Social services consist of goods that are part of major resource bases that must be managed effectively in order to fulfill the ongoing development need of the country. The public health care system (PHCS) is one of the resource bases that directly benefits from government budget allocation. Throughout Cameroon, researchers observe major differences and unequal share distribution in the access and utilization of the public health services.
These incongruities become obvious when examining the distribution of health infrastructures and health workers throughout Cameroon. A closer analysis shows that the organizational imbalance of public health establishments, along with inappropriate internal and external administrative politics (financial weaknesses and inadequate governance) in the management of PHCS are the most significant obstacles affecting the effectiveness of the health staff, the efficiency of the PHCS and the equity of public health services delivery in Cameroon.
Human Resource Distribution
First, the number of health care workers across the country is significantly inadequate with approximately 1 physician made available for about 10,000 inhabitants, compared to 1 for every 3,000 as recommended by the World Health Organization (WHO). Furthermore, it has been reported that there is about 1 nurse for every 2,250 individuals, compared to 1 for every 1,000 as recommended by the WHO. Table 2-1 shows the statistical trend in the number of physicians, nurses, midwives, dentists and other health care providers from 1980 to 2005, as well as the increase in the number of pharmacies. Even though the numbers that are displayed in this table seem large, and bearing in mind that the population has been steadily increasing since 1980, there is a discrepancy between the number of providers working in the health care industry and the number of people living in Cameroon. Indeed, in 2001 the human resource deficit in the PHCS has been estimated to total approximately 9,000 persons.
In addition to the deficient number of health care workers, there is unequal distribution of health staffs throughout the country with wide distribution disparities between urban and rural areas, which point to obvious disparities in access to care between poor and non-poor. Studies show that while the ratio of health personnel stands at 1 for 400 people in urban areas, their ratio of health personnel decreases tenfold, and is pegged at 1 for 4000 people in rural areas, requiring rural residents to travel long distances to receive the necessary medical care. Such imbalance between health workers and the population requiring the health services raises concerns about the effectiveness of the health providers, since it is likely that their competence would be diminished due to the heavy load of patients they must care for. Because PHCS facilities are selectively located, there arise problems of equity in access.
Equipment and Facilities Distribution
The distribution of equipment and facilities resources also indicates that the PHCS is poorly equipped to provide adequate health services to meet the needs of the population. The physical resources– buildings, equipment, and supplies– have been woefully deteriorating for some time. Most of the infrastructure and the equipment of the PHCS are outdated. Facilities are unevenly distributed among provinces, as well as between urban and rural areas. Table 2-2 shows that there is 1 health center for 8,500 people, 1 hospital bed for 770 people, and 1 health facility per 85,000 people, which is clearly insufficient to meet the medical needs of the population, and at the same time, provide appropriate medical care.
Though the total number of health centers has increased twofold rising from 1,893 health centers in 1990 to 2,144 health centers in 1996, the inequitable distribution creates issues of disproportionate access to health services. Therefore, though there might be sufficient facilities for providing primary care for the country’s population, the problem of uneven geographical distribution of health care facilities and the lack of trained medical personnel in remote areas, are incongruent and remain unresolved.
Health professionals and trained support staffs, valuable and indispensable assets of any health care system, are crucially scarce in the Cameroonian PHCS. Health professionals need to be trained and motivated to perform at optimal levels; however, in Cameroon, there are no incentives to encourage competent health workers to stay in the public sector or provide good quality services in the public facilities. Those health workers who remain and work in the public health sector have been primarily assigned to urban public facilities due to their general reluctance to relocate to remote areas of the country.
Consequently, there exists an oversupply of qualified health providers with an attendant oversupply of infrastructure in mostly urban areas; whereas, there is an undersupply of qualified staff with the attendant undersupply of adequate infrastructures in primarily rural areas. Hence, the shortage and uneven distribution of trained health workers nationwide as well as the insufficient and disparate distribution of health facilities promote overcrowding of many public health facilities. Taken together, these prevailing conditions limit the effectiveness of health care workers, and contribute to underutilization of facilities in other areas, all resulting in inefficiency of the PHCS. The disparities of health services across the country can be noted in Table 2-2.
