Updated health care strategies and prevention programmes in Algeria

Over the past two decades considerable progress has been made in the coverage and quality of health care services, with indicators improving steadily, alongside a decline in instances of communicable diseases. As a result, life expectancy at birth has risen from 68 years in 1995 to 76 years as of 2015, according to the latest World Bank figures. Despite the rise in life expectancy, mortality rates remain relatively high – the infant mortality rate stood at 22 deaths per 1000 live births in 2016 – though recent efforts to improve maternal care and paediatrics may see these ease in the years ahead. Another area of concern is the regional disparities in health care, particularly in the southern and the Hauts Plateaux wilayas (provinces). Lastly, Algeria’s increasingly ageing population is seeing a rise in chronic illnesses, particularly diabetes, cancers and cardiovascular diseases.

Budget

Health care is heavily subsidised in Algeria in line with the introduction of a national health care system in 1975. Most services are free for citizens at public hospitals and clinics, and the cost of most medicinal purchases is reimbursed by the government. While the large majority of health establishments in the country are still completely subsidised by the government, this is gradually beginning to shift as the private sector grows.

The Ministry of Health, Population and Hospital Reform (Ministère de la Santé, de la Population et de la Réforme Hospitalière, MSPRH) receives the fourth-largest portion in the national government budget. Despite a challenging fiscal situation, the percentage of the total operating budget allocated to health was 8.5% in 2017, the highest percentage in five years. The 2017 Finance Law outlined a health budget of AD389.1bn (€3.2bn). This was increased to AD392.2bn (€3.3bn) in the 2018 Finance Law.

Private Sector

Even though the state is heavily involved in health care, there were 8400 private specialist practices and 7000 private generalist practices as of 2015. In recent years a number of private facilities and clinics have opened across the country, both in general and specialised care, while many of the existing private establishments are expanding. Azur Medical, for instance, opened as a medical diagnostic centre in 2014, but it now has plans for additional branches of care. “Future projects include a medico-surgical clinic and maternity clinic, which are already in progress,” Dr Amina Aïssani, director of Azur Medical, told OBG.

The MSPRH’s national health policy recognises the private sector as key to filling gaps in care and relieving pressure on public facilities. In 2017 the ministry sent a bulletin to the directors of health in each wilaya, calling on them to encourage private facilities to offer 24-hour services in order to lighten the load at public hospitals. Both public and private health structures are subject to oversight by each wilaya’s director of health.

In terms of human resources, the sector is split, with 57% of all registered practitioners working in the public sector and 43% in the private sector as of 2015. Typically, general practitioners are predominantly in the public sector, while specialists and dentists are split fairly evenly. Conversely, the vast majority of pharmacists work in the private sector.

Government Strategy

Dr Mokhtar Hazbellaoui, a professor who was previously the director-general of the National Institute for Public Health, took office as the minister of health, population and hospital reform in May 2017. The current national plan for health places an emphasis on raising maternal health standards and aims to reduce neonatal mortality through prevention programmes. The government has also begun initiatives to expand family planning, prevent disability where possible and reduce the spread of communicable diseases that could be avoided through more widespread vaccination programmes. Long-term strategic planning for the sector focuses on initiatives to combat risk factors for non-communicable diseases, including the 2015-19 Anti-Cancer Plan, and an education programme to prevent smoking and drug addiction.

Reform

For the past few years the government has worked towards a new regulatory framework for the health sector to update the 1990 amendment to the 1985 Law on Health. In September 2017 Hazbellaoui unveiled a draft scheme aimed at reorganising the system of patient care and improving the coverage of health services. In addition, the Council of Ministers adopted a bill to modernise health infrastructure in October 2016. A crucial reform in the bill is the introduction of a new policy that allows patients to pay for health services, although the legislation also reinforces the provision that citizens cannot be denied access to emergency medical care if they cannot afford to pay. President Abdelaziz Bouteflika reiterated at the presentation of the bill that the right to health care remains a fundamental principle of Algeria’s social policy. In the context of lower state revenues, however, this new policy marks an important shift from full coverage.

