GABON CIVIL REGISTRATION AND UNIQUE IDENTIFICATION NUMBER SYSTEM FOR UNIVERSAL HEALTH COVERAGE: A CASE STUDY DISCUSSION PAPER August 2019 Karine Sahli-Majira Dominic S. Haazen Hippolyte Mahussi Togonou Bahie Mary Rassekh Samuel Mills GABON CIVIL REGISTRATION AND UNIQUE IDENTIFICATION NUMBER SYSTEM FOR UNIVERSAL HEALTH COVERAGE: A Case Study Karine Sahli-Majira, Dominic S. Haazen, Hippolyte Mahussi Togonou, Bahie Mary Rassekh, Samuel Mills August 2019 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Martin Lutalo at mlutalo@worldbank.org or Erika Yanick at eyanick@worldbank.org. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. © 2019 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition and Population (HNP) Discussion Paper Gabon Civil Registration and Unique Identification Number System for Universal Health Coverage: A Case Study Ms. Karine Sahli-Majiraa Mr. Dominic S. Haazenb Mr. Hippolyte Mahussi Togonouc Dr. Bahie Mary Rassekhd Dr. Samuel Millse a International consultant, Yaoundé, Cameroon b Health, Nutrition and Population, The World Bank, Washington, D.C., United States c International consultant, Cotonou, Benin d Health, Nutrition and Population, The World Bank, Washington, D.C., United States e Health, Nutrition and Population, The World Bank, Washington, D.C., United States Paper part of a series of country case studies that the World Bank Health, Nutrition and Population Global Practice has commissioned. Abstract: Gabon’s national health insurance program (Caisse National d’Assurance Maladie et de Garantie Sociale [CNAMGS]) coupled with medical coverage financing for the poorest has helped advance achievement of universal health coverage. In 1975, the National Social Security Fund (NSSF) was created in Gabon to guarantee the social protection of the population and enable financial contributions according to means, and benefits according to needs. In 2007, reforms of Gabon’s health financing system were instituted, including implementation of compulsory health insurance schemes through the CNAMGS. The responsibilities of the NSSF were transferred to the CNAMGS, which provides medical, maternity, and miscellaneous insurance and retirement pensions to insured persons and their dependents. In 2008, Gabon introduced an innovatively financed fund dedicated to the poor that extended health protection to economically disadvantaged Gabonese. The fund is managed by the same public institution that manages the private and public national health insurance schemes, enabling the poorest to have greater access to health services and better financial protection against health risks. The CNAMGS assigns an identification number to each insured individual, although this number does not have all the characteristics of a unique identification number (UIN). The assignment of a UIN at birth would allow linkage of the civil registration, vital statistics, and national identification systems, facilitating coordination between sectors and enabling individuals’ greater access to and efficiency in using services. Gabon is working to strengthen its national health information system (NHIS), to improve health system planning, resource management, and quality of care. By connecting all actors in the health system through information and communication technologies, the integrated NHIS would allow the sharing of health information, statistical data, and human and material resources. Keywords: Gabon, civil registration, unique identification number, universal health coverage iii Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Samuel Mills, The World Bank, 1818 H Street NW, Washington, D.C., 20433, United States, Telephone: +1-202-473-9100, Fax number: +1-202-477-6391, Email: smills@worldbank.org, Website: http://www.worldbank.org iv Table of Contents RIGHTS AND PERMISSIONS ...................................................................................... II LIST OF FIGURES ...................................................................................................... VII LIST OF TABLES ........................................................................................................ VII LIST OF ABBREVIATIONS ...................................................................................... VII ACKNOWLEDGMENTS ........................................................................................... VIII PREFACE ........................................................................................................................ IX PART I – INTRODUCTION ........................................................................................... 1 PART II – GABON’S NATIONAL HEALTH INSURANCE PROGRAM (THE CNAMGS) ......................................................................................................................... 3 2.1 HISTORY ..................................................................................................................... 3 2.2 ABOUT THE CNAMGS ............................................................................................... 3 2.3 ECONOMICALLY DISADVANTAGED GABONESE .......................................................... 4 2.4 CNAMGS: MEMBERSHIP AND RECORDING ............................................................... 4 2.5 MEMBER CATEGORIES................................................................................................ 5 2.5.1 Public Sector Members ............................................................................. 5 2.5.2 Private and Parapublic Sector Members ................................................ 5 2.5.3 EDG: The GIS ............................................................................................. 5 How does registration as an EDG work? .......................................................... 5 2.6 DOCUMENTS SPECIFIC TO EACH CATEGORY OF MEMBER .......................................... 6 PART III – FUNDING AND BASIS FOR CONTRIBUTIONS................................... 7 3.1 FINANCING OF GABON’S HEALTH SYSTEM ................................................................. 7 3.2 FINANCING OF THE CNAMGS ................................................................................... 9 3.3 EDG - IMBALANCE BETWEEN INCOME AND EXPENDITURES ...................................... 9 3.3.1 EDG Registration Although the level of fraudulently categorized EDG was relatively high, the level of actual EDG registrants was significantly higher. ............................................................................................. 10 Table 1: EDG in CNAMGS database (2018) According to Year of Registration ........................................................................................................ 11 PART IV – CIVIL REGISTRATION........................................................................... 13 4.1 BIRTHS AND DEATHS: LEGISLATIVE FRAMEWORK ................................................... 13 Extract from the Civil Code on Birth Registration........................................... 13 Extract from the Civil Code Relating to Registration of Deaths ................... 14 Extract from the Civil Code Relating to Rectification of Documents ........... 14 4.2 CRVS: BIRTH REGISTRATION RATES IN GABON ...................................................... 14 PART V – COVERAGE OF THE CNAMGS .............................................................. 16 v 5.1 COMPARISON OF CR AND NUMBERS OF BIRTHS AND DEATHS ................................. 16 5.2 POPULATION SIZE, POPULATION TRENDS, CNAMGS REGISTRATIONS .................... 16 5.3 ANALYSIS OF CNAMGS FILES ................................................................................ 16 5.3.1 Estimated Health Coverage Rate ............................................................... 17 Eligible Children................................................................................................... 17 5.3.2 Change in Apparent Number of Children Per Couple ............................. 17 5.3.3 CNAMGS Enrollment Rate According to the 2013 Census – Aged 65 and Older.................................................................................................................. 18 5.3.4 Mortality According to CNAMGS Files .................................................. 19 PART VI – THE ESTABLISHMENT OF A UIN ....................................................... 21 6.1 THE EGABON PROJECT ............................................................................................. 21 6.2 A UIN ...................................................................................................................... 21 6.3 CONTRIBUTION TO A UIN BY THE CNAMGS ........................................................... 21 6.4 CONTRIBUTION TO A UIN BY THE CIVIL REGISTRY OFFICE ...................................... 22 PART VII – CONCLUSION ......................................................................................... 23 7.1 CR AND UIN ............................................................................................................ 23 7.2 LINKS BETWEEN CR AND CNAMGS ....................................................................... 23 7.3 THE CHALLENGES OF THE NHIS .............................................................................. 23 7.4 EXPECTED EFFECTS OF THE NHIS ............................................................................ 24 REFERENCES ................................................................................................................ 25 APPENDICES ................................................................................................................. 27 APPENDIX 1: EXCERPT FROM THE CNAMGS WEBSITE .................................................. 27 Appendix 1.1: Registration in the Private and Parapublic Sector Insurance Schemes................................................................................................................... 27 Appendix 1.2: Public Sector Registration............................................................ 28 Appendix 1.3: Economically Disadvantaged Gabonese (EDG) ...................... 29 APPENDIX 2: CIVIL CODE OF GABON (PART I) ............................................................... 31 vi LIST OF FIGURES Figure 1: Age of Total Population of Gabon: 2013 ........................................................... 1 Figure 2: Per Capita Health Expenditures in Gabon: 1995–2014 .................................... 8 Figure 3: Total Per Capita Health Expenditures (USD) of African Countries, 2013 .......... 8 Figure 4: Caisse Nationale d’Assurance Maladie et de Garantie Sociale Income and Expenditures: 2011–2014 ........................................................................................9 Figure 5: Number of New Registrations of Economically Disadvantaged Gabonese: 2008–2017 .............................................................................................................11 Figure 6: Mortality (per 1000 population) from the CNAMGS Database: 2009–2017 ..... 20 LIST OF TABLES Table 1: EDG in CNAMGS database (2018) According to Year of Registration ............. 22 Table 2: EDG Registered with CNAMGS According to Type of Insured......................... 23 Table 3: Number of National Health Insurance and Social Guarantee Fund (CNAMGS) Registrations: 2008–2018 ...................................................................................... 29 Table 4: Eligible Insured and Dependents, According to Sector of Affiliation: 2008–2018 ............................................................................................................................... 30 Table 5: Insurance Status of Persons Aged 65 and Older According to Sex ................. 31 Table 6: National Health Insurance and Social Guarantee Fund Insured Persons and Recorded Deaths CNAMGS File: 2009–2017 ........................................................ 