Introduction With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities.
Methods In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns.
Results Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate.
Conclusion Slum residents’ ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered.
- health policy
- health systems
- public health
- other infection
- or injury
- qualitative study
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What is already known?
With COVID-19, tight restrictions on movement have brought health, social and economic consequences for slum communities.
Effective public health strategies must consider the perspectives, insights and solutions of those who live and work in slums.
What are the new findings?
Pre-COVID-19, diagnostic and treatment services were available for slum dwellers, preventive services were well used but services for mental health and gender-based violence were limited or non-existent.
Stakeholders perceive a reduction in access to all healthcare services in slums during COVID-19 lockdowns, with inconsistent and inadequate attention given to ameliorating this.
Access barriers include increased cost of healthcare, reduced household income, increased challenges in physically reaching healthcare facilities and exacerbated reluctance of residents to seek healthcare due to fear of infection and stigmatisation.
What do the new findings imply?
Clear communication with slum communities is needed about available healthcare services, infection control measures and the importance of continuing to seek care for non-COVID-19 conditions, including pregnancy and long-term conditions.
Policymakers and those planning healthcare services should ensure that the costs of accessing healthcare do not escalate and further deter healthcare usage, or unfairly disadvantage slum communities.
To ease access barriers, remote consulting to reduce face-to-face contact and the provision of mental health services and gender-based violence services should be considered.
COVID-19 is an infectious disease that has spread globally, infecting over 13 million people worldwide and resulting in >570 000 deaths by mid-July 2020.1 Unsurprisingly, cities are at the epicentre of the pandemic and, in the megacities of low-income and middle-income countries, structural and institutional inadequacies could enable the virus to spread rapidly with a heightened risk of community transmission.2–4 In slums, ‘closed spaces, crowded places and close contact’,5 coupled with poor sanitation and lack of running water, amplify barriers to pandemic control efforts from hand washing to isolation, quarantining and social distancing.6 7 While tight restrictions on movement may contribute to reduced disease transmission, there are social and economic consequences of locking down slums and the impact on access to healthcare.8–10 It is the latter that we focus on in this paper. Effective public health strategies in slums cannot overlook the perspectives, insights and solutions offered by those who must work and live with them.8–10
Our study forms part of the NIHR Global Health Research Unit on Improving Health in Slums, a multipartner, multimethod collaboration11 exploring healthcare and access in seven slums in Bangladesh, Kenya, Nigeria and Pakistan. Although the term ‘slum’ is widely debated, for this paper, we define a slum as an area of high population density that lacks sanitation, clean water, safe and durable housing, as well as basic services.12 Here, we present stakeholder perspectives on access and barriers to healthcare in these sites over two time periods: pre-COVID-19 and during COVID-19 lockdowns. We ask, how stakeholders who are seeking, delivering and managing healthcare in the sites have perceived and experienced access to healthcare services for non-COVID-19 conditions, both before and during COVID-19.
