Expanding access: Rolling out universal health cover

Like many of its West African neighbours, Côte d’Ivoire suffers from an underdeveloped and overburdened public health infrastructure. To address the country’s public health challenges, the government has adopted a strategy focusing on expanding access to basic care, in particular for women and children.

Maternal & Child Health Care

In April 2011 the Ivorian government responded to the post-conflict health crisis by rolling out a programme of free health care. However, mounting expenses, resulting from poor oversight and mismanagement of resources, forced the government to abandon the initiative by January 2012. Nonetheless, with the aid of international donors, free health care for pregnant women and children under five has remained in effect. While the re-focused programme has largely been viewed as a success, a remaining challenge is the cost of medicines, which many patients must purchase out-of-pocket from private clinics due to shortages at the public facilities.

To support financing of services, the government signed an €18m debt-reduction contract with France and the European Commission in December 2012. The deal allows for debt-refinancing through development grants that will fund the maternal and child health initiative for three years. The programme targets 270 health centres and 17 health districts and is expected to benefit 1m women and children. The partnership is intended to help bridge the gap in basic health services until public programmes are able to fill that role.

Toward Universal Coverage

In March 2014 the National Assembly voted to adopt universal health coverage (couverture maladie universelle, CMU) legislation, representing Côte d’Ivoire’s first nationwide health risk protection initiative. The CMU’s dual-enrolment structure will entail monthly premiums of CFA1000 (€1.50) and co-pays for regular members, who will have access to public and private providers, while the poor will be eligible for premium-free enrolment and no co-pay, with the stipulation that care may be obtained solely from public providers. The uniform list of covered services is expected to focus on basic care. The first phase of the CMU, scheduled for January 2015, will incorporate 4m civil servants, state pensioners, and palm oil and shea butter farmers, who benefit from preexisting organisations and administrative mechanisms that will facilitate their inclusion in the programme. Remaining sectors of the population will be incorporated in successive tranches, with the goal of covering 39% of the population (11m individuals) by 2021.

Controlling Costs

The success of the government’s health strategy will hinge on its ability to control costs. In this regard, a coherent approach will include agreement with the pharmaceuticals industry on generic drug pricing. “Medications alone represent more than 60% of health care expenses, which means that in terms of daily expenses, in the context of health care coverage, medicines and the cost of medicines will play a very important role,” said Assane Coulibaly, president of the Association of Pharmaceutical Producers of Côte d’Ivoire. As the CMU is gradually implemented, a parallel focus on developing local pharmaceuticals production would help bring down the price of medicines while buffering the sector from fluctuations in the global market. The proper integration and regulation of private health care providers will also prove essential to the long-term viability of the system.

Adequate oversight and accountability will be essential factors in controlling costs, by preventing the mismanagement and waste that undermined the free health care initiative of 2011. Streamlined data management systems, for example, will be needed to limit the scope for fraud and abuse. Maïmouna Diop Ly, principal health analyst with the African Development Bank, said that, “In implementing the CMU, it will be necessary to ensure the autonomy of the managing structures. The institutional mechanisms of implementation must ensure transparency and traceability in terms of government spending, with a regular, independently conducted audit of the funding channels and measures of accountability for each piece of the programme.”