Frequency and reasons of bypassing lower health care facilities in Lira district- Northern Uganda

Background: To improve access to health care for all who need, the government of Uganda increased the number of lower level health facilities across the country. However, many patients prefer to bypass the lower level facilities in favour of the high level facilities. Bypass of health care is the situation that patients seek care at a high level facility farther away than the nearby lower facility. Lira district has 42 lower health facilities and one referral hospital that received all referrals from the region. The ratio between patients with and without referral and the reason for bypass are unknown.The study aims to get insight into the frequency of and the reasons why patients visit Lira hospital thereby bypassing lower health facilities. Methods: We performed a one-month descriptive cross-sectional study among patients visiting the outpatient department of Lira hospital after written informed consent: qualitatively with four focus group discussions (FGD) of ten participants each and quantitatively using validated questionnaires. The questionnaire included socio-demographic questions, their complaints and the reason(s) to visit the hospital, In the FGD the reasons of bypass were discussed. The topic list includes the patients’ expectations and experience with the lower facility. Thematic analysis of transcripts was performed. Codes and categories were developed and interrogated following an iterative process. The results of the questionnaires were entered in Epidata 3.1 and analysed with SPSS18. Results: 387 out of 481(80.5%) respondents recruited by systematic random sampling, bypassed lower health care facilities and were associated with marital status, distance travelled of >10 km from the home town to the hospital and tertiary education. Lack of trust in health care providers, lack of medicines and diagnostic equipment and poor quality of health services at lower health facilities were the main reasons to bypass. Conclusion: Improvement of the lack of trust in health care providers and of the poor quality of health services in the lower health care facilities is essential to reduce the bypass problem and to realize health care for all who need within 5 km of the place where they live.