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COUNTRY REPORT: The Healthcare System of Cameroon: Socio-Economic
Characteristics; Historical Context; organizational & Financial Aspects;
Major Public Health Programs & Challenges; Strength and Weaknesses
By: Manfred Egbe
ERASMUS MUNDUS European Masters in Sustainable Regional Health Joint Degree, Department
of Public Health – Vilnius University, 2011
2
1. INTRODUCTION
Cameroon is a Central African country located at the bottom of the Gulf of Guinea between
latitude 2º and 13º North and longitude 9º and 16º East with a triangular shape covering a
surface area of 475.440km2 stretching from the South to the North on almost 1200km and on
800km from the West to the East. She is bounded on the West by Nigeria, Northeast by Chad,
East by the Central African Republic and South by Congo, Gabon and Equatorial Guinea. She
opens up to the Atlantic Ocean at the southwest; has 10 regions, 58 divisions, 306 districts, 54
administrative districts and 339 councils. English and French are her two official languages.
2. SOCIO-ECONOMIC CHARACTERISTICS, MAJOR HEALTH INDICATORS, DEMOGRAPHIC AND
HEALTH TRENDS
Macroeconomic and structured reforms were implemented by the government from 1996 with
support from development partners; it enabled Cameroon reach the decision point under the
HIPC initiatives in September 2000. Since then, social sectors including health have benefited
from many funding opportunities (Republic of Cameroon, 2004).
2.1. Demographic and Health Trends
Cameroon is a human mosaic full of over 200 ethnic groups and many national languages. Her
population is estimated to have risen to over 18 million in 2006 making an average density of 38
inhabitants per km2. The population is structured as follows: under 5 years (16.3%), 5-4 years
(28.3%), 15-24 years (20.2%) and 65+ years (3.8%) (Institut National De La Statistique, (1998,
2004). The majority of the population resides in rural areas; the urban population accounts for
48.2% of the total population with a high concentration in Douala (about 1.6 million inhabitants)
and Yaounde (about 1.4 million). The average household size as per 2007 is 4.4 persons. ECAM II
& III note improvement in peoples’ access to safe drinking water (45-53%) and electricity (41-
47%) (Institut National De La Statistique 1998, 2004).
Human Development Indicators (2005)
Indicators
Cameroon
Sub-Saharan
Africa
Least Developed
Countries
All Developing
Countries
Life expectancy
0.44
0.410
0.492
0.685
Level of education
0.660
0.571
0.519
0.725
GDP per purchasing power
parity
0.523
0.500
0.452
0.662
Human development
0.532
0.493
0.488
0.691
School enrollment
(secondary & higher
education)
62.3%
50.6%
48.0%
64.1%
GDP per capita (USD)
2299
1998
1499
5282
Source: Global report on Human Development 2007 (PNUD, 2007/2008)
Life expectancy at birth has declined due to the AIDS pandemic and endemic diseases and is
around 53.3 years (men: 52.54 years; women: 54.08 years) (CIA, 2008).
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2.2. Epidemiology & Morbidity
Cameroon like most developing countries is undergoing epidemiological transition with increase
in non-communicable diseases, reemergence of certain infectious diseases, the HIV/AIDS
pandemics, threat of SARS and pandemic flu. Efforts to fight against disease have however
produced remarkable results notably in the fight against measles, guinea worm and leprosy.
According to IFORD 2004, there is an average of more than 6 episodes of illness per person per
year with morbidity being higher in women (23.9%) than in men (21.8%). The Far North Region is
most affected by disease (32%) meanwhile the elderly (43%) and children under 5 (29%) are the
most vulnerable group. Rural areas are most affected and the wealthiest households face a lower
level of morbidity.
2.4. Transmissible Diseases (Malaria; Tuberculosis; HIV/AIDS)
Malaria represents the leading cause of morbidity; MINSANTE 2004, estimated the rate of clinical
consultation for the disease at 40.1% and mortality at 2.2%. These rates vary by region and are
highest among children under 5 years. Malaria remains a major public health problem in
Cameroon with over 930,000 cases reported in 2005 (MINSANTE, 2009)
The fight against tuberculosis has been resurgent with increased screening; 24589 new cases
were detected and treated in 2007 with a cure rate of over 74%. The prevalence is estimated at
192 cases of all forms for 100.000 inhabitants and 83 cases of pulmonary TB bacciloscopie
positive for 100.000 inhabitants. The mortality rate is 29 per 100.000 inhabitants (WHO, 2008).
