Assessment of Emergency Preparedness and Health Systems Resilience in Middle East and North African Region: The Case of Tunisia

Background : Although COVID-19 is the most recent example of a health emergency in Tunisia, the escalating frequency and complexity of global health threats have elevated the imperative for stronger and more resilient health systems. The objective of this study is to assess the capacity of Tunisia's health system to prevent, detect and respond effectively to health shocks and to generate a practical, actionable list of priorities to strengthen health system resilience and enhance emergency preparedness and response. Methods : We adapted the Emergency Preparedness and Health System Resilience Assessment (EPSRA) tool—a new and novel instrument [1] to offer a comprehensive and adaptable approach for the self-assessment of health system resilience against health shocks. The tool consists of four components: (1) Financing arrangements; (2) governance and institutional arrangements; (3) health system resources, public health, and service delivery, (4) data and information systems (including surveillance systems). Data collection involved a combination of document reviews and stakeholder meetings, relying on comprehensive and inclusive self-assessment processes, engaging relevant ministries, agencies and stakeholders. Results : The assessment results reveal substantial variations in progress across the different components. In the financing arrangements component, the country has made significant progress in contingency appropriations for emergencies and social protection mechanisms for vulnerable populations, both rated as "expanding". However, financing arrangements for surge capacity during emergencies and maintaining essential services are lagging, rated as "developing" and "beginning," respectively. The governance and institutional arrangements component presents a mixed picture. Key governance subcomponents, including the presence and maturity of policies and strategies for emergency preparedness, regulatory capacity, and community engagement are rated as "expanding" while informed decision-making processes is rated as "mature”. Weaknesses are evident in areas such as organizational structures and mechanisms for emergency response, and the socio-political and macroeconomic environment, which are rated as "developing". The health system resources, public health, and service delivery component reveals a concerning picture. Most subcomponents in this category are rated as "developing," highlighting a need for improvement in functional and reserve capacities of human resources and physical resources, training, and infrastructure development that enables both emergency response and the maintenance of essential services. For the data and information systems component, framework and operational procedures for data and information systems, infrastructure to support these systems, and the presence and maturity of key data sources are rated as "expanding” while other areas, such as the presence and maturity of early warning and surveillance systems for timely detection of shocks, the flow of data between stakeholders, and knowledge management are rated as "developing". Conclusion : The study demonstrated the feasibility of the ESPRA tool to assess a country’s health system resilience, offering key insights for practical implementation. Findings can serve as both a starting point and a platform for ongoing policy dialogues and health reform efforts at the country level.