REPUBLIC OF CAMEROON

MINISTRY OF PUBLIC HEALTH

REGIONAL DELEGATION OF PUBLIC HEALTH, NORTH WEST
North West Special Fund for Health, Bamenda

Deutsche Gesellschaft fur Techniseche

Zusamenarbei (GTZ) GmbH

PRIMARY HEALTH CARE

A GUIDE FOR DIALOGUE STRUCTURES
JUNE 2010 EDITION

The write-up and the production of this document have been sponsored by the NWPSFH and gtz

Primary Health Care: A Guide for Dialogue Structures. 2010 Edition

NWRDPH/NWPSFH
 REPUBLIC OF CAMEROON
MINISTRY OF PUBLIC HEALTH
REGIONAL DELEGATION OF PUBLIC HEALTH, NORTH WEST
North West Special Fund for Health, Bamenda

PRIMARY HEALTH CARE

A GUIDE FOR DIALOGUE STRUCTURES
JUNE 2010 EDITION
Authors of the June 2000 Edition: Reviewers
Dr GHOGOMU Nongho Amida Dr NDIFORCHU A. Victor: Regional Delegate of
Public Health, NWR
Dr NKWATE Charles Chi
Dr KONGNYUY N. Lazarus: Regional Chief of Cell
Dr KONGNYUY Lazarus
for Monitoring and Evaluation, RDPH
Mr NUMFOR John
Dr TCHEKOUNTOUO Odile C.: Research Officer
Dr MFONFU Daniel N°1, RDPH
Dr MFORNYAM Christopher Dr BAMBO Emmanuel Ngala: District Chief of
Service, Ndop Health District
Dr KUWO Pius
Mr BUNGWA Haynes Buma: General Manager,
Mr SUH Israel
NWPSFH Bamenda
Mr TAMANJI Gregory
Mr ACHIDI Zaccheus: Research Officer N°4, RDPH
Mr NDEH Donatus: Regional Delegation of Public
Health, NW
Mr BONEKEH John: Community Representative,
Ndop Health District
Mr NKWAIN Wilfred: Community Representative,
Benakuma Health District
Type setting
Mr NGWA Fritz AKUMA: Secretary/Accounts Clerk
GTZ/PGCSS-NWR

Mr TUME Amos Nsawir: Secretary NWPSFH,

Bamenda

PRIMARY HEALTH CARE: A GUIDE FOR DIALOGUE STRUCTURES 2010. © Copyright 2000, 2010 by North
West Provincial Special Fund for Health. All rights reserved.

COVER PICTURE: Partial view of the ultra-modern NWPSFH building in Bamenda

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TABLE OF CONTENTS
TABLE OF CONTENTS…………………………………………………………………… iv

LIST OF FIGURES…………………………………………………………………………. ix

LIST OF TABLES……………………………………………………………………………ix

ABBREVIATIONS…………………………………….……………………………………. xi

ABBREVIATIONS………………………………………………………………………….. xi

GENERAL INTRODUCTION………………………………………………………………. 1

Chapter 1: THE HEALTH SYSTEM IN CAMEROON………………………………….. 2

1.1. INTRODUCTION ..................................................................................................3

1.2. HISTORICAL BACKGROUND.............................................................................3

1.3. THE THREE PHASE HEALTH DEVELOPMENT SCENARIO.............................5

1.3.1 The Bamako Initiative .................................................................................5
1.3.2. The Reorientation of Primary Health Care.................................................5
1.3.3. The 2001 - 2010 Health Sector Strategy (HSS).......................................10

1.4. CONCLUSION....................................................................................................12

Chapter 2: DIALOGUE STRUCTURES………………………………………………… 15

2.1. DEFINITION…………………………………………………… ................................15

2.2. COMMUNITY PARTICIPATION.........................................................................15

2.2.1. Basis for community participation ............................................................15
2.2.2. Definition of community participation .......................................................16
2.2.3. Duties of community representatives in the dialogue structures ..............16
2.2.4. Types of dialogue structures....................................................................16
2.2.5. Definition of Zone.....................................................................................19
2.2.6. Composition of district dialogue structures ..............................................19
2.2.7. Election of Community Representatives into the various Dialogue
Structures.............................................................................................24

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Chapter 3: MANAGEMENT OF FINANCIAL RESOURCES 29

3.1. SOURCES OF FINANCES PER LEVEL ............................................................30

3.1.1. Revenue from Charges on Services Delivered ...........................................30

3.1.1.1. Health Centre........................................................................................31
3.1.1.2. Government Hospitals ..........................................................................31
3.1.2. Other Sources of Revenue ......................................................................32
3.1.2.1. Running Credits ....................................................................................32
3.1.2.2. Investment Credits................................................................................32
3.1.2.3. Parliamentary Grants............................................................................32

3.1.3. Declaration of Government Hospital Revenue............................................32

3.2. TOOLS FOR REVENUE COLLECTION ............................................................34

Chapter 4: STEPS AND PROCEDURES IN THE MANAGEMENT OF HEALTH

ACTIVITIES AND RESOURCES 38

4.1. INTRODUCTION ................................................................................................39

4.2. PLAN OF ACTION .............................................................................................39

4.3. WORK PLAN (BUSINESS PLAN) .....................................................................40

4.4. BUDGETING ......................................................................................................41

4.5. EXECUTION OF PLAN AND BUDGET AT THE HEALTH AREA .....................43

4.5.1. Custody of the Community Fund .............................................................43
4.5.2. Cash movement.......................................................................................43
4.5.3. The Health Centre Fund ..........................................................................44
4.5.4. The use of surplus ...................................................................................45
4.5.5. Government credits .................................................................................45

4.6. EXECUTION OF PLAN AND BUDGET AT THE DISTRICT SERVICE .............46

4.7. MATERIAL RESOURCES..................................................................................46

4.8. HUMAN RESOURCES.......................................................................................46

4.9. EXTERNAL FUNDING OF PROJECTS .............................................................47

4.10. COMMUNITY FINANCIAL SUPPORT .............................................................47

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Chapter 5: ORGANISATION OF DIALOGUE STRUCTURE MEETINGS AND
WRITING OF MINUTES 49

5.1. PURPOSE OF MEETINGS OF DIALOGUE STRUCTURES .............................49

5.2. PREPARATION OF MEETINGS ........................................................................51

5.3. CONVENING OF MEETINGS ............................................................................51

5.4. DELIBERATIONS AT MEETINGS .....................................................................51

5.4.1. How to conduct a meeting .......................................................................51
5.4.2. Characteristics of a Chairperson..............................................................52

5.5. CONTENTS OF MEETINGS ..............................................................................52

5.5.1. Health Area Management Committee......................................................52
5.5.2. Health Area Health Committee General Assembly ..................................53
5.5.3. District Hospital Management Committee................................................54
5.5.4. District Management Committee..............................................................54
5.5.5. General Assembly Meeting of the District Health Committee ..................55

5.6. PRESENTATION OF REPORTS .......................................................................56

5.7. WRITING OF MINUTES .....................................................................................56

CHAPTER 6: HEALTH INFORMATION MANAGEMENT SYSTEM FOR DECISION

MAKING BY DIALOGUE STRUCTURES…………………………... 59

6.1. DEFINITION OF HEALTH INFORMATION MANAGEMENT SYSTEM (HIMS).59

6.2. HEALTH INFORMATION MANAGEMENT AT ALL LEVELS ...........................59

6.4. GEOGRAPHICAL INFORMATION ....................................................................61

6.5. DEMOGRAPHIC INFORMATION ......................................................................62

6.6. SOURCES OF HEALTH INFORMATION ..........................................................62

6.6.1. Types of information ................................................................................62
6.6.2. Treatment of health statistics...................................................................63

Chapter 7: SUPERVISION OF HEALTH UNITS BY THE MANAGEMENT

COMMITTEE 68

7.1. INTRODUCTION ................................................................................................68

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7.2. JUSTIFICATION.................................................................................................68

7.3. WHO IS A SUPERVISOR? ................................................................................69

7.4. WHAT SHALL BE SUPERVISED ......................................................................70

7.5. HOW OFTEN TO SUPERVISE (PERIODICITY) ................................................71

7.6. HOW TO CARRY OUT SUPERVISION .............................................................71

7.7. CONCLUSIONS .................................................................................................72

Chapter 8: THE MINIMUM PACKAGE OF HEALTH ACTIVITIES (MPA) AT THE

HEALTH AREA AND DISTRICT LEVEL 74

8.1. INTRODUCTION ................................................................................................74

8.2. THE MINIMUM PACKAGE OF ACTIVITIES FOR THE HEALTH CENTRE ......74
8.2.1. Components of Maternal and Child Health ..............................................74

8.3. COMPLIMENTARY PACKAGE OF ACTIVITIES FOR THE DISTRICT

HOSPITAL..........................................................................................................76

8.4. THE DISTRICT HEALTH SERVICE (DHS) ........................................................76

Table 16: Areas of intervention by members of the Dialogue Structure in the

implementation of the MPA..............................................................................78

Chapter 9: PROCEDURES FOR INTERNAL AUDITING 81

9.1. DEFINITION .......................................................................................................81

9.2. TYPES OF AUDITORS ......................................................................................81

9.2.1. External Auditors .....................................................................................81
9.2.2. Internal Auditors.......................................................................................81

A) Community Fund ………………………………...………………………………….82

B) Government Credits ……………………………………………………………….. 83

C) Surplus ………………………………………………………………………………. 83

D) Donations …………………………………………………..……………………….. 83

9.4. SUMMARY .........................................................................................................90

Chapter 10: HEALTH AND DEVELOPMENT …………………………………………. 92

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10.1. HEALTH ...........................................................................................................92

10.2. COMMUNITY INITIATIVES ..............................................................................92

10.2.1. Community imposed and oriented projects............................................92
10.2.2. Community based projects ....................................................................93

10.3. IDENTIFYING COMMUNITY NEEDS AND PROBLEMS.................................93

10.4. CRITERIA FOR SELECTING REAL NEEDS AND PROBLEMS .....................93

10.5. CRITERIA FOR SELECTING REAL NEEDS AND PROBLEMS .....................94

10.6. THE ROLE OF THE DEVELOPMENT TEAM AND THE COMMUNITY ..........94

10.7 CONCRETE EXAMPLES OF COMMUNITY INITIATIVES ...............................94

10.8. SUSTAINABILITY ............................................................................................95

10.9. PROJECT COMMITTEE ..................................................................................95

10.9.1. Terms of reference ................................................................................95
10.9.2. Composition...........................................................................................96

10.10. EXAMPLES OF COMMUNITY REALIZED PROJECTS ................................96

10.10.1. The Batibo District Hospital surgical complex ......................................97
10.10.2. MHC Nkwen Ward Extension: Health Area Project (no written report
available)............................................................................................101
10.10.2.3. Target and realization .....................................................................103

10.11. CONCLUSION AND RECOMMENDATIONS...............................................103

REFERENCES ........................................................................................................104

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LIST OF FIGURES
Figure 1: National Health System pyramid in Cameroon ............................................ 6
Figure 2: Various dialogue structures from the health areas to the regional level .....18
Figure 3: Health Committee Cash Receipt Book .......................................................36
Figure 4: Daily cash entry register .............................................................................36
Figure 5: Government Receipt Book (Quittance) .......................................................36
Figure 6: Sample of a Payment Voucher ...................................................................44
Figure 7: Sample of a Cash Movement Register ......................................................44
Figure 8: Health Management Information cycle .......................................................60
Figure 9: The Health Pyramid and NHIMS ................................................................60

LIST OF TABLES
Table 1: Health Levels and their corresponding health services................................. 7
Table 2: Health Levels and their Dialogue Structures................................................10
Table 3: Dialogue Structures and their organs ..........................................................17
Table 4: Frequency of Dialogue Structures meetings ................................................21
Table 5: Sources of financing health activities at the different levels ........................30
Table 6: Hospital Revenue Declaration Form ............................................................37
Table 7: Sample Plan of Action..................................................................................40
Table 8: Sample Work Plan .......................................................................................41
Table 9: Activities against time using the Gant Chart ................................................41
Table 10: Sample Expenditure for a Health Unit........................................................42
Table 11: Dialogue Structure Meetings in the North West Region.............................49
Table 12: General Assembly Meetings of Dialogue Structures of the Health District.50
Table 13: Management Committee Meetings of the Health District ...........................50
Table 14: Sample summary of absolute values .........................................................64
Table 15: Core members per dialogue structure .......................................................69
Table 16: Areas of intervention by members of the Dialogue Structure in the
implementation of the MPA........................................................................................78
Table 17: Monthly Revenue Report ..........................................................................82
Table 18: Monthly Revenue Report ..........................................................................83

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Table 19: Monthly Declared Revenue........................................................................86
Table 20: Monthly Activities .......................................................................................86
Table 21: Monthly Activities .......................................................................................86
Table 22: Current Capital of Pharmacy......................................................................89
Table 23: Sales..........................................................................................................89

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ABBREVIATIONS
AFP Acute Flaccid Paralysis
AIDS Acquired Immune Deficiency Syndrome
ANC Ante Natal Clinic
ARV Anti Retroviral Drugs
CBGA Chief of Bureau General Affairs
CPA Complementary Package of Activities
DCS District Chief of Service
DFRP Department of Financial Resources and Properties
DH District Hospital
DHC District Health Committee
DHMC District Health Management Committee
DHS District Health Service
DHT District Health Team
DMC District Management Committee
DO Divisional Officer
Dr Doctor
DTG Diagnostic and Treatment Guide
EPI Expended Programme for Immunization
GTZ Deutsche Gesellschaft für Technische Zusammenarbeit
HAHC Health Area Health Committee
HC Health Centre
HIMS Health Information Management System
HIV Human Immunodeficiency Virus
HSS Health Sector Strategy
ITN Insecticide Treated Nets
IWC Infant Welfare Clinic
MCH Maternal and Child Health
MDGs Millennium Development Goals
MHO Mutual Health Organization
MINEFI Ministry of Economy and Finance
MPA Minimum Package of Activity
NGO Non Governmental Organization
NHMIS National Health Management Information System

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NWSFH North West Special Fund for Health
Oncho Onchocerciasis
PHC Primary Health Care
PIE Planning, Implementation and Evaluation
PLWHA People Living With HIV/AIDs
PMTCT Prevention Mother to Child Transmission
PPSC Provincial Pharmaceutical Supply Centre
RDPH Regional Delegation of Public Health
SDO Senior Divisional Officer
SIA Supplementary Immunization activities
SQI Systemic Quality Improvement
STIs Sexually Transmissible Infections
SWAp Sector Wide Approach
TB Tuberculosis
UNICEF United Nations Children’s Fund
UNO United Nations Organisation
WHO World Health Organization

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GENERAL INTRODUCTION

The National Health System in Cameroon or the Reorientation of Primary Health Care
has as one of its objectives to rationalize the use of resources through the concept of
community participation.
To ensure this, the strategy calls for the creation and functioning of dialogue structures
for each service and structure at every level of the system. A dialogue structure, seen
as a forum for communication and management brings together community members
(users) and health workers (providers) to take decisions on the health of the population.
Community members are democratically elected to serve for five years. The experience
since 1991 is that like every true democracy, each election brings in new crop of
members who are completely ignorant of the system, its principles and practices. Each
generation of community members in the dialogue structures thus needs training and
orientation to permit them work well.
The implementation of the reorientation of primary health care came at an era when the
training of health workers and their recruitment into the public service had been frozen.
Authorities and health workers charged with the implementation of the system are in
need of additional “on-the-job training”.
The training and reorientation of the dialogue structures and members of the health
team has often met with difficulties. Too many documents exist in monograph and
sometimes have conflicting information. In other places such documents are not even
available. To fill the gap, a first edition of the Guide for dialogue structures was
published. Considering the innovations that occurred in the health sector since then,
there was need to revise the document which briefly summarizes the basic principles
and practices of the reorientation of primary health care and the 2001 – 2015 Health
Sector Strategic Plan.
The authors are proposing here a document which summarizes the reflections and
practices of the reorientation of primary health care in the North West Region in
particular and Cameroon in general. It shall be used as a teaching guide and as a desk
reference to be regularly consulted by those engaged in this strategy. It permits the
harmonization of training at any level. This document is conceived and written for
members of the dialogue structures; members of the health teams at the operational
level (health professionals and pharmacy attendants), doctors and Nurses in training.
The present edition has been revised and new portions have been written or rewritten
based on constructive criticisms received from users, trainers and reviewers. We are
highly indebted to them for their fruitful contributions. Nevertheless, the authors and
reviewers do not claim that this book is complete or perfect. Its presentation and
content will be improved upon based on objective criticisms from readers and trainers.
Please address your observations to the Regional Delegate of Public Health, North West
P. O. Box 452 Bamenda, NWR – Republic of Cameroon,
Email: [email protected], [email protected]

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Chapter 1: THE HEALTH SYSTEM IN CAMEROONError! Bookmark not defined.

1.1. INTRODUCTION ...................................................... Error! Bookmark not defined.

1.2. HISTORICAL BACKGROUND................................. Error! Bookmark not defined.

1.3. THE THREE PHASE HEALTH DEVELOPMENT SCENARIOError! Bookmark not defined.
1.3.1 The Bamako Initiative ................................. Error! Bookmark not defined.
1.3.2. The Reorientation of Primary Health Care. Error! Bookmark not defined.
1.3.3. The 2001 - 2010 Health Sector Strategy (HSS)Error! Bookmark not defined.

1.4. CONCLUSION.......................................................... Error! Bookmark not defined.

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Chapter 1: THE HEALTH SYSTEM IN CAMEROON

1.1. INTRODUCTION
The present health system in Cameroon principally based on the Reorientation of
Primary Health Care and centered on the Health District System is a result of a series
of reforms from inherited colonial system. Based on the short comings of earlier
strategies, the Reorientation of Primary Health Care was conceived in 1985. Its
implementation was carefully developed and studied until 1989 when it was approved
for field trial. In 1990 the promulgation of the laws bearing on freedom of association
and on the waiver to sell drugs, reagents and small equipments in government health
units on a cost recovery basis set the pace for its effective implementation nation
wide.

1.2. HISTORICAL BACKGROUND

The Cameroonian Health Care System has undergone four major transformations:

A) From the colonial period to 1978, the Cameroonian health care system was
characterized by:
− State monopoly with little or no private initiatives
− Health Care (services and drugs) were free as the state bore the entire
costs.
− Irrational distribution of health structures and resources mainly concentrated
in towns and major economic pools at the expense of the rural milieus.
− High priority to curative activities at the expense of cost effective preventive
measures.
− A passive participation of the population (just recipients).
− Low priority given to traditional medicine by public authorities in spite of
popular glamour.
Thus with growing economic crises, this strategy became too expensive and
unaffordable. Drugs and equipment could not be replenished; training of staff was
a problem. Remote areas were abandoned to themselves. The system failed.

B) In September 1978 Cameroon was one of the many countries and organisations
that attended the WHO and UNICEF sponsored conference on Primary Health
Care in the East European Kazakhstan State capital, Alma Ata. Against the
above background, the conference resolved that in many third world countries like
Cameroon access to health care for the rural population was either poor or
insufficient. It proposed a strategy for the promotion of health for all, termed
Primary Health Care. It recognized traditional medicine and attached a lot of
importance to that practice. The effective implementation of this policy in
Cameroon started in 1982. During its implementation, the area of emphasis
shifted from the well known health professionals and classical health structures
(hospitals and health centres) to community health workers (village health

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 workers and traditional birth attendants) and their village health posts. This
vertical programme consisted of the mobilization of the community to:
1) Construct, allocate or rent a building to be used as a village health post.
2) Form village health committees for animation and communication.
3) Select a child of the soil as village health worker or traditional birth
attendant.
4) Acquire a limited list of essential drugs.
5) Ensure the training of the village health workers and the birth attendants.
At Rica, Russia, in 1987 a global midterm evaluation showed that not the PHC
concept but the so-called vertical PHC approach as outlined above had failed
colossally:
− The approach was not sustainable
− It lacked field coordination and offered room for the duplication of
interventions.
− It lacked supervision from the most peripheral health units with which it went
into competition
− There was no real planning resulting in irrational use of scarce resources.
− It was difficult to retain village health workers who either deserted, or got
entangled into embezzlement of the limited resources or into illegal
professional activities beyond their skills and competences.
− Generally the population took the village health workers for health
professionals whose performance was below expectation.

C) In 1990, Reorientation of Primary Health Care was introduced in Cameroon as a

natural outcome of the failure of the vertical PHC programme. It is the result of
two essentially African conferences seeking to redress the situation without
necessarily changing the strategy or philosophy but simply reviewing the
implementation of each concept involved. The two conferences are the 1985
Lusaka and 1987 Bamako conference of African Ministers of Health.

