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ISSN 2278 – 0211 (Online)

Reasons Why Citizens Utilize Healthcare Services across Borders in Africa: Qualitative Findings from the , 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).

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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 for healthcare in the neighboring country? What types of services they seek? How do the borderlanders evaluate healthcare services received in neighboring country? What opportunities and barriers they face carrying out this practice? What are the borderlanders’ perspectives on improving this initiative and its policy implications to the nation and adjacent nation states? The 2017/18 study, therefore, aimed at capturing the influence of events and transformations that had occurred in the Tanzania-Uganda borderlands and beyond between 2002 and 2017/18 on border crossing initiatives for healthcare. Findings from these studies facilitated establishing factors facilitating or hindering borderlanders’ initiatives seeking healthcare services in neighboring countries and their policy implications to individual nation state and between the flanking nation states in the era of increased regional integration and African integration. The aim, therefore, was to understand the context within which the Tanzania-Uganda borderlanders evaluate health problems at hand and the 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. We use the borderlanders’ experiences of seeking

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3. Results

3.1. Reported Reasons for Cross-Border Health Utilization: The 2002 Study During the 2002, we identified four subsections of the Tanzania-Uganda border that provided different but comparable border experiences to the permanent, temporary and one-time border crossers: the Bugabo, Kanyigo (the Triangle) and Missenyi (the Kagera Salient) in Rural district and Murongo/Kikagati border region in . Generally, data indicated that the Tanzania-Uganda borderlanders cross the border on daily, weekly or certain months of the year to access both non-biomedical and biomedical treatments. On the one hand, it was reported and observed that Ugandans crossed the border into Tanzania in Lukunyu, Kanyigo (Kagera Triangle) to access services at Mitaga and Kigarama Health Centers. Others proceed inland to Mugana (Catholic) Hospital for relatively more specialized services. Similarly, Ugandan pastoralists and cultivators crossed the border in Kakunyu and Bugango areas, Missenyi border region to access health services offered at Kakunyu dispensary and Bugango (Baptist) Health Center respectively. Ugandan fishermen and fish traders in Kassensero area, Rakai district, were reported entering Bukoba district at Malehe, Rubafu for treatment at Katare and Kashozi (Catholic) Health Centers. Ugandan pastoralists practicing transhumance moved and settled in steppe lands stretching between the border and Lake Burigi further south of the border in between May and mid-October each year, ‘the dry season birds’! They were reported accessing and utilizing healthcare services found in the area during their stay. District officials interviewed reported pastoralists used their income from sold livestock on Tanzania markets to access healthcare services at private or public facilities or corrupt leaders and healthcare providers who restricted them from accessing services. However, these pastoralists were reported active in contributing for development projects like health services cost-sharing and facility construction in the districts. The Tanzanian borderlanders and non-borderlanders on the other hand, were reported crossing the border seeking health services, biomedical and no-biomedical, across the border in villages and towns like Mbarara, Masaka and Kampala in Uganda. For example, borderlanders, permanent, temporally or one-time border crossers, sought specialized care services at Mulago Hospital in Kampala and others sought help from several traditional healers in Uganda. Quite a good number of Tanzanians were reported and observed crossing the border for annual (June 3rd) spiritual healing during pilgrimage services at Namugongo, Kampala.

3.2. Reported Reasons for Cross-Border Healthcare Utilization: The 2017/18 Study We asked study participants “Why are Tanzanians and Ugandans crossing the border for healthcare? Factors reported are as follows: A healthcare personnel interviewed in Bukoba Municipal Council district observed that irrespective of the border, patients would always go to health facilities perceived to have ‘good’ healthcare delivery system and services. Comparing Uganda and Tanzania, he said, As we speak today, the [Tanzania] government has increased healthcare budget 10 times compared to the previous years’ … As a result, we are currently providing quality primary healthcare services compared to most of our neighbors … After renovation and expansion, majority of health facilities in the [Kagera] region is fully equipped with medicines, equipment, power [electricity or solar] and with attractive and conducive environment for both the healthcare providers and the patients … With support from developing partners, we are running special groups- specific programs, the under fives, pregnant mothers and the elderly [60 years and above] … So, patients from neighboring countries Uganda, Rwanda and Burundi cross the border seeking for primary healthcare services in Tanzania (II, Bukoba Urban, February 28, 2018). Discussing on factors behind Tanzanians’ utilization of healthcare services across the border, the health personnel explained, I think proximity to and lived experience utilizing healthcare services from Mulago Hospital in Uganda that offers advanced healthcare services compared to Bugando [Mwanza], KCMC [Kilimanjaro Christian Medical Center, Moshi] and Muhimbili [Dar-es-Salaam] in Tanzania influence this flow. Patients from the borderlands find it easy and cheaper travelling to Kampala compared to Mwanza, Moshi and Dar-es-Salaam for advanced healthcare services ... Some patients have relatives or friends in Uganda who support them during their visits at Mulago … Majority are fluent in Luganda and other first languages in the borderlands compared to Kiswahili … Yet many of them are more familiar with Kampala and other Ugandan cities and towns in contrast to Mwanza, Moshi or Dar-es-Salaam … Some borderlanders have grown up utilizing healthcare services available in Uganda ... Other Tanzanians and Ugandans alike, cross the border seeking African therapy or spiritual healing (II, Bukoba Urban, February 28, 2018). Explaining why patients from neighboring countries utilize healthcare services in Kagera region, the Medical Officer in-Charge, Missenyi District Designated Hospital (DDH), Mugana said,

