PRIMARY HEALTH CARE SYSTEMS

(PRIMASYS)
Comprehensive case study from Cameroon
PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Comprehensive case study from Cameroon

Pierre Ongolo-Zogo
Centre for Development of Best Practices in Health, Central Hospital, University of Yaoundé

David Yondo, Jean Serge Ndongo, Nsangou Moustapha, Christine Danielle Evina
WHO/HIS/HSR/17.43
© World Health Organization 2017
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PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Contents
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Background to PRIMASYS case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
2. Cameroon: primary health care indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
3. Historical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5. Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
6. Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
7. Planning and implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
8. Regulatory process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
9. Health monitoring and information systems, Cameroon . . . . . . . . . . . . . . . . . . . . . . . . . 15
9.1 Overview of health monitoring and information systems . . . . . . . . . . . . . . . . . . . . . . . . 15
9.2 Monitoring system associated with performance-based financing . . . . . . . . . . . . . . . . . . 15
9.3 Monitoring system associated with National Health Development Plan . . . . . . . . . . . . . . . 16
10. Strategic outlook and considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figures
Figure 1. Historical background of PHC in Cameroon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Tables
Table 1. Key PHC indicators, Cameroon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Table 2. Cameroon: causes of morbidity and mortality, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . 4
Table 3. Hierarchical levels of the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Table 4. Current expenditure on health care by funding method, 2012 . . . . . . . . . . . . . . . . . . 10
Table 5. Household current health care expenditure by function, 2012 . . . . . . . . . . . . . . . . . . 11
Table 6. Distribution of human resources for health according to qualification, 2011 . . . . . . . . . 12

COMPREHENSIVE CASE STUDY FROM CAMEROON

Abbreviations
DALY disability-adjusted life-year Reo-PHC Reorientation of Primary Health Care
MTEF Medium-Term Expenditure Framework SWAp Sector-wide Approach
NGO nongovernmental organization UNICEF United Nations Children’s Fund
PHC primary health care WHO World Health Organization

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

iv
Background to PRIMASYS case studies
Health systems around the globe still fall short of worldwide. The PRIMASYS case studies cover key
providing accessible, good-quality, comprehensive aspects of primary health care systems, including
and integrated care. As the global health community policy development and implementation,
is setting ambitious goals of universal health coverage financing, integration of primary health care into
and health equity in line with the 2030 Agenda for comprehensive health systems, scope, quality and
Sustainable Development, there is increasing interest coverage of care, governance and organization, and
in access to and utilization of primary health care in monitoring and evaluation of system performance.
low- and middle-income countries. A wide array of
The Alliance has developed full and abridged versions
stakeholders, including development agencies, global
of the 20 PRIMASYS case studies. The abridged
health funders, policy planners and health system
version provides an overview of the primary health
decision-makers, require a better understanding of
care system, tailored to a primary audience of policy-
primary health care systems in order to plan and
makers and global health stakeholders interested in
support complex health system interventions. There
understanding the key entry points to strengthen
is thus a need to fill the knowledge gaps concerning
primary health care systems. The comprehensive case
strategic information on front-line primary health
study provides an in-depth assessment of the system
care systems at national and subnational levels in
for an audience of researchers and stakeholders who
low- and middle-income settings.
wish to gain deeper insight into the determinants
The Alliance for Health Policy and Systems and performance of primary health care systems
Research, in collaboration with the Bill & Melinda in selected low- and middle-income countries.
Gates Foundation, is developing a set of 20 case Furthermore, the case studies will serve as the basis
studies of primary health care systems in selected for a multicountry analysis of primary health care
low- and middle-income countries as part of an systems, focusing on the implementation of policies
initiative entitled Primary Care Systems Profiles and programmes, and the barriers to and facilitators
and Performance (PRIMASYS). PRIMASYS aims to of primary health care system reform. Evidence from
advance the science of primary health care in low- the case studies and the multi-country analysis will
and middle-income countries in order to support in turn provide strategic evidence to enhance the
efforts to strengthen primary health care systems performance and responsiveness of primary health
and improve the implementation, effectiveness care systems in low- and middle-income countries.
and efficiency of primary health care interventions

