Health Workers Crises in Cameroon

A Capstone Submitted to the Graduate Facultyof Georgia State University in Partial Fulfillment

of the Requirements for the Degree MASTER OF PUBLIC HEALTH

Ike Okosun, MS, MPH, PhD, FRIPH

Committee Chair

Bruce Perry, MD, MPH

Committee member

THE HEALTH WORKERS CRISES IN CAMEROON

Adidja AMANI,MD MPH CandidateGeorgia State University

PLAN

• Introduction•Background•Challenges of Cameroonian physicians •Some recommendations• Discussion and conclusion

 Chapter one

Introduction

Introduction

Background of the country

Pop: 19, 294,149

•70% pop < 30 years

•48% below the poverty line

•Unemployment rate: 30%

•French and English. •life expectancy 53.2 years 54.9 years Source: CIA factbook

Map1: situation of Cameroon in the rest of the world.Source: Google

IntroductionOverview of the Health system

Double burden of diseases/ malaria

•The public sector managed by MoPH. Traditional medicine/ Chinese traditional medicine •The households-75% of the medical expenditure/ No national health insurance

•The public health budget : 4% of the GDP (2010)

•Centralized system: The Ministry of Public Service , the Ministry of Finance and the Ministry of Public Health

IntroductionOverview Health system in Cameroon

. Recession in the 1980s and early 1990s

. HRH crises date back from the early 1980s

. Initiation of the government reform SAP (Ngufor, 1999).

. Recruitment frozen for 15 years

. Devaluation of the local currency

. irregularities in the payment of salaries and salary reduction of 50%

. early retirement at 50-55 years

. restricted employment years < 30 years

. financial promotion suspended

. Reduced benefits such as housing, travel expenses

. Overall a loss of 70% of income over 15 years (Ngufor, 1999).

. health sector budget decreased to 2.4% out-migration (Hyder et al., 2003).

IntroductionBackground & statement of the problem

Map2: Density of health workers and the burden of diseases, source: WHO, 2006

IntroductionBackground & Statement of the problem

. 1,555 physicians representing 0.8 physicians per 10,000 inhabitants (Ministere de la santé publique, 2009). This ratio is one of the lowest in the world (World statistic, 2010).. Cameroon will need 10, 447 physicians in 2015. Physician supply projected to reach 822 physicians. Scheffler et al., (2008)

. growing crisis in the medical field due to an acute shortage of medical doctors (Abena Obama et al., 2003, Kollo, 2007).

. In Nigeria & Ghana, delayed salaries; delayed promotions, lack of recognition, and inability to afford the basic necessities of life (Hagopiana et al., 2005)

. In Kenya, poor communication among hospital staff as well as a lack of resources and high numbers of patients with HIV/AIDS Raviola et al. (2002)

IntroductionBackground & Statement of the problem

. The effects of government reforms (SAP), on the health workforce in general and coping strategies. Ngufor (1999)

.The reasons for emigration: lack of recruitment (28.6%), desire to gain experience (28.6%) , better remuneration (26.6%) Abena Obama et al. (2003)

. Low wages, lack of recognition of their work as disincentives for young health researchers Takougang et al. (2002)

. low salary affected nurses’ job satisfaction. Ndiwane (1999)

. Challenges and demands of nurses in leadership Awasum (1993) and Fongwa et

al. (2002)

IntroductionResearch question & Impact of the Study

“why Cameroon physician’s are dissatisfied”specific objectives. Determine the challenges that physicians face during their training and career.. Identify and analyze the reasons for migration of physicians and factors that motivate physicians to remain in Cameroon. Recommend appropriate strategies to improve the conditions of physicians

.The findings of this report can be can be useful for policy-makers in the development and the formulation of effective health policies for physicians and overall to strengthen the health system in Cameroon.

Chapter two

Methods

Methods. Published and unpublished literature .Search strategy combining the following search terms: "physicians" AND "crises OR motivation OR migration OR incentives OR retention OR challenges" AND "Cameroon". . Human resources for health websites and journals including the Bulletin of the World Health Organization, Human Resources for Health, the documents and the website of the Ministry of Public Health in Cameroon, the Africa Observatory for Human Resources for Health, Google Scholar, snowballing approach.

. Articles both in French and English. No time limitation

Chapter three

The Physician Crises In Cameroon:Challenges

The Physician Crises In Cameroon

Challenges

-Low wages/Migration-Lack of equipment -lack of social benefits-Shortage and Imbalance-overwork burden

The Challenges Low wages/Migration

. Fixed monthly salaries, 140,000 FCFA (about $300) (Kingue, 2009)

. 49.3% of the Cameroonian health professionals declared their intention to migrate due to low wages. Abena Obama et al. (2003)

. similar in other countries ( Vujicic et al. 2004, Dovlo, 2004, Awases et al., 2004 ; Clarck et al., 2006

. “We have to live at a low standard compared to the status we hold. This is degrading" said a medical doctor in a study done in Uganda and Bangladesh (Ssengooba and al., 2007).