TB situation in Cameroon (1998 - 2008)
Region
Nº of cases in 1998
Nº of cases in 2007
Nº of cases in 2008
Adamawa
113
929
1035
Center
48
5640
3793
East
144
1622
1908
Far North
1026
2515
2586
Littoral
39
5784
3709
North
233
1702
2134
North West
96
2207
2134
West
318
1409
1432
South
189
998
1035
South West
55
1721
1935
Total
2261
24589
21425
Source: (Ministère de la Santé Publique, 2008)
EDS III
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notes a 5.5% zero-prevalence of HIV/AIDS in adults aged 15-49 in 2004 (NIS, 2007).
1
Third Health Demographic Survey
4
2.5. EPIDEMIC PRONE DISEASES (Cholera; Cerebrospinal Meningitis; Yellow Fever; Measles;
Polio/Acute Flaccid Paralysis; Avian Flu, Acute Respiratory Syndrome (SARS) & Chikungunya)
Cholera is endemic in the North, Far North, Littoral, West and South regions of Cameroon. The
last major outbreak occurred in the Littoral region in 2006. The effective management of
refugees from neighboring countries remains a major challenge for effective control of the
disease (Ministère de la Santé Publique, 2009 ).
Evolution of Cholera 2006-2008
Region
2006
2008
Nº of cases
Deaths
Nº of cases
Deaths
Adamawa
0
0
0
0
Center
3
1
0
0
East
0
0
0
0
Far North
0
0
0
0
Littoral
331
6
0
0
North
0
0
0
0
North West
0
0
0
0
West
0
0
0
0
South
0
0
0
0
South West
0
0
0
0
Total
334
7
0
0
Source: Health Sector Strategy Document – updated draft 2 pg. 32
Cerebrospinal Meningitis conditions prevail in cycles in the North and Far North regions situated
in and beyond the meningitis belt due to outbreaks in areas including the North West, South
West and Western regions.
Cerebrospinal Meningitis 2006-2008
Region
2006
2008
Nº of cases
Deaths
Nº of cases
Deaths
Adamawa
0
0
10
2
Center
0
0
0
0
East
0
0
2
1
Far North
0
0
26
5
Littoral
0
0
0
0
North
35
11
0
0
North West
0
0
0
0
West
0
0
4
1
South
0
0
5
1
South West
0
0
0
0
Total
35
11
47
10
Source: Health Sector Strategy Document – updated draft 2 pg. 33
Cameroon is classified by the WHO among countries at high risk of yellow fever; preventive
vaccination campaigns were recently organized at Meri, Bafia, Messamena, Akonolinga where
outbreaks were recorded.
5
Evolution of Yellow Fever cases 2003-2008
Suspicious cases
2003
2004
2005
2006
2007
2008
126
434
829
859
906
859
Confirmed cases
2
1
2
1
2
1
Deaths
0
5
12
25
17
0
Source: Health Sector Strategy Document – updated draft 2 pg. 33
Measles was the highest cause of morbidity in 1998; the number of reported cases almost
doubled between 1997 (8222) and 1998 (14,161). The number of measles cases has dropped
from 23,691 in 2001 to 528 cases in 2005 as a result of improvement in vaccination coverage
(68% in 2005); a reduction of about 98%. Mortality from measles dropped from 258 deaths in
2001 to 29 in 2005. (MINSANTE, 2002 Edition).
Evolution of Measles Cases 2000-2008
2000
2001
2002
2003
2004
2005
2006
2007
2008
Suspicious cases
14623
23934
1448
899
1038
1328
709
659
709
Confirmed cases
23691
220
232
358
528
134
41
134
Deaths
352
258
37
17
25
29
12
10
12
Source: Health Sector Strategy Document – pg. 34
In 2002, Cameroon reached the standard pre-certification of polio/Acute Flaccid Paralysis.
However there were discovery of wild polio virus cases (13 cases in 2004 and 01 in 2005). This
resurgence led to the organization of synchronized national immunization days and despite the
absence of new wild polio virus cases, routine immunization coverage, disease surveillance and
response measures are strengthened against the prospective of a new case.
