|The Courier N° 133 - May - June 1992 - Dossier : Environment and Development - Country Reports - Côte d'lvoire - Papua New Guinea (EC Courier, 1992, 104 p.)|
'The real problem in the health sector in this country is organising the service and motivating the staff'
Alain Ekra is a doctor and Professor of Cardiology. Before becoming a Minister, he was Head of the Haemodynamics and Echocardiography Department and Deputy Director of the Institute of Cardiology in Abidjan. So he knew all about medicine before he took over the political management of the Ivorians' health. In this interview, he answered questions from The Courier, starting with the poor financial situation of medicine in Cd'lvoire.
- When you hear about medicine being the poor relation of government policy, it is all relative, I think. In comparison with what goes on in the countries around us, I have to say, we ' have made real progress here in Cd'Ivoire. It is all a question of organisation. Cd'Ivoire has indeed built a lot of health infrastructure, but to be honest, things have been handled badly, alas, and now we seem to be lagging behind with our health system. It remains only a relative lag, however, given the percentage of the national budget spent on health-which goes down every year because of the economic crisis, although it is currently still CFAF 40 billion out of a general budget of CFAF 400 billion or so. That is worth remembering.
· What are the best things about the Ivorian health service and where does it fall short ?
- I said just now that the most successful things, nevertheless, are the health and hospital infrastructure in general. You won't find facilities like them anywhere else in Africa.
· But what about the medicine itself?
-I shall come to that. I am talking about the health infrastructure because I want to emphasise the fact that, even if you go into the most out-of-the-way village in this country today, you will find a health post, whereas just after independence, there was nothing outside Abidjan and one or two towns in the interior, Bonake for instance.
'The real problem is that there are not enough means'
But what are we doing in the health service? Training staff, first of all. Just after independence, there were barely 20 African doctors in this country, because colonial doctors did most of the work. But now we have 100 Ivorian doctors practising all over Cd'Ivoire and the same goes for ancillary staff, for nurses and midwives too. We have about 2345 nurses and 1500 midwives. All these staff are available to the various health centres and they do their job well-fortunately for the Ministry of Health. The Ivorian health service enables the staff to be efficient and keep up with progress in modern medicine. The real problem today is that there are not nearly enough means available to the Ministry of Health to make the infrastructure work better. Two years ago, it was disastrous. The hospitals had no medicines and no medicines means no treatment. It is unthinkable to be treated in a hospital with no medicines. But we are putting all that behind us now, I think, and the staff are now less casual and more motivated.
Weakness of the public sector
· Nevertheless, 1 heard from people directly involved with health problems that medicine costs a great deal in this country, which keeps down the numbers who can afford treatment, even for small things.
-That is partly true. I think it comes from the fact that Ivorians got used to free medical treatment as soon as the country became independent. That is the plain fact of the matter and now it is very difficult to make a distinction between those who can pay and those who really can't. Habits are such that no-one wants to pay for health. So it is not quite right to say that treatment is very expensive in this country, because there are plenty of private clinics here and people go to them. Maybe they are insured? Well, no. It isn't always those who have health insurance who go into private clinics. The real problem in the health sector in this country is organising the service and motivating the staff-and I know what I am talking about, because, as I said at the beginning of our talk, I have practised medicine myself, here in the Institute of Cardiology. With the health service as it is today, I should say that plenty of patients might prefer to go to a private clinic and pay and see a doctor-which they are by no means sure of doing in the public service. That is the real problem.
'People have to know what happens to the money they give for their health'
· Bearing in mind all you have just said, what is the current health policy:?
-It is a simple policy. As I said, we found a catastrophic situation, staff who had lost interest, a severe shortage of medicines in the hospitals and other health places and-most important- we found that infrastructure and equipment had been neglected. We wondered about a different approach. But what? Well, we think we have to try to set up a health policy which costs the State less. And that, we think, means starting with the primary structures and taking a greater interest in basic health care. So our policy is geared far more to primary health facilities - but not forgetting curative medicine of a high standard. If we are to make a start on a lasting solution to this country's health problems, then health service users have to be able to contribute to the costs. We are trying to get this idea of responsibility over to the users. They are coming round gradually-but, of course, they have to know what happens to the money they give for their health.
· What might make the people want to make an active contribution to health financing ?
-In Cd'Ivoire, you know, they have always contributed to it through the rural development fund, the system whereby the people pay a third of the costs of building health posts in their villages. Now we have a crisis on our hands, we make sure that these building schemes are done properly and then the Government-and this is the authorities' duty-have to fit them out and provide the staff. We also maintain that the population absolutely must be involved in managing the health posts, by setting up village committees, and soon, with the decentralisation we are organising, they will be able to take an active part in running much bigger structures, such as regional hospital centres and departmental and general hospitals, too. It is vital for the people to participate.
