This study poses the problem of the insufficient contribution of the urban community health system on the emergence of Douala, coupled with the urban deviations from the Sustainable Development Goals. The study is anchored on the main question, which reads: Does the urban community health system contribute to the emergence of Douala, Cameroon? From this, four specific questions, objectives, and hypotheses are established in line with the main objective which is to assess the contribution of community health to the emergence of Douala. The main hypothesis stipulates that the present state of Community Health is a limiting factor to the emergence of Douala.
The main theory exploited has been the demand and supply theory developed by Augustin Cournot in 1838, the possibilism and behaviorism theories were equally used. Concerning the methods, the geographical method of scientific research was used as well as the hypothetical – deductive and the approaches were structuralism, functionalism, and rationalism. The ten Health Districts of Douala were sampled using the quinary model, which permitted the collection of quantitative and qualitative data from institutional and non-institutional stakeholders. The primary and secondary data were analyzed with SPSS 21.0, Excel 2007, Adobe Illustrator 11 .0 and QGIS 22.0 software.
TABLE OF CONTENT
DEDICATION
ACKNOWLEDGEMENTS
ABSTRACT
RESUME
TABLE OF CONTENT
LISTOF FIGURES
LISTOF TABLES
LIST OF PLATES AND PHOTOS
LIST OF ABBREVIATIONS AND ACRONYMS
CHAPTER ONE - GENERAL INTRODUCTION
1.0 - Introduction
1.1- Justification and pertinence of the research
1.2- - The gengeral context of the study
1.3- Delimitation of the research
1.3.1. Epistemological delimitation
1.3.2. Thematic delimitation
1.3.3. Spatial delimitation
1.4- Scientific context
1.5- The research problem
1.6- Research question
1.6.1. The Main question
1.6.2. Specific questions
1.7- Research objective
1.7.1. Main objective
1.7.2. Specific objectives
1.8- Research hypotheses
1.8.1. Mainhypotheses
1.8.2. Specifichypotheses
1.9- The structure of the work
1.10- Difficulties encountered and Limitations of the research
CHAPTER TWO :LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK
2.1. Introduction
2.2. Literature review
2.3. The conceptual framework
2.3.1. The concept of community health
2.3.2. The concept of public health
2.3.3. The concept of local development
2.3.4. The concept of urban emergence
2.3.5. The concept of Urban system
2.4. Theoretical framework of the research
2.4.1. Possibilism theory
2.4.2. Behaviorism
2.4.3. The theory of demand and supply of health services
2.5. Conclusion
CHAPTER 3: EE: THE RESEARCH METHODOLOGY
3.0. Introduction
3.1- General methodological framework
3.1.1- Epistemological positioning in the building of scientific knowledge
3.1.2- The epistemological posture adopted in the building of scientific knowledge
3.1.3- The general methodology of the research
3.2- Methods and techniques of data collection
3.2.1- Sampling of investigation sites
3.2.2- Method and techniques of collecting quantitative data
3.2.3- Method and techniques of collecting qualitative data
3.3- Method and technique of data analysis and treatment
3.3.1- Method and techniques of analyzing quantitative data
3.3.2- Method and techniques of analyzing qualitative data
3.3.3- Methods of conjecture of analyzing data
3.4- Presentation of the APA model
3.5- The determination of the research period matrix
3.6- Conclusion
CHAPTER 4: R: THE FRAMEWORK OF COMMUNITY HEALTH IN DOUALA
4.1- Introduction
4.2- Administrative organization of health systems of Douala
4.2.1- Spatial distribution of health facilities
4.2.2- Relative distribution of health personnel
4.2.3- Administrative organization of health structures and units in Douala
4.2.4- Accessibility to basic health facilities andunits
4.2.5- The contribution of Mutual Health Organization
4.3- Regulatory framework of health facilities
4.3.1- Decentralization law and public health implications
4.3.2- Stakeholders involvement and participation in public health
4.3.3- Formal private sector facilities
4.3.4- Informal private sector facilities
4.3.5- Execution of health community projects
4.4- Funding structures of health institutions
4.4.1- Health service financing policy in Douala
4.4.2- Subventions of Douala health structures
4.4.3- Resources of funding of the Douala health sectors
4.4.4- Availability in health funding in Douala city
4.4.5- Douala city Health fund management
4.5- Managerial structure and practices
4.5.1- Implementation of National policy on the management of biomedical waste in Douala
4.5.2- Evaluation of duties among the Douala medical personnel
4.5.3- The welfare of health personnel
4.5.4- Organizational system in the management of health victims
4.5.5- Management of Douala health facilities
4.6- Institutional organization of community health and urban emergence
4.6.1- Territorial organization and urban emergence
4.6.2- Regulatory framework and urban emergence
4.6.3- Managerial malpractices and urban emergence
4.6.4- Ethical Considerations of Public Health
Conclusion
CHAPTER 5: E: SYSTEM OF MANAGEMENT FOR WATER AND FOOD SECURITY
5.1- Introduction
5.2- The State management of urban health security
5.2.1- The distribution of portable water implications
5.2.2- The alternative urban water supply systems
5.2.3- Management of the water sector
5.2.4- Assessment system of urban portable water
5.2.5- Management of the food sector
5.3- Decentralized stakeholders of water management
5.3.1- Governance of the water sector at the Regional level
5.3.2- Creation of sales points and parks
5.3.3- Management of the food sectors
5.4- The local population involvement in water provision and food security
5.4.1- Water sources management and food security
5.4.2- Safety methods used to treat water and food in market places
5.4.3- The consumption of fruits and balanced diet
5.4.4- The qualities of fruit consume
5.4.5- Believe and customs in the consumption of portable water
5.5- The civil society and water provision
5.5.1- Conception and implementation of community health projects
5.5.2- Provision of portable water
5.5.3- Water sensitization campaigns
5.5.4- Impact of subsidizing urban water supply
5.6- The international partners and urban water provision
5.6.1- Provision of portable water strategies
Conclusion
CHAPTER 6: : THE MANAGEMENT OF URBAN HYGIENE AND SANITATION
6.1- Introduction
6.2- Urban disease Vector management
6.2.1- Vectors and vectors-borne disease correlationship in Douala
6.2.2- Urban environmental milieus of vector concentration
6.2.3- Mitigation attempts for vector-borne diseases
6.2.4- Institutional strategies against vectors and vector-borne diseases
6.3- Urban Sewage disposal system management
6.3.1- Evacuation system of sewage
6.3.2- Management system of sewage in the community
6.3.3- Management system of sewage in the Hospital milieus
6.4- Implementation of urban hygiene and sanitation
6.4.1- Instituting urban hygiene and sanitation days
6.4.2- The clean-up campaigns
6.4.3- Restructuring of the urban milieu by the urban council
6.4.4- Administrative management of urban public space
6.4.5- The use of public spaces
6.5- Urban health private spaces
6.5.1- Stakeholder literacy disparity and its incidence on space management in Douala
6.5.2- Urban livestock rearing and poultry farming
6.5.3- Demographic variables and incidence on space management
6.5.4- The settlement pattern as constraint to urban emergence
6.6- Management of training institutions
6.6.1- First aid knowledge in the administration
6.6.2- First aid treatments in the training institutions
6.6.3- Availability of health facilities
Conclusion
CHAPTER 7: EN: MANAGEMENT OF URBAN EPIDEMICS
7.1- Introduction
7.2- Food and water borne disease management
7.2.1- Typhoid fever
7.2.2- Diarrhea
7.2.3- Cholera
7.2.4- Poliomyelitis
7.3- Vector borne diseases management
7.3.1- Malaria
7.3.2- Yellow fever
7.4- Air borne diseases management
7.4.1- Influenza
7.4.2- Tuberculosis
7.4.3- Measles
7.4.4- Asthma
7.5- Management of other diseases
7.5.1- Fungal infections
7.6- Drug supply and evaluation as per WHO of urban responses to epidemics
7.6.1- Evaluation of health-human resources as per WHO standards
7.6.2- Evaluation of the evolution of infrastructures and space
7.6.3- Evaluation of Vaccination campaigns
Conclusion
CHAPTER 8: HT: SUMMARY OF FINDINGS, GENERAL CONCLUSION AND RECOMMENDATIONS
BIBLIOGRAPHY
Appendix 1: Research Questionnaire to Households
Appendix 2: Questionnaire to Health personnel
Appendix 3: Interview Guide to medical personnel
Appendix 4: Interview guide to personnel of CUD and MINEPIA
Appendix 5: Laws, Decrees and Circulars
Appendix 6: Number of Health Districts, Health Zones and Health units in Douala
Appendix 7: Research Authorization from the University of Douala FLSH
Appendix 8: Research authorization from the Senior Division Officer Douala
Appendix 9: Research authorization from the Regional Delegation of Public Health Littoral
Appendix 10: Research authorization from the Bonassama District Hospital
Appendix 11: Research authorization from the Cité des palmiers District Hospital
Appendix 12: Research authorization from the Japoma District Hospital
Appendix 13: Research authorization from the Archdiocese of Douala
Appendix 14: Free checkup campaign of heart diseases
Appendix 15: Communiqué for hygiene and sanitation day
Appendix 16: Restriction from illegal occupation of public space
Appendix 17: Request for research authorization - police health center
Appendix 18: Request for research authorization - SOCATUR
Appendix 19: Request for research authorization - Evangelic church
Appendix 20: Request for research authorization - Radio Balafon
Appendix 21: Request for research authorization - FINEXS Voyage
Appendix 22: Request for research authorization - Equinox TV
Appendix 23: Request for research authorization - CUD
Appendix 24: Attestation of participation to scientific day on health issues
Appendix 25: Attestation of participation to Conference on health issues
Appendix 26: Letter of invitation to present scientific paper
Appendix 27: Attestation of training on Sustainable management of resources
LIST OF FIGURES
Figure 1: Location of study area
Figure 2: Determinants of Health
Figure 3: Transmission of pathogens from vector to host
Figure 4: Classical hypothetic - deductive standard
Figure 5: Location of HealthDistricts
Figure 6: Historical evolution of Primary Health Care in Cameroon
Figure 7: Spatial organization of the health sector in Douala
Figure 8: Number of Health units in Douala
Figure 9: Number of Health Zones in Douala
Figure 10: Location of health centres
Figure 11: Employment of medical personnel in private and lay private hospitals
Figure 12: Health sector expenditure circuit
Figure 13: Evolution in the number of Health Districts by division between 2012 and 2014
Figure 14: Evolution of health units by category between 2011 and 2014
Figure 15: Evolution of the status of FOSA in the littoral between 2011 and
