Healthcare access among sub-Saharan migrants and refugees in Tunisia: an interpretative qualitative study

Tunisia, situated at the crossroads of North Africa and Europe, has increasingly become an important origin, destination, and transit point for sub-Saharan migrants and refugees in recent decades. Despite growing migration flows, there remains a paucity of research on how these populations navigate healthcare access in Tunisia. This study addresses this gap by exploring migrants' experiences with and perceptions of Tunisia's healthcare system, with a focus on barriers to and facilitators of healthcare.

A qualitative study was conducted in four urban areas (Tunis, Medenine, Sousse, and Sfax) with concentrated migrant populations between May and December 2023. A purposive sample of migrants, migrant community leaders, and nongovernmental organization (NGO) staff were engaged through semi-structured interviews and focus-group discussions. Data were analysed via thematic analysis, combining inductive and deductive coding via NVivo 14 software, guided by an adaptation of Levesque's conceptual framework.

In total, 120 migrants and 43 NGO staff members participated in the study. The participants identified structural barriers such as legal status limitations, language barriers, and financial constraints, as well as social and cultural issues such as stigma and distrust of health system. While informal networks provide critical health information, they often lead to fragmented care. The private sector was perceived as better quality but unaffordable for the majority of migrants. Key facilitators included NGO support for referrals and coordination, particularly for undocumented migrants. Access was further hindered by communication gaps and limited awareness of the healthcare process.

Our study underscores the complex interplay of structural and individual barriers to accessing healthcare for migrants in Tunisia. Addressing these challenges requires culturally sensitive policies, multilingual resources, simplified administrative processes, and expanded health insurance coverage. Strengthening collaboration between NGOs, healthcare providers, and policymakers is essential to ensure equitable healthcare access for migrants.