POLICY CAMEROON

BRIEF Strategic Health

Purchasing in Cameroon
A Summary of Progress, Challenges,
and Opportunities

STRATEGIC HEALTH PURCHASING FOR UNIVERSAL

MAY 2021
HEALTH COVERAGE IN SUB-SAHARAN AFRICA

The Strategic Purchasing Africa Resource Center (SPARC), a resource hub hosted by CAMEROON AT A GLANCE
Amref Health Africa with technical support from Results for Development (R4D),
aims to generate evidence and strengthen strategic health purchasing in sub- f Population (2019):
Saharan Africa to enable better use of health resources. SPARC and its technical 25.9 million
partners created a framework for tracking progress in strategic health purchasing
and are applying it in countries across sub-Saharan Africa to facilitate dialogue on f GDP per capita (2019):
what drives progress and to promote regional learning. US$1,508
f Poverty headcount at $1.90/day
(2015): 26%
Health Financing Schemes in Cameroon f Life expectancy (2018):
Cameroon, a lower-middle-income country, aims to improve health sector performance 58.9 years
and achieve equitable and universal access to quality health services, as outlined in the
government’s Stratégie Sectorielle de la Santé 2016-2027. Specific targets related to f Current health expenditure (CHE)
strategic purchasing include: 1) performance-based financing in 90% of health facilities and per capita (2018): US$54
2) validation of the effectiveness and quality of all health care services by 2027. Cameroon f Domestic government expenditure
currently has more than 30 health financing schemes, 19 of which are dependent on donor as % of CHE (2018): 6%
funding. The main categories of schemes in Cameroon include:
f Out-of-pocket expenditure as % of
f SUBSIDIZED HEALTH CARE. The Ministry of Public Health (MOPH), through CHE (2018): 75%
various donor-funded vertical programs, subsidizes free care for specific diseases
(such as HIV/AIDS), specific population groups (such as pregnant women), or a f External expenditure as % of CHE
combination (such as malaria in children under age 5). (2018): 9%

f PERFORMANCE-BASED FINANCING (PBF) PROGRAM. Largely funded by the Source: World Bank Databank

World Bank, this program provides incentives to public, private, and faith-based
health facilities to deliver a package of basic health services.

f VOUCHER PROGRAM. This donor-funded program, Chèque Santé, improves access to maternal and neonatal care in the
country’s three northern regions. Women obtain a voucher for a package of maternal and neonatal services by paying a fee that
represents 10% of the actual cost.

f MUTUAL HEALTH ORGANIZATIONS (MHOs). Cameroon has 17 voluntary MHOs, covering 0.15% of the population with a
limited package of medical services.

f PRIVATE HEALTH INSURANCE. Voluntary private insurance covers 0.75% of the population, mostly employees of large private
and parastatal companies.

f NATIONAL HEALTH INSURANCE (NHI). Established in 2016 but not yet operational, this compulsory scheme will be financed
by public resources, household contributions, and donor funding.

Table 1 compares the purchasing functions in these schemes.

Strategic Health Purchasing in Cameroon 1

Table 1. Purchasing Functions in Cameroon’s Health Financing Schemes

Performance-Based
Financing (PBF) Voucher Program Mutual Health Private Health
Subsidized Health Care Program (Chèque Santé) Organizations (MHOs) Insurance

% of Current
Health 13% 7%
Expenditure (2015)*

MOPH program Regional Funds for Agence Régionale du MHOs Insurance companies
Main
departments Health Promotion Chèque Santé
Purchaser(s)
(RFHPs)

Departments within MOPH is the regulator. Agence Régionale MHOs are regulated Private insurance
Governance
MOPH run these RFHPs have taken du Chèque Santé is by RFHPs. The annual companies are
programs, which target over the purchasing under the authority general assembly of governed under
priority services or function from of the Regional Fund members is responsible the Central African
population groups. contract development for Health Promotion, for strategic purchasing Economic and
Providers receive and verification with clear lines decisions (benefit Monetary Community
in-kind transfers and agencies, but lines of accountability. package, contracting, zone and Cameroon’s
have limited financial of responsibility are Providers have some etc.), while the Le Code des Assurances
autonomy. unclear. Providers have financial autonomy management is in de la CIMA of 1995.
financial autonomy to to use these funds charge of implementing Provider payment
use funds according according to MOF decisions of the tariffs are defined by
to Ministry of Finance guidelines for use of general assembly and MOPH. Private and
(MOF) guidelines for public funds. day-to-day operations public providers have
use of public funds. of the organization. financial autonomy
Providers have financial over these funds.
autonomy to use these
funds.

