Renewed focus: Addressing challenges and improving coverage with the introduction of a universal health care law

After over a decade of political instability and armed conflict, Côte d’Ivoire is beginning to rebuild its public health sector. A recent vote for a 29% increase in the budget of the Ministry of Health and the Fight against AIDS (Ministère de la Santé et de la Lutte Contre le SIDA, MSLS) and large donor contributions for basic services signal a good start. According to the World Bank, total per capita health spending was $88 in 2012, up from $33 in 2002. This is primarily due to private sector growth, which stems largely from the spread of unlicensed providers; reining in the private sector through better regulation and training will enable it to serve as a sustainable engine for growth.

Structure

Whereas the public sector provides a majority of health services, the private sector accounts for a majority of health facilities. The MSLS estimates that in 2011 private health establishments numbered 2036, whereas the public health infrastructure consisted of 1910 first-contact health clinics, 83 general and regional hospitals, five specialised national institutes, and four university teaching hospitals. In addition to being largely insufficient for a population that the World Bank estimated at 19.84m in 2012, the public health infrastructure is in generally poor condition due to underinvestment. World Health Organisation (WHO) data reveal that 24.5% of expenditure on health in 2011 came from the public sector, significantly below the lower-middle-income country average of 37.1% for the same year. The proportion of the population covered by a system of health protection is limited.

According to local news reports, 95% of the population is not covered. Beneficiaries are mostly civil servants and members of certain collective associations in the agricultural sector. Per WHO data, 77% of private health expenditure was out-of-pocket as of 2012.

Regional Disparities

Significant regional disparities are a persistent feature of the health landscape. According to the 2012-15 National Development Plan for Health (Plan National de Développement Sanitaire PNDS), 90% of Abidjan residents live within 5 km of a health facility, whereas the figure is less than 50% in six of Côte d’Ivoire’s western and northern regions. This imbalance has a significant impact on maternal and infant mortality rates. The years of political crisis were a major contributor to regional inequalities in services. “Teachers, nurses, doctors and professors are primarily public servants, assigned to different regions of the country. During the political-military crisis of 2002, the country was separated into a pro-government zone and a CNO (centre, north, west) zone under the control of the rebels. These public servants left the areas occupied by the rebels, causing, in certain areas, an interruption, even a complete discontinuation of health services for the population,” explained Aïda A N’Diaye, manager coordinator and manager for investing in people at the National Committee for the Eligibility of Côte d’Ivoire to the Millennium Challenge Corporation.

Government Strategy

In response to the acute health crisis, the government launched a free health care initiative, which ran from mid-2011 until January 2012, when overburdened facilities, supply shortages and spiralling costs forced the government to restrict the programme to pregnant women and children under five. Expanding health care access to more women, children and other vulnerable groups is the core objective of the health strategy, for which CFA594bn (€891m) has been allocated in the 2012-15 National Development Plan (5.36% of the plan’s budget). Like its West African neighbours, Côte d’Ivoire has one of the highest maternal and child mortality rates in the world. In 2013 the maternal mortality ratio was 720 per 100,000 live births, representing the eighth highest in the world, according to the WHO. Child mortality stood at 108 per 1000 live births for children under five in 2012. While the country is unlikely to achieve its Millennium Development Goals for improving maternal health indicators and reducing infant mortality by 2015, the figures will likely continue to improve given their prioritisation.

Poverty remains the most significant barrier to improving health. The UN Development Programme’s 2012 Human Development Index ranked Côte d’Ivoire at 168 out of 187 countries, placing it in the middle of the pack in terms of the West Africa region, but significantly below the sub-region’s other strong economies of Nigeria (153) and Ghana (135). The PNDS reports that in 2008, the poverty level stood at 48.9% nationally, and as high as 62.5% in rural areas. Cutting this rate in half is one of the five principal objectives of the National Development Plan 2012-15. A key component of the plan to expand health care access is the universal health coverage legislation (see analysis).

Public Spending

WHO figures indicate that public expenditure on health in 2011 was just 6.8% of total government spending, well below the 2001 African Union Heads of State pledge of at least 15%. For 2014, the government has voted to increase the MSLS’s budget to CFA245.5bn (€368.3m), representing an increase over the 2013 budget of CFA190bn (€285m), though the increase is still low, at 5.78%, relative to the growing national budget. The PNDS targets health spending at 10% of the government budget by 2015.

Private Sector

The private health sector has grown substantially in the past decade, driven primarily by the rising demand of an expanding population. In the 1980s budgetary constraints led the government to curtail its investment in public health services and cap the number of medical professionals. Facing competition for limited public sector jobs, many medical school graduates opted instead to open their own private clinics. Periods of armed conflict in the 2000s further weakened the public health sector, prompting rapid and relatively unregulated growth in the private sector.

