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Cameroon eConomiC Update
Twa Geate Equt
A Special Focus on Health
July 2013
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2013 International Bank or Reconstruction and Development/The World Bank
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Telephone: 202-473-1000; Internet: www.worldbank.org
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The risk o claims resulting rom such inringement rests solely with you.
The ndings, interpretations, and conclusions expressed in this work do not necessarily relect the views o
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guarantee the accuracy o the data included in this work. The boundaries, colors, denominations, and other
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the legal status o any territory or the endorsement or acceptance o such boundaries.
Nothing herein shall constitute or be considered to be a limitation upon or waiver o the privileges and immunities
o The World Bank, all o which are specically reserved.
Photo credits:
Raju Singh/World Bank - Cover: Middle photo
Edmond Bagde Dingamhoudou/World Bank - Cover: Let & Right photos; pages vii, 1 & 25.
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table of Contents
AbbrEiATions And Acronyms .......................................................................................... v
AcKnoWLEdGEmEnTs ........................................................................................................... v
inTrodUcTion .......................................................................................................................... 1
rEcEnT Economic dEELopmEnTs ....................................................................................3
Growth ........................................................................................................................................................3
Inflation .......................................................................................................................................................4
Fiscal Performance ....................................................................................................................................5
Outlook for 2013.........................................................................................................................................6
Options for Going Forward ........................................................................................................................ 7
HEALTH in cAmEroon........................................................................................................... 15Introduction ................................................................................................................................................ 15
Cameroons Health Prole ........................................................................................................................ 15
Resource Allocation ...................................................................................................................................19
Options for Going Forward ...................................................................................................................... 25
rEFErEncEs ........................................................................................................................... 29
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Cameroon eConomiC Update
abbreviations and aCronyms
BEAC Banque des tats dArique Centrale (Central Bank o Central Arican States)
CAR Central Arican Republic
CEMAC Communaut conomique et Montaire de lArique Centrale
(Economic and Monetary Community o Central Arica)CFAF CFA Franc
CPI Consumer Price Index
CU Customs Union
DHS Demographic Health Survey
DRC Democratic Republic o Congo
ECCAS Economic Community o Central Arican States
ECOWAS Economic Community o West Arican States
GDP Gross Domestic ProductHMIS Health Management Inormation System
IMF International Monetary Fund
LPG Liqueed Petroleum Gas
MICS Multiple Indicator Cluster Survey
MOH Ministry o Health
OPSF Oil Price Stabilization Fund
RBF Results-Based Financing
SAM Social Accounting Matrix
SNH Socit Nationale des Hydrocarbures (national oil company)
SONARA Socit Nationale de Rafnage (national renery)
US$ United States Dollar
VAT Value Added Tax
WEO World Economic Outlook
WHO World Health Organization
y-o-y Year-on-year
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Cameroon eConomiC Update
aCKnoWledGements
The Cameroon Economic Updates are produced by
a Team led by Raju Jan Singh. Abel Bove and Paul
Jacob Robyn prepared the chapter on health under
the supervision o Gaston Sorgho. For this purpose,
the Team has built upon the recently-completed
Country Health Status Report or Cameroon. Franck
Adoho, Thomas Dickenson, Carlo del Ninno, and
Christian Zamo carried out the work on uel subsidies.
OtherTeam members include Simon Dietrich, Sylvie
Ndze, and Manuella Lea Palmioli.
Comments received rom Ulrich Bartsch, Jrome
Bezzina, Dominic Haazen, Santiago Herrera,
Faustin-Ange Koyasse, Katherine Manchester, Ha Thi
Hong Nguyen, Hannah Nielsen, Dominique Njinkeu,
Cia Sjetnan, and Erik von Uexkull are grateully
acknowledged. Greg Binkert (Country Director or
Cameroon), Mark Thomas (Sector Manager), and
Olivier Godron (Country Program Coordinator)
provided guidance and advice, and have been an
invaluable source o encouragement.
The Team has also greatly beneted rom consultations
with Cameroons key policy makers and analysts, who
provided important insights, in particular the ollowing
institutions: the BEAC, the Technical Monitoring
Committee (CTS), the Ministry o Economy and
Planning, the Ministry o Finance, and the National
Institute o Statistics. The Team is also grateul to their
colleagues at the International Monetary Fund.
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Cameroon eConomiC Update 1
introdUCtion
With these Cameroon Economic Updates, the World
Bank is pursuing a program o short and requent
reports analyzing the trends and constraints in
Cameroons economic development. Each issue,
produced bi-annually, provides an update o recent
economic developments, as well as a special ocus
on a topical issue.
The Cameroon Economic Updates aim to share
knowledge and stimulate debate among those
interested in improving the economic management
o Cameroon and unleashing its enormous potential.
The notes thereby oer another voice on economic
issues in Cameroon, and an additional platorm
or engagement, learning and exchange. This sixth
issue o the Cameroon Economic Updates is entitled
Towards Greater Equity A Special Focus on Health.
There has been little improvement in Cameroons
health indicators over the past two decades. The
under-ve child mortality rate has only been reduced
slightly, while lie expectancy has, in act, declined.
The burden o health care nancing is largely born by
households, and risk-pooling mechanisms are quasi-
inexistent. Furthermore, the limited public resources
allocated to health do not seem to be deployed
where they are most needed. As a result, substantial
disparities exist in health outcomes between rural and
urban areas, as well as across socio-economic groups.
The introduction o program budgeting in 2013
should improve the efciency o public spending. Line
ministries will have now more lexibility in preparing
and executing their budgets, but will also be held
accountable or results. In addition, an eective
data collection and management system would help
decision-makers monitor health outcomes more
regularly and ensure that budgetary allocations are
based on needs and perormance. Cameroon could
also begin taking steps towards an extension o
prepayment and risk-pooling mechanisms, such as
mutual health organization and mandatory ormal
sector insurance. By reducing individual costs, such
policies would increase access to health services or
the poor and protect them rom spending shocks due
to health emergencies.
A results-based approach in health, which provides
unding based on results and rewards perormance
through additional budgetary allocations and
bonuses, is currently being piloted in Cameroon.
The preliminary results o this approach are
encouraging. An extension o this initiative may be an
option to improve health services and outcomes, and
ensure greater coverage o health services.
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Cameroon eConomiC Update 3
reCent eConomiC developments
Growth
In spite o slow economic growth worldwide, recent
estimates conirm that Cameroons economy
continued to gain momentum in 2012 (Figure 1).
Growth is estimated to have reached 4.4 percent
in 2012 (compared with 4.2 percent in 2011) on the
back o continued strong perormance both in oil and
non-oil activities. Credit to the economy has, however,
been subdued, rising by 2.6 percent.
As in 2011, the tertiary sector was the main driver
o growth, expanding by more than 5 percent, with
transports, communications and nancial services
being particularly dynamic. In the primary sector,
economic growth was mainly driven by industrial
and export-oriented agriculture, especially by the
production o coee, cotton and rubber (Figure 2).
Cotton production, or instance, is estimated to have
expanded by more than a third ollowing the return
o armers to the sector coupled by an expansion o
production areas.
Problems related to electricity production and
delays in the oil sector have dampened, however,
economic perormance and pushed growth to
the lower end o our projection range. Activities in
electricity, gas, and water slowed down in 2012,
expanding by a mere 0.4 percent (compared with
3.6 percent in 2011) because o low rainall and
delays in the operations o the new gas-ired power
plant in Kribi. Worsening electricity shortalls have,in turn, hampered the aluminum sector: estimated
exports were down by a third in 2012.
In the oil sector, as expected, the downward trend
in production observed over the past years was
reversed in 2012 and oil production expanded to
22.4 million barrels, compared to 21.6 million barrels
the year beore (Figure 3). This reversal also allowed
an expansion in oil exports, narrowing the countrys
external trade deicit rom 2.3 percent o GDP in
2011 to 1.6 percent o GDP in 2012. The pick-up in
oil production was, however, lower than projected
fiGUre 1: sc Cu
Gdp Gwh, 200712(n rcnt)
2007
Primary Sector Secondary Sector (excl . oi l)
2008 2009 2010 2011 2012
6
4
2
0
2
GDP Growth
Oil
Tertiary Sector
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 2: ex pc, 2012(y-o-y rcnt chng n volum )
40
30
20
10
0
10
20
30
40
Aluminum Cocoa Logsand woodproducts
Bananas Coffee Cotton
Sources: Cameroonian authorities and Bank Staf calculations.
