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28 01 2020

ARISE at the World Urban Forum

We’re attending the upcoming World Urban Forum, and we’re really excited to be participating. This year’s theme is, Cities Of Opportunities: Connecting Culture And Innovation. The Forum Background Paper explains:

Cities are hubs of innovation often deployed to address a wide range urban challenges— water management, sustainable mobility, security, solid waste management and renewal energy. In the context of urban areas, culture and innovation are inextricably linked and engaged in a continuous process of refining each other. The city with its concentration of people, ideas, and resources serves as a catalyst to initiate and sustain innovation. The rapidly changing urban context provides the opportunity for the intersection of culture and innovation and to address persistent and emerging urban challenges.

We are involved in two panels. Please do come along and meet us.

Leveraging Crowd Wisdom to Better Understand the Technology and Ethics of Neighbourhood Deprivation ‘Slum’ Mapping, Sunday 9 February, 16:30 – 18:30, Hall 3 – Room 20
Partnerships towards an inclusive culture of health in cities, Monday 10 February, 16.30-18.30pm, NE69

Keep scrolling to find out more about these sessions…

ARISE sessions at the WUF

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Leveraging Crowd Wisdom to Better Understand the Technology and Ethics of Neighbourhood Deprivation ‘Slum’ Mapping

Sunday 9 February, 16:30 – 18:30, Hall 3 – Room 20

Recent rapid urbanization in low- and middle-income countries (LMICs) has both boosted economic growth, as well as proliferated inequalities in access to basic infrastructure, access to essential services, and social-cultural resources having severe impacts on living conditions and health outcomes. UN-Habitat estimates that a billion people currently live in slums, informal settlements, and inadequate housing, and this number is expected to double by 2050. Three significant knowledge gaps undermine the efforts to monitor progress towards the Sustainable Development Goal 11 — Sustainable Cities and Communities):

First, the data available about deprived areas in cities worldwide is patchy and insufficient to differentiate deprived areas from those with access to essential services, infrastructure, and social-cultural resources.
Second, existing approaches to area deprivation mapping are mostly siloed, and, individually, they each lack transferability or scalability.
Third, ethical and privacy standards are not well developed to guide the publishing of data on the geography and attribute information of deprived areas (e.g., socio-economic characteristics).

This networking event is coordinated by a diverse stakeholder group representing the main approaches to neighbourhood deprivation mapping. In this session, we review the strengths and limitations of existing mapping methods used to identify deprived areas, and introduce a working framework for an Integrated Deprivation Area Mapping System (IDeAMapS) that would leverage the strengths of each approach. We propose mapping deprivation on a continuous scale in small areas (e.g. grids or blocks) to provide enough detail to inform planning, while obfuscating the exact boundaries of neighborhoods to promote privacy and mitigate unintended consequences. Multiple deprivations might be mapped – e.g., degree of pollution, environmental risk, informality, and secure tenure – to enable targeting of programmes and policies. All outputs could be classified to distinguish deprived and non-deprived areas, which is important for other data collection and reporting initiatives.

As technologies, available data, and computing power rapidly evolve, new opportunities are emerging to co-create and integrate data. We must ensure that these approaches are inclusive, result in benefit to all stakeholders, and that we have mitigated unintended consequences, such as locating already vulnerable populations and enabling further marginalization via eviction, fines, harassment, or stigma. These new technologies are very promising, and have potential for positive impact if done well. At the moment, most of the existing initiatives emphasize physical environmental characteristics (e.g. informal settlements), without consideration of social-cultural data and multiple stakeholder input, including, importantly, the communities who are being mapped.

Partnerships towards an inclusive culture of health in cities

Monday 10 February, 16.30-18.30pm, NE69

Achieving inclusive and sustainable cities means ensuring that all urban residents can enjoy good health and wellbeing. There are many interlinkages between sustainable cities and health and the objectives of the New Urban Agenda. For example, clean water and sanitation and responsible consumption and production will contribute to healthy environments, clean air and therefore healthy and happier populations. However, there are barriers to achieving necessary conditions for good health and wellbeing in urban areas. There is particular need to hear the voices and experiences of marginalised urban dwellers (shaped by social class, gender, caste, sexuality, age, disability, tenancy and citizenship) in urban planning and development decisions which could impact on health.

Researchers, policy makers and practitioners advancing urban health have found that promoting a “culture of health” in all policy decisions about urbanization provides a strong base for changing the built, natural and socioeconomic environments that are critical to health and well-being. To do this, partnerships between government, civil society and the business sector are critical. This session will present examples of diverse partnerships in a range of sectors that build on community engagement to create healthy environments.

Researchers, local community and local government representatives will share experiences of approaches to ensuring healthy and inclusive urban development by engaging with the most marginalised. They will share different tools and methods to facilitate and measure this.

The World Urban Forum will take place from the 8-13 February 2o20 in Abu Dhabi, UEA.

This blog was put together by Kate Hawkins. The photo of the Abu Dhabi skyline is licensed under the Creative Commons Attribution-Share Alike 4.0 International license. Here is the original.

27 01 2020

Mapping community health services in Mukuru, Kenya

By Jane Wairutu, Eva Muchiri and Jackline Waithaka

Kenya’s health sector has set the stage for major improvements with a strategic focus guided by Vision 2030. It aims to transform Kenya into a globally competitive and prosperous country. However the burden of ill-health continues to be felt nationwide, particularly among the urban poor. Mukuru belt has the largest slum settlements in Nairobi. A community mapping exercise was conducted to provide new information on who is under-served by health services and where greater focus is needed. This blog gives insights into how the mapping was conducted and the greater contribution makes to improving the community health sector.

