Title: NIHR Global Health Research Unit on Improving Health in Slums at University of Warwick
Funder: Department of Health and Social Care

Abstract: This unit will be led by the Warwick International Centre for Applied Health Research and Delivery (W-CAHRD), University of Warwick (UoW). Its staff and facilities will form the foundation of the proposed unit. W-CAHRD was set up in 2014 with core UoW investment, in line with the institution’s strategic aim to increase international collaboration and support world-class global health research. Since inception, W-CAHRD has won 21 externally funded research projects worth £12.8 million and published 100+ peer reviewed global health papers, including a Lancet series on health in slums2,3. UoW provides core funding for a “Global Research Priorities” (GRP) programme to address the most challenging problems facing the world and to provide a platform for interdisciplinary research. W-CAHRD is represented on the programme and addresses 3 of the GRP’s 11 themes: sustainable cities, health and international development. UoW will contribute matched funds and support unit sustainability (see justification of costs). Our unit will focus on how health services are delivered and used in slums, home to nearly a billion people, and identify options to improve affordable access for this group. Access to healthcare is a critical barrier to improved health in LMICs4. Universal Health Coverage (UHC) is a key element of the current global health agenda. It requires a set of physically accessible and financially affordable service providers, and a reduced burden of out-of-pocket expenditure5. All UN Member States have agreed to try to achieve UHC by 2030. Studying disease epidemiology is unhelpful if infrastructure is not in place to address it6. In the context of rapid urbanisation, poor economic growth, urban planning and regulation, slum populations are increasing. Slums, generally situated near to urban centres, are often physically closer to health services than rural settlements. Despite this, people in slums can have poorer health outcomes than their rural counterparts. This is due to the hazardous slum environment and poor access to appropriate healthcare2. In this vulnerable and marginalised group, child and maternal mortality remain high, as do infectious disease deaths, while non-communicable disease risk is growing2,7. Health emergencies are magnified in the slum environment. In the recent Ebola epidemic, the disease was concentrated in slums, and infected residents facilitated transmission throughout the city8. Poor people in LMICs are prone to catastrophic financial loss if they fall ill, and in slums, out of pocket expenses are essential to maintain life (e.g. to buy clean water)9. Observational studies of maternity care in Nairobi have documented a near absence of public facilities in slums. Private providers of varying quality fill the void8. Just 13.9% of people living in Dhaka’s slums seek care from modern public providers, and coverage gaps exist10,11. Fragmented services may lead to poor co-ordination of care, reducing efficiency and resilience e.g. over-provision and/or under-provision of some services; reduced continuity of care; increased probability of developing drug resistance; reduced opportunities for disease surveillance. In slums, proximity to urban centres and population density mean that improvements to health service delivery could benefit many people simultaneously and have a large impact on health in LMICs. Our unit will seek to advance this issue. Objectives: Short-term •To map geo-spatially current health service delivery arrangements and understand patterns of health service use (including equity of use) in slums in major and secondary cities. Medium-term •To identify costs associated with different models of health service delivery arrangements in these slums, including by whom costs are incurred. Long-term •To model options for health service delivery in slums, considering quality, cost-effectiveness and equity of provision. •To develop capacity, communities of practice and a sustained research programme which exceeds the lifetime of the unit. Throughout •To identify, synthesise and curate literature on potential models of health service delivery relevant to the slum context. •To engage decision-makers and users in designing models of health service delivery in slums, with a view to subsequent evaluation of effectiveness and costs of viable options. To achieve the objectives work will be structured in 5 packages (WPs see Fig2,3). We have identified primary study sites, located in Kenya, Nigeria, Bangladesh and Pakistan (Fig1). These sites provide variety in social and physical factors, allowing us to examine diverse existing models of healthcare delivery. WP1: Geo-spatial mapping of health services in slums (Years 1-2). a)We will create accurate maps of the slums using participatory mapping instruments that combine local information to ‘ground truth’ data generated from Earth-observation satellite imagery. This methodology has worked in slums, with lay groups collecting data for the purposes of informing humanitarian aid organisations12. These maps have 2 functions: they will form the basis on which to overlay geo-spatial data on health service location (see b); they will inform our sampling frame in WP2. b)Local participatory mapping will be used to identify and add all health services present in the slum or available to people living in the slum to our maps, including hospitals, clinics, traditional healers, pharmacies etc. With our augmented map, we can calculate the area covered by mapped facilities and identify “blind spots”; areas that are not covered or have a high distance/travel time to existing services. WP2: Household survey of health service use by slum residents (Years 1-2). A survey of health service use will be conducted with a stratified random sample of people living in the examined slums. Health service use will be investigated using questions adapted from a validated questionnaire (e.g.13). We will ask where healthcare has been sought by participants over the past year; for what health conditions; unmet healthcare needs; satisfaction with care received (a facet of ‘quality’); and associated costs, including out-of-pocket costs. Data will be cross-referenced with WP1 to identify health services used by people living in the slums that are not recorded in the mapping, such as informal providers working from unmarked premises, services delivered at home (e.g. by community health workers) and those delivered outside the slums (e.g. secondary or tertiary care which is likely to be exclusively outside the slum area). Surveys will be georeferenced, so we can examine distance/travel time to health services. We will use Slum