AMELIORATING ACCESS TO PRIMARY HEALTH CARE SERVICES IN CAMEROON

Samuel Nambile Cumber 2,3 , * Jackson Jr N. Ndenkeh 1,2,4 , Joyce Mahlako Tsoka-Gwegweni 3 and Thomas A. Vukugah 1 . 1. Department of Biomedical Sciences, University of Dschang, Cameroon. 2. Under Privileged Children and Women Assistance (UPCAWA), Cameroon. 3. Discipline of Public Health Medicine, Department of Nursing & Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa. 4. District Health Service of Abong Mbang, Cameroon. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


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palliative care with the latter services being of sufficient quality as well as being cost-effective. This access to Primary Health Care services is very dependent on the availability of finances, infrastructure and human resources for health with the latter including the doctors, nurses, midwives, pharmacists, technicians and other paramedical personnel, as well as untrained and informal-sector health workers, such as practitioners of traditional medicine, community health workers, and volunteers in both public and private sectors (1). In developing countries, access to these primary health care services is still not yet optimal with quite a considerate proportion of the population still finding it very difficult to get the quality health care services they need. The question here lies at the level of what can be done to ameliorate the situation. To do this, all the internal and external factors have to be taken into consideration thus upgrading the health system for ameliorated health care service rendering. A large body of evidence confirms that many people in the developing world go without health care from which they could benefit greatly. The poor in developing countries are even less likely to receive effective health care. There are two sides to this access problem which include; the problem of supply of effective and quality healthcare services on one hand and underutilization of the healthcare services offered on the other hand. These two sides are obviously related through a good number of factors amongst which the most significant ones noted include financing, affordability and acceptability of these health care services(2).

