Module 7: Health Services

Urban access to health services is a complex issue that often leaves the urban poor more vulnerable and disadvantaged than their rural counterparts. First, the urban poor are overshadowed by the urban rich, and can become marginalized and stigmatized based on their income and limited access to information, among other barriers. Urban dwellers live in a more monetized economy, and do not typically have access to the free or discounted services from public sector organizations that are sometimes provided to rural communities. The urban poor are often overlooked by these programs and NGOs, and cannot gain entry to hospitals, clinics, and quality providers without paying in cash.(1)

Many countries provide subsidies in order to help the poor purchase medicine or healthcare. Unfortunately, these programs often pose additional problems for the poor. The subsidies tend to require extensive time commitments as patients must navigate a complex healthcare system, searching for providers and coordinating transportation. In this way, subsidies only provide the monetary component of aid, while creating other barriers.(2)

Proposals to improve this approach involve “voucher schemes for free care” from pre-approved practitioners who provide high-quality care. These strategies may address some of the complications with the basic subsidies, though they most likely will not eliminate all obstacles.(3)

Due to combinations of these barriers, many people postpone their visits to health providers and wait until the last minute to seek help, thereby temporarily avoiding spending money. For this reason, urban healthcare providers see a great deal of impoverished patients whose medical conditions have already become quite severe, as they have put off treatment for an extended period of time.(4)   

In addition to these structural hurdles, marginalization is commonly caused by economic discrimination. According to recent studies, the urban poor tend to receive lower-quality healthcare “even when they use the same facilities as their more wealthy neighbours.”(5) Government hospitals are also guilty of discrimination; a patient’s inability to pay often results in lower-quality and slower care. When the poor receive such second-rate care, they are further discouraged from accessing healthcare in the future, which exacerbates the problem of inequality of care.(6) 

Last, the quality of healthcare often varies tremendously by neighborhood. Though cities typically have quality health services, providers may be inaccessible to certain communities based on location and price. A study of providers in Delhi, India determined that both public and private providers that served impoverished neighborhoods were less educated about “appropriate care” than those who served the more affluent areas.(7) In these cases, the poor are marginalized based on their location of residence and their ability to access transportation.

Proliferation of the Private Sector

Urban areas are unique in that the private sector is the more prominent form of health care. Moreover, its role has been steadily increasing, particularly since the 1990s. Multiple studies demonstrate that poor urban women generally use private services more often than public services, due in part to the absence of nearby public services. One study in Lucknow, India showed that 57% of the impoverished mothers observed used private healthcare providers.(8) However, the women in these studies tended to use less qualified and often unregulated services, as these were generally the only affordable options.(9) Individuals in urban areas recognize that the private sector offers higher quality healthcare than those of the public sector. In some areas, even the “less qualified” private practitioners are more likely to offer appropriate medical advice than the best public doctors in the community.(10) City officials have noticed this trend towards private sector healthcare, and they have established several interventions in which NGOs can help to facilitate collaboration between the two sectors. This will hopefully reduce inequalities in healthcare and increase trust in public service providers.(11)

Case Study: Encampments for the Homeless in Los Angeles

The homeless comprise another sector of urban populations that lacks adequate access to health services. A study of 134 homeless individuals living in 42 encampments in central Los Angeles, California analyzed the primary barriers to healthcare. The most prominent barriers found were those obstructing access to primary health care, dental services, and drug and alcohol treatment. While many interviewees reported having acute or chronic illnesses in need of ongoing medical attention, they had limited access to primary healthcare, and therefore relied on public programs, clinics, and hospital emergency rooms. Due to the number of people in need of housing, homeless shelters cannot accommodate every person’s needs. Thus, they must carefully monitor the distribution of their services, and limit care. This means that although they provide primary healthcare to some, they restrict services to certain groups of people, as resources are scarce. Adults (and men in particular) with HIV, mental health problems, or addictions are often lower on the hierarchy of those in need of care. Due to this high demand for shelter and healthcare, many homeless people cannot access rehabilitation centers, and are forced to find alternative shelters such as semi-permanent encampments. The encampments are located in areas that are neglected or overlooked by local government. Thus, many people who are left out of the shelter system are forced to deal with their illnesses and addictions alone. Like many other impoverished urban dwellers, the inhabitants of these encampments experience a double burden due to a lack of preventative care, as well a dearth of treatment services for the health conditions that subsequently arise.(12)

