On the path to wellness: Increased expenditures to address regional disparities in access

In the 1980s Côte d’Ivoire’s health care system was a model for the region, but population growth, waning state revenues and conflict eroded the capacity of public institutions, leading to material and facility shortages and declining health for citizens. Major killers today are largely preventive diseases, such as malaria and HIV/AIDS, demanding the establishment of national programmes to coordinate and implement efforts to fight them. Yet, after decades of eroding health budgets, the Ivoirian government has declared 2013 as the “Year of Health”, pledging to greatly increase state expenditures to modernise and expand the public health care system, inspiring hope for improvements in key indicators such as maternal and child mortality rates.

GENERAL INDICATORS: According to the World Health Organisation (WHO), the Ivoirian population doubled in two decades from 8.5m people in 1980 to 16.6m in 2000, reaching 20.2m by 2011. Between 1980 and 2011, the size of the population under age 15 also more than doubled from 3.9m to 8.2m, while the number of women between the ages of 15 and 49 quadrupled from 1.76m to 4.7m. Although modest relative to averages for lower-middle-income countries, life expectancies for both men and women have improved steadily over the last decade, increasing from 46 years in 2006 to 54.3 years in 2011 for men and from 51.6 to 56.6 years for women over the same time. The WHO also reports that, in 2010, around 59% of all deaths were caused by communicable, maternal, perinatal and nutritional conditions, with notable killers including malaria and HIV/AIDS. Cardiovascular diseases and diabetes claimed around 17% of lives, with respiratory diseases and cancers accounting for 4% and 3% of deaths, respectively. In 2008 risky behavioural factors such as tobacco smoking remained low, with 14.3% of men and 2.7% of women smoking daily, although risks related to physical inactivity were higher, with 27.3% of men and 37.4% of women lacking exercise. Although elevated cholesterol levels have steadily declined since 1980, mean systolic blood pressure levels have increased since the mid-1990s, with 44.1% of men and 38.6% of women experiencing high blood pressure.

PUBLIC FACILITIES: In 2011 the public health care system had 1910 primary health care facilities, of which 1237 were located in rural areas and 514 were located in urban areas. Another 127 urban facilities were specialised centres and 32 served as urban sanitation training centres. The country had 83 higher-level health care facilities, of which 66 were general hospitals and 17 were regional hospitals, with nine specialised higher health care institutions, including four university hospitals and five specialised national institutes.

The total number of individuals employed by the public and private health care system is 4010 doctors, 8580 nurses and 435 dentists, with more than 70% of physicians and dental surgeons practising in the public sector. Approximately 80% of doctors working in the private sector first worked in the public sector. Some 1288 pharmacists, 2690 midwives, 1547 technicians and 710 nursing assistants work in the national health system, though only 44% of total pharmacists are in the public sector. According to international standards, human resource levels are fairly satisfactory, equal to one doctor for 6459 people, as compared to global recommendations of one doctor per 5000 inhabitants. There is one nurse per 2826 people and one midwife per 3717 women of childbearing age, with international standards recommending one midwife per 3000 women. But statistics mask regional inequalities, particularly between urban and rural areas. Outside Abidjan, there was only one doctor per 20,000 for the rest of the country before the war, with gaps exacerbated in western and northern areas due to instability.

IMPACT OF UNREST: The 2010-12 electoral crisis had serious consequences for the national health care system, particularly for the public system. Many hospitals and clinics were pillaged for supplies and forcibly shut down, while conflict rendered areas of the country inaccessible. Those facilities that continued operating lacked medical, transport and technical supplies, and were unable to upgrade or maintain their equipment while facing rapidly growing demand for services, especially given the number of Ivoirians wounded in fighting, displaced or affected by general health problems.