Evolution of Polio/Acute Flaccid Paralysis 2001-2008
Indicators
2001
2002
2003
2004
2005
2006
2007
2008
Nº of polio/Acute
Flaccid Paralysis
166
101
142
219
261
193
188
-
Wild polio virus cases
0
0
2
13
1
2
0
0
Quality Samples
92.7%
84.4
%
77.5%
77.2%
81.6%
84.9
%
81.8%
-
-
Source: Health Sector Strategy Document – pg. 34
Some cases of infected poultry associated to Avian flu, SARS and Chikungunya were recorded in
Maroua, Garoua and Yagoua in 2006. Actions were thus taken to combat the disease on the
ground under the coordination and supervision of the inter-ministerial committee of the Prime
Ministry.
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Evolution of Epidemic – Prone Diseases (EPD) 1998-2006
EPD
Nº of cases in 1998
Nº of cases in 2006
Cholera
-
Cerebrospinal Meningitis
4583
-
Yellow Fever (confirmed/investigated)
NA
1/859
Measles (confirmed/investigated cases)
14.16
134/709
Polio/Acute Flaccid paralysis
140
2/193
Human Rabies
77
-
The Ebola Virus
NA
NA
Chikungunya
NA
NA
SARS (Acute Respiratory Sydrome)
NA
0
Avian Influenza
NA
0
Source: Health Sector Strategy Document – pg. 35
2.6. NON TRANSMISSIBLE DISEASES (Cancer; Epilepsy; Sickle Cell Disease; Oral-Dental Diseases;
Diabetes & Hypertension; Blindness)
According to estimates in 2002, 12.000 new cases of cancer are registered in Cameroon every
year with 25.000 people living with the disease (MINSANTE, 2009). The most common cancers
are those of the breast, cervix, prostrate, liver and lymphomas. Over 80% of people get tested at
an advanced stage of the disease and most die within 12 months after diagnosis.
Epilepsy affects over 50 million people worldwide including 30 million in the Asian region and 10
million in Africa (WHO, 2006). In Cameroon, there are cases of epilepsy in the 10 regions of the
country. Epilepsy represents 15.78% of neurological consultations for adults and 1.50% of
pediatric consultations in hospitals (MINSANTE, 2002 Edition).
The prevalence of sickle cell disease was 60.50/00 (approximately 1 million people). All age groups
are affected and young people from 10-29 represent 89.2% of patients. Oral manifestations
linked to HIV/AIDS are widespread and usually include fungal infections, necrotizing gingivitis and
leukoplakia (Ministry of Public Health, 2006)
The prevalence of diabetes is 6% in Cameroon (1.000.000 people); hypertension is 24%
(4.000.000 people). The most incriminating risk factors are physical inactivity and unhealthy diet;
90% of affected people are physically inactive and consume fatty oils, salt and sugar. Moreover,
maxillofacial trauma has increased throughout the country as a result of interpersonal violence
and traffic accidents. Socio-cultural, economic factors and the low availability of quality care are
barriers to effective care of patients, resulting in debilitating complications. 180.000 people
suffer from blindness in Cameroon; the number of visually impaired is estimated at 540.000
people. (MINSANTE, 2002 Edition)
2.7. NEGLECTED TROPICAL DISEASES (Leprosy; Buruli Ulcer; Onchocerciasis or River Blindness;
Human African Trypanosomiasis; Guinea Worm; Schistosomiasis)
Following the intensification of active research findings and the change in control strategy, 1455
new cases of leprosy (paucibacillary and multibacillary) were recorded in 1998 and 465 in 2007.
7
With a prevalence of 0.25 cases per 10.000 populations today, epilepsy is no longer considered a
major public health problem however the problem of social and economic reintegration of
leprosy patients into the society abounds (MINSANTE, 2002 Edition).
Buruli ulcer is rampant in parts of the country; the first cases were reported in 1975. Since 2002,
nearly 1.000 cases were diagnosed and treated in endemic districts. Victims are children under
15 years. The number of cases is increasing as well as the discovery of new endemic sites
(MINSANTE, 2002 Edition).
