Accessing care: Investment in infrastructure helps meet demand in line with a shifting disease burden

Since the country gained independence in 1962, Algeria’s health indicators have seen a significant improvement. Life expectancy at birth currently stands at 77.3 years for women and 76.6 for men, up from an average 49 years in 1962, and the country has a vaccination coverage of 98%. Nevertheless, chronic illnesses such as cardiovascular diseases and cancer have come to constitute today’s main health burden.

In a bid to improve access to quality health services, Algeria is investing AD619bn (€5.69bn) under its latest five-year plan (2010-14). While new facilities come on-line and work on existing public infrastructure continues, the private sector has come to play an important role, particularly for the treatment of emerging and chronic diseases. Expanded coverage under the country’s social security scheme is also helping to enhance access to quality health services.

INDICATORS: According to local media reports, Algeria has one doctor per every 800 inhabitants, which exceeds the one per every 1000 people that is recommended by the World Health Organisation (WHO). Mother and child mortality rates, which currently stand at 77 deaths per 100,000 live births within the first 45 days following childbirth, have improved significantly although are still high.

However, according to Messaoud Belkessam, an advisor at the Ministry of Health, this figure, from 2012, is likely to be overstated. According to Belkessam, 97% of births are delivered in a health care facility, and the maternal mortality rate for hospital births in the four days that follow delivery stands at 20 per 100,000 live births. An enquiry is currently being carried out by the Ministry of Health to identify the discrepancy in numbers for mother and child mortality within the 45 days following delivery.

COMMUNICABLE & CHRONIC: In terms of communicable diseases, tuberculosis (TB) is the only remaining notable concern, with a prevalence rate of 59.9 cases per every 100,000 inhabitants in 2011. In its fight to eradicate the disease, the country hopes to extend TB vaccination coverage to 95% of infants by 2015. Chronic diseases represent Algeria’s main health burden today; they affect around 10% of the population and are responsible for 58% of deaths. This is due to a number of factors, including demographic growth, increased urbanisation and changes in lifestyles. Diabetes, cancer and cardiovascular diseases represent the biggest health threats.

EVOLVING SERVICES: Health services provided in Algeria have improved considerably in recent years, as reflected in the decline in the number of patients transferred abroad for treatment, which social security pays for. Indeed, within 15 years, this number has fallen from around 1500 patients a year to 400 in 2012. “A decade ago, patients were evacuated for cardiovascular surgery, which was not practised in Algeria back then. Today, however, patients can be treated in-country,” said Rachid Bougherbal, president of the Commission on Health and Social Affairs.

Foreign transfers are also a costly affair, with the cost of treating one patient abroad estimated to be equivalent to the price of treating 10 patients in-country. Transfers have therefore been limited in recent years to patients presenting a vital risk for which treatment is not available domestically. Patients are mostly evacuated for short periods to treat new and emerging diseases such as embolisation, which is slowly increasing in prevalence in Algeria, as well as brain arteriovenous malformation and infants affected by severe congenital heart defects.

To meet demand, develop services, and redirect resources towards improving conditions at home, the government has preferred to bring in foreign doctors from abroad in recent years to operate on patients in-country. This can be reflected in the rise of public spending on health care in recent years, which, according to Bougherbal, increased from AD260bn (€2.4bn) in 2010, to AD280bn (€2.58bn) in 2011 and AD404bn (€3.72bn) in 2012. Nevertheless, considering the stable financial situation, total health expenditure as a percentage of GDP in 2011 stood at just 3.9%, compared to 6.2% and 6% in neighbouring Tunisia and Morocco, respectively, according to the WHO.

MEDICAL STAFF: Some 60,000 doctors work in the Algerian health sector, however uneven distribution across the country means some regions, particularly in the south, face shortages in medical staff. “Algerian universities train around 2000 doctors on average every year. The problem lies with the distribution of staff, not with the quantity,” Belkessam told OBG.

