Letters to the Editor

THE BAMAKO INITIATIVE

In low-income countries, health system deficiencies may undermine treatment continuity and adherence to antiretroviral therapy (ART) that are crucial for the success of large-scale public ART programs. In addition to examining the effects of individual characteristics, on non-adherence to ART and treatment interruption behaviors – i.e. treatment interruption for more than 2 consecutive days during the previous 4 weeks, this study aims to extend our knowledge on the role played by healthcare supply-related characteristics in shaping these two treatment outcomes. These effects are examined using multilevel logistic models applied to a sub-sample of 2381 ART-treated patients followed-up in 27 treatment centers in Cameroon (ANRS-EVAL survey, 2006–2007).

Multivariate models show that factors common to both non-adherence and treatment interruption include binge drinking (at the individual-level) and large hospital size (at the healthcare supply-level). Among the individual factors, financial difficulties of paying for HIV-care are the major correlates of treatment interruption [Adjusted Odds Ratio (AOR) 95% confidence interval (CI) = 11.73(7.24–19.00)]. By contrast, individual factors associated with an increased risk of non-adherence include: having a main partner but not living in a couple compared to patients living in a couple [AOR(95%CI) = 1.51(1.14–2.01)]; experience of discrimination in the family environment [AOR(95%CI) = 1.74(1.14–2.65)]; a lack of regular meals [AOR(95%CI) = 1.93(1.44–2.57)], and switching antiretroviral drugs (ARV) regimen [AOR(95%CI) = 1.36(1.08–1.70)]. At healthcare facility-level, the main correlate of ART interruption was antiretroviral stock-outs [AOR(95%CI) = 1.76(1.01–3.32)] whereas the lack of psychosocial support from specialized staff and lack of task-shifting to nurses in medical follow-up were both associated with a higher-risk of non-adherence [respective AOR (95%CI) = 2.81(1.13–6.95) and 1.51(1.00–3.40)].

Results reveal different patterns of factors for non-adherence and treatment interruption behaviors. They also suggest that psychosocial support interventions targeted at the individual patient-level will not be sufficient to achieve favorable treatment outcomes if not combined with interventions focused on strengthening health systems, including appropriate drug supplies and human resources policies, as well as sustainable and equitable financing mechanisms.

Depuis le début du nouveau siècle, l'aide au développement ciblée sur la santé a connu une augmentation sans précédent, sous l'impulsion de la lutte contre le sida. L'article montre en quoi la lutte contre le sida s'est accompagnée d'un renouvellement des paradigmes économiques qui président à l'action internationale en faveur de la santé dans les pays en développement (PED) : idée que l'amélioration de la santé constitue un pré-requis indispensable de la croissance macroéconomique plutôt qu'une de ses retombées ; insistance sur l'instauration de mécanismes d'assurance du risque-maladie pour financer les dépenses de santé, plutôt que sur le « recouvrement des coûts » au point de consommation auprès des usagers des services de soins ; souci d'imposer des prix différentiels pour l'accès aux médicaments dans les PED, et d'introduire des flexibilités dans les règles internationales de protection de la propriété intellectuelle ; priorité aux programmes verticaux ciblés sur des maladies, censés servir de levier pour un renforcement global des systèmes de santé. L'article discute la pertinence de ces nouveaux « paradigmes » à la lumière des évolutions en cours de l'épidémie de VIH/Sida ainsi que du contexte international. Pour citer cet article : J.P. Moatti, C. R. Biologies 331 (2008).

Since the start of the new century, development aid targeted on health care has seen an unprecedented rise, driven by the fight against AIDS. This article shows how this struggle has been accompanied with a renewal of the economic paradigms governing international action in favour of health care in developing countries: the idea that an improvement in health care constitutes an unavoidable prerequisite to macroeconomic growth, rather than a consequence; the insistence on the founding of mechanisms for health insurance to finance the costs of health care, rather than covering the costs at the point of use by the health care users; a concern to impose price differentials for access to medicine in developing countries, and to introduce flexibility in the regulation of international intellectual property law; the priority to vertical programmes targeted on certain illnesses, thought to act as levers for a global reinforcement of health care systems. This article discusses the pertinence of these new paradigms in light of the evolution of the AIDS/HIV epidemic, and the international context. To cite this article: J.P. Moatti, C. R. Biologies 331 (2008).

This paper applies concentration curves and indices, that have been previously used to analyze progressivity in health care finance and horizontal equity in health care delivery in developed countries, to a 1998–1999 household survey about health care expenditures and utilization carried out in four francophone West African capitals (Abidjan, Bamako, Conakry and Dakar). The paper also uses statistical inference for testing stochastic dominance relationship between curves, a technique already applied in the literature about equity in taxation, as the criterion for making rigorous inequality comparisons. In all four capitals, the results strongly suggest a regressive pattern of payments for health care, with lower income groups bearing an higher burden of health expenditures as a proportion of their income than do the higher income segments of the population. As soon as dominance between concentrations curves is statistically tested, results appear less conclusive, notably for the groups of population affected by severe morbidity, on the issue of horizontal inequity in health care delivery, which requires that persons with similar medical need be treated equally. Some recommendations are made for the use of equity measurements in access to care for future evaluations of the impact of health care reforms in Africa.