Factors affecting access to health care facilities in a rural Community: The case of Bali-Nyonga Sub-Division, Cameroun

Adequate and equitable distribution of health care facilities in rural areas is critical to human capital development. The study determines distance as a factor influencing utilization of health facilities in Bali-Nyonga. The main objective of the research is to evaluate the socio-economic effect of distance to health care in Bali-Nyonga. Data for this were gathered through field observation, face to face interview and questionnaires. Data from secondary sources included publish and unpublished material which was presented in form of related literature review. The data were analyzed using descriptive measures and presented in the form of tables, chart, percentages and graphs. In Bali-Nyonga, where the condition of roads is very poor, distance from the nearest health facility emerges as the most important factor influencing utilization. The vulnerable groups of women, the age, sickly, the illiterate and the poor were not found to be more strongly affected by distance decay. The policy implication arising from this study suggest that distance to improve health care needs to be reduce to enhance accessibility and to improved health service by various socio-economic groups in the area. It was recommended to strengthen the efforts to improve accessibilities of health care facilities in the rural areas by increasing the number of health facilities,


RESUME
Une répartition adéquate et équitable des établissements de soins de santé dans les zones rurales est essentielle au développement du capital humain. L'étude détermine la distance comme un facteur influençant l'utilisation des établissements de santé à Bali-Nyonga. L'objectif principal de la recherche est d'évaluer l'effet socio-économique de la distance aux soins de santé à Bali-Nyonga. Les données à cet effet ont été recueillies par le biais d'observations sur le terrain, d'entretiens en face à face et de questionnaires. Les données provenant de sources secondaires comprenaient des documents publiés et non publiés qui ont été présentés sous la forme d'une revue de la littérature connexe. Les données ont été analysées à l'aide de mesures descriptives et présentées sous forme de tableaux, de graphiques, de pourcentages et de graphiques. À Bali-Nyonga, où l'état des routes est très mauvais, la distance par rapport à l'établissement de santé le plus proche apparaît comme le facteur le plus important influant sur l'utilisation. Les groupes vulnérables de femmes, d'âge, de malades, d'analphabètes et de pauvres ne se sont pas avérés plus fortement affectés par la dégradation de la distance. L'implication politique découlant de cette étude suggère que la distance pour améliorer les soins de santé doit être réduite pour améliorer l'accessibilité et l'amélioration des services de santé par divers groupes socio-économiques de la région. Il a été recommandé de renforcer les efforts pour améliorer l'accessibilité des structures de santé dans les zones rurales en augmentant le nombre de structures de santé, transport et sensibilisation des indigènes ruraux INTRODUCTION Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (WHO,1998). Inaccessibility to health care varies across continents, countries, communities, groups, and individuals, largely influenced by geographical, social and economic conditions as well as the health policies and systems in place. The World Health Organization (WHO, 1998) defines healthcare accessibility as "a measure of the proportion of the population that reaches appropriate health services" (WHO, 1998). In this line health care inaccessibility is a measure of the proportion of the population that is unable to reach appropriate health service. Research has shown that access to health services is closely linked to the affordability, physical accessibility, and acceptability of services, and is not based merely on the adequacy of service supply (Gulliford al,2002).Health care utilization is the use of health care services by people. The health care utilization of a population is related to the availability, quality and cost of services as well as to social-economic structure and personal characteristics of the users (Chakraborty et al 2003.). The underutilization of health services in public sectors has been almost a universal phenomenon in developing countries (Zwi, 2001). Patients, especially in the rural areas in developing countries , are far away from health facilities, and this affects their utilization of health services. Health facilities, goods and services have to be accessible to everyone without discrimination, within the jurisdiction. Health facilities, goods and services must be affordable for all. Akashi et al. (2004) point out that payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. The costs of attending health services may be known or unknown, but in either case may prevent the poor from attending facilities. Even where costs are known they may not be affordable. However, it is the uncertainty about costs that is perceived as the main financial barrier. The introduction of official fees removed some uncertainty and reduced costs by using a well-published fee schedule. Nonetheless, the continued prevalence of some under-the-table charges means that the uncertainty about what patient costs will be are a barrier for those who lack an immediate source of cash income to meet health costs (Dalton and Peacock, 2005). Awoyemi et al., (2011) showed that distance is also an important limiting factor to health care access in the Northern Nigeria. The policy implication arising from this study suggests that distance to improved health facilities and the total cost of seeking health care need to be reduced to enhance accessibility to improved health services by various socio-economic groups in the area. Princeosei-wusuadjeib.a (2008) conducted a research on the impact of poverty on the health of rural communities in Ghana: a case study of the Amanesi a west district, Ashanti region. the survey analyses the poverty situation and how poverty impacts ill health in the rural communities in the District. Hypotheses tested were that, poverty is the root cause of poor health; and that, adequate income and knowledge ensure better health for the rural communities of the Amansie West District. The numerous alarming healthcare problems in Cameroon, in general and in Bali-Nyonga in particular are causes for concern. The need to overcome distance problems is one of the greatest challenges of most rural communities. Bali Nyonga is a rural community and exhibits a number of problems which seem not to have been addressed and thus threatens healthcare utilization. The goal of this study was to access the accessibility to health care in Bali-Nyonga Subdivision, a typical rural community in the North West Region of Cameroon.