One of the reasons for the shortfall of staff in some areas is related to the poor conditions in underserved regions, which drives away a considerable number of personnel and leads many to seek work abroad, particularly in France, Canada, Tunisia and Morocco. Furthermore, while the overall number of doctors may be sufficient, Algeria is subject to a shortage in certain specialties, most particularly cardiac and paediatric surgeons, a gap which has been bridged so far by patient transfers abroad or the import of foreign doctors to perform operations locally. The country also requires additional paramedical staff. In a bid to boost their number, some private schools have been authorised to train paramedics.

EDUCATION COLLABORATION: Developing further links between the various administrative bodies responsible for medical training is also required. “One way to address the shortages in medical personnel and develop skills according to the needs of the sector and the current epidemiological transition could be through closer collaboration between the Ministry of Health and the Ministry of Higher Education and Scientific Research,” Belkessam told OBG.

Finally, to enhance sector management, the Graduate School of Management and Administration in Health was established in Algiers in 2009. The school aims to improve the management of health facilities by introducing sector professionals, university graduates and graduates from the National School of Administration to specialist managerial skills related to health services. The school’s first class, consisting of 84 students, graduated in early 2013, while another 86 are expected to graduate at the end of the year, and an additional 90 in 2014, significantly boosting the available managerial workforce for the sector.

PUBLIC FACILITIES: Public health care is overseen by the Ministry of Health, Population and Hospital Reform, and the sector is made up of 13 university hospital centres, 31 specialised hospitals, 988 polyclinics and 5376 health centres. Existing structures, however, are challenged by the current epidemiological transition the country is undergoing and adapting is proving costly and sophisticated, particularly in terms of medical equipment. As a result, the quality of public health has been affected and people are becoming wary about seeking treatment in smaller public health facilities, which has in turn led to congestion in the country’s main public hospitals. Planned health facilities, however, are expected to alleviate this overcrowding and shorten the queues for services, particularly relating to the treatment of chronic diseases.

INVESTMENT: Indeed, under its latest five-year plan, the government plans to spend €1.5bn to renovate 320 health facilities. New units are also being constructed, with the government adding a further 172 hospitals, 45 specialised centres, 377 polyclinics and 17 paramedical schools to double the sector’s inpatient capacity, which currently stands at around 63,000 beds. New health facilities, such as the hospitals delivered in Aïn Témouchent in 2011 and Chlef in 2012, are being constructed on a smaller scale, with in-patient capacity of between 250 and 350 beds. Progress in terms of greenfield projects is coming along slowly, as the priority is to complete ongoing works before starting new ones. A number of new hospitals are expected to come on-line in 2013.

While building hospitals is necessary to meet demand, the sector must also secure and effectively utilise new health care equipment available. “The issue is not so much with constructing the hospitals, it is more a problem of acquiring equipment. Importing the equipment is not difficult, but its usage and maintenance can be problematic,” Belkessam told OBG.

SOCIAL SECURITY: The national social security system covers around 23m people and is overseen by the Ministry of Labour and Social Security (see Insurance chapter). Modelled after the French system, it aims to provide universal coverage and is divided into two funds: the National Fund for Social Security for Salaried Workers (Caisse Nationale de la Sécurité Sociale des Travailleurs Salariés, CNAS), and the National Fund for Non-Salaried Workers (Caisse Nationale des Non-Salariés, CASNOS). Efforts have been made in recent years to reform and modernise the system and reduce bureaucratic procedures through the introduction of personalised insurance smartcards, infrastructure renovation and the training of human resources.

The Chifa card, a personalised smartcard, was introduced in 2007 and has so far been distributed to more than 7m people. This electronic card contains the insured person’s details (such as insurance status, health history and prescriptions), allowing sector professionals to provide better service for patients. To broaden take-up of the cards, restrictions limiting patients to seeking treatment within the wilayas (provinces) they live in were lifted for cardholders in February 2013, and their details can now be accessed at public health facilities throughout the country.