Onchocerciasis is endemic in all regions of the country to varying degrees of severity (108 of 178
health districts in 2007). The population at risk is estimated at 62% and the infected population
at 40% of the risk population. More than 9 million people live in hyper endemic areas and
approximately 1.5 million suffer from serious skin damages from onchocerciasis and 90.000 are
blind or suffer from deterioration of vision (MINSANTE, 2002 Edition).
The population at risk of Human African Trypanosomiasis disease is estimated at about 70.000
people. There are currently six active centers in the country to combat the disease and despite
the resurgence in recent years, actions have significantly contributed to reducing the prevalence
to 0.2% (about 1 case per 14.000 inhabitants) (MINSANTE, 2002 Edition).
Cameroon has been declared Guinea worm free since early 2008 by the WHO (WHO, 2009).
Schistosomiasis and intestinal helminthes affects about 2 million people with 5 million at risk.
The poorest communities are most affected and the disease leads to lower productivity,
performance and cognitive growth in children. School children 6-15 years are the most
vulnerable and affected group (MINSANTE, 2002 Edition)
Causes of under 5 Mortality
Age Group
Mortality Rate (%)
Cause of Neonatal Mortality (%)
Neonatal
(0 – 28 days)
25
Diarrhea (2%)
Tetanus (3%)
Congenital (8%)
Asphyxia (25%)
Injection (25%)
Premature (30%)
Others (7%)
29 days – 5 years
75
Malaria (23%)
Pneumonia (22%)
Diarrhea (17%)
HIV/AIDS (7%)
Measles (4%)
Trauma (2%)
Others (0%)
Source: Health Sector Strategy Document – pg. 39
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3. CAMEROON’S HEALTH CARE SYSTEM
Cameroon’s healthcare system has been greatly influenced by colonial ties: about 80% of the
population had no access to any form of regularly organized health care during the first decade
of independence and training of healthcare personnel was mainly disease oriented, serving
mainly urban-based facilities. Until 2001 four major periods marked the evolution of
Cameroon’s healthcare system:
I. The colonial period and the heyday of Eugene Jamot strategy;
II. The post independence or experimentation phase;
III. The post of Alma Ata Primary HealthCare (PHC);
IV. The period of the health sector reform through the reorientation of Primary Health Care
(RPHC).
In 1985, Primary Healthcare (PHC) holistic approach to healthcare delivery to bring health closer
to the people was adopted. Few years later, a reorientation of PHC policy was adopted by the
Ministry of Public Health (MOH) - it emphasized on decentralized planning; co-financing and co-
managing. It marked the beginning of the ‘cost recovery approach’. Via the RPHC, cost of
healthcare was divided between the government and the population; the Ministry of Public
Health supported health workers salaries, pre-service training and other inputs provided; the
population covered key non-salaried recurrent cost of PHC. In the RPHC system, the health
centers provided the framework for delivery of integrated care with continuous and
comprehensive primary care at the district hospitals. The RPHC brought a number of legal
developments in the health sector including: a framework law on health in January 1996;
9
various laws and regulatory texts relating to cost recovery; texts reorganization the country into
health districts.
These provisions resulted in the reorganization of the national health system into three levels:
central, intermediate and peripheral. Despite these improvements, some shortcomings such as
the lack of a legal framework for community participation, lack of reforms in basic training and
further education, strong centralized management of the health sector to name a fewwere
noted.
It is in this light that a multi-annual Health Sector Development Program (HSDP) financed by the
government and its development partners came to light birthing the Health Sector Strategy
(HSS) in 2001 and was later evaluated and updated in 2006 to run through 2015 enveloping the
attainment of the health goals of the MDGs. The HSDP has its basis on a Sector Wide Approach
(SWAp) defining ways in which the MOH and development partners do business, how health
resources are planned, managed and accounted for. The first HSS (2001-2010) served as the
overshadowing framework in the health sector with the following main objectives:
- Reduce morbidity and mortality (especially among vulnerable groups);
- Strengthen management and efficiency at all levels of the health system and;
- Improve geographic access to a basic package of health services.
The 2001-2010 HSS introduced some vital institutional and organizational improvements: it
restructured the MOH by reinforcing key functions like regulation, human resources
management, inspection and articulating new roles for stakeholders at different levels in the
system; revamped main public health programs (immunization, malaria, TB and HIV/AIDS) by
creating strong Central and Provincial Technical Units, mobilizing substantial resources,
delegating responsibilities and giving a renewed focus to public/private partnerships.