Inadequate Governance and Lack of Funding
Apart from the decrepit health facilities, the accompanying technical support centers are also quite outdated with inept and corrupt bureaucratic administrations. Routine procedures that should normally be completed within a matter of hours can take several days to be resolved. Such ineptitude points to a lack of administrative discipline and an ingrained culture of corruption in the public healthcare system. From administrative procedures to medical procedures, patients– especially the poor– have to bribe the personnel in order to obtain medical service delivery or they have to be prepared to undergo several trips to the healthcare institution just to receive appropriate medical care. Furthermore, there is no proper management accounting system in public health facilities, raising issues of inadequate management. Earned income from performed services are not all reported and when they are it remains quite unclear which charges correspond to which services.
A number of conflicting phenomena that retard effective development of PHCS have yet to be resolved or corrected. The conflict of interest and the agency problems arising when publicly employed physicians also manage public health facilities seems not to be a major concern of the MOPH. Physicians employed to serve public facilities may tend to divert patients to their own private clinics or they lack the necessary rigor and ethics in the delivery of medical care. There is therefore a clear shortage of competent and skilled healthcare managers and a lack of management leadership capacity resulting in extensive internal administrative weaknesses.
The lack of strategic planning in the conception and the implementation of health projects and programs also contributes to the failure of initiated health projects. Managers at public facilities, mainly possessing only basic medical background, lack the vision, the leadership capacity and the management discipline required for the function of healthcare manager. They approve projects presented to them, for example, based on subjective (highest under the table kickback) rather than objective (impact on population health status and improvement in quality of life) considerations.
They do not have competent support staff to assist them in performing business strategic evaluation, which is necessary before engaging in any project. Such preparatory analysis would include environmental scanning, strategy formulation, strategy implementation and evaluation and control of operations. Thus, the lack of strategic management capacity and the inability to learn from past mistakes and others’ experiences favor wastage of precious resources and promote inadequate governance of the PHCS.
Significantly, the PHCS is clearly under financed. Health care organizations must generate cash flow, acquire assets, and put those assets to work, just as manufacturing and banking organizations do. Though the public budget allocated to PHCS has more than doubled in the last couple of years, going from CFAF 24,048 billion or 2.16% of the national budget in 1997 to CFAF 120,844 billion or 7.82% of the national budget in 2005 (Table 2-3), it is important to note that such growth coincided with the implementation of several economic reforms and the approval of loans from the World bank (WB). Moreover, a significant amount of the monies available were heavily invested in the restructuring of some health facilities, the building of roads to increase access to care and the training of health workers.
But despite the increases in government funding, the financial allocations are indeed meager considering the ongoing needs of the growing population. For instance, the structural renovations performed were certainly not sufficient to insure quality of care delivery nor were they enough to ensure increased use of health services. Furthermore, primary health care centers and district hospitals, even those with trained staffs, lack adequate technology to diagnose many infectious diseases, and they regularly run out of medical supplies and pharmaceutical drugs.
External contribution to the financing of health care in government budget has increased also, rising from 26.53% of the total health investment in 1997 to 32.10% in the year 2000, as shown in Table 1-3. However, the management of such funds is troubling to the degree that in most cases health facilities do not receive the bulk of the monies from foreign financial benefactors.
Internal organizational structures plagued with heavy bureaucratic barriers and heavy corruptive practices prevent the proper and fast disbursement of the external fund contributions, raising issues once again of internal dysfunctional organizational structure and inadequate governance. The lack of rigorous and transparent handling of funds leaves severe deficiencies in financial accountability and encourages false reporting and embezzlement of health funds.
In addition, the MOPH has not been able to allocate monies equitably across the territory based upon the consideration of the geographic spread and economic need of the total population. Instead of using the donated funds for the revival of essential programs such as health prevention campaigns, immunization campaigns, information campaigns, and targeting services most frequently used by the poor, about 60% of government health expenditure is devoted to urban health facilities serving only about 20% of the population. Such preferential allocations create an issue of inequality in access and utilization of care. Moreover, households are then obligated to assign larger shares of their budgets for health expenditure. Meanwhile, the poverty rate has been steadily increasing nationwide.
Another factor causing the low financing of PHCS is the practice of either wrongful or unwise disbursement of funds in the sense of not considering future development and advancement. Most funds earmarked for health care development are sunk into production costs (maintenance of major equipment, payment of salaries, replenishing of inventories, and so forth) with nothing substantial left for infrastructural developments and quality improvements in delivery care.
Foreign Aid and Healthcare Expenditure
Essentially, external institutions have dictated a number of economic constraints on national budgetary decisions. Cameroon is one of those countries subscribed to the WB/IMF structural adjustment program (SAP) which imposed drastic cuts in the national budget for health which went from 120 billion CFAF or 3.3% of the total GDP in 2002 to 58 billion CFAF or 1% of the GDP in 2005.
