THE REORIENTATION OF PRIMARY HEALTH CARE IN CAMEROON

In contrast to the SANRU project, the Maternal Child Health and Child Survival project of Cameroon (known better as SESA: Child Survival in the South and Adamoua), was initially designed only as a Child Survival project, i.e., promotion of five priority health interventions with the "twin engines" of ORT and immunizations.

However, while intensives vaccination campaigns in 1986-1987 increased vaccination coverage dramatically throughout Cameroon, the achieved levels were not sustained.⁽¹⁾ A similar situation was documented in Senegal which found that intensive campaigns conducted from 1986-1989 were not sustained, interfered with other health service activities, and possessed some technical deficiencies related to the managerial characteristics of an intensive campaign. The Senegal study recommended a "reorientation of health policy that advocates district management and the administrative as well as operational integration of vertical programs".⁽²⁾

By 1989 the Cameroonian Ministry of Public Health (MOPH) and USAID concluded that the problems hampering the national health program were also adversely affecting the implementation of the SESA project. The population's lack of confidence in the health system and the resulting low utilization of MOPH health facilities severely undermined the successful implementation of the key child survival interventions planned under the project. Specifically, the project's centralized, vertical approach needed to be replaced by a decentralized, integrated strategy focused on improvement of health systems and community involvement in the management of health care. In addition, the lack of national budgetary funds available for rural health meant that the cost recovery component of the project needed to be expanded beyond the resupply of drugs to include the funding of some of the recurrent costs associated with the delivery of PHC services.

Based on this assessment, and the reviews of other donor-funded PHC projects, the MOPH devised a new PHC strategy, called Reorientation of Primary Health Care (RPHC)⁽³⁾ to emphasize decentralized planning, community co-management of health facilities, and community co-financing of health services. Each province is to be organized into health districts to supervise and support health centers co-managed by community health committees. Each health center is to have a pharmacy and cost recovery mechanism to permit funding of important recurrent costs of the RPHC program.

RPHC is based on the premise that the Cameroon government does not presently have, nor will it have in the near future, sufficient budgetary resources to finance health care services. The cost recovery approach divides the costs of health care between the government and the population. The MOPH supports health workers' salaries, pre-service training, and other inputs which are currently provided. Local communities cover the key non-salaried recurrent costs associated with the delivery of PHC services. In addition, the health system is made less costly and more efficient by improved health management systems.

With its emphasis on community financing, integration of PHC services, and revolving fund essential drug pharmacies, the RPHC addresses the major problems affecting Cameroon's health sector. The RPHC is the cornerstone of the MOPH's overall health sector strategy. In 1990 USAID and the MOPH began to reformulate all USAID-funded projects to bring them in line with RPHC. The RPHC provided USAID with a mechanism to coordinate its health and population portfolio, focus its projects on developing sustainable health systems, and forge closer donor collaboration.

USAID's integrated health systems approach to development has encouraged:

cost-effective delivery of child survival interventions, e.g., immunizations;

a rapid expansion of important services such as family planning;

a model to begin integration of public and private sector health systems;

a mechanism for recurrent cost financing for non-salaried health services; and

a mechanism to address longstanding problems, such as the funding of control measures in the early phases of epidemics.

One of the key lessons learned from Cameroon is that

By choosing an integrated health systems approach to health in Cameroon, and by implementing projects to assist the MOPH in making the transition from selective primary health care to RPHC, USAID has probably had a much greater, wider and permanent impact on health in Cameroon than if it had maintained a selective or narrowly focused approach for its projects.⁽⁴⁾

Other important lessons learned from Cameroon that are particularly relevant to systems strengthening and to the design of a regional project to continue these efforts are summarized in Box 2 (below).

The SANRU and SESA are two USAID-funded projects which have demonstrated the merits of a systems strengthening approach in health and population assistance. In doing so they had to overcome a number of obstacles in policy reform, technical support and project implementation. Key obstacles to systems strengthening are examined OBSTACLES TO SYSTEMS STRENGTHENING

Box 2

LESSONS LEARNED FROM CAMEROON

1) Coordination of donor agencies in Cameroon has been facilitated by the Reorientation of Primary Health Care (RPHC) policy to define responsibilities for planning and management at each level of the integrated health system. The integrated health system has provided a mechanism for coordinating the comparative advantages of donor programs.

2) It is necessary to plan for a mix of donor support in developing integrated health systems. Most donor agencies are unable, or unwilling, to provide the full spectrum of assistance required to develop integrated health systems.

3) Even with a clear national policy for RPHC, there is a continuing need for marketing the concept of integrated health systems to donor/partner agencies. We should never underestimate the tendency for donors, especially with pressure from headquarters, to "verticalize" their assistance and projects.

4) Implementation of decentralization should begin at the system level that has the capacity for planning, management and supervision over the functions to be decentralized. While health districts are to be the operational unit for decentralized planning and management in Cameroon, the weakness of government infrastructure and personnel at this level made it necessary to begin decentralization by concentrating systems building at the provincial level.

5) The absence of functional health districts to serve as replicable models for national decentralization can become an obstacle to getting decentralization moving at that level. Priority should be given to developing model health districts where a minimal effort is needed, e.g., in a district with a completely functional referral hospital.

6) The capacity of local NGOs manage district referral hospitals and to participate in, or even completely manage, district health services is a potential resource which is just now being seriously explored. Given the current economic situation in Cameroon, there is a need to maximize the use of existing, limited health infrastructure and resources by actively pursuing greater public/church coordination.

7) A vertical approach may be necessary in the early stages of establishing a family planning program in order to achieve faster progress. This is because the health care system has to be functional and decentralized before family planning can be integrated into it. However, the creation of centralized systems and structures may become obstacles to integration at a later stage, and may be difficult to dismantle.

8) IEC is a broad activity which needs to be linked to all support components and program interventions, just like supervision, evaluation and training. This is particularly important for child survival programs which are being reoriented to create an integrated health system including community participation.

back to "A CONCEPTUAL FRAMEWORK FOR SYSTEMS STRENGTHENING"

1. van der Geer, E.R. and Prats, J. Vaccine coverage in the Noun Department, Cameroon, 1 1/2 year following the 1986-1987 National Vaccination Days. [French]. Ann.Soc.Belg.Med.Trop. 72:37-44, 1992.

2. Unger, J.P. Can intensive campaigns dynamize front line health services? The evaluation of an immunization campaign in Thies health district, Senegal. Soc.Sci.Med. 32:249-259, 1991.

3. Essomba, R.O., Bryant, M. and Bodart, C. The reorientation of primary health care in Cameroon: rationale, obstacles and constraints. Hlth.Pol.Plan. 8:232-239, 1993.

4. Baer, F. and Hung, M. Assessment of USAID-funded Health and Population Assistance in Cameroon (1987-1994), an evaluation report prepared for USAID/Cameroon, March 1994.