Global surgery is an essential component of global health, as surgical care is an essential component of healthcare. Yet, surgical care remains inaccessible to five billion people in the world, the majority of them living in low- and middle-income countries (LMICs). This makes the sustainable development goal of safe and timely access to surgery by 2030 difficult to achieve as a global reality (1).
The rural population of Cameroon represented 41.85% in 2021 and mainly sought healthcare at first-level healthcare facilities (1, 2). In 2018, a policy brief reported an inadequate number of surgeons and resources, heavy workload, unrecognized public health concerns, inadequate funds, and geographical disparity of surgeons as the major challenges facing safe surgical care in Cameroon (3). Given the specificity of rural areas in Cameroon, we believe challenges faced by the rural population in accessing surgical care might be slightly different. In this piece, we highlight five challenges to accessing surgical care in Cameroon’s rural areas and recommend policy interventions to address them.
Five Challenges
The challenges that urgently need to be addressed to improve access to surgical care in rural communities are the following:
Lack of Infrastructure
Rural areas of Cameroon lack adequate infrastructure for surgical care, including operating theaters, diagnostic equipment, and trained personnel. This is explained in part by inadequacies in the national budget quota for health expenditures, poor governance, and other factors (4). The need for equitable infrastructural development of health institutions in rural Cameroon remains a glaring reality. Where health institutions do exist with theaters, the absence of basic theatre equipment, electricity, and running water, render the delivery of surgical care very challenging (5).
The armed conflict in areas such as North-West, South-West, and Far North Regions, has exposed several healthcare facilities to destruction or transformation into military barracks. In these regions, mainly rural health districts are subject to targeted attacks, making access to health care in general and surgical care, in particular, to become more difficult (6).
High Out-of-Pocket Surgical Care
Many individuals living in rural areas of Cameroon lack the financial resources to pay for surgical care, which can be costly (4, 7). High-paying jobs are generally found in urban areas as opposed to rural areas. Most jobs in rural areas are essentially for survival, with pay packages unable to cater to living, schooling, and healthcare needs in general. The overall expensive nature of surgical care further highlights the financial limitations faced in rural settings as far as access to healthcare is concerned 7, 8.
Private health insurances are grossly under-represented in rural areas and offer health insurance schemes designed to limit catastrophic out-of-pocket payments for healthcare. Nevertheless, these cost-effective schemes appear to be very expensive for poor populations (4, 7).
Limited Geographical Accessibility
Rural areas of Cameroon are often difficult to access due to nonexistent or poorly maintained roads, long travel times, expensive fares, and limited transportation options (9). More often, available transportation in rural areas is motorbikes which are barely appropriate for the vast majority of patients requiring surgical care (10). Nevertheless, when the roads are available and can allow cars to reach healthcare facilities, the nearest healthcare facilities, which are integrated health centers, do not offer surgical care, and patients need to travel very far to find a healthcare facility delivering surgical care (11). Long travel times combined with inappropriate transportation may result in adverse outcomes for patients ranging from worsening surgical conditions to denovo injuries or illnesses (12).
Shortage of Skilled Personnel
There is a shortage of skilled personnel, including surgeons, anesthesiologists, and nurses, in rural areas of Cameroon. Many LMICs have a density of surgeons, anesthesiologists, and obstetricians (SAO) severely below recommended minimum level of 20 per 100,000 people (12). The workforce of specialists produced by the training programs in the country gets split by the consistent brain drain towards developed countries that offer better pay packages, carrier opportunities, and quality of life. The rural areas get to see even fewer skilled personnel because of the need to concentrate such personnel in the urban areas with much greater population density and health infrastructure. In addition, the few skilled staff who get sent to rural areas to close the equity gap often decide to stay in urban areas for greater financial and personal gratifications (13).
Health Seeking Behavior (HSB) of Rural Population
MacKian defined HSB as a “series of corrective measures which individuals undertake to resolve perceived ill-health.” These HSBs are known to depend on factors such as demographic, socio-economic, cultural, religious, and organizational, among others (14, 15). In rural areas, traditional healers seem more accessible geographically and financially; the population refers to them for various health concerns (16). This is truer when a patient goes to a healthcare facility and is diagnosed with a health condition that requires surgical treatment.
Surgery can be frightening, costly and is sometimes used as a last resort when other therapeutic approaches have proved unsuccessful (17). Two very common situations are the case of a baby malposition in the uterus at the end of pregnancy, for which the gynecologist suggests a cesarean section, and a road accident resulting in a fracture requiring surgery. In each case, respectively, the pregnant woman will seek a traditional healer’s help to reposition the baby prior to the due date, and the patient with a fracture will have recourse to a traditional masseur for treatment without surgery (16). It happens that the traditional healer’s treatment fails, and the patient returns to the healthcare facility with a worsened condition, thus compromising the outcome of the surgery.
Policy Recommendations
To address these challenges, the following policy interventions are recommended:
- Improve Infrastructure: Increase investment in surgical infrastructure, including operating theaters, diagnostic equipment, and trained personnel in rural areas of Cameroon.
- Expand Financing Options: Increase access to financing options for surgical care, such as appropriate health insurance schemes, and subsidize the cost of surgical care for those who cannot afford it.
- Improve Geographical Accessibility to Healthcare Facilities: Develop and maintain roads and transportation networks to improve accessibility to surgical care facilities in rural areas.
- Increase Health Personnel Training and Recruitment: Increase the number of skilled personnel, including surgeons, anesthesiologists, and nurses, in rural areas through targeted training programs and financial incentives. Additionally, develop favorable working conditions in rural areas to attract and retain skilled healthcare personnel.
- Strengthen the Collaboration Between Traditional Healers and Healthcare Facilities: A formal referral system could be implemented with available ambulances to target lost follow-up patients from healthcare facilities.
Access to surgical care remains a significant challenge in rural areas of Cameroon. Addressing these challenges requires a comprehensive and coordinated approach involving investment in infrastructure, financing, accessibility, personnel training, and appropriate health-seeking behavior. Implementing the above policy interventions while exploring digital health possibilities can help improve access to surgical care for individuals living in remote areas of Cameroon.
Dr. Bruna Djeunang Dongho
Ghyslaine Bruna Djeunang Dongho, Ph. D., is the Senior Researcher in Global Health and Public Health at the Nkafu Policy Institute.
Solange Dabou
Solange DABOU holds a Master of science in Clinical Biochemistry from the University of Dschang and have followed a distance learning training in epidemiology and health statistics from Aix Marseille University.
Regina Sinsai
Regina Sinsai holds a Bachelor of Arts Degree in Psychology from the United States International University – Africa, in Nairobi and an HND in General Nursing from the Humanity Health Professional Training Center (HHPTC) in Yaoundé.
Evrard Kepgang
Kepgang Evrard is a young research and humanitarian passionate. He holds a master’s degree in Public health and epidemiology at the University of Dschang.
Dr Ronald Gobina is a Nephrologist, working with the Regional Hospital in Buea. He is a Health Fellow and the Director of the COVID-19 taskforce for the DLF foundation. He is member of the International Society of Nephrology (ISN) and the Initiative to Strengthen Health Research Capacity in Africa (ISHReCA).
