Opportunities to catalyse improved healthcare access in pluralistic systems: a cross-sectional study in Haiti.

OBJECTIVE: To identify determinants of intended versus actual care-seeking behaviours in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyse improved healthcare access. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In Haiti 568 households (incorporating 2900 members) with children less than 5 years of age were randomly sampled geographically with stratifications for population density. These households identified the healthcare providers they frequented. Among 140 providers, 65 were located and enrolled. OUTCOME MEASURES: Household questionnaires with standardised cases (intentions) were compared with self-recall of health events (behaviours). The connectedness of households and their providers was determined by network analysis. RESULTS: Households reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (adjusted OR (aOR)=3.17; 95% CI 1.99 to 5.05; p<0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95% CI 1.06 to 1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favoured non-conventional providers (McNemar's χ2 test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional. CONCLUSION: Addressing geographic barriers, possibly with technology solutions, should be prioritised to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.

Africa's Nomadic Pastoralists and Their Animals Are an Invisible Frontier in Pandemic Surveillance.

The effects of COVID-19 have gone undocumented in nomadic pastoralist communities across Africa, which are largely invisible to health surveillance systems despite the fact that they are of key significance in the setting of emerging infectious disease. We expose these landscapes as a "blind spot" in global health surveillance, elaborate on the ways in which current health surveillance infrastructure is ill-equipped to capture pastoralist populations and the animals with which they coexist, and highlight the consequential risks of inadequate surveillance among pastoralists and their livestock to global health. As a platform for further dialogue, we present concrete solutions to address this gap.