CHAPTER ONE

INTRODUCTION

1.1Background to the study

Concern for health has traditionally been a major global priority, yet the increasing prominence of non-communicable diseases (NCDs) presents new challenges for health systems worldwide. Globally, NCDs account for approximately 74% of all deaths, equating to over 41 million deaths annually (World Health Organization [WHO], 2021). These diseases including cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes have seen a sharp increase over recent decades, driven largely by population aging, urbanization, and lifestyle changes such as poor diet, tobacco use, harmful alcohol consumption, and physical inactivity. This epidemiological transition from infectious diseases to chronic conditions places substantial demand on healthcare systems, requiring long-term care, continuous monitoring, and significant financial resources. Healthcare expenditure (HCE) is therefore a critical factor influencing the capacity of countries to respond effectively to the growing NCD burden.

In high-income countries, healthcare spending is among the highest globally and has been linked to improved health outcomes, including reductions in NCD-related mortality. For example, the United States allocated 16.8% of its gross domestic product (GDP) to healthcare in 2020, the highest worldwide, supporting advanced diagnostic tools, treatments, and infrastructure (OECD, 2021). However, despite this high expenditure, inefficiencies and inequalities persist, with nearly 8% of the U.S. population uninsured and administrative costs constituting about 34% of healthcare spending (Centers for Medicare & Medicaid Services, 2022). These issues highlight that high healthcare spending alone does not guarantee equitable or efficient management of NCDs.

Conversely, countries that spend more moderately on healthcare but implement strategic policies often achieve better health outcomes. Japan, which spends around 10% of its GDP on healthcare, has the highest global life expectancy at 84.8 years (World Bank, 2022). This success is attributed to its emphasis on preventive care, universal health coverage, and community-based interventions. Preventive strategies such as regular screenings for chronic diseases help reduce complications and long-term costs (Ikegami et al., 2018). Japan’s integrated health delivery system minimizes wastage and directs resources to critical areas like aging populations and chronic disease management, underscoring that efficient allocation of healthcare expenditure can amplify its impact.

In low- and middle-income countries, healthcare expenditure remains insufficient to meet the rising demands of NCDs. For instance, India spent only about 3% of its GDP on healthcare in 2021, well below the global average of 9.8%, and continues to face high maternal mortality rates of 97 per 100,000 live births (NITI Aayog, 2022; WHO, 2022). The country’s rural majority, constituting around 65% of the population, experiences significant inequities in healthcare access due to inadequate infrastructure and workforce shortages. Although schemes such as Ayushman Bharat have expanded insurance coverage, persistent gaps in service delivery and infrastructure continue to hinder progress against NCDs (Jain & Bajpai, 2021).

Africa as a continent is experiencing a dual burden of disease, where rising rates of NCDs coexist with ongoing challenges from communicable diseases. NCDs currently contribute to nearly 40% of deaths in Africa, a proportion expected to increase steadily (WHO, 2021). Despite this, healthcare expenditure in Africa remains among the lowest globally, averaging only 5.1% of GDP in 2021 almost half the global average (WHO, 2022). This underinvestment hampers efforts to develop robust health systems capable of preventing and managing NCDs effectively. Many African countries allocate substantial portions of their health budgets to infectious diseases and maternal-child health, leaving chronic disease programs underfunded and fragmented. The heavy reliance on out-of-pocket payments often exceeding 40% of total health spending—disproportionately burdens vulnerable populations and leads to catastrophic health expenditures, further limiting access to NCD care (World Bank, 2022).

Within Africa, Sub-Saharan Africa (SSA) is particularly vulnerable to the emerging NCD crisis. NCDs account for about 35-40% of deaths in SSA and are projected to rise due to demographic and lifestyle changes (WHO, 2022). However, SSA’s health expenditure remains critically low, with an average of just 5.1% of GDP, well below the WHO recommended minimum to achieve universal health coverage. Health systems in this region are often fragile, with inadequate infrastructure, insufficient trained healthcare personnel, and weak surveillance systems for tracking NCD trends. Policy frameworks targeting NCD prevention and control are either lacking or poorly implemented, largely due to resource constraints and competing health priorities. Nigeria, for instance, allocates only about 3.6% of its GDP to healthcare but experiences one of the world’s highest maternal mortality rates at 512 deaths per 100,000 live births and a rising incidence of hypertension and diabetes (World Bank, 2022). The high out-of-pocket expenditure, which accounts for over 70% of healthcare financing in some areas, limits access to essential NCD services and exacerbates health inequities. In contrast, Rwanda’s healthcare system, despite modest spending of approximately 7.5% of GDP, demonstrates how strategic investments and inclusive health policies can improve outcomes, with community-based insurance schemes expanding coverage to over 85% of the population and reducing under-five mortality by more than 60% since 2000 (WHO, 2022; UNICEF, 2022).

