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| Abstract #181 - Does HIV-services decentralization protect against the risk of catastrophic health expenditures? Some lessons from Cameroon (EVAL survey, ANRS 12-116) | ||||
| Authors: Presenting Author: PhD Sylvie Boyer - INSERM | ||||
| Additional Authors: Dr. Mohammad Abu-Zaineh, Ms Jerome Blanche, Ms C Bonono, Prof Jean-Paul Moatti, Dr Bruno Ventelou, | ||||
| Aim: Scaling-up antiretroviral treatment through decentralizing the provision of HIV-care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, particularly, its role in protecting against the risk of catastrophic expenditures. This paper therefore seeks to assess whether HIV-care decentralization has a protective effect against the risk of “catastrophic health expenditures” (CHE) associated with HIV infection. | ||||
| Method / Issue: We use data from the cross-sectional EVAL ANRS-12116 survey, containing information on HIV-infected outpatients and on the healthcare supply. Health expenditures (HE) were defined as catastrophic when there share in the household budget was higher than 20%. The determinants of CHE were assessed amongst the ART-treated patients using a hierarchical logistic model (n=2,412), designed to properly investigate the separate effects of individual and healthcare supply-related characteristics. Analyses were first conducted in the whole study population and then in two subgroups of patients according the household income level per equivalent-adult (higher versus lower than the poverty line of 1.3USD per day). | ||||
| Results / Comments: The median household monthly income per equivalent-adult was approximately 20.3USD (10,000 FCFA) while the median amount of health expenditures during the previous months reached 14.2USD (7,000 FCFA). The most frequent expenditures concerned antiretroviral drugs (88.1%) and transportation (85.66%) with a median of 8.80USD (4,337 FCFA) and 6.17USD (3,041 FCFA), respectively. In addition, 11.7% of patients living under the poverty line were exempted from user fees for ART. The incidence of CHE was not significantly different across the three levels of decentralization, with 39.6% (n=1,073) of the study population estimated to have faced CHE (p=0.16). Interestingly, however, when considering household income distribution per equivalent-adult, the incidence of CHE appears to be significantly lower at the district level compared to the central level, especially for the three lowest income quintiles (e.g. median [IQR] share of HE in household income of the lowest quintile= 27.2 [10.5; 72.2] at the central level versus 16 [3.6; 40.7] at the district level). After adjusting for individual and healthcare supply-related characteristics, a positive effect of decentralized HIV-services against the risk of CHE emerges as the main health-system factor explaining inter-class variance. This result was confirmed when the model was estimated in the “poor” and “non-poor” subgroups. Furthermore, when taking into account the decentralization effect on the entitlement to free ART amongst the “poor” patients, the protective effect of free access to ART works for patients followed-up at the district level but not for those followed-up at the provincial level, suggesting that district-level HIV-services were better able to properly identify the indigent segments of the population. | ||||
| Discussion: Our findings suggest that HIV-care decentralization is likely to enhance equity in access to ART. However, decentralization appears to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced. | ||||
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