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This blog by Sweta Das and Parvathy Breeze explores the findings of a health survey in Maharashtra Housing and Area Development Authority. They list the reasons that marginalised community members avoided public health services, instead paying out of pocket for less conveniently located support from the private sector.

In Mumbai, an area with high population density and diverse socio-economic backgrounds, primary healthcare centres play a crucial role in ensuring that cost-effective healthcare services are accessible and equitable. These centres cater to a wide range of people, from children to the elderly, providing essential healthcare services and promoting overall well-being in the community.  Primary health care centres are often referred to as ‘dispensaries’ or, in the context of Mumbai, ‘Suraksha’. They offer a comprehensive range of services, including preventive and curative care such as general check-ups, immunizations for both children and adults, treatment for common ailments, health camps for early disease detection and health education initiatives. They also provide vital maternal and child health services and are key in generating awareness and disseminating information about communicable and non-communicable diseases within the community. Surakshas also provide low-cost treatment, medicines, and even certain diagnostic services. Primary healthcare institutions are essential pillars of hope, ensuring the fundamental right to life and healthcare for every citizen in need.

SPARC and Mahila Milan (a woman led collective) conducted a health survey in a Maharashtra Housing and Area Development Authority (MHADA) colony of Vashi Naka in Mumbai. They found that most residents prefer using private clinics rather than using the nearest public dispensary, even for minor health ailments and services. They do this despite the high out-of-pocket expenditures required to use private services, that in some cases even mean taking out formal loans or borrowing money from friends and relatives.

We looked into why this would be, to gauge if there were any possible interventions that we could assist with. We spoke to various members of Mahila Milan, and spoke to the in-charge and other staff at the public dispensary. We documented the challenges that community members face when accessing the public dispensary, and the issues that hinder the medical personnel from catering to the healthcare needs of community members.

Key factors that discouraged community members from seeking health care at the public dispensary

Long waiting periods

Rekha*, a member of Mahila Milan, said, “This public dispensary in Vashi Naka used to operate between 9am and 1pm only. That is too little time to cater to people from so many areas like Bharat Nagar, Ashok Nagar, Hashu Advani Nagar, Shastri Nagar and Rahul Nagar.”

People often ended up in serpentine queues waiting for hours at a stretch, not just in the outpatient department but also in the emergency rooms. “Community members told me about this one instance when they took a young ailing girl to the emergency room and were asked to wait in a really long queue. They had no idea how long they were supposed to wait,” recalled Rekha. Some people even reported being turned away without a consultation and were asked to return the next day.

Dismissive behaviour from medical staff

People visiting the public dispensary said staff were cold and unapproachable. Some people were yelled at for not maintaining proper queues. Others were met with far more disrespect and indignity. Bharati, a member of Mahila Milan, was told that patients have even heard derogatory remarks like,“Nahaake nahi aate toh bimari hoti toh hai, usme koi badi baat nahi hai,” (When you come here without showering, it is not shocking that you have some disease).

In fact, when we asked Dr. Maya*, the doctor in charge at the dispensary, about such statements, she said, “These people chew tobacco and argue for medicines here. Inke wajeh se bahut zyaada population bhi hai” (they are the reason for the increasing population too). The conversation clearly indicated that the patients were being discriminated against and perceived as slum dwellers living in unhygienic spaces.

Shortage of resources at the dispensary

There are not enough medical staff at the dispensary. Several people left with their children without treatment because there was no paediatrician available.

The dispensary pharmacy lacked medicines, especially for ailments related to blood pressure and diabetes. We found that an elderly patient was denied medicines and treatment for blood pressure, and asked to try again later.

A community leader from Vashi Nak identified the critical need for intervention to improve the dispensary’s conditions. They recognised the need for an intervention when the group attempted to access the TB patient list and identify the whereabouts of these patients. This was done as part of the ARISE project, which focused on identifying and aiding the most vulnerable TB-affected families with ration support. During the team’s initial visit, there was no consulting doctor present. On their subsequent visit, they were denied access to the patient list and instructed to return with a letter from the Medical Officer (Aarogya Adhikari) of the ward. These challenges underscored the urgency of transforming the dispensary to better serve the community’s healthcare needs.

Accountability-seeking initiative

After having heard such narratives from community members and having observed the functioning of the dispensary first-hand, SPARC and Mahila Milan decided to seek accountability from governance actors.  Mahila Milan, with the support of SPARC, wrote a letter highlighting these concerns to the Head of the Department of Brihanmumbai Municipal Corporation (BMC) – the governing civic body of Mumbai.

