Health financing and budgeting reforms in Gabon: Progress and challenges on the road to universal health coverage

Overview

Despite significant efforts, health financing reforms in Gabon have not been fully implemented. Public funding as a share of total health expenditure increased from 40% in 2001 to 65% in 2016, resulting in a major reduction in out-of-pocket spending, which currently accounts for 24% of total health expenditure. While this represents significant progress, the funding model for health is fragile. Macroeconomic difficulties, the termination of one earmarked tax and, on the expenditure side, the predominance of use of fee-for-service payments, have further endangered the sustainability of the public funding model.

Public financial management (PFM) reforms that began in the late 1990s have not yielded all the expected results either, especially in terms of health sector spending. Significant progress has been made in strengthening budgeting and spending practices. However, in recent years, there have been challenges in implementing overall PFM measures, leading to significant disruptions in the PFM system. The adoption of programme budgets for all sectors marked a significant shift. Still, several design and implementation issues have hampered results. Budgetary programmes in health are not aligned with sector priorities, are too concentrated, and do not allow personnel to set the right spending priorities. Budget execution has dropped dramatically in recent years, mostly because of budget design flaws and complexities in spending procedures. If the programme-based approach is maintained, MoH programmes should be redefined to better reflect priorities and align with the MoH mandate on policy development and guidance. Managerial reorganization may be needed to ensure a more efficient management of programme resources. Consolidating the performance monitoring framework of the sector is also needed to ensure better accountability in the use of public resources, at all levels.