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Administrative Organization of Health Care Institutions in Algeria: Between Centralization and Decentralization

BACKGROUND: This article addresses how health institutions operate in Algeria. It deals with the problem of the management of health institutions in Algeria between centralization and decentralization. This means are there spaces for health institutions in the formulation of local health policies? Algeria seeks to establish local health institutions in response to current demographic growth. AIM: This study evaluates the Algerian legislature’s success in developing a legal framework for the administrative organization of health care institutions. METHODS: This comparative study focuses on legal texts, using data from the national statistical office, the World Bank, and the official Algerian news agency. RESULTS: The study finds a close relationship between free health services and the dominance of central health authorities that finance all public health institutions, including residents’ medical expenses, screening, surgery, and rehabilitation. Non-resident patients are compensated for treatment by state insurance funds (CNAS and CASNOS). There are no charitable hospitals. Therefore, civil society and humanitarian, charitable institutions are invited to launch initiatives regarding charitable hospitals, because they will contribute to relieving pressure in public health institutions and will also help in promoting public health in Algeria. The Ministry of Health controls central health services. CONCLUSION: Algerian health law mixes central and decentralized management but does not encourage local health institutions to seek funding and administrative independence. Algeria’s health system needs to be reformed.


Introduction
Algeria is a developing country with a social policy [1] that guarantees health care to the population in its territory, whether they have insurance or not [2].
Algeria's health sector had a budget of 2,920,032,498 dollars in 2021, [3] but because of the corona pandemic, the budget has risen to 3,395,551,858 dollars [3].
It is important to point out that the manner in which public health institutions operate has become problematic because it concerns the management of public funds. We must examine the way in which the Algerian legislature has chosen to operate public health institutions. Has the Algerian legislature chosen central or decentralized administration? We should note that Algeria had around 300 hospital facilities in 2017 and 7434 basic health-care structures in 2016 [4]. Nacera MAHFOUD and Brahim Brahamia criticized national health sector financing policies in their article entitled "The problems of funding the health system in Algeria" [5], but their study was limited only to the economic and not the administrative legal aspects. Nevertheless, they found the law to be an effective means of implementing financial policies.
There are no previous studies on the administrative management of health institutions in Algeria, but we should refer to the study of Ali Dehmene Mohammed entitled "The Financial Health System Project in Algeria (2016)" [6]. It was an economic study that made no reference to administrative and legal aspects. Although many countries have been inspired by globalization and have come to regard the patient as a customer [7], Algeria still maintains a traditional policy ensuring that treatment is free and that the patient is not considered a customer. Government insurance funds also play an important role in ensuring treatment for all [8].
It is noted that Algerian health laws do not allow for the active participation of patients in the improvement of health policies. Some writers have suggested however that patients can play an important role in improving health policies through review of their opinions [9]. Therefore, our study is of particular importance. It defines the centralization of the decision-making process and the decentralization of administration, relying on the health legal documents published in the state official journal [10].

Methods
The article analyzes data on the development of health structures in Algeria. It also discusses the development of legal texts and their effectiveness in establishing a management method capable of running health structures.

Relationship between free health services and central health authority dominance
The institutional structure of the health sector in Algeria was founded on a set of conditions such as free treatment, which were stipulated in: It is important to note that the nature of Algeria's economic system makes it unable to exclude free treatment, leaving Algerian health institutions without central government financial support. It was, therefore, important to think about alternatives that would provide some kind of financial autonomy for those institutions.

Financing of public health institutions by central authorities
The state fully finances all expenses of public health institutions: • University hospital institutions • University hospital centers Public institution for neighborhood health. Table 1 shows how the state's social policy in the area of health has had a positive impact, improving health services inherited from French colonialism. The state's full financial maintenance of health institutions has increased the number of medical practitioners. Table 2 shows the development of health institutions due to government support. The national policy is interested in establishing new structures to respond to Algeria's current demographic growth. We should note that private health structures and institutions do not benefit from the financial support of the state. Private health structures and institutions which are human health exploration, treatment, and healing structures must respond to the standards set out in the health map and to the priorities set out in the health regulation scheme. The public fund insurance contributes in the compensation of private health services and drugs [11].

