Factors Contributing to Low Insurance Subscriptions in Cameroon

By Regina Sinsai, Odette D. Kibu, Constantine Asahngwa, Fobella Nkengafac, Ngo V. Ngo, Wilfred Ngwa, Solange Dabou, Brina Djeunong, Evrard Kepgang, Ronald M. Gobina, Denis A. Foretia (Download pdf)

Factors Contributing to Low Insurance Subscriptions in Cameroon

---

Access to quality healthcare is an important determinant of the strength and productivity of a country. According to WHO, Cameroon spends more money on health in comparison to most sub-Saharan countries, with most of this financing (72.5%) [1] accounted for by out-of-pocket payments. Health insurance serves as a means of financial protection. As such, through relatively small pre-paid token deposits by insurance subscribers, expensive medical services, including surgery, imaging, and emergency care are covered. The subscription fees and the nature of the access package depend on the insurance company and standing agreements with health facilities, among other specificities. For subscribers, it helps cover medical costs when one unexpectedly becomes injured or sick and may not have the finances to cover hospital bills [2]. This is the principal reason subscribing to health insurance is crucial in reducing out-of-pocket financing, especially for emergency cases.

Private health insurance (PHI) companies, community-based insurance schemes (CBHI), and National Health Insurance schemes that exist within the country may play a significant role in reducing the burden of out-of-pocket financing, increase access to quality health services and stop families from plunging further into poverty. However, health insurance in sub-Saharan Africa still remains a challenge for various reasons. Rwanda, an African country is presently thriving in providing health coverage for its citizens. With a national community-based insurance scheme, they have succeeded in providing coverage for at least 81% of their population, higher than any other African country (WHO) [3]. Low subscription to health insurance in Cameroon may be attributed to several factors.

High Levels of Poverty

Cameroon, whose population currently stands at 26.5 million people [4], is classified as a low-income to middle-income country. Poverty levels in Cameroon have remained relatively steady throughout the years, with a high disparity between the rich and the poor. Over 55% of citizens live in poverty, and 37.7% are extremely impoverished [5]. Armed groups in the Far North, the Anglophone crises, the influx of refugees and COVID-19 concurrently have contributed to the increase in poverty rates from 24.5 % in 2019 to 25.3 % in 2021 [6].

More than 80% [7] of the workforce in Cameroon originates from the private sector, commonly known as the informal sector, where wages are generally very low (minimum;36,270cfa) [8] and progressively unstable. The affordability of health services is greatly affected by one’s income [9]. With increased inflation and low wages, poor households cannot afford to subscribe to health insurance as they battle to prioritise their various needs.

Government-Backed Schemes 

Cameroon’s social health protection system is based on two systems, the government’s civil servants scheme and the National Social Insurance Fund (NSIF), more popularly known by its French acronym of CNPS (Caisse Nationale de Prévoyance Sociale). Government civil servants scheme refers to civil servants being able to access public medical assistance with limited finances as it is financed by the state budget [10]. NSIF is directed at workers under the Labour Code and is mandatory for civil servants but not for other labourers. Many labourers, however, do not recognise health as a priority hence, do not participate in social insurance plans [11].

Workers found outside of the formal sector, where a majority of the workforce is concentrated (estimated at 7.3 million people), remain uncovered as NSIF is optional for them (2020) [12]. The 10% of the population covered by CNPS benefits from standards set by the International Labour Organisation (ILO) in 1952 [13]. In a study concerning community-based health insurance (CCHI) conducted in the urban cities of Cameroon, Yaoundé and Douala, family size, health priority, and household income were determinants of willingness to join an insurance scheme. In the same study, an increase in household income was shown to also increase the desire of a household to subscribe to an insurance scheme [14].

Cheaper Alternative to Conventional Healthcare Services

Cameroon, like other sub-Saharan African countries, regards traditional medicine as an important part of healthcare, particularly in the prevention and treatment of diseases. Health-seeking behaviours and practices differ across the nation, with a tendency for plant-based therapies for a bulk of the population.

With a rich biodiversity of over 8,500 plant species and several animal groups, the use of plants and herbs through a traditional healer is common for the treatment of various illnesses and conditions [15]. However, its integration into the health system has not been certified. Although the Health Sector Strategy 2016-2027 of MINSANTE recognises traditional medicine and alternative/parallel medicine as service delivery, it was noted that the field had become heavily populated with imposters and frauds over the years. Due to poor supervision and monitoring the activities of traditional healers, supervising authorities have been unable to master and control their influx into the system [16].

Studies have shown various plants to have significant beneficial properties, including anti-inflammatory, antimicrobial, anti-parasitic, and antioxidant effects. According to a study conducted on the interest and perceptions of traditional medicines, 77.4 % of 1,000 participants confirmed having consumed traditional medicine in the last year, and a majority of the study population (88.9%) revealed that it is cheaper than modern medicine bought in pharmacies [17]. The reason for the widespread use of herbal medicine can be attributed to its affordability.

The way forward

Information regarding health insurance in Cameroon is limited, and for this reason, the various recommendations to improve the current situation require:

• Government forces to conduct mass sensitisation campaigns to educate and inform nationals on the various health financing options available in the country and the advantages they possess;
• Encouraging intersectoral collaboration between the government, NGOs, religious bodies, and cultural bodies to enhance the importance and acceptance of health insurance in Cameroon;
• Strengthen citizen subscription to National Social Insurance Fund (NSIF) by making it mandatory for labourers in the informal sector;
• Increasing the minimum wage of labourers, which would directly affect the quality of life and make it easier for households to meet their basic needs;
• Further research is required in the field of traditional medicine. The government should intensify efforts to work with traditional practitioners to produce scientific evidence on the safety, effectiveness and quality of their products before their legal acceptance into the health system. In executing this, authentic and credible traditional healers can be identified and recommended by the government;

Health insurance schemes protects individuals and communities from catastrophic expenditures. Evidence, though limited, point to factors high levels of poverty within the country, facultative insurance subscription policies and competing for cheaper alternatives to conventional healthcare services. However, more research with empirical evidence is required to ascertain these claims. Decentralising healthcare systems as cultural practices and health needs differ among regions will allow the specific health needs of each region to be addressed while maintaining the goal of attaining Universal Health Coverage (UHC). Effective implementation of a health insurance system, either communal, private, voluntary, or compulsory can be the beginning of a solution to the problem of universal health coverage.