A description and explanation of the complex landscape of faith-based organisations in Cameroon’s health sector

ABSTRACT

Over the past decade, donors have engaged faith-based organisations (FBOs) in health system reforms and health programmes in many sub-Saharan African countries, including Cameroon. Little knowledge is available concerning the types of FBOs that exist in the health sector in Cameroon. This article describes the complex landscape of Christian FBOs operating in Cameroon’s health sector and provides an explanation for that diversity. It reflects on the implications of the use of the “FBO” acronym in Cameroon and argues that the FBO typology discussion is still relevant.

KEYWORDS:

• Civil society
• Social sector – Health
• Aid – Development policies
• sub-Saharan Africa

Introduction

It is now widely accepted in international development that faith-based organisations (FBOs) are important for development, especially for the social sectors such as education and health.¹ At the 2015 Conference on Religion and Development at the World Bank, the president of the World Bank made clear that there are serious intentions to expand engagement of partnerships with religious institutions:

Faith-based organisations and religious communities are often doing the essential work on the frontlines of combatting extreme poverty, protecting the vulnerable and delivering essential services and alleviating suffering. (Joint Learning Initiative on Faith and Local Communities 2015)

Moreover, many multilateral and bilateral partners now have official strategies and definitions of FBOs and advocate for their engagement in development programmes, including health programmes. Many organisations even have positions for staff who are responsible for managing the relationships with FBOs and faith-based communities.

This seemingly unequivocal presence of FBOs in international development has not always existed. While FBOs have been actively engaged in charitable, philanthropic, humanitarian and developmental work since colonial times (Jennings 2013a), it is only since the early 2000s that bilateral and multilateral donors have increasingly allocated significant amounts of funding to FBOs. When the idea of international development and cooperation came about with the creation of Bretton Woods and the UN system after the Second World War, development was considered a strictly secular project. Religion was seen as something that would become obsolete with modernity, and the field of development treated it as taboo (Ver Beek 2002). Donors’ shift from a strict secular approach in development to advocating its importance can be explained by a number of reasons. First, space for FBOs has been growing due to the retreat of the state in the 1980s, as a result of global political and economic reforms. The rise of the religious right in the United States in the late 1980s led to the development of policies that allowed funding for religious organisations. During the Bush presidency, funding nearly doubled for Christian faith-based groups (James 2009). The fragmentation of states and their ability to provide social and health services in sub-Saharan African countries has further provided donors with no alternative than to include FBOs as recipients of funds. For example, in the Democratic Republic of Congo, a country with a fragmented state, The Global Fund has predominantly worked with non-state actors and approximately 75% of all its resources are channelled through FBOs (Benn 2017). In the context of health provision, FBOs have been seen to play an important role in health services, occupying between 30% and 40% of the market share in sub-Saharan African countries (although these numbers are contested (Olivier and Wodon 2012)) (Kagawa, Anglemyer, and Montagu 2012; Olivier et al. 2015). They have risen to prominence in the context of the HIV/AIDS epidemic in sub-Saharan Africa, where donors started to engage with these actors in the fight against the disease.

In Cameroon, donors have embraced collaboration with FBOs over the past decade. The Ministry of Health has officially acknowledged faith-based health providers and networks as partners (Boulenger and Criel 2012). It is claimed that faith-based health providers contribute approximately 40%² of health services in the national market share (Interview MoH, October 2015) (Boulenger and Criel 2012). Cameroon has a weak health system and poor maternal and child health indicators (DHS 2011). Non-state actors have been viewed as important in addressing these weaknesses. Consequently, FBOs have been the recipients of funding from multilateral and bilateral institutions, such as the French, the German bilateral cooperation, the United Nations Population Fund, the World Bank, the Global Fund to fight AIDS, TB and Malaria, and many other donors. Moreover, selected FBOs have a long-standing history with international missionary networks, such as the Baptists. Given the limited knowledge available on the state of FBOs in Cameroon, this study aims to describe the FBO landscape in the health sector and discuss the findings in light of the broadly used “FBO” acronym by the international donor community.

