The new normal: As rates of non-communicable diseases increase, a number of segments are targeted for expansion

Significant improvements have been made since independence in Algerian health care and more are under way to increase access to quality services and align the sector with international standards. Health indictors have gotten better since the 1960s – overall life expectancy at birth has risen from 49 in 1962 to 76.3 in 2010. This can be explained by a fall in child mortality rates, improved maternal health, and increased access to medicine and health services. Consequently, the median age of the Algerian population rose from 15 in the 1960s to 27 today. However, demographic growth, increased urbanisation and changes in lifestyles have resulted in a rise in chronic diseases.

ACCESS: Algeria will invest AD619bn (€5.94bn) under its five-year plan (2010-14) to improve health care access and quality, including upgrading existing hospitals and building specialised infrastructure. Access to more sophisticated forms of care to treat chronic diseases should be eased under the national social security system, which currently covers around 23m people. The private sector is taking on an increasingly large role and is absorbing a rising number of patients, particularly those seeking treatment for chronic illnesses. More efforts are expected to be made as the country works to achieve the UN Millennium Development Goals by 2015, especially in terms of maternal and child care and fighting communicable diseases.

INDICATORS: Indicators for maternal and child health have improved significantly thanks to better services and increased awareness. “Algerian women today are better educated and are aware of the existence of contraception,”’ Rachid Bougherbal, the president of the Commission on Health and Social Affairs, told OBG. “Increased access to education, the rising cost of living and the fact women are taking on more important professions has resulted in marriage at a later age.” As a result, the crude birth rate fell from 47 per 1000 population in 1970 to 20 in 2010.

According to the World Health Organisation (WHO), the under-five mortality rate was 36 deaths per 1000 live births in 2010, lower than the global average of 57, while the maternal mortality ratio stood at 97 deaths per 100,000 live births, better than the global average of 210. Statistics from the Ministry of Health, Population and Hospital Reform (MoHPHR) place the maternal mortality ratio even lower, at 86 deaths per 100,000 births. Maternal mortality is unevenly distributed, however, with higher ratios recorded in rural and highland regions and in the south due in part to a lack of quality health care in these areas. According to UN Children’s Fund, the maternal mortality ratio is two to three times higher in the south than in the north.

SHIFTING DISEASE BURDEN: Better health services and increased prevention, thanks to expanded vaccination programmes, have resulted in widespread eradication of communicable diseases. The main exception has been tuberculosis, which affected 60 out of 100,000 people in 2011, according to statistics from the Prevention Directorate at the MoHPHR. Communicable diseases (mainly tuberculosis) now account for around 22% of total deaths. Today, non-communicable chronic diseases have become the country’s main health burden, particularly diabetes, cancer and cardiovascular diseases. Chronic diseases affect around 10% of the population and are responsible for 58% of deaths. “Algeria now suffers from the same chronic diseases that affect developed countries due to the demographic shift. Treating these diseases is a costly and lengthy affair, but one that cannot be neglected considering the evolution of the population’s median age and, consequently, the rise in chronic diseases,” Bougherbal told OBG.

Cardiovascular diseases are the leading cause of mortality in Algeria, accounting for some 45% of deaths.

Diabetes and hypertension have been identified as two main causes of cardiovascular disease. The number of Algerians affected by diabetes is estimated at 1.4m people within the 20-79 age bracket. At least half of the patients suffering from diabetes are exposed to cardiovascular diseases, though the introduction of a disposable insulin pen in 2012 is expected to enable patients to better control their condition. In addition to cardiovascular disease, cancer is present in 125.5 out of 100,000 Algerians and an estimated 30,000 to 40,000 new cases are recorded annually.

PUBLIC SECTOR: Public health care is overseen by the MoHPHR, and state institutions dominate the field in terms of both patient numbers and service provision. Algerians can access health care services at the country’s 13 university hospitals, 31 specialised hospitals, 988 polyclinics and 5376 health centres. However, many of these need rehabilitating. To this end, €1.5bn is due to be spent under the government’s five-year plan to renovate 320 hospitals. Hospital Didouche Mourad in Constantine is one of the facilities currently under rehabilitation at an estimated total cost of AD400m (€3.84m). Meanwhile, some hospitals are upgrading certain departments. This is the case for the university hospital in Oran, which is currently rehabilitating its ear, nose and throat department.

To further increase access to quality services, the government is also encouraging the construction of 172 hospitals, 45 specialised centres, 377 polyclinic and 17 paramedical schools to double the sector’s bed capacity, which currently stands at just over 63,000. As part of this plan, a new hospital is expected to open in Chlef before the end of 2012 offering 240 beds.

