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Health and wellbeing at WUF

Urban public spaces for play and wellbeing?

By Dolf te Lintelo

The Tenth World Urban Forum (#WUF10) took place in Abu Dhabi earlier this month. Hosted by UN-Habitat, the human settlements arm of the United Nations, this biannual gathering brought together over 13,000 professionals, practitioners, policymakers and researchers over five days. It offered a rich variety of panels, discussions, and wider exhibitions on current trends and issues relating to the topic of Culture and Innovation in cities.

Partnerships towards an inclusive culture of health in cities

My focus at the conference converged around the themes of informality, urban displacement, and wellbeing, and I was privileged to speak on three panels. The first panel was entitled Partnerships towards an inclusive culture of health in cities. Together with Margaret Bayo from Slum Dwellers International (SDI), Sierra Leone, and Caroline Kabaria from the African Population and Health Research Centre (APHRC) in Nairobi, we represented the ARISE Consortium, which jointly hosted this networking session with the Stockholm Environment Institute (SEI) and the International Science Council (ISC). The session focused on urban health and wellbeing in relation to informal settlements and the urban form.

In this session, Jo Boufford (ISC) noted the paradox that despite the importance of the built environment for shaping health outcomes, at the global level, policymakers often don’t understand urbanism. Consequently, they frequently end up thinking about healthcare, not about the broader determinants of health in urban contexts. Jo further highlighted the necessity of urban planning schools to engage more with communities as co-planners.

My presentation outlined how the ARISE programme seeks to work closely with communities in urban informal spaces in Kenya, Sierra Leone, Bangladesh and India to identify their perspectives on what constitutes wellbeing, and how existing political economic relations and accountability dynamics shape health and wellbeing outcomes for diverse groups. Caroline Kabaria then discussed the opportunities and challenges in obtaining good quality data in these settings, whereas Margaret Bayo shared experiences on how women’s savings groups in Freetown slums helped to organise communities, communicate health messages, and conduct research to effectively engage the municipality and mobilise improved services.

Finally, Diane Archer (SEI) presented important new research that explored wellbeing in relation to urban green spaces in Thailand, to find that the latter are often scarce, and increasingly privatized. However, malls and other pseudo-public spaces are often used in similar ways to public spaces, which raises the question: do these spaces also provide important wellbeing services to city dwellers, and if so, how can we account for these? This work also entailed innovative methods to assess not just mental but also bodily perceptions of, and satisfactions with, particular urban spaces by monitoring heart rates and stress.

Harnessing public urban spaces to increase wellbeing

Diane’s was one in a rich seam of presentations across the WUF10 that paid attention to wellbeing in relation to urban public space. As a principal investigator on current research projects investigating placemaking, displacement, urban infrastructures and wellbeing – Displacement, Placemaking and Wellbeing in the City (DWELL) and Wellbeing, Housing and Infrastructure in Turkey (WHIT) – these had my special interest.

In many of the sessions, discussion focused on designated planned use and design, with examples ranging from upgrading a street, a market or a square, to totally reclaiming street spaces by banning cars and repurposing parking spaces as terraces and play areas for the benefit of pedestrians, children, the disabled and the elderly. Such public spaces were presented as prospectively beneficial to urban populations – for instance in cities like Brussels (Belgium) or Lima (Peru) – as they could foster cross-cultural interaction, harmonious relations, reduce insecurity and achieve civic trust that is essential to liveable cities. Public spaces are perhaps most important for children, whose access to these spaces has a big impact on their health and wellbeing, but public spaces also have important benefits for the community at large.

Some speakers argued that political leadership on urban planning and good urban design could have important effects on the community. For example,  providing suitable lighting in parks invited night-time use by the community and a feeling of safety, but using popular types of paving stones such as cobbles (much used in European cities) inhibit less mobile groups (for example, the elderly or disabled) from getting to and using these spaces.

Much will depend on whether planners and designers take active cognizance of current users of such public spaces, and for what purposes. In a nice training on ethnography of public spaces, Setha Low (City University of New York) explained that when shoeshiners were removed from Latin American parks to make way for better material structures that did not accommodate them, youth gangs soon took over the park, making it extremely unsafe. Planners had failed to acknowledge that street vendors play a critical role in keeping a watchful eye on what happened in the park, providing support to people, and therefore had provided safety through their presence.

Anandini Dar (a colleague on the DWELL project at Ambedkar University Delhi) noted in her talk on migrant children’s placemaking in informal settlements that in many cities of the global south, such as in India, development visions tend to exclude children from public spaces. Where city governments are unwilling or unable to support public infrastructures in informal settlements, planning and design take a backseat. Intriguingly though, some research in Delhi shows that children favour unkempt parks to formally designed play spaces, as children resist conforming and reinvent spaces in accordance to their own needs for play. Dar’s research also finds that informal settlements themselves pose many opportunities for spontaneous play and wellbeing, offering some nuance to the stories of horror, unsafety and harm that are stereotypically used to label such settlements.

