Yaoundé, September 28, 2012 – After a recent visit to the Perpétuel Secours de Loum Chantier Health Center for health services, Rose Enama could not say enough good things about the care she received.
“When I arrived, I was struck by the cleanliness of the rooms and especially by the warm welcome extended to me,” she said. “I immediately realized that this place had come back to life!”
Enama’s candid testimony speaks volumes about the positive changes observed after one year of results-based financing (RBF) in the health districts in Cameroon. RBF pilot programs show great success increasing health service utilization and improving service quality, increasing efficiency, and enhancing equity by focusing on health results rather than inputs, tightly linking budgets and financing to results.
As a result, several patients such as Enama are returning to their hospitals and health centers because quality health service is now common. In Cameroon’s four beneficiary health districts - Littoral, Northwest, Southwest, and East - the testimonies confirming the improvement in service quality speak for themselves: the availability of heath personnel, lower treatment prices, the availability of medications, the cleanliness of the facilities, professionalism, good patient care, a return en masse of patients to the health centers, judicious and transparent resource management, motivated health personnel, among other qualities.
In short, one year after the introduction of RBF in Cameroon, conditions in hospitals are improving. In terms of figures, this improvement is evident in the impressive results. In Littoral, for example, the utilization rate quadrupled, from 10% in the first quarter of 2011 to 49% in the second quarter of 2012. The availability of medications increased from 52% to 75%, and the average cost of care dropped from CFAF 36,000 (US$72) to CFAF 17,000 (US$34).
In addition, after eight months of activity, the satisfaction level of beneficiaries in the region reached 73%. Indicators are promising throughout. These data are supported by the preliminary results of the baseline survey conducted by the Institute for Demographic Training and Research (IFORD) in Yaoundé, which reveal that 92% of people questioned in the four regions are satisfied with the overall quality of services provided in the health centers using results-based financing.
The forum noted the progress achieved and the lingering challenges, and calls for its continuation
One year after the implementation of this experiment financed by the World Bank to the tune of CFAF 12.5 billion (US$25 million), a forum was organized in Yaoundé on September 13, 2012 to allow all actors involved to extract the major lessons learned with a view to its fine-tuning. Participants’ enthusiasm prevailed over the doubts that could have hindered the continuation and even the extension of RBF to other districts in the country. The Secretary of State for Health delivered the opening statement at this forum, declaring before some 120 participants that “progress to date is very encouraging.”
Nevertheless, the generally felt optimism did not preclude profound analysis of what could be considered a Cameroonian paradox. Cameroon is in fact very poorly positioned in the World Health Organization (WHO) classification of the equity of financial contributions to access to care among the 191 member countries. With an estimated maternal mortality rate of 600 maternal deaths per 100,000 live births in 2008 and an under-five mortality rate of 154 deaths per 1,000 live births in 2009, Cameroon is virtually off track to achieving their 2015 Millennium Development Goals of reducing child mortality and increasing maternal death. That is, 170 maternal deaths per 100,000 live births and 46 under-five deaths per 1,000 live births.
“However, the country is injecting considerable financial resources into its health care system,” Cia Sjetnan, Lead Program Coordinator at the World Bank’s Country Office in Cameroon. Sjetnan also explained that in 2008, “health expenditure totaled US$67.50 per person, a relatively high level compared to that of other Sub-Saharan African countries in which the figure was US$10 per person.” Yet, some of these countries are well on their way to achieving their MDGs.
This suggests that the health system financing crisis in Cameroon is less the result of the amount of this financing than of the consistency and appropriateness of its organization with respect to the functions it must fulfill.
“Cameroon is not making the most of its investments in the health sector owing to inefficient spending that does not lead to the anticipated results in terms of the quantity and quality of services,” said Gregor Binkert, World Bank country director for Cameroon. “The reason for this approach in Cameroon is to find instruments and mechanisms to provide support to the health services more efficiently, which represents a departure from traditional approaches.”
In short, in his view, the aim is to see how better results and better health can be achieved for the beneficiary populations with the funds available.
Pertinence of the recommendations to ensure the sustainability of the experiment
The question of institutional arrangements and incentives for service providers, at times forgotten in the discussions on health system reform in Cameroon, is at the center of the spirited discussions held by the community of health systems specialists, such as doctors from different health districts, policy makers, and other experts representing development partners, including the World Bank.
A strong trend has emerged indicating that results-based financing offers a promising method for enhancing the production of Cameroon’s health services. This approach, which receives support from the World Bank through the Health Sector Support Investment Project (PAISS) in Cameroon, is “a financing strategy that materialized through a contractual relationship between various actors and through which service providers and health facilities are remunerated financially or in kind based on the achievement of objectives,” said Gaston Sorgho, head of the project team in the Cameroon country office. “It is distinct from traditional input-based financing whereby health facilities receive the inputs necessary for their functioning without any contractual obligation to produce results.”
Results-based financing thus facilitates the financing of health care and health services based on the performance of health facilities and on previously defined indicators. This strategy can serve as a catalyst and help bring about a profound transformation of the public sectors in low-income countries. This is reflected in this strategy, for example, by the emphasis placed on certain measures that had been overlooked in previous reform efforts and that could be effective, such as better separation of functions and improved structuring of relationships between the different actors in a health system.
However, the conclusions reached at the forum highlighted that several preconditions must be considered in order to envisage the success of this type of strategy in the Cameroonian context. The first challenge, and the one most frequently raised in the discussions, remains institutionalization of the strategy, in other words, ensuring its sustainability, which involves integrating this strategy into budgetary and public finance frameworks, procurement regulations, and legislation and other decrees setting forth the prerogatives of public missions.
It is already clear that there is optimism about the future, as evidenced by the resolve expressed by Mr. André Mama Fouda, Minister of Public Health, regarding the prospects for RBF, “We have high hopes for the future of results-based financing in Cameroon.”