31 LIST OF ABBREVIATIONS ANINF National Agency for Digital Infrastructure and Frequencies CFAF Communauté Financière Africaine Franc (Central African franc) CNAMGS Caisse Nationale d’Assurance Maladie et de Garantie Sociale (National health insurance and social guarantee program) CR Civil registration CRVS Civil registration and vital statistics DHS Demographic and Health Survey EDG Economically disadvantaged Gabonese GIS Gabon Indigents Scheme NAG Gabonese Insured Person Number NHIS National Health Information System NSSF National Social Security Fund UHC Universal health coverage UIN Unique Identification Number WBG World Bank Group vii ACKNOWLEDGMENTS This report on Gabon, one of a series of case studies that the Health, Nutrition, andPopulation Global Practice has commissioned, provides a comprehensive view of how the Gabonese CR and identification system and the health information system has facilitated progress toward UHC. This report was prepared by Ms. Karine Sahli-Majira, Mr. Dominic S. Haazen (WBG), Mr. Hippolyte Mahussi Togonou, Dr. Bahie Mary Rassekh, and Dr. Samuel Mills (WBG). The report also benefited greatly from the input of many experts, including Ms. Carine Clert (WBG), Mr. Abdoullahi Beidou (WBG), and Ms. Mia Elisabeth Harbitz (WBG). The World Bank, Korea-World Bank Partnership Facility, and the Gavi Alliance are gratefully acknowledged for financial support. The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper. viii PREFACE The World Bank Group (WBG) Data Council endorsed the 2016–2030 Civil Registration and Vital Statistics (CRVS) Action Plan in December 2015, which has a goal of achieving universal civil registration (CR) of births, deaths, and other vital events—including reporting cause of death and providing access to legal proof of registration—for all individuals by 2030. The WBG has been working closely with development partners to provide the requisite support to countries through three interlinked initiatives: the Strategic Action Program for Addressing Development Data Gaps, Identification for Development, and the Global Financing Facility. The goal of the WBG Health, Nutrition and Population Global Practice is to contribute to the two WBG goals of ending extreme poverty within a generation and boosting shared prosperity by helping countries improve health, nutrition, and population outcomes and reduce impoverishment due to illness. Enabling countries to achieve universal health coverage (UHC) is the main way to attain this goal, by ensuring that all people have access to the health, nutrition, and population services they need without incurring financial hardship. Documentation and dissemination of CRVS-related country case studies, such as use of a unique identification number (UIN) for UHC, are critical to this process. ix PART I – INTRODUCTION Gabon, on the western coast of central Africa, has a population of 1.8 million people, of whom 87 percent reside in urban areas (Census 2013). The total fertility rate for women aged 15 to 49 years is 4.1 (3.9 urban, 6.1 rural) (DHS 2012); just over 90 percent of births take place in health facilities (DHS 2012). Under-five mortality decreased from 91 per 1,000 births in 2000 to 63 in 2012 (DHS 2012). Approximately 90 percent of adults aged 15 to 49 years are literate (DHS 2012). Gabon’s population is relatively young, with half of the total population younger than 22 (Census 2013) (figure 1). The minimum wage is 150,000 Central African francs (CFAF) (including CFAF70,000 in bonuses and allowances) per month, one of the highest in Africa. Gabon’s oil revenues have contributed to its higher per capita income than in other countries in sub-Saharan Africa, although income inequality has led to significant poverty in much of the population. Nearly 20 percent of the population is foreign (Census 2013). Foreigners residing in Gabon, two-thirds of whom are male, mainly work as laborers and come mostly from such countries as Cameroon, Mali, Senegal, Benin, and Nigeria. This large proportion of foreigners in the resident population raises questions about health and social protection, because the CRVS system includes only Gabonese nationals. In terms of health financing, Gabon spent approximately 3.8 percent of its gross domestic product on health in 2013; the regional sub-Saharan Africa regional average was 6.2 percent, and the average for countries with similar income was 6.1 percent. In 2012, health spending per capita in Gabon (~USD441) was higher than in neighboring countries (~USD153) (Mibindzou Mouelet et al. 2018). Figure 1: Age of Total Population of Gabon: 2013 Source: Gabon Census 2013 1 Gabon is working to strengthen its national health information system (NHIS), with the objective of improving health system planning, resource management, and quality of care. This work is being implemented in collaboration with the Ministry of Health, the National Agency for Digital Infrastructure and Frequencies (ANINF), and the national health insurance program (Caisse National d’Assurance Maladie et de Garantie Sociale [CNAMGS]). The CNAMGS assigns an identification number (Gabonese Insured Person Number [NAG]) to each insured individual, although this NAG does not have all the characteristics of a UIN; a national UIN is usually rooted in a civil registry (CR), which is not the case in Gabon. Therefore, the NAG can be strengthened by improving the linkages between the NAG and the CR, in effect using the NAG as the national UIN. The National Social Security Fund (NSSF) was created in 1975 with the objective of guaranteeing the social protection of the population and enabling financial contributions according to means and benefits according to needs. In 2007, reforms of Gabon’s health financing system were instituted, including compulsory health insurance schemes being implemented through the CNAMGS. The responsibilities of the NSSF were transferred to the CNAMGS, which provides medical, maternity, and miscellaneous insurance and retirement pensions to insured persons and their dependents. In 2008, Gabon introduced a fund dedicated to the poor that extended health protection to economically disadvantaged Gabonese (EDG). This fund is innovatively financed as explained below, and the public institution that manages the other national health insurance schemes manages it, enabling the poorest to have greater access to health services and more effective financial protection against health risks. 2 PART II – GABON’S NATIONAL HEALTH INSURANCE PROGRAM (THE CNAMGS) 2.1 HISTORY The CNAMGS was established in 2007. Originally, there were two funds: the NSSF, created in 1975 for private sector employees, and the National Social Guarantee Fund, for government employees and EDG. 1 The policy of free care for the Gabonese population was established with Act 3/91 of March 26, 1991, which guarantees free care for civil servants in government structures. Private sector employees have health coverage financed solely by employer contributions of 4.1 percent of wages. The National Social Guarantee Fund covers individuals who have a contract with the government, self- employed individuals, and indigent workers through a state subsidy. Compulsory universal health insurance is provided in Gabon as part of the social protection system reform that the Gabonese government initiated in 2002. Private household expenditures, primarily consisting of out-of-pocket payments to hospitals, increased from 34 percent to 52 percent between 1997 and 2001 (Mibindzou Mouelet et al. 2018). In 2004, President Omar Bongo Ondimba requested a study of the feasibility of providing compulsory universal health insurance. He created the CNAMGS to provide health insurance and social security for the poor, which had been the responsibility of the health and medical branch of the NSSF. The NSSF was largely financed through the state budget and was closed because of insufficient funds, mismanagement, and the Gabonese economic crisis of the early 2000s (Mibindzou Mouelet et al. 2018). Ordinance 002/PR/2007, dated January 4, 2007, established the Compulsory Health Insurance and Social Security Scheme to increase access to quality health care, and the Gabon Indigents Scheme (GIS) was established under this scheme. In 2011, Omar Bongo’s son and successor as president, Ali Bongo, extended the Compulsory Health Insurance and Social Security Scheme to public sector workers and, in 2013, to private sector workers, who had been covered under the NSSF. 2.2 ABOUT THE CNAMGS The goal of the CNAMGS is to increase access to health care, to reduce health costs, pool financial resources, avoid the use of informal medicine, decrease poverty, increase social inclusion, improve the health of the most vulnerable populations, and improve care by contracting with health facilities to provide services (Mibindzou Mouelet et al. 2018). 1 Ordinance 002/PR/2007 of January 4, 2007, established a compulsory health insurance and social security scheme (CNAMGS), and Ordinance 001/PR/2007 of January 4, 2007, established the system of family benefits for EDG and assigned its management to the CNAMGS. It was envisaged that these two funds would manage compulsory universal health insurance, but because of lack of consensus, the related draft law was not adopted. Based on reports of the Inter-African Conference on Social Security and the statutory auditors, it is recommended that a body specifically responsible for management of health insurance be created and that the National Social Guarantee Fund be liquidated. 3 The Ministry of Labor, Employment, and Social Welfare supervises the CNAMGS. The Ministry of Health provides health services through public health facilities and regulates care by defining standards and other guidelines. The CNAMGS has a board of directors consisting of representatives of the government, employers, and employees and is headed by a director general with the assistance of three deputy general managers, all appointed by the president on recommendation of the board of directors. The health facilities that provide services have the following characteristics: they are public or private; provide services at the primary, secondary, and tertiary levels; are accredited by the CNAMGS; and sign a partnership agreement with the CNAMGS. There were 325 providers by the end of 2014, including 99 private clinics and medical centers, 97 public hospitals and medical centers, 30 military hospitals and medical centers, and 99 pharmacies and dispensaries (Mibindzou Mouelet et al. 2018). 2.3 ECONOMICALLY DISADVANTAGED GABONESE In 2007, the CNAMGS was established to increase access to quality health care, and the EDG fund (the GIS) was established (Mibindzou Mouelet et al. 2018). Exclusively covering EDG, who account for approximately one-third of the population, the GIS is innovatively financed. On December 19, 2008, CNAMGS health insurance cards were provided to EDG, providing easier access to health care. During the Ali Bongo era (since 2011), the family allowance for EDG was increased from CFAF1,000 per child per month to CFAF4,000. Recently, this amount increased to CFAF5,000. To be recognized as an EDG and eligible for the GIS, one must be Gabonese, be aged 16 or older and have an income of less than the minimum wage (CFAF150,000/month). Children younger than 16 can be included on their parents’ insurance as beneficiaries and pay a user fee depending on the type of service used. 2.4 CNAMGS: MEMBERSHIP AND RECORDING The following is an extract from the CNAMGS website, translated into English (text available in Appendix 1). “Recording is based on the biometric data of each taxable person and his successors in title. After a photograph and fingerprints are taken, civil registration information is entered, and an identification number, the Gabonese Insured Person Number (NAG) is assigned, a receipt for the card is given to the insured., and later he will receive a biometric card. Why should you register? As with any social security organization, registration is important. It consists in registering the person who are in our files: it is the gateway to the CNAMGS. Even if you contribute, the CNAMGS cannot cover you if you are not registered. 4 “WARNING The physical presence of the principal insured is mandatory at the time of registration, as well as that of the beneficiaries (spouse and children aged 6 to 20 years). Children younger than 6 are exempt from this physical presence; they are registered upon presentation of the required documents.” 2.5 MEMBER CATEGORIES There are three main categories of CNAMGS members: public sector employees, private and parapublic sector employees, and EDG. 2.5.1 Public Sector Members Public sector members (active or retired workers) include: • Government officials and contractors • Individuals receiving a pension or a survivor's pension from the Treasury • Security and defense force agents • Paramilitary corps agents • Judiciary corps • Parliamentarians • Constitutional institution members 2.5.2 Private and Parapublic Sector Members Private and parapublic sector members (active or retired workers) include: • Private and parapublic sector employees • Nonpermanent state employees • Self-employed individuals • Private and parapublic sector retirees including those who purchase insurance voluntarily 2.5.3 EDG: The GIS The GIS, which covers only EDG, provides EDG with access to the same providers and benefits package that other insured persons have access to, although GIS beneficiaries do not have to pay membership fees. They pay a copayment for some services. The GIS covers 100 percent of maternity costs, 90 percent of costs for chronic diseases, and 80 percent of other medical expenses, with the remaining 10 percent or 20 percent being paid out of pocket (Mibindzou Mouelet et al. 2018). There has been an increase in the use of services by EDG and a decrease in direct household payments as a share of total health expenditures since the CNAMGS was established. How does registration as an EDG work? Increasing numbers of people are applying to be recognized as EDG, and the number of unqualified registrations is increasing. The following steps have been introduced to help decrease the likelihood of an unqualified registration being accepted. The applicant first fills out a status application form with the CNAMGS. The individual must show a birth certificate, an identity document, and a residence certificate. The CNAMGS conducts an investigation to verify that the applicant meets the EDG criteria, after which a 5 committee meets to decide whether to grant the applicant EDG status. If status is granted, the applicant is invited to register and then to register any beneficiaries. 2.6 DOCUMENTS SPECIFIC TO EACH CATEGORY OF MEMBER The complete list of documents that must be submitted varies depending on whether the person is the principal insured or a beneficiary. Beneficiaries must present an authenticated birth certificate (or an original and an authenticated copy) and a copy of the CNAMGS card of the principal insured. Other documents must be provided according to each individual’s situation. Some examples of documents include a copy of a pay stub, a copy of a pension certificate, a copy of a marriage certificate, an adoption order, and a certificate of nationality. Any person registered with the CNAMGS must present an original birth certificate (or a judgment replacing his birth certificate). The principal insured EDG and all dependents must provide documents identical to those of people registering for the private and public insurance schemes. 