Reproductive Healthcare

Quality care provided by skilled birth attendants (such as doctors or nurses) is absolutely critical in working to reduce maternal mortality and disability during childbirth.(13) These professionals can play a large role in preventing maternal death, the leading causes of which include complications from abortions, eclampsia, and hemorrhaging.(14) In a study of 44 low- and middle-income nations, the use of skilled birth attendants varied from 40% to 100%, and poor urban women were found to have the lowest rates of use of these providers.(15)

There are many reasons why women do not access healthcare as often as men do, including a lack of education, and an inability to pay. When it comes to pregnant women and mothers, although the woman’s level of education is related to her decision to access professional care, it has also been observed that the education of the woman’s partner greatly influences her use of skilled birth attendants as well. In Morocco, the partner’s education played an even greater role than the woman’s education in deciding whether to use a skilled birth attendant.(16) Education may also be correlated with a woman’s access to contraceptives, which help to curb maternal mortality rates.(17) Moreover, many private healthcare facilities do not provide obstetric care. According to a recent study of a slum community in Nairobi,  Kenya, 70% of women who gave birth did so at health facilities, but only 48% gave birth at facilities that provided even the most “basic emergency obstetric care.”(18) In another study of maternal mortality, most of the abortions and deliveries that resulted in maternal deaths took place outside of a health facility, yet the majority of women died at a facility. This suggests that many women are not equipped to recognize a complication or gain access to ambulances in impoverished areas that lack quality infrastructure, and where “insecurity deters movement at night.”(19) Thus, it appears that though a major inequity is women’s access to skilled birth attendants, many of the contributing factors are unrelated to the healthcare system, and instead relate to education and infrastructure. This conclusion demonstrates the concept that inequities can be reduced through multidimensional services that reach outside of the healthcare arena. 

Case Study: Reproductive Healthcare Providers in Tabriz, Iran

Even for relatively high quality healthcare providers, there is often significant room for the improvement of services. A recent study in Iran interviewed “public primary reproductive health providers” regarding their own work, and analyzed the providers’ perceptions of barriers to high-quality services. Many healthcare providers reported barriers to care and feelings of inadequacy about their services. In particular, midwives felt that they could make more efficient use of their abilities if not for several constraints. The most prominent barriers mentioned were:

• Need for multi-tasking

• Intense workload with staff shortages

• Excessive paperwork minimizing time spent with patients

• Poor management and supervision

• Lack of appropriate materials and infrastructure

• Inadequate managerial and work conditions

• Low ratio of family health technicians to midwives

The providers in this study felt that these barriers were impeding their work and their professional development. With improvements in certain policies and programs, providers would be able to expand or fully utilize their services with the hopes of broadening access to care. One possible improvement is the implementation of electronic records that could both facilitate and decrease the time spent on paperwork, and allow more time for working with patients. Second, there may be innovative ways to provide primary sexual and reproductive health services in a more integrated manner. The Islamic Republic of Iran has created a policy to integrate primary healthcare services into one unit and potentially even into one comprehensive provider. Consequently, many qualified midwives that practice a narrow range of services would have the opportunity to expand their reach and improve services such as family planning, sexual health education, and maternal healthcare. While we must be careful not to overload workers or deemphasize specialized skills, this integration has been lauded as an opportunity to make use of valuable provider skills.In this way, improvements to healthcare can come from multiple directions, including the individuals who need care, the providers, and the policymakers who can help control infrastructural programs to facilitate access and use of services.(20)

Health Services are Within the Healthcare System

Urban health services often fall through the cracks in terms of political regulation of health systems. The administrative responsibility for a city’s health typically lands “between local government and provincial or federal (state) level government,” but policy objectives become lost in the shuffle when new mayors and officials are elected, and governance changes hands.(21) As health systems become decentralized, more responsibility to deliver and fund health services falls to local governments, creating a role for which they are often unprepared.(22) Apart from governmental cohesion, comprehensive, accessible healthcare still faces two primary challenges. The first is the “exclusion gap” that must be closed by expanding services to impoverished areas and addressing marginalization and discrimination. The second challenge is to “universalize quality” and regulate public and private sectors with benchmarked quality standards.(23) In general, governments and municipalities play important roles in the improvement of health services, the most prominent of which is the ability to institute regulations. However, in order to utilize this power, officials must encourage more cohesion between departments and sectors.

