Although infectious diseases (HIV/AIDS, Malaria, Tuberculosis) dominate the allocation of scarce public health resources, there is growing evidence that chronic diseases are beginning to receive government attention [47, 48]. Unfortunately, it is impossible to quantify the Cameroonian government's level of investment in chronic diseases control with precision, since the health budget allocation is not always specified by disease groups and therefore no budgetary allocation data could be located.
The bulk of health care in Cameroon is provided by the public sector. The private sector is growing, but mainly in large cities. The sector of health insurance is embryonic. The public sector health care system consists of district hospitals and community clinics/health centers at the primary level, which are largely nurse-driven other than in major urban areas. These are complemented by secondary and tertiary care hospitals, although the latter are unevenly distributed in the country, concentrated in the more developed, urbanized areas. In terms of distribution of the health workforce, there were approximately 2 physicians, and 16 nurses and midwives per 100,000 people in Cameroon for the 2000-2009 period .
Major deficiencies exist in both the quality and access to care such that chronic diseases and their risk factors are diagnosed infrequently and managed inadequately. Clinics are swamped by large patient numbers. Health care workers do not always have the knowledge or skills, in particular communication skills, to provide optimal patient-centred care. Stock shortages of essential drugs, lack of access to others (e.g., lipid-lowering agents), and limited recourse to testing (e.g., glycated hemoglobin) hinder health care delivery. In addition, there is a need to overcome health care provider 'inertia' related to effective communication and knowledge translation with patients .
Chronic non-communicable disease control
Since 2001, a number of health policies relevant to chronic diseases management, as well as those addressing standards and norms for a primary health care package and community care workers, have been formulated and adopted by the Cameroonian Ministry of public health. The baseline Cameroon Burden of Diabetes (CAMBoD) survey provided new scientific knowledge that guided health policy and the implementation of a diabetes and hypertension program . Diabetes and hypertension were recognized as emerging public-health problems, and incorporated into a national 10-year plan for health promotion, with this leading to the creation of two bodies within the Ministry of Public Health: the Department of Applied Research; and the Department of Disease Control that focuses on non-communicable diseases. This also occurred as result of an increasing political will to develop policies and national programs to prevent and control non-communicable chronic diseases . The aim of the nationwide diabetes-hypertension control program is to promote equitable access to quality health services in order to reduce the morbidity and mortality linked to these conditions. The specific objectives of this program for the 2004-2010 period were: 1) To obtain 25% reduction in the prevalence of modifiable risk factors for diabetes and hypertension in the population through the Integrated Communication Plan; 2) To ensure optimal management of all people with diabetes detected in all health institutions in the country; 3) To obtain 25% reduction in complications linked to diabetes and hypertension, 4) To obtain 100% coverage of the Health Districts by the program; 5) To implement the National Diabetes-Hypertension Control Plan. The various strategies adopted to achieve the formulated objectives were - capacity building for home and health-service management of diabetes and hypertension, prevention of diabetes and hypertension, reduction of risk factors, reduction of complications of diabetes and hypertension, epidemiologic surveillance, management process, training and development operational research on diabetes and hypertension, partnerships for the control of diabetes and hypertension, reinforcement of institutional capacities .
Within the framework of the Cameroon Essential Non-Communicable Disease Health Invention Project (CENHIP) a number of studies have been carried out, showing that a task shifting to nurse could help to control chronic diseases . Implementation of a 26-month protocol, for the care of hypertension by trained nurses, in urban and rural areas, was shown to be effective at controlling blood pressure. This led to a drop of systolic and diastolic blood pressures by 11.7 mm Hg (95% confidence interval (CI): 8.9-14.4) and 7.8 (95% CI: 5.9-9.6), respectively (p < 0.001) between baseline and final visits . A similar program for diabetes, led to a drop of mean fasting capillary blood glucose by 1.6 mmol/L (95% CI: 0.8-2.3; p < 0.001) between baseline and final visits . These results have been used to guide the design of health care and services aspects of the national policy for diabetes and hypertension.
Involvement of traditional healers (who constitute an important parallel traditional health care system to the biomedical health) may have a beneficial effect in the fight against chronic disease . Indeed, results from a CamBoD qualitative study indicate that training of traditional healers in the fight against diabetes led them to refer their patients for blood glucose tests at biomedical health facilities more often, desist from scarifying patients with diabetes, and educate their patients, peers and other people in their communities about diabetes .
