Nomads' access to the current healthcare system is impaired by their perception of its cost, quality, and accessibility and by gender segregation in Timbuktu, Mali: A cross-sectional study CURRENT STATUS: UNDER REVIEW

Background Access to community-based healthcare services is one of the key characteristics in successful public health policy. In Mali, not nomadic communities, remote and hard-to-reach areas. Methods: In order to determine a better healthcare strategy for these nomadic populations, we conducted a cross-sectional survey in the administrative region of Timbuktu in Mali using the administration of questionnaires to community members. Results: A total of 520 individuals from two nomadic communities, Gossi and Ber, were included in the questionnaire survey. Inhabitants of the two nomadic communities were livestock breeders (27%), housekeepers (26.4%), local traders (11%), farmers (6 %) and artisans (5.5%). The median age of the study participants was 38 years (18-86 years). The participants from Gossi and Ber lived at a mean distance of 40.94 km and 23.19 km from the closest health center, respectively. The major complaints with respect to accessing healthcare were cost (35.7%), distance to the health center (46.2%), quality of the provided services (39.2 %) and means of transportation (79.4%). More than 25% of the participants from the community stated that they will never accept to being examined by a health care provider of the opposite gender. appears from the interviews results that these nomadic populations have health needs not presently covered by the current health delivery system. Tackling the method and organization of health care delivery by adapting them to the local lifestyle, culture and values could lead to significant improvements health outcomes.

Background Access to community-based healthcare services is one of the key characteristics in successful public health policy. In Mali, community-based interventions do not reach nomadic communities, remote and hard-to-reach areas.
Methods: In order to determine a better healthcare strategy for these nomadic populations, we conducted a cross-sectional survey in the administrative region of Timbuktu in Mali using the administration of questionnaires to community members.
Results: A total of 520 individuals from two nomadic communities, Gossi and Ber, were included in the questionnaire survey. Inhabitants of the two nomadic communities were livestock breeders (27%), housekeepers (26.4%), local traders (11%), farmers (6 %) and artisans (5.5%). The median age of the study participants was 38 years (18-86 years). The participants from Gossi and Ber lived at a mean distance of 40.94 km and 23.19 km from the closest health center, respectively. The major complaints with respect to accessing healthcare were cost (35.7%), distance to the health center (46.2%), quality of the provided services (39.2 %) and means of transportation (79.4%). More than 25% of the participants from the community stated that they will never accept to being examined by a health care provider of the opposite gender.
Conclusion It appears from the interviews results that these nomadic populations have health needs not presently covered by the current health delivery system. Tackling the method and organization of health care delivery by adapting them to the local lifestyle, culture and values could lead to significant improvements health outcomes.

Background
In Malian rural areas, especially in the northern part of the country, local populations experience the highest infantile mortality rates (191 per 1000 births). In other words, one out of five Malian children dies before reaching 5 years old [1]. The distribution of health structures throughout the country is disparate and based not only on demographics but also on politics and socio-economic aspects [2].
Indeed, the health services and human resources are generally concentrated in the populated urban areas of the country, 57% of the medical doctors, 47% of the nurses and 64% of the midwives are currently working in the capital city, Bamako [3].
On the fringe of the Sahara desert in the Sahel region of West Africa, 65% of Mali's land is desert or semi-desert [4]. Wealth and natural resources are unevenly distributed across the country. Those living in the northern regions of the country suffer from recurring periods of drought and widespread food shortages [5,6].
An estimated 50-100 million people or 30-60% of the world's nomadic and semi-nomadic people live in Africa. Nomadism is common in many sub-Saharan African countries including Mali [7][8][9]. Nomadic populations access health services less than the general population. Nomadic populations are also disproportionately vulnerable to infectious diseases such as malaria, tuberculosis, Guinea worm disease, leishmaniasis, onchocerciasis, Schistosomiasis, soil-transmitted helminthiases, brucellosis and trachoma [10].
Little is known how to efficiently provide essential health care services to nomadic populations and those living in remote rural areas [11]. The constant mobility of nomadic populations excludes them, or at best places them at the edge of health delivery services. The recruitment, training and community support of nomadic community health workers (CHWs) constitute an additional challenge [12]. In this study we aimed to describe the characteristics of nomadic populations and determine factors limiting nomads' access to current health services and identify health interventions accessibility-related issues among the nomads.