Strengthening Interventions in Health Services and Management

Many directions exist from which to approach health service reforms.  These include:

• Social marketing – “Awareness campaigns” inform the general population, and encourage individuals to demand higher quality care. The goal is to increase consumer demand to control the market rather than to continue operating under supplier-induced demand.(24)

• Voucher systems – Voucherssubsidize care for marginalized groups by granting free services from pre-approved, high-quality providers. This system has demonstrated preliminary success in Kenya thus far.(25)

• Improvements in universal coverage – This helps city residents obtain need-based access to healthcare regardless of their ability to pay. This is made possible with funds contributed in advance that can be pooled to finance health services that may be needed later on. Primary healthcare centers can facilitate universal access by forming a network that provides less expensive alternatives to unregulated private care.(26)

• Improvements in service delivery – Health services should respond more efficiently to individual needs. In order to do this, possible reforms include making services “more socially relevant and more responsive to the changing world.” This requires coordinating care across health sectors. Creating networks of providers helps to create “entry points” to primary care, ensuring that the patient obtains access to other health sectors if needed. When providers across disciplines are connected, it is easier to facilitate comprehensive care, as providers can recommend other doctors outside of their specialty.(27)

Other public-private interventions include:

• Distributing prepackaged medicine kits to help individuals maintain the “proper dosages and lengths of treatment”

• Using the help of NGOs or governmental groups to monitor the outsourcing of healthcare services to private providers

• Standardization of practices and diagnoses

• “Targeted training”

• Awareness campaigns regarding information about medical services and resources (28)

Case Study: Emergency Obstetric Care in Bangladesh

In order to address the high burden of maternal mortality in urban slums in Bangladesh, the BRAC (formerly the Bangladesh Rural Advancement Committee) created Manoshi, an intervention focused on women in these urban areas. Manoshi aims to strengthen healthcare for pregnant women and young children through continuous care in community “delivery centers,” and also works to encourage immediate referral to hospitals for cases of obstetric complications. The three main delays in accessing emergency care are related to seeking care, reaching a facility, and providing the care. Manoshi strives to provide education and training, financial support, transportation, and accompaniment to the hospital. By maintaining a close partnership with various hospitals, Manoshi has developed an effective emergency referral process mainly using cell phones. This system, though it has not largely impacted delays in non-life-threatening complications, has succeeded in effectively reducing delays for life threatening conditions. This program demonstrates how information and service networking systems can reduce barriers to care, enabling people who are in need of emergency care to access the appropriate emergency facilities.(29)

Community Health Workers

An important aspect of the healthcare network is the system of community health workers who link communities to personalized, high-quality medical services. In contrast to government handouts that cannot efficiently provide adequate care, community health workers can provide long-term assistance. For instance, the distribution of tuberculosis medications is an effective stopgap measure, but if patients return to the conditions or behaviors that originally put them at risk, these “handouts” will have failed to address the root issue. Instead, community health workers might travel to communities and educate residents about illnesses and realistic solutions.(30) Furthermore, community health workers serve as a bridge to other types of health services. They can be trained and sent into communities in a timely manner, and they understand the communities’ needs and can relay them to officials and policy-makers.(31) In this way, people who may not have trusted healthcare providers in the past are more likely to contact the community health workers, who will hopefully rebuild trust in the medical profession. Finally, community health workers provide useful screening services that identify high-risk individuals. At this point, such patients can be directed to the appropriate treatment services.(32)