25%-30% of professionals trained in the country are working abroad. 70-80% of Cameroonians trained abroad do not return home after their education. . 5,000 Cameroonian doctors abroad, with 600 in the US ( Ekoe, 2006)

The Challenges Low wages /Migration

. Ssengooba and al. (2007) warned that unrealistically low wages could lead to unethical behavior, demoralize and foster malpractice

Beine et al. (2006) rank Cameroon as one of the top 30 countries most affected by high rates of medical migration.

InPeru 59.4% of health personnel feel that their salary or pay is too low for the job that they do.(Urcullo, 2008)

In SA, financial reasons was the first reason to migrate (Bezuidenhout et al, 2009)

The Challenges Lack of Equipment

. Facilities severely under-supplied and lacking in medicines and proper medical equipment.

. FTMG upon their return, find that their skills are needed, but nonetheless useless because of a chronic absence of suitable material to carry out the advanced procedures for which the professionals were trained (Bundred and Levitt, 2000).

Cameroon, who found that a lack of necessary supplies impede the use of evidence-based medicine Tita et al. (2004) certain public hospitals were equipped with MRI, problem of sustainably in the long run.. 

Challenges lack of social benefits

. No social allowances and no welfare benefits to compensate for the low wages (Kingue, 2009).

. physicians in Cameroon lack health insurance. Pr Kingue (2009), . “lack of promotional opportunities’’ 1 st reason (Awases et al. 2003) in a study exploring the factors affecting the motivation of health workers,

The system of promotion is at times unclear, lacking transparent standard. This situation discourages some young doctors. .

The Challenges imbalances

. ratio of 1 physician for 50,000 inhabitants.

. inequitable socio-economic development of rural compared to urban areas, and the social, and professional comparative advantages of cities.

The Challenges

Imbalances . ENT (ear nose, throats) surgeons, cardiologists, Neurologists are basically concentrated in the cities of Yaoundé and Douala.

. excessive concentration of physicians and specialist physicians, in the metropolitan region were similar in Latin America (Urcullo, 2008)

. old staff (Minister de la santé publique, 2009)

. recruitment to the civil service was frozen for 15 years

. These imbalances severely affect certain region like the Far North, the most populous of the country with a ratio of 1 physician for 50,000 inhabitants

The Challenges

overwork burden . “Cameroon without Doctors by 2009” Africa research bulletin, 2006. . Guillozet (1974) said the “Cameroonian physician are trained to be super doctors who can teach, plan, supervise paramedical personnel, carry out ongoing preventive medical programs and public health endeavors, and a super clinician for the medical and surgical problems that surpass the skills of the many others in the team who will deliver the bulk of direct medical care.”. . see on average 50 patients a day. Data collection, reporting and analysis are given to overburdened health service providers. less than 20% of physicians district managers have professional training in health management (Okalla and Vigouroux, 2009). 

Chapter four

Some recommendations

Some Recommendations

Financial Strategies

. Government Salaries IncreaseSalary raise as the most important retention factor cited by 68% of Cameroonian physicians, 81% of Ghanaian (81%) and 84% of Ugandan Vujicic et al. (2004)

 . increase investment in the health sector that should match the 15% recommended by the African Union (2005)

. The low investment in the health sector in Cameroon explained the inadequacy, the under-equipment of the formations and health workers.

Dielman (2003) gave an indication that although financial incentives are important; they are not sufficient to motivate personnel to perform better

Some Recommendations

Financial Strategies

Alternatives To The Government Salary Increase

. “quotes-parts” is limited in scope, focusing primarily on hospitals and not to other physicians working at the central level of the MoPH.

. In Ghana, the quote part system can be equivalent to the “Additional Duty Hours Allowance” to considerably augment physician pay for direct patient care and have been credited with reducing the migration to a small extent (Hagopiana et al., 2005).

Various cash payments: for managerial responsibilities, specialization, and coordination of work teams, and payments for “productivity,” known as AETAS (Extraordinary Stipends for Work in Health)

one additional hour of work beyond the normal work shift and arrive on time.

Some Recommendations

Non- Financial Strategies

. Motivation is influenced by both financial and non-financial incentives (Mathauer and Imhoff, (2006); Dieleman et al, (2003)).

. In Zimbabwe, certain non-financial incentives can have a beneficial effect on motivation, even under adverse conditions of insufficient pay and equipment, understaffing Stilwell (2001)

Another important non-financial incentive appreciated by health workers is the appraisal awards system, given to excellent workers in Vietnam (Dielman, 2003).

According to Mathauer and Imhoff (2006), the public ranking and public congratulations appear to have a strong effect on health workers. They create competition and provide motivation to perform better.

In Cameroon, the award system exists in some hospitals but as Obama and Nko’os have highlighted, it is perceived as “unequally distributed”. The recognition and public congratulation need to be more objective and strengthened.

Some Recommendations

Non-Financial Strategies

. Policy that requires hospitals to offer duty houses for the physicians in the rural areas (Angwafor, 2006) should be extended in urban areas.

. The provision of loans for housing, mortages, land acquisition and cars as in Zambia Makasa (2009) and in Ghana (Hagopiana et al., 2005).