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Cameroon eConomiC Update4
(at 3.5 percent instead o 5.1 percent) because o
operating delays in new elds.
Economic growth remains nevertheless disappointing
in Cameroon. Poor inrastructure, an unavorable
business environment, and weak governance
continue to hamper economic activity and make
it diicult to reach the growth rates needed to
reduce poverty in a sustainable manner. The rates
o economic growth observed over the recent
past have not been ast enough to deliver tangible
improvements in the living conditions or the average
Cameroonian. Overall, poverty rates in Cameroon
have virtually stagnated between 2001 and 2007,
and disparities between regions have widened, as
pointed out in previous issues o our Cameroon
Economic Update. Meanwhile, many other Arican
countries have managed to reduce their poverty
rates, sometimes quite signicantly (Figure 4).
Ination
The pace o inlation slowed down in 2012, remaining
below the 3 percent regional convergence criterion
(Figure 5). The overall price level increased by
2.5 percent in December (y-o-y) compared to
2.7 percent over the same period the year beore.
fiGUre 4: ruc p, sc
Cu, e 2000-l 2000,(n rcnt o oulton)
Cameroon
Tanzania
Burkina
Faso
Benin
Swaziland
Zambia
Mali
Botswana
Rwanda
16
14
12
10
8
6
4
2
0
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 5: sc pc: 200612(y-o-y chng n rcnt)
Total (Headline) CPIFood Price Index
4
2
0
2
4
6
8
10
12
14
Ap
r-
06
Au
g-
06
De
c-
06
Ap
r-
07
Au
g-
07
De
c-
07
Ap
r-
08
Au
g-
08
De
c-
08
Ap
r-
09
Au
g-
09
De
c-
09
Ap
r-
10
Au
g-
10
De
c-
10
Ap
r-
11
Au
g-
11
De
c-
11
Ap
r-
12
Au
g-
12
De
c-
12
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 3: o puc 20022012(n mo rrl)
Source: SNH.
4
9
24
19
14
29
39
44
34
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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reCent eConomiC developments 5
Inlation was mainly driven by pressures on ood
prices, peaking at 4.5 percent (y-o-y) in May, but
subsiding ollowing improved ood distribution
and strong harvests. The stability o retail prices
or petroleum products has also contributed to
containing inlationary pressures.
The rise in prices is, however, unevenly spread across
the countrys territory (Figure 6). In 2012, inlation
was lowest in Yaound and Douala, the two main
cities, with rates at 1.0 and 2.1 percent on average,
respectively. Price pressures were the highest in
Maroua (Far North) at 5.5 percent. These price
pressures were partly the result o the widespread
loods in the region in August and September which
caused substantial material destruction, including
homes, agricultural land (rice ields primarily),
and killed an important number o livestock. Thedierence in inlation rates may also indicate poor
inrastructure, especially in the North, making it
expensive to transport goods.
Fiscal Performance
On the iscal side, the latest estimations or 2012
are consistent with the projections presented in
the January 2013 issue o the Cameroon Economic
Update (see Table 1). On a cash basis, the overall
2012 deicit (including grants and beore payment
obligations) is estimated to be lower than budgeted,
primarily as a result o higher oil revenues caused
by stronger-than-expected international oil prices.
Estimated total spending was in line with the
budget, with slight slippages in current spending
compensated by lower capital outlays in the last
quarter o the year. As a result, the non-oil primary
deicit is estimated to have shrunk by almost two
percentage points o non-oil GDP, going rom
8.6 percent o non-oil GDP in 2011 to 6.7 percent o
non-oil GDP in 2012.
fiGUre 6: ag i mj C(n rcnt)
0
1
2
3
4
5
6
Yaound
Douala
Bua
National
Ngaoundr
Garoua
Bertoua
Ebolowa
Bamenda
Bafoussam
Maroua
Sources: Cameroonian authorities and Bank Staf calculations.
table 1: fc pc, 201112(n rcnt o Gdp)
2011Est. 2012Budget 2012Jan Proj. 2012Est.
revenue and Gant 18.8 17.8 18.9 18.9
Oil Revenue 5.3 4.4 5.1 5.4
Non-oil Revenue 13.0 12.9 13.2 13.1
Grants 0.5 0.5 0.5 0.4
Ttal spending 21.8 20.0 19.7 20.0
Current Spending 15.4 13.8 13.5 14.1
Capital Spending 6.4 6.2 6.2 5.9
oveall balance 3.0 2.2 0.8 1.1
Payment Obligations 0.5 0.2 0.2 0.9
oveall balance n a cah ai 3.5 2.4 1.0 2.0
Sources: Cameroonian authorities and Bank Staf calculations.
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Cameroon eConomiC Update6
These narrower scal decits on a cash basis relect,
however, a continued accumulation o new payment
obligations (particularly related to uel subsidies).
These payment obligations the stock o which is
estimated to have reached about 5 percent o GDP
at end 2012 will continue to put pressure on the
Governments cash position. SONARA, the national
oil renery, as well as uel importers, aces revenue
shortalls stemming rom the Governments policy
o reezing retail prices or petroleum products.
As mentioned in previous issues o our Economic
Update, the budgeted amount or compensating
or these costs alls short o the likely actual gures:
in 2012 an estimated CFAF 450 billion (3.5 percent
o GDP) was needed instead o the CFAF 170 billion
that was budgeted. Despite the cancellation o
substantial levels o unpaid taxes, an accumulation
o new payment obligations to SONARA reaching
0.3 percent o GDP could not be prevented in 2012.
Outlook for 2013
With the construction o large inrastructure projectsand continued eorts to improve agricultural
productivity, the economic momentum observed
in 2012 is expected to carry over into 2013. The
production at the Kribi gas station (216 MW) is
expected to reduce power bottlenecks. In addition,
the arrival o a new operator in the telecommunication
sector is expected to oster investment and activity in
this sector. Furthermore, the oil sector is projected to
continue its recovery, with production estimated to
increase by a urther 15 percent in 2013. This wouldpush overall economic growth to about 5 percent
in 2013.
Uncertainty, however, will likely continue to surround
developments in advanced economies, making
any economic projections particularly challenging.
According to the most recent release rom the
European Commission, condence remains weak in
the Eurozone and will continue to weigh on investment
and big-ticket consumption decisions (Figure 7). The
regular quarterly surveys o proessional orecasters,
carried out by the European Central Bank, capture
this growing gloom. The average 2013 growth orecast
or the Eurozone has declined over the past quarters,indicating now the expectations o a continued
economic contraction (Figure 8).
More worrisome, the latest vintages o the IMFs World
Economic Outlook indicate continuous downward
revisions or projected imports or Cameroons
main export markets, with demand in many markets
expected to decline in 2013 (Figure 9). Import
volumes are now expected to decrease in Spain and
Italy the irst and ith largest export markets or
Cameroon by about 5 percent and 3.5 percent,
respectively. Furthermore, the pick-up in the economy
fiGUre 8: eu-Z 2013 Gdp Gwh m
p pjc(n rcnt)
1
0.5
0
0.5
1
1.5
2
2.5
2010 2011 2012 2013
Fourth Quarter 2012
First Quarter 2013
Second Quarter 2013
Sources: Survey o Proessional Forecasters, European Central Bank.
fiGUre 7: eu-z ecc s
ic, 201013(inx 100 = 2000)
80
85
90
95
110
105
100
Feb-10
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
Feb-11
Apr-11
Jun-11
Aug-11
Oct-11
Dec-11
Feb-12
Apr-12
Jun-12
Aug-12
Oct-12
Dec-12
Feb-13
Apr-13
Source: European Commission.
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reCent eConomiC developments 7
expected in the Netherlands and France six months
ago has given way to a prospect even gloomier than
a year ago. Although remaining in posit ive territory,
even projections or demand in China have been
subject to downward revisions.
Concerning scal perormance, on the basis o the
rst quarter, the projections or 2013 would indicatea wider overall iscal deicit in Cameroon than in
2012. Budgeted revenues are based on ambitious
expectations or the countrys economic growth
and or international prices or crude, and thereby
are subject to downside risks. Furthermore, the
cost o uel subsidies remains under budgeted,
which undermines transparency, and will weigh
again on the cash position and execution o the
budget. A continued reeze o retail petroleum prices
would require an estimated CFAF 430 billion (about
3 percent o GDP), but only CFAF 220 billion have
been budgeted. Upcoming local elections could add
urther pressure on spending, as could the resolution
o the situation o some nancially troubled banks and
nancial losses expected rom certain state-owned
enterprises.
