Côte d’Ivoire is setting the health sector back on its feet after a decade of armed conflict and political division. As the 2012-15 National Development Plan (Plan National de Développement, PND) reached its closing period, progress seemed clear and the country was geared towards rebuilding and constructing health infrastructure and facilities, training and hiring personnel, setting new standards and, ultimately, working to provide widespread health care coverage at an affordable cost. The 2016-20 PND has allocated significant funds for the improvement of health care in the country, which represents a step in the right direction and the private sector is likely to continue playing a primary role with investments in the form of public-private partnerships (PPP).
Structure
Côte d’Ivoire’s health system is made up of two central components; public and private services, as well as the public health administration. The public sector consists of a network of 1910 first-contact health facilities, 66 general, 17 regional, two specialised and four university hospitals, five specialised national institutes and four national public support establishments. In 2010 Côte d’Ivoire had 21,254 public health care agents, of which 85% were caregivers, including 3220 doctors, 7361 nurses and 2553 midwives. By 2015, this workforce had increased up to 6850 doctors and 8000 nurses. As for midwives, latest available records indicate that there were about 3800 in 2013.
The private sector today makes up the majority of health facilities, with various clinics, medical centres, pharmacies and private infirmaries; however, they are located essentially in large urban centres and in key economic areas. Government estimates suggest that 790 doctors, 1173 nurses and 184 midwives worked as private health care agents in 2007. However, according to Joseph Boguifo, president of the Private Clinics Association (Association des Cliniques Privées de Côte d’Ivoire, ACPCI), “the private sector offers roughly 40% of health care services in Côte d’Ivoire, with about 90% of total technical facilities and a capacity of about 1500 doctors and 3000 beds. However, in 2011 of the 2036 private health facilities, 1482 (73%) of them were not authorised to operate by government authorities, which poses additional problems.”
The public health administration is in charge of designing and implementing public policy on health care issues with the support of central, regional and departmental authorities. While the 2012-15 PND provided a framework for the execution of national health policy in previous years, in April 2016 the 2016-20 PND was passed. The plan aims to turn Côte d’Ivoire into an emerging country by 2020 and set out €44.8bn to promote growth and infrastructure.
Aware of existing health care challenges, the 2016-20 PND outlines a series of actions, some of which call for private sector involvement. The government foresees a total investment of CFA1.9bn (€2.8bn) for the improvement of Ivorian health in coming years, of which CFA1.7bn (€2.5bn) is dedicated to an increase in the use of improved health care services. The country hopes to reinforce sector governance, increase the quality of health care services, fight diseases, and improve maternal, infant and children’s health.
Enduring Challenges
Notwithstanding the results achieved, the health sector is still struggling with significant challenges, such as the persistence of endemic and epidemic diseases – such as HIV/AIDS and malaria – malnutrition, insufficient and unequally distributed health care infrastructure and personnel, a limited quality of health care services, expensive medications and limited health sector funding. This situation is reflected by the tracking of health indicators in Côte d’Ivoire, and it is likely to impede a demographic transition to a healthy and productive population that can contribute to economic growth over time.
Maternal and child mortality rates remain high in the country. According to the World Health Organisation (WHO), Côte d’Ivoire had a maternal mortality rate of 720 deaths per 100,000 live births and an under-five mortality rate of 93 deaths per 1000 live births in 2013. Although these numbers have declined recently, they are still below the estimated 2015 UN millennium development goals of 190 and 51 deaths, respectively. Similarly, according to the WHO, life expectancy at birth remained comparatively low in 2015, at 52 for men and 54 for women, as compared to the African average of 58.2 for men and 61.7 for women.
Mandatory Health Insurance
In 2014 the government sought to put in place a mandatory, universal health care coverage system (couverture maladie universelle, CMU), with the intent of improving health care access across the country, especially for the more socio-economically disadvantaged. In the system, the poorest people are reportedly exempt from payment, while the rest of the subscribers are required to make a contribution of CFA 1000 (€ 1.50) per month. However, implementation of the system has been advancing slowly. According to international news reports, only 1200 to 1300 people in Abidjan, a city of 6m people, had registered by February 2015.
The government has been promoting the system among stakeholders in hopes of increasing CMU awareness and participation. At the same time, some agencies are providing private health insurance, although it remains unclear how they are going to operate alongside the CMU. While some sources indicate that only 5% of Ivorians have health insurance, Boguifo told OBG that estimates of the current figure are slightly higher, ranging instead between 8% and 10%.
Public Spending
Government expenditure on health has increased over the past decade, as has general expenditure on health. According to World Bank figures, government expenditure per capita on health increased from $33 to $55 between 2002 and 2014, while total expenditure on health per capita increased from $32 to $88 in that same period. That said, government expenditure on health as a percentage of total government expenditure has remained relatively stable over this period, going from 7.6% to 7.35%, and government expenditure itself continues to represent a minority of overall health expenditure. In 2014 government expenditure on health accounted for 29% of total health expenditure, with the remaining 71% financed by the private sector.