D) In spite of all these adjustments mentioned above, some shortcomings were

observed notably
− Lack of a legal framework for community participation;
− Lack of a legal framework for the national supply of essential drugs, notably
the Regional Pharmaceutical Supply Centre (RPSC);
− Lack of reforms in basic and continuous training;
− Lack of a framework of collaboration between stakeholders;
− Lack of regulation, supervision, monitoring and evaluation;
− Strong centralized management of the sector;
− Low use of public health care structures;
− Inadequate organization of PHC in urban areas;
− Low availability and accessibility of essential medicine;
− Poor development of the referral/counter referral system;
− Predominance of the direct payment for care.
This led to the adoption of the 2001 - 2015 Health Sector Strategy (HSS)

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1.3. THE THREE PHASE HEALTH DEVELOPMENT SCENARIO
At the regional meeting of African Health Ministers and WHO in Lusaka in 1985 a
strategy to accelerate health development was developed. This strategy called
“three phase health development scenario” stresses:
a) The global and multi sectoral approach to health issues,
b) The interlinking of health and socio-economic development.
It further calls on the reorganization of the national health system into three (3) lavels
viz: central, intermediate and peripheral. Each has specific functions to reinforce PHC
activities. It clearly defines the functional relationship between the layers. It clearly
identifies the peripheral layer otherwise called the DISTRICT as the operational unit
for the execution of PHC activities. It brings the actors as near as possible to the site
of execution.

1.3.1 The Bamako Initiative

In 1987, WHO, UNICEF and African Ministers of Health met in Bamako the capital of
the West African state of Mali and formulated a series of measures styled “BAMAKO
INITIATIVE” aimed at reviving their health services which were breaking apart for
lack of funding from the community and funding agencies. The Bamako Initiative (BI)
has five principal concerns.
− Improvement of the quality of Maternal and Child Health (MCH) services so
as to pay greater attention to these groups carefully described as
vulnerable.
− Reinforcement of peripheral health structures which are the Health Centres
and first referral hospitals. They serve a majority of the population.
− Mobilization of community financing through cost recovery by sales of drugs
and services
− Enforcement of Community Participation by putting in place a system to
ensure the participation of individuals and communities in decentralized
decision taking in health matters through their dialogue and management
structures.
− Putting in place of an Essential Drugs Policy so that cheap quality drugs in
their generic forms can be made available to the population. Essential
drugs must be available and affordable.

1.3.2. The Reorientation of Primary Health Care

Using the result of the midterm evaluation of the Primary Health Care and the
recommendations of both the 1985 Lusaka conference and the 1987 Bamako
Initiative, the Government of Cameroon through the Ministry of Public Health began
to reorganize its health system under the name Reorientation of Primary Health Care.
The Reorientation of PHC in Cameroon is not a programme as such but rather the
reorganisation (readjustment or correction) of the national health system so as to
meet with the social objective of health for all. It is therefore a strategy in the national
health policy which counts on the active and effective community participation for the
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management and functioning of health services. The Reorientation of PHC has two
major components:
- The reorganization of the national health system
- The rationalization of the management of resources either provided to or
generated by the sector, within the spirit of partnership between the state
and the community. This is called co-management.
A) Reorganisation of the National Health System
The reorganization of the health system has three objectives:
1) Improve the accessibility of health to the population (take the services to the
people).
2) Increase the efficiency of health services in order to better take care of health
problems.
3) Improve the quality of health care by paying attention to the vulnerable groups
(women & children).
The reorganized health system in Cameroon has three levels viz:
1. the peripheral or operational level = Health District
2. the intermediate level = Health Region
3. the central level = National

Figure 1: National Health System pyramid in Cameroon

National
Central
level

Intermediate
Health Region level

Health District Operational level

Just as the pyramid shows, the health district or the operational level takes care of
more people than the intermediate and central level. It is there that community
participation is practiced. It is there that the community can express its felt and real
needs and the mobilization into action.

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The two upper levels are more specialized and provide the technological know-how
which may be too complicated for the operational level. They provide the necessary
support which is strategic and technical. Each level has its corresponding Health
Service and Health Care Structures. This is better illustrated in the following table.

Table 1: Health Levels and their corresponding health services

Health services for
Structures for health
Level Role administration and
care provision
technical supervision
CENTRAL Provides strategic Ministry of Public Health General, Central and
support Teaching Hospitals

INTERMEDIATE or For technical Regional Delegation for Regional Hospital

Regional support Public health

OPERATIONAL or For operational 1. District Service for 1. District Hospital

PERIPHERAL or support Public Health
2. Integrated Health
DISTRICT
2. Integrated Health Centre Centre
Office

1) Strategic Support: This involves making laws and policies, allocating,

resources (staff, money and material), defining new programmes, ensuring the
training of high level human resources and supervision of the middle level.
2) Technical Support: Translate policies, laws and programmes into activities
for which resources may be reallocated. Supervise the operational level.
3) Operational Support: Assist in the real execution of activities which may be
patient care, prevention of disease or in promotion of activities to draw
awareness and mobilize the community towards an anticipated action.

Geographically, the central level covers the entire national territory. The intermediate
level covers an administrative region. The operational level covers a further
breakdown of each Region into Health Districts and each district into Health Areas.
The break down (demarcation) of the national territory into health districts and areas
is not in keeping with the breakdown of the administrative regions into smaller
administrative units. In short the Health District has no direct administrative
equivalent.
Health Districts and Health Areas are carved out using predetermined population,
geographic and socio-economic criteria to optimally use the health services and
health care structures at each level.

Criteria for the demarcation of health districts

1. Population
A viable health area has a population of 5 000 to 12 000 in the rural setup and 10.000
to 20.000 in the urban areas. A health district covers a population of 70.000 to
120.000 inhabitants. A district may cover between five to ten health areas.
2. Geographical Accessibility
All physical obstacles (big forest, rivers, and mountains) and distances separating
each population group from its health care structure are identified. These physical
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obstacles should in no case obstruct the population from gaining access to the
principal health care structure in the area or district. As much as possible these
physical obstacles serve as limits between districts and between health areas.
3. Socio-economic consideration
Economic development of the area should be considered. As much as possible bring
together in a district or in a health area communities who can live in peace and
accept to share together their failures and successes.

A functional Health District is a geographical entity with:

1) A well defined population (70.000 - 120.000)
2) Many health areas
3) A reference hospital called District Hospital (health care structure)
4) A district health service for administration and management
5) A dialogue structure to ensure community participation in the spirit of true
partnership.

In a functional health area at least 80% of health problems will be adequately

handled at the Integrated Health Centre while only 20 % above its competence will
need the attention of the District Hospital (first reference level). This level too should
conveniently handle about 80% of the referred cases while the rest are referred for
more appropriate management to the Regional Hospital (second reference level).
Thus there is a functional relationship of referral and counter referral of patients
between the health care structures in the three levels of the national health system.

To avoid unnecessary overlapping of activities between the levels, to rationally use

the health structures per level and to ensure quality care, the present health system
determines for each level the Minimum Package of Activity (MPA) that it can deliver.
The MPA is defined as the number of activities put together at that level so as to
solve the particular problems of the population at that level of the system. It will
certainly vary per level and per locality but tied to the local disease distribution
(epidemiology) and priority given to each problem (how big the problem and how
easy it is to be solved).

At the District level, the content of the Minimum Package of Activities (MPA) must be
determined individually and developed for:
a) The Health Centre and Health Area
b) The District Hospital
c) The District Health Service.

This is further developed elsewhere.

The reorganization of health activities into Minimum Packages of Activities is simply a

more operational and rational way of presenting the eight components of Primary
Health Care which are:
1) Health Education
2) Promotion of good food and nutrition
3) Provision of safe water and basic sanitation
4) Maternal and Child Health including Child Spacing
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 5) Immunization against infectious diseases
6) Treatment of common ailments
7) Prevention and control of local endemic diseases
8) Supply of Essential Drugs.

The MPA at the Health Centre or Health Area will be more promotion and health
prevention oriented than that at the District Hospital. That at the District Hospital will
be more care oriented than at the Health Service and Health Centre. Whereas the
MPA at the Health Service will be more administrative, managerial and supportive
with the aim not necessarily to carry out independent field activities but to adequately
assist the Hospital and Health Centres to perform their functions well.

The reorganization of the system is equally concerned with the quality of health care.
It prescribes clearly that quality health care must:
- Ensure continuity by providing care from the beginning to the end of the
episode
- Ensure comprehensive care by not only treating the disease but equally
considering the physical, social and economic environment of the patient.
- Provide integrated care by ensuring that staff and equipment at each structure
are such that curative, preventive and promotional activities can be carried out
in the same place and time. It seeks to destroy the traditional separation into
preventive and curative medicine.
B) The rationalization of the Management of Health Resources
The rationalization of the Management of Health Resources has dual objectives:
- Ensure better utilization of resources allocated to or generated by the sector.
- Ensure that the community is closely involved in management so that it can
conscientiously be responsible for seeking appropriate solutions for its health
problems.

For better utilization of resources the present system emphasizes the use of modern
management tools such as the National Health Management Information System,
financial documents, plans of action with a comprehensive budget, diagnostic and
treatment guide and essential drugs formulary to rationalize treatment. These tools
and systems described in chapter three and four of this guide guarantees transparent
management and accountability.

The present health system further stresses that health is the concern of each and
every one and not the exclusive preserve of the Ministry of Public Health and health
workers. It thus promotes effective and active community participation in health by
way of co-financing and co-management in a true and democratic sense of
partnership between the state and the community and between the users and
providers. This sense of partnership is demonstrated through the implementation of
the concept of collaboration within and between the sectors in a decentralized
manner.

The sure means by which resources generated or allocated can be rationally utilized,
and through it, community empowerment and sectoral collaboration installed and
strengthened is through the institution of dialogue structures for deliberation and
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management at each level of the system. Essentially these structures which are
either organs of deliberation/decision or execution or management are composed at
each level of users and providers, of technical and non technical staff, of members of
the various health related sectors, of the public and private sector. Such a group
creates the critical mass which is ever ready to listen to the health and
socioeconomic complains of the population that seeks to identify health problems of
the community. It also seeks solutions in the form of simple and feasible package of
activities to solve these local problems. The group plans, budgets for, executes and
evaluates the actions so undertaken.

Current dialogue structures and their management organs exist at the operational
and intermediate levels for all the responsible health structures and services. At the
central level only management structures do exist for equivalent health structures.
This is summarized in the table below.

Table 2: Health Levels and their Dialogue Structures

LEVEL HEALTH SERVICE AND STRUCTURE DIALOGUE STRUCTURES
CENTRAL − SERVICE: Ministry of Health − NIL
− STRUCTURES: Reference, General, − Management Committees only
central and Teaching Hospitals
INTERMEDIATE − SERVICE: RDPH − Provincial Special Fund and its
Management Committee
− STRUCTURES: Regional Hospitals − Regional Hospital Management
Committee
OPERATIONAL SERVICE: District Health Service − District Health Committee & District
STRUCTURES Management Committee
a) District Hospital − District Hospital Management
b) Integrated Health Centre and Committee
Medicalized Health centre − Health Area Committee
− Health Area Management Committee

The composition, roles, and functioning of these dialogue structures are further
developed in chapter 2 of this text.

There is a functional relationship between these dialogue structures. Community

members who are the active members enter the dialogue structures from the bottom
and contest with peers for entry into the higher structures and organs. The lower
structures and organs report to the higher structures and organs while the higher
structures and organs supervise and redirect the lower ones. At each horizontal level
the general assembly of the dialogue structure is the supreme organ that supervises
and enacts decisions of the management committees elected from its members.

1.3.3. The 2001 - 2010 Health Sector Strategy (HSS)

The consensual adoption in 2001 of the Health Sector Strategy (HSS) marked a
turning point in the evolution of the health policy in Cameroon. It reflected the future

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vision and proposed a set of reforms to be conducted to face up to health problems
of the population. Its objectives were:
(i) To reduce global morbidity and mortality by one-third among the most
vulnerable groups of the population,
(ii) To set up a health system delivering the Minimum Package of health activities
(MPA), at one hour's walk for 90% of the population,
(iii) To practice effective and efficient resource management in 90% of the public
and private health units and services at various levels of the pyramid. These
objectives were set up in 17 strategic axes of which the implementation was
done in 08 programs and 39 sub programs.

Within the framework of implementation of the Paris Declaration on the effectiveness

of development assistance, the Government, Technical and Financial Partners and
Civil Society Organizations in 2006 seized the favourable opportunities to commit to
the establishment of the Sector Wide Approach (SWAp). This includes:
(i) Political will,
(ii) Mutual trust and shared interest,
(iii) Strong government commitment and leadership,
(iv) The ongoing decentralization process,
(v) The existence of a critical mass of human resources,
(vi) The increase in financial laws for health.

The mid - term evaluation of the implementation of the 2001 - 2010 HSS was done
with the aim of updating or attuning the latter to 2015 in accordance with the MDGs.
From this evaluation emerged a general trend with some salient points and
recommendations for updating the strategy, its alignment to 2015 in line with the
Millennium Development Goals (MDGs) as well as its implementation.

A) General trend for the 2001 – 2015 Health Sector Strategy

This concerns five main areas namely:
1) Improvement and alignment of the health policy
2) Development of health districts
3) Health of the mother, adolescent and Child
4) Disease control
5) Health promotion

The 2001 - 2015 HSS intends to strengthen the implementation of health sector
reforms to translate into reality the "Health Sector Policy Statement of 1992". In
concordance with this scenario, the health district system has been chosen by
Cameroon as the level where operations for the implementation of national health
strategies must be conducted. In addition, Cameroon like other UN member states,
has subscribed to achieving the Millennium Development Goals (MDGs) by 2015.

The health sector is particularly committed to six MDGs which are:

- N° 1: Reduce extreme poverty and hunger.
- N° 4: Reduce under-five mortality.

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 - N° 5: Improve maternal health.
- N° 6: Combat HIV/AIDS, malaria and other diseases.
- N° 7: Ensure environmental sustainability.
- N° 8: Develop a global partnership for development .

To contribute in achieving the health related MDGs, the Cameroon Health Sector
intends to work towards developing its 178 health districts through efforts to
strengthen the entire health system. It also intends to ensure the evolution of the
district health development process with the production and provision of health care
and services likely to contribute to the achievement of heath related MDGs with a
system to monitor the performance of the sector.

A) Nomenclature of the 2001 – 2015 HSS

It comprises:
I. 4 intervention areas (Domains) including 3 for health care delivery namely:
i. Health of the mother, adolescent and child,
ii. Disease control,
iii. Health promotion,
And one for health system strengthening
iv. Health district development.
II. 14 health care delivery intervention classes
III. 7 health service strengthening intervention classes
IV. 63 categories including 36 health care delivery and 27 health service
strengthening interventions;
V. 259 types of intervention including, 138 health care delivery and 121 health
service strengthening interventions.

1.4. CONCLUSION
Briefly presented above is the Health System in Cameroon otherwise called
“Reorientation of Primary Health Care”. It has come about as a result of the failure of
two earlier strategies and approaches which led to the determination of wrong
priorities and irrational use of resources. The new system based strictly on the PHC
ideology is therefore seeking to improve health care by reorganizing and rationalizing
the National Health System. Emphasis has thus shifted from hospital based care and
or development of health post to the Health District with its health service, hospital
and network of integrated health centres as the operational unit. The 2001 - 2015
HSS intends to strengthen the implementation of health sector reforms to translate
into reality the "Health Sector Policy Statement of 1992"
The definition given to PHC at Alma Ata is still as valid in the current health system
as it was in 1978. The full understanding and implementation of every concept
embodied in this definition are so important that this chapter cannot be ended without
reference to them.

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These concepts are essential health care based on practical methods and
techniques:
- Socially acceptable
- Universally accessible
- With the participation of the community
- At the cost the community can afford

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Chapter 2: DIALOGUE STRUCTURES
Er
ror! Bookmark not defined.

2.1. DEFINITION ............................................................. Error! Bookmark not defined.

2.2. COMMUNITY PARTICIPATION............................... Error! Bookmark not defined.

2.2.1. Basis for community participation .............. Error! Bookmark not defined.
2.2.2. Definition of community participation ......... Error! Bookmark not defined.
2.2.3. Duties of community representatives in the dialogue structuresError! Bookmark not de
2.2.4. Types of dialogue structures...................... Error! Bookmark not defined.
2.2.5. Definition of Zone....................................... Error! Bookmark not defined.
2.2.6. Composition of district dialogue structures Error! Bookmark not defined.
2.2.7. Election of Community Representatives into the various Dialogue
Structures............................................... Error! Bookmark not defined.

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 Chapter 2: DIALOGUE STRUCTURES

2.1. DEFINITION

Dialogue structures (health committees) are organs and forums put in place to
ensure and enhance:
a) Effective community participation in health care
b) Communication between health staff and the community.
c) Partnership between the state (health providers) and the community (users) in
health care.

In short, a good dialogue structure for health, otherwise called health committee,
should at all time be composed of at least four categories of persons:
a) Elected community representatives to validly represent the interest of the
people
b) Providers of health care, that is, members of the technical health team, non
governmental organizations, common initiative groups, or faith based
organizations active in the area of health and present in the community.
c) Representatives of health related sectors present in the community.
d) Representatives of the supervisory authority. That is, the Ministry of Public
Health and the local administration.

2.2. COMMUNITY PARTICIPATION

2.2.1. Basis for community participation

The technical health team exists for the community. The community has health
needs and it is the duty of the health team to prompt/mobilize the community to
respond to those needs. Through primary health care, essential health care is made
universally available to individuals, families and communities. It includes those
services that promote health such as keeping a clean environment, a good water
supply, care of women during pregnancy and child birth, nutrition of children,
immunization and early treatment of disease. Such services depend for success on
the active participation or involvement of the communities and individuals concerned.
The technical health team has an essential role on such services but cannot alone
ensure their success.

To achieve its goal the technical health team must be able to encourage, stimulate
and support community participation. That is, help people to rely as much as
possible on their own efforts and resources to meet their health needs. The technical
health team must work with the community.

It is in this perspective that the national declaration on the implementation of the

reorientation of primary health care emphasizes on partnership between the state
(health personnel) and the community based on co-management and co-financing of
health care to the population.

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2.2.2. Definition of community participation

Community participation is the involvement of the community in health care and

health related activities with a view to promoting self-reliance vis-à-vis solutions to its
health problems (national declaration on reorientation of primary health care). This
means that the community determines its health priorities according to its health
needs and seeks for solutions, in partnership with the technical health team and other
related sectors.

Community participation therefore includes:

a) Decision making
b) Identification of health problems and needs
c) Planning and execution of health activities
d) Elaboration of measures and strategies to solve problems and needs
e) Mobilization of resources to carry out programs, projects and health activities
f) Monitoring and evaluation of the health situation in the community.
g) Acceptance and use of health services offered by approved health facilities.

For the community to effectively and actively take part in health activities, it must be
organized into dialogue structures. Dialogue structures are therefore indispensable
instruments to foster and ensure community participation.

2.2.3. Duties of community representatives in the dialogue structures

1) Sensitize and organize the community for health promotion and prevention of
diseases
2) Mobilize the community to participate more actively and positively in the
various health programs
3) Identify health problems and needs of the community and propose strategies
to solve them.
4) Inform the health personnel on the outbreak of any disease in the community
5) Enhance and participate in outreach activities
6) Mobilize the community towards the better utilization of health services
7) Educate the population on the health policy, programs and activities
8) Promote the spirit of partnership (collaboration, team work, confidence,
cordiality, togetherness in health care etc.) between the state (health services)
and the community.
9) Participate in co-financing and co-management of health activities with the
health personnel.
10) Mobilize resources for health care in the community.

In short, community representatives shall work hand in hand with technical staff at
every level. They shall not fight each other but seek to ease the task of each group.

2.2.4. Types of dialogue structures

Dialogue Structures exist in 3 levels namely: the Region, the Health District, and the
Health Area each with a number of organs. This is illustrated in table 3.

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Table 3: Dialogue Structures and their organs
LEVEL DIALOGUE STRUCTURES ORGANS

REGION The North West Provincial Special Fund - The General Assembly of the FUND
for Health (FUND)
- The Management Committee of the
FUND
(This is the Regional Health Committee) - The Regional Hospital Management
Committee
HEALTH DISTRICT The District Health Committee (DHC) - The District General Assembly
- The District Management Committee
- The District Hospital Management
Committee
THE HEALTH AREA The Health Area Health Committee - The Health Area General Assembly
(HAHC)
- Health Area Management Committee

The health zones are created as electoral constituencies, and to facilitate contact
between the health area committee and the members of the community.

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Figure 2: The various dialogue structures from the health areas to the regional level

PROVINCIAL
1. General Assembly of the Fund
Standing Committee 2. Management Committee of the Fund
General Assembly 3. Management Committee of Regional
Management Committee Hospital

P.H
M.C
3
2
1

DISTRICT
1. General Assembly of District
Standing Committee Health Committee
General Assembly 2. Management Committee of
the District Health Committee
3. Management Committee of
H.D MC District Hospital
DHMC
3
2
1

HEALTH AREA
1. General Assembly of Health
Standing Committee Area Committee
General Assembly 2. Management Committee of
the Health Area Committee

Health Area
Management
Committee

Electoral Zones
(Quarters/Villages)
Note:
1) Vertical arrow ( ) indicates election of community members from one level to
the other
2) Horizontal arrow ( ) indicates election of community members into the various
organs of a dialogue structure at each level.
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 3) Broken arrow ( ) indicates communication and action line between dialogue
structures at various levels and between the different organs of the dialogue
structure at each level.

2.2.5. Definition of Zone

It means quarters or villages in different places. Zones should be carved out in such
a way that minority groups should constitute specific zones if need be.

