Diapositive 1

1
HIV services decentralization, health care
utilization and inequity in Cameroon
Results from the national survey EVAL (ANRS
12-116)
Sylvie Boyer1,2,3, Sandrine Loubière1,2,3,
Solange Ngo Yebga4, Mohammad Abu-Zaineh1,2,3,
Jérôme Blanche1,2,3, Camelia Protopopescu1,2,3,
Fabienne Marcellin1,2,3, Pierre Ongolo-Zogo5,
Sinata Koulla-Shiro6, Séverin-Cécile Abega4, Fred
Eboko2, Maria-Patrizia Carrieri1,2,3, Bruno
Spire1,2,3, Jean-Paul Moatti1,2,3 and the EVAL
Study Group
1 INSERM, U912 (SE4S), Marseille, France 2
Université Aix Marseille, IRD, UMR-S912,
Marseille, France 3 ORS PACA, Observatoire
Régional de la Santé Provence Alpes Côte dAzur,
Marseille, France 4 Socio-anthropological
Research Institute (IRSA) - Catholic University
of Central African States, Yaoundé, Cameroon 5
Ministry of Public Health - Division of Health
Operations Research, Yaoundé, Cameroon 6 Ministry
of Public Health - Central Hospital of Yaoundé,
Cameroon
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BACKGROUND

• Large national program for access to ART in
  Cameroon with progressive decentralization of HIV
  care
• Free-of-charge ART since May 2007
• Out-of-pocket payments still necessary at
• the time of the survey for access to treatment
• Access to care and equity in health care
  utilization are major issues

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OBJECTIVE

• To identify socio-economic and structural factors
  associated with health care utilization after
  controlling for needs factors

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PATIENTS

• The EVAL survey (ANRS 12-116)
• National cross-sectional multi-center
• From Sept 2006 to March 2007
• Random sample of 3,151 PLWHA
• aged 21 yrs diagnosed HIV? for 3 months
• 27 HIV-services from the 3 levels of
  decentralization (central, provincial district)

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METHODS (1)

• Data collection
• Individuals characteristics
• - clinical data medical records
• - socio-economic psychosocial data, healthcare
  
• utilization face-to-face interviews
• Structural (hospital-related) characteristics
• questionnaire filled in by supervisors using
  data from
• hospital activity reports health care
  staff interviews

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METHODS (2)

• Analysis Outcome
• Health care utilization
• ? Assessed using the probability of consulting a
  
• physician during the previous 6 months
• Study population
• 1,747 PLWHA ART-treated for 6 months

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STATISTICAL ANALYSES

• Multinomial logistic regression models
• with a 3-category response variable
• - ?1 consultation in the hospital of follow-up
  (ref.)
• - ?1 consultation elsewhere
• - no consultation with a physician

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RESULTS

• Frequency of consultation differs according to
  the level of HIV-services decentralization
• Central Provincial District
  
• ? 1 consultation in 82.6 54.8
  66.3
• the hospital of follow-up
• ?1 consultation elsewhere 11.9 15.4
  13.1
• No consultation 5.5 29.8
  20.7

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• Main characteristics of study population
  (N1,747)

Figures are mean (SD) or of patients
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Multivariate model for health care utilization
(1/2)
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Multivariate model for health care utilization
(2/2)
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CONCLUSIONS

• Prevailing socio-economic and structural barriers
  in physician consultations by ART-treated
  patients
• structural barriers and organizational
  constraints reduced the probability of consulting
  a physician in the hospital of follow-up
• those better off had a greater probability of
  consulting a physician other than at the hospital
  of follow-up
• Importance of the relationship between patients
  and practitioners in the decision to consult

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ACKNOWLEDGEMENTS

• Many thanks to patients
• The EVAL Study Group
• S. Koulla-Shiro (Central Hospital, Yaoundé,
  Cameroon), P. Ongolo-Zogo (Ministry of Public
  Health - Division of Health Operations Research,
  Yaoundé, Cameroon), J. Blanche, A-D Bouhnik, S.
  Boyer, M-P Carrieri, A. Dia, F. Ekoko, S.
  Loubière, F. Marcellin, J-P Moatti, Y. Obadia, C.
  Protopopescu, B. Spire (INSERM, IRD, University
  of the Mediterranean UMR 912, Marseilles,
  France), S-C Abega, C. Abé, P. C. Bilé, C. Bios,
  C-R Bonono, Y. Mehe, M. T. Mengue, H. Mimcheu, F.
  Mounsade, P.Y. Ndzomo, L. M. Ngaba, J. Ngo Mbog,
  S. Ngo Yebga, H. Nkwidjan, O.C. Ossanga (IRSA,
  catholic University of Central Africa, Yaoundé,
  Cameroon), R. Nantchouang (GERCIS, catholic
  University of Central Africa, Yaoundé, Cameroon)
• Sponsoring
• Data collection
• Statistical analysis interpretation

Cameroon Ministry of Public Health