6 PART III – FUNDING AND BASIS FOR CONTRIBUTIONS 3.1 FINANCING OF GABON’S HEALTH SYSTEM Gabon’s per capita health spending was higher than that of neighboring countries in 2012, at approximately USD441 (Mibindzou Mouelet et al. 2018). However, as a percentage, it spent approximately 3.8 percent of its gross domestic product on health in 2013; the sub- Saharan Africa regional average was 6.2 percent, and that of countries with similar average income was 6.1 percent. Therefore, it could spend a greater percentage of its gross domestic product on health. The three main sources of funding for Gabon’s health system are the national government, health insurance contributions by employers and employees and some private insurers, and private expenditures (including out-of-pocket expenditures by households and institutional spending). Between 1995 and 2014, the share of public spending grew from 36 percent of total health care spending to 68 percent (figure 2). Public spending for health significantly increased due in large part to the contribution of the establishment of the CNAMGS. With the formation of the national insurance program, the share of household direct payments in health financing decreased. On January 29, 2015, the Council of Ministers decided to reduce contribution rates for contributors associated with the compulsory health insurance and social security scheme. These are people insured in the public, parapublic, and private sectors (4.1 percent for employers [unchanged], 1.0 percent for employees [down from 2.5 percent], and 0.5 percent for retirees [down from 1.5 percent]). The portion of the monthly salary subject to contributions was capped at CFAF2.5 million. 7 Figure 2: Per Capita Health Expenditures in Gabon: 1995–2014 Source: Based on World Health Organization Health Accounts Database as found in Mibindzou Mouelet et al. 2018 Figure 3: Total Per Capita Health Expenditures (USD) of African Countries, 2013 Source: Based on 2014 National Health Accounts, as found in Mibindzou Mouelet et al. 2018 At of the end of April 2018, the CNAMGS comprised three funds: 1) the health insurance fund for public servants; 2) the fund for salaried workers in the private and semipublic sectors, self-employed workers, commercial and other professions; and 3) the social guarantee fund for EDG, students, and refugees. How to finance the EDG fund remains a challenge. 8 3.2 FINANCING OF THE CNAMGS The CNAMGS, which receives its funds from the Ministry of Finance and the public treasury, is the funding agent of the GIS. The public treasury funds the CNAMGS from the Redevance Obligatoire a l’Assurance Maladie, a compulsory tax of 10 percent of the turnover (excluding taxes) of mobile telephone companies and 1.5 percent of money transfers out of the Economic and Monetary Community of the Central Africa zone (excluding taxes) (Mibindzou Mouelet et al. 2018), such as via Western Union and MoneyGram (Obounou 2017). Each of the three plans that the CNAMGS administers (state public employee fund, private sector employee fund, GIS) has its own sources of funding and covers only its own affiliates’ 2 expenses; each fund also contributes to CNAMGS operating costs. All three CNAMGS funds are run according to the principles of a third-party payer for financing demand for health care (Mibindzou Mouelet et al. 2018). Health facilities are paid for the services that the GIS provides for its members and their beneficiaries. The CNAMGS verifies the validity of services and controls provider invoices (Mibindzou Mouelet et al. 2018). 3.3 EDG - IMBALANCE BETWEEN INCOME AND EXPENDITURES The dedicated fee system that is used to fund the GIS, which brings CFAF20 billion (USD34 million) per year into the GIS, was sufficient for the GIS during its early years, but the financial sustainability of this model is being questioned because of recent trends in revenues and expenditures, as the ratio between these two has been decreasing. The systems for civil servants and formal private sector workers are self-sufficient based on built-in contributions. Releases from the tax and treasury departments for the GIS have reportedly faced delays, which affects the funds’ credibility. The number of EDG affiliated with the CNAMGS is increasing sharply, and incomes are stagnating. Health expenditures increased from CFAF7.7 billion in 2010 to CFAF20 billion in 2014, equivalent to 55 percent of CNAMGS expenditures in 2014 (Mibindzou Mouelet et al. 2018). Expenditures are increasing because of the increase in the number of EDG combined with greater use of health care and claims for benefits. Revenues from the Redevance Obligatoire a l’Assurance Maladie are stagnant, and the accumulated unpaid contributions are high. Several mobile telephone operators do not pay their fees to the CNAMGS or pay after a long delay. Figure 4: Caisse Nationale d’Assurance Maladie et de Garantie Sociale Income and Expenditures: 2011–2014 2 In this document, affiliate refers to someone covered under a particular insurance scheme. 9 Source: Mibindzou Mouelet et al. 2018 The level of fraudulently categorized EDG is estimated to be relatively high. If an individual has been categorized as an EDG but is also employed, expenses may be paid twice, which can cause the state to lose hundreds of millions of CFAF. In an effort to verify the list of EDG, the CNAMGS checked the list of affiliated EDG, crosschecking their files with those of the NSSF, the Directorate of the Balance, and the former Business Development Center, which helped entrepreneurs create businesses and facilitate administrative procedures. In 2016, there were 12,642 duplicate principal insureds and 14,959 duplicate children in the NSSF and 129 duplicate principal insureds and 17 duplicate children in the Balance file. The cross-referencing uncovered 90,000 fictitious children registered in the balance file with false birth certificates. To limit fraudulent registrations, the Director General of CNAMGS announced the creation of a fund for self-employed individuals and small economic operators in the informal sector, as well as a broad public campaign to inform the population of the risks of making false statements. In March 2018, the Minister of the Budget and Public Accounts declared that, in accordance with the provisions of Articles 1 and 3 of the decree of March 2, 2015, on contribution rates and the ceiling on salaries subject to contribution by members of the public, parapublic, and private sectors to the Compulsory Health Insurance and Social Security Scheme, CNAMGS contributions would be levied on salaries at a rate of 1 percent. 3.3.1 EDG Registration Although the level of fraudulently categorized EDG was relatively high, the level of actual EDG registrants was significantly higher. 10 Table 1: EDG in CNAMGS database (2018) According to Year of Registration Year of Cumulative number of Number of EDG registration EDG 2008 2,744 2,744 2009 92,736 95,480 2010 262,770 358,250 2011 38,687 396,937 2012 16,310 413,247 2013 24,578 437,825 2014 25,058 462,883 2015 94,351 557,234 2016 17,048 574,282 2017 12,749 587,031 In April 2018, over half a million people were registered in the GIS. Gabon conducted EDG registration campaigns which generated enthusiasm among the population; nearly 100,000 new EDG enrolled with the CNAMGS in 2015 alone, and cumulatively over 587,000 EDG had registered by 2017 (table 1). Figure 5: Number of New Registrations of Economically Disadvantaged Gabonese: 2008–2017 300,000 262,770 250,000 200,000 150,000 92,736 94,351 100,000 50,000 38,687 24,578 25,058 17,048 16,310 12,749 2,744 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source: CNAMGS data (files provided by year of registration) 11 Table 2: EDG Registered with CNAMGS According to Type of Insured Type of insured Percent EDG Principal insured 50.1 Principal insured student 5.3 Student without principal insured rights 1.4 Religious principal insured <0.1 Beneficiary1 43.2 1The law authorizes the CNAMGS to extend health coverage to students and children under this fund, although not all are strictly considered to be EDG. 12 PART IV – CIVIL REGISTRATION CR is the “universal, continuous, permanent, compulsory recording of vital events occurring in a country’s population according to the legal requirements of each country” (United Nations 2014). It is the basis for identification of every individual at any time in the person’s educational, administrative, and social life. Registration begins with issuance of a birth certificate. Any individual who was not registered at birth will have to obtain a judgment to establish legal identification. CR is necessary in establishing the following: • The CNAMGS base (for affiliates and their beneficiaries) • The NHIS with a unique identifier • Universal social coverage system • The retirement pension base • National identity cards • The electoral file 4.1 BIRTHS AND DEATHS: LEGISLATIVE FRAMEWORK According to Article 158 of the Civil Code of Gabon, CR records are registered in each CR center in one or more registers that the President of the Civil Court numbers and initials as approval. Copies are deposited at the registry of the regional court, the town hall or the district capital, and with the Ministry of the Interior. The Ministry of Foreign Affairs manages registers that Gabon's diplomatic or consular officers retain and provides a copy. Extract from the Civil Code on Birth Registration The following articles from the CR Code illustrate the legislative aspects of birth registration, which allows citizens to obtain birth certificates proving their identity and filiation (see Appendix 2). Article 162: “In the event of the nonexistence, loss, or destruction of records, or if such records are deficient, proof thereof shall be received by title or by witnesses. In these cases, marriages, births, deaths, and other facts can be proved using domestic registers and documents or witnesses.” Article 167: “The birth certificate shall state the date, place, and if possible, time of birth; sex; given names; and surname of the child; the given names, surnames, ages, places of birth, professions, and domicile of the father and mother; and where applicable, the surname, first names, profession, and domicile of the declarant.” Article 169: “Birth declarations are made to the Civil Registrar within three days of delivery for children born in villages and district capitals and in other cases within one month.” Article 170: “The heads of rural areas shall ensure that births in their constituencies are registered at the nearest CR center within the time limits provided for in this code.” Article 172: “If the birth of a child has not been declared within the legal time limit and subject to the provisions of the preceding article, the Civil Registrar may record it only by 13 transcribing a judgment of the civil court containing, insofar as they may be established or presumed, the particulars provided for in article 167 of this chapter.” The competent court and civil registrar are those of the person's place of birth. If this place is unknown, the competent court is the court of the applicant's domicile, and that court decides where the judgment will be transcribed. If the date of birth is certain or presumed, as opposed to it not being known, the judgment includes that date in the margins of the CR registers. The following extracts from the Civil Code describe the process for the continuous updating of the files that the government maintains, such as pension files, files of insured persons and their beneficiaries, identity card files, and electoral files. Extract from the Civil Code Relating to Registration of Deaths Article 179: “The Civil Registrar of the municipality or area where the death took place shall draw up the death certificate on the declaration of a relative of the deceased or the person with the most accurate and complete information on the CR of the deceased. In the event of death in a hospital, health or educational establishment, hotel, or similar public or private institution, the directors of such an establishment shall make the declaration of death.” Article 180: “The death certificate shall be drawn up within 24 hours of the issuance of the burial permit. Except in cases stipulated in the police regulations, burial may not take place until 24 hours after death.” Article 181: “The death certificate states: (1) the date, place, and if possible, time of death; (2) the given names, surname, date and place of birth, profession, and domicile of the deceased person; (3) the given names, surnames, professions, and domicile of the father and mother; (4) the full name, date, and place of birth of the deceased person's spouse if that spouse is alive and the date of the marriage.” Extract from the Civil Code Relating to Rectification of Documents Article 189: “Civil status documents may only be corrected by virtue of a judgment given by the court of the place where the document was drawn up.” Article 193: “Each Civil Registrar shall keep a special register in which shall be mentioned, in chronological order, the supplementary or amending judgments of CR records.” These excerpts from the Civil Code describe CR. It is then necessary to inform the population on the importance of the events being recorded. The offices in charge of CR should facilitate the CR of citizens. 