Assessment of USAID-funded health and population assistance (1987-1994) [Cameroon]

Remarkable progress has been made in developing innovative approaches in health and population development, especially given Cameroon's declining economic situation. USAID's key accomplishment was to help the Ministry of Public Health (MOPH) to shift from selective primary care to a new strategy, entitled Reorientation of Primary Health Care (RPHC), emphasizing decentralized planning and community co-management and co-financing. By 1990, USAID began to reformulate all of its health projects in line with RPHC and its integrated, systems development approach. Projects like Maternal Child Health/Child Survival (MCH/CS) I and II and Reform of Health Delivery System also helped to provide a policy framework for RPHC. USAID projects following the RPHC strategy supported: cost-effective delivery of immunizations and other child survival interventions; rapid expansion of access to family planning and other key services; a model for integrating public and private health care; and mechanisms for financing the recurrent costs of non-salaried health services and for addressing longstanding problems such as the funding of control measures in the early phases of epidemics. These projects also: (1) developed high-quality training materials, adopted by other donors, for RPHC; (2) further developed important aspects of RPHC (e.g., delimitation of health areas, provincial health management information systems [MISs], and a model for health supervision); (3) integrated onchocerciasis and schistosomiasis control programs into PHC; (4) developed a provincial medical supply system; (5) decentralized medical supply logistics, health information, health care budgeting, and training to the provincial level, and deconcentrated supervision to the health district level; (6) established functioning community co-managed and co-financed health centers providing basic health services, and achieved the coverage objective of 30%; and (7) helped to establish a pilot health district in Meiganga. The capstone of USAID's health and population portfolio was the MCH/CS II project (also known as SESA II), begun in 1992. Unfortunately, this project will be discontinued with the close of the Mission. Implementation of SESA II through USAID or other donor support in the future would permit achievement of an integrated, sustainable health system for Cameroon before the year 2000. The following lessons were learned. (1) The integrated health systems approach had a much greater, wider, and more permanent impact than a selective approach would have had. It also facilitated donor coordination. (2) Even with a clear national policy for RPHC, there is a continuing need to market the concept of integrated health systems to donor/partner agencies. (3) Decentralization should begin at a level of the health system that has the capacity to plan, manage, and supervise the functions to be decentralized. (4) A lack of functional health districts to serve as replicable models can constrain decentralization. (5) The potential of NGOs to manage district referral hospitals and district health services should be actively explored. (6) Vertical national health intervention programs are important in launching specific disease control programs, but decentralization should be pursued as soon as possible. (7) Integrated disease control programs can be an entry point for increasing access to limited services, establishing principles of co-management and co-financing, and creating community enthusiasm for PHC. (8) It is necessary to determine costs (including marginal and recurrent costs) before initiating a drug supply and cost recovery system. (9) Delivery of endemic and epidemic disease control commodities can be effectively achieved as part of an integrated drug supply system. (10) Development of a national health MIS needs to be a consensus-building process. A national MIS should place more emphasis on non-computerized local feedback than on computerized feedback from a provincial or national level. (11) Supervision requires a strong training component that promotes and rewards problem solving at the health center level. (12) Coordination of supervision of NGO health services as part of a health district should be negotiated at the district and provincial levels, with administrative supervision being the responsibility of the NGO, and technical supervision of the health district supervisor. (13) Community development is a continuous process which requires training, which in turn requires increased resources and compensation. Other lessons learned show the need to: find mechanisms other than health committees to involve women in health care planning and management; link IEC to all support components and program interventions; give priority to counseling in family planning programs; and complement social marketing with counseling and targeted IEC.