Dominance of central health powers by the Ministry of Health
The management of the health system in Algeria at the central level is carried out by the ministry of health and population and the hospital reform, under the tutelage of the minister in charge of the sector, who undertakes many tasks in this regard. It is worth noting that the name of the ministry has changed several times, from 1962 until the government reshuffle of 2021. It was called the ministry of public health and population in 1962, then the Ministry of Public Health and Social Affairs in 1965, then the ministry of endowments, public health, and veterans and social affairs in the same year, then it was called in 1970 the Ministry of Public Health until 1979, then it was called the Ministry of Health in 1984, and then, the name of the ministry of public health was established until 1988, to return again to the Ministry of Health until 1991. Then, it was called the Ministry of Health and Social Affairs until 1992.
The ministry includes the following structures: General directorate of prevention and health promotion, the general directorate of health services and hospital reform; general directorate of pharmacy and health equipment; population directorate; The general directorate of health services and hospital reform is responsible for preparing, proposing, and implementing a general plan for the health organization that includes all health structures, including the private sector; preparing and proposing quality treatment programs in order to ensure balanced and complete health coverage for the population throughout all stages of life; preparing qualitative plans for the implementation of all activities aimed at improving management in the field of elderly care; neighborhood health; medical-surgical urgency, and developing highlevel treatment; preparing plans to standardize the methods of organization and management; allocating means to health structures and specifications of positions for health users who practice at the level of treatment structures; contributing to the preparation and updating of the national health map; and ensuring the follow-up of the program of the presence of public and private health structures.
We should note that the ministry is responsible for watching over the practice of health professions and public and private health structures; implementation of plans and arrangements for organizing first aid and emergency in the event of a disaster; setting standards for the adoption of treatment structures and rehabilitation of health services; as well as evaluating the completed activities, and preparing the results thereof. It includes three directorates -the directorates of treatment programs, ethics, and medical ethics -and it includes three sub-directorates: The sub-directorate for neonatal, childhood, adolescent, and youth treatment programs; the sub-directorate for treatment programs for adults and elderly persons; and the subdirectorate for ethics and medical ethics.
The general inspectorate of health, population, and hospital reform, an institution affiliated with the ministry, carries out inspections of public and private health institutions, to determine the quality of services provided to citizens in the field of receiving patients and taking care of them, as well as the management of emergency and hygiene services, and control of the management and guardianship of medical equipment.

Absence of charitable hospitals in Algeria
Experience in other countries has demonstrated an important role for charitable hospitals in community service, making health services accessible to the poor (Noble 1998) [12]. In Algeria, there is a complete absence of this type of health institution, and there is no law regulating this activity.

Discussion
Algeria adopted an administrative style in which the ministry of health, as a central body, controls the health sector, but nevertheless, there are spaces for local administration. It is important to note that the signs of decentralization appear through local health institutions, which have the authority to respond to health problems of a local nature, but they are not independent of the administrative health institutions of a central nature.

Decentralized management of health institutions
The legal framework in Algeria provides a margin for running each health department at the local level, as well as health institutions to take local decisions, but the awareness of national plans remains within the ministry's prerogatives.

Role of the health department in the decentralized management of health institutions
The department of health and population was established by executive decree No. 97-261 of June 14, 1997, which established the rules for the organization and functioning of state health and population departments. The directorate of health and population is led by a director, assisted by a secretary-general. The departments of health and population is composed of three to six services. Depending on the importance of their tasks, each service can have 2-3 offices (Executive Decree No. 97-261 of June 14, 1997).
The department of health has several functions related to the health sector, including those relating to the management of the physical structure and human resources of hospital institutions: The promotion, coordination, and evaluation of health facilities; the establishment of procedures for the maintenance of health facilities and equipment; the establishment and inspection of health facilities and public and private institutions; the follow-up and implementation of planned programs in the field of training and the improvement and evaluation of health personnel; and the supervision and monitoring of the proper conduct of professional competitions and examinations (executive decree No. 97-261 of June 14, 1997). It is important to note that this administrative institution has the authority to manage health affairs within the region's boundaries of the administrative governorate.

