Universal coverage programmes and pharmaceutical regulation set to improve access and quality of health care in Côte d’Ivoire

A renewed focus on Côte d’Ivoire’s health sector after years of political instability ending in 2011 has brought with it a number of improvements. The authorities have rehabilitated and re-equipped hospitals and health centres, developed technical platforms for facilities in line with international standards and improved access to services. These efforts are reflected in improvements in Côte d’Ivoire’s basic health indicators. Life expectancy at birth, for example, has risen from 52.8 years in 2012 to 55.1 years in 2016 for women, and from 50.2 years to 52.1 years for men over the same period.

Despite these improvements, the sector is not without its challenges, especially with regard to women’s and children’s health. In 2016 the maternal mortality rate was 614 per 100,000 live births, while the neonatal mortality rate registered 33.5 deaths per 1000 births. Additionally, Côte d’Ivoire has one of the highest global infant and under-five mortality rates, at 64.2 and 88.8 per 1000 in 2017, respectively.

In light of these challenges the authorities will continue to prioritise health care access, as is evident in the National Development Plan 2016-20 implemented to make Côte d’Ivoire an emerging market country. Specifically focused on enhanced quality of and access to health services, the plan will implement mandatory universal health coverage, which will increase demand for services and open investment opportunities for the local production of generics and other drugs.

Public Health Care

Côte d’Ivoire’s health system is overseen by the Ministry of Health and Public Hygiene (Ministère de la Santé et de l’Hygiène Publique, MHPH) and comprises 20 regional health directorates and 86 smaller health districts. There are 2027 first-contact health facilities that meet the primary health needs of the population, 84 general hospitals, 17 regional hospitals, and two specialised hospital centres dealing with pathologies. There are five university hospital centres, four of which are in Abidjan, as well as five national specialised institutes and four national public establishments, which include the National Centre of Blood Transfusing, the National Public Health Laboratory, the Emergency Medical Assistance Service, and the New Public Health Pharmacy (Nouvelle Pharmacie de la Santé Publique, NPSP), the latter of which controls the distribution of pharmaceuticals. The first radiotherapy centre was inaugurated in 2017 at the Cocody University Hospital Centre.

Private Health Care

Private health care accounts for a quarter of the Ivorian market. “The private medical sector is crucial to the development of the overall health sector,” Eric Djibo, managing director of the International Polyclinic Saint Anne Mariec, told OBG. “Although treatment costs remain higher than the public sector, stronger and healthier competition is translating into lower prices.”

Private health services are set to expand as demand outpaces that for public health services, especially as it pertains to specialisations such as oncology or radiology. Private companies are already taking notice. In 2017 a consortium of international health care providers including Swiss renal care provider Dialife and UK-headquartered NMS Infrastructure announced plans to invest $110m to build 10 dialysis centres in the capital and in the towns of Aboisso, Korhogo and Man. Additionally, Ivorian medical group Novamed announced the same year an investment of CFA18bn (€27m) between 2016 and 2020 to expand its clinical network, notably opening a cardiac clinic in the Plateaux region of Abidjan. “The lack of government spending in the health care sector has led to the private sector taking over and driving most initiatives at the moment,” Johan Descombes, head of francophone West Africa at Roche in Côte d’Ivoire, told OBG.

State Spending

Health care spending in Côte d’Ivoire falls primarily on the shoulders of households, with the government accounting for less than 40% of total health care spending. In 2015 public financing accounted for around 21% of the overall total, while 51% was provided by individual households, and 26% was classified as external health expenditure, provided by global groups such as the World Health Organisation.

Although public health expenditures increased in absolute terms between 2013 and 2019, its share in the budget remained relatively constant, hovering between 5% and 6% of the total. The public health budget allocation for 2019 is CFA386.2bn (€579.3m), accounting for 5.3% of the total CFA7.3trn (€11bn) state budget. To compare, in 2018 CFA354.6bn (€531.9m) was spent on health care, or 5.2% of overall public spending.

