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Received date: March 24, 2013; Accepted date: April 26, 2013; Published date: April 28, 2013
Citation: Ouattara AF, Houngbedji CA, Koudou BG (2013) Free Health Care in Public Health Establishments of Côte d’Ivoire: Born Dead? Occup Med Health Aff 1:114. doi: 10.4172/2329-6879.1000114
Copyright: © 2013 Ouattara AF, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Everyone should be able to access health services and not be subject to financial hardship. A cornerstone of effective access to health care and outcomes remain economic and social conditions. Obviously, improved health leads to human development. Thus, it’s absolutely necessary for African country to undergo a reform of health care systems. Several countries (Rwanda, Burundi, Burkina Faso, Kenya) are trying to establish social protection programs which will give medical cover to more of their citizens. For a long time, the State of Côte d’Ivoire was aware of the importance of free healthcare. But it was in April 2011, the country has tried to implement free health care policy in public health establishments for all citizens. Although the Ivorian health system is well structured and hierarchized, many problems related to the funding and functioning of the health establishments handicapped this policy of free healthcare. The public health policy of Ivorian government in its current form should be improved. More efforts are required in terms of funding, drugs availability, social protection, human resources, and medical infrastructure.
Free healthcare; Public health; Côte d’Ivoire
Everyone should be able to access health services and not be subject to financial hardship . Worldwide, about 1.3 billion people are not in a position to access effective and affordable health care if needed . Economic and social conditions are the cornerstone of effective access to health care and outcomes . In some countries, up to 11% of the population suffers severe financial hardship each year, and up to 5% is forced into poverty . Most of the cases occurred in Africa where health care is paid for out-of-pocket. The vast majority of Africans people are unable to pay for health provision. 170 million people are forced to spend more than 40 % of their household income on medical treatment . The lack of access to health services impoverishes some people because they are unable to work, whereas using health services impoverishes others because they cannot afford the payments. Thus, many have to sell assets or go into debt to meet the payments . Moreover, only 5-10% of people living in sub-Saharan Africa and southern Asia received formal social protection .
A key factor for human development is to improve health. However policies in sub-Saharan Africa country do not provide satisfactory health care to its inhabitants. Health must be seen as a central element of productivity, rather than as an unproductive consumer of public budgets . To overcome the vicious cycle of poverty in unhealthy citizenry it is essential to fight poverty through good quality health care delivery systems with universal access which lead to keeping people healthy, thus stimulate economic growth and also contribute to social harmony by providing assurance to the population that services are available in the event of illness . Indeed, public health is an indivisible set and its implementation requires significant changes in the delivery of health care . To overcome this issue, it’s absolutely necessary for African country to undergo a reform of health care systems.
Health financing is an important part of broader efforts to ensure social protection in health . A number of countries are trying to establish or widen social insurance programs to give medical cover to more of their citizens. For example, Rwanda started free health care in 1994 but by 1999 they realized that it was not sustainable, and they introduced community-based health insurance. Burundi introduced free services for pregnant women in 2006, although health facilities have often struggled to cope with the influx of patients amid insufficient funding. In the same year, Burkina Faso introduced an 80% subsidy policy for deliveries; and Kenya provides free antenatal care . In order to be among the countries emerging in 2020 and guarantee health access to citizens, Côte d’Ivoire, the economic powerhouse of West Africa started reforms, by firstly developing a National Health Development Plan. Secondly, since April 2011, the country implemented free health care policy in public health establishments. However, problems related to infrastructure, funding and availability of drugs are many in public health sector.
The Ivorian health system is progressively built on the healthcare system inherited from the colonial period. It is mainly provided by the public provision. The private sector is developed, to support the public sector. In addition to these two sectors, traditional medicines play a relatively important role. The public health care sector is divided into three levels. The primary level is composed of sanitary institutions of first contacts (health centers, specialized health centers, clinics) (Figure 1). The secondary level is composed of health facilities used for the first reference (general hospital, regional hospital, specialized hospital), while the tertiary level is composed of health facilities used for the second reference (teaching hospital, specialized national institute) (Table 1) .
|Types of Heath facility||Number|
|Teaching hospitals (CHU)||4|
|National specialized institutes||9|
|Regional hospitals (CHR)||17|
|General Hospital (HG)||48|
|Urban health units (FSU)||10|
|Community-based health units (FSU-COM)||39|
|Urban health center (CSU)||300|
|Specialized urban health center (CSUS)||109|
|Rural health centers (dispensaries + maternity wards)||405|
|Rural dispensaries and maternity wards||383|
Table 1: Health facilities establishments in Côte d’Ivoire .
