Meher Khelifi

Starting in Tunisia, Meher Khelifi is breaking down all barriers to address the lack of social and health insurance for rural women through technology-enabled solutions that incorporate the financial and community realities of their daily lives.

Brought up in an underprivileged household in rural Tunisia, Khelifi experienced first-hand the devastating consequences of being uninsured, when his mother Fatema died in 2016. Neither diagnosed nor treated, Fatema spent ten years treating cancer with over-the-counter painkillers.

This incident compelled Khelifi to launch a national campaign that later turned into a movement to transform Tunisia’s broken healthcare system. The campaign led to successful structural changes in laws and regulations that for the first time allowed for underprivileged rural women to be enrolled in Social Security and actually receive medical benefits. Coupled with legal reforms, the integration of modern technologies made it possible for rural women, with or without consistent income streams, to exercise their basic health rights, be insured against work-related injuries, and enjoy retirement benefits, without leaving their remote villages.

After reforming the national public health insurance scheme to create legal rights to new health services for rural women, as well as implementing mechanisms so women could access their rights, Khelifi was strongly endorsed by the Tunisian government and started implementing the “Ahmini” model (Arabic for “Protect Me”) in 2018. For the first time in Tunisia, a simple model linking women’s social security numbers to their personal mobile phones is shifting rural women from a precarious state as marginalized citizens to integrated citizens with full rights.

According to the International Labor Organization (ILO), “the Tunisian social security system is essentially state-run” through two funds: the CNRPS (National Pension and Social Contingency Fund) serving the public sector, and the CNSS (National Social Security Fund) serving the private sector, both of which are overseen by the Ministry of Social Affairs. Likewise, the social health system is implemented through two funds, the CNAM (National Health Insurance Fund) offering private and public services, and the AMG (Free Medical Assistance) providing free or highly subsidized healthcare to low-income households (ESCWA). These funds are overseen by both the Ministry of Social Affairs and the Ministry of Public Health.

On paper, services provided by these funds leave over 20% of the population without social coverage, 50% without health insurance, and most without unemployment benefits. Actual numbers are higher. Reasons for the lack of social and health coverage for vulnerable communities include (i) policies depriving those working in the informal sector from social security coverage, (ii) unawareness of the process to issue an insurance card rooted in their initial exclusion from national social security coverage and high illiteracy rates, (iii) inability to pay quarterly insurance premiums, and (iv) the centralization of public institutions and administrative offices.

The first problem that had thus far prevented rural women from enjoying social security was law No. 2002-32 of 12 March 2002 on the social security scheme for certain categories of workers in the agricultural and non-agricultural sectors that neglected their right to be covered due to their inconsistent income streams, which made them high-risk for any insurance scheme. Moreover, the ILO reports that Tunisia’s most vulnerable social category is concentrated in rural areas, and consists of informal workers, especially seasonal agricultural workers. Research by the National Gender Report of Tunisia (2015) and the Tunisian National Statistics Institute reveal that the Tunisian rural population represents 34% of the total population (~3.7 million). Of these, 800,000 women work in the informal sector.

Due to their high illiteracy rates (~40%) and residency in remote areas away from centralized working opportunities and public services, it has been difficult for rural women to be formally employed. This situation resulted in the majority of women to work informally in farming, as independent, seasonal, or daily workers, with a high likelihood of staying unemployed for extended periods of time. Consequently, only 10% of rural women have social security coverage, while 60% of them suffer from health problems, 93% of which are work-related. In fact, road accidents are not infrequent among the underserved, as showcased by recent demonstrations after the death of 12 farmers (mostly women) on their way to work in April 2019. Since it is a service they had never been eligible for, most women are unaware of the process and required papers to receive an insurance card.

In the case of rural women being formally employed, and thus eligible for social security, it was still difficult to regularly pay, because the payment structure set by the government was rigid in the way fixed quarterly premiums had to be paid. Basic healthcare requiring an $18 premium on a quarterly basis (that could not be paid on instalments) was unaffordable for many. Besides, payments needed to be made at distant locations requiring women to travel from their hometowns to the few designated locations for payment.

International organizations and local civil society actors only advocated for governmental reform since it has been a major trend since the Jasmine Revolution in 2011. Despite scattered attempts, no comprehensive measures or programs were successful in achieving real social integration for rural women in Tunisia or the region, especially that the laws in question remained unchanged. The situation is also immensely similar in neighboring Algeria and Morocco, where rural women live in remote areas, have little to no access to basic healthcare and are not part of governmental insurance schemes.

When Khelifi’s mother, Fatema, passed away in 2016, he became adamant about fixing Tunisia’s broken healthcare system, so other rural women would not suffer the same fate. Upon identifying the root causes of the exclusion of rural women from national insurance schemes, Khelifi established Ahmini in 2018, adopting a two-tiered strategy. Stemming from a rights-based approach, he had to work on a policy-level to make room for his grassroots movement, so he heavily advocated to reform the social security law that limits social benefits to individuals working in the formal sector, while developing a comprehensive and simple model that grants rural women easy social security access including medical insurance and pension funds. His vision was to have a model/prototype ready by the time the law was effective, so he could start working on-ground right away.

Khelifi actively advocated for the change of law No. 2002-32 of 12 March 2002 on all fronts and with limited resources. He joined multiple national and regional competitions to raise awareness about the cause and about his solution, winning 14 regional competitions, and garnering publicity and seed funds in the process. He built a coalition by tirelessly reaching out to parliamentarians, public officials, and international institutions to lobby for policy reform, often spending the night in ministry corridors. The fact that he had a prototype ready made his task easier, as the government identified an opportunity to advance its social inclusion portfolio.