COMPREHENSIVE CASE STUDY FROM CAMEROON

1
1. Overview
Cameroon is a lower middle-income country with is out-of-pocket payments. The maternal mortality
around 23 million inhabitants, half of whom live in ratio has increased in Cameroon during the last 20
urban areas. This bilingual (English–French) country years, despite the increasing annual per capita health
in Central Africa is made up of 10 administrative expenditure, which reached US$ 59 in 2015. Growing
regions divided into 189 health districts. Primary privatization has led to a low servicing rate for health
health care (PHC) is provided in line with the districts, particularly in rural areas, and there are stark
health district framework proposed by the World inequalities in the distribution of human resources.
Health Organization (WHO) Regional Office for
The epidemiological profile of the country is marked
Africa, entailing a nurse-based, doctor-supported
by a predominance of communicable diseases,
infrastructure of State-owned, denominational and
including HIV/AIDS, malaria and tuberculosis, which
private integrated health centres. It is supported
represent 23.66% of the overall disease burden,
by a diverse and fragmented system of community
along with a remarkable increase in mortality
health workers recruited by priority public health
due to noncommunicable diseases, including
vertical programmes. The 2016 evaluation of this
cardiovascular diseases, cancers, mental illnesses,
sectoral strategy found that 7% of the 189 health
trauma due to road accidents and accidents at work,
districts were serviced. The PHC system has achieved
and occupational diseases (1). Among children aged
high routine immunization coverage rates, high
under 5 years, lower respiratory tract infections,
coverage of malaria-preventive technologies and
malaria, diarrhoeal diseases and nutritional
high coverage of HIV screening.
deficiencies are the main causes of morbidity and
PHC performance in Cameroon is below expectations mortality. Maternal mortality remains high at 782
when compared to the current health expenditure, deaths per 100 000 live births. Between 2004 and
mostly because of growing privatization, the weak 2014, neonatal mortality slightly decreased from 29
regulatory system and lack of accountability. per 1000 to 28 per 1000 live births; during the same
Cameroon has one of the highest levels of health care period, the child mortality rate decreased from 144
expenditure occurring in the informal sector (up to per 1000 to 103 per 1000 live births, while the infant
30%, mostly in PHC). User fees are usually charged at mortality rate decreased from 74 per 1000 to 60 per
the point of use, except for some services for specific 1000 live births (2).
population groups. Up to 66% of health expenditure

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

2
2. Cameroon: primary health care indicators
Table 1 presents key PHC indicators for Cameroon, while Table 2 presents data on the various causes of
morbidity and mortality.

Table 1. Key PHC indicators, Cameroon

Indicator Results Source of information Remarks
Total population of country 23 344 179 World Bank database (2015) From the last general population census of
2007 to 2015 the population increased by
22.4%, or 2.5% annually

Distribution of population (rural/ 51.5/48.5 Third general population census

urban) (2007)

Life expectancy at birth 55.5 years World Bank database (2014) Life expectancy has increased gradually from
51.9 years in 2000

Infant mortality rate 57 per 1000 United Nations Children’s Fund Trends indicate a decrease from 61 per 1000
(UNICEF) (2014) in 2012 and 60.8 per 1000 in 2013

Under-5 mortality rate 87.9 per 1000 World Bank database (2015) Trends indicate a decrease from 150.4 per
1000 in 2000

Maternal mortality ratio 782 per 100 000 Demographic and Health Survey
(2011)

Immunization coverage 73% (rotavirus) UNICEF database (2015)

85% (pneumococcal)

Income inequality (Gini index) 0.389 United Nations Development

Programme (2014)

Total health expenditure as % of 4.1% World Bank database (2014)

gross domestic product (GDP)

PHC expenditure as % of total 21% National Health Accounts (2012) The estimate is derived from expenditure
health expenditure on ambulatory care, immunization, and
traditional medicine, while excluding
expenditures on medicines

% total public sector expenditure Not reported

on PHC

Per capita public sector Not reported

expenditure on PHC

Out-of-pocket payments as 66.3% World Bank database (2014)

proportion of total expenditure
on health

COMPREHENSIVE CASE STUDY FROM CAMEROON

3
Table 2. Cameroon: causes of morbidity and mortality, 2013
Contribution to burden of
No. Causes of morbidity and mortality Contribution to deaths (%)
disease in DALYs (%)
1 HIV/AIDS 11.48 14.24

2 Neonatal illnesses 11.27 8.47

3 Malaria 10.77 8.78

4 Lower respiratory tract infections 10.12 10.52

5 Diarrhoeal diseases 5.57 5.01

6 Nutritional deficiencies 5.03 3.74

7 Cardiovascular diseases 4.67 11.56

8 Road traffic accidents 3.95 4.38

9 Mental illnesses and substance abuse 3.53 0.86

10 Unintentional accidents 2.88 2.87

11 Cancers 2.02 4.45

12 Complications related to pregnancy, childbirth and early life 1.95 2.17

13 Musculoskeletal diseases 1.82 0.14

14 Neglected tropical diseases 1.82 0.22

15 Tuberculosis 1.41 2.08

16 Chronic respiratory diseases 1.38 1.47

17 Sexually transmitted infections 1.31 1.01

18 Cirrhosis 1.30 2.42

19 Neurological diseases 1.15 0.87

20 Chronic kidney diseases 0.76 0.83

21 Other causes 15.81 13.91

Total 100.00 100.00

Note: DALY = disability-adjusted life-year.