Already prone to relatively small health care budgets of 4.8-5% of GDP, the conflict stretched resources and made it impossible to pay salaries for health care staff, causing many doctors and nurses to leave and crippling hospital capacities. “The crisis has affected the entire industry in terms of human, physical and monetary resources available,” Vincent Barraud, an attaché covering food, fashion, housing and health for Ubifance, France’s export promotion agency, told OBG. “Even when medical facilities were able to obtain alternative technologies to replace stolen, destroyed or damaged equipment, these facilities were poorly maintained and overexploited,” Barraud added. “For this reason and because of a lack of financial resources in the public sector, the private sector has been playing an increasing role in health care provision.” However, private sector facilities were also affected by robberies and violence, forcing many health care centres to close and leaving others unable to respond to emergencies due to a lack of ambulances or specific equipment.

The retreat of state authority and the need to establish facilities to respond to national demand led to the creation of informal and illegal medical structures, potentially endangering the lives of patients and creating unfair competition for certified doctors. In 2012, 847 unauthorised private health facilities were operating in the country out of a total of 1254, with 81 illegal Chinese clinics. “These clinics treat everything from cancer to AIDS, and in the case of Chinese clinics, people cannot read the medications they are given and do not know what they are taking, but they do not have access to any other medical care,” Joseph Boguifo, president of the Association of Private Clinics of Côte d’Ivoire (l’Association des Cliniques Privées de Côte d’Ivoire, ACPCI), told OBG. “This gives you an idea of the catastrophic nature of this situation and the urgency with which it needs to be addressed,” Boguifo added.

URBAN AREAS: The conflict displaced more than 1m people, causing many to seek refuge in the south, straining public resources and services like potable water, as well as leading to a proliferation of unregulated urban shantytowns. Poor sanitation and lack of access to drinking water increased the prevalence of waterborne diseases, while uncontrolled population inflows contributed to new cases of HIV/AIDS and cholera. Anxiety from the political conflict and rising unemployment also led to an increase in the frequency of stress-related conditions, such as diabetes and hypertension, during a time when many private sector employees lost their jobs and private health insurance, causing the newly unemployed to be unable to afford health care.

EXTERNAL ASSISTANCE: The conflict resulted in a reduction in international health resources, as fears of theft or misuse led to the suspension of grants from the Global Fund in January 2011, worth €163m. However, the fund permitted the procurement and distribution of crucial medications against malaria and HIV through actors such as UNICEF, providing 6m treated mosquito nets. The UN Office for the Coordination of Humanitarian Affairs also spent $119m on assistance for Ivoirians in 2012 and budgeted $82m for 2013, enabling more than 1.2m people to access various forms of aid in 2012. Doctors without Borders established mobile clinics, aided hospitals and clinics in the west and Abidjan, and provided more than 400,000 consultations to patients.

UNIVERSAL HEALTH CARE: The absence of a national insurance system and the post-conflict health care crisis prompted the Ivoirian government to extend free health care access to all Ivoirians in June 2011. However, by January 2012, the state was obliged to abandon the experiment due to escalating expenses, which totalled CFA30bn (€45m) over nine months. High costs were the consequence of poor planning and mismanagement of resources, with the national distributor for medical supplies, the Public Health Pharmacy, endowed with only 30% of the required materials, many of which had been stolen. Medical staff misappropriated materials to be sold for a profit, leading to the censure of 20 doctors and nurses by the Ministry of Health. In February 2012 free health care was introduced to cover mothers and children under six years old, providing free care for birth deliveries and treatment of childhood diseases, and a reduction in consultation fees from CFA1000 (€1.5) to CFA650 (€0.98).

“The mother and child health care programme is important due to the vulnerability of this population and it will be much more feasible if the costs are properly calculated,” Boguifo told OBG. “What is needed is improved training for health care providers and better management of resources; health priorities must be reoriented to correspond with the state’s financial limitations to better serve the people.”

MATERNAL HEALTH CARE: Health care for mothers and children is expected to facilitate the attainment of major objectives under the Millennium Development Goals (MDGs), including a 75% reduction of the maternal mortality rate to 150 deaths per 100,000 births, a 66% reduction of child mortality to 50 deaths per 1000 live births and a 50% reduction in the prevalence of HIV/AIDS among pregnant women. Although maternal mortality rates declined 22% between 2005 and 2010, mortality rates remain high relative to lowerincome countries, at 400 deaths per 100,000 live births.

