Louise Chachoua – President, Senate Health Commission, Algeria

President of the Health Commission at the Algerian Senate, Louisa Chachoua explores recent changes in Algeria’s healthcare sector, the potential of the new drug agency, and Algeria’s capacity to become a flagship health system for the region.

A lot of things have changed since our last encounter, there is a new Minister of Health in place: the Algerian economy is going through a policy of austerity, and a new agency for drug regulation was created. What do you see as the main changes in Algerian healthcare since we last met?

The Health Bill, the drafting of which I participated in fully, was voted for on May 29th 2018, and published on August 14th. Now we are awaiting the corresponding application decrees. The bill must indeed be enforced. What is its context? Ever since 1962, Algeria has been among the top 10 countries in the world for the speed at which its human development index has increased.

This improvement did not occur in a linear fashion. It was mostly during the 70s and 80s that Algeria progressed dramatically, as there was a political willingness for it. Life expectancy went from 50 to 78 between the Independence and 2017, with a dramatic reduction of mortality rates, from 17 per thousand in 1970 to 4.5 per thousand in 2017. The members of the United Nations also had a Millennium goal for 2015 and worked to reduce child and maternal mortality rates. Algeria did not reach its objectives in that regard, even though the country did improve its numbers. Rather, birth rates went up in Algeria, since we had 600,000 births per year 20 years ago, and over 1 million per year today. Algeria is almost through epidemiological transition. I say almost because we still have diseases like measles and cholera and we have some work that remains to do about this. I cannot talk of context and not mention our financial constraints. Algeria is losing resources as our export of oil and gas is not earning as much as it used to. There are a lot of things that we can no longer afford.

So when it comes to our healthcare system, Algeria has achieved a lot of things, but still has to face a few obstacles. This is the context around the new Health Bill. There are new things in this new bill. The state has reaffirmed free care and health protection in the public and private sectors. Amongst the new features, we introduced prioritization of care, a referring doctor system and home care. We also introduced the “public institution with specific management” status for public hospitals and implemented a new audit system for our structures. We created a National Agency for the Promotion of Best Practices. We introduced digitalization, through the new electronic card and the dematerialization of patient files. We added a new integrated health information system. We updated the ethical rules in the field of organ and tissue transplantation, even if there remains some work to do in that regard. Pharmacy related regulations have also been updated. We re-developed our communicable disease prevention programs. We also added the promotion of exchange and twinning between health facilities. Finally, we created a National Council and a National Observatory of Health. All these new measures are welcome, and carriers of change.

Application decrees are very much necessary, because we want that bill to be efficient. What to start with? There are emergencies indeed. I personally think that we must first, and it is a huge project, digitalize our infrastructure. Big Data is key to everything. Medical prioritization comes second, as it is the cornerstone of an efficient healthcare system. I think that our regional districts can drive the system, coordinate at first every medical specialty through regional hubs, where our public health specialists could play a key part. Then, given the inequality between the South and the North of Algeria, we probably will have to resume the program to build University Hospitals in the South, as there are none yet. To staff the new hospitals, we will need to train the people from that region so that they stay.

What about contractualization?

It will be a way to clarify the issue of how to finance everything. In the bill, the State, the CNAS, the social Security and a few others finance everything. Everyone participates. With the new bill, the CNAS money will go to the social security beneficiaries. So what about the people who are not covered? How can we conceal that with the obligation to cure everyone? To me, it appears that we will continue to offer care to the have-nots, and the people who can afford it will be able to cover for the expense and take a private insurance if they want. Contractualization will allow for this to happen, provided it is codified.

Another issue will be that of pricing. Today, Algerian patients are refunded following a pricing chart that was established 32 years ago. So we need to update that.

What is your opinion about the new Ministry of Health’s approach?

The new Health Bill was born of the continuity between Ministers. We would like it to be fully enforced because it will enhance the situation. We had a lot of discussion about voluntary and therapeutic termination of pregnancy. We are waiting now for the application decree, so everything is explained. Also the civil service was discussed: every young doctor has to spend some time in the civil service to participate in the national interest, and help in the fight against medical deserts for instance. That system is actually pretty efficient, although we need to improve working conditions and incentives.

You have been for a long time in favor of new drug and health national agencies. Are you satisfied with the outcome of that bill in that regard?

The new drug regulation agency is yet to be created. I will be happy when it is born, and independent from the ministry’s authority. Currently, marketing authorization is granted by the Ministry of Health, and refunding is provided by another, and that is the source of all our problems of bureaucracy. The national drug agency must be implemented, staffed correctly, and its processes must be set up properly.

We are happy with everything in that Bill, but we are still awaiting the secondary regulation.

You mentioned epidemiological transition. How does engineering deal with it? What are the impediments?

Algeria made very concrete progress, today we harvest the result of all our past efforts: we eradicated malaria and poliomyelitis and all such diseases. The means are more important, that is why we have a National Cancer Plan, we work also on non-communicable diseases. All of that is costly and require infrastructure, modernization, and so on. The more money, the better result.

Nowadays, Algeria spends 900$ per capita in healthcare, and I believe it not to be enough. We will need to spend more and above all spend the money more rationally, build some new modern infrastructure, buy equipment and develop research and training.

We do have good results, let us keep it that way. Patients are demanding, healthcare science is improving, there are new technologies for which we need the economic means.

Where should the focus be on in terms of rationalizing the expense?

I believe that we need to focus on prevention and emergencies, prevention is better than cure, and modern diseases require talented and efficient emergency services.

Algeria has implemented very good prevention programs, that we keep updating and adapting to the modern environment.

What is the role of private companies in that regard?

The same than in the other countries: they can participate in research and training programs. After all, they are the ones with the money. We need the conditions to attract international interest, so they can spend their money here.

To what extent could the Algerian system be a model, or even a hub, for the MENA region?

Algeria definitely has the means, the human resource, the possibilities. We need a consensus decision between all the countries of that region, in the interest of the entire population of our nations. Let us not stint on the means and gather everyone towards the final decision. One country cannot carry such ambition on its own. Health is everything, it is the most important investment for the good of a country.

What do you aim to accomplish in the field of Health by the end of your term?

I am happy that a lot has already been accomplished, and now we have several priorities to address: financing and rationalizing the expense are key to our program, so that we can develop prevention programs and emergency services. Then we will address training and research. Provided we do that, we will have accomplished a great step ahead.

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