Journal of Ethnic and Migration Studies

ISSN: 1369-183X (Print) 1469-9451 (Online) Journal homepage: https://www.tandfonline.com/loi/cjms20

From medical tourism to regionalism from the

bottom up: emerging transnational spaces of care
between Libya and Tunisia

Betty Rouland & Mounir Jarraya

To cite this article: Betty Rouland & Mounir Jarraya (2019): From medical tourism to regionalism
from the bottom up: emerging transnational spaces of care between Libya and Tunisia, Journal of
Ethnic and Migration Studies, DOI: 10.1080/1369183X.2019.1597475

To link to this article: https://doi.org/10.1080/1369183X.2019.1597475

Published online: 11 May 2019.

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JOURNAL OF ETHNIC AND MIGRATION STUDIES
https://doi.org/10.1080/1369183X.2019.1597475

From medical tourism to regionalism from the bottom up:

emerging transnational spaces of care between Libya and
Tunisia
Betty Roulanda and Mounir Jarrayab
a
Institut de recherche sur le Maghreb contemporain de Tunis (IRMC), Tunis, Tunisia; bDepartment of
Geography, University of Sfax, Sfax, Tunisia

ABSTRACT KEYWORDS
This paper analyses the emergence of transnational care through Tunisia; Libya; medical
the case study of Libyan patients seeking care in the Tunisian city tourism; transnational space
of Sfax as a result of changes triggered by the 2011 Arab of care; Hybrid mobilities;
therapeutic circulation
uprisings. Deconstructing categories of ‘medical tourist’ and
‘medical traveller’, we examine how the evolving geopolitical
context produced specific migratory profiles (diasporic, traveller,
cross-border, war-wounded and transnational patients) and spaces
(cross-border, (intra)regional and transnational spaces of care)
between Libya and Tunisia. Given a lack of data on the topic in
North Africa, we developed a study on health mobilities and
circulations from a South-South perspective. Based on a survey
amongst Libyan patients (n = 205) in four private clinics and nine
semi-structured interviews with health professionals in Sfax, we
identified, how four key geopolitical periods shaped medical
travel to this city: (1) initial diasporic exchanges facilitated by
bilateral agreements; (2) an emerging medical tourism industry
within private health services arising from the UN embargo on
Libya; (3) the 2011 political crisis and arrival of war-wounded; and
(4) therapeutic circulations and emerging transnational spaces of
care resulting from the context of war.

Introduction
In the wake of the 2011 Arab uprisings, the Tunisian city of Sfax witnessed a significant
increase in both Libyans and the city’s private health services. These increases are inter-
related, and their link became increasingly visible in Sfax from 2012 onwards. Since the
start of the conflict in Libya, Sfax residents often have come to refer to Libyans as ‘tourists’
coming for medical care, with local health professionals seeing them as ‘a growing market’
(Rouland, Jarraya, and Fleuret 2016). Yet, while the context of civil war in Libya clearly
increased mobility, Libyans – both settling more permanently in Sfax and travelling to
the city – have been receiving medical care in Sfax ever since the first private hospitals
opened in the city in the 1960s. During the UN embargo on Libya (1991–99), more
Libyans travelled to Sfax as a result of bilateral government agreements between the
two countries. Following the end of the UN embargo and until the eve of Arab uprisings,

CONTACT Betty Rouland bettyrouland@posteo.net

© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 B. ROULAND AND M. JARRAYA

the Libyan middle class, distrustful of Libyan health service quality, used their comparative
economically advantageous position within region1 to pursue medical care in neighbour-
ing countries (e.g. Egypt, Jordan and Tunisia) or, for upper-income Libyans, further afield
in Europe (Lautier 2005). Thus, though costly and out of reach for many Tunisian
patients, Sfax’s private health services generally have been viewed as both affordable
and of good quality among Libyan patients for decades (Lautier 2008).
The 2011 Arab uprisings, however, marked a significant shift in Libyans travelling to
Sfax for their medical concerns. The political situation in the region changed drastically
and the civil war in Libya played a key role in shaping the development of private
health services in Sfax and other Tunisian cities more broadly. It led to increased move-
ment of Libyans across the region for medical care, no longer just for those seeking to
address their routine care needs but also, and more prominently, for people wounded
by the war (Rouland, Jarraya, and Fleuret 2016) and those unable to access urgent care
as a result of the country’s damaged medical infrastructure (WHO 2012). Yet, while
they have been increasingly settling, moving and circulating in Tunisia after 2011,
Libyans’ presence in the country, to date, has gone largely unstudied.2
In light of these circumstances, seeing Libyans as ‘medical tourists’ is problematic in
that it dismisses Libyans’ health-seeking as ‘a want rather than a need’ (Connell 2016,
533). In the current geopolitical regional context, Libyans seeking care in Sfax defy con-
ventional definitions of ‘medical tourism’. Within this conflict-laden context, ‘relation-
ships with tourism and leisure, as sources of pleasure and relaxation, may be tenuous
or simply absent’ (Connell 2016, 533; Hottois and Missa 2001) for patients travelling to
another country in order to receive care unavailable or hard to access in their country
of residence due to legal, care quality, financial or geopolitical reasons. We therefore
call in this article for greater attention and sensitivity to medical travellers’ geopolitical
contexts. We use this case study of Libyans seeking care in the Tunisian city of Sfax to geo-
politically and temporally contextualise, re-categorize through a focus on patient profiles
and travel conditions, and re-spatialize the links between private health service develop-
ment and the presence and growth of international patients in order to better understand
how cross-border, (intra)regional and transnational subjectivities and spaces of care are
produced. In the sections below, we first situate our contribution relative to the
growing body of critical literature on ‘medical tourism’ from a South-South perspective
(Kangas 2007; Crush and Chikanda 2015; Ormond and Kaspar 2018). We then describe
our study methods and outline four distinct geopolitical periods that have shaped Libyan
medical travel to Sfax in detail.