Options for going forward
Against this backdrop, eorts to increase the
Cameroonian economys resilience to shocks should
be strengthened, possibly through increased trade
diversiication, prudent debt management, and
increased eiciency in public spending. The latter
would include an examination o the various possible
options to reduce the budgetary burden caused by
subsidies, especially those or petroleum products.
Diversiying trade partners
W i t h h i g h - i n c o m e c o u n t r i e s c o n t i n u i n g t o
restructure, rebalance, and restore their iscal
policies to a sustainable path, export prospects to
table 2: fc pc, 2013(n Cfaf llon)
2013Budget
2013Q1
2013Est.
revenue and Gant 2649 586 2582
Oil Revenue 705 100 711
Non-oil Revenue 1878 486 1815
Grants 66 0 56
Ttal spending 2971 468 3078
Current Spending 2014 366 2207
Capital Spending 957 102 871
oveall balance 322 118 496
Arrears 26 44 44
oveall balance n a cah ai 348 74 540
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 9: 2013 i vu pjc,
m tg p(vrton n rcnt)
6 4 2 0 2 4 6 8 10 12
Italy
France
China
Netherlands
Spain
WEO Apr-2012 WEO Sep-2012 WEO Apr-2013
Source: International Monetary Fund.
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Cameroon eConomiC Update8
Cameroons traditional markets will remain limited.
In this environment, Cameroon could think about
diversiying its export markets even urther away rom
its traditional partners. A more diversiied product
base, as well as more diversiied markets, would
increase the resilience o the economy and reduce
its vulnerability to external shocks.
More than hal o developing country trade is now
with other developing countries (up rom 37 percent
in 2001). Even excluding Chinas exports to other
developing countries and its imports rom them, trade
between the remaining developing countries has also
outpaced trade with high-income countries by a wide
margin over the last decade. Interestingly, the rapid
expansion o intra-developing country trade relects
more than just trade in commodities, with the value
o developing-country exports o manuactures rising
at about the same rate as the value o commodities
as a whole.
As already pointed out in last years July issue o
ou r Cameroon Economic Update, Cameroon is
ideally positioned to take advantage o the economicopportunities oered by greater trade. Due to its
strategic location neighboring Nigeria, the Democratic
Republic o Congo (DRC), and Gabon, and potential
crossing point to the landlocked countries o Central
Arica (Chad and the CAR), Cameroon is a natural
hub or the region with the port o Douala as the main
entrance.
In addition, the country is diverse with a geography
that ranges rom Sahelian semi-desert in the norththrough grassland to equatorial orest in the south,
avoring varied economic and agricultural activities.
Furthermore, Cameroon is endowed with signicant
natural resources, including oil, high value timber
species, and agricultural products (coee, cotton,
cocoa). Untapped resources include natural gas,
bauxite, diamonds, gold, iron, and cobalt.
Seizing trade opportunities in the regional context
could provide a good learning ground or becoming
competitive on the world scene. The region seems to
oer promising markets or Cameroonian products,
especially agricultural ones, and may be easier to
enter, as their standards would be closer to those o
Cameroon. In this regard, the CEMAC Customs Union
(CU) should become a reality through the adoption
o a harmonized tari nomenclature, standards,
common customs regulations, and a regional
payment system. Beyond CEMAC, there would be a
need to acilitate trade between CEMAC countries and
the DRC, as well as the rest o the ECCAS.1 Cameroon
could also capitalize on the trading potential with
the vast consumer market in Nigeria and, through
Nigeria, access the entire ECOWAS regional market.2
Traders in Cameroon are still aced, however, with
burdensome procedures or both exports and
imports. It takes or instance 12 documents to import
a commodity and 11 documents to export one in
Cameroon as compared to an average o about 6 to
8 in a sample o emerging economies. Port efciency
needs to be improved. Dwell time at Douala the
amount o time a shipment waits at the port was
18.6 days in 2010, compared to an average dwell
time o our days in Durban (South Arica), 11 days
in Mombassa (Kenya) and 14 days in Dar es Salaam
(Tanzania). Movements o reight inland should also
be made easier and cheaper. This would require, in
addition to better roads, a more competitive transport
sector and ewer roadblocks.
Prudent debt management
The most recent joint IMF-World Bank low-income
country debt sustainability analysis indicates thatCameroons risk o debt distress remains low, opening
the possibility or some limited non-concessional
1 CEMAC reers to the Economic and Monetary Community o
Central Arica. Member countries include Cameroon, Chad, the
Central Arican Republic, Equatorial Guinea, Gabon, and the
Republic o Congo. ECCAS (the Economic Community o Central
Arican States) is a wider grouping o Central Arican States and
includes, in addition to the CEMAC countries, Angola, Burundi,
the Democratic Republic o Congo, Rwanda, and Sao Tome and
Principe.
2 ECOWAS (the Economic Community o West Arican States)includes Benin, Burkina Faso, Cape Verde, Cte dIvoire, Gambia,
Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria,
Senegal, Sierra Leone and Togo.
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reCent eConomiC developments 9
borrowing. In this context, the authorities are actively
using the room provided by the countrys low level
o public debt to tap non-traditional creditors and
the nascent domestic capital market by issuing a
Government bond and Treasury bills (Figure 10).
These provide alternative sources o inancing or
the budget, complementing any possible shortall in
scal savings.
Tapping the emerging domestic capital market could,
however, also be a source o vulnerability. In this
regard, eorts to create a liquid secondary market
or Government bonds would help sustain investors
interest in uture bond issues. Improvements in scal
reporting would also oster investors conidence,
since it will make the Governments iscal position
more transparent. Furthermore, stronger project
selection and preparation would contribute to
ensuring that the proceeds o new borrowing wouldbe put at the most productive use.
As the Government is turning to non-traditional
creditors and non-concessional external borrowing,
its debt management capacity would also need to
be strengthened, building on recent achievements.
The ongoing crisis in advanced economies oers in
this regard both opportunities and challenges. Banks
in advanced economies seem to be increasingly
interested in Cameroons economy, attracted by itseconomic growth and low debt levels. At the same
time, the nancial conditions attached to these loans
may not always be attractive or the country or be
easily analyzed.
The National Committee or Debt Management hasbecome ully operational and its Technical Committee
is meeting regularly to discuss technical issues on
debt management. The authorities are strengthening
their analytical capacity to better analyze oreign
lending proposals and are making progress in the
preparation o a Medium-Term Debt Management
Strategy. Protection against operational risks has
also improved with a more rigorous and secure debt
recording system, ensuring sae backups o the
databases. However, the legal ramework governingdebt management could be claried and institutional
responsibilities centralized.
More efective public spending
Cameroon could also try to increase the value o
the public money it spends. In many areas, public
spending does not seem to be going where it
could have the highest impact. Per student public
investment in primary education does not seem to be
driven by the needs o classrooms, or instance (i.e.
the number o students by classrooms). According
to the data rom the project logbook (Jo ur na l
des projets), the departments where the number
o pupils per classroom was the highest in 2011
fiGUre 10: puc d, 200412(n rcnt o Gdp)
0
10
20
30
40
50
60
70
2004 2005 2006 2007 2008 2009 2010 2011 2012
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 11: puc i p
euc (2012) . nu su(2011)
0
0 80 120 140604020
Number of students per classroom
100 160
6
4
2
8
12
14
10
Sources: Cameroonian authorities and Bank Staf calculations.
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Cameroon eConomiC Update10
received the least investment per pupil the ollowing
year (Figure 11).3 As we will see in the next chapter, a
similar observation can be made in the health sector.
Reducing the fiscal burdeno uel subsidies
The composition o public spending could also be
examined to enhance its eiciency. In this regard,
the increasingly signiicant burden represented by
subsidies, particularly uel subsidies, is a source o
concern. The costs in terms o GDP related to the
3The project logbook covers public investment by project. Only3050 percent o the total investment o budget (deconcentrated
and decentralized spending, as well as some centralized
expenditure) can be mapped geographically.
fiGUre 13: C fu su sc
Cu, 2012(n rcnt o Gdp)
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Cameroon Congo Chad EquatorialGuinea
Gabon Averageoil-exporters
Sources : CEMAC member countries and IMF Staf estimations.
fiGUre 15: du fu su
(xc. k) ic Gu
lc(n rcnt)
Urban Rural
0
20
40
60
50
30
10
2Thepoorest
3 4 5 6 7 8 9 Therichest
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 14: du fu su
lc(n rcnt)
Urban Rural
0
20
60
40
100
80
Fuel (minus kerosene) Kerosene
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 12: C fu su, 20082012(n rcnt o Gdp)
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
.
