Findings from this study are presented based on the predominant themes identified from the documents reviewed, dialogues and the interviews with key informants on the existing laws, policies, guidelines and structures that support or hinder cross-border health access for populations residing in border regions of East Africa.
Rights, Entitlements, and obligations
Institutionalization of the right to health and its restrictions:
From the documents reviewed, we found that the existing legal and policy frameworks focus on individual countries and are not explicit about the rights, entitlements and obligations related to healthcare access for populations residing in border regions. There was convergence across the laws and policies reviewed in regards to institutionalization of the right to health across the East African Countries however, this right to health is limited to only citizens of the respective country and also by the state capacity to provide health services.
From the interviews held with the regional policy makers., they also noted the lack of specific policies regarding or guiding access to healthcare across State boundaries in East Africa. The policy makers confirmed that health in the EAC region is still largely guided by policies that are country specific and thus the entitlements to health care services restricted within citizenship;
“We don’t have a law that formally allows people to move and access health services across borders. Each country currently remains autonomous in handling and budgeting for the health of its citizens” Policy maker 2, EAC Secretariat.
The right to health is a universal right established in numerous international and regional human rights treaties, and in all the national constitutions, as a universal right guaranteed to all (Universal Declaration of Human Rights (Article 25), International Covenant on Economic, Social and Cultural Rights (ICESCR), (Article 12); International Convention on the Elimination of All Forms of Racial Discrimination (Article 5), International Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) (Article 12); Convention on the Rights of the Child (CRC) (Article 24). These documents also mention the restriction of this right to only state citizens (See text box 1).
In the same vein, there was convergence across national level documents in regards to promoting the right to health care access for their country specific citizens. For instance, the Rwanda constitution alludes to the right to health for all Rwandans. These rights are restricted within citizenship and no provisions are made for border communities.
Implied access to authorizations for cross border health:
Guidance on interstate collaborations in emergencies
Although, there were no explicit rights, entitlements and obligations on cross border healthcare access, we noted some implied access to healthcare across borders in some texts for international treaties. For example, some guidelines addressed physical border crossing, and interstate collaborations during disease surveillance. One policy maker remarked:
“I know the animal people are more advanced on these issues but the guidelines that we follow are mainly on disease surveillance which is typically about exchange of disease related data across borders” Policy maker 2, ECSA.
“ …there is a framework for cross boarder disease surveillance and response which was included in the protocol for regional cooperation in health of EAC. It is a legal framework to ease collaboration among EA countries whenever there is an outbreak on one side of the border or a disease situation that needs intervention of either country” Policy maker 2, ECSA.
Guidelines that promote travel across countries
The regional level (East Africa) documents reviewed provided for East African Integration and promotion of free cross border movements within the region. For example, the treaty for the establishment of the East African Community compels partner states to ease border crossing by citizens of partner states by effecting reciprocal opening of border posts and keeping the posts opened and manned for 24hours. The regional documents also alluded to the need for member states to maintain common standard travel documents for their citizens (i.e. the treaty for the establishment of the EAC. The use of standard travel documents is aimed at achieving free movement of persons within the EAC member states. Considering that travel is one of the requirements for cross border health care access, facilitating border crossing or movements to some extent encourage cross border healthcare access.
Institutional frameworks and arrangements
Tools that influence or hinder access to healthcare:
From the regional and national documents, we noted that some formal arrangements in countries act as tools to facilitate or hinder informal access to health care by cross border communities. The tools included; national identity cards, passports, lazier passer, yellow fever card among others. There were also arrangements noted such as the Rwanda Community Based Health Insurance Policy which aims at ensuring universal and equitable access to quality health services to population of Rwanda. However, the CBHI covers only Rwandan Citizens and does not give provision for non-citizens. As such, the Rwandan CBHI and related access rules and cards restricted informal health care access by border resident communities from neighboring countries.
Similarly, the policy makers noted that some formal arrangements that exist in the EAC region facilitated or restricted informal health care access by cross border residents. The policy makers noted that countries with health insurance arrangements for example did not only restrict citizens from the neighboring countries to informally access health care in their countries but were also create financial hardships to their poor citizens unable to enroll or pay premiums. Many residents at the borders were said to have no insurance. On the other hand, countries with free care policy facilitated informal cross border health care access by individuals from the neighboring countries. The policy makers also noted that the need to present referral forms and previous treatment records at the health facilities also hindered formal access to health care by border residents form neighbouring countries.
