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TMIH547 Tropical Medicine and International Health volume 5 no 4 pp 288–292 april 2000

Coping strategies of health personnel during economic crisis: A case study from Cameroon Syed Muhammad Israr1, Oliver Razum2,Victor Ndiforchu3 and Patrick Martiny4 1 2 3 4

Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan Department of Tropical Hygiene and Public Health, University of Heidelberg, Germany Ministry of Health, Yaounde, Cameroon German Agency for Technical Co-operation (GTZ), Cameroon

Summary

OBJECTIVES Severe economic crisis compelled many governments in Sub-Saharan Africa to adopt structural adjustment programmes. This was accompanied by price increases and cuts in the salaries of civil servants. We explored how health personnel in one province of Cameroon coped with this situation, and what the perceived effects on service quality were. METHODS Key informant and focus group interviews with government and mission (church) health personnel; interviews with service users to validate the findings. RESULTS Government health personnel had experienced larger cuts in salaries than their mission counterparts; they no longer received allowances and incentives still available to mission personnel and appeared more demotivated. Most government and mission personnel reported legal after-hours income raising activities. Government personnel frequently reported additional ‘survival strategies’ such as parallel selling of drugs, requesting extra charges for services, and running private practices during work hours. There was a high level of self criticism among government personnel indicating a dissonance between their attitude and practices. They considered these practices negative and harmful for service users. CONCLUSION Remedial action is urgent. Options include reinstating allowances for good performance and ensuring regular supervision without blaming individual health workers for problems caused by the state of the health system.

keyword structural adjustment programme, sub-Saharan Africa, health services, Cameroon correspondence Dr Oliver Razum, Abteilung für Tropenhygiene, Universität Heidelberg, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany. E-mail: [email protected]

Introduction Severe economic crisis has hit developing countries in the past two decades, particularly sub-Saharan Africa (World Bank 1984; Abel-Smith 1986; Chen 1987). Guided by the International Monetary Fund (IMF) and the World Bank, governments adopted structural adjustment programmes (SAP). In many cases, this was associated with the devaluation of currencies, steep rises in inflation rates, and cuts in the salaries of civil servants. While gross domestic products (GDP) and productivity decreased, dependence on foreign aid, brain drain and corruption increased (Inoussa et al. 1995). This has repercussions on public servants and the services under their responsibility, especially in the health sector (Coll 1990). After salaries decreased in Zambia in 1983, many government 288

health workers migrated to the private sector or to other countries (Freund 1986). In Uganda, after massive wage decreases and price rises (Hansen & Twaddle 1991), health workers supplemented their salaries by working in private clinics and drug shops, thus spending less time on their government job (Chew 1990; Van der Heijden & Jitta 1993). Similar coping strategies have been reported from Nigeria, Ghana and other African countries (Unicef 1990). Cameroon was a comparatively wealthy exporter of coffee and oil until the mid-1980s (Anonymous 1998). When prices of exports started to decrease, terms of trade in Cameroon worsened and the GDP fell. In the past 15 years, the country and many of its neighbours in the Franc CFA zone experienced economic decline of a magnitude described as being comparable only to that of the former Soviet Union (Buchan

© 2000 Blackwell Science Ltd

Tropical Medicine and International Health S. M. Israr et al.

volume 5 no 4 pp 288–292 april 2000

Coping strategies of health personnel during economic crisis

& Crawford 1994). Government spending on the public sector and the salaries of civil servants could no longer be afforded. An SAP was initiated in Cameroon (World Bank 1994) and salaries were cut; and a 50% devaluation of the Franc CFA was imposed by the IMF and the French government in 1994 (Buchan & Crawford 1994). As a result, the value of government salaries in Cameroon fell by 70% (Anonymous 1998). Levels of corruption have reportedly increased by 70% since 1985 (Anonymous 1999). We investigated how health workers were affected by the sudden and severe economic crisis in Cameroon; in particular, what strategies they had developed to cope with price increases and salary cuts, and how they themselves perceived the effects of their coping strategies on the provision of health services.

instrument with the expectation that they would give interview participants an opportunity to talk freely, raise motives that the researchers may not have expected, and, through the group process, keep a check on exaggerated contributions. Respondents, particularly those in government service, were eager to communicate and discuss their problems. In the qualitative data analysis, motives that were brought up in more than one group discussion or were confirmed in other interviews were identified and grouped. Rare and unconfirmed accusations were left out; they were considered as reflecting exceptional behaviour of individuals rather than being representative of the health personnel in the study area. All health personnel interviewed had given consent. Complete anonymity of the informants is ensured by reporting aggregated findings and by not providing the names of the health districts and the year of the study. As only about half of the health facilities in the study area were included and staff turnover has been high since the study took place, it is impossible to identify individual respondents or link statements to them.