2.2.6. Composition of district dialogue structures

The dialogue structures are constituted in the spirit of partnership between the
technical health providers and the community at all levels.

2.2.6.1. The Health Area Health Committee (HAHC)

2.2.6.1.1. The General Assembly of HAHC

i. All elected community representatives from the zones. They are active
members and have voting rights.
ii. Health staff are ex-officio members because they are not elected. They have
voting rights. These are,
- Chief of the leading Health Centre of the Health Area
- One member of the health centre team
- District Chief of Service of Public Health, or his representative
(supervisory authority).
iii. Honorary members (have a consultative function and no voting rights). They
are:
- Heads of religious organisations active in the area
- One councillor elected by its peers from the area
- Two representatives of traditional authorities in the health area.
- One representative of the registered traditional practitioners.
iv. Co-opted members (have no voting rights but have a consultative function).
- One representative from each health related sector (agriculture,
veterinary, education, etc) brought in as technical experts.

2.2.6.1.2. Standing Committee of the HAHC

a) President: elected from community representatives

b) Vice president: elected from community representatives
c) Secretary: Chief of the leading Health Centre
d) Two auditors: elected from community representatives

2.2.6.1.3. Management Committee

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 a) Chairman: elected from community representatives
b) Secretary: Chief of the leading Health Centre
c) Treasurer: elected from community representatives
d) Financial secretary: elected from the community representatives.
e) Members: two other elected community representatives who will automatically
represent the health area at the district level.
f) District chief of service public health or his representative

2.2.6.2. The District Health Committee (DHC)

2.2.6.2.1. General Assembly of DHC

i. All the two community representatives from each health area. They are active
members and have voting rights.
ii. Health staff (ex-officio members)
a) District Chief of Service Public Health
b) Director of the District Hospital
c) The District Supervisor from the Regional level
d) Two representatives of all chiefs of Integrated Health Centres in the district.
e) Chief of Bureau Health (see new organisational structure)
f) Chief of Administration and Finance with a voting right.
iii. Honorary members: They have consultative powers and no voting right.
a) One representative of DO/SDO (Administration)
b) All mayors
c) One representative of private clinics
d) One representative of private pharmacies
e) One representative of the registered traditional practitioners.
f) All parliamentarians
g) One head of each religious organisation active in health activities in the
district.

2.2.6.2.2. Co-opted members

One representative from each of the health related sectors (Social and Women
affairs, Veterinary, Agriculture, Education, Youth and Sport, Environment, etc). Their
role is consultative. They have no voting rights.

2.2.6.2.3. Standing Committee of the General Assembly of the DHC

1) President: elected from community representatives
2) Vice president: elected from community representatives

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 3) Two auditors: One elected from community representatives (to audit both the
DMC and the DHMC)
4) The chief of bureau Administration and Finance
5) Secretary: the District Chief of Service Public Health.

2.2.6.2.4. District Management Committee (DMC)

1) Chairman: elected from among community representatives
2) Vice chairman: elected from the community representatives
3) Secretary: The district chief of service public health
4) Financial secretary: A community representative
5) District supervisor from the regional level
6) Two other elected community representatives who will automatically represent
the district at the general assembly of the Provincial Special Fund for Health.
7) The Chief Medical Officer of the District Hospital.
8) Treasurer: Service Manager of the District Hospital.
9) One Co-opted member

2.2.6.2.5. District Hospital Management Committee (DHMC)

1) Chairman: One mayor elected by his peers
2) Vice Chairman: elected from the community representatives
3) Secretary: Director of the District Hospital
4) Treasurer: the Service Manager of the District Hospital
5) District Chief of Service Public Health (member)
6) The four community representatives of the District Management Committee.
7) One staff representative elected by his peers.
8) One representative of the divisional/sub divisional treasury.

2.2.6.3. Frequency of meetings of the dialogue structures

The frequency of ordinary meetings for dialogue structures and their organs vary
from level to level. This is illustrated in table 4.

Table 4: Frequency of Dialogue Structures meetings

Level Ordinary meetings Frequency of meetings

North West General Assembly Once a year

Provincial Special Management Committee Every 4 months
Fund for Health
Regional Hospital Management Committee Every 3 months

District Health General Assembly Twice a year (every 6 months)

Committee District Management Committee Every 4 months
District Hospital Management Committee Every 3 months (at least)

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Health Area Health General Assembly Every 4 months
Committee Health Area Management Committee Monthly

In the event where a General Assembly and its Management Committee have to
meet within the same period, the management committees will meet first so as to
produce reports to the General Assembly. Similarly, the hospital Management
Committee meets first to make its reports available to the Regional or District
Management Committee as the case may be.

2.2.6.4. Duties of members of dialogue structures

2.2.6.4.1. Standing Committee of General Assembly

1) President: Participates in the preparatory management committee meeting for

each General Assembly meeting, convenes and presides at the General
Assembly meeting.
2) Vice president: Acts in the place of the president in the absence of the
President and undertakes activities as may be requested by the president.
3) Secretary (health staff): Writes the minutes of the General Assembly
meetings, distributes the minutes to participants, prepares invitations and
agenda of meetings, guides the General Assembly meetings on the official
health policy and technical issues, and co-signs minutes.
4) Auditors: Check the revenue, verify the execution of work plans and control
the utilisation of corresponding budget, control the finances of the pharmacy.
Their activities should be supervisory, advisory, and supportive, not conflicting.

2.2.6.4.2. General Assembly of dialogue structures

1) It is the supreme deliberation and decision making organ of the dialogue
structure at all levels
2) Examines the report of activities of the Management Committees
3) Deliberates and adopts measures and strategies to implement health
programs in the community.
4) Decides on the proposals of management committee on the use of surplus.
5) Examines and adopts the plan of activities and budget for the next financial
period presented by the management committee.
6) Elects community representatives to management committees.
7) Decides on any other matters duly submitted to it by either the health
personnel or community representatives.
8) Approves audit reports submitted to it to permit it judge the way the finances of
the structure have been managed.
9) Identifies and approves community initiatives.

2.2.6.4.3. The management committee

The management committee is the management organ of each dialogue structure.
As such it:

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1) Ensures the execution of activities on the plan of action approved by the
General Assembly.
2) Presents a report of activities to the general assembly.
3) Prepares and presents a costed plan of action (activity and budget) for each
activity period.
4) Determines the health priorities of the community.
5) Mobilises resources (financial, material, human) for the execution of the
approved plan of action.
6) Supervises the health facilities including the pharmacy.
7) Ensures the updating of inventory of material and equipment of health units.
8) Recruits (pharmacy attendants, and guards, etc) needed staff.

i. Chairman of Management Committee

− Represents the corresponding dialogue structure in all acts of civil life and
liaises with public authorities.
− Convenes and presides over management committee meetings.
− Co-signs the financial documents of the dialogue structure including the
bank accounts.
− Reports to the president of the standing committee on activities carried out
by the management committee.

ii. Secretary of the Management Committee

− Takes minutes in all meetings of the management committee.
− Prepares and distributes minutes of Management Committee meetings to
members.
− Prepares meetings of the Management Committee and the General
Assembly.
− Co-signs all financial documents.
− Initiates the plan of action, work plan and budget for the scrutiny of the
management committee.
− Educates and guides the management committee on health policy and
programs.
− Keeps all management committee documents for safety and easy access
to supervisors.

iii. Treasurer of the Management Committee

− He/she is the only person in the dialogue structure responsible for
receiving and spending money according to instructions. In this capacity
he/she:

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 - Co-signs all bank documents of the dialogue structure.
- Must make himself and all financial documents available to auditors,
financial secretary and supervisors as need may arise.

iv. Financial Secretary

− Prepares and presents financial reports.
− Ensures that the financial documents kept in the pharmacy are regularly
updated.
− Must make himself and all financial documents available to auditors and
supervisors as need may arise.

2.2.7. Election of Community Representatives into the various Dialogue

Structures

The modalities for elections are made on the basis of Decree No. 93/228/PM of
15/03/1993, and the Memorandum and Articles of association of the North West
Provincial Special Fund for Health as well as its Internal Regulations and
Resolutions.

The various dialogue structures for health care development in the North West
Region are ancillary organs of the FUND and are governed by its constitution and
bye-laws.

The FUND sets the period for the tenure of office for each set of officers and
prescribes the date for new elections. Thus community representatives stay in office
for five (5) years renewable once.

The management committee of the FUND is the validation committee for the
elections. This session is usually in the months of March/April of each election year.
The work of health committee members is benevolent and voluntary.

2.2.7.1 Election procedure

A) Electoral constituency: Each health area is broken into zones of 500 – 1000
inhabitants to elect two persons to represent the zone at the health area. A
health zone with over 1000 inhabitants elects three persons into the health
area committee.

B) Electoral Committee
i) Zonal level
− Chairman: President of the Standing Committee of the HAHC
− Secretary: Chief of the leading Health Centre
− Members: Traditional authority in the Health Area or his representative
Note: The Chairman of the Management Committee will replace the Chairman of the
HAHC in his own zone if the latter is standing for election.
ii) Health Area level
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 − President: The District Chief of Service Public Health
− Secretary: Chief of leading health centre
− Member: President of the Standing Committee of the DHC
− Regional Supervisor
− Traditional authority in the Health Area.
iii) District level
− Chairman: Senior Divisional Officer and in very exceptional cases the
Sub Divisional Officer. (When and where ever a health district covers
just one sub division).
− Secretary: District Chief of Service Public Health
− Regional Supervisor
− Member: Divisional representative at the Management Committee of
the FUND
− Member: Director of the District Hospital

C) Sequence of elections
Start with Zonal, Health Area, District and end with the Regional elections.
i) Zonal elections
Each zone with a population of 500 to 1000 inhabitants elects 2 community
representatives to the Health Area Health Committee.
Each zone with a population above 1000 inhabitants elects 3 community
representatives.

ii) Health area elections

Each Constituent General Assembly of the Health Area Health Committee, convened
by the District Chief of Service of Public Health elects;
− 4 community representatives to the Standing Committee of the General
Assembly of the Health Area.
a) President
b) Vice President
c) 2 Internal Auditors
− 6 community representatives to the Health Area Management Committee:
a) Management Committee Chairman
b) Vice Chairman
c) Treasurer
d) Financial Secretary
e) 2 Community Representatives who will automatically represent the
Health Area at the District Health Committee.

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 iii) Health district elections
Each Constituent General Assembly of the District Health Committee is convened by
the Chairman of the electoral committee.
− 3 community Representatives to the Standing Committee of the General
Assembly of the District Health Committee:
a) President
b) Vice President
c) 1 Internal Auditor
− 6 Community Representatives of the District Management Committee
a) Chairman
b) Vice Chairman
c) Treasurer
d) Financial Secretary
e) Members: 2 Community Representatives who will automatically
represent the District at the Fund’s General Assembly
− 4 Community Representatives of the District Management Committee are
elected to the District Hospital Management Committee as members. One
of them will be Vice Chairman of the District Hospital Management
Committee.

2.2.7.2. Basic rules

− No person holding an elected duty post at the Health Area level is eligible
for election into the district health committee
− With the exception of the District Hospital Management Committee, no
person holding an elected post at the District level is eligible for election
into the NWPSFH General Assembly.
− Entry point for election for all Community Representatives is strictly at the
Zonal level.

2.2.7.3. Criteria for eligibility

a) To be eligible for election into the Health Area Health Committee at the
Zonal level, the person must:
1) Be resident in a Zone of the Health Area.
2) Know how to read and write.
3) Be respectful and respected in the community.
4) Must not be above 65 years old.
5) Be interested in and concerned about community health problems.
6) Be able to mobilise the community for their health care activities.

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 7) Be responsible and have an independent source of income (socially
and economically viable).
8) Not be involved in parallel activities in the health domain (drug peddlers,
patente medicine dealers, running illegal health unit etc).
9) Not be a civil servant or an employee likely to be transferred out of the
health area at random.
10) Willingly and voluntarily sacrifice his time and resources for health
promotion activities.
11) Not have been involved in dishonest and fraudulent activities which
could have earned him imprisonment.
12) Not have a very close relation with someone gainfully employed by the
FUND.
13) Gender issue: Encourage the entrance of more women and minority
groups into the health dialogue structures. Where there is a tie for a
post between a lady and a male the post should automatically go to the
female contestant.
14) Any candidate who holds an elected Political Post, Traditional Rulers
and affiliates is automatically disqualified.
15) All candidates vying for any elected post at all levels MUST be member
of the Mutual Health Organisation.
b) To be eligible for election into the Health Area Management Committee
the person must:
1) Reside within a walking distance of at most 5 kilometres.
2) Be readily available at all times at the Health Centre.
3) Be able to read and write good English.
c) To be eligible for election into the District Management Committee the
person:
1) Must be able to read and write very good English.
2) Should reside in the Health Area nearest the District headquarters.
3) Should be readily available to the district technical health team at all
times.

2.2.7.4. Election and handing over modalities

1) To be elected the person must be nominated (self nomination authorised) and
seconded.
2) Election is by secret ballot
3) Election is carried by absolute majority, that is, above 50%.
4) Each candidate will choose his symbol and/or colour.
5) The elections in each District (from Zonal to District level) will be conducted
under the supervision of the highest administrative authority in the Health
District.

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6) After the Zonal elections are completed in each Health Area, the new General
Assembly is summoned into session by the District Chief of Service Public
Health for the constitution of its organs (Constituent General Assembly) and
election of its representatives to the DHC.
7) After Health Area elections are completed in each Health Area, the new
General Assembly for the District Health Committee is summoned by the
highest administrative authority on the initiative of the District Chief of Service
Public Health to form its ancillary organs and to elect representatives to the
Fund.
8) Handing over between the out going and the incoming dialogue structures at
all levels must be effected as soon as the elections are over.
9) Each District Chief of Service for Public Health must submit to the Regional
Delegation of Public Health a detailed election report including information
(bio-data) on each elected representative immediately after the district
elections.

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Chapter 3: MANAGEMENT OF FINANCIAL RESOURCES
Er
ror! Bookmark not defined.

3.1. SOURCES OF FINANCES PER LEVEL .................. Error! Bookmark not defined.

3.1.1. Revenue from Charges on Services Delivered . Error! Bookmark not defined.
3.1.1.1. Health Centre.......................................... Error! Bookmark not defined.
3.1.1.2. Government Hospitals ............................ Error! Bookmark not defined.

3.1.2. Other Sources of Revenue.................................. Error! Bookmark not defined.

3.1.2.1. Running Credits ...................................... Error! Bookmark not defined.
3.1.2.2. Investment Credits.................................. Error! Bookmark not defined.
3.1.2.3. Parliamentary Grants.............................. Error! Bookmark not defined.

3.1.3. Declaration of Government Hospital Revenue.. Error! Bookmark not defined.

3.2. TOOLS FOR REVENUE COLLECTION .................. Error! Bookmark not defined.

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 Chapter 3: MANAGEMENT OF FINANCIAL RESOURCES

3.1. SOURCES OF FINANCES PER LEVEL

The reorientation of Primary Health Care in Cameroon stresses on the principle of
“co-financing”. This means financing health activities and health development
projects through the financial contributions of all the partners: the State, local
councils, Community, local and International Non Governmental Organisations, bi-
lateral and Multi-lateral Organisations. The various sources of financing health
activities at the different levels of the dialogue structure are analysed per level in
table 5.

Table 5: Sources of financing health activities at the different levels

No Level State sources Community sources Others
1 FUNCTIONAL 1. Government 1. Payment of fees for services Donations, gifts
HEALTH AREA Credits for running 2. Mutual Health Organisation and contributions
and investment (MHO) financing from NGOs and
2. Parliamentary Associations
3. Surplus from the FUND from
grants sales of drugs
3. Local Council 4. Semester assistance from the
financing FUND
5. Project levies
2 NON 1. Investment Credits 1. Contributions especially in the Assistance
FUNCTIONAL when possible form of project levies from NGOs,
HEALTH AREA 2. Parliamentary grants 2. Mutual Health financing (MHO) Associations
and friendly
3. Local Council 3. Donations from elites and
Countries
financing development associations
3 DISTRICT Government Credits for 1. 4% from Health Centres Assistance
HEALTH running and investment 2. 4% of 63% of revenue set from NGOs
SERVICE aside of the District Hospital Support from
3. District Health Committee International
Fund from NWPSFH Organizations
4. Supervision subsidy from the (WHO, UNICEF,
NWPSFH GTZ, etc)
4 DISTRICT Government Credits for 1. Surplus from the FUND from Donations and
HOSPITAL running and investment drug sales gifts from
Local Council financing 2. Payment of fees for services NGOs,
Associations,
3. Mutual Health financing (MHO)
Foreign
4. Donations and gifts from the partners.
Community.

3.1.1. Revenue from Charges on Services Delivered

As an economic entity, each health structure is a productive unit. It generates income
from the services it provides. Services are no longer free. Whereas, in the private
sector this is the principal source of income, in public sector there is subvention in
addition to this scheme.

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3.1.1.1. Health Centre
The following rates are currently implemented in the North West Region in
Government Health Centres:
a) Consultation fees: 200 francs CFA for each consultation
b) ANC first visit (registration) 200 francs CFA.
c) Delivery fees: 1000 – 2000 francs CFA.
d) Laboratory fees: a price list from the NWPSFH fixes the price for each
laboratory test.
These fees constitute the Community Fund of the Health Centre. As will be noted,
collection of fees for essential programs like EPI has not been authorized except for
payment of cards and injection materials (disposable needles and syringes) where
and when necessary.

3.1.1.2. Government Hospitals

The following sources have been identified and some, though, not all have been
implemented in all hospitals:
− Out patient consultations
− In-patient Care
− Deliveries
− Dental Care
− Rehabilitative Care
− Radiography Services
− Medical and Medico-Legal Certificates
− Occupational Medicine
− Pharmacy Services
− Mortuary Services
− Ambulance Services
The rates have been fixed by Decree No 63/DF/141 of 24th April 1963, in part and
others have been determined by management on the other hand. This tarification is
applicable to all Government Health Units functioning as a District Hospital or as a
Medicalized Health Centre. It is worth mentioning that as far as laboratory activities
are concerned, the NWPSFH has added a supplementary laboratory fee to the
official value for every test in the North West to compensate for the cost of reagents
and small laboratory materials purchased by the Health units. This supplementary
fee is collected on Hospital Management Committee receipt booklet and paid into
Hospital Cost Recovery Fund.
When and wherever the referral system is fully operational, a by pass fee will be
established to penalize patients who by-pass their Health Centres to consult directly
at the hospital. The proceeds are considered as community funds and not treasury
fees and should be collected on the Hospital Management Committee Receipt
Booklet.
On the other hand private hospitals are called upon to play the role of District
Hospitals in places where the latter do not exist in accordance with Decree No.
87/529 of 21st April 1987 bearing on the general ties of professional acts in the health
sector.

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3.1.2. Other Sources of Revenue

3.1.2.1. Running Credits

These are credits, which are allocated on an annual basis by the state to enable
health unit’s carry out their assigned tasks. They are usually delegated for the period
of January 1st to December 31st and must be used during this period.

3.1.2.2. Investment Credits

They are credits voted and delegated for the acquisition of durable and non-
consumable assets by the state (construction, renovation, purchase of capital goods,
etc). These credits also follow the principle of annual budgeting.
This source of Government revenue is based on warranty, since the “money” is on
paper. Sometimes it becomes difficult for managers to make use of government
credits due to its long and cumbersome procedure and the liquidity syndrome in our
treasuries. The state sometime waters down this rigour by making available money
through an imprest account. This account is actually a percentage of either the
running or investment credits which is available in liquid form so that managers can
use as often as possible to do small purchases.

3.1.2.3. Parliamentary Grants

Where available this also forms part of the sources of revenue in our health units.
They are disbursed to parliamentarians to meet certain political and other needs.
The above sources are available but insufficient to meet our ever increasing health
needs. It is therefore time that we start looking at Risk sharing in our health units.
We have cost recovery which is one aspect of cost sharing. This is found to exist
between health providers and users.
Another factor is Insurance on health. The Health Committee at all the levels should
get potential groups organized (Njangi groups) so that something be put aside to be
used for registration into the Mutual Health Organisation.

3.1.3. Declaration of Government Hospital Revenue

The declaration of the revenue of Government Hospitals is guided by the following
texts:
1. Arrete No. 003/MSP/MINFI of 12th July 1993, fixes the list of government
hospitals authorized to conserve 35% of the hospital revenue for its
development.
2. Decree No. 94/303/PM of 14th July 1994, states that the “quotes parts” (rebates
or honoria) to hospital staff is 30% of total revenue collected except revenue
from sales of drugs and mortuary fees.
3. Arrete No. 003/MSP/CAB of 16th November 1994, states that some staff of the
hospital benefit from “quotes parts” following the criteria outlined in this law.
4. Decree No. 03/229/PM of 15th March 1993 states that:
a) 50% of the remaining 70% (35% total revenue) is to be paid to the state
treasury.
b) 50% of the remaining 70% (35% of total revenue) is retained for the
hospital development.

