Ripping Tunisia’s Social Safety Net to Shreds

People outside a shut bakery that is rationing bread due to shortages in Oueslatia, outside of Kairouan, on February 26, 2022. Photo by Chahd Lina Belhadj.

Samira Hammami is the sole breadwinner for a family of seven in the valley town of Oueslatia in the governorate of Kairouan, an hour west of Kairouan city. A widow for nearly two decades, she provides for herself, three kids, disabled brother, and parents in-law by collecting plastic bottles to turn in for recycling. She has to wake up at three in the morning to do this work since she’s competing against many of her neighbors who also make a living this way.

In an interview with Meshkal this February at her in-laws’ unfinished home where they all live,

Hammami said she’s struggling to pay most of her bills including electricity and water. She had to buy school supplies for her daughter on credit from the local supply store. Hammami has public health insurance coverage that is supposed to cover all her and her children’s medical bills (the “White Card/Carnet”); but despite this, a recent prescription for her daughter—after a medical scare took them to the emergency room—couldn’t be filled at the public hospital because the hospital was out of supplies. Hammami couldn’t afford to buy the prescription out of pocket at a private pharmacy, leaving her daughter without the medicine she needed. Hammami’s own diabetes and hypertension medicine are also often out of stock at public health facilities, and she’s even had to pay out of pocket for her own IV fluid at a hospital.

A portrait of Samira Hammami in her home in Oueslatia, by photographer Chahd Lina Belhadj on February 25, 2022.

Hammami’s poverty makes her eligible for support from numerous public programs in the State’s social safety net. In recent years, economic and social reform interventions by the International Monetary Fund (IMF) and the World Bank (WB) have shifted funding in Tunisia’s social welfare coverage from universal programs to programs that are ostensibly meant to target the poorest like Samira Hammami. But those “targeted” programs haven’t reached her because she doesn’t have good social connections, she explained.

“If you have someone who is well-known and in a higher position, you can get by. If you don’t, you would just rot,” said Hammami, referring to local officials. “We wish someone would remember and look at us…We’re not even humans anymore.” 

Meshkal previously documented how direct transfers of cash to the needy during the Covid-19 crisis were subject to the discretion of local officials and determined by eligibility criteria that favored male heads of household. Hammami also claimed that with State assistance, “the aid they give, it is granted to specific people they know and gets distributed under the radar.”

Existing “Targeted Transfer” Programs

Tunisia’s main direct, cash transfer program is under the National Assistance Program for Poor and Needy Families (PNAFN). According to the World Bank in its June 2020 loan program, the PNAFN program covers about 9 percent of the population, giving 180 dinars per month to households and an additional 10 dinars per child up to three. Yet in its loan document, the WB doesn’t seem to present a methodology on how targeting can be better at reaching needy people. Instead, the WB program stresses that current targeting might actually be too generous already, bringing up the risk of people getting more than one benefit from other State assistance programs, or what they call “double dipping” (on page 23).

A railway track in Kasserine on February 27, 2022. Photo by Chahd Lina Belhadj.

“The current cash transfer program uses a highly complex targeting mechanism and lacks the information on types of categories of vulnerable households including informal sector workers,” the 2020 WB loan notes, advocating instead for a shift to what it calls a Proxy Means Test (PMT) targeting mechanism. The document confidently asserts that “moving forward, the [Tunisian] government is committed to using a new targeting method (proxy means test)” (page 26).

But according to economic researchers Chafik Ben Rouine and Jihen Chandoul, the PMT method “has limitations for identifying the poorest households.”

In a recently published study by the Friedrich Ebert Stiftung, Ben Rouine and Chandoul note that targeting with PMT is “costly” and “demanding” in terms of administrative capacity. They write:

“There are many limits to targeting the “poorest” using the proxy means test, which has difficulties regarding inclusion and exclusion due to the significant information asymmetry that results from the low availability of disaggregated data and the irregularity of household surveys to monitor the situation – in Tunisia as well as other developing countries with large informal economies.”

