By Dr. Fuein Vera Kum ( Research Fellow – Economic Affairs) & Odette Kibu ( Health Policy Analyst) – PDF Version
U niversal Health Coverage (UHC) gained global prominence when the 2005 World Health Assembly adopted a resolution on UHC, followed by the 2010 World Health Report being devoted to the financing of UHC (World Health Organization, 2010). Since the publication of the 2010 World Health Report, issues related to UHC have continued to receive great attention across the globe. According to this report, health financing for universal coverage needs to be specifically designed to provide everyone with access to adequate health services (prevention, promotion, treatment, rehabilitation, and palliation). This will ensure that the use of these services does not expose the user to financial hardship” (1) . Emphasis has been placed on how to finance health systems to move towards UHC. The inclusion of UHC as one of the health-related number 3 Sustainable Development Goals (SDGs), adopted by world leaders in September 2015, has cemented its place on the Sub Saharan Africa health policy agenda (2).
According to the WHO, at least half of the world’s population still suffers from a lack of essential health care services. Statistics show that over 800 million people (almost 12% of the world’s population) spent at least 10% of their household income to pay for health care (3). It is against this backdrop that all UN Member States, in which Cameroon is a signatory, agreed to achieve universal health coverage by 2030 as part of the Sustainable Development Goals (4). In Cameroon, the Health Sector Strategy report (5) shows that household contribution accounted for close to 61% of the total health expenditures in 2013; the 3rd largest contribution in Sub-Saharan Africa after Sudan and Nigeria. However, the first phase of UHC in Cameroon targets a general population of 22,985,369 on an estimated amount of FCFA 334, 765, 241, 460 in 2019. With this gradual implementation of the UHC, the government hopes to identify and correct weaknesses faced in the implementation of the project (6). The issue is just how effective will this first phase be once implemented in a country whose health budget is less than 5% of its annual budget. This article brings out the challenges in financing healthcare in Cameroon and proposes possible ways of improving it.
CHALLENGES FACING HEALTH CARE FINANCE FOR UHC IN CAMEROON
A large proportion of the country’s population lives in extreme poverty and is unable to pay premiums. The poverty rate of the country stands at about 40% (7) and, despite this high poverty rate, household health financing in Cameroon is mostly done through out-of-pocket (OOP) payment. OOP payments for health services have caused households to incur significant catastrophic expenditures (8) which, in turn, push Cameroonians into extreme poverty. The result is that those in need of healthcare do not seek healthcare.
Despite the importance of UHC, there is evidence of decreasing domestic public funds to finance health in Low and Middle-Income Countries over the past 15 years (9). This is particularly true in the case of Cameroon where limited funds of about 4.29% of the state’s budget are available to finance healthcare in 2018/2019. This percentage is below the 15% allocation of state funds to healthcare signed by African leaders during the Abuja Summit (Abuja declaration) in April 2001 (10) where Cameroon is a signatory. Despite the limited amount of funds available to finance healthcare, most of the funds are mismanaged and centralized in urban areas; inhibiting proper public spending of the funds in the rural areas. It is evident there will be inequity in healthcare service delivery, increased OOP and increase in poverty level.
Furthermore, a large proportion of the informal sector drops out of insurance plans and are uninsured due to low employee salaries. On average, less than 17.65% of Cameroonian adults earn more than 200,000FCFA a month(11). In 2014, there were 16 insurance companies offering health coverage for an average subscription of FCFA 155,000 per adult per year (12). In 2011, it was estimated that less than 3% of the population was covered by a health risk-sharing mechanism (13).
- Increase the budget allocated for healthcare financing
Cameroon needs to adopt a crucial approach to achieve UHC, especially from the perspective of cost. UHC is NOT free healthcare. One way or the other, Cameroonians will have to pay for healthcare either through taxes and/or through a mandatory contributory scheme. A Community-Based Health Insurance Scheme (CBHI) could be adopted to spread the risk or burden of financing healthcare. This plan requires a prepayment mechanism with pooling of health risks and of funds taking place at the level of the community or a group of people who share common characteristics (such as geographical or occupational). In this plan, funds shall be used to help subsidize care for the citizens and clinic functionality. This would allow citizens to access care without paying directly for services at the moment of need based on different categories and according to socioeconomic standing.
Taxes on products that are harmful to health have the dual benefit of improving the health of the population through reduced consumption while raising more funds. Cameroon has the potential of increasing taxes on tobacco and alcohol. Statistics have shown that a 50% increase in tobacco excise taxes would generate US$ 1.42 billion additional funds(1). If all of these funds were allocated to health, it would allow government health spending to increase by more than 25% and, at the extreme, by 50%. Raising taxes on alcohol to 40% of the retail price could have an even greater impact. Estimates from 12 low-income countries show that consumption levels would fall by more than 10%, while tax revenues would more than triple to a level amounting to 38% of total health spending in those countries. Even if only a portion of the proceeds were allocated to health, OOP would be greatly reduced to health and access to health services would increase.
- Firm governance, management, and accountability of health budget
Health budget structure is an enabler for health financing reform implementation. This can help strengthen alignment between sector priorities and budget allocations. It is critical for health authorities to engage actively in health budget structure reforms to ensure that the output of the reform is tailored to and fits health-financing requirements. Health economists and health analysts should be consulted before allocating the health budget structure.
Funds made available for healthcare delivery and health systems should be decentralized at the district level to ensure targeted programming that fits the needs of each individual community. Health centers should be given financial autonomy to plan activities according to their operating needs and the needs of the community. Thus, health support systems need to be implemented in healthcare centers to help administrators better manage their assets, think more strategically about how they spend those assets, and operate more efficiently with the goal of providing affordable and quality healthcare services to its users. In addition, the government should develop, deploy and retain high-quality healthcare professionals (including healthcare leaders) and strengthen human resource information system (HRIS). Focus should be placed on community ownership of health, active community engagement, household health production and support of improved health behaviors.
- Increase in investment of health budget on preventive medicine
To make UHC affordable, Cameroon has to adopt a primary healthcare approach with significant investment in preventive measures. It is cost-effective to invest more in preventive medicine than on the treatment and management of disease such as non-communicable diseases.
Achieving Universal Health Coverage can be a reality if the aforementioned policy options are properly implemented. Though the government of Cameroon has started investing resources to achieve the first phase of UHC, it needs to focus more on increasing its health budget, proper management and accountability of healthcare spending.