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 c) Solidarity fund is 10% of the amount for quotes parts (30% of total
revenue); plus 10% of the amount for hospital development (35% of total
revenue), and is paid into a special account opened by the Ministry of
Public Health.
The finance law No 98/009 of 01/07/1998 prescribes that after the deduction of 30%
revenue for honoraria to staff, the remaining 70% (not a fraction of it) all go into the
revenue set aside. The 35% hitherto paid to the government treasury has been
suppressed. With this consideration in mind, therefore the use of hospital revenue is
thus:
1. 27% to staff,
2. 3% to National Solidarity Account for honoraria,
3. 7% to National Solidarity Account from Hospital Development Fund, and
4. 63% to the Hospital Development Fund (Revenue set aside budget).
The Hospital Development Fund (Revenue set aside budget) is a Provisionary
Budget as opposed to the annual running credits which is a Previsionary Budget. It
means that revenue collected in the course of one year is not used that year but
saved into a Blocked Saving Account. It can only be used the following year year
after the Management Committee has submitted the draft budget on its use to
hierarchy (Regional Delegation of the Ministry of Public Health) and obtained an
authorisation. Expenditures made are in the form of an imprest, the money is
available and not anticipated.
The District Hospital bank account is run by the Director of the District Hospital, the
Chairman of the District Hospital Management Committee and the Service Manager
(Econome) who doubles as the Treasurer of that committee.
Order No 005/MSP of 15/07/1994 and completed by Order No 00301/MSP of
20/09/1999 prescribes the modalities for the use of revenue set-aside for hospital
development. The conditions and procedure to follow in order to have the budget
approved are equally outlined. The effective transfer of the National Solidarity (10%)
to the appropriate account is an obligatory condition for the approval of the budget.
Amongst others, the minutes of the Management Committee that studied and
submitted the budget as well as a report on the execution of the budget of the
previous year must be attached.
Revenue collectors must deposit their proceeds into the Savings Account every ten
days. They must make monthly and quarterly revenue declaration through the District
Health Offices of attachment to the Regional Delegation, using the appropriate tools.
After deducting 10% of the global revenue for National Solidarity, the Hospital
Development Budget (Revenue set-aside) is presented in chapters as below
extracted from article 2 of order No 0030/MSP of 20/09/1999.

1. Purchase/repairs of equipment 20%

2. Hygiene and Sanitation 15%
3. Depreciation 10%
4. Security (Guards) 15%
5. Staff Incentives/Bonus 30%
6. Miscellaneous 10%
(including District Supervision Fund, NID, etc)
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Thus,
1. The effective amount of money to be distributed to staff is 27% of the 30% total
revenue.
2. The effective amount reserved for hospital development is 63% of the 70% of
total revenue. This money is put into savings account in the name of the hospital
with the following as signatories:
- The Chairman of Management Committee of the Hospital
- The Director of the District Hospital
- The Treasurer (Service Manager of the Hospital).

The solidarity fund of 10% of the quotes parts is kept aside as indicated above. The
hospital revenue is declared every ten days and put into the savings account of the
health units.

3.2. TOOLS FOR REVENUE COLLECTION

To ensure accountability for the revenue collected at each level, a minimum number
of revenue collection tools (instruments) has been instituted and must be used.

3.2.1. Health Centre

A) The Health Committee Cash Receipt Books
These are specially designed duplicate receipt books from which a receipt is issued
to the user after payment of fees for services or whenever a donation is made. It
bears the name of the Health Area Committee, well numbered and has provision for
the filling of date, name of client, amount paid in figures and words, purpose and
signatures of the receiver, pharmacy attendant (format attached).
B) Daily Cash Entry Register
This register is maintained by the Pharmacy Attendant (the Cashier of the Health
Centre). At the end of each working day the Pharmacy Attendant makes a summary
of the information on the duplicates of the receipts issued out that day and enters it in
the Daily Cash Entry Register. This register has various columns with provision for
date of operation, range of receipt numbers used for that day, sources of community
income, total collection for that day and remarks. Whenever, the Treasurer of the
Management Committee comes to collect money from the Pharmacy Attendant, he
must write in Red the date of the operation, the total sum of money collected from all
sources during the period, his name and that of the Chief of Health Centre. The
Treasurer must each time carry out his operation of checking revenue and collecting
money in the presence of the Chief of Centre and the Financial Secretary. As such
both the Treasurer and the Chief of Centre must sign the Daily Cash Entry Register
as witnesses for the transaction.
The amount of money thus collected must be entered into the Cash Movement
Register (treated else where) and deposited in the savings account of the Health
Area Health Committee.

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3.2.2. Government Hospital
A) Community Fund
The same tools as at the Health Centre are used: Receipt Books and Daily Cash
Entry Register for cost recovery fees at the hospitals.
B) Government revenue
1. Government Receipt Book (Quittance)
This numbered receipt book printed in duplicate by the Ministry of Economy and
Finance to every public revenue collector is correctly filed and issued against any
payment made to the Service Manager of the hospital or any other person acting as
revenue collector (format attached). The receipt must bear the names of the user
paying in the money, the amount of money in words and figures, the reasons for
which the money is being paid; the signature of the receiver or collector and the date.
The original is given to the user and the collector stays with the duplicate.
2. Hospital Revenue Declaration Form
This is the form which the revenue collector uses for the declaration of the hospital
revenue after every ten days and a monthly synthesis (format attached). The number
of cases for each activity is obtained from the registers of the respective units. The
revenue declared for the period is obtained from the duplicate of receipts from receipt
book (quittance) for each activity or act.

The distribution of revenue is effected as described in 2 above, and in the Hospital

Revenue Declaration Form. The hospital declaration form is signed by the revenue
collector, the Director of the District Hospital, and the Government Treasurer who
(issues an official treasury receipt for the sum of money paid into the Government
Treasury) certifies the correctness of the operations.

3.2.3. The Pharmacy

A) Drug Sales Receipt Book
Each community pharmacy has a serially numbered duplicate receipt book bearing
the name of the institution to which the pharmacy is part. For every transaction
between a user and the Pharmacy Attendant, a receipt must be issued and signed
stating the amount received and the purpose for which the money has been paid.
The user goes away with the original while the attendant keeps the duplicate.

B) Daily Financial Record Book

The pharmacy attendant at the end of each working day records the total revenue
from sales of drugs for the day in the daily financial record book and updates the
cash in hand.
Further, whenever the pharmacy attendant effects payment to the NWPSFH the
amount is checked out of this book and duly signed by the officer of the NWPSFH to
whom the money is paid. The Chief of Centre signs as witness.
In order to fight against fraud, the Management Committee of the Fund recommends
a duplicate receipt book per pharmacy to be used in collecting money and money
equivalent from the Pharmacy Attendant and transferring same to the central office.

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The collector must present this booklet or any document presented as such from
which a receipt will be issued on the spot for money collected.

Figure 3: Health Committee Cash Receipt Book

Date of Receipt Sources of income Total Remarks
operation number
(range)

Consultation Laboratory Delivery Donations Bonus

fees fees fees

Figure 4: Daily cash entry register

HEALTH COMMITTEE CASH RECEIPT

NORTH WEST REGION
Date.............................................
Name of Health Centre Committee ..................................................................................................................
Received from……………………………………………..……………Of.............................................................
The sum of .......................................................................................................................................................
Being payment for ...........................................................................................................................................
..........................................................................................................................................................................
FCFA

RECEIVER STAMP PAYER

_______________ ____________

Figure 5: Government Receipt Book (Quittance)

QUITTANCE (RECEIPT)
Recu de .........................................................................................................................................................
Received from
La somme de ................................................................................................................................................
The sum of
Pour ..............................................................................................................................................................
Being
À………..………………….……………………………………Le ......................................................................
Issued at on the

Le régisseur des recettes

Revenue collector

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Table 6: Hospital Revenue Declaration Form
Revenue Hospital Government
Number of Quotes parts
No Activities declared Development Treasury
cases B = (30% of A)
A C=(35% of A) D=(35% of A)
1 New consultations
2 Hospitalisation days
3 Surgery
4 Deliveries
5 Medical certificates
6 Medico legal
certificates
7 Laboratory
8 X-ray
9 Dental unit
10 Ophthalmology Unit
11 Occupational medicine
12 Others
TOTAL

National solidarity = 10% total B………..……and 10% total C……….……..Total ………..……….. FCFA
Staff honoraria (QP) = 90% total B……………….………FCFA to be shared to staff.
Hospital development share = 90% total C……………….………FCFA to hospital account.

Prepared on the Approved on the

………………..……….……………. ………………………………………
By……………………………..…………………… By………………..…………………………………
(Name and signature) (Name and signature)

Paid to state treasury (in letters): ………………………………………..……………………………………….

FCFA

Quittance No………………….…………………………

At……………..………………On…………….………….
NAME AND SIGNATURE OF TREASURER

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Chapter 4: STEPS AND PROCEDURES IN THE MANAGEMENT OF HEALTH
ACTIVITIES AND RESOURCES
Er
ror! Bookmark not defined.

4.1. INTRODUCTION ...................................................... Error! Bookmark not defined.

4.2. PLAN OF ACTION ................................................... Error! Bookmark not defined.

4.3. WORK PLAN (BUSINESS PLAN) ........................... Error! Bookmark not defined.

4.4. BUDGETING ............................................................ Error! Bookmark not defined.

4.5. EXECUTION OF PLAN AND BUDGET AT THE HEALTH AREAError! Bookmark not defined.
4.5.1. Custody of the Community Fund ............... Error! Bookmark not defined.
4.5.2. Cash movement......................................... Error! Bookmark not defined.
4.5.3. The Health Centre Fund ............................ Error! Bookmark not defined.
4.5.4. The use of surplus ..................................... Error! Bookmark not defined.
4.5.5. Government credits ................................... Error! Bookmark not defined.

4.6. EXECUTION OF PLAN AND BUDGET AT THE DISTRICT SERVICEError! Bookmark not defin

4.7. MATERIAL RESOURCES........................................ Error! Bookmark not defined.

4.8. HUMAN RESOURCES............................................. Error! Bookmark not defined.

4.9. EXTERNAL FUNDING OF PROJECTS ................... Error! Bookmark not defined.

4.10. COMMUNITY FINANCIAL SUPPORT ................... Error! Bookmark not defined.

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Primary Health Care: A Guide for Dialogue Structures. 2010 Edition
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 Chapter 4: STEPS AND PROCEDURES IN THE MANAGEMENT OF HEALTH
ACTIVITIES AND RESOURCES

4.1. INTRODUCTION
Management in simple terms means “Getting things done” using the available
resources (human, material, financial, time resources, etc). The Management cycle
includes planning, implementation and evaluation (PIE).
The planning phase includes identification of problems, a search for resources and
clear budgeting.
Implementation phase is execution of the plan, monitoring of activities, control of level
of realization and supervision.
Evaluation is not a terminal event. It is a continuous event. It simply measures what
has been realized against what was planned.
The dialogue structures (health staff and community representatives) will be very
much involved in the management of health activities and resources in the spirit of
co-management: partnership between the State (represented by health staff) and the
community.
In the context of health sector strategic plans and the National Health Development
plans using SQI, all health units and health system levels (health area, health district
and regional delegation) have to plan obligatorily for the MPA and CPA in the annual
work plans and strategic development plans in view of achieving the MDG by the
year 2015. This should be done to ensure a harmonious development of the health
districts to complete viabilisation and attainment of the strategic development goals.

4.2. PLAN OF ACTION

The health plan is a course of action to be followed by the dialogue structures in
order to achieve set objectives. It is based on identified priority and related needs of
the community, taking into consideration the availability and efficient use of
resources.

4.2.1. Identifying Priority Health Needs

Health needs in the community are so numerous that they cannot all be tackled at
once. Some will be tackled first and others postponed to a later time. Those needs
which the district team would like to tackle first are priority needs. For every health
unit or health district, these priority needs or interventions will depend on their status
on the scale of viability. However, there are some priority programmes whose
activities must be carried out at all levels, and thus must be planned and executed
especially in view of attaining the MDGs.
To select priority health needs, the district health team must use a set of standard
criteria:
1. Their magnitude in terms of proportion of the general population or of specific
sub groups of the population, such as women, pre-school children, school
children affected.

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 2. Severity/danger to individuals and the community. Does the condition threaten
life, cause major suffering, decrease the ability to lead a normal life, reduce
productivity, and cause deaths?

3. Amenability to intervention (vulnerability). If a problem is not amenable to

intervention because of technological requirements and other factors, it makes
little sense to include it in the list of those targeted for action. It is not
vulnerable.

4. Cost of intervention: If the cost of solving a problem is too high then it will not
be a priority.

The plan of action is based on one budgetary or financial year, that is, January to
December. The preparation of the plan of action involves planning, implementation
(execution), monitoring, evaluation and reprogramming.

The plan of action must be feasible, concrete and realistic. The plan of action can be
elaborated for the period of one year January to December or for several years. The
plan of action includes the health needs according to priorities; objectives to achieve,
and indicators to measure achievements, and also the global cost.
Table 7: Sample Plan of Action
Priority needs Objectives Activities Cost Indicator

1. Protect children 1. 80% vaccination 1. Vaccinate in all 700,00 1. Number of health

less than one year coverage at the health centres 0 centres vaccinating
against measles end of the year
2. Effect outreach in 2. Number of children
non functional vaccinated/total
health areas number

At the level of the health area the plan of action is made by the Management
Committee in November and presented to the General Assembly of the Health Area
Committee for approval in December. A copy is forwarded to the District Chief of
Service of Public Health. At the level of the Health Area the plan of action is initiated
by the Health Centre Management team, presented to the Management Committee
for study and modification by including other community felt needs. Then the latter
submits to the General Assembly for deliberation and approval. A copy is forwarded
to the District Chief of Service of Public Health.

At the Health District level the district plan of action is initiated by the District
Management team finalised by the District Management Committee and submitted to
the General Assembly of the District Health Committee for approval. A copy is
forwarded to the Regional Delegation of Public Health.

4.3. WORK PLAN (BUSINESS PLAN)

The work plan consists of a list of activities or interventions and tasks that will be
effected during a certain period to achieve the objectives of priority needs established
in the plan of action. The work plan includes:
1. Date of execution of activities
2. List of activities
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 3. Place of execution of activities
4. Person responsible
5. Cost
6. Sources of finances
Table 8: Sample Work Plan
Person Sources of
Month Activities Place Cost FCFA
Responsible finance
Vaccinate children at Chief of Centre Community
2/05/2010 Bamenda 20,000
outreach centre and 1 Nurse Fund
Buy kerosene for the Community
6/05/2010 Health Centre Treasurer 15,000
fridge Fund
Buy stationeries for the Government
7/05/2010 Health Centre Chief of Centre 50,000
health centre credits
Buy 20 bags of cement External
8/05/2010 Bamenda Treasurer 70.000
for Mbu health centre project
Total 155.000
The activities can also be plotted on a Gantt Chart.
Table 9: Activities against time using the Gant Chart
Activities January 2010
1st Week 2nd Week 3rd Week 4th Week
Planning
Implement plan
Evaluate
Report
Re-programme

This is useful for monitoring and controlling the implementation of activities by

eliminating non working days; duplication of efforts; determining the most appropriate
dates for carrying out of activities.
The work plan is made up for a period of six months, at the beginning of each
semester January to June, and July to December or a period of one year January to
December. Activities not executed in the previous semester will be put in the
following semester if they are still necessary.
The work plan is initiated at all levels by the technical staff and presented to the
Management Committee for study and submission to the General Assemblies of the
Health Area Committee and District Health Committee respectively for approval. The
production of the district plans will take into consideration the plans of the Health
Areas. The regional plans will be based on the District Health plans.

4.4. BUDGETING
The production of the plan of action and work plan is an obligatory prerequisite for
budgeting. The total cost of the plan of action and work plan constitute the budget,
financial support, needed to execute activities during the financial year January to
December. Costing of activities implies determining:

the number of persons involved

transport to the place of execution

fuel

feeding
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night allowances

other inputs, etc
Except for some standard rates defined by government or project texts the
standardisation of rates is difficult and should depend on the financial resources of
each level. The total cost of the plan should not exceed resources.
Budgeting should be done with the resources available because anticipated finances
might not be at hand at the time of execution of activities. Several ambitious plans to
construct Health Centres have ended at the foundation level.

4.4.1. Comprehensive (composite) budgeting

It must be practiced at all levels. This involves the utilisation of finances from all
financial sources available to implement activities at each level. From the plan of
action and work plan determine the total cost of activities and projects for the period
considered. Using the sources of revenue in the work plan and for the projects,
identify the amount of money to be spent from each source on activities. This
expenditure is stated in tabular form (table 10).
Table 10: Sample Expenditure for a Health Unit
Source Activities Cost CFA Total
1. Government Credits - Supervision 30,000
- Vehicle maintenance 200,000
- Night allowances 150,000
- Purchase of TV set, etc 500,000 880,000
2. Community funds at health centre
3. Surplus from drug sales
4. Others

The revenue or income, that is, the financial sources available at the corresponding
level are stated as illustrated in the following table.
Source Income Amount FCFA
Government Running Credits

Drug surplus

Investment credits

Fees for services

Total

Note: The expenditure should not exceed the income

Finances from the various sources might not be available at the same time so it is
usually necessary to make a financial plan, using the most available source, then
irregular source when ever it arrives.
Copies of the plan and budget of the health areas are sent to the district, and those of
the district to the region.

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4.5. EXECUTION OF PLAN AND BUDGET AT THE HEALTH AREA
4.5.1. Custody of the Community Fund
Each Health Area Committee must open a savings (Post office bank) account with
the following signatories.
1. Chairman of Health Area Management Committee
2. Chief of Health Centre (Secretary)
3. The Treasurer
All money collected from the Pharmacy Attendant, who serves as the clerk of the
Health Centre, by the Treasurer is deposited in the saving account. If there is no
bank account, the money is left in the Pharmacy of the Health Centre. The treasurer
does not take home money. The bank booklet and all financial records are kept by
the Pharmacy Attendant in the Pharmacy.
4.5.2. Cash movement
1. Each Management Committee shall determine the maximum amount of money to
be held in the safe at each time; the difference paid into the savings account.
2. Cash movement register: Money is collected by the treasurer from the pharmacy
attendant In the presence of the chief of centre. This operation must be entered in
the register dated and countersigned by both the Chief of centre and treasurer in
the Cash Movement Register (see format). Money collected by the treasurer is
entered under the heading –IN– as income. All expenditures incurred by the
Management Committee must be recorded in the Cash Movement Register in the
column –OUT– with full description of the corresponding operation. The Cash
Movement Register is kept by the pharmacy attendant in the pharmacy. For any
donation in cash, a receipt is issued by the pharmacy attendant and the transaction
recorded in the cash entry and movement registers under –IN–.
3. Payment voucher: All payments made by the treasurer must be accompanied by
a duly signed payment voucher (see format).
It is prepared by the treasurer, checked and signed by the Chief of centre,
approved and signed by the Chairperson of the Management Committee. The
receiver signs it with complete identification.
Each payment voucher bears a serial number, numbered from January 1st to
December 31st of each year. During supervision, health area supervisors must cross
check and countersign all correctly filled payment vouchers.

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Figure 6: Sample of a Payment Voucher

HEALTH DISTRICT____________________________

Health Area Committee .....................................................................................................

PAYMENT VOUCHER P.V. Number......................

Date...................................
Officer: ...............................................................................................................................
Pay to (Name & Address): .................................................................................................
...........................................................................................................................................
The Sum of: ......................................................................................................................
Being: ...............................................................................................................................

Prepared by the Treasurer:................................................................................................

Name/Signature

Checked by the Chief of Centre:........................................................................................

Name/Signature

Approved by Management Committee Chairman: .............................................................

Name/Signature

Received the sum of: .........................................................................................................

On the:……………………………………….Signature: ........................................................
Name:………………………………..ID Card No:…………………...Issued on.....................
At: .............................................................

Figure 7: Sample of a Cash Movement Register

Payment Sign.
Description of Sign. Sign.
Date Voucher CASH Chief of
operation Treasurer Chairman
No. Centre
IN OUT BALANCE

4.5.3. The Health Centre Fund

The following are the areas of expenditure and propositions of income generated
from service fees at the Health Centre as practiced in the North West Region.

1) 35% for sundries – stationery, soap, kerosene, and working material needed
for the running of the Health Centre. The list of needs is made by the Health
Centre team and presented to the Management Committee for approval.
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 2) 36% for incentives – serves as motivation to enhance staff performance and
also as assistance to community representatives. The incentive is shared as
follows: 70% for all staff and 30% for community representatives of the
Management Committee. Each group will set criteria for the distribution of
incentives. Means of verification will be the payment voucher for distribution of
incentives signed by all the beneficiaries.

3) 10% for supervision – outreach activities in the Health Area, participation at

meetings by both Community Representatives and staff.

4) 10% for the payment of community employed staff.

5) 5% for referral subsidy – This is a revolving fund to be used on referred cases,

and temporary and permanent paupers. Modalities are to be elaborated by the
Management Committee of each Health Area.

6) 4% for contributions to the district supervision fund. The money shall be

collected by Chief of Bureau for General Affairs (CBGA) and paid at the district
health service into the District Management Committee account). It shall be
used for fuel, transport, supervision material and sponsoring of meetings of
District Health Committees. The budget will be elaborated by the District Chief
of Service and presented to Management Committee for approval.

