WHO Meeting on positive synergies between health Systems and Global Health Initiatives, 2-3 October 2008

1. FPAE CASS-RT / Un. Ydé I GRAPS / Un. Ydé II Evaluation of access to ART and the health care system in CameroonANRS Research Program in Social SciencesDr. 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

2. 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

3. Objectives Evaluation 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 Methods Quantitative 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)

4. 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

5. 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

6. 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)

7. Study sites

8. 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/

9. To conclude • Large-scale deconcentration • However: 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

10. 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?

11. Cameroon L’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 France L’UMR 912 INSERM-IRD-U2 (www.ur002.ird.fr) Dir. : Pr. J.-P. Moatti The teams

12. 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)