The people who completed the survey were divided into three groups: parents of PKU children (n = 403), parents of PKU adults (n = 58) and PKU patients older than 16 years (n = 153). The differences among the three analysed groups were found in the number of contacts, the way of contacting a doctor/dietitian during the pandemic and satisfaction with remote contact. Caregivers of children with PKU reported better therapy compliance, more frequent contacts with specialists and more satisfaction with remote visits than adult patients. We also observed a relationship between satisfaction from remote contact and self-reported frequency of contacts with a doctor/dietitian, as well as a relationship between satisfaction from remote contact and recommended blood Phe levels reported by both patients and caregivers. Travel time exceeding three hours from the respondents’ location to their doctor was associated with higher odds of their recognition of remote contact as a method of PKU treatment only in the group of caregivers. In the caregiver groups, the reported worse access to low-Phe products during the lockdown was linked to the perceived difficulty of maintaining the diet. However, such a relationship was not found among patients. In conclusion, significant differences in the perception of the pandemic lockdown and its impact on health and treatment-related issues were found.The first pandemic lockdown dramatically impacted many aspects of everyday life, including healthcare systems. The purpose of this study was to identify problems of patients with phenylketonuria (PKU) and their parents/caregivers during that time. We aimed to analyse potential differences in the self-reported compliance and characteristics of contacts with a doctor/dietitian before and during the pandemic lockdown and the perception of access to special food and opinions on remote contacts between a particular group of respondents. All participants ( According to the 2020 NORD survey  of thoseThe confirmation of the first Polish case of SARS-CoV-2 infection came on 4 March 2020. The state’s government imposed various types of lockdown control measures; on 12 March, primary, secondary and tertiary schools all over the country ceased to function and subsequently went online. On 15 March, the borders of Poland were closed for foreigners, and on 25 March, the freedom of movement for Polish citizens within Poland was restricted chiefly to basic grocery shopping, visiting a doctor or a pharmacy or going to work that could only be performed in person. On 1 April, minors were forbidden to move unattended in public spaces, and restrictions were introduced in the operation of shops and services. Meanwhile, the activities of institutions and companies were limited, with employees delegated to remote work. Dismissals of employees have also started in many companies. The situation in health care units was extremely complicated. At the end of January, the testing of patients for the presence of coronavirus began, and in February, the first Polish patients suspected of SARS-CoV-2 infection were hospitalised. In many localities, access restrictions have been introduced, first for visitors, and later also for patients. Patients themselves also began to limit their contacts with health care units. Some of the hospitals that used to care for phenylketonuria (PKU) patients so far have been included in the network of hospitals intended for patients with coronavirus. The difficulties with the personal access of PKU patients to their specialist doctors and nutritionists began in February and March, depending on the region of the country and the specifics of a particular hospital.Indeed, COVID-19 has impacted the treatment of a variety of conditions. This was felt primarily by patients and their families but also by healthcare professionals as well as the healthcare system as a whole. The situation impacted health services in terms of the diagnosis and ensuing therapy, with healthcare professionals faced with hitherto unknown challenges that included switching from in-person to telemedicine meetings with phone- and/or video-aided visits, the introduction of social distancing and other safety measures to minimise the risk of COVID-19 transmission and coping with the shortages of personal protective equipment ,5,6,7. MIn a recently published national online survey on how PKU patients in Poland perceive health and therapy-related issues , we docuThe present study aimed to analyse potential differences in the self-reported compliance and characteristics of contacts with their doctor/dietician before and during the pandemic lockdown and the perception of remote access to special food and opinions of parents of PKU children and adults, as well as PKU patients older than 16 years who responded to the above-mentioned survey  or its cThe distribution of invitations for PKU patients and their caregivers to take part in an anonymous online survey was carried out by phone, electronic post or by sms, as well as during planned visits to PKU specialists in ten specialised PKU-treating centres all over Poland. We also requested those responsible for running local PKU communities’ websites to place the information about our survey there. Moreover, the information was shared by the patients themselves on Facebook and by telephone. This was confirmed in conversations with the patients, who informed their doctors about having completed the questionnaire. We collected our data in the time period 15 June–20 July 2020, except for one PKU treating centre that communicated with their patients via website only, which led to delays in survey distribution, so we decided to include questionnaires completed until the end of August. The inclusion criteria were a diagnosis of PKU reached by newborn screening, dietary recommendations adhered to since the diagnosis was made and systematic care in a PKU-treating centre. The exclusion criterion was persons aged under 16 years or unknown.The respondents were divided into two subsets, patients and their caregivers, who were further divided into those caring for patients under 18 years of age and those caring for adults. The latter group consisted of only 58 caregivers; therefore, in many analyses, they were combined with the group of caregivers of underage patients. Needless to say, we made sure that this was logical, justified on therapeutic grounds and did not interfere with the results obtained, since the parents’ perspectives may be different from those of adult patients themselves. Moreover, parents’ answers on their adult children’s behalf may point to possible social differences, which we decided not to pursue further as it was not the focus of our study.The non-validated questionnaire consisted of 31 questions, 27 of which were single choice, 2 multiple choice and 2 open-ended questions . All quep < 0.05.The data gathered in the questionnaires were checked for quality, completeness and consistency and exported into the statistical package JASP Team (2021), JASP (Version 0.14.1) [Computer software] and STATISTICA v. 13.3 . The results are presented as descriptive statistics, means and standard deviations (SDs), ranges and percentages. The odds ratio (OR) was calculated to compare one group of patients according to different characteristics based on specific feelings, behaviour or opinions, to other respondents. To estimate the precision of the OR, the 95% confidence interval (95% CI) was calculated. Kruskal–Wallis ANOVA and post hoc tests were used to determine statistically significant differences between the three groups. We set up the level of significance at We received 620 completed questionnaires, of which 614 were qualified for further analysis, while six were disqualified due to respondents’ age being under 16. Patients aged 16 to 44 years completed 153 questionnaires, while 58 questionnaires were filled in by caregivers of adult patients with PKU and 403 were completed by parents of children (>18 years old). There was a difference in the gender in the group in which patients completed the questionnaires independently and the group in which the questionnaires were filled in by parents of underage patients. Self-reported Phe levels before the pandemic in PKU patients aged under 18, as reported by their parents (group 3), differed from those declared by the other two groups (group 1 and group 2). Respondents from group 3 reported the best results of self-reported blood Phe levels before the pandemic, with 74.4% of them reporting Phe levels as recommended. However, during the pandemic, statistically significant differences in changes of self-reported blood Phe levels were observed only between patients from groups 1 and 3 . RespondMost respondents declared to have contacted their doctor/dietitian by phone before the pandemic, with parents of PKU patients under 18 using telehealth more often than the other groups . This waDuring the lockdown, a significant proportion of patients and caregivers reported deterioration in the supply of Phe-free formulas and low-Phe products, but there were no differences between the groups . Most ofThe parents of children under 18 differed significantly from patients in their opinions about remote contact with a specialist, with no difference in the interest in future remote contacts or in the opinions regarding replacing direct contact with a specialist with remote contact for PKU and other diseases . RegardiWe divided our patients into two groups according to their responses to the question about pre-pandemic self-reported Phe levels. The first group included patients who declared their pre-pandemic Phe levels to be as recommended, while the second group’s self-reported Phe levels were above the target range. The OR of being satisfied with remote contact with a PKU specialist for an individual reporting Phe levels before the pandemic within the target range was higher than for those with Phe levels above the target range. Similarly, the caregivers were divided into two groups in line with their responses to the question “Did you use to contact your PKU specialist/dietitian by phone prior to the pandemic?” see . The firTravel time exceeding three hours from the respondents’ location to their PKU-centre was linked to a higher OR of their acceptance of remote contact as a method of PKU therapy only in the group of caregivers .In the caregiver groups, the reported worse access to low-Phe products during the lockdown was linked to the perceived difficulty of maintaining the diet . HoweverThe most important findings of the present study comprise significant differences in self-reported blood Phe levels and satisfaction with remote medical visit between caregivers of children with PKU and adult PKU patients. According to our research, telephone contact was the most common form of communication between PKU patients and caregivers of patients with a doctor and dietitian during the lockdown. We also observed that both patients and caregivers reporting regular contact with their doctor/dietitian and recommended blood Phe levels before the lockdown