These health facilities are managed by central and external services. Central services are composed of the cabinet of the Ministry of Health and the fight against AIDS, and related services and directions. Definition, coordination and support overall health are their missions. External services are composed of 19 regional directions and 83 departmental directions or health districts in 2008. Their missions are to coordinate health activity within their jurisdiction and to provide operational support and logistics to health services . Many ministers are involved in the provision of care, through their health infrastructure (Defense, Economy and Finance, Employment and Civil Service, Social Affairs, Education, Interior). The private health sector generally is composed of multiple and various health facilities (polyclinics, clinics, and medical offices, private pharmacies and pharmacy private ambulance). However, the rules which organize the private sector are not respected, leading to several anarchic installations without prior authorization. For example, 69% of private nursing homes in the South of the country are operating illegally . In addition, some doctors and nurses in the public sector engaged illegally in the private sector. Also, there is a lack of cooperation between the private and the public sector, coupled with lack of regulation in this sector. Concerning medical staff, the ratio of medical doctors per person is 1 to 5,695 inhabitants, that of nurses per person is 1 to 2,331 inhabitants, the number of midwives per woman in age to procreate is 1 to 3,717 women .
Since 1965, the state of Côte d’Ivoire was aware of the importance of free healthcare, and showed this interest by taking a decree which established free healthcare for public employees. However, the increase in expenditure resulting from the free healthcare has led to the inability of the State to continue to bear the full cost of health. As a result, free healthcare paid to public employees of the State was abolished. In 1973, a kind of private support was created among the employees of the public through a general mutual based on third-party payment, a rate support of 70% and a contribution rate of 30% of base salary . The other people, mainly those in the informal sector and unemployed person do not have benefit from this health assistance.
Since April 2011, the State has guaranteed treatment free of charge in the public and community healthcare establishments for a cost of 27 billion CFA francs. This sum has supplied the public health pharmacy (PSP) with drugs and strategic supplies, paid the wages of healthcare staff in community-based establishments, and settled bills for treatment in all the public healthcare establishments . This period of free care was an exceptional reality; it was due to the crisis which drove people in poverty. During this period, many health services within the health establishment provided freely health care for all kind of disease. This measure raised the rate of frequentation of the public and community health care establishments. However, everyone who was sought healthcare do not really suffering from an illness necessitating emergency care. Even for a headache people went to the hospital, making it difficult to access for patients who need. Unfortunately, the government of Côte d’Ivoire has been forced to abandon the free health care for all schemes, as in the past. Now, the free health service is only available for pregnant women until delivery and free treatment for diseases affecting children under six (for example, malaria). Actually, for patient seeking care in health facilities, any payment is required during the first two days. But this kind of free benevolence, concerns only the elementary basic care. However, field’s observation show that this does not really applies. Many patients complained in hospitals. Indeed, drugs are provided to patient in case it is available in the hospital pharmacy, otherwise patient has to pay for non-available drugs in private drug stores. Sometimes, the entire prescribed drugs are not available in the hospital pharmacy. A combination of factors has penalized the Ivorian health system. The financial implication of the free health care has been enormous and the implementation of the service had been poorly planned, and public health pharmacy, the state’s central body for distribution of medical supplies throughout the country, does not have the necessary stock to cover all public health institutions demand. Moreover, only 5.3% GDP was spent on health in 2010  whereas low-income country governments supposed to devote 15% of their total budgets to health .
In the whole efforts are made to achieve equity in health, but they still insufficient. The public health policy of Ivorian government in its current form should be improved. More efforts are required in terms of increasing in the budget allocated to the health, availability of drugs by reducing the rate of stock-outs in public healthcare establishments nationwide, creating a sustainable system of care with a small participation of populations, strengthen the capacity of medical staff, create infrastructure and provide a better technical facilities for care.
The authors are grateful to Djelia Ouattara, a trainee doctor at the University Hospital of Treichville and Edith Coulibaly, a midwife. KGB is grateful to Liverpool School of Tropical Medicine.
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