Mukuru Special Planning Area

Mukuru was declared a Special Planning Area (SPA) in August 2017 because residents not only faced constant evictions but also did not have access to basic services at an affordable cost. Often, they were paying five times as much as the residents of formal areas for health, water, sanitation and education services. Being declared an SPA paved the way for the creation of an Integrated Development Plan for all sectors through a participatory process that was community led. One of the main objectives of the SPA is devising ways to promote the health and safety of Mukuru residents.

Profiling and mapping Mukuru

Men in Mukuru during CHV mapping exercise In Kenya, the health system is divided into six levels – Level One is the community level. At this level a combination of paid (Community Health Assistants) and unpaid (Community Health Volunteers) workers deliver care. They are attached to a Community Health Unit (CHU). Each CHU is responsible for 100 households that are assigned one Community Health Volunteer (CHV). The main roles of the CHVs are to: support people, households and communities to promote health; provide simple health interventions; refer patients with more complex needs to health facilities; and collect data for their supervisors to inform health planning. They are the frontline of the health system.

SDI Kenya used various techniques including satellite imagery to map the physical coverage of all CHVs and spatially identifying the unserved pockets and the number of CHUs. An individual profiling survey tool was developed and it focused on issues like CHV level of training, experience and level of satisfaction.

What did we find?

Health Facilities

Satellite image of Mukuru A profiling of health facilities had initially been carried out by the Federation, CHVs and organizations within the Mukuru SPA Health Consortium. They mapped 206 health facilities which were both private and publicly owned. But only four of them had government support. The state owned facilities are located in Viwandani and Imara Daima, one is a dispensary, while the other is a Health Centre. Currently the two facilities do not provide a 24 hour service for all the residents, they only provide outpatient services and limited emergency care. The Health Centre provides maternity care for normal deliveries, laboratories, oral health and referral services. In addition, the Health Center offers preventative care and promotes good health practices to improve well being.

The majority of residents in Mukuru get their health care from private facilities. Out of the 206 health facilities profiled, 60 (29%) were registered while 140 (71%) were not registered and operated illegally.

Community Health Services

Woman on tablet during CHV mapping of Mukuru During the mapping 388 CHVs were profiled (82%) were women and (18%) were men. The majority had two to three years of experience. On the levels of training, 363 (94%) of the CHVs said that they had undergone both basic and technical training. The training was supported by the County and National Government with support from various faith-based organisations, NGOs and CBOs working in Mukuru. These organisations included Access Afya, APHRC, AMREF and UNICEF. More than half the CHVs referred patients to the existing public health facilities.

During the mapping process the CHVs were assisted by the Community Heath Assistants who helped them in understanding the geographical areas they cover while seeking to capture details of the service providers they refer patients to. The data collection process, which fed into the upsurge in demand for health information, deployed over 40 trained CHVs from the three settlements within the SPA.

Opportunities for change

In Mukuru, as in other informal settlements in Nairobi, residents face extreme health challenges. The CHVs also face challenges. These include inadequate numbers of workers to meet the needs of the population they have to cover, interrupted supply of commodities, lack of access to specialized services, inefficiency and ineffectiveness of among other health care staff and weak implementation of the Community Health Strategy.

Spontaneous responses from the survey provided insights into the dynamics of the health care system at the settlement level paving the way for deeper understanding.

Our job entails service and service requires patience. It requires patience to serve the community even in instances where, as health practitioners, we may lack the proper working tools and facilitation to enable us conduct our activities effectively. Christine, Wape Wape

The survey further revealed the burden of cholera, because of poor sanitary conditions and unreliable garbage collection, which was considered an urgent issue among CHVs. The data obtained from the survey pointed to specific shortfalls and helped determine areas to focus on in a bid to streamline the sector.

The data will help us functionalize more Units in regards to the boundary gaps that came out from the data collection exercise. Lucy, Community Health Assistant, Viwandani

Implementation of the mapping exercise was a significant but doable undertaking, one that went further to map where services are provided to address deficiencies in service provision and generate the much-needed evidence to refine the health sector response in Mukuru.

Adopting a gender lens in health systems research

20 01 2020

Adopting a gender lens in health systems policy: A guide

Policy makers should consider gender at all levels of the health system, and in all activities. This would lead to a more equitable health system that serves everyone, and meets health goals. Many policy makers are interested in gender equity, but lack guidance on how to implement changes in the health system.

We teamed up with Research in Gender and Ethics: Building Stronger Health Systems (RinGs) to fill this gap.

Questions of gender are dealt with poorly by pre-existing health systems models. In 2018, Percival and colleagues analysed post-conflict health systems to define the attributes of a gender-equitable system. They argued that a gender-equitable health system would:

Present equitable opportunities for men women and people of other genders who are health professionals
working within the health system.
Produce relevant sex-disaggregated health information that shapes policy.
Ensure men, women and people of other genders, across the lifespan, are able to access and utilize services unimpeded by financial, social, and geographic barriers.
Address the most urgent needs of men and women across the life span in an appropriate manner.

In this guide, we define what a gender-equitable health system looks like. We provide a set of updated benchmarks that health policy makers can use. The guide is structured according to the health systems building blocks with an introduction to the issues and a set of considerations that policy makers should take into account.

Case studies from Cambodia, Democratic Republic of Congo, Kenya, Liberia, Malawi, Sierra Leone, South Africa, Tanzania, Uganda and other countries are included in the guide.

The authors and advisors of the guide were brought together at a meeting organised by the KEMRI Wellcome Trust Research Programme. This was funded by Advancing Learning and Innovation on Gender Norms (ALIGN), an initiative led by the Overseas Development Institute (ODI).

