USAID Benin: Health

USAID supported a number of studies and analyses carried out between 1993-2004, including the first national Demographic and Health Survey (DHS), conducted in 1996 and the second conducted in 2001.

According to the Ministry of Health SNIGS 2003 Annual Report (finalized in October 2004), principal reasons for health facility visits in Benin are in general:

The life expectancy at birth is 59.2, according to the Ministry of Health SNIGS 2003 Annual Report. Nearly half (46%) of the population does not live to the age of 60, according to the 1999 Human Development Report.

The GOB's National Health Policy and Strategy 2002-2006 states the GOB's intention to improve health conditions for families based on a system that integrates poor and indigent populations. Its global objectives aim to improve the quality and accessibility of health services, improve community participation and service utilization, and improve the care of poor and indigent populations. Its strategic approaches are those of decentralization, improved planning and management, prevention and reduction of incidence of major illnesses, improved family health, and establishment of an effective system of cost recovery. USAID/Benin supports the GOB strategy through its programmatic emphasis on family health (family planning, maternal and child health, and STI/HIV prevention) as well as the improved prevention and management of the principal diseases such as malaria and improved management of health services through capacity building and decentralization. It further supports it through its intermediate results of accessibility to and quality of health services as well as its emphasis on improved community based initiatives and partnership with the private sector.

The public health system is divided administratively into three levels: central, regional, and peripheral (where the Health Zone is located) community. Services are provided at four levels: regional referral hospitals (CHD); communal health centers and urban health centers (CSC); arrondissement health centers (CSA); and village health units (UVS). Some health experts believe Benin serves as a regional model for the implementation of a cost recovery system based on the Bamako Initiative and a successful national drug distribution program. The mechanism for community participation is the election of representatives to community health management committees (COGEC/COGEA). Community financing accounts for approximately 30 percent of recurrent costs.

Benin currently has twelve (12) administrative regions (Atlantique, Littoral, Mono, Couffo, Oueme, Plateau, Zou, Colline, Atacora, Donga, Borgou, Alibori); Seventy four (74) Communes and three (3) autonomous urban areas (Cotonou, Porto-Novo, Parakou; five hundred and forty six (546) administrative subdivisions; three thousands seven hundred and forty seven (3747) villages.

There are 73 communal health centers. They are normally small (100 beds or fewer) health centers that include medical, surgical and maternity units as well as laboratory facilities. At the level of administrative subdivision, there are 407 health centers, which generally contain a four-bed dispensary, a 12-bed maternity unit and an outlet for the sale of drugs. They are typically staffed by only three persons: a nurse, a midwife and a nurses' aide. The only health structure at the village level is the village health unit, of which the Ministry of Health listed 299 in 1999. These units are usually staffed by a birth attendant and a first aid health worker.

The Ministry of Health is in the process of reorganizing its structure through the creation of health zones or zones sanitaires (often called districts in other African countries). These zones are designed to facilitate decentralized planning and management as well as the efficiency of resource allocation and the rehabilitation of referral units. Each zone covers a population of 100,000 to 150,000 inhabitants. The average sub-prefecture has a population of 50,000 to 60,000 inhabitants. Each of the 33 designated zones groups two to three sub-prefectures. Through this reorganization, the Ministry of Health intends to reinforce and reorient current services, promote interventions for high prevalence diseases and ultimately promote the effective decentralization of health services.

The reference hospital in each of the zones plans, supervises, trains and provides supplies to health facilities within that zone. Although health zones are becoming the operational units for decentralized planning and management in Benin, weaknesses of Ministry of Health infrastructures and personnel shortages at health facilities within zones are obstacles to integrating primary health care activities into non-functional facilities.

At the top of the health services pyramid is the National University Hospital based in Cotonou. This facility provides medical training, conducts research and is designed to handle most medical problems that cannot be treated elsewhere in Benin. There are five departmental hospitals equipped to handle internal medicine, surgery, obstetrics, pediatrics, ophthalmology, ear, nose and throat, stomatology and radiology.

Benin has approximately one doctor per 19,000 people (the World Health Organization norm is 1/10,000) and one doctor per 2400 beds. The real situation is worse than is indicated by these figures, which include doctors employed by the University Hospital in Cotonou, which accounts for approximately one-third of all health staff (private sector included) in Benin.

According to Ministry of Health statistics for 2003, Benin has a total of 975 doctors, 2140 nurses and 1035 nurse mid-wives. (These figures are reported in the Ministry of Health's SNIGS annual statistics report for 2003.) The majority of the country's health personnel are concentrated in the southern part of the country, especially in Cotonou and Porto-Novo.