Despite these improvements the sector faced major challenges as noted in the HSS mid-term
evaluation in 2006 such as high cost of healthcare limiting access; excessively centralized
healthcare system; poor governance; slow and cumbersome flow of public sector funds; skewed
financing standards in the public sector which favors urban areas and specific disease programs;
relatively neglect of preventive and promotional healthcare and fragmented and unreliable
monitoring and evaluation systems.
Lessons from the 2001-2010 HSS mid-term review birth a participatory process that produced
an enhanced and revamped strategy with the main goal of contributing to the fight against
poverty through the amelioration of the socio-health status of Cameroon's population. The
reviewed HSS constitutes the second part of the strategy to run through 2015. Its objectives
include the following include:
I. Servicing all health districts to be able to contribute to achieving the MDGs.
10
II. Get 80% of 178 health districts complete at least the consolidation phase of the process
of servicing Health Districts;
III. Health facilities of strategic and intermediary levels play their role of support and
guidance at 100%;
IV. Reduce by 1/3 the burden of disease among the poorest and most vulnerable
populations;
V. Reduce by 2/3 under 5 mortality in children;
VI. Reduce by 3/4 maternal mortality.
The mid-term review was conducted to secure its update for the year 2015 in accordance with
the MDGs. In essence, the attainment of specific objective III will contribute to the attainment
of objectives 1 (reduction of extreme poverty and hunger), 6 (fight against HIV/AIDS, malaria
and other diseases, and 7 (ensure a sustainable environment) of the MDGs. The revised strategy
is the basis on which all health districts are currently developing their 2009-2012 plans. The
Health District is the operational unit of the Health System in Cameroon.
4. Organizational and financial aspects of public health, including description of major public
health programs
Before 2001, the healthcare system of Cameroon was organized in a pyramidal structure with
the MOH at the apex; six directorates supporting the MOH in prevention and rural medicine,
pharmacy, planning and statistics, and administration; 10 provincial delegations of public health,
representing the MOH in the provinces; 6 different levels of healthcare provision - community
services, health centers, sub-divisional hospitals, divisional hospitals, regional hospitals and the
delegation of public health. The MOH basically takes the most of decisions in policy making,
sometimes health professionals of renowned portfolio could be consulted on particular issues.
With the decentralization process being enforced in recent years, decision making in policy
making is taken another approach with donor agencies having great influence as their support is
disease focused and based on the fulfillment of certain conditions; the NHS is now structured in
three levels, each of which has administrative structures, health facilities and structures for
dialogue with specific functions: a public sub- sector; a private sub-sector and; a sub- sector of
traditional medicine. The sub-sectors also include public health facilities under the supervision
of other Ministries, private nonprofit (religious groups, associations and NGOs) and those for
profit.
With regards to financing and expenditure, Cameroon experienced an upward trend in health
spending during the year 2000-2004 with total per capital expenditures climbing from about $31
to US$51 equivalent as a result of the surge in debt relief funds. However, budget allocation is
highly unbalanced with more going to administration rather than to peripheral facilities; the
pattern of expenditures is highly skewed and centralized hindering the delivery of high impact
services that could address the main causes of morbidity and mortality. Households continue to
11
bear the greater part of the financial burden of healthcare (Ntangsi, 2000). The financial burden
on households is the result of large number of fees both formal and informal and from the use of
the cost recovery proceeds whose mechanisms are extensive and generate perverse incentives.
In the early 1990s, the 'quote parts' revenue sharing system was used by hospital managers as
incentives for staff according to performance but it is now proving difficult as it appears to create
perverse incentives to provide curative rather than preventive and promotional services; has no
defined system for measuring staff performance raising questions of transparency; is unclear
what level of bonus payments is required to improve motivation and performance; and lacks
reliable data that hinders measurement of results and performance. (ADE, 1996)
The bulk of health financing comes from domestic resources; external assistance plays a
relatively modest role in the overall financing of health services in Cameroon. External assistance
represents 20% of health financing in the sector (Ministry of Public Health, 2006)
Medium-Term Health Sector Expenditure 2003-2007
2003
2004
2005
2006
2007
Total
Budget, MOH
59.4
58.3
59.6
101.5
119.0
397.8
HIPC
19.8
18.2
17.0
18.0
73.0
Total MOH
79.2
76.5
76.6
119.5
119.0
470.8
Bilateral
5.1
13.3
3.3
21.7
Multilateral
11.2
8.5
11.2
2.8
33.7
Global Fund
14.2
8.3
10.6
12.6
45.7
Total External
16.3
36.0
22.8
13.4
12.6
101.1
MOH as % of total
.83
.68
.77
.90
.90
.82
External as % of total
.17
.37
.23
.10
.10
.18
Source: Health Sector Strategy, MOH 2006 Edition.