Adopting a gender lens in health systems research

Download the guide

18 01 2020

Upgrade where possible and relocate where necessary

By Francis Anthony Reffell and Yirah Oryanks Conteh

FEDURP/CODOHSAPA’s slogan is, “upgrade where possible and relocate where necessary”. This is what guided us when Mayor Yvonne Aki-Sawyerr asked us to advise on CrabTong/Kolleh Tong/Grey Bush (CKG) and Kingtom, two neighbourhoods seated on the Bomeh dumpsite.

Living among hazards

Freetown, the capital of Sierra Leone, was planned by the colonial government to accommodate 300,000 residents. Currently, its population is 1,055,964 – three times the original population the city was planned for over 50 years after independence. This situation has been caused by rural-urban drift necessitated by the search for greener pastures. This was further exacerbated by the 10-year civil war that saw a significant movement of the rural population to Freetown seeking security and survival.

A man walking past a heap of garbage Most of this population have found themselves occupying ‘hazard’ spots and they cannot afford to rent better housing facilities. Compounding their challenging situation, is their exclusion from social services and employment opportunities, as the available utilities are already overstretched. The FEDURP/CODOHSAPA settlement profile report of 2015 found that approximately 35% of the entire Freetown population lives in hazardous informal settlements.

Supporting local government

Mayor Yvonne Aki-Sawyerr’s request came about at a meeting she convened to discuss ways to mitigate flooding in the middle of the rainy season. It was already becoming clear that the most affected places were neighbourhoods on dumpsites – CrabTong/Kolleh Tong/Gray Bush and Kingtom fell within this category. Her hope was to relocate these settlements to avert a looming catastrophe and to make way for a waste management pipeline.

In response to the Mayor’s request, FEDURP/CODOHSAPA leadership engaged with her office to understand the model of relocation. They agreed to assist if internationally accepted best practice on relocation was respected. The Mayor affirmed her commitment to respecting these protocols.

A plan was initiated, which included joint community consultations to seek community consensus, community mapping and enumeration by FEDURP/CODOHSAPA, provision of a comprehensive financial package for affected occupants and demolition of structures. FEDURP/CODOHSAPA also committed to broker a consensus with the community since they are a trusted partner.

Community engagement

Going forward, a FEDURP/CODOHSAPA data team was constituted and engaged. Existing mapping and enumeration tools were customised to reflect this specific action. Following that, an initial joint community meeting with Freetown City Council (FCC) authorities was convened where the intended plan to relocate residents was disclosed. We explained that the mapping and enumeration exercise would take place to inform the relocation process.

While undertaking the mapping and enumeration exercise, one respondent said this:

We are only cooperating because of FEDURP/CODOHSAPA, so please make sure FCC honours its commitments otherwise you will be held responsible and we will conclude that you have compromised our values and solidarity.

For FEDURP/CODOHSAPA, this was a strong message, as this was the first collaboration with FCC to effect relocation procedures and it put our relevance in the communities to the test.

Community entitlements

Based on the data we collected, learning gleaned from an exchange with colleagues in South Africa and consultation with the FCC the following actions were recommended:

Shack owners have their structures evaluated and paid for in full
A year’s rent will be offered to tenants which they can use to relocate and rent in a safer settlement of their choice
Tenants will be offered a minimum grant to kick start their livelihood in their new settlements

We have continued to engage with the FCC and the residents and all entitlements and dues have been honoured by the council. All residents voluntarily evacuated in or before the second week of November to give way to the demolition of structures.

What did we learn?

Connecting the pieces of this process together, key lessons learned include the following:

The outcome of this process is a proof that ‘information is power!” FEDURP/CODOHSAPA’s data collection practices provided the leverage for a progressive partnership with, and trust between, the community and FCC, which has now been translated into “knowledge for action.”
Involving communities in all phases of any development process stimulates sense of ownership. There are no indications of any resistance from the residents. In this case, the role of FEDURP/CODOHSAPA has been very critical in brokering a consensus, which shows how relevant it is as a social movement in fostering community solidarity.
International exchange learning for slum dwellers and informal settlers is an important tool for capacity and knowledge building. The South African experience shared with and accepted by FCC has proven to be effective.

There is much that ARISE can take away from this experience to inform capacity building tools for co-researchers and other key community stakeholders and participants.

Francis is Founder and Director of the Centre of Dialogue on Human Settlement and Poverty Alleviation (CODOHSAPA) and Yirah is the National Federation Leader of the Federation of Urban and Rural Poor – Sierra Leone (FEDURP).

03 01 2020

Rehabilitation and relocation in Mumbai and Ahmedabad

By Vinodkumar Rao and Smruti Jukur with the support of SPARC

Nearly half of Mumbai lives in slums, some on uninhabitable lands – within an arm’s length of speeding trains or on pavements with their living overflowing on to the adjacent street. The state Government of Maharashtra (where Mumbai is situated) has made a lot of effort to house slum dwellers by bridging the housing gap in different ways.

For many slum dwellers, state relocation programmes are probably the only gateway to moving out of dangerous living conditions. But are they happier after moving out? Do their lives improve? Do their aspirations change? Do their perceptions about life change?

Too many questions, and we hope ARISE answers them.

Accountability

We want to explore answers to these questions through ARISE because ‘accountability’, which is the core theme of ARISE, is an important element of this conundrum. We need to look at accountability at many levels. Accountability of different government agencies to people before, during and after relocation; accountability of formal and informal power structures within relocated communities; and accountability of people to government agencies.

We will examine two case studies through this lens, one in the city of Mumbai and one in Ahmedabad. Both are mega cities with strong Municipal bodies. They are capitals of their states and are both major contributors to state revenues. But they also have large numbers of families living in informal settlements. Both cities have, over time, relocated several slum dwelling communities who were living on uninhabitable lands (or lands acquired for public projects) to multi-storied buildings. But the way this relocation was handled presents very different styles as well as different relationships between people and those in power. In fact, they stand quite opposed to each other!