Private Sector Role
The private sector plays a key role in Côte d’Ivoire’s health system. The ACPCI, an 80-member non-profit organisation, has sought to contribute to the sector’s development and address its challenges in collaboration with health authorities.
Since its creation in 1991, ACPCI has seen the establishment of a Joint Committee for the Management and Control of Private Medicine, including public and private sector agents that together assess, discuss and coordinate on health issues. In 2015, it witnessed the creation of a Private Sector Health Platform with a wide range of private actors involved, from doctors, nurses and pharmacists to health insurers. In January 2016 in Grand-Bassam, the ACPCI gathered 180 participants – including private agents and health authorities from 13 African countries and France – to discuss the role of the private sector in health care and the measures aimed at improving health service quality.
“There is still significant work to be done towards the elaboration of an updated national health strategy and policy, wherein the roles of the public and private sectors need to stand clearly defined. To be sure, some steps have already been taken to ensure greater public-private sector engagement on health issues. Thanks to the signing of public-private conventions, cross-sector coordination on key issues, such as fighting HIV/AIDs, is already showing results. Ideally,” Boguifo told OBG, “continued coordination efforts could significantly contribute towards a public-private collaboration in the design of an updated national health strategy and policy,” he added.
Medical Staff
While there is no shortage of medical personnel, there is a sufficient lack of paramedical staff in the country. To tackle this shortage, the French Development Agency is working with the government to support the National Health Agents Institute with financing of up to CFA8.2bn (€12.5m). This support is carried out under the framework of the 2013-15 Project to Strengthen the Health System , itself developed in the context of a debt relief and development contract signed with France in 2013. The geographical distribution of human resources in the health sector also constitutes a problem, as 40% of health care personnel work in the Abidjan district, where only 24% of the total population lives, which leaves gaps in health care services throughout the country’s rural areas.
Pharmaceuticals
In 2015 Côte d’Ivoire had 1501 pharmacies, of which 833 were shop-based and 149 were located in hospitals. In 2013 the country registered 498 pharmaceutical product stocking depots and 50 biological and medical analysis laboratories, of which 10 were managed by pharmacists. As of 2016, three private distributors and one public wholesale distributor were in charge of supplying the local pharmaceutical market in the country. The Directorate of Pharmacies and Medication enforces sector regulation, while the National Public Health Laboratory controls pharmaceutical product quality and consistency.
There are nine pharmaceutical producers and local production of pharmaceutical products represents around 10% of the total Ivorian market. Ibrahim Diawara, president and CEO of CIPHARM, told OBG, “Local production satisfies roughly 7% of domestic demand, with the remaining 93% serviced by imports. Both local producers and foreign investors are starting to look at their options for developing local pharmaceutical production, partly as a way of ensuring greater product quality in line with WHO general manufacturing practices, thereby also reducing medication costs and improving health service access. The development of the local pharmaceutical industry can be supported through the systematic cessation of imports of medication that can be manufactured from local sources, such as paracetamol.” (see analysis).
Regulation
On January 25, 2016 the State-Private Sector Coordination Committee launched a set of inspection and company control instruments with World Bank support and funding from the Japan International Cooperation Agency. The aim is to simplify control and inspection procedures and costs, and eliminate irrelevant licenses. The World Bank estimates that there are about 420 licences and 20 inspection agencies in Côte d’Ivoire in total, a majority of which reportedly do not operate within a legal framework. The control instruments aim to improve ease of business and promote transparency. However, it may also be important to go over the regulatory framework of the inspection and deliverance of licences itself. Boguifo has welcomed this initiative, in particular because of lingering proliferation of illegal private clinics. However, he has also called for a regulatory revision in the health sector to achieve further improvements.
Health Infrastructure
The government has made a priority of developing health infrastructure to answer pressing health care needs in Côte d’Ivoire. It is working with international agencies, private businesses and supporting PPPs in order to aid infrastructure development. The private sector has already been active in expanding health facilities and highlighting existing areas with room for growth in construction and modernisation (see analysis).
Outlook
Côte d’Ivoire’s health sector still faces significant challenges in many areas. Continued government efforts, as evidenced by public planning, can generate a positive impact and create opportunities for private sector involvement and investment. Foreign direct investment in such key areas as health infrastructure, equipment, personnel, services and pharmaceutical production and increased public-private collaboration can contribute to sector development.
Some initiatives in particular could help bring down the cost of individual health expenses, especially in regards to medication costs. Promoting local pharmaceutical production is emerging as an attractive avenue with benefits for investors and customers, not only in terms of product prices – but also quality.
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