Khelifi was strongly endorsed by the Tunisian government and started implementing the “Ahmini” model (Arabic for “Protect Me”) in 2018. The law was discussed and reformed in April 2019, and immediately took effect through a governmental decree (no.379). He had already reached out to major stakeholders, the largest being the National Social Security Fund (NSSF). Khelifi sealed a partnership with the NSSF in March 2019 to ensure the model’s implementation, once the reform was effective. To ensure compliance Khelifi went through a public/private partnership with a trusted private sector partner, ensuring the designation would go to him instead of being lost to other corrupt governmental arrangements.

However, the policy was not the only barrier hindering rural women from healthcare access; rural women not only needed to understand what it meant to be insured and why it was crucial, but also needed easy enrollment and payment plans. To raise rural women’s awareness on the benefits and necessity of being part of the NSSF, Ahmini organized and delivered awareness sessions in rural areas, some of which were attended by Tunisian Prime Minister Youssef Alchahed. This was done through a fleet of Ahmini-trained volunteers disseminated across Tunisian governorates.

Furthermore, Ahmini focused on remotely registering women through 570 trained volunteers present in every rural area to avoid the incurrence of additional costs (that women could not afford) by wasting precious working days to travel to the nearest city center to enroll. With 20,000 women across 24 governorates registered in just two months, Ahmini aims to extend access to all 500,000 rural women. According to Khelifi, this number will be a force to put political pressure on the system and improve the quality of public healthcare.

Khelifi was also able to overcome bureaucratic challenges in creative ways. To offer the lowest and most flexible enrollment fees and premium, Ahmini, in partnership with Tunisie Télécom (Tunisia’s national telecom company), introduced “Ahmini Lite” - a simple sim card chip inserted in phones that automatically deducts a designated amount when airtime is purchased as part of a prepaid service plan. The premium is $6/month per woman (granting insurance for all immediate family members) and each woman can break down the amount in a way that does not dent her budget, having the freedom to pay as little as 600/700 millimes/day (20/30 cents/day). This not only grants women control and flexibility as long as the $6 monthly target is met, it also alleviates the burden of traveling to distant areas just to pay off the $18 lump sum every quarter. It also allows women to keep up with enrollment and payment plans without having to travel to the city-center every quarter via dangerous roads (previously the case). As for those still without phones, Ahmini introduced e-payment, accessible in almost every local market, to further facilitate payments.

Over and above, to ensure the program reaches the poorest of the poor (women who can neither afford phones nor the insurance premium), the government offers free mobile phones, which Khelifi is complementing through an online sponsorship platform permitting individual and institutional donors to directly sponsor rural women.

Khelifi is decentralizing the affiliation of rural women to a previously inaccessible social and health insurance system, facilitating their payment in a way that is feasible and manageable, while bringing it closer to home. Currently, he is working on replicating his model in neighboring Algeria, and in Lebanon, which has a very large refugee community (most of which are uninsured). This way, Khelifi can galvanize a movement to overcome the myriad obstacles and cross-apply lessons learned in a coordinated effort to address healthcare coverage issues faced by uninsured residents of Algeria and Lebanon and in ways that Tunisia’s success stories can be used to pressure for reform in the rest of the region.

Born and raised in the suburbs of Kairouan, a land-locked city 200km away from Tunis, the capital, Khelifi grew up with little to no resources. For the lack of more affordable alternatives, his mother gave birth at home. Every day Khelifi would commute 6km to school by foot - sometimes even “barefoot”, in order not to miss out on education. Despite the difficulties, his mother persevered to provide him and his siblings with the best emotional and material support within her capabilities to succeed on their learning journeys, and her hard work paid off. Khelifi studied and joined the Higher Institute for Applied Sciences and Technology in Kairouan, graduating with an applied Bachelor’s degree in Mechanical Engineering. Upon graduation, Khelifi went to Tunis in pursuit of a steady job and stable income. He neither knew anyone nor had any connections, so he did blue collar work by working as a farmer, selling fruits and vegetables, and washing cars.

In 2016, Khelifi’s mother, Fatema, fell severely ill, and Hash was no longer enough to alleviate the pain. The family had to sell their belongings so she could get examined several years after a recurrent stomach-ache. These tests revealed that Fatema had had cancer for 10 years, and that medical intervention was impossible at such a late stage.

In this watershed moment, Khelifi took an oath upon himself to not witness this happening to other rural women. He could no longer live in a country where rural people, as opposed to those living in urban cities, have no rights. Since he was raised among rural women, Khelifi was well-aware of their concerns, their struggles, and their needs, deciding to dedicate his life to save rural women, starting with social and health insurance.

In 2017, the World Bank held a competition, asking participants to come up with proposals to integrate rural women in the healthcare system. Khelifi’s eyes sparked, and he applied. Although he did not have any money to travel to the competition, he borrowed $30 from his friend, and hitchhiked all the way from Tunisia to Algeria (1000km) to attend the competition. He won the competition and Ahmini was named the “best social entrepreneurship project in Africa.” He proudly jokes that he went to the competition by car and was finally able to fly back.

From then onwards, Khelifi tenaciously and creatively continues to fight tooth and nail for his cause and will not rest until all rural women of Tunisia and the region reap the fruits of his resistance and enjoy adequate social and health insurance.