Figure 16: Evolution of number of FOSA by division in the littoral region between 2011 and 2014
Figure 17: Decline in the State’s water supply system
Figure 18: Dominance of alternate water supply sources in Douala
Figure 19: Organigram of the Douala Development Agency
Figure 20: Major fish sales points and butcheries in Douala
Figure 21: Major farming zones and food supply routes in Douala
Figure 22: Water treatment methods by the local population
Figure 23: Major markets with high risk of water and food insecurity
Figure 24: Percentage of foodstuff consumption in the Douala metropolis
Figure 25: Evolution of precipitations and Relative Humidity
Figure 26: Evacuation and transportation of sewage to the main dump site
Figure 27: Contribution of HYSACAM to community health
Figure 28: Main deposit site of wastes in Douala
Figure 29: Livestock and birds rearing in Douala
Figure 30: location sites of livestock rearing and poultry farming in Douala
Figure 31: Fowl rearing in different periods of the year
Figure 32: Evolution of population in the Littoral Region between 1976 and 2015
Figure 33: Population evolution in Douala from 2005 to 2015
Figure 34: Number of Population in each Sub-Division of Douala in 2005
Figure 35: Location of pharmacies in Douala
Figure 36: Evolution of typhoid fever outbreak in 2014
Figure 37: Typhoid fever attacks in the ten Health Districts of Douala
Figure 38: Evolution of malarial fever in the Littoral Region between 2013 and 2014
Figure 39: Evolution of severe cases of malaria fever in 2013 and 2014 in the Littoral Region
Figure 40: Comparison of malaria cases (simple and severe) declared and treated in 2014
Figure 41: General appreciation of Health services provision in the Littoral Region in 2010
Figure 42: Evolution in the number of mosquito nets distributed between 2012 and 2014
Figure 43: Rate of loss by antigen in the Littoral Region in 2012
Figure 44: Infant mortality rate in 2011
Figure 45: Drug acquisition preferences of the population
Figure 46: The principle of Green Management 6R
Figure 47: Socio-sanitary advocacy model 6R
LIST OF TABLES
Table 1: The research summary
Table 2: Operationalisation of the concept of Community health (conceptualization)
Table 3: Spatial distribution of questionnaires in the ten Health Districts of Douala
Table 4: Summary of primary and secondary data collection and interpretation
Table 5: Chronogram of the research
Table 6: Structural presentation of the health sector
Table 7: The distribution of medical personnel in the Nyalla Medical Centre
Table 8: The distribution of medical personnel in the Japoma Health District
Table 9: Composition of medical personnel in the Health Districts of Douala
Table 10: The traceability of budgetary resources in the health sector
Table 11: List of traditional practitioners in the Bangue Health District
Table 12: Evolution of the health sector budget
Table 13: Community health indicators
Table 14: Community health agents in the Cité des Palmiers Health District
Table 15: Fundamental ethical principles and their applications in public health
Table 16: Classification of quarters according to Standing
Table 17: Sources of water consumption in different quarters
Table 18: Percentage of Fruits intake in Douala
Table 19: Climatic data of Douala
Table 20: Common products use by households against disease vectors in Douala
Table 21: Waste composition category in Douala
Table 22: Evacuation methods of domestic solid waste (DSW)
Table 23: Solid waste generation and amount collected in Douala
Table 24: Livestock rearing and poultry farming and socio-cultural background of actors
Table 25: Evolution of dominant ethnic groups in Douala from 1956 to 2005 in %
Table 26: Number of cases of typhoid fever outbreak in 2014 in the New-Bell HD
Table 27: Number of cases of diarrhea infection in the New-Bell Health District, 2014
Table 28: Number of cases of yellow fever in the New-Bell Health District in 2014
Table 29: Reported cases of measles in the New-Bell Health District 2014
Table 30: Fungal infections in Douala
Table 31: Number of medical personnel per population
Table 32: Distribution of medical personnel in the Littoral Region in 2010
Table 33: Repartition of medical personnel in the Littoral Region in 2014
Table 34: Spatial distribution of medical personnel in the ten Health Districts of Douala in 2019
Table 35: The spatio-temporal evolution of health zones and health units in Douala, between 2012 and 2019
Table 36: Evolution of healthcare provision by status and by type of FOSA in the Littoral Region between 2011 and 2014
Table 37: Roles of Community Agents during vaccination campaign
Table 38: Multi-dimensional approach of food insecurity in Douala
Table 39: Steps for Management of a Communicable Disease Outbreak
LIST OF PLATES AND PHOTOS
Plate 1: Union of community health and some selected mutual health in different Health District of Douala
Plate 2: Dumping of medical waste in Douala
Photo 1: Community health megaphones at the New-Bell Health District
Plate 3: Alternate method to fetch water by households in Nyalla
Plate 4: Artificial equipment of water treatment
Plate 5: Water provision by the civil society in Douala
Plate 6: Dumping of solid waste on the streets of Douala
Plate 7: Dredging and cleaning operations by the DUC at Camp Beteau and Mboppi (photo 2 and 3)
Plate 8: Evacuating shit from households’ septic holes in New-Bell Mbam-Ewondo
Plate 9: Collapse of households’ septic holes atNkolmintag
Photo 2: Management system of medical liquid waste
Plate 10: Manual works by the population at New-bell Bamiléké (photo 1 and 2) and Nkolmintag (photo 3 and 4)
Photo 3: A call for manual works in Bepanda 2014
Plate 11: Lack of interest in community labor in Ndogbassi II neighborhood
Plate 12: Displacement of dustbins in the towns of Yaoundé and Douala
Plate 13: Livestock rearing and poultry farming in Douala
Plate 14: Chaotic construction enhancing flood
Plate 15: Different sources of urban pollution in Douala
Plate 16: Stock of vaccines to be administered in different communities
Plate 17: Deployment of health agent to different communities of Douala
Plate 18: Households collaboration to vaccination campaigns in Youpwé
Plate 19: Sale of traditional medicines at Marché Nkololoun - New Bell
Plate 20: Stalls of traditional healers in the town of Douala
Photo 4: Drugs vending at Marché Gazon in Marché Central Douala
LIST OF ABBREVIATIONS AND ACRONYMS
ADEME: Agence de l'Environnement et de la Maitrise de l'Environnement
AES-Sonel: Apply Energy Services
AFD : Agence Franchise de Développement
AFDB: African Development Bank
CAMWATER : Cameroon Water Utilities
CDE : Cameroon Water Company Des Eaux
CFC : Crédit Foncier du Cameroun
CHSE : Comité d’Hygiène Sécurité Environnement
CIE: Comité Interministériel de l’Environnement
CIG : Common Initiative Group
CMA: Sub divisional Medical Centre
CO: Carbon monoxide
CSI: Integrated Health Centre
CSSD: Head of the District Health Service
DSW: Domestic Solid Waste
DUC : Douala Urban Council
ECAM : Enquetes Camerounaises Auprès des Ménages
EDF : European Development Funds
EDS-MICS : Demographic and Health Survey and Multiple Indicator Cluster Survey
GDP: Gross Domestic Product
GDP: Gross Domestic Product
GIS : Geographic Information System
GNI: Gross National Income
GWP : Global Water Partnership
Habitat II: Second United Nations Conference on Human Settlements
HYSACAM : Société d’Hygiène et Salubrité du Cameroun
IUNC : International Union for Nature Conservation
JCP : Journées Citoyennes de Propreté
LLTMBN: Long Lasting Treated Mosquito Bed Nets
Ltd: Private Limited Company
LTD: Public Limited Company
MAETUR : Urban and rural Lands Planning Mission
MDG: Millenium Development Goal
MINATD: Ministry of Territorial Administration and Decentralization
MINATD: The Ministry of Territorial Administration and Decentralization
MINDAF : The Ministry of Property and Land Affairs
MINEE: Ministry of Energy and Water
MINEPDED: Ministère de l’Environnement, de la Protection de la Nature et du
Développement Durable
MINSANTE: Ministry of Public Health
NPEM: National Plan for Environmental Management
NPFM : National Program for the Fight against Malaria
NUF: National Urban Profile
NWCC : National Water Company of Cameroon
PDP : Participative Development Program
PNDP : Programme National de Développement Participatif
PGES: Plan de gestion Environnementale et Sociale
Abbildung in dieser Leseprobe nicht enthalten
PRGIE: Programme Régional de Gestion de 1’Information Environnementale
QHSE: Qualité, Hygiène, Sécurité Environnement
RGPH : General Census of Population and House
SABC: Société Anonyme des Brasseries du Cameroun
SAD : Société d’Aménagement deDouala
SHARE: Sanitation and Hygiene Applied Research for Equity
SIC : Société Immobilière du Cameroun
SPSS : Statiscal Package of Social Sciences
STD : Sexually Transmissible Disease
STI: Sexually Transmissible Infections
SUFI: Scaling up malaria for impact in Cameroon
TSF: Telephone Sans Fil
UN : United Nations
UNDCP: United Nations International Drug Control Programme
UNDP : United Nations Development Program
UNEP: United Nations Environment Programme
UNO : United Nations Organisation
WB: World Bank
WHD:World Habitat Day
WHO: World Health Organisation
WWF: World Wild Fund
WWFATM: World Wide Fund for the fight against AIDS, Tuberculosis and Malaria
ACKNOWLEDGEMENT
To God be all the Glory for haven permitted this work to come to this present level. I would like to sincerely thank my supervisor Fogwe Zephania Nji (Associate Professor) for his relentless efforts and his devotedness toward this work as well as his constant caution to see that I succeed in this work. He is to me a father and a mentor who always make sure I strictly follow the scientific cannons that lead to the arena of success. Particular thanks to Meva’a Abomo Dominique (Associate Professor) who has been my source of inspiration and encouragement from the Bachelor level to the completion of this work. His availability and readiness to add values to this work are just wonderful, as well as his intellectual and moral guides are to be applauded, equally noted for not compromising with science. Immense gratitude goes to Kpwang Kpwang Robert (Professor, Dean, Faculty of Letters and Social Sciences) for accepting to run this post graduate programme in this institution, Ngo Balepa Aurore Sara (Associate Professor, Chair, Geography Department), for always encouraging me to succeed, Ba’ana Etoundi Marie Louise (Associate Professor, Vice Dean in charge of programming and Academic Affairs) for her rigor and words of motivation toward the success of this work and her passion to see that SDGs be attained, Fouda Martin (Associate Professor) for his intellectual orientations on related issues of this study. I hail Ngoufo Roger (Professor) for his intellectual inspiration toward this work, a resourceful person indeed but in silence. Thanks to Elong Joseph Gabriel (Professor), Mbaha Joseph Pascal (Associate Professor).