Methodology Location of the Study Area
The study was carried out in Bali-Nyonga a subdivision located in Mezam Division in the North West Region Cameroon, found at the transition between the grasslands and the forest to the South West. Bali-Nyonga is one of the 32 sub-divisions of the North West Region. It is situated some 20kilometers from Bamenda, which is the regional headquartering of the North West Region. Bali-Nyonga is located between latitude 5 0 54 ' North of the Equator and longitude 10 0 East of the Greenwich Meridian. It has a basin shape and covers a surface area of about 191km 2 with a population 85058 inhabitants (Bali rural council monographic study, 2005). Bali-Nyonga is of the Chamba Leko group who migrated from Chamba around the 1600. The language is Mungaka and it is found in the Western part of Mezam. Bali is bordered to the North East by Bamenda, to the South East by Santa subdivision, to the West by the Mbengwi and to the South by Batibo Subdivision. Bali-Nyonga lies at the foot of the Bamboutos plateau. From the Bamenda Descriptive survey research was use to gather information on factors affecting access to health care facilities in Bali-Nyonga Sub-Division. Target population and sampling size in the framework of our study, our target population consisted of all people living in the urbanized. The purpose sampling technique was used to select willing participants for the study in Bali-Nyonga Sub-Division. The primary sources include face to face interviews; the use of 200 questionnaires and field observations. The secondary sources included information from published and unpublished textbooks, journals, articles, and open access journal online. Data from the field was analyzed with the use of: SPSS, Excel and Quantum, GIS. All participants responded orally to a structured questionnaire provided by the investigating team. Data collected were included socio-demographic characteristics, socioeconomic information, socio-cultural information, factors of accessibility and inaccessibility to health facilities. The geographical coordinates of health facilities were obtain using a Global Positioning System. Field observation was important for the description of health facilities. Free software such as Quantum SIG (version 1.6) has made it possible to georeference health facilities in the area.

SPATIAL DISTRIBUTION OF HEALTHCARE FACILITIES IN BALI
According to the Bali district hospital statistics department, the total population of the health district is estimated at 85,804 inhabitants. Bali health district constitutes 5 health areas with 9 health centers and a district hospital (table 1)    shows a photo of Bali district hospital laboratory. Three elements labled A,B and C can be identify. The first element A is an electric heater with a drum sterelizer on it. They are used to heat and disinfect or sterilize slides and other instruments used in the laboratory to collect spa cements. The second element B is a microscope used in examining spa cements. Then C are some laboratory technicians examine a spa cement with the microscope.  On this photo, three variables can be noticed; that is A, B, C and D. A is a viewing hall where corpses are presented for viewing. B is the room where corpses are being preserved. C is a water tank that supplies the hospital. D is some community members waiting for the mortuary attendant.

