Universal health insurance is being rolled out

As it is getting closer to realising its goal of universal health care, Gabon is focusing on decentralising national health services in an effort to make governance more effective at the local level. The country is now investing in infrastructure, although a number of challenges, such as a shortage of trained staff and the prevalence of both communicable and non-communicable diseases (NCDs), persist.

Covering the period 2011-15, the National Health Strategy (Plan National de Developpement Sanitaire, PNDS) was launched in 2010 and aims to accelerate sector reforms by improving the overall governance of health care, reducing infant and maternal mortality, introducing free maternal health care and investing in infrastructure, especially hospitals.

Towards Universal Coverage

The country has been rolling out its universal health care system, the National Insurance and Social Welfare Fund (Caisse Nationale d’Assurance Maladie et de Garantie Sociale, CNAMGS), since 2008 as part of a broader effort to improve the standard of living. Initially focused on providing insurance for the most vulnerable citizens, the programme was extended in 2011 to cover government workers. Authorities are pursuing plans to expand coverage to private sector employees, who were previously covered under the National Social Security Fund (Caisse Nationale de Sécurité Sociale, CNSS).

Dr Désiré Lasségué, director-general of CNSS, told OBG, “CNSS is still in charge of eight other files, including occupational disease, industrial accidents, sanitation and social action.” According to Dr Lasségué, the handover of responsibility began in September 2013, but to avoid a gap in the delivery of benefits during the transitional period (January 1 to June 1, 2014) the two organisations continue to collaborate, with CNSS receiving contributions on behalf of CNAMGS, which in turn distributes the benefits.

It is thus a crucial year for CNAMGS, which enjoys autonomy in administrative and financial management under the supervision of the Ministry of Social Welfare, as it finalises the enrolment of the Gabonese population in a universal health care system. The registration of private sector employees started in July 2013 and a total of 182,694 public sectors workers were enrolled in 2013. The coverage of public sector workers cost some CFA7.4bn (€11.1m), while the health expenses for 478,945 Gabonese classified as most vulnerable totalled CFA10.9bn (€16.4m).

According to Yves Picard, the director of the French Development Agency (Agence Française de Dé veloppement, AFD) in Libreville, registration of employees for larger, formal sector companies was well organised by CNAMGS, but it is harder to control the process in remote areas, for instance, for firms in the timber industry. The AFD is thus advising CNAMGS, in partnership with the World Bank, on the issue of identifying workers employed in the informal sector.

Controlling Costs

CNAMGS is partly financed through a mandatory health insurance levy (redevance obligatoire à l’assurance maladie, ROAM). Coverage for the poorest members of society is funded by a 10% levy on mobile phone companies’ turnover before tax and a 1.5% charge on international money transfers.

“We have generated financial resources that did not exist before,” Michel Mboussou, the director-general of CNAMGS, told OBG, adding that CNAMGS was divided into three separate funds: the ROAM mandatory health insurance levy for Gabon’s poor; contributions paid by public sector employers for the public sector workers’ fund; and a payroll tax on employers and employees for private sector workers.

Three separate funds mean all groups receive the same package of benefits (including medical consultation, nursing and diagnostic services, comprehensive basic maternal health care services and hospital care). Apart from maternal health, which is fully covered, the cost of medical care is reimbursed by 80-90%. Indeed, these so-called co-payments make care expensive for the poorest part of the population but are necessary to address certain financial sustainability issues.

While costs certainly need to be kept under control, co-payments could be varied according to members’ ability to pay. This payment mechanism may be partially responsible for the increasing cost of the overall system, as it is the insurer that pays, and therefore neither the patient nor the doctor has an incentive to control costs. Likewise, there is a need to avoid fraudulent enrolments and prevent the scheme from becoming a magnet for citizens of neighbouring countries. Therefore, all Gabonese citizens have been provided with a policyholder ID.

Under the insurance scheme, private employers will contribute 4.1% and employees 2.5%, while retirees’ will contribute 1.5%. Retired pensioners with an income of less than CFA80,000 (€120) per month (minimum wage) are exempt. Although the system is still a work in progress and certain aspects of CNAMGS’s operations are being fine-tuned, overall it allows for better access to health services for the population at large, and the introduction of the system is a significant achievement for the country.

Basic Health Indicators

Although Gabon has one of the highest per-capita GDPs in sub-Saharan Africa – at around $12,000, according to the IMF – there is scope for improvement with regard to basic health indicators. Health care spending as a proportion of GDP remains comparatively low, at around 3% in 2011, according to the World Bank, compared to 5% in Cameroon or 4% in Equatorial Guinea.

Non-communicable illnesses linked to demographic shifts and lifestyle changes, including cancer, hypertension (affecting 37% of the population in 2008, according to figures from the WHO), obesity (15%) and diabetes (9%), are a growing concern. Dr Ishagh El Khalef, WHO advisor on vaccination and disease in Gabon, told OBG that Gabon has not yet completed its epidemiological transition, and the country still has to address communicable diseases, such as malaria – which with a prevalence estimated at 66% remains one of the leading causes of mortality – and HIV/AIDS.

Inge Valérie Tack, the country director of UNAIDS, pointed to improvements in the number of patients covered, especially by the private sector, and changes to the threshold for starting antiretroviral treatment, which helps to reduce the risk of transmitting HIV by 96% within couples, according to one study.

Smartphones & the Private Sector

From 2015 on, the WHO is planning to use smartphones for epidemiologic surveillance with the help of UNICEF. It plans to distribute smartphones and provide training in rural communities, which can help to report information about epidemics to UNICEF.

