Constructing universal care: A rapidly urbanising population is shaping the sector’s future

Significant changes are under way in Gabon’s health care industry as the government works to align the system with international standards by 2025. Under its national health policy, adopted in 2010, the government aims to deliver better quality health care to its people. Construction is under way to upgrade and build new health facilities and boost access to services and supplies, while a national insurance scheme is being rolled out across the country to make the health and social protection system more accessible, especially to low-income groups. Maternal and paediatric health care has improved, but communicable diseases remain a burden on the system. Non-communicable diseases are also rising due to demographic changes and high urbanisation rates.

Although per-capita income in purchasing power parity places Gabon as one of sub-Saharan Africa’s richest nations, social indicators remain low. According to statistics from the World Health Organisation (WHO), in 2005 the average life expectancy at birth stood at 60 years for men and 64 years for women compared to a global average of 66 and 71, respectively. The adult mortality rate averaged 291 deaths per 1000 people aged between 15 and 60 compared to a global average of 176.

STRUCTURE: Most health care facilities in Gabon belong to the public sector, with quasi-public and private facilities accounting for 17.5% of the sector. The country is divided into 10 health regions which are further organised into 51 departments. Each region, excluding Libreville-Owendo, has a public central regional hospital, and each department has a number of smaller public health facilities, such as medical centres and dispensaries.

In addition to the central regional hospitals, the public sector also runs another three main hospitals: the Jeanne Ebori Foundation Hospital in Libreville, Paul Igamba Hospital in Port-Gentil and the paediatric hospital in Owendo. These are complemented by a number of medical centres scattered across the country. The quasi-public sector operates the services provided by the country’s national social security system, known as Caisse Nationale de Sécurité Sociale. The private sector is divided between for-profit and non-profit institutions. The latter include the International Medical Research Centre in Franceville, the Albert Schweitzer Hospital in Lambaréné and the Bongolo Evangelical Hospital in Ngounié, as well as dispensaries run by religious groups, non-governmental organisations (NGOs) and the High Commission for Refugees. Provision in the for-profit segment includes private hospitals, clinics, outpatient medical practices, dental surgeries, nursing centres, laboratories and pharmaceuticals wholesalers.

MATERNAL & PAEDIATRIC HEALTH: Considering Gabon’s relatively small population of 1.5m people, improving maternal and paediatric health care was a flagship promise of the 2009 presidential campaign, as well as one the main targets to achieve in the country’s Millennium Development Goals by 2015. Infant mortality rates have fallen significantly in the last 20 years, from 155 infant deaths per 1000 live births in 1990 to 52.7 per 1000 live births in 2010. The government aims to bring this number down further to 31.5 deaths per 1000 live births by 2015. Ministry of Health (MoH) statistics for 2011 revealed that prenatal infections account for nearly half of deaths among infants aged up to 11 months, followed by neonatal infections and acute diarrhoea.

Overall, WHO reported that the under-five mortality rate is estimated at 74 deaths per 1000 live births, an improvement from 93 in 1990, yet still below the global average of 57. Mortality rates during childbirth have also dropped from 600 deaths per 100,000 live births in 1990 to 420 deaths in 2010 according to statistics from the World Bank, and the country aims to meet its target of 150 deaths per 100,000 by 2015. Improving maternal and paediatric health care will require better access to basic emergency obstetrics services and boosting the number of midwives. According to WHO, there are currently as few as four midwives per 10,000 women.

DISEASE BURDEN: Communicable diseases remain the main health concern in Gabon, although the country is witnessing an epidemiological transition, with a rise of non-communicable diseases such as cancer, hypertension and diabetes. Often associated with a “Western” lifestyle, these illnesses have risen due in large part to changes in lifestyle and an important demographic shift that has seen some 86% of the population now living in urban areas.

“There has been a change through the migration of the population to urban areas, which has led to people developing a sedentary lifestyle,” General Romain Tchoua, the deputy general-director of the Military Health Service and commander of the Omar Bongo Ondimba Military Hospital, told OBG. “This shift has led to an increase of different kinds of medical problems, such as cancer, hypertension, strokes in young people and diabetes, which are chronic and non-transmissible, as well as diseases linked to high population densities and sanitary deficiencies.”

Despite the rise of non-communicable diseases, HIV/AIDS, anaemia and malaria continue to be among the main causes of death, according to the MoH. HIV/AIDS is a particular problem among adults aged 15 to 49, while anaemia has been identified as the main cause of death for children aged one to four, and malaria for children aged five to 14.