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Mugana Hospital is a Faith-Based [FBO] health facility owned by the Catholic Church, Bukoba Diocese. Currently, Mugana is Missenyi DDH ... As such, we receive patients from the district, Kagera region and beyond ... We have several entry points from across the border Minziro, Mutukula and Kashenye ... Patients from outside our catchment area, Uganda, Rwanda and other parts of Kagera and Tanzania seek services including ANC, RCH, TB, CTC, HIV and AIDS care and treatment ... Some pregnant women bring with them clinic cards from health facilities in Uganda; all they need are good services they are told are available at this hospital ... Other services sought include surgery, goiter treatment, fibroids diagnosis and treatment, gynecological and pediatric ... Privacy and confidentiality observed by health personnel at this facility explain the confidence patients have in our hospital ... Majority of the patients are referred to us by their relatives, health personnel at health facility in Uganda or Tanzania, friends or fellow villagers ... Patients diagnosed HIV or TB positive have treatment initiated and then referred to the respective nearest facilities in the district, region or beyond (II, Missenyi, February, 28, 2018). Explaining additional reputations Mugana Hospital has over other facilities in the region, the Medical Officer in-Charge mentioned providing good services to vulnerable groups (pregnant mothers, the under fives and the elderly, 60+) attracts patients from within and outside the catchment area like Uganda, Biharamulo, Karagwe, Ngara, Muleba, Bukoba Rural, Bukoba Urban, Mwanza and other parts in Tanzania. Similarly, being an FBO; each worker at Mugana is responsible to patients and has to adhere to professional ethics (medical, pharmaceutical or nursing) and professionalism; offering standard and quality services, which guarantee satisfaction among patients attended at this facility. Sharing his experience on how Mugana staff identifies patients from across the borders, the Medical Officer in-Charge explained, “There are several ways to identify them … Checking through RCH, ANC, TB, CTC and OPD registers [where faithful patients register their true foreign addresses]; patient having difficulties speaking Kiswahili but other first languages in borderlands and Uganda; patient having an escort cum translator; or when writing referral letters to their nearest health facilities … They have to provide correct addresses to enable them access services in their countries” (II, February 28, 2018). The Commissioner, pointing at the Kyerwa district map hanging on the wall in his office, had the following observations on why neighboring countries’ citizens utilize healthcare services in Tanzania, As you can see from this map, our district shares borders with Rwanda [in the west] and Uganda [in the north]. The Rwandese cross Kagera River by boats to Murongo and Isingiro wards for social services including healthcare [Murongo and Isingiro Health Centers], commodities and sometimes security ... You know, these are ex-refugees from BENACCO, Ngara Tanzania settled in the forest reserve [Ibanda Game Reserve] that extends to Tanzania [Rumanyika Orugundu Game Reserve] … So, they know what to get from this side [Tanzania]. The Ugandans cross Murongo Bridge or by boats over Kagera River into the country mainly for healthcare services at our health facilities ... Some have relatives on this side of the border and speak same languages; hence, they [Rwandese and Ugandans] find it easy settling among our communities, making Kyerwa one of the border districts with a good number of illegal (im)migrants whom we need to identify at the village level before the enrolment [of Tanzanians] for national IDs next month [April, 2018] … They are utilizing our resources at the expense of our wananchi [the citizens] (II, Kyerwa, March 16, 2018). Isingiro Health Center Medical Officer in-Charge reported the facility receives patients from across the borders (Uganda and Rwanda) seeking healthcare services including ANC, RCH, CTC, TB, HIV and AIDS testing, care and treatment, adding, “with the expansion of this facility introducing minor surgery services, better equipment and with adequate supplies, I hope the number of patients from neighboring countries will increase” (II, Kyerwa, February 16. 2018). It was clear from interviews with borderlanders at Mutukula that majority of them seek primary healthcare services at private health facilities across the border; some as far as Masaka and Kampala. Others buy medicines from drug outlets available across the border. Yet other borderlands visit traditional (THs) and spiritual hearers in the borderlands or far in Uganda. A Bubale borderlander interviewed at Mutukula reported Ugandans from Bugango (Uganda) seek healthcare services at the Baptist Health Center in Bugango (Tanzania). Similarly, Ugandan and Rwandese pastoralists, Walalo, who enter Tanzania searching for water and pasture as far as Burigi in Muleba district (‘the dry-season birds’), utilize healthcare services available in Missenyi, Bukoba Rural and Muleba districts during their stay. Study participants in Kashenye reported given Nangoma Parish’s location in relation to the rest of Uganda, Ugandan citizens from this area utilize healthcare services in Tanzania provided at Kashenye dispensary and Mugana DDH. A member of the village government reported, “Given the nature of the problem at hand, patients from Nangoma Parish would first visit Kashenye dispensary or proceed to Mugana [Hospital] right away” (II, Kyerwa, February 6, 2018). Kashenye Ward Executive Officer (WEO) emphasized, “We are talking of the same people living on both sides of the border … They intermarry … Share culture and other social and economic characteristics … They share available resources and support each other in everything … Restricting their relatives in Uganda [Nangoma Parish] from accessing healthcare services on this side of the border would be difficult rising to, perhaps, unnecessary latent conflicts” (II, Kyerwa, February 6, 2018). Fishermen of Ugandan origin interviewed in Kashenye (at the lake shore) attested utilizing primary healthcare services at Kashenye dispensary and Mugana DDH.

