Perceptions of Contributions by International & Non-Governmental Organizations (IOs and NGOs) in the Health Care System of Buea & Limbe Municipalities, Cameroon

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Introduction
Health can be defined as a state of complete physical, mental and social well-being and not merely the absence of diseases or infirmity (WHO, 1948). In 1986, the WHO further clarified that health is a resource for everyday life. Health is a positive concept emphasizing social and personal resources, as well as physical capacities to support an individual's function in wider society. Health is a very important part of any individual and the community as a whole and for this reason many agencies both state and private as well as NGOs, has been active in this sector, (Fonchingon, 2002).
The growth of Non-Governmental Organizations (NGOs) working in health care around the globe raises questions on how they can best support governments to strengthen the local health care system. Until recently, the role of NGOs in the health care system has not been given the desired attention even though they have been playing a significant role in the improvement of the health care systems all over the world. They have in fact acted discreetly for a long time, whether in a humanitarian emergency, or response to specific situation of distress, (Michael, 2004).
The growing involvement of NGOs & IOs in the development process in underdeveloped countries is widely recognized today. Thus, NGOs have assumed or augmented some of the roles that were previously played by states as well as commercial organizations with the assumption that they bring more sustainable, participatory and efficient development, (Marcel, 2000). They are also involved in small and large-scale projects geared to poverty alleviation, socio-economic empowerment of women and efforts at gender mainstreaming tailored to improving the welfare and livelihood of the population. (Tanga and Fonchingong, 2009). Many NGOs are now participating in the capacity building of members and public by providing the proper techniques in various walks of life. There are many seminars, conferences, workshops and courses made available to the large segment of the population to acquire knowledge and to be informed about the problems that dominate their lifestyle.
Research has been carried on the developmental impact of NGOs and civil society in Cameroon with little or no attention on how they are managed and related issues of transparency and accountability (Mbuagbo et al., 2008). This is a gap which needs attention as agencies deal with NGOs in the developing countries as intermediaries strive toward poverty alleviation and positive Socio-economic change (Lewis, 2001). In recent years' development, aid agencies are disappointed with the low performance of NGOs in eradicating poverty and promoting social change. They are proposing NGOs as intermediaries between the government and the people by trying to show case the notion of participatory development (Lewis and Opoku Mensah, 2006).
According to the UNDPs World Development Report, the approach has scaled up health facilities from 44 to 400 in Benin, 18 to 357 in Guinea, and one to 559 in Mali by 2002 from the time it began in the 1980s. Many NGOs in Africa are involved in health services since the HIV epidemic. Latin America and Asia, which have the bulk of NGOs, have long history of providing both social services and advocacy work. NGOs are filling the gaps in public programs that States have failed to perform or withdraw. The World Bank (2010) has also promoted NGOs activities in countries where they did not want to channel funds directly to state. Studies have associated participation in NGOs development and activities as credit associations with increased demand for health care and seeking curative care for a sick child. Economic development programs that NGOs provide have had multiple positive effects on poor households.
The Health System in Buea and Limbe municipalities function in various ways to meet the patients' need. The local health care system faces certain operational problems, such as a shortage of medical and paramedical staff. Specifically, the local health care system lacks adequate physicians, nurses, and midwives. This problem is compounded by an inequity in the geographic distribution of health workers, the problem of aging public sector workers, the lack of regulations and an ongoing accreditation system for human resource for health education and training.
These challenges faced by the local health care system, created an awareness in the minds of many NGOs and IOs. In fact, with regards to the perceived impact of NGOs in the Health System of Buea and Limbe municipalities what do we know about the perceived impact of the NGOs and IOs? For example, what do we know about their perceived effectiveness in educating the population on health-related issues? What are the perceived results of their participation in the Health System of Buea and Limbe Municipalities?

Health System of the Buea and Limbe Municipalities
The Health System in Cameroon operates under the guide of the Ministry of Public Health. The health system is made of the Reference hospital, General hospital, Regional hospital, Health District and Health Area along with the Health Unit. All these health facilities are under the care of the Ministry of Public Health. There exist many health units, both public and private that operate both at the regional, divisional and sub-divisional levels. We also have Central Units for the distribution of drugs all over the country to pharmacies which sell drugs. These facilities are managed by health human resources even though their staffing remain insufficient. Some of the health facilities and qualified personnel are provided by the NGOs: Donors in Cameroon. The health system equally covers the Buea and the Limbe municipalities.

NGOs Working in the Health System
According to field-level findings in these two municipalities, different NGOs have been participating in the improvement of the health care system concerned. These IOs and NGOs are located on the map below (figure 1).
Source. Topographic map of Douala-Buea, 2D, 1975  Table 1 illustrates the different IOs and NGOs that have been participating in improving the allocation of health care services in the Buea and Limbe councils concerned. Table 1 illustrates some of the IOs and NGOs participating in the Health System.