Deconstructing ‘medical tourism’ and ‘medical travel’

Ormond (2016, 510) highlights how the medical tourism industry suffers from a ‘concep-
tual blind spot’ because it ignores the diversity of patients and needs. Both policy-makers
and scholar of medical tourism have tended to focus on medical treatments, and ‘techno-
logical medicine is generally spoken of as a consumer good’ (Kangas 2007, 14). Despite
worldwide growth in international medical travel since the 1990s, especially to desti-
nations in the Global South, classifications of ‘medical tourism’ and ‘medical travel’
have not been able to capture the complex array of statuses, networks, economic resources,
types of care, duration of journey, and conditions of payment (e.g. private, subsidised or
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 3

bilateral agreements) shaping health mobilities and patient profiles. Definitions of medical
tourism are either too extensive by embracing therapeutic practices that have little to do
with tourism or too restrictive by excluding intra-national and wellness travel (Knafou, in
Chasles 2011). Likewise, definitions of medical travel do not capture frequency or itiner-
ary, such as whether the travel is a one-off experience or repeated and the degree of its
(non-)linearity.
Mobilities, suggests Urry (2007, 12), ‘have been a black box for the social sciences, gen-
erally regarded as a neutral set of processes permitting forms of economic, social and econ-
omic life’. Connell (2016, 534) emphasises the gap between ‘dominant images of global
trajectories’ – a global imaginary characterised by global pictures, markets and North–
South movements – and real patient real experience. Yet, current research on medical
mobilities demonstrates that intra-regional and South-South movements represent the
bulk of contemporary medical travels (Ormond and Sulianti 2017; Ormond and Kaspar
2018). In light of this disjuncture, Ormond (2016, 510) argues for a need to pay attention
to ‘migratory nuances’ among international patients and a way to do this, according to
Kangas (2002, 2007), is to (re)focus on patients’ functional and subjective experiences.
In focusing on medical conditions and distinct experiences, studies on intra-regional
South-South medical mobilities have been able to illuminate the heterogeneous and
complex profiles of contemporary international patients (Bochaton 2015; Crush and Chi-
kanda 2015; Kaspar and Reddy 2017; Ormond and Kaspar 2018).
In deconstructing contemporary medical tourism and travel in this article, we also
argue for the significance of spatial analysis in order to develop a better understanding
of migratory contexts, subjectivities, and processes within which medical mobilities are
emerging, shaped and structured. The cross-border and regional focus adopted by scholars
looking at South-South patient mobility permits us to rescale conventional understandings
of ‘medical tourism’ into emerging transnational spaces of care or what Dewachi, Rizk,
and Singh (2018, 289) characterised as ‘therapeutic geographies’ in order ‘to better
capture the reorganisation of health care within and across borders as a result of long-
term conflicts and the dismantlement of national healthcare systems, and to map the con-
current trajectories of patients across regional healthcare hubs’. In using the term ‘trans-
national’, we refer to international connections that go beyond a focus on the nation-state
as the dominant actor yet that acknowledges its significance in controlling also transna-
tional activities, in particular as part of the analysis of geopolitical contexts advanced
here (Collyer and King 2015, 186). By ‘cross-border’, we refer to interactions across the
border with a limited spatial reach on both sides of the border. The regional terminology
advanced here refers to conceptions of macro-regionalisms, such as the ‘Maghreb’ or
‘North Africa’, not micro-regionalism constructions such as metropolitan regions (Gana
and Richard 2014).
Our case study of Libyan patients seeking care in Sfax is among only a handful of con-
tributions on intra-regional North African medical mobility over the past decade. Except
for a limited number of studies (Zouari 2010; Lautier 2013; Rouland, Jarraya, and Fleuret
2016), Libyans traveling to Tunisia in search of care have been little documented. Using
the term ‘health service export’, Lautier (2013, 2005) points to interdependencies
between the development of niche activities in Tunisia and an intra-regional market. In
one form or another, these interdependencies have existed for decades. While the
number of Libyan patients increased significantly in private hospitals after 2011, they
4 B. ROULAND AND M. JARRAYA