3.3. Borderlanders’ Evaluation of Healthcare Services Received in Neighboring Country, Uganda A borderlander and a motorcyclist (boda boda) interviewed in Minziro reported seeking treatment at Mulago Hospital two years ago for his fractured left leg from an accident along the Bunazi-Mutukula highway in May 2015. His relatives sent

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www.ijird.com June, 2018 Vol 7 Issue 6 him to Mulago Hospital the same day where he received ‘quality care services’ for the whole month he was admitted. Adding, “I have never been at Bugando or Muhimbili [Hospitals] … I cannot compare services at these facilities ... I hope we have similar services in Tanzania ... We went to Mulago because we are familiar with that facility and we have relatives living in Kampala who give us support whenever we visit Mulago” (II, Minziro, March 18, 2018). A borderlander interviewed at Mutukula reported experience buying drugs from pharmacies at Masaka in Uganda saying, “[s]ometimes, the doctors advised us to buy drugs that are out-of-stock at health facilities … Bukoba [town] is too far compared to Masaka … So, we go to Masaka where there are several, well-stocked outlets … You can hardly miss a drug you want … Drugs are sold at cheaper prices … This is one of the advantages of living in the borderland (II, Missenyi, March 17, 2018). Recalling her last pregnancy experience, a female Mutukula-resident reported five years ago she had a twin pregnancy diagnosed at a private hospital, Masaka Catholic Hospital. She was referred to Mulago two months before delivery where she was put on total bed rest. She had a cesarean section, remaining in the hospital for 10 days after delivery. She admitted receiving ‘quality healthcare services’ before, during and after delivery, adding, “This is well back before Mugana became famous … I have never been at his hospital [Mugana], but I am told they provide good services too (II, Missenyi, March 17, 2018). A hosting family of born again members (husband, wife and two children) in Nyabihanga reported on excellent monthly spiritual healing services conducted at the Uganda Healing Church of Christ in Bukulula stating, “We go to Bukulula on monthly basis (every last week) to attend spiritual healing that lasts for three days … We witness God-made miracles and come back spiritually healed and physically rejuvenated … You [researchers] should come along next week” (II, Missenyi, March 6, 2018). A Mutukula male resident reported “majority of the successful businesspersons here use juju [witchcraft or magic] mainly from Uganda. Others travel as far as Sumbawanga Tanzania, Zambia, Rwanda or the DRC in search of juju … The belief is that no one can succeed in business without juju” (II, Missenyi, March 17, 2018).