Around 80% of maternal deaths are due to direct causes such as postpartum haemorrhaging (36.1%), obstructed labour (20.3%) and complications with hypertension (18.2%). Political instability and persistent poverty have exacerbated low rates of obstetric care coverage in terms of human resources and facilities, complicating efforts to reach MDGs.

Limited improvements have also been made for infant mortality rates, which fell from 91.1 deaths per 1000 live births in 2003 to 81.2 deaths in 2011, but remain high compared to averages for sub-Saharan developing countries. Mortality for children under five was lower than regional averages until 2008, although in 2011 it increased to 114.9 deaths per 1000 live births, compared to the regional average of 107 deaths, arguably due to a lack of health care access that could be linked to the conflict and also exacerbated by the presence of malnutrition in one out of three children.

CHILD HEALTH: Although the Ivoirian state has acknowledged that it will be unable to meet its MDGs by 2015, steps are being taken to address the issues of child and mother health care through initiatives to improve nutrition, access to health care and expansive vaccination programmes. Attempts to boost indicators such as child health and immunisation rates have been encouraged by the Millennium Challenge Corporation (MCC), an independent US foundation that provides monetary assistance to developing countries working to improve key indicators in governance, economic management, and health and education. Particular vaccinations being prioritised are for measles and a combination of diphtheria, pertussis and tetanus. After issuing vaccinations to 767,927 children in 2012, the immunisation indicator rose from 55.5% of children vaccinated in 2011 to at least 89.5% by December 2013. High immunisation rates are crucial to achieving child health indicators, which are calculated based on three indicators: child mortality, access to clean water and sanitary conditions. “Child immunisation is a priority now because during the conflict, opportunities to improve the vaccine coverage rate, and therefore child mortality, were lost due to the destruction of transport vehicles, roads, facilities and materials like refrigerators for vaccines. Now, we must make up for these lost opportunities,” Aïda N’Diaye, the human development manager at the National Committee for Côte d’Ivoire’s Eligibility to the Millennium Challenge Corporation, told OBG.

Child mortality indicators have improved due to increased immunisation rates and 78% of children have access to potable water, but much remains to be done in regards to sanitation, now accessible to only 18% of the population. Sanitary conditions were particularly bad for children living in refugee camps during the conflict, making the reconstruction of homes a priority under government efforts to reduce child mortality. Initiatives to improve access to sanitation, vaccines and vitamins, decrease HIV/AIDS transmission from mother to child and reduce child mortality are organised under the National Programme for Child Health and Child Survival, in cooperation with the Ministry of Health National Programme for Sanitary Development 2009-13 and the fight against HIV/AIDs.

MALARIA: Malaria is the primary cause of death for children under five and is responsible for an estimated 20,000 deaths annually. In 2008 one in three people who visited health facilities were diagnosed with malaria, while the number of malaria patients rose to account for 43% of consultations in 2010. During the conflict, a general lack of resources and medical facilities led to reported deaths of up to 80,000 people annually, representing a significant increase in mortality attributable to medication shortages caused by many pharmacies going out of business.

Although the increase in cases and deaths in 2011 represents a setback for national efforts, the number of admissions for patients with malaria has significantly increased over the last decade, rising from merely 10 people per 100,000 in 2001 to 1000 per 100,000 people in 2011, showing a notable improvement in national capabilities to treat malaria patients. The distribution of free treated mosquito nets at the start of 2013 for two to three years and the provision of free health care for children will likely facilitate the achievement of MDG 6, which aims to reduce the incidence of malaria to 50 cases per 1000 people. HIV/AIDS: According to the UN Programme on HIV/AIDS (UNAIDS), 360,000 Ivoirians had HIV in 2011, including 170,000 women over age 15 and 61,000 children under age 14. During the course of that same year, HIV/AIDS caused the deaths of 23,000 individuals. With one of the highest HIV prevalence rates in West Africa, the state established the National Programme for Taking Charge of People living with HIV/AIDS (Programme National de Prise en Charge Médicale des Personnes Vivant avec le VIH, PNPEC) in 2001 to manage resources and implement national preventive and treatment strategies. In partnership with UNAIDS, the Ivoirian government launched a campaign in 2011-12 to reduce HIV infections to zero by spreading prevention awareness, particularly among the youth population.