2008 2009 2010 2011 2012
Sources: Cameroonian authorities, IMF Staf estimations.
decision to reeze retail uel prices have steadily
increased and are the highest in the region (Figures 12
and 13), putting pressure on other budgetary items
that may be more conducive to growth or shared
prosperity.
Subsidies on petroleum products (excluding
kerosene) benet mainly the richest segment o the
urban population: the richest 10 percent (Figures 14
and 15). By contrast, subsidies on kerosene, used
mostly or lighting, avor more the rural areas and
are less biased, although the richest still benet the
most rom this policy (Figure 16). Even in terms o
peoples income (estimated by their consumption),
uel subsidies do not avor the poorest segments
8/22/2019 Cameroon Economic Update No.6, July2013
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reCent eConomiC developments 11
o Cameroons population, representing only about
2 percent o their income (Figure 17).
Transport, public administration and orestry are the
most important consumers o petroleum products
and thus the largest beneiciaries in absolute
terms o the reeze in uel prices (Figure 18). The
transport sector accounts or 30 percent o total
intermediary uel consumption (i.e. uel not directly
used by consumers or exported), while the public
administration and orestry each account or about
15 percent. Agriculture, although representing a
large share o economic activity and employment,
is only a marginal consumer o uel even when
the transport o agriculture products is taken into
account (1.3 percent o total intermediary uel
consumption).
The need or these subsidies, as well as the various
possible options to reduce the budgetary burden they
represent, should be openly and candidly discussed.
As highlighted by other countries experience (Box 1),
a comprehensive and careully planned approach
is essential. The context and constraints to reorm
should be appropriately analyzed and understood
beore making any decisions on the sequencing,
timing, and extent o price changes. Consultations
with stakeholders and the population at large should
also be undertaken to determine an acceptable and
sufcient package o compensatory measures and
avoid surprises.
In this regard, interviews and discussions with ocal
groups undertaken in Cameroon on the subject o uelsubsidies have revealed a very low level o knowledge
on the issue. This would suggest that a signiicant
eort is still required to communicate both the cost
and benets o the current subsidy policies, and the
importance o reorm, notably in terms o scal space
available or public investments. A phasing out o uel
subsidies would create the scal space or urgently
needed investments in other sectors. Reallocating the
CFAF 430 billion (3 percent o GDP and 17 percent o
total Government revenue) projected to be spent onuel subsidies in 2013 to sectors such as education or
health could signicantly improve the living conditions
fiGUre 16: du K su
ic Gu lc(n rcnt)
Urban Rural
0
2
6
8
4
10
12
2Thepoorest
3 4 5 6 7 8 9 Therichest
Sources:Cameroonian authorities and Bank Staf calculations.
fiGUre 17: fu su sh
Cu ic Gu(n rcnt)
0
1
2
3
4
5
2Thepoorest
3 4 5 6 7 8 9 Therichest
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 18: fu Cu sc(n rcnt o totl ntrmry ul conumton)
Fishing2%
Forestry
14%
Transport
30%
Agriculture
1%
Other
37%
Public
Administration
16%
Sources: Cameroonian authorities and Bank Staf calculations.
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Cameroon eConomiC Update12
bx 1: rg fu su - sc C su
Indonesia (1997-2005)
Context: Reorming uel subsidies has been a persistent policy challenge in Indonesia. Indonesia has attempted to
tackle subsidy reorm a number o times to improve the scal position and achieve other policy objectives such as
improving energy efciency and protecting the environment.
Reforms since 1997: The rst two attempts o cutting subsidies in 19 98 and 2003 were unsuccessul. Drastic cuts
instead o a gradual approach, poor communication and general dissatisaction with the Government led to violent
protests and the measures were nally rolled back. Concerned over the increasing scal pressure rom uel subsidies,
the Government undertook two large uel price increases in 2005. As a result, the price o diesel uel doubled and that
o kerosene nearly tripled. Protests again took place in opposition to the reorm, but with less intensity than beore. The
Government was led by President Yudhoyono who was rst elected in 2004 and won a convincing reelection in 2009.
Mitigating measures: The 2005 reorms were accompanied by unconditional cash transers or the poor which
covered 19.2 million households (35 percent o the population). Other measures included the health insurance or thepoor program, school operational assistance program, and expanded rural inrastructure support project. A number
o analyses have credited the reduced intensity o protests in 2005 to the creation o these welare programs.
Lessons: A rapid reduction in subsidies can generate opposition to reorm, while a popular Government and a clear
communication strategy increase the likelihood o success. Targeted cash transers have proved to be eective and
popular mitigating measures.
Philippines (1996)
Context: The Philippines are a net oil importer. Until the late 1990s, the downstream oil sector was heavily regulated,
resulting in price subsidies o uel products when international oil prices rose. The Oil Price Stabilization Fund (OPSF)
stabilized domestic prices o uel products by collecting or paying out the dierence between regulated domestic pricesand actual import costs. Increases in domestic prices were politically difcult to implement. As a result, the national
Government had to replenish regularly the OPSF.
Reforms: Initially, the political environment was not conducive to a uel subsidies reorm, because President Ramos
had won the election only by a small margin and his party was a minority in both chambers o Congress. Nevertheless,
a public communication campaign began at an early stage and included a nationwide road-show to inorm the public
o the problems o oil price subsidies. While the presidents party was a minority in Congress, he set up a coordination
body between the executive and the two chambers o Congress and used it to prioritize the oil deregulation bill and
orge consensus on it. In 1996, the Government passed the law to abolish the OPSF and allow the prices to move
reely. The industry remains liberalized today and movements in international oil prices have been passed through
onto domestic prices.
Mitigating measures: The 1996 law included a transition period during which uel product prices were adjusted monthly
using an automatic pricing mechanism. During this period, the Government provided transers to the OPSF to absorb
price increases in excess o a threshold. More recently, the authorities announced several measures to mitigate the
impact o the ood and uel crisis in mid-2008. The Government launched a package o pro-poor spending programs
that are nanced by windall VAT revenue rom high oil prices. The policy package included electricity subsidies or
indigent amilies, college scholarships or low-income students, and subsidized loans to convert engines o public
transportation to less costly LPGs. In addition, the Government distributed subsidized rice to low-income amilies and
started a conditional cash transer program.
Lessons: The Philippines experience underscores the importance o planning, persistence, and a good communication
plan in achieving a successul outcome. The survival o the reorm to date can be attributed due to its comprehensiveness
and mitigating measures or the poor during the 2008 uel price hike which helped maintain popular support.
Source: International Monetary Fund (2013a).
8/22/2019 Cameroon Economic Update No.6, July2013
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reCent eConomiC developments 13
o Cameroons people, its human capital, and its
productivity. The eect on the overall price level would
also be limited.
An increase in uel prices could have direct and
indirect eects on the cost o living or households.
Directly, households are aected through their own
consumption o gasoline or kerosene. Indirectly, they
are also aected since petroleum products are used
as intermediary products in many sectors and their
higher price will eed into the price o the nal good
produced by these sectors.
To capture both these eects, the interdependence o
sectors needs to be taken into account and a Social
Accounting Matrix (SAM) multiplier analysis has
been used or this purpose. A SAM is an input-output
table, representing the transactions being carried
out between sectors or a given year. It describes
all the income received and expenditures made by
households and various sectors, thus capturing the
linkages within the economy.
Using this ramework, the hypothetical eect on
prices o several scenarios or uel price reorm can
be simulated or il lustrative purposes. Removing all
uel subsidies, or instance, would imply an increase
o 43 percent, 55 percent, and 105 percent or
gasoline, diesel, and kerosene, respectively, and lead
to a one-time adjustment o about 3 percent in the
overall price level (Figure 19). The highest increases
fiGUre 20: ag t pc: a G
C, 2007
(n Us cnt r tkm)
0 5 10 15
Africa: Mombasa-Kampala
Africa: Douala-NDjamena
Africa: Lome-Ouagadougou
Africa: Durban-Lusaka
China
United States
Brazil
Pakistan
West EuropeLong Distance (France)
Source: World Bank.
would be observed in transport, shing, and orestry
(7.5 percent, 7 percent and 5.2 percent, respectively).
The eects o alternative scenarios could be worked
out. Assuming these same increases as above or all
petroleum products except kerosene would suggest a
one-time overall price adjustment o about 2 percent.