expressed higher satisfaction with the contact with doctors/dietitians. In addition, we documented the relationship between travel time and the assessment of a remote visit, as well as that between the perception of compliance and self-reported Phe levels in caregivers but not in adult patients.Patients with PKU as well as other RDs faced various adversities before the pandemic. In the case of PKU, the changes seem significant, as patients had to stay at home, their physical activity changed, and in the case of adult patients and parents of children with PKU, the way of working also changed. Most previous habits became difficult to implement, and many patients were simply forced to change them overnight. Our study found that the self-reported Phe results of only about half of the patients remained unchanged during the lockdown, with the rest reporting either improvement or deterioration in levels. These changes affected all the studied groups of patients. In a recent study , we docuA study by Rovelli et al.  proved tEarlier studies have shown an increase in stress related to the spread of the coronavirus in the families of patients, impacting the habits of patients regarding walking outdoors . A signiThis study has some limitations. More caregivers of children than adult subjects with PKU and caregivers of adult patients participated in the survey, and their opinions refer to the relatively short six-week lockdown. However, from a longer perspective, the first wave could have exerted the most significant effect due to uncertainty. Due to the anonymous character of the questionnaire, we cannot refer to any objective measures of epidemiological characteristics, nutrition and compliance, but it may have resulted in more sincere responses. The survey nature of the study makes it impossible to verify the truthfulness of the answer, including self-reported blood Phe levels, before the pandemic and changes during the pandemic. The strength of the present study is the large sample size, with a very high response rate. In our study, most patients aged 16 and over were women. The observed differences in the gender structure of the studied groups most likely resulted from the emphasis placed on the prevention of maternal PKU, which may explain the greater participation of adult women and balanced gender structure in the other groups. As both patients and their caregivers were invited to complete the questionnaire, the obtained results concern a broad population of families of people suffering from PKU. Despite the high rate of return of the questionnaires, the numbers of individual groups completing the questionnaire are different. Moreover, the situation of adults on behalf of whom the parents have filled in the questionnaire is not entirely clear. However, we decided to include the group of their parents because this group of respondents (and their perspectives) seemed important. Additionally, it might differ from that of caregivers of young patients and of adult patients.Caregivers of children with PKU reported better therapy compliance, more frequent contacts with specialists during the analysed six-week pandemic period and more satisfaction with remote visits than adult patients. There was also a relationship between satisfaction with remote contact and self-reported frequency of contacts with a doctor/dietitian, as well as between satisfaction with remote contact and recommended blood Phe levels in both patients and caregivers. Moreover, the travel time and the feeling of poorer access to low-phenylalanine products were related to the different perceptions of the value of remote contacts and compliance in adult patients and caregivers. Our study also indirectly allows certain insights into the best ways of dealing with potential future emergency periods: more effort should be dedicated to the popularisation among adult patients of the remote mode of contact with specialists. Further studies are necessary to identify the most vulnerable persons and develop an appropriate strategy of medical support for individual patients and caregivers.


Environmental factors play an important role in obesity-related behaviors. Evidence indicates significant associations between weight and urban green spaces in adults, but it is not clear whether this relationship applies to adolescents. Therefore, our aim was to determine the associations between urban green spaces, greenness exposure and species richness in residential environments with physical activity and body mass index. Sixty-two adolescents between 12 and 18 years of age answered a self-administered questionnaire, providing information on height, weight, age, sex and home address. Data on socioeconomic deprivation were obtained from the European Index of Deprivation for Small Portuguese Areas. Physical activity levels were assessed using accelerometers. Urban green space counts and the normalized difference vegetation index values were measured using buffers along the roads with distances of 300, 500, 1000 and 1500 m from each participant’s residence. To quantify the species richness, the species richness index was used. Linear regression models were fitted to analyze whether urban green spaces, exposure to green spaces and species richness counts for each distance were associated with physical activity and self-reported body mass index. We did not find significant associations between the independent variables and the probability of overweight or obesity. The relationship between environmental variables, adolescents’ physical activity and body weight seems to be complex and further studies may contribute to better understanding of the topic. In recent decades, obesity and overweight have shown rapid increases and high prevalence in children and adolescents. This scenario has amplified the concern for the health of young people worldwide and has motivated researches to clarify causal factors of obesity for these age groups .A high body mass index (BMI) is strongly associated with an increased risk of developing chronic diseases, such as cardiovascular diseases , diabeteSeveral studies have shown that children and adolescents who engage in more physical activity (PA) have a lower BMI than those who are less active ,9. In thIn this context, socioecological models suggest that individual, interpersonal, environmental and political factors influence health and PA behaviors . The maiRecent studies have demonstrated that certain characteristics of the built environment, such as street connectivity and transport systems, are capable of promoting PA; therefore, environmental interventions seem to be a sustainable strategy to encourage young populations to engage in or increase PA . MoreoveAs the existing studies did not simultaneously consider the impacts of all the characteristics of the built environment, it is still difficult to indicate the characteristics that most affect the levels of PA of adolescents . RegardiAmong recreational facilities, urban green spaces (UGS) in particular have been attracting attention . This tyThe relationship between PA and BMI is well documented and the presence of UGS in the residential environment has been increasingly described as one of the determinants highly associated with overweight and obesity ,9.The negative relationship between the number of UGS in the residential area BMI has been consistently reported among child populations ,24; howeAlthough many studies have demonstrated positive impacts of UGS on human health and well-being ,27, it iGiven this scenario, green space measures, such as exposure to green spaces and biodiversity, can be assessed to help understand and comprehensively clarify the possible relationships between UGS and health .We aimed to explore whether the number of UGS, the level of green exposure and the amount of species richness in the residential environment were associated with PA and BMI in Portuguese adolescents, and whether these relationships change with adjustment to the socioeconomic deprivation index.2 [Oporto is the second city and the fourth most populous municipality in Portugal. The municipality, with an area of 41.42 km2 , has a p2 . Data were collected in 4 of the 7 public high schools in Oporto city. The schools were selected for convenience, according to the interest of teachers and school managers in participating in the study. Participation was requested from all adolescents enrolled in physical education classes and whose teachers agreed to participate in the research.The calculations for determining the sample size with a confidence level of 95% and a margin of error of 5% resulted in a total of 382 subjects .We obtained a total of 311 participants residing in the metropolitan area of Porto; however, since data referring to the species richness index were only available for the city of Porto, 249 subjects were excluded because they lived outside the limits of this municipality. The final sample size comprised 62 adolescents  between 12 and 18 years of age. Prior to data collection, both participants and their parents received a complete explanation of the purpose of the investigation and signed a written consent form to participate in the study. Ethical approval for this study was obtained from the Ethic Committee of the Faculty of Sports of the University of Porto (CEFADE 22.2013). Consent was also collected from the Education Authority and the School Board.Information on height, weight, age, gender and residential address were obtained through a self-administered questionnaire. The measure commonly used to define the weight status is the BMI and associations between BMI and health outcomes within and between populations are often used to help determine possible causes of illness . 