I wish to also thank you, Assako Assako René Joly (Professor), Lambi C.M (Professor), Fokunang Charles (Associate Professor), Tchawa Paul (Professor), Moupou Moise (Professor), Ndi Humphrey (Associate Professor) and Nguendo Yongsi Blaise (Associate Professor).
My profound gratitude to Nkumbesone Makoley Essone (Doctor), a father and a mentor who has been my backbone throughout this study, to Modika Johnson (Doctor) from whom I got lots of inspirations, Tchiadeu Gratien (Doctor), Nzalla Ngangue Guy Charly (Doctor), Nsegbe Antoine de Padoue (Doctor), Mayi Amelie Emmanuelle (Doctor), Ndimbo N. Jean Baptiste (Doctor), Njongui Thomas Eric (Doctor).
I further thank my classmates in the University of Douala for their assistance both physical and intellectual to the accomplishment of this master research, for they help me in collecting data on the field. They are; Moukam Bienvenue, Ndewe, Mawo Vigenie Yolande, Sani Edong, Boume Armelle, GANAFEI Sylvain, Christopher, Gille, Guillaume and all members of SS-CAD.
The Regional delegation of Public Health for the Littoral, the ten Health District hospitals and health units, Douala Urban Council and Sub Divisional Councils for the provision of the necessary information and map of my field of study. Special gratitude to Madam Brigitte Chatue Tchatat and to entire crew of PIC and Canadian School of Cameroon.
I solemnly sincerely thank my Mum Mrs. Bakeme Pauline who has been my source of strength and comfort throughout my study. Also to my entire family most particularly to Mr. Atangane Jacques Alain, Gweth Ruth, Wajuku Mathias, Uku Paul, Anthony, Zebulun, Ejuande Simon, Ejuande Florence, Ibiri Mado, Ejuande Lawrence Uku, Angow James, Wajuku George, Wajuku Rita, Ajara, Atangane Ange Rose, Josyane, Carelle, Samuel. Great is my joy to give special thanks to Djuita Marie-Laure who always stood by me, to Mcbright, Zoe, Emmanuel, Laryson, Ashley, Shilomite, Elisabeth and Marvelous.
I further thank Rev. Bwemba Daniel, Rev. Bache Mathias, without forgetting Mama Gweh Esther, Tabi Emmanuel, for their help and counseling. Also to elder Brice, elder Réné, Deacon Bertrand, Lizette, Sophie, Stella, Zorha, Nobel, Patrick, Zita, Gerald and all my church members.
I would not forget to sincerely thank all my classmates and friends of different levels for their tolerance, dialogue and collaboration in the frame of my studies.
Since it is impossible to cite all the names of resourceful person who contributed either directly or indirectly and from far or close toward the success of this work, I pray they accept my sincere acknowledgement to their awesome efforts.
ABSTRACT
This study poses the problem of insufficient contribution of urban community health system on the emergence of Douala coupled to the urban deviations from the Sustainable Development Goals. The study is anchored on the main question which reads; does the urban community health system contribute to the emergence of Douala-Cameroon? From this, four specific questions, objectives and hypotheses are established in line with the main objective which is to assess the contribution of community health to the emergence of Douala. The main hypothesis stipulates that the present state of Community health is a limiting factor to the emergence of Douala.
The main theory exploited has been the demand and supply theory developed by Augustin Cournot 1838, the possibilism and behaviorism theories were equally used. Concerning the methods, the geographical method of scientific research was used as well as the hypothetical - deductive and the approaches were structuralism, functionalism and rationalism. The ten Health Districts of Douala were sampled using the quinary model which permitted the collection of quantitative and qualitative data from institutional and non-institutional stakeholders. The primary and secondary data were analyzed with SPSS 21.0, Excel 2007, Adobe Illustrator 11 .0 and QGIS 22.0 software.
The results show that the urban system is characterized by socio-spatial inequalities in the distribution of health facilities and medical personnel, accessibility problems to health centers, insufficient funds available to run community based projects and the slow pace in the implementation of decentralization principles. Increase dumping of sewage and garbage on the streets, environment, bushes and into water passages; thus, favoring the multiplication of disease Vectors and spread in the community. Mitigation methods deplored by urban stakeholders namely the State, decentralized territorial authorities, local population and the civil society are limited compared to the community health challenges. This study recommends the implementation of ethical clearance in the public health sector, implementation of SDGs, the Green Management Strategy 6R should be implemented, the hospitals should have a Hospital based NGO system to manage emergency cases,. Lastly, there should be implementation of Socio-Sanitary Advocacy model in the entire Douala metropolis.
Key words: Community health, Public health, urban emergence, local development, urban system.
RESUME
Cette étude pose le problème de la contribution insuffisante du système de santé communautaire urbaine â l’émergence de Douala couplée aux déviations urbaines par rapport aux Objectifs de Développement Durable. L’étude est ancrée sur la question principale suivante; le système urbain de santé communautaire contribue-t-il a l’émergence de Douala-Cameroun? A cette question principale, quatre autres questions, objectifs et hypothèses spécifiques afin d’évaluer la contribution de la santé communautaire â l’émergence de Douala. L’hypothèse principale stipule que l’état actuel de la santé communautaire est un facteur limitant l’émergence de la ville de Douala.
La théorie principale exploitée a été la théorie de la demande et de l’offre développée par Augustin Cournot 1838; les théories du possibilisme et du comportementalisme ont été également utilisées. En ce qui concerne les méthodes, la méthode géographique de la recherche scientifique ainsi que la méthode hypothético - déductive ont été utilisées. Quant aux approches, elles étaient structuralistes, fonctionnaliste et rationaliste. Les dix districts de santé de Douala ont été échantillonnés â l’aide du modèle quinaire qui a permis la collecte de données quantitatives et qualitatives auprès des acteurs institutionnels et non institutionnels. Les données primaires et secondaries collectées ont été analysées avec les logiciels SPSS 21.0, Excel 2007, Adobe Illustrator 11 .0 et QGIS 22.0.
Les résultats montrent que le système urbain se caractérise par des inégalités socio-spatiales dans la distribution des établissements de santé et du personnel médical, des problèmes d’accessibilité aux centres de santé, des fonds insuffisants disponibles pour mener des projets communautaires et la lenteur dans la mise en reuvre des politiques de décentralisation. Le déversement croissant des eaux usées et des ordures dans les rues et dans l’environnement, les buissons et les caniveaux; favorisant ainsi la multiplication des vecteurs de maladie qui se propagent dans la communauté. Les méthodes d’atténuation déplorées par les acteurs urbains, â savoir l’Etat, les collectivités territoriales décentralisées, la population locale et la société civile, sont insuffisantes par rapport aux problèmes de santé communautaire. Alors, cette étude recommande la mise en reuvre de la clearance éthique dans le secteur de la santé publique, la mise en reuvre des ODD, la Stratégie de gestion verte 6R, les hopitaux devraient avoir un système d’ONG qui s’occupe de la gestion des cas d’urgence. En somme, il devrait avoir une mise en reuvre du modèle Militantisme socio-sanitaire dans toute la métropole de Douala.
