CHAPTER TWO
2.4. HEALTH SECTOR
2.4.1 Organisation of the health care system
Table 2.3 • The administrative structure of the health sector
Level Administrative Functions Healthcare Dialogue
structures structures structures
Central Services in the Policymaking, Referral General Boards of
MoPH formulation of Hospitals, Directors or
concepts, policies University Management and strategies. Teaching Hospital Committees Co-ordination and and Central
regulation Hospitals
Intermediate Provincial Technical support Provincial Provincial Special Delegations to health districts Hospitals Fund for Health
and proQrammes
Peripheral Health Districts Implementation of District Hospitals, DMC, DHC, HC, and Health Areas programmes Sub-divisional MC
Medical Centres and Health Centres Source: Ministry of Public Health (2001 :22)
The country's pluralistic health system allows alarge and diverse public, private and traditional medicine sectors to co- exist. The health sector comprises government health facilities and international partners. The private health sector is divided into lucrative (private-for-profit), non-lucrative (not-for-profit), and private voluntary health structures (religious denominations, various associations and non-governmental organisations). The latter comprise the following:
• Catholic: 179 health institutions, of which eight are hospitals.
• Protestant: known under the association of FEMEC, 163 health institutions, of which 28 are hospitals.
• The Ad Lucem Medical Foundation (La Fondation Medicale Ad Lucem): seven hospitals and 11 health centres (Nkoyock 2002:37).
Traditional medicine, being an ancestral component, is gaining ground in the country. Although there is no national policy, the Ministry of Public Health is endeavouring to have this sub-sector integrated into the administrative set up of the MoPH. So far, the government has set up a Medicinal Plant Research Centre, known as the Institute of Medical Research and Study of Medicinal Plants (IMPM) (Ministry of Public Health 2001 :23).
Generally, the public health sector contributes to about 83% and the private sector 17% of health services.
International partners provide support in the development of the health district system and in the implementation of priority programmes (Ngufor 1999; Ministry of Public Health 2001 :25).
In order to bring the private and public sectors together in the 10 provinces, health care services are directed, monitored, co-ordinated and supervised by aMinistry of Health Officer and the Provincial Delegate of Health. While at the divisional hospitals, the Health Delegate oversees the activities of the hospitals, as well as the rural preventive and curative health services, that comprise the district hospitals and the specialized and basic health centres (Ngufor, Asaah and Bangue 1997).
2.4.2 Administrating and financing health facilities
In the health sector, the Ministry of Public Service and Administrative Reforms recruit civil service workers. The Ministry of Economy and Finance pays their salaries and they are effectively employed in the MoPH. That is, issues of professional and career progress are handled in the Public Service and the MoPH is in-charge of the professional practices and ethics of the medical professionals. The Ministry of Economy and Finance addresses salary-related matters. The major drawback of this situation is that reforms or actions taken by each of these ministries invariably touch on health personnel (Ngufor 1999). The financing of health facilities is divided among the state, household and committees. The following section will look at those concerned with the financing of health services.
2.4.2.1 State
The Constitution of Cameroon recognizes health as a fundamental right for all Cameroonians. Although the Constitution regards health as a fundamental right, this is hardly reflected in the allocation of the country's national budget. According to data from the Ministry of Economy and Finance, the budget for 1996-97 was FCFA 1113 billion, of which 3.3 per cent was spent on health, and 5.8 per cent and 0.2 per cent were spent on education and social welfare, respectively. In 1998-99, the national budget was FCFA, 1 230 billion of which 2.4 per cent was spent on health, while 7.4 per cent was spent on education and 0.2 percent on social welfare (Ngufor 1999).
Agood number of health structures are decrepit and either need to be rehabilitated or destroyed. While several health structures have a wide range of equipment, much is non-functional and obsolete. According to the Ministry of Public Health (2001 :28), two provincial hospitals do not have aradiology unit; three provincial hospitals do not have adelivery room and six provincial hospitals do not have a resuscitation table for newborns. The deteriorating nature of health facilities, the devaluation of the FCFA in 1994, coupled with the slash in salaries of civil servants in 1992-93, have
2.4.2.2 Household
The money collected from the payment for essential drugs, consultations, and for other procedures carried out in hospitals, has been used to revamp activities in the public hospitals such as the recruitment of additional staff according to available vacancies. External assistance (cash or material) and donations is also sought from private enterprises, NGOs and philanthropic organisations.
2.4.2.3 Committees
The management committees of the hospitals are democratically elected and they comprise representatives of the population, according to the health catchment areas and health districts. Members of the committee are called upon to manage the health problems of their localities, in conjunction with health personnel (Director of the hospital and the medical staff). The committee is involved in the identification of health problems, their priority setting, implementation of identified strategies, supervision and monitoring of health activities and evaluation of programmes and their implementation.
At the provincial level is the Provincial Special Funds for Health (PSFH) to provide a provincial"superstructure". It is composed of representatives of health districts democratically elected to ensure the management of health problems throughout the province.
2.4.3 Structure of health facilities
The health facilities have been classified into seven categories, arranged in descending order. Table 2.4 illustrates the categorisation.
The first level hospitals are the fourth referral point and are the best equipped in terms of equipment and infrastructure.
These hospitals are created by a Presidential Decree and have most of the medical specialists. Each has an administrative council appointed by the President. A director oversees the daily activities of the hospital and is answerable to the administrative council. The administrative council is composed of representatives from all the ministries, health professional associations and from the population.
Table 2.4: Levels of government health facilities
Level Type of hospitals Referral point No. of Hospitals No.
