universal health insurance Cameroon

SYNDICATE OF CAMEROON MEDICAL DOCTORS SCMD)
“2017 Universal Health Insurance for all”
02 August 2016
By SCMD

Actively participated in the drafting of this document
Dr BASSONG Pierre Yves Dr NGO ITALEN HI NGOCK
Dr KAMTA NGUI Claude Bernard Dr TACHE Philippe Marien
Dr NDOUDOUMOU Patrick Christian Dr KITIO ZOGNI Juvelil
Dr LAAH NJOYO Sylvain Dr FOKA Fabrice
Pr ZEH Odile Fernande Dr EPOPA Patricia
Dr SEME ENGOUMOU Ambroise
Dr OKO Apollinaire Legrand
Dr NSONG AKONO MINLO Antoine
Dr ATAH SIELENOU YOUPA Jude
Dr AZAMBOU KENTEU épouse DJOMNANG

I-INTRODUCTION
2035 Emergence will go through a technological and industrial development. The latter is mainly based
on human capital, itself dependent on population health. It would be unrealistic to foresee the
emergence with populations that struggle to treat themselves. The health of Cameroonians will remain
the backbone of any achievements. Many nations have developed for the best, after embracing a
system with universal access to health care. The immediate introduction of universal coverage for basic
health insurance is as a starting point to the long walk. The Syndicate of Cameroon Medical Doctors
(SCMD) in the wake of the vision of the Head of State of Cameroon needs immediate universal health
insurance to cover the health emergency plan carried out across our country. Urgency shown by
unprecedented scandals in hospitals, such as the death of Dr. Ngo Nkana at the Douala General
Hospital due to medical negligence and disemboweling (post-mortem caesarian section) of Madame
Koumatekel in an open air by a care giver at the Douala-Laquintinie hospital. It would be ill looked and
unfortunate not to draw some lessons from the deaths of these noble citizens. In this logic and without
supporting the ‘programmed deaths’ of our citizens by the health care system, medical doctors bring
fought their contributions by providing facts on the feasibility of this proposal.
Health has a price, several nations in sub-Saharan Africa, sometimes poorer than Cameroon have
initiated the basic health insurance with universal coverage; why not Cameroon? The State in its
sovereign role should mobilize and organize all sons, daughters and friends of the nation to pay that
price. This is an achievement that cannot be done without paying a high price, but a price for worth it.
No citizen will say no to this effort of national solidarity, only political factors could be an obstacle to
achieving what should be the foundation of our walk towards the emergence in 2035.

II-OBJECTIVES
Establish a single system of financing health by including key sectors of the society. The health
insurance company would be responsible for:
- A defined percentage of medical care for each inhabitant in the management of common
diseases.
- The total coverage up to 100% of chronic diseases such as hypertension, chronic kidney
disease, cancers....
- The total coverage in the management of psychiatric illnesses.
This system does not exclude the parallel organization of mutual complementary institutions to
participate in financing the cost of care if it overruns.

III-FUNDING MODE
When we speak of universal health insurance, skeptics immediately raise the issue of funding.
Funding possibilities are endless and feasible, only the political will of decision makers is a limit to
the development of this system. In the following, we list a host of financing options:
1. Insurance contributions
 for employees: a fixed percentage of basic salary (e.g. 5% of salary)
 for those in the informal sector: a percentage of their income calculated on the taxable value
(5% income)
 for the self-employed: a monthly plan (1000 francs per month for preschool children, students
and the unemployed citizens)
 which should be able give us an approximate minimal sum of 300 billion CFA francs to
support the health insurance fund;
2. Establishment of a health tax in different sector
2.1-Boarding at airports Income taxes
The Douala International Airport receives about 500 000 passengers per year; and that of Yaoundé
Nsimalen about 200 000. A health tax 5,000 f CFA per passenger would generate about 3, 5 billion
francs CFA to the health insurance fund.
2.2 Taxation-berthing of ships in port
The Autonomous Port of Douala hosts 11 million tons of cargo, a health tax 10,000 per ton of goods
gives 110 Billion f CFA.
2.3-Health tax on alcoholic beverages:
Alcohol is responsible for many problems in our society: liver cirrhosis, cancers, psychiatric problems,
neuropathy, hypertension, diabetes ... it appears quite normal that alcohol should be taxed for the
management of the health problems of Cameroonians.
With 620 million liters of beer consumed by Cameroon in 2013 on only domestic production; by
imposing 100 francs per liter of beer, or less than 50 francs for a beer bottle, this will allow Medicare
to gain at least 62 billion FCFA to the health insurance fund. This, besides imported beer; indeed in
2010, Cameroon imported nearly 11 Million liters of alcohol; which would give around 1 Billion FCFA
to the health insurance fund.

