La crise des ressoources humaines de la sante au Cameroun.

1. Health Workers Crises in
Cameroon
A Capstone Submitted to the Graduate Faculty
of Georgia State University in Partial Fulfillment
of the Requirements for the Degree
MASTER OF PUBLIC HEALTH
Ike Okosun, MS, MPH, PhD, FRIPH Bruce Perry, MD, MPH

2. THE HEALTH WORKERS
CRISES IN CAMEROON
Adidja AMANI,MD
MPH Candidate
Georgia State University

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

4. Chapter one
Introduction

5. 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

6. Introduction
Overview 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

7. Introduction
Overview 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%

8. Introduction
Background & statement of the problem

9. Introduction
Background & 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

10. Introduction
Background & 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)

11. Introduction
Research 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.

12. Chapter two
Methods

13. 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.

14. Chapter three
The Physician Crises In Cameroon:
Challenges

15. The Physician Crises In Cameroon
Challenges
-Low wages/Migration
-Lack of equipment
-lack of social benefits
-Shortage and Imbalance
-overwork burden

16. 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)

17. 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)

18. 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..

19. 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.
.

20. 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.

21. 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

22. 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).

23. Chapter four
Some recommendations

24. Some Recommendations
Financial Strategies
. Government Salaries Increase
Salary 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

25. 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,”

26. 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

27. 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.

28. 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)

29. 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).

30. 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)

31. 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 &

32. 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).

33. Chapter five
DISCUSSION & CONCLUSION

34. 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.

35. 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)

36. 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.

37. 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 direction
It 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

38. Thank you!