4.2 CRVS: BIRTH REGISTRATION RATES IN GABON Well-functioning CRVS systems are the best continuous source of demographic data. When accurate CR data are compiled into vital statistics, they provide continuous data at the national and lower administrative levels. 14 The 2009 annual report on the situation of women and children in Gabon (Gabon MOH 2009) highlights that, at the beginning of the program in 2007, approximately 30 percent of Gabonese children did not have a birth certificate and that the children most affected were those of indigenous populations. A study conducted in a few villages that had a high proportion of indigenous populations showed that 93 percent of children there were not registered. When childbirth took place at home in a rural community, the likelihood was lower that a birth certificate would be generated. Parents also did not always see the necessity of registering births, and when they did, the remoteness of administrative sites and the onerous administrative procedures dissuaded them. In 2012, Demographic and Health Survey (DHS) data indicated that there were great improvements in registration of child births. Nationally, 90 percent of children five years of age and under had been registered; 72 percent of these children had a birth certificate. The proportion of children whose birth was registered did not vary greatly according to age or sex. The proportion of girls (70 percent) and boys (73 percent) with a birth certificate was similar. Seventy-four percent of children in rural areas and 71 percent in urban areas were registered. Eighty-six percent of children in households in the highest wealth quintile and 92 percent in the lowest quintile were registered, and 72 percent of children in households in the highest wealth quintile and 75 percent in the lowest quintile had a birth certificate (DHS 2012). There is some variation by province in terms of registration of births (the range is 80 percent to 96 percent) and children possessing a birth certificate (the range is 57 percent to 88 percent). In Nyanga Province, for example, 92 percent of births were registered, and 88 percent of children had birth certificates. In Estuaire Province, not including Libreville, 80 percent of births were registered, and 64 percent of children had birth certificates (DHS 2012). 15 PART V – COVERAGE OF THE CNAMGS 5.1 COMPARISON OF CR AND NUMBERS OF BIRTHS AND DEATHS Neither the Directorate General of Statistics nor the administrative authorities in charge of civil registers publish birth and death vital statistics. The official reference documents used are the published population censuses and the DHS. In the below section, the annual numbers of births and deaths are taken from these two sources (DHS 2012; Census 2013). The numbers of births and deaths are estimated for subsequent years based on these two sources of demographic data. These estimates are then compared with statistics extracted from CNAMGS files to assess the population health and social coverage rate. The purpose of such comparisons is to assess the rate of health coverage. 5.2 POPULATION SIZE, POPULATION TRENDS, CNAMGS REGISTRATIONS Gabon had a population of 1,811,079 in 2013, up from 1,014,976 in 1993. This represents a growth rate of 2.9 percent on average per year, of which 2.5 percent (an increase of approximately 43,000 inhabitants per year) can be attributed to the difference between birth and death rates, and 0.4 percent (an increase of approximately 11,000 inhabitants per year) can be due to net migration (Census 2013). 5.3 ANALYSIS OF CNAMGS FILES The data that the CNAMGS provide are from new registrations that have been added since the creation of the fund in 2008. Individuals and pensioners registered with the preexisting funds, the NSSF (for the private sector), and the Caisse Nationale de Garantie Sociale, which primarily serves civil servants and EDG, were in principle transferred to the CNAMGS, which covers all insured persons. Because the CNAMGS is the only national health insurance 3 everyone with insurance is registered through the same overall system. For example, if one parent is affiliated as a civil servant, and the other parent is affiliated in the private sector, they are both registered in the CNAMGS files. A child of the couple is therefore to be registered only once. The entry of new members and removal of individuals (for example, due to deaths and removal for other reasons) change the total number of CNAMGS members; however, transition from a government office or private sector to another does not change the total number of members because the CNAMGS provides health insurance for all sectors of the population. 3Except for insurance that foreigners take out on an individual or family basis with, for example, the Caisse des Français à l'Etranger. These exceptions do not apply to Gabonese nationals. 16 5.3.1 Estimated Health Coverage Rate The data in table 3 are presented as a summary of the CNAMGS’s 11 annual files from 2008 to 2018. At the beginning of 2018, the number of CNAMGS members exceeded one million out of a total estimated Gabonese population of approximately 2 million. Excluding all foreigners (insured or uninsured), the current coverage rate of the Gabonese population is estimated to be 65 percent. EDG represent more than half of the registered population and approximately one-third of the Gabonese population excluding foreigners. Table 3: Number of National Health Insurance and Social Guarantee Fund (CNAMGS) Registrations: 2008–2018 Registrations Economically Public Private Information Total disadvantaged funds sector incomplete1 Gabonese funds funds Principal insured 346,244 97,678 120,685 1,178 565,785 Spouse (beneficiary) 1,286 6,691 5,885 2 13,864 Child (beneficiary) 239,501 163,930 92,222 266 495,919 Total 587,031 268,299 218,792 1,446 1,075,56 8 Number of insured 0.69 1.70 0.76 0.23 0.88 children per principal insured2 Source: CNAMGS data, calculations by authors 1 In particular on place of birth 2 Number of children insured divided by number of principal insured A new registrant may be a principal insured or a beneficiary (spouse, newborn, child not yet registered). The cumulative number of eligible children, regardless of year of registration, represents all registered children of the principal insured. Eligible Children The average ratio of beneficiary children to principal insured from the public funds is more than twice those of the private sector funds or the EDG funds. The average number of live births per woman is 4.1 (DHS 2012). Some insured have no dependent children. 5.3.2 Change in Apparent Number of Children Per Couple The ratio of child beneficiaries to principal insured changes each year and is different by sector of those insured. Table 4 shows the average number of eligible children according to the sector with which the principle insured is affiliated. In the first years of the CNAMGS, from 2008 to 2012, differences between the number of children per insured person (and spouse) according to sector were small. 17 Table 4: Eligible Insured and Dependents, According to Sector of Affiliation: 2008– 2018 Year Public sector Private sector Economically Disadvantaged Gabonese Insured Children Average Insured Children Average Insured Children Average and number of and number of and number of spouse children spouse children spouse children 2008 53 63 1.2 155 123 0.8 1,838 906 0.5 2009 2,607 3,434 1.3 4,646 3,684 0.8 60,323 32,413 0.5 2010 42,200 33,244 0.8 9,027 7,291 0.8 160,934 101,836 0.6 2011 22,870 33,169 1.5 1,748 1,629 0.9 21,723 16,964 0.8 2012 11,508 14,047 1.2 483 680 1.4 5,389 10,921 2.0 2013 8,861 15,659 1.8 55,989 25,082 0.4 9,149 15,429 1.7 2014 7,061 25,853 3.7 27,886 25,853 0.9 11,980 13,078 1.1 2015 5,014 17,962 3.6 13,919 12,698 0.9 62,964 31,387 0.5 2016 2,445 10,211 4.2 8,331 8,676 1.0 8,101 8,947 1.1 2017 1,750 9,381 5.4 4,386 6,506 1.5 5,129 7,620 1.5 2018 31 168 5.4 135 150 1.1 94 28 0.3 5.3.3 CNAMGS Enrollment Rate According to the 2013 Census – Aged 65 and Older As with children, the health and social coverage rate for people aged 65 and older must be determined. Data for table 5 and the accompanying text are taken from the 2013 Census and are relevant to people aged 65 and older. Insurance Coverage, Disability, and Care for Elderly Adults Insurance coverage for adults aged 65 and older is widespread, although not universal. Seventy-two percent are insured, with women (74 percent) slightly more likely than men (70 percent) to be insured. The 2013 Census indicated that 72 percent of the population aged 65 and older had CNAMGS insurance, compared with 65 percent of the total population. A slightly greater proportion of women aged 65 and older are insured than of men in the same age group. 18 Table 5: Insurance Status of Persons Aged 65 and Older According to Sex Status Men Women Total Men Women Total Number Percent Insured 19,563 31,357 50,920 70.1 73.8 72.3 Not insured 4,611 6,086 10,697 16.5 14.3 15.2 Not reported 3,748 5,074 8,822 13.4 11.9 12.5 Total 27,922 42,517 70,439 100.0 100.0 100.0 Source: Census 2013 5.3.4 Mortality According to CNAMGS Files Table 6 shows the number of deaths recorded per year between 2009 and 2017 and the number of insured persons. 1,076,183 insured persons were registered at the beginning of 2018 and 1,996 cumulative deaths were recorded in the CNAMGS files during the period of 2009 to 2017. Table 6: National Health Insurance and Social Guarantee Fund Insured Persons and Recorded Deaths CNAMGS File: 2009–2017 2009 2010 2011 2012 2013 2014 2015 2016 2017 Deaths, n 577 1,177 52 85 45 5 13 11 0 Insured 107,271 354,721 98,232 43,054 130,238 112,668 144,500 46,797 34,854 persons, n Cumulative 577 1,754 1,806 1,892 1,937 1,942 1,955 1,966 1,966 deaths, n Cumulative 110,5051 465,226 563,458 606,512 736,750 849,418 993,918 1,040,715 1,075,569 insured persons, n Mortality 5.4 3.3 0.5 2.0 0.3 0.04 0.1 0.2 0.0 per 1000 1Including 3,234 affiliates at the end of 2008 Population data were estimated from 2013 Census data. Other data were extracted from CNAMGS files. Source: Table 6 is based on the data extracted from CNAMGS files Figure 6 depicts the data from table 6 (affiliates and recorded deaths and annual mortality based on the CNAMGS data. Approximately 2,000 deaths over nine years are recorded in the CNAMGS (2009-2017) files, an average of just over 222 deaths per year, for a mid-term membership value of 592,000. This translates to an average annual mortality of less than 0.5 per thousand members. Crude mortality, according to the results of the 2012 DHS, is slightly less than 10 deaths per thousand inhabitants. Therefore, deaths in the CNAMGS database are likely under-reported. 19 Figure 6: Mortality (per 1000 population) from the CNAMGS Database: 2009– 2017 Source: CNAMGS database 20 PART VI – THE ESTABLISHMENT OF A UIN 6.1 THE EGABON PROJECT E-health refers to health information and services delivered or enhanced through the internet and related technologies (Eysenback 2001) and includes the public and private sectors. In 2016, the eGabon Project was approved to support the delivery and management of public health services by improving the timeliness and availability of information and to promote information and communication technology services, including the development and introduction of e-health applications and services (World Bank 2016; Hurpy 2019), to better meet the needs of medical staff and health system administrators by establishing a new NHIS that uses information and communication technologies. 6.2 A UIN The NHIS is integrated into the eGabon project. Its implementation is based on assigning each citizen a UIN. The CNAMGS will thus have a UIN for each individual (not only for its members) enabling health and social information to be continuously updated for all individuals, regardless of their status. Ideally, when CR and civil identification systems are well-integrated, the UIN assigned to each individual at birth can yield several benefits. It accounts for the flow of people into and out of the identification management system such that a birth registration with the CR leads to the creation of an identity in the civil identification management system, and death registration with the CR in turn cancels that identity from the identification management system. It further enables continuous updating of an individual’s vital events information throughout the life cycle and can facilitate the efficient exchange of reliable data between institutions for identity verification purposes, which ultimately results in improved public and private service delivery. In the CR system in Gabon, if a UIN was established, it could contribute to a comprehensive and secure integrated system that would give every Gabonese citizen and resident a unique national identification number. This UIN would be useful for citizens in gaining access to social services such as education, health, and social welfare. A UIN would contribute to achievement of UHC by enabling greater effectiveness and efficiency of the system’s administration, better health services, better treatment and follow-up, better claims management processes, and a strong UHC database. Gabon has not established a UIN system, but this work is underway. 