How is Côte d’Ivoire health care system expanding coverage

After the return to political stability and peace in 2012, health care has been an area of focus for the government and the private sector alike. In recent years the government has worked on expanding hospital infrastructure alongside universal access to health care. Greater regulation and integration of private sector players – which serve a large portion of the population – is also a top priority of the government, particularly given continuing gaps in access to health care outside of urban centres.

Structure & Oversight

Responsibility for the provision of health care sits with the Ministry of Health, Public Hygiene and Universal Health Coverage (Ministère de la Santé, de l’Hygiène Publique et de la Couverture Maladie Universelle, MSHP-CMU). The health system is organised in a pyramidal form with three levels. At the tertiary or central level, the key actors are the Cabinet of the Minister and central level directorates. The main service providers are tertiary hospitals. At the secondary or regional level, there are 20 regional health offices and the main service providers are regional hospitals. At the primary or district level, there are 113 district offices charged with implementing health policies. In total, there are over 4000 public and private health facilities across all levels of the health pyramid in the country.

General Indicators

Securing funding is critical to efforts to rebuild and expand the country’s health system. While annual government spending on health care rose from CFA330.4bn ($568m) in 2016 to CFA440bn ($760m) in 2022, the sector’s share of the total budget fell over that period from around 7.8% to 4.4%. International development partners have played an important role in bridging the funding gap, which is expected to exceed CFA1.1trn ($1.8bn) over the 2020-23 period.

According to a report by World Bank partners, the Ivorian government would need to increase its health budget every year by 25% and allocate 14% of its budget to health by 2024 to meet sector development requirements. Low levels of investment in the sector are reflected in the country’s health indicators. Despite its lower-middle-income status, Côte d’Ivoire’s epidemiological profile remains comparable to low-income countries and health outcomes are among the poorest regionally and globally. While life expectancy has been increasing, it remains the lowest in West Africa, at 58 years. Similarly, infant mortality rates have been declining but remain high, at almost 58 per 1000 live births in 2020. Côte d’Ivoire’s maternal mortality ratio stood at 617 deaths per 100,000 live births in 2017. It is among the highest in the world, though it is slowly decreasing.

Disease Burden

Communicable, maternal, neonatal and nutritional diseases are the leading causes of death and disability in Côte d’Ivoire, representing approximately 58% of the disease burden in 2019, down from 72% in 1990. Infectious diseases such as malaria, HIV and tuberculosis impose a significant burden. Côte d’Ivoire has the second-highest HIV prevalence in West Africa, at 2.1%, and there are 16m cases of malaria every year. While these figures are high, the trend in recent years has been notably downward. HIV prevalence, for example, almost halved between 2010 and 2020.

While the incidence of infectious disease is on the decline, urbanisation and increasingly unhealthy lifestyles have led to a rise in non-communicable diseases (NCDs), a common trend in developing countries that can place further burden on the health system. In 2000 NCDs accounted for 24% of all premature deaths; by 2019 this figure had reached 36%. The most prevalent NCDs in Côte d’Ivoire are cardiovascular disease, chronic respiratory disease, cancer and diabetes. Data on the incidence of other NCDs is not up to date, but according to a 2017 government survey, 6.2% of the population had diabetes and an estimated 17.8% of adult women and 7.3% of adult men were obese – figures which are likely to have increased in the intervening years. Much of the government’s work to address the rise of NCDs has focused on treatment, while NGOs such as the Obesity and Diabetes Association of Côte d’Ivoire have focused on awareness-raising campaigns to promote care, prevention and cure.

The health sector’s response to Covid-19 was initially slow, largely owing to limited vaccine supply and public distrust. The country received its first batch of the Oxford-AstraZeneca vaccine in February 2021 and administered 40,153 doses in the first month. By the end of 2021, 1.3% of the population had been fully vaccinated. However, a three-week mass vaccination campaign in February 2022 saw over 2m people vaccinated, bringing the total number of vaccine doses administered to 10.1m and the percentage of the fully vaccinated populace to 8%.

Public Health Care

The primary level of the Ivorian health care system consists of facilities called urban health centres (centres de santé urbaine, CSUs), rural health centres (centres de santé rurale, CSRs) and rural dispensaries. Although CSUs and CSRs both constitute the primary care level, they differ significantly in the services they provide. CSR facilities are usually run by a small unit of nurses and midwives and offer very basic services. In contrast, CSU facilities are significantly larger; have on staff more than five nurses and midwives each, at least one generalist physician; and offer all services provided at CSR facilities. They also offer more laboratory tests, diagnoses, basic surgery and non-communicable disease interventions.

The secondary level consists of regional hospitals that offer every service offered at CSU facilities, as well as treatments for more complicated ailments. Lastly, the tertiary level offers specialised care for conditions that are not treated at the primary or secondary level and involves complex diagnostics.

The public health system faces a number of challenges, including underfunding, infrastructure shortfalls, a lack of skilled health workers, medication shortages and inadequate coverage in rural areas outside of major cities. According to a 2017 study, 45% of primary and secondary facilities lacked reliable electricity supply and 35% did not have ready supply of water. Long distances to the nearest facility and weak referral systems pose a barrier to accessing health care, with 32% of the country’s population living outside a 5-km radius from a health facility.