Mots clés: Santé communautaire, Santé publique, Emergence urbaine, Développement local, Système urbain
CHAPTER ONE: GENERAL INTRODUCTION
1.0- Introduction
This chapter aims to present some relevant aspects surrounding the study beginning from the justification of the study, the general context, delimitation of the research, scientific context, research problem, the research question, research objective and the research hypothesis
1.1- Justification and pertinence of the research
The academic significance of this study is to obtain the PhD degree in geography. It was noticed that the aspects related to health and environmental issues in urban settings remain a major concern for policy makers and the populations. However, urban insecurity is much more influenced by health problems, which leads us to choose geographical studies. In fact, the realities decry on the urban health have led us to specialize in health geography. This present study which is centered on the topic: Influence of the Urban Community Health System on Emergence of Douala, Cameroon has a multidimensional interest . This study marks a continuation of previous studies realized in the domain of health. This thesis aims to make a socio- spatial study of all the strategies and practices of actors in the domain of community health and urban emergence in Douala. It would therefore make cartography of the various strategies and practices of actors in the town of Douala. This study would determine the extent to which the institutional framework of health care provision in Cameroon determines the level of efficiency of the basic healthcare facilities.
Emphasis shall be laid on the existing literature reviews on public health and decentralization policies and more precisely on community health and urban emergence in an urban setup. It shall equally, through analytic bibliography brings out the limits of existing works on the subject matter. The study is interesting at this level because it adds additional knowledge to the existing works, thereby taking research to a higher dimension and allows Geography to play its role as a scientific discipline at the Carrefour of other sciences and the results shall be used in future studies.
1.2- The general context of study
The WHO-UNICEF (2000) recorded that if the world population without access to good sanitary system (good cleaning up system of solid waste from homes) was around 1.1 billion in 2000, the figure may likely increase in the nearest future. Poor sanitary facilities are responsible for the propagation of fecal-oral diseases such as diarrhea (4 billion cases annually and 2.2 million deaths) or intestinal worms. It is estimated that water, sanitation and hygiene interventions can reduce diarrhea diseases by one quarter to one third (Montcho S.A. 2014). Sanitary interventions are harder to conduct in spontaneous quarters due to high population densities, meaning that many technological options are not feasible. Such slums are good site for disease transmission (Rémi, K. 2006). In 2004, only some 59% of the world population had access to improved health care facility; implying that 4 out of 10 people in the world have no proper access to health care facility. A good proportion of the population is obliged to defecate in the open or use unsanitary facilities, with a serious risk of exposure to sanitary-related diseases. Though sanitary coverage slightly increased to 49% in 1990, a huge effort needs to be made to expand coverage to the SDG target level of 75%, even if investing in health care infrastructure involves a long project cycle. If the SDG on sanitation is to be achieved, innovative approaches need to be developed to reduce the time span from policymaking to services delivery. The global data on sanitation hide the dire situation in some developing countries 50%, implying that only one out of two people has access to some sort of improved sanitary facility.
In 2000, 189 nations adopted the United Nations Millennium Declaration where the Millennium Development Goals were made. The Millennium Development Goals and particularly Goal 4, focused in the reduction of child mortality by two thirds for children under five. According to the World Health Organization (2004), 1.1 billion people lacked access to water supply in 2002; this makes the population vulnerable to disease infections as poor health conditions in urban settlements are accountable for the death of thousands of children every day in the world and retards local development (United Nations, 2006). In the like manner, the WHO (2004) established that each year 1.8 million people pass away because of diarrhea disease, and 90% of these deaths are with children under five years. In 2004, only 59% of the world population had access to improved sanitary facility; in other words, 4 out of 10 people around the world have no access to improved sanitary facility. They are obliged to defecate in the open or use unhealthy facilities with a serious risk of exposure to diseases. Tinyami Erick Tandi et al., 2015, underscored that the public health sector is considered one of the driving forces of most developing countries’ health systems, due to some of its core objectives of preventing, improving and providing health services to their populations. According to the 2006 World Health Report, the WHO estimated that over 4.3 million more health workers are needed to bridge the gap of health personnel globally, of which about 1.5 million (35 %) are required in Africa alone in order to boost local development.
In Latin America, in the 1960s, community development attempted to promote the integration of marginal groups into modernization processes. The Brazilian Paulo Freire develops the concept and methods of popular education, based on a link between education, the development of identity and the organization of popular groups into social actors. Collective action aims to transforming the social structures that affect the daily lives of the populations. These ideas were driven by a strong stream of opinions and practices.
In Europe, the Anglo-Saxon world is the forerunner. As early as the 19th Century, young academics moved to poor neighbourhoods to educate people and discovering their living conditions and soughting the causes to change them. Then, after the Second World War, community projects channel private initiatives to elicit rapid responses to post-war economic and social problems, the state authorities only came in later in these dynamics. Later in the 1960s, community development projects were born in several European countries; they were based on the experiences of the previous social movements and also cultural movements.
When considering the African continent alone, data of 2010 from the United Nations revealed that over 413 million inhabitants being 40% live in town were faced with health challenges. The World urbanization prospects, (2009) recorded that Regions presenting the lowest coverage of sanitary facilities but with increasing populations are sub-Saharan Africa (37%), Southern Asia (38%) and Eastern Asia (45%).
According to the National Urban Profile of Cameroon, some 67% of the urban population lives in slums, experiencing an annual growth of 5, 5%. Elong, (2003) observed the manner in which the urban populations settled on the geographical space of Douala and how this occupation is a threat to their health. This idea was equally supported by Mara, (1996a), who stressed on the point that these populations cluster in spontaneous quarters where the living conditions there are unappealing, houses are dilapidating and high production of domestic solid wastes. The economically underprivileged population settled there and children are exposed more to unhealthy conditions. The production of dirt and exposure to sanitary risks results from human activity (Tchuikoua, 2010).
The health system has evolved in the course of the years since the 1930s. In the United States, where the Chicago School (composed mainly of sociologists) developed community organizing projects in working-class neighbourhoods based on the participation of the inhabitants: psychosociological theories in vogue at the time, which tended to psychologize delinquent behaviors.
The report from the WHO, 2017 reveals that the evolution of primary health care (PHC) in Cameroon covers two main periods: before and after the International Conference on Primary Health Care, Alma-Ata, 1978, the main outcome of which was the Alma-Ata Declaration on Primary Health Care. Before the Alma-Ata Conference, two approaches had been adopted. The first was a medical approach based on colonial- inspired vertical programs (urban public hospitals and rural denominational hospitals) in which good health was synonymous with absence of disease. This was also interesting because selected care was free of charge and the communities were loyal to the health workers. Based on the strength of this, a “health services” approach was applied. This was of course characterized by the four “demonstra tion zones of public health action” put in place in 1967 under the inspiration of the WHO and intended to introduce progressively selective health care and services deemed economically viable. Interestingly, this approach introduced the concept of village health teams and village dispensing pharmacies managed by local health personnel through a cost recovery mechanism underpinned by working capital. This was so because the communitybased health activities had positive effects and stimulated demand and communities were willing to contribute to the financing of health facilities and activities, including village pharmacies. It should be underscored here that the Community involvement was mostly passive and not active as it was supposed to be on the field.
After the Alma-Ata Conference which fostered the idea that health should go beyond the provision of care and enhance community participation so as to bring in a significant impact on health status, Cameroon adopted a number of health reforms in 1982. It was somehow disappointing when the Ministry of Public Health noted in a 1988 survey that there had been selective implementation of PHC through vertical programs carried out in parallel to and independent of the health system. Indeed, the system had not been restructured to integrate PHC; the use of community health workers without proper training was inefficient. Almost all mechanisms to ensure proper community participation were non-existent and health workers did not receive continuing professional development for supervision of community health personnel.
The subsequent Reorientation of Primary Health Care (Reo-PHC) involved a realignment of the National Health System towards the social goal of Health for All. The purpose of Reo-PHC was to ensure universal access to PHC services through a decentralized management process focused on the Health District level, with the institution of the integrated health centre as the first level of contact with the health system. The aim was to integrate health activities at the level of the health centre while empowering the communities engaged in financing and management. This reorientation, supported by technical and financial partners through Regional pilot experiments, has not, however, fully achieved the desired objectives. National seminars in 1993 and 1994 resulted in the development of a legislative and regulatory framework that placed the Health District as the foundation stone for PHC implementation, including the institution of district health management teams and district dialogue structures in the form of district health committees and district management committees. This restructuring formed the basis of the Health Sector Strategy 2001 - 2015 and its updated version of 2007.
The Cameroon health sector has undergone several stages of evolution in its functioning system back in the pre-colonial époque to the post colonial era. Each stage of the evolution is marked by specific reality in a bit to improve on the health situation of the population. The most recent changes have been the 2001-2015 Health Sector Strategy (HSS) policy frameworks for government action on health which expired in 2015. An evaluation of its content and its implementation led the development of a new HSS that covers the period 2016-2027. More interesting here is that this new strategy aligns with the Growth and Employment Strategy Paper (GESP) and with the Sustainable Development Goals (SDGs). This new strategy had the technical support of the Ministry of Economy, Planning and Regional Development (MINEPAT) and experts from the World Health Organization (WHO) in collaboration with partner administrations, private sector representatives, technical and financial partners (TFPs) and the civil society. This evolutive process of the health sector at the national level is in line with the local context in the Douala metropolis. The Douala city is experiencing the development of the new HSS which is expected to end in 2027.
