The tight movement restrictions introduced around the world to curb the spread of the novel coronavirus disease have had far-reaching consequences . These include effects on access to healthcare. People living in slums have been particularly hard hit.
Slums are characterised by structural and institutional inadequacies. These spaces enable viruses to spread rapidly and heighten the risk of community transmission of diseases. Also, slum residents face a disproportionate burden of ill-health . Effective public health strategies in slums can't overlook the perspectives, insights and solutions offered by those who work and live in them. Identifying challenges and finding solutions with those closest to the issue is essential.
In a recent study , we explored healthcare and access to services in seven slums in Kenya, Nigeria, Bangladesh, and Pakistan. We were looking for insights of how health services are perceived in these communities before and during COVID-19-related lockdowns.
Overall we found that slum communities had access to diagnostic and treatment services and made use of preventive services before the pandemic. But services for mental health and gender-based violence were limited or non-existent. Access to all healthcare services decreased during COVID-19 lockdowns. Barriers included increased cost of healthcare, reduced household income, increased challenges in physically reaching healthcare facilities. Residents' fear of infection and stigmatisation made matters worse.
Understanding the impact of lockdowns on people's access to healthcare and health service seeking behaviour is important to finding solutions to health service disruptions.
Healthcare before COVID-19
We conducted household surveys in the seven slum sites as part of our study. Healthcare use rates varied by site. The rates were lower in sub-Saharan Africa than South Asian sites, but all are relatively low compared to high income countries. The lowest outpatient consultation rates of visits per person per year were reported in Nigeria at 0.5-0.6. In Kenya, Pakistan, and Bangladesh consultations rates were between 1.2 and 1.9. In an international context, the median OECD rate is approximately 6 to 7 visits per person per year.
We also conducted in-depth interviews and group discussions with over 850 healthcare workers and community members in the seven settlements between March 2018 and May 2020. Pre-COVID-19 engagements were conducted through face-to-face workshops and individual meetings.
Healthcare was expensive for all residents, particularly the cost of drugs. Pharmacists and patent medicine vendors were seen as as key providers of treatment and advice for illnesses such as colds and flu, diarrhoea, stomach ache and headache, allergies and first aid.
Preventive services in maternal and child health, including immunisations and antenatal care, were mostly available for free in the public sector.
But mental health services were limited in Nigeria, Kenya and Bangladesh. In all sites, traditional and spiritual healers were reported to provide services related to mental health and wellbeing.
Healthcare during COVID-19
In April 2020, as COVID-19-related lockdowns were imposed in each country, we initiated a fourth phase of rapid cycle stakeholder engagement. For safety reasons, we switched our mode of engagement to individual telephone conversations. We captured perceptions on state and community responses to the pandemic, challenges facing non-COVID patients and service delivery and access during lockdown.
At the community level, stakeholder accounts revealed disruptions to healthcare services. Access to basic human needs such as food was also interrupted. Most residents survive through highly insecure employment in the informal sector, often undertaking multiple jobs that pay low daily wages – this was also disrupted.
The cost of buying medicine was already a problem for many residents. In Pakistan, health workers said patients sometimes reduced their medication dosages to make it last longer. In Nigeria, residents and patient medicine vendors described negotiating prices of drugs at the point of sale.
In all these slum communities, residents have been hit hard by societal responses to COVID-19. Reductions in local services and shutdowns made it difficult to reach healthcare facilities and the cost of drugs increased. In Bangladesh and Nigeria, private pharmacists and patient medicine vendors identified lockdown-related disruptions in the supply chain leading to price increases.
In addition, residents avoided formal healthcare where it exists for fear of being diagnosed or becoming infected with COVID-19. Some residents and health workers used their mobile phones for health consultations. Others turned to locally available healthcare services – often staffed by providers with minimal healthcare training – and to traditional healers.
Our findings about the impact on healthcare access of COVID-19 lockdowns were consistent across all four countries. They were also similar to the predictions made in earlier research.
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We found evidence of individual responses to the pandemic such as health workers providing remote consulting using their mobile phones. Support from the state and non-governmental agencies varied. For example, some provided support to tackle COVID-19 and mitigate the impact of the lockdown but neglected the specific needs of women. Some pharmacies assisted regular customers with credit and medication. But there were reports of low stocks and indications of stockpiling .
The inability to provide for basic needs such as medication is a factor in increasing stress and mental illness in these settings. There were no reported new services for mental health and gender-based violence with the onset of COVID-19 lockdowns in the communities we studied. This contrasts with initiatives in other slums, such as in Brazil where community leaders have used their existing community innovation organisation to provide healthcare.
Implications for policy and practice
Our findings suggest that for slum communities, effective communication about COVID-19 and about health service provision is needed. People must know which services are available, what precautions are being taken to prevent virus transmission, and who should seek healthcare.
Pharmacies and patient medicine vendors can be used to communicate information to the community. For example placing posters in their shops and sharing information verbally can be effective as residents rely on these providers for their basic healthcare.
Traditional healers have a recognised role in communication about COVID-19. Where there are existing good relations between formal healthcare and traditional healers, they can be called on to direct patients to formal healthcare when it is in the patient's best interest.
Policymakers and those planning healthcare access must consider the impact of COVID-19 containment strategies. This is especially important to ensure that slum communities are not disadvantaged to a greater extent than other communities. They need to ensure that healthcare costs and the costs of reaching healthcare facilities do not escalate and further deter healthcare usage. Provision of additional mental health services and services targeting gender-based violence should be considered.
In the face of COVID-19, slums are a challenge for controlling the pandemic. Strengthening their fragile healthcare provision would help mitigate the effects of COVID-19 and future pandemics.
This research was funded by the National Institute for Health Research (NIHR) Global Health Research Unit on Improving Health in Slums using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care.
Bronwyn Harris receives funding from the National Institute of Health Research (NIHR), UK.
Frances Griffiths receives funding from the National Institute of Health Research, UK
Dr. Rizvi works as a Co-Investigator in the NIHR Global Health Research Unit on Improving Health in Slums project at the Aga khan University, Pakistan.
Pauline Bakibinga receives funding from the NIHR and the MRC (UK), Gates Foundation.
Syed A K Shifat Ahmed works as a Research Fellow in the NIHR Global Health Research Unit on Improving Health in Slums project at the Independent University, Bangladesh.
By Funke Fayehun, Senior lecturer, University of Ibadan, University of Ibadan And
Bronwyn Harris, Senior Research Fellow, University of Warwick And
Frances Griffiths, Professor of Medicine in Society, University of Warwick and South Africa Research Chair in Health Policy and Systems, University of the Witwatersrand, University of Warwick And
Narjis Rizvi, Associate Professor, Aga Khan University And
Pauline Bakibinga, Associate Research Scientist, African Population and Health Research Center And
Syed A K Shifat Ahmed, Assistant Professor, Independent University, Bangladesh