3.4. Perceived Opportunities, Challenges and Implications of Cross-Border Healthcare Services Utilization Discussing on this issue, the Mugana DDH Medical Officer in-Charge reported increasing number of patients from outside their catchment area, “would lead to heavy workload and or burn out among staff … My worry is, what would happen if we no longer receive supplementary support from the government and NGOs we are currently partnering with? I hope this partnership will continue for some years for the benefit of our citizenry’s health” (II, Missenyi, February 28, 2018). The health personnel interviewed in Bukoba Municipal noted, If we get so many patients crossing the border to Tanzania for treatment, we may find our health facilities recording say, HIV, TB, Malaria cases or vital events [births and deaths] not originating from Tanzania, resulting to high prevalence than reality … Similarly, public facilities that sorely depend on government supplies [medicines and equipment] that match their catchment areas’ monthly requirements may exhaust their kits before the end of the month resulting into shortages that are not real. In turn, such shortages would limit intended communities’ rights to healthcare (II, Bukoba Urban, February 28, 2018). Discussing challenges Mugana staff face in the course of attending patients from across the bower the Medical Officer in-Charge stated, Please note, all patients from across the border meet set contributions like other citizens ... So, as hospital management we have no problem treating these patients ... We receive support from funders, the government and NGOs [For example, MDH (Management and Development for Health) supports CTC and RCH departments] supplementing equipment and supplies we need ... The only challenge we face is that once we have referred patients to facilities in Uganda, we do not get feedback on their adherence to the treatment and we cannot make follow up of patients we put on treatment ... However, our hope is that since they travelled all that distance to this facility, paid charges involved and underwent diagnosis processes; they cannot fail going for free services available at home (II, Missenyi, February 28, 2018). A young man aged 37, owning and running a drug outlet in Mutukula commented, It is not necessary that one has to cross the border to access healthcare services. The media – radio, internet, TVs, Newspapers and health materials – do not know borders … They send health education and promotion messages across the borders … Borderlanders on this side benefit from health messages and information aired in their first languages on Ugandan radios and TV channels ... Ugandans understanding Kiswahili benefit from similar messages aired on Tanzanian radios and TV channels (II, Missenyi, March 17, 2018).

3.5. Recommended Strategies to Improve Cross-Border Healthcare Services Utilization Referring to the Kashenye-Nangoma Parish context, study participant in this area recommended keeping existing relationships going on. Ugandans in need of healthcare services should have access provided they abide to minimum conditions controlling border crossing and guidelines at respective health facilities. The Nyabihanga family proposed, “Waving official travel documents requirement for borderlanders staying on the other side for say 12 hours or a week would ease our lives … those who cross the border several times a month … We could be allowed using non-immigration IDs [identities] like voter’s ID or official letters from our village or ward secretaries” (II, Missenyi, March 6, 2018).

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The Bukoba Municipal Council Medical Officer and the Medical Officer in-Charge, Mugana DDH urged Tanzania and Uganda governments with support from the African Union Border Program (AUBP) to regulate their health delivery systems so that citizens in the borderlands access healthcare services on either side of the border, which would assure timely diseases detection and control. In the view of the Medical Officer in-Charge, Mugana DDH, establishing disease control centers in the borderlands could create a ‘buffer zone’ that would restrain diseases from spreading inland (II, Missenyi, February 28, 2018). A lady who delivered twins at Mulago hospital five years ago said, “We should be free to seek quality healthcare services from either side of the border but observe immigration and other border crossing regulations in place” (II, Missenyi, March 17, 2018).