Malaria is the top reason of medical visits in Gabon among all age groups, accounting for 40-50% of diagnosed cases of fever at health care facilities, according to regional media reports. Efforts to reduce the rate of infection are under way, and include both treatment and expanded preventive measures. UNICEF reported that the use of mosquito nets increased from 18% in 2006 to 55% in 2008, while treatment rose from 41.3% to 48%. Furthermore, an anti-malarial vaccine known as RTS,S/AS01E is being developed at the research unit of the Albert Schweitzer Hospital in Lambaréné. So far testing has achieved a 56% protection against malaria and 46% against severe malaria (see analysis). HIV/AIDS PREVALENCE: The most recent figures from the MoH show that 63,000 citizens are HIV-positive. On an annual basis, an average of 5000 people contract the virus, which is the cause of death for approximately 2000 people each year. Some research shows that prevalence is falling. World Bank statistics estimate that the prevalence of HIV/AIDS fell from 8.1% to 5.4% between 2005 and 2010, although these figures are debated.

High infection rates are concentrated in the main cities of each region. According to a study carried out by the MoH in 2010, which surveyed people aged 15 to 49, the highest rate of HIV/AIDS infection was recorded in Port-Gentil, where 8.7% of the population within that age range was found to be HIV-positive, followed by Mouila (8.1%), Libreville (7.2%), Oyem (6.2%), Lambaréné (5.6%), Koula-Moutou (5.4%), Tchibanga (4.2%), Franceville (3.1%), and Makokou (3%). Adults between the ages of 30 and 34 represented the largest HIV-positive age group, accounting for about 8.3% of the population.

PREVENTIVE MEASURES: Under its Expanded Programme on Immunisation (EPI), which began in 1974, the country is looking to establish vaccination coverage. The budget allocated for the EPI was increased from CFA500m (€750,000) in 2010 to CFA700m (€1.05m) in 2011. One of the government’s main objectives is to vaccinate all infants aged up to 11 months against a number of diseases. For instance, an immunisation campaign against measles was carried out in January 2012 that inoculated some 170,000 children.

Additionally, the government runs awareness campaigns to help better control potential outbreaks. For example, the government and a number of NGOs are active in raising awareness on the importance of using mosquito nets to prevent malaria. A broad HIV/AIDS awareness campaign was carried out by the Sylvia Bongo Ondimba Foundation calling for “zero transmission, zero deaths, zero discrimination”. An extensive awareness campaign was carried out across during the African Cup of Nations (Coupe d’Afrique des Nations, CAN) that took place in early 2012, targeting younger demographics. However, prevention and awareness campaigns are still largely out of reach in rural communities.

GOVERNMENT PLANS: Gabon has instituted an ambitious national development plan under the Emerging Gabon strategy to match its health care system with international standards by 2025. Therefore, a national health plan (Plan National de Développement Sanitaire, PNDS) has been devised to give the country a boost in reaching the 2015 Millennium Goals and to accelerate reforms by improving governance in the sector, reducing infant and maternal mortality, introducing free maternal health care and investing in infrastructure, particularly hospitals, a number of which are due to be built.

To achieve its goals, the government is working with a range of development partners. The state finances health care while partners such as NGOs tend to provide technical assistance. Between 2005 and 2009, average spending on health care accounted for 5.6% of the government’s budget, well below the average 8.3% spent in sub-Saharan African nations. Gabon’s health care spending accounted for 1.4% of GDP in 2009 while the average regional rate stood at 2.1%. However, average spending rose to 6.4% of the government’s total budget in 2010 and 2011, showing a marked increase. Total spending in 2011 was estimated at CFA257bn (€385.5m).

INFRASTRUCTURE: The government is expected to spend CFA292.5bn (€438.75m) by 2016 to construct new health care facilities across the country, including four university hospital centres (centres hospitaliers universitaires, CHUs). The work is being undertaken in partnership with VAMED Management and Services, the Austrian health consulting and development group. CHU Agondjé was completed in 2011 and the next in line will be in Owendo, due to open in 2013. VAMED has been active in building and running hospitals across the country over the past decade, including the hospitals in Port-Gentil, Koulamoutou and Franceville, built in 2002; the Omar Bongo Ondimba Military Hospital in Libreville in 2005; and the regional hospitals of Lambaréné, Makokou and Tchibanga in 2008. The group is currently managing the renovations at CHU Libreville.

Works are also ongoing at the international CHU in Lambaréné in collaboration with the Albert Schweitzer Foundation, which will specialise in the research and treatment of tropical diseases and HIV/AIDS, as well as other illnesses such as tuberculosis and malaria. The work is expected to be completed in 2013, the year the Schweitzer Foundation will celebrate its 100th anniversary. Founded in 1913, the foundation treats approximately 30,000 people a year and is a major player in health care research and development. Elsewhere, the Angondjé Cancer Institute in Libreville is also due to be completed in the near future and is expected to make significant strides to allow better diagnosis of cancer.