already represented the majority of patients in private health facilities in Tunisia prior to
the Arab uprisings. However, stereotypical misconceptions about Libyans are widespread
in Tunisia – resulting from the ambiguous legal status of Libyans in the country since
2011, perceived by the local population and press as ‘refugees’ (without recognised legal
status or asylum) or ‘medical tourists’ (Boubakri 2015; Rouland and Bachmann 2015).
These popular misconceptions, scholars suggest, result from a lack of recent data and
inadequate statistical tools for measuring population movements triggered by the
Libyan civil war. Little information exists on the condition of Libyan patients’ mobilities,
journeys, care experiences, networks or financial resources.

Tunisian health sector restructuring

At the beginning of the twenty-first century, Tunisia benefitted from the internationalisa-
tion of medical resources including standardisation of protocols, clinical infrastructure
and equipment. Tunisia ranked as the leading exporter of health care in North Africa
and the sector witnessed one of the highest annual growth rates worldwide, estimated
at around 20.8 per cent for 2003–10 (Lautier 2013, 7). Unlike other countries in the
region, a developed medical infrastructure and a range and quality of provision on par
with that in the global North was available at competitive prices (Lautier 2013, 9).
High-quality Tunisian health care resulted from political measures to promote health
care following Tunisia’s decolonisation and independence.
Despite its geographical proximity to the European Union (EU), the development of
private health services in Tunisia in these early years was the result of an influx of patients
mainly from Libya (who accounted for 80 per cent of patients in private clinics) but also
from Algeria, Mauritania and the EU (Lautier 2008, 2013; Rouland, Jarraya, and Fleuret
2016). The development of private health services in Tunisia was less the result of
broader global dynamics than of neighbourly relations and regional demand. Before
2011, a study conducted among Libyan patients demonstrated that middle- and upper-
class patients were more attracted by the quality of Tunisian health services rather than
being repelled by a lack of medical resources in Libya.3 Lautier (2013) estimates the earn-
ings from health service exports in Tunisia at USD 205 million but acknowledges the lack
of reliable instruments to measure and quantify flows of patients and their economic
impact with any precision. In addition, private Tunisian health care is expanding
because of a significant rise in middle-class West Africans seeking care services absent
in their countries, such as IVF treatments (Ghorbal 2016). Since 2011, the number of
medical facilities has increased steadily in Tunisia (see Table 1). At the same time, the
public sector has deteriorated in terms of facilities and work conditions.

Table 1. (Para)medical staff numbers in Tunisia (2000-14).

Number of (para)medical staff 2000 2005 2010 2014
Total number of doctors 7444 9422 12,996 14,127
Number of public health doctors 4147 4727 6723 6844
Number of private doctors 3297 4695 6273 7283
Total number of paramedical staff 27,392 29,607 34,195 43,197
Number of senior technicians 7500 8677 – 13,346
Number of nurses 19,814 20,930 23,836 29,851
Source: INS 2016.
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 5

While most medical resources are concentrated in Tunisia’s coastal cities (Daoud
2011), Tunis and Sfax have traditionally attracted the majority of Libyan patients
because there were the only cities offering a large range of services and treated 48.6 per
cent and 46.6 per cent, respectively, of all Libyan patients in Tunisia (Lautier 2005).
Sfax is the country’s second largest city with approximately 600,000 inhabitants (INS
2016) (see Figure 1). Primarily an industrial area (phosphate production and agricultural
export), it has a broad range of medical services. Its public health infrastructure includes a
medical school and two university hospitals, with a third under construction. In addition,
the city has three regional hospitals (Jarraya, Beltrando, and Daoud 2007). University hos-
pitals offer a source of highly-skilled labour that facilitates the development and consoli-
dation of the city’s private health sector. Thus, from what was once a niche sector, Sfax
now welcomes the second highest number of foreign patients in Tunisia (mainly patients
from Libya) and is home to Tunisia’s second highest concentration of health services.

Figure 1. Location of Sfax.