The SAP policies required already indebted countries to: (1) shift from production of domestic consumption food to producing cash crops for export; (2) abolish food and agricultural subsidies to reduce government expenditure; (3) severely cut health, education, and housing program funding and reduce salaries; and (4) devaluate the currencies and privatize government-held enterprises. The reform designed to stabilize the economy exerted adverse effects instead on the economy of borrowing countries like Cameroon.
In reality, [the World Bank] imposed harsh measures, which exacerbated poverty, undermined food security and self-reliance and led to resource exploitation, environmental destruction and population displacement. The health sector was particularly adversely affected, and few proactive steps were taken to protect vulnerable populations and ensure ongoing availability of basic services.
Following the expenditure cuts, especially in the national budget for public health, the following conditions occurred: (1) the integrated health centers lost qualified personnel and a shortage of basic health materials ensued; (2) the training of health workers was interrupted, which in turn affected the motivation level of doctors and health workers; (3) there was a shortage of medical supplies, a breakdown of transportation and problems of inadequate management; and (4) medical consultations and hospitalization declined despite the increases in acute infectious diseases. More generally, the quality of care delivery in public facilities declined and studies showed that more patients sought care in private institutions despite their higher costs.
In addition to all the obstacles of an already struggling PHCS, the combined effects of infectious disease epidemics of tuberculosis, malaria, and HIV/AIDS, further strained the public health sector beyond its limits. The failure of the public health system to provide appropriate medical care for individuals who had contracted these diseases– large segments of the population — led the latter to choose more expensive private medical services.
Consequently, as shown in Table 2-4, the household budget for health expenditure skyrocketed and rose from 4% in 1983/84 to 9.6% in 1995/96 resulting in a household spending on health from $14 to $20.6 per capita. The increase is mainly due to elevated out-of-pocket payments charged for private medical services, raising the issue of inequality once again in the use of care. The WHO has estimated that the cost of a basic package of health care delivered to 90% of the population in a low-income country like Cameroon would be a $13 per capita (table 2-5).
However, a further analysis of the region matrix in table 2-5 and the distribution of household per capita health expenditures by population decile (which is a partial source to income group matrix) in table 2-6 reveals even more drastic inequalities in the distribution of health expenditure across income groups and between urban and rural regions.
Thus, in 1998, the per capita household expenditure for health by the poorest 10% of the population was only $5.4 while for the richest 10% it was $90.4. This translates in the utilization of private health services– more effective delivery– by the part of the population with higher income and the utilization of public facilities–less effective delivery– by the poorest portion of the population. The wide middle class will seek medical care from public, private or traditional providers based upon their current financial means.
The table 2-5 highlights the wide inequalities in the distribution of health expenditures between urban and rural areas (and to a lesser extent among rural areas). In Douala and Yaounde (the two largest towns holding about 40% of the population) the capita health expenditures were $51.9 and $46.1 respectively compared to $18.5 and $18.9 in the rural plateau and rural savanna. Such imbalances are due to the fact that households have higher incomes in urban areas, government spending is higher in urban areas and enterprises, both public and private, are concentrated in urban towns.
An evaluation of the performance of the PHCS reveals, therefore, that the principal elements and characteristics of successful health systems including accessibility to facilities, appropriateness of medical treatments, effectiveness in access of care, efficiency in delivery of care and equity in use of care, are all seriously lacking in the Cameroonian PHCS.
Effectiveness: Public Health Care System Performance
In Cameroon, public health facilities perform below expectations due to organizational, managerial and financial issues. This below average performance results in reduced effectiveness of public healthcare providers, inefficiency of the PHCS and unequal access to health services by a large portion of the population who needs it the most.
Budgetary cut backs have also led to a moratorium on the construction and equipping of health facilities, a freeze on the recruiting of public health employees, and a shortage of sufficient qualified personnel. In addition, the distribution of health workers across the country is inappropriate due to discrepancies in regional distribution of health facilities. In a major way, salaries have been slashed with the attendant consequences of the lack of motivation and lower performance (low morale) among health personnel.
As a result overall, the main quality indicators have deteriorated in the light of WHO standards. The per capita ratio of physicians, nurses, hospital beds, health centers and pharmacies shown in Table 1-1 indicate major discrepancies in the distribution of health resources across the territory. Human resource planning is to be revised and working conditions are to be ameliorated in order to attract more care providers in the public sector, increase productivity and effectiveness of the PHCS.
