Reproductive health in Cameroon

Cameroon was initially colonised by the Germans. After the Second World War, they lost their mandate over Cameroon. The latter was then shared between the French and the English. The French ruled the East while the English ruled the West. Cameroon got her independence in 1960 and became the Federal Republic of Cameroon, made up of the former East and West Cameroon. She later became the Republic of Cameroon in 1972.

1.2. Geography

Cameroon is situated in the Golf of Guinea, extending from the Atlantic Ocean in the south to Lake Tchad in the north. She lies between the 2nd and 13th Latitudes and the 9th and 16th Longitudes. She has a surface area of 475 442 square kilometres.

She is bounded in the south by the Atlantic Ocean (320 km of cost), the Republics of Congo and Gabon, on the east by the Republic of Central Africa, on the north by the Republic of Tchad and on the west by the Federal Republic of Nigeria. She has both the sahelian and equatorial types of climate. Temperatures range between 15 and 40 degrees centigrade. The rainfall averages between 900 and 4 000mm.

One third of the country is covert by forest (the south region) , savanah in the North

1.3. Economy

Cameroon is essentially an agricultural country producing mainly coffee, banana, cocoa, oil palms, wood, rubber and cotton. The currency is francs CFA. The gross national product per capita is 610 US dollars *

1.4. Government

Cameroon has the multiparty system of government with a Presidential politic system. The other power are Legislative with National Assembly and Judiciary.

The president appoints the Prime Minister and Head of Government who in consultation with the latter appoints the ministers. There about 30 ministries including the ministry of public health.

1.5. Culture

Cameroon is a bilingual country. The two officials languages are both French and English.

There are more than two hundred ethnic groups each with a dialect.

The main Religious bodies are Catholic, Protestant and Muslim. Those who can read and write are 75.1% and 52.1% for men and women respectively **

1.6. Education

Cameroon has 2 millions students in Primary and Secondary Schools; 35 000 in Universities and Higher Schools. 6 Universities exists in the country .

1.7. Demography

The population of Cameroon is projected to 14 323 000 of which 49% and 51% are men and women respectively ***. The population of women of reproductive age (WRA) is 23% or 4 000 000 in absolute terms. The annual population growth rate is 2.83%***. The mean fertility rate is 6.1 children per WRA ***. The crude birth rate is 42.5 per 1000 population while the crude mortality rate is 17.5 per 1000 population***.

1.8. Health ressources

- Ministry of Public Health Annual Budget 1998/1999 : 38 099 000 000 FCFA (US $ 6,349,835)

SOURCES :Loi des Finances de la Republique du Cameroun adoptée par l'Assemblée Nationale - Session de Juin 1998

1.9. Organisation of the Health System in Cameroon

Reproductive Health is a component of public health which is managed by the Ministry of Public Health. There are health units which are divided into categories depending on their level of competence. These are in descending order:

i) category one: General Hospitals of which there are three including one University Teaching Hospital;

ii) category two: Central hospitals of which there are three including one Parapublic;

iii) category three; provincial Hospitals of which there are 10

iv) category four: District Hospitals of which there are 136;

v) category five: Sub-Divisional medical centres and

vi) category six: Integrated Health Centres.

In addition to these are mission hospitals and private individual clinics and hospitals. The Ministry of Public Health is divided into directorates and divisions according to specialty as follows:

I) Directorate of human resources

ii) Directorate of finance and infrastructure

iii) Directorate of pharmacy and drugs

iv) Directorate of community health

v) Directorate of hospital medicine

vi) Division of cooperation

vii) Division of studies, planning and communication.

Viii) Division of maternal mental health

2. The evolution of Reproductive Health in Cameroon

Reproductive Health has evolved almost parallely with the health system in Cameroon. The primary health care (PHC) approach was adopted in 1982. It was redefined in 1987 after the Alma-Ata conference with the aim of achieving the main objective which is health for all by the year 2000. The District Health approach was also initiated. A Health District (HD) is a unit in which the community participates actively in the management of its health. It is semi-sufficient in the sense that it can carry out essential health services and only refer difficult cases to the provincial or central level. There are 360 HD in Cameroon.

*World Bank 1998, ** UNESCO 1995, *** United Nations 1998 (WHO Stastitics 1998)

2.1. Arguments for Reproductive Health in Cameroon

Reproductive Health is a concept which has been existing since. It was only reoriented following observations in the early 1970s. It was observed that :

i) maternal mortality was on the rise compared to developed countries;

ii) large family size despite limited resources;

iii) families delivered many children because they feared that some will die-thus they delivered many so that some will die and they will still have some;

iv) perinatal and infant mortality rates were on the increase;

v) children are highly valued in Cameroonian societies;

vi) women were dying from pregnancy-related causes that could be prevented (haemorrhage, sepsis, preeclampsia/eclampsia etc );

vii) a sizeable proportion of the society could not have children when they wanted ( involuntary infertility);

viii) pregnancy and delivery were considered by their partners as the woman's issue only - men only decided on the number of children;

ix) there were few qualified personnel to take care of women during pregnancy and labour;

x) many births took place at home or were conducted by untrained traditional birth attendants (TBA);

xi) many young girls 14-19 years were bearing children.

