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)