Elective surgery: The state is busily investing in infrastructure and new systems

In recent years, Gabon’s health strategy has centred on heavy investment in infrastructure. With a number of facilities undergoing refurbishment and expansion, two programmes – a national health survey and an initiative to strengthen local government – will give authorities a more accurate picture of the disease burden. Major challenges remain regarding both communicable and non-communicable diseases (NCDs), but efforts to set up a responsive, efficient care system should speed up progress in the coming years.

STRUCTURE: Gabon is divided into 10 health regions – the nine provinces and the capital – and 51 departments. The main concentration of facilities is in Libreville, where 40% of the population lives. The capital has several key public structures, including Libreville Hospital Centre and Jeanne Ebori Foundation Hospital. It is also home to Omar Bongo Ondimba Military Hospital, which offers free care for military personnel and fee-based services for the general public.

The government is committed to decentralising care services. Regional hospitals outside Libreville make up the second tier of public health structures. The third tier includes roughly 700 facilities, such as medical centres, general health and specialised maternal clinics, infirmaries, dispensaries and rural outposts. Quality and staffing in smaller structures varies greatly by department. The Ministry of Health (MoH) aims to create and enforce a set of norms on operating conditions, services and human resources by 2020. However, the effort to ensure quality standards is complicated by the sparse rural population. Some 86% of the population lives in urban areas, and rural structures face understaffing and interruption of supplies. The quasi-public sector plays a key role, made up of structures owned by the National Social Security Fund, which are being transferred back to the state under its reform plan and the new universal public health care scheme.

PRIVATE SECTOR: Both for-profit and not-for-profit establishments have flourished. The two main private hospitals, the Bongolo Evangelical Hospital in Ngounié and the Albert Schweitzer Hospital in Lambaréné, offer not-for-profit services. There are also not-for-profit dispensaries run by non-governmental organisations, the UN Human Rights Commission and religious organisations, as well as a network of for-profit pharmacies, medical clinics and dental clinics.

Private partners also provide critical support to government structures. For example, Austria’s VAMED has been engaged by the government to refurbish and extend four hospitals in and around Libreville. The company has been present in Gabon since the late 1990s, and today provides services for nine public facilities. While the state is responsible for funding, medication purchases and patient care, VAMED performs a variety of support services, depending on the specific location, including hospital administration, technical maintenance and building management. In 2012 the company launched a series of training seminars for current hospital employees to increase their level of training and help boost employee efficiency.

INFRASTRUCTURE: Under the National Health Strategy (Plan National de Développement Sanitaire, PNDS) adopted in 2010, the state has made a push to upgrade service quality and expand hospital capacity. World Bank figures indicate that capacity rose from 1.3 beds per 1000 people in 2008 to 6.3 in 2010. The MoH is now conducting a renovation programme, focused on Libreville, which aims to add 1000 beds by 2015.

UNIVERSITY HOSPITAL CENTRES: Specifically, the government is now working to transform five existing hospitals into University Hospital Centres (Centre Hospitalier Universitaire, CHU). A 168-bed CHU in Angondjé, a northern suburb of Libreville, was the first to open in October 2012. It will eventually offer specialised services in oncology, neurology and cardiology. The Angondjé CHU houses the country’s first dedicated cancer institute, which is now operational.

Work has also begun on a 151-bed CHU in Owendo, which will specialise in trauma and orthopaedics, while Jeanne Ebori Foundation Hospital will be turned into a 270-bed centre focused on maternal and paediatric health. Both are expected to be complete in 2015. The capital’s main hospital, Libreville Hospital Centre, is being refurbished and transformed into a CHU focused on general surgery and emergency services. Its existing emergency facilities have been rehabilitated and a new surgical block was built in 2012.

In 2011 the government committed €780,000 to build a fifth CHU in Lambaréné, which will work with the Albert Schweitzer Hospital to address tuberculosis, HIV/AIDS and malaria. The investment will help expand infrastructure, including in-patient wards and infectious disease research laboratories. Construction is expected to be complete by 2014.