General Data on External Assistance
External assistance
1997
1998
1999
2005
Public assistance for development (millions USD)
498
424
434
414
Bilateral ratios
66%
72%
59%
Public assistance for development/GNP
6.3%
5.0%
5.2%
Source: Cameroon – European Community Cooperation, 9th European Development Fund (EDF)
The pattern of health expenditure is nonetheless not fully aligned with the burden of disease
with four diseases (HIV/AIDS, TB, malaria and maternal & child illnesses) representing up to 45%
of the total DALYs of the Medium-Term Expenditure Framework for 2002-2007.
Major Public Health programs
Malaria, measles, lower respiratory infections, malnutrition, diarrheal and STI (HIV/AIDs
inclusive) diseases remain the top causes of death in the country; the state has as such come up
12
with health programs to counter these health challenges. Current major health programs
include the following:
- schistosomiasis and geohelminthiasis research and control program;
- HIV/AIDs program;
- program for the fight against malaria;
- program for the fight against tuberculosis;
- program for the fight against leprosy;
- program for the fight against trypasomiasis;
- program for the fight against buruli ulcer;
- program for the fight against cancer;
- national program for the fight against guinea worm (cecite);
- program against onchocerciasis and
- Program against polio).
These programs have clear strategic plans and the impact of some like the fight against malaria
is already being seen, with a drop in the dead rate from malaria. They all fall under the five
strategic areas of MOH focus for the period 2010-2015:
- the fight against disease;
- improvement of the health of the child and mother, adolescents and survival of the
child;
- preparation and response to emergencies and disasters;
- health promotion; and
- Strengthening the healthcare system.
5. STRENGTH AND WEAKNESSES
The health care sector being one of the most demanding sectors in the country, pressures the
government to work hard and implement more innovative policies, efficient strategies,
programmes, projects and plans for effective health care delivery to the public. They are as such
striving to solve the serious challenges facing the healthcare sector. There are opportunities for
career development for skilled health personnel funded by the government; in-service training;
study leave with salary still paid; regular refresher courses and workshops, and postgraduate
programmes are available locally and overseas, some on government scholarship.
Though some credit could be given to the state who is the main health provider, for its efforts in
health delivery, there is yet a great gap to fill; the distribution of resources is inequitable and
severely disfavors some regions. Hopefully with the implementation of the decentralization
policy in the country, the situation will change for good. In addition, shortage of health care
workers coupled with increased trend of infectious and communicable diseases; poor
13
management (poor political and management environment that does not permit nor encourage
healthcare workers perform at best level); and the complete absence of a National health
insurance policy that makes care to be inaccessible for many, are some of the major weaknesses
of the healthcare system.
6. MAJOR CHALLENGES
There are a number of health challenges that Cameroon is faced with: inadequate approaches
to meeting healthcare needs evident in the demographic indicators; brain drain of its health
workers that disproportionately affects healthcare; inability to sustain health technology
transfer (especially after the withdrawal of potential sponsors); the emergence of chronic/new
diseases. Two major challenges to health have been made obvious with the introduction of the
2001-2015 HSS: strengthening the DHS (District Health System) and ensuring the proper
implementation of health programs to achieve the MDGs on health. To these challenges are
related the following: developing human resources needed for the proper functioning of health
facilities and the provision of quality care; ensuring geographical and financial access to
essential medical products for the most vulnerable; bringing the country to response effectively
to emergencies and human disasters and their consequences; reducing the levels of maternal
and infant mortality by implementation of integrated and efficient interventions; tracking
determinants of poor health and creating environments conducive for good health etc.
14
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