Multiplicity of Schemes and Non-Alignment of the Healthcare Package Within the Framework of Strategic Health Purchasing in Cameroon: Reflections and Perspectives

Strategic health purchasing (SHP) is attracting growing interest among decision-makers in low and middle-income countries. With limited resources, available resources must be used effectively and efficiently to maximize health system objectives. SHP is one approach that can contribute to improving the performance of health systems to achieve greater health outcomes cost-effectively.¹ 

The key policy issues on SHP are the services to be purchased, from whom to purchase them, under what conditions and at what level. Defining a comprehensive healthcare package in a transparent way is one of the key functions of the SHP. In this blog, we share some reflections on the misalignment of the healthcare package in Cameroon and provide some thoughts on how to improve it.²

In a recent study, Results for Development (R4D) International identified, analyzed and classified 30 health financing schemes in Cameroon grouped into five different categories:

• 19 free/subsidized healthcare policies,
• 4 risk-sharing mechanisms,
• 2 results-based financing (RBF) mechanisms,
• 4 government budget support mechanisms, and
• 1 payment mechanism at the point of care delivery.

Of the 30 financing schemes, five showed elements of an SHP approach:

1. Universal Health Coverage(UHC)
2. Results-Based Financing (RBF)
3. Health voucher systems
4. Private health insurance
5. Mutual health insurance

The health financing schemes have a clearly defined set of benefits, but most of these benefits overlap.  The misalignment of the healthcare package leads to considerable gaps in coverage of certain population groups, inefficiency and inequity. Some people have no or very little cover, while some groups are covered by multiple schemes. For example, childbirth is over-insured by different schemes. The RBF programme allocates subsidies to health facilities for each birth in a health facility, while health voucher systems, private insurance and mutual health insurance all reimburse the full amount or 80% of delivery costs for each birth occurring in a health facility. This means that the same person is able to enjoy the services offered under all three schemes, and potentially, a provider can bill one or more schemes for the same patient.

Poor alignment leads to inefficient use of scarce resources. Instead of funding the same services, resources should be directed towards priority activities/indicators often not covered, such as chronic diseases that burden the Cameroonian population.  This imbalance of coverage increases inequities within the population, as certain population groups are excluded. This is the case of the elderly, who often suffer from chronic diseases and rely on their families to pay for healthcare services. 

Quality assurance is another challenge observed as it is not always guaranteed in the different schemes. Only the RBF and the health voucher schemes have clear criteria for monitoring the quality of the services provided, and health facilities are regularly evaluated. The scores obtained are used as a condition for signing a contract. For mutual health insurance and private insurance, contracts with providers have explicit reference to compliance with the national protocol for patient treatment. However, it is not clear enough to ensure that providers comply with these guidelines and provide good quality care. Many studies explain that the low rate of enrolment in mutual health insurance – less than 1% of the population – is due to the low quality of care, particularly due to inadequate equipment in health facilities, insufficient numbers of qualified staff and insufficient medicines ^3. The quality of care is also questionable in rural areas, where there is a natural monopoly of health facilities.

Resource constraints increase pressure on the priority-setting processes. The benefit package should be selected according to consistent and transparent criteria, in line with the objectives of the health care system. Benefit packages, as observed in the different health financing schemes in Cameroon, are neither coherent nor transparent. Such a state of affairs will always be prone to criticism as it unduly favors certain groups of patients.

Generally, two main challenges appear to be major reasons for the misalignment of the healthcare package offered under the five funding schemes. They are inadequate coordination of these schemes within the Ministry of Health, leading to duplication and inefficiency in using resources and the lack of regulation of healthcare packages.

Progress towards UHC remains difficult; however, anticipating certain challenges will ease this process. To align the healthcare package and progress on these issues in the Cameroonian context:

• Ministry of Health should prioritize improving the coordination of different funding schemes;
• Center policy discussions on vulnerable population groups when designing funding schemes for greater equity.⁴
• Regulate the provision of healthcare packages to ensure the quality and fidelity of implementation of interventions;

The definition of clear criteria should not be overlooked. This would help to explain the reasons for the adoption or rejection of specific products and services and help the health system gain more trust from users and contribute to a sustainable transition to UHC. Decisions on the selection and alignment of healthcare packages must be evidence-based to increase the capacity of the health system to expand service delivery on the basis of equity and to promote UHC.

Finally, the selection and alignment of healthcare packages should be seen as dynamic and progressive approaches that respond to new data and capabilities as they emerge and thus lead to a relatively consistent and predictable process of inclusion and exclusion over time.

References:

1.  Reinhard B: Josep F, Ray R; Elke J: Strategic Purchasing to improve Health System Performance: Key issues and International trends
2. Kara H, Edwine B, Ayako H, Warisa P, Walaiporn P:  Strategic Purchasing: The Neglected Health Financing Function for Pursuing Universal Health Coverage in Low- and Middle-Income Countries, Int J Health Policy Manag 2019
3. N François Colin, P ONGOLO-ZOGO, PMTA OBAMA; Scaling up Enrolment in Community-Based Health Insurance in Cameroon, http://www.who.int/alliance-hpsr/projects/alliancehpsr_snppolbriefcameroon09.pdf
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.

This blog was written by Denise Diane Magne Tamga¹ and Isidore Sieleunou¹  R4D International, Yaoundé¹ – Cameroun