With regard to assistance from the private sector, French energy company Total supports the German International Cooperation Agency and UNAIDS as part of its corporate social responsibility programme. In addition, Total, Singapore’s Olam, brewery Société des Brasseries du Gabon, Société d’Exploitation du Transgabonais and several mining companies have invested in their own awareness and prevention campaigns, AIDS-screening tests and treatment centres.

Infrastructure

In recent years Gabon’s health strategy has centred on heavy investment in infrastructure. Under the PNDS, the state has made a push to upgrade service quality and expand hospital capacity. The Ministry of Health (Ministère de la Santé, MS) is carrying out a renovation programme focused on Libreville, which aims to add 1000 beds by 2015. One of the main objectives of the PNDS is decentralising services. An estimated 700 facilities such as medical centres, clinics, infirmaries and dispensaries have been decentralised nationwide.

In addition, Montreal’s USI International Health Unit will train 30 health services managers in an effort to improve the management of the Mouila and Oyem regional hospital centres and the International University Centre for Research and Health at Lambaréné.

Most of the regional hospital centres are run in partnership with international firms. Austria’s VAMED has been present in Gabon since 1998 and has carried out eight hospital projects from planning to construction and manages 12 health facilities in the country. University Hospital Centre (Centre Hospitalier Universitaire, CHU) Angondjé (168 beds) and CHU Owendo (151 beds) are new facilities managed by VAMED, while Libreville Hospital Centre is being transformed into a CHU focusing on emergency services and general surgery. The CHUs will provide training programmes for students. Since 2002 VAMED has also managed the regional hospitals of Port-Gentil, Koulamoutou, Franceville, Lambaréné, Makokou and Tchibanga on behalf of the MS under a deal covering hospital administration, technical maintenance and building management. Since January 2013, VAMED has also had a contract for training post-graduate medical students.

Both for-profit and not-for-profit establishments are expanding across Gabon, although only the Bonogolo Evangelical Hospital in Ngounié and the Albert Schweitzer Hospital (ASH) in Lambaréné offer free services. ASH, which celebrates its 100-year anniversary in 2014, is one of the leading malaria research centres, according to the US National Institutes of Health, but currently has only three doctors for 80 beds. Additionally, ASH owes the state €600m and suppliers €250m, and has annual financing needs of €9m, of which only €4m is currently allocated, according to Hansjoerg Foturi, ASH’s financial director.

Investment 

Since 2010 the Gabonese government has financed more than half of the health care budget, with 6.6% of the national budget allocated to the sector in 2011. Per-capita expenditure on health has exceeded $515 since 2011. Development partners in this sphere – the WHO, UNICEF, the UN Population Fund, the African Development Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria – tend to provide technical rather than financial assistance. As an upper-middle-income country, Gabon is not entitled to receive much financial assistance.

The AFD supports the MS in the implementation of the PNDS. According to Picard, it provides cash contributions on a per-project basis. For instance, €10.5m was delivered in 2013/14 for maternal health care, focusing on equipment and infrastructure, with the funds going to the purchase of seven ambulances and the maintenance of seven maternity wards.

In March 2014 King Mohammed VI of Morocco visited the new Libreville Cancer Treatment Institute accompanied by President Ali Bongo Ondimba. The institute was created in partnership with the Lalla Salma Foundation for Cancer Prevention and Treatment and is located at the CHU Agondjé. It is equipped with a radiotherapy department, a nuclear medicine department, an outpatient chemotherapy unit, a medical physics unit, a biomedical maintenance unit, and a histopathology and tumour biology laboratory, and includes a technical ward and a hospitalisation ward with 18 beds. Moroccan medical staff are responsible for training and health care at the institute.

Statistics

Although there is a national system for health-related information, in general Gabon has a lack of relevant data and weak statistical systems. The nationwide Demographic and Health Survey (Enquête Démographique et de Santé, EDS) is helping direct governmental spending to priority areas by evaluating the weaknesses of current health coverage.

Gabon’s immunisation coverage has increased from 38% in 2006 to more than 76% in 2009, according to UNICEF, as a result of government efforts. No cases of polio or yellow fever have been detected in the country since 2008. Malaria prevalence is at 505 per 100,000, and anti-malaria treatment is free for pregnant women and children under five. Prevalence of HIV/AIDS is at 2.2% for men and at 5.8% for women, according to UNAIDS, while antiretroviral therapy coverage is estimated at 62.6% (72.7% for HIV-positive pregnant women, but only 24.4% for HIV-positive children). The under-five mortality rate is 65 per 1000 live births, according to the EDS, while the maternal mortality ratio is 230 per 100,000 live births and life expectancy at birth is 62 years, WHO data shows.

Human Resources

The health sector faces a severe shortage of qualified medical personnel and specialists. According to the MS, as of 2010 there were 12,000 people working in Gabon’s health services, with 9500 staff in the public sector. There were only six doctors and four midwives per 10,000 population. Under the PNDS, the government aims to develop human resources and implement a new hospital policy to reform hospital management and improve governance. Between 2012 and 2016 CFA881m (€1.3m) is expected to be spent to train medical personnel and CFA2.5bn (€3.8m) on reforming the National Health Institute by reviewing training programmes for nurses and midwives. At present the University of Health Sciences trains most of the country’s health professionals, although health administrators and paramedical staff are trained at other schools. According to ASH’s Foturi, 60% of specialists are currently foreigners.

Outlook 

Progress has been made, and the extension of public health insurance coverage to the most vulnerable in society is a major step forward. However, challenges such as a shortage of trained medical personnel remain, and the country still has much work to do to meet the goals set for its health care sector.