These and many other issues prompted the few Gynaecologists at the time like Professor Nasah to reflect on RH which was then only concern with the mother and child. Professor Nasah even wrote a book titled " Care of the Mother in the Tropics".

2.2. Why RH became a necessity

RH services were aimed at the following:

i) reduce maternal mortality;

ii) reduce infant mortality rate;

iii) introduce the notion of high risk pregnancy and bring men to participate in taking decisions about pregnancy;

iv) introduce the notion of family planning;

v) train enough medical personnel to take care of women during pregnancy and delivery;

vi) train TBA to be able to recognise high risk pregnancies and or difficult labours and transfer the woman on time

2.3. Structure of RH

As stated above, RH is a concept and does not necessarily need separate structures (buildings, personnel, services etc) to put it in place. All that is needed is that health authorities become aware of the need and introduce it to all services and personnel concerned. The required personnel is trained or recycled accordingly to understand the concept and to perform the necessary services in an integrated manner.

Vertical approaches to health problems have long been shown to be less cost effective and less equitable than an integrated approach. Also, the different elements of RH are so closely linked and interrelated that one structure can handle many of them at the same time. Therefore, elements like STD/AIDS diagnoses, treatment and prevention, family planning, complications of illegal abortions, infertility, neonatal care (vaccinations, screening for malnutrition etc), pregnancy and post partum care ought to be treated together. This will not only save time and reduce the need for infrastructure and personnel but it will also be time saving for the clients and so increase compliance. In this system all that is needed is a good reception service to receive and orientate clients.

The referral system is from the health centres to the to the DH. From the DH to the Provincial hospitals ( PH). From the PH to the Central Hospitals or the General Hospitals. The flow chart shows the patient movement.

INTEGRATED AND MEDICO-SOCIAL HEALTH CENTRES

SUB-DIVISIONAL MEDICAL CENTRES

DISTRICT HOSPITALS

PROVINCIAL HOSPITALS (10)

CENTRAL HOSPITALS (3)

GENERAL HOSPITALS (2)

RH falls under the directorate of community medicine and the division of mother and mental health in the ministry of public health. RH services are offered at all the levels. In addition to the above structures are parallel or complementary services like:

i) medico-social centres which primarily take care of STD cases including AIDS (diagnosis, treatment and prevention) ;

ii) mother and child care centres (Protection Maternelle et Infantile (PMI)) which offer prenatal care, vaccination of infants and pregnant women, and family planning and

iii) high risk clinics which take of pregnant women with an increased risk for both the mother and child (grand multipares, elderly primis, adolescents, scarred uterus etc).

2.4. TRENDS

RH has moved from a stage where it used to be considered as concerning only the mother and child to a level where it involves both women and men. It has also moved from curative activities alone to include both curative and preventive activities. The scope of Rh has also widened. This has been partly due to the increasing demands for better health for women and also for the increase in life expectancy . The latter has increased from 52.9 years (1992) to 54.5 years (1997) for men and 57.4 years to 59 years for women ****. However, alternate sources estimate life expectancy within the period 1995-2000 at 45.5 and 48.4 years for men and women respectively***. A general consensus is that life expectancy is increasing and so will new RH problems like menopause come up and need to be taken care of .

SOURCES: **** MPH Cameroon annual report to WHO 1998, *** United Nations in WHO member country statistics 1998

Definition of RH periods and related problems

i) prepubertal period :

The period between 10 and 13 years. The problems here are those of transition from childhood to adolescence and eventually adulthood. these problems are often increased when a pregnancy occurs.

ii) adolescence:

The period between 10 and 19 years. The problems in this age group are those of transition from childhood to adulthood. They are characterised by ego development, experimentations and explorations of the unknown.

iii) menarche:

This is the period of onset of menses and therefore the beginning of reproductive life proper. It is characterised by physiological and anatomic changes some of which are often embarrassing to the young girl who must of the times is not prepared for these changes.

iv) Reproductive age:

This is considered as the period between 15 and 49 years. It is the age when sexual activity and child bearing are maximised. It goes without saying that this is the age where most of the RH activities are concentrated. In our environment it is marked by ignorance, the desire for many children, poverty etc.

v) perimenopause:

The period around menopause (45- 50 years). It is characterised by irregular cycles and the occurrence of cancer especially what of the breast.

vi) postmenopause:

The period after menopause. This period that is characterised by the aging of the ovary is not yet posing problems in our environment. This explains why hormone replacement therapy is little known in our country. The changes are often very passive and so go unnoticed even by the woman.