Health Policy

In March 2018 the government adopted a decree regulating telemedicine to ensure remote or otherwise underserved populations have access to high-quality care. The decree also highlighted the role of technology in increasing health care accessibility. Ivorian officials also announced in early 2018 a reform of the Public Health Code, the roots of which dated back to the 1953 French Health Code and were out-of-date with the modern health scene in Côte d’ Ivoire. The draft health code covers medical professionals, pharmaceutical products and the practice of traditional medicine. In December 2018 the legislation was handed to the MHPH, where it awaits consideration first by the Council of Ministers and then the National Assembly.

Officials are also working to strengthen the health sector’s infrastructure and human resources. In 2016 the government, in partnership with the World Bank, kicked off the Strengthening Epidemic Emergency Health and Response System Project to rehabilitate 100 health centres in 25 districts. As of December 2018, 85 had been delivered. In terms of human resources, in 2016 there were 3540 doctors, 10,038 nurses and 4011 midwives in Côte d’Ivoire, and in November 2018 the authorities announced plans to increase the health care workforce by over 80% with the recruitment of an additional 14,431 health professionals by 2022.

Access to Care

Health care access remains a challenge for most Ivorians, as around 47% of the population were living below the poverty line in 2017 and out-of-pocket costs are high, with such expenditures accounting for 36% of total health spending in 2015. Access in rural areas is also an issue. “There are some regions where 40% of the population lives over 5 km from a health centre,” Seydou Kouyaté, clinical instructor at Health Alliance International, told OBG.

Even if a community is within close proximity to a health facility, doctors are overstretched, with 65% of the country having less than one doctor per 10,000 inhabitants and rural populations being particularly hard-pressed for access. In areas without access to care many turn to traditional medicine.

The lack of financial and physical accessibility partly explains the low rate of use of public health services at 45.3% in 2016. While low, this is an improvement over 27.5% in 2013. The lack of trained medical professionals, long wait times and the sometimes poor quality of provision also deter individuals from seeking care. To compensate for this the MHPH deployed 10 mobile clinics across the country in 2017 to provide consultations, cervical and breast cancer screenings, and vaccinations. While improvements regarding access are being made on behalf of the government, there is an opportunity for further development as universal health insurance becomes mandatory and growing numbers of Ivorians join the middle class.

Insurance Schemes

According to the US Agency for International Development, fewer than 10% of Ivorians had adequate health coverage as of 2016. To address this, the country has been progressively implementing Universal Health Coverage ( Couverture Maladie Universelle, CMU) since 2015, making health insurance coverage mandatory. Monitored by the National Health Insurance Fund (Caisse Nationale d’Assurance Maladie, CNAM), CMU has two schemes: the contributory basic general scheme offering a package of care for about CFA1000 (€1.50) per month per insured person and funded at 70% by the CNAM, and the non-contributory medical assistance scheme for the financially vulnerable population. The CMU began a pilot phase in April 2017 with the enrolment of 108,469 students. As of July 31, 2017, 2.2m individuals were enrolled, or 70% of the targeted population of 3.2m.

The generalisation phase of the CMU is expected to take place in the beginning of 2019 and will reduce out-of-pocket household expenditures and alleviate the risk of impoverishment due to significant health costs. “The CMU plan implemented in 2018 has been a welcome and applauded development,” Karim Bamba, managing director of CNAM, told OBG. “So far, CNAM has successfully extended health care coverage to a number of Ivorians, including students, and is now planning to roll out the plan to other parts of the population, including workers in the informal sector.”

A number of private health insurance plans are available, although coverage is largely limited to individuals in higher socioeconomic income brackets. There is also a network of health mutual funds, the use of which may increase as medical costs in the private sector rise. “The CMU is an immense leap forward for the country and for medical inclusion,” Olivier Blé, general manager at Ubipharm-CI, told OBG. “A fragment of Ivorians possesses medical insurance. Provided generalisation is successful, the CMU will improve access to health care and bring the medical sector forward by involving a number of companies in the process.”