6 B. ROULAND AND M. JARRAYA

The Sfax case study

Sfax constitutes an interesting case for studying the growth of private health services and
their use by Libyan patients in the period post-Arab uprising. Previous studies have
focused on the economic growth of private health services in Tunisia (Lautier 2005,
2013; Zouari 2010) or the migratory conditions of Libyans settling since 2011 (Rouland,
Jarraya and Fleuret, 2016; Boubakri 2015; Mouley 2016). Ongoing development propelled
by the growth of the private health sector (i.e. renovation, expansion and construction of
private clinics) and associated activities like residential and commercial construction are
linked to the presence of Libyans in Sfax. Exploratory methods, combining semi-struc-
tured interviews amongst health professionals and a survey of Libyan patients in four
private clinics, were used to broaden our understanding of the use of health services by
Libyans in Sfax.
We interviewed nine health professionals working predominantly in the private sector.
This included four medical specialists who also held financial interests in a private clinic:
an otolaryngologist, a cardiologist, a paediatrician and an orthopaedic surgeon. We also
spoke with a general manager and financial director of a private clinic, a medical
tourism agency director4 and a medical officer working at a public hospital. In addition,
the research is informed by informal discussions on the subject with members of associ-
ations and international organisations, and related scholars working on migration issues.
The semi-structured interviews explored the development of private medical services and
the growth of Libyan patients post-2011, their treatment needs, treatment pathways and
how they accessed services. For health professionals working in private clinics, questions
concerned the organisational structure (e.g. financing, operating models, core services and
partnerships).
We also implemented a questionnaire survey of Libyan patients in Sfax from May to
June 2015 (n = 205). In the absence of official data, sampling according to sex, gender
or districts was impossible. We chose instead to conduct the survey within four private
clinics located on strategic roads into the city (see Table 2). The clinics included facilities
that allowed us to interact with Libyan patients near the clinics and their car parks, cafe-
terias, waiting rooms, main entrances and pharmacies. Our sample included 72 people in
Clinic A (35.1 per cent of total), 61 in Clinic B (29.8 per cent), 60 in Clinic C (29.3 per cent)
and 12 (5.9 per cent) in Clinic D. The questionnaire sought: (i) to identify the main reason
for travel, journey duration, frequency of medical travel, itinerary and networks; (ii) to
examine health status (real/perceived; physical/psychological) and the use of healthcare
services (e.g. needs, services and specialists consulted, satisfaction with health services,
and payment terms); (iii) to evaluate conditions in Sfax (e.g. accommodation, relation-
ships with the local population and neighbourhood location); and (iv) to determine

Table 2. Survey sample by gender and age.

Age Males Female Total
No response - 0.5% (1) 0.5% (1)
≤ 19 years 1.5% (3) 0.5% (1) 2.0% (4)
20–44 years 66.3% (136) 3.4% (7) 69.8% (143)
45–64 years 24.4% (50) 1.0% (2) 25.4% (52)
≥ 65 years 2% (4) 0.5% (1) 2.4% (5)
Total 94.1% (193) 5.9% (12) 100% (205)
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 7

marital status. Overall, the questionnaire aimed to collect primary data of Libyan patients
in Sfax, a phenomenon undocumented since the 2011 Arab uprisings. The survey aimed to
evaluate to extent to which and in what ways conflict influenced medical journeys from
Libya to Sfax, paying specific attention to needs, networks and resources. One limitation
of the survey arose from the gender imbalance of people interviewed (193 males against 12
females) and an overrepresentation of young males (136 males aged between 20–44 years
and 50 males aged between 45–64 years) (see Table 2). The under-representation of Libyan
women in public areas inside and around the clinic made it difficult for us to speak with
them. In an interview, the Sfax orthopaedic surgeon attributed the increasing insecurity
people face in reaching the Libyan-Tunisian border to explain the decrease in the
number of females and elderly among patients and those accompanying patients to Sfax.
This study also has inevitable limitations, primarily due to social divisions within
Libyan society. Because we specifically chose to not identify patients’ ethnic backgrounds
or political orientations, due to the potential tensions doing so could create, we limited our
ability to understand the war’s shadow economy and the number of soldiers and armed
combatants seeking treatment. There was also the need to establish interview trust (e.g.
when discussing health issues) and commercial sensitivities of health professionals.
Finally, during the 2015 fieldwork period, our survey was the first to capture data about
Libyans in Tunisia post-2011. There has since been further study by other scholars (see,
e.g. Mouley 2016; Rosenthal 2018).
Data was processed and analysed using Sphinx software. Based on analysis of the inter-
views and questionnaires and drawing on pre-existing literature, we were able to identify
four chronological periods characterising the presence of Libyan patients in private health
services in Sfax.