This resulted in a meeting being held between the health officer of the ward and members of Mahila Milan to discuss the challenges and issues pertaining to the functioning of this dispensary. In the meeting, the Mahila Milan leaders talked about the health camps conducted in different areas and the issues related to the dispensary located in Vashi Naka and Maharashtra Nagar. One of the important aspects discussed by the leaders was the availability and accessibility of a gynecologist in the dispensary. In response, the Medical Health Officer mentioned the ongoing work on the transformation of these dispensaries. As a response the Medical Health Officer asked the leaders to visit Kokriakar dispensary where the in-charge of appointing the gynecologist sits so that they can urge the in-charge to station one in the area. There was a sense of assurance and support that was given by the Medical Health Officer. And asked the leaders to keep conducting the health camps in M east ward.

On a visit to the dispensary a few months later, Mahila Milan found some of the necessary changes had been made. Mahila Milan member Bharati said, “Now the working hours of the dispensary have been extended until night, with two shifts of the out patient department services in mornings and evenings. They have also made arrangements for the waiting patients to be seated instead of standing in the queue.” She also found that a list of doctors and their designated consultation time was put on public display, a diagnostic lab was introduced and the pharmacy was better stocked.

Dr. Maya also corroborated these improvements as part of the new upgrade scheme called  HBT (Hinduhridayasamrat Balasaheb Thackeray) which targets the effective working of the dispensaries, which began on the 2nd of Oct 2022. by the BMC. She said, “We have newly recruited specialist doctors like paediatricians, dentists, gynecologists, and dermatologists. We also have separate doctors appointed for the out patient department services.”

Perspectives of the medical personnel

While we wanted greater accountability from governance actors for better functioning of the dispensary, we felt it was equally crucial to hear the perspectives of the medical personnel as well.

Ramesh, a staff nurse at the public dispensary, told us that the lack of adequate staff hindered their ability to properly manage and treat the large number of patients visiting the dispensary. “But, some patients also create chaos and make things difficult for us. Some of them fight in the queue with each other and with the staff. Some of them just refuse to maintain silence. And, then there are also the ones that spit tobacco on the premises of the dispensary. This is all very triggering for us here,” he explained. For him, this could be the reason behind some of the health staff behaving indifferently towards the patients.

Dr. Maya told us in an interview, “The working hours of our dispensary have been extended to two shifts and a diagnostic centre is also set up now. This is all part of a new State government scheme for effective working of public dispensaries.”

Services provided at the dispensary now include out patient department services, specialist consultations with gynecologists, dermatologists, dental services, paediatrics, dieticians, a low-cost general diagnostic laboratory, pharmacy, dressing room, and a DOTS centre. Medical staff present in the dispensary now include one Medical Officer in charge, a GNM (General Nursing and Midwifery), a multi-purpose health worker (MPW), a data entry operator, a lab technician, and a pharmacist. Even the evening shift is now staffed properly with one doctor in charge, GNM, MPW, lab technician, and pharmacist.

When questioned about the major challenges faced by the medical staff, Dr Maya said, “So far, the biggest issue is catering to such a large population with just one doctor and so few medical personnel here.”

With not enough dispensaries in the vicinity to cater to the population in the area, they face a large crowd of patients every morning. “It’s overwhelming for us doctors as well. I have to handle more than 150 patients a day,” she said. She also explained that the doctors at the dispensary are overburdened with a plethora of tasks like attending to patients, record keeping, attending various meetings and training and even visiting other institutions when needed.

In more than two decades of experience in healthcare institutions in Mumbai, Dr. Maya has seen a gradual increase in the number of dispensaries and their working hours. “It is great to see that, for sure. But, this has been a slow process because of the lack of space and funds allotted for construction and upgrading of dispensaries. I believe we have a long way to go before the number of doctors and dispensaries is made proportional to that of the patients,” she explained.

She said the extension of the working hours of this dispensary in Vashi Naka is beneficial for the patients, especially for women as they often tend to be busy with household chores in the mornings. Women are also relieved that this dispensary now has a gynecologist available twice a week.

