Accessibility and availability of health care services to internally displaced persons, in Kitgum and Pader districts, northern Uganda ()
1. INTRODUCTION
Over two decades of a protracted civil war between the Lord’s Resistance Army (LRA) rebels and the government armed forces, led to the displacement of an estimated 1.6 million persons from northern and eastern regions of Uganda during 1986-2009 [1]. Most of the displaced persons originated from the Acholi sub-region, in the districts of Gulu, Lamwo, Amuru, Kitgum, Nwoya and Pader, that bore the brunt of the war.
In 2005, the vast majority 95% or 279,000 and 93% or 267,000 of the populations of Pader and Kitgum districts respectively were displaced into squalid internally displaced persons camps. A total of 64 internally displaced persons camps were established, 30 in Kitgum and 34 in Pader districts respectively [2].
During the peak period of displacement in 2005-2006, the health indices in the Acholi sub-region were poor with high crude and under five mortality rates, estimated at 1.54 and 3.18 per 10,000/day respectively. The crude mortality rate (CMR) and the under five mortality rate (U5MR) in Gulu district IDP camps were high, estimated at 1.22 and 2.31 per 10,000/day respectively. These mortality rates were both above the emergency thresholds of 1/10,000/day and 2/10,000/day respectively and the national estimates of 0.46/10,000/day and 0.98/10,000/day respectively [3].
During emergencies, displaced populations especially women and children are extremely vulnerable to ill health owing to a variety of socio-cultural, economic and physiologic reasons [4,5]. Several factors including insecurity, poverty, poor nutrition, inadequate water and sanitation, and lack of adequate health services predispose displaced populations to high levels of morbidity and mortality [4]. Excess mortality in displaced population settings is often caused by the same diseases that affect the non displaced populations including acute lower respiratory tract infection (ARI), malaria, measles, diarrhoeal diseases and malnutrition [4,6].
In situations of emergencies the health system is heavily burdened, and the problems of the quality of services and inadvertent discrimination may arise, yet it should ensure respect for human rights and the attainment of the highest standard of health [7]. Displaced populations including IDPs and refugees face various challenges in accessing health care due to socio-economic, geographic, cultural factors [8]. The un-availability of health services means that displaced population living in under serviced areas, may not obtain appropriate services. A study by Reitz (1995) highlights the need to bring health resources and care centres to areas where marginalized populations are highly concentrated [9].
Since 2007, the phenomenon of displacement has gradually evolved into return home (resettlement) and the camp population shifted into decongestion settlements in northern Uganda. Today the majority, over 90%, of the population in the Acholi sub-region has returned home. The objective of this study was to examine accessibility to and availability of health care services to internally displaced persons (IDPs) in Kitgum and Pader war affected districts, northern Uganda.
2. METHODS
2.1. Study Sites
The study was carried out in Kitgum and Pader districts in northern Uganda. In 2007, there were an estimated 629,617 internally displaced persons i.e. 310,111 IDPs in Kitgum and 319,506 in Pader districts respectively [10]. The districts had a total of 67 IDP camps i.e. 24 camps in Kitgum and 43 in Pader district respectively. figure 1 shows the location of the study district in northern Uganda.
2.2. Study Design
We carried a cross-sectional study comprising internally displaced community members including adults and adolescents, service providers at the central and local district levels (including Ministry of Health and local district health services providers and humanitarian relief i.e. UN agencies, international NGOs and community based organisations (CBOs).
2.3. Data Collection Procedures
We sampled 15 of 24 IDP camps (62.5%) in Kitgum district and 20 of 43 (46.5%) camps in Pader using both purposive and random sampling techniques. The camps were stratified by parishes, population size, and security considerations and randomly selected into the study.
Administratively, a camp is sub-divided into blocks and zones. A block constituted a study cluster. We selected households based on the modified WHO Expanded Programme of Immunization cluster sampling technique [11]. The centre of the cluster was identified. A bottle was spun to determine the initial direction of movement. A random starting household was identified by listing all households from the centre to the end of the cluster and a random starting household was chosen, and the next selected for interview was the nearest to the one where the interviewed had been conducted.
In a household, either a male or female adult head of household was interviewed. We selected male or female respondents in the proportion of 40% to 60% respectively. However, after every third household, an adolescent aged between 14 and 19 years was identified and interviewed. A total of 51 respondents (adult/adolescent) were interviewed per cluster in Kitgum and 40 in Pader district. In total 1383 individuals comprising 720 (52%) of respondents in Pader and 663 (48%) in Kitgum district were interviewed.
We held 27 in-depth interviews and conducted 52 focus group discussions. The key informants included camp commandants, and Local Council I, II and III Chairpersons, in charge of health units including health centre II and III. In addition, leaders of community-based organisations (CBOs) were interviewed. At the district level, civic authorities including local council (LC V) chairpersons, resident district commissioners, chief administrative officers; and in the health sector, the district health team members such as the district health officer (DHO), medical superintendent, medical officers, the person in charge of the nurse training school (the matron), district health visitor, and personnel responsible for health centre IV were interviewed. Finally, we interviewed various
Figure 1. Map showing study districts, Kitgum and Pader, northern Uganda.
humanitarian relief workers from agencies including United Nations High Commission for Human Rights (UNHCHR), United Nations Children’s Fund (UNICEF), World Health Organization (WHO), and Non-Governmental Organisations as shown (in Table 1).
We held 27 in-depth key informant interviews with 14 staff from international and local humanitarian agencies (UN/NGO/CBOs), 8 with district health staff, and 5 with community and district civic leaders.
We conducted a total of 52 focus group discussions (FGDs) (Table 2). The FGDs consisted of adult-men and women, adolescent, and community leader groups. Women and men were divided in both adult and adolescent FGDs. There were eight to ten persons per group. The discussions took about one hour each. The focus group discussions were taped recorded.
More than half of the FGDs (28 of 52, or 52.8%), were carried out with adults (men and women), 16 of 52 (30.8%) with adolescents (males and females), and 7 of 52 (13.5%) with community leaders.
Data collectors (research assistants) were trained for three days. The study instruments comprising (questionnaire, focus group, and key informant guides) were translated into the local language-Luo/Acholi and back into English. The data collection tools were pre-tested. Quantitative data were captured, cleaned, and edited. The completed questionnaires were checked by the principal investigator daily for accuracy, completeness and consis-
tency before the data collectors left the IDP study sites/ camps. Quantitative data were checked for completeness, sorted, coded and captured using EPI data version 3.02 packages. The data were entered in Epidata version 3.1 and analyzed using SPSS version 12.00 software package. Qualitative data were analyzed manually. Content analysis was based on condensation and abstraction of main themes.
3. RESULTS
As shown in Table 3, more than a quarter of the respondents 26.1% (25.7% males and 26.4% females) were below 19 years of age. The majority of adult respondents 61.4% (57.3% males and 64.2% females) were in the age group 20 - 49 years. 24.2% of respondents (9.1% males and a significantly higher proportion of females, 37.4%) had no formal education while 56.8% of respondents had attained at least primary level education. Most respondents 75.2% (73.9% males and 76.4% females) have lived in encampments for a period ranging between one and ten years.
Table 4 shows that most (78%) respondents (79.5% in Kitgum and 76.5% in Pader) live within 5 km of a health facility. The main reasons for choice of a health facility are proximity to health facility 29.6% (males 29.1% and females 30.1%), availability of free treatment 22.7% (males 21.5% and females 23.9%); availability of drugs