How Côte d'Ivoire is improving access and quality of health care

Côte d’Ivoire is an economic powerhouse in West Africa, posting average growth of 8% between 2011 and 2018. However, the rate of GDP growth in real terms fell to 6.7% in 2019 and is expected to contract to 2.7% in 2020 due to the Covid-19 pandemic and subsequent widespread shutdowns. Looking to the future, the IMF expects growth to rebound to 8.7% in 2021 – highlighting the country’s economic resilience.

Despite the dynamic economy, Côte d’Ivoire lags behind less-developed countries on a number of health indicators. The sector was severely affected by years of underinvestment due to political and military conflict. In the years since the conclusion of the conflict, however, the Ivorian government has made a concerted effort in recent years to improve access to services, rehabilitate and build facilities, and develop technical platforms aligned with international standards. There remains room for improvement in terms of quality, especially as the country rolls out universal health coverage.

Performance

In 2018 Côte d’Ivoire ranked 165th out of 189 countries in the UN Human Development Index. Although life expectancy at birth rose from 50.6 years in 2006 to 57.4 years in 2018, it is still among the lowest in the world, according to the World Bank. Côte d’Ivoire also underperforms in other indicators. The maternal mortality rate was 617 per 100,000 births in 2017, one of the highest in the world, while the neonatal mortality rate was 33.5 deaths per 1000 births. However, these indicators are set to improve as health care spending increases, alongside population and economic expansion. Projected health care spending, excluding pharmaceutical drugs, is $2.3bn for 2021, up from an estimated $2bn in2019 and $1.8bn in 2016. A growing middle class, higher incidences of non-communicable diseases (NCDs) and the implementation of a universal health care programme are expected to further increase health-related expenditures.

Infectious Diseases

Malaria is the top cause of death in Côte d’Ivoire, with an incidence rate of 348.8 per 1000 in the general population and almost 50% in children under the age of five. The disease accounted for 33% of medical consultations in 2017. The death rate peaked in 2014, at 4431 per 100,000, before falling to 3133 in 2018. Despite the improvement, the rate was nonetheless higher than the 1023 deaths seen in 2010. International assistance has been essential, with the Global Fund to Fight AIDS, Tuberculosis and Malaria, a non-profit foundation and the largest donor to Côte d’Ivoire, contributing $27.5m in 2018.

The country is one of the most affected by HIV/AIDS in West Africa, with a prevalence rate among adults aged 15 to 49 of 2.6% in 2018, although this is down from 4.7% in 2006. There are an estimated 460,000 people living with HIV, according to the Joint UN Programme on HIV/AIDS, with 63% aware of their status, 55% undergoing antiretroviral therapy – which is free of charge in Côte d’Ivoire – and 41% with undetectable viral loads. The number of new infections decreased from 48,000 in 2000 to 17,000 in 2018, as greater awareness helped to limit transmissions.

Tuberculosis is another endemic disease in Côte d’Ivoire, with 142 out of 100,000 inhabitants infected as of 2018, down from 153 in 2017. In 2018, 21,303 individuals had the disease, the majority of which – 21,034 – were new and relapsed cases.

Chronic Diseases

The UN Economic Commission for Africa forecasts that NCDs such as such as cardiovascular disease, cancer, chronic respiratory diseases and diabetes will surpass infectious diseases as the main cause of mortality in Africa by 2030. Due to a combination of urbanisation, sedentary lifestyles and a lack of the resources for diagnoses, the risk of dying from NCDs in sub-Saharan Africa is the highest in the world, according to the World Health Organisation (WHO).

It is estimated that NCDs account for 37% of all deaths in Côte d’Ivoire. The incidence of high blood pressure nearly doubled, jumping from 13.7% in 1979 to over 25% in 2018. Diabetes was prevalent in 4.8% of the population in 2017, while in 2016 around 9% of all adults over the age of 18 were obese, according to figures from the WHO. Broken down by gender, females had a higher incidence of obesity, at 13%, than their male counterparts, at 5%. The incidence of cancer is also on the rise, jumping from 12,002 new cases in 2012 to 13,209 in 2016. The government expects the number of diagnoses of cancer could increase substantially, to reach over 17,000 by 2030.

Public Health

The Ministry of Health and Public Hygiene (Ministère de la Santé et de l’Hygiène Publique, MHPH) is responsible for the health system and comprises 20 regional health directorates and 86 smaller health districts. There are 2027 first-contact health facilities, 84 general hospitals, 17 regional hospitals and two specialised hospital centres in Côte d’Ivoire.

There are five university hospitals – four of which are in Abidjan – as well as five national specialised institutes and four national public establishments: the National Blood Transfusion Centre, 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 regulates pharmaceutical distribution.

Despite the available infrastructure, further improvements to the quality of and access to care are needed. “The challenges are significant,” Arouna Diarra, president of the National Order of Pharmacists of Côte d’Ivoire, told OBG. “Many Ivorians are going to places such as Europe and the Maghreb to seek care because there is a lack of equipment to run diagnoses here.” To address this concern, the authorities rehabilitated and re-equipped a number of hospitals and health centres in recent years to improve access to services. In 2016 the government launched a programme in partnership with the World Bank to rehabilitate 100 health centres in 25 districts. As of December 2018, 85 had been delivered. More recently, in December 2019 President Alassane Ouattara announced plans to build, rehabilitate and equip 50 hospitals and 600 health centres.

