Infrastructure investment and pharmaceutical regulation implemented in Côte d'Ivoire

While the conflicts of 2002-07 and 2010-11 damaged infrastructure and restricted funding, recent years have seen the government invest in rebuilding the health sector from a low base. The 2012-15 National Development Plan (Plan National de Développement, PND) made valuable progress on key indicators such as the infant mortality rate and access to health services, while major contributions from international development agencies have helped reduce the burden of HIV/AIDS, malaria and tuberculosis.

The 2016-20 PND aims to maintain progress across the board by creating a larger role for private sector involvement, broadening the scope of regulation, advancing supply chain management and continuing investment in new infrastructure. Demand for private health care is likely to expand in step with economic growth, while a hunger for ICT-based solutions presents another potential investment area.

Sector Structure

Health care in Côte d’Ivoire comprises the public, private and traditional medicine segments. An unregulated sector also exists in parallel to more formal health care provision, notably through sales of contraband medication in urban areas. Like many African countries, Côte d’Ivoire’s public health care system is organised according to a pyramid structure. Under this structure, 1967 first-contact health facilities constitute the primary level of care for many citizens throughout the country, predominantly those located in rural areas geographically removed from more comprehensive hospital facilities.

At the secondary level are 68 general hospitals, 17 regional hospitals and two specialised hospital centres that handle cases beyond the expertise and capacity of first-contact facilities. The tertiary level comprises centres dealing with cases of second referral: these include university hospital centres, such as the Cocody University Hospital Centre (Centre Hospitalier Universitaire de Cocody, CHU Cocody) in Abidjan, as well as specialised national institutes, such as the National Institute of Public Health and the Abidjan Cardiology Institute. Another important body within the public health system is the New Pharmacy of Public Health (Nouvelle Pharmacie de la Santé Publique, Nouvelle-PSP), which handles the distribution and regulation of medication nationwide (see analysis).

The public system is managed via a three-part administrative structure. The central level comprises the Ministry of Health and Public Hygiene (MHPH), which directs the formation and implementation of health policy via the national health system. At the second level are 20 regional health directorates, which support 82 health districts in executing the national health policy. These districts represent the third level and are responsible for coordinating health care within their jurisdiction, and providing operational and logistical support for health services.

Private Health Care

While public sector offerings continue to make up the backbone of the health care system, there is also an extensive network of private sector care, and demand for these services is growing. Côte d’Ivoire is home to more than 2000 private health care facilities, including various clinics, medical centres, pharmacies and infirmaries. Health centres run by religiously affiliated groups offering primary care are also relatively prevalent, with 49 such centres recorded in 2015.

Following strong economic growth averaging 8.9% between 2012 and 2016, then hovering around the 7% mark in 2017, the IMF forecast a growth rate of 7.3% for 2018. However, with an expanding middle class, and an increasing number of expatriates coming to work and invest in sectors such as mining and petrochemicals, the demand for private health care is likely to increase in the years to come, making it a potential high-growth area. “Currently, expatriates typically go back to their country of origin for health issues,” Walid Zahreddine, director-general of Nouvelle Clinique Médicale Farah, told OBG. “If the technical capacity can be developed, there is no reason why they shouldn’t stay here for treatment.”

Rural-Urban Divide

Private facilities are predominantly located in large urban centres and key economic areas. This reflects a wider pattern of access to care, where urban cities are better served than rural areas, particularly when it comes to advanced or specialised treatment. Furthermore, the first-contact health facilities that primarily serve rural towns are oftentimes operated by only a handful of staff members. In 2015 over 29% of the population lived more than 5 km away from a health facility, and given that almost 50% of the population lives in rural areas, redressing this balance will be one of the government’s major long-term challenges.

Conscious of this gap, the French Development Agency (Agence Française de Développement, AFD) has given funding priority to rural areas in the north of the country near the Liberian border, where incidence of disease and infant mortality is highest. “One of the worries is that the health system remains very centralised. Although there is a semblance of decentralisation in the pyramidal organisation of public health services, the outer limits of the network are still not served by sufficient resources,” Marion Martinez Valiente, former health project manager at the AFD, told OBG.

