Introduction

In Cameroon, the HIV epidemic remains a public health problem. Although the prevalence in the general population dropped from 4.3% to 2.7% between 2011 to 2018 (EDS, 2018), the prevalence in major cities like Yaounde is higher at 4.4 % CAMPHIA 2018) with an estimated number of 85736 People Living with HIV (2021 Spectrum). The existence of Users Fees has been reported as a major challenge to accessing quality services by the communities of People Living with HIV(PLHIV), consequently contributing to the delay in the attainment of the 95-95-95 2030 targets.
In response to this, the government of Cameroon through the ministerial decision N°0498/D/MINSANTE/SG/CNLS/GTC/SP of 04 April 2019 enacted a policy for the elimination of ‘USERS FEE’’. The policy aims to remove all fees charged at health facilities for the provision of diagnostic, care and treatment services to PLHIV. To ensure that PLHIV continue to receive quality services with the rollout of this policy, there is a need for continuous monitoring at the facilities with routine feedback from the receivers of care. It is in this regard that the National Network of PLHIV in Cameroon (RECAP+), with support from USAID, UNAIDS and the government of Cameroon is rolling a nation-wide project on Community Led Monitoring and Advocacy (CLM) for the provision of quality services to PLHIV which free of charge. This is done through improved community participatory monitoring systems and has the following objectives;
1. Strengthen the existing system to monitor the elimination of HIV-related user fees at health facilities and share findings with all stakeholders,
2. Foster health facility compliance in quality and quantity with the new government policy focused on eliminating user fees at HIV service delivery points,
3. Empower PLHIV and communities to leverage evidence gathered to demand improved access to and quality of services.

Description

The community led advocacy model is currently being carried out as a nation-wide program in Cameroon since September 2021. In the city of Yaounde a total of 9 Community Based Organisations, 6 health districts and 81 health facilities have been enrolled in the monitoring program.

The main activities carried out are;
• Monthly data collection by site a monitor using two questionnaires (PLHIV and Health personnel) at health facility level
• Data verification by data clerks, transmission and analysis at central level by Monitoring and Evaluation specialist
• Generation of monthly dashboards and sharing with stakeholders. Presentation of dashboard and advocacy during national coordination meetings with stakeholders
• Holding of meetings with head of health facilities to discuss problems identified in health facilities
• Participation in coordination meetings at all levels to discuss results and advocate for a change

ReCAP+ through 48-member Community Based Organisation (CBO) conducts weekly community sensitization activities to create awareness on the user fees elimination policy and the CLM program. In the city of Yaoundé, a total of 9 CBO and 81 health facilities have been enrolled for the program. PLHIV and affected persons are informed and encouraged to denounce malpractices (related to the quality of the services and the non- application of the USER FEES policy) in the selected health facility level using the newly developed CLM-ReCAP+ mobile application found on playstore or using the ReCAP+ CLM website.
Furthermore, ReCAP+ uses the existing coordination mechanism of the Cameroon health system to conduct its advocacy activities at all levels of the health pyramid.

• At health Facility; This marks the beginning of the advocacy to the head of the health facility once a problem is identified during data collection process

• At health district level: There exist monthly district coordination meetings made up of; chief of district health service, director of the district hospital, the chief of health centers in district, mayors, Civil Society Organisations (CSOs), Community Based Organisations (CBOs), Non-Governmental Organisations (NGOs) operating in the health district. During this meetings ReCAP+ through its district CBOs presents the findings from the CLM and advocates for a change when a problem is identified. The purpose of this is to engage these key stakeholders in solving the problem but if not successful, the advocacy is taken to the next level.
• At regional level: Quarterly regional coordination meeting made up of: the regional delegate of public health, coordinators of health programs (HIV/AIDS, T.B, Malaria etc), administrator of the regional fund for health promotion, director of regional hospital, the chiefs of the various district health services, Mayor and other stakeholders (CSOs, CBOs, NGOs) operating in the region. ReCAP+ via its regional CBO presents findings of the CLM project during the meeting and advocate for a change by engaging the regional delegate most in particular. If advocacy is not successful at this level, the problem is carried to the central level
• Central level: Semestrial coordination meeting exist as well as many other coordination meetings of different ministerial departments. However, ReCAP+ at the central level mainly operates (presentation of monthly dashboard and advocacy) via the “National user fees core group” platform which regroups all regional delegates, coordinators of HIV programs and the regional funds for health promotion as well as other stakeholders (technical and financial partners, NGOs, CSOs, CBOs). If advocacy is not successful at this level, a letter is written to the Minister of Public Health and audience booked (still to be realized).

Data Collection

Data is collected from two main sources. PLHIV and health personnel through self-administered questionnaires. An average of 243 health workers and 584 beneficiaries of HIV services are expected to complete the questionnaires from 81 health facilities and 6 health districts in the city of Yaounde. This collection is carried out by site Monitors who are supervised by Community Based Organisations (CBOs). The data collected is routine programmatic data.

1. Percentage of HIV health care providers who are aware of the existence of the national policy on free user fees on HIV/AIDS services during the reporting period per type of health facility: This is the proportion of healthcare providers who are aware of the existence of the free user fee policy. Health care providers should be aware of all the components of the policy.
2. Percentage of health facilities who adhere to the national policy on free user fees on HIV/AIDS services during the reporting period per type of health facility: This is the total number of health facilities that offer for free the HIV/AIDS services contained in this national policy. Health personnel in these health facilities should offer for free ALL these HIV/AIDS services in the policy.
3. Number of people sensitized during advocacy meetings to raise awareness on free user fees policy by category of health personnel (frontline providers, health administrators, and their health staff), type of health facility, and region: This is the total number of people sensitized during advocacy meetings to raise awareness on free user fees policy by category of health personnel
4. Percentage of PLHIV who are aware of the free user fees policy on HIV/AIDS services within the period per means of sensitization: This is the proportion of PLHIV interviewed during a period who know the existence of this free user fees policy and at least a means of sensitization. When PLHIV is not aware of some of the HIV/AIDS services that are supposed to be offered for free, the PLHIV is considered to be partially aware. When the PLHIV is not aware of any of the free HIV/AIDS services, he is considered to be unaware. A PLHIV is considered to be fully aware If s/he knows all the HIV/AIDS services that are supposed to be offered for free
5. Percentage of PLHIV who have benefited from the free HIV/AIDS services during the reporting period per type of HIV/AIDS services: This is the percentage of PLHIV interviewed during a period who have benefited from a free user fee policy. Here the percentage for each of the HIV/AIDS services is computed.
6. Percentage of PLHIV who have paid for HIV/AIDS services indicated in the user fee policy during the reporting period per type of HIV/AIDS services: This is the percentage of PLHIV interviewed during a period who paid for these HIV/AIDS services during the reporting period. Here the percentage for each of the HIV/AIDS services is computed.
7. Percentage of PLHIV who have not benefited from free HIV/AIDS services during the reporting period due to stock out of inputs: This is the percentage of PLHIV interviewed during a period who did not benefit from the free user fees policy because of a stock out of inputs. Here the percentage for each of the results for each of the HIV services is computed.

Results, Outputs, and Outcomes

The preliminary results from the rollout of the intervention are seen on the table below;

The key finding reveal that there is an increase awareness and adherence to the national policy on the elimination of users fee at the level of the health facility. Over the last three months the proportion of PLHIV who have benefited from HIV free services has increased from 88% in January to 90% in March 2022. In addition to this there has been a 2% decrease in the number of people who have paid for HIV services.

Lessons Learned

i. Highly qualified staff in key positions are imperative in the successful implementation of a CLM system; when key personnel are highly experienced, there can easily identify risks and problems and put in place mitigation measures ahead of time
ii. When there is acceptance of the CLM system by the government, it leads to close collaboration between the government and the civil society organizations, easing the acceptance of the system at all levels as well as implementation at all levels
iii. When CBO support is poor coupled with poor staff renumeration, it leads to high turnover; high turnover will greatly influence progress in attaining results thus, negatively affects successful project implementation due to continuous recruitment and training of new comers
The success of the program require commitment from the Key stakeholder to address the problems presented through the community led monitoring.

Conclusion

Thanks to this CLM advocacy model;
- PLHIV have increased knowledge of the HIV user fees elimination policy and the various free services.
- The number of health facility adhering to the policy have increased and more PLHIV are demanding for HIV services, more PLHIV are receiving frees services; initial and follow-up consultations, hospital booklets, patient’s file, prenatal follow-up tests, early infant diagnostics for HIV, antiretroviral drugs, infection prevention drugs, viral load and CD4 monitoring.

The advocacy model is a best practice because it aligns to the existing coordination mechanism of the Cameroon health system thus, reducing the cost of organizing other meetings for advocacy by bringing together people and, reducing the risk of COVID-19 contamination. Also, everyone is involved most especially PLHIV through weekly community sensitization of the general population and specific groups of PLHIV. Furthermore, through the advocacy a virtual communication platform has been put in place to harness direct feedback from the communities of PLHIV regarding the quality of services in the selected facilities. This activity would not have been successful if not for the support from the facility management, the Ministry of health and community based Organisations.