“During the war, lots of doctors left the war zones and went to Abidjan. This posed a big problem because in the absence of legitimate health facilities, many illegal health clinics were opened which do not meet minimum health standards, and where unqualified people are practising medicine without a medical licence,” said Joseph Boguifo, president of the Association of Private Clinics of Côte d’Ivoire. The PNDS estimates that of the 2036 private health establishments operating in 2011, nearly three-quarters (73%) were non-authorised.

Workforce

As is true for much of sub-Saharan Africa, Côte d’Ivoire’s health workforce deficit is substantial. Whereas the WHO recommends a minimum density of 2.3 health workers per 1000 people, Côte d’Ivoire’s ratio as of 2010 was 0.14 physicians and 0.48 nurses and midwives. According to the PNDS, nearly 40% of health professionals are concentrated in Abidjan, although the city is home to 24% of the population.

Pharmaceuticals

The pharmaceuticals market is characterised by heavy reliance on imported drugs. “As of today, 94% of the total medicines consumed on the local market are imported, mainly from France where most of the central purchasing offices are. The remaining 6% are produced locally, and is mainly generics,” Ibrahima Diawara, managing director of domestic producer Cipharm, told OBG. While locally manufactured drugs compete at prices similar to those imported from Europe, both are undercut by cheaper imports from Asia. Counterfeiting and falsification of ingredients is a widespread problem, which has grown in recent years as regulatory crackdowns in the US and Europe have led counterfeiters to take advantage of the less-policed African market. “At the moment, the government is not very active in supporting the local pharmaceuticals industry. However, local production is recognised at the level of the WHO, the UN Industrial Development Organisation and the African Union as a strategy for combating counterfeit and substandard drugs, because when drugs are produced locally there is a measure of operational oversight and traceability of inputs that isn’t possible for drugs coming from China and India,” Assane Coulibaly, president of the Association of Pharmaceutical Producers of Côte d’Ivoire, told OBG.

Recognising the need to boost domestic production, the government has granted authorisation to Moroccan pharmaceuticals firm Cooper Pharma Maroc to open a plant in Côte d’Ivoire.

A New Product

Though small, the domestic pharmaceuticals industry shows signs of growth. Two local producers are now expanding into the market for infusion products (intravenous fluids) of which there are frequent shortages. With the help of a CFA2.5bn (€3.8m) loan from the West African Development Bank, local producer Pharmivoire Nouvelle is expanding and modernising its infusions production facility, while Cipharm will use CFA2bn (€3m) in financing from capital investment outfit Cauris Management and loans from local banks to add infusions to its product base. “Infusion products are often imported in Côte d’Ivoire, but with the new production plants, we will be able to satisfy most of the local demand. Infusion products are not easily imported because they are liquids, and therefore heavy, making them expensive to import, which in turn drives up the price on the local market,” said Coulibaly.

Consumer Market

The consumer market for pharmaceuticals is substantial and growing. The pharmaceuticals distributor, Distribution Pharmaceutique de Côte d’Ivoire (DPCI), owned by the Coopérative Française d’Exploitation de Récupération Pharmaceutique, achieved a turnover of CFA27bn (€40.5m) in 2013, representing a 22% increase over 2012. DPCI also doubled its storage capacity and launched a website where pharmacists can place orders and process payments electronically. The firm told OBG it expects to increase its product listing from the current 7000 to meet the general trend of 5-6% annual growth in consumption, which has been driven mainly by anti-malarial drugs.

International Participation

International partners and donor organisations play a significant role in the sector in collaboration with the government and private sector actors. Foreign participation falls into three categories: laboratories and research, the funding of treatment, and the establishment of hospitals and clinics. The Institut Pasteur of Côte d’Ivoire serves as the national reference laboratory for tuberculosis, while the US Centres for Disease Control operates the Retrovirus Côte d’Ivoire project, a laboratory combating HIV/AIDS. In the area of treatment, the US President’s Plan for Emergency AIDS Relief is the largest donor to the health sector with a budget of $140m focused on funding antiretroviral treatment. The government has also signed an €18m debt re-financing deal with France and the European Commission that will enable the funding of maternal and child health care for three years. The African Development Bank provided $863,000 in financing for the rehabilitation of the Séguéla Regional Hospital Centre in north-western Côte d’Ivoire. The renovations were completed in 2013. The initiative comes as part of the larger ongoing Post-Crisis Multi-Sector Institutional Support Project to restore public health services in the central, western and northern regions of the country.

Outlook

Côte d’Ivoire’s health sector challenges cut across multiple areas: staffing, infrastructure, training, regulation, national coverage and funding. Improving the quality and equity of care will require sustained interventions in all areas, in particular expansion of access to basic services and better regulation of the private sector. The adoption of the universal health care law and renewed prioritisation of maternal and child health indicate the government’s recognition of health challenges and its willingness to address them.