Because subsidies or kerosene do not account or the
bulk o the scal costs, excluding them rom a price
adjustment would not erode much the potential scal
savings o this action. This scenario would generate
scal savings o about CFAF 350 billion (2.7 percent
o GDP). Yet another example where the prices or all
petroleum products except again kerosene would rise
by CFAF 150 would lead to a one-time overall price
adjustment o only 1.1 percent, but save the budget
about CFA 210 billion (1.6 percent o GDP).
These one-time price adjustments could be urther
contained through accompanying measures. The
price structure or petroleum products contains or
instance a number o taxes that could be revisited
and simpliied. Furthermore, as mentioned in last
years July issue o the Cameroon Economic Update,
over-regulation plagues the transport systems in
Cameroon. Transport prices charged to shippers tend
to be disconnected rom the actual vehicle operating
costs. The system seeks to protect existing transport
fiGUres 19: pc Chg puc(n rcnt)
0
1
2
3
4
5
6
7
8
Transport Machinemaintenance
Waterand
sanitation
Vehiclemaintenance
Agricultureproducts
ForestryFishing Overallpricelevel
Sources: Cameroonian authorities and Bank Staf calculations.
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Cameroon eConomiC Update14
operators at the expense o encouraging competition.
Inefcient operators and aging truck leets are thus
kept aloat, pushing down the quality o road transport
services to the lowest level possible, since there is
no incentive to oer better services. As a result, the
average transport price on the Douala-NDjamena
corridor, or instance, is about 11 cents per ton Km:
almost double than that o China, three times higher
than in Brazil, and more than ve times higher than in
Pakistan (Figure 20).4
4 Teravaninthorn and Raballand (2009).
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Cameroon eConomiC Update 15
HealtH in Cameroon
Introduction
Over the past two decades, Cameroon has achieved
one o the smallest reductions in the under-ve child
mortality rate in the world and lie expectancy has even
declined. The burden o health care nancing is largely
born by households and risk-pooling mechanisms
are quasi-inexistent. The limited public resources
allocated to health do not seem to be deployed where
they are the most needed. As a result, substantial
disparities exist in health outcomes between rural and
urban areas, as well as across socio-economic groups,
thereby perpetuating poverty and vulnerability.
In light o the aim o making Cameroon an emerging
economy, the lack o progress in health outcomes
should be a source o concern. The role o human
capital has been recognized as being indispensable
to economic growth. Good health raises human capital
and thereore the economic productivity o individuals
and, thereby, the economic growth rate o the country
as a whole. Better health increases workorce
productivity, whether skilled or unskilled, by improving
general physical and mental capacities, such as vigor,
cognitive unctioning and reasoning ability, and by
reducing illness and incapacity. Furthermore, good
health helps improve levels o education by increasing
levels o schooling and scholastic perormance.
Without a labor orce with the minimum levels o
education and health, an economy is not able to
sustain an appropriate and continuous growth path.
The availability o appropriate and timely data on
health is problematic in Cameroon. No annualreport on health statistics has been produced in
over a decade. This does not mean that there is no
data on health generated in Cameroon, but there is
little standardization, collection, consolidation, and
analysis. Health centers routinely ll in reports to the
district authorities which are ofcially in charge o data
collection, planning, and monitoring and evaluation. In
addition, donors and the regional MOH administration
regularly request reports on health activities. This
routine data is, however, rarely compiled at the
national level. As a result, Government and donors
rely on ad hoc and punctual surveys such as national
household survey or Demographic and Health
Surveys (DHSs) to assess and measure outcomes in
Cameroons health sector.
This chapter draws on the recently-completed
Country Health Status Report or Cameroon and is
able to describe Cameroons health prole, discuss
the resources allocated to health (inancial and
staing), and suggest some options going orward.
The introduction o program budgeting in 2013 should
improve the efciency o public spending, narrowing
the gap between needs and budgetary allocations.
In addition, a more eective data collection and
management system would be called or; prepayment
and risk-pooling mechanisms such as mutual health
organization and mandatory ormal sector insurance
may need to be extended; and approaches rewarding
perormance currently being piloted in Cameroon
could be rolled out urther.
Cameroons Health Prole
Over the last two decades, there has been littlechange in Cameroons health indicators. The
under-ve child mortality rate has slightly improved.
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Cameroon eConomiC Update16
About 16 more children out o every 1,000 survive
their rst ve years in Cameroon than two decades
ago. This slight progress pales, however, compared
to an average o 65 additional children surviving in
Sub-Saharan Arica (Figure 21). Lie expectancy in
Cameroon has even declined since 1990 by about two
years, while countries in Sub-Saharan Arica have on
average gained about ve years (Figure 22).
As a result, Cameroons health indicators lag behind
those o the rest o Sub-Saharan Arica and behind
those observed in countries to which Cameroon is
economically comparable (Figures 23 and 24). For
instance, Cameroon has one o the highest under-ve
child mortality rates in the world (122 deaths per
1,000 live births), exceeding the average in developing
Sub-Saharan Arica (108 deaths per 1,000 live births)
with malaria, pneumonia and diarrhea being the main
causes o death. Similarly, its maternal mortality ratio
is also higher than the average or Sub-Saharan Arica
and has increased substantially over the past decade.
The ratio is slightly higher than those observed in
countries such as Liberia and Sudan, and even higher
than neighboring CAR and Chad. Pregnancy and
fiGUre 21: Chg U-5 Ch m
r, 19902010(r 1,000 lv rth)
90
80
70
60
50
40
30
20
10
0
CAR
Cameroon
Burundi
Ghana
Lowermiddle
income
BurkinaFaso
Low
income
Sub-
Saharan
Africa
Senegal
Benin
Nigeria
Sources: World Development Indicators, Bank Staf calculations.
fiGUre 22: Chg l excc
bh, 19902010
(n yr)
4
2
0
2
4
6
8
Cam
eroon
CAR
Coted'Ivoire
B
urundi
Sub-S
aharan
Africa
S
enegal
Nigeria
Lower
middle
income
Low
income
Burkin
aFaso
Benin
Ghana
Sources: World Development Indicators, Bank Staf calculations.
fiGUre 23: U-5 Ch m, 2011(r 1,000 lv rth)
0
20
40
60
80
100
120
140
Cameroon
Sub-SaharanAfrica
(developingonly)
Low
income
countries
Lowermiddle
incomecountries
Middleincome
countries
Source: World Development Indicators.
fiGUre 24: m m, 2010(r 100,000 lv rth)
0
100
300
200
400
500
600
700
800
Cameroon
Sub-SaharanAfrica
(dev
elopingonly)
Low
income
countries
Lowermiddle
inco
mecountries
M
iddleincome
countries
Source: World Development Indicators.
8/22/2019 Cameroon Economic Update No.6, July2013
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HealtH in Cameroon 17
childbirth remain signicant risk actors or mortality:
One woman dies every two hours rom complications
rom pregnancy or childbirth, and one pregnancy out
o 127 is atal.
Within Cameroon, substantial disparities exist in
health outcomes between rural and urban areas and
across socio-economic groups. According to data
rom DHS, progress has been made between 2004
and 2011 in reducing inant mortality rates both in
rural and urban areas, and across income levels
(Figures 25 and 26). Reductions in under-ve child
mortality rates have been most pronounced in the
middle quintiles. Indicators o malnutrition (height
and weight or age) also suggest that the nutritional
status o the population has overall improved since
2004, although the share o children signiicantly
below the average has increased in the poorest
quintile (Figure 27). Despite this progress, mortality
levels remain substantially higher, however, among
the poor and in the rural areas (Figures 28 and 29).
For instance, the under-ive child mortality rate in
households in the poorest quintile (i.e. the poorest
20 percent o households) is more than twice as high
as that observed in households in the richest quintile.
At the regional level, a similar story can be told.
Signicant progress has been made to reduce inant
and under-ve child mortality in many regions, but
major geographic discrepancies remain (Figures 30
and 31). The greatest reductions in chi ld mortality
were observed in the East (90 per 1,000 live births)
fiGUre 25: Chg i m r
lc, 20042011(r 1,000 lv rth)
Urban Rural
30
20
10
0Infant Mortality Under 5 Mortality
Sources: DHS-MICS (2011), DHS (2004), Bank Staf calculations.
fiGUre 26: eu U 5 mr sc-cc su, 200411(r 1,000 lv rth)
30
20
10
5
15
25
35
0The poorest Q2 Q3 Q4 The richest
Sources: DHS-MICS (2011), DHS (2004), Bank Staf calculations.
fiGUre 27: Chg mu, 200411
sc-cc su(n rcnt low -2se)
10
5
0
10
5
Height-for-age Weight-for-height Weight-for-age
Poorest quintile Second Middle Fourth Richest quintile
Sources: DHS-MICS (2011), DHS (2004), Bank Staf calculations.
fiGUre 28: i m r blc, 2011(r 1,000 lv rth)
0
50
100
150
200
Infant Mortality Under 5 Mortality
Urban Rural
Sources: DHS-MICS (2011), Bank Staf calculations.