The evolution of medical mobilities between Libya and Sfax

Phase 1: early diaspora exchanges facilitated by bilateral agreements
The phenomenon of Libyans seeking private care in Sfax began in 1962 with the opening
of the first private clinic, Meignié. The only private clinic available for all regions in
Central and Southern Tunisia at the time, Meignié was followed by the opening of
other clinics – Bessatine (1986) and Zaituna (1989) (Rouland, Jarraya and Fleuret 2016,
10). From the beginning, Libyans were the prime clients for Sfax private-sector health pro-
fessionals. From the early 1960s to the late 1980s, the use of private health services by
Libyans in the city was shaped by the Libyan diaspora’s economic and familial relation-
ships, consolidated through business and marriage. Sfax benefitted from its proximity
to the Libya-Tunisia border, and Libyans from Tripolitania accessed Sfax for commercial
services and to support family relations. The cultural closeness and long-lasting diasporic
connections were frequently raised during the interviews:
In Sfax, links with Libyans go far back in history, with inter-marriage and home ownership –
the presence of Libyans is not new. (Sfax private clinic supervisor, interview)5

The geopolitical context also played a role. In 1973, the Libyan and Tunisian governments
signed a bilateral agreement increasing rights of citizens of both countries around labour
mobility, residence and travel.6 This bilateral agreement marked the foundation of a free-
8 B. ROULAND AND M. JARRAYA

trade area between Tunisia and Libya – leading quickly to the growth of (in)formal inter-
actions in the border region and circulation between the Sfax and Tripoli areas. In 1988,
the Libyan-Tunisian border opened, ending Libyan and Tunisian citizens’ need for travel
visa between the two countries and establishing a transit space that continues even post-
2011. These measures were decisive for intensifying the circulation of goods and people,
transforming the border into a space of shared activity and ‘large informal open-air
market’ (Boubakri 2000, 41). Research on formal supranational regions in the global
South (see, e.g. Ormond (2013)) on the role of the Association of South East Asian
Nations (ASEAN) and Crush and Chikanda (2015) on the Southern African Development
Community (SADC)) has made clear that: ‘Porous international borders are crucial to
medical travel and have resulted in the emergence of formal trans-border health regions
in the North and spontaneous informal regions in the South’ (Connell 2016, 531). Our
case study likewise demonstrates the significance of both long-lasting informal diasporic lin-
kages and formal cross-border political arrangements for medical travel (Chandoul et al.
1991; Boubakri 2000; see also Chee and Whittaker 2019, on the impact of diasporic linkages
in medical travel).
We can therefore summarise this first geopolitical phase of medical mobility as a com-
bination of three key factors that spurred the emergence of a medical spatial system:
endogenous and pioneering local private-sector medical service development in Sfax,
exogenous demand from the Libyan diaspora, and a bilateral agreement fostering trans-
border circulation.

Phase 2: the UN embargo and growth of private health facilities

In the period between the start of the UN embargo of Libya in 1991 and the eve of 2011
Arab uprisings, the number of private health services increased considerably in Tunisia,
especially in Tunis and Sfax. Medical travel developed on top of already existing Libyan
diasporic and cross-border healthcare pursuits due to a restrictive geopolitical situation
that inadvertently strengthened regional cooperation. In 1991, the UN Security Council
embargo on Libya led to increased exchanges, mobilities and complementarities
between Libya and Tunisia.
At the same time, the Tunisian public health system was entering into gradual decline
and health services privatisation grew during this period. Public-sector problems include
overcrowded and unavailable services, outdated medical equipment and failing infrastruc-
ture (Rouland, Jarraya and Fleuret 2016). With the success of the first private clinics in
Sfax and increased waiting times in Libya, the private sector appeared to have great
promise, and it became a refuge for medical professionals seeking job security amidst
economic and political turbulence. Given Sfax’s concentration of medical resources (e.g.
training, personnel and infrastructure), medical professionals after the year 2000
became shareholders of the private clinics and the engine of local entrepreneurship in
Sfax.7 The number of private clinics increased from three to twelve in Sfax between
1998 and 2011. Healthcare professionals relied on their own professional networks and
cooperated in relatively small ventures (with facilities having no more than 60–120
beds each) that involved a large number of fellow shareholders.
Libyans were attracted to Tunisia due to its competitive pricing, quality of care and the
availability of a wide range of health services (Lautier 2005, 2013). In addition, more
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 9

Libyan patients were going to Tunisia because their healthcare costs were borne by the
Libyan state (Lautier 2008, 108). While not all medical expenditures were covered by
the Libyan state, civil servants and oil company employees were particularly privileged.
Tunisia became a prime destination, particularly for the growing middle class who had
more specific and sophisticated care demands and distrusted Libyan healthcare services
(Lautier 2013, 3) – echoing the privatisation and internationalisation of health care in
Asia (Connell 2016, 2).
From the late 1990s to 2011, private health services in Sfax expanded toward a
medical tourism industry on an intra-regional scale (Boumedienne, 2012; Zouari
2010). The specific geopolitical context in Libya at that time, combined with already-
existing bilateral agreements, strengthened both Libyan patient networks and healthcare
professionals’ networks, with Tunisian doctors travelling regularly to Libya. Tunisians
do not typically regard Sfax as a tourist destination given its limited amount of accom-
modation and leisure activities as well as its high levels of pollution. However, the con-
centration of medical resources and skills of doctors, the city’s historical centre
(medina) and shopping opportunities have consolidated Sfax’s positive reputation
among Libyans, thus increasing the inflow of Libyans from the Tripolitania region to
such an extent that it came to be dubbed ‘Little Tripoli.’
To summarise, this second phase of medical mobility is characterised by the rise of both
private health services and Libyan patients in Sfax due to endogenous factors (i.e. local
resources and actors developing private initiatives) and exogenous factors (i.e. inter-
national geopolitical context strengthening interactions between both countries), facili-
tated by political relations and geographical, linguistic, and cultural and religious
similarities.

