1. 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 Moatti Chair 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

2. 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

3. Guidelines for ART decentralization 1 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<1200 c/mm 3 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

4. Rapid national scale up of access to ART in Cameroon YearNb 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%) 2008 june 132 53,238 (58%)

5. 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)

6. 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)

7.  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)

8. 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 7670.06 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

9. EVAL Physicians’ survey No 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 protocols61 (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 care4.0 [2.0; 7.0] Employment status : - in public hospitals : civil servant60 (76.9%) - in private hospitals : contractual12 (63.2%) Monthly income perceived from the hospital x 10 3 FCFA 250 [200; 300] Monthly income considered as a fair remuneration x 10 3 FCFA 400 [300; 600] Not at all or rather not satisfied with the income perceived74 (76.3%) 1$= 496.6 FCFA at the time of the survey Physicians knowledge and experience Working conditions

10. 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 almost15 (37.5%)10 (45.5%)17 (48.6%)0.33 Task shifting in consultation: - yes15 (37.5%)8 (36.4%)18 (51.4%)0.01 Opinions on the ART policy implementation Workload: - too heavy18 (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%) 14 (63.6%) 15 (42.9%) 11 (31.4%) 15 (42.9%) 0.06 0.01 0.31

11. 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

12. 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 (CHW’s) 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

13. 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

14. Characteristics of ART-treated patients (>6months) in the EVAL Survey (n=2,132) < 1hrCentral (n=760) Province (n=761) District (n=611) Pval. Mths <HIV diagnosis 22.924.916.10.001 Triomune ART regimen 52.9%80.9%86.1%0.001 CD4<200 21.1%21.5%21.9%0.82 Highadherence 4 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

15. 4 OUTCOME VARIABLES -average monthly gain in CD4 cells/mm 3 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

16. Multilevel mixed effects models (ref= central level of care) Coef/ IC 95% ProvincialP valDistrictP val CD4 Gain/mth -0.27 (-049/-0.04) 0.02-014 (-035/0.07) 0.19 High Adherenc e 2.19 (1.03-4.68) 0.041.97 (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 (0.00/0.69) 0.05

17. 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

18. 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

19. 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?