COVID-19 pandemic was declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) on 30 January 2021. Since then, the total number of COVID-19 cases has continued to increase at an alarming rate in several countries worldwide. After confirmation of the first cases, Cameroon launched the Incident Management System (IMS). Several measures were adopted to combat the disease, including restricting travel and economic activities (e.g. closing workplaces and schools, banning gatherings of over ten people, limiting travel) and observing protective measures such as social distancing, hand washing, wearing masks, etc. The Cameroonian government also prepared a COVID-19 preparedness and response plan to address the crisis. In this blog, we analyze the effects of institutional and financial provisions’ ‘ and resource mobilization and allocation decisions, from document review supplemented by interviews with key respondents, to deepen understanding of the effectiveness and efficiency of interventions in Cameroon’s response COVID-19.
Institutional and Financial Provisions
Financing measures have played a major role in facilitating a rapid and organized response, notably through providing appropriate services and lifting financial barriers to enable rapid diagnosis and treatment of Covid-19. A Special Allocation Account,[1] referred to as CAS COVID-19, was created by the President of the Republic with an initial allocation of one billion CFA Francs. The purpose of CAS COVID-19 was to provide financial support to the “Special National Solidarity Fund for the fight against Coronavirus and its economic and social consequences” and facilitate better monitoring of the use of resources mobilized in the response’s framework, as well as fulfil transparency and accountability requirements.
The fund is structured into four programmes in line with the overall strategy to respond to the pandemic. These include health system strengthening, economic and financial resilience, strengthening research and innovation, social resilience, and strategic purchasing. CAS COVID-19 was organized in terms of resources and used in two main forms: on the one hand, revenue constituted by payments from the general budget, non-tax payments from natural or legal persons for the fight against Coronavirus, contributions from technical and financial partners (International Monetary Fund, World Bank, etc.) in the form of grants or loans; and on the other hand, expenditure corresponding to the achievement of the objectives of the overall response plan. While the limit of resources to support the fund was set at 180 billion CFA francs for the 2020 financial year by the National Assembly, individual contributions of between 20,000 and over one million CFA francs were made by bank transfer cheque or deposits. Several administrations were beneficiaries because a Task Force had been set up to make decisions on allocating resources within the response framework. Coordination was done using a multi-sectoral approach, with an inter-ministerial committee coordinated by the Prime Minister as Head of Government.
The Cameroonian government also used exceptional and derogation procedures, notably the awarding of special contracts by the Minister of Public Health to purchase equipment and consumables and the provision of services, which exempted COVID-19 contracts from all public procurement procedures. In addition, all equipment and consumables purchased were exempt from Value Added Tax (VAT) and customs duties. All this significantly reduced delays in the payment of service providers and facilitated the rapid allocation of resources. A respondent stated: “Well, for payment of service providers, the ministry took advantage of special contracts, the special contracts process administered by the President of the Republic, which allowed contracts to be awarded without going through all the usual commissions, whose procedures were simplified, as was the payment, which also had to follow a simpler path than the normal payment path.”
The implementation instruments for specific health financing schemes, such as Performance-Based Financing (PBF)and payment methods for service providers, have been reviewed. In particular, the COVID-19 indicators have been added to the evaluation matrix for stakeholders, and a mechanism for making financial resources available in advance to health facilities (FOSA) prior to the verification of care has been put in place to enable them to have funds regularly to function better. The costs of the indicators have also been reviewed.
Revenue Mobilization and Allocation Decisions
With the crisis, there were budget reallocations in the ministries. All the ministries revised their budgets to provide an amount for the COVID-19 response: “Well, you know that we are in a resource-scarce situation and the health crisis came on suddenly! So the government has really… there have been many restrictions, the government has even gone so far as to revise the budgets of all its ministries to draw on this and contribute to the Covid management fund, so it hasn’t been easy for the government. The initial planning had to change many things to release funds for the management of Covid cases, so it hasn’t been easy for the government. We had to readjust many things to be able to cope”, says an institutional stakeholder.
Indeed, as part of the response, we have witnessed the revision of Law No. 2019/023 of 24 December to lay down the finance law of the Republic of Cameroon for the 2020 financial year[2]. Apart from health, education, training, social and women affairs, some administrations have lost an average of 20% of their initial budget. Indeed, the revenue and expenditure estimates of the general budget voted at 4951.7 billion CFA francs have decreased in absolute value by 542.7 billion CFA francs and by 11% in relative value, bringing the overall expenditure to an amount of 4409.047 billion CFA francs.
For initiatives such as the PBF, the contingency emergency response component (CERC) was launched, making it possible to raise 5 million CFA francs. Financial partners were also approached to mobilize resources. The funds were directed towards specific expenditure lines such as managing COVID-19 patients, active tracing of cases, awareness-raising, prevention and disinfection. None of the care structures had autonomy over resource allocation decisions: “The funds we received came with lines of expenditure… The expenditure lines were staff motivation, the different stakeholders involved, operation of the regional management system, investigation of alerts, hygiene and decontamination,” said one health facility manager.
Mechanisms put in place for payment of health services and personnel as part of the response to COVID-19
In Cameroon, the vast majority of health care funding is provided by households, with more than 70.6% provided through direct payments. In COVID-19, care for patients was free of charge, according to the official discourse by government authorities in general and the Minister of Public Health in particular, as broadcast in the media. All inputs related to the treatment protocol in force in the country, namely the combination of hydroxychloroquine, azytromicyn, paracetamol and zinc, were provided by the Ministry of Public Health. In addition, accommodation and meals were provided: “… The government declared COVID-19 care free of charge, so when a patient arrives with a COVID-19 diagnosis, he/she is referred directly to the approved care center where he/she is attended to free of charge… So the care is free, supported by the state… This means that the patient does not pay any money; the state pays on behalf of the patient. Treatment is free of charge“, said a health professional.
