www.ijird.com June, 2018 Vol 7 Issue 6 ISSN 2278 – 0211 (Online) Reasons Why Citizens Utilize Healthcare Services across Borders in Africa: Qualitative Findings from the Tanzania, Uganda Borderlands Switbert R. Kamazima Senior Lecturer, Department of Behavioral Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania Agatha F. Ngowi Lecturer, Department of Public Health, School of Nursing and Public Health, Dodoma University, Tanzania Abstract: Literature available on cross-border healthcare services utilization focus on the US-Mexico, European and Asian borders. As a result, there is limited understanding of this phenomenon along African border except South Africa. We conducted a qualitative study in the Tanzania-Uganda borderlands to understand the context within which the Tanzania-Uganda borderlanders evaluate health problems at hand, available or missing enabling factors to solve the perceived health problem and hence the direction taken to solve it provided the outcome benefits override costs involved. Findings indicated that nature of health problem, availability or missing healthcare needed at home, social networks, economic and cultural capital and cross-border resources sharing experience influence cross-border healthcare services utilization. It was concluded one’s health is cardinal to human life that one would do anything to have and sustain and is, therefore, prioritized over citizenship and patriotism, challenging traditional ways of thinking about public health and the notion of health systems contained within the nation state. Further multidisciplinary research is recommended to increase our understanding of region-specific cross-border healthcare utilization issues. Keywords: Cross-border healthcare utilization, Tanzania-Uganda border, Tanzania, qualitative study, healthcare services 1. Introduction Literature available on cross-border healthcare services utilization has several features and gaps that inform this paper. First, much of the literature present experience from borderlands in the developed world, US-Mexico (Landeck &Garza, 2001; Byrd & Law, 2009; Homedes, et al., 2013; US-MBHC, 2014) and European borderlands (Rich & Merrick, 2006; Mäkinen, 2007; Footman, et al., 2014). With the exception of the Republic of South Africa (The Limpopo Department for social Development; 2011; Crush, 2015) a few studies have focused on African borderlands experiences (Kamazima, 2003; Allen, 2013; Walther & Vollmer, 2015). Hence, there is limited documentation of health seeking behavior across-borders in Africa and its impact to involved countries’ healthcare systems, economy, healthcare quality and national peace and security. Second, researchers focus on health seeking behaviors for biomedical services, which narrows the definitions of health seeking behavior (all those things humans, individually or in groups, do to prevent diseases and to detect diseases in asymptomatic stages), illness behavior (all those activities designed to recognize and explain symptoms after one feels unhealthy), health behavior (a combination of knowledge, practices, and attitudes that together contribute to motivate the actions an individual or groups take regarding health) and health systems (“all the activities whose primary purpose is to promote, restore or maintain health”, WHO, 2007). These definitions recognize that healthcare is provided and sought beyond the biomedical, public health sectors and beyond nation-state borders, a practice that is intensifying with the increasing regional integration and globalization. In addition, increasing ‘buying and selling’ of healthcare services or the commoditization of health and free movement of people mean healthcare seekers or transnational healthcare consumers will continue crossing borders for healthcare services and products beyond geographical territories and regions (Warner, 1999; Byrd & Law, 2009; Glinos, et al., 2010; Su, et al., 2011; Footman, et al., 2014; Suphanchaimat, et al., 2015; Homedes, 2016; Durham & Blondell. 2017). INTERNATIONAL JOURNAL OF INNOVATIVE RESEARCH & DEVELOPMENT DOI No. : 10.24940/ijird/2018/v7/i6/JUN18108 Page 240 www.ijird.com June, 2018 Vol 7 Issue 6 Similarly, focusing only on biomedical care provides insufficient explanation of the utilization (or healthcare seeking behavior) of available resources of (both biomedical and non-biomedical) health delivery system in the nations, regions and the world. In turn, this focus misinforms the interpretation of the process of illness response or health seeking behaviors (in the country and beyond) and limits the understanding of the disease burden of a country in question (Durham & Blondell, 2017). Furthermore, focusing on biomedical healthcare seeking behavior is much invalid