Data and Methods
This study adopts a descriptive research design. The study acquired qualitative and quantitative data. The obtained information describes the perceived participation of NGOs within the health care system in the Buea and the Limbe municipalities with a specific aim of evaluating their perceived political, educational, and socio-economic roles. The questionnaires were designed and administered to the selected sample areas of the two municipalities: Buea and Limbe municipalities. Follow-up interviews were conducted by the researchers to further reinforce the first-hand data. All of these were aimed at collecting primary data which were analyzed and presented using appropriate statistical techniques. Furthermore, secondary and tertiary data were obtained from published sources such as books, journal, articles, and dissertations.
Questionnaire items and their responses were coded and Statistical Package for the Social Science (SPSS version 2.0) was used to analyze the collected data from the field, where descriptive statistics such as frequency and percentage distribution of variable was calculated and presented using statistical tables, bar graphs, pie chart which indicated frequencies and their conversion into percentages for easy quantitative and quantitative analysis.

Primary Health Care Services (like dialogue on health) by IOs and NGOs
This study carried out investigation to verify if IOs and NGO carry out primary health care services. NGOs carry out primary health care services such as sanitization campaigns, distribution of face masks and mosquito nets and subsidizing health care services including the distribution of pharmaceutical drugs.

Sanitization on Hygiene and Sanity
This study carried out investigation to verify if IOs or NGOs carryout sanitization campaign through educating the population on the importance of cleanliness in their environment. From the results, 74.7% respondents opined that IOs or NGOs carried out such sanitization campaigns. On the other hand, 10.1% respondents felt that NGOs have not been effective. From these statistics, it is seen that IOs/NGOs were mostly perceived as agents implementing sensitization campaign like advising the population to clean their environment.
The IOs and NGOs have been playing several functions as far as the policy role in the health care system. For example, do they try to advocate and implement health programs? The various opinions of the different individuals were assessed to discover whether the NGOs actually influence policy making as far as the health system is concerned. The result shows that 69.6% respondents perceived that IOs or NGOs influence policy making in their Municipalities as far as Health Systems. On the other hand, 13.3% respondents stated that IOs and NGOs did not influence policy making health system. From these statistics, IO and NGOs were generally perceived as influencing policy making in the health care system of the Buea and Limbe Municipalities.  As noted in Table 2, UNICEF carried out many activities beginning with risk communication and community engagement to households targeted for receiving humanitarian support in 2020 during the Pandemic.

Distribution of Face Mask and Barrier Measures Instituted by IOs and NGOs
The distribution of facemasks during the outbreak of COVID 19 in the communities was an important aspect in the prevention of COVID 19 in Buea and Limbe since some people were not able to get a facemask due to their location and money. Some IOs and NGOs went to the communities to distribute these maskss to enable inhabitants prevent this disease. This shows the role played by some IOs and NGOs like Doctor without Borders among others in the prevention of COVID 19 in the study area.
Source. Field work, 2020  Face mask distribution was also evaluated based on frequency.  From the chart, 4, 41.8% respondents were aware that the distribution of face masks occurred once a month, while 35% felt it occurred once per week. Furthermore, 14.6% respondents were of the opinion that the distribution of face mask is twice a month with another 6.3% respondents stating that the distribution of face masks happened every two weeks. Finally, 1.3% respondents felt the distribution occurred after 2 weeks but before the end of a month, while 1% had no response. From the statistics, those that perceived IOs and NGOs participation in the distribution of face masks were aware of various scheduled distributions.

Distribution of Mosquito Nets by IOs and NGOs
The IOs and NGOs in the Buea and Limbe municipalities also distributed mosquito nets to fight against malaria.  Table 3 explains the perception of whether or not these distributions occur. Indeed, 63.3% respondents were aware that IOs and NGOs distribute mosquito nets. On the other hand, 22% were unaware and 14.6% respondents gave no response. Table 3 shows there is a large segment of the population that is unaware and comprises an opportunity for NGOs and IOs to further reach-out to improve community awareness especially during the rainy season when mosquito prevalence is accentuated because of standing water. Table 4 below demonstrates the perceived frequency in which mosquito nets were distributed. From these statistics, the distribution of mosquito nets as perceived in the community, occurred every after 6 months or once per rainy season. Source. Field work, 2020

Educational Participation of IOs and NGOs in the Health System
The educational role carried out by the IOs and NGOs in the health care system consists of workshops, seminars, and public relations through media on the importance of maintaining a healthy lifestyle. Even door-to-door activities have occurred.
Our survey results indicates that 60.1% respondents felt IOs and NGOs carried out sensitization and education missions that strengthened their community. On the other hand, 15.8% respondents were of the opinion that IOs and NGO did not carry out sensitization on health-related issues in their locality. The remaining 24% had no opinion.
Overall, the IOs and NGOs carried out sensitization on health-related issues in the locality. For example, they sensitized the general public on how to control the spread of COVID-19 through washing of hands and the wearing of a face mask. Other outreach efforts targeted the prevention of HIV/AIDS and many other illnesses. This is an essential aspect of health awareness among community members since some community members became infected with diseases out of ignorance. Therefore, IOs and NGOs especially Doctors Without Borders, struggled to make sure that community members are guided on health-related issues, which enables community members to better manage sickness and diseases or prevent them altogether. IOs and NGOs in these municipalities priotize children and even infants because they are quite susceptible to pathogenic attack since they are still developing as opposed to the elderly who are resistant to pathogens.

