New surgical methods piloted as health sector looks to adapt in Algeria

Algeria has made significant strides to improve access to quality medical care and tackle communicable diseases. While basic health indicators are very good, the changing socioeconomic landscape and improved living standards have coincided with a rise in chronic diseases such as diabetes and cancer.

Years of accumulated oil revenues have enabled the government to fund the health care system generously and invest heavily in clinics, hospitals and preventative measures. In 2014 life expectancy in Algeria was 75 years, according to the World Bank, just ahead of neighbouring Morocco and Tunisia (both 74). Yet despite the progress made, there is still room for improvement given the country’s changing health issues and health care needs.

Reform

The government presented a new piece of legislation to the Council of Ministers at the end of 2015 with the aim of reforming the health sector. The reform is awaiting a vote by the Council of Ministers before being submitted to Parliament for final approval. “This legislation is expected to enable the health system to function on the basis of improved means of management,” said Messaoud Belkessam, director of communication at the Ministry of Health, Population and Hospital Reform (Ministère de la Santé, de la Population et de la Réforme Hospitalière, MSPRH). The reform has three main sections, including one on budgetary and financial management that is a major point of contention.

Currently, the vast majority of health establishments are 100% subsidised by the government. “This has become problematic, as this subsidy was not contingent upon results, which creates disparities in terms of quality of care,” Belkessam told OBG. Rachid Bougherbal, director of the National Centre for Sports Medicine, elaborated on this issue, telling OBG, “Due to this unconditional subsidy, many hospital directors became spenders rather than managers, which has weighed down our health system.”

To address this issue, the government has been testing a new status at around 100 facilities. Rather than being 100% subsidised by the state, these pilot sites have been given the status of hospital establishment, in which the state guarantees the coverage of basic fundamental expenses, such as salaries, but the establishment has the right to levy its own funds and even top up existing wages by, for example, charging patients fees for their care.

Changing Roles

The line between the public and private sectors is therefore going to be blurred by this reform, as both private and public sector doctors can handle the basic health issues. Under the new system, the government will be able to sign agreements with private clinics and hospitals to conduct public health operations on their behalf, a first for this public and heretofore state-led system.

The new reform project plans to extend this pilot status to every public health facility in the country. “There will be some safety nets for the establishments located in remote places that may not be able to raise their own funds as easily as an establishment in Algiers that can sign a service agreement with a company to cover their employees for instance,” said Belkessam. The MSPRH insists that this reform will not lead to onerous financial obligations for the establishments, as the basic functioning expenses will continue to be covered by the state.

Patient Costs

Additionally, the reform programme aims to improve patient cost coverage. All patients with limited financial means or in precarious financial situations will see their medical costs covered by the state, while those enrolled in a social security fund, such as the National Social Security Fund for Salaried Workers, will also be covered.

Treatment for chronic diseases like cancer will be paid for by the state, as will any preventative care and awareness campaigns. Undeclared workers or employers who do not pay into the national social security fund for their employees will be given a deadline to register and legalise their situation without any penalties. After that timeframe – which remains to be determined by the government – penalties will apply for those outside the system.

E-Health Initiative

Algeria launched the Chifa card in 2007. A personalised electronic smartcard, it carries medical information about the beneficiary, from their insurance status to current and past prescriptions. According to the National Fund for Non-Salaried Workers, more than 2m people were given access to the card in 2015.

Other ongoing “e-health” programmes include the joint mobile health clinic initiative that was launched in the wilaya (province) of Tamanrasset by phone operator Ooredoo and the Algerian Red Crescent in January 2016. Managed by the Algerian Red Crescent, the first mobile clinics began operations in July 2015 to provide health services to people in remote regions, as well as to provide health care educational programmes for young people living in these areas.

Communicable Diseases

At a July 2016 meeting of the Regional Commission for the Certification of Polio Eradication, the World Health Organisation (WHO) representative in Algeria commended the country’s efforts in controlling and reducing instances of HIV/AIDS, tuberculosis and malaria.

According to the MSPRH, communicable diseases are currently responsible for less than 5% of morbidity and fewer than 1% of deaths in Algeria, meaning that the majority of cases of both come from non-communicable diseases. The WHO slightly nuances this estimate in a study demonstrating that non-communicable diseases were estimated to be responsible for 77% of total deaths in 2014.