SPECIALISED INFRASTRUCTURE: To face the rise in non-communicable diseases and align the health sector with the country’s epidemiological transition, the state is investing in the construction of specialised health infrastructure. Indeed, under its five-year plan, the government is expected to construct up to 45 new specialised health care centres. Significant progress has already been achieved in terms of infrastructure dedicated to oncology. Out of the 45 planned specialised centres, 15 will be devoted to cancer treatment, bringing the total number of the country’s oncology centres to 22 by 2014. At least six of these became operational in early 2011. In 2012 alone AD21bn (€211.9m) was allocated for cancer care.

In May 2012 a new centre opened its doors in Batna costing an estimated AD5bn (€48m). The centre will primarily serve patients seeking treatment coming from Batna, Khenchela, Oum El Bouaghi, Tébessa and Biskra, as well as other regions of the south-east. A new centre is also planned for El Hassania in the wilaya (province) of Chlef, however only 30% of the works have been completed so far. Once operational, the centre is expected to offer services in surgery, chemotherapy and radiotherapy, and will alleviate the burden placed on centres in Algiers, Blida and Oran where most people from this wilaya have been seeking treatment. A national institute for cancer research is also expected in Oran in 2013, with 40% of the work having so far been completed.

HOSPITAL STAFF: More than 54,000 doctors work in public health care. Local media has reported the country to have one doctor per every 800 inhabitants, which exceeds minimum recommended by the WHO – i.e., one doctor per every 1000 people. “Algerian doctors are well trained; however, the sector does lack paediatricians,” Dr Jamal Eddine Khodja Bach, the general director of the Al Azhar clinic, told OBG. The country still faces a shortage of staff in certain specialities, such as cardiac and paediatric surgeons. Additionally, with the gradual delivery of new infrastructure, the sector is facing a shortage in other professions as well, such as paramedics and midwives. The decision to increase the years spent studying midwifery from three to four has left the sector short of some 4000 staff at present.

PRIVATE CARE: Private investment in health care has been experiencing sustained growth since its authorisation in 1988. The increasing demand for quality services has translated into more patients accessing health care at private facilities offering specialised procedures, particularly for the treatment of chronic diseases. As the waiting list for treatment in the public sector grows, due partly to the rehabilitation of existing facilities and incomplete new infrastructure, the fast turnaround offered in the private sector is attracting more people. There are an estimated 250 private clinics across the country, with 4000 beds, around 10% of total capacity. However, most of these private clinics are located in the urbanised north of the country.

The National Fund for Social Security for Salaried Workers (Caisse Nationale de la Sécurité Sociale des Travailleurs Salaries, CNAS) has contracted a number of private clinics in the country to allow more people to access care at these facilities. An increasing number of patients are opting for treatment in private clinics as more specialities provided by these structures are accounted for under the social security scheme.

CNAS-AFFILIATED: Indeed, the CNAS has established agreements with 130 private clinics, mainly for the treatment of chronic diseases. In addition, agreements have been signed with private practitioners, laboratories and some 10,000 pharmacies nationwide.

Al Azhar, a private clinic in Algiers affiliated with the CNAS, offers treatment in some 10 specialities, including cardiology. The clinic performs around 850 heart surgeries a year, as well as a further 5500 procedures in other areas. A new clinic that opened in 2011 in Sétif specialising in cardiology and cardiovascular surgeries is also registered to provide treatment to CNAS members. The clinic, which was established at an estimated cost of €4m, is expected to reduce the number of patients crowding health structures in Algiers and Constantine. With CNAS providing more coverage for specialised treatment in private facilities, the number of patients opting for private care is expected to rise, as is the number of private clinics.

Work is expected to begin on the country’s first private hospital in Sidi Abdallah in 2013. The facility, which is being built at a total of cost of some €31.5m, is expected to be delivered in September 2016, and will have capacity of 180 beds.

EXPANDING MEDICAL COVERAGE: The public medical insurance system is managed by the Ministry of Labour and Social Security. The government spends about 40% of the health budget on the social security system, which is divided into two health care funds with discrete responsibilities – CNAS and the National Fund for Non-Salaried Workers (Caisse Nationale de Sécurité Sociale des Non Salariés, CASNOS).

“Some 70% of the population benefits from the social security scheme, which covers 100% of the cost of chronic disease treatment,” Bougherbal told OBG. Spending incurred by the social security system amounted to some AD135bn (€1.3bn) in 2010 and approximately AD186bn (€1.79bn) in 2011.

The country is working on extending coverage to the remaining segments of the population who are still not enrolled in the system. Coverage is also being expanded to take into account an increasing number of pathologies, which should ease access for patients and reduce the number of transfers abroad.

To ease transactions and speed up reimbursement procedures, the CNAS introduced its “chifa” card in 2007, which is a magnetic card containing the insured’s personal details. So far some 7.1m cards have been distributed and have already been used by 6.9m people, resulting in more than 81m electronic bills.