Phase 3: from medical traveller to war-wounded after 2011

The Arab uprisings in Tunisia 2010 and in Libya 2011 had different outcomes: Tunisia
underwent a delicate political transition after the regime fell in January 2011, whilst the
Libyan uprising led to an escalation of violence and civil war and insurrection spread
from Benghazi to Tripoli (Bensaâd 2015, 20). In addition to Libyan refugees fleeing to
Tunisia, Libyan war-wounded replaced Libyan medical travellers in Sfax’s private
clinics, with provision profoundly affected by the 2011 crisis (Rouland, Jarraya and
Fleuret 2016). In parallel with the deterioration of basic services and the collapse of the
Libyan economy, the intensification of armed conflict increased the number of war-
wounded. A Sfax orthopaedic surgeon interviewed explained this change in terms of
patient profiles and needs post-2011: he went from mainly treating Libyans injured by
car accidents to mainly treating gunshot wounds.
During the first phase of the Arab Spring, many private clinics closed in Sfax because of
the lack of Libyan’s patients (see Figure 1). However, the influx of war-wounded led to
them re-opening and to their overcrowding:
In 2011, the sector experienced crisis: 80 per cent of the patients were wounded Libyan sol-
diers and, in an exceptional period, boats full of wounded people arrived and we [private
healthcare providers] were obliged to care for them.

(Sfax private clinic supervisor)

10 B. ROULAND AND M. JARRAYA

‘Obligation’ here implied, first, the fraternal relationships between the two countries that led
to acts of solidarity (e.g. Tunisian families helping Libyans in the border region) and, second,
the presumption that private healthcare providers treating wounded Libyans would be reim-
bursed by the Libyan state for the care they provided. Because of the nature of the trauma
patients presented with and the orthopaedic surgery they required which necessitated
lengthy recovery periods, Tunisian private healthcare had higher average costs per case
after 2011. As the closest city to the Libyan border and with the highest concentration of
medical services and transport infrastructure (e.g. roads, runway and harbour), Sfax
became the prime destination for Libyan war-wounded from the Tripolitania and Cyrenai-
que (Benghazi) regions as well as for ongoing medical needs induced by trauma.

With the civil war entering stalemate after 2011, the profile and needs of Libyan patients in
Sfax changed dramatically and payment terms became more uncertain. Sfax private clinics
entered into significant debt as treatment costs rose and bills went unpaid by the unstable
Libyan state.

Phase 4: therapeutic circulations as an emerging transnational space of care?

A major effect of the Libyan crisis has been the redrawing of the region’s migratory land-
scape, which includes Libyans’ greater need to travel abroad for medical care. From 2011
and until recently, the number of Libyan patients in private clinics was growing exponen-
tially (Rouland, Jarraya and Fleuret 2016). Whilst a large majority of Libyans in our survey
were from the Tripolitania area (186) (and mainly Tripoli (76)) which borders Tunisia, the
drastic erosion of medical services in Libya drives patients from further afield to seek care
in Sfax. For example, Libyan ambulances arrive from the more distant Cyrenaique and
Fezzan regions (Sebei 2017). Libyan ambulances were highly visible in Sfax (though less
so in other Tunisian cities) at the time of our study, suggesting that Libyans may circulate
between both countries. Nevertheless, the travel conditions to reach the Libya-Tunisia
border have changed considerably as a consequence of the Libyan armed conflict, exposing
people to multiple risks. Libyan ambulance drivers thus often adapt their itineraries to
avoid areas in conflict between local militias (Sebei 2017).
Our survey points towards a contemporary pattern of frequent and multiple medical
care-motivated journeys to Sfax (see Table 3). This corroborates the Tunisian Directorate
of Borders and Foreigners estimate that Libyans crossing the border do so an average of
four to five times per year (Mouley 2016, 19). The nature of patients’ care needs requires
repeated travel for follow-up consultations or specific treatment (e.g. treatment of chronic
illnesses or post-operative check-ups):
[T]hey come one day for a simple consultation or hospitalization but they are not residents. A
Libyan might arrive today from Tripoli for a post-operative follow-up and would normally
leave tomorrow. (Sfax orthopaedic surgeon working in several private clinics)

Since 2011, specialised care (e.g. orthopaedic surgery, cardiology, neurology and oncol-
ogy) needs rose.
The influx of new Libyan patients since 2001 increased local competition in Sfax
whereby health professionals sought to attract new patients through the use of different
partnerships in Libya or in Sfax. Thus, nearly one in three respondents’ first contacts
with medical professionals in Sfax were brokered by a local facilitator in charge of
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 11

Table 3. Survey respondent characteristics.