Attention during 2012-13 was then geared towards better managing health care for HIV-infected Ivoirians, an initiative that was begun in 2008 with the state’s provision of free antiretroviral (ARV) drugs. Since 2009 over 250,000 Ivoirians have accessed ARVs, but according to the Global Fund to Fight AIDS, Tuberculosis and Malaria, only one in seven eligible for treatment have received it. A decline in national health care coverage during the post-electoral crisis also led to an estimated 17,000 new HIV infections in 2011.

Priorities for the PNPEC 2011-15 include lowering the prevalence rate of HIV/AIDS to 2.5% by 2015 (MDG 6); increasing national coverage and access to HIV counselling services, testing, care and treatment; preventing mother-to-child transmission of HIV during birth; and continuing educational and preventive initiatives. In 2013 the state successfully mobilised $8m in national revenues to fund HIV initiatives, but it still depends on international donors for 90% of its AIDS-related funding. With a funding gap of $247m, additional governmental efforts will be needed to secure financing.

TUBERCULOSIS: Combatting tuberculosis (TB) is a priority closely tied to the fight against HIV/AIDS due to the fact that an immune system weakened by HIV/AIDS leads many infected patients to die from TB. According to the Global Fund to Fight Aids, Tuberculosis and Malaria, of the estimated 480,000 Ivoirians living with HIV in 2011, 150,000 had TB. In 2008 the WHO estimated that a high number of Ivoirian TB patients – 9% – are multi-drug-resistant thanks to receiving inadequate or inconsistent treatment.

In 2001 the state established the National Programme to Fight Against TB to reduce morbidity and mortality statistics related to TB and to coordinate preventive and curative efforts. Despite a 0.5% increase in the number of TB cases per 100,000 people between 2010 and 2011 due to the crisis, national efforts have been largely successful at significantly reducing the incidence of TB from 308 cases per 100,000 people in 2003 to 190 cases in 2010. In accordance with MDG 6, the government has established an aim to reduce the incidence of TB to under 75 cases per 100,000 people by 2015.

THE YEAR OF HEALTH: Public expenditures on health were low compared to overall spending over the past 10 years, representing 0.9% of GDP against a regional average of 2.2%. They averaged 4% of spending between 2006 and 2010, despite recommendations from the WHO that 15% of total state expenditure should go towards health. Of these resources, only 16% are invested in care improvements versus 70.9% of funds allocated to operating costs, which has led to low health coverage, a lack of technical equipment and insufficient regional distribution of health care providers.

In recognition of the many health care challenges, President Alassane Dramane Ouattara declared 2013 to be the “Year of Health”, prioritising the modernisation, expansion and reorganisation of the public health care system to better address the needs of the population. The state plans to increase health expenditures to 15% by 2020, spending around CFA378bn (€567m) on health care reforms, while sponsoring tax deductions for businesses contributing to MDG projects.

Under the National Development Plan (NDP) 2012-15, the government aims to ensure accessibility to health care for all citizens through the construction of a basic health centre and maternal care provider within 5 km of each home, including smaller health centres located in isolated rural areas. However, as of 2007, only 44% of the population lived within 5 km of a facility, while 27% lived between 5 km and 15 km away, and 29% were obliged to travel over 15 km for treatment – a trend exacerbated by the vandalism and destruction of facilities during the recent crisis. Investments will also be made to re-equip health facilities and improve ratios of doctors and nurses per patient.

