Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health Mr. Dainius Pūras Country Visit to Algeria, 27 April to 10 May 2016

Preliminary observations

Algiers, 10 May 2016

Members of the press,
Ladies and gentlemen,

I would like to begin by sincerely thanking the Government of Algeria for inviting me to assess, in a spirit of dialogue and cooperation, the realisation of the right to health in the country. During my visit, I met with high-ranking Government officials, members of the Legislative branch and relevant health-related institutions. I also met with the National Human Rights Commission, and with representatives of international organizations, and with a range of civil society actors, including professional associations in the health care sector.

I had the opportunity to visit health facilities at different levels in Algiers, Blida, Djelfa, Sétif, Tipaza, and Oran, including health screening and follow up units in primary schools (Unités de dépistage et de suivi, UDS), policlinics, university hospitals, a healthcare unit in a prison, psychiatric units in general hospitals, and child mental health centres. I take this opportunity to thank the UN Resident Coordinator and the UN Country Team for their crucial support to my visit. 

You will find in this room a short document that explains my responsibilities as the UN mandate as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health). I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realisation of the right to health.

After two weeks in the country, I have gathered a wealth of information and testimony, which will help me assess the realisation of the right to health in Algeria.  Today, I will only present some of my preliminary observations, which will be elaborated in more detail in a report to be presented to the UN Human Rights Council in Geneva, in June 2017.

General context and achievements

Since Algeria gained independence in 1962, it has made considerable achievements in improving the health status in the country through a sustained commitment to public health policy. Heath-related indicators have seen drastic improvements since independence.  The life expectancy of most sectors of the population has increased considerably, maternal and child mortality rates have been reduced, and successful vaccination campaigns have been introduced. The country has also embarked in important social reforms, including universal free access to health care and education. 

Revenues from hydrocarbon exports have allowed Algeria to ensure macroeconomic stability and economic growth and development over the past few decades.  This, together with a clear commitment by public authorities, has paved the way for some of the achievements regarding the realisation of the right to health.

The health sector in Algeria has developed with a strong focus on primary care and universal free access for most of its population, including non-nationals. Considerable investments have been made to develop health infrastructure and make services available and accessible, as well as to address the underlying determinants of health, including poverty, education, food and nutrition, and housing.

Despite the current financial crisis linked to the crash of international oil prices since mid-2014, the country has maintained its commitment to improving the health of its population. Today, there are serious attempts to address the challenges of the ongoing demographical and epidemiological transition from a country where almost 55 per cent of its population is below 30 years old, and non-communicable diseases have become the main issue of concern. 

Algeria is currently a member of the UN Human Rights Council (2014-2016), and it has signed and ratified almost all international human rights treaties, except for the Convention of Enforced Disappearances and most of the Optional Protocols on individual complaints of the various treaties .  Over the past few years, the country has received the visit of some independent experts of the Human Rights Council but it has yet to issue a standing invitation. At the regional level, Algeria has been active taking important health-related initiatives, in particular linked to the eradication of malaria and the fight against HIV/AIDS. 

The Algerian constitutional and normative framework recognises the right to health and other related rights, as well as the right to be free from violence and discrimination. There are a number of public policies, programs and initiatives that stem from this framework, including important efforts in recent years to fight cancer.  I commend efforts made to address regional inequities in access to health such as twinning programmes (jumellages), the use of tele-medicine, and mobile health units.

Main challenges and populations in vulnerable situations

The next two decades represent an important juncture for Algeria to reach two important and interrelated objectives: achieve the Sustainable Development Goals by 2030, including by investing in individual and societal health; and ensure the effective realisation of the right to health of its population. 

At the international level, Algeria has introduced reservations to some of the treaties which, together with a delay in reporting to some of the treaty monitoring bodies, can seriously undermine the accountability of the Government and efforts undertaken so far in the right to health area.

Algeria did not achieve MDG5 on reducing maternal mortality rates by 2015, and still has a high neo-natal mortality rate.  Despite commendable work done with UN agencies on these issues, availability and quality of relevant health-related data, as well as of good analytical studies, remain an important challenge that seriously compromises public policy efforts in health and health-related sectors.  I encourage the authorities to invest in nationally led evaluations of health policies and programmes.  