Conceptualising access in context
Healthcare access is a complex notion and there is no commonly agreed definition or singular ‘access’ approach.13 14 However, there has been renewed interest in understanding access as: i) relational and dynamic, a process that is jointly negotiated and produced between those seeking (individuals, households, communities) and providing services (health workers, organisations, policies) and ii) multidimensional, finding expression in the affordability (financial access), availability (geographical/physical access) and acceptability (sociocultural access) of care.13 14 Drawing on the study by Levesque et al, we define access as ‘the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use healthcare services and to actually have the need for services fulfilled’.13 Given the ‘highly contextual’,15 geographically bound12 nature of our study (table 1) and the urgency for policymakers to understand and respond to community needs in addressing COVID-19, we have focused on experiences and perceptions of stakeholders living and working in each site, that is, at the micro-level of the health system where health policies are experienced and ‘tested’.16 We have also engaged with stakeholders responsible for planning, funding and implementing services locally—those operating at the meso-level of the system.16 The instrumental and ethical value of identifying challenges and finding solutions with those closest to the issue is well recognised.15 17 Insights from micro-level and meso-level are important for informing change at the macro-level where policies are formulated and decided16; and for generating community awareness and ownership of solutions for improving healthcare access.17
The seven slums for our study are described in table 1. We include in the table detail from community mapping, household and facility survey and fieldnotes collected pre-COVID as part of the wider study11 in order to provide the reader with an understanding of what we know about these sites to assist with interpretation of stakeholder perceptions. This work indicates a range of healthcare facilities within each site. Healthcare use rates vary by site, with rates higher in South Asian sites than those in sub-Saharan Africa but all are relatively low compared with high-income countries. Healthcare costs are high for residents, particularly drugs.18
Selection and recruitment of stakeholders
We purposefully selected stakeholders for diversity within the micro-level and meso-level of each country’s health system. At a micro-level, health workers included pharmacists and patent medicine vendors (PMVs), polio workers, clinical officers, nurses and community health workers and assistants. Residents were selected for diversity of age, gender and religion, as well as leadership roles in the community. Pregnant women and women with children were included in group discussion in all sites and in Kenya, the team also recruited people identifying themselves as living with disabilities and members of youth groups. At a meso-level, we selected district/county health service managers. We identified stakeholders through our organisational networks, site contacts and interactions with community leaders, residents and health service providers.
Pre-COVID-19 stakeholder engagements were conducted through face-to-face workshops and individual meetings over three phases: (i) inception meetings to introduce the project, identify key stakeholders and map out broad issues raised; (ii) micro-level community engagement using semi-structured guides to explore perceptions of common illnesses, health-seeking behaviours, healthcare service availability, including preventive services and access challenges and (iii) feedback and discussion of study results. Each country team read relevant available policy to inform the engagements. Individual discussions (20–50 min) and group engagements (1–3 hours) were facilitated by researchers trained in the methods and ethics of qualitative stakeholder engagements, in a language common to all participants. They were audio-recorded, transcribed and translated into English, and supplemented by notes from regular team debriefings.
In April 2020, as COVID-19-related lockdowns were imposed in each country, we initiated a fourth phase of rapid cycle stakeholder engagement involving weekly discussions (15–30 min each) with stakeholders located at the micro-level and meso-level of the health system, namely community leaders, residents, health workers, volunteers and managers. Based on preliminary findings from our pre-COVID engagements (which directed us to key stakeholders and their roles in each community), discussion with local leaders/community advisors, and our wider contextual knowledge, participants were selected for their role/expertise, site-familiarity and involvement with the COVID-19 response. They were recruited by fieldteam members who lived in the site (Bangladesh, Nigeria) and/or had been working there prior to the lockdown (Kenya, Pakistan). For safety reasons, we switched our mode of engagement to individual telephone conversations, each lasting 10–30 min. We ensured that in each site, at least one stakeholder per category was engaged each week. We captured perceptions on state/community responses to the pandemic, challenges facing non-COVID patients and service delivery and access during lockdown. Each team read websites of media, governments and global agencies (eg, WHO, International Monetary Fund) throughout data collection and used these as a resource during stakeholder conversations to both prompt stakeholders and act as a check on what they were saying. Detailed notes were made of each discussion.
All data were encrypted and stored on a secure server at the University of Warwick for analysis.
During pre-COVID engagements, stakeholders at micro-level and meso-level were asked to identify common illnesses for which community residents frequently sought care. Lists were compiled for each site and categorised into communicable and non-communicable diseases (table 2). From online reports from media, government and global agencies, we summarised key COVID-19 containment and relief measures instituted in each country (table 3). With the remaining data we carried out thematic analysis,19 guided by our understanding of access as dynamic and multidimensional in terms of availability, affordability, acceptability,13 while staying open to emergent themes. Four researchers (one per country-team MA, PK, KA, SAKSA) coded and extracted the transcripts and notes into an Excel template. Codes were reviewed in consultation with the broader team and developed into initial themes, then refined through further coding. The whole team met frequently to resolve differences and reach agreement about final themes. These were compared across countries and overtime (both before and during the COVID-19 pandemic).