Study setting
The study was conducted in two districts of the Timbuktu region in the commune of Ber in the district of Timbuktu and the commune of Gossi in the district of Gourma Rharous, both of which are located at about 900 km from Bamako, the capital city of Mali [4].

Study population
The study was performed among Kel Tamasheq, Songhai, Arab, Fulani and Bozo people. The main lifestyle of these populations is pastoralism that requires a nomadic lifestyle for a significant part of the community. The population is made of encampments with 25-35 people each. Each encampment regroups around 3-5 families with 5 to 7 households each living in 4-6 tents around a leader who is usually the eldest family member. They settle with their animals around a waterhole sometime in transhumance between northern and southern parts of the country depending on the season and availability of food for their animals. With these conditions and cultural values, nomads prefer not to stay in these communities due to the constant search for new pastures for livestock. They spend most of their time and effort caring for their animals. Therefore, it seems as if the welfare and the health of their animals is as important as their own wellbeing [13].

Study design
We conducted a cross-sectional survey from January to March 2011 in the communes of Ber and Gossi by administrating a questionnaire to community members. In each municipality, 3-4 nomadic communities who were related to the two study communes were randomly selected. Reachable villages during the study period were selected to represent the nomadic communities at each study site. Only adults capable of giving informed consent (age 18 years old and above) have been included in this study.

Sample size and statistical considerations
The sample size has been estimated by using Epi Info software; assuming 95% confidence level, power of 80 % and 20% of no access in healthcare among the nomadic population. The level of significance was set at 0.05 (two-tailed). Data were analyzed using chi-square tests to compare proportion as appropriate by SPSS 20.0. [14]. Missing data were not included in the analysis as there were very few missing values. The graphs were generated by using GraphPad Prism 8. Chi square test was use to proportions.

Data collection methods and instruments
A questionnaire regarding health care and suggested solutions was administrated to community members by trained enumerators. The content of the questionnaire referred to health issues nomadic communities faced such as the lack of medicine or means of transportation in emergency, for example pregnant women in case of delivery complications, cost of treatment, low frequentation rate of the area's health center, the relationship with their animals. In this study, key informant guides for 6 in depth interview were used to better understand the local context and help for data interpretation.

Limitations
Any method of gathering information (documentary analysis, interviews, questionnaires, etc.) must be used, observation) has biases and limitations. We used a questionnaire for data collection and this study could therefore have information biases. In order to minimize these biases, we have explained the questions to the participants in a very precise manner.

Results
A total of 520 of surveys were accepted for analysis. The sex ratio of participants was 1.34 in favor of men with a median age of 38    In both Ber and Gossi, 63% of those surveyed in this study were illiterate. The other types of training most encountered among our respondents in both cities were schooling in an Arab school or primary schooling in a conventional school (respectively 19.04% and 10.96% of those surveyed in this study).
The distance to the health care facility was not too far away for 40% of our respondents; this distance was similar to that (35.58%) of those who felt it was too far away (  Lack of resources (financial and mean of transportation) was an obstacle for 60.96% of respondents.
This rate was statistically significant compared to that of those who said otherwise (14.62%). Over 63% in the study population had a monthly income less than $120 US Dollars (Table 3). The most common barriers to nomads' access to health services included health care cost and means of transportation, visits to traditional healers, refusal of opposite gender medical examination and distance to the health center. Health care cost and means of transportation, visit traditional healers were the most frequent barriers among all of them cited (Fig. 1). Respondents asserted a lack of resources in 60.96% of cases.
People settled in sites where there is no health center were located at an average distance of 40.94 km and 23.19 km respectively of Ber and Gossi. This distance is statistically higher in Ber than in Gossi (Mann-Whitney U test p < 0.0001), (Fig. 2).
Health care cost is the main reason for non-access to health centers, with about 60.96% of respondents stating that they cannot afford to pay for consultations. Over 77% of respondents stated that they will never accept being examined by a practitioner of their opposite gender (Fig. 3).