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Cameroon eConomiC Update18
and the South (50 per 1,000 live births), while the rate
hardly changed in Douala5. Child mortality remains
nevertheless extremely high in the poorest parts o
the country, such as the North or the Far North, where
close to 20 percent o the children born die beore
their ith birthday (191 deaths and 168 deaths per
1,000 live births in the North and the Fart North,
respectively).
5 Changes in under-ve mortality rates between 2004 and 2011
may be over-estimated or the Eastern region because o sample
size constraints in that region in the 2011 DHS-MICS.
fiGUre 31: U 5 m rg, 2011(r 1,000 lv rth)
0
50
100
150
200
250
North-W
est
Douala
Yaound
East
West
South
Littoral(excl
Douala)
Centre(excl
Yaound
)
South-W
est
Adamawa
FarNorth
North
Sources: DHS-MICS (2011), Bank Staf calculations.
fiGUre 30: Chg U-5 Ch m
rg, 200411(r 1,000 lv rth)
100
60
20
40
80
0
20
East
South
Yaound
North-West
West
FarNorth
South-West
North
Littoral(excl.
Douala)
Adamawa
Douala
Centre(excl.
Yaound)
Sources: DHS-MICS (2011), DHS (2004), Bank Staf calculations.
Similar observations can be made in terms o
utilization o health services. While the use o pre-natal
health service is close to 100 percent or the richest
quintile o the population, it is below 60 percent or
the poorest. The richer you are, the more likely you
are to beneit rom delivery assisted by a qualiied
proessional (nurse and/or doctor). The poorest are
more likely to be assisted by a riend or a traditional
midwie. Coverage or assisted deliveries among therichest quintile is almost ive times higher to that
observed in the poorest quintile (Figure 32).
Geographically, the Northern Regions have the ewest
assisted deliveries (Figure 33). Between the two most
recent DHS surveys (2004 and 2011), the percentage
fiGUre 32: a d
sc-cc su, 2011(n rcnt)
0
20
40
60
80
100
Poorest
quintile
Second Middle Fourth Richest
quintile
Source: DHS-MICS (2011).
fiGUre 29: U 5 m r
sc-cc su, 2011(r 1,000 lv rth)
0
50
100
150
200
The poorest Q2 Q3 Q4 The richest
Sources: DHS-MICS (2011), Bank Staf calculations.
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HealtH in Cameroon 19
preventing individuals rom alling into poverty as the
result o catastrophic unplanned medical expenses,
and protecting and improving the health status o
populations by ensuring inancial access to these
essential services.
The way health care is inanced aects the overall
perormance o health systems. Direct purchasing
o health services when needed by an individual
(user ee) is a driver o inequity, as it depends on
this individuals wealth. This eect can be mitigated,
however, through prepayment mechanisms such
as health insurance, pooling the risk at the level o a
group o contributors. Alternatively, public spending
inanced by general taxation and external support
could und the delivery o health services and acilitate
cross-subsidization rom the wealthy to the poor.
In light o the poor results in health indicators,Cameroon overall spends quite a lot compared
to Sub-Saharan Arican countries (Figure 35).
o childbirth deliveries that were assisted by a health
proessional increased on average rom 61.7 percent
to 63.6 percent. In the Far North, however, only
21.8 percent o births were attended by skilled
personnel, compared to 93 percent in the Littoral and
91.6 percent in the West.
Substantial dierences in maternal mortality also
show that pregnancy-related deaths are substantially
higher in rural than in urban areas. Women and
newborns in poor and rural communities have a
higher risk o death and higher chances o early
childbirth (young people aged 10 to 24 in these
segments o the population have a 33 percent
pregnancy rate). Similarly, as shown in Figure 34,
the proportion o children aged 1223 months with
ull immunization varies rom 30.9 percent in the FarNorth to 82.5 percent in the North West.
Resource Allocation
Why are there such great variations in health
outcomes across geographic locations and socio-
economic status? An ef cient and well-perorming
health system should ensure that individuals have
access to eective preventive and curative healthcare. A good health care inancing strategy would
thus aim at reducing inequalities in access to services,
fiGUre 33: a d
rg, 2011(n rcnt)
0
20
40
60
80
100
Douala
West
Littoral(excl.
Douala)
North-West
Yaound
South
South-West
Center(excl.
Yaound)
East
Adamawa
North
FarNorth
Source: DHS-MIS (2011).
fiGUre 34: pcg ch g
1223 h u cc, 2011
Bua
Douala
Ebolowa
Bertoua
Bafoussam
Bamenda
Ngaoundr
Garoua
Maroua
YAOUND
N I G E R I A
C H A D
C E N T R A L A F R I C A NR E P U B L I C
C O N G OG A B O NEQUATORIAL
GUINEA
EQUATORIALGUINEA
N O R D -
O U E S T
S U D -
O U E S TO U E S T
L I T T O R A L
C E N T R E
S U D
E S T
A D A M A O U A
N O R D
E X T R E M E
N O R D
Bua
Douala
Ebolowa
Bertoua
Bafoussam
Bamenda
Ngaoundr
Garoua
Maroua
YAOUND
N O R D -
O U E S T
S U D -
O U E S TO U E S T
L I T T O R A L
C E N T R E
S U D
E S T
A D A M A O U A
N O R D
E X T R E M E
N O R D
N I G E R I A
C H A D
C E N T R A L A F R I C A NR E P U B L I C
C O N G OG A B O NEQUATORIAL
GUINEA
EQUATORIALGUINEA
Bno
u
Vina
Djr
em
Sanaga
Kade
i
Boumba
DjaKom
Nyong
Mbam
Mbu
Faro
Lom
Wouri
Gulf o f
Guinea
LakeChad
10E 12E 14E 16E
12E
10E8E
14E 16E
2N
4N
6N
8N
10N
12N
2N
4N
6N
8N
10N
12N
0 40 80 120
0 40 80 120 Miles
160 Kilometers
JUNE 2013
30.9 EXTREMENORD35.2 SUD
38.1 NORD
47.3 EST
51.6 CENTRE(EXCLUDINGYAOUND)
53.7 ADAMAOUA
63.7 OUEST
66.3 LITTORAL (EXCLUDINGDOUALA)
75.2 SUD-OUEST
82.5 NORD-OUEST
PROVINCECAPITALS
NATIONAL CAPITAL
PROVINCEBOUNDARIES
INTERNATIONAL BOUNDARIES
This mapwas producedby the MapDesignUnitofThe WorldBank.The boundaries,colors,denominations andanyother informationshownonthis mapdo notimply,onthe partofThe WorldBankGroup,anyjudgmentonthe legalstatus ofanyterritory,oranyendorsementoracceptance ofsuch boundaries.
GSDPMMap DesignUnit
CAMEROON
VACCINATIONS, 2011
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Cameroon eConomiC Update20
Cameroon spends US$61 per person on health,
above the average or Sub-Saharan Arica excluding
South Arica (US$ 51), and in line with countries
such Senegal and Nigeria. These numbers include
spending in health sector rom Government, external
donors, and private sources (i.e. out-o-pocket
payments rom beneciaries).
Public spending in the health sector in Cameroon
is, however, low. While public resources allocated to
health have progressively increased over the past
ten years, they remain one o the lowest in Arica
in terms o GDP (Figure 36) at 1.5 percent o GDP.
Relative to the total budget o the Government, the
share allocated to the health sector in Cameroon
also alls below the average o Sub-Saharan Arican
countries and has only recently moved above theaverage o CEMAC countries (Figure 37). The budget
share allocated to health in Cameroon also alls short
o the WHO recommendation o 10 percent, as well
as o its Abuja commitment. The Government o
Cameroon pledged in 2001 in Abuja, along with other
members o the Arican Union, to allocate 15 percent
o its annual budget to the health sector. In spite o
this, public spending or health over the last decade
has never exceeded 9 percent o the total budget.