In addition to offering a wider array of services and meeting international standards, the CHUs will provide research and training programmes for students. Gabon faces a shortage of qualified medical personnel to staff public facilities, which is complicated by the fact that most students go abroad for their education. The CHUs will provide training opportunities in general practice, as well as in more specialised fields such as orthopaedics, cardiology and paediatrics, which should keep more high-level personnel in the country.

Meanwhile, the introduction of a universal health insurance scheme in 2014 should ensure quality care for a broader swathe of the population. By transferring a portion of health spending to public and private employers, the government hopes to lessen out-of-pocket spending and encourage low-income citizens to seek out quality medical care (see analysis).

INVESTING: Public spending has accelerated to help meet PNDS goals. According to the World Health Organisation (WHO), health expenditure rose from 4.8% of total government spend in 2000 to 6.6% in 2011. Given government efforts to boost hospital infrastructure and launch universal health insurance, the MoH’s proposed investment budget was increased year-on-year from €63m to €89m in 2013. Most health spending came from the private sector until 2010, when public expenditure passed the 50% mark for the first time. Public spending as a percentage of total health expenditure rose by almost 10 percentage points between 2007 and 2011, from 43.9% to 53.4%.

A particularity of Gabon compared to other African countries is the very low percentage of external resources used for health. External resources dropped from 3.5% of health spend in 2007 to 1.1% in 2011.

Per capita expenditure on health grew from $409 (PPP int. $) in 2007 to $515 in 2011. This is above many other upper-middle income countries, such as Angola, with $215, and Namibia, with $365. It is also above the annual per capita expenditure of neighbours Cameroon ($128) and the Republic of the Congo ($109), but one-third of the $1643 in Equatorial Guinea.

STATISTICS: One way to improve the efficacy of public spending is to strengthen transparency, to gain a clearer sense of trends and pressure points. The sector has been held back by a lack of reliable, up-to-date statistics about disease burden and the distribution of human resources. Improving statistics-gathering is critical to avoid waste, improve prevention efforts, and reduce maternal and infant mortality. Two projects are currently under way with this in mind.

The first, a nationwide health and demographic survey (Enquête Démographique et de Santé, EDS), stands to have the more immediate impact. The first nationwide EDS was conducted in 2000, but much of the data from that is out-of-date. With support from the WHO and the African Development Bank (AfDB), including a €580,000 AfDB donation, the state carried out the second EDS across 2011 and 2012, with 9755 households interviewed. The EDS 2012, which was published in April 2013, indicates that maternal mortality during childbirth has been reduced by 39%, and infant mortality rates have been improved as well thanks to increased prevention efforts.

The results also show that the HIV prevalence rate dropped below the 5% mark for the first time. However, progress on vaccination rates was slower than expected. By highlighting the strengths and weaknesses of current health coverage, the EDS should help direct spending to priority areas.

Secondly, the MoH is working to strengthen health governance at the local level. Legislation introduced in January 2012 provides for the creation of health councils in each of the 51 departments. The councils will be responsible for keeping electronic records of births, deaths and the disease burden in each community. The data will then be centralised in an online database at ministry level. This should help adapt policies to local demands and improve the picture of the national health burden. Only a handful of councils have become operational so far, and the programme will require considerable spending on personnel and equipment. “If the system works as intended, it should allow Gabon to leap ahead on several issues, primarily the monitoring and resource allocation for maternal and infant health,” Jean Damascene Khouilla, the general director for health at the MoH, told OBG.

COMMUNICABLE DISEASES: Malaria, tuberculosis and HIV still represent the bulk of the disease burden, although NCDs are gaining ground as urbanisation and economic growth begin to change lifestyles.

Malaria is the leading cause of consultation and hospitalisation across all age groups, with 23,150 cases per 100,000 people in 2010. Health centres have distributed insecticide-treated mosquito nets to 70% of the population, accompanied by public information campaigns on usage and preventive behaviours.

Gabon has been lucky in that some of its older institutions have been particularly aggressive in looking to reduce incidences of the vector-borne disease. The Albert Schweitzer Hospital has been recognised by the US National Institutes of Health as one of the five leading facilities in Africa engaged in malaria research, and is leading clinical trials on a potential vaccine. Initial testing achieved a 56% protection rate against standard strains and 46% against severe malaria.