The annual budget The annual budget is The annual budget The annual budget is The annual budget is
Financial
is based on the based on projected is based on payment based on projected based on projected
Management
budget preparation utilization of targeted rates for services and member contributions. revenue from member
circular that provides services and the expected utilization by Budget overruns are premiums. Budget
guidance for preparing previous year’s the target population. not allowed but still overruns are not
the MOPH budget expenditure. Budget Budget overruns are occur. The general allowed and rarely
and the Medium overruns are not not allowed and rarely assembly must approve occur.
Term Expenditure allowed but still occur. occur. the use of reserves to
Framework and Donors sometimes cover deficits.
is approved by supplement budgets
Parliament. Budget when deficits occur.
overruns are not
allowed but still occur
frequently. Sometimes
donors finance the
budget deficits.

Malaria, tuberculosis Outpatient Package of maternity Consultations, Packages of preventive

Benefits
(TB), HIV, and maternity consultations, TB, care services laboratory, X-rays and and curative services
Specification
services vaccinations, maternity other diagnostic tests,
care and family medications, and
planning, nutrition, and hospitalizations
community care

Loose agreements with Selective contracting Selective contracting Selective contracting Selective contracting
Contracting
public providers with public and private with public and private with public and private with public and private
Arrangements
providers; quality providers providers; quality providers
standards included in standards included in
contracts contracts

In-kind payment; no Fee-for-service Fee-for-service Fee-for-service Fee-for-service

Provider
financial transfers
Payment

Monthly facility activity Monthly facility Monthly facility activity Reports by medical Some patient satisfac-
Performance
reporting on DHIS2; activity reporting on reporting on DHIS2; advisors tion interviews after
Monitoring
visits by supervision DHIS2; RFHP quarterly RFHP monitoring hospitalization
team verification of health
visits and quality of
care

* Global Health Expenditure Database

Strategic Health Purchasing in Cameroon 2

Progress and Challenges in Strategic Health Purchasing
Cameroon has made some progress on strategic purchasing through the PBF and voucher programs, which have well-defined benefit
packages that are aligned with the payment mechanisms, selective contracting arrangements with providers, and output-based provider
payment, mostly simple fee-for-service.

Highlights of progress and remaining challenges in each of the purchasing functions are described below.

GOVERNANCE. There are multiple purchasers with wide variation in institutional arrangements. The main purchasing agency is the
government, through the MOPH and RFHPs. PBF is the only scheme with a clear purchaser-provider split. Health facilities have financial
autonomy over PBF funds, but public facilities must follow public financial management guidelines for planning, budgeting, execution,
and accounting for public funds, which may impose some limitations. For example, facilities are required to return part of their surplus
revenues to the central level rather than being able to retain them for use at the facility level.

FINANCIAL MANAGEMENT. All of the schemes have a defined process for setting the purchaser’s budget as well as mechanisms to
track budget execution/spending. Budgetary spending controls are not well enforced, however, and budget overruns occur frequently.

BENEFITS SPECIFICATION. All of the schemes have specified benefit packages, but the packages are not harmonized and transparent
processes for revising the packages are lacking. The subsidized schemes have disease-focused benefit packages, while the benefit
packages for the PBF and voucher programs aim to address high maternal and child mortality in Cameroon by prioritizing services for
women and children. The PBF and voucher programs have explicitly defined service delivery standards, while the other schemes do not.
Misalignment of benefit packages and MOPH programs leads to significant gaps and overlaps in coverage for certain populations, as well
as inefficiencies.

CONTRACTING ARRANGEMENTS. All but the subsidized care scheme have contracts or agreements in place between the purchaser
and providers. Most subsidized health care schemes include only public providers, but the PBF, voucher program, MHOs, and private
insurers have selective contracting with private providers. The PBF and voucher program contracts specify the range and quality of
services to be provided, standard treatment guidelines, and claims information to be submitted to the purchaser. In other schemes,
quality is often not a factor in contracting decisions, and contracts are rarely suspended or canceled for poor performance.

PROVIDER PAYMENT. Most of the schemes rely on fee-for-service payment to providers, which is linked to the scheme’s service
delivery objective of increasing utilization of priority services. PBF provides additional financial incentives for achieving targets, while
the voucher scheme’s payment is divided into a fixed payment for the service and a variable payment linked to quality and adherence
to contractual obligations. The funding flows and payment systems across different schemes are not harmonized and create conflicting
incentives for providers. In some cases, the incentives lead providers to focus solely on specific services or indicators that result in higher
payment.

