By Odette Kibu, MPH (PDF Version)
The emergence of surgical diseases is progressively increasing with a high disease burden in low- and middle-income countries. This is because the epidemiological transition is shifting from communicable diseases towards non-communicable diseases(1). It is estimated that 11% of the global burden of disease requires surgical treatment, predominantly those resulting from injury and cancer(2). Reports from the World Health Organization (WHO) shows that 5 billion people currently do not have access to safe, timely and affordable surgical care and anaesthesia worldwide(3). In low- and middle-income countries, 9 out of 10 people cannot access the most basic surgical services. Improving access to safe, timely and affordable surgery saves lives, prevents disability and promotes economic growth for the country. As the burden of surgical diseases increases disproportionately, affecting the population of Cameroon, adequate surgical care is required. Yet, these services are not provided because the Cameroon health sector faces tremendous challenges as it attempts to provide safe surgical care to patients.
MAJOR CHALLENGES FACING SAFE SURGICAL CARE IN CAMEROON
- Inadequate number of surgeons and resources
There is a direct relationship between a shortage of health personnel and quality of health services offered. Cameroon is classified by WHO as having a shortage of health personnel. The country had a density of about 1.15-2.28 health personnel per 1000 people in 2006 and in 2010; that number dropped to 0.083 health personnel per 1000 people. Of that number, only 0.1 percent represents doctors (Cameroon data portal). In 2014 data from WHO showed that the distribution of surgeons, anaesthesiologist, and obstetricians in Cameroon was1-14.99 per 100,000 people (0.01-0.1499 per 1000 of the population). Out of the 6 medical schools in Cameroon, only the faculty of medicine and the biomedical Sciences University of Yaoundé provides training of approximately 90 doctors per year in various fields of specialisation, including surgery. This lone government university is not able to produce the number of surgeons that can satisfactorily serve the population of Cameroon. However, in 2016, the Pan African Association of Christian Surgeons (PAACS) came up with a vision to train 100 African surgeons by 2020 in 9 different African countries. The Mbingo Baptist Hospital is one of the sites for such a praiseworthy initiative. The implication is that PAACS will train approximately 11 (100/9) surgeons per country by 2020. The Cardiac Care Centre of Shisong experiences a high influx of cardiac patients because it is the lone cardio-surgical centre in Central/West Africa equipped with ultra-modern technologies. In 2010 the Centre trained, in Italy, only 3 doctors as surgeons. Despite the fact that the private sector is working hard to increase the number of surgeons, that number is still limited.
- Heavy workload
Surgery is always a complex procedure to carry out; requiring the doctor’s undivided attention. Due to the limited number of surgeons posted to health facilities, the few available surgeons face overwhelming workloads which negatively impact the efficiency and efficacy of surgical care administered to patients. This is detrimental in the operating room environment and may jeopardize surgical performance and patient outcome, leading to postoperative complications or death.
- Unrecognized public health concern
Surgical care is often expensive and fewer resources are put in place to address the public health consequences of unsafe surgical procedures. This is a result of the low percentage of Gross Domestic Product (GDP) spent on health care (4.26%). With little attention given to surgical care, efficient monitoring and evaluation of safe surgical procedures in Cameroon becomes a dubious objective. Most patients die or often suffer from preventable complications immediately after surgery due to poor safety in surgical procedures. Safety measures are not being monitored or reported.
With funding, access to healthcare and provision of quality healthcare services are made easier. Health expenditure consists of cost of paying for associated health services with the objective of promoting, restoring and improving the health of individuals. In 2014, Cameroon allocated 4.26% of its GDP to health expenditure. This, therefore, shows that there are inadequate funds for improvement such as healthcare service availability and the resources to administer safe surgical care. In the same light, many doctors in Cameroon think practicing medicine in Cameroon is a calling; and not a profession. This is to say they do not get paid well enough due to the inadequate funds allocated to the healthcare sector. In Cameroon the average salary of a newly-graduated medical doctor is about 235,000FCFA. Most doctors take the option of specialising and practising surgery abroad where they are sure to get a clear job description outlining responsibilities, do that job and get well paid. This factor leaves Cameroon with few or no doctors or surgeons in some health facilities. Hence, doctors that are not well trained as surgeons take up the role of carrying out surgery whose outcome is accompanied by post-surgical complications. The Abuja Declaration, of which Cameroon is a signatory, called on member states to increase public health expenditure to about 15% of the annual budget. As of 2011, only six countries had been able to meet and surpass the 15 percent target; Rwanda 23.8%, Liberia 18.9%, Malawi (18.5%), Zambia (16%), Togo (15.4%) and Madagascar (15.3%). Cameroon has not been able to meet the 15% target, as stipulated thus, due to low health expenditure, Cameroon on its own, cannot afford to adequately equip its operating rooms and surgical wards with all the equipment and materials it needs to administer safe surgical care to patients. Essential and Emergency Surgical Care (EESC) are generally inadequate with unavailability of an oxygen concentrator supply, a lack of on-site blood banking, and little pain management guidelines and human resources(4).
Geographical Disparity of Surgeons
Statistics from the Ministry of Public Health show that Cameroon has 49 surgeons with more than 50% located in Yaoundé and Douala. This impedes equity in administering life-saving surgical care to the entire nation. According to the Vice President of the National Order of Medical Doctors in Cameroon (ONMC),“As of now, ONMC has 7,200 medical doctors and statistics from the Ministry of Public Health indicate that there are only 2,100 medical doctors who are civil servants, with about 50% of them residing in Yaoundé and Douala.” Geographic disparities are due to the fact that healthcare personnel prefer to reside in urban settings where their clients have higher salaries and where there is a greater chance of professional advancement.
Safe surgery saves lives by reducing the number of surgical deaths and complications. Cameroon’s healthcare system needs well-structured decentralised health systems with well-trained surgeons. A strong regulatory body needs to be implemented to monitor and evaluate surgical procedures. Healthcare financing in Cameroon can be properly addressed if the government can adopt and replicate policies used by some countries (Rwanda, Liberia, Malawi, Zambia, Togo, and Madagascar) to attain the target of the Abuja Declaration; a greater percentage of the GDP should be allocated for health expenditures. Surgeons should be provided with refresher courses to keep them updated and informed with the evolution of Surgical procedures, equipment and technologies. If these challenges are managed properly, then Cameroon’s surgical services will improve.
Odette Kibu is a Health Policy Analyst at the Nkafu Policy Institute.