A rapid spread of HIV
· The experts, even national sources, say that the AIDS situation is fairly critical, as the virus has spread fairly rapidly in this country. Why has III V spread rapidly here ? Do Ivorian men and women have any specific behaviour patterns which might explain it?
-First of all, if it has been found that AIDS has spread rapidly in this country, then this country must be congratulated for recognising the fact and saying so. Many countries fail to say what the exact situation is and issue entirely misleading figures. We have set up an AIDS epidemiological system which is very good at detecting the disease and we are now able to say exactly how many cases we have.
Why has the incidence of AIDS rocketed in this country ? For very much the same reasons as in the other countries of Africa or anywhere else. There are traditional problems and there is individual behaviour. Africans have always said that AIDS isn't an illness and that it is being used to prevent them from living their lives... Condoms aren't really accepted yet either. All that has something to do with it. Then, if you look closely, there is the drug problem which has started to affect Africa, especially a crossroads like Cd'lvoire. All these things explain why HIV has spread so fast here.
· So you do not just have the classic AIDS victims who have caught it through sexual contact or blood transfusions, but just as many who have been contaminated through drug abuse as there are in Europe ?
-Absolutely. We are aware of the phenomenon. It cannot be explained otherwise. There is also the fact that Cd'lvoire is known to welcome visitors. Everyone can come and go and that has something to do with it too and it is difficult to control. But it would be wrong to hide the fact that most of the many cases recorded here are Ivorians and not foreigners.
· A very high percentage of your AIDS victims are very young, which could well undermine the country's economic future and not just its economic future...
-Indeed, the age bracket with the highest incidence in both sexes is the 5-39s. This is a disaster and there is no doubt that it could seriously undermine the country's future. We are aware of the fact and we are trying to do something about it with prevention and information. There are regular awareness sessions for young people in Abidjan to try to wake them up to the fact that AIDS is a grave danger.
· Does this campaign include anything in the schools, for example, and, if so, what? am thing particularly about sex education in schools here...
-I have to say no. Sex education is not on the syllabus very early on, but we do bring the parents into it. It is up to the parents in the early stages, I think, and we carry on the good work with the older pupils and in the advanced classes in high schools and colleges. That is the age at which they are made aware of it all. There have been a lot of seminars for practically all the high schools and colleges in the economic capital (Abidjan, Yamoussoukro, where President Houphouet-Boigny was born, being the administrative capital) and in the interior. The job is done, although it has to be admitted that, for various reasons, it is done modestly.
· Minister, what criticism do you have of the various forms of cooperation, starting with Community cooperation, in the health sector ?
-To be honest, there is very little to criticise in our relations with the Community. We ask for aid and our partners and friends give us what they can.
As to cooperation in general, all I can say is that the people who assist us do not force their opinions on us. They would be open to criticism if they did. We get on, but imposing a policy on us I would find rather humiliating-and I have to say that it is a problem I have never come up against in my job here as head of the Ministry. So, as far as cooperation is concerned, I am satisfied-particularly with cooperation with the EEC.
· The Community does a lot for public health in this country, doesn't it ? Can you summarise the main areas concerned ?
-Overall, I think, we are satisfied with the fields of Community assistance and particularly with the medicines supply operation where Community aid is very effective. As I said just now, when I took over here, there were no medicines in the hospitals, but things are far better now. I have just done a grand tour of western Cd'Ivoire and realised that the people are happy because they have basic medicines. That is thanks to EEC cooperation. The Community is also helping us with the AIDS campaign by improving the blood transfusion facilities-go to the transfusion centre and you can see just what has been done-and with staff training, as you said. It has been efficient in this cooperation and I have to say that we are hoping it will do a lot more, particularly in the health sector. The EEC could also help with our policy of rehabilitating infrastructure. It's more a question of rehabilitating than building these days, for there is no point in putting up vast complexes which are difficult to manage. To sum up, what I should say is that, when it comes to cooperation in the health sector, the biggest and the best comes from the EEC.
· Unlike other African leaders, you in the health sector here do not seem worried about the Community cutting its aid to Africa in general and its health services in particular so it can concentrate on the countries of Eastern Europe...
-I don't think it will. In the beginning, I did think about it, I have to say, but I do not think that the European Community, with the great union soon to be formed, can drop Africa. It would be a shame. My belief is, as the President of the Republic said, that the raw materials are in Africa and the countries of Europe will always need them. They will be forced to help us develop. In my opinion, the Twelve's commitments to Eastern Europe are no threat to the future of relations between Africa and the Community. L.P.