Dweller Association collected data14 to augment our findings. WP3: Curation and synthesis of the literature on models of health service delivery relevant to the slum context (Years 1-4). We will perform systematic reviews and overviews of the literature concerning relevant models of health service delivery with specific reference to “delivery arrangements” as defined in Lavis’s taxonomy of structures and implementation strategies within health systems15. WP4: Simulation-based interactive design of optimal service models (Years 2-3). We will draw on insights from WP1-3 to develop simulation models representing alternative approaches to slum health service delivery. These will be used to evaluate affordability and efficiency of services as they currently operate, and provide a policy tool to predict the impact of adopting new approaches, or improving the organisation of existing ones, including estimates of resilience to seasonal or unexpected (e.g. conflict or epidemic related) demand surges. Models will take a broad economic perspective, populated by health service resource use data collected from providers identified in WP1, and patient/ household costs identified in WP2. We will estimate cost-effectiveness by modelling the impact of service configuration on health outcomes as far as possible given available data. The models will allow us to estimate the impact and value-for-money of existing and proposed service configurations, taking affordability and logistical constraints into account, in line with WHO Choosing Interventions that are Cost Effective (WHO-CHOICE) methodology16.The idea is to design optimal services according to resource and staff available and to provide a pathway of improvements, including the option of improving technical efficiency of existing models. WP5: Engaging stakeholders and implementing viable options for health service delivery in slums (Years 1-4). A series of workshops with stakeholders such as healthcare commissioners, providers and people who live in slums will be held in the cities studied. In year 1, workshops will seek to understand local policy-drivers, questions and concerns of local people relevant to the work and develop and prioritise research questions to be addressed by the unit. Year 4 workshops will examine viable models of health service delivery in slums informed by the evidence gathered in WP1-4. E.g. printed maps will facilitate discussion on the optimal location of future services; simulation models will provide a decision aid. WP5 will culminate with formulation of an action plan to implement favoured models of care with selected commissioners or providers of health services. Opportunities for pilot evaluation studies will be examined. While WPs are specified above, we have capacity to respond to emerging global health research requirements. Notably: WP3 is designed to be flexible to allow evidence synthesis activity to support our developing work programme; specific PhD projects will evolve in response to stakeholder priorities (including those of our academic partners) explicated in Year 1 workshops; in years 3-4 we have allocated flexible researcher time to exploit data collected and methodology developed, and to pursue promising leads arising during years 1-2.

Lay abstract: Our Unit focuses on health services in slums. Many of the world’s poorest people live in slums, over-crowded neighbourhoods often made up of makeshift or derelict housing, without running water or sanitation. People living in slums have many health issues seen in the rural poor (dangerous childbirth, malnutrition, infectious diseases) alongside increasing risk of diseases linked to cities (traffic accidents, violence, heart disease). Even if slum residents live close to health services, they can have difficulty getting needed care. This can be because city authorities do not have the will or the resources to meet the needs of those living in the slums. It can also be because people living in slums can’t afford the cost of health care, or the time off work to seek care. The result is that many people living in slums go to low quality or unqualified clinics, or to various places (such as clinics run by charities to tackle specific issues e.g. HIV) but without joined-up care. Improving health services in slums will have a large impact on health in low and middle income countries. Because slums are overcrowded, better health services could benefit many people at once. Our unit aims to make progress in this direction across seven slums in Africa and Asia. Our goals are: 1. To map current health services and facilities and understand how these are used. 2. To build on these maps to identify costs associated with how health services run in each site and the quality of these services as well as identifying costs to the patient and their households. 3. To systematically update our knowledge on disease prevalence in slums, current healthcare provision models in slums and elsewhere in cities to include services which help to prevent disease and general literature on financing and the design of health services in low and middle income countries. 4. To generate viable options for health service delivery in slums and cost these options relative to likely benefits. 5. To work with decision makers and slum communities in designing the models of health service delivery, with a view to a subsequent evaluation of effectiveness and costs of viable options. Further to the above plan of work we aim to build a research programme which survives after our funding ceases and create a platform of funded activities into the future. The University of Warwick is working with the University of Ibadan in Nigeria, the African Population and Health Research Center in Kenya, The Aga Khan University in Pakistan and the Independent University Bangladesh, as well as policy organisations and slum communities. The project runs from 1st June 2017 until 31st March 2021. During the project we will produce the following tools and information to support people who make decisions relating to health service planning: • Detailed slum maps, which have already been demonstrated to support health service delivery by aid organisations during crises (such as cholera outbreaks). • Knowledge of current demand and supply of health services in slums vital to planning future services. • A body of evidence on health service delivery relevant to slum populations, so policy-makers can learn what is happening in this area globally so that good practice is shared and failures are not duplicated. Outputs will support improvements in the organisation and effectiveness of health services, thereby delivering measurable benefits to one of the world’s most vulnerable population groups.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE