title: Does HIV services decentralization protect against the risk of catastrophic health expenditures?: some lessons from Cameroon.
abstract: OBJECTIVE
  Scaling up antiretroviral treatment (ART) through decentralization 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, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics.
  
  
  RESULTS
  Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE.
  
  
  CONCLUSIONS
  The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.
authors.affiliation: Marseille, France. sylvie.boyer@inserm.fr
authors.forename: Sylvie
authors.initials: S
authors.lastname: Boyer
authors.forename: Mohammad
authors.initials: M
authors.lastname: Abu-Zaineh
authors.forename: Jérôme
authors.initials: J
authors.lastname: Blanche
authors.forename: Sandrine
authors.initials: S
authors.lastname: Loubière
authors.forename: Renée-Cécile
authors.initials: RC
authors.lastname: Bonono
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Moatti
authors.forename: Bruno
authors.initials: B
authors.lastname: Ventelou
mesh_terms: D000328:Adult; D002163:Cameroon / Q000453:epidemiology; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000191:economics* / Q000706:statistics & numerical data / Q000639:trends; D005260:Female; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology / Q000628:therapy*; D005102:Health Expenditures / Q000706:statistics & numerical data / Q000639:trends*; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data / Q000639:trends; D006298:Health Services Administration / Q000191:economics* / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000191:economics; D012307:Risk Factors; D055815:Young Adult
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