Cardiology

Cardiology treatments are one of the two families of treatments completely covered by social security. Indeed, cardiovascular disease is considered to be the first cause of mortality in Algeria. According to a WHO study, cardiovascular disease was responsible for 41% of non-natural deaths in 2014. Men and women alike between the ages of 30 and 70 years old have a 20% chance of developing and dying from cardiovascular disease, according to the same study.

Cardiovascular disease treatment is completely reimbursed by the state, which has significant cost implications. The operation for an artificial heart valve – typically costing around AD650,000 (€5380). Additionally, such procedures require highly skilled staff. “Despite much progress made in local cardiology, some private hospitals have had to hire foreign doctors, particularly heart surgeons, as some procedures such as open heart surgery have taken some time to be mastered and integrated in medical school curricula,” said Bougherbal.

Oncology

Cancer accounted for 10% of deaths in people between the ages of 30 and 70 in Algeria in 2014, according to a WHO study. The same study showed that men and women under the age of 70 have more than a 5% chance of developing cancer in their lifetime, the third-highest probability after cardiovascular diseases and “other non-communicable diseases” – excluding diabetes, which comes in at fourth position, and chronic respiratory disease which is the fifth most likely.

In the government’s Public Investment Plan 2015-19, more than AD100bn (€827.2m) is being allocated for oncology and anti-cancer centres. In that vein, 15 new specialised oncology centres are in the pipeline to reinforce the six existing centres.

Five new cancer centres are due to open by the end of 2016, according to the minister of health, Abdelmalek Boudiaf, as reported by APS News. They will be located in Tlemcen and Sidi Bel Abbès in the north-west of the country, Tizi Ouzou in the north, as well as Laghouat and Adrar further south.

Also in Tizi Ouzou, the 120-bed Chahids Mahmoudi Private Hospital for cancer screening and treatment was inaugurated in May 2016. The hospital is intended to provide the latest cancer screening and treatment methods, including a fully equipped radiology centre, Algeria’s first cyclotron for proton therapy, as well as different scanning and radiotherapy centres to treat specific types of cancer.

New treatment is also being introduced. Algeria has been progressively implementing chemotherapy since its invention in the 1940s, as well as radiotherapy and hormone therapy. In a statement made during the country’s first national anti-cancer awareness exhibition held in Algiers in February 2016, Hassan Mahlouf, the head of oncology at Rouiba Hospital in Algiers, said that immunotherapy is poised to be the latest cancer treatment introduced in Algeria, putting the country on a par with many developed nations that have begun to implement this kind of treatment. Additionally, a new biotechnological treatment for breast cancer was being launched in 2016 free of charge to the patient and at a cost to the government of around AD9m (€74,400) per patient.

The MSPRH’s eight-point 2015-19 Anti-Cancer Plan specifically calls for the construction of 19 additional cancer treatment centres at a cost of some AD4.5bn (€37.2m) each, five radiotherapy centres and five privately run clinics. According to Boudiaf, Algeria already has 34 operational cancer centres in Algiers, and 53 nationwide.

Preventive Care

Once the health care reform is voted into law, the state will be exclusively responsible for the cost of preventive care and awareness campaigns. The 2016 annual vaccination campaign, for instance, cost the state AD10bn (€82.7m), up from AD3bn (€24.8m) in 2015. The programme, which makes a number of vaccines compulsory, has enabled Algeria to attain a 98% vaccination rate.

That said, it is believed that more could be done in terms of preventive care and campaigns, particularly among the youth population. Diabetes is responsible for 7% of deaths among people between the ages of 30 and 70 in Algeria, according to the WHO, and is increasingly being diagnosed in children. “Diabetes in children is a recent phenomenon where more prevention could be done,” said Bougherbal. “Algeria only has five or six institutes to train sports teachers for primary, middle and high schools. Some schools don’t even have gymnasia or playing fields. This lack of physical activity could easily be prevented by investing more in such infrastructure and training.”

Legislation

The latest piece of legislation designed to improve public health was introduced in May 2016 as part of a draft bill that features several articles regarding tobacco and its consumption, including one banning the sale of tobacco to minors, re-stipulating that smoking is prohibited in public places, and banning any form of promotion or advertising of tobacco products.

Article 88 aims to modify the design of cigarette packets to include the existing general warning about tobacco harming health, but also introduce specific drawings and symbols representing different warnings from the health services regarding the damaging effects of tobacco consumption.

A similar bill banning smoking in public places was passed in 2001, but according to Bougherbal the ban is not always effectively enforced. Public authorities will need to ensure that the upcoming legislation on mechanisms to improve public health is properly implemented, and that control mechanisms are put into place to oversee its implementation.