A National Cancer Committee based in the Ministry of Public Health exists since 1990, and has been organizing periodic screenings/sensitization campaigns for breast, prostate and cervical cancers (two or three times a year) . In 2002, a national cancer control policy or program was adopted . However, data on the activities and achievements of this program is scarce.
The Cameroonian government has started to prioritize chronic non-communicable diseases in his health agenda. However, this is mostly happening for diabetes, probably because the vast majority of the available evidence to formulate policies originates from the local diabetes research community.
Fiscal and regulatory interventions
Tobacco control policies are not prioritized in Cameroon. Although there is a national tobacco control program, no data on the trends in tobacco exists, to evaluate such a program. A number of tobacco control measures theoretically exist in Cameroon, including some limited smoke-free provisions/legislation (current national smoke free legislation covers healthcare, educational and government facilities), an advertisement ban and some labeling requirements. However, implementation and enforcement of these measures are still problematic. It is usual not to have health warnings on cigarette packages and advertisements in Cameroon. Though Cameroon has ratified the WHO's Framework Convention on Tobacco Control (FCTC), none of the existing measures is FCTC-compliant [53, 54]. The national tobacco control and taxation bill do not include all aspects of FCTC. There is a need to render the tobacco control program more effective, enforce the legislation that prohibits smoking in all indoor public places, close the loopholes that allow the tobacco industry to continue to advertise freely; and increase public awareness of the health hazards associated with cigarettes and other tobacco products; as well as restrict young persons' access to cigarettes.
To date, there is no national nutritional policy in Cameroon. Although there is a law on food labeling, which mandate that information on the nutritional value of foods, microbial content and additives be clearly displayed on packaging, it is too recent to have been effectively implemented . However, any such implementation should account for the functional illiteracy of a fraction of the Cameroonian population (32%) . The food sector needs formal regulation that would mainly aim at foreign multinational food companies that are the main suppliers of snacks sold locally and food rich in additives and trans-fats.
There are also no regulations regarding the nutritional content of meals served in schools, or the amount of physical education required in schools, even if theoretically physical activity is part of the curriculum in secondary schools. It is important to note that very few schools may actually have on-campus catering facilities.
Nation-wide campaigns to promote physical activity, good nutrition, and tobacco control do not exist. Sporadic activities are often organized around particular events such as the world diabetes day, world heart day, etc... However, studies in the field of diabetes suggest that awareness campaigns for the prevention of chronic diseases can achieve very good results. Indeed, a 4-year long intensive health promotions activity within the framework of the CAMBoD pilot study, in a semi-urban population, raised the level of diabetes awareness among adult Cameroonians . These health promotion activities used all conventional (mass media, health facilities, distribution of health education materials) and non-conventional (meetings in market places, in churches/mosques, health education activities in schools, drama on diabetes in TV/radios) methods. These findings lay the groundwork for further studies and provide evidence policy making.
Role of the private sector
In Cameroon, the private sector has traditionally been an under-utilized partner for health promotion, primary and secondary prevention of chronic diseases, and cost-effective management. It is unclear how much the local and multinational companies installed in the country spend in the health of their employees. The concept of health insurance is relatively new in the Cameroonian environment. It would therefore be difficult to conceive of local prevention strategies that revolve around health insurance, such as wellness program initiatives and benefits in which health-seeking behaviors such as health-risk assessments, gym membership, purchase of healthy foods, opportunistic screening, chronic disease management programs, and worksite wellness interventions, would be fully or partially subsidized and in some cases incentivized.
Within the framework of the CAMBoD project of sentinel surveillance implemented in four sites, a public-private partnership was established, involving a number of pharmaceutical firms to supply diagnostic equipment for the early detection of diabetes and support the provision of training for medical and paramedical staff in diabetes care . This initiative has been contributing to improvements in diabetes care. Also, the Cameroonian Ministry of Public Health signed an agreement with one pharmaceutical company in 2006, to ensure a reduction in the price of insulin. Partnerships were also sought with non-profit organizations. Rotary Clubs were invited to back a pilot project to offer free comprehensive care for children with type 1 diabetes in Cameroon . The Cameroon Ministry of Public Health assumed responsibility for the provision of care at the sentinel sites that provided research data under CAMBoD. The project is currently been extended into other provinces, with the objective to cover all of Cameroon's ten provinces .
Additional efforts are needed to encourage further engagement of the private sector in activities directed at the prevention and management of all chronic diseases. This could be done through corporate social investment activities, e.g., the provision of dedicated research and training funding, the implementation or support of school- or community-based programs promoting physical activity, healthy eating, and tobacco control, as well a social marketing campaigns focusing on healthy choices and health-seeking behaviors.