The lack of resources, such the shortage of medicines at the pharmacy, equipment in the dispensary, and frequent power cuts affect their ability to meet the needs of the patients. “Patients shout at us when they do not get medicines from the pharmacy here. How do we even make them understand that there is an acute shortage of medicine?” said Dr Maya. “We also have our own limits in terms of providing facilities and services. Sometimes, the way patients behave with the staff and get impatient, it gets overwhelming for us. And, there are no security personnel for us,” she added.

“I have been raising these concerns and issues to the higher authorities because I strongly feel a resolution would help us make the dispensary a lot more effective and efficient,” she said.

She acknowledged that dispensaries act as the primary point of contact for the communities to address their health needs. Without accessible and affordable dispensaries that can duly cater to the community’s needs, the spread of private multi-specialty hospitals is inevitable, and consequently so is the rise in out of pocket expenditure for the community.

Conclusion and the way forward

Conversations with medical staff, community members, and members of Mahila Milan revealed the many structural and systemic problems that hindered the proper functioning of this public dispensary. However, problems like a lack of dispensaries, poor ratio of medical staff to patients, lack of funds for resource-based needs, improper and/or discriminatory behaviour towards patients, inadequate attention to patient needs like medicines and diagnostics, are not specific to this dispensary alone. These, unfortunately, characterise the broad range of problems that plague most public health care systems.

Without systemic interventions and political will to improve public healthcare systems, the socio-economicly marginalised are being pushed to penury by accessing healthcare services at private clinics. Dispensaries like this one in Vashi Naka act as the primary point of contact in terms of healthcare, and timely solutions will help the community access good, low-cost healthcare facilities and services. Our experiences and conversations at the dispensaries and with the community tell us that it is not enough to just build more dispensaries or allocate more resources.

This case study stemmed from the conversations that happened during the health survey undertaken by SPARC and Mahila Milan. Our learnings, observations, and recommendations then coalesced into intervention efforts for an improved functioning of the dispensary. And, while we acknowledge that our letter to the governance actors is far from being the only factor that paved the way for the changes noticed in the dispensary, we do think this sheds light on the possibilities for how health systems could see significant improvements when civil society organisations and communities come together to identify challenges and then seek accountability and/or advocate for improvements.

*The names used in the blog are pseudo-names to protect the individuals’ identity

Earlier this month colleagues from across the consortium attended the International Conference on Urban Health in Atlanta, USA. The team pulled together a fascinating panel presentation that looked at intersectional analyses from across the ARISE consortium. The panel consisted of colleagues from across the consortium, and our four focus countries and was well attended by delegates from across the world.

The panel was chaired by Dr Surekha Garimella of The George Institute for Global Health, India. Surekha started the session by outlining how globally, more than half of all people live in urban areas and 60% are projected to do so by 2050. She explained that one in three urban dwellers now live in precarious, marginalised areas, including informal spaces; an estimated 881 million people in low- and middle-income countries. She also spoke about how the nature of informality and the unequal power relations present in society deny people their human rights and entitlements and result in structural violence.

Surekha said, “Within ARISE we want to focus on tackling the social and political systems that shape these issues, ultimately addressing issues of structural violence.” She explained how one of the consortium’s core principles is using an intersectional approach to understanding health and wellbeing, moving beyond the single axis framework that is dominant and drawing inspiration from African American colleagues and activists that developed this approach.

Surekha went on to explain how people are shaped by their simultaneous membership of communities and the interaction between these interactions and connected systems of power. That power manifests in many ways and actions, and recognition of the inequality of power is central to our understanding of intersectionality. Throughout the presentations from colleagues we shared examples of multiple forms of vulnerability and how we make sense of it all.

As a consortium, we really wanted to make sure we brought the voices of the communities we work in, and the co-researchers we work with, to international gatherings such as ICUH. Surekha’s introduction was followed by videos from co researchers in Bangladesh, Kenya, and India, sharing their experiences and telling their stories. We heard from Miriam Abwanda, a deaf woman living in Kenya; Sanjoy Kumar Sanz, a male co-researcher working with us in Bangladesh; and Rupa Khatri, a female waste worker in Shimla, India.

Samuel Saidu from COMAHS, Sierra Leone talked about his PhD research around the health seeking behaviours of young people living in informal settlements in Freetown. He also centred the voices of his co researchers and community members. A young man from Moyiba, discussing how he would define health and wellbeing said, “I think [a young boy’s] health is defined as the state in which I can care for myself when I am sick and when I have no diseases or bacteria affecting my body.” While a young woman from Cockle Bay said, “Wellbeing is when I can do everything myself especially when I am not struggling to pay school fees or what I should eat for the day. I can do everything for myself without getting others involved with my burden.”