. Decent pension on retirement

. Medical insurance for the physicians and their families

. In Malawi incentives include free basic and postgraduate training; free meals for health workers on duty (Windisch, et al, 2009). . school fees for children, transportation and duty allowance.

Some Recommendations

Non-Financial Strategies

. Policy that requires hospitals to offer duty houses for the physicians in the rural areas (Angwafor, 2006) should be extended in urban areas.

The system should rewards doctors who obtain titles and certificates, participate in courses, undertake teaching roles, produce scientific work, publish, and receive awards as proven to be succesful strategy in Peru (Urucullo, 2008)

. The medical doctors can themselves change the situation by establishing powerful unions that will give them more voice to negotiate as it is the case in Latin America (Urucullo, 2008)

Some Recommendations

Reduced the working hours

. Reopen a training cycle of the Administrators of Health in the administration school ENAM (MoPH, 2007) . Task shifting lead delegation of tasks, to improvements in access, coverage and quality of health services (Dovlo, 2004, Moris et al. 2009) . Lehmann et al. (2009) Task shifting holds the potential of enabling countries to build sustainable, cost-effective and equitable health care systems. . In Mozambique the introduction of "tecnico de cirurgia" was a successful solution to a critical problem of scarcity of human resources for health (cumbi et al. 2007).

Some Recommendations

Retention Strategies. Compulsory contracts with medical students so that they had to perform three years of public work after graduation or face high fines as in Thailand (Wibulpolprasert and Pengpaibon, 2003).

. Tie the access to medical training to a commitment to practice a certain number of years in the country or else to reimburse the real costs of training as proposed by the World Bank

. Offer competitive student loans at entry into health training institutions on condition that the students would be legally bonded to work in Cameroon until they repay back. Makasa (2009) argued that these graduates would have settled into society (married with children) and may be reluctant to leave at this stage.

Some Recommendations

Retention Strategies

. Establishment of regional medical schools as a measure to reduce the numbers of professionals moving to other countries for reasons of furthering their studies. Wibulpolprasert and Pengpaibon (2003)

. In Fiji the creation of local or regional postgraduate training schools increased retention of doctors in the Fiji. (Oman et al. 2004)

 .A non-private practice allowance. In Thailand, an extra US $ 400 for doctor in the public service who agreed not to engage in private practice Wibulpolprasert and Pengpaibon (2003

. Quotas of recruitment in the Public sector should be increased by a high level political dialogue (GHWA, 2007).

. Sub-standard training in island nations in the Pacific bassin (Feasley &

Lawrence, 1998)

Some Recommendations

Distribution Strategies. Emulate the Zambian “rural retention” program, where doctors are given monthly allowances, a one-time payment to upgrade their housing, a car loan, all in return for 3 years of service at a rural facility (Makasa, 2009).

. Offer finance professional education through loans to students that must not be reimbursed when one accepts to work in an under-served area (World bank, 1993).  . Give special hardship allowance to rural working doctors as in Thailand where doctors receives a monthly prime that 3 times their basic salary (Wibulpolprasert and Pengpaibon, 2003).

. In Vietman, paying special allowance to doctors working in certain geographical areas have increased their retention (Dielman, 2003).

Chapter five

DISCUSSION & CONCLUSION

DISCUSSION & CON

. Scheffler et al., (2008), discrepancy between the projection need of 10, 447 physicians in 2015 and the potential to train only 822 physicians.  . Increase the number of school of medicine will not automatically correct the distribution but might create an oversupply of doctors (Suwanakaji et al.,1998)

Boosting salaries is clearly important but is a long-term solution is needed. Van Lerberghe et al. (2001) argued that to increase salary to “fair’ levels of health workers in the public sector “is not a realistic option”, “not imaginable”, ‘politically difficult”. Following the same logic Vujicic et al.

(2004), a little raise are unlikely to affect in an appreciable way the supply.

Discussion & Conclusion

. HIV/AIDS in Kenya and SA cited as push factors (Raviola, 2002, Bezuidenhout

, 2009)

. Retention strategies. Tie and contracts. However, implementing such a strategy could be difficult to manage and is unlikely to be successful unless recipient countries agree to comply with the source country’s policies (Benetar , 2007 ; Dovlo, 2005)

. Sub-standard training in island nations in the Pacific bassin (Feasley &

Lawrence, 1998)

Discussion & Conclusion

. Our report was the first to our knowledge to examine the challenges physicians face in Cameroon and how to improve their situation

. Most of the information we found on Cameroon were from the website of the Ministry of Public Health (MoPH), some presentations done during Human resources for Health conferences or the archives of the national news paper, Cameroon Tribune.

. Although the search methodology was systematic, the paucity that accurate and complete data prevent the drawing of systematic conclusions.

LIMITATIONS

This report highlighted the need for more investment in collecting and publishing on a representative sample of physicians across the country for informed decision-making.

Future directionIt is important for Cameroonian physicians to write more on their conditions. There is a need to promote evidence-based decision-making and share information with those who can benefit from it, in this case the government and donors.

This work could be improved if we had a face to face interview with a representative sample of the physicians on the ground.

Thank you!