4. Discussion One of the findings from the 2002 study in the Tanzania-Uganda borderlands was that the borderlanders crossed the border for healthcare services. On the one hand, Rwandese and Ugandan pastoralists in Kakunyu were reported and observed utilizing healthcare services at Kakunyu dispensary. Ugandans from Bugango (Uganda) were reported and observed utilizing healthcare services at the Baptist Church Health Center located in Bugango on the Tanzania side of the border. At Mutukula, the borderlanders in Tanzania reported accessing healthcare services, both biomedical and non-biomedical (African therapy and spiritual healing) available on the Ugandan side. In Minziro, Ugandans were reported and observed utilizing healthcare services at Minziro Health Center on the Tanzania side. In Kashenye, Kanyigo area, Ugandans from Nangoma Parish were reported and observed accessing healthcare services at Kashenye dispensary and Mugana Hospital. Similarly, fishermen of Ugandan origin camping at Malehe reported utilizing healthcare services at Katare Health Centre in Bugabo. On the other hand, Tanzanians were reported seeking healthcare services at Mulago Hospital in Uganda. Traditional and spiritual healings were other healthcare services reported Tanzanians sought across the border. What remained unclear, though, was “Why were people crossing the border for healthcare services in an adjoining country?” Findings from the 2017/2018 study indicated complementing factors like nature of health problem (perceived causes and possible solutions) faced; proximity and familiarity with healthcare services available across the border; social networks (referrals and support); unawareness of healthcare services available at home; perceived or reported quality and types of services provided/available across the border; service availability, acceptability and affordability; fluency in language(s) used/spoken; being familiar with systems across the border than at home and cross-border resources sharing experience influence cross-border healthcare services utilization. Healthcare systems, health rights and obligations (medical costs and co-pays or cost sharing), health policies and treatment guidelines are more-or-less similar in Tanzania and Uganda. Hence, cross-border medical flows between the two countries take the south-south (Crush, 2017) or low-low (Durham & Blondell, 2017) pattern. Combinations of reported reasons, therefore, come into play influencing decision making processes over direction taken seeking for health solutions. For example, a family in the borderland with a sick member concludes on the causes and perceives biomedical care a possible solution to the health problem at hand, say going to Mugana hospital. However, availability, affordability, familiarity and perceived quality of healthcare (Glinos, et al., 2010); fear to be diagnosed having or treated for a certain diseases at home facility; convenience and faster services abroad compared to hinterland in far cities (say Mwanza, Moshi or Dar-es-Salaam); ethno-linguistic (language, culture) similarity or same backgrounds across the border than hinterland (Ploae, 2017); high costs for accommodation, travel, food or being away from home for long time; social networks (knowledge of health providers and services available abroad) and perceiving health services across the border relatively cheap and time saving (Allen, 2013) would dictate going to Mulago Hospital in Uganda. In this situation, seeking care for ill family member across the border becomes a pressure but a right thing does and consoling even if the patient is not cured (Allen, 2013). Similarly, individuals and families would cross the border seeking remedy for illnesses perceived to have non-biomedical causes and whose solutions are considered available across the border, say spiritual or traditional healing. Certainly, the borderlands have long-rooted socioeconomic and political history. Residents in pre-colonial Kingdoms, Buganda, Ankole, Karagwe, Kiziba, Bugabo and Kyamutwara experienced periods of peace/cooperation and conflicts; sharing resources and services among them (Kilaini, 1990; Kamazima, 2003). For varied reasons, the colonialists and missionaries (the Germans, 1884-1916 and British, 1923-1961in Tanganyika/Tanzania and British, 1884-1962 in Uganda) introduced western medicine in their territories. In Bukoba Province (1910-1959), for example, health facilities established as dispensaries and later expanded into hospitals include: Rubya Hospital (1920-1930s opened in 1956), Mugana Hospital and St. Joseph Hospital Kagondo. In Uganda, they established Mulago (1913) and the British expanded it to a ‘New Mulago hospital’ in1962. Mulago became a referral hospital for patients from health facilities in Bukoba Province. After independence of the two countries in the early 1960s, Mulago continued serving patients referred from Kagera region and beyond. A huge part of present Missenyi district, was part of Buganda Kingdom, hence residents utilized healthcare services from health facilities in present Uganda (Masaka and Kitovu Catholic and Mulago Hospitals) till its annexation to Tanganyika in 1920 (Kamazima, 2003; 2018); explaining in part, why Tanzanians in this area would seek and utilize healthcare services across the border, in Uganda. Similarly, Nangoma Parish, in Uganda was part of Kiziba Kingdom until the establishment of the Tanzania-Uganda 1°00´S terrestrial border (1885 to 1904). Majority of Nangoma Parish residents recognize Mugana hospital their longtime source of healthcare services. Similarities amongst borderland contexts in Africa suggest findings from this study are not unique to the Tanzania- Uganda borderlands. The arbitrary African borders imposed by the European powers after the Berlin Conference (November