Source: Health Sector Strategy 2016–2027 (3).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

4
3. Historical background
The evolution of primary health care (PHC) in had been selective implementation of PHC through
Cameroon covers two main periods – before and vertical programmes carried out in parallel to and
after the International Conference on Primary Health independent of the health system. Indeed, the
Care, Alma-Ata, 1978, the main outcome of which system had not been restructured to integrate
was the Alma-Ata Declaration on Primary Health Care PHC; the use of community health workers without
(4, 5). Before Alma-Ata, two approaches had been proper training was inefficient; mechanisms to
adopted. The first was a medical approach based on ensure proper community participation were
colonial-inspired vertical programmes (urban public non-existent; and health workers did not receive
hospitals and rural denominational hospitals) in continuing professional development for supervision
which good health was synonymous with absence of of community health workers.
disease. The selected care was free of charge, and the
The subsequent Reorientation of Primary Health
community followed the health workers’ instructions.
Care (Reo-PHC) involved a realignment of the
Following that, a “health services” approach was
National Health System towards the social goal of
applied, characterized by the four “demonstration
Health for All (7). The purpose of Reo‑PHC was to
zones of public health action”1 put in place in 1967
ensure universal access to PHC services through
under the inspiration of WHO and intended to
a decentralized management process focused on
introduce progressively selective health care and
the health district level, with the institution of the
services deemed economically viable. The approach
integrated health centre as the first level of contact
introduced the concept of village health teams and
with the health system (8, 9). The aim was to integrate
village dispensing pharmacies managed by local
health activities at the level of the health centre, while
health personnel through a cost recovery mechanism
empowering the communities involved in financing
underpinned by working capital. Evaluation of the
and management (10). This reorientation, supported
system showed that (a) community-based health
by technical and financial partners through regional
activities had positive effects and stimulated demand;
pilot experiments, has not, however, fully achieved
and (b) communities were willing to contribute (to
the desired objectives.2 National seminars in
some extent) to the financing of health facilities and
1993 and 1994 resulted in the development of a
activities, including village pharmacies. Community
legislative and regulatory framework3 that placed
involvement was mostly passive.
the health district as the foundation stone for PHC
In the wake of the Alma-Ata conference, which implementation, including the institution of district
enshrined the notion that health should go beyond health management teams and district dialogue
the delivery of care and promote community structures in the form of district health committees
involvement in order to make a significant impact and district management committees. This
on health status (6), Cameroon adopted a series restructuring formed the basis of the Health Sector
of health reforms in 1982. However, the Ministry Strategy 2001–2015 and its updated version of 2007.
of Public Health found in a 1988 survey that there

1
Zones de démonstration d’action de santé publique.
2
UNICEF study, 1999.
3
Presidential decrees reorganizing the Ministry of Public Health, 7 March 1995, 19 August 2002 and April 2013, and Framework Law 96/03 of 4 January 1996
pertaining to the health sector.

COMPREHENSIVE CASE STUDY FROM CAMEROON

5
Figure 1. Historical background of PHC in Cameroon

PHC development: Since 1999

Promotion of health district approach,
Health Sector Strategy 2001–2015
• Implementation of PHC: PHC activities carried out at the health
areas level / community health workers to be revamped
• Dialogue structure gradually put in place / functionality
questionable / judiciary framework still expected

Community 1995
development approach Organization of the health system: national, intermediary,
peripheral / health district
• Health = human condition
Health district: health area management
• Community = help attain the condition committee, district health
by participation in decision-making Dialogue management committee, district hospital
structures management committee
Regional special fund for health /
essential drug programme

1993
National Declaration on the Implementation of the
Reorientation of Primary Health Care: partnership
between government and communities based
on co-financing and co-management

1988
PHC implementation found to be vertical without effect,
need for reorientation (Ministry of Public Health)
1982–1988
implementation of Alma-Ata
principles, adopted reforms (1982)

Alma-Ata 1978
Primary health care reforms

Health service approach Post Cameroon independence (1960–1978)

• Health = WHO definition / orientations • 1967: Demonstration of public health actions – zones in 4 areas: gradual
• Community = help deliver services introduction of rationalized and economically sustainable health activities /
health team spirit / village health committee