Strategies and programmes are in place to address these shortfalls. Since 2012 the government has prioritised the rehabilitation and construction of hospitals and health centres. From 2012 to 2019, 271 first-class health facilities were built and a further 371 were rehabilitated. Between 2019 and 2021 the government secured CFA800bn ($1.3bn) to upgrade and expand health care infrastructure as part of a larger programme to build 20 hospitals and rehabilitate 22 others. By 2024 its aim is to mobilise double that amount from international donors and investors.

Plugging human resource gaps is another government priority. “The state is making efforts to expand health infrastructure, but the challenge in terms of human resources remains significant,” Seydou Kouyate, executive director at Health Alliance Côte d’Ivoire, told OBG. “Most health workers prefer to stay in Abidjan, leading to a shortage of doctors and surgeons in regional hospitals.” However, starting in the first half of 2022 the government has moved to address this, transferring doctors of all specialities from Abidjan to regional health centres to improve service provision around the country, Kouyate added.

Universal Coverage

Limited accessibility to health facilities in rural areas, a lack of trained professionals, long waiting times and poor service quality have historically deterred many from seeking care. Around 10% of Côte d’Ivoire’s population has adequate health coverage. To this end, the government implemented universal health coverage ( couverture maladie universelle, CMU) in late 2019, following a successful pilot programme. The CMU is monitored by the National Health Insurance Fund (Caisse Nationale d’Assurance Maladie, CNAM) and has two tiers of payment. The first is a monthly contribution scheme of CFA1000 ($1.65) per insured person, 50% of which is paid by the policyholder’s employer if they work in the formal sector. CNAM covers 70% of medical expenses, and the patient bears the remainder out-of-pocket.

There is also a non-contributory medical assistance system which provides free health insurance to the poorest segments of the population. The CMU is a compulsory health insurance scheme which, in theory, every person residing in Côte d’Ivoire must join. Within six months of rolling out the system nationally, 2.3m people had enrolled. According to the latest government figures, 3.2m people, or around 12% of the population, had CMU as of the end of 2021. By 2023 the government is hoping to increase enrolment to cover 38% of the population.

Private Care

The private sector plays a significant role in the provision of care in Côte d’Ivoire, delivering 25% of health care services and 80-90% of pharmaceutical products. Private establishments are mostly concentrated in urban areas of the country, particularly in and around Abidjan. There are close to 2000 private health care establishments across Côte d’Ivoire. The majority of these facilities focus on primary care and consultations. There are 13 polyclinics offering multiple services. A significant gap exists in the market for specialist services.

Although private hospitals and pharmacies serve millions of patients, many of these facilities are not adequately regulated due to limited government resources. A census carried out by the MSHP-CMU in 2016 found that 70% of private health facilities were not fully authorised to operate. To address this problem, the government has sought to organise and increase the private sector’s involvement in the health system through mechanisms such as public-private partnerships. Legislation adopted in 2019 set out measures to overhaul the management of the health system by transforming public health centres into public hospital establishments (établissements publics hospitaliers, EPHs), increasing the revenue of public hospitals and improving the quality of services. EPHs will remain under state supervision but will be run as private businesses with a results-based management approach to increase revenue and reduce costs.

The country has been working to tackle the lack of modern medical equipment and technologies that are an integral part of health care. A 2017 survey of the public sector revealed that 22% of facilities had all the required items for infection prevention and 4% had all the equipment necessary to diagnose and monitor patients.

In July 2021 the government secured $300m in financing from World Bank to provide credit to small clinics that have difficulty obtaining loans to buy or rent the necessary equipment. With access to technology, clinics will be able to expand and take on more patients. In the long term, the government hopes to establish Côte d’Ivoire as a regional destination for medical treatment in part through the transition to newer technologies and easier access to funds.

Pharmaceuticals

The government has made efforts to mitigate, monitor and prevent shortages of drugs. The private sector has an important function in the pharmaceutical industry in Côte d’Ivoire. According to the law, public primary care facilities must procure all their drugs from the public sector through the state-controlled New Public Health Pharmacy. In practice, however, and to overcome drug shortages and ensure access to medication, the private sector plays a large role in drug provision and supply chains. There are four private wholesale distributors, eight factories producing about 6% of the pharmaceutical market and 1100 private pharmacies.

Although drugs are available via the private sector, their high price can limit access for some segments of the population. “Less than 50% of drugs in the market are generic, and this is a major problem because brand-name drugs are expensive,” Arounan Diarra, president of the Conseil National de l’Ordre des Pharmaciens, a professional body of pharmacists and other pharmaceutical market players, told OBG.

Local prices for both generic and brand-name drugs in Côte d’Ivoire are much higher than international reference prices. Pharmacies and hospitals are also highly dependent on drugs imported from other countries. More than 90% of pharmaceutical supplies are imported, which has left Côte d’Ivoire’s pharmacies and hospitals vulnerable to the supply chain disruptions brought about by the Covid-19 pandemic.

Outlook

The government is prioritising the rollout of the CMU while expanding its Covid-19 vaccination campaign. Meanwhile, infrastructure projects such as hospitals and clinics are moving ahead. In the medium to long term, the government wants to shift some of the burden to the private sector. This will generate investment opportunities, ranging from the manufacturing of pharmaceuticals and contracts for hospital management, to the construction of new facilities.