Tunisia is considered a middle-income country and is located in North Africa. Its current population is approximately 12 million people based on the latest statistics by the World Bank data in 2018. Although Arabic is the official language of the country, French is spoken fluently by the majority of the population. Tunisia shares borders with Algeria in the west, Libya in the east, and is situated in the southern border of the Mediterranean Sea below the Italian Peninsula. Tunisia was colonized by France in 1881 but declared its independence in 1956 to become officially the Republic of Tunisia. Economically, Tunisia has been struggling since 2011, following the Arab spring revolution, with a current real GDP growth of -1% according to the IMF. According to the World Bank, the main sectors of the Tunisian economy are agriculture, accounting for 10.4% of the GDP and employing 15% of the workforce, industry, representing 22.7% of the GDP, and services (tourism and communication technologies), representing 63.6% of the country’s GDP (The economic context of Tunisia, 2020).
Table 1: Country information:
| Country Name | Tunisia |
| Population | 11.57 million (2018) |
| Area | 163,610 km² |
| GDP (PPP) | 39.87 billion USD |
| Languages | Arabic, French, English |
| Currency | Tunisian Dinar (TND) |
In terms of healthcare, the public health care system in Tunisia is funded by taxation and covers medical services for residents and citizens within the public system. Coverage for medical care within the private sector, audiology services for example, follows certain criteria and requires a pre-approval.
In the aftermath of the independence in 1956, the medical system in Tunisia followed suit of France. France adopted a 3-year education program for certification to practice audiometry with a possibility of an additional two years for a master’s to become an audiologist (Onisep, 2020).
Tunisia’s first school of audiometry was founded recently in 2015. The program is a three-year program, following the French system, without the option of pursuing a master’s degree currently.
Generally, the position of an audiometrist in Tunisia has similar licensure requirements for practice as a hearing aid dispenser in the US. The duty of audiometrists is mostly limited to basic audiometry and hearing aid programming which does not include in-depth diagnostics, results, counseling, cochlear implants, vestibular, or pediatrics. Currently, there are only 4 audiologists and about 60 audiometrists active in the private sector.
An organization in support for the Deaf community called “Association Voix du Sourd de Tunisie (A.V.S.T)” was created in 1983. Despite the progressive position of audiological care, Tunisia has no early identification and intervention program.
Information regarding incidence of hearing loss and equipment available on the national level is very scarce. To the best of our knowledge, only two hospitals have acquired otoacoustic emission devices, Charles Nicolle and Nabeul. For auditory brainstem response (ABR), three hospitals perform it: Tunis, Nabeul, and Monastir. Similarly, there is no national data regarding the incidence of hearing loss in Tunisia. We were able to find two research studies on two state levels, Tunis and Nabeul.
The first project was made by the neonatology department of the Charles Nicolle hospital Tunis. The data included 3,260 newborns that underwent a newborn hearing screening in the period between one day after birth and one month of age. The results showed three cases of mild bilateral hearing loss (0.9 %), five cases of unilateral profound hearing loss (1.5%) in the right ear, and one case of anacusis (Nouaili, E.B.H. et al., 2010).
The second research study was an OAE hearing screening performed at Mohamed Tlatli Hospital Nabeul state conducted by Asma Bouaziz Abed, et al.
The goal was to determine the frequency of the hearing loss among newborns and infants under six months of age. The research included 397 infants aged between four days and five months with a risk. They received a hearing screening with an ABR and OAE. The results showed no hearing loss in 360 infants and 37 (9,32%) with some type of hearing loss whether unilateral or bilateral. Twenty-seven infants out of the 37 diagnosed positively were referred to an ABR, which was negative in 20% of the cases. In 1.76% the ABR displayed the word refer (Abed, A.B. et al., 2013).
To this day, there are no audiology schools in Tunisia; however, an audiometrist school was founded in 2015. The school is accredited by the Ministry of Higher Education in Tunisia, and its curriculum consists of a 3-year education with a thesis at the end of the final year.
In public hospitals, only clinical audiology would be performed for diagnostic purposes. These services are reimbursed 100% through the Tunisian universal healthcare (CNAM). However, If the patient needs hearing aids then he is referred to the private sector in an audiometrist office. The following services are provided usually supervised by an ENT:
In the private setting, audiometrists can only perform pure-tone audiometry for dispensing purposes. The following services are provided by audiometrist:
Government hearing aids compensation through the public insurance “Caisse National d’Assurance Maladie” (CNAM). If a patient qualifies for hearing aids, the public insurance will compensate depending the following criteria:
According to the Tunisian Ministry of Health, as of 2017, the number of professionals in different sectors related to audiology is as follows (Mokdad, M. et al., 2019). However, few of these numbers, such as the audiometrists, were procured through unions and other sources which make them approximate due to lack of online reports in human resources on allied health professions.
