February 2013, Cameroon

Policy Brief:
Improving the Governance of the Health system in Cameroon
The Governance diagnosis of local health service delivery in Cameroon1 analyses the governance challenges in the health sector in Cameroon, with a particular emphasis on health service delivery at the local level. The report is a qualitative study that took place in the districts of Limbe (South West Region) and Abong Mbang (Eastern Region) in November 2011. Focus group discussions and in-depth interviews were conducted with health workers, clients, communities and other stakeholders in the health system. The report and the underlying work were done by the Royal Tropical Institute (KIT) contracted by the World Bank through a Governance Partnership Facility fund. This policy note summarizes the main governance issues identified through the study at the local level, and discusses challenges that currently impede advances in health service delivery outcomes in Cameroon. The Governance diagnosis of local health service delivery in Cameroon considered governance primarily in terms of implementation processes that lead to gaps between policy and practice and, in the health sector, in terms of interaction between policymakers, regulators, purchasers, service providers, clients and citizens, with a specific focus on the operational level of Cameroons health sector.

Background
In 2011 Cameroon was ranked 150th out of 187 countries on the Human Development Index (HDI). With an index of 0.482, the country is situated slightly above the average of countries with low human development (0.456) and of countries in sub-Saharan Africa (0.463). Cameroon holds an income index of 0.431, with a gross national income per capita of $2,031 ($USD, constant at 2005 rates). The HDI for health is situated at 0.499, with health expenditures amounting to 1.3% of GDP in 2010. It is estimated that about 40% of the population is living below the poverty line, or approximately 8 million people (out of a total population of 20 million). Cameroon is performing poorly for the majority of World Health Indicators and on the Millennium Development Goals objectives. Life expectancy has decreased from 55 years in 1990 to 51 years in 2011, while the mortality rate among the population aged 1560 years increased from 321/1000 in 1990 to 403/1000 in 2008. Despite a continual regression of the HIV prevalence over time (5.3% in 2004 to 4.3% in 2011),
Figure 1 : IDH, Cameroon vs Africa, World

Source : UNPD HDI 2011

the prevalence remains higher than the majority of neighboring countries in West and Central Africa. The mortality rate for malaria-related deaths (116/1000) also exceeds that of the African region (104/1000). Cameroon has the 32nd highest infant mortality rate in the world, though it decreased from 74/1000 in 2004 to 59.7/1000 in 2011 and a yet high under-five mortality rate though decreasing (from 148 to 122/1000 between 2004 and 2011).

Governance is a major challenge to Cameroon's development and to reducing poverty. Few of the Worldwide Governance Indicators for Cameroon have shown significant progress since 1996, and the country is still ranked among the 20 countries with the lowest governance scores in the world2. However, in 2011, Cameroon ranks 134 out of 183 countries in Transparency Internationals Corruption Perception Index, with a slight improvement compared to past years. The pervasiveness of governance challenges affects most economic transactions and hampers the volume and quality of public services. The Government of Cameroon (GoC) has acknowledged this situation, governance being one of the seven pillars of the Cameroon PRSP (DSCE 2010-2020). The GoC has recently taken several concrete steps to improve governance in general as well as in the health sector: (i) the inclusive preparation of a new national Anti-Corruption Strategy for 2010-2017 that sets out objectives, strategies and activities for all sectors, including health; (ii) the creation of a specific anti-corruption unit for the health sector, the Cellule Ministrielle de lutte contre la corruption (CMLCC) that had, by the end of 2010, established the framework and tools to fight corruption, created a denunciation system and set up 312 local committees to fight against corruption (CLLCC); and (iii) in 2011-2012, the piloting of Rapid Results Initiatives in a dozen hospitals aimed to combat corruption and improve services. Additional initiatives include (iv) the decentralization process targeted the health sector (among others) in 2010, with the intention to transfer budgets and responsibilities to the municipalities and urban communities; (v) the publication of the first National Human Resources for Health census in late 2011, thereby opening the door to the establishment an HRH information system (HRH -IS) that will track the allocation/ availability of health staff and facilitate HR decisions. With regards to drugs, new measures to fight unauthorized drug sales have been introduced, in particular (vi) the creation of a regulatory body that will improve the control of the purchase and distribution of drugs (SYNAME) and (vii) awareness -raising campaigns to inform communities that drugs are available in health facilities and warn them about the risks associated with illegal drugs.

