The present institutional framework does not allow a good management of the health system151
The lack of coordination among central government services affects system management. Several ministries run the health care system. Chief among these are the Ministry of Health, which provides overall guidance and management for the system; the Ministry of Labor and Social Security, which takes care of theCaisses d’Assurance Maladie; the Ministry of Finance which, together with the Ministry of Health, negotiates public sector health budgeting; and the Ministry of Higher Education, which is primarily responsible for the training of physicians. For the system to function properly, these institutions must satisfactorily cooperate. In fact, interministerial cooperation is very limited. In addition, the relationship between the Ministry of Health and the Ministry of Labor and Social Security is particularly strained, in part because of the unresolved issue of how to share the operational expenses of public health facilities. The Ministry of Higher Education establishes the content of the teaching program at medical faculties—though with negligible input from the Ministry of Health, which in principle is best placed to assess training needs.
Coordination is also insufficient among the main ministerial departments. In the Ministry of Health, for example, the setting of public health priorities is not reconciled with the financial resources that are actually available. There is ample room for strengthening contacts and the sharing of information among institutions that are responsible for these matters.
Another source of difficulties is the separation between the bodies responsible for investment and those responsible for operations (recurrent) outlays in public health institutions. The Ministry of Health mirrors the institutional budget separation within the Ministry of Finance. Two separate sections of the budget office deal with capital and recurrent expenditures respectively. Similarly, budget negotiations over investments and recurrent credits take place separately. Often, the recurrent charges necessary to keep an investment project running smoothly are not provided for during the fiscal year in which the investment component is completed, with negative consequences for the utilization of the new health centers or facilities financed. Moreover, there is no sector specialization within the Ministry of Finance. Each investment and recurrent expenditure officer monitors a large number of health districts, but covers only a portion of each. Officers thus have little detailed familiarity with the great number of files for which they are responsible.
Current efforts by the Ministry of Finance to develop program budgeting and budgeting-by-objectives may help to improve coordination.
The lack of a strong local player harms themanagement of the system (see Annex T). Algeria has five health regions (Center, East, West, Southeast, and Southwest). Each has had a Regional Health Council since 1997. These bodies represent the principal stakeholders in the system—the state, the social security funds, physicians, associations, and so forth. The health councils are supposed to coordinate activities and promote consensus-building in the field. In practice however, their role is essentially advisory; and their operational responsibilities are limited. Each of the 48 wilayas has a Direction de la santé et de la population (DSP) representing the Ministry of Health at the deconcentrated level. The Decree of July 14, 1997, governs their organization and operations and gives them a broad mandate—planning and coordination of public health activities, prioritization of health care, distribution of funding among health institutions; evaluation and supervision of their activities; monitoring of investments; and training programs among others. In reality, they have sufficient resources neither to properly carry out these tasks nor to serve as an effective interface with the Ministry of Health at the local level. Moreover, the wilaya health authoritiesdo not have the critical reach to deal with the broader challenges related to geographical distribution and coordination among health care providers.
Decentralization of the health system is very limited. As a result, the central government is not able to fulfill what should be its key role, overall stewardship for the system.
The management of hospitals is excessively rigid. Hospitals belong to the category of public institutions called établissements publics administratifs (EPA). The EPAs operate along the lines of a traditional state bureaucracy, applying standard rules of public accounting and public service statutes for personnel management. When it comes to budgeting, managers have next to no autonomy. In the case of recurrent expenditures, for example, a hospital manager who wants to transfer funds from one budget category to another must obtain central approval through a ministerial order. In the case of personnel expenditure, modifications cannot be made at all.
Relations are unsatisfactory between hospitals and the central government. Because of the public administrative status of hospitals, managers can be subject to suffocating oversight. Numerous controls a priori limit a manager’s capacity to take initiative. At the same time, the government has set no precise objectives to guide actions. There are no contractual arrangements between the DSPs (or the Ministry of Health) and the hospitals that might otherwise help to define expected outcomes and ensure the minimum resources (inputs) necessary for achieving them. Finally, the activities and performance of hospitals is subject to no evaluation whatsoever.
The budgetary process does not respond to a strategic orientation. As a consequence of institutional segmentation, the recurrent budget is prepared in an inertial way. It has little to do with a hospital’s real needs.
Hospitals receive very little guidance from the DSPs or the central government in preparing their budget forecasts. There are no indications concerning the pace of expenditure increases, priority activities, and so forth.
Hospital budgets are essentially based on the previous year with a small increase.
DSPs receive the hospital budget requests and transmit them to the Ministry of Health without major amendments.
The Ministry of Health negotiates with the Ministry of Finance based on these budget proposals.
