in student enrollment will call for a substantial effort to develop the needed teaching staff. In the case of secondary education the present enrollment structure, in terms of its dis- tribution among the various faculties, means that it will not be possible, in addition to supplying the new needs, to replace the expatriate teachers during the Plan period in certain subjects such as mathematics, physics and chemistry, and French. On the other hand, the output of the University in other subjects, for which teaching is the main outlet, such as Arabic, History and Geography, will far exceed recruitment opportunities in secondary educa- tion. According to the Fourth Plan the number of secondary teachers will in- crease from 5,560 in 1973/74 to 6,280 in 1976/77; the number of Tunisian teachers will increase from 3,750 to 5,390, while that of expatriate teachers will fall from 1,810 to 890. 20.47 The capital budget of the education system for the 4 years of the 1973-76 Plan is nearly D 40 million, or 14 percent of the total capital ex- penditure of general Government provided for in the Plan. During the preceding Plan period (1969-72), the capital expenditure on education amounted to D 36 million, i.e. 20 percent of the Government's capital budget. To this must be added D 4 million a year assigned to the schools of agriculture and D 1 million a year assigned to vocational training. During the same period, the operating expenditures of the education system will rise by 8.4 percent a year to D 72 million in 1976. According to the Plan forecasts, total education expenditure (capital and operating) in 1976 would account for 6 percent of GDP, i.e. slightly less than in 1970/71 (6.5 percent). G. Elements of a New Orientation 20.48 Considering that the objectives of education are essentially to con- tribute to economic growth, to the social development of the people and to greater social equality between population groups, the preconditions for achieving these objectives are three: - 95 - (i) the efficiency of education investment must be improved, by adapting the teaching to the needs of the economy and of the individuals; (ii) conditions must be fostered that allow equality of access to education and to tlhe advantages it brings; (iii) education planning must be developed so that it may better satisfy the needs of society. The Government's policy and the measures taken during recent years are con- sistent with this orientation. However, there is a need to give even greater attention to the factors, both inside and outside the education system, that would help to expand the number and range of productive jobs, to narrow the artificial differences in wage levels, to ensure a smoother transition from school to working life, and to facilitate access to both scholastic education at all levels and other forms of education. (i) Basic Education 20.49 Formal education to a minimum level of verbal and quantitative skills associated with literacy is essential for self-learning, further formal educa- tion and more active participation in economic and social life. It is also important to define as precisely as possible what constitutes an adequate level of literacy and what kind of education this calls for, so that the necessary adjustments may be made. Curricula, textbooks and practical work for the primary or basic cycle need to be revised to adapt them better to the dominant economic and social activities in the country. This would contribute both to the social objective of universal literacy and to raising productivity and improving the participation of the poor. Other basic reforms of primary education that could be studied include increased local contribution to school construction, raising the primary entry age, automatic promotion, mastery learning, the use of school leavers as para-professionals, and accelerated training aimed at re-entry of young people and adults into the school or university system. 