Thinking and working politically to realise Universal Health Coverage: Insights from Cameroonian-German cooperation
Cameroon embarked on a new Universal Health Coverage journey in 2023, the foundations for which have been laid over many decades. By adopting a political economy lens, German Development Cooperation has leveraged limited resources to great effect.
On April 12 2023, the Minister of Public Health, Dr Manaouda Malachie launched Universal Health Coverage (UHC) Phase 1 in Mandjou locality, Bertoua – some 350km east of the capital Yaoundé. Surrounded by Cameroon’s top administrative, political and traditional authorities, Dr Malachie set out the government’s intentions, saying, ‘we want to make sure that people who do not have access to health care services will access them and, while they do so, they do not find themselves with financial hardship’ (CAN, April 2023).
The launch – described by the Ministry of Public Health as ‘one of the most significant socio-political reforms of the Cameroonian government’ – represents a critical landmark in Cameroon’s UHC journey, supported by German Development Cooperation and other development partners over so many years (Ministère de la Santé Publique, April 2023).
Adopting a political economy lens for UHC
In his address to the nation on 31 December 2017, President of the Republic of Cameroon Paul Biya announced his intention to provide Universal Health Coverage (UHC) to all citizens. However, fluctuating political will and a challenging implementation context have often combined to stall progress.
Embarking on the road to UHC is an inherently political process, requiring multi-level negotiations and agreement on the redistribution of both power and resources, for example between ministries competing for scarce resources and between central institutions and devolved health system structures. Achieving progress requires in-depth understanding, and a delicate balancing act, of often-competing ideas and interests – there will always be those who stand to gain and those who stand to lose.
The Cameroonian-German Health Programme, implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry of Economic Cooperation and Development (BMZ), has accompanied the Government of Cameroon on its UHC journey. Working in concert with BACKUP Health and alongside the BMZ-funded KfW Development Bank, the programme draws on multisectoral support in health financing, social protection and digital health, as well as on a synergistic combination of bilateral and global development cooperation.
Today, UHC is one of the government’s top health priorities. Parliament approved a nationally-financed budget line for UHC equivalent to euros 53.56 million for 2023, and a further euros 39 million for 2024 to continue implementation of UHC Phase 1. By adopting a political economy lens across the different components of the health programme, German Development Cooperation has been able to leverage limited resources to enable and accelerate these reforms.
Enabling robust ownership of UHC reforms
Throughout its long partnership with the Government of Cameroon, German Development Cooperation has focused on facilitating change rather than imposing solutions. This has meant being responsive to the needs and priorities of government partners and ensuring they are in the driving seat for the reforms, whilst nudging them in the right direction based on the evidence of what works.
The Head of the Technical Implementation and Coordination Unit for UHC in the Ministry of Health, Dr Anicet Désiré Mintop, conveys the closeness of the relationship when he says,
The history of health in Cameroon cannot be written without taking German support into account. This support has helped us to transform our health system according to our own needs.Dr Anicet Désiré Mintop
Developing leadership and cooperation – the P4H network
Germany is a founding member and active partner of the Providing for Health (P4H) network, a global network of countries, and bilateral and multilateral development partners, committed to health financing and social protection reforms in support of UHC. Drawing on the experience of its members, P4H brings to Cameroon an in-depth understanding of the social, economic and political conditions within which technical reforms such as UHC sit.
Over the last five years, Cameroon has participated in the P4H-run Leadership for UHC (L4UHC) programme, with Burkina Faso, Niger and Senegal, and more recently Chad. By facilitating open, high-level discussions between stakeholders from different sectors and geographies, L4UHC supports government leaders to build strategic alliances, to identify and tackle the challenges for UHC in their countries, and to plan and implement the needed reforms.
The P4H focal person in Cameroon, Ms Aminata Tou (funded through BACKUP Health), works alongside the Cameroonian-German Health Programme, promoting coordination and alignment both across government, and between government agencies and development partners. Emphasising the criticality of a multi-sectoral approach, Ms Tou says, ‘health financing and social protection issues go well beyond the scope of a single ministry or a single partner, so it is important to work together and to coordinate actions to achieve more effective results’. These efforts have helped build strong relationships of trust and enhanced the value of development cooperation.
Strengthening governance – the Regional Funds for Health Promotion
A further essential element of the ‘UHC puzzle’ is governance. Introduced in the 1980s with support from German Development Cooperation, Cameroon’s Regional Funds for Health Promotion (Regional Funds) aimed to improve access to essential medicines. They were so successful in strengthening the governance and transparency of drug financing that they were scaled up nationwide.
