Countering NCDs in Algeria

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Long considered maladies of affluent urban populations in mature Western economies, non communicable diseases (NCDs)– such as diabetes, cancer, chronic respiratory and cardiovascular diseases – have been spreading silently and unchecked throughout the African continent to the point where they are now reaching epidemic proportions and becoming a major determinant in a deterioration of standards of living and productivity.

“Given their current trajectory of economic development, most countries in the North Africa region are afflicted with a significantly higher than expected burden from diabetes and cardiovascular disease”

Tom Achoki, University of Washington

“Over the last three decades, there has been demonstrable progress across many countries in Africa in improving population health, but the rising burden of non-communicable diseases triggered by factors such as unhealthy diet, smoking and physical inactivity, risks undoing and eroding those recent gains,” observes Tom Achoki, Clinical Assistant Professor at University of Washington. “Given their current trajectory of economic development, most countries in the North Africa region are afflicted with a significantly higher than expected burden from diabetes and cardiovascular disease so it is crucial to raise the red flag and start urgently adopting measures targeting priority NCDs and their risk factors such as obesity,” he affirms.

The World Health Organization (WHO), for its part, very much concurs. “I’m afraid we’re currently staring at a scenario in which NCDs are beginning to surpass conventional causes of death such as malnutrition and infectious disease…In North Africa especially, NCDs are already responsible for more than a third of all deaths and our projections are telling us that, by 2030, lifestyle disease will have already become the primary cause of mortality continent-wide,” warns Oleg Chestnov, the WHO’s assistant director-general for non-communicable disease.

How, then, does Algeria fare in facing this emergent public health challenge? In terms of its exposure to the threat, the news is far from good. The rate of diabetes in the country has reached as high as 12 per cent of the entire population, with between 10,000 and 20,000 new cases being detected every year, according to the Algerian Federation of Associations of Diabetics. Meanwhile, the Algerian Society of Cardiology reports that cardiovascular disease ranks as the leading cause of mortality accounting for a massive 41 per cent of all deaths nationwide, placing the country substantially higher than many of its neighbors on this score. Naturally the trigger signs are also clearly present with over 50 per cent of Algerian women and 36 per cent of men diagnosed as obese in the latest statistics from the Public Hospital Establishment (EPH).

All of this has been placing considerable stress upon the public health apparatus and corresponding budgets. In the words of Mohamed El-Ghazi, former Minister for Labor, Employment and Social Security, “diabetes, high blood pressure, cardiovascular disease and strokes today account for about 90 per cent of total drug expenditure, costing in excess of some 17 billion dinars.” “Innovative, cutting-edge therapies to address these kind of illnesses tend to very costly to the point where sometimes they actually exceed the social security’s funding capacity, so we’re going to have to really rethink the way that we reimburse next generation pharmaceuticals and how we go about delivering public healthcare,” admits Djaouad Brahim Bourkaib, General Director of Social Security in the Ministry of Labor.

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Fortunately the Algerian authorities are already taking tangible steps to try and prevent this situation from spiralling further out of control and have launched major initiatives to bring all stakeholders together to raise awareness about mitigating NCDs, to further advance preventative healthcare and early diagnosis mechanisms, and to fashion a rationalized drug reimbursement framework that is more fit for purpose for confronting contemporary challenges.

“Chronic, lifestyle disease represents one of the biggest existential threats to our healthcare system and the welfare of our nation… we will be resolute and join forces in countering this menace,” promises Abdelmalek Boudiaf, former Minister of Health, Population and Hospital Reform.

International experts such as Assistant Professor Tom Achoki have resoundingly applauded this holistic and integrated approach. “The brute reality is that no single organization has the capacity to meet all the capabilities and health data needs for effective management of population health, so it’s going to be essential to collaborate and co-opt stakeholders from across government, private industry, the scientific and medical communities and civil society,” he reflects. “In order

to effectively manage a challenge of this scale and proportion, changes will be necessary: health system stewards will need to have good quality health data, an apparatus must be established to appropriately process and act upon this data and more research will be required in areas such as dietary policies (taxes, subsidies, & regulations)… these are all preconditions to the construction of an integrated healthcare delivery system that can reverse Algeria’s epidemiological tendencies,” he elaborates.

With regard to changing attitudes and behaviors and raising awareness about lifestyle changes that can prevent the onset of NCDs, much is already being implemented. “Decisions are being taken at the central level to educate principals of schools to adhere to our vision of physical and nutritional education with great emphasis placed on prevention and awareness, on better food hygiene and the cultivation of healthy active living,” confirms former Minister El-Ghazi.

Progress is equally manifested in the advancement of mechanisms for early diagnosis of life style diseases like type-2 diabetes. To date, Danish outfit Novo Nordisk, which has been collaborating closely with the authorities, and indeed state pharma manufacturer Saidal has registered more than 139,000 visitors to its Changing Diabetes® Mobile Clinic initiative and screened 48,400 people across 20 cities.

Most ambitious of all, however, has perhaps been the authorities’ resolution to reconfigure the pharmaceuticals reimbursement apparatus so as to fashion a new structure that is financially sustainable and yet can still guarantee access to the latest generation therapies to patients of chronic, lifestyle illness. To do this, Algeria has had to position itself as one of the first movers within Africa to embrace Heath Technology Assessment (HTA) and Pharmacoeconomics.

“On a systemic level, we will now integrate health economics into our evaluation processes, in a simple way: cost control to equivalent performance and evaluation of cost-efficacy ratios, for example.”

Djaouad Brahim Bourkaib, Social Security

“On a systemic level, we will now integrate health economics into our evaluation processes, in a simple way: cost control to equivalent performance and evaluation of cost-efficacy ratios, for example. We will also integrate more experts in health economics into the list of our experts for assessments with the reimbursement and pricing committees. In addition, laboratories are now invited to submit medico-economic and pharmaco-economic aspects alongside clinical assessment, so that we have overall visibility on the file before deciding on its eligibility,” explains Social Security’s Director General, Djaouad Brahim Bourkaib.

Addressing this issue, the 2017 Finance Act sets out two major principles. On the one hand, the authorities will implement performance contracts, well-used internationally, to which they will give local specificity through consultation with the parties concerned, allowing the social security system to fund future therapeutic successes, and share in the risk on possible therapeutic failures. On the other hand, the second principle consists of calculating quantity and price limitation, according to the adoption of predictive target populations in the case of drugs that would focus upon a specific subcategory of patients. In that case too, contracts between the payer and the laboratory will enable the social security apparatus to support the expenses on each patient’s treatment, after prior agreement on the criteria of eligibility and depending on the patient’s medical file. “I think we can strike a balance regarding the risks taken on both sides, the whole rationale being to find a system that is acceptable to all the parties, and in the best interest of patients,” confidently affirms Bourkaib.

Writer: Louis Haynes

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