Mumbai

Mumbai made a political promise to house slum dwellers, an opportunity that was used by organised slum dwellers to their advantage. They demanded that state institutions pay for housing slum dwellers displaced by infrastructure projects (also inherently addressing the issue of people living on precarious lands, such as along the railway tracks or on pavements). People voluntarily moved into buildings, sometimes further away from their original locations. This was thanks to the work of organised slum dwellers federations and a government agency that invests in building robust rehabilitation and resettlement (R&R) processes beyond construction.

There is a specific cell in the state agency responsible for R&R, headed by a competent authority with fair decision making powers. It facilitates, oversees and finances the work, ensuring people’s movement into relocated colonies is smooth and that they are provided adequate post movement support until they settle into their new surroundings. Investments are also made in setting up and supporting cooperative societies that are given official powers to regulate and oversee the maintenance of the buildings. This is all thanks to a robust R&R policy, that was developed for an important infrastructure project. It continued to serve as a template for further projects that required the relocation of slum dwellers.

Ahmedabad

In contrast, the projects in the city of Ahmedabad have no such policy frameworks or any specific cell within state agencies to facilitate the process of relocation. Most relocations do not indicate any willful movement of affected slum dwellers. There is minimal post-relocation support. In comparison to the situation in Mumbai, where people are very vocal with elected representatives and government officials, the relocated dwellers in Ahmedabad seem politically disenfranchised. There is little interest in strengthening any local processes and a general sense of hopelessness prevails among residents and organisations who have worked at these sites.

After relocation

In spite of the contrasts in the two cities, specifically in relation to accountability, their post-relocation challenges are similar. In fact, the issues that relocated slum dwellers face seem to have a pattern across cities in India. These include, little understanding of forming formal cooperative structures, poor management of garbage, issues with access to basic services, transportation access, and many others that point to poor maintenance.

So far, all studies indicate that investing in systems of participatory action is crucial to addressing the issue of housing the poor. This is essential and a no-brainer approach to ensure sustainable housing. But, as people get access to housing or secure tenure, new sets of challenges emerge. This is a fairly new area that is not debated much, but which deserves attention.

Questions for the future

Most dense cities house slum dwellers on lands that are uninhabitable and sometimes outright dangerous for those living on them. Building safe habitats for slum dwellers essentially means resettling elsewhere or stacking houses up vertically. Therefore, the need to explore what methods can improve the living conditions of residents’ post-movement into relocation sites becomes imperative and urgent.

ARISE gives us the opportunity to look deeper into many aspects of relocation. The governance structures, political relationships, organisation of residents, and other determinants need further investigation. As this is also the formalisation of informal tenure, formal accountability structures actually develop during this period and it is essential to understand them. After all, how one lives and how one feels about their living arrangements has direct bearing on one’s health and wellbeing!

Common knowledge says “pakka makan” (a formal and strong house) got most people to move. But did they get what they came for?

18 12 2019

“No easy solutions for urban informal settlements”: Bangladesh stakeholder workshop

By Wafa Alam, Tasnuva Wahed and Bachera Aktar

Informal settlements are not a one-dimensional box.

Dr. Hossain Zillur Rahman, BRAC Chairperson

At a recent workshop, stakeholders discussed the health, well being, housing and water and sanitation related challenges faced by the residents and the governance systems in urban informal settlements. They talked about important issues such as migration and urbanization in Dhaka city (Bangladesh) and accountability mechanisms for service providers and community residents. While there are many problems, there is no comprehensive national urban policy which addresses these issues.

Key messages

Urban informal settlements in Dhaka are complex.
Multi-sectoral coordination is required to address these complexities.
Research on these complexities are needed to inform policy makers.

Rural-urban migration

Thousands of migrants come to Dhaka city every day. This shift from rural to urban areas of Bangladesh is attributable to natural disasters like river or land erosion, lack of job opportunities and a general slow rural economy. However, as identified by Brig. Gen. Dr. Md. Sharif Ahmed, Chief Health Officer, Dhaka North City Corporation, poor income generating opportunities are not the sole reason for this shift. Poor access to quality services also drive people to move out of rural areas. He added that strengthening the quality of education and providing employment opportunities by supporting agriculture and cottage industries in rural areas are vital.

On the issue of rural to urban migration in Dhaka city, Dr. Zillur Rahman said,

We need incentive-based thinking to reduce migration.

He talked about multiple pathways to address migration such as making secondary cities more attractive, improving villages and developing commuter satellite cities around Dhaka.

A holistic approach to health

Ensuring quality health and well being related services in the complex landscape of the urban informal settlements is a major challenge. Multiple actors including government departments, the private sector and NGOs work simultaneously to provide services for the urban poor. Dr. Rahman emphasized the need to identify and map the roles of the stakeholders working in urban Dhaka as a strategy to improve the health outcomes of the vulnerable and marginalized urban communities. The complexities of urban informal settlements need to be looked at with a holistic approach, where humanitarian and development approaches come together, and become part of policy thinking.

Brig. Ahmed talked about the importance of coordinated efforts between stakeholders working in urban areas, and the need for better coordination between the Ministry of Health and Family Welfare, Ministry of Local Government, Rural Development and Cooperatives, private sectors and NGOs.

A lack of coordination between NGOs, donor agencies and government bodies gives rise to problems such as disparity in service concentration, duplication of services and poor referral mechanisms; making it more challenging to improve the well being of the residents of urban informal settlements.

