Joseph Maabo Tankwaa and Isidore Sieleunoua
aR4D International, Yaoundé – Cameroun
Access to quality and affordable healthcare is one of the core objectives of any health system. To achieve this goal, Cameroon has implemented many financing strategies/schemes and undertaken a series of reforms to attain Universal Health Coverage (UHC) by 20351.
A recent study identified not less than thirty health financing schemes classified into the following groups: 19 free/subsidised health policies, four risk-sharing mechanisms, two results-based financing, four government budget support and one payment at the point of service2 schemes. Many schemes are related to vertical programs, with 19 of the 30 schemes focusing on specific disease control with strong dependence on external funding (17/19 linked to vertical programs are almost exclusively dependent on external funding). The study also revealed that out of the 30 schemes, only 5 (National Health Insurance, Performance Based Financing, Voucher system, Private health insurance, Mutual Health Organizations) had some elements of strategic health purchasing in addition to being vehicles for the achievement of UHC, as stated in relevant policies.
The multiplicity of schemes in Cameroon can be traced, historically, back to the post-colonial period (60’s-70’s), during which the government’s priority was to design programs to eradicate major diseases rather than designing a comprehensive health financing policy3. The program-oriented health financing system led to several schemes with no central coordination and database management system. Though external funding provided a considerable amount of resources to the health system through these schemes, it further worsened the fragmentation. The consequence of this situation is that it does not ensure efficient use of available resources or an effective pooling to extend care coverage.
The governance function of strategic health purchasing in Cameroon is very challenging due to multiple purchasers and the resulting fragmentation of the health financing system. The health administration’s high centralisation gives public purchasers minimal autonomy to decide or influence decisions affecting their ability to achieve both financial and wider health system objectives. Implementing strategic health purchasing in Cameroon is constrained by a lack of clarity in the government’s roles and responsibilities, and across different ministries, purchasers, and purchasing administrators. The lack of a well-defined mandate, coupled with an unclear division of power between the Ministry of Health and purchasing entities over key decisions, is one of the underlying causes of incoherent decisions on the benefit package, provider payment methods or contracting policies and even conflicts amongst the stakeholders. This was evident during the National Insurance Scheme’s policy-making phase, where some tension was already perceptible between stakeholders because of a lack of clarity on whether the Ministry of Public Health or the Ministry of Labor and Social Security will be responsible for its implementation.
Cameroon has multiple pools (scheme) and multiple providers, with different benefit packages for every scheme. The entitlement to benefit from any of the pools varies from scheme to scheme, but beneficiaries within a scheme receive the same benefit package with no difference in cost coverage. A closer look at the different schemes highlights the misalignment within the different benefit packages. There is evidence of beneficiaries receiving similar coverage from several schemes. For example, in the north region, a pregnant woman can be entitled to free antenatal care from both the free/subsidised and voucher systems because both schemes have included that service in their benefit package. Fragmentation limits the extent to which available prepaid funds are redistributed and financial risk related to health, spread; as such, fragmentation is a cause of health system inefficiency. Thus, there is a strong need to wisely align the several benefit packages to seek equity, efficiency, and coverage gains, as seen in Thailand4.
In Cameroon, line-item budgets to government providers co-exist with other payment mechanisms such as fee-for-service for contracted health services fromthe purchasing agency. These mixed payment systems are highly fragmented, often conflicting and have not been adequately analysed to understand how to harmonize them with a focus on a system perspective that jointly looks at all provider payment methods. These multiple funding flows and payment methods affect provider behaviour, favouring schemes where the incentives are higher, such as the performance-based financing program5. The government recognises that the overlapping funding flows might lead to incoherent and peverse provider incentives, reducing efficiency and performance6. There is thus a need to align provider payment method to create coherent incentives across the system with the ultimate aim of promoting equity, efficiency and quality.
