Table 2 Summary of qualitative findings and policy and practice implications

Social Structure

Poor communities are complex in structure and do not rely solely on the administrative leadership for social cohesion or social action. Community members often identify more closely with community subgroups, community leaders, NGOs and even resident health private practitioners, and are primarily reliant on their own family and neighbours for assistance. This supports a case for a health promotion strategy to work locally with community subgroups and families and their networks rather than relying solely on the administrative organization and procedures.

Social Insecurity

There are many aspects of social insecurity in communities that impact on health and well-being. These include physical, income and health insecurity. This social context for health and well-being indicates that the primary determinants of poor health in these communities can best be understood in structural rather than behavioural terms. This supports a case for a more comprehensive social policy approach to address the structural factors rather than a reliance on health education strategies for individual behaviour change.

Social isolation

There are particular subgroups of the poorest families in the four communities that are particularly at high risk of social exclusion and social isolation – these include single mothers, young school-age children (but not attending school) and teenagers. Social programmes should target these most vulnerable groups to provide them with a minimum level of social opportunity for development and social protection.

Social Protection

Health workers assess the poverty status of their patients, and patients know they are being assessed for their capacity to pay. As a result, mistrustful relationships can develop between government health centre staff and community members. On the other hand, those people with exemption cards expressed confidence in attending health facilities. This makes the case for extending the health equity fund or related health protection schemes to increase the use of health care services by the very poor.

Health Networks

Informal networks are likely to be the most influential factor in determining health care-seeking behaviour. The quality and cost of health care services are routinely discussed among families, friends and neighbours. This being the case, the most powerful advertisement for improving health care and health care access is the quality, attitude and cost of services provided directly to the communities, enabling community members then to share this information through their local social networks.

Health Markets

There is no single unified health care system in the urban context. There is instead a health care market with a wide range of choice of provider and type of service, even for the urban poor. The poor are “shopping for health.” A better understanding of the dynamics of this health care market for the poor could guide policy makers towards improving mechanisms for quality health care and social protection.