Methods The study was conducted in one province of Cameroon. Data on trends in salaries and prices were retrieved from official government statistics and from a mission hospital in the study area. Twelve focus group discussions were held with doctors, nurses, pharmacists, and laboratory technicians, both in government and mission (denominational) health facilities. The aims were to elicit what coping strategies these health cadres had observed among colleagues and what strategies they had adopted themselves; and to find out how they perceived the effect of their coping strategies on the performance of health services. Seventy-eight users of government and mission health facilities were asked about the health workers’ performance in individual semistructured interviews with the aim of validating health workers’ reports on effects of their coping behaviour on service performance. The perspective of the service managers was elicited in 12 key informant interviews with the Chiefs of Bureau of major health programmes in all districts of the province and with field supervisors of the Essential Drug Programme. The latter still provides a ‘good performance allowance’ which is conditional on work performance. Focus group discussions were chosen as the main research

Table 1 Cuts in salaries* among government health personnel

Results Trends in salaries and prices, and the health workers’ perception thereof Salaries were cut in January 1993 for government and mission health personnel and again in November 1993 for government personnel (Tables 1 and 2). The relative decreases were far larger for government personnel but their salaries (except of doctors) had been higher before the cuts. In January 1994, within months of the salary cuts, the Franc CFA was devaluated by 50%. The effect on the price index is shown in Table 3. Food prices increased by more than 50% in the first quarter of 1994 alone. Government health personnel described their economic condition after the salary cuts and the price increases as ‘disastrous’, ‘deplorable’, ‘frustrating’ and ‘very painful’. They complained that payment of allowances had also been discontinued and advancements halted. They found it very difficult to meet even basic expenditures for food, transport,

Categories of health personnel

1992 (before cut)

January 1993 (after first cut)

November 1993 (after second cut)

Decrease relative to 1992 level

Doctors Senior nurse Lab technician Pharmacist

234 123 123 141

204 110 110 113

101 062 062 063

2 57% 2 50% 2 50% 2 55%

*In thousands CFA francs. Source: Ministry of Health, Yaounde, Cameroon.


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Table 2 Cuts in salaries* among mission health personnel Categories of health personnel

1992 (before cut)

January 1993 (after cut)

Decrease relative to 1992 level

Doctors Senior nurse Lab technician Pharmacist

304 116 114 066

259 107 106 063

– 15% – 08% – 07% – 05%

‘We, at least, do not need to borrow from others’. Yet they also worried about the future:

Table 3 Price index in Cameroon 1993–95, selected months* Dec 93

Mar 94

Mar 95

Dec 95

100 100 100

152 130 139

167 134 139

160 142 143

*Source: Ministry of Economy and Finance, Yaounde, Cameroon.

medical treatment and electricity. ‘Most of the salary goes to house rent, school fees and other basic utilities. The small amount that is left I give to my wife. God knows how she manages …’. Comparing their economic status to that before the crisis they said ‘We cannot spend the money as we used to, now we think thrice before spending a single franc’. In addition to their present problems they worry about the future: ‘Present salaries provide no guarantee for future security and protection, since there is no saving at all’. A prevailing feeling is that of being treated unfairly. The SAP is perceived as having a particularly hard effect on health staff compared to other government personnel. ‘Most of the health personnel does not deserve such an embarrassing reward for their efforts, considering their qualifications, skills, quality and quantity of work’. Many government health workers perceive that their economic situation negatively affects their motivation: ‘Low salaries do not allow one to practice medicine ethically, our morale is down, and this encourages malpractice’. 290

‘fair and still better off than the government health personnel’. They conceded that

*In thousands CFA francs. Unpublished data from a mission hospital in the study area.

Food Transport Schooling

The majority of mission health personnel described their salaries as

‘We have hand-to-mouth salaries and cannot save for the future’. Overall, they appeared less frustrated and demoralized than their government counterparts.

Reported survival strategies of health personnel Measures to reduce consumption Both government and mission personnel said that they reduced consumption to cope with the economic situation they were facing. Strategies frequently mentioned were skipping meals, eating low quality food, selling household items, reducing social activities such as holiday visits and travelling, withdrawing their children from school, and using second-hand clothes. Government personnel in particular remarked that ‘we are living on borrows and credits’. A trend to go back to rural areas where cost of living is perceived to be cheaper was also reported. Income-raising activities, unrelated to profession The most common survival strategy, reported by almost all respondents, was growing food such as yam, corn, plantains, oranges, and green vegetables around their dwellings. Many were also involved in ‘petty trading’, i.e. the sale of daily utility items during or after working hours. Income-raising activities, related to profession Nurses and doctors in government service reported that some of their colleagues would discourage patients from buying medicine and other supplies at the hospital pharmacy supplied by the Essential Drug Programme. Instead, they would sell drugs directly to the patients. Sometimes, these would be cheap and low quality drugs obtained from unreliable sources. Operation theatre staff would pretend a shortage and sell surgical gloves, syringes, drips, etc. to the patients. ‘Under the table’ charges for the provision of routine services were also reported. All government medical cadres had heard of colleagues who ran a private practice. Consultations would take place either at the patient’s residence or at private clinics held after or during official working hours. Service users largely © 2000 Blackwell Science Ltd