Survey questions Responses
Purpose for journey to Sfax
For health reasons 178 (86.6%)
Not for health reasons 25 (12.2%)
Not only for health reasons 2 (1.0%)
Days spent in Sfax before return to Libya
No answer 18 (8.8%)
< 2 Days 32 (15.6%)
Between 2 days and a week 58 (28.3%)
Between 1 and 2 weeks 44 (21.5%)
Between 2 weeks and one month 9 (4.4%)
> A month 5 (2.4%)
Dependent on treatment progress 36 (17.6%)
Not applicable (resident in Sfax) 3 (1.5%)
Number of medical journeys to Sfax during the year of the survey
No answer 7 (3.4%)
First trip 58 (28.3%)
Second trip 31 (15.1%)
Between 3 and 4 trips 72 (35.1%)
Between 4 and 6 trips 17 (8.3%)
More than 6 trips 16 (7.8)
Not applicable (residing in Sfax) 4 (2.0%)
Number of journeys to Tunisia before 2011
No answer 5 (2.4%)
None 39 (19.0%)
Between 1 and 3 43 (21%)
Between 3 and 5 34 (16.6%)
Between 5 and 10 50 (24.4%)
More than 10 34 (16.6%)
Total observations 205

guiding patients to particular private healthcare facilities (see Table 4).8 Moreover, one-
third of our respondents’ first contacts with medical professionals in Sfax were identified
through word of mouth based on family or friend networks. In the Libyan ethnic context,
‘family’ also means one’s tribal affiliation. Practitioners in Sfax explained that familial net-
works have always been important to retain and attract new patients. Similarly, one clin-
ician explained that he was providing free care occasionally for the most vulnerable people,
considering this act as an investment with long-term benefits in terms of networking. The
findings thus suggest that Libyan respondents’ strategies for seeking care as well as those

Table 4. Libyan patients in Sfax.

Survey questions Responses
How respondents found the private clinics
Local guides 86 (42.2%)
Family and friends 60 (29.4%)
Libyan ambulances 50 (24.5%)
Libyan consulate in Sfax 3 (1%)
Other 6 (3%)
No response 1 (0.5%)
Who takes care of respondents’ medical costs
Libyan state insurance 19 (9.3%)
Private Libyan insurance 28 (13.7%)
Personal resources 153 (74.6%)
Other 5 (2.4%)
Total 205
12 B. ROULAND AND M. JARRAYA

developed by health professionals for attracting new Libyan patients rely on heterogeneous
formal and informal, institutional and private, and local and transnational networks.
In the case of patients transported by ambulances, private clinics are chosen based on
established agreements between Libyan insurers and Sfax’s private clinics. As a conse-
quence of the stalemate in the war in Libya, three-quarters of Libyans surveyed said
they pay with private resources (153), with others using public (19) or personal resources
(28) and private insurance (see Table 4). In light of the Libyan state not paying the medical
bills since 2011, several private clinics in Sfax have begun to refuse payment by private or
public insurance card. The existence of two self-proclaimed Libyan governments makes
reimbursement of medical bills problematic, and private insurers do not always fully reim-
burse private clinics’ treatment costs:
The private insurers are more or less creditworthy, but the Libyan state does not reimburse us
anymore. For example, if we make an agreement with Company X which has 1000 employees
and insures their family members, we estimate that will be a market of 3000–4000 people
[…]. Each patient insured by the company has a letter attesting to their medical coverage.
At the end of the month, we send the invoice to the company which pays it on behalf of
the employee.

(Private clinic financial director)

If the private insurer ceases to reimburse the clinics, clinics also stop receiving patients.
A private medical practitioner notes how the pre-treatment deposit system was unable to
prevent clinics entering into debt:
For example, an insurer pays a EUR 200,000 deposit to the private hospital [… and] sends
you the patients. You treat the patients until you reach EUR 200,000 and then ask the
insurer for more money. But EUR 200,000 is quickly reached with war-wounded patients
because of the very violent nature of their trauma, the anaesthesia and the repeated oper-
ations. You work, the insurer asks you to wait, and then you find yourself EUR 500,000 in
debt. We pressure them by saying ‘We won’t work with you anymore’, and then they pay
EUR 100,000.

(Sfax orthopaedic surgeon)

Libyan conflicts (tribal and political divisions) are extra-territorialised in Tunisia.

Violent conflict between different tribal communities limits mutual aid amongst
Libyans travelling for medical care to Sfax. Libyans are also subjected to inflated treatment
costs. But they continue to pursue treatment in Sfax:
Libyans represent between 80 and 85 per cent of private clinic customers. Without Libyans,
there would be no private clinics anymore.