While Ben Rouine and Chandoul will present their study in an October 7, 2022 webinar, this particular finding is also backed up by another recent study published by Development Pathways which noted that:

“Poverty-targeted programs are often riddled with large exclusion errors due to an assumption that ‘the poor’ is a fixed group that can accurately be identified,” adding that in Tunisia’s PNAFN program, “83 per cent of those in the bottom 20 per cent of the welfare distribution were wrongly excluded.”

From Hammami’s perspective, she’d rather have a decent job over the direct cash aid anyways.

A portrait of Samira Hammami (L) in her home in Oueslatia, with her neighbor Saida. Photo by photographer Chahd Lina Belhadj on February 25, 2022.

“I met officials lots of times and asked them to remove me from their aid plan for poor families and give me a job instead or give my son a job… They give me 200 TND [per month], how would that amount help 7 people?” she said.

Minimum wage is about 400 TND per month for full-time workers—already far too low to keep up with rising inflation in recent years.

Feeding People is Progressive

So what’s a better alternative to targeted transfers that fail to reach the poorest people? In their study, Ben Rouine and Chandoul find that universal programs—like price subsidies for certain consumer goods—are actually more progressive, better at reducing poverty, and more equitable than targeted transfers in Tunisia. They note that this is particularly true at the level of food subsidies, but also for energy subsidies as well as other universal programs like education and health.

A market in Hay Ettadhamon on March 12, 2022. Photo by Chahd Lina Belhadj.

“Food subsidies benefit the poorest more than the richest and…the relative benefit decreases as wealth increases,” Ben Rouine and Chandoul write, citing a 2013 study conducted by two Tunisian State institutions and the African Development Bank. That study, they note, has been regularly misrepresented by the media, the WB, and the IMF in ways that present the total opposite of the study’s actual findings. That’s because World Bank and IMF papers and policy positions have focused on the absolute benefits of those subsidies rather than relative benefits. The study itself is clear enough on page 15: “The system of food subsidies is therefore in Tunisia a progressive system from a relative perspective.”

Oranges rotting in a market in Hay Ettadhamon on March 12, 2022. Photo by Chahd Lina Belhadj.

Yet this progressive system of redistribution is being phased out as Tunisian officials make promises to the IMF to reduce subsidies in order to receive a new $4 billion loan which is needed to pay off other creditors. As Tunisia struggles to buy wheat on the international market due to a credit crunch and faces soaring prices and diminishing supplies due partly to the Russia-Ukraine war, those subsidized foods are already scarce in many bakeries and supermarkets. The Ministry of Commerce currently subsidizes the price of grains, cooking oil, milk, sugar, pasta and couscous, but already they have reduced subsidies for many of them or have not put enough onto the market that people can actually find them. In summer 2021, officials reduced sugar subsidies, which many claimed was done to convince the IMF that the Tunisian government was serious about implementing austerity reforms.

All these cuts to progressive, inequality-fighting food subsidies are affecting the poorest Tunisians viscerally.

A market in Kairouan on February 26, 2022. Photo by Chahd Lina Belhadj.

“You must buy five dinars worth of products for the vendor at the grocery store to agree to give you a bottle of cooking oil that usually costs 900 millimes [0.9 dinars],” said a woman in Kairouan’s Battha market, referring to subsidized oil that is in scarce supply.

At a bakery in Oueslatia this February, Meshkal witnessed people lining up to get bread made from subsidized flour during the short window of time that the bakery opened and sold what limited stock it had at the time.

A man holds baguettes at a bakery in Kairouan that is rationing bread due to shortages in subsidized flour. Photo by Chahd Lina Belhadj, February 26, 2022.

Meshkal noticed that most bakeries in Kairouan would shut down by noon due to lack of supplies. Several female customers waiting at the Oueslatia bakery complained to Meshkal about the lack of State supervision on food prices, saying that each grocery store sets prices on their own for basic food supplies.

Women wait outside a bakery in Oueslatia, Kairouan governorate that is rationing bread due to shortages in subsidized flour. Photo by Chahd Lina Belhadj, February 26, 2022.

“If I cook lunch, I won’t be able to cook dinner,” said Mounira, who did not give her last name. She claimed that many basic food stocks were only available to those with personal social connections.