Medical approach Colonial period and before

• Health = absence of disease
Cameroon independence (1960)
• Community = follow the doctor Dr Eugene Jamot strategy / mobile team / vertical programmes,
colonial interest oriented: hospital development

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

6
4. Governance
The health district is the operational unit for PHC.4 accountability system. The inappropriate targeting of
Organized in a territory comprising one or more official development assistance and the prominence
municipalities, the district shall, by decree, be of vertical public health priority programmes have
managed by a district management team. A district led to fragmentation of PHC in Cameroon, resulting
health committee and a hospital management in enormous challenges concerning harmonization
committee constitute the dialogue structures of the vision and priorities among actors at the
responsible for translating community participation operational level of the national health pyramid.
into practice and promoting the ownership of Table 3 shows the various levels of the health system
health services by local actors (9). According to the hierarchy.
1996 Constitution and the laws and regulations
Co-management of the non-community budget
on the decentralization of the State of 2004, the
(various solidarities) within the partnership
municipalities are responsible for public health and
framework is interpreted differently by officials
sociocultural development. However, there have
of the Ministry of Public Health and community
been numerous governance failures in health districts,
representatives. The former consider it their
in particular the opacity of management procedures,
private “turf”, while the latter, though aspiring
the marginalization of some local institutions in
to be “co-managers”, lack understanding of the
decision-making concerning health issues, the
expectations and attitudes of the former. Reo-PHC
inefficient functioning of health information systems,
is far from being a reality on the ground. The actors
the weak rule of law, and the many deficiencies in the
have not been appropriately redirected towards this

Table 3. Hierarchical levels of the health system

Level Administrative structures Competences Health structures Dialogue structures
Central Prime Minister’s Office Development of Central hospitals National Council of
Office of the Minister of Health concepts, policies General hospitals and teaching Health, Hygiene and
and strategies hospitals Social Affairs
General Secretariat
Coordination National Essential Medicines Supply
General inspectorates
Regulation Centre
Central directorates
Centre Pasteur
National Laboratory for Quality Control
of Medicines
National Observatory of Public Health

Intermediate Ten regional delegations Technical support to Regional hospitals Regional funds for health
health districts Regional supply centres of promotion
pharmaceutical products

Peripheral 189 health districts Implementation of District hospitals District health committee
programmes Health clinics District management
Medical centres committee
Integrated health centres Area health committee
Dispensaries Management committee
Health care centres

Source: Health Sector Strategy 2016–2027 (3).

4
Ministerial decrees No. 0016/A/MSP/SG/DMH/SDH/PFSP/BFSP of 5 November 2001 creating health districts; and No. 0035/A.MSP/CAB of 8 October 1999
fixing the modalities for creation, organization and operation of health districts.

COMPREHENSIVE CASE STUDY FROM CAMEROON

7
new approach, which probably explains the low level level gave direction in the areas of monitoring,
of development of health districts (7%) by the end control, regulation and standards (3). A gradual
of 2015 and the lack of involvement of communities, decrease in the number of vertical programmes was
despite the establishment of a number of dialogue intended, while health districts developed expertise in
structures by the Ministry of Public Health, including providing integrated and comprehensive intervention
the 10 regional funds for health promotion. packages to the population. The multiplicity of vertical
programmes had resulted in systemic inefficiency,
The strategic paper on the Health Sector Strategy
duplication of services and resource wastage, even if
2001–2015 had among its major objectives the
the results had been satisfactory in terms of coverage
decentralization of the health system, including
of the target population.
empowerment of health districts while the central