For the investment budget, a distinction must be made between centrally managed and decentralized investment projects. Only investments relating to the centres hospitalo-universitaires (CHU) and certain specialized hospital facilities are managed at the central level. For this type of investments, the decisionmaking process is relatively simple: The Ministry of Health selects the projects that it likes based on available information and its own priorities. Common issues in the management of these investments are not related to the budget procedure, so much as to other factors—gaps in the health map, lack of accurate information on institutional performance, or simply capacity in project preparation. On the contrary, at the deconcentrated level (DSP and wilayas), there are different kinds of inadequacies in the budgeting procedures for investments. For example:
Hospitals submit their needs to the DSP and the wali. The wali makes the decision, with the DSP consigned to the role of technical advisor. Not surprisingly, projects that are selected are often shaped as much by the local political context as by technical considerations.
After reaching the Ministry of Health, the proposed investment project is merely transmitted to the Ministry of Finance.
Investment appropriations are allocated to the wilayas in lump sums.
The Sector strategy
Despite multiple efforts developed by health authorities to draft partial strategies, it is only in October 2006 that the ministry of health put together a comprehensive document that defines priorities for the entire health sector. A previous useful document is the draft Health Bill (Avant projet de loi sanitaire), which was prepared in 2003.152 The preamble describes how the context has changed since the 1985 Health Act and why reforms are called for. It states the main objectives of the proposed reforms and the measures contained in the law (Box 8.1). It provides an excellent starting point and could be strengthened. Afterwards, a comprehensive strategy is approved on October 7th 2006 (National Health Policy, Ministry of health, 2006).
Box 8.1 Content of the Draft Heath Bill (February 2003) The preamble to the bill stresses the need to adapt the health system to the new challenges—in particular, the epidemiological and demographic transitions and increasing demands from the population for a better protection and improved quality of care. It details the principles guiding the bill, which mirrors the main objectives of the health system—namely,
universality and equality of access to health care.
solidarity, equity and continuity.
rational use of care and health facilities.
decentralization and intersectoriality.
evaluation and control.
Several measures are proposed to address the new challenges and meet these objectives.
Create a National Health Council in charge of defining public health priorities and preparing reports on the health status of the population.
Introduce a set of measures such as free screening and treatment for noncommunicable diseases.
Devise specific health programs for prioritized categories such as mothers and children, women, teenagers, elderly people, and poor people.
Decentralize the health system with the creation of health regions, regional health agencies, and regional health care delivery plans.
Integrate the private sector in government policy by submitting private providers to the same general rules as public institutions and holding them to contracts with the Ministry of Health as conditions for operation.
Develop information systems at every level of the health sector.
Create an agency for the accreditation and evaluation of heath services.
Grant new status to public health institutions to allow them greater autonomy.
Obligate public hospitals to contract with the regional health agencies in order to qualify for government funding.
10. Prepare national health accounts on an annual basis.
A major effort is being made to gather data and analyze the health care system. The Ministry of Health publishes an annual statistics report providing data on system resources and their utilization. Entitled “The Health of Algerians” (La santé des Algériennes et des Algériens), the document provides a yearly snapshot of the state of public health and of the health care system. The “health map” was partly updated in 2005. The report on hospital reform, which has not yet been published, analyzes and proposes a number of particularly useful reforms. National health accounts (NHA) were published for the first time in 2003. This is an exercise that should be updated regularly but, as the NHA report indicates, this will require provision of additional resources.
But multiple gaps prevent the drafting of a sound strategy. The health map does not include epidemiological data, so it is not possible to establish the linkage between institutions and facilities and public health needs. As of 2005, the health map shows data on private-sector capacities, but these are still not taken into account in projections. Finally, the standards applied for equipment—in particular, the number of beds per capita—have not been updated since 1980. They are ambitious and should be reexamined. Besides, the NHA contain no incidence analysis of health spending, thus it is not known whether improved health access has really benefited the most vulnerable population groups. Finally, there is very little information on the activity of health institutions and on the quality of the care that they provide.
Data are not widely disseminated. It appears that some documents are known and used only by the offices that prepare them, rather than serving to guide the overall activity of the Ministry of Health (for example, in the case of the health map). In the public health field, many thematic programs are defined based on the problems identified in the wilayas—for example, combating hospital-acquired infections, and the national tuberculosis campaign. Yet the link between these programs and their funding is not always made.
Finally, most of these problems can be explained by inadequate resources in information systems and qualified personnel, both at the central and wilaya levels. For example, the ministry’s planning directorate has only one information technology expert and one statistician on staff, far too few to computerize the system and collect and exploit data.
