Strengthening human resources for health through multisectoral approaches and leadership: the case of Cameroon
S Kingue a, E Rosskam b, AC Bela a, A Adjidja a & L Codjia c
a. Ministry of Public Health, Yaoundé, Cameroon.
b. Webster University, Geneva, Switzerland.
c. Global Health Workforce Alliance, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
Correspondence to L Codjia (e-mail: email@example.com).
(Submitted: 11 March 2013 – Revised version received: 24 July 2013 – Accepted: 02 August 2013.)
Bulletin of the World Health Organization 2013;91:864-867. doi: http://dx.doi.org/10.2471/BLT.13.127829
Although Cameroon has an acute shortage of human resources for health (HRH), it lacks the economic resources to support the mass recruitment of new health workers. Only 27% of the individuals who completed their training at nursing schools in Cameroon between 1990 and 2009 were recruited by the Ministry of Public Service.1 The training in health care that does take place in Cameroon is also seldom matched with employment needs. In 2011, for example, severe staff shortages in the fields of mental health, ophthalmology and anaesthesia–resuscitation were known to exist, but almost all health science students at training schools in Cameroon were intending to work as nursing aids, state registered nurses or laboratory technicians in other fields of medicine. Approximately 66% of the health workers in Cameroon are employed in the public sector but more heath workers are needed in both the public and the private sectors (Table 1).2
Much of the current HRH crisis in Cameroon can be attributed to low government spending on health – a mere 4.6% and 5.1% of the gross domestic product in 2000 and 2012, respectively3 – and a lack of effective coordination between the key stakeholders. Poor coordination has led to the duplication of interventions, the use of conflicting procedures and a general waste of resources.
Substantial increases in the Cameroonian health budget are not likely to occur in the near future. The main strategy for reducing HRH problems in Cameroon is therefore to capitalize on the existing potential – primarily by improving the coordination and effectiveness of the key stakeholders’ current efforts to improve the health system.
In response to the HRH crisis, the Cameroonian government developed an HRH emergency plan for the years 2006 to 2008. Implementation of this plan led to the recruitment of 5400 health workers, the opening of new training schools for health workers, the revision of the training curricula for paramedical staff, and a simplification of the process that contract or temporary workers need to follow to become permanent employees in the public sector. Between 2007 and 2010, Cameroonian HRH received increased financial support from external sponsors. Over this period, the International Monetary Fund and the World Bank – via the Heavily Indebted Poor Country initiative – and the French government – via the Contrat de Désendettement et de Développement – together contributed about 7359 million African Financial Community (CFA) francs towards the salaries of health workers in Cameroon.
The HRH emergency plan for 2006–2008 did not solve the maldistribution of HRH in Cameroon, where health care is concentrated in urban areas; the low allocation of financial resources for HRH, or the absence of an accreditation system for HRH training. External resources were therefore mobilized to develop new approaches to address these challenges. The mobilization process started in 2007, with a 2-day conference on HRH organized by the Global Health Workforce Alliance. This conference resulted in the Douala Plan of Action.4 In 2010 – with financial support from the World Health Organization (WHO), the Global Health Workforce Alliance, the French Development Agency and the European Union – Cameroon’s Ministry of Public Health formally adopted and implemented a “country coordination and facilitation” process. The aims were to clarify the main challenges to effective HRH in Cameroon and to subsequently create an integrated, participatory and comprehensive HRH-development strategy – for the years 2011–2015 – that would address these challenges.
The country coordination and facilitation process for HRH development was a catalytic force that ensured the mobilization and coordination of the key stakeholders. The stakeholders became jointly responsible for reviewing national HRH problems, setting strategic priorities and developing a national, strategic HRH plan. As part of the process undertaken to address the problem of HRH maldistribution, financial resources were mobilized, the extent of the maldistribution was evaluated and a retention policy for health workers was developed.5 The main aim of the retention policy was to ensure the presence of health workers in rural areas of Cameroon that are difficult to access.6
To address the problem of poor stakeholder coordination, a meeting with over 200 participants was convened.7 This meeting led to several recommendations, including the development of a multisectoral coordinating committee and a multisectoral technical working group for HRH in Cameroon. In 2010, these recommendations led the Cameroonian Ministry of Public Health to mobilize a national coordinating committee composed of representatives of all the key stakeholders. This committee currently acts as the umbrella organization for developing HRH, raising awareness of issues surrounding HRH and high-level HRH advocacy. It also manages an HRH technical working group, an HRH national observatory and a multidisciplinary HRH research group.8 The members of the committee include 11 ministerial administrators and representatives of development partners (n = 2), the private sector (n = 1), decentralized local and regional authorities (n = 1), civil society organizations (n = 1), chambers of commerce (n = 1), professional associations (n = 4), trade unions (n = 2), medical and nursing schools (n = 2) and patient associations (n = 1), plus other experts on an as-needed basis. The committee meets twice a year routinely and ad hoc at other times. Before the country coordination and facilitation strategy was implemented, the committee responsible for HRH in Cameroon met relatively rarely and only on an as-needed basis.