Terminology and discourse of faith-based organisations

There is a substantial body of literature that engages with the terminology of FBOs and its challenges. Attempts have been made to create categories for FBOs, such as Clarke’s five types of FBOs (Clarke 2008): representative; charitable or developmental; socio-political; missionary; illegal or terrorist. While these categories provide an overview of the different types of FBOs, the classifications are malleable, and a single FBO may fit more than one type. Many authors have challenged this categorisation and called for further discussion about typologies of FBOs (Jennings 2013b; Jeavons 2004; Tomalin 2012). Clarke’s matrix has been challenged for not accounting for how the context shapes the way in which faith is deployed. Clarke’s distinction between active, passive, persuasive, and exclusive deployment of faith – whereby “passive” implies that faith is not a key driver, and “active” indicates that faith plays a major role in shaping the activities of the organisation, has further been problematised. For example, Jennings highlights the difficulty of making these distinctions, as the terms may be interpreted differently within various organisations, by outsiders and in different contexts. A missionary organisation, for example, may deploy faith “actively” at times through religious teachings and “passively” at other times, while providing health care (Jennings 2013b). This differential understanding leads Jennings to conclude that differences should also be made between Clarke’s categories and whether or not they are embedded within institutional religious hierarchies or non-institutional hierarchies. This provides a more nuanced overview of the organisational structure, including its funding structure and sources (Jennings 2013b).

Tomalin points out that Clarke’s definition speaks to mainstream donors with categories in which they are familiar: for example, the fifth category of radical or illegal organisations is not a definition by which an FBO would self-identify (Tomalin 2012). As noted by Jennings (2013b) and others, establishing the extent and manner in which people deploy their faith is a very subjective exercise. The usefulness of the concept of FBOs is further questioned in the context of countries where secularism is neither evident nor practiced (Tomalin 2012; Schmid et al. 2008). Moreover, there are examples of FBOs that have adapted to the international development discourse by avoiding faith expression, in order to qualify for funding. According to Tomalin (2012):

The perceived bias towards organisations that do not explicitly articulate their faith identity and a model of religion that neatly separates the religious from the secular suggests that donors are attempting to manage and contain religion in ways that do not correspond with the way it manifests in many developing contexts.

Some health system literature describes FBOs as faith-based health providers belonging to the private providers or private non-profit providers that are part of the health system, paying little to faith attributes (Mackintosh et al. 2016). However, there is some acknowledgement of, but limited details on, the fact that FBOs can be involved in various health services, including in the pharmaceutical market, health professions education and health care provision (Mackintosh et al. 2016). There is also substantial literature that deals with the problematic terminology of FBOs in the health sector (Schmid et al. 2008; Olivier 2011; 2016). Olivier presents the broad range of actors in the health sector and identifies faith-forming entities such as churches; religious NGOs; community-based religious entities; networks (such as Christian Health Association); and health facilities (Olivier 2011). Olivier highlights that there are hidden religious entities involved in health that do not make it onto the religious map. There is also resistance from some entities to describe themselves as religious as this may influence whether they get funded (Olivier 2011).

With donors’ marked interest in FBOs, many have created working definitions and strategies to work with FBOs. Donor agencies use broad categories, while acknowledging diversity within these. For instance, the World Bank (2014) states that:

Faith-based organisations are often structured around development and/or relief delivery programmes and are sometimes run simultaneously at the national, regional and international levels. Moreover, faith-based and religious entities contribute distinctive assets, resources, and capabilities in combatting poverty and boosting shared prosperity.

Similarly, the UNFPA definition states, “Faith-Based Organisations (FBOs) are religious, faith-based or faith-inspired which operate as registered or unregistered non-profit institutions” (2014). While diversity is acknowledged, the working definition includes service providers and community faith leaders, although these are arguably very different categories. Moreover, while there is a differentiation between Muslim and Christian groups (Balchin 2011), there is little discussion of different Christian denominations, which (as this research shows) is relevant to improve our understanding of these actors.

Although the problem regarding the diversity of what the FBO acronym constitutes is consistently made, the use of the FBO acronym, albeit some inconsistencies, is commonplace among bilateral and multilateral organisations (DFID, BMZ/GIZ, SIDA, UNFPA, World Bank, UNAIDS). This suggests that in development practice the FBO acronym has become a buzzword embedded in development language, and as Cornwell argues thus runs the risk of no longer be closely examined (Cornwall and Eade 2010). This study builds on literature that has cautioned for the use of the FBO buzzword and described FBOs in the health sector (Schmid et al. 2008; Olivier 2011; Haugen 2019) and it responds to a recent call for more case examples describing what FBOs constitute (Haugen 2019). Although concerns about the simplification of the reality of FBOs through the use of the FBO buzzword were raised almost a decade ago, we argue that given the continued use of the acronym in development practice, there is a need for specific examples that challenge the continued use of the acronym and accentuate the role that donors play within that.