As a result, out o the US$61 per Cameroonian spent
on health in 2010, the Government contributed
only US$ 17 (i.e. 28 percent o which US$ 8 were
provided by international donors). Compared to
other CEMAC countries, Cameroon has been or the
last decade the country that has allocated the lowest
share o its public spending to health (Figure 38). The
cost o health care is thus largely borne by households
and Cameroon has one o the highest levels o direct
payments rom the users (out-o-pocket) relative to
total health expenditure in all o Sub-Saharan Arica.
Out o 37 countries in Arica with available data or
2009, Cameroon had the th highest level o out-o-
pocket spending relative to total spending (Figure 39).
fiGUre 37: puc Hh exu,
200110
(n rcnt o bugt)
4
6
8
10
12
14
16
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Abuja commitment WHO target Sub-Saharan Africa
CEMAC Cameroon
Source: World Development Indicators.
fiGUre 35: Hh exu, 2010(n Us$ r ct)
0
20
10
40
30
60
50
80
70
DRC
Ethiopia
CAR
Burundi
Mozambique
Gambia
Chad
Benin
Kenya
BurkinaFaso
Senegal
Cameroon
Nigeria
Ghana
CotedIvoire
Sub-
Saharan
Africa*
Source:World Development Indicators.* excluding South Arica, Somalia and Zimbabwe.
fiGUre 36: puc Hh exu,
sc Cu, 2010(n rcnt o Gdp)
0.0
1.0
0.5
2.0
1.5
2.5
3.5
3.0
4.0
4.5
Cameroon
Nigeria
Kenya
Gabon
CAR
Benin
Ethiopia
Sub-
Saharan
Africa
Low
&middle
income
Ghana
Burundi
Senegal
Mozambique
BurkinaFaso
Source: World Development Indicators.
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HealtH in Cameroon 21
Usually when user ees are charged, all patients
pay the same price regardless o their capacity to
pay. Consequently, the risk o nancial catastrophe
and impoverishment is high. When prepayment
mechanisms are not available and patients pay at the
point o service, the sick bear all o the nancial risks
associated with paying or care. The user must decide
i he can aord to receive care, and oten or poorhouseholds this means choosing between paying or
health services and paying or other essentials, such
as ood or education. Oten households are orced to
sell household goods or livestock in order to cover
the cost o health services. According to the 2011
Cameroon Demographic and Health Survey-Multiple
Indicator Cluster Survey (DHS-MICS), among
households who sought any type o health care, the
poorest income quintile was eight times more likely
to cover medical expenditures through the sale o
household goods than the richest quintile (Figure 40).
One way to reduce reliance on direct payments is to
encourage risk-pooling and prepayment methods toinance health care. Risk-pooling mechanisms are,
however, quasi non-existent in Cameroon. In 2006,
there were 120 micro-insurance schemes covering
approximately one percent o Cameroons population.
Since then, Cameroon has put in place a Strategic
Plan or the Promotion and the Development o
fiGUre 38: puc Hh sg, sc
Cu, 1995-2012(n rcnt o totl hlth xntur)
0
20
40
60
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Low & middle income Sub-Saharan Africa
Cameroon CEMAC
Source: World Development Indicators.
fiGUre 40: suc Huh Hh
C fcg, 2011(n rcnt)
0
80
60
40
20
The richest Fourth Middle Second The poorest
Salary/liquid funds
Savings
Loan (with & without interest)
Sale of goods or animals
Sources: DHS-MICS (2011), Bank Staf calculations.
fiGUre 39: ou--ck Hh exu, 2009(n rcnt o totl hlth xntur)
0
20
10
40
30
60
50
80
70
90
Namibia
Botswana
EquatorialGuinea
Mozambique
SouthAfrica
Lesotho
Djibouti
Rwanda
C
apeVerde
Zimbabwe
Liberia
Senegal
Zambia
Bu
rkinaFaso
Burundi
Ghana
Av
erageSSA
Niger
Benin
Guin
ea-Bissau
Ethiopia
Tchad
Congo
Kenya
Mali
Gabon
Uganda
Eritrea
CAR
Togo
Cameroon
Sudan
C
ted'Ivoire
SierraLeone
Guinea
Source: World Development Indicators.
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Cameroon eConomiC Update22
Mutual Health Insurance (20052015), which
aims to cover 40 percent o the population by 2015
through mutual health insurance schemes, but little
progress has been made with only one percent o
the population being covered in 2010. Here, also,
important regional disparities can be observed, with
health insurance coverage in the North-West about
thirty times higher than in the East (Figure 41).
Even when public resources are allocated, available
data suggest that they may not be deployed where
they are most needed. According to the data rom the
DHS and rom the project logbook, or instance, public
investments do not seem to be related to the needs
o the population. Regions where under-ive child
mortality was high in 2004, or instance, received on
average less investment in health in per capita terms
during 201012 (Figure 42).6 The same observation
can be made with regards to assisted deliveries:
regions with lower rates o assisted deliveries in
2008 received, on average, less public unding in
subsequent years (Figure 43).
A similar story unolds regarding health personnel.
Cameroon enjoys one o the highest densiti es onurses and doctors in Sub-Saharan Arica (Figure 44).
With 1.9 doctors per 10,000 people, or instance,
Cameroon is signiicantly above the average o
1.3 doctors per 10,000 people in Sub-Saharan Arica.
The country has also almost twice as many doctors
as the minimum recommended by the WHO (1 doctor
per 10,000 people). The main issue regarding
6 These numbers take also into account each regions area torecognize that providing a given service to a population sparsely
scattered will cost more than i the population was more densely
concentrated.
fiGUre 41: Hh iuc Cg, 2009(n rcnt o oulton)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
North-West
Adamawa
South-West
West
Littoral
South
Centre
FarNorth
North
East
Total
Sources: Etude Diagnostique des Mutulles de Sante au Cameroun
(2010), Bank Staf calculations.
fiGUre 42: puc i Hh
(g 2010-12) . Ch m (2004)
rg
Adamawa
Center
EastFar North
Littoral
North
North-West
West
South
South-West
0
0.01
0.02
0.03
0.04
0.05
0.06
50 70 90 110 130 150 170 190 210 230
Under 5 Child Mortality (per 1,000 live births)
Sources: Cameroonian authorities and Bank Staf calculations.
Several actors contribute to the low coverage and
sustainability o these schemes. Inormation and
awareness among the beneciary populations are not
widespread. Membership is low and in turn revenue
collection is limited. Relations with contracted health
care providers are poor. In addition, inancial and
technical support as well as leadership rom the
associated ministries tends to be limited.
Longer-term plans or expanding prepayment and
incorporating community and micro-insurance
into the broader pool are also important. Pools that
protect the health needs o only a small number o
people are not viable in the long run. A ew episodes
o expensive illness will wipe them out. Multiple pools,
each with their own administrations and inormation
systems, are also inefcient and make it difcult to
achieve equity. Usually, one o the pools will provide
high beneits to relatively wealthy people, who will
not want to cross-subsidize the costs o poorer, less
healthy people.
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HealtH in Cameroon 23
human resources in the health sector is thus not the
numbers, but their distribution across the country.
The distribution o health proessionals is highly
urban-ocused and varies signiicantly by region
(Figures 45 and 46). The majority o physicians inthe country are based in urban areas and more than
hal o Cameroons health workorce is employed in
three administrative regions: the Center, Littoral and
the West, which are home to the three largest cities
in Cameroon (Yaound, Douala, and Baoussam).
The Center Region (including Yaound), home to only
18 percent o the population, accounts or almost
40 percent o the physicians. On the other hand, the
Far North, which is also home to 18 percent o the
population, has only eight percent o physicians. In
addition, absenteeism in Cameroon is a problem,
especially in rural remote areas, and contributes tothe migration o health personnel towards urban
centers. Data rom a recent World Bank study (2012a)
showed that only 32 percent, 45 percent and 58 percent
o health acilities in the South-West, North-West and
East regions, respectively, operated with ull sta on
the day o the survey.
fiGUre 44: phc d, sc Cu, 2009(r 10,000 ol)
Physicians density (per 10,000 population) WHO recommendation (minimum)
0
2
4
6
8
10
Liberia
S
ierraLeone
Malawi
Niger
Ethiopia
Rwanda
M
ozambique
Burundi
Chad
Guinea-
Bissau
Mali
Lesotho
Eritrea
Togo
Zambia
Senegal
Benin
BurkinaFaso
CAR
Ghana
Congo
Guinea
DR
C
Uganda
Average
SSA
Kenya
C
ted'Ivoire
Zimbabwe
Cameroon
Gabon
Botswana
Namibia
CapeVerde
S
outhA
frica
Source: World Development Indicators.
fiGUre 43: puc i Hh
(g 2010-12) . a d
(2008) rg
Adamawa
Far North East Center
Littoral
North
North-West
West
South
South-West
0
0.01
0.02
0.03
0.04
0.05
0.06
1009080706050403020100
Assisted Deliveries (in percent of total)
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 45: Hh s rg
du, 2011(n rcnt o totl)
0
20
10
40
30
50
Center
Littoral
West
FarNorth
SouthWest
North
North-West
East
Adamawa
South
Nurses Doctors
Source: Cameroon Health Workorce Census (2011).