The HRH technical working group in Cameroon is responsible for the development of HRH policies and strategic plans and the subsequent monitoring of their implementation. It meets four times per year to respond to the central HRH issues. Meetings of both the coordinating committee and the technical working group follow established agendas and focus on specific needs. For example, the committee’s agenda includes creating synergy among the various ministries involved in health sector improvement; ensuring coherence among health sector activities, resources and actors; coordinating and informing the key HRH stakeholders; and seeking sustainable funding solutions with interested partners. The agenda of the technical working group includes creating synergy among the different activities aimed at health sector improvement by ensuring coherence in activities, resources and operators; harmonizing the various health sector interventions; coordinating and informing the actors responsible for implementing the interventions; following up on Cameroon’s commitments to developing its health sector; encouraging multisectoral participation; ensuring coherence in the implementation of health sector strategies and other strategies, such as those to stimulate growth and employment; finding sustainable solutions to the problem of health financing in dialogue with all interested partners; following up the key indicators of the evolution of the health system; and coordinating and supervising health sector reviews.
Since 2006, strong leadership has facilitated the process of moving to an evidence-based approach to HRH development in Cameroon. It has encouraged collaboration between the ministries involved in the Cameroonian health sector, fostered relevant discussion and dialogue, increased trust between the various stakeholders, and promoted a consensus view and approach. The nongovernmental organizations and national societies involved in health care in Cameroon have been able to expand their role, increase their visibility and improve their credibility with the national government and other stakeholders. Even health workers in remote areas have been able to contribute to the HRH planning process.
Implementation of the HRH emergency plan resulted in the recruitment of 6417 additional health workers in Cameroon between 2007 and 2009. Such recruitment increased the number of active health workers in the country from 11 528 in 2005 to 15 720 in 2009 – a 36% increase.9 Over the same period the number of Cameroonian institutions for higher education in health sciences was increased from five to seven in a further attempt to address the shortfall in health workers in general and of specialist physicians and midwives in particular. Training at degree level has been expanded to cover an additional 14 medical specialties, bringing the total to 26, with the aim of more than doubling the number of specialist physicians active in Cameroon – to 130 – by 2014. The number of training schools for paramedical staff in Cameroon increased by 54% between 2007 and 2013 with the creation of 37 new schools, including 10 for the training of midwives. Over the same period, the number of paramedical workers active in Cameroon increased from 4000 to about 9000. The aim is to have 81 training schools for paramedical staff and at least 250 midwives trained per year by 2014.
Payment to health workers increased considerably too. Between 2007 and 2010, the monthly gross salaries of government-recruited assistant nurses, nurses and physicians had risen by a mean of 8.75% – to 102 540, 147 352 and 217 578 CFA francs, respectively.1
As a result of the implementation of the country coordination and facilitation process, all HRH stakeholders are now involved in all strategic planning that relates to the national health system. The Cameroonian government is currently developing a strategy for universal health coverage that will include the development or expansion of social insurance for public sector workers and their families, private health insurance schemes and community-based health insurance schemes. The aim is to have at least 40% of the population of Cameroon covered by health insurance by 2015.5
An external evaluation of the country coordination and facilitation process was conducted in 2012 with funding from the European Union. The data collected in this evaluation indicated that the process had been successfully implemented in Cameroon. This success was largely attributed to precise methods that permitted – and still permit – stakeholders to be identified and then engaged on the basis of their specific interests and their potential contributions to solving the HRH crisis.10 Several lessons can be learnt from the results of the external evaluation (Box 1). Investing in the country coordination and facilitation process and applying it appear to be cost-effective and sustainable ways to build stakeholder consensus on the actions needed to address HRH challenges. A return on investment can be demonstrated. Policies and legal frameworks to promote the retention of health workers and, in particular, to develop and scale up effective strategies for the retention of health workers in rural areas should help developing countries such as Cameroon to achieve universal health coverage and the health-related Millennium Development Goals by 2015. The education of potential health workers should follow competency-based curricula that are responsive to – and respectful of – population needs.
Box 1. Summary of main lessons learnt
- In the improvement of human resources for health, strong leadership is needed to ensure effective coordination and communication between the many different stakeholders.
- A national process of coordination and facilitation can produce a consensus-based view of the main challenges involved in the area of human resources for health.
- Once the main challenges have been identified, the stakeholders can plan appropriate interventions that are coordinated, evidence-based and coherent.
- Situational analysis of HRH in Cameroon. Yaoundé: Ministry of Public Health; 2010.
- General census of health personnel. Yaoundé: Ministry of Public Health; 2011.
- Health expenditure, total (% of GDP). Washington: World Bank; 2013. Available from: http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries [accessed 10 September 2013].
- Conference “Human Resources for Health in Africa: experiences, challenges and realities”, Douala, Cameroun, 6–8 June 2007: Douala Plan of Action – adopted. Geneva: Global Health Workforce Alliance; 2007. Available from: http://www.who.int/workforcealliance/PLANDACTION2DOUALA_en.pdf [accessed 10 September 2013].
- Plan de développement des ressources humaines du système de santé du Cameroun, 2013–2017: plan d’actions et plan d’actions prioritaires. Yaoundé: Ministry of Public Health; 2012. French.
- Situational analysis of health human resources in Cameroon. Yaoundé: Ministry of Public Health; 2010.
- Report of the meeting with stakeholders in the health sector, 16–21 April 2011, Yaoundé. Yaoundé: Ministry of Public Health; 2011.
- External evaluation of CCF countries. Geneva: Global Health Workforce Alliance; 2011.
- General census report of staff in the health sector. Yaoundé: Ministry of Public Health; 2011.
- Martins J. Report of the end of program evaluation: strengthening health workforce development and tackling the critical shortage of health workers. Geneva: World Health Organization; 2012.