Does this then mean that these children should be left to their own devices? Far from it. Children, and their capacity for imagination and play, must be recognised and become an active part of public planning and design. This could shift focus away from providing highly structured places and objects of play to shape urban environments that encourage playfulness for wellbeing.

Piles of plastic on a dump site

Single-use soft plastics – an ever-lasting and hard problem

By JK Lakshmi

The prospect of a national ban, or at least discouragement, of single-use plastics in India is welcome. The obvious targets are disposable shopping bags, utensils (containers and cutlery), and disposable water bottles. But single-use plastics have made their insidious way into our lives in other goods where they are not so obvious. Wrappers of virtually everything ready-to-eat, not-yet-ready-to eat, and never-to-be-eaten are composed of single-use plastic. Manufacturers, distributors, vendors, and buyers of most retail products have a huge shift to make in their thinking and practice if they are to successfully eliminate plastic wrapping. Another arena that uses single-use plastic to signal hygiene is the restaurant/fast food industry that generates hillocks of transparent gloves and caps in food service. The ‘flex’ banners that people print and put up to announce everything from the birthdays of their idols to directions to the toilets at a conference are mostly unusable for another occasion.

The examples here are all of plastics that are best avoided, but still find a few voices to defend them in that they can, in theory, be recycled, although the majority of them are not, in practice. ‘In theory’ because even after people carefully segregate their waste at home or in offices, they often come up short against recyclers or scrap-dealers who do not accept soft plastics, as their trade is not very lucrative. As for the unsegregated waste dumped in public places, waste-pickers choose among the recyclables to collect the most lucrative categories of waste, and soft plastics clearly do not make much economic sense for them to toil over. This leaves the big bulk of soft plastics to make their adverse journey to water bodies, or animal bodies, or end up in unhealthy fires. The big question before us on this is how, when the trajectory of used plastic is not assuredly environment-sensitive, and is on the contrary, practically guaranteed to be environment-degrading, governments can let the production and circulation of soft plastics go on.

But, in addition to these products that are clearly single-use plastic for all to see are some products that incorporate single-use plastic so seamlessly into a multicomponent object that they may not be perceived as single-use plastics – a case in point is the typical commercially produced menstrual absorbent pad. This is a product that places convenience (not necessarily comfort) above all else, certainly above ecological health, and in most cases, over economic health too. Its greatest attraction is that it doesn’t need to be assembled before use, and disassembled or cleaned after use either. But the price for this convenience is paid by the environment.

Unlike in some of the pads in the past where the plastic shield could be removed after use, and the plant-based absorbent disposed of in household garbage or sewage, the pads of today are not amenable to disassembling and disposal via composting, and reuse or recycling. This means that by virtue of being part of a pad, plastic that could have been recycled, and absorbent material that could have been composted do not take those routes, but contribute together to garbage dumps, mass for open burning or incineration, and landfills, and also, often, to the detriment of wildlife through ingestion or inhalation. This is undoubtedly too steep a price to pay for the convenience of peeling off and dumping a pad after use. This holds true for diapers too, the difference being in the composition of the material contained (menstrual discharge/urine/stool), and also in the compactness of the product (diapers being bulkier than menstrual pads).

A concerted effort is called for to put an end to this dangerous practice:

  • Policies need review and reformulation –- for waste segregation at source; clear and economically sound pathways for the recycling of all waste that cannot be composted; and composting of all compostable waste to annihilate garbage dumps and landfills –- to fully realise the intent of the ban on single-use plastic;
  • Manufacturers of one-time use pads and diapers need to develop more environment-sensitive and user-friendly products, and guide users on post-use treatment; and
  • Users need to contemplate the ramifications of their choices of product and post-use treatment processes, and resolve to follow less ecologically profligate ways.

This blog was first published on Animol Planet and is reproduced here with permission.

Participatory mapping in Sierra Leone

Participatory predicaments: Inclusion, safety and capitalising on community strengths

By Kim Ozano, Abu Conteh, Laura Dean and Kate Hawkins

ARISE will engage with communities in participatory method design, data collection and analysis to develop priorities and actions. To make this a reality we are debating the community based participatory approaches we will use. It’s a rich and challenging discussion! In this blog we outline some issues which are taxing us. How can we build on existing community strengths? How can we ensure that the most marginalised community members are included in our research? What safety challenges will we face in the research process? So, if you have experienced any of the same dilemmas, please comment below. It would be great to talk and share experiences!

How to build on existing community structures

ARISE wants to engage and work with existing community structures and processes. However, how to do this is not straightforward. We have had a lot of discussions about the best way to introduce the project and how to capitalise on the strong work that is already underway in relation to accountability and health.

Researchers and co-researchers (their community counterparts) recently met in Sierra Leone. There is a lot going on in the informal settlements of Freetown. Community members are actively collecting data contributing to local development and advocating for change. Because of this, co-researchers wanted to take advantage of these pre-existing structures in the ARISE research. They felt very strongly that setting up parallel ‘research specific’ systems was risky because they might not properly respond to the situation in informal settlements.