As part of its plan to offer training and continuing education to sector staff, the Ministry of Labour and Social Security signed a cooperation agreement with the International Labour Organisation in June 2013 to establish a high institute of social security (Ecole Supérieure de la Sécurité Sociale) in Algiers, which is expected to be operational in 2015. The institute will have capacity for up to 400 students, who will be divided among five continuing education programmes.

The country is also looking into ways to reform the system’s funding mechanism, an issue which has come to prominence after reimbursement for medicine in 2012 reached AD125bn (€1.15bn), exceeding the threshold set by the WHO, according to Tayeb Louh, the minister of labour, employment and social security. With the rising costs of medicine and the increase in the number of insured patients, the government is currently examining alternative sources of funding in addition to salaried workers’ contributions.

PRIVATE CARE: First authorised in 1988, the private health sector is still relatively small. There are no private hospitals, and only an estimated 250 private clinics, which are located primarily in the northern part of the country, operate today. However, increased demand for high-quality services, a faster turnaround and treatment for chronic diseases constitute some of the main factors driving private sector growth.

As demand for private health care continues to rise, however, one of the most decisive factors behind the sector’s expansion is perhaps the number of contracts established between private health providers and CNAS. This enables more people to receive health care services that are not easily accessible to them in public facilities, particularly cardiac surgery, for which rising demand is stretching the capacity of the nation’s specialist surgeons. The private sector brings in foreign surgeons temporarily to perform all the operations in a short space of time.

The contracts established with CNAS have therefore become extremely important; indeed, recent years have seen the scheme contract more than half of the country’s existing private clinics as well as practitioners, pharmacies and laboratories. With CNAS providing coverage to some 75% of the population, these contracts have played a major role in enhancing access to services, most importantly for the treatment of chronic diseases.

ADDING CAPACITY: Despite recent growth, the private sector’s contribution to bed capacity stands at just 10% of the total, according to a report by the Austrian Consulate. New projects, however, such as the planned private hospital in Sidi Abdallah, should boost this number. The facility will constitute the country’s first private hospital and is expected to be delivered by 2016 at a total cost of €31.5m and offer an inpatient capacity of 180 beds.

NON-COMMUNICABLE DISEASES: Cardiovascular diseases are one of the main health burdens and the single leading cause of mortality in Algeria today. The private sector has taken on a major role in the treatment of cardiovascular diseases and consequently helped bring down the number of medical transfers abroad. This trend can be attributed to the fact that treatment of these diseases – and cardiac surgery in particular – are fully accounted for by CNAS. Nevertheless, health providers continue to be challenged by the lack of cardiac surgeons, especially paediatric heart surgeons, and are often compelled to bring in foreign staff to perform the operations.

Training domestic personnel in this area is therefore a priority as new specialised units come on-line. Indeed, construction of a new facility specialising in paediatric cardiology was recently completed in Tizi Ouzou and equipment is being installed. Foreign specialists, notably from Jordan, France and Brazil, have already trained the hospital personnel at the Abderrahmani clinic of cardiology. Two additional similar hospitals are expected in Algiers and Annaba.

Diabetes affects an estimated 1.4m people aged between 20 and 79. Perhaps one of the greatest challenges facing Algeria is a lack of awareness of the disease, as an estimated 50% of affected people are unaware they have it. Public education programmes and campaigns have therefore flourished in recent years to enhance prevention, particularly in collaboration with major pharmaceuticals firms.

In addition, around 40,000 new cases of cancer are diagnosed annually in Algeria. The prevalence of the disease is estimated to have increased from 80 per 100,000 people in the 1990s to 120 per 100,000 in the 2000s. As life expectancy rises, this number is expected to grow to 300 per 100,000 inhabitants over the next decade. Under the government’s five-year plan to construct 45 specialised health centres, 15 will be devoted to oncology.

One centre has already been completed and delivered in Ouargla in 2012, and two centres in Sétif and Batna have also been completed, however, equipment has yet to be acquired and installed. Two more centres planned for Annaba and Tlemcen are expected to be completed by the start of 2014. In addition, work on centres for Tizi Ouzou and Oran is around 25% complete. Centres are also planned for Béjaïa, Tiaret and Medea, though construction contracts had yet to been awarded at the time of press.