The Millennium Development Goals and the Agenda 21 are some of the bases of inspiration in bringing susceptible solutions toward the challenge of community health and urban emergence so as to ameliorate the social welfare of the local population. The provision of social amenities and better social welfare are prerequisite to attain sustainable development and urban emergence. Moreover, this study through the law of demand and supply, it would show the rate of demand of social amenities by the local populations and the limited supply of them. This study is interesting on the political plan given that the government of Cameroon has set 2035 as the year where the nation would become an emergent nation. For the nation to become an emergent nation by 2035, the state would obviously considers essential aspects which lead to an emergent nation, one of such is the health conditions of its citizens which further influence many other dimensions of the nation. The study is interesting here because it would bring out clearly the various actions which have been undertaken by different urban actors toward the problem and also set forth better practical measures to be implemented in order to eradicate the challenge of community health and urban emergence in Douala.
Furthermore, the Government of Cameroon plans to implement the program named the Cameroon Millennium Villages Program (CMVP) with the financial support of the Government of Japan, the financial contribution of Japan was announced during TICAD in 2007 and in partnership with the United Nations system, the MDG Centre for West and Central Africa and Millennium Promise of the University of Columbia’s Earth Institute. This program intended to improve the living conditions of the target population in 2 clusters of Cameroon by offering them a range of supports which will go long way to contributing to the achievement of the Millennium Development Goals (MDGs). The program aimed to contribute to the implementation of the growth and employment strategy paper (GESP) of the government by piloting application at the cluster level and with the MDGs serving as the reference point. The urban setups are characterized by deteriorating socio-economic conditions and accelerating degradation of its environment and natural resources. The CMVP was to bolster sustainable development and human security through community focused innovative investments multi-sectoral packages which are specifically tailored to the needs and priorities of each of the local communities.
The Douala metropolis is expected to fully benefit from these programs in each of the health districts. The activities of the program include; maternal and infant health, food provision, gender equality, sustainable agricultural and many other community projects. The four main agricultural zones in the Douala city are pending to blossom in this new agricultural dynamic. The program equally saw the presence of many partners such as the Government of Japan; UNESCO, UNFPA, WHO, UNIDO, UNICEF, FAO, UNIFEM, WFP, ECA, UNAIDS, ILO, HCR. The program focused on capitalizing the efforts of all development stakeholders in different communities especially the government at central and decentralized levels, with emphasis on grassroots actors with a special attention to women and children who are more vulnerable to disease infection. They are referred here as private individuals, community organizations, private sector organizations, and local government.
The increase in the urban growth of Douala during the past ten years couples with the inflow of the Internally Displaced Persons (IDP) from the North West and from the South West Regions has widen the gap between the demand and the supply of health facilities. This sudden increase in the number of persons into the town without corresponding health facilities places the entire community at risk. Community efforts are highly demanding at this level to meet up with the MDGs and as well as the vision 2035 sets by the president of the republic of Cameroon.
1.3- Delimitation of the research
This research tries to reframe and gives the extent to which the study considers and explains some important concepts. This is interesting because some concepts are large in their definitions, different scientific disciplines; researchers and school of thoughts define them according to their understanding and to their contexts.
1.3.1- Epistemological delimitation
This study lies in the epistemological trend of the works of Marx Sorre (1933 and 1966) and of the New Geography which was spearheaded by the school of Chicago. The New Geography considers Man, Society and Space at it base of operation and considers distance as a measure, interaction as an object and location as a form. It further integrates health geography and disease geography in its operation. Expressed from the way distance is taken as a major interaction between objects, localisation of form and modelling like an approach. This was the road or idea propounded by the Determinist School of Thought and the milieu. This School of Thought then resulted to the Functionalist School of Thought with dimensional operationalisation as the best way in which human activities can be located through modelling. The Possibilist School of Thought used as the fundamental theory of concepts explains that human intellect has risen above, to the extent that the physical barriers that the environment offered have been overcome today by technological development thereby making what was impossible to be possible today.
The epistemological delimitation considers the notion of space from Denise Retaillée as the central concept of scientific geography. Just before then two concepts preceded, the first was developed by Jacques Lavy who talked of paleo-geography in which geographers are more chorographers who describe the earth, pacing or not, and try to find general laws (before the nineteenth century). The second stage of classical or Regional or Vidalian scientific geography (globally between 1870 and 1970-84), named after its founder in which the central notion is that of Regional territory associated with the study of landscapes. This notion of space makes it possible to reflect and organize the relation of humans to their environment, not only a natural environment (classical geography) but also a human environment made of people, places, territories, ideas, learning, etc.
Before the notion of space dominated the geographical field, this science used other notions: the Region; the kind of life; combinations; the landscapes. Concepts put in place by Paul Vidal Blache in the late nineteenth century and early twentieth century and then used until the 1960s in France. In this perspective, space is seen as the study of concrete physical territories around lines of force defined by the homogeneity of landscapes through mainly natural elements.
It is a word used with an ill-defined meaning and it is often confused with:
-terrestrial extent;
-area ;
-country;
-location ;
-even Region;
-or (even worse) territory.
Space seen by other sciences:
If we take again the original meaning of the word space, we must do it in Latin: spatium, it is a race field, an arena, but also an extension, distance or a duration, time lapse.
In mathematics, space is an important concept, but it is limited to an environment conceived by abstraction of the perceptual space. In Euclidean geometry, according to Poincaré, it is continuous, infinite, three-dimensional, homogeneous, and isotropic). In non-Euclidean geometries, space can have different (undefined) dimensions.
In astronomy it is referred to as the cosmological space.
Philosophy is the first to be interested in the idea of space, especially in the 17th and 18th Centuries. From Plato to Isaac Newton, space is seen in a classical way around the idea of positioning; we are close to the idea of Region or country in this sense of the word.
Platon develops in Timée his theory of space. It is characterized by the identification of space and matter. Platon identifies the world of physical bodies with that of geometric shapes. A physical body is simply a part of space limited by surfaces containing only a vacuum. His physics is geometric! The elements were provided with defined spatial structures: water (icosahedron); air (octahedron); fire (tetrahedron); earth (cube); ether (dodecahedron).
At Aristote, space defines the place as the immovable envelope of a body. For him, there is no void; space is the sum of all the places occupied by the bodies.
With George Berkeley (1685-1753), we go towards a cultural vision, a relationship to space limited by the sensory limits of the human being (the 5 senses).
René Descartes thinks space as "an extended substance" that relativizes space and corresponds to a unique reality. The space makes it possible to understand the threedimensional continuum. According to him, the body is understood from the notion of extension (an innate primitive notion of which we become aware from the sensory experience of our coroporeity) whereas space is a more abstract concept that expresses greatness; space becomes an object of geometry, therefore of abstraction.
Trevor J. B 2008 sees Health geography is a sub discipline of human geography which deals with the interaction between people and the environment. His ideas are based on the view that health geography sees health from a holistic perspective encompassing society and space. It encloses the role of place, location and geography in health, wellbeing and disease. He further argues that health geography is closely aligned with epidemiology but distinguishes on spatial relations and patterns. Whereas epidemiology is predicated on the biomedical model and focuses on the biology of disease, health geography seeks to explore the social, cultural and political contexts for health within a framework of spatial organization. Researches in health geography rely on two basic aspects: the patterns, causes and spread of disease, and the planning and provision of health services. Some research areas in health geography relevant to public health are; Services, infrastructures and land-use planning, Disease surveillance, modeling and mapping, Environmental health risk factor assessment, Health service use, Inequalities in health outcomes (Jones K et al; 1987, Dahlgren G. 1991, Mayer J.D. 2000). Paal V. 2010 consider health geography as a discipline which deals with spatial-geographical matters in connection with health and health care. In the same order of idea, it establishes two main fields which are the spatial properties and spatial- temporal changes of health (diseases and epidemics etc.), the other focuses on the revelation features of the system of health care (location and accessibility), and their social economic analysis.
The epistemological thoughts of health geography just as seen by Checkoway H. 1989, Twisk 2003, and Shaw M, 2001, it deals with the spatial characteristics of the state of health of an individual, their spatial-temporal changes as well as the revelation of the features of health care systems and the analysis of their social-economic effects. Health geography is divided into two main research areas namely the medical geography and health care geography (the geography of health care provision). Medical geography is closer to medicine and physical geography while health care geography studies the state of health care from a sociological and economical point of view and its research areas are closer to human geography.
The ideas from the different Schools of Thought led to the application of concepts related to community health and urban emergence in Douala by bringing out the role played by man in his environment. The urban setup of Douala has been transformed by the local population to satisfy their desire at the expense of their health. This work repositions man at the centre of his community and also the way man interacts with his milieu.
1.3.2- Thematic delimitation
The present study can be structured into the following points:
The framework of community health in Douala, this thematic is limited to the administrative organization of health systems, regulatory framework of health facilities, Funding structures of health institutions and to managerial structure and practices of community health in Douala.
The system of management for water and food security extends its tentacles to the State management of urban health security, decentralized stakeholders of water management, the local population involvement in water provision, the civil society and water provision and the international partners and urban water provision.
The management of urban hygiene and sanitation is limited to urban disease Vector management, urban sewage disposal system management and to the implementation of urban hygiene and sanitation.
The management of urban epidemics is limited to food and water borne disease management, Vector borne diseases management, air borne diseases management, evaluation of urban disease management strategies and to drug supply and evaluation as per WHO of urban responses to epidemics.