2), while the BMI z-scores were categorized into normal weight (1 standard deviation (SD)), overweight (>+1SD) and obesity (>+2SD) [The BMI values were calculated as weight in kilograms divided by height in meters squared (kg/m (>+2SD) . For anaData regarding the socioeconomic deprivation of the sample subjects were obtained from the European Index of Deprivation for Small Portuguese Areas (EDI-PT) .The EDI-PT is a sensitive measure to capture health inequalities, as it is associated with the development and health of the population . The prePhysical activity (PA) levels were assessed using the Actigraph model GT3X+ accelerometers . Participants used an accelerometer attached to an elastic belt positioned on the right side of the pelvic girdle throughout waking hours for seven consecutive days, except during bathing and water activities.The epoch was set to 30 s, and for data analysis purposes only participants with a minimum of 600 min of daily use for 4 weekdays and 1 weekend day (or with 3000 min of use over 4 days) were included .The cut-off points proposed by Evenson  were useA total of 226 public green spaces were considered, with no restrictions on size, location or characteristics, covering the universe of public green spaces available in the study area that could be freely (free of charge) used by the population. Polygons of green spaces and entrance places were obtained from digital city maps, as described in previous studies .Using the location of each child’s residence as a starting point, the following measures based on a network of geographic accessibility to green spaces were calculated: number of available green spaces within 300, 500, 1000 and 1500 m from the residence and school (score). When the green spaces were delimited , we used the distance to the entrance; otherwise, the distance to the limit was used.For the calculations, we used ArcGIS software version 10.5 and the Network Analyst extension, using an updated street network dataset provided by the Environmental Systems Research Institute.The normalized difference vegetation index (NDVI) was used to analyze the greenness exposure . To captThe underlying principle employed in the NDVI calculation is that chlorophyll in healthy vegetation absorbs radiation in the VIRS region (630–690 nm) of the electromagnetic spectrum and reflects radiation in the NIR region (760–900 nm). It is a unitless index ranging from −1 to 1, with higher values corresponding to a higher density of healthy vegetation. For this study, images with 5% or less of Landsat 8 cloud cover  were used during the spring–summer (vegetation peak) period of 2016–2017 . ArcMap 10.5 was used to process satellite images and QGIS 3.8.2 was used to extract the average NDVI for each participant.In order to quantify the species richness, we used the species richness index (SRI). This index was obtained from a species richness report previously compiled by Porto City Council and the Research Center for Biodiversity and Genetic Resources (CIBIO) ,43. The To express the concentrations of species in the habitats that surrounded the residences, we summed the numbers of different species present in the habitats located within different network-based buffers  multiplied by the total area of each habitat, then subsequently we divided the resulting values by the buffer area in square meters. https://www.exalar21.com/home|accessed on 13 November 2019) [Such an approach has been used in previous studies, such as the EXALAR XXI project  ,45. Adjusted linear regression models were used to analyze whether UGS counts, exposure to green spaces (NDVI) and SRI for road distances of 300, 500, 1000 and 1500 m were associated with PA and BMI. The models were applied to the entire sample and by gender. The EDI-PT of the residential neighborhood was included in the model as an adjustment variable.The likelihood ratio tests were performed to compare the power of a predictive model. Collinearity diagnostics were run on the variables included in each model. Odds ratios were calculated for 95% confidence intervals.The intraclass correlation coefficient (ICC) was also calculated to provide a better understanding of the proportion of variance due to group differences .All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 25 .2. About 83% of the adolescents did not achieve daily PA recommendations of 60 min of MVPA, with the average MVPA being about 41 min.The sample characteristics are presented in n = 14) of the sample was overweight or obese. The average BMI for the normal weight group was approximately 20 kg/m2 for both sexes. Descriptive statistics for each variable by gender and by BMI categories are shown in p = 0.04).In relation to the UGS average at 300 m, the residential environment for boys with normal weight contained fewer green spaces when compared with the environment for boys with overweight / obesity  suggested that clustering between neighborhoods and schools was non-existent; therefore, a multilevel analysis was not used .The crude regression models performed individually with each predictor  did not Since socioeconomic deprivation seems to play an important role in the relationship with overweight and obesity, we developed a model with adjustment for the socioeconomic deprivation index see ; howeverLikelihood ratio tests showed that the addition of variables to each subsequent model did not significantly improve the model fit. Collinearity diagnostics did not reveal major concerns, with no variance inflation factor scores above three.An increasing number of studies have sought to assess the relationship between urban nature and human health, using many different research approaches and obtaining heterogeneous results.In our study, the socioeconomic deprivation index was inversely related to BMI in boys and no significant results were found for the other variables. Potential confounding variables were included but the size of the effect did not change. Regardless, our findings raise some interesting points for discussion.There is a general consensus that green spaces close to residential areas support human health and that their distance to a subject’s home is important .The European Environment Agency (EEA)  recommenIn this context, McCrorie et al.  stated tIn particular, the objective measures of PA, accessibility to the UGS and exposure to green spaces seem to be very relevant with regard to the identification of environmental determinants about the use of UGS and the relationship with the health of populations ,53,54.Except for the weight and height obtained by self-report, in our study we mainly used information from objective measures, with the latter method seeming to be more advantageous compared to the subjective measures; thus, we consider that our results are likely to be quite reliable, although we emphasize that the environmental determinants related to UGS in favor of health seem complex and interrelated .In addition, despite the unanimity of the benefits of UGS for health populations, certain environmental determinants of the use and provision of UGS may not be universal, since each city has a specific structure and a peculiar group of inhabitants . Although UGS have generally been treated as a type of homogeneous environment, some studies have separated the spaces into relatively broad typologies, suggesting that some types affect health to varying degrees; that is, not all UGS are equal in their health benefits . The composition and configuration of urban green spaces are usually measured through metrics of the landscape . Among tAlthough some studies have postulated that more green closer to home may be important for health , in our Recently Ekkel and de Vries  conducteEventually, if similar approaches are replicated elsewhere, they may be able to provide more information about the mechanisms by which exposure to green spaces may or may not influence PA and BMI in juvenile populations.In this context, the relationship between UGS and health is becoming prominent in the urban planning agenda and in development policies, which already refer to the positive effects of the presence, use and design of UGS ,56.Despite the UGS being integrated into policies and urban planning development, the role of these spaces in supporting biodiversity and the links between biodiversity and human health have received insufficient attention, with the few existing studies on these subjects presenting inconclusive results .This study was one of the first to explore the influence of species richness on adolescents’ PA and BMI, for which we found no significant results.Interestingly, the results from the study by Schwartz et al.  highlighIn contrast, the study by Leemans and De Groot  concludeHowever, Mills et al.  found thIn addition to the interaction between UGS and biodiversity, the interaction of SES with the environmental context has also gained some relevance. Our results showed the existence of an inverse relationship between the socioeconomic deprivation index and the boys’ BMI values. Some studies conducted with children and adolescents have highlighted the fact that areas with greater material deprivation or lower levels of wealth have higher prevalence of obesity or overweight, regardless of the socioeconomic position of the household ,67.However, Gordon-Larsen et al.  disagreeAccording to Noonan , there aThe method used for analyzing socioeconomic deprivation could be an important factor in terms of inconsistencies, since there are several existing measures, including the education of parents or guardians and household income.Although this study does not report significant results related to PA and overweight or obesity, further studies may be important to improve knowledge in the search for an understanding of the mechanisms by which access to green spaces, greenery and the presence of species richness in urban environments influence PA and weight in adolescent populations.Studies of the determinants of urban health are complex because cities are constantly changing, resulting in different living conditions within and between cities. In this sense, the availability of green spaces can vary considerably between different urban areas. Currently, there are no standards that accurately establish the quantity or ideal characteristics of green spaces associated with benefits for human health. Although this study tried to fill a knowledge gap, certain limitations need to be recognized. First, since it was a cross-sectional study, it was not possible to make an inference about causal directions. Second, although self-reported anthropometrics are valuable sources of data, the self-reported bias can have important consequences for the accuracy of screening for overweight and obesity . PreviouThird, we had no information about possible confounding variables, such as concerns about safety, traffic or related to overall aesthetics environments’, which made impossible testing their effects. In addition, it is likely that there are other attributes of green spaces  that we did not capture that could influence the levels of adolescent PA, and which consequently could impact BMI values.p values depend on both the effect size and the sample size, the sample used probably did not provide enough power to find statistical differences [Fourth, despite being considered an a priori estimate of the ideal sample size for this research, the smaller geographical extent of the species richness dataset forced us to conduct the study using a smaller sample. This may have influenced the results, especially with regard to the probability of detecting statistical significant associations between variables . Furtherferences .Despite these weaknesses and the lack of evidence on the relationships between the amount of UGS, green exposure and the amount of species richness inserted in the residential environment with PA and BMI for Portuguese adolescents, the results of this study are a relevant contribution to the literature as they provide are groundbreaking.In this study, we did not find relations between the number of urban green spaces, green exposure and species richness in residence areas with PA and incidence rates of overweight and obesity among a Portuguese adolescent population. The relationships between the amount of UGS, exposure to green spaces and the richness of species with PA and BMI seem to be complex, and further studies are needed for a better understanding of this topic.


Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania.Globally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and A descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data.While TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community.Similar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability. Over the past few decades, the global community has been advocating for Community-Based Health Insurance (CBHI) schemes in order to increase access to healthcare services and thus achieve Universal Health Coverage (UHC). The CBHI is voluntary, non-profit health insurance, normally organized at the community level, mainly targeting those working in the informal sector –4. CBHIsLike other LMICs, Tanzania has been implementing Health Sector Reforms (HSRs) since 1990 s. As part of the HSRs, CBHI schemes were introduced in order to organise and mobilise community initiatives to finance health services. The Community Health Fund (CHF) and Tiba Kwa Kadi (TIKA) are types of CBHI schemes which are currently implemented in Tanzania. CHF was piloted in few districts in Tanzania in 1996 as an initiative to make healthcare services available and affordable to the people residing in rural areas; and those in the informal sector. In 2001, the government enacted the CHF Act and declared CHF a voluntary prepayment health financing mechanism to be rolled out countrywide . TIKA waFollowing the weakness in the performance of CHF in terms of enrolment, fund management and benefit coverage, the then Ministry of Health and Social Welfare (MoHSW) decided to transfer the management of CHF operations to the National Health Insurance Fund (NHIF) in 2009, as the latter has more experience and expertise in the health industry . The chaFrom the onset to the recent reviews of evidence, low membership has been persistently observed in CBHI schemes in LMICs –11, and Many studies conducted in Tanzania have mainly examined rural-based community health insurance and, therefore, there is scanty evidence on how the TIKA scheme is implemented in urban Tanzania. In order to inform policy and practice, there is a need to investigate the implementation of CBHI schemes in urban settings. To that end, this study investigated the implementation of TIKA scheme in urban districts of Tanzania. Understanding facilitators and barriers to the implementation of the urban-based CBHI scheme is important in order to inform the ongoing efforts to achieve Universal Health Coverage.This study adopted a descriptive qualitative case study design . DescripSimple random sampling technique was used to select four urban districts which were implementing TIKA. In each district, the study involved the district hospital, two health centres and two dispensaries whereby health centres and dispensaries were selected randomly. The study was conducted in public health facilities only because TIKA was not implemented in non-public health facilities. Purposive sampling technique was utilized to recruit respondents and participants based on their involvement in the implementation of TIKA. Interview guides were developed and tailored to specific categories of respondents. Furthermore, catchment streets surrounding health facilities were included in the study. In these streets, the study involved local government officials, community health workers and members of health facility committees. These officials were purposively selected because of their involvement in the implementation of TIKA scheme. The information collected from these respondents included facilitators and barriers to the implementation of TIKA scheme.A total of 12 focus group discussions (FGDs) were conducted (3 in each district) with members of the TIKA scheme. Participants in the FGDs were recruited in the involved health facilities on the day of data collection. FGDs comprised 8–12 members; both men and women. The researchers worked with local guides to recruit FGD participants, but the guides were not present when FGDs were conducted. Furthermore, in-depth interviews were conducted with key informants at the national, district and health facility levels. FGDs were conducted at health facility and interviews were conducted in the respondent’s workplace or home. In-depth interviews and FGDs were conducted in Kiswahili language and lasted between 30 and 45 min. The focus of the study was to understand how TIKA scheme was implemented and factors that facilitated and hindered uptake of the scheme. Table Secondary data were collected through document reviews at the district levels. The documents reviewed included district annual plans, minutes of health committees and TIKA registers. Whereas minutes provided information on the process of developing and implementing TIKA scheme in respective districts, district annual plans and TIKA registers provided information on the uptake of the scheme, including enrolment rates.The data obtained from in-depth interviews, FGDs and reviewed documents were analysed using thematic approach . First, This section presents the findings on the implementation of TIKA scheme in Tanzania. The section is organised into four key themes, which are establishment and management of the scheme, enrolment procedures and premium payment, benefit package and portability of services, and purchasing of healthcare services.Within the context of decentralisation in Tanzania, following a pilot study in 1996 and 1998, district councils were given mandate to establish and implement CHF/TIKA schemes. TIKA scheme was essentially backed by the 2001 CHF Act and guided by the Cabinet Directive No. 36 of 2007. However, the implementation of the scheme varied across districts in terms of annual contribution rates and benefit packages. Annual contributions were determined by the respective district, and amounted to TZS 10,000–30,000 . An analysis of district health reports and minutes as well as interviews with most district health managers revealed that Council Health Management Teams (CHMTs) had the mandate to initiate a draft of TIKA by-laws in collaboration with the office of the Council Attorney. The draft TIKA by-laws were discussed in the Council Health Service Boards and in Council Social and Economic Committees and Finance Committees; and opinions were gathered from the local community through community meetings. The draft was then endorsed by the Full Council and sent to the respective ministries for approval.At the national level, the scheme was managed by the then Ministry of Health and Social Welfare . The Ministry was responsible for formulating the Policy and coordinating the establishment of TIKA. On the other hand, the Ministry was also responsible for training, supervising, monitoring and implementing the scheme in district councils. The Ministry also provided matching grants to districts through the NHIF management. At the district level, the management of the scheme was under the CHMT on behalf of the office of the District Executive Director (DED). The CHMT is headed by the office of the District Medical Officer (DMO), assisted by the Council Heath Services Board (CHSB). At the level of the facility, TIKA scheme was headed by facility medical officers in-charge. While at the community level, the scheme was managed by the people through Village Councils and health facility committees. The Village Council was responsible for approving by-laws and other decision while the facility heath committees were responsible for supervising, monitoring and approving the decisions made at the facility level.Interviews with most district health managers revealed that the establishment of TIKA scheme took long time particularly the institution of by-laws. For example, in Kibaha and Kinondoni Municipalities, while the establishment of TIKA started in 2009, the scheme was launched in 2012 and 2015 respectively. According to district health managers, gathering opinions from the community members and ministerial approval of by-laws took the most time, as illustrated by one respondent:“The most difficult step in establishing TIKA scheme was gathering opinions from the community members. We spent a lot of time as many community members were not attending meetings. This not only delayed the process but also resulted in many community members lacking knowledge of the scheme” .Another respondent added: The approval of the by-laws took a long time. This was a legal process and so there were many procedures to follow. After we submitted our by-laws, there were several rounds of comments. To be open, this step took almost a year. We made follow-ups to the Ministry several times, and in most cases, we were told that we were not the only district which had submitted by-laws. This process took a long time .The findings also revealed that the establishment of TIKA was hampered by inadequate financial resources to facilitate gathering of opinions from stakeholders and sensitization. Indeed, most districts had not allocated budget for TIKA establishment in their annual plans because they thought that it was the responsibility of the NHIF to support districts financially during the establishment of TIKA scheme in their districts, as exemplified by one respondent:“TIKA was new in our district and we did not have budget to finance different activities such as community sensitization and collecting opinions from different stakeholders. We received TZS 10,000,000/=  from the NHIF but these funds were not enough. So, we decided to gather public opinions in only few streets .Another respondent added:Another important component which was expensive is sensitizing stakeholders, including members of the community. We had limited financial resources to finance all activities. We decided to skip some of the activities” .“Apart from limited financial resources, the sensitization process itself was very challenging. For example, it was not easy to explain the benefits of the TIKA scheme to people. This was mainly because some districts such as Kibaha, Iringa and Songea had been implementing the rural based CHF scheme, whose performance proved poor. Thus, community members were not convinced that TIKA would make a difference, as illustrated by some respondents:The main challenge was sensitizing community members; to make people understand that TIKA scheme was important in enabling community to get access to healthcare services. Many community members could not differentiate TIKA from CHF, which had been implemented earlier in their community” .“A similar view was held by another respondent thus;The key challenge was convincing members of the community to join TIKA scheme. The District had since late 1990s been implementing CHF, and the major challenge was shortage of drugs and other services. These largely contributed to low enrolment or renewal of membership. Thus, it has been challenging to convince members of the community to join TIKA as they think it is just the same” .