Understanding Barriers to Accessing Healthcare Among the Most Deprived of the Deprived – the Case of the Batwa in Southwestern Uganda

Abstract

Background: Social deprivation of the Batwa indigenous community has led to high levels of illiteracy, alcohol abuse and poor health outcomes. There are still significant gaps for understanding barriers to accessing healthcare in this context, and how they can be addressed to improve health outcomes. Our study identifies these barriers and proposes relevant solutions for orienting healthcare interventions. Methods: We used a mixed-methods convergent design. We conducted a cross-sectional survey with 107 Batwa individuals identified through a random household (80%) sampling method, in all Batwa settlements, in Kanungu District. Quantitative data was analyzed using STATA 15 for descriptive and multivariate analysis, and Arc-GIS was used for map generation. We also conducted semi-structured qualitative interviews (25) with Batwa individuals, traditional healers, health providers and policymakers. Interviews were analyzed using conventional thematic content analysis and results were jointly presented with quantitative findings. Results: Quantitative findings indicate that distance from the health facility and monthly household income had a strong independent association with access to healthcare. These findings were supported by the qualitative findings that suggest that out-of-pocket payment for transportation, user-fees and food security for patients and their caregivers, play a central role in limiting access to healthcare. Individuals eventually opt for alternative traditional therapies as a quick-fix, due to lack of financial means, eventually borrowing money from peers and community saving schemes, to access conventional health facilities. These expenditures exacerbates their state of deprivation, and places them in an antagonistic relationship with the hospital that initially provided free healthcare services, prior to instituting a use-fee policy. Conclusion: Improving financial protection for user-fee services offered through not-for-profit health facilities must be extended beyond community health insurance subsidies, and where possible, policies for assisting this community that existed previously should be reinstated. In an environment where traditional and modern therapies coexist, integrating traditional and modern therapeutic approaches must be envisaged to accommodate community practices. In order to sustain health benefits from these interventions, there is a need to comprehensively address the distal determinants that currently prevent this community from accessing financial resources.