Table 5

Key themes and quotes from stakeholders living and working in the study sites during the COVID-19 pandemic

StakeholdersBangladeshPakistanKenya (sites 1 and 2)Nigeria (sites 1–3)
Increased cost of healthcare alongside reduced household income with COVID-19 lockdownInitial price hike due to lockdown
Community residents and leadersSince the shops have closed, they are having problems regarding food supply. They are not being able to buy food. (Bangladesh/Resident/Female)Prices of basic necessities are increasing day by day, and with lockdown and reduced household income, people cannot afford to buy basic items. (PK/Resident/Male)Since wearing masks was made a requirement, a lot of people have had to reduce spending on other household items in order to afford them (referring to masks). (Kenya 2/Resident/Female)Access to healthcare is quite hard for people now… Drugs are now expensive and people who need to use drugs continuously may not be able to afford the drugs anymore. (Nigeria 1/Community leader/Male)
Healthcare workers, including pharmacists, patent medical vendors (PMVs), nurses, doctors and volunteersDue to the citywide lockdown and closure of public transport, the medical supplies are slowly decreasing and therefore the price of medicines is going up. (Bangladesh/Pharmacist/Male)
The supply of medicines is as normal. If the pharmacy does not have one particular medicine, they will restock it within a couple of days. She does not know if the prices have increased or not in this shutdown. (Bangladesh/Health worker/Female)
Prices of drugs related to fever and influenza have gone high in the past few days and supply are also short in the market. The drug stores who have these drugs available are charging high prices which people cannot easily afford so they have to take loans from others. (Pakistan/PMV/ Male)
Public hospitals where drugs are available free of cost are also having shortage of drugs and people have to buy them from outside where the drugs are quite expensive and not all the people can afford it. (Doctor/Female)
Cost of non-pharmaceuticals that are related to COVID-19 prevention has gone up, eg, masks and gloves. Price for other things has remained the same, although supplies have been disrupted. (Kenya 1/Clinical officer/Female)
There is no price hike in our facility. Being a public facility, the government cannot raise the price of its services at this time, although most essential supplies have been delayed making the patients purchase them outside which is expensive for them. (Kenya 2/Nurse/Female)
People can no longer afford to buy drugs, as drugs are expensive now. Also, buying drugs as vendors during this pandemic is a challenge because not all offices and companies are opened. (Nigeria 3/PMV/Male)
People are complaining that there is no money… available antimalarial drugs and injections are therefore given/administered for free. (Nigeria 2/Nurse/Female)
Lack of income for slum households due to lockdown
Community residents and leadersSince there is no business at this moment he is suffering financially. Although his meagre savings are helping him for now, he is concerned about the future. He is embarrassed to ask his neighbours for any help. (Bangladesh/ Resident/Male)Most people living here are working on daily wages. Some people were doing double jobs to earn money while many took loans. Now, they have to pay the loan and are very much worried. They do not have food to eat. (Pakistan/Community Businessman/Male)Many have lost their income since most are casual labourers due to closure of many non-essential businesses such as hotels and restaurants. (Kenya 2/Resident/Male)There is low inflow of income and community members are finding it difficult to afford healthcare…if there is a serious case that requires going to the hospital, friends and family may help raise funds. (Nigeria 3/Resident/Female)
Healthcare workers, including pharmacists, PMVs, nurses, clinical officers, doctors and volunteersDue to financial problems created by the lockdown, people are having trouble affording or paying for general healthcare services. She herself has diabetes and is having difficulties in purchasing medicines like many others in the lockdown. (Bangladesh/Health worker/Female)People do not have enough money to buy medicines sometimes it happens that people come with a prescription of 1 week and due to less amount available they buy medicines for 3 or 5 days only. (Pakistan/PMV/Male)
Most of the people coming to the clinics are working on daily wages and they are badly affected after lockdown. After getting the prescription people ask how much these drugs will cost, some also ask if there are any free samples available at the clinic. (PK/Doctor/Female)
The economic situation has become extremely difficult. A lot of people have been laid off and a lot of companies have closed down.(Kenya 1/Health Volunteer/Male)
Factories have also closed down or downsized, thus many people are now out of work. (Kenya 2/Health worker/Female)
…sales have not been like before. Customers have been requesting to buy drugs on credit as they complain of not having money … people are not going out as much as before. (Nigeria 1/PMV/Male)
