Financial barriers to HIV treatment in Yaoundé, Cameroon: first results of a national cross-sectional survey
Sylvie Boyer a, Fabienne Marcellin b, Pierre Ongolo-Zogo c, Séverin-Cécile Abega d, Robert Nantchouang e, Bruno Spire a & Jean-Paul Moatti a
a. INSERM / IRD U912 (SE4S), Université Aix Marseille, 23 rue Stanislas Torrents, 13006, Marseille, France.
b. ORS-PACA, Observatoire Régional de la Santé Provence Alpes Côte d’Azur, Marseille, France.
c. Ministry of Public Health, Division of Health Operations Research, Yaoundé, Cameroon.
d. Socio-anthropological Research Institute, Catholic University of Central African States, Yaoundé, Cameroon.
e. Social Integration Research and Study Group, Catholic University of Central African States, Yaoundé, Cameroon.
Correspondence to Sylvie Boyer (e-mail: email@example.com).
(Submitted: 20 November 2007 – Revised version received: 02 June 2008 – Accepted: 14 August 2008 – Published online: 20 February 2009.)
Bulletin of the World Health Organization 2009;87:279-287. doi: 10.2471/BLT.07.049643
After the Bamako Initiative, which was launched at a meeting of African ministers of health in Mali in 1987, many developing countries introduced or expanded cost recovery policies by charging patients new or higher user fees at the point of care delivery, since this was recommended as a way to increase health-care funding and improve access to primary health care and public health services.1 In all sub-Saharan African countries, which pay the highest toll to the AIDS pandemic, more than half of total health expenditures are borne by households in the form of direct out-of-pocket payments at the point of service delivery.2,3 Increasing empirical evidence suggests, however, that the persistence of user fees for antiretroviral therapy (ART) and HIV/AIDS care decreases adherence4–8 and treatment effectiveness.9 Other evidence also highlights that user fees undermine both access for the poor and the equity of ART programmes, even when associated with subsidizing schemes and exemption mechanisms targeted at the poorest sectors of the population.10 WHO’s public health approach for scaling up access to treatment for HIV/AIDS in developing countries has explicitly endorsed the provision of “free-of-charge ART at the point of delivery” as a key component for reaching the goal of universal access to HIV/AIDS care and treatment by 2010.11
Cameroon has initiated one of the most dynamic ART programmes in Africa, with more than 55 000 HIV-positive patients benefiting from ART in June 2008. This figure represented about 58% of the estimated number of patients in the country requiring ART.12 Until May 2007, treated patients had to pay user fees for ART as well as for laboratory tests and physicians’ consultations, even though 40% of the population lived under the poverty line.13,14
Data from the first phase of the national survey EVAL (ANRS 12–116) allowed us to assess the extent to which user fees created a financial barrier for access to care among ART-treated HIV-positive patients in Yaoundé, the capital of Cameroon.
The Cameroonian health-care sector includes the public and private (lucrative and non-lucrative) sectors and a traditional sector. Following the recommendations of the Conference of Harare on strengthening district health systems based on primary care (1987), the government adopted a three-level pyramidal health-care model with health districts as the cornerstone. Cameroon also agreed to the above-mentioned Bamako Initiative in 1987 and by the beginning of the 1990s, fees for inpatient and outpatient services, drugs and biological tests were being charged in all health-care facilities.15
Monthly ART prices were established for all HIV treatment centres until May 2007 at 3000 francs de la communauté financière africaine (FCFA), or about 6 United States dollars (US$), for Triomune®, and 7000 FCFA, or about 14 US$, for other treatments (at 1 US$ = 492.6 FCFA). The price for an initial biological check-up and bi-annual biological monitoring, including CD4 count, was established at 3000 FCFA.16 Amounts for other services, such as medical consultations, drugs for opportunistic infections and hospitalization, were fixed by each health-care provider irrespective of a patients’ socioeconomic status.
In addition, patients who were identified as “indigent” could be exempted from user fees for ART, up to a maximum of 10% of patients in each HIV-treatment centre. In practice, however, assessment of indigence, which social workers carried out on the basis of occupation, marital status, number of dependants and availability of financial support from a family member, was not completely standardized between health-care facilities.