“TIKA was designed to cover urban community groups which were not covered by government or private health insurance schemes in order to reduce the burden of out-of-pocket payments. Initially, enrolment was centrally coordinated by district health management but from 2012, the central government decided to decentralize enrolment and management of funds to dispensaries, health centres and hospitals. Each health facility was directed to open a bank account for managing the funds collected at the health facility. The premium covered an individual; unlike CHF, which covered the family, father, mother and four children. Interviews revealed that, initially, all districts replicated the rural-based community health fund to urban areas. In almost all districts, a member was supposed to pay a premium of 10,000/= Tanzanian shillings . However, from 2011, the government piloted a new model of CHF called improved (re-designed) community health fund (iCHF). Among the improvements included enrolment by the village enrolment officers, introduction of provider-purchaser split and pooling of funds at the regional level. Other improvements were monthly reimbursement of facilities based on the number of clients receiving healthcare and increased portability of healthcare services across districts and regions. Additionally, annual premium rate increased to TZS 30,000 . Consequently, the government issued a circular to all districts to implement iCHF in 2018. This is to say, all districts in Tanzania no longer implemented CHF/TIKA from 2018, but iCHF instead. Despite the new reforms, membership to iCHF remained voluntary in both rural and urban settings. Almost all respondents had the view that the government should consider making health insurance compulsory to all Tanzanians with a view to increasing risk pooling and hence financial resources that can be used to improve the quality of healthcare services. A vast majority of district health managers recommended that the government should fully or partially subsidise individuals who are not able to pay the premium.Before 2018, benefit package in all the four study districts was limited to one primary healthcare facility where a member had registered; and TIKA cards were not portable across providers. The iCHF pooled funds to the regional level and thus expanded the benefit package and portability of services across districts and regions.In this study, TIKA registers for 2018 were reviewed, followed by analysis of interviews with most district health managers and in-charges of health facilities. The findings indicated that, in the early years of establishment of TIKA, the enrolment rate was relatively higher. In the subsequent years, however, enrolment started to decrease as many members did not renew their membership mainly due to poor quality of the health services offered in the health facilities, as commented by some respondents:When we started implementing TIKA, we sensitized people on the importance of the scheme, and many people joined the scheme. Soon thereafter, we started receiving complaints from members about the quality of healthcare services, especially shortage of medicines. Unfortunately, we had no money to purchase medicines as we had not received matching grants from the central government .Consequently, members did not get the expected healthcare services. You know, our public health facilities face some challenges, especially shortage of medicines. This situation discouraged people from joining the scheme as well as renewing their membership .FGDs with TIKA members in almost all districts confirmed that low enrolment and renewal of membership were mainly caused by poor quality of healthcare services. Members also reported that the package of services offered was limited to primary healthcare services within their respective districts. This meant then that in case members got referral to higher level facilities, they had to cover the costs of the services. In addition, one could not get healthcare services outside the district of residence. However, in Kibaha and Iringa districts, benefit packages were expanded to enable members to receive healthcare services in district and regional hospitals. Nevertheless, many members of the community did not see the importance of joining the scheme or renewing their membership, as commented by some respondents:“Many people prefer expanded benefit packages to allow them access to services even beyond their district or region. As a result, some people decide to pay TZS 50,400 (USD 25) for the national health insurance fund (NHIF) for their children instead of TZS 10,000 (USD 5) for TIKA scheme. This is because NHIF has expanded benefit packages compared to TIKA” .As indicated in Fig. Before 2018, TIKA funds reverted back to health facilities through the Comprehensive Council Health Plan (CCHP) activities budgeted from cost-sharing funds. There was no separation between the provider of services and the purchaser as the district authority was both the provider and the purchaser of the services. Payments to health facilities were largely input-based rather than output-based. The review of documents indicated that the government had been implementing a number of health financing reforms aimed at, among others, improving CHF/TIKA. For example, in 2012, the government issued a circular to all districts directing health facilities to open facility bank accounts, which are credited by funds from the insurance reimbursement , user fees and basket funds. Since 2017/2018, the government started the implementation of the Direct Health Facility Financing (DHFF) and Facility Financing and Accounting Reporting System (FFARS). Following the scaling-up of the iCHF since 2018, health facilities will be reimbursed for services provided to the iCHF members (fee per service). In this new arrangement, CHF funds are pooled at the regional level and managed by the Regional Administrative Secretary (RAS).This study aimed at examining the design and implementation of the community-based health insurance scheme in urban settings in Tanzania. The findings of the study indicate that TIKA scheme faced structural and operational problems which affected the uptake of the scheme. The most important challenge was low uptake of the scheme; which was attributed to the poor quality of healthcare services and limited benefit packages. Structural and operational problems have been frequently reported in earlier assessments of rural-based community health insurance schemes in Tanzania –15. SimiWith regard to design and management of TIKA scheme, the findings suggested that the voluntary nature of TIKA scheme resulted in many members not renewing their membership after expiry. These findings suggest that although CBHI schemes are one way to organise and mobilise community initiatives, they cannot be expected to provide a major source of funding to finance health systems for UHC. It is understood that the government has drafted ‘the Tanzania Health Financing Strategy 2016–2026: Path towards Universal Health Coverage’ document, whereby some plans have been put in place to reform CHF/TIKA schemes by making it compulsory. However, the Health Financing Strategy has yet to be approved and launched by the government. The government should fast track the implementation of the health financing strategy and ensure that the national health scheme is funded from general government revenue or other forms of taxation that subsidize those unable to pay.Globally, there is an increasing call to change the voluntary nature of community-based health insurance schemes , 25. A lThe findings revealed that the decentralized management of the TIKA scheme made it impossible to centrally collect and manage funds, thereby reducing pooling of resources. This situation not only increased fragmentation but also made it difficult for districts to receive matching grants from the central government. The findings thus support the new initiatives of the government which centralize CHF/TIKA scheme at the regional level and transfer the management of the CBHIs to the National Health Insurance Fund. This is because the new initiatives, which were scaled-up across all districts/councils gradually since 2018, have addressed some of the challenges raised in this study. For instance, enrolment is done at the village level by enrolment officers while there is also purchaser-provider split and funds are pooled at the regional level. Moreover, facilities will be reimbursed in their bank accounts each month based on the number of clients receiving care along with portability of benefits across districts and regions. With these new reforms, the councils no longer implement TIKA, but rather the improved community health fund (iCHF). It would be of interest in the future to see how these new initiatives will improve enrolment and access to healthcare services and their contribution to achievement of UHC. In the proposed new health financing strategy, the government plans to merge different health insurance schemes into a single national health insurance. This would help overcome the current fragmented nature of health financing mechanisms in Tanzania thereby promoting universal coverage of healthcare services. Costing studies in Tanzania have shown that in order to make CBHI work, major improvements would be needed, but given the wider health insurance financing context and health seeking behaviours, it is questionable as to whether such improvements are feasible, scalable and valued for money , 27.While within the NHIF there is a directorate to oversee the operations of the CHF/TIKA, there is a need to further centralize the management of the CHF/TIKA from regional to the national level since the current centralization to the regional level does not allow CHF/TIKA cards to be used beyond the region. Furthermore, centralizing the management of CHF/TIKA funds may likely increase resource pooling and the size of revenue collectively available to fund health services. A large body of evidence shows that the larger the degree of risk pooling in a health financing system, the less people will have to bear the financial consequences of their own health risks, and the more likely they are to have access to the care they need , 8, 25.This study largely informs improvements in the ongoing efforts to achieve Universal Health Coverage. The study reiterates that although CBHI schemes are one way to organise and mobilise community initiatives, they cannot be expected to provide a major source of funding to finance health systems for UHC. The major limitation of the study is that it was conducted when the government was in the course of reforming the TIKA scheme. This is the basis of the urge to assess these new initiatives in terms of improved enrolment and access to healthcare services as well as contribution to achievement of UHC.This study concludes that both rural and urban-based community health insurance schemes face significant structural and operational challenges which subsequently result into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging CBHI schemes into a single national pool with decentralised arms with national support while maintaining local accountability. The national health financing mechanism should be funded from general government revenue that subsidizes those unable to pay. This would increase risk pooling of resources, improve reimbursement process and, in turn, increase the viability of the schemes. There is also a need to strengthen governance at the local level through district and subdistrict level governing bodies to overcome the potential loss of control and participation by lower levels and communities.