Rapid feedback to policymakers and media
Patient and public involvement
As part of the wider study, prior to project initiation, we consulted with community leaders and residents through launch events and individual consultations in each site. Community members were recruited to fieldwork teams in Nigeria, Kenya and Bangladesh and were involved in conducting stakeholder engagements. Community leaders (Bangladesh, Nigeria, Pakistan) and Advisory Groups (Kenya) are advising on our dissemination plans.
Between March 2018 and May 2020, we engaged with a total of 860 stakeholders across the seven sites. In the pre-COVID period, we reached 774 people through 51 workshops/meetings and 110 individual discussions. In April–May 2020 of the COVID-19 era, we spoke to 86 people via phone (table 4). First, we present stakeholders’ perceptions about the burden of illness and access to care prior to the declaration of COVID-19 as a pandemic. Then we share emerging issues in the early COVID-19 period.
Stakeholder perception of illness burden and access to care before COVID-19 in the slum communities
Building on stakeholder engagements in each site, we developed a list of 14 common illnesses for which residents frequently sought care (table 2). Respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension were perceived as common in each country. Hepatitis was perceived as common only in Pakistan. Beyond these common illnesses, health workers in Pakistan and Kenya mentioned that sensitive or stigmatised conditions, such as sexually transmitted infections or HIV, were often ignored or left unaddressed within households until symptoms were serious. Community leaders and residents described a range of health providers in each site providing diagnosis and treatment, which matched the findings of the facility survey undertaken as part of the wider study (table 1). They were aware that some clinics refer emergencies and complicated cases to hospitals outside the site. In all sites, pharmacists and PMVs were presented as key providers of treatment and advice for illnesses such as colds and influenza, diarrhoea, stomach ache and headache, allergies and first aid.
Preventive services in maternal and child health, including immunisations and antenatal care, were reported by almost all stakeholders in all sites. They were perceived to be well-used by residents and supported by private traditional birth attendants (TBAs) and midwives, who were said to provide referrals and recommend immunisations. In Nigeria and Kenya, these are (mostly) available for free at point of use in public sector services. Primary-level screening services, delivered through fixed/mobile primary healthcare clinics, community health workers or health campaigns, were identified by health workers, managers and community residents for hypertension (Kenya, Nigeria), tuberculosis (Nigeria, Pakistan), HIV (Kenya, Nigeria) and vectorborne diseases, for example, malaria, dengue fever (routinely in Bangladesh and more occasionally in Nigeria and Kenya, via a bednet campaign). In Bangladesh, residents and health workers, including pharmacists, mentioned that private pharmacies have facilities for blood sugar-level testing and blood pressure measurements. In Pakistan, community residents, female health workers and pharmacists explained that screenings for hypertension, diabetes and HIV are only available at secondary/tertiary levels in the public sector, or by private providers. Stakeholders reported limited availability of public sector mental health services in all countries, except for Pakistan, where residents and health workers reported that there were no such services within the site. However, in all sites, traditional and spiritual healers were reported to provide services related to mental health and well-being. For gender-based violence, limited health services were identified by residents and local authorities in the two Kenyan sites but not the others.
Following the declaration of COVID-19 as a pandemic, the governments in all four countries instituted a range of containment and relief measures, including lockdowns, movement restrictions, curfews and financial aid packages (table 3). At the community level, stakeholder accounts reveal disruptions to healthcare service access as well as interrupted access to basic human needs like food. Illustrative quotes for each theme from each country are presented in table 5. Within the results text we provide additional illustrative quotes. To protect participant confidentiality, all quotes are attributed using the following convention: country-site/stakeholder role/gender.
Perception of access to care with the imposition of COVID-19 lockdown
With the imposition of restrictions due to COVID-19, stakeholders across all sites and categories reported disruption to services (table 5). Some facilities, including some pharmacists/PMVs, were no longer functioning at all. Others were only providing emergency care (eg, the non-governmental organisation (NGO)-run maternity centre in Bangladesh). While a few were operating on reduced or minimal services where opening hours were limited, stocks of medicines and other supplies were compromised and staff numbers low (or sometimes none) as staff could not get to work due to the lockdown:
Outpatient services are reduced because not all members of staff are able to come to work. Our ambulance goes round to pick staff who live close by (Nigeria Site 3/Nurse/Female)
Stakeholders reported reduced availability of some preventive services, including immunisation and reproductive, maternal and child health preventive services. In Kenya, routine growth monitoring and health promotion for children under 5 years was suspended. In Bangladesh and Pakistan, community-based immunisation and family planning programmes were suspended. In all sites, services delivered by community health workers in households were stopped due to movement restrictions.