2.5 The components of RH in Cameroon

RH was redefined to mean a state of wellbeing of the reproductive organs concerning their functions and functioning and not only the absence of disease. Taken in this sense the components are:

i) Adolescent care:

Adolescent reproductive health as an entity is not yet developed in Cameroon. It is only of recent (1996) that the ministry of Public Health created a sub-division for adolescent health. This is associated with maternal health. However, before this time and even now adolescents received health services in different units. For example pregnant adolescents were taken care of in high risk clinics, adolescents with STDs consulted at medico social centre etc.

Medical services exist in schools (dispensaries) but only in theory or are there only to establish that a student is ill and refer he or she to the hospital. Very often it is a student volunteer who shows interest in medicine who is sent to do a short training in a dispensary during holidays who manages the school dispensaries. These are often not equipped or contain only first aid drugs for dressing wounds before referring the student to the hospital. There are really no activities like health education or counselling in schools.

ii) Mother child care clinics (PMI):

These services have been existing for long. They are being renamed "maternal and infant health and family planning services" (in french "Santé Maternelle et infantile/Services en Planification Familiale (SMI / PF)". These centres offer services to pregnant women like prenatal caring, vaccinations of the women and also new born and infant care. This latter includes vaccinations, weighing and diagnosis and treatment of minor illnesses. They also offer family planning services. They also take care of high risk pregnancies in areas where high risk clinics are not existing and refer the patients to the doctor or hospital.

iii) High risk clinics:

These only exist in big cities like Yaounde. Women with increased risk for the mother or the foetus are followed up in these clinic more closely than those with apparently no risk.

iv) Family Planning clinics:

These clinics are located in the hospitals or PMIs. These clinics are taken care of by Nurses who have undergone training in family planning. They offer all the services with the exception of sterilisation in which case they refer the patient to a hospital.

iv) STD and dermatological clinics:

These clinics are called medico- social centres. They are located only in big cities. They were initially called venereal disease centres (centre vénérien). The name discouraged people from frequenting them. It is important to note that HIV screening is not done in these centres. They also carry out educational and preventive activities. This activity is also carried out at the PMIs. It is also important to note that men have not yet developed the attitude of using these centres.

The following services are also being offered in hospitals during routine consultations. They have no special clinics.

i) premarital counselling;

ii) infertility diagnosis and treatment for the couple;

iii) menopause complications;

iv) genital cancer screening , diagnosis and treatment;

v) care of men with sperm abnormalities (andrology) and

vi) counselling couples or individuals on the transmission of chronic conditions like sickle cell and or Rh negative problems.

It is important to note that psycho-social and sexology as well as genetic services are lacking in our settings.

3. Health Strategy for Cameroon

3.1. Introduction

The health policy for any government is aimed at having a healthy public. A healthy public policy is a concern for health and equity in all areas of policy. The goal of healthy public policy is to promote health. This is in line with the familiar WHO concept that health is determined by reference to "physical, mental and social wellbeing and not merely the absence of disease or infirmity" emphasises the significance of the social welfare of populations and not merely the medicalisation of disease. Even though medical science occupies a central position in health, the latter is the outcome of a combination of many factors: biological, genetic, environmental and socio-economic.

The elements that condition a population's health go beyond physiological factors to include gross national product, wealth distribution and access to income-earning capacity and opportunities, availability of and access educational resources, the urban and rural living environment and physical infrastructure, and, for instance, political structures through which individuals and groups can influence distribution of resources that affect health status (Women's Health and Human Rights by R.J. Cook WHO)

3.2. Cameroon Government Policy

In 1982, Cameroon subscribed to the strategy of Primary Health Care (PHC). In 1985, she undertook a reformation process aimed at putting into place the PHC strategy which she called a Reorientation of PHC@. This was reiterated in 1987 following the Alma-Ata conference. The main aim was to achieve health for all by the year 2000. This reorientation aimed at reinforcing the District Health System (DHS) and the effective implication of the community in the management of their health in what could called a contract between the state and the community. Between 1989 and 1991, more reflections were made on the practical implementation of this system. Since 1992 some significant changes have occurred. These included among others the realisation of the DHS with eminent advantages like

i) a better rationalisation of the health coverage;

ii) an end was put to the further creation of health centres;

iii) existing health centres became integrated and more responsible, serving as intermediate between the population and the community;

iv) the notion of contract between the state and community in the management of health issues became clearer and

v) health programmes were integrated at the peripheral level.

An intersectorial collaboration approach concerning decision making at higher levels was also adopted. In 1976, the President signed a decree ordering the creation of a High Council of Health, Hygiene and Social Affaires (decree no 76/450 of 08/10/76). This interministerial collaboration unfortunately never worked. At the level of the ministry of Public Health, a coordination and follow up committee was created in 1992 in order to avoid incoordination of ministerial decisions. As a follow up of this a decree was passed in 1996 for the creation of the National Council for the civil protection (decree no 96/054 of 12/03/96). Still in the search for improvement of cooperation, another law had been passed

(law no 96/03 of 04/01/96) governing state action and other parties in the domain of health.