People would buy drugs only as last resort and after they must have tried other means. The money which should be used to buy drugs, they would prefer to use it to eat and would only buy the drugs when it is highly necessary. (Nigeria 3/Nurse/Female)
Increased challenges in physically accessing healthcare facilities and services
Community residents and leadersThe pharmacies are told be open 24/7 but usually the pharmacies here close by 20:00–21:00 hours therefore people coming after hours cannot get medicines if they need. (Bangladesh/Community leader/Male)
There are currently no MBBS doctors in the area. There are mainly village doctors like pharmacists with diploma. The few MBBS doctors who used to provide treatment services are not coming during the pandemic…All health programmes like immunisation are completely closed now. (Bangladesh/Community leader/Male)
Vaccination services provided by the community health workers have been stopped completely. (Pakistan/Community member/Male)Residents are accessing care only at nearby facilities due to the time of the curfew and also to avoid using public transport which could lead to infection. (Kenya 2/Resident/Male)The issue of transportation as a result of movement restriction is a challenge. People cannot visit their healthcare providers and healthcare providers cannot also visit patients at home to treat them; except those within trekkable distance. (Nigeria 3/Resident/Female)
Healthcare workers, including pharmacists, PMVs, nurses, clinical officers, doctors and volunteersDoctors and clinics outside the slum who work closely with pharmacies inside the slums have requested the pharmacists not to send any patients to them as the facilities are not offering services now. (Bangladesh/Pharmacist/Male)
Pre-COVID-19, there used to be a MBBS doctor who would visit the centre every Saturday, but that service has also been halted, due to the transport shutdown. (Bangladesh/Health worker/Male)
A drug seller located close to the clinic reported that the flow of patients to the clinic has decreased and so the patient coming to his store has also decreased. (Pakistan/PMV/Male)
Only those people whose problem is unavoidable and they are unable to cure it at home are coming to the clinics. (Pakistan/Doctor/Female)
The curfew, has had an impact on the operating hours of the health facility. Initially, the day shift would end at 17:00 hours but now it ends by 16:00 hours, this means that by about 15:30 hours we start reducing the queue of patients. (Kenya 1/Health worker/Male)
COVID-19 has disrupted supply of essential commodities such as medicines, which are running out of stock, and we are afraid our patients might not get proper treatment from us. If we cannot perform a laboratory test in the health facility, then we are limited in our capacity to make diagnosis. (Kenya 1/Healthcare provider/ Male)
As a result of the curfews, stores including PMVs have to close by 20:00 hours and anyone who needs drugs by this time may not be able to get. (Nigeria 3/PMV/Male)
Turn out at health facility is low because of the imposed lockdown… Only people within this vicinity still visit the Primary Health Clinic. (Nigeria 3/Nurse/Female).
… drugs are no longer available in the health centre because the government is focused on eradicating COVID-19. Thus, other illnesses and diseases are being neglected. (Nigeria 1/Nurse/Female)
Exacerbated reluctance of residents to seek healthcare due to fear and stigma
Community residents and leadersResidents are reluctant to seek medical care or visit hospitals if they have fever, cough and cold for the fear of being isolated or quarantined and not being allowed to come back home. (Bangladesh/Community leader/Male)People have the fear of disease in their mind but due to non-affordability they cannot take proper safety measures. (Pakistan/Resident/Female)There is stigma for suspected COVID-19 cases discouraging people from seeking care. (Kenya 2/Health worker/Female)
Many parents are no longer taking their children for their vaccination shots. (Kenya 1/Resident/Male)
People are now being careful about their health as nobody wants to fall sick. Also, people would rather treat themselves at home than visit health facilities for the fear of being diagnosed with COVID-19. (Nigeria 3/Resident/Female)
Healthcare workers, inc. pharmacists, PMVs, nurses, clinical officers, doctors and volunteersPeople in slums are scared that they will be reported to the police if they are tested for the virus. Some of the residents even think the virus infects only sinners and God will protect the good and poor people like them. (Bangladesh/Pharmacist/Male)People are not very much aware of the disease and so they are not very fearful. (Pakistan/PMV/Male)
Few people are aware of the disease and taking it seriously, they are avoiding to come to the clinic. (Pakistan/Doctor/Female)
Pregnant women are becoming increasingly afraid of getting infected with the virus, especially because of the unknown effects to their unborn babies. (Kenya 2/Health volunteer/ Female)Community members still have access to regular healthcare provision, but some are sceptical about going to the hospital at a time like this and therefore would rather patronise patent medicine shops. (Nigeria 3/PMV/Male)