In Kenya, a nurse explained that her primary care centre had diverted its emergency resources to COVID-19 preparedness:
Health facility has been forced to spend its emergency kitty on COVID preparedness. All money has been diverted to COVID. (Kenya Site 2/Nurse/Female)
In Nigeria, a health worker reported the arrival of a variety of resources for COVID-19 preparedness:
Support was provided for primary care health workers from the local government, Family and Community Development Initiative (FCDI) and Aids Prevention Initiative in Nigeria (APIN). These supports are in form of protection such as hand sanitizers, hand wash, face masks, gloves and basin for hand washing (Nigeria Site 1/Nurse/Female)
Health workers and managers reported that their national governments had issued guidelines for prevention of COVID-19 and for accessing care for COVID-19 cases. However, they were unaware of guidelines for continuing provision of healthcare for non-COVID-19 illnesses and preventive services in all but Bangladesh, where some mentioned recommendations for use of telemedicine and guidance for hospitals.
The general reduction in availability of healthcare to access was exacerbated for many residents because of increased costs of healthcare alongside reduced household income, increased challenges in physically reaching healthcare facilities and exacerbated reluctance of residents to seek healthcare due to fear of infection and stigmatisation.
Increased cost of healthcare alongside reduced household income with COVID-19 lockdown
Community leaders and residents explained that most residents survive through highly insecure employment in the informal sector, often undertaking multiple jobs that pay low daily wages. Before the pandemic, the cost of buying medicine was a problem for many residents. In Pakistan, health workers mentioned that patients sometimes reduce the dose of their medication so it lasts longer. In Nigeria, residents and PMVs described negotiating prices of medicines at the point of sale. Residents said that they would sell assets or borrow from neighbours or relatives to meet transport and healthcare costs in an emergency.
Price hike due to lockdown
In all sites, stakeholders across categories noted an initial increase in the cost of many health-related items, including facemasks, hand sanitizers, disinfectants, gloves and drugs, especially those bought from private providers:
Prices of drugs have increased greatly and this has affected the ability of people to buy drugs. (Nigeria Site 1/PMV/Male)
In Bangladesh and Nigeria, private-for-profit pharmacists and PMVs identified lockdown-related disruptions in the supply chain leading to price increases. However, staff working in public sector services in Nigeria, Kenya and Pakistan reported no rise in drug prices. Moreover, in Nigeria (site 2), a nurse mentioned that fees had been removed for various drugs in response to COVID-19-induced financial hardship within the community. However, drug shortages and supply chain issues in the public sector meant that in some cases, people had to purchase drugs from private-for-profit pharmacies and drug stores.
Lack of income for slum households due to lockdown
In all sites, stakeholders reported that, for most, work for a daily wage was halted during lockdown. Other residents lost their jobs as companies were shut or went out of business. The few on salaries generally had these reduced. The lack of income caused widespread distress, leaving residents unable to buy enough food, pay rent or afford healthcare.
The COVID-19 pandemic has affected the economic ability of community members to access healthcare …people do not have enough money for food, hence, they cannot use what they have to buy drugs. (Nigeria Site 2/Community member/Female)
A pharmacist in Bangladesh explained that:
Around 80%–85% of the residents are stuck inside the slum with no work or mode of income so poverty is becoming the main problem. Therefore, people are more at risk of dying of hunger and poverty at this point than the disease outbreak. (Bangladesh/Pharmacist/Male)
He said that consequently, pharmacies were extending credit to their regular customers during lockdown.