6.3 CONTRIBUTION TO A UIN BY THE CNAMGS At the time of each registration, the CNAMGS records information contained in an affiliate's birth certificate and creates a 10-digit unique identifier, called the NAG, for each principal insured and each beneficiary. The CNAMGS file contains information on year, 21 province, department, and commune of birth and information extracted from the birth certificate (when one has been presented), including a birth certificate number. The CNAMGS also records biometric data (facial photography, fingerprints) for the principal insured and beneficiaries. Although fingerprints are taken, the automated fingerprint identification system for tracking duplicates is not in place. The NAG and data can be used in the establishment of a UIN in Gabon. However, the transcription of the information given in CR documents is not uniform from one registration to another. 6.4 CONTRIBUTION TO A UIN BY THE CIVIL REGISTRY OFFICE Civil registers are kept in the nine provinces, 48 departments, 56 communes, and 152 cantons. Each of the CR centers keeps annual registers. CR records indicate the type of event, the place of registration of the event, and a record number. A national UIN could be created to be rooted in the CR that already exists. 22 PART VII – CONCLUSION 7.1 CR AND UIN Gabon’s CRVS system has many strengths and has areas where it could be improved; statistics must be regularly published and available because of the many services that are based on these statistics in the context of its social and economic development. Vital statistics are an essential component of human development planning. The population must be better informed of the benefits of CR. A central digitized vital statistics database should be established, with procedures for continuous updating of information. The assignment of a UIN at birth would allow linkage of CRVS and identification systems, facilitating coordination between sectors and enabling individuals’ greater access to and efficiency using services. 7.2 LINKS BETWEEN CR AND CNAMGS The CNAMGS is developing strategies to verify the authenticity of CR records. This is an important step in the coordination between the health, justice, and security sectors, among others, based on CR data. Linkages between the CNAMGS and CR centers are being developed. To this end, the CNAMGS has created monthly information forms for CR centers to complete to be informed regularly of CR vital events concerning insured persons. This approach should be followed to verify the effects and measure the usefulness of these procedures. These advances, although necessary, are not sufficient. They would allow the CNAMGS files to be updated and, in the process, reduce errors inherent in such files, as well as fraudulent declarations. It is estimated that current health and social security coverage is approximately 65 percent, highlighting the importance of continued increases in coverage of the CNAMGS toward achieving UHC. 7.3 THE CHALLENGES OF THE NHIS As part of the eGabon project, the government has launched a project to strengthen the NHIS. A goal of the NHIS is to digitally standardize Gabon’s health sector. In the Emerging Gabon Strategic Plan, the digital economy has been identified as a critical area for diversification in Gabon. The health sector is one of the priority sectors for use of information and communication technologies. From January 30 to February 16, 2017, the NHIS project team, composed of the ANINF and health sector stakeholders, met to develop a strategic master plan for the NHIS. The NHIS is still fragmented and lacks centralized data integration. Health data are collected on paper and for administrative purposes only. There could be improved coordination between the health and vital statistics offices. By connecting all actors in the 23 health system through information and communication technologies, the integrated NHIS would allow the sharing of health information, statistical data, and human and material resources. 7.4 EXPECTED EFFECTS OF THE NHIS The integrated NHIS aims to serve the population in several ways. In the short term, it is hoped that people would receive better care, that there would be greater accountability of expenditures, and that access to care would be equitable regardless of place of residence. In the long term, it aims to ensure that people would have access to their medical records from home and would be able to make appointments online through a patient portal; for health professionals, digital technology could increase access to reliable information in real time for better care of patients and to help them organize their work. The eGabon project aims to strengthen the development of the NHIS in Gabon. Although it would be important and can play a role in registration of vital events through the automation of birth and death registration and linkages with a national CRVS system, it can only be done within a functional CRVS system. Therefore, the UIN needs to be established and the flow of information to other actors in the CRVS system (e.g., municipalities, district courts, Ministry of the Interior, CNAMGS) needs to be strengthened in order for a functional system that meets the information needs of all to be developed. Gabon’s political commitment to serving the poorest coupled with medical coverage financing for the poorest and a national CNAMGS management scheme has helped advance achievement of UHC. 24 REFERENCES Biyogo Bi-Ndong, Gaston, Aboubacar Inoua, Jean Pierre Mbeng Mendou, and Jean ChristianNkoghe Eny. 2004. “Assurance Maladie au Gabon.” Paper presented at the Symposium on Health Coverage in French-speaking Africa (WBI-IMA Paris, 26-30 April, 2004). Centre des Liaisons Européennes et Internationales de Sécurité Sociale (CLEISS). 2011. CLEISS Report on the Social Security System of Gabon. Retrieved on August 8, 2019 from https://www.ilo.org/dyn/travail/docs/1066/Cleiss%20report%20on%20Gabon's%2 0social%20security.pdf. Eysenbach Gunther. 2001. “What is e-health?” Journal of Medical Internet Research 3 (2): e20. Gabon, Direction Générale de la Statistique. 2015. Résultats globaux du Recensement Général de la Population et des Logements de 2013 du Gabon (RGPL2013) (Overall Results of Gabon's 2013 General Population and Housing Census). Libreville. Retrieved on August 8, 2019 from https://www.mays-mouissi.com/wp- content/uploads/2016/07/Recensement-general-de-la-population-et-des- logements-de-2013-RGPL.pdf. Gabon, Direction Générale de la Statistique, and ICF International. 2013. Gabon: Enquête Démographique et de Santé 2012 (Demographic and Health Survey 2012). Calverton and Libreville. Retrieved on August 8, 2019 from https://dhsprogram.com/pubs/pdf/FR276/FR276.pdf. Gabon, Direction Générale de la Statistique et des Études Économiques, United Nations Population Fund (UNFPA), and ORC Macro. 2001. Gabon: Enquête Démographique et de Santé 2000 (Demographic and Health Survey 2000). Calverton. Retrieved on August 8, 2019 from https://dhsprogram.com/pubs/pdf/FR122/FR122.pdf. Gabon, Ministries of Health, Social Security and National Solidarity. 2017. Plan National de Développement Sanitaire 2017-2021 (National Health Development Plan 2017–2021). Libreville. Gabon, Ministries of Health, Social Affairs, Solidarity and Family of Gabon, Direction générale de la protection de la veuve et de l'orphelin, with the support of UNICEF. 2009. Analysis of the situation of orphans and vulnerable children in Gabon. Libreville. Hurpy, Charles Pierre Marie. 2019. Disclosable Version of the ISR - eGabon - P132824 - Sequence No : 05 (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/211341551641974977/Disclosable- Version-of-the-ISR-eGabon-P132824-Sequence-No-05 Mibindzou Mouelet, Ange, Moulay El Idrissi, and Paul Robyn. 2018. “Gabon Indigents Scheme: A Social Health Insurance Program for the Poor.” Universal Health Coverage Study Series No. 31. Washington, DC: World Bank. Musango, Laurent and Aboubacar Inoua. 2010. Assurance Maladie Obligatoire au Gabon: un atout pour le bien être de la population. World Health Report 2010 background paper, no.16. Obounou, Brice W.O. 2017. “Gabon health care system: a 20 year analysis.” International Journal of Community Medicine and Public Health 4 (7): 2208-11. 25 United Nations. 2014. Principles and Recommendations for a Vital Statistics System, Rev. 3. New York: United Nations Statistics Division, Department of Economic and Social Affairs. p. 65. World Bank. 2016. “Projects and Operations. eGabon.” Retrieved on August 8, 2019 from http://projects.worldbank.org/P132824?lang=en. World Health Organization (WHO). 2015. “The road to universal health coverage: a case study on Gabon.” World Health Organization website (features), December 11. Retrieved on August 8, 2019 from https://www.who.int/features/2015/uhc- gabon/en/. World Development Indicators (database): “Gabon.” World Bank, Washington, DC,Retrieved on August 8, 2019 from https://data.worldbank.org/country/gabon. Other sources of information used: • Final report of the health mapping field mission, by GeoThem Sarl • Strategic Master Plan of the Gabonese Health Information System (SDSSIS) 2017 - 2022, Prof. Cheick Oumar Bagayoko and the NHIS Gabon project team • Powerpoint presentation "Strengthening the NHIS" Project Strategic Master Plan for the Health Information System (SDSSIS) of Gabon, Prof. Cheick Oumar BAGAYOKO • Gabon Social Security Code, 1975 • Decree implementing the Social Security Code • http://aninf.ga/travaux-du-NHIS-vers-luniformisation-numerique-du-secteur- sante-au-gabon/ 26 APPENDICES APPENDIX 1: EXCERPT FROM THE CNAMGS WEBSITE 4 Appendix 1.1: Registration in the Private and Parapublic Sector Insurance Schemes This sector registration affects workers in the private sector (active or retired), as well as their dependents: o Private and parapublic sector employees o The non-permanent workforce of the state o Self-employed workers o Private and parapublic sector retirees o Voluntary insured persons Primary Insured For Employees and Pensioners (Retirees or Beneficiaries of a Reversion Pension): o Authenticated birth certificate (or original birth certificate + unauthenticated copy) o Identity document or receipt, passport, driver’s license for Gabonese and residence permit for foreigners; For employees only: o Copy of last pay stub For pensioners only (Retirees or Beneficiaries of a Reversion Pension: o Copy of pension title If applicant is married: o Copy of marriage certificate Beneficiary who are entitled to receive insurance coverage For all Rights holders (Spouse and Child) o Legalized birth certificate (or original birth certificate + unlegalized copy) o Copy of CNAMGS card of principal insured For only a CHILD that is ENTITLED for insurance (aged 0 to 2 years): o Copy of birth certificate or birth certificate o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship in custody of principal insured without being his direct child: e.g., grandchild, nephew) For only a CHILD that is ENTITLED for insurance (aged 3 to 5 years): o Copy of Health Record (cover page and vaccine pages) o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship For only a CHILD that is ENTITLED for insurance (aged 6 to 20 years): o Copy of school documents (report card, school card, school certificate for current year) o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship. 4 Source: CNAMGS website 27 o N.B.: The physical presence of the child (aged 6 to 20 years) is mandatory. For SPOUSE Rights holders: o Marriage certificate o Identity document (National identity card or receipt, passport, driver’s license for Gabonese and residence permit for foreigners) For Persons who have acquired Gabonese nationality: o Certificate of nationality Where to register? In the 9 CNAMGS provincial delegations, depending on where you live. N.B.: The documents submitted must be legible. If necessary, originals can be requested. Appendix 1.2: Public Sector Registration The following is a list of public sector employees (working or retired) and their beneficiaries: o Government officials and contractors o Individuals receiving a pension from the Treasury and those receiving a survivor's pension o Security and defense force agents o Para-military corps agents o Judiciary corps agents o Parliamentarians o Members of constitutional institutions The contribution of the public official In accordance with Decree 0537/PR/MSPSSN of 20 October 2015 (*) and in consideration of the assumption of responsibility for health care by the CNAMGS: o The Public Sector Agent (in active employment) contributes up to 2.5% of his taxable salary (basic salary + allowances and any taxable bonuses). o The Employer State contributes 5% to the benefit of the public servant in active employment. o The retired public servant or beneficiary of a pension (above the minimum wage) contributes up to 1% of his pension. Pending the entry into force of Decree 537, mentioned above, the current transitional contribution rates are set as follows: o Employers: 4.1% o Employees: 1% o Retirees: 0.5% o The ceiling for contributions to the CNAMGS is CFAF2,500,000. Documents needed for registration Principal Insured For active agents and pensioners (Retirees or Beneficiaries of a Reversion Pension): o Legalized birth certificate (or original birth certificate + unlegalized copy) 28 o Identity document (national identity card or receipt, passport, driver’s license for Gabonese and residence permit for foreigners) For active agents only: o Copy of last pay stub For pensioners only (Retirees or Beneficiaries of a Reversion Pension: o Copy of pension title If applicant is married: o Copy of marriage certificate Entitled Beneficiaries For all Rights holders (Spouse and Child) o Authenticated birth certificate (or original birth certificate + unlegalized copy) o Copy