Methods

This research followed a qualitative case study design, and aims to understand the FBO landscape in the health sector in Cameroon and review this in light of the broadly used “FBO” acronym. Data sources include documents and policy papers, 32 in-depth interviews and three focus group discussions (FGDs). There were eight interviews with Ministry of Health officials, 12 with donors and 12 with FBOs. The three FGDs were conducted with FBOs. Purposive sampling was applied and participants recruited through snowball sampling. Recruitment was ceased when saturation was reached. Data were collected during 2015–2017. The first author conducted the interviews and FGDs lasting for about 60 min on average. Information about the study was provided, written consent obtained, and confidentiality and anonymity were guaranteed. Interviews were audio-recorded, transcribed, anonymised and analysed following thematic analysis with the assistance of NVivo10. The thematic guides included a description of activities, partnerships and identities of/with FBOs, including faith identities.

We acknowledge the limitations of assessing the relevance of faith and religion in a religious context such as Cameroon. Thus, in our data collection procedures a distinction was made between religion, understood as “values, rules and social practices” and faith, understood as being “less rule-bound and ritualized … ” (Clarke and Jennings 2008). The data presented in the results section refers to all categories and themes that were created as a result of the qualitative thematic analysis. The study received ethical approval from the Cameroonian research in health ethics committee (Nr. 2015/08/638/CE/CNERSH/SP). The data were collected in Yaoundé, the North West and the South West regions. However, the donors interviewed fund FBOs in several other regions in the country. The authors are well aware of other religious beliefs in Cameroon, especially Islam. We wanted to include the Islamic health sector but were limited due to restricted access to that part of Cameroon for security reasons.

Results

Complex landscape of faith-based organisations in the health sector in Cameroon

This research shows that FBOs operating in the health sector are very diverse. The study identifies six different types of Christian FBOs operating in the Cameroonian health sector: international faith NGOs, faith-based networks, faith-based health providers, faith-based Centres of Excellence, faith-based health professions schools, and religious leaders and informal church networks that promote health and healing in their communities (Table 1). Table 1 includes a brief overview of the features of the organisations within those sub-categories to illustrate the differences and provides some examples. The first category, international faith NGOs, refers to faith-based organisations that conduct temporary health-related programmes. These programmes may take place at faith-based hospitals or at hospitals or in communities independent from the faith-based health sector (although the Ministry of Health would normally have to be informed about such activities). The Ministry of Health and donors do not view these organisations as part of the health system but rather as part of the international donor community (Interview MoH 5, 2016).

Table 1. Types of Christian faith-based organisations (FBOs) in the Cameroonian (CMR) health sector.

Type	International faith-NGOs	Faith-based networks	Faith-based health care providers	Faith-based “centres of excellence”	Faith-based health professionals schools	Informal faith-based church groups
Description	Temporary programmes, they are not part of the health system but may fund a project in a faith-based health provider	Networks that represent their members (faith-based health providers) at national policy level	Hospitals at district levels or health centre level. Hospitals of various Christian denominations. They have varying degrees of functionality: often dependent on funding.	Provide specialist services that function as district hospitals. Recognised by the Ministry of Health as Centres of Excellence.	Provide best training in CMR. Provide unaccredited in-house training programmes. Various Christian denominations.	Provide support to individuals and the community through church networks. These are not registered or officially linked to the Ministry of Health.
Example	Catholic Relief World Vision	Catholic (OCASC) Protestant (CEPCA) FALC	Baptist health centre Mbingo Baptiste Hospital Presbyterian hospital	St. Elisabeth Catholic Hospital Mbingo Baptiste Hospital	Catholic University St. Elisabeth Catholic Hospital Mbingo Baptiste Hospital	Pentecostal churches that promote health and healing through spiritual enlightenment. Religious leaders

