Evaluation of access to ART and the health care system in
Cameroon
ANRS Research Program in Social Sciences
Dr. Fred Eboko, IRD UMR 912 INSERM-IRD U2 Marseille
WHO Meeting on positive synergies between health Systems and Global Health Initiatives, 2-3 October 2008
Ministère de la Santé Publique du Cameroun
FPAE CASS-RT / Un. Ydé I GRAPS / Un. Ydé II
A scientific answer to the challenges of Public Health
Context Continuous decrease in prices of ARV in Cameroon A new policy of decentralization A national and international issue
An objective Evaluate an ongoing process and propose objective insights
ANRS research program includes 4 projects :– Decentralization of ARV access in Africa: Evaluation of the treatment of
patients on ARV in district hospitals using a streamlined follow-up approach (STRATALL)
– Impact of the Cameroonian access to ARV program on the treatment and living conditions of the HIV infected population (EVAL)
– The problem of access to ART in Cameroon. Issues, Advances, Limits and Perspectives of decentralization of health care (POLART)
– Scaling up and procurement of drugs and biological monitoring tools
ObjectivesEvaluation of the Impact of access to ARV on the living conditions of PLWHA– Adherence and medical effectiveness– Quality of Life– Risky sexual behaviors
Evaluation of the impact on the health system– Impact on medical knowledge and practice– Changes introduced in the organization of Health Care
MethodsQuantitative– Cross-sectional survey among 3151 HIV+ adults and 317 healthcare
personnel included in 27 treatment centers– Data capture of treatment centers characteristics
Qualitative : Semi-structured interviews of patients and healthcare staff
EVAL ANRS 12 116 Pr. Moatti (Inserm Marseille), Pr. Abega (UCAC Yaoundé)
A relatively high quality of healthcare in decentralized treatment centers– Average increase in CD4 count for patients treated for at
least 6 months not different from that found at a national level: 12.5 cells /µL/ month
– Higher adherence for those patients treated at a district treatment centers: 61.2% of patients have a high adherence score versus 44.5% in centralized treatment centers
– Physical Quality of Life comparable to that found at central service level and a better Mental Quality of Life
FEASABILITY SHOWN FOR DECENTRALISING OF ART TREATEMENT
EVAL ANRS 12 116 - Principal results
Organizational or Structural factors limit the effectiveness of treatment centers
- Disruptions of ARV and reagent supply for CD4 examinations
- Lack of psychosocial support by specialized personnel (social workers)
- Insufficient numbers of doctors in the HIV team– Lack of procedures for task delegation from physicians to
nurses
EVAL ANRS 12 116 - Principal results
POLART ANRS 12 120Dr F. Eboko (IRD/FPAE), Pr. Sindjoun (GRAPS, Un. Ydé 2)
Objectives - Identify actors involved in the decentralization of ARV
treatment (institutions, local associations of PLWHA, international Cooperation)
- Analyze their roles and structures- Analyze the effect of external partners’ involvement in
the process of decentralization- Understand the qualitative factors which differentiate
health care quality of one site from another
Methods - Qualitative Study :
Interviews with patients: Therapeutic Itineraries and biographies Interviews with the different actors (institutions, local
associations of PLWHA, international Cooperation)
Study sites
Elements of analysis
Decentralization can come in a variety of forms: deconcentration, devolution, privatization
Decentralization of access to ARV in Cameroon corresponds in a general way to a process of deconcentration
The involvement of external actors in certain provinces or health facilities leads to other types of decentralization which are not exclusive from each other: - Between devolution and privatization: the hospital “Fondation Suisse de
Petté”- Between decentralization and saturation: The intervention of the Swiss
MSF at Doula Reinforcement of the relative autonomy of UPEC at Nylon and of CMA at
Congo 2 but saturation of services due to the reputation and quality of health care/
To conclude
Large-scale deconcentrationHowever: unequal distribution of actors in Cameroon Towards negotiated decentralization?
No cause and effect connection between epidemiological dynamics and deployment of international actors The south, Adamaoua and the East: “abandoned” provinces?
Nevertheless, ARV health care is widespread, continuous and of a scale previously unheard of in Cameroon
The contribution of the Cameroonian program to international questions
Long term and free financial sustainability of access to medicines? Optimal degree of decentralization to enable scaling-up?
New distribution of tasks between healthcare providers (“task shifting”) to find solutions to the Human Resources crisis?
Impact of AIDS program on the fight against other diseases (tuberculosis, malaria) and on the global reinforcement of the health care system?
The teamsCameroonL’UCAC :
– Institut de Recherche Socio-anthropologique (IRSA) Dir. : Pr. S.C. Abega
– Groupe d’Études, de Recherche et de Conseil sur l’Insertion Sociale (GERCIS)Dir. : Pr. R. Nantchouang
L’Université de Yaoundé 2 – Groupe de Recherches Administratives, Politiques
et Sociales (GRAPS) Dir. : Pr. L. Sindjoun
L’Université de Yaoundé 1 :– Center for Applied Social Sciences – Research
and Training (CASS-RT)Dir. : Pr. P. Nkwi
Fondation Paul Ango Ela pour la géopolitique en Afrique Centrale (FPAE, Yaoundé)Dir. : Mme K. Ango Ela
FranceL’UMR 912 INSERM-IRD-U2
– (www.ur002.ird.fr)
Dir. : Pr. J.-P. Moatti
Thanks
Patients
Healthcare professionals and personnel of Healthcare facilities
Minister for Public Health in Cameroon
National Committee for the Fight against HIV/AIDS
Provincial Delegation of Public Health
National Agency for research on AIDS and Hepatitis B & C
French Cooperation (SCAC)