Cardiovascular Journal of Africa: Vol 31 No 5 (September/October 2020)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 5, September/October 2020

AFRICA

269

of tobacco dependence.

However, locally relevant clinical

guidelines for the management of pharyngitis and RHD as well

as for CVD prevention are lacking.

Tunisia does not have a

registry for people with a history of rheumatic fever and RHD,

although a system exists to measure the quality of care provided

to people who had suffered acute cardiac events.

Standard

treatment guidelines for diabetes mellitus and other NCD, or

conditions such as hypertension have been developed.

16,17

Essential medicines and interventions

In Tunisia, all the essential CVD medicines are available in the

public sector,

as are warfarin and clopidogrel.

Data regarding

total cholesterol measurement,

priority CVD risk stratification and

secondary prevention of rheumatic fever and RHD are available at

the primary healthcare level (Habib Gamra, pers commun).

Secondary prevention and management

The percentage of people with a history of CVD taking aspirin,

statins and at least one antihypertensive agent is 38%.

In 2012,

32.9% of hypertensive persons received medical treatment,

however, the percentage of high-risk patients with AF receiving

oral anticoagulants was unknown.

Part D: Cardiovascular disease governance

Strategies that address NCD, which include CVD and risk factors

such as diabetes, have been developed, although not much work

has been done in this area

since no dedicated budget is available to

ensure implementation. However, Tunisia has an operational unit

or department in the ministry of health (MoH) that is responsible

for NCD.

22,23

Furthermore, the prevention and control of RHD

in Tunisia is efficient through the acute articular rheumatism

monitoring programme.

However, a national surveillance

programme that includes CVD and their risk factors is lacking.

Regarding tobacco use, Tunisia has formulated a national

tobacco control plan andmulti-sectoral co-ordinationmechanism

for tobacco control.

Collaborative projects between the Tunisian

MoH and that of higher education and scientific research

and technology have been reported by Hassen Ghannem.

No information is available on the total annual government

expenditure for cardiovascular healthcare.

Tunisia was part of the WHO-CHOICE project, which

incorporated a cost-effectiveness modelling tool that gathers

national data to be used for developing the most effective

interventions for leading causes of the disease burden.

The

model can be adjusted according to the specific needs of the

country and assist policymakers in planning and prioritising

services at a national level.

The benefits of CVD prevention and

control for population health and the economy have also been

modelled, according to Saidi

et al

Assessment of policy response

No legislation exists in Tunisia mandating health financing for

CVD or that of essential CVD medicines at affordable prices.

However, van Mourik

et al

reported that Tunisia is one of the

countries where medicines are provided free of charge in the

public healthcare sector.

Legislation exists banning smoking in indoor workplaces

and public areas, other public places, public transport, all

forms of tobacco advertising, promotion and sponsorship, as

do measures to protect tobacco-control policies from tobacco

industry interference.

However, that mandating clear and

visible warnings on at least half of the principal display areas of

tobacco packs does not exist.

According to

The Report

, there seem to be policies that

ensure equitable nationwide access to healthcare professionals

and facilities in Tunisia,

including those ensuring screening

of individuals at high risk for CVD.

However no sustainable

funding from taxation is available for CVD.

Taxes on unhealthy foods or sugar-sweetened beverages have

been introduced at 25% of the excise tax (

Discussion et adoption

par l’assemblée des représentants du peuple dans sa séance du 9

décembre 2017

23,29

Tunisia is one of the few African countries

with a policy that entirely reduced the affordability of tobacco

products through increasing tobacco excise taxes.

In 2018, the

excise tax of the final consumer price of tobacco products was

74%. No data were found on excise tax of the final consumer

price of alcohol products, or legislation banning the marketing

of unhealthy foods to minors, and clear and visible warnings

on foods high in calories, sugar or saturated fats. No policy

interventions were available promoting a diet that reduces CVD

risk or those facilitating PA.

Stakeholder action

In Tunisia, non-governmental organisation (NGO) advocacy

for CVD policies and programmes as such has not been

demonstrated.

No information about active involvement of

patients’ organisations in advocacy for CVD/NCD prevention

and management is available or that regarding advocacy

champions and or patient engagement for RHD groups.

However, the involvement of civil society in the development

and implementation of a national tobacco control plan is

available.

A community-based intervention with multi-sectoral

interventions was implemented in Tunisia, which demonstrated

the effectiveness of reducing risk factors in the community,

workplace and schools from 2010–2014.

However, the

involvement of policymakers and political will was recommended

to reinforce the intervention, have a better impact, and to ensure

a long-term effect.

Specific activities by cardiology professional associations

aiming at a reduction in the premature CVD mortality rate of

25% by 2025 are also not known. In an interventional study at

six workplaces, screening and health-promotion initiatives were

suggested, ‘to avert the excessive risk for CVD,’ which included

BP measurements.

As part of the data collected for Tunisia, the following strengths,

threats, weaknesses and priorities are summarised.

Strengths

Tunisia implemented a CVD registry in three geographical

populations, which provided incidence and fatality data for the

first time in 2001.

These authors suggested the data should

be integrated into the local health system. A decrease in the

incidence of RHD was reported by Belguith

et al