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

8
5. Financing
A historical approach to the development of PHC in national solidarity through the public budget and
Cameroon, taking account of such markers as the international solidarity through public aid to health
Alma-Ata Declaration (1978), the Harare Declaration development. Since 1994 a regulatory regime for
on Strengthening District Health Systems Based fiscal federalism has been in force, with health
on Primary Health Care (1987), and the Bamako committees and management committees of public
Initiative (1987), sheds light on the complex diversity health facilities given responsibility for the pricing of
of actors and mechanisms involved. If the health PHC services, determination of the level of the costs,
fiscal space has expanded over the last decade with and the allocation of local tax resources generated for
the end of the structural adjustment programme, the operation according to a distribution schedule
there is still no taxation directly allocated to health. updated in December 2016. As for denominational
Cost recovery at the point of care constitutes the and private health care facilities, pricing is more
main purchasing mechanism for PHC services, and related to market rules and principles, with marginal
prepayment through microinsurance, mutual funds regulation of prices under the responsibility of the
or health insurance remain of marginal importance. Ministry of Commerce.
Addressing the three funding functions of primary
The framework of analysis of the National Health
health care (resource collection, pooling of resources, 5
Accounts does not allow determination of the
and purchasing of health care and services) is
relative magnitude of expenditures associated with
impeded by the lack of specific documentation.
primary health care. The financial resources for health
Prior to Alma-Ata, the majority of certain selected come from the government, private companies,
PHC services were free, except for medicines and technical and financial partners, nongovernmental
drugs in dispensing pharmacies and remunerated organizations (NGOs), households and benefactors.
services in hospitals and health centres. After Alma- An analysis of the breakdown of current expenditure
Ata, PHC services were free or partially subsidized shows that households contributed over 70% in 2012
on the basis of standardized but differentiated care (Table 4). The share of the Ministry of Public Health’s
between public and private health facilities. With budget in the overall State budget has stagnated
the onset of the economic crisis (1985/1986), which at around 4.87%, far below the commitment under
resulted in the imposition of structural adjustment, the Abuja Declaration on HIV/AIDS, Tuberculosis and
there were frequent shortages of subsidized drugs Other Related Infectious Diseases, which invited the
and consumables. Under the Bamako Initiative African States to allocate 15% of their budgets to
(1987), widespread use was made of cost recovery health (11). Private funding represents 55%, of which
to access PHC services, with the exception of a few 52% is paid by households. External financing of
public health programmes such as the Expanded PHC programmes was estimated at 65 billion Central
Programme of Immunization. African francs in 2015, mostly geared towards three
domains: maternal, child and adolescent health
PHC funding now has two main sources: (a)
(34%), disease control and health promotion (38%),
community based, through fee for services at
and health district development and servicing (28%).
the point of delivery, purchase of medicines,
human investment, donations and legacies;
(b) non‑community based, in the form of

5
National Health Accounts, 2011 and 2012.

COMPREHENSIVE CASE STUDY FROM CAMEROON

9
Table 4. Current expenditure on health care by funding method, 2012
Amount (million Central
Funding method %
African francs)
Public administration systems and contributory schemes for health 98 547 14.60

Voluntary private health payment plans 54 543 8.07

Optional health insurance schemes 38 230 5.66

Non-profit institutions serving households (+ development agencies) 1 509 0.22

Business financing schemes 14 804 2.19

Out-of-pocket payment of households 47 4221 70.27

Rest of the world (non-resident) financing schemes 47 566 7.05

Other financing plans 4 0.00

Total 729 424 100.00

PHC procurement mechanisms vary according to for children aged under 5 years and postpartum
government priorities, and may be categorized as women; treatment for acute, severe and moderate
follows. malnutrition; cancer chemotherapy; and
haemodialysis.
• Gratuity payments are the main mechanism
• Out-of-pocket payments are the most
used by the State (public funding) for the control
widespread purchasing mechanism, greatly
of communicable and noncommunicable
contributing to the inaccessibility of care for many
diseases for all or part of the population. Priority
inhabitants. In 2009, spending on health care in
diseases include epilepsy, onchocerciasis,
Cameroon was estimated at 680 billion Central
tuberculosis, leprosy, intestinal helminthiasis,
African francs, more than 75% of which is borne
schistosomiasis, Buruli ulcer, trachoma, and
by households. According to WHO, around 95%
lymphatic filariasis. Focus areas for specific
of household expenditure is disbursed at care
treatment include hydrocele surgery; provision of
delivery points during episodes of disease.6
insulin for diabetes; malaria in children aged 0–5
• Performance-based payment has been
years; intermittent preventive treatment of malaria
deployed by the government since February 2011
for pregnant women; insecticide-treated bednets
through the World Bank-funded Health Sector
with long duration of action; chemoprophylaxis
Investment Support Project in a few regions in the
of seasonal malaria; HIV testing for pregnant
form of a pilot project to improve the quality of
women, spouses and children aged 0–5 years;
care and the health of the population.
prevention of mother-to-child transmission of
• Prepayment mechanisms are poorly
HIV; management of diabetes among young
developed, contributing to marginal financing
people aged 0–18 years; family planning; and
of PHC. The open market sector for voluntary
immunization.
health insurance is dominated by about 15 private
• Subsidies are in place for the management
insurance companies. The coverage rate by risk-
of certain diseases with social impact, in order
sharing schemes varied from 0.1% in 2001 to
to encourage the participation of households.
about 2% in 2015, for example through company
Examples include a voucher scheme for pregnant
health services, commercial insurance schemes,
women; obstetric kits; vitamin A supplements
and health mutual funds (158 rural community
6
WHO data, 2009 and 2010.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

10
 mutual funds covered 1.5% of the population by their employers (12, 13). The poor coverage
compared to the 40% target in 2010, versus 43 rate of health insurance schemes partially explains
funds in 2013 covering nearly 43 000 people or the amount of expenditure in the informal health
0.2% of the population). Commercial insurance sector, estimated at 27%.
schemes target the high and intermediate income
Table 5 shows household current expenditure by
groups, including formal sector workers covered
health care function.