Case Study: Lady Health Workers in Pakistani Slums

Female community health workers in Pakistan aim to improve health conditions in slums by providing door-to-door primary health services and helping to fill unmet health needs. These women, referred to as “Lady Health Workers” (LHWs) in the slums of Pakistan, must have certain qualifications before they can become health workers. These include recommendations, educational requirements, and training programs. LHWs are responsible for providing some basic care, and are trained to assist with maternal and child health issues. If a situation falls outside of their qualifications, LHWs refer the case to an appropriate provider. Each of these women “serves around 1000 people or 150 households in her own community, for which a small allowance is provided by the Ministry of Health.” As a result, LHWs have contributed tremendously to health improvements in Pakistani slums. They have amplified family planning and immunization efforts, promoted the use of skilled birth attendants, and managed diarrhea, respiratory ailments, and fevers with effective treatment. In general, LHWs have helped prevent innumerable health issues by building community involvement and spreading awareness about issues such as tuberculosis, malaria, hepatitis, and family planning, all in a personalized manner.(33) 

Footnotes

(1) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(2) Ibid.

(3) Matthews, Z., et. al., “Examining the ‘Urban Advantage’ in Maternal Health Care in Developing Countries.”PLoS Medicine 7 (September 2010): 1-7.

(4) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(5) Matthews, Z., et. al., “Examining the ‘Urban Advantage’ in Maternal Health Care in Developing Countries.”PLoS Medicine 7 (September 2010): 1-7.

(6) Ibid.

(7) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(8) Srivastava, N.M., Awasthi, S., and Agarwal, G.G. “Care-Seeking Behavior and Out-of-Pocket Expenditure for Sick Newborns Among Urban Poor in Lucknow, Northern India: A Prospective Follow-Up Study.”BMC Health Services Research 9 (April 2009).

(9) Matthews, Z., et. al., “Examining the ‘Urban Advantage’ in Maternal Health Care in Developing Countries.”PLoS Medicine 7 (September 2010): 1-7.

(10) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(11) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(12) Cousineau, M.R. “Health Status of and Access to Health Services by Residents of Urban Encampments in Los Angeles.”Journal of Health Care for the Poor and Underserved 8 (1997): 70-82.

(13) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(14) Abdhalah Kasiira, Z., et. al., “Maternal mortality in the informal settlements of Nairobi city: what do we know?”Reproductive Health 6 (April 2009).

(15) World Health Organization. “Hidden cities: new report shows how poverty and ill-health are linked in urban areas.” 17 November 2010.

(16) Ibid.

(17) Abdhalah Kasiira, Z. et. al., “Maternal mortality in the informal settlements of Nairobi city: what do we know?”Reproductive Health 6 (April 2009).

(18) Matthews, Z., et. al., “Examining the ‘Urban Advantage’ in Maternal Health Care in Developing Countries.”PLoS Medicine 7 (September 2010): 1-7.

(19) Abdhalah Kasiira, Z., et. al., “Maternal mortality in the informal settlements of Nairobi city: what do we know?”Reproductive Health 6 (April 2009).

(20) Mohammad-Alizadeh, S., et. al., “Barriers to High-Quality Primary Reproductive Health Services in an Urban Area of Iran: Views of Public Health Providers.”Midwifery 25 (2009): 721-730.

(21) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(22) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(23) Matthews, Z., et. al., “Examining the ‘Urban Advantage’ in Maternal Health Care in Developing Countries.”PLoS Medicine 7 (September 2010): 1-7.

(24) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(25) Matthews, Z., et. al., “Examining the ‘Urban Advantage’ in Maternal Health Care in Developing Countries.”PLoS Medicine 7 (September 2010): 1-7.

(26) World Health Organization. “Hidden cities: new report shows how poverty and ill-health are linked in urban areas.” 17 November 2010.

(27) Ibid.

(28) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(29) Nahar, S., Banu, M., & Nasreen, H. E. (2011). Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study. BMC pregnancy and childbirth, 11(1), 11.

(30) Shetty, P. "Health Care for Urban Poor Falls Through the Gap.”The Lancet 377 (February 2011): 627-628. 

(31) World Health Organization. “Hidden cities: new report shows how poverty and ill-health are linked in urban areas.” 17 November 2010.

(32) Cousineau, M.R. “Health Status of and Access to Health Services by Residents of Urban Encampments in Los Angeles.”Journal of Health Care for the Poor and Underserved 8 (1997): 70-82.

(33) World Health Organization. “Hidden cities: new report shows how poverty and ill-health are linked in urban areas.” 17 November 2010.