The remit of the Regional Funds has since expanded to include responsibility for – among other things – strengthening the voices of citizens in health service delivery and financing, purchasing health services on behalf of the population, and monitoring and control. As Wendy Ngondo, Administrator of the South West Regional Fund for Health Promotion, explains
Regional Funds have played a really key role in laying the foundations for UHC in Cameroon. They provide the decentralised structures to strengthen governance and accountability, and are improving financial management.Wendy Ngondo
Working wisely to address fragmentation
Under the new UHC Scheme, most Cameroonian citizens will continue to contribute something towards the costs of their healthcare. The first phase of UHC focuses on enabling access to services for pregnant women, children under five years, people living with HIV and AIDS, and those suffering with tuberculosis. Over time, the different programmes providing access to free or highly subsidized health services will be integrated.
Chief among these is the Chèque Santé, a voucher scheme providing access to a package of maternal and newborn care services, implemented with funding from BMZ through the German Development Bank KfW and Agence Française de Développement (AFD). The scheme has played an important role in establishing the operational reforms necessary to devolve the purchasing of health services to the Regional Funds, and is helping to improve governance and transparency through improved monitoring of the number and quality of services.
For the time being, the Chèque Santé will continue to be the principal conduit for financing health services in half of Cameroon’s ten regions, while the UHC Scheme will be implemented in the other half. As Josselin Guillebert, Director of the Cameroonian-German Health Programme (Pro-PASSaR, Projet Planification Familiale et Appui au Système de Santé pour la Résilience), explains,
For Phase 1 of UHC, the Government has worked wisely, combining the different schemes already in existence, such as the Chèque Santé and free HIV care to extend coverage of basic services to under-served people.
Joined up thinking for UHC – the role of BACKUP Health
The global programme BACKUP Health works to strengthen Cameroon’s health system and to improve alignment of health system actors with respect to global financial institutions, such as the Global Fund which provides the country’s malaria drugs. The FAGEP programme (Fonds d’Achat pour la Gratuité Effective de Paludisme) is a collaboration between the German bilateral health programme, the P4H network, and BACKUP Health, and provides a further example of the kind of joined-up thinking for UHC for which the Cameroonian-German Health Programme is known.
Working within the devolved health system structures, FAGEP enables the Regional Funds to purchase malaria drugs from approved market suppliers when out of stock at health facilities. It then reimburses the Regional Funds through the same systems in use by other UHC initiatives, such as the Chèque Santé. With guaranteed free-of-charge malaria services, patients and their families will seek care much sooner in cases of fever, thus avoiding the most severe and deadly cases.
No UHC without digitalisation – the role of openIMIS
Cameroon recognised early on the potential for digitalisation to integrate and streamline its many health programmes, and was one of the first countries to adopt the openIMIS software in 2013. While the software was initially used to digitalise the management of micro-health insurance schemes in the South West and North West regions, it has since been adapted for a wide range of uses, including social health insurance, vouchers, social protection for internally displaced people, and free HIV and malaria services.
GIZ and KfW have worked with other development partners in digital health over many years, investing in digital infrastructure and building national IT capacities. Key digital health partners include UNICEF, Swiss Tropical and Public Health Institute and AFD.
As testament to the long-term support by development partners and the proven capacity of openIMIS to align the business processes of different health and social protection schemes, the Ministry of Health selected openIMIS in 2023 as its principal software for UHC. Saurav Bhattarai, Advisor at GIZ’s Global Initiative Social Protection Innovation and Learning, says, ‘one could even say that the new UHC Scheme has been made possible thanks to the facilitating role played by openIMIS across many different health financing schemes’.
Taking this argument still further, Emanuel Batoum, Head of the IT Unit in the Ministry of Health, points to the wider enabling role played by digitalisation,
UHC presents a unique opportunity to advance Cameroon’s digital health agenda. Why? Because you cannot achieve UHC without digitalisation.
The art of development cooperation
The Cameroonian-German Health Programme approach is founded on an in-depth understanding of the political, economic and institutional factors that shape UHC, combined with high quality technical cooperation – this blend has proved to be a critical enabler of Cameroon’s health reforms to date.
The Ministry of Health is committed to ensuring some 25 million citizens have access to basic health services through the UHC Scheme and, by October 2023, almost two million people had already signed up. With the government firmly in the driving seat and the UHC reforms well underway, 2024 promises to be an exciting year.
Success must build upon those factors that have helped to propel Cameroon on its UHC journey. Chief among these is the integration and digitalisation of Cameroon’s many health financing and social protection schemes. Digitalisation is the oil that keeps the UHC engine running and a second article, later in the Spring, will further examine the role of openIMIS in the development of Cameroon’s broader digital pubic health.
As Julius Murke, Advisor for Pro-PASSaR, says, ‘if you develop a clear, shared vision, and can provide very operational support that is informed by Cameroon’s political economy, you can really achieve transformational change’.
Corinne Grainger, February 2024