One of Africa’s newest struggles for liberation: Cameroon’s Anglophone crisis, which emerged from legal and education grievances in 2016, rapidly escalated into a secessionist political conflict that is threatening the unity of the country, with potential to degenerate into a complex emergency. In an exploratory, qualitative, analytical, and descriptive case study research tradition involving document/content analysis, we apply the Robert Strauss Centre’s complex emergency framework to investigate the potential of the Anglophone crisis, whose ramifications lead us to consider it an acute complex emergency. Our contention is based on the fact that 72.5% of the variables in all the complex emergencies fall within the relevant to extremely relevant ranking criteria. Furthermore, the establishment of a nexus between the Anglophone crisis and a natural hazard-induced disaster suggest an escalation of the crisis to an unbearable level. Using the high probability of a novel eruption at Mt. Cameroon coupled with the eminent threat of the spread of the COVID-19 virus, we contend that unless otherwise, the crisis has immense potential to cumulatively evolve into a “Complex Disaster Emergency” (CDE) in the Anglophone regions of Cameroon. Amidst the existential challenges in providing humanitarian assistance in the conflict region, and by applying the Robert Strauss Centre’s complex emergency framework, this article concludes with an early warning for an impending CDE that could heighten humanitarian challenges unless there is foresight and goodwill by relevant actors to immediately commence a process of adequate contingency planning. Arguably, human-induced disasters are increasingly at the origin of complex emergencies, given their capacities to rapidly disrupt livelihoods, their multi-causal nature, and the propensity to interrelate political, economic, social, and environmental factors including internal armed conflict  become complex emergencies is very sparse. Frameworks for disaster management and humanitarian systems have been lopsided in their focus on responding to particular types of crisis/emergencies  to establish the consequences of the Anglophone crisis, (2) to ascertain the status of the Anglophone crisis as a potential complex emergency, (3) to analyse the risk of an imminent Mt. Cameroon eruption in the crises region, and (4) based on the findings from (1)–(3), to conceptualise a new complex emergency paradigm.This research can potentially contribute to contemporary international frameworks that provide a roadmap for safer and more resilient communities to crises and disasters. For instance, the 2030 Agenda for Sustainable Development focuses on specific challenges that countries face in pursuit of sustainable development, especially “African countries, least developed countries...as do countries in situations of conflict...” UN : 7. FurtLa République du Cameroun while their English-speaking counterparts (Anglophones) in present-day North West and South West Regions who were under the British administration (Southern Cameroons Trustee Territory) had the option to merge with either La République du Cameroun or Nigeria. During a United Nations-organised plebiscite on February 11, 1961, the British-administered Southern Cameroons voted to reunite with the former German Kamerun (French Section) to form the Federal Republic of CameroonThe Anglophone crisis is rooted in Cameroon’s troubled colonial history that eventually gave birth to its dual bi-lingual heritage . Cameroon became a German colony on July 14, 1884, but after the First World War, during the Versailles treaty in 1919, German Kamerun was forfeited to be administered by Britain and France who carved the territory into two parts: 20% to Britain and 80% to France. The French (Francophone) section achieved independence on January 01, 1960, as United Republic of Cameroon. On February 4, 1984, his predecessor and current President, Paul Biya, further altered the name of the country to La Républic du Cameroon . Since the union of the two Cameroons, the Anglophones who currently constitute around 14% of the population  changed the federal structure of the country in favour of a unitary state called The latest phase of the Anglophone crisis started as peaceful street demonstrations in October 2016 by lawyers’ and teachers’ trade unions, who amongst many grievances, were against the obligatory use of the French language in schools and Law courts in the two English-speaking regions. The government responded harshly by imprisoning the protest leaders and its security forces launched a violent crackdown on protesters. The response was the insurgence of armed secessionist groups since January 2018, who have been demanding the independence of the Anglophone regions aka the Ambazonia Republic. Since then, there have been violent armed confrontations between the secessionist groups and the regular military HRW .The Anglophone crisis has added to the other humanitarian emergencies in Cameroon. The mayhem and violence caused by the insurgency of the Sunni Islamist group (Boko Haram) in Northern Nigeria led to the influx of thousands of refugees into Northern Cameroon. Boko Haram’s bloody and violent incursion into Northern Cameroon has caused insecurity with outrageous consequences on the livelihoods and economy in that part of the country . These hazards are confined to a major topographical feature of geological origin in the country known as the Cameroon Volcanic Line2 that straddles the continental margin at the Gulf of Guinea in the South West Region. The volcanic edifice has a volume of 1200 km3, with over 100 craters and cones on its summit and flanks, and is thought to have a near-continuous eruption sequence over the last 10 million years, being most active within the last 3 million years  in the South West Region is host to Mt. Cameroon, the most active and largest volcano on the Cameroon Volcanic Line and West/Central Africa. Mt. Cameroon is a huge elliptical stratovolcano with a height of 4095 m above sea level and an area of about 3000 kmMt. Cameroon is a threat to population centres in the South West Region, where the Anglophone crisis is raging. Past eruptions have caused extensive/expensive damage to property, displaced hundreds of people, and affected thousands more with huge implications for agrarian livelihoods  defines complex emergency as “A humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing United Nations country program”. The key characteristics of complex emergencies highlighted are extensive violence, deaths, population displacement, widespread socio-economic damage, need for large-scale multifaceted humanitarian assistance, political hindrance of humanitarian assistance, and significant security risks for humanitarian workers UNOCHA .The various conceptualisations of complex emergencies largely focus on the co-occurrence and interaction between multiple instabilities with a variety of root causes, catalysts, and dynamics where the “complexity” requires the intervention of multiple agencies. This is compatible with the view of complex emergency adopted in this article.Complex emergencies have increased considerably in Africa since early 1980s to 112 between 2005 and 2014, affecting around 79 million people  project that assessed volcanic hazard risks on Mt. Cameroon  with dreadful repercussions for the population of the region APF .The government’s loss of full control of the region creates an environment of insecurity for the population, humanitarian space, and the belligerent forces. There is power tussle between the government and militia/secessionist groups to control geographical areas. The Interim Government of the Republic of AmbazoniaThe traumatised population has been caught between government and separatist forces. Communities in areas where the armed groups operate dread the presence of security forces, alleged to kill indiscreetly in communities hosting separatist fighters. According to Lazar , the levThe Anglophone crisis is characterised by human rights violations. On January 17, 2017, the government shut down Internet access in the restive region for 93 days to curtail dissent amongst the population. This was regarded by many local and international organisationsGovernment security forces have been accused of using excessive force, extrajudicial killings, torture, and ill-treatment of suspected separatists and detainees. They have also razed and burnt property including houses in more than 170 villages in the Anglophone region. A notable case is the alleged massacre of 21 unarmed civilians in Ngarbuh village (North West Region) on February 14, 2020.Contemporary data on political freedom in the crisis region is staggering. An estimated 81% of Anglophones have less freedom to express their political views than a few years earlier and they are twice more likely to fear violence and political intimidation than Francophones Lazar . The resThe Anglophone crisis has caused over 900,000 internally displaced persons and 60,000 refugees Craig . ThousanThe conflict is having a serious toll on the health of the population. Internally displaced persons and the populace that fled to the bushes are living in unsanitary and unhygienic conditions. There is rampant open-air defecation enabling the possible spread of diseases in the crowded living conditions in the bushes. The most vulnerable are the elderly, pregnant/lactating women, young girls out of school, and children under the age of 5.The insecurity has caused the closure of many health facilities. Many hospitals and health centres  have been attacked and torched. Others have been abandoned because their staff are afraid of being kidnapped or caught in the crossfire UNOCHA . As of DThe COVID-19 pandemic has exposed the fragile state of Cameroon’s health system . The OCHA  for the 2018 fiscal year and the overall losses to Cameroon’s economy were estimated at Franc CFA 269 billion (around $489 million) for the same period. Road contractors have been attacked and threatened and their equipment vandalised/destroyed causing many to stop/abandon projects. Indeed, more than 80% of the public contracts awarded in the Anglophone region for the 2017/2018 fiscal year were not executed  have been publicly attacked, beaten, kidnapped, or killed. In February 2018, armed men killed the supreme chief of the Balondo people in Ekondo Titi (South West Region). A few months later, 8 chiefs in Fako Division were kidnapped.In the North West Region, women have carried out burial rites in some of the crisis hotspots—a role traditionally reserved for men. Women were forced to bury corpses in Belo village (Boyo Division) in July 2018, when all the boys/men had fled from the security forces. Furthermore, dramatic footages emerged from the press and social media in January/February 2019 showing women carrying out burial rights in Bafut village (Mezam Division) after a military raid on armed separatist groups caused all the men to flee from the village  with the pretext of searching for separatist fighters. Under the same guise, soldiers raided the same place on 24 September 2019 and almost killed the brother of the paramount Fon of Bafut (Abumbi II) when he was shot and wounded. They then allegedly looted the museum in the palace and took several rare centuries-old artefacts. In both instances, no separatist fighters were found  compared to the other types of complex emergencies. On this basis, we conclude that the Anglophone crisis is arguably an acute complex emergency. While acknowledging this analysis is subjective, it paints an incredibly good overall picture of the Anglophone crisis, as seen through the lens of the Robert Strauss Centre’s complex emergency framework.6 m3 to 6.6 × 107 m3 of lava  and Limbe , including villages like Muea, Ekona, Muyuka, Mutengene, and Tiko  that could arise if a Mt. Cameroon eruption overlaps with the established acute complex emergency. In complex emergencies, there is a tendency to overlook the risk of other hazards that could interfere or worsen the challenges of dealing with the existing crisis. Already extremely stretched by multiple humanitarian crises including the COVID-19 pandemic, the prospect of the Cameroon government and humanitarian actors to deal with multiple or dual intersecting