1.3.3- Spatial delimitation
The town of Douala which has been retained in the frame of this study as our study zone , is situated on the estuary of Wouri at about 30 km from the Atlantic Ocean, c lose to the equator between latitude 4° and 4°10’ North and between longitude 9°35’ and 9°80’ East. Fortunately, the town happens to be the economic capital of Cameroon with a total surface area of 21000 hectares which is administered by the Douala Urban Council (DUC). According to Ejuande E.W. 2016, this latter was created by the law N°87/015 of 15 July 1987, it has a population of about 3 500 000 inhabitants which are repartitioned in the six (06) Sub-Divisions of the town. Keeping aside the Manoka rural council, the other 05 Sub-Divisional Councils are further subdivided into 120 quarters.
The town of Douala is found in the Littoral Region of Cameroon and in the Gulf of Guinea which opens to the Atlantic Ocean. The figure1 presents the physical location of the study area.
Abbildung in dieser Leseprobe nicht enthalten
Source: MINSANTE 2018© Ejuande E.W.
Figure 1: Location of the health districts of Douala
1.4- Scientific context
This research proposes a socio-spatial study of community health and urban emergence in Douala-Cameroon. Hence, a thematic mapping is indispensable to sort out all the different ways in which the problem is felt in the entire urban space as well as bring out the already existing works of other researchers on this thematic.
According to Bertelsmann Stiftung 2018; Berne, 2019 and WHO 2019, 45% of the global population (3.4 billion people) used a safely managed sanitation service in 2017 and 31% of the global population (2.4 billion people) used private sanitation facilities connected to sewers from which wastewater was treated. About 14% of the global population (1.0 billion people) used toilets or latrines where excreta were disposed of in situ and 74% of the world’s population (5.5 billion people) used at least a basic sanitation service. These data do not in any way override the crucial health challenges of the population because the findings also revealed that 2.0 billion people still do not have basic sanitation facilities such as toilets or latrines and 673 million still defecate in the open, for example in street gutters, behind bushes or into open bodies of water (Still D.A., 2006). This sanitary crisis is linked to water challenges observed in many towns of Cameroon like Douala where there is quantitative and qualitative weaknesses in the water sector (Kouagheu J. 2017, Nguendo Yongsi, H.B. et al., 2008). Ejuande E.W. 2016 noted that irresponsible practice in the domaine of hygiene and sanitation always have ugly outcomes because poor sanitation has a strong linked to transmission of diseases such as cholera, diarrhoea, dysentery, hepatitis A, typhoid and polio and exacerbates stunting (Swaddiwudhipong W, et al. 2012). It also reduces human wellbeing, social and economic development due to impacts such as anxiety, risk of sexual assault, and lost educational opportunities (Jacky Ndjepel 2014). Moreover, the report of the WHO 2019 revealed that inadequate sanitation is estimated to cause 432 000 diarrhoeal deaths annually and is a major factor in several neglected tropical diseases, including intestinal worms, schistosomiasis, and trachoma.
Some 827 000 people in low- and middle-income countries die as a result of inadequate water, sanitation, and hygiene each year, this representing 60% of total diarrhoeal deaths. Poor sanitation is believed to be the major cause in some 432 000 deaths and diarrhoea tops the league of being a major killer.
Furthermore, open defecation perpetuates a vicious cycle of disease and poverty in a community and countries where open defection is most widespread have the highest number of deaths of children aged less than 5 years as well as the highest levels of malnutrition and poverty (Massimo Berruti & Sangita Vyas 2014).
Though the health sector in Cameroon shows little progress in particular domains, example is the overall national average for the use of modern family planning methods which increased from 14.4% to 15.4% among married women. Most health indicators remain alarming and significant efforts are needed to improve the situation, particularly in the area of reproductive health. According to EDS-MICS 2018, the maternal mortality rate rose from 782 to 467 deaths per 100,000 live births between 2011 and 2018 (Expert in health production 2020) and this increase in the number of death is linked to the absence of specialists (Esther Cubo et al., 2017).
The total fertility rate decreased slightly from 5.1 to 4.8. About 25% of adolescents aged 15 to 19 have already started procreating. This early reproduction and barriers to accessto health services have contributed significantly to obstetric fistula, an estimated incidence of nearly 2,000 cases each year.
According to Tchoungui Oyono L. 2018 and the Ministry of Public Health, there is a lack of equity in access to care compounded by the lack of universal health coverage. The minister acknowledges that there is also a significant disparity in health coverage in regions and districts with insufficient infrastructure. Some medical facilities set up, such as medical imaging centres are no more functioning due to lack of maintenance and the population has insufficient physical access to health care. This is due in particular to the uneven distribution of health infrastructure and equipment, their dilapidated nature and the lack of maintenance.
The Cameroon's health system is characterized by very high costs for specialized medical care and according to the findings of Lefebvre B. 2011, some specialized services do exist, but they are poorly equipped. For instance, chronic respiratory diseases be managed in 1st category and 2nd category hospitals, unfortunately in many cases equipment or medicines are lacking or insufficient.
The 2001-2015 Health Sector Strategy enabled to get significant results in terms of improved coverage of some interventions. Little progress was made in this domain with high expectation still remaining to achieve universal access to quality health care. The 12th December 2012 marks the holding of General Assembly of the United Nations and the adoption of Resolution A/67/L.36 for universal health coverage. This resolution invites Member States to adopt a multi-sector approach and address the determinants of health per sector, integrating health into all policies, as appropriate, while taking into account its social, environmental and economic determinants in order to reduce inequalities in this area and to promote sustainable development (UNICEF- 2019).
The year 2015 served as a transition between the Millennium Development Goals (MDGs) set in 2000 and the Sustainable Development Goals (SDGs), which aim to induce inclusive and sustainable development in different countries. The third objective aims to reduce maternal and child mortality, to eradicate epidemics related to major communicable diseases, and to reduce early mortality due to non-communicable diseases by 2030. The Sustainable Development Goals are a bold, universal agreement to end poverty and all its dimensions and craft an equal, just and secure world - for people, planet and prosperity. The UN General Assembly Summit in September 2015 sets the pace for the 2030 Agenda for Sustainable Development which was adopted by the UN’s 193 member states. It ended up by proposing 17 Sustainable Development Goals (SDGs) and their 169 targets to be attained by member states. The year 2016 marks the first year of the implementation of the SDGs (WHO 2014).
The environmental conditions in which many of the town dwellers live in the world today have devastating consequences which are also a great health problems to them (Ejuande, 2016). The environmental problems constitute a great threat in many developing countries today (Fotso G. H. 2012), Cameroon in general and the town of Douala in particular face these problems. It is because of the pertinence of this subject that the Millennium Development Goals (MDGs) have set target 11, which proposes by 2020, improving substantially the lives of at least 100 million people living in popular quarters and facing health challenges which retard local development.
The economic and social views of community health and urban emergence in the context of decentralization as noted by Meva’a, Abomo D. et al., 2013 pointed out that the inflow of population into the town contributes to local development in the welcoming area and also stands as a factor of urban disorder and wastes production. The situation aggravates the already existing community health problems faced by the local populations.
1.5- The research Problem
This study considers and examines different points of view from a set of authors whose contributions to the study of community health have enriched the world of science. The literature review would lay emphasis on some key aspects of community health.
Empirical Observation
The town of Douala which is an entity of the republic of Cameroon and representing the field of study has been experiencing some dynamisms at the level of public health, community health, local development and urban emergence as the country is gearing toward becoming an emergent nation by 2035 and equally making efforts to implementing the policies of decentralization. Many observations have been made in the entire town of Douala which have motivated, galvanized and added more weight to this study. The observations were made based on some dimensions of community health system such as; the provision of potable water and food security, hygiene and sanitation in the living space, vaccination against infectious diseases, prevention of epidemics and provision of essential drugs. It has been observed that the different actors (institutional and non-institutional) who intervene in the framework of community health, play a paramount role in promoting the health conditions of the populations and enhancing development at local and national levels so that the country becomes an emergent nation by 2035. The observations bring to light the ugly sides of the actors in their logics, strategies and practices in the urban system of community health and urban emergence of Douala-Cameroon.
It has been observed that the provision of potable water in quantity and in quality still remains a real nightmare, the rate of water and food pollution is increasing day-by-day thereby causing more infections to the populations and degrading the environment (Sugden S., 2006). The examples of the cholera outbreaks of 1971, 1972, 1984, 1985, 1991, 1996, and 2004 are still fresh in our memories; these evidences make the entire territory of Douala to be more vulnerable to epidemic attacks of all nature. Increasing food insufficiency has led to hunger and starvation causing malformation and malfunctioning of the metabolic system. The production and disposal of domestic solid and liquid waste is a serious health challenge in the town of Douala. The domestic solid wastes and even industrial wastes are usually deposited on road junctions, on streets; others are incinerated or deposited in the nearby bushes and the nearby streams. The disposal of domestic and industrial liquid waste has a similar pattern of disposal which is most in the nearby streams, on the environment, bushes and less of septic holes. Some companies located at elevated altitude or situated upstream usually disposed off their industrial liquid waste in the closest drainage basins. Some examples here are the Guinness Company which clears off their industrial liquid waste in the Mbanya drainage basin, the SCDP discharges in the Mboppi drainage basin, the UCB discharges in the Bobongo drainage basin, etc...
Moreover, the observations on the field reveal that the town is experiencing an increasing rate of illicit sales of drugs by unqualified individuals (most often the entire family from the children to the aged population administer treatment on patients), multiplicity of private health centers and health care units with little or no deontological knowledge about the profession. Patients’ health status becoming a public debate rather than a private and secret issue; the medical personnel who are supposed to keep patients’ health reports secret are now discussing and diffusing the reports from one individual to the other. Closely linked to the aforementioned empirical realities are the problems of lack of family planning, early pregnancies, abortion, stillbirth, increase child mortality and lack of proper prenatal and post-natal maternal care.