The reform adds grounds for legal abortions, prohibits cloning, and amends rules surrounding the transplantation of organs and tissue. It also provides for the preparation of specific health programmes for adolescents and certain disease groups. Another major component of the reform is allowing cancer treatment to be covered whether the treatment occurs in a public or private facility, as it is not currently covered by the public health system. Patients would be able to apply for approval from the state to cover all or part of the treatment cost. To guide governance moving forward, the bill establishes two new authoritative bodies: the National Health Council and the Committee for the Prevention and Fight against Non-Communicable Diseases.

Another objective of the reform is to bring Algeria’s health sector up to international norms in terms of ensuring human rights. The bill introduces the concept of non-discrimination on the grounds of origin, religion, age, sex, social or family situation, health situation or disability. Furthermore, it includes amendments to strengthen the practice of free, informed consent for medical procedures.

The bill also provides a legal framework for the establishment of health e-cards for patients. The government announced the launch of its SIHATIC system in February 2017, but the project still has some way to go, as it was only in its organisational phase as of May 2017. The objective of the SIHATIC system is to make patient information available to be updated and shared among medical practitioners. This will benefit patients, make processes more efficient and provide policymakers with broader information. At the time of print the bill was still in draft form, awaiting approval from the Parliament.

Maternal Care

Efforts to improve the relatively high rates of maternal and infant mortality are well under way. In 2000 there were no maternal and paediatric hospitals in Algeria, but there are now 30 such hospitals and over 400 centres specialising in maternity care. A 150-bed obstetrics clinic is expected to open in the capital at the end of 2017, while an 80-bed maternity centre at the Algiers University Hospital and a 120-bed paediatric centre specialising in infant cardiology at Bou Ismaïl are both expected to be inaugurated in late 2018.

The MSPRH is also seeking to reduce the birth rate through family-planning initiatives, as Algeria is experiencing a new baby boom, with the number of births increasing by roughly 70% since 2000 to reach over 1m in 2016. The ministry has targeted reducing the birth rate from the average of three children per woman in mid-2017 to 2.1 by 2035.

Cardiology

Cardiovascular diseases remain the largest cause of mortality in the country, accounting for 42.5% of deaths in 2016. To cope with the high volume of cases, human resource capacity in this area is generally higher than that of other medical specialties. Cardiology treatment is fully reimbursed by state, which imposes a large financial burden as treatments can be very expensive. For example, the operation to receive an artificial heart valve costs around AD650,000 (€5390) on average.

Cancer

Impacted by changing lifestyles and an ageing population, the country has witnessed a notable rise in the number of cancer cases. As of 2016 there were around 480,000 Algerians with cancer, of which 43,000 new cases were diagnosed that year. Breast cancer is the most common type of cancer for women, with around 8000 new cases diagnosed each year, while lung cancer is the most common type for men, with 2200 new cases diagnosed in 2015.

Cancer has become the second most common cause of death after cardiovascular diseases, and the country’s capacity for treatment has not kept pace with the rising number of incidences. According to the Algerian League for the Defence of Human Rights, more than 12,000 cancer patients die each year as a result of inadequate care. “There are around 20 entities that cover cancer in Algeria; however, the number of sick patients is very high, and the entities are unable to cover all of the cancer cases,” Dr Toufik Hamadache, director of the private Fatéma Al Azhar Oncology and Radiotherapy Clinic, told OBG.

The government launched the 2015-19 Anti-Cancer Plan as a means of constructing new cancer treatment centres, training more medical practitioners and launching prevention campaigns. Of the 13 centres discussed in the plan, six are already operational and seven are under construction.

The 2015-19 Anti-Cancer Plan emphasises collaboration with the private sector, especially where public services are strained. Private clinics, such as Fatéma Al Azhar, are encouraged to offer cancer treatment services. “The plan acknowledges that the public sector cannot respond to all of the needs and that the private sector has a role to play, notably in the demand for radiotherapy,” Hamadache told OBG.

Radiotherapy

The availability of radiotherapy treatment has been gradually increasing in Algeria, but there is still a large deficit in infrastructure and technical capacity. “When we talk about 43,000 new cases of cancer per year, at least 30,000 of these will need radiotherapy. Since each accelerator can take only 500 cases per year, Algeria in reality needs at least 50 or 60 accelerators,” Hamadache said. As it stands, Algeria has a total of 34 functional radiotherapy accelerators, 24 of which are in the public sector and 10 in private clinics. While the three new cancer treatment centres set to open in 2017 will add a further nine accelerators, this still leaves a large deficit, presenting an opportunity for the private sector to invest in the radiotherapy segment.