Discussion:-
A functional health system should compose of important elements such as infrastructure, human resources, data system and financial system all of which have equal and complementary roles(3). In Sub-Sahara Africa, there is a general problem of availability of the various forms of resources needed for the effective provision of quality healthcare services. A bulk of the public expenditure on health continues to be absorbed by hospital-based care delivered at some distance from poor rural populations (2). In addition to the issue of insufficiency of health professionals, there is also the issue of migration of a very significant proportion of the few trained health workers leading to shortage of health professionals subsequently crippling the provision of healthcare services(4). Cameroon is one of the countries in Sub Saharan Africa experiencing a crisis in the availability of human resources for health (HRH), which is adversely affecting progress towards the health-related Millennium Development Goals (MDGs).The major causes of the crisis are the poor production and recruitment planning of health personnel. Additional factors in the crisis include uneven geographical distribution of available health personnel, low salaries, poor working conditions and migration to developed countries (5,6). Also, only 6.1% of the state's budget is allocated to the Ministry of Public Health for health related expenditures which is less than half of the 15% as indicated in the Abuja Declaration in April 2000 (7,8). For instance in 2010, according to the Ministry of Public Health, the public sector had a density of 0.09 medical doctors and 0.32 nurses per 1000 population at the national level. At the regional level, the Centre had a density of 0.27 medical doctors and 0.44 nurses per 1000 population, while the North had 0.02 medical doctors and 0.19 nurses for every 1000 inhabitants(1). Health facilities are variably distributed all over the national territory with more than half of these facilities falling in the public sector and more than 3/4 of them providing healthcare services at the primary level(6). Never the less in a general context these health facilities suffer the problem of lack of infrastructure and/or personnel for their proper functioning thus affecting greatly the availability, quality and affordability of services they render. The most represented regions in Cameroon with health facilities include the West, Centre and the Littoral regions while regions like the North and Adamawa regions have the least number of health facilities(6). In a developing context, the above factors make access to Primary Health Care services very difficult especially in distant villages. In bigger cities with all the concentrated health personnel like Yaoundé and Douala, there is still the problem of accessibility. The reason in this case being the exorbitant cost of health care services as well as corruption, informal payments, money mindfulness and unwelcoming attitudes from a considerate proportion of health personnel. This renders access to health care services very difficult, especially for the city slump dwellers. The situation is even worsened by the fact that these persons in need of healthcare services have to pay for these services out of their pockets leading to increase in other measures adopted by the population to acquire the services they need like self-medication and traditional healers which most at times are unproductive and even detrimental to their health (9). In Cameroon, there is also the problem of underutilization of healthcare services linked to gender and cultural factors. Some examples include; males will choose the traditional healing over public services, tradi-practitioners believed to heal diseases like HIV/AIDS, in Muslim parts of the country, male gynecologists having difficulties in providing their services unless they inspire confidence in the community where they work etc (9).
Cameroon is a Central African country with a population of 20,549,221 distributed in an area of 475km 2 that is divided into ten regions further divided into 58 Administrative districts, 360sub-districts and 339 councils(6). The demographic characteristics vary between these regions which amongst other factors affect access to Primary Health 73 Care services. According to data from BUCREP in 2010, 52% of the total population was living in the urban areas (1). According to WHO in 2010, the above city slump dwellers constituted 46.1% of the total city population which keeps growing in an exponential rate due to increased urban migration (10). Cameroon like many other African countries still grapples with infectious diseases such as HIV/AIDS, tuberculosis, malaria amongst others as well as a growing problem of non-communicable diseases like cancers, diabetes and cardiovascular diseases (11). There is the reorientation of Primary Health Care in the country with the National Health System made up of three levels; the Central level responsible for the planning, policy drafting, sponsorship as well as general monitoring and evaluation of implemented health programs, the Intermediate level made up of the various Regional Health Delegations involved in translating policies, laws and programs into activities in which resources may be allocated and the Peripheral level made up of the various Health Districts and their corresponding Health Areas responsible for the implementation the health programs from the higher levels(1).
In developing countries, there is the need to invest in health in terms of infrastructure as well as build strong human resources for health. This should not only concern provision of healthcare professionals like physicians and nurses, but also community health workers and other paramedical workers. This is not done only by increasing the number of qualified workers through training and recruitment but also ensuring their equitable geographical distribution. This coupled with the provision of appropriate working environments for the latter's while putting in place mechanisms to reduce the migration rate of health workers to other developed countries (5). This could be done by providing them with the infrastructure needed to do their work, considering their financial situation like increasing salaries and promoting revenue sharing. Also, providing other logistics especially for those working in rural areas like homes and transportation means and task shifting from doctors to non-physician clinicians and nurses can prove to be crucial (3,12).The education system should be upgraded such that health workers will have the possibility of furthering their education or going in for specialization within the country especially in the domains essential for the National Health System (13).
Other radical measures can be implemented by developing countries like reclaiming compensation from the developed countries pulling their health professionals. Another way is putting in place laws that don't allow the award of a visa to any health professional who underwent training in the country especially with subventions from the government until they work locally for at least a pre-decided number of years. Also, matching visas with study duration abroad can be awarded for those who want to study abroad with no means of changing status or upgrading it especially in the domains not very effective back home (12,14). The best way to implement the above measures is by giving favorable and competitive loans to students at entry into health training institutions on condition that the students would be legally bonded to work with the Cameroonian government until they repay (12). Evidence of the effectiveness of these radical measures is still very disputable but can be mirrored from the education and scholarship system put in place in countries like the UK and the USA which ensure the return of students who take up research/specialization positions there under scholarship. These radical measures none the less in the context of Cameroon, will so much depend on the amelioration of recruitment and working conditions above as well as the concept of patriotism vulgarized in those given permission to specialize abroad (12). To be able to reclaim compensation from countries brain draining health workers, accurate and updated information about the workforce in the country should be available as well as their movements so that the exact figures of migrants can be gotten for various destination countries (15).
In addition to the above measures, in order to ameliorate the availability of primary healthcare services, the barrier of distance to health facilities should be lowered either taking people to services or services to people. An improved transportation system is the solution of first choice but since it is very costly via impossible to achieve in the context of Cameroon, more feasible methods can include those that seek to lower the price of travel for healthcare or provide credit to cover travel expenses (2,16). On the other hand, in line with underutilization of the above healthcare services, strategies have to be put in place that ensures affordability of the services offered. Out of pocket payment of services strengthens the constraining effects of current income and price on utilization which even worsens when there are no borrowing opportunities (2). This can be handled through short and long term measures like granting exemptions to groups; principally the poor eligible through well-defined criteria, using price subsidies especially in very essential healthcare services and for very vulnerable groups and vulgarizing pre-payment methods which pool risks across individuals and credit schemes. These measures will allow risks to be smoothed across time, thus weakening the household budget constraints on healthcare demand (2). In 2006, Kamgnia in her study stipulated that the poor households could turn away from traditional/self-healing to the public healthcare facilities if they get compensated for at least 46.20% of the lower poverty line, while the intermediate group receives a compensation of 74 at least 14% of the upper poverty line (9). Also, to break through gender and cultural barriers, there is the need to build therapeutic and clinical relationships based on trust and mutual respect. Also in a situation of absolute necessity, indigenous health workers should be employed to promote culturally safe health service delivery in the culturally diverse country.
There is also a need for community based collaboration through which stakeholders and policy makers support and champion the efforts of the community in ameliorating access to health care services while constantly carrying out operational research in order to ameliorate the effectiveness and outcomes of the collaboration (17). In practical terms, communities should be encouraged to engage fully in their own development by putting in place support funds for health projects with aim to ameliorate access to health care services like training of local community workers, equipping health facilities amongst others (17).