Bilateral social security agreements in practice: confronting formal state mechanisms to individuals’ healthcare arrangements

The transnationalisation of healthcare has led to changes in the interplay of national healthcare and social protection systems. Bilateral social security agreements (BSSAs) are a telling example of the willingness of States to adjust to mobility patterns. Pensions and health care benefits are the primary benefits that BSSAs generally cover. However, healthcare coverage is often limited and its operationalization is often complex. Looking at the case of Tunisia regarding healthcare, the paper discusses the use (or lack thereof) of BSSAs by Tunisians from the diaspora. If these formal mechanisms appear to be innovative tools enabling States to work beyond their borders, the paper demonstrates that their effective implementation poses considerable administrative challenges, resulting in the disinvestment of individuals from such transnational social protection instruments. Based on data collected through a multi-sited ethnography between France, Belgium and Tunisia, the paper argues that BSSAs are still far from addressing the reality of transnational health practices. Indeed, barriers and obstacles in accessing healthcare in the country of residence lead parts of the Tunisian diaspora to turn actively towards the private healthcare sector in their country of origin. After pinpointing the limits of BSSAs, the paper discusses the growth of the medical private offer in Tunisia and explores the notion of diasporic medical mobilities. By mobilizing the concept of “transnational healthcare arrangement”, it examines the imbrication of formal and informal transnational social protection strategies.