of CNAMGS card of principal insured For only CHILD ENTITLED (aged 0 to 2 years): o Copy of birth certificate or birth certificate o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship in custody of principal insured without being his direct child: e.g., grandchild, nephew). For only CHILD ENTITLED (aged 3 to 5 years): o Copy of health record (cover page and vaccine pages) o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship For only CHILD ENTITLED (aged 6 to 20 years): o Copy of school documents (report card, school card, or school certificate for current year) o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship o N.B.: The physical presence of the child (aged 6 to 20 years) is mandatory. For only SPOUSE rights holders: o Marriage certificate o Identity document (national identity card or receipt, passport, driver’s license for Gabonese and residence permit for foreigners) For persons who have acquired Gabonese nationality: o Certificate of nationality Where to register? o In the nine provincial delegations of CNAMGS according to where one lives NB: The documents submitted must be legible; if necessary, the originals can be requested. Appendix 1.3: Economically Disadvantaged Gabonese (EDG) Documents to provide for registration Principal Insured o Authenticated birth certificate (or original birth certificate + unlegalized copy) o Identity document (national identity card or receipt, passport, driver’s license) o Residency certificate o Copy of marriage certificate if applicant is married o Certificate of nationality if applicant has acquired Gabonese nationality 29 Entitled Beneficiaries For all Rights holders (Spouse and Child) o Authenticated birth certificate (or original birth certificate + unlegalized copy) o Copy of CNAMGS card of principal insured For only CHILD ENTITLED (aged 0 to 2 years): o Copy of birth certificate or birth certificate o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship in custody of principal insured without being his direct child: e.g., grandchild, nephew) For only CHILD ENTITLED (aged 3 to 5 years): o Copy of health record (cover page and vaccine pages) o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship For only CHILD ENTITLED (aged 6 to 20 years): o Copy of school documents (report card, school card, or school certificate for current year) o Adoption order, for adopted children o Guardianship judgment (issued by the Court), for children under guardianship. o N.B.: The physical presence of the child (aged 6 to 20 years) is mandatory. For SPOUSE Rights holders only: o Marriage certificate o Identity document (national identity card or receipt, passport, driver’s license) 30 APPENDIX 2: CIVIL CODE OF GABON (PART I) 5 BOOK I - - PEOPLE TITLE I - NATURAL PERSONS Chapter V - Proof of civil registration and identification of natural persons Article 153: A person may be identified by any means of evidence. However, births, marriages, divorces and deaths are provided for by means of civil registration documents. They can also be proved in cases admitted by law and by means of possession a notarized deed. Section 1 - General provisions concerning civil registration records Article 154: Civil registration documents shall be written legibly and with indelible ink; they shall state the year, day, place, and, if possible, the time that they are received; the given names, surnames, professions, residences, and, if possible, dates and places of birth of all those named therein. Article 155: The Civil Registrar shall record only the information prescribed by law. Article 156: The Civil Registrar shall read the documents to the persons appearing before him and witnesses. Mention is made in the acts of the accomplishment of this formality. Article 157: The Registrar who received it, the persons appearing before the court, and witnesses shall sign the deed. If the latter (persons before the court and witnesses) cannot or do not know how to sign, this will be mentioned on the deed. Article 158: Civil registration records shall be recorded in each civil registration center in one or more registers previously listed and initialed by the President of the Civil Court and kept in triplicate. One of these copies shall be deposited at the registry of the High Court; the second copy shall be kept at the town hall or, failing that, by the district chief; and the third copy shall be kept at the Ministry of the Interior. In the case of registers kept by Gabon's diplomatic or consular agents, the Ministry of Foreign Affairs will keep them and issue extracts. Article 159: The civil registration documents concerning Gabonese nationals drawn up outside Gabon by foreign public authorities shall be transcribed, ex officio or at the request 5 Note: The Civil Code has been translated into English and the translation has been provided in this document. 31 of the persons concerned, by the diplomatic or consular agents of Gabon having territorial jurisdiction into the civil registration registers kept by the diplomatic or consular agents Brief mention shall be made in the margin of the register on the date of these acts. When, as a result of the breakdown of diplomatic relations or the closure of the diplomatic or consular post having territorial jurisdiction, the transcript cannot be made in accordance with the preceding paragraphs, the document shall be provisionally deposited with the Ministry of Foreign Affairs, which shall issue the copy. As soon as circumstances permit, this department must have the act transcribed as described above. Article 160: Subject to what will be said about birth certificates, every person has the right to be issued a complete copy of a civil status document, as well as the references made in the margin, or an extract of this document, under the conditions provided by decree of the head of state taken after opinion of the Supreme Court. Article 161: The acts of the civil registration are authentic until the registration of forgeries of what the civil status officer has personally done or established and only until proof to the contrary of the veracity of the declarations received by him. The same shall apply to full and partial copies of such documents, provided that they bear the signature and seal of the issuing officer. Orders, judgments, and verdicts in civil registration matters shall be binding on all persons under the same conditions as the acts that they rectify. Article 162: In the event of the nonexistence, loss, or destruction of records, or where such records are deficient, proof thereof shall be received by title or by witnesses. In such cases, marriages, births, deaths, and other vital events may be proven by domestic registers and by witnesses. Civil status documents can be changed or omissions added only under the supervision and after judgment of the civil court of the place where such change or addition is to be made and, in the case of documents that Gabonese diplomatic or consular agents draw up or transcribe, by the capital's court of first instance. The decisions thus made are transcribed on their date on the registers of the civil registry of the place where the document should have been transcribed, or has been transcribed, but are deficient; mentions are made in the margin on the date of the omitted document. Article 163: If a civil registration document or a court decision in civil registration matters cannot be transcribed on the registers for that the provision ordering it provides, such transcription shall be made on the registers of the place of residence, or failing that, on those of the town hall of the first arrondissement of the capital. Article 164: As soon as a judgment given in civil registration matters has become final, the President of the court that made the final decision shall send an extract from it to the Civil Registrar concerned for the purpose of transcribing his decision on his records. 32 The Civil Registrar where the certificate was or should have been received shall automatically transcribe the provisions of supplementary judgments of civil registration certificates that have become final into the registers of the current year. The provisions of judgments on the recognition of children, adoption or revocation of adoption, divorce, and change of first name or surname shall be automatically transcribed in the margin of the birth and marriage certificates of the persons concerned. Article 165: Civil registration registers are kept under the supervision of the public prosecutors or their delegates or, failing that, of the presidents of the high courts or their delegates. Article 166: The appointment of civil registration officers, the keeping of registers, the conditions for opening or closing civil registration centers, and their powers shall be governed by laws, ordinances, or regulatory decrees. Section 2 - Birth certificates Article 167: The birth certificate shall state the date, place, and if possible, time of birth; sex; and given names and surnames of the child; the given names, surnames, ages, places of birth, professions, and domicile of the father and mother; and where applicable, the surnames, first names, professions, and domicile of the declarant. Article 168: The birth certificate shall bear in the margin the particulars that this code and special laws prescribe. Article 169: Birth declarations are made to the Civil Registrar within three days of delivery for children born in villages and district capitals and, in other cases, within one month. Article 170: In the absence of the father and mother or their representative, the doctor or the midwife having been present at the birth may declare the birth. Unless the father or mother has expressly authorized the use of the given names, they may indicate to the registrar only the sex, date, time, and place of birth of the child and, as far as possible, the mother's name. The heads of rural villages shall ensure that births in their constituencies are registered at the nearest civil registration center within the time limits provided for in this code. Article 171: Any person who has found a newborn child is required to make a declaration to the Civil Registrar of the place of discovery, providing the clothes and other belongings found with the child and declaring all the circumstances of time and place where the child was found. A detailed report shall be drawn up that, in addition to the information provided for in Article 154 of this code, shall set out the date, time, place, and circumstances of the discovery; the apparent age and sex of the child; any features that may help establish the child’s identification; and the authority or person to whom the child was entrusted. This information shall be recorded on the date of the event in the civil registration registers. 33 Following and separate from these notes, the Civil Registrar shall draw up a certificate in lieu of a birth certificate. In addition to the information provided for in article 154, this document indicates the sex of the child, the given names and surnames given to him or her, and a date of birth that may correspond to the child’s apparent age and designates as the place of birth the place where the child was discovered. If the child's birth certificate is discovered or the child's filiation is judicially established, the record of discovery and the provisional birth certificate shall be cancelled at the request of the public prosecutor or the parties concerned. If the date and place of birth of the child become known, the public prosecutor shall mention this in the margin of the document drawn up, in accordance with the second paragraph of this article. Article 172: If the birth of a child has not been recorded within the legal time limit and subject to the provisions provided for in the preceding article, the civil registrar may record it only by transcribing a judgment of the civil court containing, insofar as they may be established or presumed, the particulars provided for in article 167 of this chapter. The responsible court and civil registrar are those of the person's place of birth. If this place is unknown, the responsible court is the court of the applicant's domicile and decides where the judgment will be transcribed. If the date of birth is certain or presumed, as opposed to unknown, the judgment indicates the date of birth in the margins of the civil registration registers. Mention of the judgment shall also be made, where appropriate, in the margin of the discovery reports or declarations provided for in the preceding articles. Article 173: A judgment ordering that the adopted child cease to belong to his or her family of origin shall replace a declaratory judgment at birth. It must contain, insofar as they are known or presumed, without violating the decree of origin, the particulars provided for in Article 167 of this chapter. Subject to the penalties provided for in this code or in special laws, the civil registrar may not issue any copy or extract of the original birth certificate without authorization of the president of the civil court in whose jurisdiction the act was drawn up or of the child's domicile. The president will rule on a simple request. Article 174: In the event of a birth on a Gabonese navy vessel or aircraft, the commanders of that vessel or aircraft shall record the birth. The deeds must then be submitted for transcription to the civil registrar of the first district of the capital. Article 175: A true copy of the birth certificate or judgment in its place may only be issued to the person concerned, the person's representative, or the