Table 2: Healthcare professionals in numbers
| Healthcare Professionals | Numbers | Density Per 10000 Habitants |
| Audiologists | 4 | |
| Otolaryngologists | 340 | 0.3 |
| Neurologists | Unknown | |
| Nurses | 28739 | |
| Physicians | 14892 | 13.02 |
| Speech Language Pathologists | Unknown | |
| Hearing Aid Specialists | Approx. 60 |
There are currently 4 audiologists in Tunisia, so there is no defining body that represents them or official scope of practice. The current audiologists are practicing with a license provided by the Ministry of Health with a more expanded scope of practice than audiometrists which includes:
Aside from the surgical services, ENTs can provide the following audiological services:
As mentioned previously, there were only two studies related to audiology that we are aware of and could have access to its data.
The first project was made by the neonatology department of the Charles Nicolles hospital Tunis. It consisted of a hearing screening on newborns to determine the incidence of hearing loss within a sample of newborns.
The second research study was an OAE hearing screening performed at Mohamed Tlatli Hospital Nabeul state conducted by Asma Bouaziz Abed, et al.
The goal was to determine the frequency of the hearing loss among newborns and infants under six months of age.
Currently, we are not aware of any ongoing audiological work in Tunisia
Link: http://www.fedsante.com.tn/chambres/chambre-syndicale-nationale-des-audio-prothesistes/
Currently, only audiometrists have a clear scope of practice (in French):
http://www.santetunisie.rns.tn/images/cahier_charge/c_charge_fr/C16_fr.pdf
AUDIOLOGY CHARITIES
The association was created in 1983 and has 25000 members. The main objectives of this group are to support deaf young people in order to facilitate their social integration, defend the rights of the deaf, and promote cultural and sports activities.
Rotary Club Tunis Les Berges du Lac
The club was created in 2009 and has currently 24 members. Their main goal is to improve the quality of life of others through action in the areas of water, mother and child, literacy and health. They recently procured hearing aids for two children in need to help them return to school. The club took care of the cost of the hearing aids and the fees of 4 years follow-up appointments with an audiometrist.
Tunisia’s public health system suffers from lack of funding. Public hospitals are lacking personnel and equipment in order to compete with the private sector. The absence of digitized systems makes it difficult for professionals to access patient information, health history, or previous testing. This is why it is hard to find data on a national scale.
In addition, hearing aids compensation is insufficient compare to other countries and criteria of eligibility are not up to date to the international guidelines especially for children and the elderly.
Audiologists also are not recognized officially by the Ministry of Health, as the profession is fairly new, and the course of study is not taught in the country. At this moment only audiometrist are recognized with a three-years diploma.
However, Tunisia is in a transitional period and the current government is showing more of a concrete interest to restructure the health system in the country. Digitization of the country, investments, and funding of the public health system are currently hot topics and hopefully are expected to see concretization soon.
Diplôme d’Etat d’audioprothésiste. (n.d.). Onisep. http://www.onisep.fr/Ressources/Univers-Formation/Formations/Post-bac/diplome-d-etat-d-audioprothesiste
Melliti, A., Melliti, S., & Sherwood, L. (2019). The history of audiology in Tunisia: Student audiogram. Student Academy of Doctors of Audiology
Mokdad, M., Brayek, A., Abidi, B., & Gam, W. (2019, March). Santé Tunisie en chiffre 2017. (pp. 93–94). Tunisian Ministry of Health. http://www.santetunisie.rns.tn/images/docs/anis/cartesanitaire/Sante-Tunisie-en- chiffres-offre-de-soins-2017.pdf
Nouaili, E.B.H., Chaouachi, S., Bezzine, A., Hamadi, M., Mbarek, C., Benlallehom, L., & Marrakchi, Z. (2010). Dépistage systématique de la surdité en maternité par oto- emissions acoustiques provoquées (O.T.E.A.P): Etude pilote. La tunisie Medicale: 88(7), 482-485.
The World Bank. Country Profile – Tunisia | Data. (n.d.). https://databank.worldbank.org/views/reports/reportwidget.aspx?Report_Name=CountryProfile&Id=b450fd57&tbar=y&dd=y&inf=n&zm=n&country=TUN
The economic context of Tunisia. (2020, July). Nordea https://www.nordeatrade.com/fi/explore-new-market/tunisia/economical-context
Tunisia [Map]. (2019). In One World- Nations Online. https://www.nationsonline.org/oneworld/map/tunisia-political-map.htm