However, on a practical level, health facilities were often short of certain drugs such as zinc, antibiotics or anticoagulants, which patients had to buy on their own; on the other hand, some hospital structures did not have a large capacity test patients. The administration of Covid-19 tests was sometimes deliberately limited to avoid shortages. Patients were sometimes referred or directed to other testing centers. In addition, the thoracic scanner, which was financially inaccessible to most patients, was the preferred method of diagnosis in many private health facilities. In one region in the country’s far north, patients had to wait a long time for their COVID test results before being admitted to the health facility. Despite their frail state, the equipment needed for the tests was located far away from the city. The problem of access to care is noted below by a health professional: “…I am currently handling a case, we have run out of medication at the moment …you see and …today we have 11 positive cases and the 11 positive cases. It is difficult to write prescriptions without medication …you make people leave knowing that they are positive, that makes them anxious, without medication….” It thus appears that the provision of free treatment to COVID-19 patients has faced considerable challenges in the field, reflecting the gap between policy formulation (theory) and implementation (reality), especially when these policies use a top-down approach as in the fight against the COVID-19 pandemic in Cameroon.
With the allocation of COVID-19 funds, health staff and volunteers received monthly bonuses. The conditions for payment of bonuses varied according to the health facility. The quota of people tested determined the payment, the number of missions carried out, performance criteria such as punctuality, attendance, participation in meetings, the grade of the staff involved, etc. However, this motivation is “not commensurate” with the risks associated with the pandemic, and some of the payment criteria have “nothing to do” with the management of COVID-19. The government has recruited several volunteers to strengthen outreach, diagnosis and management activities. In several cases, volunteers reported working for several months receiving no salary or bonus. In some health facilities, staff were critical of the way bonuses were paid out.
Effectiveness and Efficiency of Allocated Resources
At the beginning of the response, the management of COVID-19 cases was centralized in Douala and Yaoundé, the country’s two major cities. The government of Cameroon opted for decentralization, which has been the main pillar of the fight against the pandemic. Indeed, local management has been transferred to regional health authorities and districts, while regional hospitals have been set up as COVID-19 care centers. Funds were allocated directly to the latter for pandemic preparedness and response to improve the technical efficiency and effectiveness of the overall response. This decentralization appears to have helped improve access to inputs, enabled more staff to be involved in the response, contributed to mass testing of people, and improved alert management. Prevention was the strategic choice, although not evidence-based. It was more about limiting the spread of the disease and in-hospital transmission and maximizing staff protection. Measures related to case management included establishing a national management protocol based on the cases, the drugs to be used, and the approach to healthcare. It was also based on severe and mild cases and the setting up of management structures.
However, in the distribution of resources, particularly financial resources, each district had received equal amounts to the tune of ten million CFA francs (approximately US$18,500) per district, regardless of the epidemiological situation and contextual realities. Also, the budget lines were insufficient in relation to the needs. For example, the allocations did not meet the expectations of some health districts. One head of a health facility confessed that although it was a “breath of fresh air”, there was a certain amount of unrest among the staff involved in response to Covid-19 in certain regions because the distribution of resources was just done randomly with no relation to the indicators associated with the management of COVID-19: “The administration alone distributed the budget lines according to priorities. It’s true that at one point, we made requests in relation to what was being done elsewhere, but that had little impact because until now, discouragement has come well afterwards, as you can see. Since then, many people have lost motivation; they no longer want to give their all, some say they don’t see the point, the usefulness of risking their lives for…so we’ve had to deal with a lot of burnouts among the staff involved in the response, they no longer want to get involved if there’s no motivation.”
The health facilities approved for case management have experienced a disruption in their income due to the drastic drop in attendance rates. The pandemic has impacted consultations, para-clinical examinations, and vaccination, among others, to such an extent that quota shares have decreased by over 70% in some health facilities. The current coronavirus pandemic has been a source of major crisis for the health system in Cameroon but constitutes an opportunity for fundamental reforms. If the government, together with its financial partners, mobilized a certain number of resources that were considerable support in the fight against COVID-19, the allocation and use of these resources towards greater effectiveness and efficiency deserve to be looked at closely. Funds for the response to COVID-19 have been directed towards a two-tiered response. The focus has been on prevention first, then management. Cameroon’s level of preparedness for future responses still needs improvement. For example, the emergency number should be permanent so that it can be used for other pandemics such as cholera; a budget should be set aside to deal with emergencies; staff at the operational level should be retrained and involved at all levels of decision-making in the event of a pandemic; provide resuscitation services; create special centers in the regions or districts ready to intervene in the event of a pandemic; create operational molecular biology laboratories and possibly initiate actions to promote the local development of an entire pharmaceutical industry. It is also important to fight against inequalities by facilitating access to care in a pandemic.
[1] Circular No. 00000220/C/MINFI of 22 July 2020 specifying the modalities of organization, operation and monitoring-evaluation of the Special National Solidarity Fund for the Fight against the Coronavirus and its social economic effects.
[2] Ordinance No. 2020/001 of 03 June 2020 amending and supplementing certain provisions of Law No. 2019/023 of 24 December 2019 to lay down the finance law of the Republic of Cameroon for the 2020 financial year.
The authors of this blog are Gislaine Takoguen and Isidore Sieleunou from Research for Development International, Yaounde, Cameroun.