Remodeling existing services

Brig. Ahmed identified poor housing conditions, limited access to safe water, drainage and sanitation facilities and lack of access to quality health services as some of the major challenges faced by the urban poor in Dhaka. While the City Corporation is working to improve the condition of the urban poor, their contribution is not enough to support the growing number of people in need.

Also, as urban informal settlements are not recognized as legal lands, the residents lack access to basic public services. These residents rely on NGOs for basic health and well being related services. NGOs often have to close down their programmes as donors wrap up. That’s when these people are left with no choice but to pay high prices for services and face extortion at the hands of the local mastaans. Often, these mastaans are local leaders who are affiliated and have patronage from political leaders, government and law enforcement agencies.

Dr. Rahman recognized urban centers as being extremely land scarce and said that in such settings giving access to land to solve daily problems like housing may not be feasible. This means we need to come up with innovative solutions or revamp existing services. He gave the example of ‘evening clinics’ as a solution that may be able to meet the need of the urban poor women who are unable to access health centres during the day, when they are busy earning a living by working as domestic aides or in the ready made garments industry.

Two-way accountability is important

Often the residents of informal settlements in Dhaka are paying higher prices for access to basic services like water and electricity. This is the result of poor governance and accountability in those settlements which allow local mastaans in the communities to take control of the facilities and sell to the residents at a higher cost. This issue of accountability needs to be explored from the horizontal and vertical aspects, that is, the accountability of the service provider, as well as that of the user, according to Dr. Rahman.

Generating new knowledge for Bangladesh

Knowledge is an important vehicle through which overall objectives of improving well being can be achieved

Dr. Rahman

Dr. Rahman stressed that new knowledge should be disseminated downwards to communities being researched and upwards to policy makers in Bangladesh. This will help communities understand and improve their current state. When research findings flow into policy thinking, it will also help generate new types of projects.

Research to understand the complexities in informal settlements, such as the ecological and locational diversities that exists between informal settlements, is vital.

The workshop ‘Working Together Towards Health Equity in Urban Informal Settlements’ was held on the 5 September 2019 in Dhaka, Bangladesh. It was jointly hosted by the ARISE Hub Bangladesh and Pathways to Equitable Healthy Cities under the Center of Excellence for Urban Equity and Health, BRAC James P Grant School of Public Health, BRAC University. The workshop was attended by stakeholders from government departments, NGOs and research institutions, who shared information about their work in urban informal settlements and their suggestions for improving urban health.

13 12 2019

COPASAH launch Charter on Accountability and Health

READ THE CHARTER: https://www.copasah.net/uploads/1/2/6/4/12642634/copasah_sa_charter_and_call_to_action.pdf

We had the good fortune to attend a webinar where COPASAH launched their new Charter and Call to Action for Social Accountability for Health. This comes hot on the heels of the successful Symposium which was held in New Delhi in October.

The Charter is grounded in human rights, particularly the right to health. It recognises the commitments made at Alma Ata and within the Sustainable Development Goals. But the Charter is very future facing.

What’s going wrong?

New social, political and economic forces are exacerbating pre-existing inequities, argues The Charter. This is eroding democracy and public systems. This includes unethical and exploitative private sector action. At the same time, multilateral systems – like the UN bodies that exist to protect our rights – are losing their teeth. Unfortunately, the research world is often a part of the problem:

Dominant practices of evidence-based policy making trivialise the lived experiences of ordinary people. Prevailing approaches favour aggregate data over more complex narratives that better represent the lived reality of marginalised people.

COPASAH vision for the future

Signatories to the Charter pledge to ensure that marginalised communities have access to accountability systems and to the promotion of solidarity, empowerment and leadership. Collective action is key to this, and the leadership of women and other disadvantaged people.

The Charter outlines a vision where adequately supported public services meet the needs of the marginalised. At the same time it argues that the private sector should be regulated, transparent and accountable. We should build a system where profit does not trump the rights of the people.

Both communities and health workers play a key role in providing health care. But they are often overstretched, working under pressure and blamed for weaknesses in the system. The Charter suggests that we must work together – taking our lead from the most marginalised – to monitor weaknesses in accountability systems and collectively press for change.

What next?

The Call to action in the Charter provides detailed guidance to researchers on their methods and more general engagement with communities. It urges research bodies to promote community participation and ensure the work is led by community priorities. As a result new knowledge should support communities in their struggles for accountability and the realisation of the right to health.

Many thanks to Ravi Ram (Kenya) and Aminu Magashi Garba (Nigeria) for their insightful presentations and for all COPASAH members for their inputs into the Charter and the Call for Action.

A woman sits cross legged on the floor. She is wearing white bottoms and an orange top. Her hair is tied back in a short scarf. She holds her arms out in front of her in a graceful dance move. She looks down to her fingertips. Her eyes are lowered. The carpet underneath her is an orange colour and behind her is dark wood paneling.

10 12 2019

The right to health: Supporting marginalised people living and working in urban informal spaces

By Rachel Tolhurst, Shrutika Murthy, Lana Whittaker, Prasanna Saligram and Surekha Garimella

‘Our rights, your accountability’ was a slogan used by social accountability practitioners from around the world at the COPASAH Global Symposium. Human rights are a fundamental underpinning of many people’s movements to demand accountability for health equity. But how do we understand rights to health? Who can we hold accountable to ensure that the right to health of marginalised people living and working in urban informal spaces in the Global South is realised? These are questions we have been grappling with in ARISE.

READ THE NEW COPASAH CHARTER ON SOCIAL ACCOUNTABILITY FOR HEALTH.

