The right of access to healthcare: an analysis of how legal and institutional frameworks constrain or facilitate access to healthcare for residents in border areas in the East African Community

Background: Despite many countries working hard to attain Universal Health Coverage (UHC) and the Health-related Sustainable Development Goals, access to healthcare services has remained a challenge for communities residing along national borders in the East Africa Community (EAC). Unlike the communities in the interior, those along national borders are more likely to face access barriers and exclusion due to low health investments and inter-state rules for non-citizens. This study explored the legal and institutional frameworks that facilitate or constrain access to healthcare services for communities residing along the national borders in EAC. Methods: This study is part of a broader research implemented in East Africa (2018–2020), employing mixed methods. For this paper, we report data from a literature review, key informant interviews and sub-national dialogues with officials involved in planning and implementing health and migration services in EAC. The documents reviewed included regional and national treaties, conventions, policies and access rules, regulations and guidelines that affect border crossing and access to healthcare services. These were retrieved from official online and physical libraries and archives. Results: Overall, the existing laws, policies and guidelines at all levels do not explicitly deal with cross border healthcare access especially for border residents, but address citizen rights and entitlements including health within national frameworks. There is no clarity on whether these rights can be enjoyed beyond one’s country of citizenship. The review found examples of investments in shared health infrastructure to benefit all EAC member countries – a signal of closer cooperation for specialized health care, this had not been accompanied by access rule for citizens outside the host country. The focus on specialized care is unlikely to contribute to the every-day health care needs of border resident communities in remote areas of EAC. Nevertheless, the establishment of the EAC entail opportunities for increased collaboration and integration beyond the trade and customs union to included health care and other social services. The study established active cooperation aimed at disease surveillance and epidemic control among sub-national officials responsible for health and migration services across borders. Health insurance cards, national identification cards and official travel documents were found to constrain access to health services across the borders in EAC. Conclusion: In the era of UHC, there is need to take advantage of the EAC integration to revise legal and policy frameworks to leverage existing investments and facilitate cross-border access to healthcare services for communities residing along EAC borders. The study utilized a qualitative research design using document review, Key informant (KI) interviews, and dialogue meetings conducted between May 2018 and February 2019. The study was conducted in Uganda, Rwanda, Kenya and Tanzania. The four countries were selected based on their geographical connectedness and unique healthcare system features. This step involved a review of international/regional treaties, conventions, country specific laws, regulations/guidelines/ key legislative acts and policies in order to gather data on existing laws, policies, guidelines and structures that support/hinder cross-border health access in East Africa. We extracted clauses or specific texts that had implication for border crossing and access to healthcare services among communities residing in border regions of East Africa. The East Africa Countries targeted included Uganda, Kenya, Tanzania and Rwanda. Documents were identified and obtained from a pragmatic and purposive search of international and national electronic databases of treaties/conventions, and websites of the East African government entities and professional bodies. We started off with a search for strategic documents including the universal declaration of human rights, country specific constitutions, national development plans, visions for the health care sector, health policies among others (see Table 1). Documents alluding to health care access at all levels The electronic database search yielded 12 documents for Uganda, 13 for Kenya, 9 for Tanzania, 12 for Rwanda, 9 for East Africa Community (Regional Documents) and 8 for International treaties and conventions. Of all documents 63 were considered relevant for this study. We used abstraction form to capture particulars of the document, and clauses/specifications. The parameters that guided the literature search and review are rights, entitlements, obligations and institutional arrangements for cross-bordar access to health care for non-residents (Table 2). Definition of the parameters that guided the literature search and review The data extraction tools were operationalized to pick the needed information and abstraction was done by a multidisciplinary team. Two independent researchers reviewed each document in order not to miss out any clauses and later built consensus around the extracted clauses. The review focused on healthcare access within border regions and not on other topics such as professional mobility not seeking work opportunities or receive training across the border. This study also involved policy makers at regional level as key informants to the status of implementing the EAC integration and specifically health integration. The policy makers included two technical representatives from East Central and Southern Africa Health Community (ECSA) Head Quarter, two representatives from the EAC secretariat, and two representatives at the East Africa Parliament. An interview guide for the Key Informant interviews was to gather information on the current legal and policy frameworks as well as practices that facilitated healthcare access across the border in the EAC. The guide was in English and the interviews were conducted in English – an official language for the EAC. The interview guide explored the existence of laws, policies, and guidelines that support and cross-border health access in East Africa; and other arrangements that promote, protect and fulfill health access rights for people residing in cross-border regions of East Africa. The guide included questions such as; (1) at regional or country level, what guidelines are there for allowing or not allowing people to cross and use health services in the neighboring countries; and (2) under what situations, do persons from the opposite side of the national borders receive health care services for treatment such as HIV, maternal delivery and routine vaccination. Six interviews with policy makers at regional level (East Africa) were undertaken. The KIs included four representatives from the East African Community Secretariat, and two from the East Central and Southern Africa Health Community. Interviews were conducted by one of the authors of the paper (AR) and the participants were purposively selected based on their positions, and experience in policy making at national and regional level. Prior to collecting the data, the study team reviewed the interview guide in detail. All interviews were digitally audio recorded and subsequently transcribed verbatim. Over 100 national and subnational stakeholders were engaged in four different deliberative meetings held at selected borders areas. Each meeting constituted about 20–25 participants, and at the beginning of every meeting, participants were informed about the purpose of the meeting, including intensions to analyze and publish excepts from the meeting deliberations. The stakeholders engaged through these dialogues included officials responsible for health, migration and related program staff in EAC secretariate. The meeting deliberations focused on practices, guiding laws, rules and tools affecting cross-border access to healthcare, and innovations and arrangements that promote, protect and fulfill health access rights for people residing in cross-border regions of East Africa. The guiding questions included; what institutional arrangements exist at sub-national level that facilitate or limit cross border healthcare access? How can access to healthcare be improved for cross border communities in the EAC? These broad questions were used to structure and guide the meeting and the contributions of the participants. The meetings also served as dissemination avenues for the findings from the review of legal and policy frameworks. These findings also contributed to the meeting deliberations. The meetings were conducted in English the official language in East Africa, and the meeting participants were able to dialogue competently in English without the need for translations into Swahili or other dialects. The data extracted from the various documents (international, regional and national) were collated. Data was later analyzed using thematic content analysis [16]. Research team members reviewed the summary extracts and jointly generated codes to categories the data according to enabling or constraining factors, migration, rights, obligations and entitlements of citizens for health access. The research team held working meetings to discuss the codes and categorize them. By analyzing and sorting codes, the research team identified consistent and overarching themes as well as supporting sub-themes. The Key Informant interviews and dialogue meetings were also analyzed using thematic content analysis [16]. We developed a coding framework using deductive codes based on the questions used the interview guide and meetings. illustrative quotations for each theme were identified, discussed and prioritized [17].