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

Introduction Gains to ensure global healthcare access are at risk of stalling because some old resilient challenges require new solutions. Our objective was to study a pluralistic healthcare system that is reliant on both conventional and non-conventional providers to discover opportunities to catalyze renewed progress. Methods A cross-sectional study was conducted among households with children less than 5 years of age in Haiti. Households were randomly sampled geographically with stratifications for population density. Household questionnaires with standardized cases (intentions) were compared to self-recall of health events (behaviors). The connectedness of households and their providers was determined by network analysis. Results A total of 568 households (incorporating 2900 members) and 65 providers were enrolled. 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 (aOR=3.17; 95%CI 1.99-5.05; p< 0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95%CI 1.06-1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favored non-conventional providers (McNemar’s Chi-squared 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 prioritized to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome. Article Summary ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by the National Institutes of Health [DP5OD019893] to EJN. Internal support was provided by the University of Florida. These funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: University of Florida Institutional Review Board Ruth K and Shepard Broad Building 1300 Center Drive Gainesville, FL 32610 Phone: (352) 273-9600 Comite; National de Bioethique 29, avenue de la Ligue Feminine ci-devant 1e avenue du Travail Port-au-Prince Haiti Phone: 509-3701-5766 All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data is available at the Dryad data repository.