HIV represents less of a challenge than in many African countries, and national prevalence fell from 5.4% in 2007 to 5% in 2011, although this does not account for the large number of patients who drop out of treatment programmes. The percentage of those with advanced HIV infection who have access to antiretroviral therapy rose from 48% in 2009 to 53% in 2011.

Funding for testing and medication is available, and social or operational reasons, including stigma or the absence of dedicated civil society groups, may be behind this treatment gap. The government increased its budget for combatting HIV by 150% in 2012, and UNAIDS is currently working with the government to develop a 2013-17 investment case that will focus on community-based efforts to ensure continuity of treatment, such as equipping local health structures with smart phones to stay in touch with patients. Future investment programmes will also need to focus on high-risk population groups.

Tuberculosis presents a major challenge. Prevalence dropped from 527 cases per 100,000 population in 2000 to 450 in 2011, although, as with HIV, this may be related to the number of patients who fall out of the treatment programmes. Gabon signed a convention in March 2013 with France’s Pasteur Institute, which specialises in infectious and tropical diseases. The Institute will work with Gabonese partners, including the CENAREST public health laboratory, to study how tuberculosis has become multi-resistant and which pharmaceuticals are most effective against it.

VACCINATION: Gabon’s Expanded Vaccination Programme (Programme Élargi de Vaccination, PEV) aims to achieve 90% coverage nationwide for all antigens. The scheme saw improvements in most areas in 2012, though the national goal has not yet been met. The PEV budget rose from €750,000 in 2010 to €1.13m in 2012. Immunisation against diphtheria, pertussis and tetanus (DPT) among children aged 12-23 months has held steady at 45% in the last five years.

In 2010 DPT was replaced by the more comprehensive pentavalent vaccine, which also protects against hepatitis B, meningitis and pneumonia. Pentavalent coverage rates improved from 75% in 2011 to 82% in 2012, with 20 of 51 departments above 80%.

Measles immunisation in infants aged 12-23 months has remained at 55% in the last five years, while overall measles immunisation dipped from 72% coverage in 2011 to 71% in 2012. PEV officials signalled a measles epidemic in early 2013, with 66 cases in Libreville highlighting holes in vaccination efforts. The government announced it would launch vaccination campaigns in the near future to prevent a spread.

MATERNAL & INFANT HEALTH: Progress has been made in reducing maternal and infant mortality rates, but much remains to be done if the 2015 Millennium Development Goals (MDGs) are to be met. Prematurity and low birth weight are another major issue.

The government and private partners have pushed to increase the number of births being attended by trained professionals, and the benefits are beginning to be seen. Maternal mortality per 100,000 live births fell from 519 in 2000 to 316 in 2012, according to the WHO. Infant mortality dropped from 91 deaths per 1000 live births in 2000 to 65 in 2011.

Under-five mortality dropped from 82 deaths per 1000 live births in 2000 to 66 in 2011. In 2010 the primary cause of death in this category was prematurity (16%), followed by malaria (15%), pneumonia (11%), birth asphyxia (10%), HIV (8%) and diarrhoea (7%). Malaria, prematurity and diarrhoea have maintained the same impact, while that of HIV and measles has waned in the last decade. The MDG targets are still far off, however, and several factors continue to stymie efforts, including insufficient access to maternal health centres and a shortage of trained personnel.

NCDS: Focus on NCDs has sharpened in recent years, but no studies have yet been conducted to ascertain their full impact. Lifestyle changes accompanying economic growth have had a tangible effect; the WHO estimates that NCDs accounted for 41% of deaths among adults in 2008, with cardiovascular disease and diabetes accounting for most of these. The MoH estimates that diabetes affects up to 5% of the population. Obesity is almost three times as common in adult women than in men, so targeted prevention and awareness programmes will be needed to reduce its impact.

OUTLOOK: One of the primary challenges facing Gabon’s health sector is the shortage of trained personnel. The addition of five CHUs should create increased opportunities for in-country training, but the education system is not calibrated to the needs of the health network, and here foreign and private-sector partnerships fill a crucial need. Much remains to be done to meet Gabon’s MDGs, yet efforts to make health governance more effective at the local level should help the authorities to identify weak points in the system and allocate resources more effectively.