Discussion
Most of the study population (47%) were illiterate and were mostly represented by the age group of 38-47. The reluctance on the part of older people to send their children to formal education system may be due to a loss of confidence between the country authorities and other partners as part of studies or miscellaneous development projects. There were more men among the study participants because the prevailing perception in these communities amongst women is that it is the men's responsibility to represent or to talk on behalf of the community. Also, in Tamashek settings, women are inaccessible from men, unwilling to speak to a stranger or a man who can be her husband because of customs and being Muslim (100% of the study population was Muslim). Most of the study enumerators were men, so it is possible that some women would not have felt comfortable speaking with them during the study. This is a limitation on our study.
Tamasheq was the most widely-spoken local language (65%). Tamasheq is the language of the Tuareg desert nomads and it is the common point of a whole group (cluster) of ethnic groups known as "Kel Tamasheq (meaning people of the Tamasheq language)". Most of the population was literate in Arabic for learning the Holy Quran or "tifinagh (Tamasheq alphabet). So if they are not educated they may certainly not value these mass public interest interventions. The linking with nomadic ancestral values is a key element that hinders social and health development. The standard of living is not very high hence; the society is based on a very strong tribal model and mutual assistance.
When implementing public health interventions, the actors must take into account these factors for the success of the programme [15][16][17]. This is likely the reason that people don't participate in public health interventions.
In Mali, the number of qualified health personnel is inadequate at all levels of the health system. It is also unequally distributed over the country. The same scenarios is observed for health infrastructure [18][19][20]. The nomadic community pays a heavy price because of population lifestyle and the extent of the occupied area.
The most used means of transportation to reach the health center was the car in nearly 40% of cases.
This give evidence of the inadequacy of fix health centers in nomadic area. All these centers are leading by nurses except the health center of Gossi which is led by a physician. Furthermore, 41.15% of our study participants lived less than 5 km from the nearest health center. This is due by the fact that the investigators because of the insecurity were not able to go very far from the village of Ber Approximately 39.04% of respondents found that the cost of care was too expensive against 11.54% who thought that the cost of care was affordable compared to neighboring countries like Burkina Faso or Algeria or Niger. However, there is a cultural problem: many of these people have, cattle, and other animals but do not want to sell their animals for cash to resolve health needs. In 2006 El Moctar et al.
found in Ber that 96.6% of people said they were ready to go to the health center if care was free [21]. Lack of money was cited as the main obstacle to access to health care among women respondents (53%) [12]. Studies indicate that the most vulnerable do not receive all necessary care when the needs are greater than elsewhere. Inequality in access to care is present almost everywhere in nomadic areas even in sedentary and nomads' communities. More than 63.26% of the study participants had an average monthly income lower than120$. The cost of health care is a burden increasingly unbearable for the socially and economically vulnerable communities; [11,22,23].
Another factor cited was the use of traditional medicine, 44% of the participants visits first traditional healers and marabouts (person who use Koranic verses to treat diseases) in case of illness. El Moctar et al. report that 57.4% of nomadic communities use traditional medicine and modern medicine as an alternative. Although cost is important, this factor should not be overestimated in the analysis of the conditions of access to basic health services. Many studies have shown the link between improved quality and increased attendance within nomadic population [19,26,27 ].

Shortcomings Of Health Systems In Mali
Advanced strategy (for health areas located beyond 5 km from community health center) and mobile strategy (mobile for remote health areas and nomadic areas located beyond 15 km from community health center) currently used to achieve non-functional health areas are often considered as the best approach in nomadic areas. An evaluation made by AVSF/ADESAH in 2010 reported that 84% of respondents said that the actions of the joint mobile health component (human and animal health) were in line with their needs [28]. Furthermore, a lot of people would prefer a fixed center for several reasons like cost, stability of personnel, health facilities, short stays of the mobile team on sites, nonfunctionality of certain markets (weekly local markets), the lack of communication & community leadership. All these reasons make the above-mentioned approaches inappropriate for better access to health care. The data presented in this article will certainly have changed since the 2012 crisis, which is still going on, and we believe that access to care would have become worse than when we collected the data.

Conclusion
On completion of the study, it appears that despite the efforts from the Malian government and its health partners, the increase in health centers and strategies, access to basic health interventions is meeting expectations in nomadic areas. This study shows the importance of a set of factors that should be considered to improve access to health interventions in nomadic areas. These factors include the underutilization of health services, quality of services offered, the attachment to ancestral nomadic values, poverty, gender and the current strategies recommended by health policies.
However, nomads are interested in all strategies that will allow them to participate in the management of their health problems. Researchers obtained individual informed consent from all the study participants. Information was anonymous and treated as confidential.

Consent for publication
Not applicable

Availability of data and materials
The datasets generated and analyzed during this study are presented in Tables 1, 2  Frequency of the most common barriers to nomads' access to health services mentioned by the respondents Figure 2 Variation of the median distance between respondents' location and the closest health center in Km Perception of respondents about the lack of resources and the acceptance of the consultation by the opposite gender

Supplementary Files
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