PREVENTIVE MEASURES: The Prevention Directorate at the MoHPHR manages disease prevention. Expanded vaccination programmes, which are obligatory and free, have played an important role in eradicating almost all communicable diseases in the country. In 2010 the coverage rate for the BCG vaccine against tuberculosis was 99%, 90% against hepatitis B and 88% against measles. Although the prevalence of tuberculosis has significantly decreased, dropping from 300 cases per 100,000 inhabitants following independence, to 59.9 cases in 2011, the government is continuing to fight the disease. Under its new plan, the state aims at extending vaccination against the diseases to at least 95% of infants by 2015. It also aims to detect and treat at least 90% of contagious cases by developing a national network of laboratories, training more health personnel and ensuring a regular supply of medicine to hospitals.

Campaigns targeting non-communicable diseases are increasing to make the population aware of health risks and understand the causes. “Prevention policies are developed in accordance with the country’s epidemiological transition,” Smail Mesbah, the general director of prevention and health promotion at the MoHPHR, told OBG. These campaigns encourage healthy lifestyles and inform the population about care options.

PUBLIC HEALTH CAMPAIGNS: An estimated half of all Algerians with diabetes are not aware they have the disease. Diabéduc, an awareness programme, was launched in 2010 by the pharmaceuticals firm Sanofi-Aventis in collaboration with the Algerian Association for Diabetes to help patients affected with diabetes better understand their illness. Additionally, a free phone number has been set up to field calls and questions from patients as well as professionals.

Algeria is also one of the first countries in North Africa to develop a national public health programme with a focus on fighting cancer and other non-communicable diseases. Launched in 2003, the initiative features plans to open a diagnostic centre in each wilaya and daïra (county). Mobile mammography programmes are encouraged by associations such as El Amel and the National Association of Oncology, which tour the country to increase awareness among women about the importance of getting regular mammograms. In 2010 the CNAS launched a national initiative for early detection of breast cancer, providing women with access to free mammograms from the age of 40.

PHARMACEUTICALS: Pharmaceuticals are regulated by the MoHPHR’s Pharmacy and Medication Department. Medicine is a costly affair for the health sector, with only one-third of domestic needs met by local production, meaning that Algeria relies heavily on more expensive imports. The level of domestic production is low in comparison with neighbouring Tunisia where local production meets over 50% of the country’s needs.

“Algeria is the second-largest importer of medication on the continent, after South Africa, costing the country around $3bn in 2012,” Bougherbal told OBG. This bill is getting larger due to the emergence of chronic diseases, but also due to the country’s demographic growth, rising levels of purchasing power among Algerians and expanded CNAS coverage, which now encompasses a wider range of products and pharmaceuticals treatments.

In an effort to reduce spending, the government is looking to limit imports and instead develop and modernise local pharmaceuticals production. Bans have been imposed since 2008 on imported medicine that can be produced locally. The number of banned products is expected to reach 800 in 2012. This should give local production a boost and help the country achieve its objective to cover up to 70% of its needs by 2014.

NEW MEDICINE: Algeria is looking to develop pharmaceuticals projects in line with the epidemiological transition it is current undergoing, and thus the focus of development is on drugs that will help fight the emergence of chronic diseases. Since the country now shares a disease burden similar to that in developed countries, it is showing a keen interest in collaborating with international firms to develop medicine at home and ensure a transfer of know-how and technology to local players. This was reflected in a partnership signed in April 2012 between the private Algerian firm Biopharm and AstraZeneca to build a pharmaceuticals firm in Algiers that will produce drugs targeting chronic diseases, such as cardiovascular diseases and cancer.

Another partnership was signed in April 2012 between Saidal, a state-owned pharmaceuticals company, and Denmark-based Novo Nordisk, to produce insulin for the treatment of diabetes patients. The €15m investment is due to take two phases. The first phase will consist of upgrading the production facilities at Saidal’s existing Constantine unit through the training of Algerian staff and ensuring Saidal, which currently contributes around 9% of domestic insulin production, benefits from the technological know-how of the Danish company. The second phase will involve the production of Novo Nordisk’s full range of insulin products in Algeria, for which Saidal will control all phases – production, distribution and sales.

Saidal has also entered a €25m agreement with the National Investment Fund (Fonds National d’ Investissement, FNI) and Kuwait-based North Africa Holding Company (NAHC) to establish Saidal-North Africa Holding Manufacturing-FNI, which will specialise in the production and sale of drugs for cancer treatment. Facilities are expected to be operational by 2014 and produce up to 17 different pharmaceuticals products. The firm will establish units in Sidi Abdellah and Algiers, and Saidal will control 49% of shares, while NAHC and FNI will hold 49% and 2%, respectively.

OUTLOOK: The impact of the state’s ongoing actions to increase access to quality health care will, of course, take time to materialise. Much work remains to be done in the public sector in terms of developing infrastructure to respond to the demand for an increasingly specialised health care system. At the same time, the role of the private sector is progressing rapidly and should continue to grow as the CNAS contracts more private clinics and extends its coverage for the treatment of chronic diseases to enable more widespread access and thus improve the health outcomes for citizens.