Closing the Health Insurance Gap for Cameroon’s Health Workforce

By Regina Sinsai, Dr Constantine T. Asahngwa & Dr Ronald M. Gobina

Executive Summary

Healthcare workers (HCWs) are essential to Cameroon’s health system, yet most lack adequate health insurance coverage. Current schemes—NSIF, employer-based plans, and UHC—fail to protect HCWs from catastrophic health costs. This brief examines the coverage gap, its implications, and policy actions to safeguard the health workforce.

Introduction

Healthcare workers (HCW) are pivotal to the functioning of any health system. Irrespective of the healthcare financing model used, HCW remain committed to healthcare delivery and more often than not in resource limited settings, they are compelled to make adaptations on a case by case basis. Optimal care may be traded for affordable care and patients subject to less specialized care where referral is unbearable for the patients due to cost of transportation or other geo-sociopolitical realities.

An often neglected aspect in the life experience of every HCW is their need to make adaptations relative to HCW being humans who will at some time or another become users of the healthcare as patients. Healthcare workers will therefore, need to finance their healthcare. In addition, HCW constitute a vulnerable group, given the disproportionate risk they face from daily exposure to high-risk environments, occupational stress and infectious diseases such as COVID-19, Hepatitis B, Hepatitis C, HIV and TB, just to name a few.

The first phase of Universal Health Coverage (UHC) in Cameroon rolled out in April 2023 successfully enrolled 3.4 million vulnerable individuals in just under two years. (1) However, HCW are not included in the current group of enrolled vulnerable individuals and as such do not benefit de facto from any financial protection against ill health.

This policy brief examines the current landscape of health insurance coverage in Cameroon, the specific challenges health workers face in accessing meaningful insurance benefits, and evidence-based policy recommendations to improve coverage and protect the health workforce from catastrophic health expenditures.

Status of health coverage for healthcare workers

Health workers in Cameroon are at the forefront of disease prevention, diagnosis, treatment, and rehabilitation, serving over 27 million citizens, through a decentralized mix of public, private, and faith-based facilities. (2) Upholding good health for this workforce is essential as it directly affects the quality and availability of services they offer to the population. (3) Because access to healthcare services in Cameroon is largely out-of- pocket (4), health workers with poor health insurance are at risk of financial hardship when faced with ill health. As per the Cameroon Labour code No. 92/007 of 14 August 1992 (5), employers are mandated to provide benefits, including National Social Security Fund (NSIF) occupational injury insurance for their workers, yet implementation lags, particularly for informal and rural staff. For this reason, health insurance among health workers is not always evident, regardless of the numerous existing schemes. (6)

Healthcare personnel working for the government (civil servants) benefit from schemes managed by the government, offering a degree of coverage found in decree No. 2000/692/PM of September 13, 2000. (7) According to Article 3 of this decree, the State is primarily responsible for contributing to medical care including pharmaceuticals, evacuation, hospitalization etc..) for all illnesses or accidents affecting civil servants, and their families. However, the scheme’s effectiveness, the details regarding the governments benefit package as well as the funding sources for civil servants remain largely unknown.

The National Social Security Fund (NSIF), a mandatory social protection scheme providing coverage for occupational health challenges among civil servants including health workers covers merely, 5.24% of the population. (8) The benefit packages in this scheme allow civil servants to benefit from old-age pension, early retirement pension, death, work related disability, and funeral grants to the employees or their beneficiaries. (9) Healthcare workers within this scheme exposed to occupational hazards, are eligible to receive comprehensive medical care and financial protection as part of their employment right. However, other illnesses and medical conditions not brought about by the professions are not catered to. While public sector workers benefit from mandatory coverage, participation in the NSIF for healthcare workers in the informal sector- such as contractual and faith-based employees- is voluntary. Because most employers fail to register their employees—often due to lack of awareness—this leaves informal workers without access to these benefits and forces them to seek other health insurance options available in the market.