Inayat Singh Kakar of The George Institute then spoke about the experiences of women waste workers in Shimla, India. She explained how, despite women making up the majority of the door-to-door waste workforce, decisions on demands and strategy are largely taken by men, with issues specific to women often missing from the demands of the collective. Inayat spoke about how ARISE worked to create spaces where women could lead, through consistent dialogue between women workers and researchers and exposure visits and interactions with collectives led by women.

We then heard from Kenyan colleagues, with Linet Okoth presenting on behalf of her LVCT health colleagues Inviolata Njoroge and Robinson Karuga. The presentation focused on the experiences of people with disabilities (PWDs). Linet explained that approximately 5% of Kenyans are PWDs, that health inequities arise from unfair conditions faced by persons with disabilities, and health access for PWDs is even more constrained due to limited resources. The experiences of PWDs were further explored through the community based participatory research approach Photovoice.

Next, we heard from Bachera Aktar from the BRAC James P Grant School of Public Health at BRAC University in Bangladesh. Her presentation focused on the intersectional gender analysis of factors influencing access to healthcare among women living in informal urban settlements undertaken by ARISE. Bachera spoke through the methodology and key findings, as well as the intersectional factors influencing women’s access to healthcare, weaving in the voices of respondents.

A community researcher in Kollyanpur said, “Many girls in our area suffer from genital infections and menstruation-related problems but are hesitant to discuss with their parents, and cannot also seek treatment because of embarrassment. As a result, those minor problems gradually become major health risks over time.”

Finally we heard from Abu Conteh from Sierra Leone Urban Research Centre on his PhD research looking at how infectious disease and non-communicable diseases (NCDs) impacting the poor, particularly in fragile settings. Abu also discussed the impact of COVID-19 in areas already under pressure, and how health outcomes are already precarious in informal settlements; influenced by intersecting inequities.

We are so glad to have had the opportunity to share our work with an international audience, and have been able to centre the voices and experiences of our co researchers and communities and highlight the importance of an intersectional analysis of inequity and marginalisation.

Art can be a powerful tool for storytelling, experience sharing and a catalyst for change. As well as the wealth of research produced by the ARISE consortium, over the course of the project we have also worked with local communities in informal settlements to tell their stories through various art projects.

Conversations around urban health can sometimes take place without strong representation of those from urban informal settlements and the Global South. We wanted to bring the voices of these underrepresented communities to ICUH 2023 through a multimedia exhibition showcasing photography, video and audio presentations from communities in our focus countries of Bangladesh, India, Kenya, and Sierra Leone. We invited conference attendees to drop in to this creative space, and learn more about our work, hear the stories of the communities we are working with, and meet our colleagues. Below you will find details of the different creative projects included in our showcase.

Photography projects

ARISE Photovoice project – Nairobi, Kenya

This exhibition was created using a selection of images from a Photovoice project undertaken with  community members and co-researchers, living in Korogocho and Viwandani informal settlements in Nairobi, Kenya.

Co-researchers gathered images, which were then coupled with in-depth interviews, which allowed for deeper understanding of the images. The whole process was consultative and co-creation with diverse community groups helped us to unearth important themes and priorities in the research work.

The exhibition is a selection of some of those images which help describe the experiences and priorities of people living in informal settlements. The images, taken by older people, community health volunteers, people with disabilities, and children who head households, cover themes such as environment and utilities, water and hygiene, work and education, health, disability and accessibility.

Waste pickers and mosquito-borne disease: A photovoice project in India

Waste pickers in India are extremely vulnerable to a range of health problems due to their poor living and unsafe working conditions, and struggle to access the health services they are entitled to. This research uses a community-based participatory research method and focuses specifically on mosquito-borne diseases in two districts of Andhra Pradesh, exploring how they impact the lives of waste pickers, the extent to which waste pickers are reached by preventive interventions and potential opportunities for better prevention and control of these diseases.

Photovoice was used to understand community perspectives, highlighting how issues such as poor housing, inadequate water supply and lack of drainage increase waste pickers’ vulnerability. Disconnection from the health system and local government impacts the ability of waste pickers to access preventive interventions and seek care. This project was led by Bea Egid and Pavani Pendyala.