All these laws and actions actually improved the health status of Cameroonians. But unfortunately the economic crises became evident. The government under pressure from the World Bank instituted a structural readjustment programme. Among other measures was the slicing of workers salaries by more than 70%. This reflected on standard of living, health status and health projects with serious consequences as will be seen under the RH situation.

3.3. National Resources

The following is the national health resources situation:

Number of physicians	1007*(1996)
Number of midwives	69* (1996)
Number of nurses	4998* (1996)
Number of pharmacists	59* (1989)
Number of dentists	55* (1996)
Number of other health care providers (including community health workers)	6968*(1996)
Total national health expenditure as % of GNP	4.3* (1989-90) / 1.4** (1990-95)
% of national health expenditure devoted to local health care	8.0* (1980-82)
Total government health expenditure as a % of GNP	0.6* (1995-96) / 1.0** (1990-95)
Total government health expenditure as per capita (PPP$)	3.3(1995-96) / 24* (1994)
% of recurrent government health expenditure as a % of total government health expenditure	81.6* (1995-96)
% of recurrent government health expenditure going to salaries	54.8 *(1995-96)

3.4. International assistance

Total international aid received as a % of public expenditure on health for the year 1996 was 66%***.

The amount of external money for the budgetary session 1995/96 was 12797 million Fr CFA (600 Fr CFA=1US$) for a total health budget of 18167 million Fr CFA giving the 66% above***

It is important to note that foreign aid to health has been increasing as shown below

Year	1990/91	1991/92	1992/93	1993/94	1994/95	1995/96
Amount ($US million)	2185	5226	8157	7979	3828	12797

* MPH, ** World Bank, *** volet santé avril1996.

4. Reproductive Health situation

4.1. Genesis of RH

RH is a concept that has been existing parallely with the other medical disciplines. It is only undergoing modifications with new impetus being added to it as more knowledge is acquired on the subject through research. important changes at the level of organisation in Cameroon include;

i). Since 1994, PMI/FP have been progressively integrated into the health system at all levels with the support of international funding agents;

ii) The former Directorate of family and mental health was replaced by the Sub-Directorate of family health, placed under the Directorate of Community medicine in 1995. This was in order to integrate the activities of MCH/FP at both the national and operational levels among the PHC activities.

these changes are reflected in the activities of the components of RH.

4.2. Mother and Child health Care/ Family Planning (MCH/FP)

This is the component that takes care of pregnant women, infants and child-spacing or planned and responsible parenthood. The objectives of this component are:

i) reduce maternal mortality rate by proper surveillance of pregnancy to detect risk cases and refer early enough for proper management;

ii) educate women on the notion of high risk pregnancy, the importance of planned and responsible parenthood and thus promote family planning;

iii) offer routine cost-effective care to newborn and infants in order reduce malnutrition and infant deaths.

the following examples show how these objectives have been achieved or not.

i) the proportion of pregnant women whose pregnancy is supervised by a qualified personnel (nurse, midwife or medical doctor/gynaecologist increased from 605 in 1994 to 73% in 1997 (WHO 1998);

ii) similarly the proportion of women whose labour is attended to by qualified personnel increased from 54% in 1994 to 585 in 1996 (WHO 1998);

iii) the proportion of infants consulted by qualified personnel in 1994 was 50% (Ministry of public Health (MPH) ( recent figures are not available);

iv) the level of contraceptive use increased from 3% in 1990 (Akam E. 1990) to 10.5% and 24.9 % in rural and urban areas respectively in 1991 (Leke 1993) the overall national level reported in DHS 1991 is 5%;

v) maternal mortality decreased from 220 per 100000 in to 130 per 100000 in the Central maternity (Leke), however, national maternal mortality rates have increased from 450 per 100 000 in 1995 to 547 per 100 000 in 1997 (UNICEF reported by WHO 1998);

vi) in 1993, the infant mortality rate was 84 per 1000 (United Nations 1993), in 1997 it was estimated at 58 per 1000 (UN), the probability of dying before the first birthday is 126 per 1000 ( MPH 1995);

vii) one woman out four is anaemic (WHO 1991).

4.3. High Risk Clinics /Approach

This approach consists of identifying or targeting women with increased risk during pregnancy and following them more closely. This approach was introduced in the University Teaching Hospital and the Central Maternity Yaounde in the mid 1970s. Later evaluation showed that maternal mortality dropped from 220 to 130 per 100 000 live births in these centres. It has consequently been introduced throughout the country. Some high risk cases include:

i) grand multiparity (>5 deliveries): this constituted 18.5% of the total obstetric population in 1982, and accounted for 48.5% of maternal mortality (Leke 1984) It is attained in Cameroon at the age of 27 years.

ii) elderly primi (>30 years) , older gravidas (.35 years) and teenagers ( 10-19 years) constitutes high risk groups.

iii) Natural child spacing is well practised in Cameroon (21 and 21 months breast-feeding respectively for urban and rural areas but without any attempt at birth limitation (Leke).