In Rwanda the services are available with insurance and can be accessed with a card, but there are many people who don’t have a card especially the vulnerable groups the poor who are close to the border areas. And what they do, they seek all the services from Uganda so on the opposite side you will register all cases because […] you can cross easily without any hindrance. Policy maker 1, EAC Secretariat.
“You find that there are a number of reasons that could influence why they cross to the other side. One of them is free services. Uganda is one of the countries in the region which offer free health services. So, people will cross over to Uganda to look for free services and go back to their country”. Principal Health Officer HIV AIDS Programming-EAC
One of the policies that actually hinder access is the adamant request for […] referral forms and the need to use previous treatment notes/records. That also I think hinders access to services. Principal Health Officer HIV AIDS Programming-EAC
Opportunities for cross border health care access
The regional documents reviewed showed opportunities that could be harnessed to improve cross border health care access. One of the opportunities that can be used to improve cross border health care access is the “Multi-National East African Community Regional Centres of Excellence (CoE) for Skills and Tertiary Education in Higher Medical and Health Sciences Education, Research and Health Services Program” (EASTECO 2018) (14). According to this program supported by a infrastructure grant from Africa Development Bank, Kenya is earmarked to host the East African Kidney Institute, while the East African Oncology Institute will be located in Uganda. Tanzania will host the East African Heart Institute, while the East African Biomedical Engineering and Health Rehabilitation Institute will be established in Rwanda. These centers are aimed to enable the EAC increase its capacity and competitiveness by expanding top-end higher education and specialized medical services. Although these centers of excellences are for high level care and less for cross border health care access, this futuristic policy explicitly allows people in the EAC to seek health care from member states irrespective of citizenship.
Another opportunity that could be sieved to improve cross border health care was the existence of regional bodies such as East Central and Southern Africa (ECSA) Health Community and EAC that promote cross border collaboration among member states. ECSA and EAC promoted cross border collaboration among member states. For instance, The ECSA Health Community has been working with countries and partners to raise the standard of health for the people of the ECSA region by promoting efficiency and effectiveness of health services through cooperation, collaboration, research, capacity building, policy development and advocacy (see text box 2).
The key findings from the dialogue
Dialogues by the officials responsible for health, migration and related program staff where unanimous about the need to revise policy tools and guidelines to sustain cross-border collaboration and enable communities to access services where they are available without discrimination. They also raised several operational issues to improve. These included mostly the following:
- Build on the episodic collaboration and projects for HIV, TB and epidemics that usually allow joint collaboration and sharing of resources and investments in the border communities. It was noted these have ad hoc, made remarkable accomplishments but not sustained.
- The budgeting and service planning were said to be locked to national estimation of need thus not taking cognizance of the services use communities from neighboring country. Dialogue meetings recommended the need to revise policies and guidelines to enable the resource planning and budgets to take care of additional service needs of the communities across the border.
- There was a need to take care of synergies in health investments to benefit from economies of scale and avoid wasteful and duplicative investments to each side of the border separately. It was noted that hospitals investments were costly and if these are available and in close distance on one side, laws and guidelines should make this accessible by communities on both sides of the border.
- The twine issue of stigma and adherence was attributed to cross border health access. To ensure their privacy, many cases of HIV and TB were said to seek care across the border. This practice makes the home health system miss targets or report high default rates for chronic care. The need to share data and have joint coordination meetings by neighboring district officials was proposed.
- Subnational governments especially were decentralization has taken place should be encouraged to negotiate for their communities to enable cross-border planning and resource sharing especially were this is vital to enable sub-national operationalization of the UHC agenda. At the Uganda-Kenya (Busia) border, dialogue meeting observed the opportunity arising from the decentralized administrative zones in both countries and a need to empower them with laws and resources to plan and finance cross border cooperation for human and animal health.
- Broader political conflicts among states can also pose greater barriers to health care access. During the course of this study, temporary decline in bilateral political relations between Uganda and Rwanda were ongoing (15) . Respondents reported a major decline in service utilization especially on the Uganda side as a result of a stricter border lockdown measures arising from the conflict.
“The ongoing drama between Uganda and Rwanda government that led to the restriction of movements across our border [Gatuna-Katuna border post] has greatly influenced client attendance at our border health facility [Kamuganguzi HC III] because many of our clients especially on Antiretroviral Therapy (ART) were from the neighboring villages on Rwanda side”. Health Manager, Kabale stakeholders’ dialogue.