Lives During the Pandemic in Urban Informal Settlements: A photo project from Bangladesh

Photographs included in the Lives During the Pandemic in Urban Informal Settlements photobook were taken with community members from Green Land (Khulna), Bajekazla (Rajshahi) and Shyampur (Dhaka) communities. It tells the stories of how most marginalised people in urban informal settlements of Bangladesh were affected by the COVID-19 pandemic, and how they came together to respond to the challenges.

This action was stimulated and facilitated by ARISE project and is one element of the project’s research supporting health, wellbeing and accountability. The stories are emotional, and they draw on memories of the initial phases of COVID-19. They also offer hope, documenting how communities can provide social and material support in times of strife.

Shadowing waste workers on their waste-picking routes in Vijayawada, India: Photo essay

Located on the banks of the Krishna river in the Indian state of Andhra Pradesh, Vijayawada is the second largest city in the state by population and the third most densely populated urban built-up area in the world, with around 31,200 people per square km.

As with most cities, Vijayawada has a waste disposal problem. Waste pickers working in the informal sector in Vijayawada are scattered across the city and live in slums, some even live on the fringes of these slums. Shrutika Murthy shadowed waste picker ‘Suvartha’, in the hopes of further understanding her work and experiences, while Prasanna Subramanya Saligram shadowed waste picker ‘Kishore’. Both Shrutika and Prasanna are part of The George Institute for Global Health India.

Documentaries

ARISE documentary – Freetown, Sierra Leone

This short video documentary filmed in Freetown, Sierra Leone, documents the approach and impact of the ARISE project in informal settlements.  Our five-minute film looks into ARISE work on health accountability and community empowerment, the role of community members as co-researchers in our participatory research approach, and how we have worked to document the realities of life in informal settlements.

Power of Light documentary – Freetown, Sierra Leone

To celebrate the 125th anniversary of Liverpool School of Tropical Medicine, world renowned artist Luke Jerram worked to install 21 solar powered LED streetlights in the informal settlements of Freetown, Sierra Leone in collaboration with ARISE. We installed the permanent lighting in public areas including water collection areas, alleyways, and toilets.

The Power of Light documentary follows the project, as Luke and the ARISE team collaborated with local artists to create paper lanterns around ARISE themes of safety, education, work, play and pride, they were paraded through Freetown as part of a street lighting opening ceremony.  The 60 small LED lights used to illuminate the lanterns were then given away to the participating children afterwards enabling them to navigate at night more safely and do their homework in the evenings.

Water, sanitation and hygiene in Kenya’s informal settlements – Nairobi, Kenya

This video, filmed in Korogocho and Viwandani informal settlements in Nairobi, looks at the issues surrounding water, sanitation and hygiene in Kenya’s informal settlements.

Life and wellbeing in the slums of Dhaka – Dhaka, Bangladesh

This short documentary provides an insight into life in the informal settlements of Dhaka.

Audio projects

Songs of the waste workers – various cities, India

ARISE partners worked with professional artists to record awareness raising songs, sung by waste workers in India. These songs discuss themes of housing, sanitation, safety at work and workers’ rights, among other issues that effect this vulnerable population. The songs are played in the background of our videos about shadowing waste workers in Vijayawada.

We are excited to say many of our ARISE colleagues will be attending or represented at this year’s International Conference on Urban Health taking place in Atlanta, USA, from the 6^th to the 9^th of November. Our team has had a number of panels, presentations, workshops and posters accepted. We are also going to be showcasing some of the incredible art that has been created with communities across Bangladesh, India, Kenya and Sierra Leone as part of our research. Scroll on for more information, and we hope to see you there!

ARISE ICUH SCHEDULE 2023

ARISE Exhibition

Research, Art and Storytelling: A showcase of art produced as part of the ARISE consortium

Tuesday, 7 November, 2023 • All day drop in

Room: Old 4^th Ward

Art can be a powerful tool for storytelling, experience sharing, and a catalyst for change. As well as the wealth of research produced by the ARISE consortium, over the course of the project we have also worked with local communities in informal settlements to tell their stories through various art projects. Conversations around urban health can sometimes take place without strong representation of those from urban informal settlements and the global south. We would like to help bring those voices to ICUH 2023 through our exhibition. Our multimedia showcase will feature photography, video and audio presentations from communities in our focus countries of Bangladesh, India, Kenya, and Sierra Leone. Feel free to drop in to this creative space, learn more about work, hear the stories of the communities we are working with, and meet our colleagues.