An additional CFA58.5bn (€87.75m) will be directed to the rehabilitation of one national hospital, five regional hospitals, 38 medical and health centres, and 246 dispensaries. Libreville’s hospital is undergoing renovations to become a CHU specialising in surgery. Upgrades are expected to be completed by 2016. Owendo’s Children’s Hospital is being transformed into a CHU specialising in orthopaedics and trauma. Renovations are ongoing at the Jeanne Ebori Foundation Hospital, which will become a national centre for maternal and paediatric health by 2014.

DEVELOPING HUMAN RESOURCES: The health sector in Gabon suffers from a shortage of qualified medical personnel and specialists. Under its current health plan, the government aims to develop human resources and a new hospital policy to reform hospital management and improve governance in all regions. Therefore, the government is allocating CFA90.5m (€135,750) to develop human resources by identifying the sector’s various professional categories and determining the exact number of medical personnel needed to improve their distribution across the country and establish a computerised system for human resources management. These improvements would allow more transparency in the sector and address the shortage of medical personnel in rural parts of the country.

Furthermore, CFA881m (€1.32m) is expected to be spent between 2012 and 2016 to train medical personnel and CFA2.5bn (€3.75m) on reforming the National Health Institute by reviewing programmes for training nurses and midwives, integrating new therapeutic protocols, and taking into account maternal, neonatal and paediatric health. Finally, some CFA24.8bn (€37.2m) will be spent to establish a statistical system for data collection and reporting, and to help assign medical personnel across the sector.

PHARMACEUTICALS: The National Pharmaceuticals Office (Office Pharmaceutique National, OPN) is the wholesaler overseeing the purchase and distribution of medicines to public health centres and dispensaries. However, inefficient supply and distribution due in large part to stock disruptions and weak reporting on inventories have been problematic. Therefore, the OPN is being transformed into a central purchasing centre to supply public and private facilities and ensure better management and supply of medicines across all health care providers.

The government will spend CFA15bn (€22.5m) to ensure all health facilities have access to the medicines they need by reviewing the current legislative frame regulating pharmaceuticals products, granting health facilities higher budgets for the purchase of medicine and providing regular oversight of the list of medications required by each facility.

INSURANCE: The National Insurance and Social Welfare Fund (Caisse nationale d’assurance maladie et de garantie sociale, CNAMGS), a universal health insurance plan to provide free health care and access to medicine, is being implemented across the country. Introduced in 2007, CNAMGS is a major health care reform for the country that is modelled after similar systems in France and other European countries. It covers 80% of fees incurred for general and specialist consultation and services, outpatient care and hospitalisation, and 100% of fees incurred for maternal health care services.

“CNAMGS is a unique offering in sub-Saharan Africa and a number of African nations are seeking to implement the Gabonese model in their own countries,” Michel Mboussou, the general director of CNAMGS, said. “What makes CNAMGS unique is that besides it being a fund for health care and medicine, it is also a fund for solidarity.” The system is funded by a 10% levy on the revenue of mobile phone operators and 1.5% fee on money transfers while the state provides the rest of the funding.

Coverage is being realised in three phases. The first segment of the population to be covered by CNAMGS was the lowest socio-economic group, accounting for approximately one-third of the population, in December 2009. In January 2011, public sector employees were brought into the system. Workers contribute 2.5% of their salaries while the government contributed up to 4.1% to the scheme. Retirees, meanwhile, contribute 1.5% of their pensions. Coverage was next extended to students in October 2011. Private sector employees will be entitled to CNAMGS before the end of 2012. Teams have been deployed to rural communities since 2009 to raise awareness of CNAMGS. The number of people currently covered by CNAMGS now exceeds 600,000.

IMPACT OF CAN: The CAN football tournament had a significant impact on investment in medical services, prompting the authorities to increase capacity to respond to both the special needs of players as well as the influx of visitors.

Key among the preparations was the upgrading of health facilities and reinforcement of emergency services. “The CAN was a challenge, but also an exceptional experience for Gabon during which facilities were upgraded and emergency services were reinforced,” Jean-Damascène Khouilla, general director at the MoH, told OBG. “The Gabonese people will benefit from the investments made during the CAN.”

To enhance the emergency services system, a health commission was created for the event and more than 1000 first-aid workers were trained. New equipment was provided, including two helicopters fitted with medical equipment for each of Franceville and Libreville as well as a fleet of 14 new ambulances. Additionally, a new multipurpose heath centre was built in Bongoville and a new emergency service opened at the Libreville Hospital, while services were reinforced at the military hospital, health centres in Angondjé and the regional hospital in Franceville.

OUTLOOK: The government is committed to delivering a well-performing health care system, and the new national insurance programme is expected to play an important role in increasing access to medical services and improving results, especially for the poorest and most vulnerable segments of the population. Still, while there is progress, it is clear that Gabon has some way to go before it realises its goal of providing universal health care to all by 2025.