Demand and supply-side barriers and opportunities to enhance access to healthcare for urban poor populations in Kenya: a qualitative study.

OBJECTIVE: To explore the barriers to and options for improving access to quality healthcare for the urban poor in Nairobi, Kenya. DESIGN AND PARTICIPANTS: This was a qualitative approach. In-depth interviews (n=12), focus group discussions with community members (n=12) and key informant interviews with health providers and policymakers (n=25) were conducted between August 2019 and September 2020. Four feedback and validation workshops were held in December 2019 and April-June 2021. SETTING: Korogocho and Viwandani urban slums in Nairobi, Kenya. RESULTS: The socioe-conomic status of individuals and their families, such as poverty and lack of health insurance, interact with community-level factors like poor infrastructure, limited availability of health facilities and insecurity; and health system factors such as limited facility opening hours, health providers' attitudes and skills and limited public health resources to limit healthcare access and perpetuate health inequities. Limited involvement in decision-making processes by service providers and other key stakeholders was identified as a major challenge with significant implications on how limited health system resources are managed. CONCLUSION: Despite many targeted interventions to improve the health and well-being of the urban poor, slum residents are still unable to obtain quality healthcare because of persistent and new barriers due to the COVID-19 pandemic. In a devolved health system, paying attention to health services managers' abilities to assess and respond to population health needs is vital. The limited use of existing accountability mechanisms requires attention to ensure that the mechanisms enhance, rather than limit, access to health services for the urban slum residents. The uniqueness of poor urban settings also requires in-depth and focused attention to social determinants of health within these contexts. To address individual, community and system-level barriers to quality healthcare in this and related settings and expand access to health services for all, multisectoral strategies tailored to each population group are needed.

Mobile consulting as an option for delivering healthcare services in low-resource settings in low- and middle-income countries: A mixed-methods study.

OBJECTIVE: Remote or mobile consulting is being promoted to strengthen health systems, deliver universal health coverage and facilitate safe clinical communication during coronavirus disease 2019 and beyond. We explored whether mobile consulting is a viable option for communities with minimal resources in low- and middle-income countries. METHODS: We reviewed evidence published since 2018 about mobile consulting in low- and middle-income countries and undertook a scoping study (pre-coronavirus disease) in two rural settings (Pakistan and Tanzania) and five urban slums (Kenya, Nigeria and Bangladesh), using policy/document review, secondary analysis of survey data (from the urban sites) and thematic analysis of interviews/workshops with community members, healthcare workers, digital/telecommunications experts, mobile consulting providers, and local and national decision-makers. Project advisory groups guided the study in each country. RESULTS: We reviewed four empirical studies and seven reviews, analysed data from 5322 urban slum households and engaged with 424 stakeholders in rural and urban sites. Regulatory frameworks are available in each country. Mobile consulting services are operating through provider platforms (n = 5-17) and, at the community level, some direct experience of mobile consulting with healthcare workers using their own phones was reported - for emergencies, advice and care follow-up. Stakeholder willingness was high, provided challenges are addressed in technology, infrastructure, data security, confidentiality, acceptability and health system integration. Mobile consulting can reduce affordability barriers and facilitate care-seeking practices. CONCLUSIONS: There are indications of readiness for mobile consulting in communities with minimal resources. However, wider system strengthening is needed to bolster referrals, specialist services, laboratories and supply chains to fully realise the continuity of care and responsiveness that mobile consulting services offer, particularly during/beyond coronavirus disease 2019.

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: results of pre-COVID and COVID-19 lockdown stakeholder engagements.

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.