387 out of 481(80.5%) respondents recruited by systematic random sampling, bypassed lower health facilities and were associated with marital status, distance travelled of >10 km from the home town to the hospital and tertiary education. Lack of trust in health care providers, lack of medicines and diagnostic equipment and poor quality of health services at lower health care facilities were the main reasons to bypass.
Of the 481 participants, 94 (19.6%) had referral letters, 387 (80.5 %) had not and had by passed lower public health facilities. The majority 347 (72.1%) of the respondents were female and 134 (27.9%) were male. 196 (40.5%) of the participants had attained primary education, 52 (11%) had tertiary education. The majority were Christians 457 (94.4%), 323 (67.2%) were married. Significant differences in characteristics between by-passers and non by-passers attending the outpatient department of Lira hospital were being married and living more than 10 km from Lira hospital (Table 1) There was a significant difference in bypassing between those who attained tertiary education and those with no formal education [odds ratio 0.475 (0.465-486)] (Table 2). The most cited reason to seek health care at Lira hospital was trust in qualified health care providers (31.5%), followed by availability of health care provider (20.5%) and medication (15.2%). Other reasons were recommendation by friends or family (12.8%) and living close to the hospital (10.8%). Lack of trust in the service of health providers (30.9%), lack of drugs (20.2%) and lack of diagnostic equipment (16.9%), long waiting time (5.4%) and attitude of the staff (4.1%) were the main reasons for bypassing lower level facilities and to seek care at higher level facilities.
Three main themes emerged from the FGD transcripts: lack of trust in the service and in the style of handling patients of the health care provider, lack of drugs and inadequate diagnostic equipment in the lower health care facilities
Lack of trust in the service and in the style of handling of the health provider
Lack of trust is for the health providers and the health facilities an important issue. Participants repeatedly mentioned that they do not trust the competence and capability of health providers at the lower level facilities and that providers lack the required skills to deliver the necessary services.
“When I went to the health centre to deliver my third baby, I found one nurse who was the same person at the reception for registration, who was supposed to dispense drugs and she was the same one to attend to me. By the time she came to help me during labour my baby had already died” (27- year- old female, FGD 1)
“I went to the lower health centre due to stomach pain for 3 days. I was told that the woman (nurse) went for a seminar and the “doctor” was away (went to Lira town). So I decided to go to Lira Regional Referral Hospital” (34-year –old female, FGD 2)
The lack of requirements to provide health services at lower health care facilities contributes to the lack of trust in these facilities. Participants expressed their disappointment about the health providers’ rude style of handling patients when patients go for consultation at the lower health care facilities.
“One night upon arrival at about 10:00 pm having been in labour for over one day, the nurse told me to go and bring a lantern and kerosene for her lighting otherwise she would not attend to me. She said it in a very rude and mean way even though she could see that I was in pain. When I went back home I was brought on a ‘boda-boda’ (motorcycle) to Lira hospital. So since then I come to the hospital when I am sick or any of my family members is sick” (31-year- old female, FGD2)
“Two months ago I went to the health centre IV to get treatment for a serious wound on my leg which was dirty and smelling bad. As I was entering the examination room, the doctor in charge started yelling at me that I am “smelling bad” and asking why I have taken all this time while am rotting alive and he continued saying many nasty things. I regretted so much for my condition and was so embarrassed for a person of my age. I simply needed help and that is why he is a doctor to help us and make us get better and probably not smell bad”. (45-year-old male, FGD3)
Lack of drugs
Another reason for bypassing lower health care facilities as mentioned by the FGDs participants was lack of drugs due to stock outs even for the simple conditions like malaria.
“I arrived at the health centre, was seen by the nurse and she told me the drugs are out of stocks so you can go and buy from the drug shop” (23-year-old female, FGD 2)
“When I got no medication at the health centre, I waited for transport for three hours before reaching Lira hospital the next day to get some form of medication” (40 –year-old female, FGD1)
“My baby was hot and was diagnosed at a nearby clinic to have malaria. But when I took my child to the government health centre to get treatment I was told that the drugs for malaria are finished. Yet I saw the lorry bringing drugs the previous day and we were told that the drugs are available so I wondered. I decided to bring my baby to the main hospital” (22- year -old female, FGD2)
Inadequate diagnostic equipment and resources
Inadequate diagnostic equipment was the most serious reason impeding the participants of the FGDs to attend the lower level health care facility.
“ When I took my baby to the hospital, I was informed that the nurses were able to test for malaria but when I took my child and suspected him to have malaria they could not test for malaria. She then sent me to do it in a private lab in a nearby clinic and then take the results to her. So I decided to come straight to Lira hospital” (21year old female, FGD1)
“I have a real testimony of what happened to me. I was feeling dizzy and having a lot of headache and very weak and I wanted to know what was wrong with me like less blood or malaria. So when I reached the health centre, I found the nurse and described my problem to her and she told me something called the strips were finished and she could not check me. I got ‘stuck’ as I was very weak and could not move farther, so my brothers arranged and brought me to Lira hospital” (34-year-old male, FGD4).
“We the village people thought that the health centre was nearer to us to treat us but also to test before treating to know what is wrong. But most times you are simply given drugs without testing. So I thought if they are not able even to test for things like malaria which is the common problem then what is the use of the health centre”. (41years, male, FGD 4)