EVAL (ANRS 12–116) is a national cross-sectional multicentre survey funded by the French National Agency for Research on AIDS and Viral Hepatitis and approved by the Ministry of Public Health in Cameroon and the Cameroonian National Ethics Committee. The first phase of the survey was undertaken between the 7 September and 20 October 2006 in six public hospitals (five national reference and one district hospital) which deliver HIV/AIDS care and ART in Yaoundé and its surroundings. Eligibility criteria included being over 21 years of age and having been diagnosed as HIV-positive at least 3 months earlier. In each hospital, survey participants were randomly selected among eligible patients, and refusals to participate were recorded. Patients who agreed to participate had to complete a written informed consent form and were referred to a trained interviewer after their clinic visit. At the end of a 45-minute interview, a blood sample was collected for a CD4 count.
Clinical data, including type of ART regimens prescribed and immunological status (CD4 counts) at ART initiation, were obtained from medical files by care providers. During face-to-face interviews, information was obtained from patients on sociodemographic and economic characteristics, disease history, treatments and medical follow-up, adherence to ART, detailed health care expenditures over the previous month and occupational status.
Financial difficulties in purchasing ART were assessed with the question: “During the last 3 months, were you ever unable to buy your HIV medicines because of lack of money?” Adherence to ART was measured through a validated list of questions17,18 about the doses taken and compliance with the dosing schedule during the prior 4 days. This allowed us to compute scores for “high”, “moderate” and “low” adherence to ARV drugs; for the multivariate analysis, adherence scores were dichotomized into two categories: high and moderate/low.
The present analysis was focused only on the subsample of patients who were on ART at the time of the survey (study population). However, we applied the χ² or Fisher test to compare their sociodemographic characteristics with those of patients eligible for ART who did not effectively have access to the treatment.
Logistic regression was used to identify the sociodemographic, economic and clinical factors associated with self-reported financial difficulties in purchasing ART. All variables that yielded a P-value lower than 0.25 in the univariate analysis were tested in the multivariate model. A forward selection procedure was used to identify statistically significant factors in the multivariate model (α = 0.05). The model obtained was re- run after introducing the CD4 count at the last assessment and adherence to ART to test for an association between these two outcomes and patients’ self-reported financial difficulties, after adjustment for potential confounding factors. SPSS software, version 14.0 for Windows (SPSS Inc., Chicago, IL, United States of America) was used for all analyses.
Characteristics of the study population
A total of 843 HIV-positive patients were randomly selected among eligible patients who attended the six public hospitals during the survey period, and 707 of them agreed to participate in the survey (response rate, 83.9%). No significant differences were found between participants and non-participants except for median CD4 counts (participants: 315 cells/µl; non-participants: 212 cells/µl: Mann-Whitney test, P < 0.0001) and transportation time to the hospital (< 1 hour for 72.6% of participants versus 22.9% for non-participants; χ² test, P < 0.0001).
Among the 707 participants, 532 (75.2%) were on ART at the time of the survey. Of the non-treated patients, 73 (41.7%) fulfilled the clinical and immunological criteria for ART according to existing guidelines in Cameroon. ART-treated patients had significantly higher sociocultural status than patients who were not treated even though they were eligible for treatment at the time of the survey, both in terms of education and living conditions: 77.2% had a high school or university education versus 67.1% of non-ART-treated eligible patients (P = 0.05), and 41.9% had tap water at home versus only 26.0% of non-ART-treated patients (P = 0.009).
As shown in Table 1, the average age of ART-treated patients was 38 years, and 90.8% of them lived in urban or semi-urban areas. More than two-thirds were women, half reported living in a stable relationship, and nearly two-thirds reported being economically active. The median household monthly income was 63 000 FCFA (128 US$) (interquartile range, IQR: 40 000–116 600 FCFA or 81–237 US$); thus, 54.0% of study patients lived under the poverty line.13,14,19 The average time since ART initiation was 19 months, and half the patients received the generic antiretroviral combination Triomune®.20
Table 1. Factors associated with self-reported financial difficulty in purchasing ART over the past 3 months among ART-treated HIV‑positive patients in Yaoundé, Cameroon, 2006
Patients’ health-care expenditures
The median monthly direct out-of-pocket health expenditure of ART-treated patients was 9800 FCFA (IQR: 6300–18 600), or 20 US$ (IQR: 13–38). Of this amount, 3000 FCFA (IQR: 3000–7000), or 6 US$ (IQR: 6–14), went mainly to the purchase of ART; 1000 FCFA (IQR: 600–2,000), or 2 US$ (IQR: 1–4), went to transportation costs to the hospitals, and 1600 FCFA (IQR: 0–3,000), or 3 US$ (IQR: 0–6), went to health-care professionals’ consulting fees. These amounts comprised 47.0%, 12.0% and 6.0% of the total expenditure, respectively. Other expenditures went to medication other than ART, biological tests, hospitalization and traditional medicine.
