Universal health coverage and factors associated with enrolment in the town of Souza-Cameroon | BMC Health Services Research

Universal health coverage (UHC) is designed to ensure that the entire population has access to the preventive, curative, palliative, rehabilitative, and health-promoting services they need throughout their lives, without the risk of financial hardship [1]. It is based on strong, person-centred primary healthcare, which is of sufficient quality to be effective [1]. In many countries, growing social pressures and the ever-increasing costs of healthcare services have led governments to introduce models of protection against the risk of illness [2, 3]. Although the approaches vary according to local contexts, they all share the same objective: to guarantee equal access to care [4], to ensure equitable treatment of illnesses, and to protect people against the financial risks associated with healthcare expenditure.

Globally, progress towards achieving universal health coverage, set as a target in the Sustainable Development Goals (SDG 3.8), is slow [1]. Since 2015, health service coverage has stagnated, while the proportion of the population exposed to catastrophic out-of-pocket health expenditure has risen steadily since 2000 [1]. This trend is observed in all regions and in the majority of countries. The service coverage index has risen from 45 in 2000 to 68 in 2021, but recent progress has been weaker: between 2015 and 2021, only three additional points were gained, and there has been no improvement since 2019 [5]. In Africa, the situation regarding universal health coverage (UHC) remains worrying, with major disparities between countries. However, the region has made significant progress: the average service coverage index has risen from 23 in 2000 to 44 in 2021 [5], showing a significant improvement but still insufficient to achieve the targets set. This progress is accompanied by increased efforts, notably the increase in health spending as a percentage of GDP in 23 African countries by 2024, bringing them closer to the 5% target set by the African Union [6]. However, this figure still falls well short of the targets set in the 2001 Abuja Declaration, which called on African Union member states to allocate at least 15% of their national budgets to the health sector. In Cameroon, the service coverage index has also evolved, rising from 22 in 2000 to 44 in 2021, reflecting a similar dynamic to that of the region [5].

Despite these advances, coverage remains limited in Cameroon: in 2021, only 6.46% of the population benefited from social health protection, with a very low mutualisation rate of around 2% [7]. Challenges also persist in terms of access and quality of care, exacerbated by insufficient human resources and fragile healthcare systems [8]. The absence of universal healthcare coverage has serious consequences for public health and the economy. Individuals who are not covered are often forced to face unexpected health expenses, plunging them further into poverty [9]. This lack of access to healthcare leads to an increase in untreated illnesses, lower productivity, and increased pressure on already fragile healthcare systems [10]. What’s more, the absence of UHC exacerbates social inequalities, making the most vulnerable populations even more exposed to health risks [11].

Although many African countries have integrated Universal Health Coverage (UHC) into their national health strategies, progress remains slow [12]. As part of its strategic vision to guarantee equitable access to quality healthcare for Cameroonians, the Cameroonian government has initiated a process aimed at eventually providing the country with universal health coverage [13]. Despite efforts to improve people’s health, the country has a service coverage index of only 44, with fragmented funding between the state, community mutual insurance schemes (1.3% coverage), social security, and private insurance (0.2%) [14]. The financing of the Cameroonian healthcare system is essentially based on State budget al.locations, coordinated by the Ministry of Public Health, and on direct payments from households, which account for 70% of total healthcare expenditure [14].

In Cameroon, implementation of the Universal Health Coverage (UHC) is still in its infancy and has yet to achieve optimum efficiency on a national scale. As part of the pilot phase, the East region has been chosen as a pioneering site to test the scheme, with the official launch of the first phase on April 12, 2023, in Bertoua, under the chairmanship of the Minister of Public Health [15]. This mechanism aims to facilitate access for all citizens to a range of quality healthcare services, without money being an obstacle. Phase I of the UHC covers promotional and preventive care, such as vaccination and screening, as well as some curative care, illustrating the government’s commitment to equitable access to health services. This phase also includes services that are heavily subsidized by the state, such as hemodialysis, while mechanisms for public contribution, such as health vouchers, are mobilized to facilitate access to care. However, by 2023, public allocation to healthcare has fallen from 5.9% in 2019 to 3.3%, leaving households to finance around 72% of healthcare expenditure [16, 17]. The aim of this study is to identify the socio-demographic factors, knowledge, and perceptions that influence the enrolment of Souza residents in the UHC.

By analyzing these elements, we hope to formulate practical recommendations for improving health policies and reinforcing equitable access to care. This research also aims to fill a gap in the literature on UHC in Central Africa, a field that has yet to be fully explored, by shedding light on the equity gaps and financial barriers that hinder universal access to care in low-income contexts [18]. In Cameroon, UHC is still at an early stage of implementation, with a pilot phase covering mainly preventive and promotional care, as well as some basic curative care. The care basket includes, among other things, vaccination, screening, and a range of subsidized services such as hemodialysis, gynecological and neonatal care via the health voucher, as well as free treatment of HIV/AIDS, tuberculosis and malaria for children under five. However, actual coverage of the population remains limited. Financing mechanisms include health vouchers and direct contributions from beneficiaries, who are still required to cover a significant proportion of costs. Governance of the scheme is based on coordination between the Ministry of Public Health, healthcare providers, local authorities, technical and financial partners, and the beneficiaries themselves. Highlighting these aspects will provide a better understanding of the structural and financial challenges facing UHC in Cameroon, and thus strengthen the relevance and scope of the recommendations arising from this work.