20.50 The purpose of the certificate of primary education under the present system is essentially to select students for secondary school and not to at- test to a particular level of education. Since only about 25 percent of the school population continue their formal education beyond primary, and the remaining 75 percent are left to develop their skills and knowledge for employ- ment as best they can, it seems essential that the primary cycle be geared chiefly to the needs of this 75 percent. Because the curriculum is directly linked to the examination system (since the weight given to a subject in the examination, and the form the questions take, largely define the method and content of teaching), it is essential to redefine the role of the primary certificate and to devise methods of selection that are appropriate to the amended curricula and, at the same time, efficient and equitable. - 96 - 20.51 The present system of examination of cognitive achievement, which is heavily biased in favor of French language ability, has the effect of dis- criminating against rural and low-income students. While bilingual instruction has been the subject of considerable debate in the past few years, little evi- dence exists to suggest either how efficient or how fair the suggested alter- natives are. This information should be collected and evaluated to provide insight into the issue. Furthermore, although technical workers require psy- chomotor ability, students are not tested for it and it is not correlated with cognitive achievement. Thus, an important group of students who could learn to be skilled technicians, if promoted to intermediate school, are excluded. Questions that need to be studied include the efficiency of available peda- gogic methods and methods of improving reading comprehension and developing non-cognitive skills. (ii) Secondary and Higher Education 20.52 Given the present numbers of students in the pipeline, let alone the increases projected for 1973-1976, it may be expected that the system will increasingly produce dropouts and certificate holders who will not find jobs to match their school qualifications or aspirations. It would follow that the number of years of schooling required for middle and upper level jobs should be reduced and part of the resources now spent on education allocated to other uses. The financial cost of successfully producing one university graduate, with uncertain prospects of finding a job, could create four new jobs in manufacturing. Once the basic skills for communication and further self- education have been provided, formal education opportunities could, in the light of the limited resources and jobs available, be geared more closely to the minimum educational requirements of the jobs that can be created, even if this means providing retraining later. For such a policy to be effective requires efforts to curtail excess demands for education on the one hand and to expand employment opportunities on the other. 20.53 The demand for post-primary training is inflated for a variety of reasons: (i) the supply of jobs is growing more slowly than the supply of school places; (ii) the income differential between modern and traditional sector employment remains artificially high and is widening; (iii) employers and government tend to give preference to educational "longevity" even though additional increments of formal education may add only marginally, if at all, to productivity, and (iv) the cost of education borne by the individual is out of line with the potential benefits. There is, as a result, a private demand for education far in excess of the economic demand in terms of higher-income, modern-sector employment opportunities. Educational enrollment should accord- ingly be more clearly related to the employment market. To reduce the demand for education to a more realistic level, consideration might be given to making the beneficiary (as opposed to his family or society as a whole) bear a larger or rising proportion of his educational costs as he proceeds through the system, with appropriate subsidies and loan programs. (iii) Vocational Training 20.54 For terminal pupils at primary, and also at higher levels, there is an urgent need for a more comprehensive effort to establish practical, - 97 - job-oriented