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15, 1884 to February 26, 1885), separate different African societies (40-45%) across two or more nation states. According to Michalopoulos & Papaioannou (2012), Africa had about 834 societies at the time of the partition. Created nation state borders made 10% and 20% of 231 and 164 societies’ homeland respectively, falling in more than one country. For example, The Maasai have been split between Kenya (62%) and Tanzania (38%), the Anyi between Ghana (58%) and the Ivory Coast (42%), and the Chewa between Mozambique (50%), Malawi (34%), and Zimbabwe (16%) … The Malinke (Mandinka) … are split into six different countries; the Ndembu … are split between Angola, Zaire, and Zambia; and the Nukwe, are split between Angola, Namibia, Zambia, and Botswana.” The Malinke or Mandika (of the former Mali Empire from 13th century) now live in Gambia, Guinea, Mali, Sierra Leone, Côte d’Ivoire (Ivory Coast), Senegal, Burkina Faso, Liberia, Guinea-Bissau, Niger, and Mauritania (Wikipedia). The Afar of Ethiopia are split amongst Ethiopia, Eritrea and Djibouti, and the Anyuaa and Nuer are split between Ethiopia and South Sudan (Gashaw, 2017). Other societies include the Tabwa are split equally between DRC and Zambia, the Luo and Kurya split between Kenya and Tanzania, the Somali split among Somalia, Ethiopia, Kenya and Djibouti and in this case study, the Baganda and Baziba are split between Tanzania and Uganda.

4.1. Two Sides of Cross-Border Healthcare Services Utilization Indeed, cross-border healthcare services utilization has received both support and opposition from different actors. On the one hand, proponents view this practice or transnational medical consumerism, benefiting both the medical markets and medical providers in countries providing care and the transnational medical consumers who receive medical services that are otherwise not readily available in their home countries (Miller-Thayer, 2010). In turn, perceived benefits from this health seeking behavior, favor further border crossings for healthcare to continue pending on the existence of perceived conducive conditions (Durham & Blondell, 2017). Data from this study did not capture how much money providers get from serving clients from across the border. However, it was clear that Tanzanian patients were quite satisfied with services received at Mulago hospital, other health facilities and drug outlets in Uganda. In countries like the U.S. A. and Canada, for example, where market pricing of medical services, lack of insurance coverage and availability exclude the poor majority from medical resources in their home country, cross-border healthcare services utilization behavior (in Mexico) is informed by other elements like health perceptions, knowledge, needs, and practices (Miller-Thayer, 2010). Tanzania has introduced the Community Health Insurance Fund (CHIF) that has limited coverage and not every citizen has joined. However, the perceived nature of the health problem at hand and other factors in that context rather than insurance policies will continue informing direction taken to solve the immediate health problem. With reference to the US-Mexico border, Miller-Thayer (2010) observed transnational medical consumers include seniors (‘snowbirds’: 55 years or older, from northern United States or Canada, who spend winter months in the warm U.S. South), year-round border residents, and day and weekend border crossers. The implication is that as long as these groups exist, cross-border healthcare utilization behavior and practices (in Mexico) will prevail, calling for innovations in international cooperation projects on health and the facilitation of healthcare access for at-risk populations from the U. S. and Canada in Mexico. At the present, “many employers along the border offer border policies to their employees. These policies, which cover care in Mexico with no or lower patient co-pays than a comparable U.S.-only plan, save money for both the worker and the employer” (Miller-Thayer, 2010), thus influencing transformations in the insurance market in the U. S. that otherwise would not have happened. As the Tanzania-Uganda borderlanders (permanent, temporary and the pastoralists – (the ‘dry season birds!’ practicing transhumance between May and mid-October) are there to stay so are cross-border healthcare services utilization behaviors and practices. Deep-rooted socioeconomic and lived cross-border experiences will continue influencing these behaviors and practices. As the borderlanders suggested, governments should facilitate accessing services on either side of the border. The intensification of the East African Community (EAC) and now the implementation of the African Union Border Program (AUBP) would facilitate this transformation. Establishing health facilities in the borderlands and harmonizing health insurance policies between the two countries would be an added advantage to the borderlands and the borderlanders (Yameogo, n.d.). Clients from adjoining countries would use home insurance policies to access quality healthcare services at such facilities. Having healthcare providers fluent in borderlanders first languages would reduce communication barriers reported by similar studies. The use of social media, internet and networks (friends, family members, neighbors, healthcare providers and other individuals who have used the services across the border) “play an important role in shaping transnational healthcare practices and mitigating risks through transferring of crucial information about which pharmacies, dentists, and opticians to visit, where to find the best prices on medications, and where and how to cross the border” (Miller-Thayer, 2010). As one borderlander observed, one does not need to cross the border to access health services. The media send health messages that know no borders. We observed, at least there is a cell phone in every household, majority of the households have access to the radio and quite a substantial number of them have television (TV) sets. Ugandan and Rwandese radio and TV stations air health education and promotion session in the borderlanders’ first languages (IIs, Kagera, 2017/18) making messages comprehensible compared to messages aired in uncommon language(s). The implication is that messages crafted in Burundi, Uganda or Rwanda targeting the borderlanders benefit Tanzanians in the border regions. Similarly, messages crafted in Tanzania benefit Burundi, Rwandese and Ugandans understanding Kiswahili.