1 General Hospitals 4thReferral 3
2 Central Hospitals 3rdReferral 3
3 Provincial Hospitals 2ndReferral 9
4 District Hospitals 1stReferral 130
5 Sub-divisional medicalised health centers 97
6 Integrated health centers 1164
7 Mobile Health services
These hospitals have full autonomy and the proceeds received from their activities are used to recruit personnel and to maintain equipment. Although they are state-owned institutions, they do not have a right to a state budget. The state provides financial assistance in the form of subvention and donations. They are allowed to seek external assistance.
These hospitals support the training and research in the country. There are three of these hospitals in Cameroon - two in Yaounde and one in Douala.
The second level hospitals, also known as central hospitals, are the third referral points. There are three of such hospitals throughout the country. The Ministry of Public Health appoints the management committee and there is a director to oversee the day-to-day activities of the hospitals. These hospitals are entitled to astate budget and patients are attended to at very minimal fees. Like the first level hospitals, proceeds are used to up-lift the activities of the hospital. The medical personnel, support staff and workers of these hospitals are civil servants, paid by the State (Ministry of Economy and Finance).
The third level hospitals or second referral are the provincial hospitals. They are situated in all the provincial capitals.
They are directly under the auspices of the Provincial Delegate of Public Health. The management committees and the
"superstructures" assist in the management of these health facilities. The committee is headed by the Director of the Provincial Hospitals' who is appointed by the Minister of Public Health.
Levels four or first referral hospitals are district hospitals. They constitute the interface between the population and the health service. A district hospital is composed of one or more non-integrated health centres to support the integrated health services. The district hospitals serve as the first level referral point for patients from the health centres.
Levels five and six comprise of health areas and centres. Each district is divided into health areas and each health area is supposed to have a population of 8 000 to 10 000. The seventh level of health service is the mobile health service. This service is not operational, although it is mentioned in the hierarchical structure of the health sector.
In order to assist the MoPH and the health structures, the pharmaceutical sub-sector improves the accessibility of drugs to the population. It is made up of community pharmacies in health centres and provincial drug centres to stock and supply essential drugs to the peripheral facilities. At the central level, there is a national essential drug supply centre, charged with the importation and distribution of essential drugs to the provinces. There are also the private for- profit pharmacies, dealing in brand label pharmaceuticals. The health sector also has a quality control laboratory for the study of the quality of drugs (Ngufor 1999). The table of health facilities and hospitals excludes the private and missionary hospitals and clinics.
2.4.3.1 Training and continuing education of health personnel
Cameroon officially has two Faculties of Medicine and Bio-medical Sciences, of which only one is functional. This trains General Practitioners and Specialists (Surgery, Gynaecology-Obstetrics, Public Health, Paediatrics, Internal Medicine, Anaesthesia and Intensive Care, Clinical Biology, Radiology and Morbid Anatomy), as well as nursing officers. Training in some former paramedical disciplines (Health Technology, Physiotherapy, Medicallmaging and Pharmacy) has been suspended. The same applies to the training of local Health Administration Personnel, Dieticians and Nutritionists. Specialists from the areas of Pharmacy, Dental Surgery and Biomedical Engineering and Technicians continue to be trained abroad. Medical doctors and other specialists trained abroad have not been easily employed and integrated into the Ministry of Public Services (Ngufor 1999).
Yaounde has 48 training institutions for paramedical personnel. These institutions are unevenly distributed throughout the country. For example, there is one training school to 129751 inhabitants in the South West Province, as against one training school to 839 750 inhabitants in the Far North Province.
2.4.3.2 Evaluation of health care services in Cameroon
There is no national in-service training policy and supervision is the only strategy for continuing medical education.
However, some health personnel, especially those in the public services, take part in in-service training courses
through workshops, conferences and seminars, both within and outside the country. These types of training initiatives do not improve the functioning of a specific health structure, as the impact is hardly felt in the field.
A Directorate of Human Resources Management is in charge of evaluation and supervision of health services. This service is situated in the MoPH and supervision and evaluation is done as follows: A supervision tool was created for all personnel performance at all levels of the three-phase health scenario in Cameroon. According
to the structure, supervisors from the central level supervise the regional staff twice yearly. The regional teams supervise the district personnel four times ayear and the district teams supervise the health centre personnel once a month (Ngufor 1999).
2.4.3.3 Professional ethic
Discipline is rigorous in the private sector due to "hire and fire" practices. However, there is a total attitude of laissez- faire in the pubic hospitals. Due to the low salaries received by medical doctors and nurses, their attitude toward work has been that of complete laxity at all levels of the health pyramid. Holistic health is no longer a subject of emphasis among health personnel. Thus there is areduction of consultation time per patient, preceded by long queues and waits in front of consultation offices. In addition, there is absenteeism and lateness at work, indicating alack of assiduity and professional consciousness (Ngufor 1999).
2.4.3.4 Professional associations and standards
Health personnel are organised into professional associations. In Cameroon, the statistics of the medical professionals stand as follows: 2 169 medical doctors (both general and specialists), 6424 state registered nurses (laboratory technicians and midwives), 230 pharmacists and 48 training institutions. In theory, each association has a code of ethics that must be respected during practice. Other professional association are:
• The National Medical Association of Cameroon which is the main organisation of physicians in Cameroon.
According to the code of medical ethics, all medical doctors trained in Cameroon and/or abroad are expected to register with this association before practising medicine. But this has not been the case because there are many doctors who are practising and are not members (Ngufor 1999).
• The Association of Paramedical Personnel covers nurses, midwives and laboratory technicians, of all grades.
Other professional associations include the Association of Pharmacists and the Association of Dental Surgeons.