There were a few reports that governments, NGOs and philanthropists were providing some relief:
One NGO is providing financial aid to each family and buying residents food… Another NGO gave aid to hundreds of families (rice, pulses, oil, salt) (Bangladesh/Community leader/Male)
Similarly, table 3 identifies a range of immediate and long-term government and donor actions intended to mitigate the economic consequences of COVID-19, many aimed at low-income communities. Yet, in all sites, there was general agreement that such aid was ‘not enough’. (Pakistan/Community member/Female)
Increased challenges in physically accessing healthcare facilities
Community leaders and residents described pre-COVID-19 challenges of reaching healthcare facilities outside of the slum, particularly for emergencies. There are state-provided ambulances but in all study sites it was difficult for ambulances to enter due to congestion, narrow streets and haphazardly parked vehicles. In an emergency, a patient would usually be rushed by private transport (eg, motorcycle/tricycle) to the nearest hospital. Healthcare workers and residents in all sites explained that for pregnancy-related emergencies, a slum resident might first call a traditional birth attendant who sometimes, if necessary, would accompany patients to hospital. However, this practice was reportedly declining in Bangladesh with residents generally able and preferring to access the NGO-funded maternity centre in the site. With COVID-19, stakeholders reported that the lockdown had reduced the ability of people to move around, even for emergencies. Furthermore, reduction in local healthcare provision meant people had to travel further for their care, but this too was difficult.
People find it difficult to go to the health centers or go to buy drugs as they may need to trek some distance. (Nigeria Site 3/Nurse/Female)
In Bangladesh, the public hospital generally used by slum dwellers was designated for patients with COVID-19, thereby requiring residents to seek care elsewhere for other health conditions.
Exacerbated reluctance of residents to seek healthcare due to fear and stigma
Across sites, it was reported that slum residents were reluctant to go to a hospital outpatient clinic for symptoms such as cough and fever for fear of being suspected of having COVID-19. Stakeholders explained that residents were concerned that if doctors in hospitals, working with protection, were contracting the infection and some were dying, how could they hope to avoid infection and if infected, death? Health workers thought fear of infection was one reason for a reduction in the number of residents seeking healthcare from facilities that were open:
About 10 to 15 patients visit the health facility daily. However, since they became aware of the pandemic, their visitation has reduced especially for general conditions like malaria etc. (Nigeria Site 1/Nurse/Female).
Fear of being quarantined and stigmatised were also identified as barriers to care-seeking in all of the sites:
Recently, there were medical teams from the government visiting the slum to collect samples from people with COVID-19 like symptoms. However, on the first day, hardly anyone showed up for testing. This was mostly due to the fear of stigmatisation. (Bangladesh/Health worker/Male)
Responses to the reduced access to health facilities during lockdown
Stakeholders identified efforts by health facilities, health workers and/or residents to overcome access problems caused by the lockdown.
Mobile consultation using phones
To mitigate the challenge of physical access, some health workers and residents reported using their phones for healthcare:
We have given out telephone numbers for the rapid response team to help with COVID-related cases. We also have a health facility telephone numbers for patients to call and talk to a health worker for non-communicable conditions that need monitoring. That way we can continue providing other services besides COVID-19 and ensure continuity of services. (Kenya /Member of the subcounty health team/Female)
People call us over the phone for consultation they tell their symptoms and we try to help them as much as we can. (Pakistan/Doctor/Female)
In both Kenyan sites, a private-public partnership provided pregnant women with an emergency number for a free taxi transfer to a health facility at night during COVID-19 curfew hours. In Pakistan, female health workers were reported to be providing maternity-related advice over the phone or arranging consultations by appointment.
Healthcare workers were also using their phones to gain advice from other team members when needed:
When pregnant women visit the centre with cases that cannot be handled by the nurse on duty, the nurse calls the matron or other senior staff for help on what to do. (Nigeria Site 1/Nurse/Female)
Increased patronage of local available services
Before the pandemic, residents in all sites reported that for common ailments such as fever or diarrhoea, they would usually start with home remedies (eg, boiled rice water in Pakistan) and self-medication (such as oral rehydration solutions or syrup purchased from the nearest drug store). Only if symptoms persisted, would they then visit a primary care clinic, doctor’s chamber or hospital outpatient clinic near to them within or outside the site. In Pakistan and Nigeria, some mentioned that they might also visit a faith or traditional healer.