PERFORMANCE MONITORING. Provider performance monitoring occurs in some form across all of the schemes, but it is generally
not automated and is not often used for purchasing decisions. The PBF purchaser routinely monitors provider performance, and
provider payment is directly tied to the accuracy and timeliness of data. The voucher program’s purchaser routinely monitors provider
performance and has documented significant reductions in institutional maternal and neonatal mortality rates compared to women and
newborns not covered by the program. In the other schemes, inadequate and fragmented monitoring and information systems make it
difficult to proactively identify adverse provider behaviors and implement corrective measures.

Table 2 summarizes progress made in strategic purchasing functions along the dimensions of progress defined by SPARC for the five
operational schemes in Cameroon. (See the annex for a detailed explanation of how the levels of progress are indicated using , ,
and .)

Strategic Health Purchasing in Cameroon 3

Table 2. Progress Made Across Purchasing Functions in Cameroon

Subsidized PBF Voucher Private

Purchasing Function Indicators of Strategic Purchasing Health Care Program Program MHOs Insurers

Governance Purchasing functions have an institutional home

that has a clear mandate and allocation of
functions.

Providers have autonomy in managerial

and financial decision-making and are held
accountable.

Financial Purchasing arrangements incorporate mechanisms

Management to ensure budgetary control.

Benefits A benefit package is specified and aligned with

Specification purchasing arrangements.

The purchasing agency further defines service

delivery standards when contracting with
providers.

Contracting Contracts are in place and are used to achieve

Arrangements objectives.

Selective contracting specifies service quality

standards.

Provider Provider payment systems are linked to health

Payment system objectives.

Payment rates are based on a combination of cost

information, available resources, policy priorities,
and negotiation.

Performance Monitoring information is generated and used at

Monitoring the provider level.

Information and analysis are used for system-level

monitoring and purchasing decisions.

Despite these areas of progress, a number of challenges limit strategic health purchasing in Cameroon. Low public financing, at only 6% of
current health expenditure (CHE), and high out-of-pocket (OOP) spending, at 75.6% of CHE, mean that strategic purchasing is limited in its
potential impact. Only 20% of CHE is managed by the various health financing schemes. Fragmentation of financing schemes, with their
multiple payment systems, reduces purchasing leverage that could enable progress toward universal health coverage (UHC) in Cameroon.

Unclear division of power between the MOPH and purchasing entities leads to overlaps in functions for defining benefit packages, provider
payment systems, and contracting policies. Purchasing agencies are not held accountable for using funds efficiently, ensuring access to high-
quality health services, or reporting on performance indicators. Further, health facilities have limited autonomy in financial management
and have no opportunity or power to negotiate with purchasers on benefit packages or payment rates.

Strategic Health Purchasing in Cameroon 4

Opportunities to Improve Health Purchasing
Cameroon has many small pockets of progress in strategic purchasing, but the positive effects on the health system are limited because of
the high degree of fragmentation and small amount of funds flowing through each mechanism. The country could build on the progress to
date by harmonizing or consolidating purchasing power in fewer schemes. The planned NHI may be an opportunity to reduce fragmentation
of health financing by merging the numerous donor-funded vertical programs and government subsidies and channeling high out-of-pocket
spending into prepayment for the compulsory scheme.

Another viable strategy before the NHI becomes operational may be to harmonize benefit packages across the numerous schemes to
reduce overlap and duplication and to engage enrollees when defining or revising benefit packages. Purchasers may also design payment
systems more strategically and give providers greater autonomy in financial management while holding them accountable for service
quality and compliance with purchasing and accounting rules.

Finally, Cameroon may benefit from building on improvements to the purchasing functions and information systems developed under the
PBF and voucher schemes to achieve the country’s 2027 goals of linking payment to provider performance and validating effectiveness and
quality of health care services.

SPARC and its technical partners view strategic purchasing as a way to improve resource allocation, provide coherent incentives to
providers, and improve accountability for health resources. As next steps, SPARC’s partner in Cameroon—Research for Development
International—will validate the SPARC findings with Cameroonian stakeholders and determine appropriate actions to make further
progress in strategic purchasing as a way to achieve UHC in Cameroon.
This policy brief is based on a strategic purchasing progress assessment whose details are reported in the following publication:
Sieleunou I, Tamga DDM, Tankwa JM, Munteh PA, Tchatchouang EVL. 2021. Strategic Health Purchasing Progress Mapping in
Cameroon: A Scoping Review, Health Systems & Reform, 7:1. www.tandfonline.com/doi/full/10.1080/23288604.2021.1909311