Healthcare system

Algerian healthcare system has achieved impressive results in terms of availability and access to care, and has been strengthened in terms of infrastructure, equipment and workforce. The population has financial coverage for most of the public health services, which has contributed to the drastic improvement of health indicators. 

During the two weeks in the country, I visited various healthcare structures at different levels.  The facilities I visited were in relative good condition, and services provided seemed adequate.  However, I am aware of studies that showdeficiencies in infrastructure and equipment, as well as in availability and quality of health workforce, especially in remote areas, including the study conducted by the National Human Rights Commission in 2008/2009. 

The current health system has a strong focus on primary (proximity) care and specialized services, which is a good basis for reaching full coverage. But important challenges remain regarding equitable access to and quality of services, and excessive emphasis on specialized medicine. I have observed a disproportionate reliance on hospitals care compared with the attention paid to outpatient care, and health promotion and prevention.

There seems to be a lack of good governance and incentives to properly manage the different levels of the healthcare system in order to encourage the use of primary care.  Algeria should invest in strengthening the role of general practitioners, improving their capacities and competencies, as well as that of their teams (nurses, social workers, assistants), and establishing innovative incentives to consolidate their position as “gatekeepers” of the system.

Moreover, due to the low quality of the care provided in the public sector, the private sector is growing fast in an unregulated manner leading to a system that offers better quality care for those who can pay (out of pocket) and hence increases inequalities in accessing health care.

The achievements of the healthcare system could be reinforced by investing in the meaningful participation of all stakeholders, including users of health services (patients), independent civil society, and local authorities. Consultations organized in June 2014 for the elaboration of the new Health Law (Loi Sanitaire) are a positive sign. I trust that the new law and related decrees will be adopted soon, and will request more information from the authorities about the draft law.  However, more efforts are needed to ensure proper monitoring and accountability in the healthcare sector, including through the establishment of and collaboration with independent mechanisms. 

I will now touch upon issues and the situation of certain groups and sectors of the population that have emerged during my visit as relevant in fully realising the right to health in Algeria.

Violence as a cross-cutting right to health issue

For historical reasons, the harm done by violence is well known to Algerian society. 

During the 1990s, the country experienced civil unrest and a decade of extreme violence known as “the black decade”.  During this time, the country faced violence by armed groups, which has caused deep trauma amongst the population, and which has yet to be adequately addressed at different levels. 

During my visit, I have observed that there is a legacy of tolerance towards certain forms of violence in certain contexts, and against some groups and sectors of the population. To a large extent, violence against children and women is largely condoned by society. 

Corporal punishment, including against children, remains lawful in the family, alternative-care settings, and penal institutions.  Abused women, including by their husbands, do not always receive adequate protection and services, and are socially stigmatised. 

Recent legislative measures are to be commended, such as the ones on the protection of children (Law 15-12 of 2012), and on the protection of women against violence (amendments to the Criminal Code, 2016).  I have requested more information about these recent legislative changes that I will study them in the coming months. 

However, these normative changes are only first steps. Implementation requires adequate budgetary allocations, the establishment of appropriate services and protocols as well as general awareness raising and sensitization and the training of key professionals (healthcare workers, police, and teachers). Sustained concerted efforts by the authorities and all stakeholders are necessary, including organizations representing women and youth.

I encourage the authorities to continue the work on inter-sectoral campaigns to end violence across the country with the technical assistance by relevant UN agencies.

Preventing violence is crucial to ensure the full enjoyment of the right to health and to effectively address the objectives under the SDGs. This needs to be done through investment in modern supportive services for children, women, families, and youth, as well as through sensitization of the general public that no form of violence - even “mild” ones- should be tolerated, and victims should be protected and not blamed.

Right to health of women

Women in Algeria have enjoyed the overall improvement of health indicators since independence, including increased life expectancy, and the fight against infectious diseases. Algeria should be commended for the efforts made over the past few years to address the prevention and treatment of cancer, including breast and cervical cancers.

The ongoing demographic transition has implied an important decrease in fertility rates.