public prosecutor and, for minors, the parents or guardians. In case of absence or after the death of a person, a 34 certified copy of the birth certificate or judgment in its place may also be issued to the spouse, ascendants, or descendants in direct line. Any other interested party may obtain a copy pursuant to an authorization that the district court of the place where the document was received if it was issued free of charge and at the written request of the interested party. In the event of refusal by the court of first instance, the president of the court of first instance shall decide on the appeal, which may be exercised in the form of a summary judgment. The depositaries of the registers shall be required to issue to any applicant extracts indicating, without further statement, the year, day, time, and place of birth and the sex and given names and surname of the child as they result from the statements in the birth certificate or the minutes, declarations, and judgments in their place, as well as the statements made in the margin of these acts. Extracts specifying, in addition, the surname, first name, profession, and domicile of the father and mother may be issued only under the conditions laid down for certified copies, unless the heirs of the deceased or a government requests the issuance. The extracts provided for in the two preceding paragraphs shall not mention the source of the statements they contain, nor shall they reveal any difference between those established and those simply presumed. No mention shall be made of any missing particulars. Article 176: The act of recognition of a natural child shall be entered in the registers on the date of recognition If a registrar has not drawn it up, the public official who received it shall transcribe it. To this end, the document is served within 15 days on the civil registrar who is the custodian of the child's birth certificate, although the recognition made by testament may, at the request of the testator, be served within 15 days of the day on which the public officer becomes aware of the birth. The registrar prepares the transcript within five days of service, excluding public holidays. The recognition certificate is mentioned in the margin of the birth certificate, if there is one. In the event of recognition (of a newborn) during a sea or air journey, the commander of a Gabonese vessel or aircraft shall record it, in the forms and under the conditions laid down in a regulation of public administration. Section 3 - Marriage certificates Article 177: The marriage certificate shall state: (1) the given names, surnames, occupations, ages, dates and places of birth, domicile or residence of the spouses; (2) the consent of the father and mother or of the guardianship Council, in cases in which it is required; (3) the nationality declared by the spouses, upon being told by the Registrar; (4) the given names, surnames, ages; (5) the choice made by the spouses of monogamy or polygamy; (6) the matrimonial regime that the spouses have chosen and, if there has 35 been a contract, the date of that contract, as well as the name and place of residence of the notary or civil status officer who received it. The spouses must expressly and jointly declare the elections referred to in paragraphs 5 and 6 above, and the registrar must mention them in the marriage certificate. In case of disagreement on these choices, the marriage cannot be performed. Subject to the provisions of articles 178 and 311 of this code, these choices shall be respected until the dissolution of the marriage. The registrar shall draw up the marriage certificate immediately after the marriage has been performed and shall send a copy of it to the registrars of civil status of the spouses' places of birth. Article 178: The spouses may, during the marriage, waive the monogamous option. This renunciation is evidenced by a joint declaration made before a notary or a civil registrar, who must previously speak with each spouse separately. The civil registrar who is celebrating the union must, when drawing up the marriage certificate, mention the declaration referred to above. The family record book established at the first marriage will also be amended. In the event that the first marriage was subject to the community management, the spouses must proceed with the liquidation and partition of this community. The second union may not be celebrated without a copy of an inventory, deposited in the minutes of a notary, containing a determination of the property dependent on the community, being presented to the civil registrar. In the event that the community does not have any property, this will be mentioned in the marriage certificate. Section 4 - Death certificates Chapter I - General rules Article 179: The civil registrar of the municipality or location where the death took place shall draw up the death certificate on the declaration of a relative of the deceased or the person with the most accurate and complete information on the deceased's civil registration. In the event of death in a hospital, health or educational establishment, hotel, or similar public or private institution, the director of such establishment shall make the declaration of death. The death of a serving member shall be declared by the head of the unit to which he or she belongs, unless the member is living with his or her family or his or her death occurs during a leave of absence or away from the place where his or her unit is stationed. Any enforcement officer who, in the performance of his duties, is called upon to declare a death, shall send all the information set out in article 181 below to the civil registrar of the place of death within five days. Article 180: The death certificate shall be drawn up at the latest within 24 hours of the issuance of the burial permit. Except in cases provided for in the police regulations, burial may not take place until 24 hours after death. If there are signs or indications of violence or other circumstances arousing suspicion, burial may be performed only after a judicial police officer, assisted by a doctor or surgeon, has drawn up a report on the condition of the body and the related circumstances, as well as any information he may have collected on the given names, surname, age, profession, place of birth, and domicile of the deceased person. Article 181: The death certificate states: (1) the date, place, and if possible, time of death; (2) the given names, surname, date and place of birth, profession, and domicile of the 36 deceased person; (3) the given names, surnames, professions, and domicile of the deceased person’s father and mother; (4) the given names, surname, and date and place of birth of the deceased person's spouse, if that spouse is still alive, and the date of marriage; and (5) the first names, surname, age, profession, and domicile of the declarant and, if applicable, the relationship with the deceased person. No indication of the circumstances of the death shall be given in the records, unless the identity of the body is unknown. Article 182: The death is mentioned on the deceased's birth certificate. When a death occurs elsewhere than where the deceased was domiciled, the civil registrar who drew up the death certificate shall send a copy of the certificate to the civil registrar of the deceased's last domicile within eight days, which shall be immediately entered in the registers. Article 183: In the event of death during a long sea voyage in a Gabonese Navy vessel, the master of the vessel shall draw up the death certificate. In the event of death during a short air or sea voyage, the registrar of the place where the body was deposited shall draw up the death certificate. Chapter II - Declarations of death Article 184: When a person has disappeared under conditions such that his death is certain, although his body has not been found, any interested party may apply to the court for a declaratory judgment declaring the death of that person. The responsible court is the one where the person whose death the plaintiff wishes to establish had his domicile or residence at the time of his death or the one where the event leading to the death occurred. Article 185: If several persons have disappeared during the same event, their deaths may be declared according to collective judgment that the court of the place of disappearance, the home port of the vessel or aircraft, or failing that, the court of first instance of the capital renders. Article 186: When the court declares death, it shall fix the date of death with regard to the presumptions drawn from the circumstances of the case and, failing that, the day of disappearance. It may also order a further investigation into the circumstances of the alleged disappearance or death. Article 187: Individual death judgments and individual extracts from collective death judgments must be transmitted to the civil registrar of the last residences of the disappeared to be transcribed on their date. Article 188: If the person whose death has been declared judicially reappears after the declaratory judgment, this declaratory judgment shall be annulled at the person’s request or that of the public prosecutor's office by the court that made it. Mention of the annulment of the declaratory judgment of death shall be made in the margin of its transcription and in the margin of the birth certificate of the person. Section 5 - Correction of civil registration records. Article 189: Civil status documents may only be rectified by virtue of a judgment given by the court of the place where the document was drawn up. 37 Corrections will be required in the event of errors, omissions, or changes of surname or first names. The President of the capital's High Court orders the correction of civil registration documents that Gabonese diplomatic and consular agents draw up or transcribe. Only the court that issued it can order correction of a judicial decision in civil registration matters. Article 190: The person to whom the document relates, the public prosecutor, or anyone with a current and natural interest in the correction may request correction. Article 191: The judgment that the court renders in matters of correction of civil registration records may be appealed to the competent court. Article 192: The public prosecutor shall immediately transmit verdicts or judgments on correction to the Civil Registrar of the place where the corrected document is located. Their arrangements shall be recorded in the margin of the acts corrected within three days of receipt of the dispatch of those verdicts or judgments. The dispatch of the document can only be delivered with the corrections ordered. Article 193: Each civil registrar shall keep a special register in which shall be mentioned, in chronological order, the supplementary or amending judgments of civil registration records. Article 194: If the solution appears appropriate, the court may order the annulment of the vital event certificate to be corrected and the establishment in its place of a new act. In this case, the operative part of the judgment is transcribed in the margin of the annulled act, which must be crossed out through the register using two diagonal lines. Section 6 - Sanctions relating to civil registration Article 195: Any contravention by the agents responsible for keeping or maintaining records of the provisions of the regulations made for their application shall render them liable to anyone who as a result suffers prejudice. Article 196: If the registrar or his delegate refuses to draw up a certificate of vital event in accordance with the declarations made, any interested party may appeal against this refusal before the courts. The same shall apply if a depositary refuses to issue a copy or extract of a document from such registers. If the appeal is successful, the registrar or his delegate may be sentenced to a fine not exceeding CFAF10,000. In the event of rejection of the appeal, the person who lodged the appeal shall bear the costs of the proceedings. Article 197: The penalty of five days’ to one month's imprisonment and a fine of CFAF2,000 to 4,000 or either of these two penalties will be for: (1) the civil registrar who, being required to draw up or register a civil status document, has not done so within the time limit prescribed by law; (2) the civil registrar who, being required to communicate a civil -status document to another civil registrar, has not done so within the time limit prescribed by law; (3) the civil registrar who contravenes the other provisions of this chapter. 