The experience of Tunisian public healthcare system toward decentralization to the reduction of health inequalities in low-, middle- income countries.

From 2014 to 2021, Tunisian government had a firm will to implement a progressive decentralization of welfare state governance, as outlined in its democratic Constitution. The Tunisian public healthcare system was selected as a pilot sector for experimenting with decentralization to reduce disparities in access to and quality of health services across different regions. This paper aimed to formulate an effective strategy for healthcare system decentralization in low- and middle-income countries, drawing on past experiences of its implementation. Country case study resulted the best methodology to achieve that goal. Top heath management, figured out by regional hospitals' directors, was consulted to describe the technical, managerial and cultural "heritage" collected during the development process of the decentralization reform in public healthcare system in Tunisia. Findings revealed the Tunisian healthcare system decentralization should be, in first instance, the establishment of different decentralization paths according with regional pre-conditions, and then, of common protocols and procedures at national level for overcoming current differences between Tunisian territories. Decentralization process must be tailored to the specific needs of the regional Tunisian contexts to be effective but with a national control on that. Drawing from the Tunisian experience, proposed suggestions were valuable for the definition of an effective national healthcare system decentralization reform strategy more generally in low- and middle- income countries, especially in Middle East and North Africa region's countries. Due to the common recent democratic history and welfare state approach, these countries could use this "heritage" to apply effective decentralizing reform strategies for reducing territorial inequalities, in this case territorial health inequalities.