The second category constitutes faith-based networks, and this study identified three very different types of networks. Each has unique organisational structures and different faith denominations. The Fondation ad Lucem (FALC), for example, is a small network that represents 39 hospitals with a Catholic denomination. It is governed by a board of directors independent from the Catholic Diocese in Cameroon. The Organisation Catholique de la Santé du Cameroun (Catholic Health Association of Cameroon (OCASC)) represents 266 hospitals and eight health profession training schools. It is a relatively well-functioning network that has regular contact with its health providers in the periphery. It is governed through the Catholic Diocese in Cameroon. The Conseil des Églises Protestantes du Cameroun (Protestant Health Association of Cameroon (CEPCA)) represents ten denominations (Table 2) that in themselves form small networks at a regional level. Some of these smaller networks, such as the Baptist network, are strong and independent networks; however, they are not well linked with CEPCA or other networks. The CEPCA receives limited funding and rarely interacts with hospitals and health professions schools in the periphery (Interviews FBOs 21, 23, 2015). The FALC and OCASC networks have some, but limited, contact with each other. OCASC and CEPCA technically represent a number of faith-based providers that also have health profession training schools but do not sufficiently represent these at the policy table in practice (Interviews FBOs 21, 26, 29, FGD 1-3, 2015).

Table 2. List of faith-based organisations and networks that are part of the national protestant network CEPCA.

Église Fraternité Luthérien Cameroun

Union Église Baptiste du Cameroun

Église Évangélique Lutherie du Cameroun

Cameroon Baptist Convention (CBCH)

Union des Églises Évangélique du Cameroun

Presbyterian Church Buéa

Église Évangélique Cameroun (EEC)

Adventiste

Église Presbytérien Cameroun (EPC)

Mission Chrétienne

The third category, faith-based health providers, constitutes a very diverse group. This is reflected in the various locations (urban, rural, throughout the country), their place in the health system (some are integrated into the health system through official contracts, others are not), their level of provision (either district or health-centre level), their varying degree of functionality (due to low patient numbers and limited funding), and their different Christian denominations. The fourth category, faith-based Centres of Excellence, provide specialist health care services. “Centre of Excellence” status is not an official recognition but rather a narrative that is consistently used to describe them (Interviews MoH 1, 2, 3 donors 9, 2015). Each one has a different area of expertise. For example, the Presbyterian Hospital in Bafoussam has a long history of providing some of the best ophthalmic care in the country; it is arguably the leading eye-care institution in Cameroon and the Central African sub-region. Batouri Catholic Hospital is one of the largest referral hospitals in the Eastern Province in Cameroon and serves large populations from both Cameroon and the Central African Republic; the hospital is renowned for a well-functioning community programme that supports victims of gender-based violence. The Protestant Hospital of Ngaundere, also referred to as the “Norwegian Hospital”, is one of the most important referral hospitals in the three northern regions in Cameroon. It is well known for its expertise in obstetric surgery and fistula repairs. These two hospitals receive continuous support from UNFPA. St. Francis Catholic Hospital is renowned for its cardiac centre; it is the national and regional referral centre for cardiovascular surgery in Cameroon and the entire Central African region. Similarly, Mbingo Baptist Hospital is a referral hospital in both Cameroon and the West and Central African Region. The Baptist network regularly turns down funding opportunities because they receive so much funding and cannot absorb it all; for example, they turned down participation in the Global Fund even though they were explicitly invited (Interviews FBOs 32, 21, 27 and donors 20, 2015).

The fifth category is the health profession training programmes. These are often linked to the faith-based Centres of Excellence. In some cases, they stand alone as a Catholic or Protestant university. They provide the best quality of training in the country, according to the Ministry of Health and donors, and at the same time offer unaccredited in-house training programmes that are completely unregulated (Interviews MoH 1, donors 17–19, 2015).

In theory, faith-based providers and health profession schools are represented by their respective networks. However, in practice, faith-based providers and schools are often poorly linked to the faith-based networks at the policy level (Interviews FBOs 21, 25, 32; FGD 1–3, 2015).

The sixth category includes informal churches and networks and religious leaders. In the North West and South West regions, the Pentecostal groups are one example of such an organisation. While these are also FBOs operating in the health sector they are not formally linked to the health system. Many of these groups are illegal due to concerns over their genuineness (MoH Interview 5, 2015; MoH Interview 4 2017).

Religion and faith as a common denominator?