Not only is there a shortage of human resource personnel, but there are also supply management deficits. Inventories are not kept accurately, so doctors and nurses can help themselves to medications directly on shelves, and supply depends on availability of resources rather than based on any demand assessment. This means that inventories and supplies are replenished whenever funds permit. Moreover, supplies are not equally distributed among health facilities. Urban health facilities tend to receive more stock and resources than rural or remote health facilities, but medication and medical materials are in more grave demand in these latter areas. In some rural facilities, syringes and surgical material such as gloves and bedding are re-used.
Some facilities even lack beds for patient and the laboratory material to perform blood or other tests. Thus, equipment that are needed for the care of ill patients are regularly in excessive quantities compared to other areas, and are lacking in other areas or where there are none at all. All these factors engendered by internal and external mismanagement at both the financial and the organizational levels affect the rate of use of public health services, and, ultimately undermine and negate the efficiency and the effectiveness of the PHCS.
Efficiency: Utilization of Public Health Facilities
Several constraints have arisen during the last decade, which led to a significant decrease in the utilization of the public health care system. The government suspended recruiting and training of health care personnel because of lack of funding. Table 2-1 shows that there are fewer than 20,000 health care workers for a population of almost 17,000, 000 people. The prevailing (accepted) corruption in public health facilities is manifested through the observation of health personnel offering health care services which are normally free in exchange for financial favors. In Cameroon, though many medical services such as vaccination and delivery of essential drugs, are supposed to be free of charge, more often than not, personnel charge patients with nominal fees for these services. Moreover, the culture of “clientelism” is deeply rooted in the PHCS.
Notably, medical services afforded to patients are prioritized not based on the severity of patients’ illnesses, but rather on the level of rapport between the health staff and the patients or the amount of money the patients have at their disposal to be used to bribe the health staff. Health managers and health providers in the concerned facilities do not regularly investigate or follow up patients complaints simply because they belong to the same professional pool as those personnel who exploit the patients and accept bribes for routine medical care. Moreover, the lack of incentives from the MOPH to reinforce the delivery of free services and the fact that MOPH authorities are responsible for nominating those health managers, all factors which serve to undermine the effectiveness of any civil action against the malpractices observed in public health facilities.
In essence, as an intern in the Hospital La Quintinie in Douala in 2000, this researcher witnessed instances when patients bribed health personnel to receive health services they had already paid for at the cash register. This researcher also saw bodies being dumped in the front yard of the hospital and remaining there for hours before being dispatched to the morgue. In another instance, this researcher was informed of an individual who had sued a physician for negligence.
The doctor had received a telephone call late at night relating to the difficult delivery of one of his patients; however, the doctor had asked the nurse to deal with the issue and turned off his cell phone, which resulted in the death of the patient. However, the case was dismissed and the physician, who did not even receive a temporary suspension or a reprimand, is still working at that facility. Also, seriously ill patients are still left unattended in waiting areas for extended hours. This situation fosters long lines and extensive waiting times, altogether discouraging many patients from seeking medical care in public health facilities.
The efficiency of the public health system can be judged by the utilization of the services by the people for whom they are intended. According to the North West province records, during 1989 and 1995, there were 173,450 consultations in religious missions facilities versus 129,569 at government health centers in the northwest region. In other words, there is a two fold increase in the utilization of nonprofit facilities. That data attest to the low utilization of public health care services and implies that the quality of health services delivered is inferior in the public sector and, therefore, less sought. The evidence from the northwest province suggests a steady decline in health care provision by public facilities.
The share of the government in both health centers and hospital consultations fell from 72.9% in 1989 to 50.1% in 1995 while the share of mission consultations increased from 25.5% to 47% and the private sectors from 1.6% to 2.9%. The bed occupancy rate in hospitals fell from 45% in 1985 to 23% in 1996. Therefore, it becomes apparent that many patients clearly demonstrated preference for health services offered by nonprofit organizations and for profit establishments instead of those offered in the public sector. Such utilization factors underscore the failure of the PHCS in providing efficient health services.
In fact, the poor, for whom public services are primarily intended, incur overall financial losses when using public health facilities. First, they must travel long distances to receive uncertain and inconsistent medical attention. Second, added to the time wasted on the road to reach health centers, they have to wait long hours to receive inadequate and inappropriate care or no care at all. The opportunity cost in terms of income loss and hours of labor is high compared to the quality of life improvement they might have gained. This prevents many low-income patients from utilizing public health facilities unless their diseases are in a well-advanced state and require immediate attention.
