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The map of the world is in phase of being redrawn, according to the surgical specialties and the fields of intervention: plastic surgery, eyes and dental in Tunisia, treatment of the skin diseases in Turkey, organ transplant, in particular renal and transplant of the liver in Thailand, surgery of eyelids in the Panama, the in vitro fertilization in Spain â€¦
The competition begins to rage among destinations which invest in infrastructures, regulations and communication. All demand a part of a very juicy cake. Professionals of health and tourism, as well as all the strategic studies agree with considering the potential of this new crenel as “enormous”. Tourism, the transverse character of which in all other activities be it economic, ecological, agricultural, cultural, social etc, cannot make any more the dead end on the principles governing its own development and has to show in the next years of innovation and imagination to answer a request which has become increasing. For Africa generally and Tunisia in particular, tourism constitutes a crucial control lever to contribute to impulse the development. In Tunisia the quality of training in health and in tourism as well as its adjacent broadcasting countries can establish a competitive advantage at the level of medical tourism.
Being a growing niche these last years, medical tourism in Tunisia is widely becoming within the reach of potential applicants. Strong of its entry to the zone of the free – exchange with Europe at the beginning of this year, Tunisia is positioned as a partner of choice. A wide program is established to make of the country a pole of quality and future in terms of export of health services. However this commitment is conditioned by the integration and the raising awareness of the various stakeholders in such adequate steps.It is of this fact that most of the persons in charge and the actors operating in the tourist sector have to meet around a real consensus on the concept of medical tourism, and launch the challenge in front of an open to criticism present and a more or less desirable and optimistic future. The various stakeholders of the Tunisian tourist system establish then a relevant space of reflections and exchanges towards the development of medical tourism, these are main things of concern by the optimal management, the health, the integration of the population, the promotion, the competitiveness, the quality and the durability and this can raise only decisions and fixed approaches collectively on the basis of the forward-looking reflections generating the best scenarios which can lead to improve medical tourism in Tunisia.
Even if the concept of medical tourism was not as well important as it is it today, the current situation allowed to report the necessity of better promoting it and of organizing it to reach the objectives assigned by the project of development of the tourist sector and that of the health, and so we are engaged in this research work which concerns at the same time, the present and the future to explain and understand the realities which allow to support the potential evolutions to reach a sustainable development. This work tries to emphasize a solution of the dilemma to maintain the development and the decision-making support by analyzing the change of the attitudes of the stakeholders implied in the tourist system and that of the health in Tunisia.
1. Current status of tourism sector in Tunisia and Methodology
1.1. Tourism in Tunisia: inventories of fixtures
The tourist sector plays a leading role in the economic development of Tunisia, considering its important contribution for the growth of the Gross domestic product (In 2009 it contributed to 7 % of the GDP  (Gross Domestic Product) and 20 % of receipts in currencies, in the equilibrium of the balance of payments, in the polarization of any kinds of the investments, besides the job creation and the energization of the economic activity generally.
This sector knows a continuous development and carried out a qualitative jump at every level, thanks to the multiple assets which the Tunisian tourist product has and which make of Tunisia a privileged tourist destination.
The geographical setting of Tunisia, which opens on two banks of the Mediterranean Sea, the wealth and the variety of its cultural and natural heritage and its profound acquired experience on tourism, have made of our country a general-purpose tourist destination. The development which the tourist sector has known in Tunisia is reflected through the increasing rise of the number of the tourists who reached approximately 7 million tourists in 2008, (+ 4.4 % with regard to 2007)  .
Within the framework of the IXth plan, the strategic orientations turned around four axes:
The diversification and the enrichment of the tourist product and the location on the promising markets;
The improvement of the quality of the services;
The upgrade of the infrastructure and the maintenance of the tourist environment;
The consolidation of the role of the private sector in the tourism.
1.2. Medical tourism in Tunisia:
Tunisia made a commitment in the continuous improvement and development of the strategic sectors to be known; the education, the health and the tourism. Indeed the health and the services which are connected to it are considered as a promising crenel and an important engine of the economic and social development. For some years Tunisia lives a dynamics of growth in this domain which smoothed it among leader countries on an international scale. So much so, it occupies the second position in the field of the tourism of health after South Africa according to the African scale and the second world destination in thalassotherapy after France.