Strategic Purchasing Africa

Resource Center (SPARC)L O G O
Amref Wilson Airport, Lang’ata Road
Nairobi, Kenya
info@sparc.africa
PU ESOLC

www.sparc.africa
Annex. Strategic Purchasing Progress Indicators

Purchasing An agency or agencies have responsibility for carrying out one or more purchasing functions, but mandates are not
functions have clearly defined and capacity is weak.
an institutional
An agency or agencies have responsibility for carrying out most or all purchasing functions and capacity is improving,
home that has but some overlaps and gaps in responsibilities remain. Mechanisms are in place for stakeholder engagement.
a clear mandate
Governance

and allocation of An agency or agencies have responsibility for carrying out all purchasing functions, capacity is strong, and there are no
functions. overlaps or gaps in responsibilities. There is inclusive and meaningful stakeholder engagement.
Providers have Public providers have no autonomy or extremely limited autonomy to carry out financial and managerial functions, and
autonomy in they have limited ability to respond to financial incentives created by provider payment systems.
managerial and
Public providers are given a larger degree of financial and managerial autonomy, but accountability mechanisms are
financial decision- weak.
making and are
held accountable. Public providers are given a large degree of financial and managerial autonomy, and accountability mechanisms are
effective.
Purchasing A defined process is used to set the purchaser’s budget, and mechanisms are in place to track budget execution/
Management

arrangements spending, but these mechanisms are not well enforced.

Financial

incorporate
A defined process is used to set the purchaser’s budget, and mechanisms are in place to track budget execution/
mechanisms to spending. These mechanisms are enforced, but budget overruns routinely occur.
ensure budgetary
control. A defined process is used to set the purchaser’s budget, and mechanisms are in place to track budget execution/
spending. These mechanisms are enforced, and budget overruns rarely occur.

A benefit package A benefit or service package is defined and reflects health priorities, but it is not well specified, is not a commitment,
is specified and and/or is not aligned with purchasing mechanisms.
aligned with
A benefit or service package is defined, reflects health priorities, and is a commitment, but it is not well specified and/
purchasing or not aligned with purchasing mechanisms.
arrangements.
Specification

A benefit or service package is defined, reflects health priorities, is a commitment, is well specified, and is aligned with
Benefits

purchasing mechanisms, and a transparent process for revision is specified.

The purchasing The purchaser defines some general standards for delivering services in the package (e.g., for gatekeeping), but
agency further enforcement through contracts is weak.
defines service
The purchaser defines some general service delivery standards and some specific service delivery standards
delivery standards (e.g., number of prenatal care visits) that are enforced through contracts.
when contracting
with providers. The purchaser defines general service delivery standards and specific service delivery standards in line with national
service delivery policies and clinical protocols, and service delivery standards are enforced through contracts.
Contracts are in Loose agreements are in place between the purchaser and public providers for specified services in exchange
place and are for payment instead of or in addition to input-based budgets. Formal agreements may be in place with some
used to achieve private providers.
objectives. Formal agreements are in place between the purchaser and public providers for specified services in exchange
for payment or in addition to input-based budgets. Formal agreements may be in place with some private
Arrangements
Contracting

providers.
Formal agreements are in place between the purchaser and public and private providers to help achieve specific
objectives, and they are linked to performance.
Selective The purchaser has loose, nonselective agreements or contracts with all public providers and selective contracts with
contracting some private providers based on some definition of quality standards.
specifies service
The purchaser contracts at least somewhat selectively with public and private providers based on accreditation or some
quality standards. other definition of quality standards.
The purchaser contracts selectively with public and private providers based on uniformly applied quality standards.
Provider payment Some output-based payment is used.
systems are linked
to health system Output-based payment is used, and payment systems are linked to specific service delivery objectives.
objectives.
Output-based payment is used and is linked to specific service delivery objectives; payment systems are harmonized
across levels of care, and they allow purchaser budget management.
Payment
Provider

Payment rates
Provider payment rates are determined based only on the purchaser’s available budget.
are based on a
combination of
cost information, Provider payment rates are determined based on the purchaser’s available budget and at least one other factor
available (e.g., cost information, priorities, or negotiation with providers).
resources, policy
priorities, and
Payment rates are based on a combination of cost information, available resources, policy priorities, and negotiation.
negotiation.
Monitoring Some form of monitoring happens at the health provider level (e.g., supportive supervision visits, monthly activity
information is reporting, claims audits, quality audits).
generated and
used at the Provider-level monitoring is at least partially automated and is used for purchasing decisions.
Performance
Monitoring

provider level.
Provider-level information is automated, fed back to providers, and used for purchasing decisions.
Information Some form of analysis is carried out at the system level (e.g., service utilization, medicines prescribed, total claims by
and analysis are service type).
used for system-
level monitoring System-level analysis is automated and carried out routinely.
and purchasing
decisions. Information and analysis are used for system-level monitoring and purchasing decisions.