Information management systems
A key backbone for strategic health purchasing and its governance is the data and information management system for payment and making informed decisions. Simply put, there is no strategic health purchasing without information. Cameroon’s health information management system is fragmented across levels (central, regional, district), programs and different purchasing agencies and are neither sufficiently standardised nor inter-operable. These multiple data systems contain relevant information but cannot be used as a single database to inform purchasing decisions. Fragmented information systems are an obstacle to realising the potential benefits from strategic purchasing. A step toward defragmentation is developing the eHealth National Strategic Plan in 2019 with support from the I-TECH/University of Washington, in synergy with the Johns Hopkins Cameroon Program (JHCP) and CDC-PEPFAR. However, past experiences have shown that implementation, in Cameroon, remains the rock where good ideas go to die, because reforms very often start with great enthusiasm and ceremony, then get bogged down with challenges and fall into oblivion.
The move towards Universal Health Coverage and opportunities of alignment in Cameroon
Progress towards UHC is an inherently political process that entails many health policy reforms and restructuring of the health financing architecture. The government of Cameroon initiated a process to provide the country with a fully operational Universal Health Coverage scheme by 2035. To achieve this goal, an intersectoral National Technical Group dubbed UHC – TWG, co-chaired by the minister of Public Health and the Minister of Labor and Social Security, was created in 2015 to pilot the process and make proposals to the government on different aspects of this scheme6. To adequately address each dimension of the so-called UHC cube, experts identified and adopted four basic principles to guide UHC development in Cameroon. These included: universality, national solidarity, general responsibility of the State, and mandatory affiliation. Among other reforms, the decision to create a single funding pool and a biometric matriculation system specifically addressed fragmented and misaligned health financing schemes7. The intention is to explicitly combine or pool different funding sources to address inequities arising from fragmented pools between insured and uninsured populations. The architecture proposes the establishment of a single national structure for the technical and financial management of the UHC scheme in Cameroon. This institution shall have the status of a public enterprise with administrative and financial autonomy. Different categories of the population require that specifically adapted mechanisms be put in place to facilitate enrollment and collection of premiums and the scheme will have to address these. For purposes of transparency and accountability in the UHC scheme’s management, all stakeholders, particularly the beneficiaries and civil society, shall be involved in the UHC scheme’s management structure. In addition, Cameroon has opted for a biometric registration system into the UHC scheme.
The implementation of the UHC scheme is an entirely new experience for the country, and it will be beneficial to borrow from the experience of country peers who are relatively more advanced in developing their UHC schemes. Strong governance is needed to define consistent policy objectives, facilitate dialogue and stakeholder consultations, monitor and evaluate UHC progress, and align strategic purchasing reforms with other health financing reforms. For future country reform efforts, a change in the implemntation of purchasing mechanisms will be needed, shifting from an isolated view focused on one mechanism, to an approach that recognizes the benefits and challenges of different provider payments mechanisms and therefore opts for a mixed model. Applying a system perspective in both design and implementation of strategic purchasing reforms will also contribute towards its institutionalisation in the health system. Effectively managing the underlying dynamics and sequencing of reforms, with effective use of information will be critical success factors in this endeavour. Lastly, knowledge management, experience exchange and networking for strategic purchasing as initiated and promoted by the Strategic Purchasing Africa Research Center (SPARC) are vital.
1. Ministry of Health. Proposal for a universal health coverage system architecture in Cameroon. 2016. National technical working group for UHC, Yaoundé, Cameroon
2. SPARC 2019, Report of the Progress of Strategic Purchasing Arrangements in Cameroon
3. Gauvrit E, Okalla R. La difficile mise en place des districts sanitaires urbains. Bull APAD [Internet]. 2001 Jun 1
4. Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammatacharee J, Jongudomsuk P, Sirilak S. Achieving universal health coverage goals in Thailand: the vital role of strategic purchasing. Health Policy Plan. 2015 Nov 1;30(9):1152–61.
5. Sieleunou I, Turcotte-Tremblay AM, De Allegri M, Taptué Fotso JC, Azinyui Yumo H, Magne Tamga D, Ridde V. How does performance-based financing affect the availability of essential medicines in Cameroon? A qualitative study. Health Policy and Planning. Dec 2019.
6. Ministry of Health. Proposal for a universal health coverage system architecture in Cameroon. 2016. National technical working group for UHC, Yaoundé, Cameroon
7. Nde CJ, Raymond A, Saidu Y, Cheng NI, Nzuobontane D, Atemnkeng JT, et al. Reaching Universal Health Coverage by 2035: Is Cameroon on Track? Univers J Public Health. 2019 May;7(3):110–7