Main findings
The key challenges to good governance at the service delivery level can be grouped into two main themes: (i) resource mobilization and allocation and (ii) human resource management. The health system is characterized by the persistent centralization and vertical allocation and management of financial, material, pharmaceutical and human resources, albeit one of the first sectors in Cameroon to begin the decentralization process. Because of its structure, resource allocation in the health sector is both highly unpredictable and prone to financial and material leakages. These systemic challenges Figure 2: Evolution and comparison of direct payment by households fall under two major types of outcomes that affect amongst total health expenditure health service delivery: a) Poor stewardship in resource mobilization, allocation, and spending Inadequate budget allocations. Compared to other countries in the region (CEMAC), public financing for health, at less 5% of the governments budget (2013) and less than 20% of the total health expenditure, is well below that of its CEMAC3 partners and the average for sub-Saharan countries (Figure 2). In Cameroon, health sector financing comes primarily from direct household payments - estimated at more than 70%4 of health expenditure; a situation that has changed little since 2000. This limits access to essential health services and contributes to higher mortality levels among the poor,

Source: WDI, 2012; in Cameroon Health CSR, World Bank 2012

thereby creating high levels of inequality in health outcomes (Figure 3). Annual financial inputs from the central level represent approximately 20% of the annual income of health facilities; in addition, the flow of resources from the central level to the local level and vice versa (through the Solidarity Fund) is inefficient and is prone to leakage as credit vouchers and other funds are transferred between the central and sub-national levels. In 2009, only 37.9% of public sector primary care facilities (Integrated Health Centers - IHC) declared having received from the administration, an amount of resources corresponding to that shown in the finance law6.

Figure 3: Life expectancy at birth (ordinate) against total health expenditure per capita US$ (abscissa), for countries with comparable GDP US$ PPP (1800-3000$)

Source : WDI, 2012 Inefficiencies in budget allocations. Between 2007 and 2009, programs dedicated to maternal and child health, Figure 4: Part of health sector budget allocation against priority secwhich is a national priority according to the Health Sector tors between 2007-2009 Strategy, received only 5% of the Ministrys budget allocation(fig.4)7. In 2009, the central administration received 37% of the budget, against 5% for the intermediary level and 58% for the peripheral level8. In 2009 operational costs represented 76% of the total budget, compared to 24% for investments. The allocation process to the periphery level is still hampered by a number of obstacles, including the fact that the district health budget is largely earmarked and not based on needs. Health facilities do not always receive the operating budget or materials Source : WDI, 2012; RaSSS Cameroon, World Bank 2012 needed to provide basic services, leading them to find alternative ways outside the health system to acquire essential drugs, such as the purchase of street drugs and referral to clandestine health clinics.

Weak transparency at the local level. All decisions regarding the allocation of health resources are taken at the central level and information on how allocation decisions are made is almost non-existent at the district level. At the district level, oftentimes the District Medical Officer (DMO) is the only person who knows what the district receives in terms of national budget allocations and such information is not shared with other members of the district management team or other local stakeholders. Consequently, multi-stakeholder management committees have little real involvement in resource management at the district and facility level, and very few know the level of resources provided by the central government, NGOs or other cost-recovery sources. This lack of transparency and difficulty ascertaining how finances are managed or understand the actual financial situation of facilities is a major source of demotivation of Health Areas Health Committees (HAHC) and lack of action on local priority problems. Furthermore, the financial accountability mechanisms for central budget funding allocations to health facilities are not functional. Each district or health facility is supposed to have annual audits, which are often not carried out due to a lack of technical capacity and financial resources. The lack of a strict control of the financing system, particularly on the monetary entries that come directly through the users fees system still nourishes exploitation of patients by health care providers. Informal payments and gifts are widely institutionalized among staff . There is still a common perception, on both the supply and demand side that informal practices such as bribery and under-the-table payments are acceptable. Health professionals cite low salaries and poor living conditions as justification for using informal strategies to increase their income. Another argument put forward by health facility staff for diverting resources