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Cameroon eConomiC Update24
Incentives or health sta to work in diicult
environments or to perorm are limited. Even though
bonuses to health sta are provided, they are based
on skills (i.e. training) and vary based on grade and
years o services rather than perormance. Similarly,
there are limited career options or opportunities
or career development working in rural areas. In
act, being ar rom urban centers tends to have a
negative impact on promotion opportunities. Overall,
health sta are thereore better o working in urban
centers, where living conditions are better, salary
and premium identical, and the chances o being
promoted higher relative to sta in rural areas.
Financial incentives are, however, not the only driver
o motivation. A recent survey o health proessionals
conducted in the Center, North and East Regions o
Cameroon showed that an increase o 50 percent
in salaries was not as important as good working
conditions, i.e. the availability o equipment and
material (Figure 48).7 Were health workers, doctors
and nurses to be given appropriate equipment and
supply o medicine, they would be more than twice
more likely to choose a rural posting than without this
incentive. Rewarding working in difcult conditions
by accessing training and oering opportunities to
progress career-wise is also an important actor o
motivation to ensure retention and service delivery
in remote areas.
7 The survey covered 351 health proessionals (doctors and
nurses) and medical students.
fiGUre 47: U 5 Ch m r (2004)
. Hh p d (2011)
North-West Far North
Adamawa North
South-West East
West
South
Littoral
Center
4
6
8
10
12
14
16
18
90 110 130 150 170 190 210
Under 5 Child Mortality Rate (per 1,000 live births, 2004)
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 48: pc ru J pg(o rto)
0
0.5
1
1.5
2
2.5
Infrastructure
50%B
onus
Career
Development
Lodging
Urban
Transfer
25%B
onus
Accessibility
Sources: Cameroonian authorities and Bank Staf calculations.
fiGUre 46: nu dc
rg, 2011(r 10,000 ol)
0
0.5
1
1.5
2
2.5
North-West
FarNorth
Adamawa
North
South-West
East
West
South
Littoral
Center
Public Private
Sources: Cameroon Health Workorce Census (2011), Bank Stafcalculations.
Furthermore, the distribution o health workers does
not seem to ollow health needs. Looking at the inant
mortality rates across regions in 2004 and the density
o health workers (measured as a ratio to population)
in 2011, density is the lowest in the regions where
health outcomes are the poorest (Figure 47). The
North, Far North and Adamawa Regions had the
highest inant mortality rates in the country, but some
o the lowest densities o health workers.
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Cameroon eConomiC Update 25
Options for Going Forward
Program Budgeting
The introduction o program budgeting starting in
2013 should improve efciency o public spending.
The new approach places the line ministries at the
center o the budget cycle. These ministries will have
now more lexibility in preparing and executing their
budgets, but will also be held accountable or results.
As such, program budgeting addresses many o the
critical short-comings that have aected the countrys
public expenditure management in the past: excessivecentralization o the budget processes, leading to low
budget execution and poor strategic allocation o
resources; and poor value-or-money and quality o
service delivery.
Production and use o highquality data
In this new budget environment, one major
challenge or Cameroon will be to ensure that
resource allocation in the health sector is evidence-
based. Setting up an eective data collection and
management system would be critical to help
decision-makers monitor health outcomes more
regularly, and ensure that budgetary allocations
are based on needs and perormance. Data to
be collected would have to be prioritized and
standards provided or, to ensure that the additional
data collected by external actors are comparable
and usable. A well-designed unctioning health
management inormation system (HMIS) would not
only enable the Ministry o Public Health to design
evidence-based policy and be reactive to unoreseen
shocks (e.g. capturing early signs o epidemic), but
also assess implemented policies.
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Cameroon eConomiC Update26
bx 2: m Hh e d: ru-b fcg
What is Results-based nancing?Results-Based Financing (RBF) is an instrument that links nancing to pre-determined results, with payment made
only upon verication that the agreed-upon results have actually been delivered. RBF or health reers to any program
that transers money or goods to either patients when they take health-related actions (such as having their children
immunized) or to healthcare providers, when they achieve perormance targets (such as immunizing a certain percentage
o children in a given area).
What Makes Results-based Financing different?
Traditionally unding or health has been directed toward inputssalaries, construction, training, equipment. Improved
health was assumed to ollow, but this has not always happened. Despite billions o dollars over the last dec ade, many
countries in Arica are still alling short, particularly in areas that require a unctioning health system. Sub-Saharan
Arica, or instance, has the highest rate o maternal deaths in the world with an average o about 900 deaths per
100,000 live births. Child deaths and malnutrition are also serious problems.
The undamental issue is the poor perormance o the public health care system, including low levels o physical access
in some places; poor quality o care; a lack o adequate incentive structures or health workers; weak management;
and inadequate data o sufcient quality to monitor and evaluate progress. Individuals must demand services; health
workers must be motivated to deliver adequate care; and the institutions they work or must be encouraged to make
the systemic changes required to achieve health goals. RBF lips the whole equation on its head, starting with the
resultmore children immunized, or exampleand letting health workers and managers on the ground decide how
to achieve them.
The Potential of RBF
A number o developing country experiences strongly suggest that RBF can work. There are currently three countries
(Rwanda, Burundi and Sierra Leone) with nationwide programs and 14 countries with ongoing pilots. These programs help
improve health; strengthen health systems; spur innovation, creativity and country ownership; and encourage reorms
that coner authority and lexibility to local service-delivery levels, ostering problem-solving where it is most n eeded.
When poor patients or households have been oered nancial or material rewards or adopting health-promoting
practices, they respond and health indicators improve. Similarly, when health workers and acilities are given bonuses
upon achieving targets, those targets tend to be met. Results-based nancing has also been shown to help to increase
patient demand or health services.
In addition to improving health, results-based nancing can also contribute to strengthening a countrys health
inormation system. Because accurate monitoring and evaluation o RBF schemes require the development o robust
health inormation and management systems, incorporating the RBF concept, even into donor unds aimed at specic
diseases, reinorces eorts to improve the timeliness, credibility and accuracy o national reporting and monitoring,
thus contributing to improving the overall capacity o a countrys health system.
Source: L. Morgan (2012)
In Rwanda, Burundi and Burkina Faso, or example,
the Ministries o Health are able to maintain an
up-to-date HMIS thanks to the use o incentives and
sanctions or the generation and use o HMIS data
at the health acility, district and sub-national levels.
Health acilities receive poor perormance points
and even inancial sanctions i they do not submit
their monthly HMIS report on time. Management o
acility-level data is a key criterion in the evaluation
o the perormance o managers.
Risk-sharing mechanisms and accessor the poor
Cameroon could take steps towards designing
policies that oster access by the poor to health-
enhancing services and protect the poor rom
catastrophic health spending. The extension o
prepayment and risk-pooling mechanisms such
as mutual health organizations, mandatory ormal
sector insurance and potentially cross-subsidization
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HealtH in Cameroon 27
between the two could contribute to reducing
nancial risks associated with illness.
Second, the introduction o pro-poor inancing
mechanisms, such as conditional and unconditional
cash transers and vouchers or health services, could
improve equity and eiciency by increasing public
investments in health while reducing private spending
by the poor. The introduction o voucher-type
systems such as kits obsttricaux to subsidize the
monitoring o pregnancy are currently being piloted
in the Far North, North, Adamawa and East regions.
Getting the incentives right
The national health workorce should be distributed
in a manner that responds to the severe geographic
imbalances in health outcomes in Cameroon and
improve coverage o essential health services. The
question is how to ensure health personnel will
stay in rural areas. In this regard, health workorce
retention policies should include a combination o
both monetary and non-inancial incentives. The
package could include the provision and maintenance
o supplies and equipment or the delivery o a
clearly deined set o basic services, in addition to
salary bonuses or rural postings. Implementation o
this policy may be mo