Communicable Diseases

The most common communicable diseases in Côte d’Ivoire are malaria, HIV/ AIDS and tuberculosis. Malaria is the leading cause of death in the country, with an incidence rate of 348.8 per 1000 in the general population and almost 50% in children under the age of five, and accounting for 33% of health care consultations in 2017. Malaria deaths have decreased in recent years, from 4431 per 100,000 in 2016 to 3222 per 100,000 in 2017. International assistance has been imperative in fighting the disease. Côte d’Ivoire received $25m between 2006 and 2017 from the US as part of the President’s Malaria Initiative, a US programme aimed at containing and eliminating the disease in sub-Saharan Africa and South-east Asia.

Côte d’Ivoire is one of the countries most affected by HIV/AIDS in Western Africa, with a prevalence rate of 2.9% in 2017, down from 4.7% in 2006, according to the Joint UN Programme on HIV/AIDS (UNAIDS). According to a national survey conducted in 2018 by the President’s Emergency Plan for AIDS Relief (PEPFAR), a US governmental initiative to address the global HIV/AIDS epidemic, and the US Centres for Disease Control and Prevention, 37.2% of people living with HIV were aware of their status, 88% were undergoing antiretroviral therapy and 76% of those receiving medication had experienced viral suppression.

The authorities, in coordination with international groups, are working to further improve these numbers. “Partners have made quite an effort to reach the 90-90-90 UNAIDS target by 2020,” Kouyaté told OBG, referring to a target of diagnosing 90% of people living with HIV/AIDS, providing treatment to 90% of those diagnosed and achieving a viral suppression rate of 90% for those receiving medication by 2020. In 2018 the US announced plans to contribute CFA77bn (€115.5m) through PEPFAR from October 2018 to September 2019 to help Côte d’Ivoire fight HIV/AIDS and eventually help the government create a generation without HIV/AIDS.

Tuberculosis is another disease highly endemic in the country, with 153 out of 100,000 inhabitants infected with the disease as of 2017. That same year, 21,309 individuals declared having the disease, 47% of which reside in Abidjan, the most populated city. The numbers have remained relatively constant, with 22,911 declared cases in 2011 and 21,204 in 2006.

Non-Communicable Diseases

According to the UN Economic Commission for Africa, non-communicable disease (NCD) will top infectious diseases as the top cause of mortality in Africa by 2030. With growing urbanisation and more sedentary lifestyles, Côte d’ Ivoire has not escaped the trend; incidence of high blood pressure jumped from 13.7% of the population in 1979 to over 25% in 2018. Diabetes prevalence hit 4.8% in 2017, and there are indications that a number of cases have gone undiagnosed. Obesity rates doubled between 1991 and 2014 standing at 10.3% in 2016. As lifestyle diseases become more prevalent, the authorities are working to strengthen related services. In the National Health Development Plan 2009-13, NCDs were made a priority health issue. Initiatives were implemented on the national level focusing on the prevention of NCDs, cancer, metabolic diseases, and alcohol and tobacco use, as well as programmes to promote mental health, nutrition and oral health. The authorities also implemented the 2015-19 Integrated Strategic Plan for the Prevention and Care of NCDs in a bid to control their spread. Since 2012, 15 diabetes and high blood pressure clinics have been established. Health officials are also working to train 600 doctors about the disease.

Pharmaceuticals

The purchase of pharmaceuticals in Côte d’Ivoire is centralised under the NPSP, which supplies to four wholesalers, 850 private pharmacy operators and 542 pharmacy depots. There are eight local production facilities, of which four are currently in production. Local manufacturers account for an estimated 6% of the total domestic pharmaceutical market, with the rest supplied by imports. The NPSP improved the availability of essential medicines with enhanced storage capacity, bringing the availability of essential medicines to 90% against 23% in 2011.

The construction in Bouaké of the first regional NPSP agency should further improve the availability of medicines in the country as the facility moves to decentralisation to provide more efficient services. “The restructuring of the NPSP has translated into more efficient processes, more transparent procedures and overall into an improved supply chain,” Ibrahima Diawara, managing director of Cipharm, told OBG.

