Exploring how to increase access to healthcare services for border resident communities in East Africa

Access to healthcare remains a big challenge in Africa. The situation is particularly appalling for border resident communities as they are often not given priority by policy makers. The existence of different state territorial sovereignty, administrative frameworks with different currencies, support services, legal/regulatory systems, and languages make healthcare access for border resident populations even more complex. Unlike in the central areas; in some sparsely populated border areas, the nearest facility may be in another country. Another significant barrier lies in the economic deprivation to which the border areas are usually exposed.
In this era of Universal Health Coverage, how are communities residing along national borders going to be served without any financial burden as well as ensuring their overall wellbeing? This is an overarching question we intend to contribute to. This will be done through a study conducted at five paired-cross border sites in East Africa. Specifically; four interrelated objectives are proposed;
Objective 1: This will explore the existing legal-institutional contextual constraints and enablers to access to cross border healthcare services for border resident communities, by way of two main methods; 1) review of administrative and legal documents and 2) Key Informant Interviews with border officials and managers of political administrative units near the border.
Objective 2: This objective will explore the health systems constraints and implications for serving border communities. Key informant interviews will be the main methods for this objective. District or county health managers and providers will provide the bulk of this category of respondents. CBOs working to improve health services will also be included in the survey as key informants.
Objective 3: This objective will determine how border resident communities navigate legal-institutional and health systems constraints and enablers to health service access. Two main methods will be used a) Survey of those that successfully manage to access services across the border and b) Focus Group Discussions (FGD). For the survey, Appreciative Inquiry (AI) approach will be taken to probe the access pathways for those that have successfully navigated access to three selected services on the other side of the border. We will undertake FGDs to help to mitigate the limitation of surveying only those that successfully navigated the access barriers. The FGD participants will include potential services for cross-border services ie 1) mothers attending child immunization services, and 2) community leaders - including community health workers.
Objective 4: This objective aim to identify feasible actions to advance the access and coverage agenda to services for the communities residing along state borders. This will be done through; 1) convening stakeholders to deliberate on the findings from objectives 1, 2 and 3 in order to influence policy and practice and 2) sharing the study findings with the highest regional policy platforms. At these meetings we shall engage sub national, national, and regional policy practitioners to make salient the need to plan for border resident communities. Relatedly, the findings will also be disseminated at local, regional and international conferences in addition to publishing in peer review journals.
The survey is anticipated to increase understanding of healthcare access issues and the health systems implications for serving border resident communities. In turn border resident communities will benefit from improved cross border healthcare provision and greater EAC cooperation in health care delivery.

The goal of any health system is to improve the health of the population it serves (WHO 2000). For UHC realisation, health systems should respond to the needs of the population and enable access to health care services without creating financial hardships and ensuring equity in access [WHO 2010]. However, this is particularly challenging for health systems serving communities resident along international borders where several legal-institutional and health systems constraints exist. Evidence from the European Union where political integration prevails highlights health systems challenges including variations in information systems, treatment modalities and standards enforcement among countries [Derose KP et al, 2011].
Whereas research has been conducted to understand determinants of access to health services in developing contexts in general [EAC Secretariat, 2015], there is a dearth of evidence on access enablers and barriers facing communities resident along the international borders in developing countries. This study aims to address that gap in knowledge, policy and practice. Opportunity exists to ride on the current economic and political integration discourse for the East African Community (EAC) to stimulate policy dialogue among key stakeholders on the interventions that are necessary to overcome the barriers and/or to leverage identified enablers to a wider scale. The four project objectives are: 1) To explore the existing legal-institutional constraints and enablers to cross-border health care services among communities resident along EAC borders. 2) To explore health systems constraints and implications for serving communities resident along EAC borders.3) To determine how communities resident along EAC borders navigate legal-institutional/health systems constraints to health service access. 4) To explore feasible solutions to advance the access and coverage agenda to health services for the communities resident along EAC border

This study seeks to explore healthcare access constraints and enablers as well as the health systems implications for serving border resident communities in East Africa. The findings of this study will be used to increase understanding of healthcare access issues for border resident communities among the different actors/stakeholders at the different levels i.e. local (border site), sub national, national, and regional. Among the actors/stakeholders to be targeted include; service providers, health systems managers, border managers/ other public authorities, policy makers at different levels, and funders.

The ideal situation would be to influence the East Africa Federation to pass legislation that allows cross border health systems to function in a more collaborative way. The beneficiaries (the border resident populations) will in-turn benefit from this intervention through increased access to and uptake of integrated healthcare services at cross-border sites in East Africa. This will come as a result of improved access to health services due to well coordinated healthcare provisions, people centered service delivery approaches, relaxed regulations etc.

Relatedly, this study will provide evidence to inform policy and practice. The study findings will be shared with county/district health offices, implementing partners working with cross border populations, public authorities, funders and policy makers. These results could also benefit other national border settings or can be used elsewhere. The gaps and opportunities identified by the study will be used by the stakeholders to develop action plans in relation to practice, policy, and funding. Some of the anticipated action plans include; actors/organizations networking strategies, revised or re-aligned healthcare interventions, budget allocations, bi-laws, and new or revised policies that ease access barriers at border sites.

The proposed study also has potential to benefit several academic areas in the fields of health policy, health system management, health diplomacy and international relations, economics, geography, political science, epidemic intelligence service, field epidemiology, public health, emergency management and community development that related to the topic of cross-border health care access. The gaps and opportunities identified in this study can be used by scholars, students and faculty within the research institutions in the region to establish research networks to address cross-border health issues in the region.

We propose to stimulate stakeholder engagement and collaboration within and across health systems, organizations and borders through the planned joint stakeholder engagement activities at the different levels. For example; local/sub national validation and dissemination meetings, regional stakeholder meetings, and the engagements with the Directors' Joint Consultative Committee (DJCC) which is the highest technical committee of the ECSA Health Community. We shall identify and actively engage relevant users of research and stakeholders at appropriate stages. In the engagements, stakeholders will be tasked to do action planning for improved cross border healthcare access and continued networking among actors and organizations. These processes will benefit the overall health systems through triggering better coordination of border health care systems exemplified by budget collaboration and establishment of cross border task forces at local level. This in turn will strengthen the capacity of stakeholders to analyze and resolve their own problems functionalising the EAC goal.

This project will also impact national governments in the East African Federation. In particular, through joint networking and monitoring of cross border healthcare programming by governments; increased efficiency and effectiveness of cross border service delivery; and establishment of a supportive regulatory environment for cross-border health programming.