is that resources transferred by the central state are public, do not come out of the community pocket, and that it is therefore is morally acceptable. Both patients and health facility staff reported informal activities, such as selling drugs under the table, institutionalizing gifts, charging patients informally, overbilling and running private practices within public facilities. The fact that public sector providers are devoting some of their paid service time to moonlighting in the private sector is also common. Finally formal service charges are collected, but leakages often occur through misreporting.
Box 1. Accelerating deliveries in order to access gifts Two members of staff at a public facility told us that there are various ways of generating informal income. Staff in the maternity department generally prefer quick deliveries, but this preference is accentuated by competition over access to gifts from patients. As a result, practically all women in labor receive Oxytocin, which is sometimes administered quickly and in high doses, regardless of risks of severe complications, in order to maximize the chance of delivery during the watch of the staff who welcome the patient, and who will consequently benefit from the gift. Although they are occasionally uncovered during inspection visits by facility managers or senior staff, such violations usually go unreported as they take place un-witnessed behind closed doors, and most patients lack the knowledge or power to report them.
Source: Governance diagnosis of local health service delivery in Cameroon, KIT, 2012, p.45.

Weak chain of governance in the collection and management of user fees. Responsibility for managing user fee revenue officially lies with the facility manager and health management committee, who are supposed to be direct representatives of the community. In practice, however, the division of responsibilities between health facility staff is blurred and there are no clearly defined separations of functions. Various factors contribute to leakage at the operational level. Oftentimes there are multiple payment points at one health facility, which complicates tracking of facility revenue; underreporting of services provided is frequent; management of prices, billing and payments are in the hands of a few individuals without external verification; and difficulties in accessing services in a timely manner foster bribery.

Figure 5: Chain of governance challenges in the collection and management of user fees

Source: Governance diagnosis of local health service delivery in Cameroon, KIT, 2012, p 27.

b) Human resources management: Inequity in allocation, weak internal and external accountability Human resource management is highly centralized and lacks transparency, with recruitment, salaries paid and decisions regarding staff benefits taken at the central level or at the discretion of authorities, without clear criteria or objectives. In addition, Regional Health Delegations are not allocated staff quotas based on an analysis of priorities or needs, leading to an inequitable and inefficient distribution of health professionals. Centralized planning does not allow for adequate flexibility and gap filling at the decentralized level, particularly regarding shortage of qualified staff in rural remote areas. In terms of personnel allocation, some regions fall far behind national norms, a situation often directly responsible of poor health results. The regions that have the lowest density of health personnel (the national guidelines call for 1.53 doctor per 10,000 population and 8.81 nurses per 10,000 population) are also the regions that have the poorest health outcomes and greatest health needs (e.g. the North, the Far North) (Figure 6). Weak management of drugs. The drug supply chain still provides ample opportunities to make money through drug procurement, mutually agreed additional purchases, false labeling and even fake drugs. As delivery sched-

ules are not based on individual facility needs, and because many health facilities use the capital that needs to be reinvested in drugs to carry out other tasks, the pharmacies are often left without the necessary funds to restock drugs. Supply outages are an important source of corruption: they encourage parallel and illicit drug sales in and out of public facilities. Finally, because of other flaws in the control and monitoring system, payment for free essential drugs and double drug billing in the operating theatre before operations are carried out are common practice.

Figure 6 : Infant mortality rate and distribution of doctors and nurses*, by region