With disrupted healthcare access during the COVID-19 lockdown, stakeholders in all sites said residents were relying even more on home remedies and locally available in-site services for all of their health needs. As table 1 shows, pre-COVID services available in the sites were mostly pharmacies or PMVs (often staffed by assistants without formal qualifications), traditional healers and some private health centres (usually small facilities for specific conditions). Going to their usual primary care or hospital clinics when they are not improving or are getting worse would be a last resort for residents, if a possibility at all.
In these slum communities, residents have been hit hard by societal responses to COVID-19, with reduction in local services, difficulties reaching healthcare facilities and increased cost of drugs. Slum residents are avoiding formal healthcare where it exists for fear of being diagnosed or becoming infected with COVID-19. Some residents and health workers are using their mobile phones for health consultations. Others are turning to locally available healthcare services, often staffed by providers with minimal healthcare training, and to traditional healers.
Our stakeholder perceptions of the illnesses common in the slum communities are broadly similar to the patterns of communicable and non-communicable health conditions previously reported in African and Asian slum settlements.22–25 Pakistan is known to have relatively high prevalence of hepatitis.26 Mental health issues were not perceived as common although there is evidence that slum dwellers are at higher risk of common mental disorders than non-slum dwellers.27 Primary care—both preventive and responsive—was described as available in the slums pre-COVID-19 but included considerable use of providers who are not part of formal health systems. There was little provision for mental healthcare and, in only the Kenyan sites, were services for gender-based violence mentioned despite its prevalence and impact on slum dwelling women.28
The findings of our stakeholder engagement about the impact on healthcare access of COVID-19 lockdowns are consistent across all four countries and seven slums and are similar to the predictions of experts.10 29 We found evidence of individual responses to the pandemic from within healthcare such as health workers providing remote consulting using their mobile phones. WHO advises the use of mobile consulting to protect health workers and patients but gives little detail about how.30 However, there is growing evidence of the potential for mobile consulting to enhance provision of healthcare to remote and marginalised populations,31 although this is not without some loss in the quality of the patient-health worker encounter.10 31 Support from the state and non-governmental agencies varied with some providing support to tackle COVID-19 and mitigate the impact of the lockdown,10 but without mention of meeting the specific needs of women.32 Although some pharmacies assisted regular customers with credit and medication, there were reports of low stocks and indications from the media of stockpiling. The inability to provide for basic needs, which for many includes medication, is a factor in increasing stress and mental illness in these settings.33 34 Any reduction in provision of immunisation, even if temporary, should be avoided because of the potential for an increase in incidence of infectious disease such as measles.35 Pre-COVID-19, there was little provision of services for mental health and gender-based violence and there are no reported new services with the onset of COVID-19 lockdowns. This is despite the impact the lockdowns are likely to have on mental well-being36 and the rise in gender-based violence that is beginning to be reported globally.37–39
We found little evidence of strategic action on the part of the communities in the study sites at the current time. This contrasts with initiatives in other slums, such as in Brazil where community leaders have used their existing community innovation organisation to provide healthcare.40
Strengths and limitations
We have been able to compare the perspectives of stakeholders experiencing and delivering healthcare pre-COVID and during COVID-19 lockdown. Our seven slum sites were in four countries on two continents providing diversity of context and increasing the transferability of our findings to other slums. We purposively engaged diverse stakeholders to ensure we were hearing from different groupings within the slum communities and from different types of healthcare provider. The country teams contextualised the stakeholder engagement findings with available policy and media coverage. However, what we report is the perspective of stakeholders who may not, for example, realise an apparently closed health facility is functioning by providing remote consulting or that what they experienced was transient as health services adapted to the lockdown. Yet, perceptions are important drivers of health-related behaviours.41 We focused our engagement with people at the micro-level and meso-level of the health system as this is where the effect of policies is experienced.16 This allowed us to recognise their challenges and solutions and feed them back to policymakers at the macro-level.15 17
Participants were recruited by fieldworkers with site familiarity, working through organisations with experience of community-level research. However, we only reached (i) those self-identifying as disabled and (ii) belonging to formally constituted youth groups in two research sites and are likely to have missed engaging with people from other vulnerable groups. The research teams undertaking stakeholder engagements were trained to convey to the stakeholders that they were the experts and we, as researchers, needed to hear from them. We used facilitation techniques that aim to reduce power dynamics in groups. Despite this it is likely stakeholders were influenced by social desirability, their expectations of the research and researcher positionality.42 The shift from face-to-face interactions to telephone calls reduced non-verbal cues which can be important in deepening the conversation.43 However, many stakeholders were already familiar with the project so rapport was established—important for interview quality regardless of mode.43 Telephone calls enabled safe, timely stakeholder engagement which would not have been possible face-to-face during COVID-19 lockdowns.
