Achieving equity in UHC interventions: who is left behind by neglected tropical disease programmes in Cameroon?

ABSTRACT

Background: The UN’s Sustainable Development Goals (SDGs) which pledge to leave no one behind for Universal health coverage (UHC) raise the importance of ensuring equitable health outcomes and healthcare delivery. As Neglected Tropical Diseases (NTDs) affect the most disadvantaged and hard to reach populations, they are considered a litmus test for Universal health coverage.

Objective: Here, we assess the challenges of implementing Mass Drug Administrations (MDAs) for schistosomiasis prevention and control, in a context of expanded treatment where both community and school-based distribution were carried out, assessing which groups are missed and developing strategies to enhance equity.

Methods: This is a qualitative study applying ethnographic observations, in-depth interviews (109) and focus group discussions (6) with key informants and other community members. Participants included community drug distributors, teachers, health workers, and implementing partners across four schistosomiasis endemic regions in Cameroon. Data collected were analysed thematically.

Results: Programme implementation gaps have created circumstances where indigenous farmers (originally from the region) and migrating farmers (not originally from the region known as ‘strangers’ and ‘farm hands’), women of reproductive age and school-aged children are continuously missed in MDA efforts in Cameroon. Key implementation challenges that limit access to MDA within this context include inadequate sensitization campaigns that don’t sufficiently build trust with different groups; limits in CDD training around pregnancy and reproductive health; lack of alignment between distribution and community availability and the exclusion of existing formal and informal governance structures that have established trusting community relationships.

Conclusion: Through identifying key populations missed in MDAs within specific contexts, we highlight how social inclusion and equity could be increased within the Cameroonian context. A main recommendation is to strengthen trust at the community level and work with established partnerships and local governance structures that can support sustainable solutions for more equitable MDA campaigns.

KEYWORDS:

• Equity
• mass drug administration (MDA)
• missed populations
• neglected tropical diseases (NTDs)
• marginalised communities

Responsible Editor Maria Emmelin, Lund University, Sweden

Responsible Editor Maria Emmelin, Lund University, Sweden

Acknowledgments

We thank the participants from the different communities in the Barombi Mbo and Kotto health districts, Malanteoun health district, Edea health district and Yaoundé, who participated in the study. We are grateful for help from the District Health Officers from the various health districts and also from all the Yaoundé Cameroon Countdown team, who collaborated in collection and analysis of data in this study on different technical aspects. This study could not have been done without their effort and hard work.

Disclosure statement

All authors declare no competing interests.

Author contributions

MCM, and KO have written the article. ST, RT, LATT, and EK have reviewed and edited the article, providing technical/scientific expertise. MCM, MST, NTM and SN have contributed with data collection, analysis and subject expertise from the field. All co-authors beyond the two writers have extensively reviewed the article and contributed to its final content in equal parts.

Ethics and consent

Study protocol was approved by the Liverpool School of Tropical Medicine Research Ethics Committee and the Cameroon National Ethical Committee of Research for Human Health.

Paper context

Much research has taken place to understand neglected tropical disease programmes and associated implementation challenges in Cameroon, but there exists limited research that examines who is consistently left behind by these annual health interventions. In five schistosomiasis endemic communities composed of rich and diverse cultural and socio-economic backgrounds where migrant farming families, women of reproductive age and school-aged children make up a huge part of the population, we explore why they are constantly missed.

Additional information

Funding

This project was funded by COUNTDOWN project (Grant ID—PO6407) which is a multi-disciplinary research consortium dedicated to investigating cost-effective, scaled-up and sustainable solutions, necessary to control and eliminate the seven most common NTDs by 2020. COUNTDOWN was formed in 2014 and is funded by UKAID, part of the Department for International Development' with UK Foreign, Commonwealth and Development Office (FCDO) Grant number 6407.