Evaluation of access to ART and decentralization of health care

delivery in Cameroon

French Agency for AIDS Research (ANRS) Program in Economic & Social Sciences

Ministère de la Santé Publique du Cameroun

FPAE CASS-RT / Un. Ydé I GRAPS / Un. Ydé II

National ART Programme in Cameroon

Use of preexisting decentralized framework of health care system (<1992- 174 districts) for ART delivery:– In 2001- 2002: from reference centers in central hospitals to provincial

hospitals (24 ATCs)– From 2005: 106 MUs in district hospitals (WHO public health approach

for care algoithms) including 35 from private sector

Generic oriented procurement of ARV drugs (70% total) through monopoly of imports for CENAME (National Agency for Drug Procurement)– Decrease of monthly ART prices for patients: from 250,000 FCFA in

2000 to between 3,000 and 7,000 FCFA in 2004 (1$= 496.6 FCFA)– Gratuity of ARVs introduced in May 2007

85% of total AIDS budget (139,2 Million US$-2004/2007) funded by foreign aid

Independent evaluation of national ART program in Cameroon

Cross-sectional survey in a random sample of 3,151 adults, HIV diagnosed for at least 3 months and seeking care in 14 ATCs & 13 MUs in 6 provinces (response rate = 90%)

Survey in the exhaustive sample of HIV care physicians in the same centers (n=97, resp. rate= 92%) and stratified sample of other healthcare personnel (n= 208, resp.rate= 82%)

Data collection on characteristics of the 20 public and 7 private health facilities

Semi-structured interviews (n=25 health personnel & 53 patients)

EVAL ANRS 12 116 (methods)

Characteristics of HIV-infected patients in the EVAL Survey (n=3,151)

Central(n=1112)

Province(n=1017)

District(n=1022)

Pval.

Female 70.8% 71.5% 70.9% 0.93

Mean Age (sd) 37.9(9.2)

38.0 (9.2)

36.9 (9.4)

0.012

Edu>Primary 72.3% 51.5% 39.3% 0.001

Living in couple

52.8% 43.0% 47.1% 0.001

<Poverty line 65.9% 76.8% 82.5% 0.001

Informal sector 40.4% 54.1% 61.1% 0.001

ART-treated 78.0% 83.5% 73.4% 0.02

Eligible Non ART treated

9.0% 5.9% 10.3% 0.001

Multilevel mixed effects models (ref= central level of care) ART-treated patients (n=2,132)

Coef/ IC 95%

Provincial P val District P val

CD4 Gain/mth

-0.27(-049/-0.04)

0.02 -014(-035/0.07)

0.19

HighAdherence

2.19(1.03-4.68)

0.04 1.97(1.03-3.77)

0.04

Phys HRQL

0.09 (-017:0.34)

0.50 -0.03(-0.25/0.19)

0.77

Mental HRQL

0.19(-0.20/0.58)

0.34 0.34(0.00/0.69)

0.05

Direct out-of-pocket costs related to HIV infection (by month – median) (n=2,132 ART-treated pts)

CAMEROON

Yde & Dla

Prov. District

Health expenditures (exp.)* (in FCFA X 103)- TOTAL (exp. >0 : 98%)- ART (exp.>0 : 88%)- Transportation (exp. >0 : 85%)- Consultations (exp. > 0 : 33%)- Other drugs (exp. >0 : 20%)

8,63,01,02,05,0

6,63,01,21,05,0

5,83,02,01,01,5

Proportion of expenditures in household income by quintiles- 1st quintile- 5th quintile

27,2%3,5%

9,0%2,3%

16,0%2,0%

- Catastrophic Health Expenditures (≥ 20% households’ resources) : 44%

CAMEROON EVAL ANRS SurveyFactors associated with the risk of catastrophic health exp.* (n=2412)

Coeff p

Monthly income by equivalent adult (1st quintile = ref.)- 2nd quintile- 3rd quintile- 4th quintile- 5th quintile

-1.1-1.8-2.4-3.0

************

Wealth index -1.3 ***

Free access to ART (interaction term) : - Constant- Free access: provincial level- Free access: district level

-1.3-0.1-0.9

***NS**

Transportation length to the hospital < 1 hour -1.1 ***

Consultation with a private doctor outside the reference hospital 0.4 **

Consultation with a traditional healer: constant - variance of random effect

0.70.7

****

Decentralization: - central level (ref.)- Provincial level - District level

-0,6- 0,6

****

* Adjustment variables: gender, age, matrimonial status, area of residence, CD4 at initiation, time since HIV diagnosis, nb of perceived symptoms / technologic level of the medical centre