(Private clinic finance director)

The local economy is also responding to Libyan patient demand. In response to the
growth of health services, new residential and commercial areas are strategically developed
adjacent to medical structures. The local real-estate market is boosted by the growth of
medical services and related activities (e.g. construction or renovation of private clinics,
consulting offices and pharmacies) (Rouland, Jarraya and Fleuret 2016). Villas and out-
buildings attached to houses near the private clinics are available for Libyan patients to
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 13

Table 5. Evolution of medical mobilities between Libya and Sfax relative to the geopolitical context.
Private health services Spaces of
Phase Geopolitical context Mobility profile development care
1960s-90s: 1973 bilateral agreement Diasporic Limited Cross-border
Systemogenesis and opening of the
border
1991-2011: UN embargo on Libya Medical Privatisation and Bilateral
Development of medical travellers corporatisation
tourism industry
2011: Crisis Arab uprisings: conflict War-wounded Crisis Regional
begins
Post-2011: Transnational Stalemate in the Libyan Therapeutic Interdependencies Transnational
space of care civil war circulations

rent; and many also rent apartments in the modern section of Sfax (Sfax Jadida) built in
the 2000s that offers shopping and restaurants.
Characterising this phenomenon is, therefore, complex. Libyans seeking care in Sfax are
not conventional medical tourists. Rather, political instability has led to the displacement
of earlier forms of medical mobility and to the emergence of a form of transnational
medical mobility. Each form is articulated by its highly context-specific geographical, cul-
tural and historical relationships and interdependencies (see Table 5).

Conclusion
This paper exemplifies the heterogeneity of international patient mobilities and the funda-
mental need to contextualise them in time and space. Both political instability and regional
relations provoked a range of transformations: from wants to needs; from interactions to
interdependencies; from intra-regional to transnational care spaces. The political crisis in
Libya contributes to the rise of transnational patients as well as the development of private
health services in Sfax and other Tunisian cities. Both processes are inextricably linked to
the diversification of Libyan patients; the plurality of their networks, both formal and
informal, for organising treatment and travel; and an increase in patients’ vulnerability.
In light of the conflicts in the Middle East and North Africa, healthcare landscapes
have been totally reconfigured: transnational spaces of care are shaped by new therapeutic
geographies (Dewachi, Rizk, and Singh 2018). This transnational perspective on thera-
peutic geographies calls our attention to multidimensional factors around how medical
mobilities are shaped over time and space within specific geopolitical circumstances.
Context matters, and we argue for the need to pay attention to it in every case and to cri-
tically question and deconstruct the catch-all category of ‘medical tourist.’ This study
serves as an example of how to develop more nuanced approaches to the heterogeneity
of mobilities for medical purposes, including the geopolitical contexts in which they are
embedded and the underlying spatialities that shape and are shaped by these mobilities.
Our study shows how these mobilities continuously change and the importance of
understanding such an evolution. Since late 2016, the stalemate in the Libyan civil war
has served to further impoverish the Libyan middle class and limit their resources to
pay for medical care. There has been a corresponding decline in the number of Libyan
patients treated in private medical facilities in Tunisia. Yet the Tunisian private healthcare
sector remains resilient in part because, since 2016, more patients from Algeria and Sub-
14 B. ROULAND AND M. JARRAYA

Saharan countries have begun going to Tunisia for medical care, especially for cancer
detection and treatment and fertility treatments, thus further diversifying the Tunisian
private health industry. As with the Libyan patients before them, these new patient mobi-
lities are shaping new transnational spaces of care in Africa, engaging in regionalisation
from the bottom up.

Notes
1. World Bank (2019) Open Data estimates for the year 2010, Libyan gross domestic product
(GDP) per capita at USD 12,120 (peaking at USD 14,396 in 2008) against USD 4140 in
Tunisia (peaking at USD 4310 in 2008).
2. It is estimated that nearly 1 million people (including 660,000 Libyan citizens) entered
Tunisia from Libya (UNHCR 2012).
3. In the 2000–10 period, there were 19 doctors in Libya per 100,000 inhabitants compared to
11.9 in Tunisia (WHO 2012).
4. Medical tourism companies operate as traditional travel agencies, except that they provide
medical travel services including the cost of care and related expenses.
5. The existence of Libyan patronyms resulting from mixed marriages in the city is a good indi-
cator of longstanding interactions between Sfax and Tripolitania.
6. This agreement was part of an ambitious political project to unify Tunisia and Libya to create
the Arab Islamic Republic in 1974.
7. Healthcare professionals suggested private clinics are managed by between forty and sixty
shareholders
8. ‘Samsar’ means ‘guide’ or ‘gate-keeper’ in Arabic.

Disclosure statement
No potential conflict of interest was reported by the authors.

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