crises in the Anglophone region is daunting. The analysis in the previous section has revealed the high likelihood of a volcanic eruption on Mt. Cameroon in the nearest future. We posit that any major eruption that overlaps with the ongoing acute complex emergency would lead to more population displacement, fatalities, damage to infrastructural developments, and livelihood assets. Inevitably, more suffering, destitution, and poverty will ensure. Such concurrent events would overwhelm the humanitarian response requiring even more humanitarian assistance. In short, the “complexity” of the existential Anglophone crisis would increase, escalating the established acute complex emergency to a higher level conceptualised as CDE. Figure This article serves as an early warning for a potential CDE in the South West Region that could further complicate the existential acute complex emergency. Considering only 40% of the humanitarian assistance needed in the region has been provided Craig , a CDE wArguably, the Anglophone crisis was inevitable due to the incumbent government’s negligence in adequately identifying, monitoring, managing, or responding to emerging socio-economic and political risks for several decades. The reluctance of the government to rapidly resolve legal and educational grievances in the Anglophone region peacefully and tactfully seem to have transformed it into an acute complex emergency. For over 4 years now, violence has become an indispensable adjunct of socio-economic, cultural, and political endurance creating a tense living environment where insecurity thrives.Despite the escalating conflict and its growing longevity, the government has been intransigent to separatist requests to discuss the form of the state (independence from French Cameroon) in the presence of an international mediator. The government continues to predominantly use military means to resolve the crisis and separatists seem to have vowed to continue fighting for independence. The national dialogue held in October 2019 to end the crisis has not yielded much fruits. Rather, the fighting and mayhem persists. Those actually benefiting are probably the private for-profit organisations supplying arms to the belligerent forces.The conflict is becoming more complex, entrenched, and likely to be protracted since many actors are involved.This article has revealed the conspicuous horrendous consequences of the crisis. The loss of livelihoods and huge displacement of people are exacerbating hunger and poverty especially for the most vulnerable. The dominantly agrarian livelihoods in the region have been seriously affected. Meeting the basic needs of the population like having at least two meals per day is a daunting prospect for the vulnerable population. In consequence, inflation has been soaring due to dwindling outputs and regular interruptions in the supply chain of agricultural products and manufactured goods from other regions of the country.While there is much attention to the short-term impacts of the conflict, the cascading effects may cause a systemic crisis. Warfare and insecurity continue to disrupt education, communication, transportation, movement of goods/services, and cashflow. This poses a grave threat to the country’s economy that has already lost trillions of Franc CFA. The long-term consequences on education will also be far reaching. For instance, the credibility of the General Certificate of Education results from 2019 going forward, especially for candidates in the troubled regions, leaves much to be desired owing to ineffective studies since the sitting Ordinary Level candidates were in form 3 when the crisis started. As for the Advanced Level students, they entered high school in September 2017 when the crisis had affected the region for almost a year.Since the Anglophone crisis is occurring against a backdrop of other humanitarian emergencies, there is additional pressure on the humanitarian stakeholders to deal with the multiple conflicts. The diversity and amount of relief needed continuous to soar tremendously. The impact on critical infrastructure and disruption of trade with implications for the smooth functioning of the markets is bound to escalate the needs as well. It is therefore not surprising that the humanitarian actors on the scene are struggling to cope with the speed and rising scale of destitution, hunger, and displacement.Non-governmental organisations operating in the conflict zone have rightfully condemned human rights violations. But the government has reacted furiously when cautioned against the excessive use of force on innocent civilians and threatened to ostracise non-governmental organisations that speak against such activities. Governments’ overreaction is jeopardising the decent work of the non-governmental organisations with implications for the survival of the affected population. The government should increase its effort to document and bring to book those accused of human rights abuses.A key outcome of this article is the imminent eruption of Mt. Cameroon that could dramatically escalate the Anglophone crisis (established in this article as an acute complex emergency), into a CDE. Consequently, having knowledge and understanding of the longer-term dynamics of the acute complex emergency and how it can be transformed into a CDE is critical. Considering that complex emergencies cause enormous human suffering and toll, the priority is to save lives by providing protection, security, and essential relief/needs to the affected population  in preparation for a potential CDE is needed to identify the underlying patterns of vulnerability and enhance the resilience of the affected population. Second, contingency planning for effective crisis communication is a critical consideration especially in Buea where strategic/critical institutions essential to DM are located. Having appropriate communication strategies to sensitise the population is essential. Third, security will be fundamental for any response operation to be successful. In view of the ongoing conflict, it will be vital to set up security corridors in case of urgent evacuation. Forth, contingency evacuation plans should be set up that identify the poorest and most marginalised communities that would be prioritised for relocation, relief, and rehabilitation purposes. Fifth, preparedness to implement mitigating interventions requires a conducive funding environment. More funds will have to be allocated in preparation for a CDE. This remains questionable, given that most funding countries are currently diverting huge resources to combating the COVID-19 virus. Sixth, like funding, issues with interagency coordination/cooperation have been undermining the effective performance of Cameroon’s DM system  incidents occurring concurrently. A number of recommendations have been suggested to that effect.The recommendations challenge Cameroon’s DM frameworks and both internal and external humanitarian actors to embrace and expand their knowledge base on potentially more complex humanitarian crises. Transforming such knowledge into timely risk assessment would better prepare them for a CDE scenario. However, being proactive to prevent human-induced conflict is paramount. Even when mistakes have been made and civil unrest has metamorphosed into armed conflicts, as is the case of the Anglophone crisis, it is wise to speedily resolve them so that the conflicts are not protracted. As the Anglophone crisis persists, the militia groups are gaining more experience at warfare and their diaspora sponsors are mobilising more funds to upgrade the weapons of the separatist fighters. Government’s anticipated military solution to the conflict is, therefore, implausible. We believe there is still enough time to avert a full-blown civil war in the Cameroons if the government can embark on a peaceful path towards resolving the crisis. This can rapidly be achieved through rational, sensible, reasonable, and inclusive political dialogue with the secessionist leaders, mediated by agreed-upon third parties.This exploratory research has contributed to diagnosing the ramifications of the Anglophone crisis, determined the status of the crisis as acute complex emergencies, and proposed a new complex emergency paradigm (CDE). Nevertheless, there is an urgent need for in-depth scientific research to narrow down the time interval before the next Mt. Cameroon eruption. Further investigations on the potential dynamics and complexity that may arise when complex emergencies and disasters occur simultaneously and the implications for societal vulnerabilities would be beneficial to the humanitarian community. These areas of research would facilitate the building of resilience capacity and elicit a more timely and appropriate response to CDE-type scenarios.


Like other Canadian provinces, Quebec managed shortages of Personal Protective Equipment (PPE) in the early weeks of the COVID-19 pandemic. Two years later, with hindsight, what lessons can we learn from this logistics crisis? It is precisely to better understand the decisions made by the supply chain players in the province of Quebec that this paper was written. To fully understand the events, this paper first describes the Quebec healthcare system. Then it retraces the series of events and actions during the first wave, at a time when it was most challenging to procure PPE. It also specifies the main characteristics of the supply chain in the Quebec healthcare sector. Finally, it analyzed these data to come up with recommendations to help public decision makers adopt better supply chain management practices. The supply of Personal Protective Equipment (PPE) was one of the most critical issues in the first wave of the COVID-19 pandemic. In a race against the clock, most of the industrialized countries were searching for the same products to meet increasingly desperate needs. But now, two years later, with hindsight, what lessons can we learn from this logistics crisis? It is precisely to better understand the decisions made by the supply chain players in the province of Quebec that this paper was written. This case made up part of a national CIHR Rapid Research Grant (# CIHR Ref. VR5 172669) entitled “Development of an Implementation Framework to Advance Provincial and National Health System Supply Chain Management of the COVID-19 Pandemic.”Before presenting our recommendations, we first describe the methodology of our study and the Quebec healthcare system. Then we chart the series of events and actions of the first wave, when it was most challenging to procure PPE. Finally, we analyze these data to come up with recommendations to help public decision makers adopt better supply chain management practices.The case is built on interviews of supply chain managers from eight Quebec hospitals, selected to reflect the diversity of healthcare institutions in the province and regional differences in the pandemic’s impact. A purposive sampling was used to obtain a diversity of respondents following some relevant criteria. For example, we wanted to have respondents from regions harshly affected by the first wave of COVID-19. We also wanted to get information from hospitals with different missions: short-term hospitals, long-term care centres, and university hospitals. The eight selected hospitals cover almost one quarter of all establishments in the province. The interview guide intended to collect information about the organizational structure of the hospital and its logistics department, during and after the first wave of the pandemic. We also interviewed two PPE suppliers and several managers from Quebec’s Ministry of Health and Social Services logistics directorate and from the healthcare purchasing group. These last two organizations played a central role in the provincial management of PPE. In total, more than 20 semi-structured interviews, lasting 60 to 120 minutes each, were conducted between September 2020 and February 2021. When presenting his reform, the minister mentioned explicitly the Kaiser Permanente model as one of the most performant IDN in the United States.In the province of Quebec, a reform carried out in the spring of 2015 decreased the number of public health institutions from 182 to 34. Quebec’s new institutions not only manage