Even so, there is an increasing need for locally produced medicines to reduce dependence on imports. “With the CMU increasing the volume of medicines needed, the question is if imports are able to sustainably and inclusively cover the demand for effective, safe and affordable generic medicines,” Assane Coulibaly, lead ECOWAS coordinator for the Pharmaceutical Good Manufacturing Practices (GMPs) Roadmap Initiative in the Department of Trade, Investment and Innovation at the UN Industrial Development Organisation (UNIDO), told OBG. “The pharmaceutical industry is at the embryonic stage. Domestic production covers only a small fraction of drugs used,” Coulibaly explained. “There are many projects under way that we hope will boost local production of medicines to 15-20% of all drugs used in the next two years.” Focusing on local production, Coulibaly continued, will not only reduce lead times and the expenses associated with inventory management, but also improve accessibility to medicines.

There is a specific need to develop the local production of generics to meet the growing demand for quality and affordable medications, especially as the CMU reaches the generalisation stages. The vast majority of generic medications are currently imported from China and India, but there has been movement toward local production. In December 2017 Moroccan generic producer Pharma 5 started construction of its first plant outside Morocco in Abidjan. The CFA60bn (€90m) facility, expected to be operational in 2019, has an initial capacity of 100m tablets and 10m sachets per year.

Quality Control

Central to the development of a local pharmaceutical industry will be the implementation of international quality standards. “From a qualitative point of view, GMPs are based on the concept of ‘quality by design’, which states that quality is built during the manufacturing process and improves continuously,” Coulibaly explained. “Therefore, quality control on imported finished product generic drugs does not effectively fight against the proliferation of substandard, counterfeit or falsified medicines within the region. The only alternative against this problem is local or regional production under the control of local regulatory bodies. It is in this context that ECOWAS, through the West African Health Organisation (WAHO) and in collaboration with UNIDO, initiated the Pharmaceutical GMPs Roadmap in 2016.”

According to Ange Désiré Yapi, the director-general of NPSP, the fight against fraud and substandard products is not yet over. “Although the situation has improved greatly thanks to public initiatives and the reinforcement of procedures, we are still seeing a high number of fraudulent products on the market,” he told OBG. Thus, plans are in the works to further regulate the industry and target counterfeit medicines specifically. In March 2017 legislation was passed to criminalise the counterfeit of medicines, and in December 2018 the authorities announced the creation of the Ivorian Pharmaceutical Regulatory Authority, an independent regulation institution. Once operational, the authority will control pharmaceuticals being sold on the market, and be able to conduct quality control inspections. “The pharmaceutical sector is in need of regulatory reform,” Diawara told OBG. “We are seeing the illegal import of substandard and counterfeit drugs, and the trend is not decreasing. The market needs more active organisation in order to ensure overall quality of products.”

Regional Prospects

The local production of pharmaceuticals presents a number of opportunities for exports, especially at the regional level. “The drug market extends to the entire West African region,” Coulibaly explained. “Therefore, the entire value chain must be mobilised within the framework of regional integration. Embracing neighbouring countries is the only way to guarantee the economic viability and sustainability of the local generic drugs production chain.”

With some 362m inhabitants in West Africa, a regional pharmaceuticals market is estimated at $5bn, with significant room for expansion. Recognising this potential, a process of regional integration is under way, with projects such as the World Bank’s West African Medicines Regulatory Harmonisation Initiative for ECOWAS aimed at making medicines more accessible and safer in the broader region through the standardisation and strengthening of regulatory systems with the assistance of regional and international actors.

“The WAHO is in the process of establishing the conditions for the harmonisation of drug regulations in the ECOWAS region,” Coulibaly said, noting an ECOWAS common Customs tariff. “These important regulatory harmonisation efforts need to be supported economically through a regional, integrated, competitive and sustainable productive sector,” he added, citing the possible use of public-private partnerships for further development of the pharmaceutical industry.

Outlook

Although Côte d’Ivoire’s main health indicators have improved significantly over the years, a number of challenges remain with regard to maternal, neonatal and infant health. The universal health care plan is set to improve provision with commitments to boost operational infrastructure, increase the workforce and manufacture more local generic pharmaceutical drugs. The announcement of the construction and rehabilitation of several health facilities in 2018 is a step in the right direction and is set to reinforce the attractiveness of Côte d’Ivoire’s health care industry.