Mobile consultation using phones
Responses to the reduced access to health facilities during lockdownCommunity residents and leadersThere are video-call consultation options with professional doctors but they usually charge fees which is difficult for slum residents. Then, there is also this group of people who are uneducated or do not have adequate technological skills to use these services. (Bangladesh/Community leader/Male)People call their doctors to whom they have been going since long time who know their condition very well and take guidance from them. (Pakistan/Resident/Male)Using mobile phones to access healthcare is a good thing because it can reduce waiting lines at the health facilities and reduce self-medication because people can consult healthcare providers first. (Kenya 1/Resident/Male)Community members use their phones to call health workers to discuss health issues. They also use it to read text messages relating to health and safety from Nigerian Centre for Disease Control. (Nigeria 2/Resident/Female)
Healthcare workers, including pharmacists, PMVs, nurses, clinical officers, doctors and volunteersThere are hotline numbers for coronavirus-related services being disseminated on TV and everyone is aware of those, so they can call these numbers in cases of coronavirus-like symptoms. The information and awareness about where to contact and how to get consultation …is widely available and well known in the community. (Bangladesh/Pharmacist/Male)
Over the phone, health workers are regularly getting updates on their patients’ health. They are also using this platform to inform the patients on the dos and don’ts in this pandemic to prevent virus transmission. (Bangladesh/Health worker/Male)
People in the community are mostly illiterate and they do not know much about using phone to consult a doctor. (Pakistan/PMV/Male)Most mobile communication is between community health volunteers and the community. (Kenya 2/Health Volunteer/Male)Community members more often call health workers to make enquiry about their health condition. They are either told what to do or referred to the PHC for medical examination. (Nigeria 2/PMV/ Male)
The community members sometimes call the health workers. They have the contact number of the PHC. Whenever they have any health problem, they call the contact person at the PHC to know if the centre is open and whether they will be attended to when they come. (Nigeria 2/Nurse/Female)
Increased patronage of local available services
Community residents and leadersOnly pharmacy vendors who have done certain short-term pharmacy courses/diplomas are available and are advising for and selling medicines for acute conditions but there are no professional doctors now inside slums to prescribe medicines formally. (Bangladesh/Community leader/Male)People consult female health workers for minor illnesses and also in case of major illness these workers guide them where to go. (Pakistan/Resident/Female)
The earning power of most of the people is affected; people are avoiding to go to the doctor to save money and they are trying home remedies. (Pakistan/Resident/Male)
People are more dependent on chemists than before. This is because of the long queues at the health facilities (where people are being instructed to stay 1.5 m apart). (Kenya 2/Resident/Male)There are (auxiliary) nurses in the community who offer home treatment and they still provide drugs and treatment during the pandemic. (Nigeria 3/Resident/Female)
Healthcare workers, including pharmacists, PMVs, nurses, clinical officers, doctors and volunteersPatients are afraid of going to hospitals. Patients with non-COVID-19 illness are not getting proper treatment. Many private hospitals have closed and doctors have decreased their visits. So now patients with diabetes, hypertension are struggling and are relying on pharmacies for any health issues. (Bangladesh/Pharmacist/Male)
There are no healthcare services here now, except for the handful of pharmacies (Bangladesh/Health worker/Female)
People coming to get over-the-counter drugs for their illnesses have increased, many people come and they tell their symptoms and ask for medicines. (Pakistan/PMV/Male)
People are coming to pharmacies with their old prescriptions and they buy the same drugs prescribed earlier. (Pakistan/PMV/Male)
Over-the-phone consultations have increased after lockdown. (Pakistan/Doctor/Female)
Many people who need to access healthcare prefer to visit the chemists. (Kenya 2/Health volunteer/Male)The COVID-19 pandemic is having a continued negative effect on community member’s ability to access healthcare. People are now using herbs (agbo) which is very cheap. (Nigeria 2/PMV/Male)
(Since the lockdown) most people patronise the PMVs for their health problems. Others use private hospitals and traditional/faith-based healers. If the health problem is beyond the capability of PMV or traditional healer, they present at the (public) primary healthcare centre. (Nigeria 2/Nurse/Female)