Role of the university hospital institution in the decentralized management of health institutions
The first university hospital institution in Algeria was established in the city of Oran by Presidential Decree 03-270 of October 13, 2003. It established, organized, and operates the university hospital institution, a public institution of a special character with moral personality and financial autonomy, operating under the administrative custody of the minister for health and the ministry of higher education and scientific research. Its mandate includes the organization of the scientific and educational activities of the hospital institution, the determination of the conditions for student enrolment and guidance, and the approval of the deliberations of the governing council on matters relating to higher education and research in the medical sciences. The university hospital foundation is run by a board of directors and managed by a director-general, assisted in the exercise of its powers by a scientific board (presidential decree 03-270 of October 13, 2003). We should note that this type of health institution is considered the most efficient because it is equipped with high capabilities and works in cooperation with the local university.

Role of the university hospital centers in the decentralized management of health institutions
The university hospital centers were established in 1976 by Order No. 76-12 of February 20, 1976. By Decree No. 97-467 of December 2, 1997, establishing the rules for the establishment, organization, and operation of university hospital centers, the university hospital center is a public institution of an administrative character that enjoys moral personality and financial independence and is established by executive decree on the joint proposal of the minister for health and the minister for higher education and scientific research. The minister for administrative health exercises custody of the university hospital center, the university hospital center is charged with the tasks of diagnosis, detection, treatment, prevention, training, study, and research, in cooperation with the educational institution and/or higher education in the medical sciences concerned (Order No. 76-12 of February 20, 1976).

Role of the specialized hospital institutions in the decentralized management of health institutions
The specialized hospital institutions were established by Executive Decree 97-465 of December 2, 1997,s on the regulation of the rules for the establishment, organization, and operation of specialized hospital institutions, a public institution of an administrative nature with moral integrity and financial independence. They provide health services for a particular disease, a disease of a particular organ or organ, or a group of a certain age. The hospital which specializes in its field of activity is responsible for the implementation of prevention, diagnosis, treatment, and medical readjustment and recovery activities, as well as for the implementation of national, regional, and local health programs, contributing to the rehabilitation and improvement of health users (Executive Decree 97-465 of December 2, 1997).

Role of the public hospital institutions in the decentralized management of health institutions
Public hospital institutions were established by executive decree 07-140 of May 19, 2007, on the establishment, organization, and operation of public hospitals and public institutions for neighborhood health. The public hospital institution is defined as a public institution of an administrative nature that enjoys moral personality and financial independence and is placed under the guardianship of the guardian. The state hospital institution consists of a diagnostic, treatment, hospitalization, and medical rehabilitation structure covering the population of one municipality or group of municipalities. The physical content of this institution is determined by a decision of the minister in charge of health. Its tasks are to provide comprehensive and sequential care for the health needs of the population (executive decree 07-140 of May 19, 2007).

Role of the public institution for neighborhood health in the decentralized management of health institutions
It is a public institution of an administrative nature that enjoys moral personality and financial independence and is placed under the tutelage of the wali (local governor). The public institution of neighborhood health consists of a group of multi-service clinics and treatment rooms covering a group of residents. The tasks of the public institution for neighborhood health are to take care of prevention, bottom-up treatment, and diagnosis of disease, intravenous treatment, general medical examinations, basic specialist medicine, and other tasks in an integrated and sequential manner (executive decree 07-140 of May 19, 2007). It is noted that this type of health institution is considered the closest to the citizen because it is the primary reception institution, and it is widely spread throughout the territory of the state. Moreover, it is able to understand local health problems.

Conclusion
There has been a development in health-care structures in Algeria, where Algeria has a central model in the design of health sciences. Health institutions at the local level have a small operating space. Furthermore, https://oamjms.eu/index.php/mjms/index local health institutions are unable to provide selffinancing for health services because of free treatment that is appropriate to the social nature of the state. Algeria has adopted a model that mixes central and decentralized management of the health sector.