Women have access to the educational system at all levels, are represented at all levels of national and local government, and form a large part of the healthcare workforce, including medical personnel.

However, serious challenges remain when it comes to the full realization of women’s right to health, including barriers in accessing health-related services, evidence-based education and information. The healthcare sector is one of the public sectors best placed to ensure that women are adequately supported, protected and empowered through accessible and quality services.

Maternal and neo-natal mortality remain high in Algeria, and the country fell short of meeting MDG5 on reduction of maternal mortality.  The majority of these deaths are preventable and the numbers are higher in remote rural regions. Important work is currently being done by the Government with support from UN agencies to reduce maternal and neo-natal mortality; however, the commitment at the highest level of Government needs to be accompanied by practical measures to ensure substantive equality throughout the country. 

Therapeutic interruption of pregnancies is allowed in Algeria under a few exceptions; however cases of rape and incest are not included which may drive women towards unsafe clandestine abortions. In addition, the prevalence of violence against women, including domestic violence, poses a serious human rights and public health issue that should be addressed without delay. To break the vicious cycle of violence there must be clear and strong political will to ensure that the normative and policy framework protects and empowers women.  In this sense, the certain aspects of the normative framework must be reinforced and effectively applied. As I said, during my visit I have learnt about recent amendments to the Criminal Code in this direction, and I hope to study them in the coming months.

Right to health of adolescents and youth

Given the ongoing demographic transition, with lower fertility rates and increased life-expectancy, adolescents and youth comprise a very important part of Algerian population and offer a unique opportunity to the country to reap the demographic dividend. This group therefore plays a decisive role in effectively achieving health-related SDGs.

In 2012, the UN Committee on the Rights of the Child (CRC) raised some important issues related to the right to health of children and adolescents but many of them seem not to have been adequately addressed as of yet.  For example, sexual and reproductive health services for adolescents remain inadequate, and comprehensive age-sensitive sexual and reproductive health education and information is generally unavailable.

This is why I would like to underline the need to design and implement an inter-sectoral public policy for sexual and reproductive health rights aimed at adolescents within and outside the educational system. This policy should take into account sexual and reproductive health rights, healthy sexuality, prevention of unplanned pregnancies, use of all forms of contraceptives, and sexually transmitted diseases, including HIV/AIDS. 

Overall, I have observed a lack of effective implementation of policy measures addressed at children due to insufficient financial and technical resources. To date, an independent national institution for the promotion and protection of children has not been established.

Adolescents and youth should be meaningfully involved in all matters and decisions affecting them. Services need to be adolescent and youth friendly, so that adolescents trust them and do not avoid them. This is especially important with regard to mental health and emotional well-being of adolescents, including the prevention of suicide, and early identification of mental health conditions.  It is also crucial when it comes to adolescents who use drugs. 

In addition, it is crucial that young people who are planning to have children or who already have them receive support services that allow them to develop adequate parental skills.  During my visit, I was informed that unmarried couples and single mothers face important barriers in accessing health care services due to stigma and negative attitudes by health workers. 

People living with HIV/AIDS

Algeria has a low prevalence of HIV/AIDS and the country has put in place important programmes to fight the spread of the disease and ensure access to treatment to those living with HIV/AIDS, including through testing centres and a programme for the Elimination of Mother to Child Transmission (EMTCT).

However, prevalence of HIV/AIDS remains high amongst key populations, including men who have sex with men, sex workers, people who use drugs, and migrants. These groups face serious barriers, stigma and discrimination, both in law and in practice, and tend to avoid using healthcare services.  While I commend recent policy changes targeting these key populations, more efforts are needed to actively reach out to them both as a preventive measure but also to ensure access to services.

SDGs aim to eliminate HIV/AIDS by 2030. Algeria has made considerable efforts and could achieve this goal. However, this cannot be accomplished without ensuring zero discrimination in healthcare services.  During my visit, I learnt that there are still many challenges as HIV/AIDS remains a taboo in Algerian society.  People living with HIV/AIDS face different forms of discrimination and stigmatisation when accessing health care and treatment, and important regional disparities remain. Normative changes are necessary to make sure that Algeria attains the goal of eliminating HIV/AIDS by 2030.