4.5.4. The use of surplus

The North West Provincial Special Fund for Health distributes surplus from the drug
programme to the various health units with functioning pharmacies in the Region.
The surplus serves to finance health unit activities and is directly managed by
dialogue structures. The projects financed have to be health related. Justification for
the use of money should be made and the utilisation should be in line with the plan of
action and work plan hitherto presented before the money is released.

The justification should include: amount of surplus received, expenditures with all
relevant documents, balance, comment by District Chief of Service of Public Health.

The supervision of the use of surplus is the responsibility of the District Chief of
Service of Public Health and the Region.

A report is made through the District Chief of Service of Public Health to the Regional
Delegate of Public Health and to the Fund.

Payment of new surplus will be made only to those health areas who have submitted:
- A copy of the financial report of the current year and budget for the following
year presented to the General Assembly.
- A copy of minutes and attendance list of the General Assembly.
- A plan of use of the new surplus

4.5.5. Government credits

Government credits to Health Centres are managed according to the financial laws.
They constitute a component of the comprehensive budgeting. (See Chapter 3)
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4.6. EXECUTION OF PLAN AND BUDGET AT THE DISTRICT SERVICE
The activities of the district service are essentially sponsored by government credits
which have defined management procedures.
Apart from the Government Credits the District Health Service receives in cash the
following funds:
1. District Supervision Fund which is 4% of the revenue generated by all health
units in the district, including the District Hospital.
2. Supervision subsidies from the Regional Delegation of Public Health.
3. District Health Committee Fund paid directly by the North West Provincial
Special Fund for Health to the various committees to enable them function.
4. PHC supervision fund paid by the NWPSFH to the districts.
5. Other sources.
The district opens a savings account in which it deposits money coming from 1, 2, 3,
4 and 5. The account has as co-signatories the Chairman of the District Health
Management Committee, the District Chief of Service and the Treasurer of the
District Management Committee (Service Manager).
The management of these funds is the same as Health Centre Fund of the Health
Area. All the finances of the district service are used in comprehensive budgeting
(composite budgeting). All financial records are kept at the district service. A report
on the utilisation of funds is forwarded to the Provincial Delegate of Public Health.

4.7. MATERIAL RESOURCES

The inventory of material resources in government institutions is made by the Stores
Keeper. The Management Committee must:
1. Study the inventory lists and update them quarterly.
2. Ensure that any new material and equipment is recorded by the Store Keeper
and that it also has independent ledgers for equipment room by room and
updated every two months.
3. Ensure the judicious use of material resources by health staff and the
community users of the health units.
4. Carry out some maintenance (preventive and curative) and purchase of simple
materials with the available funds.

4.8. HUMAN RESOURCES

The technical staff of state health units are employed and paid by the state. Health
units are only authorised to recruit three categories of staff namely pharmacy
attendants, night watchmen and cleaners.
The environmental hygiene of the health unit is the responsibility of the community
who can carry out human investment. Otherwise the environment could be kept clean
by hiring labour internally. The internal sanitation of the health unit is the
responsibility of the care taker of the patients and the staff.

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Community representatives to the dialogue structures assist the technical staff in the
field in mobilising the population and in the execution of activities as need arise.

4.9. EXTERNAL FUNDING OF PROJECTS

The external funding of projects is based on the needs expressed by the
Management Committee. The needs should be expressed in terms of infrastructure
and material resources adapted to the health units.
The external supply of drugs directly to state health units in the region is forbidden. If
drugs are donated to any of these health units, the Management Committee must
bring all the drugs to the Fund for quality control and modalities for utilisation.
The execution of the project should be based on a plan of action elaborated by all the
partners involved.
The Management Committee plays a very important supervisory role. A quarterly
report on the state of the project, including level of achievement and cost, must be
made by Management Committee and forwarded to all the partners involved at the
higher level.

4.10. COMMUNITY FINANCIAL SUPPORT

This is obtained from free will financial contributions from the community for
community initiated projects. All communities should endeavour to perform
community initiative projects to enhance the development of infrastructure and
equipment of their health centre. It should include the external and internal population
of the health areas.

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Chapter 5: ORGANISATION OF DIALOGUE STRUCTURE MEETINGS AND
WRITING OF MINUTES
Er
ror! Bookmark not defined.

5.1. PURPOSE OF MEETINGS OF DIALOGUE STRUCTURESError! Bookmark not defined.

5.2. PREPARATION OF MEETINGS .............................. Error! Bookmark not defined.

5.3. CONVENING OF MEETINGS .................................. Error! Bookmark not defined.

5.4. DELIBERATIONS AT MEETINGS ........................... Error! Bookmark not defined.

5.4.1. How to conduct a meeting ......................... Error! Bookmark not defined.
5.4.2. Characteristics of a Chairperson................ Error! Bookmark not defined.

5.5. CONTENTS OF MEETINGS .................................... Error! Bookmark not defined.

5.5.1. Health Area Management Committee........ Error! Bookmark not defined.
5.5.2. Health Area Health Committee General AssemblyError! Bookmark not defined.
5.5.3. District Hospital Management Committee.. Error! Bookmark not defined.
5.5.4. District Management Committee................ Error! Bookmark not defined.
5.5.5. General Assembly Meeting of the District Health CommitteeError! Bookmark not defin

5.6. PRESENTATION OF REPORTS ............................. Error! Bookmark not defined.

5.7. WRITING OF MINUTES ........................................... Error! Bookmark not defined.

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 Chapter 5: ORGANISATION OF DIALOGUE STRUCTURE MEETINGS AND
WRITING OF MINUTES

5.1. PURPOSE OF MEETINGS OF DIALOGUE STRUCTURES

i. To enhance communication and interaction between all partners involved in
health care delivery (health care providers, the community; and other health
related sectors)
ii. To coordinate health programmes and activities in the community
iii. To identify health problems presented as community needs.
iv. To develop appropriate measures to solve them
v. To assess or evaluate the state of affairs (activities, health etc.)
vi. To elaborate plan of action, Workshop and budget
vii. To develop strategies to implement health programmes and activities in the
community.

Table 11: Dialogue Structure Meetings in the North West Region

Meetings Convener Purpose
1. Constituent General The Governor of the To elect community representatives to:
Assembly North West Region
− The Standing Committee,
− The Management Committee,
− Regional Hospital Management
Committee and to Sub Committees
2. Ordinary General Assembly The Governor North − To deliberate and take major
Meetings West Region decisions affecting the life of the
Fund,
President of the Standing
Committee − Receive Management report of the
past year
− Examine and approve audit report
− Vote new Budget
− Vote plan for distribution of surplus
3. Extra ordinary General The Governor of the To solve urgent health related matters
Assembly of the NWPSFH North West Region
4. Ordinary Management The Regional Delegate – Planning, and assessment of planned
Committee of the NWPSFH Chairperson of the activities of the Fund
Management Committee

5. Extra ordinary Management The Regional Delegate – To deliberate and solve urgent health
Committee Chairman of the related matters.
Management Committee

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Table 12: General Assembly Meetings of Dialogue Structures of the Health District

Level General Convener Participants Purpose

Assembly
Meetings
District Constituent The Senior Newly elected Community To elect community
Health General Divisional Officer Representatives from representatives to:
Committee Assembly or Divisional Health Areas, Health Staff Standing Committee,
(DHC) Officer and other co-opted District Management
members Committee, Hospital
Management
Committee, NWPSFH
Ordinary President of Community Deliberate on health of
General Standing Representatives from the community,
Assembly Committee Health Areas, Health Supreme and binding
Personnel, Honorary decisions concerning
Members, co-opted health in the district.
members.
Extra Ordinary President of Same as above To solve urgent health
General Standing related matters.
Assembly Committee
Health Area Constituent The District Chief Newly elected community To elect community
Health General of Service representatives from representatives to:
Committee Assembly zones, Health staff and the Standing Committee,
(HAHC) honorary members Management
Committee, DHC
Ordinary President of Community Deliberate on health of
General Standing Representatives from the community; take
Assembly Committee zones: Health Staff, decisions on health in
Honorary Members, Co- the health area.
opted members
Extra Ordinary President of Same as above To solve urgent health
General Standing related matters.
Assembly Committee

Table 13: Management Committee Meetings of the Health District

Level Ordinary Meetings

District District Management Committee

District Hospital Management Committee

Health Area Health Area management Committee

In Summary:
1. An extra-ordinary management committee meeting can be convened to solve
urgent health related matters.
2. All management committee meetings are convened by the respective
Chairpersons.

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 3. The participants to the meetings are the members of the respective
management committees.

5.2. PREPARATION OF MEETINGS

This includes defining:
1. The purpose or objective of the meeting,
2. Type of the meeting,
3. Main subject matter or content,
4. participants,
5. Place (venue),
6. Time and duration,
7. Agenda,
8. Distributing any relevant documents to participants preferably three days
before the meeting.
9. Acquisition of material and logistics for the meeting.
Every Management Committee makes preparations for its respective General
Assembly Meetings and submits the draft agenda and invitations to the President of
the Standing Committee for approval and signature.

5.3. CONVENING OF MEETINGS

1. By written invitation stating the type of meeting, purpose, place, date and time
and bearing the signature of the President of the Standing Committee or the
Chairperson of the Management Committee depending on the type of
meeting.
2. Through announcements: Mass media (radio, television, press) or town criers;
churches, etc. with the same information as in the written invitation.

5.4. DELIBERATIONS AT MEETINGS

5.4.1. How to conduct a meeting

a) The quorum: Check how many people are in attendance. Is the number
sufficient to start the meeting and take decisions? Usually at least 50% of the
invitees is a sufficient quorum to run a health committee meeting. If for the 3rd
time, the quorum is not met, the deliberations can go ahead.
b) The Agenda: It is a list of items which shall be discussed. This list is
presented, debated, modified and adopted for discussion.
c) The Opening remarks: Official statement made by the person presiding over
the meeting. It is usually a word of welcome and a presentation of the purpose
of the meeting.
d) The Minutes of the previous meeting: The minutes of the very last meeting
are read, corrected and adopted.
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 e) Matters arising from minutes: It concerns brief discussions on decisions
taken, activities and events discussed at last meeting for which a follow up
was needed.
f) Specific items: This may be activity reports, financial report, audit report, fact
finding report, supervision report, presentation of a programme of activities
and the budget, etc.
g) Discussion and decisions: Each presentation is followed by a discussion on
the topic for better understanding and decision. Such decisions are taken in
the form of recommendations and resolutions. For each resolution, it is good
to state who is charged with its execution, when and with what means.
Sometimes a resolution may create a sub committee to examine the problem
further before proposing a pragmatic solution.
h) Other matters: This permits the organizers to present and discuss matters
which do not form the core purpose of the meeting. Discussion is done as in
(g) above.
i) Closing remarks: The presiding officer officially closes the meeting.
j) Minutes: The minutes of the meeting must be developed and presented to the
presiding officer by the secretary. The secretary and the president must co-
sign the minutes after they have been read, corrected and adopted in the next
meeting, before they are circulated.
k) Conduct during meetings: During meetings, one person speaks at a time
after having taken permission from the President/Chairperson. The person
addresses the Chair and the house. The speech must be brief and relevant to
the topic under discussion.

5.4.2. Characteristics of a Chairperson

For any meeting to be successful, the person who presides over it must have the
following characteristics.
a) He/she must compose himself/herself and prove to be a real democrat
knowing fully well that his/her role is that of a moderator over the meeting.
b) Be prepared to listen to the opinion of other members and make corrections
where applicable.
c) Must have a good insight of the matter or issue he/she is handling.
d) Knows that the will of the majority triumphs, not the Chairperson dictating.

5.5. CONTENTS OF MEETINGS

5.5.1. Health Area Management Committee

a) Assess the level of implementation of plan of action, work plan and budget
approved by the General Assembly of the Health Area Health Committee.
b) Review the health coverage of the community, using the monthly reporting
forms of the health centre: HMIS data collection forms, vaccination returns,
etc.
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To appreciate:
- Consultations at health centre,
- Infant Welfare Clinic (IWC)
- Pregnant women attending Antenatal Clinic
- AIDS control
- Family planning
- Revenue
- Etc.
c) Identify health needs and develop strategies to solve them,
d) Examine the internal audit report and adopt corrective measures,
e) Review the functioning of the pharmacy bringing out any problems especially
that of shortages and ways of recuperating them.
f) Prepare the General Assembly Meeting and submit agenda and invitations to
the President of the General Assembly of the Health Area Health Committee
for approval.
g) Prepare plan of action, work plan and budget and submit to the General
Assembly for approval.

5.5.2. Health Area Health Committee General Assembly

a) Examine the report of the Health Area Management Committee.
b) Receive and deliberate on brief written reports of zones from the
representatives of each zone, which should include:

Vaccination of children

Hygiene and sanitation

Health Education on AIDS/STIs control

Deaths and their causes

Food hygiene and protection

Other health needs.
c) Assess the health coverage of the health area using the reports presented by
the health centre staff:
The month’s data collection form of the National Health Management Information
System for the previous six months should be received to appreciate the evolution of
activities and measures adopted to improve health coverage. Decisions taken should
be based on the objective analysis of the health centre technical report.
d) Examine and adopt the plan of action, work plan and budget for the health
area presented by the Management Committee.
e) Approve health area report for the district health committee presented by the
community representatives to the district.

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5.5.3. District Hospital Management Committee
Assess the execution of the hospital plan of action and the corresponding budget.
Assess the performance of the hospital using the month’s report of activities
presented by the Director of the DH concerning:
• Consultations
• Deliveries
• Surgical operations
• Hospitalization
• Deaths and causes
• Hospital sanitation
• Community participation in the hospital
• Revenue
Study the internal audit report of the hospital including the pharmacy and
elaborate corrective measures for any identified problems.
- Identify problems of the hospital and determine realistic measures to solve
them.
- Prepare a plan of action and budget for the hospital.
- Make a work plan for new activities or projects for the hospital.

5.5.4. District Management Committee

- Assess the level of execution of district work plan and the corresponding budget.
- Appreciate the health coverage of the district from technical monthly reports
presented by the technical health team, especially concerning:
• Consultations at health units
• Vaccination of children and pregnant women
• Attendance at child welfare clinics and at antenatal clinics
• Deliveries
• AIDS/STIs control
• Other health programmes
From the analysis of reports identify health needs and develop strategies to solve
them.
- Study the internal audit report and develop corrective measures for
discrepancies identified.
- Make a review of situation of pharmacies in the district from supervision reports
of the district health team bringing out problems especially shortages incurred
and measures to recuperate the money.

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 - Prepare a plan of action, work plan and budget for the district.
- Prepare the General Assembly meeting and submit the agenda and the
invitation to the President of the standing committee of the general assembly of
the district health committee for approval and signature.
- Listen to and deliberate on the report of the North West Provincial Special Fund
for Health Management Committee presented by the Divisional
Representatives.
- Prepare the district report for the NWPSFH.

5.5.5. General Assembly Meeting of the District Health Committee

1) Examine the reports of the District Management Committee meetings.
2) Review written reports from each health area co-signed by at least one
community representative and the chief of centre in case of a functional health
area, which should include;
- The population of health area
- Number of new monthly consultations for the last six months at health
centre
- Monthly new attendance at child welfare clinic
- Monthly deliveries at health centre
- Revenue from fees by activity (consultation, deliveries, etc)
- Number of General Assembly Meetings of the health area Health
committee held
- Number of meetings of the health area management committee.
- Vaccination of children and pregnant women
- Environmental hygiene
- AIDS Control Activities
- Family planning
- Deaths and possible causes in the health area.
- Other health activities carved out.
3) Appreciate the health coverage of the district from the technical report
presented by the health team on:
- Vaccination of children, especially less than one year, for all the vaccines.
- Child Welfare Clinic
- Antenatal Clinic
- Deliveries at health centre
- AIDS/STIs
- Family Planning,
- Hygiene and Sanitation
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 - Control of diseases, endemic and epidemics.
4) Adopt measures and strategies to improve health coverage of the district in
areas and domains with low coverage.
5) Examine the internal audit report and adopt corrective measures.
6) Examine and approve the plan of action, work plan and corresponding budget
for the health district presented by the district management committee.
7) Adopt plan of action and budget of the district hospital presented by the
hospital management committee.

5.6. PRESENTATION OF REPORTS

For every meeting to be meaningful, reports must be presented. These reports will
show the level of implementation of activities in the action plan. This enables you to
know how you have executed your activities with the meagre resources at your
disposal.
Apart from the fact that reports enable you to keep pace with your action plan, it is
also a forum for knowledge sharing, learning from each other what is happening in
the health area. These reports may be:
a) Zonal Reports
b) Technical Reports
c) Financial Reports
a) Zonal Reports
These are reports written by the health committee representatives of each health
zone or quarter or village as the case may be with some health areas. The reports
show the level of implementation of preventive and promotion activities carried out in
the zones within the given period.
b) Technical Reports
The report is given by either the chief of centre in case of a health area or the District
Chief of Service in the case of district meetings. The report should be on preventive,
curative and promotion activities. It may be purely a technical report but it has to be
highlighted for the Community Representatives to appreciate.
c) Financial Reports: Income/Expenditure
At the health area level, this report is given by the Financial Secretary supported by
the Treasurer, while at the District level the report is given by the Financial Secretary,
supported by the Service Manager and the District Auditors. This report is very
necessary for efficient and transparent management.
There must be evaluation to see how effective the reports are on the health
programme. Evaluation of the reports will also determine the level of new inputs in
the health machinery.

5.7. WRITING OF MINUTES

The minutes of a meeting include:

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 1. Title of meeting
2. Date
3. Time
4. Place or venue
5. Purpose or objective of meeting
6. Bureau of meeting
- President/Chairperson
- Vice President
- Secretary
7. List of participants
8. Topics discussed and decisions taken
9. For each topic state the problem at stake, how it was discussed and the
decision taken. Avoid long stories and be as impersonal as possible.
10. Date of next meeting
11. Minutes are signed by President/Chairperson and Secretary
12. Minutes shall be circulated to participants and the higher level.

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CHAPTER 6: HEALTH INFORMATION MANAGEMENT SYSTEM FOR DECISION
MAKING BY DIALOGUE STRUCTURES
Er
ror! Bookmark not defined.

6.1. DEFINITION OF HEALTH INFORMATION MANAGEMENT SYSTEM (HIMS)Error! Bookmark

6.2. HEALTH INFORMATION MANAGEMENT ALL LEVELSError! Bookmark not defined.

6.4. GEOGRAPHICAL INFORMATION .......................... Error! Bookmark not defined.

6.5. DEMOGRAPHIC INFORMATION ............................ Error! Bookmark not defined.

6.6. SOURCES OF HEALTH INFORMATION ................ Error! Bookmark not defined.

6.6.1. Types of information .................................. Error! Bookmark not defined.
6.6.2. Treatment of health statistics..................... Error! Bookmark not defined.

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CHAPTER 6: HEALTH INFORMATION MANAGEMENT SYSTEM FOR
DECISION MAKING BY DIALOGUE STRUCTURES

6.1. DEFINITION OF HEALTH INFORMATION MANAGEMENT SYSTEM (HIMS)

HIMS is defined simply as a system used for the collection, analysis and
interpretation of health statistics to produce relevant information that can be used in
the achievement of determined or set of objectives at all levels of the health pyramid
(health area, health district, Region). The NHIMS serves as follows:
 Serves as a data bank at all levels of the Health pyramid.
 Facilitates evidence-based decisions
 Permits rapid decisions to be taken when faced with a threat of an epidemic.
 For rational use of resources especially where these are scarce.
 For evaluation of indicators.

6.2. HEALTH INFORMATION MANAGEMENT AT ALL LEVELS

The HIMS is a continuous cyclical activity which consists of
1. Entering into specific registers data or statistics on health services provided to
the population.
2. Collection or extraction of data (statistics by tallying).
3. Compilation of data by filling out return forms.
4. Analysing the data collected to obtain information.
5. Determination of the level of achievement of objectives by comparing present.
coverage and past coverage to set objectives.
6. Taking decisions and setting new objectives.
7. Defining strategies and determining resources to achieve new objectives.
8. Making plans of action and work plans.
9. Implementing the work plans.
10. Monitoring and evaluating and re-planning in order to attain the best possible
health coverage for each health programme or health activity.
11. Writing and publication of reports.
12. Giving feed back to the producers of the health information and also
transmitting the information to the next higher level.

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Figure 8: Health Management Information cycle

Registration of data

Establish and implement plan Collection/extraction of data

of action

Define Strategies and

determine resources
Compilation of data

Decision to set new objectives

Report writing and publication Analysis of data

Determine level of achievement

(EVALUATION)

Figure 9: The Health Pyramid and NHIMS

Central
Level
Departments

Burea o
Regional Level Healt
Information
RDP

Peripheral Level Statistics

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6.3. WHO USES THE HEALTH INFORMATION MANAGEMENT SYSTEM?

1. The Managers and the management teams at all levels of the Health Pyramid

2. The decision making structures

By the Managers and management teams, we refer to:

1. Chief of Centre and his technical team

2. The District Chief of Service (DCS), the Director of DH and collaborators;
3. The Regional Delegation, the Director of the Regional Hospital and technical
collaborators;
4. The Minister of Public Health, Directors of Central and General Hospitals and
their collaborators.