2.4- Tobacco Tax for Health
The harmful effects of tobacco on health are multiple and affects both the mother and the fetus before
birth, with children suffering more than adults. Tobacco kills 66,000 a year in Cameroon and should be
expected to cover the cost of its damage.
With a national consumption of 141 cigarettes per capita per year, a tax of 5 frs per cigarette will allow
the insurance fund to take possession of nearly 16 billion FCFA.
2.5-Hydrocarbon
The combustion of hydrocarbons is one of the main sources of air pollution, this pollution is
associated with increased occurrence of lung disease in different age groups in our society. The
Cameroon on average consumes 11 million barrels per year. By imposing the consumer 10 francs per
liter of fuel; it would bring about 17 billion francs CFA to the health insurance fund.
Domestic gas is consumed up to 90,000 metric tons or approximately 7.2 million gas cylinders year, a
health fee of 200 francs / bottle will give 1.5 billion CFA francs to the health insurance fund.
2.6- Health tax on accident-prone roads
In Cameroon, as elsewhere, road kills, and it appears quite normal taxing movements to finance health
care of populations. This taxation may concern:
 The road tolls to include a health tax: $ 6 billion in 2013; the amount of road
toll could be doubled to enable revenue 6 billion health tax.
 Transport tickets: a surplus of CFAF 100 per ticket sold for inter urban
transport.
2.7- Tax on national and international money transfer
In 2008, money transfer towards the CEMAC countries represented 0.5% of GDP or about 83 billion.
By imposing an agreement with COBAC at a rate of 0.15% that will provide at least 140 million just for
transfers from abroad, not counting those in destinations abroad and internally. This would gain no
less than 250 million for the financing of health.
2.8- Telephony Tax

With a turnover of over 500 billion in 2013 for the Duo telephony leader; a health tax on phone
sector even at 0.5% will bring together at least 3 billion for health insurance
By putting together the section mentioned in paragraph 1 and 2, this would replenish the
insurance fund insurance of at least 520 billion CFA francs or more than 2/3 of the Cameroonian
health expenditure as "the main report on the second survey on the monitoring of public
expenditure and the level of beneficiary satisfaction in the areas of education and health in
Cameroon "and these, excluding the contributions of the State, businesses and development
partners.
3. State contributions
The contributions of the state in the health sector is 5.8% of the national budget in 2016. In April
2001, Cameroon ratified the Abuja agreement which called on the states that have ratified to grant
the health sector 15% of their budgets. This has only increased by 0.9% for over 11 years. We
propose that the Cameroon government meets its commitments by increasing its contribution to
the health sector to at least 12%.
4. Contribution of businesses
Which could be the equivalent of 5% of gross salary for employees.
5. Reception of Aids/Donations by health development partners
IV- ORGANIZATION OF EXPENDITURE
Some changes appear necessary in our health care system to successfully assume the existence of UHI.
These changes are:
1- Regulating the accreditation of personnel involved in the management of the health of Cameroon
The accreditation of personnel directly involved in the management of patients guarantee a minimum
level of mastery of each staff working directly on the patient. This accreditation should be the
responsibility of different orders. The concept of accreditation in certain conditions involve the loss of
accreditation such as a loss of license to practice in his field of expertise. The various license boards
concerned are:
- The Cameroon Medical Council
- The Council of dentists
- The National Association of Nursing, Midwifery and medico-technical Professionals
2- The establishment of an entity responsible for the implementation of standards