According to the 1995 household-survey, 14.8% of health providers were traditional healers, 43.8% of consultations took place in public facilities, and 56.2% took place in private facilities– though 50% more expensive. There is a clear decrease in the utilization of public health facilities over private health clinics. The decaying public health care buildings, major components of the health care infrastructure, and the lack of competent health workers actually send negative messages to patients who, therefore, prefer to obtain appropriate care at higher costs at private institutions for those who can afford it. Table 2-7 further illustrates the low level of government health spending relative to private spending and household spending.
There is a grave degeneration of medical ethics in several public health facilities. Often, under qualified health workers perform specialized services they have not been trained for. In some hospitals, nurses are performing surgeries, delivering anesthesia and prescribing medicines. In other health facilities, the record of services provided is inaccurate and patients’ files are non-existent.
The overall number of health care personnel in public health care facilities has decreased against a background of a growing population, resulting in a gap between the health services demand and the supply in the whole territory and an underutilization of public medical services. Underutilization promotes wastage in health care resources and inefficiency (low utilization) while favoring the development of over-crowding in other health units, which in itself prevents proper and adequate delivery of healthcare to patients. Moreover, the vast regional imbalances between the distribution of health care facilities and health care workers exacerbate the problem of underutilization of public health care facilities.
Equity: Health Disparities Across the Nation
There are significant differences in the state of health and the access to care between the poor and low-income households and the non-poor, as well as between urban and rural inhabitants. Most people turn to formal health services in cases of illness. Among those who have declared themselves ill in 2001, 3/4 was able to seek consultation at a formal health centers, versus 1/4 in informal facilities. Formal health centers are more frequently visited by the non-poor and informal facilities by the poor. It appears that non-poor seek medical help more often than the poor maybe due to superior financial capacity.
Another indicator of discrepancy between poor, non-poor, rural and urban residents is the vaccination rate. Thus, the immunization rate for non-poor children is better than that for poor children and children are better protected in cities than in rural areas. Table 2-5 reports inequality in the rate of consultation in formal and informal facilities between poor and non-poor in rural and urban areas. From that table, it appears that both income groups allocate similar budgets for health expenditure.
However, the average health expenditure among the rural and poor residents is three times less than that of non-poor and urban dwellers. Thus, lower spending for health care services is reflected in the lower consultation rate of non-poor which is indicative of their health status. Thus, the infant (12 to 23 months) immunization rate for poor in rural areas was 66.9% and 53.1% for poor in urban areas while it was 89.5 for non-poor in rural areas and 70.2% for non-poor in urban areas.
Finally, the non-poor have to travel slightly lower distances to receive medical care than the poor which in turn increases their access to health services. According to regional health map data, 54% of people live less than five kilometers from an integrated health center.
This average figure, however, conceals wide regional disparities, ranging from 43% of people living less than five kilometers from an integrated health center in the province of Adamaoua to 78% of people living less than five kilometers from an integrated health center in the Littoral province. Moreover, the household survey statement notes that rural people must travel five times farther than urban dwellers to reach the nearest health facility. Even more striking, 98.9% of the people who must travel 6 km to a health facility live in the countryside, indicating the serious problem of rural access to appropriate health care services.
Table 2-5 shows the division of health spending in urban areas (Douala, Yaounde, and other towns) and in rural areas. From this table, it is obvious that urban dwellers spend more on health care than rural dwellers mainly due to higher income since households in cities spend on average $34 on health care versus $16.7 on average on health care, which is about half of what urban dwellers spend on healthcare. Though government spending seems to be significantly higher in comparison to direct foreign aid and religious mission share of health spending, it must be emphasized that an increasing share of MOPH budget is financed through foreign financial donations (Table 1-3).
Table 2-8 is a perfect illustration of the lack of equity in the distribution of health services (whether in formal or informal facilities) among the different population groups in Cameroon.
From Table 2-8, it appears that annual average health spending per capita is three times higher in urban than in rural areas (39,00 CFAF vs. 13, 000 CFAF) and four times higher among the non-poor than it is among the poor (32,000 CFAF Vs 6,900 CFAF). Yet the cost of health services rose nearly three times as fast as the average inflation rate over the last five years by some 70% (13,000 CFAF to 22,00 CFAF), which led to a considerable decrease in the demand for health services, especially for the poor whose utilization of health services declined.