Thus far, the organisations lumped under the “FBO” umbrella which donors usually refer to have little in common. This leads to the question of to what extent religion and faith are a common denominator. The importance and relevance of religion as a factor for the engagement of FBOs has been perceived differently by the donors who engage FBOs. Similarly, FBOs themselves appear to portray a rather flexible relationship with both religion and faith. Some donors engage FBOs because they required an alternative to the state. For example, faith-based providers at district level were engaged by donors because they were perceived as being part of the health system and there was no alternative to the state (Interview donors 8, 9, 2015). The faith aspect was not an important factor when they were engaged. Conversely, faith is a very important factor that motivates some donor engagement in the context of engagement of faith-based Centres of Excellence (Interview donors 20, 2015). Donors and international missionary networks engage them because it is argued that their faith attributes set them apart from the rest of the health system. However, some donors feel that they make easier collaborators because they are well-established hospitals and health profession schools with a long history, rather than because of their faith attribute (Interview donor 10, 2015).

FBOs themselves had varying degrees of flexibility as to the importance of the faith attributes in their organisations. All FBOs showed some degree of flexibility when faith was discussed in the interviews. For example, the Fondation Ad Lucem (FALC) provides an interesting case study in that they were initially a Catholic missionary organisation, then turned into a private provider, and with the advent of the French debt relief programme they defined themselves as a faith-based network. They also refer to themselves as the “hidden Catholics” (Interview FBO 22, 2015). In other words, during the process of becoming part of the FBO group in receipt of the French debt relief funding, FALC changed its faith narrative to qualify for the funding.

The Catholic health providers at the regional level mentioned that “faith is not as strict as it used to be” (Interview FBO 28, 2017); for example, staff working for Catholic providers no longer have to be Catholic simply because there are not enough health workers available for hire. In fact, many of their staff are not practicing Catholics. The flexibility with the importance of faith was also observed when a former employee of a Catholic provider had to sign a waiver that he would not counsel patients in areas that do not meet the rules of the Catholic doctrine, but in practice ended up doing what was best for the patient anyway (Interview FBO 24, 2016). There were no consequences to him breaking the rules because the clinic depended on his services (Interview FBO 24, 2016). Moreover, some Catholic health professions schools are in the process of exploring whether they could send their midwifery students to public or Baptist hospitals so that they learn modern family planning methods (FGD FBO 2, 2015).

Moreover, one network explained that they have adapted the way in which they talk about faith to donors, so that they could apply for certain funding. For example:

We [FBO] have had to learn how to present these [family planning] projects to church leaders. It is all a question of how it is presented. We cannot talk about family planning directly, instead we have learnt to talk about the health of mothers and babies. I was surprised by how many church leaders engaged in that project, it worked really well. (Interview FBO 23, 2015)

In a similar vein, one of the FBOs runs a large-scale women’s health programme that engages with family planning programmes and a cervical screening and vaccination programme funded by universities in the U.S. and a pharma company. Human papilloma virus (HPV) vaccines for young girls has led to controversies in many countries worldwide because girls are vaccinated at an early age and before their first experience of sexual intercourse (Tomkins et al. 2015). Those opposing the vaccine disagree with its early introduction because it allegedly promotes sex before marriage. However, this opposition does not seem to be an issue in this context. The very same institution runs the Surgical Christian Fellowship funded by Pan-African Academy of Christian Surgeons. One of the core features of the training is Christian teachings and Bible study, and the programme is only accessible to surgical candidates of the Christian faith (FGD FBOs, 2015). In other words, in the same institution we find faith fluidity.

Discussion

Explaining the diverse FBO landscape

This study identifies three important influencing factors that explain the diversity of FBOs in the health sector in Cameroon. First, historical factors play an important role in shaping FBOs, as has been previously discussed in the context of Tanzania (Jennings 2013a). FBOs are important in Cameroon because they have a long history of providing care; many have had a presence since prior to independence, and because many have acted as district and regional hospitals, they have arguably built the foundation of the Cameroonian health system. Moreover, the long-standing relationships between some FBOs and the international, usually faith-based community are an important factor that explains why some FBOs have developed into faith-based Centres of Excellence and others have not. Mbingo Baptist Hospital, for example, has had strong links with the Baptist Church in the United States since the 1960s and has been able to sustain that funding since then. Similarly, St. Elisabeth Hospital and Cardiac Centre in Shisong, which has had strong ties with the Catholic St. Francis network in Italy since the 1930s, managed to flourish into one of the most respected hospitals in the region. The continuity of funding for these institutions, despite economic crises, has allowed them to grow and subsequently attract funding from other international donors. Some of these Centres of Excellence have various partners, ranging from pharmaceutical company Roche to Christian health training programmes, and regular donations from international faith-based donors such as Samaritanpurse. Some of these faith-based Centres of Excellence have benefitted from long-standing funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Elisabeth Glaser Paediatric AIDS Foundation’s (EGPAF) large-scale HIV/AIDS Prevention of Mother to Child Transmission programme. Some FBOs have even had to turn down funding opportunities due to an inability to absorb those funds. However, not all faith-based providers have enjoyed such development and are part of a well-funded network. If strong historical ties and continued funding from international donors were not maintained, they experienced much hardship, and many Cameroonian FBOs had to close their doors. Several FBOs interviewed in this study continue to struggle under financial and human resource pressures.

