GIZ Professional Forum on ‘The Political Economy of Health and Social Protection’ 2011 An analysis of two examples from Cameroon - The Aunties as sexual health Advocates - Micro Health Insurance (MHI) to improve quality of care Ahawo Komi

“Aunties” unwed young mothers advocates for sexual health in Cameroon Rationale of the approach Girls in Cameroon have followed worldwide trends towards sex before marriage, early sexual initiation and multiple sexual partners with a high risk of getting pregnant, being removed from school, forced into early marriage, harmed by unsafe abortion, and acquiring sexually transmitted infections including HIV GTZ launched the “Aunties” Project which borrows from the tradition that a girl’s auntie used to be her most trusted confidante, teacher and counselor on sexual matters.

“Aunties” unwed young mothers advocates for sexual health in Cameroon Achievements by mid-2010 12,000 unwed young mothers recruited and trained in basic sexual and reproductive health. 3,000 Aunties provide sex education in schools 4,300 were provide counseling to young people more than 240 local Aunties associations created. the potential of reaching as many as 300,000 students per year

“Aunties” unwed young mothers advocates for sexual health in Cameroon Achievements by mid-2010, Cost for training an auntie €76 to €81. sustainability easy since the project depends on volunteerism and donations in-kind. Aunties’s use of condom Before, 26% after training , 47%. Since training, 19% had returned to school and 63% had taken other action to improve their economic prospects,. 88% Aunties accepted routine offer of testing to trainees and 100% had taken the result.

“Aunties” unwed young mothers advocates for sexual health in Cameroon Specific challenges Many other problems raised by Aunties : rape, harmful practices like breast “ironing” and post-partum belly “massage” etc. Lake of framework and government support slowed the scaling up of the approach. The point view of men Gender inequity Few attention paid by authorities to evidences of the project

How did the project got political support? “Aunties” unwed young mothers advocates for sexual health in Cameroon How did the project got political support? The use of a bad example and the internet! Worldwide vigorous campaign against breast ironing considered as terrible acts of physical and psychological violence This traditional method to hide as much as possible the sexual maturity of a girl highlighted the work of Aunties. Cameroon’s Ministry for Women’s Empowerment is extending the Aunties’ Project through all 58 of the country’s Women’s Support Centres.

“Aunties” unwed young mothers advocates for sexual health in Cameroon Lessons learned To draw the attention of political authorities and get their commitment for a radical change, evidence is good but not enough! The worldwide support (internet) can be of a good help to lobby and bring local political changes.

Micro Health Insurance (MHI) to improve quality of care Rationale of the approach MHI implemented in Cameroon have signed protocol agreements with health facilities before the Ministry of Public Health (2006) published a legal framework. The MHI were at the beginning (few membership, poor financial capacity). Most of the health facilities who signed the contract felt not obliged to comply with it. Some refused! Many shortcoming :Over prescription, poor quality of care affected consumer trust and threatened the development of MHI PLWHIV are not admitted as such in the MHI (fear of bankruptcy)

Micro Health Insurance (MHI) to improve quality of care Specific challenges MHI is advocated as one important option for developing countries to ensure social protection in health How do newly created MHI bring health facilities : to comply with a suitable health treatment protocol, get paid after approval of prescriptions and bills by the medical adviser agree with sanctions in case of non-performance? Instead of growing rapidly, the financial power of MHI should be enhanced but how? Important fact : a good number of unpaid bills come from hospitalization of PLWHIV

Strategy Micro Health Insurance (MHI) to improve quality of care GTZ accepted to support an experience of introducing the treatment of HIV (without ART drugs) into the standard benefit package offered by MHI. Subsided reinsurance fund has been created the reimburse MHI for the care of PLWHIV Medical advisors are selected among District Medical officers, trained and receive incentives from MHO

Achievements Items 2006 2007 2009 observance 38% 42% 68% Use of condom Micro Health Insurance (MHI) to improve quality of care Achievements Items 2006 2007 2009 observance 38% 42% 68% Use of condom 13% 23% 53% Membership PLWHIV 777 4514 PLWHIV treated 919 1450 average cost/PLWHIV treated 35€ 42€

Micro Health Insurance (MHI) to improve quality of care Achievements MHI that are in the program became credible partners to all type of health services Compliance to protocols became effective Districts forums to discuss about quality of care are created or developed. MHIs are now dialogue structures with health facilities where the community can file complaints about the quality of care and be listened to. Rejected bills for non conformity to protocols are now accepted!

How did the project got political support? Micro Health Insurance (MHI) to improve quality of care How did the project got political support? The use of HIV as an entry point! It was difficult to a health facility to refuse an organization that takes care of HIV The economic argument was an asset. Because some of the contracts were signed by the hierarchy, health facilities were obliged to work on their system e.g. create therapeutic protocols

Micro Health Insurance (MHI) to improve quality of care Lessons learned A Local organization with economic power can tackle a big machinery by focusing on its interest and renown. The networking of small organizations with the same interest and the same methodology brings rapidly political changes!

Conclusion Most of the time, good political decision are made from bad examples or event even without evidence! Do not hesitate to use them when there is no issue! Thanks !