Government Strategy

The framework for execution of the national health policy exists under the 2016-20 PND, which succeeded the 2012-15 PND in April 2016. The plan aims to turn Côte d’Ivoire into an emerging country by 2020 and has budgeted €45.7bn for numerous projects to promote growth, well-being and infrastructure over the four years.

Of this figure, 8%, or €3.6bn, has been allocated for health initiatives, of which 23% will be spent on new investment and 77% put towards functional and operational costs. The national plan, as it pertains to health, is divided into the following categories: strengthening governance and leadership at all levels of the health care pyramid; improving internal and external financing structures; growing the availability and usage of quality services; reducing morbidity and mortality rates due to common diseases by 50% before 2020; improving the health of mothers, newborns, children, adolescents and youth; and reinforcing the principles of health promotion and disease prevention.

The 2016-20 PND sees the private sector as essential to progress in the health sector. The document envisages that private business will contribute 15% of necessary financing for the execution of the strategy, with 60% coming from the public sector and the remainder to be provided by development partners. Nonetheless, government strategy with regards to the private sector could be more fully articulated and, according to Joseph Boguifo, president of the Private Clinics Association, needs to be more integrated. “Public and private health care policies are very distinct. They are seen as separate industries with different policies, rights and obligations. There is no single countrywide health care strategy, and that is what Côte d’Ivoire needs,” he told OBG.

State health expenditure for 2017 was set to reach CFA400bn (€600m), up from CFA329bn (€493m) in 2016, with an emphasis on rebuilding and expanding existing infrastructure. Among the facilities receiving a revamp are the country’s first centre for radiotherapy, which was expected to open in late January 2018, and a new mother-infant care hospital in the town of Bingerville, which will come on-line in March 2018.

Ict Solutions

Health care infrastructure development has created opportunities to apply technological solutions in areas such as patient care, data administration and supply chain management (see analysis). Corine Ouattara, an entrepreneur working in the e-health segment, believes that integrating ICT into the health systems can lead to faster, more efficient access to care. Ouattara is currently promoting Pass Santé Mousso, a solution that allows medical data to be stored in a small object, such as keyrings or bracelets. Other e-health solutions from the private sector include Sycelim e-Santé, a health insurance planner, and Bloodbook, a directory for blood donors.

ICT is also being implemented at the public level. One hospital that has received backing to pilot the use of ICT technology in its day-to-day operations is CHU Cocody, which received support from both the MHPH and the Ministry of Digital Economy for its digitisation programme. While many hospitals in the country use electronic programmes for their daily financial operations, CHU Cocody is one of the first to seek ICT solutions to closely track patient histories. “We started digitising the hospital in 2014. We’re not aiming to do this for 100% of our operations, but at least 50-60%,” Dr Meite Djoussoufou, managing director of CHU Cocody, told OBG.

Successfully digitising patient records would allow hospitals to justify their resource needs with concrete data, ultimately allowing for a more efficient and effective distribution of funds throughout the national health system. “Even having 50-60% of our operations digitised would allow us to be more efficient and have concrete results that are better organised and more traceable,” Dr Djoussoufou added. Electronic information storage has the potential to improve the level of care provided to patients, as well as generate opportunities for research and education through the creation of large quantities of medical data.

Health Insurance

In May 2014 the government began its journey to implement mandatory, universal health care coverage (couverture maladie universelle, CMU). With the intent of improving access to health care services, the CMU has a two-pronged approach, constituting a basic general scheme and a non-contributing medical assistance scheme.

In February 2015 the government announced that the monthly contribution to the basic general scheme would be CFA1000 (€1.50) per person over the age of five, while under the medical assistance scheme, all health care services will be entirely free for those who are considered to be low income or in extreme poverty. The National Health Insurance Fund, founded in January 2015 to consolidate, manage and regulate existing health financing schemes, will cover residents eligible for the medical assistance scheme.