Rights to health

The UN Charter for Human Rights and Covenant on Economic and Social and Cultural Rights enshrine the right to health in international law. This extends beyond healthcare to the ‘underlying determinants of health’ and is therefore indivisible from other human rights such as the rights to food, water and shelter. Many of the struggles discussed at the Symposium focused on claiming the right to healthcare, which was a priority for community-based activists. However, we also heard powerful testimonies of how biomedical models of health that have been imposed as part of imperial, neo-colonial, patriarchal and neo-liberal regimes may be experienced as a form of violence. For example, how they have damaged and undermined indigenous and traditional models of health such as Latin American models which are grounded in the natural, social and spiritual world or care for women in childbirth provided by dais in India.

A more holistic understanding of health and well-being, in line with the WHO definition of health, is rarely pursued within ‘basic packages of care’, which focus on preventing mortality. A wonderful performance-based discussion on well-being facilitated by Anita Santhanam, reminded us of the need to find a common language to express our wider well-being (or ill-being) and to embrace and promote the care dimensions of healthcare and the multiple processes that are needed to promote well-being. ‘Colonised’ hierarchies of knowledge in global health, such as the dominance of the ‘gold standard’ of randomised control trials, may detract from efforts to find consensus about health between marginalised people and the people who are accountable to them.

The right to health also relates to freedoms such as the right to control one’s own body, including sexual and reproductive freedom, and the right to be free from interference, such as being free from torture. At the Symposium the sexual and reproductive rights of women and girls, women’s control over their bodies and freedom from gender and sexual violence were prominent topics. These rights should be protected by the state, but also involve the development of stronger accountability processes within communities. We need to find ways of ensuring that we are accountable to each other as human beings to treat each other non-violently, with respect for bodily autonomy and dignity, within families and communities, without this detracting from the struggle against more remote institutions and states.

Who is accountable?

The UN Committee on Economic, Social and Cultural Rights stated in 2000 that nation states have a three-fold obligation to respect, protect and fulfill the right to health, but also that actors beyond the state have obligations in this regard. These include health professionals, local communities, civil society organisations, and the private business sector. Most of the movements celebrated at the Symposium focus on increasing the accountability of the state for their obligations towards citizens.

Marginalised people in urban informal spaces often face challenges in making rights claims to the state. For many, ‘informality’ means that they lack state recognition of their right to live and work in the city and thus their rights to housing, clean water or sanitation. This lack of formal citizenship often undermines their eligibility for entitlements such as food rations or access to health services. Institutions of the state may nonetheless be present in their lives to some extent, sometimes in malign forms, including in police harassment and caste-related stigma and discrimination in health services.

State capacity to fulfill its obligations may also be weak due to neoliberal reforms leading to a skewed understanding of what it means to be a responsive state. Whilst states have an obligation to continuously move towards realising the right to health, many lack both the will and capacity to do so. In many contexts the democratic space and legal basis for rights claims is also shrinking. Lines of accountability are also being re-drawn due to neo-liberal globalization, with accountability flowing towards global capital.

In urban informal spaces, many non-state actors (people and institutions) create a complex web of governance and service provision, supplying water, toilets, electricity, dispute resolution and health services, usually outside of the regulatory reach of the state. How do marginalized people hold these actors to account for their obligations to respect, protect and fulfill their rights to health, in the absence of a legal framework of entitlements? Are there more direct social or political bases of accountability that can be leveraged?

In ARISE we aim to learn more about what people already do in practice and how to strengthen this. One of the exciting things about the COPASAH Symposium was the large number of accountability practitioners sharing their experiences. One such strategy was moving beyond an adversarial approach to working with healthcare providers. To see them as allies with whom social accountability can be built, on a foundation of community solidarity.

Women and providers working together

In one of the ‘practitioner huddles’ at the Symposium, conversations revolved around the barriers in accessing quality health services and the methods that were adopted in order to overcome them. Historical and cultural process were held responsible for deep-rooted biases within health systems and how these perpetuate the exclusion and marginalisation of certain communities. The lack of a tradition of ‘accountability’ within the government further complicates matters – as very often government officials are themselves unaware of the law and their associated obligations. It was argued that it is not the mere existence of a law that is important but its implementation.

Women, along with some of the community health practitioners, explained how indigenous women are discriminated against and mistreated at health facilities because of their cultural beliefs. Indigenous women are penalised for not giving birth to their children at health facilities and threatened with the prospect of their children not being ‘registered’ as citizens.

Women and practitioners also emphasised the importance of taking a people-centred approach and building the capacities of vulnerable communities, to effectively monitor health policies and services. Communities have been trained in accessing information, understanding government structures, collecting evidence from the field and advocating their demands to different stakeholders as part of this process.

Whose rights?

The UN declaration of Human Rights states that “All human beings are born free and equal in dignity and rights”, yet intersecting inequalities and power relations from the global to the local level undermine this. Many people living and working in informal urban spaces experience extreme marginalization and discrimination because of multiple intersecting identities such as caste, class, ethnicity, disability, religion, sexual orientation and gender.

The ‘social suffering’ related to being ‘othered’ and not afforded the dignity of being fully human is an important dimension of ill-health and ill-being. A critical aspect of strengthening social accountability is the realization of the rights of people ‘marginalised by design’ to freedom from discrimination, violence and to full societal participation. Many inspiring examples of feminist, anti-caste and egalitarian approaches to building social accountability movements were presented at the Symposium.

Lessons from intersectional politics also stress the importance of identity-based movements through which oppressed people create new, ‘de-colonised’ identities, realising their ‘power with’ and ‘power within’. In ARISE we are grappling with questions of how to support such identity-based movements as well as promoting the inclusion of the most marginalized within broader social movements that may be required to hold the powerful to account. We are standing on the shoulders of the many giants of accountability practice we had the privilege to learn from at the Symposium.