Employer-based and private health insurance (PHI) options such as Zenithe, AXA, Activa, AGC among many others, are schemes that offer family plans, group health insurance, employee plans and recently, individual premiums that cover a broad range of services, including consultations, hospital care, laboratory work, and sometimes specialist care. (10, 11)  However,  the packages offered by PHI’s companies vary in cost and benefit as they are highly dependent on the needs of the client and company policy. Uptake and subscription to PHI schemes is low nationwide, resulting from expensive premiums, complicated administrative procedures and complex claims processing. (12)  Regardless of the challenges, several companies- including international NGO, and major food enterprises- choose to provide insurance for their workers, an initiative noticeably absent for health workers themselves.

The recently implemented UHC in Cameroon is another scheme that promises preventive and curative services, through healthcare packages targeting the vulnerable populations. Such populations include pregnant women and neonates, children aged 0-5 years, people living with chronic conditions (HIV/AIDS, tuberculosis, kidney failure), available throughout the country, with the exceptions of services for Pregnant women + newborns, available in the Far North, North, Adamawa, East and the South. (13) The program coverage permits all citizens to access preventive services. Despite its promises, the scheme remains limited as citizens of all ages and gender do not benefit from curative services, and the benefit packages fail to address other pathologies and conditions commonly experienced healthcare personnel.

Importance of health insurance coverage for health personnel’s

Health workers are constantly exposed to higher risk of occupational hazards, including infectious diseases, injuries, and burnout due to long working hours, increased workload, physical demands etc…. (14,15) Over a long period of time, this could lead to the deterioration of healthcare personnel wellbeing and performance, ultimately compromising the ability to provide quality care to patients, even to those who are insured. With an effective insurance scheme, workers are likely to experience financial security, especially during an unexpected medical condition. For HCWs, it also serves as a valuable retention tool, making health sector employment more appealing and helping to reduce turnover. (16)

Challenges to health personnel coverage

Several factors serve as barriers that impede health workers from subscribing and accessing to health insurance schemes and gaining effective protection. Many healthcare workers are not adequately covered by health insurance schemes, in a population of above 27 million, only a small portion (7%) is covered by any form of health insurance scheme. (8) Despite the existence of formal coverage mechanisms, out-of-pocket payments constitute the majority of healthcare financing in Cameroon, exposing healthcare workers to exorbitant health costs in times of sickness. Although health insurance costs vary, depending on age, company and coverage levels, they are generally considered high, costing an adult an average of average of 155,000 FCFA (265 USD) annually. Healthcare workers like nurses earn who earn as little as 30,000 CFA in some medical facilities (17) and doctors less than 200,000 CFA on a monthly basis (18) cannot comfortably afford insurance schemes. With low pay, healthcare workers may experience financial vulnerability in attempts to meeting their basic needs and also subscribing to health insurance schemes. Moreover, the lack of knowledge regarding existing insurance benefits, eligible services, and procedures for claiming reimbursements serves as a significant barrier to coverage for healthcare personnel, reducing effective utilization of available protect schemes. (12)

Recommendations

Expand CNPS coverage to encompass comprehensive health services: beyond covering for occupational health conditions, incorporate a ‘health’ section within NSIF that would cater for preventive, outpatient, and specialist services.

Create a unique package for healthcare workers within UHC scheme create a package specifically for health workers (starting with nurses) classifying them as a “Priority Vulnerable Group,” who are eligible for highly subsidized enrollment.

Extend mandatory coverage to all health workers, as part of National Social Insurance Fund (NSIF) policy reform regardless of contract type or employment status, especially those in public facilities, community health programs, and NGOs.

Create a Mandatory “Institutional Coverage” for health facilities:  this will require all registered or licensed hospitals and large clinics (public, private, and confessional) to offer a minimum health insurance package to staff as a condition for their annual operating license.

Improve Access to Information: sensitize healthcare workers about various health insurance options through targeted education and outreach programs

Investment in research: The government should support research in the domain as it would help, identify gaps in the health sector which can be used to inform policy adjustments.

Conclusion

Access to health insurance for health workers in Cameroon is not a luxury—it is a strategic necessity. Protecting HCWs through comprehensive insurance coverage is critical for health system resilience. Integrating HCW coverage into UHC reforms and enforcing mandatory schemes will improve retention, equity, and health outcomes.