Health seeking by people living with non-communicable diseases in a pluralistic health system: the role of informal healthcare providers.

Background: There is a growing global burden of non-communicable diseases (NCDs), including diabetes, hypertension and cardiovascular diseases. NCDs constitute a growing public health concern in the Low and Middle Income Countries (LMICs), amplified by rapid urbanisation and urban inequality. Urbanisation and associated inequalities, have profound impacts on healthcare provision and health seeking decision making by marginalised populations living in urban informal settlements. The thriving nature of informality, shown through the spread of urbanisation, health pluralism and informal healthcare provision is seen as a mechanism for coping with urban inequalities. Limited understanding of the drivers of health seeking both within policy and practice remain a huge gap in designing a people centred healthcare delivery that meets the needs of people affected by NCD health problems in marginalised urban settings.

Methods: We employed qualitative methods including 18 key informant interviews (KIIs), 3 focus group discussions (FGDs) and 15 narrative interviews, with purposively sampled people living with NCDs, as well as formal and informal healthcare providers, and community chiefs. We analysed our data using the qualitative framework approach, applying the adapted health belief model to understand how health seeking decisions are made by people impacted by NCD lived experiences in informal settlements.

Findings: Syncretic beliefs were evident among people living with NCDs in urban informal settlements, showing that people interact with diverse healthcare providers at different times, based on the type and severity of ill health. Health seeking was also influenced by healthcare access barriers, and participants' biomedical, cultural and religious beliefs about disease causation. Despite the ongoing medical pluralism and syncretic belief systems, the Sierra Leonean health system is yet to understand and adapt to these contextual factors in its response to the NCD epidemic. Moreover, the rigid operational boundaries between formal and informal healthcare service providers continue to impact on the unmet healthcare needs of people living with NCD conditions in marginalised urban settlements in Freetown, Sierra Leone.

Conclusion: Informal healthcare providers play a critical role in the provision of healthcare services for people living in low resource settings, building a trusted relationship between formal and informal health providers can help to optimise healthcare service delivery that meets the needs of people affected by NCD conditions in marginalised urban settlements.