The pilot phase of the CMU was launched in April 2017, with 150,000 students eligible to seek services at 17 care facilities. Review of the pilot phase will focus on gaps, operational processes and possible improvements. Though scheduled to start in January 2018, implementation of the CMU has been delayed as the pilot phase has been extended to other demographics.

The rollout of universal coverage will require private health insurers to adjust their strategies accordingly. Although private health insurance has been an area of growth in Africa for a number of years, there remains an imbalance between the coverage offered by private companies and the cost of treatment at private facilities in Côte d’Ivoire, according to Zahreddine. “Companies provide products that cover users for medical costs of up to CFA8000 (€12), CFA12,000 (€18) or CFA14,000 (€21), but no clinic can feasibly offer services at that cost, hence the people insured need to make up the rest,” he told OBG.

Pharmaceuticals

The national health care programme is also set to impact the pharmaceuticals segment. “The development of the universal health care programme prompted us to restructure our drug supply chains to accommodate tighter spending caps, but by its implementation in early 2018 we should have made all the necessary adjustments and be able to provide the full range of pharmaceutical products stipulated under the new programme,” Ange Désiré Yapi, director-general of Nouvelle-PSP, told OBG.

The evolution of the pharmaceuticals segment is fundamental to the success of both public and private health care. In 2015 Côte d’Ivoire had 1501 pharmacies, of which 833 were standalone shops and 149 were located in hospitals. In 2013 the country registered 498 pharmaceutical product stocking depots, and 50 biological and medical analysis laboratories – 10 of which were managed by pharmacists. As of 2016, three private distributors and one public wholesale distributor were in charge of supplying the local pharmaceutical market.

The Directorate of Pharmacies, Medication and Laboratories (Direction de la Pharmacie, du Médicament et des Laboratoires, DPML) enforces industry regulation, while the National Public Health Laboratory controls pharmaceutical product quality and consistency. “It’s been a very dynamic sector for several years now. Côte d’Ivoire is trying to become a sort of role model for the region,” Martinez told OBG. “The creation of the agency is at quite an advanced stage, but it still needs to be approved by the national assembly before it is promulgated. No fixed date has been set, but the political will to speed up the process has been very encouraging,” Martinez told OBG. “The Ivorian health system remains very centralised and the outer limits of the public health services network are still lacking sufficient resources.” Marion Martinez Valiente, former health project manager at the AFD, told OBG. To this end, a ministerial ruling was granted for the creation of the Ivorian Authority for Pharmaceutical Regulation (Autorité Ivoirienne de Régulation Pharmaceutique, AIRP) in March 2017, with the agency expected to become operational in 2018.

Regulation

The AFD has been supporting the DPML in the creation of an independent pharmaceutical regulatory agency, which would be the first of its kind in the region. The AFD is also supporting the Nouvelle-PSP in financing 40% of the construction of a second pharmaceutical warehouse in the city of Bouaké, which will increase Nouvelle-PSP’s regional capacity and help decentralise the management of the supply chain. Still, one of the biggest challenges facing the pharmaceuticals segment in Côte d’Ivoire is the existence of a parallel market on which stolen or imitation medicines are sold. In addition to evading taxes and harming businesses, medication that circumvents regulatory processes and prescription procedures is dangerous. “The sale of counterfeit medication in the streets constitutes a major public health problem. The financial value of this market today is thought to approach almost 30% of pharmaceutical activity,” Charles Boguifo, president of the National Order of Pharmacists of Côte d’Ivoire, told OBG.

Several publicity campaigns have been launched to dissuade the public from purchasing unregulated medication. These include the “I Speak Out Now” campaign, organised by the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the “Le médicament de la rue tue!” (“Street medicine kills!”) campaign, spearheaded by the Fondation Chirac.

Harmonisation Programme

One initiative that could facilitate regional pharmaceutical trade and limit the extent of counterfeit drug trafficking is the African Medicines Regulatory Harmonisation programme, which receives support from the World Health Organisation (WHO) and the World Bank. Up until the end of 2017 the WHO and the World Bank were implementing the harmonisation programme in East Africa, but with that project having closed down, the focus is expected to shift to ECOWAS countries.

