Barriers to Accessing Primary Health Services In Rural Sierra Leone And India

A Comparative Assessment of Community Perceptions And Utilization

Abstract

Background: Universal access to primary health care (PHC) has become the bedrock of initiatives to achieve universal health coverage yet rural populations in low- and middle-income countries (LMICs) still suffer significant inequities. Both situated in divergent health system setups and economic conditions, Sierra Leone and India faces comparable obstacles to rural health access including lack of infrastructure, inadequate manpower and socio-cultural barriers. With this objective, the present study was an attempt to compare community perceptions and utilization of PHC services in rural areas of Sierra Leone and India to understand the main barriers and enabling factors. Method: A cross-sectional, sequential explanatory mixed-methods study was conducted between January and March 2025. Interviews were conducted with 188 participants (92 from rural areas in Sierra Leone; 96 from rural areas in India) using structured questionnaires. The survey collected demographic factors, perceptions of PHC service quality and access, and patterns of use. Quantitative data were analysed descriptively, chi-squared and binary logistic regression to determine predictors of PHC access. Results: The results indicated that 68.5% of respondents in India accessed PHC, in comparison to 52.2% in Sierra Leone. The most common barriers faced in the two countries were distance to facilities (67.6%), lack of drugs (61.2%) and lack of skilled staff (58.3%). Significant relationships were described for PHC use with educational level (χ² = 10.45, p < 0.01), work status (χ² = 7.63, p < 0.05) and location of proximity to health care services (χ² = 14.27, p < 0.001). The odds ratio from the logistic regression analysis was 2.7 (95% CI = 1.6–4.5) for those living within 5 km of the health facility to use PHC services. Conclusions: Enhancing the accessibility of PHC in rural Sierra Leone and India requires an integrated, equity-oriented strategy focused on health system strengthening, community engagement, and technological innovation. As the emergency period is likely to be a time of high transmission, the results of this study further emphasise the need for simultaneous attention to both supply- and demand-side constraints, and this investment should include in health infrastructure, work force strengthening and innovative approaches, with a focus on culturally sensitive community engagement of all populations in the quest for health for all.