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

Abstract

Objectives: To survey on the availability and use of primary care services in slum populations.

Design: Retrospective, cross-sectional, household, individual and healthcare provider surveys.

Setting: Seven slum sites in four countries (Nigeria, Kenya, Pakistan and Bangladesh).

Participants: Residents of slums and informal settlements.

Primary and secondary outcome measures: Primary care consultation rates by type of provider and facility.

Results: We 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.

Conclusions: People 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.

Keywords: international health services; organisation of health services; primary care; public health.

Figure 1

Age-adjusted (to INDEPTH population) visit rates per person-year to different outpatient care providers for adults and children (under 12) for new and existing conditions.

Figure 2

Proportion of outpatient doctor and nurse consultations for a new condition by facility type.

Figure 3

Proportion of outpatient consultations for a new condition by doctor or nurse.

Figure 4

Predicted proportions of visits to different provider types for an outpatient doctor and nurse consultation if price and travel time were all equivalent versus actual proportions of visits.