The standards here are different:
- Clinical guidelines of care and management of diseases
- The service organization standards
- Standard equipment
- The introduction of in-service and hospitals booklets
3- The establishment of an entity responsible for the accreditation of health facilities before
reception of funding from the UHI
This accreditation is linked to compliance with standards and specification loads.
This entity would be responsible for assessing the functioning of accredited hospitals.
4- Reimbursement for hospital care with a cap on health expenditures by disease and individuals.
V- IMPACT OF UNIVERSAL INSURANCE ON CURRENT PROBLEMS OF THE HEALTH SYSTEM
1- The benefits of UHI
1-1- On access to care
Universal access to basic health insurance enable all Cameroonians to go to the hospital at the
slightest health problem as with better health outcomes; resulting in early treatment of diseases and
thus reducing complications.
1-2- On Health indicators
- - Reduction of Maternal Mortality
- - Reduction child mortality
- - Increased life expectancy
1-3- On the economy and jobs:
- - Improvement of the national economy by reducing work absenteeism
- - Reduced rate of absenteeism at school
- The development and widespread of insurance businesses on the one hand and parallel jobs
of the health sectors such as stretcher bearers, ward mates on the other hand. Indeed a
stretcher bearer is driven to transport the sick, their vigilance limiting complications related to
the mobilization of patients which cuts down the expenditures of the insurance company.

Similarly, the professional development of certain unskilled labor such as hospital the cleaning
staff and ward mates will improve the hygienic conditions of hospitals thereby leading to less
complications related to decubitus positions and nosocomial infections.
- A widespread consumption of generics drugs and medical supplies maybe lead to medium-
term development of the pharmaceutical industry.
- The empowered hospitals become autonomous and thus can benefit from bank financing for
example the establishment of an Imagery service in a hospital will be done on the basis of a
"business plan" that will reassure the bank about the possibilities of Refunds.
1-4- On the quality of care
Refundable aid will be administered by authorized persons and they will be expertly qualified
people in the field or capacity by experts who will sponsor the project. Reimbursable care should
follow the protocols that will be established, allowing standardization of care and for that, supervision-
control mission will be needed.
1-5- On Human Resources
Reimbursable care will be carried out by personnel authorized by the insurance fund. This will require
a health code to define the tasks and responsibilities of each health personnel. The agreement granted
to some and others will simply side usurpers and other practitioner’s nicknames (illegal practitioner
and street pharmacy ...). Hospitals will for this purpose improve the size and quality of health workers
by recruitment and training.
1-6- On clandestine medicine
Reimbursable care should be issued by approved establishments, eliminating ipso facto illegal
settlements.
1-7- On Equipment
Reimbursable care must be justified on the basis of well conducted diagnostics, it will not be
reimbursed for care of stroke if they did not do a CT scan, thereby encouraging the race for hospital
equipment.
1-8- On the management and hospital performance

Empowered, hospitals funding will be based on the provision of care offered entirely by healthcare
workers. The hospital's resources depending on the services offered, the director will be obliged to
provide quality results hence the need for good management.
1-9- On formalizing and computerization of hospitals
Care being reimbursed by insurance, the healthcare provider and the hospital delivering these services
must be approved by the insurance fund. Traceability will be required to ensure the authenticity of the
agreement hence computerization of the system will be necessary. But also for reasons of good
management of patients, data exchange between colleagues will be possible only by a well-developed
computer system. The hospital whose survival depends mainly on reimbursements will develop an IT
service and statistics worthy of the name. Improved statistics opens the door to reliable research.
1-10- On the drug:
Hospitalized patients receiving daily treatment and suddenly limit of loss of money via unused
medication. Indeed in our hospitals, 100% of patients have prescription drugs they could not take.
Disappearance of street drugs, as only authorized pharmacies will be reimbursed.
Regulation and harmonization of public drug prices because there will be a need for universal cost
repayment.
1-12- On the reference system and the servicing of the health district
The reorganization of care will allow patients to consult a specialist on request of the general
practitioner/primary care physician. This will congest first, second and third category hospitals and a
better distribution of the workload.
2- The limits of the UHI
2-1 Cost of care overruns
Some compatriots may require or seek care than the amounts specified. They will in that case receive
a supplementary mutual health insurance or pay out of pocket.
2-2- Certain treatments will not be covered by the UHI
2-3- Corruption in hospitals to increase their finances