in the developing countries where “indigenous medical practice continues to be the only source of therapy available to the majority of African peoples” (du Toit & Abdalla, 1985); “where a small proportion of trained healthcare personnel exists (3% in sub-Saharan Africa) and about 80% of the population depends on traditional medicine for their primary healthcare needs … [and western medicine] is not accessible to, or the first choice for, everyone” (Dhwty, 2015). A combination of social structural and institutional factors has been reported barrier to healthcare access to many people in the low-social economic status (SES) in any country. Social factors include lack of health insurance, unawareness of community health services and health rights available, low-SES, low education level, place of residence, marginalization, language barriers, high healthcare costs, stigmatization and occupations without health coverage or sick days. Unavailability of healthcare providers, facility ownership, non-adherence to care treatment and best practices protocols and guidelines, remote location of facilities, poor transportation, lack of medicines and medical supplies, perceived decreased costs abroad and user fee/cost sharing or co-pay system are among the reported institutional or pragmatic barriers to accessing healthcare services. These barriers describe the situational characteristics for many borderlanders in the world and the Tanzania-Uganda borderlands in particular. Important to note, perhaps, is that “although many of these factors are similar across populations, exactly how they interact and influence the actions of people is often unique to a population in the context of the environment they live in” (Prosser, 2007). Empirical data on cross-border utilization of health services exist on the US-Mexico (Miller-Thayer, 2010; Dejun, et al., 2011; United States-México Border Health Commission. 2014), the European Union borders (Busse, 2006; Footman, et al., 2014) and to some extent on Asian borders (UNHCR, 2009; Wahyono, 2015). More information on this issue is increasing with interventions from the IOM with Migration and Health Programs (IOM, 2013), (2014) and UNHCR initiatives (UNHCR, 2009). However, there is very limited data on this phenomenon on African borders (Allen, 2013) except South African borders (Crush, 2017). In this paper we demonstrate that the Tanzania-Uganda borderlanders have been utilizing healthcare services (formal, informal and African therapy) on either side of the border since its establishment in 1904. We argue, under intensifying integration in the East African region and the African nations’ commitment to soft border governance for a united and integrated Africa that encourage free trade and free people’s movement across-borders, obviously issues of health policy, healthcare delivery, quality and equity of care and healthcare financing will have to be addressed (Gilnos, 2012; Homedes, et al., 2016; Rich & Merrick, 2006; Footman, 2014). Knowledge on how patients’ movements have been taking place and how they have affected healthcare services is a key step towards the understanding and organizing healthcare services for the border regions. We present findings from two qualitative studies (2002 and 2017/18) conducted on the Tanzania side of the Tanzania-Uganda border to inform on factors influencing border crossing practices for healthcare, types of services sought and the borderlanders’ evaluation of healthcare services received in neighboring country (satisfaction), the borderlanders’ perspective of improving this initiative and its policy implications to the home nation, adjacent nation states and the region. 2. Materials and Methods Findings presented in this paper come from two qualitative studies conducted using a combination of methods: observation, oral traditions, life stories, in-depth interviewing and documentation on the Tanzania-Uganda border in 2002 and 2017/18. Study participants in the two studies were borderlanders (females and males) aged 18 and above and who had lived in the borderlands for a year and more. In 2002, we captured borderlanders’ and the political elite’s border crossing experiences to access care on either side of the border and their views on how to improve this inventiveness for borderlanders’ improved health and enhancing cross-border interaction and cooperation. Similarly, the study participants were asked to recommend on how to manage such border crossing practices for the protection of peace and security in the borderlands, between the borderlands and the immediate authorities and between the two nation states. In the 2017/18 study, we asked study participants similar questions: what factors influence border crossing practices