Universal coverage: Preparing a public insurance system for launch in 2014

Until 2009 the majority of health expenditure in Gabon came from the private sector. A small segment of the population has private health insurance, but most private spending is out-of-pocket. Access to quality care in Gabon is out of step with the country’s position as an upper-middle income country, and the government has made an effort to jump-start spending and create a more efficient public health system. Now it is preparing to activate its universal health insurance scheme, the first such programme in the CEMAC region.

The programme – managed by the National Health Insurance and Social Welfare Fund (Caisse Nationale d’Assurance Maladie et de Garantie Sociale, CNAMGS) – is in its final enrolment phase, focusing on private sector employees. As of May 2013, 600,000 people were enrolled – half of the target population. By late 2013 CNAMGS hopes to issue ID cards and begin collecting payments from the insured. There will be a two-month lag between the first deductions and activation of the system, in order to build up financial reserves. CNAMGS plans to launch service by early 2014.

BENEFITS: The scheme should strengthen the health sector in several ways. First, CNAMGS aims to shift some of the burden of private spending from individuals to employers. The total value of health services administered in 2012 was €18m, with 45% coming from private expenditure. Under the insurance programme, salaried workers will contribute 2.5% of their pay to the fund, while the state and private employers will each contribute 4.1%. Costs for the low-income bracket will be entirely covered by taxes on mobile phone operators and international money transfers.

By reducing out-of-pocket spending, health services and conventional medication will become accessible to a higher proportion of the population. Most of those enrolled in the scheme so far – 442,000 people – are in the Gabonais Économiquement Faibles bracket, which includes low-income groups and students. This is followed by 131,000 public employees and 25,500 private employees. The set reimbursement structure should also help promote the use of generic drugs. However, stock interruptions have been a problem for health centres in the past, and Gabon’s distribution network will need to be improved for the programme to function at full capacity, particularly in rural areas.

Finally, understanding which services are in demand, and in which parts of the country, will help rationalise spending and improve planning. Insufficient information has been an obstacle in the past. CNAMGS’ interaction with health centres should help keep track of the quality, quantity and price of services offered.

WORKING OUT THE KINKS: The existing health network already faces difficulties in meeting demand, and providers expect a major uptick when insurance benefits are activated in 2014. CNAMGS has approved 85 pharmacies and 139 health structures to participate in the insurance scheme, of which 84 are public and 65 private. The state is working to expand hospital capacity by 1000 beds by 2015, but the anticipated rise in demand may clog the system in the near-term.

The programme will also have a tangible impact on the domestic insurance industry. Private health cover represents 15% of total premiums, for turnover of €19.8m in 2011. Insurers are preparing to lose this important revenue stream when the CNAMGS scheme launches. However, it opens the door to the development of complementary health insurance, which could cover the remaining cost of services or elements not included under CNAMGS, similar to the French mutuelles system. “CNAMGS will work with private insurance firms to minimise any change in coverage for those with private insurance. The goal now is to find an equilibrium between basic and complementary insurance,” CNAMGS’ general director, Michel Mboussou, told OBG.

Fraudulent enrolments and a steep learning curve for the new activity of public health cover may be complications, yet the system is on track and bodes well for the development of Gabon’s health sector. Other countries in the region are reportedly considering a similar move and stand to benefit from Gabon’s experience.