A number of international firms have already begun to do so; for example, in March 2015 the US company Varian Medical Systems created a branch in Algeria in partnership with Cialfarm, a subsidiary of Algeria’s group ETRHB Haddad. Varian Algeria is a key player in the maintenance of radiotherapy accelerators. It has 11 customers and 21 accelerators, and plans to manage a maintenance logistics base as well as a training centre for radiotherapy equipment technicians in Algeria.

Prevention

Given that tobacco is the cause of some 15,000 deaths in Algeria annually, making up around 35% of total cancer diagnoses, the government has launched a plan that seeks to lower the incidence of lung cancer through a reduction in tobacco consumption. It is hoped that this plan will also lower incidences of cardiovascular, respiratory and infectious diseases, as tobacco is cited as a source of these as well. The prevalence of tobacco addiction is high in the country, with a survey conducted by the MSPRH in 2010 finding that 27.1% of men and 1.7% of women smoked. The rate of addiction is highest for those aged 26-35 years, at 33.4%. The prevalence of smoking has an important impact on public spending; according to a National Social Security Fund survey from 2016, 27.7% of Algerians receiving social insurance are addicted to tobacco. To counter this, the National Social Security Fund has begun an awareness campaign on the risks of tobacco. The 2015-19 Anti-Cancer Plan also includes initiatives to increase awareness about early detection of cancer. It encourages women above the age of 40 to receive systematic mammograms and men to have prostate exams to check for cancer. The authorities are also working with experts in the field to launch screenings for colorectal and digestive cancers.

Diabetes 

Nearly 5m people in Algeria suffer from diabetes, according to the Algerian Federation of Food Industries. This high number is often attributed to changing lifestyles, following the sharp increase in imported Western foods that have high sugar levels. Indeed, imports of sugary products increased by 36.9% year-on-year in the first seven months of 2017. As a means of preventing the disease, an inter-ministerial decree to strengthen nutritional labelling requirements was passed in September 2017. Furthermore, rules to limit the allowed levels of salt, sugar and fat in food products are being considered.

Vaccination

The country’s public vaccination programme – which is free of charge and compulsory – has been largely successful, with the national coverage rate reaching over 90%. The coverage rate of routine vaccinations for students in their first year at university is even higher, at 94.3%. The latest addition to the vaccination programme came in 2014, when the MSPRH brought in hepatitis B vaccines for students enrolled in biomedical sciences.

Human Resources

While the number of medical practitioners has more than doubled since 2000, human resources in the sector remain strained. According to the most recent available figures from the World Bank, Algeria had 1.2 medical physicians per 1000 people as of 2010. “The biggest concern in the private sector is finding qualified personnel and doctors,” Dr Aïssani of Azur Medical told OBG.

The deficit in human resources is particularly acute in cancer treatment. As part of the 2015-19 Anti-Cancer Plan, training for doctors and biologists has begun at the National Higher Institute of Paramedic Training in Oran, which has become the leading training centre for cancer-related specialists, ranging from oncologists to analysis of cytopathology. However, radiotherapist training can take at least 10 years of study after secondary school, which means that although these courses have already begun, there is a lag. As a result, despite the gains in raising the number of cancer treatment facilities with radiotherapy accelerators, the personnel needed to operate the equipment are still in training. In the interim, these facilities will need to rely on international doctors.

There is also substantial deficit in nurses and paramedics. As of May 2017 there were 100,000 nurses in Algeria, which translates to a relatively low rate of 2.4 nurses per 1000 people. The MSPRH has begun a programme to train 72,000 paramedics, which should improve emergency response services.

Medical Tourism

Transfers of patients abroad have decreased by 90% since 2000, reflecting the considerable improvements that have taken place in the domestic system. However, a large number of Algerians still go abroad for more complex medical treatments. France granted 1600 medical visas for Algerian citizens in 2014, and it is estimated that many more Algerians visiting France on tourist visas seek out medical treatments while there. A sizeable number of Algerian medical tourists also travel to Tunisia, Morocco and Turkey.