4.4 Adolescent RH

This is unfortunately not yet a reality in Cameroon. It is only of recent that it is drawing the attention of the public. This is probably because of the high rate of adolescent sexuality and child bearing which posses an economic burden on the parents and the society. Whereas adolescents constitute a sizeable proportion of the population. A few examples of the consequences of their sexual activity will illustrate the problem: in 1984 38.6 % of the obstetric population in the central maternity was adolescents (Leke 1993); sixty-five percent are married by the age of 16 years ( DHS 1991); thirty-two percent of the illegal abortion complications received in the central maternity are adolescents (maternity statistics 1992), the average age of menarche and semenarche is 13 1/2 and 15 years respectively; about 70% are sexually active by 16 years with 4 % delivering before 16 years, only 4% of the pregnant adolescents (married or not desired to be pregnant; knowledge on contraception is from the media in 53%, school mates - 21%, peers-16% and only 9% from parents.

However, adolescent RH is now on the national agenda. Ways are being explored to improve on the utilisation of existing health services by adolescents. Age that was once a barrier to contraceptive use (Paul Nkwi 1995) thus excluding adolescents from using pills is no longer.

4.5. Newborn / Infant Care

Cameroon has benefited only little from the technology of newborn care. Equipped newborn centres are only in the big cities like Yaounde and Douala. Children born with birthweights <2000g are very likely to die while those with birthweights ,2500 g have just a slightly increased chance of surviving. The mean birthweight is 3200g. About one out of four children of 0-5 years is anaemic (DHS 1991); infant mortality rate seems to have increased from 84%o in 1992 to 93%o in 1995 (MPH 1995); The main causes of infant mortality are: malaria-43%, diarrhoeal diseases-17.6%, measle-12.3% (DHS 1991); the proportion of infants correctly immunised against diphtheria, tetanus and whooping cough in 1996 was 46% (WHO 1998); the proportion of infants reaching their first birth day that have been correctly immunised against measles and tuberculosis is 46% and 54% respectively (WHO 1998). Breast feeding is almost 100% and more than 90% in rural and urban areas respectively. Women are highly motivated because breast feeding serves as a natural means of spacing birth. Also, the government encourages iit by giving a maternity leave of three months. The few women who work in offices practice mixed feeding. Another thing that encourages breast feeding is the high cost of artificial milk.

4.6. Child Health and Development

This is directly linked to the intrapartum and peripartum periods. Care during these critical periods is at the maternities. Although a good number of women especially in the rural areas still deliver at home or with traditional birth attendants (TBA). Further development is determined by so many factors. Even though Cameroon is food sufficient there are still some cases of malnutrition due to lack of balanced diets and parasites.

4.7. Post-Reproductive period (menopause)

The mean age for menopause is 49±1 years (Shasha 1990). The majority of women have no clinically manifesting symptoms and so the period often passes unnoticed. Though occasionally we see women with pathological fractures resulting from osteoporosis. Traditionally, menopaused women can do certain things, go to certain places or even talk to notables which they could not do during their active periods. In some cultures the woman during her menses neither cooks nor shares the room with her husband. Because menopause does not really constitute a problem studies in this domain are scarce.

4.8. Genital cancer screening programme

The two most frequent female cancers are breast and cervical constituting more than 70 % diagnosed female genital cancers. These cancers are often diagnosed in the advanced stage and so the population believes that cancer is not curable, that when one has it, it is a curse and the one is bound to die. Data on these cancers at the national level is lacking. Other less frequent female genital cancers are in order of decreasing frequency, ovarian, endometrial and vulva. Because of the attitudes and beliefs of the population about cancer, a national cancer screening programme is organised periodically. Unfortunately this takes place only in Yaounde and Douala. The rural population that is most involved is not included.

5. Family planning / RH Projects

5.1. Evolution of FP in Cameroon

Contraceptive methods are etymologically the techniques used to prevent conception or pregnancy. These are also known as child spacing methods.

In the early days of independence (1960-1970) tribes were very powerful as far as decision making at the national level was concern. Each tribe therefore wanted to increase its population as fast as possible. Even though the problem of infertility had not been studied in any detail until Nasah in 1973 (Nasah and coll 1973), the concern of tribes was the fear of their eventual extinction. The tendency was thus to procreate as much as possible and so family planning was not known. however, families practised child spacing by prolonging breast feeding (21 and 20 months in rural and urban areas respectively (Leke 1993), it was not to limit the number of children.