Of all households, 40.4% faced monthly catastrophic health expenditures, defined as expenditures representing at least 20% of the household’s total monthly income.21 Dependence on loans or financial help from sources outside the household to pay for the previous month’s health expenditures was also reported by 39.8%.
Financial difficulty in purchasing ART
Financial difficulty in purchasing ART during the previous 3 months was reported by 20.1% (107) of ART-treated patients. For all these patients, irrespective of follow-up hospital, the largest proportion of health-care expenditures went to the purchase of ART (median range: 37.2–71.4%).
Patients who faced financial difficulty in purchasing ART were significantly younger than other ART-treated patients (Table 1, univariate models). They also had a significantly lower average household income, and health expenditures comprised a larger proportion of their income (19.1% versus 13.1%, P < 0.0001). Univariate analyses also showed that sons or daughters of the head of the household faced less financial difficulty in purchasing ART than the head of the household, his/her spouse or his/her sibling.
These results were confirmed in the multivariate model (Table 1).
Adherence to ART and immunological response
Good adherence to ART during the 4 days before the interview was found in 56.6% of ART-treated patients. Patients who reported financial difficulties in purchasing ART were significantly less likely to have good adherence than those who did not (29.9% versus 63.4%; P < 0.0001). They were also significantly more likely to have a CD4 count < 200 cells/µl at the time of the survey (29.0% of patients versus 18.8% of patients without financial difficulties: P = 0.02). No significant difference was found in CD4 count at ART initiation. A multivariate analysis adjusted for patients’ socioeconomic characteristics confirmed these two relationships (Table 2).
Table 2. Association between self-reported financial difficulty in buying ART during the previous 3 months and (i) adherence to ART and (ii) last CD4 count among ART-treated HIV-positive patients (n = 532) in Yaoundé, Cameroon, 2006
Even though antiretroviral drugs are commonly subsidized within the public sector in African countries to make them affordable for patients, user fees for ART are still charged in many of these countries. Increasing evidence from HIV/AIDS treatment programmes in Africa shows that user fees and cost recovery policies put HIV/AIDS treatment beyond the reach of an overwhelming majority of affected households.10,11 In addition, literature reviews on empirical evidence gathered since the 1980s clearly show that problems of sustainability, efficiency and equity faced by public health systems in developing countries have persisted and often worsened after the introduction of user fees.22,23
The HIV/AIDS care subsidizing policy developed by the Cameroonian government and sustained financially by the Global Fund has allowed an increasing number of HIV-positive patients to receive ART. However, the results of our survey confirm that user fees for ART remained a major barrier to delivery of appropriate HIV treatment for significant segments of the population.24,25 Indeed, one out of five ART-treated patients reported not having purchased antiretrovirals at least once during the previous 3 months because of lack of money. Moreover, multivariate analysis, while not intended to demonstrate any causal relationship, showed a correlation between non-adherence to ART, reduced immunological response to treatment and financial difficulties in purchasing ART, even after adjustment for confounders. These findings from a representative sample of patients confirm the results of pilot programmes.5,7,8,26
Evidence from our survey remains limited to Yaoundé, one of the two most prosperous areas of Cameroon, and its immediate surroundings. The effect of user fees on ART is probably greater elsewhere, although this requires confirmation through studies at the national level. ART-treated patients in our sample tended to have higher sociocultural and economic status than members of the general population of the same age and gender living in Yaoundé (data not shown).27 Caution should be exercised, however, when drawing conclusions from this in terms of equity in access to care, since epidemiological evidence suggests that more educated groups in Cameroon have a higher prevalence of HIV infection.27 Nonetheless, in this sample of patients living with HIV/AIDS who knew of their positive serostatus and had sought HIV/AIDS care, the few who were eligible for ART (circa 10.3%) but did not have effective access to it had a significantly lower socioeconomic status than those who received ART.
Another limitation of our survey is that the use of a single question and self-report to assess patients’ financial difficulties may have introduced a social desirability bias. However, observed correlation between declarations and lower income levels and detailed documentation of health-care expenditures suggest that real difficulties faced by patients were captured at least to some extent.