Referential:
In Cameroon, the Law of 05 December 1974 conferred to municipalities the competences to manage their respective jurisdictions in terms of planning, hygiene and sanitation. Basing on the strength of this law which sets the pace to decentralization of power to decentralized territorial authorities to fully engage in socioeconomic, sociopolitical and socio-cultural development; the decentralized territorial authorities are expected from the onset to pursue whole heartedly the idea while bearing in mind that they would be in possession of all the necessary resources (financial and material resources) and power to fully implement the above law. Closely linked to this law is the law N 96/12 of 05 August 1996 on the environmental management and planning which formerly prohibits the creation of improper dustbins in the heart of settlement areas , Decree N 92 -252-PM of 06 July 1992 laying down conditions for the creation of lay private he alth centers and Decree N 95/013 of 07 February 1995 organising health service at the district level. Moreover, the SDGs of the United Nations were signed by member countries of which Cameroon fully took part by expressing the desire to implement the 17 goals in the entire triangle of the country. Paradoxically, some great metropolises in Cameroon such as Douala are facing great challenges to conform to these prescriptions.
The main research problem
From what precedes, looking at the text of laws and the realities on the field, a major contrast arises between “that which should be and that which is”. Now therefore, this study poses the problem of insufficient contribution of urban community health system on the emergence of Douala coupled to the urban deviations from the Sustainable Development Goals.
The debate guiding the research problem
Community health in an urban setup has always found a favorable echo in the midst of public opinion and scientific community. The scientific community looks at it to have resulted from different approaches and perception of the subject matter.
According to Assako, A. R.J., (2003), Meva’a, A. D. et al., (2010), health risks in an urban settlement leads to the proliferation of communicable diseases like malaria, typhoid fever ... in the entire inhabited zone thereby affecting the majority of the population. According to them, these disease infections resulted from unsanitary conditions the populations live and the water sources as well as the water quality are the causes of these disease infections. Disease vectors such as cockroaches, mosquito, and rats... settled on the domestic solid and liquid wastes found on the streets and in open dustbins; they later pollute water sources and foodstuff as they land on these latter thereby transmitting infections to humans (Toyi, A., 2001). Mosquito on their path suck the blood from infected persons and later transmit disease to healthy people.
On the other hand, several authors have carried out research on the social aspects of health risks and one of the existing research works is that of SHARE (2014), which clearly demonstrated that the women and girls are particularly disadvantaged as a result of multiple socio-cultural and economic factors which deny them equal rights with men. This is evident because the female sex lacks the facilities and means to manage the simple biological necessities of defecation and menstruation which makes them more vulnerable to health risks. The UNDCP (1995) found out that health problems impair family life and productive employment, diminish the quality of life and may threaten survival as tobacco and alcohol consumption account for nearly 5 million deaths annually worldwide.
Moreover, Philippe, D.C. et al., (2013) put forth the idea that the social mutations occurring worldwide may have adverse effects on the health of the populations. Furthermore, the phenomenon of demographic explosion has greatly increased the population of Cameroon and that of Douala in particular. According to ECAM II (2001), urbanization has increased to 53, 4% in 2004 against 37, and 8% in 1987; this means that more than half of the population lives in urban centers. Such an increase is very unfortunately accompanied with insufficient qualitative and quantitative sanitary equipment; the excess populations in such an urban setup are compelled to live in unsanitary conditions and being vulnerable to disease infections.
Considering the stakes of the study, health risk can leads to political stake in the sense that it raises political debates within the civil society on the quality of health care services offer to the local populations. It further raises the challenge of sanitary coverage to be achieved in the town of Douala and beyond. Example of this political debate is that of Laquintinie Hospital on the 12 of March 2016 where a pregnant lady “late Koumate Monique” lost her life in the course of delivery a twin. This situation greatly stirred up the political atmosphere at national and the international levels, making stakeholders to question the type of health care system put in place by the government of Cameroon.
The local populations living in any given unsanitary urban setup as in Douala are very vulnerable to disease infections. Given that the inhabitants are constantly confronted with disease infections, they would spend their little financial and material resources for treatment, buying of drugs and hence, it would leads to the challenge of impoverishment of households. The economic stake here become very challenging because the more resources spent on the treatment of a disease, the higher the cost of living and the lower the standards of living mostly if the household sources of revenue do not change.
The lack of proper sanitary measure causes diseases (Élong, J. G. 2003). The main stake here is the proliferation of infectious diseases such as malaria, typhoid fever... which record increasing number of casualties. According to Massimo, B. and Sangita, V. (2014), Poor sanitation perpetuates a vicious cycle of disease which stands as a major challenge to overcome. Jane-Francis Tatah et al., (2013) further underlined the fact that insufficient sanitary measures set the pace for infectious diseases like cholera which has become endemic in Douala (Ngandjio A, et al. 2009).
Furthermore, another call for concern here is that of high morbidity and mortality rates occurring in the town of Douala. Poor sanitary conditions in an urban setup increases mortality worldwide; a case in hand is diarrhea which records 04 billion cases per year and responsible for 2.2 million deaths as underscored by Rex Banza, K. (2007). Beside this challenge to overcome is that of frequent absenteeism and excuses from work. Households often stay off from work or usually come late due to their deplorable state of health and this retards the general social and economic activities of the society.
Aspects to be studied
Relevant aspects which call for attention are to be studied within the framework of this study, they concern the organizational framework of community health, hygiene and sanitation of the living space, potable water management, food security, demand and supply of community health facilities, epidemic and drug supply in the town of Douala
1.6- Research question
This section of the study is structured into two segments namely the main research question and the specific questions.
1.6.1- The main question
Does the urban community health contribute to the emergence of Douala-Cameroon?
1.6.2- Specific questions
i).What are the organizational mechanisms that govern the urban system of community health of Douala?
ii)Does the management system of potable water and food security guarantee the emergence of Douala?
iii)Can the present state of hygiene and sanitation contribute effectively to the emergence of Douala?
iv)How far can the vaccination campaigns and the prevention against epidemics contribute to the emergence of Douala?
1.7 - Research objectives
1.7.1- Main objectives:
Assess the contribution of community health to the emergence of Douala
1.7.2- Specific objectives
i)Analyze the mechanisms that govern the urban system of community health of Douala
ii)Examine the various strategies and practices of stakeholders to manage potable water and food security
iii)Characterize the various actions undertaken to improve the state of hygiene and sanitation in the town of Douala.
iv)Analyze the various preventive methods against epidemics in the town of Douala
1.8 - Research hypothesis
1.8.1- Main hypothesis
The main research hypothesis in this study stipulate that the present state of Community health is a limiting factor to the emergence of Douala
1.8.2- Specific hypotheses
i)The administrative system stands out as the mechanism that govern community health of Douala
ii)The management of potable water and food security contribute more to socio- spatial disparities than to urban emergence of Douala-Cameroon
iii)The emergence of Douala is pending with the present state of hygiene and sanitation
iv)The epidemics prevention methods and disease control are constraints to urban emergence of Douala
1.9 - The structure of the work
This study examines various contributions of community health to urban emergence in Douala; it lays emphasis on the role played by different stakeholders in the urban setup and e qually accesses each of the stakeholder’s contribution. The study is structured as shown on the Research Synoptic table 1.
Table 1: The research summary
Abbildung in dieser Leseprobe nicht enthalten
1.10- Difficulties encountered and limitations of the research
This study did not go without difficulties. The first difficulty encountered was limited financial means to effectively cover the entire town of Douala. This is explained by the fact that the study area is large enough; the town is cosmopolitan with different new realities which require careful study and specific solutions. Another difficulty was at the level of obtaining administrative data. The administrative data were not easy to obtain and mostly health data. Most of the medical personnel were constantly occupied while others were either on mission. The study also witnessed language barrier since some respondents could not express themselves in English or in French. Above all, given the importance of this study, it was up for us to go beyond all the difficulties and permit the study to go through. Language barrier was overcome by learning local languages and making use of interpreters. The administrative difficulties were solved by developing patient and taking repeated rendezvous. The first limit of the study is that we were unable to collect specific data in a given time intervals during high episode of rain and inundation like in the years 2000, 2010 and 2015. The study could not explore in depth all the related notions of community health and urban development in Douala but only concentrated on few concepts. Nevertheless, this study is open to receive critics in order to ameliorate and propel it to higher levels.
CHAPTER TWO: LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK
2.0 - Introduction
This chapter explains the approaches used by different authors in explaining how community health evolved in different part of the world including the various ways used in classifying the indicators. The concepts and literature review applied by different authors are brought out in the proceeding paragraphs. The review of some concepts and the critics brought out form an integral part of this chapter. It includes the views of those authors whose works have been consulted in the review.
2.1 - Literature Review
This section brings to light the scientific reflexions and technical propositions on the questions of community health and local development in great metropolis like Douala. Looking at the already existing research works, it is obvious that this theme of study ties squarely with the ongoing research works on urban development in sub-Sahara African countries and Cameroon becoming an emergent nation by the year 2035.