Before 1980 Cameroon was pronatalistic and there was a law (Law no 29/69 of 20.5.69) prohibiting the sale of contraceptives or any form of anticonceptional publicity. Also certain legislations like the laws on family allowances, birth allowances, supplementary for underaged children and reduction of taxes as a function of the number of children were in favour of increased number of children.

But things did not remain the same . By 1976, the authorities started reflecting on the adverse effects of a high population increase on the economy and social life. In 1980 during one of the President's policy speech he officially made mention of the consequences of a rapid and uncontrolled population increase on employment, urbanisation , health etc. As follow up, in 1981 the government chose individual couple awareness to limit births under what was known as responsible parenthood in the 5th five year plan(1981-1986).

Consequently, a national commission was set up and the result was that contraceptives could be prescribed. In Yaounde there was a child spacing clinic that was functioning officially since 1977 in the University Teaching Maternity Unit of the Central Hospital and the Teaching hospital (CHU). This was at the initiative of Prof. Nasah. Family planning thus gradually spread throughout the country.

In 1992, the MPH/Directorate of Family Planning and Mental Health (FPMH) with the assistance of the Programme for International Training in Health (INTRAH) listed potential barriers to FP and developed scientifically justifiable medical policies towards FP (Paul NKWI 1995). Still in an effort to improve both the quality and access to FP services the MPH/DFPMH and INTRAH created a set of national service delivery guidelines which were distributed to all service delivery units in the country. In 1993 the policy guidelines were standardised with the collaboration of SEATS Project of John Snow Inc. (JSI) and since then seminars and training sessions are being organised for Fp service deliverers.

5.2. Main actors:

The following bilaterals, multilaterals and NGO's international agencies collaborate with the government, national organisations, social groups and individuals in the field of research, interventions and evaluations of projects related to FP and other RH domains:

1. World Health Organisation (WHO)

2. United Nations Development programme (UNDP)

3. World Bank

4. United Nations International Children's Educational Fund (UNICEF

5. United States of America, Agency for International Development (USAID)

6. Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO)

7. German Technical Assistance (GTZ)

8. International Training in Health (INTRAH)

9. Family Health International (FHI)

10. United Nations Population Fund (UNFPA)

11. The Program for Appropriate technology in Health (PATH)

12. International Children's Center (ICC)

and many other's.

6. Associations

6.1 The "Association Camerounaise des Femmes Médecin" (ACAFEM)

This was formed in the early 1990s. The objectives are to bring together female physicians, promote research activities among members and evaluate health activities. One research that they carried on the "Traditional Practices that affect RH of women in Cameroon showed that immediately after delivery women used hot water to massage their abdomen and episiotomy/perineal wounds in order to promote uterine involution and wound healing respectively, pregnant women were not allowed to eat certain foods leading to malnutrition and anaemia , women used douching regularly claiming that they were being more hygienic thus predisposing them to frequent vaginal infections.

6.2. The Society of Gynaecologists and Obstetricians of Cameroon (SOCOC)

This society was created in the early 1990s. It hosted the Society of African Gynaecologists and Obstetricians (SAGO) in 1994. It meets every three months to discuss RH issues and research projects and or results.

6.3. The Cameroon National Medical Conference

This is open to all doctors. It holds yearly at March. Each year it decides on a term. One of such terms was "How to decrease health cost" and the topics discussed included RH components like infertility management.

6.4. The National Committee for the Fight against Cancer***.

The main objective is to reduce the incidence and prevalence of clinical gynaecological cancers in Cameroon by the year 2000, by organising regular information, education and sensitisation campaign.

The incidence of clinical cervical cancers is estimated at 40/100 000 women aged 20 and above with a prevalence of 2750 cases.

Only 10 000 Pap's smear are carried out every year, (1 for 200 women) and concern particularly urban women. The majority of women (70%) lives in rural area and they don't have financial, geographical and educational accessibility to screening methods. It is estimated that 90% of patients with cervical cancer are from rural areas.

The Committee carry out mass campaigns twice yearly (April and December) in Douala and Yaounde with an attendance of 1000 women at each campaign. The main target of the Committee now are these majority of rural women.

The common gynaecological cancer in Cameroon are:

Gynaecological cancer	%
Breast cancer	21.5
Cervical cancer	21.5
Cancer of the Ovary	6
Endometrial cancer	less frequent
Lymphomas (Burkitt lymphoma)	frequent in young women (teenage)

Cervical cancer is the fourth more common cancer in general in Cameroon(11%). By the end of year 1997, the prevalence was 2750 cases. It is the first gynaecological cancer, with cancer of the breast with 21,5%. The main types are carcinomas (99,9% with a predominance of squamous carcinomas) Malignant lymphomas (Burkitt's lymphomas) are frequent in young women (teenage).