training schemes to assist in absorption into the labor market. Specialized training activities undertaken by several ministries might use- fully be brought together into one unified system of extra-mural, second- chance institutions catering for both adults and school leavers. These institu- tions could essentially give instruction in village or rural crafts and train- ing in modern industrial and business skills, and by catering for all-round needs (craft-skills, agricultural knowledge, small-scale business, elementary management and general economics), could assist people to improve their future livelihood, particularly in rural areas, and orient young people towards opportunities on the land and in self-employed activity. Of equal importance in the modern urban sector is the development of comprehensive programs for on-the-job training. 20.55 Finally, consideration could be given to the desirability of a formal break of one, two or more years :Ln academic training to give students a greater awareness of the alternatives open to them and of their own preferences and aptitudes and, with greater maturity, to benefit more from further academic training. Introduction of such a break at this stage of Tunisia's development could interrupt the pattern of growth of education expenditure and provide a breathing spell in which to resolve some of the difficult problems confronting the Government. Such a proposal could, for example, be adopted to ease the problem of staffing in rural development programs identified in other parts of this report. All persons successfully completing secondary education could be required to give one year of community service to the rural areas, including teaching, on a subsistence-level pay scale as a prerequisite for higher edu- cation. This concept could also be usefully applied again by requiring a further year of service as part of the program leading to final qualification; this could be counted as part of the individual's military service. - 98 - 21. SOME OBSERVATIONS ON HEALTH, NUTRITION AND FAMILY PLANNING A. Introduction 21.1 Impressive progress has been made in the health field. Since Inde- pendence, health care has been virtually free for everyone. Modern medicine had become well established in the chief cities, but by 1964 the departure of most of the European doctors had left the health services seriously under- manned. Since 1964 an effort has been made to extend and improve health serv- ices, despite a lack of qualified medical and other personnel. B. Health 21.2 Over the period 1955 to 1970 the gross death rate fell from 20 to 14 per 1000 and the infant death rate from 155 to 106 per 1000. The chief causes include the improvement of preventive and curative health care as well as changes in the age structure of the population. Table 21.1: VITAL STATISTICS (Muslim Population Only: N/IIOO) 1945 1955 1960 1965 1970 Gross Death Rate 26.0 20.3 19.3 17.8 13.7 Infant Death Rate 202 155 90 113 106 Life Expectancy (Years) 38 /1 47 /1 54 /2 55 56 /1 Tunis only. /2 Rate corrected by a coefficient of 1.4. Source: Ministere de la Sante Publique, Retrospectives de la Tunisie, 1962-1971, L'Annuaire Statistique. Ministere du Plan, Retrospectives Decennales. La Mortalite et le cout de la Sante Publique en Tunisie. Cahiers du CERES Serie Demographique No. 1, June 1967 and No. 2, January 1968. Although records of incidence of diseases were maintained before Independence, they display erratic variations from year to year which suggest errors in col- lection. Table 21.2 shows the trends in some epidemic illnesses. Malaria and typhus have been virtually eradicated. - 99 - Table 21.2: TRENDS IN EPIDEMIC ILLNESSES (Ca3es Reported) 1946 /1 1955 /1 1967 1971 /2 Typhoid Fever 833 484 666 935 Typhus 512 27 - 45 Malaria 7,855 1,507 2,565 95 /1 Cases reported for Tunis only. 7-2 Estimate based on Appendix Table 1, this chapter. 