Drug policy and the right to health of drug users

Drug use was, until recently, a taboo in Algerian society.  However, I have visited two health centres, in Oran and Algiers, which had specific programmes and services for drug users. Such structures and programmes seem to have a good approach, including the provision of harm reduction services, but should be accompanied by appropriate prevention, education, and information programmes. 

The health and related sectors, including education and youth ministries, need to be more active in promoting evidence-based prevention, services and treatment for people who use drugs. In line with these programmes, Algeria should make sure that its normative framework does not criminalize minor drug offences, and it should continue promoting non-punitive/ non-custodial measures towards drug use. 

Right to health of migrants, refugees and asylum-seekers

Algeria is a major transit hub for irregular mixed population movements.  Over the past few years, the number of migrants in the country has increased, including migrant workers and undocumented migrants.  According to Algerian law, irregular or undocumented migration is subject to different forms of penalties.    

Overall, migrants, have access to healthcare services free of charge, including irregular ones. However, there is a lack of reliable disaggregated data to assess and monitor their situation from the right to health perspective. This is a concern since mobility has been identified in Algeria as a determining factor for the HIV/AIDS epidemic and other communicable diseases. 

Algeria lacks a legal framework to recognise the rights of refuges and asylum-seekers with the consequence that they are often treated as irregular migrants.  In the absence of a legal status and necessary civil documentation, refugees, asylum-seekers, and stateless persons face administrative difficulties in obtaining birth certificates for their new-born children in Algeria which could hinder their access to basic social services, including health services. This should be addressed without delay, also in the context of SDG target 16.9 regarding the provision of legal identity for all, including birth registration.

The right to mental health and persons with developmental and psycho-social disabilities

Algeria ratified CRPD in 2009 and should proceed without delay to its effective implementation.  In my view this implies, first, to move away from a medical model which puts excessive emphasis on medical diagnosis and to abandon old fashioned practices which lead to the exclusion of people based on diagnosis. For example, children with moderate and severe levels of developmental disabilities, after they are evaluated by medical doctors and psychologists, are referred to centres which are under the jurisdiction of the Ministry of National Solidarity of the Family and Women Condition. This could be considered as a violation of their right to education. All children, including all children with disabilities, should be enrolled in the school system, and individual educational plans should be developed to appropriately address the level of development of each child.

Algeria should be commended for taking the first steps to develop general mental health services for children and adults; however such initiatives still remain pilot projects and should be replicated. I consider it a good sign that psychologists are working in the health and education sectors and that psychiatrists are working in proximity or primary health centers.  Essential medicines to treat mental health conditions are generally available.
However, this is not enough for modern mental health policies and services to be in place.

Algerian mental health sector is excessively reliant on psychiatric hospitals, and the number of mental healthcare workers at inpatient level is higher than at outpatient level. It should actually be the opposite; outpatient services within general hospitals should outnumber inpatient mental health services. Instead of building new psychiatric hospitals, each general hospital should have an inpatient psychiatry unit to make mental healthcare more accessible to all and avoid stigmatization.  

Members of the press,
Ladies and gentlemen,

There are opportunities to achieve the progressive realisation of right to health in Algeria, but public authorities need to step up efforts to address certain structural and systemic issues to make sure that “no one is left behind”.

From the perspective of the SDGs, many right to health-related issues are inter-sectorial and should be addressed with horizontal approaches that promote the effective use of primary care, incorporate the concerted efforts of all stakeholders, including citizens and civil society, through meaningful participation and consultation.  Healthcare systems on their own cannot address all right to health issues.

Non-discrimination, equality, participation, and accountability, which are crucial for the realization of the right to health and related rights, should be the basis to consolidate a “health in all policies” approach and to establish mechanisms to ensure the good governance of the healthcare sector. 

Let me conclude now by saying that I am sincerely grateful to the Government of Algeria for inviting me to visit the country.  This visit has enabled me to have a better understanding of the right to health and related rights in Algeria. This invitation indicates that there is a commitment to ensure and guarantee the enjoyment of the right to health, and I hope that my recommendations will assist the country in moving forward. 

Thank you.