guest column:Narjis Rizvi/ Pauline Bakibinga/ Syed A K Shifat Ahmed THE tight movement restrictions introduced around the world to curb the spread of the novel coronavirus disease have had far-reaching consequences. These include effects on access to healthcare. People living in slums have been particularly hard hit. Slums are characterised by structural and institutional inadequacies. These spaces enable viruses to spread rapidly and heighten the risk of community transmission of diseases. Also, slum residents face a disproportionate burden of ill-health. Effective public health strategies in slums can’t overlook the perspectives, insights and solutions offered by those who work and live in them. Identifying challenges and finding solutions with those closest to the issue is essential. In a recent study, we explored healthcare and access to services in seven slums in Kenya, Nigeria, Bangladesh and Pakistan. We were looking for insights on how health services are perceived in these communities before and during COVID-19-related lockdowns. Overall we found that slum communities had access to diagnostic and treatment services and made use of preventive services before the pandemic. But services for mental health and gender-based violence were limited or non-existent. Access to all healthcare services decreased during COVID-19 lockdowns. Barriers included increased cost of healthcare, reduced household income, increased challenges in physically reaching healthcare facilities. Residents’ fear of infection and stigmatisation made matters worse. Understanding the impact of lockdowns on people’s access to healthcare and health service seeking behaviour is important to finding solutions to health service disruptions. Healthcare before COVID-19 We conducted household surveys in the seven slum sites as part of our study. Healthcare use rates varied by site. The rates were lower in sub-Saharan Africa than South Asian sites, but all are relatively low compared to high income countries. The lowest outpatient consultation rates of visits per person per year were reported in Nigeria at 0,5-0,6. In Kenya, Pakistan, and Bangladesh consultation rates were between 1,2 and 1,9. In an international context, the median OECD rate is approximately 6 to 7 visits per person per year. We also conducted in-depth interviews and group discussions with over 850 healthcare workers and community members in the seven settlements between March 2018 and May 2020. Pre-COVID-19 engagements were conducted through face-to-face workshops and individual meetings. Healthcare was expensive for all residents, particularly the cost of drugs. Pharmacists and patent medicine vendors were seen as key providers of treatment and advice for illnesses such as colds and flu, diarrhoea, stomach ache and headache, allergies and first aid. Preventive services in maternal and child health, including immunisations and antenatal care, were mostly available for free in the public sector. But mental health services were limited in Nigeria, Kenya and Bangladesh. In all sites, tr