21.3 Health inputs include public expenditures for equipment and operation of health services and private expenditures on items ranging from medicines to nutritious diets. These are summarized in Table 21.3. Given the rapid in- crease of population over the period, the rates of change are even more signi- ficant than they at first appear. Current expenditures on health almost qua- drupled in terms of constant prices. Access to clean water supplies almost doubled. Table 21.3: MAJOR INDITkTORS OF PROMOTION OF PUBLIC HEALTH 1956 1965 1970 Clean Water Supplies (percentage of population benefitting) 29 40 n.a. T.B. Preventive Campaign (percentage of population tested) 34 n.a. n.a. MDs/10,000 people 16 15 13 Current Expenditures in Dinars per capita (1964 constant prices) 1.207 1.934 2.200 Capital Expenditures (000x current dinars) 412 1,000 2,700 /1 Estimate. Source: Ministere de Sante Publique, Retrospectives de la Tunisie, 1962-1971 L'Annuaire Statistique. Ministere du Plan, Retrospectives Decennales. La Mortalite et le Cout de la Sante Publique en Tunisie. Cahiers du CERES Serie Demcigraphique No. 2, January 1968. - 100 - Table 21.4: UNIT COST OF HOSPITAL CARE (1964 Constant Dinars) Current Expenditure 1955 1960 1965 1970 Dinars/bed /1 613 632/2 531 Dinars/day /2 2.7 3.1 3.7/3 /1 Based on the assumption that 75 percent of the current budget goes for hospital expenditures. /2 Based on the number of patient days. /3 Estimate. The total investment for the 1962-1971 period was D 11 million, of which 69 percent went into facilities in Tunis, and 9 percent into Bizerte, Sfax and Sousse, leaving 22 percent for the rest of the country. 21.4 The effectiveness of health expenditures is not easy to measure. Measures of output, such as death rates, are not entirely suitable. Further- more, there is virtually no cost-accounting data for health services. Thus, with a few exceptions, it is difficult to trace the trends in unit costs over time or establish indicators of management efficiency. Despite these limita- tions, it is useful to note the trends in several aspects of hospital care. Table 21.5 below suggests that bed occupancy has fallen from 94 percent in 1965 to 75 percent in 1971. On the other hand, the average length of stay has decreased from 17 to 9 days, almost doubling the number of patients that could be served (assuming that the quality of the care and the type of illness treated is unchanged over the period). Costs per bed in constant prices fell during the 1960s. On the other hand, each doctor had almost twice as many beds to look after in 1965 as in 1955. Much more detailed cost-accounting informa- tion would be needed to obtain an accurate measure of the efficiency of the Tunisian health system. 21.5 The available data do not show how equitably the health services paid for by state funds are distributed, since they give no indication of the socio-economic status of the patients. However, there is a high cor- relation between the per capita income of the region and the volume of health services. For instance in the Tunis region 53 percent of births took place in hospitals or clinics, compared with only 4 percent in Kasserine (Table 21.6). It is possible that some women come from the poorer regions to Tunis for lying-in, but they would normally be those who could afford the transport and other costs. The same is true of the distribution of MDs. In proportion to population, there are ten times as many MDs in Tunis as in Kasserine. - 101 - Table 21.5: MEASURES OF EFFICIENCY 1955 1960 1965 1971 Patients/Bed (for 1000 people) 18 26 24 - Hospital Beds/MID 10 19 21 - Beds Occupied/Total Beds 94 78 64 75 Average Length of Stay (days) 17 - - 9 Dinars/Bed /1 613 632 /2 531 - (1964 constant prices) /1 Based on the assumption that 75 percent of the current budget is spent on hospital expenditures. /2 For 1959. Source: Ministere de la Sante Publique, Retrospectives de la Tunisie, 1962-1971 L'Annuaire Statistique. Ministere du Plan, Retrospectives Decennales. La Mortalite et le Coul de la Sante Publique en Tunisie. Cahiers du CERES, Serie Demographique No. 2, January 1968. Table 21.6: DISTRIBIUTION OF MEDICAL SERVICES, 1971 Percent Children Population/ Population/Bed With Hospital Population Paramed. Governorate 1971 Delivery /1 Per MD /2 1971 Tunis 226 53 2,912 490 Cap Bon 462 40 9,139 1,123 Bizerte 