Table 5. Household current health care expenditure by function, 2012

Amount (million
No. Health care function Central African %
francs)
HC.1.1 Curative care 130 280 27.47

HC.1.5 Delivery (traditional delivery) 717 0.15

HC.1.5.2 Hospitalization (traditional medicine) 136 0.03

HC.1.5.3 Consultation (traditional medicine) 3 032 0.64

HC.1.5.nec Other traditional healing care 500 0.11

HC.4.1 Medical laboratory services 27 936 5.89

HC.4.2 Imaging services 9 711 2.05

HC.4.3 Patient transport 438 0.09

HC.5.1.1 Prescription drugs 219 459 46.28

HC.5.1.2 Non-prescription drugs 3 270 0.69

HC.5.1.3 Other non-durable medical goods 5 657 1.19

HC.5.1.4 Drugs purchased on the street 33 195 7.00

HC.5.1.5 Condoms and other contraceptives 1 426 0.30

HC.5.1.6 Traditional medicines 28 280 5.96

HC.5.2.1 Eyeglasses and other optical products 2 155 0.45

HC.5.2.2 Hearing aids 331 0.07

HC.5.2.3 Other orthopaedic appliances and prostheses 391 0.08

HC.5.2.9 Other durable medical goods, including medical & technical 355 0.07
equipment

HC.6.1 Information, education and advisory programmes 98 0.02

HC.6.2.1 Vaccines 2 382 0.50

HC.6.3 Early disease detection programmes 1 041 0.22

HC.6.4 Health monitoring programme 2 521 0.53

HC.9 Other health care services not classified elsewhere 910 0.19

Total 474 221 100.00

Source: National Health Accounts (2012).

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6. Human resources
According to data from the third general census, The demotivation and frustration of community
the ratio of health personnel to population is 1.07 health workers are related to abuses of authority
per 1000 inhabitants (3, 14). The differential analysis and low, irregular and discriminatory wages. The 5%
confirms that the large deficit of specialists in increase in the wages in the public sector in 2014
medicine, maternal health, obstetrics, and child care did not catch up with the loss of purchasing power
contrasts with the self-sufficiency in nurses and the of health personnel after the wage cuts of 1992 and
inadequate absorption by the public and private 1993 and the devaluation of the Central African
sectors. While the prospects for an increase in trained franc in 1994. Health professionals at the operational
personnel are in some respects favourable – given level denounce the harsh living conditions in rural,
the national annual increase of trained doctors landlocked areas, the lack of socio-educational
and pharmacists since 2012, and implementation infrastructures, insecurity, sociocultural problems,
of a strategic plan for the development of medico- arbitrary assignments and noncompliance with the
surgical specialities since 2010 – the training in regulations governing the management of careers
community-centred health care that has long been (16, 17).
the hallmark of the Yaoundé School of Medicine has
Table 6 shows the allocation of human resources for
been evanescent for a decade, while three private
health by cadre in Cameroon.
schools have been training community health
workers since 2013 (15). Table 6. Distribution of human resources for
Inadequate distribution of staff is a bottleneck in the health according to qualification, 2011
implementation of PHC. The very high concentration Cadre %
of human resources in urban areas contrasts with Traditional healers/matrons 0.54
the shortage in rural areas (14). Disparities are sharp Pharmacists 0.42
between administrative regions and between
Support staff 17.47
districts. The 2014 personnel census revealed that
Paramedics 11.85
147 districts out of 181 had less than 50% of the
staff required. The economically wealthier regions – Specialists 1.10
Centre, Littoral and West – concentrated 11 777 out General practitioners 3.72
of 19 709 health workers, or 59.75% to serve 42.14% Nurses 49.61
of the country’s total population. This situation has a
Pharmacy assistants 3.08
negative impact on PHC outcomes, for example the
Dental surgeons 0.15
coverage of preventive services for mother-to-child
transmission of HIV, which is lower in rural areas, and Administrative staff 4.51
tetanus immunization coverage (80% in urban areas Other health professionals 6.32
against 68% in rural areas). The four regions with Social workers 0.27
the lowest numbers of health care staff contribute
Community health workers 0.98
to more than three quarters of the 4500 maternal
deaths recorded. Source: Ministry of Public Health (14).