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Crush (2015) observed two categories of medical tourists to South Africa. 1) The conventional North-South tourists from Europe and North America “who travel to access South Africa’s world-class private medical facilities.” The country is becoming destination for cosmetic surgery, fertility treatment, drug rehabilitation, (illegal) transplant and stem cell tourism. 2) The south-south movement of middle class medical tourists (formal and informal from SADAC region to South Africa) motivated by lack of access to basic or required services at home. Adding, “[t]he high demand and large flow of patients from countries neighboring South Africa has prompted the South African government to try and formalize arrangement for medical travel to its public hospitals and clinics through inter-country agreements in order to recover the costs of treating the non- residents.” However, in the South African context the problem is that “for the ‘disenfranchised’ medical tourists who fall outside these arrangements … medical xenophobia in South Africa may lead to increasing exclusion and denial of treatment” leading to xenophobic attacks as experienced in that country in the 1990s, between 2000 and March 2008 and 2015 (Wikipedia). The message is that with limited or declining medical resources in a receiving country, citizens and the elite could turn to social boundaries, borders and citizenship to exclude non-citizens alleging them of utilizing their country’s healthcare resources at their expense (Okumu, 2010; Kamazima 2017; 2018). Cross-border healthcare intervention projects and program implementers would need to have strategies in place to evade similar situations. Indeed, Medical Associations and pharmaceutical companies have advocated ‘dangers’ associated with cross-border healthcare services utilization: compromising treatment procedures at home and consulting ill-trained and unprofessional medical personnel (Miller-Thayer, 2010). In the view of such opponents, the US institutions, for instance, present that specific risks of medical tourism depend on the area being visited and the procedures performed. However, some general concerns include: 1) Communication may be a challenge, thus receiving care at a facility where one does not speak the language fluently might increase the chance that misunderstandings will arise about his/her care. Data from this study indicated Tanzanians in the borderlands prefer visiting facilities in Uganda where healthcare providers speak their first languages and Ugandans in Kashenye preferred going to Mugana Hospital in Tanzania, where providers and communities share most of their backgrounds. In Limpopo Province, South Africa, healthcare providers reported frustration due to language barriers when serving migrants from Zimbabwe and use of translators somewhat led to misdiagnosis for some cases (Dept. of Social Development Limpopo, 2011). 2) Medication may be counterfeit or of poor quality in some countries; 3) Antibiotic resistance is a global problem, and resistant bacteria may be more common in other countries than in the US and 4) Flying after surgery can increase the risk for blood clots. However, proponents respond, Social networks that exist among transnational consumers and providers mitigate many of the risks associated with buying medical supplies and services in a foreign country … Consumers are challenging the ethnocentric notion that healthcare in the United States is better than in other nations. Their empirical experiences debunk the myths of risk and danger that corporations, government, and the media perpetuate, a message these transnational medical consumers distrust because they view its sources as motivated by greed rather than concern for improving people’s health. Their networking adds an element of safety; they can rely on the experiences of those who have gone before them and they can access the knowledge of those familiar with the new system to reduce their risk of harm (Miller- Thayer, 2010). The Tanzania-Uganda borderlanders do not face similar fears for several reasons. Medical training in East Africa started during the British rule at Makerere University serving students from Uganda, Tanganyika/Tanzania, Kenya, Zanzibar, North and South Rhodesia (Zambia and Zimbabwe) and Nyasaland (Malawi). In 1963, independent Kenya and Tanganyika governments formed university colleges in Nairobi and Dar-es-Salaam respectively as constituent colleges of the University of East Africa. Makerere became the third constituent college. The three colleges followed the same curricula as inherited from Makerere University. The governments of the three East African countries split the University of East Africa in 1970 establishing the Makerere University, University of Nairobi and University of Dar-es-Salaam, the national universities for Uganda, Kenya and Tanzania. The Inter-University Committee (IUC) was established the same year to facilitate contact and cooperation among the three universities. In 1977, the East African Community (EAC) collapsed living the IUC operating with meager resources to meet its objectives (Wikipedia). However, in 1980, a series of consultations with higher learning authorities led to the establishment of the Inter- University Council for East Africa (IUCEA) succeeding the IUC. Based in Kampala, it served until 1992 when it failed carrying out its duties due to lack of financial support from the three governments. The IUCEA was revived in 2002, receiving legal status and integrated in the EAC cooperation framework in 2009. Based in Kampala, the IUCEA, overlooks that any university college and degree awarding institution applies and gets admitted to the IUCEA membership “as long as it is properly incorporated in the EAC Partner State where it is operating and is pursuing objectives that are consistent with the functions of IUCEA as spelt in the Act [IUCEA Act 2009]” (Wikipedia). The implication is that medical professionals’ training and assessment in East Africa follow more-or-less similar curricula ensuring graduates acquire the same competencies necessary for serving the region’s citizenry in the health sector. Studies on the US-Mexico cross-border healthcare services utilization prove “that while poorer U.S. residents go to Mexico in search of affordable health services, more affluent Mexicans come to the U.S. for health services and citizenship” (Homedes, et al., 2016). Tijuana residents, for example, seek reproductive health services, expecting to claim U.S. citizenship for their children and eventually for themselves. This was not the case along the Tanzania-Uganda border. Pregnant mothers from Uganda seek just reproductive health services in Tanzania not citizenship. Certainly, ‘perceived and real’ economic