Pharmaceuticals

The country’s pharmaceutical segment – comprising producers, importers, distributors and pharmacists – is a dynamic one, having over 9960 pharmaceutical offices as of 2015. There are several major international pharmaceutical companies present in Algeria. Notably, this includes Sanofi, the fourth most profitable pharmaceutical company globally, which has been present in the country since 1989. France’s Sanofi established a partnership with Winthrop Pharmaceutical Saïdal in 1999 for the domestic manufacturing, processing and marketing of medicines. The firm now has two factories in the country and has invested €85m to build another at Sidi Abdallah, in the north-eastern wilaya of El Oued. The new factory is set to produce 80% of the volume Sanofi distributes in Algeria.

Local Production

Sanofi Algeria currently produces 50% of its portfolio locally. The domestic pharmaceutical segment has some way to go to achieve the government’s goal of meeting 70% of national demand for medicine with domestic production by 2019. According to Mustapha Youbi, public affairs director of Sanofi, there are 84 local production units in total in Algeria, which collectively produce around 60% of the volume in the market. Localisation of pharmaceutical production is strongly incentivised by the government, largely through a policy introduced in 2008 that restricts imports for products that could be produced locally with existing production facilities. Another incentive is the faster registration process for Algerian-produced medicines. Registering locally produced medicine is generally done in one year and reimbursed in an additional year, whereas for imported medicines registration can take two years, with two further years needed for reimbursement. Tax incentives also exist in the form of fiscal exonerations to promote local production; pharmaceutical companies are eligible for tax exemptions for the first five to eight years until production factories begin operations.

Profit Margins

The regulatory environment surrounding profit margins favours domestic manufacturers. For medicines produced locally, the margin for the producer is 20%, with 10% for the distributor and 20% for the pharmacy. By comparison, when you import medicine the margin is 10%, shared between the importer and distributor, with the pharmacy still taking 20%. Many producers in the sector view the profit margins as a constraint, particularly compared to the margins found in Morocco and Tunisia. An inter-ministerial council was set up in July 2017 to examine a draft law to revise profit margins and a commission was created to consider the changes.

Registering Medicines

There are over 6000 registered medicines. The Directorate of Pharmacy of the MSPRH manages policy regarding the sector in coordination with technical partners, such as the National Laboratory for the Control of Pharmaceutical Products (Laboratoire National de Contrôle des Produits Pharmaceutiques, LNCPP). Pharmaceutical producers are required to have a control laboratory for their own products, and the LNCPP controls for quality before they enter the market. When it comes to pricing, there are dual processes that exist in registration and reimbursement, which poses ongoing issues. “We are faced with the problem that when you apply for registration, the price is fixed at the level of the MSPRH, and when producers approach the Ministry of Labour for reimbursement, they are challenged again on the price,” Youbi told OBG. Industry players have called for these two procedures to be unified, but any action is yet to be announced.

Drugs Shortage

In March 2017 Messaoud Belambri, the president of the National Union of Pharmacists, told local press that there was a shortage of as many as 140 different medicines, including painkillers used for cancer patients as well as other morphine derivatives. The government attributed the supply tensions to production being transferred from one factory to another and the shutdown of production in an Austrian laboratory. Import restrictions, which limit the stock of medicines, further exacerbated the issue. To mitigate the risk of shortages in the future, the MSPRH is weighing potential safeguards such as importing drugs with longer validity dates, creating back-up stocks of high-risk medicines, strengthening regulations and controls over the sector, and promoting generic drugs.

R&D

While there is strong potential in Algeria for clinical trials, there are still some gaps in areas such as regulation. The government has been working on setting up a cluster for clinical research to allow pharmaceutical companies, biotechnology institutes and universities to brainstorm and assess opportunities to gather epidemiological data. “There have been significant evolutions unfolding, but in general the health sector needs to further develop clinical research as a medical, scientific and economic lever for the country,” Dr Amine Sekhri, general manager at Roche, a Swiss pharmaceuticals company, told OBG.

Outlook

Overall, health indicators are improving thanks to strategic government planning and continued widespread coverage of health care for citizens. Further, opportunities for private sector growth and investment are strong, particularly in the pharmaceutical industry; however, finalising reforms and addressing persistent concerns of stakeholders will be key to ensuring targeted progress takes place.