Sector Reforms

In July 2019 the National Assembly adopted a bill that set to significantly change the management of the health system. The legislation transforms public health centres into public hospital establishments (etablissements publics hospitaliers, EPHs), increasing the revenue of public hospitals and improving the quality of services. The newly formed EPHs will remain under the supervision of the state but run as private businesses with a results-based management approach to increase revenues and reduce costs.

Universal Care

Limited access to care due to the high cost remains an issue for most Ivorians, especially as 47% of the population lives below the poverty line and health centres are not easily accessible in many rural areas. While the use of public health services increased from 27.5% in 2013 to 45.3% in 2016, the lack of trained professionals, long waiting times and poor quality deter many from seeking care. This has consequences, with as many as 80% of Ivorians, especially those in rural areas, turning to traditional medicine, according to a 2019 study by Sciences Po in Paris, Human Dignity and the Ivorian Human Rights Movement.

To boost access to care the government implemented universal health coverage (couverture maladie spending ($14) and developmental assistance ($11), which includes groups like the WHO. It is expected that annual health care spending will nearly double to $128 per person by 2050, $43 of which will be out-of-pocket.

Health spending in the national budget rose from CFA330.4bn ($568m) in 2016 to CFA446bn ($776.7m) in 2020. The share of the sector’s expenditure in the budget remained stable, however, hovering between 5% and 6% of the total. Officials are looking to boost this percentage, with Adama Koné, the former minister of finance, telling local press in July 2019 that the government aims to increase this to 15% in the coming years.

Private Care

Around a quarter of Ivorian health care is provided by private firms, a share that is set to expand to meet growing demand, especially for specialisations like oncology and radiology. In a bid to leverage this demand, private companies are entering the market. In 2017 a consortium of international firms including Ivorian medical group Novamed announced it would invest CFA18bn ($30.9m) between 2016 and 2020 to expand its network both at home and abroad, notably opening a cardiac clinic in the district of Deux Plateaux in Abidjan. More recently, UK-headquartered NMS Infrastructure announced in September 2019 that the company had signed a €326m agreement with the MHPH to construct six hospitals in Bouaké, Boundiali, Kouto, Katiola, Ouangolodougou and Minignan.

Technology

Like other countries, Côte d’Ivoire was affected by the Covid-19 pandemic in early 2020, confirming 1275 cases and 14 deaths as of April 30. Health technology has played an important role in managing the impact of the disease. To aid in the response, in April the integrated Anticoro platform – developed by 10 local start-ups in collaboration with the MHPH and the Ministry of the Digital Economy and Post – was launched, offering educational tools, health self-screening and remote temperature reading, as well as a range of solutions useful for dealing with the pandemic, such as e-commerce, digital payment solutions and digital health services. Data on symptoms is collected and shared with the app’s administrators, allowing for the mapping of at-risk persons and enabling the country’s health officials to engage in contact tracing.

Companies are also joining in the fight against the Covid-19 pandemic. At the end of April 2020 telecoms company Orange announced it would donate CFA325m ($559,000) to health research facilities, non-government organisations, charitable associations and municipalities. Société Générale, Coris Bank, Banque Nationale d’Investissement and Sahelo-Saharan Bank pour l’ Investissement et le Commerce also made a cumulative contribution of CFA200m ($344,000).

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, with domestic manufacturers accounting for an estimated 6% of the pharmaceuticals local market. The remainder is supplied by imports.

The CMU is expected to drive the growth of the local generic pharmaceuticals market, as demand for pharmaceuticals is set to rise as more individuals gain access. “Our biggest challenge is in developing our pharmaceutical industry,” Diarra told OBG. “Côte d’Ivoire is dependent on imports, but this is not viable in the long term.” It is also expected to alleviate the problem of counterfeit medications. “The CMU provides a good opportunity to eliminate counterfeit medicines,” Ange Désiré Yapi, managing director of the NPSP, told OBG. “A considerable number of people now have access to medications they did not have before, allowing for the progressive phasing out of fake medicines.”

Imports from Asia and Africa have boomed, but some experts have raised questions regarding the insufficient level of commitment of pharmaceutical regulatory authorities in countries of origin to quality and traceability. “`High-quality generic medications produced in Europe are unfortunately not widely exported to Africa,” Assane Coulibaly, lead ECOWAS coordinator for the Pharmaceutical Good Manufacturing Practices Roadmap Initiative in the Department of Trade, Investment and Innovation at the UN Industrial Development Organisation, told OBG. “Medicines from Asia may be cheaper, but their quality remains unpredictable.” To address this, the Ivorian Pharmaceutical Regulatory Authority was established in December 2018. The independent institution will monitor medications sold on the market to protect the country against counterfeits.”

Outlook

Health care spending is expected to increase significantly in the coming years, driven by economic growth, a growing middle class and the expansion of the universal health care scheme. This is likely to put pressure on capacity while providing opportunities for both public and private investment to build and rehabilitate health centres, as well as develop the local pharmaceutical industry. It remains to be seen what impact Covid-19 will have on the sector in the long run, but efforts since 2011 to expand the access and quality of health care services to meet growing demand and rising expectations stand the sector in good stead.