295 39 5,852 812 Sfax 508 28 7,774 1,039 Sousse 437 27 8,139 816 Beja 602 15 12,869 1,333 Gabes 541 15 13,176 1,032 Djendouba 639 13 11,500 1,747 Le Kef 525 10 11,690 1,638 Gafsa 724 8 11,406 1,789 Kairouan 625 7 12,583 1,452 Medenine 696 5 11,565 1,574 lKasserine 1,396 4 22,900 1,991 Tunisia 400 6,486 907 /1 For 1965. /2 For 1971. Source: Ministere de la Sante Publique, Retrospectives Decennales, 1962-1971. Note: Total number of beds is 12,571, of MDs 793, of whom 50 percent are foreign, and of paramedicals 5,664. For some rural areas, e.g. Kieble, there is one MD for 25,000 people; in Dou, only one for 40,000. - 102 - 21.6 The biggest problem is the provision of adequate health services with limited resources. The Tunisian system is based on European standards. Nurses are not permitted to screen patients; anyone who arrives at the clinic and wants to see the MD can. About 75 percent of the current expenditures on health go to the big hospitals in the urban areas. Fifty percent of the MD's are foreign and do not speak Arabic. This problem can be partly solved by means of greater use of paramedical personnel for whom short training courses in simple medicine and hygiene suitable for persons with little formal educa- tion have proved to be effective. C. Nutrition 21.7 Proper nutrition is essential to the health, not only of the present generation, but also that of future generations. The mother's nutrition be- fore and during pregnancy influences the child's health. There is evidence that protein deficiency in a mother's diet harms at least two generations of female offspring. To keep abreast of these problems, in 1969 the Tunisian Government established the National Institute of Nutrition and Food Technology, which is now carrying out research and educational activities. 21.8 About one-third of Tunisian children die before the age of five. The chief reason for this is malnutrition of both mothers and children. While few die from marasmus or Kwashiorkor, malnutrition lowers the resistance of children to normally non-fatal infections like diarrhea and measles. The extent of the malnutrition is indicated by the fact that 25 percent of the pop- ulation consumed less than 2,000 calories and 55 grams of protein each day, and 61 percent of the population received less than 20 percent of their protein in the animal form. Table 21.7 shows that, in 1966, malnutrition was more wide- spread in rural than in urban areas. Because of the stagnation of agricultural production in the 1960s, fewer calories and protein were available. In 1973 per capita consumption levels were lower than when the survey was made in 1966. Table 21.7 suggests that 30 percent of the rural population is getting less calories than it may need and that 70 percent get less than 30 percent animal proteins. - 103 - Table 21.7: DAILY CONSUMPTION PER CAPITA, 1966 Percentage of the Population Rural Urban Total Average Consumption Calories 2,250 2,600 2,340 Protein (grams) 63 74 65 (% animal) (17) (34) (22) Consumption Below: 2,000 calories 30 12 25 55 grams protein 30 12 25 20 percent animal protein 70 34 61 Source: "Comite Sectoriel de la Nutrition et de la Planification Alimentaire", Rapport du S/Comite de l'Economie Alimentaire August 1968, pp. 3, 5; "Economic Aspects of Nutrition Improvement in Tunisia", USDA, Washington, D.C., 1970. 21.9 Research on malnutrition in Tunisia is being conducted by the National Institute of Nutrition and Food Technology, the National Institute of Child Health and Yale University. In an important experiment under non- laboratory conditions, they are trying to determine what effect different types of food supplements and pediatric care have on the mental and physical development of children between birth and two years of age. The preliminary results indicate that, after the age of 12 months, medical care and nutrition do have a significant influence upon the sensory motor abilities 1/. In con- junction with data from an earlier Tunisian study, the new data suggest that almost half of the differences between income groups are attributable to this cause 2/. D. Family Planning 21.10 Tunisia has a total population of about 5.5 million, 45 percent of whom live in the five governorates of Tunis (North and South), Sousse, Sfax and Bizerte, where the average density is 200 per square kilometer. The rate of growth increased from less than 2 percent in the 1930s to 2.3 percent by 1960, and to 2.5 percent by 1968. Population growth prospects were studied in Chapter 3, where it was seen that the effect of family planning programs on fertility will be important. 