Barriers to accessing ART
In our sample, the comparison of patients who received ART with those who did not receive it despite being eligible for it showed that the latter face greater financial barriers. Qualitative interviews conducted in parallel with this survey have also revealed mechanisms through which financial barriers may limit access to ART among medically eligible patients. One such barrier involves the out-of-pocket payments required for biological tests to determine eligibility for ART. Once patients overcome this, effective initiation of ART is then decided by a “therapeutic committee”, composed of caregivers and social workers, who take into account a set of clinical and biological eligibility criteria as well as the “socio-economic capacity” of patients to comply with prescribed regimens. At the time of the survey, when Global Fund money for providing ART free of charge had been exhausted, a patient clinically and biologically eligible for ART could be denied it because of insufficient financial resources to sustain it in the long term.
Free access to HIV/AIDS care
Following the examples of Brazil and Senegal, other countries, including the Congo, Ethiopia, Kenya, Nigeria and the United Republic of Tanzania, have recently adopted universal free access to ART in the public sector.10 Research in Benin,28 Malawi29 and the United Republic of Tanzania30 has highlighted that a free HIV/AIDS care package has led to a dramatic increase in HIV testing and treatment uptake.
In April 2007, following these experiments and the preliminary results of the ongoing evaluation of its national AIDS programme, the Government of Cameroon adopted a policy of free access to ART at the point of delivery. Although this is an important step towards the goal of universal access to HIV/AIDS care and treatment, it is not enough to resolve all financial difficulties for ART-treated patients. In our sample, ART-treated patients still devoted a median of 4000 FCFA (8 US$) per month to non-antiretroviral drugs. This means that even with free antiretrovirals, about one-quarter of ART-treated patients in Yaoundé will still face catastrophic health-care expenditures. By repeating this cross-sectional survey in the near future, we will be able to measure the effect of the free ART policy in Cameroon on treatment adherence and effectiveness.
Our results strongly support WHO’s recommended policy of free access to HIV/AIDS care and treatment at the point of delivery11; they have, in fact, already contributed to a major change in pricing policy in Cameroon. However, governments and policy-makers may harbour legitimate concerns about free treatment and care policies for patients with HIV. One such concern has to do with the loss of resources for health care and the uncertain sustainability of funding for ART programmes. Abolishing user fees would certainly lead to some loss of resources for HIV programmes. In Senegal, for instance, the average monthly direct contribution per capita in 2006 ranged from US$ 7 to 11.30. Yet the total of such contributions comprised less than 10% of the entire budget of the national ART programme.31 Furthermore, these resource losses will be partly offset by the decrease of administrative costs previously devoted to cost recovery and by savings due to improved adherence and treatment outcomes.
One should note, however, that abolishing user fees may mean higher “opportunity costs” for national and local decision-makers. In most sub-Saharan countries, more than half of total expenditures for HIV/AIDS care and 70% of the cost of ART programmes come from foreign sources.32 National authorities may not favour free care policies that could lead to long-term dependence on external donors. Because more than 80% of HIV-positive persons in sub-Saharan Africa are estimated to be unaware of their own serostatus, there are pressing calls to scale up HIV testing and counselling to increase treatment uptake.33–35 In this context, governments may see user fees as a means for dealing with increased demand, since the available infrastructure and human resources are often far less than those needed to deliver appropriate treatment.
The policy of abolishing user fees also calls for a revision of existing health financing models. One interesting experimental scheme to implement free HIV/AIDS care would be to create a “purchase fund”, financed by donors and national governments, that would reimburse HIV/AIDS care providers based on invoices for their care. According to a study conducted for the Senegalese government, this would be technically feasible and financially sustainable.36
Another concern surrounds the potential effect of providing free HIV/AIDS care on access to all essential health services for the whole population, especially for the poor. Eventually, free HIV/AIDS care policy and new models of financing could be extended to priority care or prevention activities for other diseases.
Attainment of the goal of universal access to HIV/AIDS care appears to depend, among other factors, on successful implementation of a free care policy at the point of service delivery. The epidemic of HIV infection creates an opportunity to implement new financing mechanisms for health care with the public resources of national governments and funds from international donors,37 a step that is necessary to bring effective ART and appropriate care to HIV-positive individuals in low-resource countries. ■
We thank the Cameroonian Ministry of Health and the French National Agency for Research on AIDS and Hepatitis (ANRS) for their support. Our thanks also go to the six hospitals that participated in the survey and their medical teams. Finally, we thank all the patients who agreed to take part in the study.
Funding: Our work was supported by the French National Agency for Research on AIDS and Hepatitis. The authors have not entered into any agreement with the funding organization that may have limited their ability to complete the research as planned, and they have had full control of all primary data.
Competing interests: None declared.
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