Primary care doctor and nurse consultations among people who live in slums: a retrospective, cross-sectional survey in four countries

Abstract

ObjectivesTo survey on the availability and use of primary care services in slum populations.DesignRetrospective, cross-sectional, household, individual and healthcare provider surveys.SettingSeven slum sites in four countries (Nigeria, Kenya, Pakistan and Bangladesh).ParticipantsResidents of slums and informal settlements.Primary and secondary outcome measuresPrimary care consultation rates by type of provider and facility.ResultsWe completed 7692 household, 7451 individual adult and 2633 individual child surveys across seven sites. The majority of consultations were to doctors/nurses (in clinics or hospitals) and pharmacies rather than single-handed providers or traditional healers. Consultation rates with a doctor or nurse varied from 0.2 to 1.5 visits per person-year, which was higher than visit rates to any other type of provider in all sites except Bangladesh, where pharmacies predominated. Approximately half the doctor/nurse visits were in hospital outpatient departments and most of the remainder were to clinics. Over 90% of visits across all sites were for acute symptoms rather than chronic disease. Median travel times were between 15 and 45 min and the median cost per visit was between 2% and 10% of a household’s monthly total expenditure. Medicines comprised most of the cost. More respondents reported proximity (54%–78%) and service quality (31%–95%) being a reason for choosing a provider than fees (23%–43%). Demand was relatively inelastic with respect to both price of consultation and travel time.ConclusionsPeople in slums tend to live sufficiently close to formal doctor/nurse facilities for their health-seeking behaviour to be influenced by preference for provider type over distance and cost. However, costs, especially for medicines are high in relation to income and use rates remain significantly below those of high-income countries.

Perceived quality of care and choice of healthcare provider in informal settlements

“…We report strong positive correlations in S3 Text. In our previous research [5], we find that there is a significantly longer average time to visit hospitals as opposed to clinics, which we also observe here. Several other studies looking into health-seeking behaviour also make this assumption [11,13,14].…”

“…Surveys were conducted for each slum in the form of a questionnaire on an individual and HCP level. In the case of individuals, the survey comprised 506 questions and focused on the respondents' socioeconomic circumstances, as well as their relationship to, and interactions with, HCPs-described in detail elsewhere [5,21]. The individual-level survey was conducted on thousands of individuals for each slum, as detailed in Table 1.…”

“…They conclude that "there is strong evidence that patients know about unobservable features of health facilities" and that this contributes towards their decision making when seeking healthcare [14]. A more recent study [5] formalises this notion further, positing three broad factors that influence a person's choice of healthcare provider: (i) monetary costsuch as out-of-pocket expenses to include the costs of travel, the service itself (e.g., consultation, medicines, tests), lost earnings; (ii) inconvenience-including effort and time; and (iii) a latent factor, which is often referred to as 'perceived quality' [12,13,15]. In this study, we observe people's health seeking behaviour with respect to cost and inconvenience in order to provide evidence on perceived quality.…”

“…The situation is different for the urban poor. A recent study [5] shows that people living in informal settlements have access within 40 minutes to a very wide variety of sources, from single-handed practitioners to clinics and hospitals (both publicly and privately funded).…”

A socio-ecological framework examination of drivers of blood pressure control among patients with comorbidities and on treatment in two Nairobi slums; a qualitative study

“…An earlier study by Buigut et al [54] in the study area showed that seeking care in a public health facility was associated with increased odds of experiencing catastrophic health expenditure and for this reason many informal slum residents would forgo health service utilization. A more recent collaborative study looking to improve slum health in the study area also found that many households in the study area spent a significant proportion of their money on healthcare [55].…”