For example, representatives from the Federation for Urban and Rural Poor (FEDURP) believed members who are community mobilisers would be good at raising awareness and explaining the purpose of the research. However, communities didn’t always think these community mobilisers were ‘trustworthy’. As a result, other FEDURP members – who are passionate about accountability and health – might be better at data collection or facilitation. These passionate change makers need to be identified by community members as opposed to being handpicked by powerful community members. We discussed how incentives can compromise organic processes to identify change makers and should only be offered later in the research process. Therefore, the process of selecting co-researchers was systematic, trying to select the best from FEDURP, community representatives and community mobilizers. Selection was based on skills such as facilitation, mobilization, community activism and awareness raising skills, particularly on health.

Defining researchers, co-researchers and participants

FEDURP felt part of the ARISE research consortium, particularly as they had been part of the original consortium planning process. They were confused about whether this made them co-researchers or researchers. FEDURP is a representative organisation for people living in informal settlements. Does this immediately make all its members co-researchers? If FEDURP is a core-part of the ARISE family, should all co-researchers in Sierra Leone be members of FEDURP? Members of FEDURP, who also live in informal settlements, became further confused when they considered that they could also be ‘participants’ in the research process.

As we moved through our conversations it became clear that co-researchers should not be considered a uniform group with a ‘one-size fits all’ definition for their engagement, roles and responsibilities. Community members and organisations might move through different positions/spaces of participation in a fluid way. Co-researchers and researchers must develop trust with each other, the process cannot be forced or pre-designed, rather organically developed alongside the research.

How to facilitate the engagement of marginalised groups

Pre-existing community platforms for engaging co-researchers are unquestionably valuable to a new research project like ARISE. However, we want to ensure that marginalised or vulnerable community members are equitable participants in the process. These people may be less able to participate in pre-existing community development and advocacy. So, we will need to look for new ways of engaging to make the process inclusive.

We have been grappling with the dilemma of what to do when marginalised groups are disempowered and as a result unable to participate as co-researchers. Co-researchers – who have local knowledge on what is feasible and acceptable – could adapt participatory methods to better engage marginalised groups. Getting a better understanding of how marginalised groups like to communicate (e.g. through storytelling, drama, drawing pictures) and working with them to create outputs may help them feel more empowered. Informal discussions and ethnographic observation – interacting with marginalised groups in their own settings – might spark ideas. We also considered using ‘gatekeepers’ (or powerful people or institutions who provide an entry point to marginalised communities). For example, disabled persons organisations will usually know how to communicate with their constituency and support their participation.

Working with children and young people

Children and adolescents in urban informal spaces are often vulnerable to ill-health and have difficulty accessing accountability. However, we are concerned about how to ensure that we have a clear process of consent for their engagement in the research. Often children do not have a parent or guardian that can agree to their participation. We must strike a balance between the democratic principles of participation and empowerment and the ethical challenges of appropriate management, support and protection. Collaborative projects with young people are key to understanding their experiences of health and well being. But young people are often excluded from, or left out of, research projects.

Other marginalised groups

People with cognitive or intellectual disabilities may not be able to provide consent through conventional processes and we will need to account for this in the way we work. Sex workers and  LGBT people may not want to be involved because they don’t want to be identified. These groups might be reached through community agents who have connections with them. We will continue to explore this ongoing dilemma during our research.

How to minimise risk and harm

We want to ensure our work is ethical and that people are safe. Community members and co-researchers might be put at risk if: tensions arise about the choice of co-researchers; communities are hostile to data collectors; or the findings of the research cause ructions.

Our discussions have thrown up a number of strategies to mitigate risk. We will involve communities in selection of co-researchers. That way they have ownership over the process and are more likely to support the research. We will try and be open and transparent in our working practices – communicating our intentions and the process. Research teams will keep an open dialogue going to keep abreast of emerging risks. It is important that ethics and safety are central to researcher training on participatory methods. They will be are aware of the boundaries of their role as researchers and put the safety and wellbeing of communities first.

Concluding reflections on participatory research

As ARISE is rolled out, we are thinking critically about power and participation. What does this mean in practice and in terms of generating equitable research partnerships?  We are particularly keen to disrupt the balance of power between ‘researchers’ and the ‘researched’. Working through ethical dilemmas together and documenting this process will help us to learn and share with the wider research community.

There is no single blueprint for participatory research. It is a process rather than a set of uniform steps with predictable outcomes. Because we all come from different starting points, we have created an internal community of practice to exchange ideas.

We welcome, through the comments below this blog, insights from others who have experienced similar dilemmas.

World Urban Forum in Abu Dhabi

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.

Mukuru community health mapping

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 exerciseIn 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 MukuruA 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 MukuruDuring 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.

Upgrade consultation research

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 garbageMost 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

A member of FEDURP CODOHSAPA researching relocation options in FreetownGoing 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).

Relocation colony in Ahmedabad

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

Relocation Colony at Natwar Parikh Compound 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?

 

Bangladesh stakeholder workshop

“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.

COPASAH audience

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.

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

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