Around a dozen adults and children are waiting patiently for their check-ups. Sitting behind a small table, Etienne Esua listens to the patients, dresses wounds and pricks fingers to perform rapid malaria tests.

“When a test shows that a person has malaria, but the symptoms are not severe, I treat the patients with drugs,” Mr Esua says.

The consultations are taking place on the veranda of an ordinary house in a village in the South-West region of Cameroon. Mr Esua is not a medical professional, but a community volunteer trained by Médecins Sans Frontières (MSF) to provide basic healthcare to some of the region’s most vulnerable and hard-to-reach communities.

Violence displaces people – which hinders access to healthcare

For the past four years, Cameroon’s North-West and South-West regions have been rocked by armed violence between government forces and non-state armed groups, which has displaced more than 700,000 people. The humanitarian needs are huge.

Displaced communities face difficulties accessing basic services, including healthcare. The crisis has severely affected the public health system. Many health centres have closed or are not functional; medical workers and facilities are being directly targeted by violence; and insecurity is hindering the supply of drugs and medical equipment.

Given this high level of insecurity, humanitarian organisations like MSF face serious problems to reach displaced communities, who often hide in the bush for their safety.

Healthcare in the community, by the community

To provide medical aid in such challenging conditions, MSF has set up a decentralised model of care in the South-West and North-West regions, which is delivered directly in the community, by the community. It relies on volunteers like Mr Esua.

“Community health volunteers are the bridge between the health facilities that we support and the vulnerable communities that don’t have access to health centres,” says Yilma Werkagegnehu, MSF field coordinator. “Communities don’t have access either because they are displaced, because health structures are closed or because they can’t afford to pay for medical services.”

MSF currently works with 106 community volunteers in several health districts near the towns of Mamfe and Kumba in the South-West region. Similar activities were conducted in the North-West until December 2020, but have been put on hold following a decision from the authorities to suspend MSF activities in the region until further notice.

People from communities trained to treat those in need

Community health volunteers have been recommended and selected by community leaders and are trained by MSF to detect and treat simple diseases like uncomplicated cases of malaria and respiratory tract infections, malnutrition and diarrhoea. They also learn how to carry out health promotion activities to prevent people from getting sick and how to look out for signs of sexual abuse and psychological distress. While they might not be medical professionals, these volunteers are still trained to adhere to medical ethics, and to treat those in need, regardless of background.

In 2020, community volunteers provided more than 150,000 free medical consultations in the South-West and North-West region.

The community health volunteers are paid incentives for their work and receive backpacks filled with medicines. They meet regularly with MSF supervisors to discuss their work, get advice and share medical data. Their backpacks are refilled before they return to visit remote communities, often walking for several hours a day.

Being able to refer patients to MSF facilities

If a treatment is beyond their capacity, community volunteers can refer patients to MSF-supported health facilities where they receive free treatment if they meet certain criteria, such as children with severe malaria, women with complicated pregnancies, victims of sexual violence or patients with intentional injuries.

One of the referred patients is a seven-year-old girl named Dorcas. She is sitting on a bench next to her mother outside the MSF-supported Presbyterian General Hospital in Kumba, South-West region. Her left leg is in a cast.

“The girl was injured in a traffic accident and was referred to the hospital by one of our community volunteers,” says Dr Guisilla Dedino. “She was assessed in the emergency room and was diagnosed as having an open fracture of the left leg. An MSF surgeon operated on her; she is making progress, with the fracture showing good signs of healing.”

Challenges of healthcare in a conflict context

Travelling from remote villages to health facilities is a major challenge for many people, due to insecurity, bad road conditions and lack of transport. MSF offers a free, 24-hour ambulance service that operates seven days a week, collects eligible patients at designated pick-up points and takes them to MSF-supported health centres and hospitals.

Where we cannot go, MSF provides money for public transport so that patients can reach health structures or pick-up-points. Managing a decentralised model of care and ambulance service is not easy in an insecure environment such as South-West Cameroon.

“Our community volunteers are sometimes harassed by armed men,” says Paulo Milanesio, MSF emergency coordinator for the South-West region. “We are in constant dialogue with different stakeholders to guarantee their safety.”

“We need everyone to understand that community volunteers and ambulances provide a much-needed lifeline for vulnerable communities who would otherwise be deprived of medical care,” Milanesio says.