Republic of Cameroon

Despite its lower-middle-income status, Cameroon was recently ranked 153rd out of the 188 countries tracked in the Human Development Index (HDI 2014) and, indeed, it is one of a group of countries whose HDI scores have declined in the past two decades. Contributing to this HDI deterioration is slow progress on key health outcomes.

According to World Bank estimates, over the past 20 years under-five mortality declined by 54 percent, from 172 per 1,000 children under five (1998) to 80 per 1,000 (2016). Over that same period the maternal mortality ratio declined by 20 percent, from 750 per 100,000 live births (1998) to 596 per 100,000 (2015). However, mortality for mothers and children remains high and is mismatched to Cameroon’s economic status and relatively high per-capita health spending ($138 in 2014). For example, maternal mortality in Cameroon is 9 percent higher than the average rate for Sub-Saharan Africa and more than double the average rate for lower-middle-income countries.

Additionally, Cameroon suffers regional disparities in health and nutrition outcomes, with the three northern regions and the East region performing considerably worse than the national averages. For example, the proportion of girls between ages 15 and 19 who have begun child bearing is 44.2 percent in the East Region and 23.4 percent in the Far North Region, while in the capital, Yaounde, the rate is only 7.6 percent. Similarly, these four regions experience under-five stunting rates that are higher than the national average (32 percent): 42 percent in the Far North Region, 34 percent in the North Region, 38 percent in the Adamaoua Region, and 36 percent in the East Region.

Plan Development, Partnerships, and Investment Case

To address these critical gaps, the Government of Cameroon led a consultative process with key partners on RMNCAH-N to plan support for partner alignment and government prioritization. The RMNCAH-N investment case was ratified in late 2016 and included interventions to address both health and nutrition outcomes as well as health financing reforms.

There are three areas of focus that run through the investment case: (1) improving allocative efficiency, (2) increasing the utilization of priority health services, and (3) strengthening broader health systems. The allocative efficiency and partner alignment efforts focus on two dimensions: rebalancing public health expenditure between the tertiary level and the primary/secondary levels (RMNCAH-N service prioritization being part of this effort) and focusing resources in high-burden and low-resource parts of the country, namely the four priority regions: East Region, Adamaoua Region, North Region, and Far North Region.

As part of the consultative process, the RMNACH-N investment case is supported through domestic funds from the Government of Cameroon, the World Bank IDA and Islamic Development Bank, and the GFF-Trust Fund, as well as by Gavi, the Global Fund, the UN Population Fund (UNFPA), UNICEF, WHO, the German Corporation for International Cooperation (GIZ), the German Development Bank (KfW), Agence Francaise de Dévelopement (AFD), the US government, UNITAID and the Bill & Melinda Gates Foundation. The private sector is also supporting the investment case, with Addax Petroleum contributing $155,000 in 2017–18 to equip rural hospital maternal and newborn care units in priority regions.

The Government of Cameroon used the investment case to inform its 2018 national budget, developed at the end of 2017. Despite a decline in the overall health budget that resulted from a fiscal consolidation, the Direction des Ressources Financieres et du Patrimoine (DRFP) in the Ministry of Public Health reports a substantial increase in the health budget allocation to priority regions identified as being high-burden as part of the investment case.

Additionally, in 2017 the government committed to a series of fiscal and policy reforms in the public sector as part of a budget support program with the World Bank. The GFF process provided the analytical underpinnings for the health sector reforms, including a trigger that commits the government to increase the health budget allocation to the primary and secondary levels from a baseline of 8 percent in 2017 to 20 percent by 2020. The investment case was a useful tool for informing the dialogue between the ministries of health and finance.

Increasing Uptake of Essential Services

Cameroon has been working to increase the uptake of the essential health services included in the investment case through an expansion of facility-level performance-based financing and demand-side efforts such as Chèque Santé (health vouchers), which seeks to activate demand for maternal and newborn health services and reduce the burden of out-of-pocket expenditure. The government of Cameroon expects to achieve full coverage of the performance-based financing system in the investment case priority regions by mid-2018.

Early progress noted

The increased service utilization seen in Figure 1 is partly accounted for by the expansion of the national performance-based financing program to the Adamaoua, North, and Far North regions (the East Region was already implementing this prior to 2017). In 2017, the country expanded performance-based-financing contracting to an additional 921 facilities (there were 1,428 total facilities under contract in the last quarter of 2017). However, 55 percent of this growth was concentrated in the four priority regions identified in the investment case, even though these four regions only account for 20 percent of the healthcare facilities in the country.

There is also data to suggest that once facilities are under contract they show improvements in productivity. In the North and Far North regions, there were 34 facilities that had contracts for the first time and reported results starting in the first quarter (additional facilities were added throughout the year). By the fourth quarter, the number of skilled births that these facilities had attended increased by 71 percent. This suggests that the combined efforts of partners working on the supply side and the easing of demand-side bottlenecks to service access are driving improvements at the facility level. 2

Increasing Access to Family Planning

In addition to maternal and child health services, the Investment Case also places a priority on increasing access to modern methods of contraception, diversifying the method mix, and improving access to contraception among adolescent girls. Nationally, only 21 percent of married women were using a modern method of contraception as of 2014 (MICS 2014). As of 2014, investment case priority regions had the lowest rates of use of such modern methods in the country, at just 3.5 percent in the Far North Region, 6.1 percent in the North Region, 7.7 percent in Adamaoua Region, and 14.5 percent in the East Region.

Early progress noted

Family planning visits in facilities using performance-based financing increased over the course of 2017, with growth in visits for both short-term methods and long-acting reversible methods. This progress has been supported by several financiers and technical partners, including support for commodity procurement through UNFPA Supplies and supply-side efforts such as performance-based financing. (Figure 2.)