Inadequate incentives: the quote part system. Source : EDS MICS 2011 and Recensement Gnral des Personnels du secteur de la sant du Cameroun December 2011. Poor performance is in part due to a weakness (or *includes both public and private sectors lack of) an incentives system. Internal accountability mechanisms are hardly applied, except for the quote part system. The quote part is mentioned by some managers as a strategy used to reduce informal practices. In principle it works as a form of incentive: the more services you provide, the higher the revenue and the higher the quote part. However, this does not seem to work out in practice. This system, aimed at improving motivation and performance, has become a source of conflict in many facilities and actually suffers from variations between the policy and its implementation and from a general lack of transparency. The rules allow the setting of a percentage for the quote part (30 percent), based on salary scales, retention of 10 percent of revenues from services for the National Solidarity Fund (only for hospitals), and 10 percent of revenues from sales of drugs for the Provincial Special Funds. There is a general perception on the part of non-managerial staff that the allocation process for quote part distribution is not transparent nor based on merit. Firstly, people do not know what the facilities revenues are, hence what the 30% for the quote part is based on. Secondly, people do not know how the quote part is allocated and why different people receive different amounts. Even the senior staff who carry out the initial scoring do not know how the money is divided up afterwards. Allocation is felt to be influenced by nepotism. Thirdly, unequal treatment (higher scoring for doctors) is resented by staff while senior staff do not like the system being too equal and feel that the quote part should be divided up according to value delivered. Fourthly, the introduction of additional criteria aimed at disciplining staff and improving performance, for example in Limbe district hospital has had an adverse effect: staff found the system too rigid and strict, leading to internal friction and demotivation.
Box 2. Signatures are not for free Health Management Committee (HMC) chairman According to policy, the chair of the HMC should not sign financial reports if they are not acceptable (misuse of funds). In one recent case, however, the HMC chairman succumbed to pressure from a local health authority, and not have the facility painted in return for his signature
Source: Governance diagnosis of local health service delivery in Cameroon, KIT, 2012, p.46.

Internal accountability is weak. Internal accountability in district hospitals, primary care facilities and district health management teams remains limited. The lack of standard mechanisms for performance monitoring encourages inefficiencies. Staff are evaluated irregularly, often subjectively, without recourse to processes and appropriate evaluation tools. Unsanctioned misuses of public resources are the norm . Sanctions are limited, mainly because the overall cycle of accountability is unclear and because perceptions of the gravity of various misdemeanors and the sanctions that should be applied differ considerably. Overall, lack of trust in human resource management is high: many health workers and administrators are frustrated by opaque decision-making processes and health staff often do not have confidence in their managers or colleagues.

External accountability mechanisms are ineffective. Horizontal accountability through dialogue structures such as health area health committees (HAHC) and health management committees (HMC) is both fragile and subject to change. Information, transparency and participation by HAHC and HMC need further reinforcement and capacity for tangible changes to be observed. Although some HMC members are involved in the control and oversight of facility activities, their nomination is not based on regulatory and consensual criteria, their actual accountability and representation remains limited and they have little to no participation in decision making regarding spending. The flow of information from service providers to HMCs is irregular and incomplete, which hampers their effectiveness. HAHC members also feel excluded from decision-making processes, and seem to consider that their own representatives at the HMC are often not accountable to them. Low social accountability between users and service providers. Direct client participation remains difficult due to lack of information about services and prices, difficulty in organizing representation, fear of reporting and lack of effectiveness of supply-side instruments to include citizens voices. Their perception of local health services and willingness to express their needs and take action against malpractice is influenced by the general mistrust of the public sector. Patients are afraid to complain or report abuse, for fear of retaliation the next time they visit a health facility. This implies that, in terms of accountability mechanisms, the direct patient -provider relationship might be the most difficult to change. Yet this is also the relationship that has the most direct impact on the perception and use of services.
Box 3. Rumors surrounding the distribution of mosquito nets In November 2011 community members, citizens and HMC representatives complained that mosquito nets sent to their district in September as part of the national anti-malaria campaign had still not been distributed. They suspected that the nets had been sold, while the local council blamed the delay on an incorrect census, the DHS claimed that there was limited funding for distribution, and HAHC representatives put it down to the lengthy upstream process. Eventually it emerged that personal contacts had been used to recruit a group of local NGOs to distribute the nets, bypassing the HAHC, which had voluntarily conducted the census but was not allowed to distribute them. The local radio station raised the issue but found itself caught between citizens demanding explanations on the one hand and the district health services trying to make excuses on the other. The nets were never fully distributed, and rumors surrounding the campaign remain unresolved.
Source: Governance diagnosis of local health service delivery in Cameroon, KIT, 2012, p.34