short-term care hospitals but also long-term care centres and community services. This can result in institutions consisting of about 100 facilities spread over an area of thousands of square kilometres. The network of public long-term care hospitals is completed with private-unfunded and private-funded institutions. This last category is made up of private organizations that have a service agreement with the regional institution to offer “beds” and long-term care, often for semi-autonomous patients. the spring 2015 reform created the conditions for revaluating healthcare logistics in institutions. The reform has been accompanied by the creation of logistics departments, and a logistics director now sits on each board of directors.Unlike most other provinces in the country, Quebec’s Ministry of Health and Social Services has its own logistics directorate. The traditional role of this directorate is to coordinate procurement and logistics initiatives between institutions within the system or between these facilities and other parts of the government. The directorate does not carry out operational activities such as product or service contracting or inventory management. Rather, its primary role is to provide guidance on supply chain issues. While the role of logistics has progressed incrementally in the Quebec health system since the 2000s, As with other commodities in the healthcare sector, contracts for PPE in Quebec are very often awarded through group purchasing organizations that leverage the consolidated volumes from their member institutions to obtain low prices for these items. The use of group purchasing organizations puts pressure on suppliers to stay competitive to obtain or retain a significant market share. This phenomenon is not unique to Quebec as group purchasing organizations are found elsewhere in Canada and in the United States.8 It should be noted that, in winter 2019, a further Quebec government reform merged the three healthcare purchasing groups into a single organization that would no longer be accountable to the Ministry of Health and Social Services but instead to the Treasury Board. This new organization was to enter into service on April 1, 2020, but this was pushed back to September 1, 2020, due to the pandemic.One feature of Quebec’s healthcare sector had been the presence of three purchasing groups that handled the contracting of about 30% of the healthcare institutions’ procurement budget.To provide a timeline of the decisions made by the main players in the Quebec healthcare sector,  Canada was almost entirely dependent on foreign markets for these items prior to the COVID-19 pandemic. The characteristics of the PPE supply chain (low-cost strategy and production offshored to Asia) had led to China, and specifically the Wuhan region, becoming the world’s main PPE production centre. The first impacts of the pandemic arrived just at the start of the Chinese New Year festivities on January 24, 2020, and the subsequent four-week interruption in China’s economic activity. Also, the Wuhan area was placed under a strict lockdown to stop the spread of the virus. China’s reduced activity during this time meant that global PPE production capacity was significantly truncated for over two months. Under these specific circumstances, the window of opportunity for securing an inventory of PPE had become very narrow.The timeline of events shows that, long before the COVID-19 pandemic struck Quebec, there was a logistics crisis in the supply of PPE. Unlike in Europe or the United States, where 50% of PPE needs are generally met by local production,Starting in early February 2020, the Health Ministry’s logistics directorate established a PPE crisis unit, which became the control centre for provincial needs and the offer available on the supply market. This unit began with just a few individuals, but it incorporated other employees from the health system (institutions and purchasing groups) as new needs or problems arose, and it eventually became the COVID-19 operations team. Up to 60 people were directly involved in this committee, which had regular contact with the industry’s major suppliers. Its mandate was initially focused on PPE management, but it eventually also took on needs relating to screening tests and to the purchase of treatment equipment, such as respirators, for the hospitals.After conducting interviews with stakeholders, we identified four basic features that undermined the efficiency of the PPE procurement process during the pandemic. First, relations between the Health Ministry’s logistics directorate and the 34 healthcare institutions had historically been consensus based. The directorate did not seek to impose guidelines. It took time to consult with, and listen to the opinions of, the various partners. However, this type of management by consensus was ill-suited to a crisis, when it became critical to be able to make decisions quickly.Second, information systems were unfit for logistics operations. These systems were originally developed with a view to financial reporting. For instance, the products coming out of the regional warehouse of a healthcare institution is considered an expense, although the product may be physically stored in a care unit. This shortcoming makes it more difficult to know the actual stock conditions in a given hospital. Also, these information systems are not able to produce consumption forecasts. And finally, each healthcare institution has its own product nomenclature , making it complex to get an exact snapshot of stocks in healthcare institutions.Third, relations with suppliers were mostly limited to transactions. Quebec’s regulatory framework in this area may be the most complex among Canadian provinces. In 2008, Quebec adopted a law and regulations on contracts for public organizations, which included some 250 articles. That number has now more than doubled. This framework sets parameters for the contractual process and the nature of relationships with suppliers. Given this context, relationships between healthcare institutions and suppliers tend to be highly transactional in nature. Generally, very few performance indicators are used in healthcare institutions’ logistics departments, and when they are, they are used at a very low frequency rate. The logistics departments of healthcare institutions are often reactive to any disruptions that may arise in the course of day-to-day operations.Lastly, embryonic performance management systems were in place. Research by Beaulieu and Roy showed that there was no real performance management system for logistics activities in healthcare institutions prior to the system’s reform. However, the monitoring of early pandemic signs should be done at the provincial level. There should be a provincial authority in charge of this. In the specific context of health, two teams could possibly take on this responsibility: public health decision makers or logistics decision makers. In theory, public health decision makers should be the ones monitoring for the potential emergence of a pandemic. However, it is difficult for public health departments to predict how a pandemic might impact on the supply of products and supplies, such as PPE. The Quebec experience shows that these decision makers primarily base their decisions on scientific evidence from multiple validated sources. Quebec’s public health department issued an initial advisory on COVID-19 just as the window of opportunity for implementing an effective logistics contingency plan was closing. However, supply chain decision makers are accustomed to making predictions and weighting risks. These approaches would make it possible to propose preventive measures such as stocking up on products and launching an operational pandemic management team.Identify predictors to anticipate the emergence of future pandemics: One Quebec hospital made a massive PPE purchase in mid-January, anticipating the effects of the pandemic (see Table 1). This institution took note of early warning signs, for example, the geographic spread of the virus combined with its mode of transmission, that were visible to all. In fact, pandemics can be anticipated, especially in North America, which tends to be the last place in which they gain a foothold.Develop procurement expertise: This is required to make purchases that consider the particular characteristics and challenges of international markets and to analyze the risks associated with supply sources. During the pandemic, it was necessary to negotiate directly with foreign manufacturers, and very few buyers from the public sector were familiar with the specific regulations involved in international procurement.Define a centralized logistics-management structure and allocation policies for a pandemic or other crisis: A centralized structure would simplify communications between suppliers and healthcare institutions, thereby reducing competition within the system. Personal protective equipment allocation policies must be regularly updated to reflect the current situation. We are not calling for a permanent centralized structure; however, the experience in Quebec and elsewhere confirms that such a structure is necessary in times of crisis.Ensure that key information for a demand-management system that’s indispensable during a pandemic is kept up to date: It is simpler to maintain this basic information from day to day than to try to update it in the midst of a crisis. Until this crisis, logistical information management was not a priority in Quebec’s health sector, and a great deal of effort was required to overcome this shortcoming during the pandemic.Maintain close collaboration between logistics decision makers and the infection prevention and control departments in healthcare institutions: This kind of collaboration would give logistics managers more legitimacy when it comes to ensuring respect for PPE user protocols, and expertise for quality control in purchasing. The institutions that were able to quickly implement this type of collaboration avoided pointless purchases of the wrong products and were able to control consumption within their institution.Improve collaboration between healthcare institutions and suppliers: Such collaboration can give suppliers more insight into demand, so that they can suggest solutions in the event of shortages. In return, suppliers could share strategic information on markets and their constraints with healthcare institutions. For Quebec’s healthcare sector, such a collaborative approach is a radical change of philosophy in terms of supplier management.In the light of these observations, we offer some recommendations based on best practices, in order to be better prepared for future crises.One fundamental challenge intersects with several of the formulated recommendations: breaking down organizational silos to foster communication between logistics decision makers, clinical decision makers, public health decision makers, and suppliers. This communication must not be thought of exclusively in terms of information technology but should encompass other integrative mechanisms . Preventive measures constitute a first-level response to help managers concentrate their efforts into finding solutions to unexpected problems once a crisis occurs. Furthermore, public decision makers should not limit their focus to only preparedness measures. Even though PPE management in Quebec was the starting point for these recommendations, many of them also address long-standing shortcomings in the logistics chain that are also present in many other jurisdictions in Canada and in other industrialized countries. Public deciders should support investments into new information technology and into skills training and development for the logistics staff of health establishments, and they should implement new practices with suppliers. The idea here is not only to prevent a new procurement crisis but also to enhance the day-to-day performance of the logistics chain. This is a real challenge that will require a great deal of perseverance, since the logistics chain for healthcare is possibly the most complex of all.Last, these recommendations fall mostly under the heading of preparedness measures, which do not prevent crises but rather minimize their management challenges.