A bakery owner in Kairouan told Meshkal that the scenes they’ve witnessed recently of people desperate for what little bread they have are gravely worrying.

“The day has come where people of Kairouan are going hungry. This never happened before,” the bakery owner said without giving his name.

At the market, a chicken seller said he’s noticed the increasing desperation among his customers.

“I had two women stand in front me this morning and they could not buy a chicken each, so they agreed to buy one together and split it among them. People can no longer afford to survive on their own,” he said without giving his name.

A chicken-seller at Kairouan’s Battha market on February 26, 2022. Photo by Chahd Lina Belhadj.

Healthcare, Education as Universal Subsidies

Another domain where the social safety net is being cut is in education and healthcare. According to Ben Rouine and Chandoul, “IMF programs usually indirectly impact both sectors: fiscal consolidation, local currency devaluation and debt servicing payments are causing public spending on healthcare and education to decline.”

“IMF pre-pandemic programs in Tunisia did not mention spending on either education or healthcare,” they add.

Often this means that the poorest are most affected. Emna Cherif is the director of the Hay Ettadhamon hospital, which mostly serves the working class neighborhoods of Ettadhamon and neighboring Douar Hicher. Despite having a responsibility to cover the health needs of 400,000 residents, Cherif said the hospital lacks many of the resources it needs.

“Like any hospital in Tunis, there’s a lack of medicine, a huge lack of medicine. They aren’t available in the Central Pharmacy. When I put in an order for 80 medicines, for example, they give me only 20. They don’t have the other 60. Zero, zero, zero: the whole year is like this,” she told Meshkal during an interview in her office this March.

Hay Ettadhamon hospital director Emna Cherif in her office on March 12, 2022. Photo by Chahd Lina Belhadj

“Yes the budget is insufficient, but if the medicine was available I can do a budget overrun for citizens, no problem, I can buy it… But the basic problem is the medicine isn’t available,” she said.

The other problem Cherif has noticed is that “many” people who used to have the White Carnet/Card (free coverage) or the Yellow Carnet/Card (discounted coverage) through the State’s employer-based insurance program CNAM no longer have it because there’s been so many layoffs during the Covid-19 crisis.

For those with CNAM insurance, the State insurance fund is having so many financial issues that they are way behind on reimbursements. Khadija, a university professor in Monastir, explained to Meshkal that her parents’ reimbursements from CNAM for prescription drugs for chronic illnesses used to be reimbursed within four weeks. But this February they went four months without reimbursement payments from CNAM. They also negotiated for months with CNAM over reimbursement for a knee implant, she said, with CNAM offering far less than full reimbursement each time. Many others also complained of such delays on a Facebook group dedicated to inquiries about social security programs like CNAM.

Cherif said the hospital’s resource problem has been helped somewhat by the European Union’s (EU) “Essaha Aziza” program, which gave Tunisia its first ever ICU-equipped ambulances, one of which is in Cherif’s hospital. Yet the EU has also made its assistance to Tunisia conditional on freezing public sector hiring, which may be the reason why Cherif hasn’t been able to hire drivers to drive the three ambulances that the EU donated. It might also explain why Cherif’s hospital serving 400,000 residents only has one cardiologist and can’t hire more.

New ambulances at the Hay Ettadhamon hospital, but staff said they are unable to hire drivers. Photo by Chahd Lina Belhadj on March 12, 2022.

“There is insufficient specialization,” said Cherif. “If you go to have an appointment in any specialization in any general hospital, it will take six months…there can be a lot of complications until your appointment….For example we only have one cardiologist; poor thing, she herself had to have surgery on her head and left. So for more than six months, she’s been on sick leave. Citizens are suffering.”

In the meantime, specialized doctors who are facing the freeze in public sector hiring, poor working conditions, and deteriorating purchasing power due to inflation are instead going to Germany and France to find better jobs, amounting to what many call a brain drain.

This article was produced as part of a reporting partnership between Meshkal and Friedrich Ebert Stiftung. Support for this article also comes from readers like you via Patreon at If you read Meshkal’s reporting, please consider making a donation to keep the project going.