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 (< districts) for ART delivery: –In : 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$= FCFA) –Gratuity of ARVs introduced in May % of total AIDS budget (139,2 Million US$- 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 (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) 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% ProvincialP valDistrictP val CD4 Gain/mth (-049/-0.04) (-035/0.07) 0.19 HighAdhe rence 2.19 ( ) ( ) 0.04 Phys HRQL 0.09 (-017:0.34) (-0.25/0.19) 0.77 Mental HRQL 0.19 (-0.20/0.58) 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 10 3 ) - TOTAL (exp. >0 : 98%) - ART (exp.>0 : 88%) - Transportation (exp. >0 : 85%) - Consultations (exp. > 0 : 33%) - Other drugs (exp. >0 : 20%) 8,6 3,0 1,0 2,0 5,0 6,6 3,0 1,2 1,0 5,0 5,8 3,0 2,0 1,0 1,5 Proportion of expenditures in household income by quintiles - 1 st quintile - 5 th quintile 27,2% 3,5% 9,0% 2,3% 16,0% 2,0% - Catastrophic Health Expenditures (≥ 20% households’ resources) : 44%

CAMEROON EVAL ANRS Survey Factors associated with the risk of catastrophic health exp.* (n=2412) Coeffp Monthly income by equivalent adult (1 st quintile = ref.) - 2 nd quintile - 3 rd quintile - 4 th quintile - 5 th quintile *** Wealth index-1.3*** Free access to ART (interaction term) : - Constant - Free access: provincial level - Free access: district level *** NS ** Transportation length to the hospital < 1 hour-1.1*** Consultation with a private doctor outside the reference hospital0.4** Consultation with a traditional healer: constant - variance of random effect 0.7 ** Decentralization: - central level (ref.) - Provincial level - District level -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