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www.ijird.com June, 2018 Vol 7 Issue 6 development in the U. S. ‘pulls’ many citizens from developing countries to hunt for permanent residency or citizenship in that country. Mexico residents, therefore, take advantage of the jasi soli [whoever is born on the American soil is an American citizen irrespective of parent(s)’ nationalities] citizenship granting system in the U. S. to meet this end.

5. Conclusion and Recommendations Healthcare services utilization across the Tanzania-Uganda border has been going since the establishment of the border by the colonialists in 1904. The Tanzanian borderlanders go to Uganda for primary and advanced healthcare services; other Tanzanians seek advanced care at Mulago Hospital. The Ugandans, cross the border to Tanzania mainly for primary healthcare services. Although not captured in this study, it is possible that some Ugandans seek advanced healthcare services at Bugando, KCMC or Muhimbili Hospitals in Tanzania. In addition to biomedical care, border crossers seek African therapy and spiritual healing on either side of the border. Lack of healthcare service needed, social networks, perceived quality of healthcare, unacceptability of services in home country and economic and cultural (ethno-linguistic) capital are key determinants for cross-border healthcare service utilization. As long as differences in healthcare systems exist between Uganda and Tanzania and cross-border healthcare services consumers’ agency, needs and willingness to traverse the border for opportunities identified across the border remain on the rise, this long-time practice will continue. The political elite, policy makers and development partners should remember that “one’s health is cardinal to human life that one would do anything to have and sustain. One’s health is, therefore, prioritized over [citizenship and] patriotism” (Miller-Thayer, 2010), challenging “traditional ways of thinking about public health and the notion of health systems contained within the nation state” (Durham & Blondell, 2017). National health systems and polices should, therefore, encourage and facilitate citizens’ access to quality and equitable healthcare services at home or across the borders. This qualitative study has just scratched the surface of this public health and policy concern along the Tanzania- Uganda border and the region. It is recommended conducting further multi-disciplinary research covering both sides of the borders to increase our understanding of region-specific issues like: characteristics of borderlanders and other citizens crossing the border for healthcare; characteristics of providers attending patients from neighboring nation(s); cross-border healthcare utilization decision making process; predictive factors; types of services sought; barriers, opportunities and perceived quality of services provided abroad; impact on the economy of both countries; impact on healthcare services prices; influence on insurance market; healthcare providers’ perspectives on border crossing for healthcare behaviors and practices; impact on healthcare services quality and implications to nation states’ health systems and health policy.

6. Acknowledgements The authors acknowledge financial support to conduct fieldwork in the four border districts on the Tanzania-Uganda border from the Rwechungura and Kwesigabo families, Kagera, Tanzania; cooperation from the borderlanders, study participants; village, ward, division, district, and region authorities; and Dr. M. R. Kazaura, Dr. M. J. Ezekiel, Neusta P. Kwesigabo and Johanitha T. Joram for reading and commenting on earlier versions of this paper.

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