1/ "Nutrition and Child Growth and Development in Tunisia: Interim Progress Report", March 1973, Tunis. 2/ "Social Class and the Impairment of Growth and Health", in Change in Tunisia; Essays from the Social. and Health Sciences, forthcoming. - 104 - 21.11 Since over half of Tunisia's married women are concentrated in the five governorates listed above, the logistics of the delivery of family plan- ning services are relatively favorable. Moreover, in Tunisia, unlike some other countries, the usual family limitation methods do not meet with strong resistance for religious or social reasons. A national survey of knowledge, attitudes and practice made in 1964 indicated a large demand for family plan- ning services. A public family-planning program (the first in Africa) was introduced on an experimental scale in the same year, with financial and technical assistance from the Ford Foundation and the Population Council, and expanded into a national program in 1966. Since 1968 USAID and SIDA have also provided substantial financial support. While the program made rapid progress in its first two or three years, a "plateau" was reached in 1968, and in 1970 it was estimated that the program was reaching only about 2.5 percent of women of fertile age each year. The failure to advance fur- ther was attributed to weaknesses of organization and staffing and the over- crowding of the urban maternity hospitals. 21.12 The program took the form of counselling women on family planning and offering acceptors a wide choice of contraceptive methods in the course of free consultations at five large maternity hospitals, 89 Maternal and Child Health (MCH) Centers and 189 rural dispensaries. Outside the large hospitals, the consultations were conducted by teams, each consisting of a gynecologist (usually an expatriate), a midwife, an assistant nurse and a driver. It was found that the effectiveness of this team system was limited by the shortage of doctors, who had to be assigned in priority to curative medicine. This pressure was strengthened by the transfer in 1969 of much of the administrative and financial control of the program from the Directorate of Maternal and Child Health Services and Family Planning (MCH - FP) in the Ministry of Health to regional health administrators. The MCH - FP Directorate was also handicapped by administrative weakness which hindered the distribution of contraceptive supplies. - 105 Table 21.8: ACTIVITIES INDER THE FAMILY PLANNING PROGRAM Percent Annual 1968 1971 Change Contraception and Abortion Primary Insertion IUDs 9,199 9,638 1.6 Abortion 2,246 2,705 6.4 Free Pills (users: monthly me&n) 1,779 6,285 /2 53.0 Private Sale of Pills 7,292 Deliveries Maternal and Child Health Beds 996 1,312 9.6 Deliveries at MCH 51,792 57,329 3.4 Deliveries/Bed 52 43 -6.0 Mean Stay/Bed (Days) 7 *- Consultations Centers 89 /1 80 -3.5 Total Consultations 98,951 71 104,986 2.0 Mean Consultation/Center 1,112 /1 1,312 5.7 Post Partum Education Educators 51 /1 33 -135 Total Consultations ,, 4,752 Consultations/MCH Deliveries 8 Motivation Program Invited for interview 19,526 /1 20,856 2.2 Came for interview 3,949 7T 3,905 -0.5 Accepted contraception 3,745 /1 3,845 0.9 /1 In 1969. /2 1970 data. Source: 1968: IBRD "Appraisal of a Population Project", March 1971, Washington, D.C. 1971: Ministere de la Sante. 