By decision making structures, we refer to the various dialogue structures and their
management committees which are:
− Health area health committee,
− Health area management committee,
− District health committee,
− District health management committee
− District hospital management committee
− Provincial Special Fund for Health Management Committee
− Regional hospital management committee.

Researchers in the health sector even the administration right from village level will
need the HIMS findings to plan development program in the various areas. In short,
the use of HIMS is not limited to the health sector alone.

In principle health information generated should be used first by the person who
generated it for local action before forwarding it to the next level.

6.4. GEOGRAPHICAL INFORMATION

a) For each Health Area/Health District, the following have to be determined.
− The geographical boundaries
− Administrative boundaries
− Its administrative attachment
− The names of health areas, villages, quarters and zones
− The different community groups present in the geographical demarcation
− The further break down into smaller units (health areas for districts, health
zones for health areas) to facilitate program operations in relation with the
population of the catchment area.
b) Geographical map (Health District and Health Area).

Identify the physical features which can influence the level of accessibility to the
geographical demarcation.

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6.5. DEMOGRAPHIC INFORMATION
Health activities are people oriented. It is important to know how many people, male
and female, adult and children are living in each health area and each health district.
These are known as target populations. It is this population figure that shall be used
as a measuring stick to know what fraction of the population of each district or area
has been satisfactorily served. The population figure is called the denominator. The
population of each district or area can be determined by two methods;

1. The population of a community in a given year or period can be calculated by

projection. That is the total population from the national census is multiplied by
the growth factor to obtain the present population.

2. Do a head count of members of the community by the health committee.

- Maintain a census register according to household.
- Update the census register quarterly by adding names of new comers and
births and by removing names of out gone people and those who have died.
This method is more difficult and costly but is more useful and reliable. You need
to sensitize the people and prepare them for the exercise which can be twinned
up with home visits to reduce cost.
It is preferable to carry out a health census since each health centre will
eventually be operating a dating file system.
Equally, the result of a health census permits the easy breakdown of the population
into target groups corresponding to expected population for each specific program or
activity. The following target groups are commonly used.

1. Children less than 1 year (00 – 11 months), 4% of the total population

2. Children less than 5 years (00 – 59 months), 18% of the total population
3. Children aged 5 – 14 years , 28.3%
4. Pregnant women, 5% of the total population
5. Women of child bearing age 14 – 49 year, 23% of the total population
6. Adolescent, 15– 24 years, 20.2%
7. People aged 65 and above, 3.8%
8. Population living within 5 km from the health centre. This is called immediate
health centre population.

6.6. SOURCES OF HEALTH INFORMATION

6.6.1. Types of information
1) Census register for population
2) Health Registers from:
- General Consultations (medical and surgical consultations)
- Refocused Ante Natal Clinics
- Infant Welfare Clinics (IWC)
- Special clinics
- Cash entry and cash movement
- Clean deliveries
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 3) Reports of Health activities such as:
- Supervision, monitoring and follow up
- Training activities
- Minutes of meetings
- Seminars
4) Personnel management
5) Inventory of material
6) Infrastructure
7) Drug management
8) Financial information
9) MHO information

6.6.2. Treatment of health statistics

a) Registration of the statistics
The primary sources from which data for health information management are
extracted have been enumerated above. These documents must be specially
designed to facilitate collection of the right information and the extraction of data. The
health care providers must be current with the reporting of their activities.
b) Extraction of data
There are specific data collection tools (forms) on which to enter the data for each
activity or intervention carried out. At the end of each clinic, activity or day, the health
care provider must answer the question: “How many people have been served by
that activity, clinic or that day?” To do this, he uses a tally sheet to extract the raw
data in figures from the primary source of information.
c) Determination of coverage rate
It is easier to compare ratios than absolute figures. The results are always presented
in percentage per month, or per year. To do this you express the number of people
who benefited from the service or activity as a percentage or fraction of the target
population for whom the activity was intended e.g.

Number of children 00 – 11 months who had BCG in one year months

= EPI Recruitment rate
Number of children 00 – 11 months who were in that year

d) Determination of objectives in terms of coverage rate

Fix the objective to be attained. For example: the EPI objective for the Region is now
80% for completely vaccinated children.
e) Comparison of the actual coverage rate
The actual coverage rate per activity achieved shall be compared with the expected
coverage rate to see to what extent the objective set has been attained. This is best
done by plotting first the expected coverage rate and secondly the true coverage in
the form of graph or histogram.
In the Region each health centre has a monitoring chart on which to plot its
performance;
- Birth declaration
- Death declaration
- Morbidity per health area
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From the chart it can be clearly seen how well or badly the centre is performing, by
observing the difference between the expected and the actual coverage curves.
f) Using the coverage rates for management decision
1. The technical team (management) will judge the performance as to whether it
is satisfactory or not.
2. Identify the causes for poor performance or excellence
3. Propose solutions to improve on performance
4. Discuss 1, 2 and 3 with all the production staff for their commitment to
proposed solutions.
5. Present 1, 2 and 3 modified by 4 to the management committee for
discussion, recommendations and resolutions.
6. When ever it meets, the general assembly will receive the report and
deliberate on it.
7. Forward the filled forms to hierarchy and in the comments section write the
measures taken at the first level.
8. The district level will also study the forms and comment, make feedback
instructions to the health areas.
g) Presentation of Health Statistics within the framework of NHIMS
Table 14: Sample summary of absolute values

Male Female 00-11 Months 12-59 Months

50 80 123 600
10 20 150 200
45 32

Bar Charts
90
80
70
60
50 East
40 West
30 North
20
10
0
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

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 6.7. CONCLUSION

The use of the Health Information Management System for decision making and
management of health activities will help the dialogue structures in the following
ways;

1. To identify health problems and needs of the community at all levels.

2. To identify appropriate solutions to the identified problems/needs.

3. To set realistic objectives towards the solutions of the problems

4. Monitor and appreciate the achievements of their set objectives for health
programmes and projects in the community.

5. Evaluate the impact of their health programmes on the health status of the
community.

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Chapter 7: SUPERVISION OF HEALTH UNITS BY THE MANAGEMENT
COMMITTEE
Er
ror! Bookmark not defined.

7.1. INTRODUCTION ...................................................... Error! Bookmark not defined.

7.2. JUSTIFICATION....................................................... Error! Bookmark not defined.

7.3. WHO IS A SUPERVISOR? ...................................... Error! Bookmark not defined.

7.4. WHAT SHALL BE SUPERVISED ............................ Error! Bookmark not defined.

7.5. HOW OFTEN TO SUPERVISE (PERIODICITY) ...... Error! Bookmark not defined.

7.6. HOW TO CARRY OUT SUPERVISION ................... Error! Bookmark not defined.

7.7. CONCLUSIONS ....................................................... Error! Bookmark not defined.

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 67
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 Chapter 7: SUPERVISION OF HEALTH UNITS BY THE MANAGEMENT
COMMITTEE

7.1. INTRODUCTION
In this chapter, we are going to treat the important subject of supervision of health
units by members of the management committee both at the district and health area
levels. We will start with some basic definitions.

7.1.1. What is supervision?

Supervision in the broad sense refers to the series of measures taken to check that
plans, norms, instructions etc. are effectively applied and to verify for evidence
(indicators), and oversee activities being carried out by staff in order to appraise the
situation and help to improve. It is encouraging and supportive and not policing and
laying of blame.

7.1.2. Types of supervision

We normally distinguish between two types of supervision: Vertical supervision and
Horizontal supervision, depending on the level at which it is taking place:
a) Vertical supervision refers to the measures taken by the higher level in a
system to ensure that staff effectively applies instructions, norms, rules and
regulations that have been put at their disposal in order to help them improve
their performance. This is supervision by a higher management organ. In this
type of supervision there is a difference in the competence level of the person
who supervises (supervisor) with respect to that of the person being
supervised (supervisee); For example, the supervision of the District Chief of
Service of Public Health by the Regional Delegate of Public Health.
b) Horizontal supervision is similar to vertical supervision except that the
person supervising and the one being supervised are of the same level. All the
persons involved in the exercise are working at the same horizontal level. A
typical example is the supervision carried out by members of the Management
Committee of the health unit or service which the committee has the
responsibility to manage.
In both cases, the main aim of supervision should be to help to improve.

7.2. JUSTIFICATION
It is necessary and important for members of the management committee to fully
participate in the supervision of health units for the following reasons:
• It facilitates the identification of problems within the health unit under the
responsibility of the management committee and helps it to seek solutions for
improvement.
• It permits each management committee to have a self-appraisal and know
how well or how badly it is performing and decide on the measures to correct
the situation.
• It also permits the management committee to have a “trial balance sheet” of
its activities and from there, be able to identify its weaknesses and areas
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 needing further explanations and/or training from the higher supervision
bodies.
• It enforces team spirit amongst members of each management committee
and the staff of the health unit.
• Last but not the least; it permits the management committee to control the
property of the health unit under its responsibility. In fact, over the years,
supervision or controlling of a health unit by its management committee has
either been inexistent or too weak. As a result of this, health units have been
losing a lot of property, drugs, equipment, community funds, buildings etc.
These properties are often lost through burglaries, embezzlements,
shortages by staff, misappropriation and lack of maintenance.

7.3. WHO IS A SUPERVISOR?

Each Health District has three types of health structures:
1. The District Health Service
2. The District Hospital
3. The Integrated Health Centre
According to the texts in force, each of the three units or structures has its
Management Committee. The District Health Service has as its management
structure the District Management Committee (DMC), the District Hospital has as its
management structure, the District Hospital Management Committee (DHMC) and
the Integrated Health Centre has as structure the Health Area Management
Committee (HAMC). This is better illustrated in table 15.
Table 15: Core members per dialogue structure
Position DMC DHMC HAMC

Chairman Community Representative Community Representative Community Representative

Treasurer Service Manager Service Manager Community Representative

Secretary District Chief of Service Director of the DH Chief of Health Centre

Members Two community Two community Two community

representatives representatives representatives

Supervision of health units implies the checking or overseeing of the activities carried
out by the management committee members themselves and secondly the activities
performed by the health care providers, be they government or community employed.
Each management committee must supervise itself before supervising those
regularly employed in the health unit.
As will be seen later, most of the aspects to be supervised are highly technical and
will need a lot of technical inputs to interpret and understand. As such it is highly
advised that community representatives should not carry out this exercise single-
handedly. Each supervision team should be mixed, both for horizontal and vertical
supervision, consisting of one technical staff, preferably the secretary of the
management committee or his designee on the one hand and of a community
representative, preferably the chairperson of the management committee or his
designee from amongst the two other community representatives in the committee. In
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short, the chairman and secretary of each management committee shall do
supervision jointly. However, it should be stressed that the absence of any of the two
should not be a reason for not carrying out supervision, as their designees are
equally competent to carry out the exercise.

7.4. WHAT SHALL BE SUPERVISED

i. Plan of action
The supervisors must supervise the preparation of the plan of action and its
realisation. Periodically, they determine the level of execution of the approved plan of
action and find out, where applicable, the reasons for not fully executing it.
ii. Budget
As seen in the chapter dealing with financial resources, each level or better still each
unit has to prepare a comprehensive budget, stating all the sources of income as well
as all the areas of expenditure. The supervisors must oversee the preparation of this
budget and ensure that all inputs are clearly stated and accounted for. Along with the
supervision of the plan of action, each supervision team must monitor the level of
realisation of the budget and highlight issues facilitating or blocking its realisation. It is
the place of the supervisors to:
• Fight against over expenditure and deficits
• Ensure the regularity of each financial operation
• Enforce the correct use of financial documents
• Ensure that only the accepted fees and predetermined rates are being
collected
Ensure that all money collected is duly banked or kept in a savings account and that
withdrawals are carried out only by the three officials duly mandated to be co-
signatories to the account, one of which must be a community representative
(chairperson of the management committee, as stipulated in the chapter on
finances).

iii. Equipment and logistics

• Participate in the reception of all newly-acquired equipment and logistics
• Ensure that the equipment list is regularly updated
• Ensure the correct use of equipment and logistics
• Identify broken down equipment for repairs or replacement
• Participate in the determining of equipment and logistics as well as prioritising
them.
iv. Buildings and general surroundings
The buildings and premises housing the unit should be regularly checked to:
• Ensure that adequate security measures have been taken
• Ensure that the environment is clean
• Ensure the availability and cleanliness of toilet facilities
• Identify defects and leakages for early repairs

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 v. The Pharmacy
The District Hospital and Integrated Health Centre each has a Pharmacy section. It is
run by a community-recruited and paid staff who forms an integral part of the health
unit’s staff strength. Each pharmacy receives drugs directly from the NWPSFH’s
central drug store in Bamenda. It is supervised every two months by a specialised
drug supervision team from the central store. These supervisors collect money and
where necessary, drugs from each pharmacy back to the central pharmacy.
However, because the interval between such supervisions is too long and the
effective time spent by the supervisors at each pharmacy is relatively short, many
difficulties have been encountered which have resulted in the ever-increasing
financial shortages incurred by staff in these pharmacies.
To remedy the situation, the Management Committee of each health unit must be
responsible for regularly supervising the functioning of its pharmacy. The DMC also
has the responsibility of verifying that the HAMC has been effectively supervising its
pharmacy. How to carry out this important exercise is the object of a different
document “Guidelines for controlling a pharmacy: A manual for the management
committee”. These two documents shall be used together.

vi. Functioning of the Management Committees at all levels

As earlier indicated, each management committee must supervise its proper
functioning before going out to supervise others. It is also necessary that the District
level, through the DMC supervises the functioning of the HAMC. This supervision is
important in that it permits peer learning and provides an opportunity to collect
information from the HAMC.
The main areas to be supervised should at least include the following:
- The regularity in the holding of management committee meetings
- The attendance of members at meetings
- Problems hindering the functioning of the management committee
- The number of supervisions carried out by the management committee at the
health unit at a given period
- The frequency of supervision of the HAMC by the DMC

7.5. HOW OFTEN TO SUPERVISE (PERIODICITY)

There is no specific time periodicity for the supervision of each health unit. The more
often these units are supervised, the better. It is suggested that because of its
sensitive nature, each community pharmacy should be supervised at least once
monthly. The other activities may be supervised every fortnight or monthly. Horizontal
supervisions carried at intervals longer than one month are ineffective. In reality,
horizontal supervisors should have supervised their various units at least twice before
any external supervisor ever comes in. The vertical supervision of HAMC should be
included in the work plan of the district and all supervisors duly informed.

7.6. HOW TO CARRY OUT SUPERVISION

We should distinguish between planned (announced) supervision and surprised
(unannounced) checks. Surprised supervisions which are more properly termed
“control visits” are carried out whenever rumours point to certain malpractices which

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could not have been identified were the supervision announced. In a system that is
functioning well, there will be less surprised supervisions than planned ones. In both
cases, the execution of the supervision must pass through three main stages:
i. The preparatory stage
The supervisors must prepare for the supervision and know exactly why they are
going to the unit and what they are going to look for. In announced supervision, they
should make sure that the supervisees know exactly when they are coming. For
controls the supervisors must define clearly the objective of the exercise and how
they intend to proceed on the field.
ii. Actual supervision at the health unit
The supervisors must not enter the service like police officers or professors coming to
levy blames on service providers but rather as comrades in arm coming to learn more
on the functioning of the service. This includes as well the supervision of the HAMC
by the DMC where the DMC should not go there with a spirit of superiority but with an
open mind ready to learn from their colleagues. During the supervision, they must
have a cool head, listen patiently, but critically, have a critical appreciation of all
documents presented and make notes of any observations. Whenever necessary
allow the local staff to give their reasons for why they do certain things in one-way
and not the other. Provide appreciation where necessary.

iii. Exploitation of supervision results

Supervision results shall be written and co-signed by the supervisor and supervisee,
in the supervision register or checklist and findings discussed at the management
committee meeting, where appropriate solutions or actions will be carried out for
identified problems. A supervision report must be made, distributed and filed.

7.7. CONCLUSIONS
Supervision at each unit and of lower units by the management committee is an
indispensable tool for the management and smooth running of the health units. The
management committee at each level should therefore take it seriously and not wait
to complain after the services or units have gone into decay.

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Chapter 8: THE MINIMUM PACKAGE OF HEALTH ACTIVITIES (MPA) AT THE
HEALTH AREA AND DISTRICT LEVEL
Er
ror! Bookmark not defined.

8.1. INTRODUCTION ...................................................... Error! Bookmark not defined.

8.2. THE MINIMUM PACKAGE OF ACTIVITIES FOR THE HEALTH CENTREError! Bookmark not
8.2.1. Components of Maternal and Child Health Error! Bookmark not defined.
Maternal and Child Health consists of: ................ Error! Bookmark not defined.

8.3. COMPLIMENTARY PACKAGE OF ACTIVITIES FOR THE DISTRICT

HOSPITAL................................................................ Error! Bookmark not defined.

8.4. THE DISTRICT HEALTH SERVICE (DHS) .............. Error! Bookmark not defined.

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 Chapter 8: THE MINIMUM PACKAGE OF HEALTH ACTIVITIES (MPA) AT THE
HEALTH AREA AND DISTRICT LEVEL

8.1. INTRODUCTION
The two structures directly involved with the provision of health care at the district
level are:
- The Health Centre (HC) for the Health Area and
- The District Hospital (DH) for the whole district.
Each level offers specific health services defined by the government and for which it
is best adapted, that is, has the appropriate staff and technology that can best deal
with the health problems of the community. The activities at the HC are known as the
Minimum Package of Activities. These activities involve a lot of interaction between
the health service and the community (human relations) while those of the district
hospital are more disease focused and thus are said to be complimentary.
The district system is organized in such a way that the Health Centre is the entry
point and once in it, there should be no barriers in moving from one level to the other
and information about the patient should accompany him/her to and from within the
system. This is ensured by an effectively functioning referral and counter referral from
the health centre to the district hospital and vice versa. It also ensures that good
quality care i.e. care which is comprehensive, continuous and integrated is provided
to the population.

8.2. THE MINIMUM PACKAGE OF ACTIVITIES FOR THE HEALTH CENTRE

These are mostly prevention oriented, promotional, and to a lesser extent curative
care, which includes treatment of common diseases as well as chronic diseases such
as tuberculosis, leprosy, hypertension, diabetes, HIV/AIDs etc; early detection and
treatment of common diseases to avoid complications; the use of essential drugs to
improve access to treatment and the referral of those cases above the technical
competence of the health centre.
For chronic diseases needing long term treatment, the continuity of care component
creates a good link with the more educative aspect of preventive care. Home visits
provide an opportunity to support these patients take their treatment continuously and
to reduce the dropout rate.
90 - 95% of the common diseases of the population can be effectively handled by the
health centre. The use of Diagnostic and Treatment Guide (DTG) for curative
consultation as well as development of good human relationship between the
provider and the users increases the confidence of the population in their health
centre which reduces the number of unjustified referrals as well as by-pass of the
centre by patients to go directly to the district hospital.

8.2.1. Components of Maternal and Child Health

Maternal and Child Health consists of:
- Refocus Antenatal care
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- infant and pre-school care
- vaccination
- control of diarrhoea diseases and
- family planning

8.2.1.1. Refocus Pre-natal consultation has the following objectives:

- To follow-up pregnancy and carry out clean deliveries
- To prevent mother to child transmission of HIV
- To treat illnesses associated with pregnancy
- To identify high risk deliveries early enough for prompt referral
- To train mothers on breast feeding, and essential nutrition
- To immunize against tetanus.

8.2.1.2. The infant and pre-school clinic or IWC carries out the following
activities:
- weighing of children
- immunizations
- education of mothers on nutrition, breast feeding, family planning and oral re-
hydration
- Growth monitoring and screening for factors that could impair normal
development.
- De-worming

8.2.1.3. Health promotion and rehabilitation includes:

- environmental hygiene and sanitation
- school health
- provision of sufficient quantities of potable water
- information, education and communication adapted to the local health priorities
e.g. AFP, Measles, Tetanus EPI, Onchocerciasis, Tuberculosis, HIV/AIDS,
Malaria, Leprosy, Helminthiasis etc
- Social re-insertion of the handicapped.
Health promotional activities are carried out in the community and require active
community involvement. However, the health services in providing technical
guidelines as well as health education to the community on what attitudes and
behaviours to adopt to live healthy lives as well as maintain a healthy environment,
must be a model to be imitated. It therefore makes no sense for the health services to
talk about a clean environment, use of latrines, provision of potable water etc. when
the health centre and hospital are always in the bush, have no functional latrine, no
water, nor provision for proper disposal of waste, the buildings are never renovated,
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etc. which is what currently exists in most public health facilities in our region. This
situation makes the population not to take the health team (composed of technical
staff and community representatives) who go for inspection of compounds, schools,
markets and special premises serious.

