Republic of Cameroon

Despite its lower-middle-income status, Cameroon was recently ranked 153rd out of the 188 countries tracked in the Human Development Index (HDI 2014) and, indeed, it is one of a group of countries whose HDI scores have declined in the past two decades. Contributing to this HDI deterioration is slow progress on key health outcomes.

According to World Bank estimates, over the past 20 years under-five mortality declined by 54 percent, from 172 per 1,000 children under five (1998) to 80 per 1,000 (2016). Over that same period the maternal mortality ratio declined by 20 percent, from 750 per 100,000 live births (1998) to 596 per 100,000 (2015). However, mortality for mothers and children remains high and is mismatched to Cameroon’s economic status and relatively high per-capita health spending ($138 in 2014). For example, maternal mortality in Cameroon is 9 percent higher than the average rate for Sub-Saharan Africa and more than double the average rate for lower-middle-income countries.

Additionally, Cameroon suffers regional disparities in health and nutrition outcomes, with the three northern regions and the East region performing considerably worse than the national averages. For example, the proportion of girls between ages 15 and 19 who have begun child bearing is 44.2 percent in the East Region and 23.4 percent in the Far North Region, while in the capital, Yaounde, the rate is only 7.6 percent. Similarly, these four regions experience under-five stunting rates that are higher than the national average (32 percent): 42 percent in the Far North Region, 34 percent in the North Region, 38 percent in the Adamaoua Region, and 36 percent in the East Region.

Plan Development, Partnerships, and Investment Case

To address these critical gaps, the Government of Cameroon led a consultative process with key partners on RMNCAH-N to plan support for partner alignment and government prioritization. The RMNCAH-N investment case was ratified in late 2016 and included interventions to address both health and nutrition outcomes as well as health financing reforms.

There are three areas of focus that run through the investment case: (1) improving allocative efficiency, (2) increasing the utilization of priority health services, and (3) strengthening broader health systems. The allocative efficiency and partner alignment efforts focus on two dimensions: rebalancing public health expenditure between the tertiary level and the primary/secondary levels (RMNCAH-N service prioritization being part of this effort) and focusing resources in high-burden and low-resource parts of the country, namely the four priority regions: East Region, Adamaoua Region, North Region, and Far North Region.

As part of the consultative process, the RMNACH-N investment case is supported through domestic funds from the Government of Cameroon, the World Bank IDA and Islamic Development Bank, and the GFF-Trust Fund, as well as by Gavi, the Global Fund, the UN Population Fund (UNFPA), UNICEF, WHO, the German Corporation for International Cooperation (GIZ), the German Development Bank (KfW), Agence Francaise de Dévelopement (AFD), the US government, UNITAID and the Bill & Melinda Gates Foundation. The private sector is also supporting the investment case, with Addax Petroleum contributing $155,000 in 2017–18 to equip rural hospital maternal and newborn care units in priority regions.

The Government of Cameroon used the investment case to inform its 2018 national budget, developed at the end of 2017. Despite a decline in the overall health budget that resulted from a fiscal consolidation, the Direction des Ressources Financieres et du Patrimoine (DRFP) in the Ministry of Public Health reports a substantial increase in the health budget allocation to priority regions identified as being high-burden as part of the investment case.

Additionally, in 2017 the government committed to a series of fiscal and policy reforms in the public sector as part of a budget support program with the World Bank. The GFF process provided the analytical underpinnings for the health sector reforms, including a trigger that commits the government to increase the health budget allocation to the primary and secondary levels from a baseline of 8 percent in 2017 to 20 percent by 2020. The investment case was a useful tool for informing the dialogue between the ministries of health and finance.

Increasing Uptake of Essential Services

Cameroon has been working to increase the uptake of the essential health services included in the investment case through an expansion of facility-level performance-based financing and demand-side efforts such as Chèque Santé (health vouchers), which seeks to activate demand for maternal and newborn health services and reduce the burden of out-of-pocket expenditure. The government of Cameroon expects to achieve full coverage of the performance-based financing system in the investment case priority regions by mid-2018.

Early progress noted

The increased service utilization seen in Figure 1 is partly accounted for by the expansion of the national performance-based financing program to the Adamaoua, North, and Far North regions (the East Region was already implementing this prior to 2017). In 2017, the country expanded performance-based-financing contracting to an additional 921 facilities (there were 1,428 total facilities under contract in the last quarter of 2017). However, 55 percent of this growth was concentrated in the four priority regions identified in the investment case, even though these four regions only account for 20 percent of the healthcare facilities in the country.