To this end, the West African Health Organisation (WAHO) launched the ECOWAS Medicines Regulatory Harmonisation project in November 2017. The success of this movement will depend on Côte d’Ivoire realising its dedicated pharmaceutical regulatory authority, the AIRP. An ECOWAS harmonisation project would effectively create a single visa for pharmaceutical products to be legally permitted throughout member states, with the AIRP expected to work closely with other countries’ regulatory agencies, such as Ghana’s Food and Drugs Authority and Nigeria’s National Agency for Food and Drug Administration and Control.

Local Production

Efforts to harmonise regulation across the ECOWAS region could also promote local production growth by facilitating the movement of locally produced drugs throughout the economic community. “To boost the local manufacturing industry, we must ensure complementaries instead of competition within the region,” Olivier Blé, CEO of UbiPharm, told OBG. “We expect that current discussions on the regional harmonisation of standards and imports will foment additional investment in pharmaceutical production.” As of late 2017 the proportion of local pharmaceutical production stood between 7% and 10%. Côte d’Ivoire still lags behind its neighbours in this area, with Nigeria and Ghana both recording a rate above 30%. Critics say that local production within ECOWAS has thus far been hampered by the unfavourable conditions of the ECOWAS Common External Tariff (CET), which taxes local products while applying minimal rates to external imports. Nonetheless, steps are being taken to reverse these measures.

At the 78th Ordinary Session of the Council of Ministers in June 2017, ECOWAS council ministers recommended the adoption of a proposal from the director-general of the WAHO, Xavier Crespin, for renewed commitment from ECOWAS member states to encourage local pharmaceutical production. With Côte d’Ivoire aiming to grow the proportion of products made locally to 20-25% by 2020, it may look to follow the route taken by Nigeria, which has imposed an import adjustment tax of 20% on four pharmaceutical products, including antibiotics and antimalarial drugs. Such exceptions to the CET terms are allowed as temporary measures to encourage local production and ensure public access to essential products. Ibrahima Diawara, CEO of Cipharm, a pharmaceutical company in Abidjan, said Côte d’Ivoire needs to adopt stricter measures, similar to those carried out by its neighbours, to aid local production. “While other countries in the region ban the import of products that are also locally manufactured, in an effort to protect the local industry, Ivorian-made pharmaceutical products only benefit from a 15% markup on imports, even for public sector tenders,” said Diawara. “To ensure the development of local manufacturers, priority should be given to products sourced locally.”

International Assistance

The ongoing construction of a new factories indicates that the share of local production will expand in the years leading up to 2020, although much of the growth will come from international companies. In December 2017 the Moroccan pharmaceutical company Pharma 5 launched construction of a new factory in the Yopougon industrial zone. The project is expected to cost CFA60bn ($112m) and generate direct employment for 200 people and indirect employment for 2000 more. The factory will be Pharma 5’s first outside of Morocco. Another Moroccan company, Cooper Pharma, is constructing a 12,800-sq-metre unit in Abidjan, with operations expected to begin in 2019. The factory will produce liquids during its first phase and solid medications in its second phase. Additionally, Cooper Pharma has declared its ambitions to provide cheap access to quality medication for the Ivorian population, and to share production and quality-control know-how with its African neighbours. In June 2017 Tunisian company Société Arabe des Industries Pharmaceutiques began construction of a CFA10bn ($18.7m) factory in Grand-Bassam. The manufacturer specialises in the production of antibiotics and medication for cardiovascular pathologies, diabetes, neuropsychiatry and gastroenterology, among others. The factory will employ more than 150 Ivorians, with new graduates comprising 50% of this number.

Outlook

While substantial progress has been made, Côte d’Ivoire’s health system is still recovering from the conflict period. Between 1990 and 2015 average life expectancy in Côte d’Ivoire decreased by 219 days, despite an 11.2% increase in GNI per capita during the same period. Though it will be several years before investments in infrastructure and regulation efforts benefit the entire population, initiatives such as mandatory health care coverage and an independent pharmaceutical regulatory agency are necessary steps to develop and promote health in Côte d’Ivoire.