Characteristics of health facilities in Saint Elizabeth's Catholic health Centre
The Saint Elizabeth's Catholic Health Centre is one the oldest health Centre in Bali-Nyonga. This sophisticated health centre was created by the Roman Catholic mission to carter for health needs of the Bali-Nyonga people. This health center is well furnished. Here, some important facilities are available like the ultrasound and echography unit. Table 3 shows some of the pieces of equipment available.    shows Saint Elizabeth's Catholic health centre Bali-Nyonga taken from the sky using a drone. Building A is the doctors' house. The doctor is resident in the centre for emergency. Building B harbors the children, women, men and private wards. Here there is a small conference hall, nurse's station, consultation, laboratory and the matron's office. Building C contains a labor, delivery room and maternity. In building D, we have a canteen and an ultrasound and echography unit. Building E kitchen and F an external toilet. Buildings G, H and I is the residence of the health centre's matron and some sisters. From the photo, the Saint Elizabeth's Catholic health center Bali-Nyonga has an organized structure.

Characteristics of health facilities in Bali
Integrated health Centre Information from field shows that, Bali Integrated health centre is the oldest health institution in Bali-Nyonga. With the creation of the Bali district hospital, some of its services were reduced. It now handles mostly antenatal care and delivery service. It also treats small lailments, while severe once are being referred to the Bali district hospital. The plateau technique of Bali-Nyonga integrated health center (IHC) is as presented in table 4 below. Photo 8 shows a photo of the Bali Integrated health Centre. It is a part view, showing some external toilets and the building the contains the pharmacy, laboratory, labor room, delivery room, maternity and a hall can be seen with a sign post on its wall.

Factors of accessibility to health care in Bali Nyonga
According to information gathered from field, the characteristics of health facilities insufficient health personnel's, lack of finance by the people, poor road network limiting health care accessibility in Bali-Nyonga.

Income per month
There is a direct relationship between employment level and income per month. Results from field survey indicated that the level of incomes of the people are too low.Table5. Cultural factors influencing health accessibility in Bali-Nyonga Cultural factors play an important role in determining health accessibility in Bali-Nyonga. These factors are the cultural beliefs, of the people, language barrier, as well as the use of traditional medicine in healing. As well as the attitude of the doctors. Table 6 presents the reaction of our respondents with respect to social factors of accessibility in the study area.

Language barrier
Bali-Nyonga like any other areas in Cameroon is subjected to the use of two official languages English and the French languages. This poses a threat to health care accessibility as patients who cannot express themselves in English or French are not capable expressing their health problems and this is a limiting factor to health care accessibility table 6.

Traditional beliefs
This is another limiting factor to health care accessibility in Bali-Nyonga. Results from our field survey indicated that some people do not go to the hospital because they believe very much in traditional medicine and as such they do not go to the hospital. They also believe in ancestral healing. Table 7 shows the effects of culture on health accessibility in the study area.