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7. Planning and implementation
After Alma-Ata, the implementation of reforms been repeated. On the other hand, annual workplans
started without proper planning or integration of for vertical programmes are regularly developed and
pre-existing interventions. The 1988 assessment implemented with some efficiency. Communities
confirmed the relative effectiveness of vertical have been little involved in planning whereas they
programmes independent of the health system and are regularly called upon for the implementation
not related to the ideals of PHC. However, no structural of interventions at the operational level (for
reform had been initiated to integrate PHC services; example, social mobilization for immunization,
community health workers had been identified in vaccinovigilance).
the communities and recruited without appropriate
The main planning tools in the health sector
training and supervision on the ground; and
include the sectoral and ministerial Medium-Term
participation of the community in the identification
Expenditure Framework (MTEF) and the government
of health priorities was virtually non-existent. These
roadmap and programme budgeting. Community
observations led to a new policy direction, as
participation remains marginal, and there is a lack of
enshrined in the 1993 National Declaration on the
technical staff and management structures to ensure
Implementation of the Reorientation of Primary
the involvement of the community as a partner, in
Health Care. However, there was no integrated
accordance with the canons of PHC and on the basis
strategy for policy implementation. Several planning
of co-financing and co-management, as stipulated
mechanisms have been imposed by technical and
in the National Declaration on the Implementation
financial partners as a consequence of the national
of the Reorientation of Primary Health Care.
planning policy being abandoned in the context of
the structural adjustment programme (7). Plans are being developed to improve community
participation. For example, a policy brief on
The first national approach to health sector planning
community health workers produced by the
occurred in 2000, though health districts had
Centre for the Development of Best Practices in
been set up in 1994 and the Framework Law on
Health proposed and developed three options:
Health had been adopted in 1996. The first Health
(a) establishment of a national mechanism for the
Sector Strategy 2001–2015, updated in 2007, was
management and coordination of community
followed by the failed introduction of a Sector-
health workers in accordance with the objective
wide Approach (SWAp) in 2006/2007. Multiannual
of developing the health districts; (b) transferring
development plans at the level of the health districts,
the management of community health workers
consolidated at the regional level, were developed in
to municipalities; and (c) co-management of
a participatory manner using the same approach at
community health workers by municipalities and the
the national level. However, the experiment has not
health district services.

COMPREHENSIVE CASE STUDY FROM CAMEROON

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8. Regulatory process
The Cameroonian system has shortcomings in users. The weak enforcement of laws and regulations
several areas, including (a) the obligation of civil pertaining to licensing health professionals and
servants to be accountable for the deployment of PHC services jeopardizes the quality of services (18).
resources and the achievement of objectives; (b) Several informal health care centres and dispensaries
the capacity to undertake a number of activities, as well as street vendors of medicines are diverting
including monitoring the quality of services; (c) up to 27% of household health expenditures.
providing the needed infrastructure, medical The National Drug Commission operates in a very
equipment and products in conformity with approximate manner and the professional orders
standards; (d) development of guidelines, norms are still centralized within the legislative framework
and standards; and (e) protection of the interests of adopted in the early 1980s.