Socio-economic approach
According to the UNO-Habitat (2010), close to one billion of human beings clustered themselves in slums or in popular quarters which are generally dirty, not planned, they are irregular and are found in the heart of big towns and cities of the south (Fogwe, Z.N. 2005). This idea was further sustained by Meva’a, A. D., (2012), who emphasized that the clustering of these populations on a central place results in mass production of sewer and garbage. This situation seems to obey the second law of demand and supply since the increase in population size leads to increase production of dirt. The findings of Tchuikoua (2010) are of paramount importance at this juncture of the study in order to better assimilate the problem of community health; he looks at the rate of production of dirt in Douala to be by far greater than the carrying capacity. The cost of evacuating these wastes is by far greater than the payment of about 07 billion of francs CFA meant for wastes evacuation. As the urban population keeps on swelling over time and given that the living standards in well planned areas are expensive; popular, spontaneous and mostly precarious settlements now serve as refuge ground for the bulk of the urban population. Since the rate of increase in the urban populations of Douala is estimated to be 5%, this increase stands as an extra burden to the Council to evacuate the wastes produce by them.
The concept of health determinants has been changing through history. At the time of Ar istotle’s Ethics and Policy (3), the concept of health was located in the broader field of living well, both morally and socially. Aristotle identifies three kinds of resources for living well: goods of the body, goods of the soul, and external goods. Analysis of extensive literature dealing with development of the health concept points to the existence of at least three categories, where the first focuses on internal balance, the second on external factors, and the third one on the equilibrium between the first two. The quality of interaction between an individual and his or her external environmental factors has been recognized as crucial for one’s health. Further studies focused on mechanisms of interaction and its components. Health services and functions have long been deemed exclusively critical among a string of external factors.
Looking at the gravity of sanitary risks on the inhabitants of unhealthy environment at the world at large, it is realized that the environmental conditions in which millions of town dwellers in the world live have very dreadful and even catastrophic consequences on their health as Diabagaté, (2007) noted. Many recent projections suggest the overall urban population living in dirty popular quarters worldwide would increase steadily in the upcoming years by an estimated 27 million new slum residents annually from 2000-2020 and this represent a danger to human welfare just as UN-HABITAT (2003a) recorded. At the moment, the one billion individuals living in unsanitary urban popular settlements comprise roughly one- third of the world’s total urban population, 43 percent of the urban population in the developing countries, and 78 percent of the urban population in the poorest, least developed countries (UN-HABITAT 2003a, 2006). Poor sanitation is one of the most accurate indicators of urban poverty and health problems (Tapsirou, H. 2010) and according to the World Health Organization (WHO), over 600 million urbanites live in low quality shelters or other areas plagued by overcrowding and inadequate provision of sanitation services, including potable water and safe waste disposal. The number of people without access to these services is still on an increase, irrespective of the general improvements in urban sanitation programs. In the last twenty years, sanitation coverage has made great strides, but it continues to be less accessible to the urban poor.
According to the UNDP-World Bank Water and Sanitation Program, in 1990, 453 million urbanites “had no sanitation services,” and despit e efforts to ameliorate this crisis, in 1994, this number had increased to 589 million people. The challenge of sanitation intervention is to keep up with the growing population. According to Wright, Albert M. (2011), the current rate at which sanitation programs are being introduced to communities is by far lower than the rate of overall population growth, resulting in more underserved people, despite several attempts to increase coverage. Added to this is the fact that, the exceeding population growth results in overcrowding, exacerbating sanitation issues in mostly urban milieu. Coulibaly et al., (2004) described the problem of sanitary risks in another dimension by arguing that on the overall the sanitary facilities in the African cities (60 - 95%) are generally dominated by the autonomous systems (SAA) (WC + septic tanks, latrines, etc.). Still in this context of reasoning, it has been underscored that half of the people living in developing countries do not have access to even a basic toilet and this presents a major risk to public health since these populations without access to basic toilet would adopt malpractices of defecating everywhere on the environment. Furthermore, Strauss et al., (2000) qualify the sanitary situations in third world towns to be generally dominated by self-purification works. They often repress wastewater which trickles down in living quarter streets emitting strong foul odors which renders the milieu unhealthy.
Moreover, Elong, J. G. (2003) equally argued to sustain this idea that the water intended for consumption are very often contaminated because of drinking water connection with the sewage and worse of all is the poor management of domestic solid waste which litter on the streets. This fact can cause high health risks and environmental pathologies arising from it are very important (OMS, 1992). The same problems of sanitary risks are noticed in the drainage system as there exist poor drainage of wastewater and storm water, leading to the proliferation of ponds, stagnant water which are breathing grounds for mosquito vectors of diseases like malaria (Fogwe et al., 2016). Basing on the report of WHO (1985), diseases attributable to poor sanitary conditions currently kill more children globally than AIDS, malaria, measles and diarrhea is the single biggest killer of children in Africa. Safe sanitary measure is widely acknowledged to be an essential foundation for better health, welfare and economic productivity, but progress in reducing the burden of sanitary related diseases borne by poor people in developing countries remains slow and is holding back progress on all other development outcomes.
To further expatiate on this point, Dongo et al., (2008) and Nkumbesone (2016) confirmed the idea that the absence of good sanitary measures greatly contributes to the deterioration of health. The same idea was developed by Farthing (2000) who argued that diarrheal diseases are caused by several parasites including Salmonella (most frequently occurred) and are located in unhealthy environments which lack adequate modern sewerage system or are associated with poor environmental hygiene. Such a situation according to these authors is very common in most cities in developing countries where poor environmental conditions prevail and children below five years of age are the most vulnerable.
The community health system has been developed across the globe in different ways which can be used as a pattern to others. Taking the case of Korea, the Korean government introduced a system known as Community Health Practitioners (CHPs) as front-line primary health care providers to address the health disparity between urban and rural areas. Through their dedicated contribution in the past 30 years, the CHPs have improved Korea's public health through the successful control of high birth rates, a lowered maternal and infant mortality rate in the 1980s, eradication of parasitic infection, and containing many communicable diseases including hepatitis B. it should be noted at this level that, the rapid changes in the health care environment and demands for health care among rural residents have required changes in the roles and functions of the CHPs. They are challenged by fundamental changes in the public health system addressing various health issues due to a rapidly aging society, pandemic of chronic disease, new infectious disease, and climate changes.
Over one billion individuals live in extreme poverty and are forced to survive on less than one dollar a day (Mitlin D., 2004). In the case of Cameroon, from 2001 to 2007, the proportion of the population living below the national poverty line did not vary significantly as it dropped from 40.2% to 39%. The Poverty Reduction Strategy Program (PRSP) of Cameroon was launched in 2003-2006 and targeted socioeconomic development to include the MDGs. In the main time the GDP experienced an average real growth rate of 3.32%, whereas during the preceding 2000-2002 periods in which no official poverty reduction program was implemented, the average real GDP growth rate was comparatively higher, standing at 4.23%. In 2001, of a population estimated at close to 15.5 million inhabitants, 6.2 million were considered as poor. According to ECAM3 stat istics, the country’s population in 2007 was estimated at close to 17.9 million inhabitants of whom 51% were women and 49% men, while 43% were aged below 15 years and only 3.5% was aged 65 years. Poor people were 7.1 million. This situation led to the significant increase in the number of poor people within different communities of the urban and the rural areas with associated community health challenges on a daily base. It is therefore evident that the growth targets of Cameroon as set by the PRSP 2003 were not met, and that the country had difficulties capitalizing on its stable macro-economic framework and exploiting the opportunities that were offered between 2001 and 2007, especially in terms of pledged resources after it reached the decision and completion points of the Heavily Indebted Poor Countries (HIPC) Initiative. Basing on the strength of this, the Government of Cameroon committed itself to reducing extreme poverty through a clear political will expressed at the top level of state. The Cameroon government places the attainment of the MDGs on the country’s agenda and support efforts aimed at reducing poverty and consolidating human development in the Cameroon Vision 2035, set by the president.
Sanitary approach
According to Sadik (1994), urban gigantism increases the needs as regards housing, water, hygiene, energy, health care, educations, social services, food and the difficulties of sustainable sanitation. This same idea was developed by Djuikom et al., (2006) who analyzed sanitary risks in another dimension by arguing that rivers, spring and wells represent the major sources of water supply to the human and animal populations in the tropical zones and their pollution constitute a serious health risks (WHO/UNICEF, 2000). The lack of potable water and poor sanitary conditions has caused many diseases and the spread of deadly diseases worldwide (Massimo, B. & Sangita, V. 2014); hence, good sanitary conditions are essential in making life livable.
One of the most significant diseases which arise from poor sanitary conditions is diarrhea. Deaths resulting from diarrhea are estimated to be between 1.6 and 2.5 million deaths every year. Most of the affected are young children below the ages of five. Other diseases which are caused by poor sanitary conditions include schistosomiasis, trachoma, and soil-transmitted Helminthiases. Poor sanitary conditions account for almost 50 percent of underweight child since it has a direct link to diarrhea. About 3.8 million Cameroonians lack access to adequate sanitary facilities (Katte et al., 2003) and most of the diseases resulting from poor sanitary conditions have a direct relation to poverty . Moreover, according to Murray and Lopez, (1996); UNPD, (1998); WHO, (2000), it is annually estimated worldwide that four billion cases of diarrhea are responsible for 2, 2 million deaths, 200 million people attacked by schistosomiases and 400 million people infected by intestinal worms.
[...]
- Citation du texte
- Emmanuel Wonomu Ejuande (Auteur), 2020, The Influence of Urban Community Health System on the Emergence of Douala, Cameroon, Munich, GRIN Verlag, https://www.grin.com/document/1354772
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