CANCER TREATMENT: In addition to the 15 planned centres, extensions are currently being carried out at the radiotherapy department in Constantine, and existing equipment has been renewed. With work progressing, more investment is being directed towards radiotherapy equipment, which still lags behind neighbouring countries. In September 2013, the government partnered with American Varian Medical Systems and Swedish Electa, two major manufacturers of linear accelerators, to ensure the supply of the machines, their maintenance and training personnel.

The new centres are urgently needed. Indeed, women diagnosed with breast cancer can wait up to eight months to receive surgery, causing some 3500 women to die annually from the disease. “It is critical to care for chronic diseases and work on a well structured anti-cancer plan that could make drugs and radiotherapy treatments available for all patients,” Dr Jamal Eddine Khodja Bach, general manager at Clinique Alazhar, a private clinic in Algiers, told OBG.

An estimated 10,000 cases of breast cancer are registered annually. Thanks to the arrival of centres in Sétif and Batna and the extension in Constantine, appointment waiting time is expected to be halved by the first quarter of 2014. Prevention is also key in raising awareness on the necessity of seeking early diagnosis and treatment of cancer.

A report by the American Cancer Society showed that Algeria’s cancer survival rate, measured five years after the original diagnosis, was 39% in 2008, compared with the 89% in the US and 80% in Spain. As these new specialised centres come on-line and extensions at existing facilities are carried out, the need for personnel is expected to grow, particularly for more paramedical staff in oncology. The country is currently negotiating an agreement with Harvard medical school to train this workforce.

PHARMACEUTICALS: Imports of pharmaceuticals reached $2.23bn in 2012, rising year-on-year by 13.6%, according to the National Centre for Informatics and Statistics. “Algeria seeks to reduce its imports of medicines by encouraging local production and by prohibiting the importation of products manufactured locally,” Boumediene Derkaoui, CEO at Groupe Saidal, Algeria’s largest pharmaceuticals company, told OBG.

In a bid to reduce the import bill, Algeria is developing local pharmaceuticals production with the aim of meeting 70% of the country’s needs by 2014 (see Industry chapter). To reach this objective, the government has been encouraging collaboration with foreign manufacturers. French Sanofi, for example, has plans to invest about €70m in a manufacturing unit in Sidi Abdellah, making it the company’s biggest investment on the continent. Construction of the factory began in September 2013.

Although an increasing number of partnerships have been signed between various foreign and local producers in recent years, pharmaceuticals production today only meets one-third of the country’s needs. Authorities have sought to enhance collaboration with private operators to stimulate local production, as well as ban the import of medicine that is already produced locally. Although the move was intended to protect the Algerian consumer and stimulate the industry, it has resulted in drug shortages, as local production has proved insufficient to meet demand and administrative constraints have resulted in Customs blockages of imported products.

“Pharmaceuticals production is a promising industry and there is plenty of potential for growth,” Bouzid Zamoum, general director at the Algerian Pharmaceutical Laboratory, told OBG. However, there are also an important number of difficulties to overcome. “Administrative constraints are one of the biggest challenges facing the sector. There needs to be support measures and incentives for investors. The production of some medication can be very costly and controlling prices makes business unprofitable. A constructive dialogue needs to be set up to guarantee long-term investment,” Zamoum added.

OUTLOOK: With the population aged 60 and over expected to account for 14% of the total by 2030 – up from 8.1% today – chronic diseases are likely to continue to be a prominent issue affecting Algerians’ health. Adopting appropriate preventive measures, alongside building the specialist services and workforce needed to treat these concerns, will be key in improving health indicators.

In the meantime, the private sector is expected to help alleviate the pressure on public infrastructure. Continued collaboration with CNAS should facilitate the sector’s expansion, while better social coverage will result in increased access to quality health services. Meanwhile, further investment in infrastructure, equipment and specialised training of medical personnel by the state should help the sector stay in line with the country’s epidemiological transition.