21.13 Since 1970, efforts, supported by an IBRD loan of $7.2 million made in March 1971, have been made to deal with these problems. The MCH-FP Di- rectorate was made directly responsible to the Minister of Health, and a dis- tinguished woman gynecologist was appointed Director. The services of pedia- tricians and other physicians attached to the MCH centers and of general prac- titioners are being enlisted to sujpplement the work of the mobile teams, and special resident midwives are to reside at the centers. There is to be in- creased use of paramedical staff, for whom additional training facilities are being provided. The loan is also financing the construction of additional - 106 - maternity hospitals and MCH centers and the services of management consultants who are advising on the organization and administration of the family planning system. 21.14 For 1970 it was estimated that of the 198,000 births which would otherwise have occurred, 12,135 or 6 percent were averted 1/. The intra- uterine device (IUD) accounted for about 66 percent of the births averted, abortion and tubal ligations 24 percent, and other methods 10 percent. Statistics of the family planning program are given in Table 21.9. 21.15 The data reflect the levelling off after 1968. Mean consultations per center rose from 1,112 in 1968 to 1,312 in 1971. Nine centers were closed. At the same time the number of post partum counsellors, an important factor in the acceptance of contraception, fell from 51 to 33. The rate of post partum consultation was only 8 percent of the total deliveries of infants at the Maternal and Child Health Centers (MCH) 2/. 21.16 The total cost of the family planning program in 1970 was D 559,000, of which 47 percent was provided by foreign assistance. For the period 1973- 1976, it is predicted that the number of new women using pills and IUDs will increase from 42,400 to 59,000, or about 4 to 5 percent of women in productive age. Table 21.9 AGENCIES OR GROUPS AFFECTED BY FAMILY PLANNING PROGRAM (1973) A. Within Family Planning Program 1. Policy body 2. Relations with other national organizations 3. Relations with donors 4. Administration 5. Budget, accounting 6. Facilities, equipment, supplies 7. Personnel 8. Personnel recruitment 9. Personnel training 10. Supervision 11. Delivery of services 12. Transportation 1/ "Evaluation of Family Planning Programs Using Service Statistics", Working Paper No. 137, November 1972, Washington, D.C., World Bank. 2/ "Les Travaux d'evaluation sur le programme national tunisien de planning familial", African Population Conference, Accra, December, 1971. - 107 - 13. Medical and contraceptive policy and research 14. Evaluation 15. Research 16. Program review 17. Public information B. Within Health Ministry 1. Ministers and cabinet 2. Regional health administrations 3. Pediatrics 4. MCH 5. OB 6. Health education C. Within Government 0. Coordinating council 1. Prime Minister, or President 2. Plan Ministry 3. Education Ministry 4. Finance Ministry 5. Economy or Labor Ministry 6. Agriculture Ministry 7. Foreign Affairs Ministry 8. Defense Ministry 9. Justice Ministry 10. Health Ministry 11. Social Affairs Ministry 12. Information Ministry D. Other National Organizations 1. The political party(s) 2. The women's organization 3. Social science research organization 4. (Junior Chamber of Commerce) 5. Family organization 6. Religious organization(s) 7. Professional organizations (medical, obstetrical, sociological, psychological...) E. Foreign Organizations Governmental USAID SIDA CIDA Peace Corps - 108 - Dutch USHEW USIA NORRAD - Norway Multilateral WHO UNDP-UNFPA UNESCO UNICEF FAO ILO IBRD Private IPPF Pathfinder Population Council Ford Foundation PPFA CARE-MEDICO Rockefeller Foundation AFSC Population Reference Bureau OXFAM World Education Universities Johns Hopkins North Carolina University of Chicago Royal Tropical Institute Rennes School of Public Health Tulane Harvard Prepared by: Melvyn Thorne, M.D., Johns Hopkins University. 1 0o - Table 21.10: ACTIVITY OF THE FAMILY PLANNING PIDGRAM (No. of Persons) Initial Reins er- Insertions tions Of New Pill Use of / Use Of J/ Years Of I.U.D. I.U.D. Users Pills Condoms 1964 1.154 - 25 - 1965 12.832 50 34.3 143 538 1966 12.077 310 350 208 423 1967 9.657 429 591 290 402 1968 9.304 475 4.780 1.779 94j3 1969 8.696 508 7.867 4.181 1.558 1970 9.638 618 9.959 6.285 2.254 Total 63.358 2.390 23.890 lst half 1970 5.905 337 5.209 6.124 2.249 1st half 1971 6.968 438 5.939 7.314 2.418 Use Ofi/ Tubal Abortion New Total Years Jelly Ligature (Legal) Visits Visits 1964 - 293 - 6.160 12.620 1965 208 384 3h2 16.672 39.5h2 1966 150 1.396 1.396 16.176 41.517 1967 85 742 1.331 13.600 41.535 1968 193 1.627 2.246 20.432 67.986 1969 286 2.513 2.860 31.357 127.700 1970 340 2.539 2.705 35.362 184.419 Total .. 