The second influencing factor can be attributed to changes in the national health system due to health system reforms, which is well described in the literature (Hearn 2002; Green et al. 2002). The most important reform is the move from the primary health care model to market-driven health reform, largely as a result of the rise of neo-liberal policies and subsequent structural adjustment programmes (Green et al. 2002). Reduction in spending for health led to reductions or complete withdrawals of subsidies from the state for FBOs. Many FBOs which lost their funding could sustain themselves only through user fees and increasing these over the years. However, market-driven reforms also opened up opportunities for some FBOs. For example, some FBOs became key recipients of global health funding because of these changes in the health system. In Cameroon, three faith-based networks were made direct beneficiaries by the French Cooperation, illustrating the move away from government-funded health programmes to investment in the faith-based sector (Boulenger and Criel 2012).

The third influencing factor – inevitably linked to the preceding two – that determines FBOs identities and activities is linked to questions of power in international development policy and practice. The trend of the “good governance” era, which emphasises the important space for non-state actors, irrespective of being faith-based, as well as the global trend to fund religious organisations following the election of George W. Bush and the events of 9/11, were important factors that influenced FBOs’ ability to qualify for funding and get a seat at the policy table. In 2012 a national partnership strategy was launched in Cameroon, supported by various multilateral and international donors, which gave FBOs in Cameroon a seat at the policy table (Ministry of Health 2012). This created an opportunity for funding and gave rise to the politics of naming. Olivier (2011) has previously described this:

The development and public health sectors are each driven by their own powerful institutions and power plays a key role in deciding who gets named and supported. In mapping, the power of naming fixes on whose map REs [religious entities] are placed, while REs in turn must decide if it is to their benefit (or detriment) to be mapped.

The politics of naming was observed in this study where FBOs describe their religious and faith fluidity. For example, some FBOs define themselves as networks or Centres of Excellence to qualify for funding by large donors. In this case study being named was to FBOs’ benefit rather than their detriment.

The heterogeneity of examples of FBOs presented in this article as well as the faith fluidity arguably points to the inadequacies of the way in which donors may be thinking about religion and faith. This builds on research that has expressed this concern (Olivier 2011; Haugen 2019; Haustein and Tomalin 2017). The binary separation between faith-based and secular organisations and separation of faith from other aspects of life, particularly in settings where the majority of the population is religious is one of these concerns (Olivier 2011). Jones and Petersen (2011) highlight the problem, the instrumental nature of the study of religion and development, in other words that FBOs are created for development. In the Cameroonian context, this critique is appropriate since religion in Cameroon is very important and a separation of religious and secular is an artificial divide. Yet, what are the practical implications of this for development practice and FBOs?

Implications of the continued use of FBO acronym for Cameroon

Substantial concerns have been raised over the continued use of the FBO acronym, and the negative implications in continuing to do so. Over a decade ago the African Religious Health Association Programme cautioned “that naming has the potential to destroy, or at least divert a local initiative, perhaps even the spontaneous caring characteristic of so many Res [religious entities]” (ARHAP CTARHAP 2006). Moreover, Olivier (2016) highlights that the advocacy for FBOs may have actually confined religion to a specific space in development thinking and practice. In a similar vein, Haugen (2019) argues that the use of the acronym essentialises FBOs, religion and culture. Thus, the complexity of religion and the practices and partnerships of FBOs with non-religious actors are poorly understood if we simplify their activities and identities. This research adds to that through illustrating the very diverse FBO landscape in only one sector and one religious denomination.