The patient's age distribution is the following* (1997):

AGE (years)	%
0 - 19	0
20 - 29	4
30 - 39	10
40 - 49	32
50 - 59	30
60 - 69	20
70 - 79	4
>80	0

Majority of cervical cancer patients are seen at advanced stages :

Clinical aspects	% of cases
Ulcerated cervix	50
Ulcerated and fungating	25
Fungated cervix	25

The main clinical stages found are :

Stages	%
Stages I	25
Stages II - III	70
Stages IV	5

Surgery, radiotherapy chemotherapy are available but very costly . Less than 10% of few who try the treatment have achieve it. The prognosis is generally bad, less than 10% five years survival for stage I cervical cancer.

***Sources :

1) MBAKOP A. & coll. : Cancers au Cameroun. Guide Pratique. Ed. Comité National de Lutte Contre le Cancer/Comité National d'Epidémiologie - SOPECAM 1997

2) MBAKOP A. :Present situation of Cervical Cancers in Cameroon. 1997

7. Research Activities/ National Organisations

The following organisations carry out research in various domains of RH, either national projects or in association with international organisations:

i) Ministry of Public Health (MPH)

ii) Ministry of Higher Education (Higher Teacher's Training College (ENS)

iii) Ministry of Scientific Research

iv) University of Yaounde -the Faculty of Medicine and Biomedical Sciences (FMBS)

v) World Health Organisation Collaborating Centre -Human Reproduction Programme (HRP)

vi) Network for research in RH (CRESAR)

Just to mention that the WHO collaborating Centre was opened 11 years ago. It carries research projects in human reproduction activities. During 1997 the centre had 23 ongoing research projects: 8 in the field of reproductive biology, 8 on maternal and infant health, 1 on abortion, 4 on contraception,1 on infertility and 1 on STDs. Five of these projects were funded by HRP, 12 were funded by national sources and the rest from international sources.

8.Some set backs (Not yet available)

8.1.Government Policy
8.2. Economy Crisis
8.3. Political situation
8.4. Communication difficulties
8.5. High illiteracy rate
8.6. Lack of publishing facilities for research results
8.7. Increasing population
8.8. Gender Issue

9. Perspectives for future projects implementation

9.1. Objectives and indicators of RH till the year 2003 ( Development plans are made for every five years).

Goals:

i) Offer quantity and qualitative RH services to the population.

- Quantitatively, the number of pregnant women attended to by qualified personnel should increase from the current 80 % to 90% or more; the number of women attended to in labour by qualified personnel should increase from the current 64% to 70% or more; the number of women of child bearing age using modern method of contraceptives should increase from the current 16% to about 20% or more; ?

- qualitatively, quality services should be able to attract more users and thus and thus improve on the quality of life. We therefore expect more women to use the MCH services with a reduction in the current maternal mortality rate to less than 420 per 100 000; similarly quality services for adolescents would enable them to better utilise FP services so that the number of unwanted pregnancies and unsafe abortions which is currently responsible for some 40% of the causes of maternal mortality to less; etc

In general, improving Rh means ensuring quality information to all, detecting high risk cases and referring early enough for specialised management, providing good roads so that referred cases can arrive the centres etc, offering quality training and recycling of personnel and providing good working conditions.

ii) improve the health status of women during the reproductive years so that they can enjoy quality RH. This means that more women should be allowed to take decisions on matters directly affecting their lives like the number and when to bear children, prevent STDs so that the 70% of the 30% of women with infertility with tubal pathology may decrease to 30% or less and the infertility rate decreased to 25% or less.

iii) improve prenatal care so that the proportion of children born with normal parameters as accepted by international standards may pass from the current 90% to 95% or more; offer immunisation to children so that the rate of correctly immunised children by one year passes from the current 50% to 70% or more ; the overall goal would be to reduce the current infant mortality rate of 84.0 per 1000 to less.

iv) improve the RH of adolescents so that they may enjoy RH in the real sense as defined by WHO.

v) The overall goal of RH will be to develop strategies which will enable individuals to enjoy RH right by promoting gender equality, contraception, abortion services (caring for those who have unsafe abortions without discrimination or judging) etc.

9.2. Objectives (Indicators of RH)

The following are the set indicators to be monitored ( the list is not exhaustive)

i) maternal mortality ( fall below the current 420 per 100 000)

ii) infant mortality ( fall below the current 84.0 per 1000)

iii) women of reproductive age using modern contraceptive (increase above the current 16%)

iv) increase the rate of detecting complications of pregnancy, referral systems etc so as to reduce the deaths resulting from them which currently account for about 40% of maternal deaths.

v) increase the number of correctly immunised women and infants so as to reduce the deaths resulting from these illnesses.

vi) reduce the prevalence of anaemia in pregnancy from the current 26.3 % to 20% or less

vii) Increase the number of pregnancies and deliveries attended to by trained personnel.

