2018年-世界发展银行全球_Gabon_Indigents_Scheme___A_Social_Health_Insurance_Program_for_the_Poor_32页_1mb

Summary of Gabon Indigents Scheme: A Social Health Insurance Program for the Poor

Core Content

The Gabon Indigents Scheme (GIS) is a social health insurance program established in 2007 as part of a broader health financing reform in Gabon. It is designed to provide financial protection to the poorest segment of the population, who are defined as Economically Weak Gabonese (GEF), representing 33% of the total population. The GIS is managed by the National Health Insurance and Social Coverage Fund (NHISCF), which also oversees other health insurance schemes in the country.

The GIS ensures that beneficiaries have access to the same health services and benefits package as formal sector workers, without paying membership fees. This promotes equity in healthcare access. The benefits package covers 80% of common illnesses, 90% of chronic diseases, and 100% of maternity costs, with beneficiaries required to pay a 20% copayment for services.

The program is financed through an indirect tax called ROAM, which is 10% of the turnover of mobile phone companies (excluding taxes) and 1.5% of money transfers out of the CEMAC zone (excluding taxes). However, the ROAM tax was abolished in 2017, and the GIS is now funded by a Special Solidarity Contribution, which applies to individuals and legal entities with an annual turnover of at least CFAF 30 million.

Main Views and Key Information

1. Health System Overview

Gabon's health system is divided into three sectors:

• Public sector: Includes civilian and military health services, structured in a pyramidal model with three levels: peripheral (primary care), intermediate (secondary care), and central (tertiary care). The system has 6 regions and 36 health divisions, though the 2015 reorganization has not been fully implemented.
• Parapublic sector: Comprises health providers linked to the National Social Security Fund.
• Private sector: Includes for-profit and nonprofit health facilities, pharmacies, and laboratories.

2. Health Financing Trends

• Health expenditure in Gabon has increased significantly, especially after the establishment of the NHISCF.
• In 2014, government spending accounted for 68% of total health expenditure, up from 36% in 1995.
• ROAM was a major source of funding for the GIS, but its income has stagnated, raising concerns about the financial sustainability of the scheme.
• The share of direct household payments in total health expenditure has declined, indicating progress in reducing out-of-pocket spending.

3. GIS Financial Sustainability Concerns

• The exponential growth of health expenditure by GIS between 2010 and 2014, from CFAF 7,673,069,023 to CFAF 20,041,897,053, has increased the financial burden on the NHISCF.
• The stagnation of ROAM income and the slowdown in economic growth due to the oil price crisis pose serious risks to the program's long-term viability.
• Additional public resources are needed to expand coverage under the CNAMGS, but these may depend on budget prioritization and more efficient use of existing funds.

4. GIS Implementation and Impact

• The GIS has improved access to healthcare for the poor, enabling them to use the same services as the general population.
• Despite copayment requirements, the program has increased utilization of health services among the poorest.
• The GIS has also reduced the reliance on direct household payments, contributing to financial risk protection.

5. Health Challenges in Gabon

• Maternal mortality remains high at 277 per 100,000 live births, although it has declined.
• Child mortality under five is 40.5 per thousand, slightly below the 2015 MDG target of 42.6 per thousand.
• Noncommunicable diseases (NCDs) have become a major health concern, with NCDs accounting for 34.3% of current health expenditure in 2014, surpassing communicable diseases (32.3%).
• Malaria and tuberculosis remain significant public health issues, with low control measures implementation.

6. Population and Economic Context

• Gabon has a young population with an average age of 26 years, and 87% live in urban areas.
• According to the 2013 GSPH, 32.7% of the population lives in poverty, and 3% are extremely poor.
• Gabon is an upper-middle-income country, but it faces high unemployment (16.8%) and significant challenges in addressing NCDs and communicable diseases.

7. Future Directions

• The pending agenda includes improving financial sustainability, enhancing benefits package management, and strengthening accountability.
• The CNAMGS is central to achieving universal health coverage (UHC) in Gabon, and its expansion is crucial.
• Economic restructuring and tax reforms are expected to provide additional resources, but the uncertainty of economic growth remains a challenge.

Conclusion

The GIS represents a key innovation in Gabon’s health financing system, aimed at equity and financial protection for the poor. While it has made positive contributions to improving healthcare access and reducing out-of-pocket costs, financial sustainability remains a major concern due to stagnant funding sources and economic volatility. The program highlights the importance of innovative financing and political commitment to achieving UHC, but also underscores the need for efficient resource allocation and cost control measures to ensure its long-term success.