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. Healthcare providers, healthcare users and stakeholders mentioned insufficient equipment, frequent drug stock-outs and long waiting times as major quality issues in the provision of quality health services. On the other hand, the respondents differed in their opinions on general satisfaction with quality of care with healthcare providers reporting good quality care in the same sites where healthcare users reported poor quality care.
1. Access to primary healthcare
Free health services
Provision of free health services by some public facilities was perceived by respondents 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 respondent 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 or laboratory services [FGD Respondent 1 (young man), Kenya].
However, some respondents 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 X dispensary with my insurance card, I was rejected (everyone laughs) [FGD Respondent 1 (elderly woman), Tanzania].
Respondents mentioned that high costs of care, long distance to health facilities, unavailability or shortage of health personnel, limited operating hours of healthcare facilities and patronage of PMVs were barriers to accessing healthcare.
Out-of-pocket payments and inability to afford high costs of care
Some respondents 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 (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 Respondent 6 (young woman), 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 (young man), Kenya].
Distance to health facilities
Far distance to healthcare facilities posed a challenge to respondents. The cost of seeking healthcare was 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 (middle-aged woman), Okpok Ikpa, Nigeria].
Unavailability of health personnel
Respondents commonly reported unavailability of doctors and nurses in health facilities.
You know at times the doctors and 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 and there is no competent nurse there [FGD Respondent 2 (young man), Olorunda, Nigeria].
I went there the first time I didn’t get the doctor, the second time I didn’t get the doctor. It was the third time that I received the services I needed [FGD Respondent 4 (young woman), Kenya].
The last time I visited there, the District Health Assistant-in-charge was not available. I had to travel to another town to buy drugs from a patent medicine store [FGD Respondent 2 (middle-aged women), Ogane-Uge, Nigeria].
Health service days and hours
Most respondents reported public facilities did not operate for 24 hours during the day and during weekends, unlike in private facilities.
Many times I had wanted to go to voluntary counselling and testing, but my husband was at work (during weekdays). If you go to facility A, you find that the hospital is closed over the weekend and that is when my husband has the time (Sunday afternoon) to visit the clinic. So it’s a real problem [FGD Respondent 3 (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 (elderly woman), Kenya].
2. Quality of primary healthcare
General (dis)satisfaction with quality of care
There was a variety of responses regarding quality of care. While some respondents reported satisfaction with quality of care, others reported dissatisfaction.
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 (referring to the services) [FGD Respondent 6 (middle-aged man), Okpok Ikpa, Nigeria].
I think the quality is good (referring to a private facility). I can give (referring to satisfaction rating) them good [IDI with an elderly man, Uganda].
You can meet a doctor or nurse and he will not listen to you (referring to a public facility). While you are still explaining how you feel, even before you finish, they write you prescription to get medicine (mmh). Now you keep asking yourself what is this medicine for [FGD Respondent 3 (young woman), Tanzania)?
Health personnel factors
Retention of qualified health personnel in public facilities was reported to be challenging due to low remuneration. Furthermore, health personnel working in public facilities were said to be sometimes unprofessional toward their clients. On the other hand, respondents 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 healthcare provider in a private 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 Respondent 1 (elderly man), Olorunda, Nigeria].
But again government employees don’t treat people well. You can ask them a good question and they answer you with an attitude. So, if you have money, you better go to private hospitals or to chemist [FGD Respondent 1 (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 health 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 short waiting time in a private facility) unlike the main hospital (referring to a long waiting time in a public facility) where you go in the morning and it takes almost the whole day for you to be 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 (referring to early in the morning), people will already be many there and the doctor will not come until 11.00 am because government work is not the work that you will be sweating over [FGD Respondent 5 (elderly woman), Ikire, Nigeria].
So, it (referring to long waiting time) forces you to go to the chemist no matter the cost since in the public facility, there is a long queue [FGD Respondent 2 (young man), Kenya].
Some respondents reported that healthcare was free in public facilities, but drugs were frequently out-of-stock; hence, 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 and not the complete dose [FGD Respondent 3 (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 (elderly man), Kenya].
There were no drugs in the clinic, and even common detergent was not available. I regretted going there [FGD Respondent 2 (young woman), Ogane-Uge, Nigeria].
Interrupted power supply
Erratic electricity supply was reported by several respondents 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 Respondent 1 (elderly man), Ikire, Nigeria].
Lack of equipment
The lack of equipment used 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 (young man), Kenya].
3. Health-seeking behaviour
Most respondents reported that their first action during a minor illness was self-treatment at home with local herbs, often administered through enema, or medicines previously bought from PMVs. This practice was widely reported in the Nigerian sites where there is a traditional belief that enema purges the body of impurities. The next line of action was to visit a PMV. If medicines bought from a PMV was not effective, respondents would then seek treatment in 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 and herbs that can help us in this community to wash our system [FGD Respondent 2 (middle-aged woman), Okpok Ikpa, Nigeria].
Sometimes I use Aloe Vera when I feel I have malaria (mmh). We also use it well and feel better [FGD Respondent 4 (elderly man), Tanzania).
From home to patent medicine vendors
Some respondents reported visiting patent medicine vendors (PMVs, also referred to as chemists) 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 Respondent 7(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 Respondent 6 (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 Respondent 1, (young man), Kenya].
From health facilities back to patent medicine vendors or traditional healers
After undergoing a consultation with health personnel, some respondents bought medications prescribed by doctors from PMVs due to frequent drug stock-outs in health facilities. There were instances in which respondents 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 Respondent 5, (middle-aged woman), Okpok Ikpa, Nigeria].
Some people are referred back to their homes to use native treatment [FGD Respondent 6, (young man), Ikire, Nigeria].
Religion and traditional medicine
A few respondents reported seeking care in outreach programmes organised by churches during which people were tested and given medications. It was a common practice in a few sites for: people 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 (pastors) will give them drugs and test them for about three days and go back again [FGD Respondent 1 (elderly man), 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 a 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 Respondent 3 (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 Respondent 4 (middle-aged woman), Okpok Ikpa, Nigeria].
Patronage of patent medicine vendors
Services provided by patent medicine vendors (PMVs) were perceived to be more affordable and accessible than those provided by healthcare providers in health facilities. In addition, they (PMVs) were flexible with instalment payments for fee-for-service and regularly had medications. Furthermore, 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 to buy your drugs [FGD Respondent 3 (young man), 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 (middle-aged man), Okpok Ikpa, Nigeria].
They (doctor) may give you prescriptions and you buy the medicines 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 me drugs according to my complaints [FGD Respondent 3 (young woman), Okpok Ikpa, Nigeria].
Quackery by Patent Medicine Vendors (Chemists)
Some PMVs, referred to as Kosongbo (a Yoruba term which means “run into the bush when you see law enforcement agents”) in western Nigeria, 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 Respondent 2 (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 he was eventually diagnosed with Tuberculosis [FGD Respondent 5 (young man), Kenya].
If it is a bad chemist you patronize, he could sell expired drugs to you which won’t work. You would then start moving from pillar to post (which means to seek help from one place to another) [FGD Respondent 2 (middle-aged man), Okpok Ikpa, Nigeria].