NEW FACILITIES: Major upcoming construction projects in the health care sector include the building of the Mother-Child Hospital in Bingerville by the Children of Africa Foundation. Although additional details were not available at the time of publication, the health care management and consulting specialist firm, Denos Health Management, was awarded a contract to advise on the project. A $4m-5m initiative to build five hospitals is being led by the Didier Drogba Foundation, for which the captain of the Ivoirian National Team serves as the president. Work started on the first hospital in Abidjan in June 2013, according to press reports.

PRIVATE SECTOR: The private sector is overseen by three professional organisations. Created in March 1991, the ACPCI encompasses 55 legal structures recognised by the state and represents its members’ professional interests and their commitment to providing quality health care. The other two associations, the Syndicate for Private Doctors and the National Order of Doctors, represent the interests of certified doctors. A separate organisation, the Syndicate of Private Pharmacists of Côte d’Ivoire (SNPPC), oversees the activities of private pharmacies.

In 2011 the private health care system accounted for 2036 facilities, including 463 health centres, 964 infirmaries, 101 dental offices, 718 pharmacies, 136 clinics and 13 polyclinics. However, only 554 private institutions were authorised to operate by the Ministry of Health, making the majority of these institutions illegal. Around 80% of all private sector structures are located in Abidjan, with the rest largely in urban areas.

Major legal establishments include the Polyclinique Internationale Sainte Anne-Marie (PISAM), the largest private hospital in the region. Launched in the 1980s, the institution was a model hospital for the continent and treated patients from across the region, although the frequency of conflict in the 2000s limited the number of foreign patients and hospital resources. PISAM currently employs 300 people, including 100 doctors, and it houses 216 beds, providing services in more than 18 medical specialties.

Private establishments provide 30-40% of the country’s health care services, though only 10% of Ivoirians are covered by private health insurance, which is primarily offered to employees of major firms and government ministries. Currently, private coverage is the only existing national option for insurance because of a lack of government funds for a public option. As the majority of Ivoirians are unable to afford private health insurance, instead they are forced to pay out of pocket for medical services.

Until recently there has been little coordination between public and private health services to tackle medical issues. “When the government implements major programmes against afflictions such as malaria and AIDS, the private sector is automatically excluded from these efforts, which is a serious problem if one wants to launch a national programme,” said Boguifo. “However, there appears to be political will on the part of the government to bridge this gap.” In 2008 the EU published a study in partnership with the ACPCI to help bridge the gap between the public and private sector. The results prompted the creation of a permanent commission to encourage dialogue between the two sectors. Although the initiative was put on hold during the recent conflict, the premise of the commission was enshrined in the NDP 2012-15, facilitating future cooperation on national health care initiatives.

COSTS: Patients in the private sector pay CFA10,000 (€15) for a general consultation and CFA12,000 (€18) for a specialist consultation during working hours. Although private prices are significantly higher than public ones, which are subsidised to cost CFA3000 (€4.50) and CFA5000 (€7.50) for general and specialist appointments, respectively, scarce state resources relative to the number of public patients ensures several days of waiting time to get an appointment and limited contact with the doctor during and after consultations. Waiting times in the private sector are in hours instead of days, and patients receive an average of 15 minutes per consultation, compared to a public sector average of 5 minutes per consultation.

Despite higher prices, the private sector faces eroding profitability due to increasing operational and materials costs relative to consultation fees, which have been largely fixed since 1995 to ensure that services remain affordable. The devaluation of the African franc in the 1990s doubled private sector costs, while subsequent price increases for basic materials such as vaccines have gone up by as much as 70% in recent years. “As prices for basic goods keep increasing, it becomes harder and harder to maintain prices at affordable levels,” said Simon Doua Blé, the administrator for health services at PISAM. “The more inflation increases, the more you are unable to improve the quality of your services through equipment upgrades and other necessary improvements without increasing the price of your services,” Blé told OBG.

OUTLOOK: Degraded by conflict and facing population growth, the Ivoirian medical system requires sustained investments in physical and human resources to address national health needs. Particular emphasis must be put on the expansion of facilities to rural areas to improve health indicators, although the provision of free maternal and child health care will likely facilitate large improvements in mother and child mortality rates.