Infrastructure Development

Alongside investing in providing quality health care, the government is also spending heavily on building new facilities and refurbishing older ones in order to ensure that the health sector keeps up with both a growing population and evolving medical needs, despite the nationwide budget cuts brought on by the recent fall in oil and gas prices.

“By 2017, 87 new hospitals of capacities varying from 60 to 240 beds will be inaugurated, with more being expected by 2018 and 2019,” said Belkessam. “That said, the larger projects have been frozen, namely the construction of five large new teaching hospitals, despite foreign contractors having already been selected for the job.”

After almost five years of renovations, Didouche Mourad Hospital, near Constantine, reopened in April 2016. Several departments were renovated, including the paediatric unit, the emergency room, the operating room and more specialised wings like obstetrics, gynaecology and oncology. The hospital has 240 beds, and the AD400m (€3.3m) renovations refurbished and re-equipped 13 wings and 28 units to improve the quality of patient care.

A new teaching hospital and two local clinics were also opened in Algiers in July 2016. Zemirli Teaching Hospital will specialise in treatment for road accident victims, while the clinics in the districts of Tessala El Merdia and El Achour are expected to relieve pressure in the capital’s larger hospitals.

Outside of Algiers, two large hospitals are being constructed in the wilaya of Tamanrasset, in southern Algeria, while a 120-bed hospital is also under construction in Tamanrasset’s sub-province of Salah, according to Prime Minister Abdelmalek Sellal.

The Algerian pharmaceuticals industry is also set to receive a significant boost with the completion of the Sidi Abdellah Biotechnical Centre by 2020. The project is expected to attract up to $12bn in foreign investment for the local pharmaceuticals industry, thanks to an Algerian-US biotechnological partnership through which nine investment projects are being carried out by US pharmaceuticals firms, out of a total of 48 ongoing projects.

Training

Though Algeria has been particularly active in the construction of new hospitals that are compliant with international medical norms, staffing often does not keep pace. “We lack the adequate amount of well-trained staff to run these hospitals,” said Khaled Mohabeddine, chairman of private clinic Clinique Diar Saada. “Little has been done in terms of matching the construction objectives in Algeria with the training of additional doctors.”

Local medical training is considered to be of good quality, with the latest technology and teaching equipment available in public universities, but many of the country’s top graduates continue to go to Europe to continue their training. Though some eventually come back, “there is a problem of generational renewal,” said Mohabeddine.

Pharmaceuticals

With demand for medication increasing at double-digit rates, Algeria’s pharmaceuticals import bill increased by almost 30% year-on-year over the first four months of 2016. The country imported 7770 tonnes of medication, up 4.6% compared to the same period in 2015. Consequently, the value of imports rose by 29% from €424.1m in the first four months of 2015 to €547.1m in the first four months of 2016.

Para-pharmaceuticals goods – such as hair, skin and baby care products – were imported at a cost of €25.3m for 580 tonnes, against €17.1m for 440.3 tonnes in the first four months of 2015, equating to a 48% rise in value for a 32% increase in volume. In an attempt to reduce Algeria’s import bill, the MSPRH issued a decree in December 2015 to reinforce the prohibitions already imposed in 2008 and 2012 on the importation of drugs being produced locally. Since 2009 the state has invested €100m-120m to rehabilitate local pharmaceuticals factories.

In addition, the government called upon public pharmaceuticals company Saidal to increase its production to a minimum of 30% of national output in August 2015. Algeria currently has around 75 production units across the country. There are 169 investment projects to boost the local production of medication, of which Saidal initiated six, with the rest being run by private local and foreign operators.

Major market pushers include Sanofi, which has announced plans to invest €70m in a third plant in Algeria to produce 100m units per year at full capacity, as well as Novartis. The first half of Saidal’s joint insulin production project with Danish multinational pharmaceuticals company Novo Nordisk is expected to come on-line in the second trimester of 2017.

Outlook

Huge progress has been made over the past five decades on improving access to high-quality affordable health care. Now that Algeria has successfully contained and reduced instances of communicable diseases, focus is shifting towards preventing and treating lifestyle-related non-communicable diseases such as diabetes.

While funding has been maintained to develop new medical infrastructure and substantial reform of the sector is in the works, increased focus on preventing lifestyle-related chronic diseases, particularly from a young age, are also gaining traction. With regard to the pharmaceuticals industry, additional involvement of private actors would further boost local production and reduce the import bill.