Some hospitals might be tempted to falsify statistics to improve their finances. It will be necessary
to develop a monitoring system of supervision accompanied by disincentives.
2-4- Foreign citizens who could join the UHI
VI-Conclusions
Fifteen African countries sometimes less developed than Cameroon have had Universal Health
Insurance (UHI) for several years. Every day, Cameroonian citizens pay with their lives, the high price
of the absence of the UHI. Yet it appears at the end of the simulations, at the top of the problems of
UHI in Cameroon is the absence of political will, as resources are available and what is left to do is
mobilize all actors and all resources. Cameroonian medical doctors grouped under the Syndicate of
Cameroon Medical Doctors (SCMD) openly say they are fed up with this situation and call for the
immediate establishment of a Universal Health Insurance and promise to continue to refuse to work
under these conditions if the Cameroonian government is determined not to adopt this proposal in
the 2017 financial law which had ignored this legitimate claim of its citizens.
SIGN
President Private SCMD President Public SCMD
NGO ITALEN HI NGOCK BASSONG PIERRE YVES

How can we finance a health insurance fund in Cameroon in 2017 (summary)
Regardless of the contributions of the State of Cameroon, businesses and development
partners in the above presented financing scheme, about 75% of the financing needs are
already covered.
HEALTH INSURANCE
FUND (HIF)
(Common Plate)
Levy a tax of 35 francs CFA on each
bottle of liquor. Could Bring at least 63
billion FCFA to the HIF
Charge a health tax on
tobacco by 5 francs CFA per
cigarette stick.
bring at least 16 billion
FCFA to the CAM
Cameroonian monthly
contributions:
-5% of the basic salary for
employees.
-5% of income for people in
the informal sector
-1000 frs CFA / month per
person for other citizens to
non-employees  Bring forth
at least 300 Billion CFA francs
Contributions from
development partners
Charge a health tax on hydrocarbons:
- 10 francs per liter of fuel
- 200 francs per bottle of gas Bring
forth at least 18.5 billion F CFA per
year to the HIF
To charge a tax on shipments at
airports of 5000 frs / passenger.
Will yield about 3.5 billion
CFA francs / year for the HIF
Charging 10,000 CFA francs per ton of
goods through ports and airport of
Cameroon
 Bring at least 110 billion CFA francs
for the HIF
Contributions to the State of
Cameroon (health sector
budget at least 12% of the
national budget)

Levy a tax on domestic and
international money transfers
Exp: 0.15% would give about 140
million / year to the HIF
Levy a tax on accident prone roads:- Road
toll of 1000 with 500 francs donated to the
HIF: at least 6 Billion F CFA- A surplus of 100
CFA francs per tiket sold for inter urban
transport
Levy a tax on telephone Exp: 0.5%
corresponds to 5 CFA francs for 1000
call credit
 Will bring forth at least 3 billion
FCFA per year to the HIF
Ask a monthly contribution from
businesses of 5% of employees'
basic salary

PLANNING ACTIVITIES PRESIDING THE INTRODUCTION OF UNIVERSAL HEALTH INSURANCE
(SCMD 2nd AUGUST 2016)
There is an emergency and time is no longer on our side
PERIOD
ACTIVITIES
September
2016
0ctober
2016
November
2016
December
2016
June
2017
social
consultation
debate on the
contributions of
different social
groups to pool
funding for health
care
Working Group of
Experts on purely
technical aspects
of health
insurance
Adoption of a law
at the National
Assembly on the
creation of a
health insurance
Integration of the
contribution of
the state in the
2017 Finance Act
Creation of the
health insurance
fund of Cameroon
(CAMAC),
organization and
deployment
Involvement of
Cameroonians
into CAMAC
Law on
compulsory
health insurance
for all
Cameroonians

universal health insurance Cameroon

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