Evaluation of access to ART and decentralization of health care delivery in Cameroon French Agency f

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Evaluation of access to ART and decentralization
of health care delivery in Cameroon French
Agency for AIDS Research (ANRS) Program in
Economic Social Sciences Dr. Fred Eboko,
IRD UMR 912 INSERM-IRD U2 Marseille
FPAE CASS-RT / Un. Ydé I GRAPS
/ Un. Ydé II

• Pr Jean-Paul Moatti
• Chair of ANRS Scientific Committee on Public
  Health Social Sciences
  

Ministère de la Santé Publique du Cameroun
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National ART Programme in Cameroon

• Use of preexisting decentralized framework of
  health care system (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
  

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Guidelines for ART decentralization1

• Initial evaluation of diagnosed HIV? patients
  physical examination CD4 count or complete cell
  blood count (CBC) when CD4 counter not available
  
• For patients eligible for ART pre-therapeutic
  check-up including CBC at the district level CBC
  and CD4 count at the other levels or when
  available
• Evaluation of ART eligibility using the WHO
  classification (2005) when CD4 count not
  available
  
• - WHO stage III or IV and WHO stage II when
  Total Lymphocytes
• Collegial decision by the therapeutic committee
  about ART protocols
  
• 4 first line regimens available 2 NRTI 1
  NNRTI
  
• 1 National guidelines for the district level,
  2005
  

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Rapid national scale up of access to ART in
Cameroon

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Independent evaluation of national ART program in
Cameroon

• Requested by Ministry of Public Health of
  Cameroon
  
• Carried out by Universities of Yaoundé and ANRS
  research teams
  
• Evaluate an ongoing process and propose
  recommendations for improvement
  
• Cross-fertilization of quantitative and
  qualitative methods
  
• Included 4 research 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.
  Political Issues, Advances, Limits and
  Perspectives of decentralization of health care
  (POLART)
• Scaling up and procurement of drugs and
  biological monitoring tools (CEPN)
  

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EVAL ANRS 12 116 Pr. Moatti (Inserm Marseille),
Pr. Abega (UCAC Yaoundé)

• Objectives
• Evaluation of the Impact of access to ART on the
  living conditions of PLWHA according to levels of
  care delivery
  
• Efficiency
• Equity
• Democratization
• Evaluation of the impact on the health system
• Impact on medical knowledge and practice
• Changes introduced in the organization of health
  care
  
• Institutional impact on decentralization of
  health care delivery
  
• Data collection between September 2006 March
  2007
  

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EVAL ANRS 12 116 (methods)

• 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 (n97, 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 (n25 health personnel
  53 patients)
  

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Characteristics of the 27 ART-delivery centers in
the EVAL Survey Availability of equipment comp
lete cell blood count, CD4 cell count,
transaminases, glycemia, creatinemia, amylasemia,
pregnancy test, viral load, triglycerides and
cholesterol
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EVAL Physicians survey

• No significant differences according to the
  level of decentralization in terms of (n97)
  
• N () or median IQR
• Good knowledge of national protocols
• - right answers to 5 in 6 questions on
  national protocols 61 (62.9)
  
• Good knowledge of criteria of ART eligibility
• - right answers to 4 in 5 questions on
  criteria of ART eligibility 74 (76.3)
  
• Knowledge on ART management
• - score ranging from 0 to 35 points 28 23
  30
  
• Number of years of experience in PLWHA care 4.0
  2.0 7.0
  
• Employment status
• - in public hospitals civil servant 60
  (76.9)
  
• - in private hospitals contractual 12
  (63.2)
  
• Monthly income perceived from the hospital x 103
  FCFA 250 200 300
  
• Monthly income considered as a fair remuneration
  x 103 FCFA 400 300 600
  

Physicians knowledge and experience
Working conditions
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EVAL Physicians survey

• But some significant differences in terms of
  practices and opinions on the ART policy
  implementation (n97)
  

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EVAL Physicians survey - qualitative data

• Structural constraints at the three levels of
  decentralization
  
• Poor working conditions
• Lack of equipments and frequent breakdowns
• Low wages and insecure employment / status
• Generalized dissatisfaction and demotivation
• Patients poverty
• Incapacity of patients to pay for prescribed
  treatments and recommended biological tests
  
• ART supply deficiency shortage
• Lack of appropriate HR qualification, especially
  for psychological care

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EVAL Physicians survey - qualitative data

• Organizational constraints
• A doctor-intensive policy
• - No definition in the national policy of a task
  shifting strategy and procedures
  
• Large physicians workloads and insufficient time
  per patients
  
• Or conversely unorganized and high
  task-shifting
  
• Involvement of Community Health Workers (CHWs)
  without a clear definition of their roles
  
• Conflicts of roles
• Tensions between healthcare workers
• Exclusion and frustration
• Desire to move from HIV-services and to give-up
  the profession
  

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Characteristics of HIV-infected patients in the
EVAL Survey (n3,151)

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Characteristics of ART-treated patients
(6months) in the EVAL Survey (n2,132)

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Multivariate statistical analysis (EVAL-patients
survey

• 4 OUTCOME VARIABLES
• average monthly gain in CD4 cells/mm3 since
  initiation of treatment,
  
• adherence to ART in previous 4 weeks (high vs
  moderate/low),
  
• physical and mental HRQL (MOS-SF12)
• Two-level models (mixed effects regression) for
  hierarchically structured data (patients nested
  within care centres)
  
• All variables at panalysis initially introduced in the multivariate
  model
  

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Multilevel mixed effects models (ref central
level of care)

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• Eval Survey- qualitative interviews of managers
  and health professionals
  
• 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
  
• Trend toward recentralization of drug
  procurement supply chain
  
• Problems of referral between levels of care
• Growing tensions between physicians involved in
  HIV care and colleagues
  
• Perceived inequity between HIV and other diseases

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Main lesson of the EVAL study

• Decentralization of ART-delivery is clinically
  feasible and brings additional benefits (more
  equal access to ART for the poor, better mental
  quality of life, more adherence)
• Potential negative impact on decentralization of
  health system if verticalization is pursued
  without more integration in global reform for
  
• Human resource crisis
• Health financing
• Procurement of drugs

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Issues for the future of the Cameroonian program

• 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?