8.3. COMPLIMENTARY PACKAGE OF ACTIVITIES FOR THE DISTRICT HOSPITAL

This is dominated by patient care. The scope of these activities is expanded to take
care of those problems which the health centre cannot handle. These include:
- Management of referred cases from the health centres and counter referrals
as well as referral to the regional level,
- Management of medical as well as surgical emergencies,
- Surgical interventions,
- Dental as well as ophthalmologic care,
- Laboratory investigations not done at health centre level,
- Radiology and ultra-sound examinations etc.
The hospital, therefore, has personnel who are more skilled and specialized in
curative care and utilize more sophisticated technology for diagnosis and treatment
than the health centre.
Though preventive and health promotional activities are provided at the hospital, this
is not a priority. The rationale for carrying out some of these activities is to reduce the
incidence of missed opportunities. That is to say a child or pregnant woman, who has
not been vaccinated by the health centre, should be vaccinated when she attends the
hospital, because this might be the only opportunity to be vaccinated to avoid
contracting the disease.
Considering the highly technical nature of the services offered at the District Hospital,
it can be seen that Community Representatives have few areas in which they can
directly assist. Their role is therefore mostly limited to the attributions of members of
the Hospital Management Committee.
The above activities which are the basic minimum required to guarantee that the
health needs of the population are met cannot be effectively carried out by the health
staff alone. This is because the staff is insufficient in number and also they do not
possess all the skills and means needed for the effective and efficient implementation
of the package.
They have to work hand in hand with members of the dialogue structures to achieve
their goal of making quality health care accessible to a majority of the population, and
also give meaning to the concept of community participation in health care.
The need for community participation is clearly felt at the health centre and health
area level where human relations play an important role than at the level of the
district hospital.

8.4. THE DISTRICT HEALTH SERVICE (DHS)

The main function of the DHS is to put in place the basic structures of the health
district and ensure that they develop in accordance with the national health policy
taking into consideration the local realities with the ultimate aim of having a viable or
autonomous district.
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It does so by:
- Elaborating a multi annual district health development plan.
- Elaborating and implementing district annual operational plans.
The plan should take into consideration the problems of the health areas with their
health centres, those of the district hospital and any other problems that are relevant
for the development and functioning of these structures and the district as a whole.
Plans should be developed using a bottom-up and not top-down approach with the
Systemic Quality Improvement (SQI) approach.
- Monitoring, supervising and evaluating of health services and programmes in
the district.
- Promoting and strengthening community involvement in the health sector.
- Organizing public health activities in the district e.g. Supplementary
Immunization activities (SIA) or mass vaccination campaigns, control of
epidemic and endemic diseases etc.
- Promoting inter-sectoral collaboration.
- Mobilizing and rationalizing the use of available resources for the development
of the District.
- Putting in place a health information system adapted to needs.
- To attain these objectives, the District Health Team (DHT) which is a technical
team must work in collaboration with members of the District Health
Committee (DHC).
- The DHC through the DMC participates in the elaboration and implementation
as well as evaluation of the district operational plans.
- Mobilizes the resources for health promotion and development of services.
- Advocates on behalf of the district at the district development committee and
other organizations.

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Table 16: Areas of intervention by members of the Dialogue Structure in the implementation of the MPA

PACKAGE ACTIVITIES OF DIALOGUE STRUCTURE

1. Curative Care Mobilize population to:
- utilize the service
- pay for services
- register with MHO
- report early to health centre when ill
- buy drugs from health centre pharmacy and not from hawkers
- facilitate movement of referred cases to district hospital
- Do contact tracing.
2. Maternal, Child - mobilize parents to allow pregnant women and children attend these
and adolescent clinics
Health
- Encourage parents to get children vaccinated
- participate at out reach activities
- help in dispelling rumors and false beliefs
- promote the acceptance of family planning especially among the male
folk
- promote adolescent life skill education
3. TB, Oncho, - TB: encourage community members to consult if coughing for more
Malaria, than 2 weeks, encourage those affected to take drugs and do their
HIV/AIDS control tests. Psycho social support for patients on treatment which is
free.
- ONCHO: undertake Mectizan distribution, encourage community
members to take the drug and detect reactions and refer.
- MALARIA: carry out home based management of simple malaria and
promote the use of Insecticide Treated Nets (ITN) by the household
- HIV/AIDS: encourage voluntary counseling and testing, assisting those
on Anti Retroviral Therapy (ARV) to take their treatment regularly.
Treatment is free
- Encourage pregnant women and their spouses to go for PMTCT
- To encourage the PLWHA to join support groups.
- Leprosy/ Buruli Ulcer/Guinea Worm: be vigilant to encourage
community members having patches that are suggestive of leprosy,
direct members of the community who have ulcers that do not heal to
the HC.
4. Health - organize and participate in clean up campaigns
Promotion
- inspect public places and private compounds
- protect water sources
- Identify and report out-breaks of diseases and disasters to health staff
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 - sensitize on the risk of disasters and of certain behaviours e.g.
promiscuity, drug consumption
- report on births and deaths in the health area
- mobilize population to generate resources for health development
- pass on health information to the population
- Advocate on behalf of the health service at the village development
committee and other organizations.

In order to effectively carry out the above tasks, the members of the dialogue
structures need to be trained so as to improve and update their skills, provide them
with the relevant technical knowledge and also familiarize them with the tools which
they need for their tasks. By so doing, they will be motivated to work with enthusiasm
and confidence, and will gain the respect of both their communities and health staff.

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Chapter 9: PROCEDURES FOR INTERNAL AUDITING
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9.1. DEFINITION ............................................................. Error! Bookmark not defined.

9.2. TYPES OF AUDITORS ............................................ Error! Bookmark not defined.

9.2.1. External Auditors ....................................... Error! Bookmark not defined.
9.2.2. Internal Auditors......................................... Error! Bookmark not defined.

A) Community Fund
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B) Government Credits
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C) Surplus
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D) Donations
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9.4. SUMMARY ............................................................... Error! Bookmark not defined.

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 Chapter 9: PROCEDURES FOR INTERNAL AUDITING

9.1. DEFINITION
Auditing is a control measure with the main objective of ensuring the judicious and
accountable management of activities and resources in order to attain a set of
objectives in any given institution. Emphasis will be placed in this context on the
activities and financial resources.

9.2. TYPES OF AUDITORS

9.2.1. External Auditors
They are accounting experts who each year are awarded a contract on a competitive
basis to control the accounts of the North West Provincial Special Fund for Health at
the head quarters and outstations.
This process involves all money generated by the Fund and partners and used at all
levels in the health system. At the level of the district, auditors are specifically
concerned with sales of drugs in the Community Pharmacies, District Health
Committee Funds, PHC Supervision Funds, surpluses and any grant in aid awarded
to a health unit.
It is only after the external audit that surplus or loss can be declared. In the case of a
surplus the management of the Fund distributes the surplus and presents to the
Management Committee for scrutiny and presentation to the General Assembly for
approval. It is very important for the district and health area health committees to
cooperate with external auditors by accounting for any finances received and by fully
participating in the inventory/auditing process so that the auditors’ reports can be a
true and fair picture of the financial transactions of the pharmacies in the health units
for the year.

9.2.1.1. Regional Supervisors.

They are supervisors from the Fund, technical supervisors from the health district and
the Regional Delegation of Public Health.

9.2.1.2. Auditors from the Ministry of Public Health.

From time to time, the Ministry of Public Health sends out officials from the
Department of Financial Resources and Properties (DFRP) to control the health
units. They may be reinforced by other officials from Ministry of Economy and
Finance (MINEFI).

9.2.2. Internal Auditors

At the Health Area, there are two elected community representatives in the Standing
Committee of the General Assembly of the Health Area Health Committee.
At the health district level the internal auditors are elected Community
Representatives in the Standing Committee of the General Assembly of the District
Health Committee and the Chief of Bureau General Affairs in the District Health
Service.
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Auditing can be done at any time especially when there are rumours of suspicion or
misappropriation. Under normal circumstances, an audit is conducted before every
management committee and General Assembly meetings. This is simply a
verification exercise whose report is presented and discussed at the meetings.
Since auditing is conducted on financial documents, available cash and commodities
in stock, the person to be audited must be informed ahead of time to prepare and put
together all the necessary documents.

9.3. INTERNAL AUDITING AT THE HEALTH AREA

9.3.1. Revenue
A) Community Fund
This constitutes all the sources of income earned from the services rendered in the
health units; namely consultation, delivery, ANC, circumcision, laboratory fees etc. It
can also be called cost recovery fund.
From registers of the Health Centre, determine for the period considered, the number
of cases of:
- new consultations
- deliveries
- new ANC
- laboratory tests, and
- other revenue generating activities

The following procedures must be followed when carrying out internal auditing:
I. State the fees per activity
II. Verify in the Receipt Booklet if receipts issued correspond to all cases from
the registers. Obtain the declared monthly revenue.
III. Cross check the Daily Cash Entry Register to ensure that all revenue
collected are recorded and correspond to that obtained from the receipts.
IV. The auditors then report their findings as follows.
Table 17: Monthly Revenue Report

ACTIVITIES Number of Cases Declared Revenue Expected Revenue

New Consultation
Deliveries
Laboratory Tests
New ANC
Others (Specify)
TOTAL

To get the expected revenue, the authors multiply the number of cases by the fees
per activity. If there are any discrepancies between the declared and expected
revenue the possible reasons for them are identified.
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 V. Examine the Health Area Health Committee Bank Account Book.
a) State the bank account number
b) Verify if for each operation the Chairperson of the Management
Committee, the Treasurer, and the Chief of Centre did sign.
c) Verify too from the pass book whether the bank situation in the book
agrees with the movements and balance in the Cash Movement Register.
B) Government Credits
State the amount of credits per line per semester for that year and indicate as to
whether or not the credit cards have all been received.
C) Surplus
State the amount of surplus and any other subsidy received from the NWPSFH for
the period.
D) Donations
State the amount and sources of donations especially national for the period
considered.

9.3.2. Expenditure
a) Auditors verify whether the Health Area has a work plan with the
corresponding budget for the period considered.
b) Is the budget comprehensive (composite)? State the various amounts:

Source of funding Amount

Community Fund --------------- Francs CFA
Government Credits --------------- Francs CFA
Surplus --------------- Francs CFA
Others --------------- Francs CFA
c) Payment Vouchers
- Verify if expenditures made were planned.
- Verify if payment vouchers are duly prepared and signed by the treasurer,
Chief of Centre, Chairperson of the Management Committee and the
customer.
- Verify if prices are realistic.
- State the monthly total expenditure using the payment vouchers for the
period considered.
Table 18: Monthly Revenue Report

Payment Voucher Amount

Number Date

Total

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d) Cash Register
• Check if revenue taken out of the Daily cash entry register is effectively
entered as income in the Cash Movement Register.
• Verify if the payment vouchers identified above correspond to those in cash
Movement Register under expenditures.
e) Examine the Bank Account Book
The balance in the bank Account book and cash in hand with the treasurer
should correspond to the balance in the cash book. In the case of the
pharmacy, the total sales on the last day of recording must agree with the
physical cash in the safe of that pharmacy.
f) Daily Use Register
In checking the Daily Use Register the auditor must be able to determine
whether the total number of drug item sold in a day agrees with the amount
recorded in the stock card and whether the total cash sales in a particular day
is the same amount transferred to the financial record book.
g) Financial Record Book
If all the daily sales totals have been transferred to the Financial Record Book,
then the auditor must confirm whether the running total is correct as shown by
the pharmacy attendant.
h) Examine the Materials and equipment acquired within the period of audit.
i) Surplus and Subsidies from the NWPSFH: verify the utilization as above
examining:
 plan of action for its use
 payment vouchers
 cash movement register
 material acquired or work done
 bank account book
 Justification for the use of surplus and subsidies forwarded to the
Regional Delegation of Public Health and the NWPSFH.
j) For specific projects verify the progress of work and the corresponding
financial records stating the sources and amount of funding.
k) If there are discrepancies at any level, identify the reasons and contributing
factors; then make recommendations.
l) Make an audit report following the steps outlined and present it to the Health
Area Management Committee for appreciation and stating corrective
measures before the report is presented to the General Assembly of the
Health Area Health Committee.

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9.4. INTERNAL AUDITING AT DISTRICT SERVICE
The two Auditors in the Standing Committee of the District General Assembly will
carry out this work. The two persons are a Health Staff who is Chief of Bureau for
General Affairs at the District Service and one elected Community Representative.
The audit exercise in this service will consist of:
1. Verification of a budgeted plan of action
2. Verification of the budget to ensure that in-puts from all partners are included
(Comprehensive/composite budget)
3. Stating amount for each component of the budget
a) Community Fund
- PHC Supervision Fund
- Subsidies form NWPSFH
- Contribution for Supervision from Health Areas
b) Government Credits
c) Other Sources
4. An assessment of the level of execution of work plan and budget
5. Checking the payment vouchers
6. Verifying the cash movement registers to ensure that expenditures are
recorded and that the balance corresponds to cash in hand or non-committed
credit situation.
7. Examining the Bank Account Book to determine balance and movement of
cash.
8. Stating the level of utilization of Government Credits, précising the amount
used in the execution of work plan compared to amount budgeted.
9. Examining the utilization of other financial resources available.
10. Writing and presenting a final report to the District Management Committee for
appreciation and corrective measures.

9.5. INTERNAL AUDITING AT DISTRICT HOSPITAL

The internal auditors are the same persons as for the District Health Service (see
4 above). The procedure is the same.

9.5.1. Revenue
I. Calculate the total monthly revenue declared on the Monthly Revenue
Declaration Form.
II. Verify from the Receipt Booklet that the monetary value of all the receipts
issued corresponds to the revenue declared for the period considered.
III. Make a report of the monthly declared revenue as follows.

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Table 19: Monthly Declared Revenue
ACTIVITIES DECLARED REVENUE
1. New Consultations (Dr.)
2. Hospitalization
3. Deliveries
4. Major Surgery
5. X-Ray
6. Laboratory
7. Dental Unit
8. Ophthalmology
9. Etc
TOTAL
IV. Determine the Number of the activities from the Registers in the various
units, including the Doctor’s Consultations
Table 20: Monthly Activities

ACTIVITIES NUMBER OF CASES

1. New Consultations (Dr.)
2. Hospitalization days
3. Deliveries
4. Major Surgery
5. X-Ray
6. Laboratory
7. Dental Unit
8. Ophthalmology
9. Etc
TOTAL

V. State the official fees per activity.

VI. Calculate the expected monthly revenue per activity and compare with the
declared revenue.
Table 21: Monthly Activities

Activities Number of cases Declared revenue Expected revenue

1. New Consultations (Dr.)
2. Hospitalization days
3. Deliveries
4. Major Surgery
5. X-Ray
6. Laboratory
7. Dental Unit
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8. Ophthalmology
9. Etc
TOTAL
If there are discrepancies between declared and expected revenue identify the
possible reasons.

9.5.2. Expenditure
I. From the monthly revenue declaration form, bring out
a) The total solidarity fund = 10% Quotes parts (30% of total monthly
revenue).
b) Plus 10% Revenue reserved for Hospital Development (70% of total
monthly revenue)
c) Quote parts = 30% Total Monthly Revenue minus Solidarity Fund i.e. 30%
- (10% of 30%) = 27% of total revenue
d) Hospital Development Fund = 70% Total Revenue minus National
Solidarity Fund i.e. 70% - 10% of 70% = 63% of total revenue
II. Verify from reports if the “quotes parts” is distributed to hospital staff, stating
dates and total amount distributed; and postal or bank receipts by means of
which the Solidarity Fund is regularly sent to the Delegation of Public Health.
Kindly state dates and amounts.
III. Use of the Hospital Development Fund
a) Does the Hospital have a savings bank account? If yes, state Bank
Account Number.
Cosignatories of this account are:
- Chairperson of Hospital Management Committee
- Director of the Hospital
- Service manager of the Hospital
b) State the monthly revenue deposited in the account for the period
considered.
Month/Date Amount

M1

M2
c) Is there a plan of action and corresponding budget for the utilization of the
Hospital Development Fund according to the directives of the Minister of
Public Health by Arrete N005/MSP of 15th, July 1994 and Arrete N0
0030/MSP of 20/09/99.
d) Have the draft budget been forwarded to the Minister of Public Health for
approval? This must be done by end of October every year for the budget
of the year beginning next January.

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 e) Have the budget been approved by the competent authority? If not why?
What action is being taken to correct the situation?
f) What is the level of execution of the approved hospital development
budget at the time of auditing?
g) In so doing, compare the execution of budget to the execution of plan of
action, and verify:
- payment vouchers
- cash movement register
- material and equipment acquired; and work done
- money saved for the depreciation of equipment
- Bank account for balance and other savings
IV. Use of Surplus, verify
a) plan of action for the surplus
b) payment vouchers
c) cash movement register
d) material and equipment acquired and work done
e) bank account
f) Justification for the use of surplus to the Regional Delegation of Public
Health and NWPSFH.
V. Finances of Special Projects
Examine the monthly project reports and financial reports.
VI. State Amount of Government Credits used for the realization of activities and
projects in the Hospital.
VII. Write a detailed audit report using the headings and steps outlined above.
State reasons for any financial discrepancies, use of funds without
justification and other observations. Make recommendations.
Present the audit report to the Hospital Management Committee for
appreciation and corrective measures. The audit report is thereafter presented
to the General Assembly of the District Health Committee for adoption.
VIII. The Audit Report is signed by the two Internal Auditors, the Director of the
Hospital, and the Service Manager.
∗ In case there is discrepancy and the Director + Service Manager hesitate to
sign, let them make their comments and sign.

9.6. INTERNAL AUDITING OF THE PHARMACY

1) The Chief of Health Unit or his designated representative joins the two
internal auditors at each level to audit the pharmacy, because of the
technical nature of pharmaceutical products.
2) Sales of drugs are suspended for a few hours on the auditing day.
3) Start auditing from the annual inventory or the most recent audit of the year
considered.
4) Determine the current capital situation of the pharmacy:

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 I. State in cash the quantity of drugs in stock after the annual inventory or
last audit.
II. From the current capital situation card record all the supplies from the
NWPSFH since the annual inventory or last audit, stating date, quantity
of drugs in cash, and the cumulative total.
Table 22: Current Capital of Pharmacy
Date Operation Capital Cumulative Capital
20 January 2009 Annual Inventory 1.000.000 1.000.000
25 December
Supplies (since the last inventory) 2.000.000 3.000.000
2009

5) Assess sales of Drugs since annual inventory or last audit.

I. Verify from RECEIPT BOOK
- If prices of drugs correspond to those on price list.
- If there are bulk sales and why?
II. Calculate the monthly sales using the DAILY FINANCIAL RECORD
BOOK, and then the cumulative sales since the annual inventory or last
audit.
Table 23: Sales

DATE/MONTH AMOUNT CUMULATIVE SALES

III. For period being considered, verify receipts of cash forwarded to NWPSFH
and state clearly.
1. The receipt number
2. The amount collected
3. The date of issue
4. The name of the receiver
Your report should be presented in this form.
Amount to Name of
No. Receipt No. Date
NWPSFH Receiver

IV. Determine the cash in hand.

a) Count the cash available
b) Note the amount of money in the form of postal money order
(mandate). The sum of the two constitutes the cash in hand on the day
of audit.
c) Check if cash in hand corresponds to the amount in the Daily Financial
Record Book.

6) Assess the quantity of drugs in stock to obtain its cash value on the auditing day.
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 I. Make sure that the pharmacy attendant fills the STOCK CARD for each
drug to the date of auditing.

II. Using the stock card for each drug, calculate the total value of drugs in
stock on the day of the auditing; this constitutes the first capital for the
following period.

9.4. SUMMARY

The total cumulative current capital in cash from the annual inventory of the year
considered or the last audit equals the total cumulative sales plus the value of drugs
in stock on the date of auditing.

Date of Auditing _______________________________________

Total cumulative current Cash value of drugs in stock on

Total cumulative sales
capital date of auditing

I. Verify the containers of drugs to ensure that the unopened tins and cartoons are
full by shaking those that cannot be opened, and counting them.
II. Note the dates of supervision of the pharmacy by the
- Management Committee
- District Health Team
- The NWPSFH
- The Regional Supervisor
III.Write up the audit report using the steps described above. State all
discrepancies, possible reasons, measures to correct and your
recommendations.

The audit report is signed by the

- Two Internal Auditors
- The Pharmacy Attendant
- And the Chief of Health Unit

The audit report is presented to the corresponding Management Committee for

appreciation and corrective measures; before presenting it to the General Assembly
of the respective Health Committees for adoption. A copy is forwarded to the higher
level – District/Region.

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Chapter 10: HEALTH AND DEVELOPMENT
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10.2. COMMUNITY INITIATIVES .................................... Error! Bookmark not defined.

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10.2.2. Community based projects ...................... Error! Bookmark not defined.

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10.7 CONCRETE EXAMPLES OF COMMUNITY INITIATIVESError! Bookmark not defined.

10.8. SUSTAINABILITY .................................................. Error! Bookmark not defined.

10.9. PROJECT COMMITTEE ........................................ Error! Bookmark not defined.

10.9.1. Terms of reference .................................. Error! Bookmark not defined.
10.9.2. Composition............................................. Error! Bookmark not defined.

10.10. EXAMPLES OF COMMUNITY REALIZED PROJECTSError! Bookmark not defined.

10.10.1. The Batibo District Hospital surgical complexError! Bookmark not defined.
10.10.2. MHC Nkwen Ward Extension: Health Area Project (no written report
available)................................................ Error! Bookmark not defined.
10.10.2.3. Target and realization ......................... Error! Bookmark not defined.