Examples of good practices

Rapid Results Initiatives (RRI) in the Health Sector. This initiative, started in 201110, aims to eradicate conditions that are conducive to acts of corruption using the Rapid Results Approach, which requires actors to identify issues and develop concrete solutions to implement in 100 days, with clear leadership and support from their hierarchy. For example, a RRI, implemented in 2012 in 8 hospitals, led to a 30% increase in health service delivery and a 57% increase in revenues. The process also strengthened managerial and stewardship capacity by introducing coaches and leaders within the Ministry of Public Health able to define and accompany the implementation of concrete changes in health facility management. The Centre for Development of Best Practices in Health CDBPH is a research unit that was established in June 2008 at the Yaound Central Hospital. Its aim is to foster knowledge transfer and exchange for better health in Africa. CDBPH is a knowledge brokerage unit designed to link health researchers with health decision makers. This initiative aims to assist researchers by collecting, synthesizing, re-packaging, and communicating relevant evidence in user-friendly terms that stakeholders at many different levels can both understand and use effectively. The CDBPH also serves decision makers in the sector by providing capacity building opportunities, evidence summaries, and identifying needs and gaps related to Evidence to Practice.

Individual local level initiatives. During the survey, Box 4. Initiatives to boost performance in a district the Governance diagnosis team found that several hospital district facilities were locally fighting corruption and A few months ago the director of a district hospital intropoor health facility management. One district hospital duced various measures to boost the poor performance and of the facility and motivate staff: A single cash payment director improved the quality scoring procedure by (i) point system to reduce informal/parallel payments; Internal adding an additional set of performance criteria that supervision over a quarterly cycle, with a focus on learning would allow staff to be evaluated on a quarterly basis rather than control. Results are used in one -to one motivational sessions and to organize refresher courses; Weekly and sanction points deducted from the quote part, (ii) team meetings where heads of department discuss proinstalling a single cash payment point system to re- gress and challenges; Other initiatives proposed but not yet duce informal/parallel payments, (iii) organizing week- implemented include badges to identify personnel; maternal audits to learn from patients experiences; asking paly team meetings to discuss progress and challenges. tients to fill in short questionnaires while they are waiting In another case, the Prefect (i) closed down clandes- (pro-active) instead of suggestion boxes (passive), which are not used; Regular meetings to improve the quote part tine health facilities; (ii) illicit drugs were found and system. When the director arrived she saw that this was destroyed, (iii) facilities that were posting exorbitant not being applied according to the rules, and suggested prices for health services were sanctioned; (iv) staff returning to the regulatory system set by the Ministry and using it as a performance management. members received official recognition, and (v) good Source: Governance diagnosis of local health service delivery in behavior became an important criterion for allocating Cameroon, KIT, 2012, p.39. quote parts. Other initiatives include (i) badges to identify personnel; (ii) maternal audits to learn from patients experiences; and (iii) asking patients to fill in short questionnaires while they are waiting (pro-active) instead of suggestion boxes (passive).

Options to improve governance of the health sector in Cameroon

Generation of relevant information. In Cameroon, the health management information system (HMIS) is inherently sporadic, providing incomplete reporting at all levels of the system. Functional monitoring and evaluation mechanisms allow for tracking the implementation of policies and priority programs, measuring results and making adjustments where necessary. Without such tools, health systems operate blindly. By increasing access to and utilization of computerized management information systems, health programs and administrative units can improve reporting and rational, informed decision-making. To improve clarity on health outcomes, strengthening the national system for routine reporting, retro information and circulation of information could be prioritized. To facilitate this reform, the Health Information Unit, housed within the Direction of Studies and Planning in the Ministry of Public Health, should gain greater autonomy, exposure and resources. This could potentially be achieved through converting the Unit into a Division or Direction within the Ministry. To improve the comprehensiveness of information collected, service delivery output indicators, which play a complementary role to outcome indicators (which are collected through non-routine means such as representative population surveys such as Demographic and Health Surveys), could be collected and measured monthly and aggregated nationally on an annual basis. Currently, individual vertical programs collect detailed sets of program -specific indicators and are not compiled or harmonized to provide in-depth understanding of health system performance. The Plan Stratgique de Renforcement du Systme dInformation sanitaire 2009 2015 is a potential starting point for developing is a sound structural framework for action. Its objectives and methodology offer concrete proposals that can be quickly updated for systemic needs. Ensuring planning based on data and need. The finalization of the health map and of the HR census will give the government access to better planning tools that could be complemented by a greater consideration of needs identified by the facilities. Currently the distribution of the health workforce is not aligned with population health needs. Overall policy coherence and a resource allocation focusing on MDGs and specific regional health issues are fundamental for the improvement of governance of resources and responsiveness to population health needs. Reinforcement of linkages between budget formulation and monitoring mechanisms at the central level and local level could also provide stewardship, as well as enable better outcomes at the service delivery level.