8.864 10.880 139.759 515.319 1st half 1970 362 1.427 1.419 19.385 93.291 1st half 1971 364 1.352 1.522 21.381 117.798 Source: Ministry of Health j/ Monthly Average | ~~~~~~~~4f f D T Lc f R A IV C A /V 5i f A 2 ~~~T U NISIA ~s ITRANSPORTATION NETWORRKx L o BE,4S z fr i ~' D br"7v h ,o n topt, \i 0' [~~~~~~~~~~~~~~~~~~~~~. Am-a . ..5= _et - ~ ~ t5 /\ s v < i z > / i <; \ Enfidovill1e O / AMIA44e - \M,7 , / {f } 1 V ,5L~~~~~~~~~~~~~~~~~~~~~~s- - --~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~U -O Xf S .GA F5ZNs] 34-~ ~ ~ z _> > e < Nei§ > 1, +, Xt/ t\ _ 0 -i6tt: ;1! |~~~~~~SLAD O _1 JEP5AtfOf6X; _ 5W%e ;> _S \y,/D h S _ > W X~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. .,J 00O D.) ! °ER' I n3;~~~~~~T P ,a \ > j/\\Ait , / } < stO;F yE*1D -ltebWM - J SA \1 : s- t - -s 1 2s t f < C k |~~~~~~~~~9 IBRD 10697 TUN I S I A w M~~~~ft- I 'EF§^A,.V,AA S11A TOUR I SM , : B~ ON <~~~~~~~~~'j/0,,n Teor / fX LeK4e oj/ 3 -/ > EnfdovAtle U MMAmfr _636° ~ ' 2 //< AS j Jf \ 76 & -fKERKENNA 47f _0 / <. % \ ISLANDS -34. ) c E D - Main Tourism Areas ~ oba ION- SICf - u, 0 t)tftosslS) ~~~~Raiwas __ ra u Jn _35D~~~~~~~~~~~~~~~~~~~~~~~~~~~- AN OF f -z. Riverso ~~ / . { / n \ r-$ tT'K~~~~~~~~~r- ERBA NN -. \ tr/ ratoa Rounciares ~0 D- ~ QJ i [=i~ MaiLnEI TuimSAea Mom Ro id A° Ft REot Riv;ders \ \. '2 f ~~ ~ ~ ~ ~~nerao l gol i|daries, ,1 'nNg MILES'\ t\ 0~ ~ ~ ~ ~ ~ ~~~~~5 /^l Eiin iqrrc 10- TUNISiA PROPORTIONAL DISTRIBUTION Med 'terranean Sea OF THE POPULATION BY PROVINCE Jrban populelicn ., Densely popula,ed areas c l populated areas POPULATION DENSITY, 1966 CENSUS Less than 20 -.->ux, - B E J A \, TUNI-- B E U L ; 80-59.9 ~~~~~1 2~~~~~~~~~~~60-79.9 B E A 00or more Provinc al boundaries E KE . - ternatiOa boundaries A~~~~ ~ ~~~ Li~ GE R3e S,- z-ttw,'i > s ,. ,, g .,1 . .E , T.,s' 36,'t'a AF R I C A <)~~~~~~~~~ Allr IR' U. A N < ALGERIA Y KASSE RN I - N j G A~~~~~~~~~~~~~ F SA X > --_r-8 1~~~ SFA ,--r _ X 3c- q o( o 3o 40 roo MILES 0 20 40) 60O 80 KILOMETERS -34~ ~ ; CHOTT EL OJERID -\ / I\,kz d\ w s- G A B E S oA ' .' iMEDENINE . > >o -> Vl MEDNI NLIBYA OCTOBER 1970 IBRD-3'51 MAP 3 e- 10o 12- 7UNISIA M edit er r a n e a n S e a -MATERNITY FACILITIES & M.C.H. NETWORK sierte TUNI 0Ras Djebel | EX3STINI MATZF41TY FACILITIES IMenel Bourjibo X 1o Farira J 3 R.fl4.C.s AND MATERN:TY 11OSPITALS - Flaou rio ~~~~~~~PROPOSED By PROJECT. oMateur Aak el / HL EXISTING M C.H. CENTERS &\tedjencne as £ M.C.H. CENTERS PROPOSED BY PRO- iB I Z E R T E IKoe a 0 LOCALITIES ) Tebors iA ---PROVINCIAL DCUNDARIES *ZoouieCMadien urs Mamno0ba AnKa eseTmTC f\ Hoi6 U Mec zel Bou Ze < 'Ain Oraharr`> A* SM % Beni KhcZIed/ INTERNATIONAL BOUNDARIES ?DJENDOUgA( I*Bi A TI NI Am A MA BE J A 0Medjez Er Bab sGro oa Kora oBw Salem Gampola aseka 0TeSIEur f t Da ni Khbcjr so ~ ~ ~ N Tebhasir / ^0 Dled°UbJZ T bo suk (~~ ) A-NJAB E UL tNabeiji Ghrdimaou AT oUA Zaghouan Hammamet 0 5o0 30 40 50 A3* PontduFGhsI 0Golour BouArada Ld1 MILES ) *0" > % s~~~~~~~~~~~ J *l~~/ OE /idavrille a 2tlD 40 60 6 PD1 ;Le Kef t KILOMETERS N L L -36- / * Tcdjercuine OMaktar \ SblKha Kebira 7LEKEF Tu na:'sta E Ta~~~Hdjerou*iniieM nNastralh x , K- -..Mame ( ar Hellal | Kairouan0 A S SbouubK EFruCA A I 6tThala 'SOUHSSoE ALOE R~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~A K~~~~~~~~~~~L0 sai,r Essaf \ ~ ~~~~ ( 1SfxRE H e ,ASiA FSA£di A i Ben Nasrcli6ch' KASS ER N L-E im LaCeb A Sbei?Iaj &~~ / Kosserine /a A I ) AijeTiOnO C'- SidiBoZd FAX & £oRIguer/Menzel Co'Ke'A A )~~~~~~~~~~~~~~~~~~~~~ ( NeftaO Tozeur , / (ox sv u v < ffLE DE~~~~ DJERA G A F S A / Bir Al iBen K helif \ ~ ~ ~ ~ ~ ~ £ -, Mtoa * ~~~~~ £Jv- MEDENI sn ad\\ Maknossy Ela~ Guettar/ L' - 34*r j9: IR 3Res ( Hefts? ameur~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~lHlmc' AI S 'K \A