38 certified copy of the birth certificate or judgment in its place may also be issued to the spouse, ascendants, or descendants in direct line. Any other interested party may obtain a copy pursuant to an authorization that the district court of the place where the document was received if it was issued free of charge and at the written request of the interested party. In the event of refusal by the court of first instance, the president of the court of first instance shall decide on the appeal, which may be exercised in the form of a summary judgment. The depositaries of the registers shall be required to issue to any applicant extracts indicating, without further statement, the year, day, time, and place of birth and the sex and given names and surname of the child as they result from the statements in the birth certificate or the minutes, declarations, and judgments in their place, as well as the statements made in the margin of these acts. Extracts specifying, in addition, the surname, first name, profession, and domicile of the father and mother may be issued only under the conditions laid down for certified copies, unless the heirs of the deceased or a government requests the issuance. The extracts provided for in the two preceding paragraphs shall not mention the source of the statements they contain, nor shall they reveal any difference between those established and those simply presumed. No mention shall be made of any missing particulars. Article 176: The act of recognition of a natural child shall be entered in the registers on the date of recognition If a registrar has not drawn it up, the public official who received it shall transcribe it. To this end, the document is served within 15 days on the civil registrar who is the custodian of the child's birth certificate, although the recognition made by testament may, at the request of the testator, be served within 15 days of the day on which the public officer becomes aware of the birth. The registrar prepares the transcript within five days of service, excluding public holidays. The recognition certificate is mentioned in the margin of the birth certificate, if there is one. In the event of recognition (of a newborn) during a sea or air journey, the commander of a Gabonese vessel or aircraft shall record it, in the forms and under the conditions laid down in a regulation of public administration. Section 3 - Marriage certificates Article 177: The marriage certificate shall state: (1) the given names, surnames, occupations, ages, dates and places of birth, domicile or residence of the spouses; (2) the consent of the father and mother or of the guardianship Council, in cases in which it is required; (3) the nationality declared by the spouses, upon being told by the Registrar; (4) the given names, surnames, ages; (5) the choice made by the spouses of monogamy or polygamy; (6) the matrimonial regime that the spouses have chosen and, if there has 35 been a contract, the date of that contract, as well as the name and place of residence of the notary or civil status officer who received it. The spouses must expressly and jointly declare the elections referred to in paragraphs 5 and 6 above, and the registrar must mention them in the marriage certificate. In case of disagreement on these choices, the marriage cannot be performed. Subject to the provisions of articles 178 and 311 of this code, these choices shall be respected until the dissolution of the marriage. The registrar shall draw up the marriage certificate immediately after the marriage has been performed and shall send a copy of it to the registrars of civil status of the spouses' places of birth. Article 178: The spouses may, during the marriage, waive the monogamous option. This renunciation is evidenced by a joint declaration made before a notary or a civil registrar, who must previously speak with each spouse separately. The civil registrar who is celebrating the union must, when drawing up the marriage certificate, mention the declaration referred to above. The family record book established at the first marriage will also be amended. In the event that the first marriage was subject to the community management, the spouses must proceed with the liquidation and partition of this community. The second union may not be celebrated without a copy of an inventory, deposited in the minutes of a notary, containing a determination of the property dependent on the community, being presented to the civil registrar. In the event that the community does not have any property, this will be mentioned in the marriage certificate. Section 4 - Death certificates Chapter I - General rules Article 179: The civil registrar of the municipality or location where the death took place shall draw up the death certificate on the declaration of a relative of the deceased or the person with the most accurate and complete information on the deceased's civil registration. In the event of death in a hospital, health or educational establishment, hotel, or similar public or private institution, the director of such establishment shall make the declaration of death. The death of a serving member shall be declared by the head of the unit to which he or she belongs, unless the member is living with his or her family or his or her death occurs during a leave of absence or away from the place where his or her unit is stationed. Any enforcement officer who, in the performance of his duties, is called upon to declare a death, shall send all the information set out in article 181 below to the civil registrar of the place of death within five days. Article 180: The death certificate shall be drawn up at the latest within 24 hours of the issuance of the burial permit. Except in cases provided for in the police regulations, burial may not take place until 24 hours after death. If there are signs or indications of violence or other circumstances arousing suspicion, burial may be performed only after a judicial police officer, assisted by a doctor or surgeon, has drawn up a report on the condition of the body and the related circumstances, as well as any information he may have collected on the given names, surname, age, profession, place of birth, and domicile of the deceased person. Article 181: The death certificate states: (1) the date, place, and if possible, time of death; (2) the given names, surname, date and place of birth, profession, and domicile of the 36 deceased person; (3) the given names, surnames, professions, and domicile of the deceased person’s father and mother; (4) the given names, surname, and date and place of birth of the deceased person's spouse, if that spouse is still alive, and the date of marriage; and (5) the first names, surname, age, profession, and domicile of the declarant and, if applicable, the relationship with the deceased person. No indication of the circumstances of the death shall be given in the records, unless the identity of the body is unknown. Article 182: The death is mentioned on the deceased's birth certificate. When a death occurs elsewhere than where the deceased was domiciled, the civil registrar who drew up the death certificate shall send a copy of the certificate to the civil registrar of the deceased's last domicile within eight days, which shall be immediately entered in the registers. Article 183: In the event of death during a long sea voyage in a Gabonese Navy vessel, the master of the vessel shall draw up the death certificate. In the event of death during a short air or sea voyage, the registrar of the place where the body was deposited shall draw up the death certificate. Chapter II - Declarations of death Article 184: When a person has disappeared under conditions such that his death is certain, although his body has not been found, any interested party may apply to the court for a declaratory judgment declaring the death of that person. The responsible court is the one where the person whose death the plaintiff wishes to establish had his domicile or residence at the time of his death or the one where the event leading to the death occurred. Article 185: If several persons have disappeared during the same event, their deaths may be declared according to collective judgment that the court of the place of disappearance, the home port of the vessel or aircraft, or failing that, the court of first instance of the capital renders. Article 186: When the court declares death, it shall fix the date of death with regard to the presumptions drawn from the circumstances of the case and, failing that, the day of disappearance. It may also order a further investigation into the circumstances of the alleged disappearance or death. Article 187: Individual death judgments and individual extracts from collective death judgments must be transmitted to the civil registrar of the last residences of the disappeared to be transcribed on their date. Article 188: If the person whose death has been declared judicially reappears after the declaratory judgment, this declaratory judgment shall be annulled at the person’s request or that of the public prosecutor's office by the court that made it. Mention of the annulment of the declaratory judgment of death shall be made in the margin of its transcription and in the margin of the birth certificate of the person. Section 5 - Correction of civil registration records. Article 189: Civil status documents may only be rectified by virtue of a judgment given by the court of the place where the document was drawn up. 37 Corrections will be required in the event of errors, omissions, or changes of surname or first names. The President of the capital's High Court orders the correction of civil registration documents that Gabonese diplomatic and consular agents draw up or transcribe. Only the court that issued it can order correction of a judicial decision in civil registration matters. Article 190: The person to whom the document relates, the public prosecutor, or anyone with a current and natural interest in the correction may request correction. Article 191: The judgment that the court renders in matters of correction of civil registration records may be appealed to the competent court. Article 192: The public prosecutor shall immediately transmit verdicts or judgments on correction to the Civil Registrar of the place where the corrected document is located. Their arrangements shall be recorded in the margin of the acts corrected within three days of receipt of the dispatch of those verdicts or judgments. The dispatch of the document can only be delivered with the corrections ordered. Article 193: Each civil registrar shall keep a special register in which shall be mentioned, in chronological order, the supplementary or amending judgments of civil registration records. Article 194: If the solution appears appropriate, the court may order the annulment of the vital event certificate to be corrected and the establishment in its place of a new act. In this case, the operative part of the judgment is transcribed in the margin of the annulled act, which must be crossed out through the register using two diagonal lines. Section 6 - Sanctions relating to civil registration Article 195: Any contravention by the agents responsible for keeping or maintaining records of the provisions of the regulations made for their application shall render them liable to anyone who as a result suffers prejudice. Article 196: If the registrar or his delegate refuses to draw up a certificate of vital event in accordance with the declarations made, any interested party may appeal against this refusal before the courts. The same shall apply if a depositary refuses to issue a copy or extract of a document from such registers. If the appeal is successful, the registrar or his delegate may be sentenced to a fine not exceeding CFAF10,000. In the event of rejection of the appeal, the person who lodged the appeal shall bear the costs of the proceedings. Article 197: The penalty of five days’ to one month's imprisonment and a fine of CFAF2,000 to 4,000 or either of these two penalties will be for: (1) the civil registrar who, being required to draw up or register a civil status document, has not done so within the time limit prescribed by law; (2) the civil registrar who, being required to communicate a civil -status document to another civil registrar, has not done so within the time limit prescribed by law; (3) the civil registrar who contravenes the other provisions of this chapter. 38 Gabon’s national health insurance program (Caisse National d’Assurance Maladie et de Garantie Sociale [CNAMGS]) coupled with medical coverage financing for the poorest has helped advance achievement of universal health coverage. In 1975, the National Social Security Fund (NSSF) was created in Gabon to guarantee the social protection of the population and enable financial contributions according to means, and benefits according to needs. In 2007, reforms of Gabon’s health financing system were instituted, including implementation of compulsory health insurance schemes through the CNAMGS. The responsibilities of the NSSF were transferred to the CNAMGS, which provides medical, maternity, and miscellaneous insurance and retirement pensions to insured persons and their dependents. In 2008, Gabon introduced an innovatively financed fund dedicated to the poor that extended health protection to economically disadvantaged Gabonese. The fund is managed by the same public institution that manages the private and public national health insurance schemes, enabling the poorest to have greater access to health services and better financial protection against health risks. The CNAMGS assigns an identification number to each insured individual, although this number does not have all the characteristics of a unique identification number (UIN). The assignment of a UIN at birth would allow linkage of the civil registration, vital statistics, and national identification systems, facilitating coordination between sectors and enabling individuals’ greater access to and efficiency in using services. Gabon is working to strengthen its national health information system (NHIS), to improve health system planning, resource management, and quality of care. By connecting all actors in the health system through information and communication technologies, the integrated NHIS would allow the sharing of health information, statistical data, and human and material resources. ABOUT THIS SERIES: This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. 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