Access to information and effective deliberative space at local level. The current management of programs and activities, at the central and local level should be based on high quality and comprehensive information. The District Health Services do collect data, but this is purely for reporting purposes rather than their own planning processes. Data generation at the service delivery level is cumbersome, time consuming and rarely completed. Data transmission is strictly vertical and upward with no routine feedback and dissemination, often leaving other local actors oblivious to the quality and quantities of activities performed, thus limiting local participation in decision-making and reform. Service delivery supervision by district health management teams is close to inexistent and with limited impact. Coordination, monitoring and supervision mechanisms at the regional and district levels need to be reinforced. For this, information on service delivery, population health outcomes, resources locally available should be made accessible to local dialogue structures such as health facility and health area management committees. Local stakeholders such as the local government, community representatives, municipal councils, local associations and NGOs, and religious leaders should be allowed to participate in the prioritization process, planning, budgeting and monitoring and evaluation of the provision of health services through regular stakeholder consultation meetings that allow for transparent and open interrogation of the actions performed by local health actors such as health facility staff and district management teams. Strengthen local government. The articulation between roles and responsibilities of local government and elected representatives (decentralization and deconcentration) is still a concern. The acceleration of open discussions and generation of concrete policies would reinforce local participation and confidence in the health system, particularly if one considers the large share of the health budget allocated to district autonomy (65%). Accountability and transparency at the operational level depends largely on the autonomy and control that can be exercised, as well as of reinforcement of their supervision, feedback and performance capacity and willingness. In this process, the emergence of active local governments and civil society representatives with the technical and organizational capacity to strengthen inter-sectoral coordination and horizontal accountability should be prioritized. Changes in the incentives/sanction system at the service delivery level . The Ministry of Public Health could consider supporting a rapid implementation of an (i) enhanced supervision system, (ii) the introduction of positive incentive schemes based on merit and results, and (iii) an acceleration of good governance initiatives such as the RRI. Performance-based Financing (PBF), an innovative financing approach that encompasses all three abovementioned strategies, is currently being piloted in 26 districts in the North-West, South-West, East and Littoral regions. Preliminary results show improvements in health facility management, including greater transparency in the distribution of incentive mechanisms such as quote part payments. In turn, managerial autonomy established through contractual arrangements has led to more efficient mobilization and use of human, material and financial resources at the operational level. Transparent and unbiased health facility staff evaluations have also contributed to improved health workforce productivity.

. KIT, World Bank 2012. The report is the result of a quality Governance diagnosis conducted in two health districts in Cameroon, Limbe (South West Region) and Abong Mbang (Eastern Region). The Study is one of the background paper to the World Bank Country Health Status Report.
2

. World Bank 2012. The WGI Cameroon rank (out of 100 countries, the lowest rank the worst) : i) Voice and Accountability,17th ii) Political Stability and Absence of Violence,27th iii) Government Effectiveness,18th iv) Regulatory Quality, 23rd v) Rule of Law, 15th and vi) Control of Corruption 18th.
3 4

. CEMAC: la Communaut Economique et Montaire de l'Afrique Centrale . WHO Global Health Observatory National Institute of Statistics (2010), 2nd survey on the monitoring of public expenditures and the level of recipients Satisfaction on the Health sectors in Cameroon, PETS2. National Institute of Statistics (2010), 2nd survey on the monitoring of public expenditures and the level of recipients Satisfaction on the Health sectors in Cameroon, PETS2.

5. 6. 7.

The predominant share given to the fight against disease is due to a very important funding from the Global Fund in 2007. In the case of viability of the health district field, the increasing share is due to the fact that in 2009, there was an important increase in human resources and provision of care
8.

Provisions requested in the 2011-2013 Health CDMT are as follows, 9%for maternal and child health, 26% for the fight against disease, 1% for health promotion and 63% for the Health District viability. In CDMT Sant, 2011 -2013, Ministry of Public Health, 2010.
9.

Pharmaceutical Supply Centers (CAPP) are supplied by the national drug procurement center CENAME Through the multi-donor technical assistance program to the CONAC Changing Habits, Oppose Corruption (CHOC), and with support of the World Bank

10.