Nearly a billion people living in urban slums are physically closer to hospitals than rural populations, yet they often have worse health outcomes and face catastrophic financial costs when they fall ill. This research unit will map how health services are delivered and used in slums across major and secondary cities in low- and middle-income countries, identifying why access remains poor despite proximity to care. The problem is urgent: slum populations are growing rapidly due to urbanisation and weak regulation, yet public health facilities are often absent, forcing residents to rely on costly private providers of variable quality. In Dhaka’s slums, only 13.9% of people seek care from modern public providers. Fragmented services lead to poor coordination, drug resistance, and missed opportunities for disease surveillance—as seen when Ebola concentrated in slums and spread through cities. If successful, this work could reshape how health systems are designed for dense, underserved urban populations. By modelling cost-effective, equitable service delivery options, the unit aims to improve maternal and child survival, reduce infectious and non-communicable disease burdens, and protect slum dwellers from financial ruin when they get sick. The findings could directly inform Universal Health Coverage targets that all UN member states have agreed to achieve by 2030.
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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
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