Verbatim quotes were used to illustrate participants’ perspectives of access to and quality of primary healthcare. The main findings showed limited access to healthcare and unacceptable healthcare quality. Having health insurance was an enabling factor in utilising healthcare in East Africa while use of herbal medicines and other traditional medicine practices delayed or deterred seeking modern healthcare. Patients, care health providers and other stakeholders mentioned insufficient equipment, frequent drug stock-outs and long waiting times as major quality issues, but differed in their opinions on general satisfaction with quality of care, with healthcare provides sometimes reporting high quality of services in the same centres where patients reported low quality.
1. Access to primary healthcare
Free health services
Provision of free health services by some public facilities was perceived to facilitate access to primary healthcare by providing free drugs and tests, but this was often associated with long waiting time. On the other hand, private facilities were thought to be unaffordable to many users, even though waiting time was shorter.
What I like most about the government hospital is the fact that you don’t pay. If you are lucky and you find when drugs are available, you will get drugs. And even testing will be done for free, and drugs you get for free and even if its HIV they test you for free, (IDI with an elderly man, Uganda).
A participant whose opinion reflected most other participants’ perception was that having a health insurance was a facilitator of access to primary healthcare irrespective of the cost of treatment.
It (referring to a type of health insurance scheme) caters for all health services regardless of the illness. It doesn’t categorize if its amputation, laboratory services (FGD, Respondent 1, a young man, Kenya)
However, some participants had varying opinions regarding inability to access certain services which necessitated out-of-pocket expenditures in certain health facilities that did not accept health insurance cards from some insurance providers.
X health insurance scheme helps very little because they have to pay for some services in cash, sometimes people have to dig into their pockets. It doesn’t cover everything because there are some drugs you’ll be told to buy (KII with a Religious Leader, Kenya).
Again the cards that ought to be used (participant mentions names of some insurance providers) are supposed to be accepted and used for outpatient services. They are not used for accessing services (KII with a Community-based Organisation Leader, Kenya).
I went to the X dispensary with my insurance card, I was rejected (everyone laughs) (FGD with women, Tanzania).
Participants mentioned inability to afford high costs, distance to health facilities, unavailability of or shortage of health personnel, limited operating hours of healthcare facilities, and patronage of PMVs.
Out-of-pocket payments and inability to afford high costs of care
Some participants reported having challenges in accessing health services due to exorbitant fee-for-service charged in private facilities.
The last time I went to X health facility, something entered my ear. ..They gave me a letter and sent me to another health facility, but I didn’t have money. So I tore the letter and stayed with that thing inside my ear. (FGD, Respondent 3, a young woman, Kenya).
You also pay for investigations. Nothing is for free. You have to pay for everything. For us who are poor, we face a lot of challenges getting medical services (FGD with women, Tanzania).
When I asked them to attend to me first since I was bleeding they asked me for money which I didn’t have then. …I was forced to deposit my phone after which they attended to me. So I had to go sort the finances out and come later to collect it. (FGD, Respondent 2, a young man, Kenya).
Distance to health facilities
Far distance to healthcare facilities posed a challenge. The cost of seeking healthcare is further increased by transportation costs.
Most people trek. Like those without a car or a motorcycle, once you are sick and you stand by the road and there is no bike to take you there (referring to the health facility), you have to walk there. Like where I live, I trek o! (o is an exclamation in Nigeria used to emphasis or buttress an argument). It takes me like one hour twenty something minutes. (FGD, Respondent 1, a middle-aged woman, Okpok Ikpa, Nigeria).
Unavailability of health personnel
Participants commonly reported unavailability of doctors and nurses.
You know at times the doctors, the nurses have their other private clinics so they leave the other side of the government and go to the other side of the private. So when you go there, you may not get them easily. (IDI with a young man, Uganda).
They don’t even have the capacity to handle malaria. They only have a Community Health Officer, there is no competent nurse there (FGD, a young man, Olorunda, Nigeria).
I went the first time I didn’t get the doctor, the second time I didn’t get the doctor until the third time is when I received the services (FGD, Respondent 4, a young woman, Kenya).
Healthcare facility days and hours
Most discussants reported public facilities did not operate for 24 hours in a day and during weekends, unlike private facilities.
Many times I’ve wanted to go to voluntary counselling and testing but my husband is at work…if you go to facility A, you find that the hospital is closed over the weekend and that is when my husband has time, on Saturday afternoon. So it’s a real problem (FGD, Respondent 3, a young woman, Kenya).
For example in Facility B, if opening time is 9:00am, if you go there at 12:00 pm they will not serve you because the time is gone. (FGD, Respondent 7, a middle-aged woman, Kenya).
2. Quality of primary healthcare
General (dis)satisfaction with quality of care
There was a variety of responses regarding quality of care with some participants reporting satisfaction while others reported dissatisfaction with the quality of care.
We are not condemning the health facility (referring to a specific health facility). I remember a team of white people came here and I was operated upon. I enjoyed it very well (FGD, Respondent 6, a middle-aged man, Okpok Ikpa, Nigeria).
I think the quality is good (referring to a private facility), I can give them good (IDI with an elderly man, Uganda).
You can meet a doctor or nurse so he will not listen to you (referring to a public facility). While you are still explaining how you feel, but even before you finish, they write you prescription to get medicine (mmh). Now you keep asking yourself what is this medicine for (FGD with women, Tanzania).
Health personnel factors
Retaining qualified health personnel in public facilities was reported to be challenging due to low payments. In addition, health personnel working in public facilities were said to be sometimes unprofessional toward their clients. On the other hand, patients reported that health personnel in private facilities were unqualified and lacked training.
We try as much as possible to employ qualified medical personnel … for high standards in the provision of services. … For remuneration, we don’t pay them what they expect to be paid so sometimes we lose staff. So staff turnover is higher than what we desire (KII with a Health Service Manager in a private health facility, Kenya).
Even those ones (referring to private facilities) don’t have qualified staff. They are not trained. Some people who have worked in pharmaceutical shops are just recruited and they just dress them up to attend to people. (FGD, a man, Olorunda, Nigeria).
But again government employees don’t treat people well, you can ask them a good question and they answer you with attitude so if you have money you better go to private hospitals or to chemist (FGD, Respondent 1, a young woman, Kenya).
Hmmm at times nurses tend to be rude (IDI with a young woman, Uganda).
Respondents reported that waiting time was longer in public facilities due to late arrival of doctors. Long queues in these facilities were said to be the reason why people visited the PMVs.
…. You don’t take time (referring to a private facility), not like the main hospital (referring to a public facility) where you go in the morning, then take almost the whole day when you are fully attended to because of the population (IDI with an elderly man, Uganda)
If you go to the General Hospital, just have it at the back of your mind that it is when God releases you that you will leave the place. By now people will already be many there and the doctor will not come until 11.00 am because government work is not work that you will be sweating over (FGD, an elderly woman, Ikire, Nigeria).
So it forces you to go to the chemist no matter the cost since in the public facility there is a long queue (FGD, a young man, Kenya).
Some participants reported that healthcare was free in public facilities, but drugs were frequently out-of-stock forcing patients to go to PMVs.
Even after the doctor sees the person, he just hands him a prescription to buy his drugs outside the hospital and as such people buy the quantity they can afford not the complete dose (FGD, a young man, Ikire, Nigeria).
The city council has indicated that the health services are free and when you seek help they prescribe drugs but upon going to retrieve them you are told they have none (FGD, Respondent 6, a middle-aged man, Kenya).
Interrupted power supply
Erratic electricity supply was reported by several participants in Nigeria.
It is very difficult to get medical tests done in this community, even at the public hospital. I have to buy three litres of fuel (referring to the purchase of petrol to power the hospital-owned electric generator which is the responsibility of the hospital) each time I want to have a blood test done as ordered by the doctor. I have done this six times over the last two months (FGD, an elderly man, Ikire, Nigeria).
Lack of equipment
The lack of equipment to conduct basic tests was reported to negatively impact the quality of service delivery.
Again service delivery is a challenge since they (referring to public facility) lack equipment to carry out tests (FGD, Participant 5, a young man, Kenya).
3. Health-seeking behaviour
Most participants reported that their first choice for treating a minor illness was to treat themselves at home with medicines previously bought from PMVs and/or local herbs, often administered through enema. This was widely reported in Nigeria where there is a traditional belief that this purges the body of impurities. The next line of action was to visit a PMV and only if that was not possible or effective would patients go to a health facility.
Self-medication at home
Self-medication with herbs and drugs bought from chemists was reported to be a common practice to treat illness at home.
I pump o (referring to self-administration of herbs through the anus using a pump-like device) because in this our community, we believe in tradition. Once you are sick, the first thing that you would do is to wash your system out before treating. … we have leaves, herbs that can help us in this community to wash our system (FGD, a middle-aged woman, Okpok Ikpa, Nigeria).
Sometimes I use Aloe Vera when I feel malaria (mmh) I can only laugh well and drink, we also use it well and feel better (FGD with men, Tanzania).
From home to patent medicine vendors (PMVs, also referred to as chemists)
Some participants reported visiting PMVs when there was no relief from herbs and drugs used for self-medication at home.
You have to take enema to wash out all the dirt from the stomach from what you ate. This will give you some relief but if it doesn’t, you have to go to the chemist to get some drugs (FGD, an elderly man, Okpok Ikpa, Nigeria).
From patent medicine vendors (chemists) to health facilities
Health facilities were visited when drugs bought from PMVs did not relieve symptoms or when an illness was exacerbated.
From the chemist if that disease does not subside, we can now find way to go to the health centre (FGD, a middle-aged man, Okpok Ikpa, Nigeria)
The convenient way is getting medication from the chemist and if the conditions persist we seek help from the hospitals (FGD, a young man, Kenya).
From health facilities back to patent medicine vendors or traditional healers
After undergoing a consultation with health personnel, some participants bought medications prescribed by doctors from PMVs due to frequent drug stock-outs in health facilities. There were instances participants were referred back home to take herbs.
… The doctor in the health facility instructed me to buy the drugs from the facility’s pharmacy. But when I went there it was unavailable, so I went and bought the drugs from a chemist (FGD, a middle-aged woman, Okpok Ikpa, Nigeria).
Some people are referred back to their homes to use native treatment (FGD, a young man, Ikire, Nigeria).
Religion and traditional medicine
A few participants reported seeking care from an outreach programme conducted by a church in which people were tested and given medications. It was common practice in a few sites for patients to consult their pastors for prayers and receive supernatural healing, pregnant women to seek help from churches where herbs and prayers were prescribed and traditional birth attendants (TBA) to prescribe a combination of traditional medicine and prayers to pregnant women for a safe delivery. The TBAs and spiritual homes sometimes referred cases to the health facilities.
There are times churches will come with loudspeakers and invite people to come, they will give them drugs and test them for like three days and go back again (FGD with men, Olorunda, Nigeria).
….when I visit them (sick persons), they say they were prayed for by their pastor so they are well. The challenge is that you cannot force them to go to hospital (KII with a village leader, Kenya).
Pregnant women go there (referring to the church). When you go there, the pastor’s wife will attend to you and give you enema so the baby warms up in your belly. If you need drugs, she advises you on what to take. If it is a good pastor’s wife, she will tell you to go to the hospital (FGD, a middle-aged woman, Okpok Ikpa, Nigeria)
There are some people who go to church to give birth but are unable to and they refer them to me. As a Traditional Birth Attendant (TBA), you have to be god-fearing. Whatever is expected of you to help, you have to until she delivers. They live with me in my house. I take them through fasting and prayers until they give birth. I refer difficult cases to the hospital and also refer them for immunization (FGD, a middle-aged TBA, Okpok Ikpa, Nigeria).
Patronage of PMVs
PMVs were perceived to be affordable and accessible than health facility-based services. In addition, they (PMVs) were flexible with payments of fee-for-service in instalments, regularly had medications in stock and their clients did not have to wait in long queues to be attended.
What is the point of going to the hospital when you would be given a prescription to take to the chemist? It is cost effective to take the little money you have to the chemist first of all and buy your drugs (FGD with young men, Ikire, Nigeria
Another thing I’d like to add that really impressed me about the chemist man (PMV) is that I didn’t have enough money to purchase the drugs, so he asked me to go and bring the money to him later. I was satisfied with his service (FGD, Respondent 4, a middle-aged man, Okpok Ikpa, Nigeria).
They (doctor) may give you prescriptions and you buy there (hospital) but they may be selling them (medications) for a higher price than a chemist (IDI with a young woman, Kenya).
I go to the chemist to mix drugs for me since the chemist is close to me. They attend to me quickly and give my drugs according to my complaints (FGD, Respondent 3, a young woman, Okpok Ikpa, Nigeria).
Quackery by Patent Medicine Vendors (Chemists)
Some PMVs, sometimes referred to as Kosongbo in Nigeria, which means “run into the bush when you see law enforcement agents” in Yoruba”, reportedly misdiagnosed their clients and prescribed medications to treat conditions that the medications were not indicated for. A few PMVs were also reported to profiteer from the sale of substandard or expired medicines.
I had palpitations and asked a Kosongbo to treat me, he gave me moduretic (an antihypertensive medication) which he said I should take twice daily, I almost lost my life in the process and was rushed to the hospital for treatment (FGD, a young woman, Ikire, Nigeria).
Again let me also point on the community chemists. Most of the community members are not aware that these are business people who will mostly diagnose one with typhoid. If your situation is complicated you are diagnosed with typhoid. I recall a case where a son went to a local chemist and was diagnosed with typhoid and was given up to seven jabs (referring to injections). Eventually we went to a public hospital with the situation not improving and was eventually diagnosed with Tuberculosis. (FGD, a young man, Kenya).
If it is a bad chemist you patronize, he could sell expired drugs to you which won’t work. You’d then start moving from pillar to post (which means to seek help from one place to another) (FGD, a middle-aged man, Okpok Ikpa, Nigeria).