Implications for policy and practice
Our findings suggest that for slum communities, effective communication is needed about COVID-19 and about health service provision: what services are available, what precautions are being taken to prevent virus transmission and who should continue to seek healthcare? This can build on lessons learnt from the Ebola outbreak44 and COVID-19-related guidance for marginalised populations.45 It could take the form of an information hotline, radio broadcasts and messages on social media. Communication with pharmacies and PMVs for onward communication to the community (eg, posters for their shops and information shared verbally) may be effective as residents rely on these providers for much of their healthcare. Traditional healers have a recognised role in communication about COVID-19.46 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 (eg, pregnancy and long-term conditions such as diabetes). To support these communication initiatives, local healthcare providers should plan for remote consulting21 31 to reduce patient contact and reserve personal protective equipment for necessary face-to-face contact.
Policymakers and those planning healthcare access are responsible for considering the impact of their COVID-19 containment strategies specifically on slum communities so these 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 pose a challenge. It is in this arena that we can observe how nations protect the most vulnerable in their society and, controlling the pandemic in slums is necessary for the benefit of the local and wider population. Strengthening their fragile healthcare provision would both help mitigate the effects of COVID-19 and future pandemics and contribute to meeting health-related sustainable development goals.47 48 In the face of COVID-19, slums are a challenge for controlling the pandemic for the benefit of the local and wider population and a challenge to nations to protect the most vulnerable in their society. Strengthening their fragile healthcare provision would both help mitigate the effects of COVID-19 and future pandemics and contribute to meeting health-related sustainable development goals.47 48
We are grateful to all of the study participants who gave so generously of their insights and time. We are thankful to the two anonymous reviewers for their constructive comments on the manuscript. MA gratefully acknowledges support provided by the Warwick Institute of Advanced Study Global Challenges Research Fund Fellowship No. IAS/32013/19. FG receives funding as South Africa Research Chair in Health Policy and Systems from the National Research Foundation, South Africa. RJL is supported by the NIHR Applied Research Collaboration (ARC) West Midlands, UK.
Handling editor Seye Abimbola
Twitter @GodwinYeboah, @shukrifmohamed, @j_p_albuquerque, @GrantTregonning
Contributors SAKSA, MA, KA, PB, Y-FC, NC, FF, FG, BH, PK, RL, AO, NR, JS, SS, SIW, RW and GY conceived and wrote the first draft of the paper. All authors contributed to the interpretation and subsequent revision of the paper. All authors approved the final version of the manuscript.
Funding 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.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval All participants provided informed consent to participate before taking part in the study. The NIHR Global Health Research Unit on Improving Health in Slums was granted full ethical approval by the University of Warwick Biomedical and Scientific Research Ethics Sub-Committee (REGO-2017-2043 AM01), the Ministry of Health, Lagos State Government (LSMH/2695/11/259), Research Ethics Committee of the Oyo State Ministry of Health (AD13/479/657), Amref Health Africa (AMREFESRC P440/2018), the National Bioethics Committee Pakistan (4-87/NBC-298/18/RDC3530) and the Bangladesh Medical Research Council BMRC/NREC/2016-2019/759).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No additional data are available.