Cameroon exemplifies the challenges faced by many low- and middle-income countries in SSA regarding healthcare financing and NCD management. With healthcare expenditure at roughly 4.1% of GDP, Cameroon’s spending falls below the WHO threshold of 5% recommended for adequate healthcare delivery (World Bank, 2022). The country confronts a dual disease burden: persistent infectious diseases alongside a rapidly increasing prevalence of NCDs such as cardiovascular diseases, diabetes, cancers, and chronic respiratory illnesses. Rapid urbanization, dietary changes, sedentary lifestyles, and rising tobacco and alcohol use are key contributors to this trend (WHO, 2022). However, the healthcare system remains predominantly focused on communicable diseases and maternal-child health, resulting in insufficient infrastructure, shortages of trained health workers specialized in chronic disease care, and limited access to essential NCD medicines.

Financial protection against healthcare costs is weak, with out-of-pocket payments comprising about 42% of total health expenditure, disproportionately affecting the poor and rural populations. This financial barrier often causes delays in seeking care, treatment interruptions, and poor health outcomes for patients with chronic diseases. External aid, accounting for approximately 15% of health financing, tends to prioritize infectious disease programs, leaving a significant funding gap for NCD prevention and management. Preventive measures targeting NCD risk factors such as tobacco control, promotion of physical activity, and nutrition education remain underfunded and inconsistently implemented. Screening and early diagnosis programs for hypertension, diabetes, and cancers are limited in reach and quality, contributing to late-stage disease presentation and increased treatment costs.

Despite these systemic challenges, Cameroon has achieved progress in selected health areas, notably immunization and malaria control. Expanded vaccination campaigns have led to a 75% reduction in measles cases since 2010, reaching over 90% coverage by 2020 (UNICEF, 2021). Malaria prevalence has also declined by approximately 40% between 2000 and 2020 due to intensified control measures (Roll Back Malaria, 2022). These successes underscore the potential benefits of targeted investment even within constrained resources. Nonetheless, the growing burden of NCDs demands a more comprehensive and strategic reorientation of healthcare expenditure in Cameroon. Strengthening primary healthcare, expanding universal health coverage, increasing public investment in preventive and curative NCD services, and improving resource allocation efficiency are essential to reducing NCD morbidity and mortality and achieving sustainable health system improvements.

This study, therefore, aims to investigate the effect of healthcare expenditure on the prevalence, management, and outcomes of non-communicable diseases in Cameroon. It seeks to generate evidence that can inform policy formulation and resource allocation strategies to optimize health system responsiveness to the rising NCD challenge in Cameroon’s context.

1.2 Problem statement

Despite ongoing efforts to improve health outcomes, Cameroon continues to face significant challenges in addressing the rising burden of non-communicable diseases (NCDs), which now account for an increasing share of morbidity and mortality. While healthcare expenditure is a critical driver of health system performance, Cameroon’s health investments have yet to translate into substantial improvements in NCD prevention, management, and outcomes. The healthcare system struggles with inadequate resource allocation, limited infrastructure, and insufficient skilled personnel to effectively manage chronic conditions such as hypertension, diabetes, cancers, and cardiovascular diseases. This situation is compounded by growing disparities in access to quality healthcare between urban and rural populations, where rural areas often lack basic diagnostic and treatment services for NCDs, leading to delayed diagnosis and poor disease control. As a result, NCDs impose a growing economic and social burden, threatening to overwhelm an already fragile healthcare system and impede national development goals.

Furthermore, although Cameroon’s healthcare spending has increased modestly in recent years, the impact of this expenditure on reducing NCD-related morbidity and mortality remains unclear. Inefficiencies such as bureaucratic delays, poor governance, and suboptimal allocation of funds to direct patient care and preventive programs limit the effectiveness of health investments. A significant proportion of resources are diverted to administrative overheads or focused disproportionately on communicable diseases, leaving NCD programs underfunded and poorly integrated within primary healthcare services. This misalignment of priorities has resulted in fragmented care delivery and widening health inequities, particularly affecting vulnerable groups who face high out-of-pocket costs and limited access to essential medications and services. This study seeks to critically examine how healthcare expenditure influences NCD outcomes in Cameroon, with the objective of identifying key barriers and opportunities to optimize resource use and improve population health in the face of the growing NCD epidemic.

1.3 Research questions

1.3.1 Main Research Question

The main research question of this study is; what is the effect of healthcare expenditure on Non Communicable Diseases in Cameroon?

1.3.2 Specific Research Questions

1. How does public healthcare expenditure affect Non Communicable Diseases in Cameroon?
2. To what extent does private healthcare expenditure affect Non Communicable Diseases in Cameroon?
3. How does Out-of- Pocket expenditure affect Non Communicable Diseases in Cameroon?

1.4 Research objectives

1.4.1 Main Research Objective

The main objective of this study was to investigate the effect of healthcare expenditure on Non Communicable Diseases in Cameroon

1.4.2 Specific Research Objectives

1. To examine the impact of public healthcare expenditure on Non Communicable Diseases in Cameroon
2. To assess the effect of private healthcare expenditure on Non Communicable Diseases in Cameroon.
3. To evaluate the influence of Out-of- Pocket expenditure on Non Communicable Diseases in Cameroon

1.5 Research hypotheses

1. H₀₁: Public healthcare expenditure has no significant impact on Non Communicable Diseases in Cameroon
2. H₀₂: Private healthcare expenditure has no significant impact on Non Communicable Diseases in Cameroon
3. H₀₃: Out-of- Pocket Expenditure has no significant influence on Non Communicable Diseases in Cameroon