A wide variety of health facilities, pharmacies and other services exist in the private sector, and most of these are situated in the urban centers. In addition, many religious institutions and some non-governmental organizations (NGOs) run hospitals or dispensaries, or provide training, health education, and other health services. It is estimated that the private/NGO/confessional sector actually provides at least 30% of health services in Benin. Overall, 19% of medical personnel work in the private sector, including approximately 37% of physicians, 16% of nurses and 14% of nurse midwives.

Traditional healers constitute an important element of Benin's health care system in Benin. As in many African countries, in Benin it is thought that most people seek treatment from traditional healers before accessing modern or "western" treatment. In recognition of the important role played by traditional healers, the GOB has developed programs encouraging traditional practitioners and modern health providers to work together. Traditional birth attendants also exist at the community level.

Each of the sub-systems described above uses different methods for financing health services. Until 1990, public sector services did not require formal payment, as these services were fully financed through the national budget. The percentage of Benin's national budget allocated to health has been up and down over the past several years, from 8.8% in 1987 to 3.2% in 1992, to 4.9% in 1996 , 6.7% in 1998, and 5.1% in 1999 (SNIGS report for 1999).

As public funds became increasingly scarce in the early 1990s, the public health sector became increasingly reliant on both donor funding (largely for investments) and cost recovery (for non-personnel recurrent costs). According to SNIGS annual statistics report for 1999, donors supported 84% of the health sector's overall budget.

The health sector also suffers also from systemic governance problems resulting in low absorptive capacity, only about 30% of total external funding is spent. The Ministry of Health budget process still does not adequately present planned expenditures by function.

Benin is generally viewed as a success story for the Bamako Initiative, with user fees having been implemented in almost all facilities. However, consistency throughout the country in ability to recover costs is not present, and most health center revenues come from the sale of drugs, which can have negative effects on the rationalization of drug prescription and the containment of overall costs.

In 1989, through a health project financed by the World Bank, the Ministry of Health established two levels of community health management committees. These committees consist of the COGEA (comité de gestion des Arrondissements), a group of elected representatives from the localities of each administrative subdivision, and the COGES (comité de gestion sous-préfectoral), a group of representatives from each COGEA in the subprefecture.

Through the creation of these committees, the government sought to institutionalize community participation in delivery of health services, and to more clearly define the role of the state, communities, and donors in the development of the health sector. These committees were also created to involve communities more fully in health prevention activities and to provide an institutional guarantee that resources collected through cost-recovery activities would be retained and managed by these committees and used for replenishing drug stocks and for financing other non-salary recurrent costs. Unfortunately, as of the writing of this document, texts setting forth the roles and responsibilities for COGEA and COGES are still being debated among the Ministry of Health, donors and community members. The Ministry of Health, apparently, would prefer to limit the power and reach of COGEAs while donors and communities want to expand the role of COGEAs to allow them to play a more meaningful role as leaders in community health.

In theory, the COGEA participates with the staff of the CCS in the preparation of budget estimates to be reviewed and approved at the sub-prefecture level prior to submission to the Ministry of Health. The COGES and COGEA are also supposed to be responsible for health promotion activities, for planning annual activities for the CCS, and for monitoring the use of CCS finances. A World Bank assessment in 1995 reported that the performance of these committees varies greatly. Many COGES/COGEA members were found to lack motivation due to a number of factors, most notably a lack of understanding of their roles and functions, lack of skills in community financial management and in "group animation" techniques, and lack of financial remuneration. The World Bank report also noted that although the by-laws state that elections of COGES and COGEA members should be held every two years, elections are not held that frequently. In January 2000, the Ministry of Health began pushing for the "renewal" of COGEAs, however the Ministry's time frame for the renewal process does not allow sufficient time for a participatory electoral process. The debate over how and when to renew these committees continues.

A strength of the Benin health system is the provision of essential drugs by the Centrale d'Achat des Medicaments Essentiels (CAME), which buys generic drugs and sells them to health facilities at low cost. As a consequence, many common drugs, such as chloroquine, are widely available. However, health center staff are obliged to physically go to the CAME to collect drugs and the private sector is not supplied through the CAME. In addition, a continuing problem identified in a 1996 UNICEF report, however, is the uncontrolled circulation of low-priced drugs produced in Nigeria and sold in Benin. Many of these drugs of dubious quality are sold in open markets, unlabeled and undated. Although the sale of these medicines is officially banned, they continue to be sold and purchased in large quantities, particularly along Benin's border with Nigeria.

For more information contact USAID-Benin

Family Health

Health Sector in Benin