In the light of the study carried out by the French Agency of development (AFD) in 2005 on the exports of health services of developing countries, we notice that Tunisia is very competitive on the subject. The study has henceforth highlighted a strong potential in the field of medical tourism which can have more questionable performances in the future. The recent study of the World Bank on ” the world integration of Tunisia: a new generation of reforms for boosting growth and employment ” on 2008, confirms this performance by identifying medical tourism as one of the emergent crenellations.
In fact not enough reliable and detailed statistics exist on the subject.
The statistics which exist show that in 2007 more than 100000 foreign patients of diverse nationalities visit Tunisia for health care against 42000 in 2003
number of well-kept Tunisians abroad is crossed the 1.152 in 1987 to reach 180 persons in 2006.
24 % of the turnover of the private hospitals deprived results from the export of health services with foreign patients. The Libyan clientele is dominant, that is 80 % of the well-kept foreign patients, whereas the European patients constitute 11 % as well in number as in turnover. This European demand can be the object of a remarkable development in the years which come with the ageing of the population in Europe and the mobilization of the tourists with the aim of treatment, care or other similar services. The most mobile of them are the Italians (68 %) and the Germans (63 %).
The exploration of the market of medical tourism brings to light four big demands for Tunisia, as such:
The inter-Arabic and the mediterrean market: the importance and the regularity of the flows of Arabic patients coming from nearby countries particularly Libya drove numerous clinical Tunisian to organize an offer of services specialized for this clientele. The qualitative advantage of Tunisia could be widened in the other local markets, in particular Algeria, which constitutes approximately 3 % in foreign number of patients and in figure of business exported of private hospitals deprived. Also, the other adjacent African markets present a potential which begins to be exploited.
Henceforth, some private hospitals of Tunisia signed agreements with Mauritanian institutions. The presence of the African Development Bank also contributes to improve the fame of the private hospitals Tunisians and to attract a new African clientele.
A niche to develop the tourists and the European expatriates: the market of the care to the European tourists is difficult to estimate. Indeed, the number of patients in private hospitals seems very low compared with the flow of 2,8 million European tourists. Nevertheless, the medical tourism of the European represents a strategic stake for the improvement of the medical and technical level and for the fame and the reputation on the international plan. It also constitutes an important factor for the development of the paramedical tourism and the well-being, such as thalassotherapy, massages, etc.
This method implies that the researcher case-studies his data. “The work of analysis is made as one goes along, important parts of this analysis matching the data collection” (HOURS Becker, 1958 quoted by [Aktouf1992], p197). Now, it is not the approach which we followed because we became a researcher on a well-determined subject (the project of development of the medical tourism in Tunisia). Nevertheless, we shall use the techniques of the participating observation namely: the daily observation accompanied with notes taking, with collection of archives and with retrieval systems (Fortin1988). The participation entails inevitably relations of nearness, even an intimacy with the actors of a given ground. The observation constitutes in its part a “natural” activity of every participant. But in its most rigorous academic meaning of a word, it is supposed to lean on a remote stake objectivized by these same human relations.
3.2. The active and semi-directive with no leading questions interview:
This technique could be interesting for the implication of the researcher which it proposes. According to Alex Mucchielli  : ” the maintenance is opened and centered, it rests not on the reactions of the interviewee to precise questions but on the expression free of its ideas on a given subject (â€¦) .In this technique, the interviewer does not ask questions but contents with following the progress of the thought of his interlocutor. He presents syntheses regularly, but he is active at most.
3.3. The Mactor Method: crucial control lever of the strategic prospective.
The theory of actors’ games supplies a set of tools of rather vast analysis but to the applications limited by the mathematical constraints and the often restrictive hypotheses. The method MACTOR (Method of Actors, Tactics Objectives and Recommendations) propose an approach of analysis of the game set of the actors and some simple tools which allow to take into account the wealth and the complexity of the information to be treated, by supplying the analyst with the intermediate results which enlighten him on certain dimensions of the problem.
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