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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
Pr Jean-Paul MoattiChair of ANRS Scientific Committee on Public Health & 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
Guidelines for ART decentralization1
Initial evaluation of diagnosed HIV patients: physical examination + CD4 count or complete cell blood count (CBC) when CD4 counter not availableFor patients eligible for ART: pre-therapeutic check-up including CBC at the district level; CBC and CD4 count at the other levels or when availableEvaluation 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<1200 c/mm3
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
Rapid national scale up of access to ART in Cameroon
Year Nb of ART Facilities
Nb of ART-treated (adults) (%rate of coverage)
2001 18 600
2003 23 9,000
2005 89 17,940 (22%)
2007 109 45,817 (53%)
2008june
132 53,238 (58%)
Independent evaluation of national ART program in CameroonRequested 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)
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
EVAL ANRS 12 116 Pr. Moatti (Inserm Marseille), Pr. Abega (UCAC Yaoundé)
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 the 27 ART-delivery centers in the EVAL Survey
Availability of equipment = complete cell blood count, CD4 cell count, transaminases, glycemia, creatinemia, amylasemia, pregnancy test, viral load, triglycerides and cholesterol
Median(IQR)
Central(n=8)
Province(n=6)
District(n=13)
Pval.
Nb beds 234 (120-300)
164 (37-230)
120 (93-166)
0.19
Level Equipment
9.0 (8.2-9.0)
9.0 (8.5-9.0)
7.0 (4.5-8.0)
0.004
CD4 cell count 7 6 7 0.06
FTE Phys. 4(3-7)
2(2-4)
3(2-3)
0.028
FTE Total 18(16-21)
13(10-18)
12(8-15)
0.018
Nb HIV+ pts 699(299-2608)
732 (421-1166)
150 (83-441)
0.001
Nb ART Initiation/mth
50 (34-114)
43(28-57)
15(11-28)
0.002
Nb HIV+/phys 211(126-514)
335(129-797)
61(35-164)
0.009
EVAL Physicians’ surveyNo significant differences according to the level of decentralization in terms of (n=97):
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]
Not at all or rather not satisfied with the income perceived 74 (76.3%)
1$= 496.6 FCFA at the time of the survey
Physicians knowledge and experience
Working conditions
EVAL Physicians’ survey
But some significant differences in terms of practices and opinions on the ART policy implementation (n=97)
Central level(N=40)
Provincial level (N=22)
District level (N=35)
P-value
Practices
Participation to the therapeutic committee: - At each meeting or almost 15 (37.5%) 10 (45.5%) 17 (48.6%) 0.33
Task shifting in consultation: - yes 15 (37.5%) 8 (36.4%) 18 (51.4%) 0.01
Opinions on the ART policy implementationWorkload: - too heavy 18 (45.0%) 5 (22.7%) 7 (20%) 0.04
Perception of policy implementation: - Score ranging from 0 to 21 - Median [IQR] 11 [9;13] 10 [9;12;5] 13 [10;15] 0.04
Disagreements with decentralisation policy : - Inadequacy of technical means- Inadequacy of supervision- Inadequacy of decisional autonomy
25 (62.5%)29 (72.5%)21 (52.5%)
16 (72.7%)16 (72.7%)14 (63.6%)
15 (42.9%)11 (31.4%)15 (42.9%)
0.060.010.31
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
EVAL Physicians’ survey - qualitative data
Organizational constraintsA 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 (CHW’s) without a clear definition of their roles
Conflicts of rolesTensions between healthcare workersExclusion and frustration Desire to move from HIV-services and to give-up the profession
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
Characteristics of ART-treated patients (>6months) in the EVAL Survey (n=2,132)
< 1hr Central(n=760)
Province(n=761)
District(n=611)
Pval.
Mths <HIV diagnosis
22.9 24.9 16.1 0.001
Triomune ART regimen
52.9% 80.9% 86.1% 0.001
CD4<200 21.1% 21.5% 21.9% 0.82
Highadherence4 wks
44.5% 58.1% 61.2% 0.001
ARV shortage 3mths
14.1% 11.7% 4.4% 0.001
1st visit <1mth after HIV diag
56.6% 56.2% 64.3% 0.001
Catastrophic Hlth Exp
42.1% 43.5% 46.3% 0.23
Waiting time <1hour
43.0% 83.7% 95.1% 0.001
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 p<0.2 in univariate two-level analysis initially introduced in the multivariate model
Multivariate statistical analysis (EVAL-patients’ survey
Multilevel mixed effects models (ref= central level of care)
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
High Adherence
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
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
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
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?