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Coping strategies of health personnel during economic crisis

confirmed these findings. Mission health personnel did not mention any of these survival strategies related to their profession. Escapist strategies Government health personnel reported high attrition rates. They said that some of their colleagues had left government service to seek work in a neighbouring country or had chosen premature voluntary retirement and a compensation payment. Again, mission health personnel did not mention these strategies. Perceived effects of survival strategies on service quality and service utilisers

nel for staying in their present job is the absence of any reasonable alternative. Other reasons include: retirement benefits, relaxed working atmosphere, job security, per diem for out-stationed activities and the absence of a strict monitoring and supervisory system. Staff of the Essential Drug Programme are eligible for a ‘good performance allowance’. They considered this extra monetary incentive as an important motivating factor. Mission health personnel saw it as their religious obligation to work in a church hospital. In addition, they mentioned various incentives as reasons for holding on to the present job, including loans facilities, almost free medical services for dependants, housing facilities, job security, regular salaries and a good working environment.

Effects on service quality

Discussion

Government health personnel conceded that many of their income-raising activities resulted in lateness, reduced working hours and absenteeism.

There is, with all probability, not a single health service which does not nurture a small number of health workers who abuse their position to gain economic advantages. This case study from Cameroon, however, shows a different problem: a high level of demotivation among all cadres of government health personnel and a widespread adoption of coping strategies which negatively affect service performance. Mission personnel appeared to be less frustrated and less involved in income-raising activities during working hours. Government health personnel may have exaggerated their situation to gain sympathy while mission personnel may have been selective in their responses to guard their and their institution’s reputation. Yet superiors and service users largely confirmed the coping behaviour reported by health personnel, and similar findings have been reported from other African countries (Chew 1990; UNICEF 1990; Van der Heijden & Jitta 1993). In a cross-sectional study like this, a causal relationship cannot be established, but the temporal association of massive salary cuts, price increases, elimination of incentives and reported adoption of coping strategies by health workers is obvious. Changes over time in the level of general corruption in Cameroon support this interpretation (Anonymous 1999). The findings of this study thus illustrate how the implementation of a national economic structural adjustment programme can have negative repercussions on the performance of health personnel. This is particularly worrying because an SAP frequently involves the introduction of service fees. Service users rightly expect improved rather than worse quality and availability of services when fees are introduced. Furthermore, informal charges and the diversion of patients from government to private clinics have, in effect, turned the government health services into private services in disguise. This reduces financial accessibility of health services and thus equity. Mission health personnel appeared to have maintained higher levels of motivation and professional standards (their actual level of technical performance was not assessed, how-

‘Income raising activities affect the duty hours seriously. If one is not satisfied economically, one is bound to steal some of the official duty hours to go and harvest’. Respondents justified their income raising activities: ‘We also have children, and it is our duty to take care of them as well’. Most respondents, however, readily admitted that timeconsuming activities like private practice had a negative effect on service quality and thus on their patients. When on the job, many government health workers said they felt demotivated and frustrated. As a consequence, they often perceived themselves as aggressive and less attentive to patients. Effects on service users Various survival strategies reported by the government health personnel such as informal – charges, extra charges for services and interventions without clear indication, involved considerable costs to the patients. Government health personnel realized that health care in the public sector had thus become expensive and a de facto private service. Users of the government health services agreed; they mentioned geographical accessibility as the primary reason for their choice of health care provider. Users of mission health services frequently mentioned the good quality of services as the main reason for their choice. Little additional information was gained from the interviews with users; they largely confirmed what the health personnel had reported. Reasons for staying on the present job, despite low salaries The most common reason given by government health person-


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ever). Again it is not possible to establish a causal association but the key informants assumed that the continuing provision of incentives and the existence of a monitoring and supervisory system contributed. The similarly positive attitude among the staff of the Essential Drug Programme within the government system supports this interpretation. These cadres also receive a good performance allowance along with strict supervision. At the time of the study, government health personnel still showed a high level of self-criticism in regard to their coping behaviour, indicating a dissonance between their attitude and practices. They had not yet become indifferent or cynical, still maintained a positive view of their patients and their duties, and considered the coping strategies as negative and potentially harmful to service users and quality of care. Remedial action should be taken urgently while health personnel still have this positive attitude towards their patients and work. Options might include reinstating allowances for good performance and ensuring regular supervision without blaming individual health workers for problems caused by the state of the health system (Berwick 1989). Health workers in many other countries are facing, or going to face, comparable economic changes. The findings of this study imply that measures to maintain motivation and dedication of health personnel need to be taken at the time when an SAP is planned. Once health personnel has adopted coping strategies, major remedial efforts will be required to amend the damage done to the health services. This aspect of SAP has not been given enough attention despite its impact on the health of the population.

Acknowledgements The study was conducted while Dr Israr was enrolled in the MSc course ‘Community Health and Health Management’ at Heidelberg University, Germany, on a scholarship from the German Academic Exchange Service (DAAD). Thanks to GTZ which made the study possible.

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