352 - Aids: Cameroon takes up the challenge
50 % of Cameroonians in need of treatment against HIV now have access to such health care. In the early 2000s only 1 % had such a possibility yet in less than ten years their numbers have gone from just a few hundred to nearly 80 000.
From the beginning of the decade, a fall in the price of antiretroviral medicines( 1) started the trend. Then decentralization of access to care, set in train by the government in 2002, followed by the availability of tritherapy( 2) free-of-charge, since May 2007, have allowed this incredible progress. Commissioned by the Cameroon Ministry of Public Health, the IRD researchers and their partners in the South and the North( 3) have set up an assessment programme on this bold decentralization reform, with the support of the French Agence Nationale de Recherche sur le Sida et les hépatites virales (ANRS, France). They find that today, the health care provision for patients is achieving performances at least as good in the district services( 4) as in Yaoundé or Douala, the political and economic capitals.
In Cameroon, half the patients eligible for treatment of VIH/Aids now follow a therapy, compared with only 1% of them in 2000. This is a substantial increase in patient health-care provision, the most rapid improvement in Central and West Africa. To make it possible, at the beginning of the decade the Cameroon government introduced a far-reaching programme to decentralize therapy delivery. At the request of the Cameroon Ministry of Public Health, and the support of the ANRS, the IRD researchers and their partners( 2) assessed this ambitious policy and have shown it to be a success.
A more equitable system
To measure the strengths and limitations of this programme aiming to facilitate access to treatments, in 2006 the multidisciplinary team set up, over all the country’s ten regions, four biomedical, social sciences and public health research projects.
In terms of the criteria studied patient adherence to treatments, immune system restoration and improvement in the quality of life the clinical results for patients of the decentralized establishments were at least as good as in the central medical care services. This is being achieved in spite of fewer human resources and simplified care provision. For some criteria, they are even better. For example, patients are more assiduous in pursuing treatment than in the large urban conglomerations. The time elapsed between diagnosis of the infection and the first consultation for therapy is also significantly shorter in the district services. In addition, the decentralized system reinforces the equity of access to antiretroviral tritherapy: these establishments naturally reach a more rural population, with lower level of education and more often living below the poverty-line.
The assessment results emphasize the positive role of the treatment on the patients’ sense of awareness made possible by repeated contacts with the health-care system (doctors, care personnel, associations, etc.). Unsafe sexual practices with the principal partner are about half as frequent in the people taken care of as in those who do not have continuing therapy.
Towards easier access to treatment
With a prevalence( 5) rate in 2004 of 5.5% for 15-49 year age group, Cameroon has experienced a “generalized” epidemic. About 500 000 persons are now living with the disease. In 2002, the Cameroon government embarked on an ambitious policy of decentralization of its health services. The objectives for the period 1998-2008 were to reduce by a third the morbidity and mortality of the most vulnerable groups, set in place a health centre that would provide the “minimum range of activities” less than one hour’s walk away for 90% of the population and also efficient resources management in 90% of the health service structures. Thanks to generic drugs and backing by international finance schemes for Aids control, the Ministry of Health was able to provide facilities for dispensing tritherapy spread over the whole of the country. It accomplished this by using the decentralized health units already existing in the districts, revitalizing and extending their activities. Antiretroviral medicines were made free-of-charge in May 2007, which strengthened this system further. These measures meant that the number of Cameroonians with Aids having access to treatment rose from a few hundred in 2001 to 78 000 at the end of 2009.
Obstacles still to be overcome
Continuing decentralization of the health care system is coming up against a number of obstacles. These are the structural limits to operation of the Cameroon health system, the crisis in human resources, with a severe shortage of health care personnel, and the dependence of the treatment programmes on international finance, such as the Aids programme, 80% financed by international aid. Now, in the current economic crisis, the Cameroon government can fear a fall in international aid in the short term.
In the industrialized countries, these tritherapy treatments have been proving their worth in Aids control for several years. However, in Sub-Saharan Africa where 70% of the people affected by HIV live, access to these treatments were still extremely limited, by their cost and complicated procedures. Problems, especially for financing and human resources, remain to be solved to ensure the extension of access to antiretroviral treatments. Yet Cameroon is showing the example of great advances of an overall policy, by combining the driving influences from several domains: social, scientific, political, national and international.
3. These investigations were conducted in conjunction with research scientists from the Universities of Yaoundé I and II, the Université Catholique d’Afrique Centrale, the University of Aix-Marseille II, the University of Montpellier I, the University Paris-Nord, the CNRS and INSERM, with the support of ANRS.
Redaction DIC – Gaëlle Courcoux
Translation – Nicholas Flay