Photo credit: The image was taken by Rachel Tolhurst and shows Anita Santhanam’s performance on well-being at COPASAH

A woman in an orange top with dark, long hair which is tied back is seen from behind. She is in the foreground and in the background you can see she is walking down a narrow alley in an informal settlement. She is walking towards shops and three men in the distance who are walking around.

03 12 2019

Harassment in Informal Settlements in Dhaka

By Wafa Alam, Shafinaz Sobhan and Bachera Aktar

Everyday many young men and women migrate to Dhaka city from rural areas of Bangladesh in search of work and in hope of a better life. Many of these people end up in informal settlements where they live in unhealthy and unsafe conditions, often subjected to harassment.

According to the Bangladesh Bureau of Statistics 2015, there are more than 3,000 informal settlements in Dhaka, with over 1 million households. Unfortunately, people living in those informal settlements are exposed to higher degree of violence and crime. Traditional gender roles often make adolescent girls and young women more prone to different forms of harassment, be it at home, in the community and on the streets.

What harassment do women face?

The types of harassment faced by young women in the slums of Dhaka ranges from name calling and bad comments to giving perverse looks, inappropriate touching, physical abuse and sexual harassment. School and college going girls, women living away from their husbands, and female garment workers are particularly vulnerable to such abuse.

The ‘mastaans’ (local goons), local shopkeepers and sometimes the unemployed boys tease girls and young women in the streets. During one of our visits to a slum in Dhaka, an adolescent boy said:

These powerful men (mastaans) tease girls and they know no one will protest because of their strong political backup.

These practices are often so normalized and socially perpetuated that people don’t even protest, let alone report incidents.

Stigma and blame

There is widespread stigma associated with harassment which means that it is often young girls, and not the abuser who is held responsible. This also means that families stop girls and women from seeking justice for fear of having their reputation tarnished. A young girl residing in Korail slum said:

My mother thinks that if I act (dress and behave) properly, then everything will be fine, but if I don’t, then boys will definitely say things.

She also said that when boys teased her on the streets, her mother told her not to give an ear to such comments. Her mother always tells her:

You are born as a girl, and you should behave like one. You don’t have to show that you are brave.

Incidents of harassment are often not shared with anyone due to fear of being blamed. One study reported that only 2.1% of the women inform community leaders about their experience of domestic violence, while 1.1% of the women seek police’s help.

A survey conducted by Save the Children showed that around 80% of the girls living in informal settlements in Dhaka are married off before the age of 18 and one of the reasons for early marriage was also found to be fear of sexual harassment. Young girls are restricted from going out alone, or going out at night due to safety concerns in the community. Together with all the issues explained above, the long existing practices of child marriage and other issues are perpetuated when a girl reports an incident of harassment, further depriving them of their basic human rights like education. This is aggravated by the lack of support from community and law enforcement.

Imperfect justice

In the few cases of harassment that are actually reported, police are either reluctant to get involved, or are in favor of the accused. There have been cases were the police coerced the victims to settle the matter out of court, or fix marriage between the victim and the accused, as they receive financial benefits from doing so.

Parents of the victims also seek help from local community leaders. The local leaders hold ‘shalish’ (informal court) where the accused may be beaten or charged a fine, if found guilty, or even forced into marriage. However, there are incidents where these local leaders also seem to only take strict action in case of influential people, and in other instances they victimize people who do not have important connections in the community. The consequences are often, if not always, faced by the girls and their families. If the families try to protest, they may be forced to vacate their house and move to another area.

However, over the years, communities have become more responsive towards incidents of harassment in their slums. Slum chairman, club presidents and members hold regular meetings where they talk to family members, men and women, and help them solve such problems. Women are now more concerned about their own safety due to awareness campaigns, rallies and the influence of the media.

These measures still do not consider that incidents of harassment are heavily under-reported. Moreover, while the situation has largely improved, there is still a long way to go before the communities transform into conducive support networks for the victims and harassment is indiscriminately eliminated.

26 11 2019

Understanding violence in the slums: Resilience or normalization?

By Joseph Kimani

The mere existence of slums is violence. Poverty is the worst form of violence meted on human beings by fellow human beings…The present system is naturally violent. We have to build a non violent system, a ‘civilization of tenderness.’ Fr. Alex Zannetoli

Violence is a monster that is omnipresent in low-income areas. Slums have become synonymous with violence, crime, criminalization of youth and ‘illicit’ income activities. The feeling of oppression and deprivation makes the entire settlements a no-go-zone. As a result, innocent, poor, marginalized and vulnerable members of communities who cannot escape or leave the settlements are trapped hence affecting their health and wellbeing.

But violence within slums is not inevitable. It is the consequence of structural violence against poor and marginalized people and state responses that exacerbate the problem.

Living conditions

In Nairobi slums the population density stands at 466 people per acre compared to 18 people per acre for the rest of the city. Since the 1990s city space in Kenya, occupied by the poorer half of its population, has not increased. While informal settlement’ populations may have doubled in this time, the rate and scale of improvements have failed to match unrelenting densification and consolidation. There are challenges experienced by residents living in densely populated neighborhoods. In a neighborhood like Mathare Valley (one of the oldest settlements in Nairobi) there are high levels of intergenerational and concentrated poverty. A young man in Mathare explained this process:

Here in our hood, you will find a young man who is at 17 years whose father was a thief, his grandfather a thug all killed by the police…this young man (now a teenage father) will die and leave behind his “wife” and a young child who will grow without even knowing who his father was. At this rate, this child will end up dead…if the child is a girl, she might also be having a story of disadvantage inherited from her mother or father too.

Densification in the slums without secure tenure is associated with poor housing. Slum structures lack adequate sanitation thus exposing young girls and women to sexual violence and degradation. Poor drainage and physical infrastructure puts pressure on households to pay heavily to access essential services that are of low quality: “…a significant poverty penalty which means that they pay a greater economic and social price for poor quality services such as water, sanitation, child care and health care.”