Subsidization of Hospital Bills
Over half the respondents, (55.7%) perceived that NGOs subsidized hospital bills for the community (Figure 4). On the other hand, 23.4% respondents stated NGOs do not subsidize the hospital bills of the community. 21% were not informed of their actions in this domain. From the statistics, it is generally seen that NGOs subsidize jgg.ccsenet.org Journal of Geography and Geology Vol. 15, No. 1;2023 hospital bills for the community, a situation that enables the poor in the community to afford health care services especially in severe cases. This practice has increased the health status of members in the community. The following statistics shows how one NGO (BEPHA) has participated in the improvement of the health care systems in the Buea and Limbe municipality from 2010 to 2019.
Source. Field work, 2020 With the outbreak of COVID-19 pandemic, subsidization has become constant but oriented towards pandemic prevention measures. This data affirm that IOs and NGOs have been at the forefront of filling gaps with the health care system, even though not everyone in the two municipalities profited from the NGOs' activities. The subsidization modalities vary amongst the IOs and NGOs. For example, some do just referrals like CARITAS (150 referrals cases were made by CARITAS). Meanwhile, others such as BEPHA subsidize the health care procedures later. However, to benefit from these activities, an individual or the entire household must be registered member of these organization.

Vaccination Campaign by IOs and NGOs
The NGOs have been assisting the State in carrying out various vaccination campaigns to improve the health care system of the Buea and Limbe municipalities. The IOs and NGOs play crucial roles in the community to increase the health status of people that are vulnerable to diseases that can be pre-empted or minimized by means of vaccination(s). In these campaigns, health practitioners invite the community and vaccinate them according to the drug prescription (age group, gender, health status) with such activities being coordinated by local authorities since some practitioners may not be certified to offer professional health care services. Therefore, local authorities also play a vital role during the vaccination process by sensitizing the population as facilitators between IOs/NGOs and the local population.  From the results in Table 5, 63.92 are aware of campaigns while 36.70 are unaware of campaigns carried by IOs and NGOs. In fact, 10.13% of the respondents were of the opinion that IOs and NGOs carry out vaccination campaigns against polio, and 17.72% of the respondents were of the opinion that these IOs and NGOs carry out vaccination campaigns against malaria. Also, 7.60% respondents were of the opinion that IOs and NGOs carry out vaccination campaigns against meningitis. Furthermore, 4.4% respondents were of the opinion that they carry out vaccination against tetanus. From the statistics, it is seen that IOs and NGOs carry out vaccination against polio, malaria, meningitis, tetanus, and yellow fever. However, among these vaccinations, polio and malaria were seen as the major diseases the community was treated from. The prevalence of malaria in the area is due to the nature of the environment which serves as breeding grounds for mosquitoes. These mosquitos increase the morbidity and mortality rate of the children and the elderly. This situation is more severe in children and the old since their immune system is weaker as opposed to the middle-aged persons in the community. The NGOs carry out this vaccination in collaboration with the Ministry of Public Health.

Community Dialogue, Counseling and Training on Health-related Issues
The NGOs usually organize community dialogues on health-related issues to educate the population. For example, telling people how to prevent HIV/AIDS and equally on how to prevent the out spread of Corona Virus (Picture 2).
Source. Field work, 2020 Photo 2. Community dialogue organized by the NGOs Working with the community head, the survey found out that 67.7% respondents perceived that community dialogues were organized by IOs and NGOs. When doing this, they select educated persons within the community to speak to their fellow men since they can best listen to them than the NGOs agents. IOs and NGOs also train people on how to take care of the sick by means of organizing seminars or conferences in the community. Such training includes understanding the signs and symptoms of the disease in members of the community who are suffering from a particular disease. After receiving these trainings, members of the community are better able to handle their sick brothers and sisters are members of the community.
Source. Field work, 2020  Vol. 15, No. 1;2023 According to Figure 5, inter-annual variation in the training fluctuated and ranged from 5,000 in 2010 to 25,000 in 2015, then 6,000 in 2019. This affirms the fact that, the NGOs have been at the forefront to improve the health care system in the two municipalities. Nonetheless, the NGOs still struggled to meet the health needs of these communities as they try to pass on professional skills to the local population.

The Provision of Drugs by IOs and NGOs
The NGOs usually distribute drugs free of charge to most with a particular emphasis on pregnant women and children in the Buea and Limbe municipalities. NGOs such CARITAS provide drugs and food items to the local population. These items are given for free to the local population to support them maintains a healthy life. Figure  5 below shows the number of children who received drugs from NGOs from 2010 to 2019.
Source. Field Work, 2020 Figure 6. Number of children who received drugs According to Figure 6, drugs provision ranged from 10,000 in 2010 to 60,000 in 2015 than 22,000 in 2019. This affirms that IOs and NGOs have been participating in the health care system as it pertains to the children's health in these two municipalities. Once again, the NGOs still struggled to meet all the health needs of these municipalities in relation to drugs provision, which comprises an on-going concern.

Discussion
There are many IOs and NGOs, both international, national and even local that have been working discretely to improve the health care system. In Central Africa and Cameroon in particular, some of the NGOs that work in the health system include: (1) Doctors Without Borders, (2) Red Cross, and (3) UNICEF. Some NGOs work at the national level. Examples include BEPHA, Ayah Foundation and CARITAS. All these NGOs work in different ways to meet the health needs of people. For example, in Cameroon, Doctors without Borders works to improve access to primary care and responds to increasing needs. In 2019, they supported about 30 hospitals in the Southwest region and ran a free 24-hours ambulance service, along with managing over 9000 referrals throughout the year. Doctors without Borders also focuses on emergency care, especially for victims of armed and sexual violence, children and pregnant women. These activities are not only concentrated in a particular area. Instead, they cut across the entire regions of Cameroon.
Cristia, Garcia Prado and Peluffo (2015) evaluated a coverage extension program in Guatemala that expanded access to health care in the rural regions of the country through two contracting out modalities with existing NGOs. The programs supported basic care, malaria, dengue, sexually transmitted diseases, HIV and AIDSs, environmental health water quality surveillance, sanitation and food hygiene. Bringing this instance to Cameroon in general and the Buea and Limbe municipality in particular, the NGOs have been putting their efforts in improving the health sector in all aspects of life. Our research shows that a majority of those surveyed in Buea and Limbe municipalities recognize that NGOs and IOs have positive tangible impacts on the health care system and the socio-economic factors associated with health care. This scenario parallels NGO/IO activities in Ethiopia, where seven percent of the health facilities are operated by NGOs, most of which are at the primary level. Moreover, these NGOs/IOs in Ethiopia also provide financial and general curative, preventive and rehabilitative healthcare services (Wamai, 2008(Wamai, , 2009).
Within Cameroon, some of the NGOs' development activities include; health education and training, environment, women's development, capacity building and research HIV/AIDS sensitization and community-based organization (Tanga and Fonchingong, 2009 the management and funding of the health sector activities in Cameroon with Buea and Limbe inclusive, as defined in the new policies and programs of the state, remains more than ever a possible solution to overcome constraints to the objectives assigned by the World Health Organization (WHO, 2006) "Working Together for Health." The cost of health services is very often above what the population can afford.
Only a system of solidarity and mutual assistance can ensure the success of this participation and effective contribution to reducing poverty in the country (Nzima, 2014). To this extent, our findings indicate that the population of Buea and Limbe is generally aware of the activities of NGOs and IOs as they relate to health care. However, our findings also show that there are still segments of the population that are unaware or perhaps indifferent to these activities, especially as they pertain to vaccination campaigns and the provision of subsidies. These findings pose a challenge for government agencies and NGOs/IOs as they seek to close such gaps in the future.

Conclusion
A healthy person is a wealthy person and if people live in a poor health condition, they are liable to die early and this will affect all sectors of the livelihood of Mankind. One of the most important actors to this issue has been the NGOs and IOs. The role of these organizations in the health care system and their contributions cannot be ignored especially in underdeveloped countries. Continued collaboration between the NGOs, the local population and the Government in order to make the health care system more advanced and available to the population of these two municipalities remain an important overall facet of health care policy.
Our findings indicate that the population generally is aware of the NGOs and IOs as they relate to the local health care system and that, in the future NGOS and IOs need to more effectively engage the local population from identification of health challenges, to the management and monitoring phase, for them to be more effective and sustainable in managing health related issues. Though the study was constrained by the lack of finance to visit more communities and organize more discussion groups on concerns raised during data collection, one of its findings reveals that NGOs and IOs could be more effective in the health care system in order to focus more intensely on: (1) transferring health related skills to the local communities with or without the continued presence of NGOs in their communities; (2) discovering why people are ignorant or indifferent to vaccination campaigns and then taking appropriate steps to address this situation; and (3) increasing the awareness of subsidies provided by NGOs.