There is also data to suggest that once facilities are under contract they show improvements in productivity. In the North and Far North regions, there were 34 facilities that had contracts for the first time and reported results starting in the first quarter (additional facilities were added throughout the year). By the fourth quarter, the number of skilled births that these facilities had attended increased by 71 percent. This suggests that the combined efforts of partners working on the supply side and the easing of demand-side bottlenecks to service access are driving improvements at the facility level. 2


Uptake of Priority Maternal and Child Health Services in Priority Region Facilities Using Performance-based Financing (PBF), by Quarter, 2017

Maternal Health Services in Priority Region PBF Facilities
Skilled Delivery and Postnatal Care Cases in Priority Region PBF Facilities
Number of Children Receiving Complete Vaccine Course

Increasing Access to Family Planning

In addition to maternal and child health services, the Investment Case also places a priority on increasing access to modern methods of contraception, diversifying the method mix, and improving access to contraception among adolescent girls. Nationally, only 21 percent of married women were using a modern method of contraception as of 2014 (MICS 2014). As of 2014, investment case priority regions had the lowest rates of use of such modern methods in the country, at just 3.5 percent in the Far North Region, 6.1 percent in the North Region, 7.7 percent in Adamaoua Region, and 14.5 percent in the East Region.

Early progress noted

Family planning visits in facilities using performance-based financing increased over the course of 2017, with growth in visits for both short-term methods and long-acting reversible methods. This progress has been supported by several financiers and technical partners, including support for commodity procurement through UNFPA Supplies and supply-side efforts such as performance-based financing. (Figure 2.)


Family Planning Visits to Facilities Using Performance-based Financing in Priority Regions, by Quarter, 2017

Pilot Project for Adolescent Sexual Health

Throughout the year, preparations for a pilot project focused on quality counseling and contraceptive uptake in sexually active adolescents were undertaken in the East Region by the Family Health Directorate in the Ministry of Public Health in collaboration with UNFPA and the World Bank. This pilot will begin in mid-2018 and will test a technology solution for improving the counseling experience of adolescent family planning clients as well as an evaluation intended to better understand the supply and demand-side response to family planning subsidies.

The priorities articulated in Cameroon’s investment case are being reflected in the national budget, in the activities of health sector actors, in improvements in the utilization of priority health interventions, and in efforts to strengthen the health sector broadly. As Cameroon enters its second year of investment case implementation, greater scale will be achieved, and there will be ever more emphasis placed on partner engagement and communication. In particular, there will be support focused on the national health management information system, including data quality and completeness and the use of data to understand service utilization trends, and on strengthening efforts to track partner and government financing for investment case priorities. This focus will strengthen the “learning-system approach” that will be key to sustaining progress on RMNCAH-N outcomes in Cameroon.

We didn’t have a good water source, we used to have electricity problems, some of our patients did not have sheets on their beds…Now we have a well and we have water flowing at the health center, always.”

– Sister Vera Ngalim, St John the Baptist Catholic Health Center

Democratic Republic of the Congo

In the Democratic Republic of Congo (DRC), the GFF was launched in April 2015. The government put in place a GFF platform that brought together the key government health stakeholders, other line ministries, civil society representatives, and development partners. The GFF platform took the lead in developing the country’s RMNCAH-N investment case, which prioritizes the interventions laid out in the National Strategic Development Plan 2016-2020. The Ministry of Health, with representatives from civil society organizations, focused on defining RMNCAH priorities; UNICEF conducted a health system bottleneck analysis; WHO provided support in costing the investment case; and the GFF Secretariat helped with the resource mapping exercise with the support of the government and several donors.


United Republic of Tanzania

Between 2010 and 2015, Tanzania saw notable improvements in life expectancy (from 61.6 to 64.9 years), infant mortality rate (from 51 to 43 per 1,000 live births), under-five mortality rate (from 81 to 67 per 1,000 live births), and under-five stunting prevalence (from 42 to 34.4 percent). However, during this period the country’s maternal mortality rate increased from 454 to 556, and its total fertility rate remained stubbornly high at 5.2 (as of 2015). The increase in maternal mortality elevated maternal health to a national priority. To address this and other lingering challenges in RMNCAH-N, in 2015 Tanzania began implementing its RMNCAH-N investment case, known as One Plan II.



Nigeria has always been committed to the principles of universal health coverage and has adopted policy documents and legislation to that effect. However, indicators of Nigeria’s health outcomes and actual coverage of basic health services show under performance, both in absolute terms and relative to other countries at similar levels of economic development. Key drivers of underperformance include a health system unable to ensure universal coverage of primary health care services and weak accountability for results. The health sector has long been underfunded, and its structural and institutional frameworks have placed concurrent responsibilities on all three tiers of government (federal, state, and local) without any mechanism for intergovernmental accountability.