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14
9. Health monitoring and information systems, Cameroon
9.1 Overview of health monitoring and (including registration of births and deaths) 18%,
information systems access to census information 38%, access to
information on health mapping 39%, and access
The midterm evaluation of the first Health Sector to information on human resources 59%.
Strategy 2001–2010, carried out in 2006/2007, led to • Field actors have limited interest in the collection
its being updated in line with the achievement of the of data as the data are generally not transformed
Millennium Development Goals in 2015. The 2001– into information for integrated planning. Very
2015 Health Sector Strategy reinforced the role and often, information is not considered as a resource,
viability of the health district by strengthening the and being transferred to a data collection unit is
health district system, including through integration perceived by the staff as a form of punishment.
of reforms in line with the Alma-Ata Declaration, • The lack of analysis and exploitation of data at
leading to greater institutional, technical and the local level, the low levels of feedback, and
economic autonomy for health districts. inadequate sharing of data between public and
With regard to the performance of monitoring and private actors within the health pyramid reinforce
information systems in Cameroon, an evidence- the perception that the data collected are useless.
based policy brief (19) noted the following in 2010. These weaknesses undermine the monitoring and
evaluation of the use of resources, the supervision
• None of the health districts went farther than of the servicing process of health districts, and
the start-up phase in the process leading to equity-oriented planning.
autonomy.
• Routine population-related data were poorly Though the development of multi-year health
reported, including in the areas of epidemiology, development plans at the health district level and
the budget, mapping of health facility services, their consolidation at regional level in a structured
infrastructure and equipment, and human and organized manner were put in place in 2008,
resources. monitoring and evaluation are confined to each
• The updated health sector strategic paper implementation structure, including programmes,
considered health information as a priority​​ without merging into an integrated monitoring and
intervention area, with the aim of having 90% evaluation plan, as provided for in the Health Sector
of health facilities managed using proper Strategy 2001–2015. PHC activities were taken
documentation. Specifically, this involves (a) into account in the pilot phase of the World Bank-
properly organized data collection; (b) analysis supported Cameroon Health Sector Investment
of the data; and (c) using the data for continued Support Project through performance-based funding
improvement of the quality of services and in some health districts, and in the monitoring and
care. While provision can be made for the evaluation mechanisms for the National Health
creation, in the medium term, of an integrated Development Plan 2012–2015.
system of budgetary and health information,
9.2 Monitoring system associated with
there is currently no mechanism in place for its
implementation. performance-based financing
• An analysis by the Health Metrics Network gave Performance-based financing is being implemented
the following scores on a scale from 0% to 100%: as part of the Cameroon Health Sector Investment
data management 28%, civil registration system Support Project, with the support of the World Bank.

COMPREHENSIVE CASE STUDY FROM CAMEROON

15
The project objective is to improve the quantity and 9.3 Monitoring system associated with
quality of health services offered to the population, National Health Development Plan
with particular emphasis on maternal and child
health and combating disease. A monitoring and evaluation framework was
established to align with the 2012–2015 National
The monitoring and evaluation system for Health Development Plan. This framework was based
performance-based financing has focused on: on three main activities: monitoring, sectoral review,
• establishing, monitoring and evaluating perfor- and evaluation. Apart from these activities within
mance indicators for the management process, programmes and some health districts, no planned
outcome indicators, and impact indicators; monitoring and evaluation activities were carried
• illustrating the relevance, effectiveness, efficiency, out. Despite these shortcomings, some significant
equity, accountability and transparency of results have been recorded by the National Institute
performance-based financing interventions; of Statistics (2), as follows.
• monitoring and evaluating the flow and use of • Infant and juvenile mortality decreased from 144
financial, human, material and logistic resources per 1000 to 103 per 1000 between the periods
in the implementation of performance-based 1999–2004 and 2010–2014 (though not reaching
financing; the target of 76 per 1000).
• detecting bottlenecks at all stages and at all levels • Overall HIV prevalence decreased from 5.5% to
of the implementation of performance-based 3% between 2004 and 2014, though with marked
financing, in line with best practices, in order to disparities between regions and certain social
undertake appropriate and timely solutions; groups.
• showing the different actors, in particular the • Distribution campaigns for long-lasting
beneficiaries, in an objective and transparent insecticide-treated nets achieved a 54.8%
manner, the efforts made to ensure user coverage rate amongst children aged under 5
satisfaction in terms of preventive and curative years in 2014 against 0.9% in 2000.
care under the Minimum Package of Activities • Free care for children aged under 5 years with
and the Complementary Package of Activities. malaria has been effective since 2013.
These activities were monitored and evaluated • Full vaccination coverage for children aged
by the Health Sector Investment Support Project, 12–23 months increased from 48% to 75%, while
but unfortunately in less than a quarter of health immunization coverage against measles rose from
districts in four regions. 64% to 89% between 2004 and 2014.

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

16
10. Strategic outlook and considerations
The Cameroonian health system has adopted its from the central State to the municipalities. The
Health Sector Strategy for 2016–2027. The strategy option chosen was the adoption of performance-
is aligned with the Growth and employment strategic based funding as part of the State budget allocation
document 2010–2020 (20), with the development framework for the purchase of care and services.
of the health district as a strategic priority objective The architecture of universal health coverage has
and with universal health coverage as the ultimate recently been adopted, though the weak regulation
goal. The proposed structure of the community-level of the health sector and the liberalization of training
health services aims to strengthen the integration of for health care professionals continue to conspire to
health programmes and accelerate the development relegate PHC and the concepts of community health
of the health district model. There is continuing to the background, to the benefit of curative care in
debate on how to implement decentralization of a profit-oriented environment.
public health through the effective transfer of powers

COMPREHENSIVE CASE STUDY FROM CAMEROON

17
References
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This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support

interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development

of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to
strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience
of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems
in selected low- and middle-income countries.

World Health Organization

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