The example of cameroon
External shocks to health systems: the importance of community participation and inclusion towards resilience
Von Basiru Isa Manjo, Marc Bonenberger, Alphonse Um Boock and Bart Vander Plaetse / FAIRMED - Gesundheit für die Ärmsten
Recurrence of armed conflicts in the Central African Republic (CAR) caused waves of displacement into neighbouring Cameroon. Until 2016, almost 260,000 refugees have fled CAR and settled in three regions of Eastern Cameroon. As the health system was not prepared to adequately respond to these large population increases, this led to a rapid decline in local health outcomes. In a reaction to the crisis, the UNHCR mandated FAIRMED, a Swiss-based international NGO, to set-up community health and built a resilient health system capable of responding to future pressures. This article describes the methodology used by FAIRMED and preliminary results after setting up the programme.
FAIRMED agents’ accompanying the Meidougou health center on an outreach activity on vaccination of children (Photo: Oumar Franky)
The persistence of armed conflicts in the Central African Republic (CAR) in the past decades progressively brought local populations to flee and find refuge in neighbouring countries, including Cameroon. According to the UNHCR, in 2016, Cameroon hosted 259,145 refugees from CAR (UNHCR statistics, unpublished). These refugees have settled along the Adamawa Region, Northern Region and Eastern Region, all of which share borders with CAR. Some health districts such as Kette in the Eastern Region recorded an increase of over 40% of their population. These external shocks caused by the high influx of refugees have not been without consequences for the already fragile local health system in affected districts
One of these consequences has been the rapid deterioration of the quality of care and the subsequent decline in local health outcomes. Many health centres, where they existed, were unable to adequately provide appropriate health services for both local populations and refugees, as they lacked human resources for health, medicines and health information
In response to this humanitarian crisis, the United Nations High Commissioner for Refugees (UNHCR), together with the Government of Cameroon, mobilized the international community in order to obtain funds and provide assistance to refugees and to the hosting areas. In addition to funds, the UNHCR mobilized NGOs whose expertise is relevant to support implementation of immediate and long-term solutions.
UNHCR mandated FAIRMED, a Swiss-based international NGO, to implement community health in three regions. FAIRMED has been working in Cameroon since 1960. This decision was motivated by FAIRMED’s long-standing experience in community health as well as the success of a pilot program in collaboration with SDC in one of the districts currently strongly affected by the refugee crisis.
The current project covers three regions (East, Adamawa and North) with eight health districts made up of 53 health areas where refugees have settled within the local population. The overall population in the project area is 561’891 people. Of the total refugee population, 67% (179’765 refugees) are covered by the project. Under the coordination of community health agents, they are involved in a range of activities including assessing their community’s health needs and priorities, planning and implementing local interventions, and assessing their level of success.
FAIRMED agents accompanying the health committee members of Yamba to develop their plan of action for 2016 (Photo: SAIDOU)
The overall aim of the intervention led by FAIRMED is to contribute to the strengthening of a sustainable health system in the targeted regions by involving both the host communities and the refugees. Its action aims to lead to an improved health status for all.
Our methodology is structured around the following steps:
Identifying community health agents
FAIRMED, in collaboration with the Ministry of Public Health, assisted the community (refugees and local) in the selection of community health agents by providing community leaders with a set of criteria for them to identify suitable candidates. The most important criteria were understanding and speaking the local languages, gender, willingness to work on a voluntary basis, and expressing a high motivation to serve the communities. The ability to read and write was desired, but not mandatory. The purpose of this strategy was to mobilise community participation in the health system in a context where resources are scarce and the demand for health services is rapidly growing.
Strengthening the capacity of community health agents
The capacity of the community health agents and the health workers at the local health centres has been strengthened. The training program covered the role of community health agents, the importance of community participation in building a sustainable health system, general health concepts, referrals, epidemic diseases and methods of prevention, elementary health care, management skills, communication techniques and some record keeping. The capacity building activities also focused on the development of individual leadership within the community.
FAIRMED agents meeting with the community leader in Kombo Laka to present to him the need to for his implication in the management of health problems. (Photo: Oumar Franky)
Involvement and participation of the community
The project encouraged the involvement of the community to pro-actively participate in the development of a healthy socio-sanitary environment. Activities consisted in the setting-up and hosting of dialogue platforms, which brought together community health agents and health workers. Three types of platforms were set up: district health committees at the district level, as well as a health committee and a management committee in each health centre. These platforms are led by the community health agent, assisted by the health worker as the secretary.
Health education in a refugees community
The strategy permits the health services to reach the community and ensures accountability of the health system to the community by involving them in the daily management of health centres, including the internally generated funds of the these centres.
Cost recovery of drugs and health services ensures their availability at affordable prices in the community pharmacies and health centres, and facilitates equitable access for all segments of the communities, including the refugees. Price lists are reviewed and revised routinely every two years in open workshops that bring together the community (both refugees and local populations) and health workers. In close collaboration with the Ministry of Public Health, FAIRMED organises these workshops and moderates them. The resulting price lists take into consideration the economic power of the community and the need of the health system to cover its costs.
Mobilization of other community resources
FAIRMED lobbied for the involvement of the municipal councils into the local health facilities. As these councils dispose funds and invest in their areas of jurisdiction, FAIRMED and the UNHCR organised meetings with the mayors and stressed the important role they could play in improving the health conditions of their populations. The municipal councils thus contributed resources to improve healthcare facilities, for instance by recruiting nurses and equipping some health centres in the project area.
FAIRMED agents presenting management tools to the management committee of KOMBO-LAKA. (Photo: Oumar Franky)
In the eight health districts of the project intervention zone, 790 community health agents were selected by their communities, of which 35% are refugees. They reflect the ethnic, gender, geographical and social diversity of the local population and the refugees. Female community health agents were particularly encouraged to take part in the project due to their ability to represent and articulate women’s interests and health needs.
The capacity building of the community health agents and health workers has led to the development of a partnership within them. Prevention and promotion activities such as mobilisation, sensitization, home visits, health education, and vaccinations are now supported by community health agents. Under the supervision of FAIRMED and the regional delegation of public health, each community health agent assures that these activities are effectively carried out in his/her community and reports to the health committee of the health area.
In total, 53 health and management committees have been set-up in the health centres. Their work has improved health coverage of the local and refugee populations. They participate in identifying, planning, executing, monitoring and evaluation of the health programs and are accountable to the community. In addition, they ensure the participation of the community and make their voices heard at the central level.
Cost recovery led to the harmonisation of prices, and to a better affordability and accessibility of health services for poor people. The price lists were translated into the local languages and are now available in all communities. This helped to increase transparency and boosted confidence of the communities in the health system, which, in turn, has led to higher utilisation of health services and more funds generated by health centres.
By mobilising the local authorities, the council of Meiganga in the Adamawa region became more aware of the health problems and the need for her participation. The council, under the auspices of the Ministry of Public Health and technical support from FAIRMED, thus employed 14 health workers that were posted in areas with limited or no human resources for health.
Thanks to the participation of all community entities, the health system of three regions in Cameroon progressively recovered from the shocks caused by the high influx of refugees. It is now better able to provide appropriate health services. The use of community health agents has considerably reduced human resource shortages, especially in areas which previously suffered from low health worker coverages. Community involvement has ensured the availability of health services and has improved the geographical access of the community to the health centres. Cost recovery and the contribution of resources from the municipal councils have improved financial participation of the communities. All these have led to higher health service utilisation and the construction of a more resilient health system that is better prepared to respond to future shocks.