9.3. Population and Development

The above objectives can only be achieved if future project planning and implementation takes into account the eventual socio-demographic changes (population growth, urbanisation, life expectancy, crude birth and death rates, schools, job availability and basic social amenities like water, electricity, health units etc.

The population is expected to increase in absolute terms by 400 000 each year taking into account the annual population growth rate of 2.8 and a current population of 14 000 000. Life expectancy is expected to increase from the current 54.5 years and 59 years to 55 and 65 for men and women respectively; infant mortality is expected to decrease from the 126 per 1000 to about 100 or less.

All these demographic changes will affect urbanisation with its inherent problems. Therefore this needs to be taken into consideration when drawing up development plans.

9.4. Health Policy and Strategy

The government has undertaken by since 1976 the initiative by making a law governing the creation and organisation of a superior council for Health, Hygien and Social Affairs (Decree no 76/450 of 8/10/76) which had never been implemented. It is hoped that will become active. At the level of the MPH, the coordination committee that was created in 1992 to follow up projects in order to promot intersectorial cooperation and which held only for two years and stopped will resum. At peripheral and intermediate levels, intersectorial collaboration between administrative authorities, health personnel and the community will increase so that RH can advance.

All these collaborations needs that the government should increase the fraction of the state budget allocated to health to at least 10% as recommended by the UN.

9.5. Approach

Cameroon has a low prevalence of modern contraceptive use (16%), a low rate of utilisation and provision of antenatal services, with a high maternal mortality ; the population is increasing disproportionately to the resources and social amenities, the concept of RH is still new even to health personnel, government policy towards international organisations interested in RH are not flexible etc. A change in this approach is needed to advance RH.

9.5.1. Holistic Approach

RH is a concept . The definition and components require that the concept be integrated at all levels of the health care system. Treating components in isolation is not cost effective and has been shown to decrease compliance. Thus it is hoped that focus will not only be on MCH/FP as has been in the past, but will be widened to include all the components of RH. Also, Rh does not specialists at all levels. The scope of RH services and providers can widened to include all existing health structures and personnel. All that is required is creating awareness, motivation and cooperation.

9.5.2. Client and Patient Oriented

RH as defined does not require that one be physically ill before seeking it. Rh clients are not necessarily patients. If they are considered as clients, which they should, then research should be carried out regularly to discover what they need or lack. Services should then be orientated towards the unmet needs or services. Also health personnel need to know that they are selling their services to potential users and not the current practice where health personnel feel that RH is a disease state and who ever is ill has no choice.

9.5.3. In like manner

RH should not be medicalised. Barriers to acquiring or offering RH should not exist. people with competence in RH should be allowed to offer the services. The current practice where only doctors insert Norplant and or carry out bilateral tubal ligation should be discouraged as it does not adapt in our context with few doctors. Nurses can do it and even better because they have the time. Also, it has been shown that a pelvic examination is not necessary for prescribing oral contraceptives. This means that women can procure them from the pharmacy without a medical prescription.

9.5.4. The success of RH lies in education, information and counselling

To this effect the government passed a law ( Decree no 95/040 of 07/03/95 replacing the former department of Health Education in the MPH with the department of Education for Health, Government Communication and Public Relations. Accordingly, two trained journalists were posted to the MPH. They have as a mission, the transformation of mass educational messages for easy comprehension. This idea is good but apparently the more than 60% of rural residents, the majority of whom can neither read nor write, nor possess Radios / TV sets. In some places Cameroon Radio and TV does not even reach there. How do they get the health messages? The government or international agencies should explore ways of reaching this important fraction of the population which is also those who need RH most. May be posters with health messages placed at strategic places like palaces or church premises could serve more.

10. Necessary inputs for the future

10.1. personnel training, recycling and management

Cameroon has relatively qualify human resources to manage RH services (see table on health resources). The problem is that of role defining and assigning funtions to the right (qualified) people. The problem of personnel management is crucial for RH advancement. However, this does not mean that she does not need to train and or recycle personnel. RH technology is changing fast and Cameroon needs to train or recycle her personnel in order to meet of with modern RH technology.

10.2. Infrastructure

The present infrastructure belonging to the MPH at levels is enough for offering RH services. Most of the structures are under utilised. All that is required is reorganisation of the structures to accommodate the different components of RH.

10.3. Research

Research is the key to development . So it is too for RH achievement. The government has taken measures to promote research as :

i) the creation of the department of studies, planning and health information in the MPH in order to promote operational research;

ii) the training of personnel at both the district and provincial levels in research in order to promote research at these levels.

iii) The system where each graduating student from the FMBS presents a research thesis is aimed at encouraging research at an early stage.

All these measure are good but they need to be backed by necessary funds and proper utilisation of research results.

10.4.Government Policy (Not yet available)

11.Annex (Health Indicators/Resources)

Trends in socio-economic development
Health and Environment + Health resources
Health services
Trends in health status
Demographic distribution of population (not yet available)