10.11. CONCLUSION AND RECOMMENDATIONS....... Error! Bookmark not defined.

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 Chapter 10: HEALTH AND DEVELOPMENT

10.1. HEALTH
The real measure of health is the ability of the individual to function in a manner
acceptable to himself and to the group of which he is part. The World Health
Organization (WHO) defines health as a “state of complete physical, mental and
social well being and not merely the absence of disease or infirmity”. Health and
well-being are determined by factors such as good water, enough food, good roads,
employment, habitat etc.
It is the economic growth of a society together with its social improvement such as
health, education, housing, water supply, good roads etc. The relationship between
development and health is a two-way interaction. The socio-economic status
(income, occupation, education, living conditions etc.) has an influence on the level of
health e.g. malnutrition is often due to poverty and ignorance. The improvement of
health resulting from health education, good roads, good nutrition, environmental
sanitation, etc can exert great influence on the economic level of individuals, families,
groups and the nation.

A healthy population in a healthy environment has a healthy labour force, reduces

absenteeism from various activities and healthy school population free of all
predicaments to foster its development.

10.2. COMMUNITY INITIATIVES

Community initiatives are development projects or activities or programmes initiated
and managed (planned, executed and evaluated) by the community to achieve goals.
Community initiated activities and projects are either community imposed or
community oriented or community based.

10.2.1. Community imposed and oriented projects

Community imposed programmes, activities, and projects are planned and decisions
made at the higher levels by professionals and imposed on the community (Top-
Down Approach).
Community oriented programmes, activities and projects are those in which the
professionals (health care providers) initiate to improve with the consent of the
community on its economic status.
Community imposed and oriented projects are very often not long lasting because;

1) The population concerned usually fails to identify itself with and own the
project (rejection phenomenon).
2) The mobilization of local resources is usually little or inexistent.
3) The project will continue on external funding sources. It is not sustainable as
the project dies when external funding ends.

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10.2.2. Community based projects
Community based programmes, activities and projects are those initiated in the
community with the community members actively involved in all the aspects of its
realization. Community based projects use a bottom – up approach with lots of
support and initiatives from the bottom (the community itself).
They have the following characteristics:
1) They are people from the concerned community.
2) The project is naturally and socially an appropriate solution to identified
community problems.
3) The community appropriates the project and ensures its sustainability through
the mobilization of local resources.
4) Adequate utilization of services is assured.
5) Successful community based projects easily gain support from government
and other external agencies.
6) Lessons and experiences learned from community based projects can be
harnessed usefully to improve competence (knowledge and skills) of said
community in further handling of more complex integrated socio-economic
projects.

10.3. IDENTIFYING COMMUNITY NEEDS AND PROBLEMS

Through brainstorming, the dialogue structures (the development team and the
health committee) come out with a list of the community needs and problems. Some
will be real needs and some will be felt needs.
a) Felt needs: These are needs that a community recognizes that it needs e.g.
telephone in a less developed community is a felt need.
b) Real needs: These are needs that a community recognizes as its needs as a
result of technical knowledge, information and advice e.g. water supply in a
community without good and enough water is a real need for that community.
A felt need in one community can be a real need in another community depending on
the level of development reached by that community.

10.4. CRITERIA FOR SELECTING REAL NEEDS AND PROBLEMS

Community supportive programmes, activities and needs are:
a) Those which when realized will have meaningful impact upon the lives of the
majority of the population especially the disadvantaged.
b) Those which favourably influence the long-range welfare of the community
c) Those which help the community stand on its feet.
d) Those which genuinely encourage responsibility, initiative, decision making,
and self-reliance at the community level.
e) Those which build upon human dignity.

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10.5. CRITERIA FOR SELECTING REAL NEEDS AND PROBLEMS
Due to the fact that resources are often limited and considering the complex nature of
some projects, it is not advisable to plan to execute more than one project at a time.
There is therefore need to prioritize and set targets for the selected projects. The
criteria for setting priorities can include:
a) Which of the needs/projects is more pressing? Is there a threat to health or
life?
b) The ease to have resources for the realization of the project
c) Is there a plausible or likely explanation for the programme, activity or need?
Can lessons be drawn from it?
d) Are there conflicts of interest?
e) The ability of the community to sustain the project when realized?

10.6. THE ROLE OF THE DEVELOPMENT TEAM AND THE COMMUNITY

The management of resources generated by the state and the community in
partnership is carried out by the Management Committee of the dialogue structure.
The state is represented at each level by the technical team and the community by
the community representatives at that level. The management committee is
responsible for all management duties including planning. Its role in project
execution includes:
a) Selects the priority project
b) Sets target for execution
c) Draws general plan of action
d) Regularly draws a work (by project committee) plan
e) Draws the budget for execution
f) Plans how to mobilize resources for execution
g) Forms a project committee
h) Presents the plan for adoption by the General Assembly of the dialogue
structure.

10.7 CONCRETE EXAMPLES OF COMMUNITY INITIATIVES

 Promotion of health activities
 Construction, renovation and rehabilitation of health units
 Purchase and maintenance of medical equipment
 Environmental hygiene and sanitation
 Agricultural/food production and transformation
 Construction and maintenance of improved physical accessibility structures
 Training and education of other community members.
NB: The health committee with its management organ (the MC) constitutes a
subcommittee of the integrated development committee of each community, be it at
the village (health area) level, the sub divisional (district) level, or the divisional level.
The above examples of community initiatives are often carried out within the
framework of the integrated development committee initiatives.

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10.8. SUSTAINABILITY
Sustainability is the ability to maintain a project functioning after the initial investment
funds for its realization have been exhausted. A sustainable project is therefore a
project, which after it has been realized could become financially self-sufficient after
the initial investment of funds. Health care is sustainable when there is a long term
ability to mobilize and allocate sufficient resources for producing the desired services.
There goes the local saying that “oil from a raffia palm beetle can be used for frying
the same beetle”. Finances generated through cost recovery from a well managed
health establishment can effectively sustain that establishment. Some health
programmes are part of larger integrated development projects, which provide
productive activities to finance those which are not self supporting e.g. the dialogue
structure of MHC Nkwen Health Area used to rent out part of its land for vehicle
washing point, sale of wood and food sheds. These activities generated about
17.000 francs monthly for the health area. This amount increased the income of the
health area realized from cost recovery.

In 1983 the health committee of the Kedjem Ketingoh health Area planted a fuel
plantation and also managed a sweet potatoes farm. The sweet potatoes farm
yielded enough money for the post. One year wood from that plantation was used to
repair the health centre (the health post was transformed to a health centre).

Many health and health related projects often collapse because they are not
sustainable and lack effective management. The incomes generated from cost
recovery and subsidy from the state cannot effectively sustain many health units.
Therefore, it is necessary to generate income from other sources.

10.9. PROJECT COMMITTEE

It is a sub committee of the health committee, in charge of a project. Membership is
reinforced with competent staff from other sectors, and competent members of the
community.

10.9.1. Terms of reference

It is responsible to the management committee, the general assembly and the
community.
a) It ensures that a plan is drawn and approved for the project
b) It recruits workers (skilled and unskilled)
c) It mobilizes resources for the project
d) It draws a work plan from the plan of action
e) It purchases the necessary materials
f) It monitors the project regularly
g) It maintains proper records for the project
h) It reports about the project each time the management committee is meeting
i) It writes a detailed report about the project when it is realized.

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10.9.2. Composition
It is an ad hoc committee whose members depend more on competence, honesty
and trust in the community than on membership of the dialogue and management
structures. Once the project is realized and its report presented and adopted, it
ceases to exist.

10.9.2.1. Health Area

a) Chairman: Community representative (a retired technician if available)
b) Secretary: the staff representative in the dialogue structure
c) Treasurer: Community representative who is eligible.
Members:
d) The District Chief of Service Public Health or his representative
e) One member of the traditional authority (representative of all the traditional
rulers)
f) Two community representatives from the general assembly.

10.9.2.2. The District Service

a) Chairperson: A community representative from the District Service
Management Committee
b) Secretary: The Chief of Bureau Health
c) Treasurer: A community representative who is eligible
d) The District Chief of Service Public Health
e) The Director of the District Hospital
f) The District Supervisor from the regional level
g) The Representative of the Divisional Officer(s)
h) The Representatives of the Mayor(s)
i) One Community Representative.
Note:
i. Retired/unemployed technicians could be co-opted for particular projects.
Their term of office would be when the project is completed.
ii. The project committee is the life wire of projects, hence only dynamic and hard
working people should be chosen as members.

10.10. EXAMPLES OF COMMUNITY REALIZED PROJECTS

Two successful community based projects realized in two different districts are
thus presented as case studies.

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10.10.1. The Batibo District Hospital surgical complex

10.10.1.1. The Batibo Health District

Presentation
The Batibo Health District with a population of 71,000 inhabitants covers two
administrative units: Batibo and Widikum Subdivisions. The district is carved out into
health areas, some of which are functional and some are non functional. There are
mission health centres and private nursing units.
The dialogue structures are composed of:
a) The health committee and management committee
b) The district dialogue structure with:
- The district health committee
- The district management committee
- The district hospital management committee
The Provincial Supervisor of that district is a member of the standing and district
management committee.

10.10.1.2. The surgical complex

The Batibo District Hospital Surgical Complex is the 12th development project
realized, was initiated among other 18 projects in 1992. The projects identified in
order of priority include:
1. install electricity in the hospital
2. extend pipe borne water to the wards
3. create an improved surgical theatre
4. open a hospital pharmacy
5. improve relationships between health services and community, and the
coordination of health centres
6. convert the incomplete building into a Pediatric Ward
7. construct roofed corridors to link the hospital buildings
8. increase the number of beds and beddings
9. construct modern pit toilet with shower facilities
10. create an improved physiotherapy unit
11. plant flowers and trees to demarcate the hospital boundaries
12. construct a real surgical theatre and surgical wards
13. build a nutrition centre
14. construct a water storage tank
15. build and equip an x-ray department

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 16. construct a mortuary
17. build a real paediatric ward
18. fence the hospital
The execution of the complex project started in January 1995 when the General
Assembly of the dialogue structure adopted the plan (see page 14) to construct the
surgical complex so as to solve problems from the improvised theatre, and to achieve
objectives.
When the plan drawn by the Provincial Delegation of Public Health was adopted,
strategies for the construction were put in place as follows:

10.10.1.3. Creation of two fund raising committees

a) a committee for the local population
b) a committee for elites out of Batibo and donor organizations

Hospital Development Fees

The institution of hospital development fees of 500 francs CFA.
This amount was paid once as consultation fees. Children, students, apprentices
and desperate patients were exempted.

The Creation of a Project Committee

Composition
1. Chairman: District Chief of Service Public Health
2. Secretary: Chief of Bureau Health
3. Treasurer: President of the Standing Committee of the District Health
Committee.
Members
1. Chairman of the District Management Committee
2. Chairman of the District Hospital Management Committee
3. Service Manager of the District Hospital
4. Two Community Representatives of the District Management Committee.
Terms of reference
The committee was charged with the following responsibilities:
a) Choosing the site for the building
b) Recruitment of workers
c) Purchasing of building materials
d) Organizing community human investment
e) Establishing appropriate records to ensure accountability and transparency
f) Drawing quarterly work plan of action
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 g) Writing quarterly update of the evolution of the project.
The sensitization and the mobilization of the administration, Chiefs of Health Centres,
Dialogue Structures, Elites, Fons and Chiefs, the entire community was quite
positive. The appeal for aid from philanthropic groups, NGO’s, prominent
personalities, Embassies, High Commissions and the funding agencies were also
very positive. Fund raising rallies were organized and the appeal for equipment,
German International Corporation (GIZ) and Clinic Care International donated
equipment worth CFA 8.500.000 francs and 6.000.000 francs respectively.

10.10.1.4. Monitoring and evaluation of finances

The following methodologies were used to monitor and evaluate the money received.
a) Receipts: The duplicates of receipts issued for money received were regularly
checked
b) Register: A register was opened for those who donated CFA 1.000 francs and
above.
c) Thermometer drawing. Large thermometer drawing placed on the notice
board was used to show the public the level of its mercury according to the
monthly cumulative total finances received.

Feedback to the community donors

Letters of appreciation were always sent to all those who contributed to the
realization of the project. The letters indicated the list of donors, amount received,
the expenditure, further needs and appeal for more financial support.
10.10.1.6. Update report
An update of the evaluation of the project was made quarterly. It consisted of:
 Total finances received
 Sources of finances
 Level of achievement of the project
 Expenditure
 Financial support necessary to complete the project
 Lists of donors
 Appeal for more support.
The updates were displayed on the hospital notice board and sent to individuals,
Embassies and Associations.

Finances raised as of March 1998

The total amount of money realized for the project through donations and the various
fund raising activities amounted to CFA 51.332.567 francs.

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Bankers during the operation were:
i. CCEI, Bamenda
ii. SCB Credit Lyonnais, Bamenda
iii. Credit Union, Batibo
iv. Post Office, Batibo
Plan of action and budget:
 The plan was drawn by the project committee and adopted by the General
Assembly of the Dialogue Structure in March 1995
 22nd of April 1995 – launching of fund raising
 May – June 1995 – Making of cement blocks and acquisition of stones
 1st July 1995 – Initiation of the project foundation
 30th september1995 – completion of foundation
 14th October 1995 – laying of foundation stone
 November – December 1995 – Raising of walls
 January – February 1996 – Roofing
 March – April 1996 – Ceiling/metal works
 13th April 1996 – fund raising rally
 May – June 1996 – Plastering and flooring
 July – September 1996 Glass works
 October – December 1996 – Equipment
 January – March 1997 – Finishing touches
 April 1997 – Inauguration
It was estimated to cost CFA 57.000.000 francs.
Evaluation of Project:
The project was evaluated as follows:
The execution of the plan of action

The project was started on 1st July 1995 and realized in March 1998 instead of
March 1997 as it was envisaged.
The balance sheet of income and expenditure

The income of 51.332.567 francs balanced with the expenditure of 51,332,567
francs. This was due to the fact that the project was evaluated at different
phases and the demand for more funds depended on the estimate of the work
left.
a) Community participation
It was quite possible. The community contributed 34% of the total cost. The
community was actively involved in all aspects of the project. The 34% does not

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include labour. It should be noted that the community contributed 71% of the total
cash of the 11 projects realized.
b) Funding organizations
Out of the applications made to 12 organizations, 4 responded with CFA 31.700.000
francs and GIZ adding to its own cash donation equipment worth CFA 8.500.000
francs.
c) Partnership between the state (represented by the health team-development
team) and the community (represented by the district health committee). It was
cordial and quite active in all the kinds of participation.
d) Inter-sectoral collaboration
The related services ranging from administration to school and churches whole –
heartedly supported the execution of the project.
e) The District Technical Health Team
Their dynamism coupled with generosity (time was sacrificed and vehicles used)
motivated all to contribute in their own way.
f) Supervision
It was both vertical (the Provincial Delegation of Public Health, the British High
Commission and Embassies) and horizontal (the Project Committee).
g) Total Cost
The total costs including equipment from GIZ stood at CFA 59.832.576 francs.
h) Problems
Three major problems:
i. The absence of a service vehicle for the District Health Service and an
ambulance for the District Hospital
ii. Lack of second doctor
iii. Lack of investment credits from government.

10.10.1.5. Sustainability
The report does not indicate how the effective running costs of the hospital would be
maintained.
An appraisal
“This project has revealed that developing existing government institutions is cheaper
and more effective through a community initiated project managed by the same
community, and supervised by the donors, than channelling resources through non
governmental organizations whose impact is most of the time felt and short lived at
the level of the community. Similarly it exposes contracts given to contractors who
often do only 50% of the expected work. The Batibo experience could work in most
decaying state health institutions provided the community is trained to be as
respectful, transparent and dynamic” as the authors of the project report see it.

10.10.2. MHC Nkwen Ward Extension: Health Area Project (no written report available)
The project was initiated by the Health Area Health Committee among other projects
of the health area. The projects, which were identified and prioritized, were as follows:
1. Extension of the out patient department
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 2. Construction of Pit latrine
3. Road construction
4. Ward extension
5. Extension of maternity; it is on going
6. Purchase of equipment (part realized)
7. Construction of fence
8. Construction of theatre.
* The first three have been realized.

10.10.2.1. Objectives
a) Reduce congestion
b) Reduce the rate of infections
c) Create more space for patients
d) Provide quality care

10.10.2.2. Strategies put in place

Drawing of the plan
a) It was drawn by the Provincial Delegation of Public Health
b) Formation of Development Committee.
Composition

Chairman: He was elected from the General Assembly of the Dialogue
structure

Three Technical Staff and some Community Representatives.
c) Mobilization of resources:
Funding

Nkwen Urban and Rural Communities

Elites

Foreign donors

Politicians and NGO’s
Contributions

Community 35%

Donors 65% from foundation level.
Bankers
The money was kept in Amity Bank in a special account.
The signatories were:
1. Chairman of Development Committee
2. The Medical Officer in Charge of Nkwen MHC
3. The Treasurer of the Development Committee
4. The Donor
The chairman and the treasurer are members of the dialogue structures (community
representatives).
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10.10.2.3. Target and realization
The project was planned for five years from 1996 and was realized in two years
period – 1998.
Equipment
Some equipment was supplied by:

Soroptimists (NGO)

Hon Clement Zamcho, Parliamentarian.

Evaluation
It was done by the community and the donor. The higher echelon of the health
system was not actively involved. Apart from the plan drawn by the Delegation of
Public Health, only moral supportive role was played.

10.10.2.4. Sustainability
The local running costs of MHC was generated from
 Cost recovery ; consultation fees, laboratory fees, birth attestation forms
 Rent of part of MHC land for wood sale which yielded 2500 francs monthly,
food shed which yielded 5000francs monthly.
Note: This information was given by Dr Mrs. Mayer – Medical Officer in Charge of the MHC and Mr
Wanzie J.C. Chairman of the Management Committee.

10.11. CONCLUSION AND RECOMMENDATIONS

Factors which can stimulate active community participation include among others:
i. Dynamic leaders
ii. Community initiated (based) projects
iii. Accountability/transparency.
These ingredients were present in the projects, thus stimulated the communities and
others concerned to actively participate in the projects. The dynamism of the leaders,
transparency and the successful realization of the previous projects accounted for the
huge participation and success of the studied projects. In partnership, the active
involvement of all the partners is essential. Self-reliance is not shifting government
responsibility to the community.
In community participation, unrealized projects or those which collapsed after they
have been realized greatly hinder community from participation in other projects.
Community imposed projects are carried out in such a way that they effectively
encourage greater dependency, unquestioning acceptance of outside regulations and
decisions, and in the long run are crippling to the dynamics of the community. When
a project is conceived, planning should not only consider resources for effective
execution but also those for maintaining the project after realization. Land for the
District Services, District hospitals and Health Centres are wasting. The example of
MHC Nkwen can be emulated. Building houses for rental, renting out land for
farming etc. can generate a lot of income for health establishments. When doing this
it should not be forgotten that recruitment of health personnel and putting up of
structures are other examples for the communities to emulate. Environmental
hygiene especially should be considered when doing all this.
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REFERENCES
1) CMC, Sustainability, Contract N° 158 Geneva Dec. 1993 and Jan. 1998.

2) David C. et al Bureaucracy and the Poor Closing the Gap; Kumarian Press 1985

3) Decree N° 002/209 of 19 August 2002 Organizing t he Ministry of Public Health.

4) Eyong E.J et al The Batibo Hospital Surgical Complex. Community Project. Batibo March
1998.

5) Health Sector Strategy, 2001 – 2010

6) Order N° 033/CAB/MSP of 21/9/1998 defining modal ities for the creation of health dialogue
structures

7) Order N° 0001/A/MSP/CAB of 16/11/1994 prescribin g the attributions of management

committees in Public Health establishments.

8) Peter O. & David M. Approaches of participation in Rural Development. Geneva 1987.

9) Decree N0. 68/DF/419 of 15 October, 1968

10) Law 90/053 of 19 December 1990 (Financial Special Derogations for Health Institutions)

11) Decree N0.93/228/PM and 93/229/PM of 13 March 1993 (text of applications of the above 2)

12) Decision N0. 0381 of 15 June 1993 (Essential Drugs)

13) L’ Arrête N0.001/a/MSP/CAB of 16 November 1994. (attributions of management committees)

14) Law N0. 96/03 of January 4 1996 ( portant loi-cadre in the domain of health in Cameroon)

15) Decision N0. 0290/L/MSP/CAB of 16 February 1998 (constitution de l’equip national de

development sanitaire au Cameroon)

16) Law N0. 98/009 of 1 July 1998 (autorisant la conservation de 100% des recettes des
formations sanitaire publique)

17) L’Arrêté N0. 0033/CAB/MSP of 21 September 1998 (fixant les modalités de création des
structures de dialogues et de participation communautaire dans les districts de sante).

18) L’Arrêté N0. 0035/A/MSP/CAB of 8 October 1999 (portant modalité de création, d’organisation
et de fonctionnement des district de sante)

19) Decree N0.96/055 du 12 mars 1996, création et organisation de Laboratoire Nationale de

Contrôle de Qualité des Médicaments et d’Expertise.

20) L’Arrêté N0.0016/A/MSP/SG/DMH/SDHPFSP/BFSP du 05 novembre 2001 portant création de

districts de sante.

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