ORIGINAL ARTICLE Health system challenges of NCDs in Tunisia Habiba Ben Romdhane • Faten Tlili • Afef Skhiri • Shahaduz Zaman • Peter Phillimore Received: 29 January 2014 / Revised: 20 October 2014 / Accepted: 3 November 2014 / Published online: 16 November 2014 Ó Swiss School of Public Health 2014 Abstract Objectives The objective of this study was to present a qualitative ‘situation analysis’ of the healthcare system in Tunisia, as it applies to management of cardiovascular disease (CVD) and diabetes. A primary concern was the institutional capacity to manage non-communicable dis- eases (NCDs). Methods Research took place during 2010 (analysis of official documents, semi-structured interviews with key informants, and case studies in four clinics). Walt and Gilson’s framework (1994) for policy analysis was used: content, actors, context, and process. Results Problems of integration and coordination have compounded funding pressures. Despite its importance in Tunisian healthcare, primary health is ill-equipped to manage NCDs. With limited funds, and no referral or health information system, staff morale in the public sector was low. Private healthcare has been the main development filling the void. Conclusion This study highlights major gaps in the implementation of a comprehensive approach to NCDs, which is an urgent task across the region. In strategic planning, research on the health system is vital; but the capacity within Ministries of Health to use research has first to be built, with a commitment to grounding policy change in evidence. Keywords Tunisia Á Arab health Á Health system challenges Á Non-communicable disease Á Health Á Policy Introduction Tunisia is a Northern African country, located between Algeria and Libya, with a population of about ten million. In many respects, it is typical amongst emerging South and East Mediterranean countries undergoing rapid demo- graphic and epidemiological change (Ben Romdhane et al. 2002, 2005). A review of the epidemiological profile shows that non-communicable diseases (NCD), such as cardio- vascular diseases (CVD), cancer, and diabetes, now exceed communicable and traditional infectious diseases as the main causes of morbidity (70.8 % of cases) and mortality (79.7 % of deaths), and there is a growing literature on the burden of NCDs and their risk factors (Ben Mansour et al. 2012; Bouguerra et al. 2007; Elasmi et al. 2009; Ben Romdhane et al. 2012; Saidi et al. 2013). Across the Middle East and North Africa (MENA) region, economic development has intensified the trend towards urbanization, and brought improved health care, education, drinking water and sanitation. But these same developments have been accompanied by changes in economic activity, family structure, lifestyle and nutrition which have fostered the growing epidemic of NCDs (TAHINA 2006, Atek et al. 2013). This article is part of the supplement ‘‘The rising burden of non- communicable diseases in four Mediterranean countries and potential solutions’’. H. B. Romdhane Á F. Tlili Á A. Skhiri CVD Epidemiology and Prevention Research Laboratory, Faculte ´ de Me ´decine de Tunis, Tunis, Tunisia F. Tlili Institut National de Sante ´ Publique, Tunis, Tunisia S. Zaman Á P. Phillimore (&) Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK e-mail: peter.phillimore@ncl.ac.uk Int J Public Health (2015) 60 (Suppl 1):S39–S46 DOI 10.1007/s00038-014-0616-0 123