Item
Agree Disagree Frequency % Frequency % Many people in Bali-Nyonga do not visit the hospital because they do not know how to express themselves in English or French language 100 50 100 50 Bad cultural practices have led to increase in the death rate of many Bali-Nyonga people since they belief in their ancestor for treatment and healing   Table:7 shows that out of the 200 participants, an equal number 100(50%) of the responded agreed and disagreed respectively to the fact that English and French languages are a barrier to hospital visits; 180(90%) accepted that bad cultural practices and ancestral beliefs leads to neglect of health while 20(10%) refused; 160 (80%) agreed that notables do not seek modern medical care because they do not want to expose their bodies and fatigue powers to the health personnel while 40(20%) disagreed; 40(20%) accepted that because of the believe that medical treatment is the white's own way of treatment many people do not go to the hospital while most 160(80%) refused; and finally, when asked whether Bali-Nyonga indigents are forbidden by their ancestors not to visit hospitals, 160(80%) agreed while 40(20%) denied the assertion.
The attitude of health personnel Attitude also plays an important factor in determining health care accessibility in Bali- Nyonga. This attitude is demonstrated by the health care personnel that is the doctors to the patients. In some cases patients wait for long before they are being attended to by the health personnel. The doctors on their part are not welcoming to the patients. In some cases, patients are obliged to bribe the doctors before they are being attended to. The health officials also practice discrimination wherein they give much time to the rich at the expense of the poor. In some cases when patients come to the hospital, the doctors do not have time to attend to them as they rather spend time in chatting about their businesses. Also, absenteeism on the part of the doctors is also a big problem as most of the doctors are not always on duty and at times when a patient is admitted in the hospital there is usually no body to attend to the patient because of high absenteeism on the part of the doctors. Table8.The summary of the effects of attitude on personnel health accessibility in Bali-Nyonga. Source: Field work 2019 Table 8 shows that out of the 200 participants, 80(40%) of the responded agreed that many health personnel do not attend to their patients on time while 120(60%) disagreed; 60(30%) accepted that health personnel do not have a welcoming altitude towards patients while 140(70%) refused; 160(80%) said Health personnel do not treat patients in hospitals equally. They discriminate the poor while 40(20%) refused; 180(90%) said health personnel spend time browsing and charting with friends rather than attending to the needs of their patients; and 60(30%) affirmed that they receive bribe from some patients before given them treatment while 140(70%) denied the assertion.
The effect of distance on health accessibility in Bali-Nyonga Distance is the amount of space between two points. Here we are referring to the amount of space between homes and the nearest health post in Bali-Nyonga. According to the Bali district hospital statistics department, the total population of the health district is estimated at 85,804 inhabitants. Bali health district constitutes 7 health areas (Bali Urban, Bossa, Gungong, Won, Njenka, Wosing, Bawork) with 9 health centers and a district hospital. These health centers are located according the various villages in Bali-Nyonga. In order to determine the distance covered by patients to get medical care, the researcher administered a questionnaire to patients and found that majority of the indigenes (70%) live in areas of at least 4km from the nearest hospital as shown on the table9

Level of education
According to the level of education the population is grouped into those who completed only primary school, those who completed the secondary, high school and graduates of the utilization. The literate tends to utilize healthcare services than the illiterates as shown on the table below.
Education has an important impact on utilization of healthcare of health care facilities . The table  11 shows the highest proportion of 25% of rural household heads has primary education. A larger percentage of 56.5% of household heads who have tertiary education utilize modern healthcare facilities while a higher percentage of 57.9% have households whose heads did not have access to formal education do not utilize healthcare facilities. Also, 60% of households whose head have adult literacy education did not utilize health care facilities.

Discussion and Conclusion
From the findings, the financial status of the people of Bali-Nyonga to purchase for health care services is very low. They have very low income because of the types of activities in which they are engaged. These activities are primary and secondary activities. The primary activities are characterized by small scale farming which will always result in low income thus limiting their power to afford health. About 148 out 200 people of Bali-Nyonga testified that visiting of traditional healers and road side drug vendors is come due to poverty.All these has greatly implicated they health situation of Bali-Nyonga people.
From the findings, the following recommendations were made: The government should provide loans to the people of Bali-Nyonga at a very low interest rate so that they can increase their farm size in order to raise income to afford health care services. Those who are engaged in trade also need to be granted loansat very low interest rate encourage them borrow so that they can increase their business scale which will yield them high income rate that can purchase health care services. Government should increase the capacities of most of the health centers with equipment and personnel. The Bali Council should grade and rehabilitate the roads leading to hospitals.