There are practical consequences for the continued use of the “FBO” acronym in Cameroon. Donors make broad generalisations about these actors and their abilities and have poor understanding of their activities and identities. For example, it is assumed that all FBOs have a very high standard of care and practice because some (e.g. the Centres of Excellence) have a particularly good reputation. With that assumption, donors may invest in FBOs although some might not have the capacity to absorb funding, thus creating opportunities for poor governance. Moreover, just because there are successful experiences with a few FBOs it does not mean that some of the faith controversies, such as family planning, are no longer relevant (Tomkins et al. 2015). If the relationship between FBOs and the state is poorly understood or assumptions are made about ways in which FBOs function and collaborate, it may deepen challenges that already exist, as has been described in the literature (Boulenger and Criel 2012). Finally, the positive narrative of FBOs and assumptions about them may lead donors to invest funding in FBOs at the expense of more suitable recipients that could be found in the public sector. In other words, the advocacy work for FBOs has implications for the implementation of programmes if because of the simplification we fail to engage with the reality in practice.

Conclusion

Olivier (2016) states regarding FBOs “there is likely not much can be done to this framing now”, nevertheless, we believe that the discussion over typology and its problems should continue. Case study examples such as the one presented here can help stimulate these concerns and provide an evidence base to challenge donors when these do not sufficiently engage with the complexity in practice. This study aimed to contribute to limited knowledge about FBOs in Cameroon. It described the complex landscape of Christian FBOs operating in the health sector in Cameroon, with six types of FBOs operate in the health sector in Cameroon identified: international faith-NGOs, faith-based service providers, faith-based networks that supposedly coordinate health providers’ activities, faith-based Centres of Excellence that provide specialist services, faith-based health professions training institutions, and informal faith-based church groups.

However, within these categories is much diversity, in terms of the faith narrative, their organisational structure and financial capacities. Furthermore, these actors do not necessarily operate as a coherent group; even within the Christian denomination some of the smaller networks have very limited contact with one another. The three influencing factors – history, health reforms, and the politics of development policy and practice – have each affected individual FBOs in different ways. The common denominator of these three factors is the fact that they are all largely influenced by international actors such as missionary networks or donors. It is arguably the historical relationships between FBOs and their missionary networks, and the process of donor relationships and engagements, that have played a major role in shaping these actors. This paper does not propose a model for a new typology of FBOs. Instead, it contributes to concerns that have been previously raised about the problems with the typology with a case study from a setting that has received little attention in the literature. We do not merely suggest that the FBO buzzword should not be used, and it has arguably served a purpose for advocacy. Rather, we call for further discussion and evidence on the implications of the continued use of the FBO buzzword in practice.

Acknowledgements

We would like to thank the participants of the study. Thank you also to the anonymous reviewers for supporting and significantly improving the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Sibylle Herzig van Wees

Sibylle Herzig van Wees holds a PhD in Development Studies from the School of Oriental and African Studies (SOAS), University of London, and a Masters of Public Health in Developing Countries from the London School of Hygiene and Tropical Medicine. She has worked for the German International Cooperation (Deutsche Gesellschaft fuer Internationale Zusammenarbeit (GIZ)) in Cameroon for several years. Sibylle has also worked as a global health educator at King’s College London and is currently a Global Health Lecturer at Uppsala University in Sweden.

Emmanuel Betsi

Emmanuel Betsi is a Cameroonian sociologist and independent consultant in public health and applied health sciences. He has taught at the nursing schools in Sa’a and at l’ENISFAY in Yaoundé, and has several years experience of implementing, supervising and evaluating various public health programmes for the Ministry of Health, the United Nations, and international and national NGOs. He is currently coordinating a large-scale voucher project titled CHEQUE SANTE in the Adamaoua region, which aims at reducing maternal and infant mortality.

Maturin Désiré Sop Sop

Maturin Desire Sop Sop is a Senior Lecturer in Geography and Head of Service of Research and Cooperation at the University of Bamenda. His research focuses on health geography, epidemiology and public health. He has served as a consultant with World Health Organisation and the German International Cooperation (Deutsche Gesellschaft fuer Internationale Zusammenarbeit (GIZ)) and produced geographical health information maps.

Notes

1 In this article we use the acronym FBO to mirror the language used in much of the literature. We fully appreciate the limitations of this acronym and acknowledge the use of other acronyms such as religious entities.

2 Although this number is commonly used, we found no information on its original source during the data collection.