Employment and education

The youth-led Safety and Market Survey in 2018, facilitated by SDI Kenya, found that youths used lack of jobs as the excuse and reason for participating in crime and violence. Other studies showed that crime by teenagers between the ages of 14-17 years old was in the increase. A coordinator with Ghetto Foundation, a Mathare Community Based Organization stated:

I have noticed lots of young men and women getting involved in drugs and substance abuse in the months of Decembers to March. By this time parents or guardians are confused as to what to do with their children who are unable to continue with the next level of education (post-primary and post-secondary level).

While there have been increases in the number of school going children being retained in education until completion, the Ministry of Education in Kenya has conceded that if all primary school years are taken into account, it means only 40 per cent of those who started Standard One were admitted to secondary school. Children who drop out miss out on training and educational opportunities that require at least a secondary school certificate. They are likely to earn less in their lifetime and suffer more ill-health.

While this pattern seems predictable and obvious, it is important to note there are few programmes, policies or systems to ensure theses transitions are smooth and purposeful. Community members are left waiting for support from non-state actors while resources that seems available from County government are not used to address this problem.

Political processes

Kenyan electioneering happens every five years. In the fourth year heightened campaigns are accompanied by deep messages of ethnic hate and violence becomes a way of politicians balancing their political selfish interests. During this period, young men are recruited by various political interests to use force and intimidate their opponents. The zoning of some regions and areas as belonging to others and the issue of treating other communities as a threat is entrenched in the minds of young people. The youth get charged into participating in violence by attacking other communities and get rewarded for it.

Post-election violence in Kenya is solved after politicians agree to share power as individual leaders and call for ceasefire. Once normalcy resumes, no one remembers to ‘de-militarize’ or ‘de-mobilize’ the already psyched up youth from acts of violence, hate and crime.

Policing practices

While there is a lack or absence of state intervention in the provision of secure tenure, amenities and infrastructure within slums there is a very heavy presence of police that intimidate, kill, and harasses young people with impunity and with little accountability. In a recent Kenyan TV interview (Town hall discussion by Citizen TV 14^th October 2019 11pm) a representative from the Kenya National Human Rights Commission explained that police are discriminating in their application of rule of law. He, stated that, every month in the slums of Nairobi about 23 young people (mainly men) suspected to be criminals are killed by the police. This has contributed to low levels of trust between the state and youths in the slums. On the other hand, the police or state authorities blame young people for normalizing crime and violence.

During a dialogue forum between youth and police, a young person rose to present a concern, perplexed, he asked:

What is wrong with us robbing or attacking strangers…I think if we don’t steal or attack our own neighbors then you guys should not interfere period!

Those in attendance were unable to connect where this kind of hate was brewing from. There appears to be a growing sense of gratification if someone is involved in violence and more so if the attack is on an outsider.

Young men and women are in a state of hopelessness and powerlessness. In September 2019 youths participating in a conflict management training vented about a number of issues. In their analysis of conflict and power, participants talked about structural violence and horizontal violence. On horizontal violence, they raised concerns about state use of excess force to deal with young people. Issues of extra judicial killings and continuous police harassment were discussed. In addition, participants talked of how youths have lost their self and social esteem and suffer from psychological and emotional traumas without redress. This has pushed some of them into a state of powerlessness. A youth participating in the discussion exclaimed:

No wonder, nowadays boys in our hood are joining Islam in big numbers – and not for faith matters but in order for them to be buried as soon as they are killed. We don’t want to put our mothers into the burden of fundraising for funerals…

Gender inequity

The SDI Kenya Youth Safety and Market Survey Focus Group Discussion in Kisumu interrogated the issue of sexual and domestic violence. In one of the responses young women claimed that, dealing with the issue was complicated given the political protection the male perpetrators enjoyed. One woman said:

A lot of times I feel sexually harassed by the same young men who hang in a base (a place where three or more young people meet and is perceived to be a gang space) near our house. My father is helpless, and all our neighbors are scared you might be raped. They did that to another woman, and nothing was done to them. I am scared to confront them since I don’t want them to attack my parents. I am hoping one day, they will get to be arrested.

Efforts by civil society and the local administration to curb domestic violence has not yielded results raising doubts as to whether residents are just coping with the situation or helplessly accepting the problem. A recent case in the media of a woman who had been stabbed 14 times by her husband left many surprised when she went to court to state that she had forgiven him and wanted him released so that they can continue with their marriage. Are people giving up in regard to justice systems or are they afraid of losing their loved ones?

Courage for the future?

Those who have the courage to deal with the issues do not get enough support from those mandated to do so. The health and wellbeing of the community is slowly deteriorating as segments of slums become occupied by young men who women who have given up with themselves, the community and the state.

In Mathare, Korogocho, Kibira or Mukuru slums you will find young people occupying structures/houses that are along the riparian or edges of the settlements away from the main streets or open spaces. “We appear once on the road to harvest and then disappear again. We know the police will kill us and the community will celebrate our death. We don’t care!” a young person in a focus group discussion claimed.

Unpacking these challenges, requires a multi-sectoral approach and multiple stakeholders who will stand in solidarity with the community. The approach to address the inequity, injustices and lack of accountability and responsiveness by those with the mandate to tackle injustice should be systematic and must engage those living in affected neighborhoods. In Kenya, 70% of the population is below ages 35 years old therefore making slums more of youth dominated zones. The solutions should be youth-led and must restore the dignity, sense of worth and power to plan and manage resources in addressing their own problems and opportunities.

Photo credit: worthbak under a Creative Commons Licence