ARISE Panel

Voices and Challenges of Marginalised and Vulnerable Groups in Urban Informal Settlements in Nairobi, Kenya: Building on a spectrum of community-based participatory research (CBPR) approaches

Tuesday, 7 November, 2023 • 10.45 – 11.45am

Room: Sweet Auburn

This session will discuss the social and economic disparities facing urban populations in African cities and the impact on their health and wellbeing. Presenters will share research findings on intersecting marginalities and vulnerabilities among the urban poor in rapidly urbanising cities in Africa.

Authors: Caroline Kabaria, African Population and Health Research Centre, Nairobi, Kenya; Robinson Karuga, LVCT Health, Nairobi, Kenya; Ivy Chumo, African Population and Health Research Centre, Nairobi, Kenya; Blessing Mberu, Department of Demography and Population Studies, University of Witwatersrand, Johannesburg, South Africa.

ARISE Panel

Combating disparities and driving health equity in urban informal settlements across Bangladesh, India, Kenya and Sierra Leone: Intersectional analyses from the ARISE consortium

Tuesday, 7 November, 2023 • 10.45 – 11.45am

Room: Buckhead

The ARISE hub seeks to understand and address linkages between urban informalities and health well-being outcomes for those living in urban informal settlements. Central to this approach is applying intersectionality theory to understand how power relations (due to gender, age, disability, chronic disease) shape vulnerability to ill health. This panel will convene speakers with a breadth of knowledge to reflect on how interconnected power dynamics shape experiences of structural, symbolic, and everyday violence and how this influences health seeking practices and priorities for funders, governance actors and policy makers to promote health equity in these settings.  We will draw on ARISE’s research conducted in partnership with residents of  informal settlements across Bangladesh, India, Kenya, and Sierra Leone and introduce the ARISE equity analysis framework. We will illustrate how power differences contribute to and shape ill-health and wellbeing in urban informal settlements.

Authors: Abu Conteh, Sierra Leone Urban Research Centre; Partho Mukherjee, The George Institute For Global Health, India; Inviolata Njoroge, LVCT health, Kenya; Samuel Saidu, College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Sierra Leone; Farha Musharrat Noor, BRAC James P Grant School of Public Health, BRAC University, Bangladesh; Md. Sohrab Hossen, BRAC James P Grant School of Public Health, BRAC University, Bangladesh; Surekha Garimella, The George Institute for Global Health India; Inayat Singh Kakar, The George Institute for Global Health India; Rosie Steege, Liverpool School of Tropical Medicine, UK; Sally Theobald, Liverpool School of Tropical Medicine, UK; Kate Hawkins, Pamoja Communications, UK; Helen Elsey, University of York; Laura Dean, Liverpool School of Tropical Medicine, UK

ARISE Workshop

Accountability and responsiveness of health systems in informal settlements: A layered approach to demonstrating impact using nested country Theories of Change

Wednesday, 8 November, 2023 • 12.00pm – 1.00pm

Room: Sweet Auburn

This interactive workshop with the in-country MEL leads will demonstrate how a nested Theory of Change approach that encompasses different contexts and priorities has been developed in practice and share the key lessons learned. Participants will have a chance to engage with the outcomes framework and consider how it might be adapted and applied in their context whilst also walking through the process through which each country’s theory of change was nested within the programmatic TOC.

Authors: Joe Taylor, Institute of Development Studies, UK; Louise Clark, Institute of Development Studies, UK; Jiban Karki, Liverpool School of Tropical Medicine, UK; Anthony Mwaniki, LVCT Health, Kenya; Nazia Islam, BRAC James P Grant School of Public Health, BRAC University, Bangladesh; Sia Tengbe, Sierra Leone Urban Research Centre, Sierra Leone; Sweta Dash, The George Institute for Global Health, India

ARISE presentation as part of Women’s Health session

Delivery of Health services to pregnant adolescents in informal urban settlements in Kenya: Perspectives in policy versus practice

Tuesday, 7 November, 2023 • 3.00pm – 4.15pm

Room: Centennial

In Kenya, teenage pregnancy rates are at 18%, and have further increased due to the COVID-19 pandemic. Adolescent girls living in informal urban settlements are exposed to rapid socio-economic transitions and multiple intersecting health risks and may be particularly disadvantaged in accessing sexual reproductive health services. This presentation will outline how understanding vulnerabilities and service-seeking behaviours from different perspectives is important to support the development and implementation of progressive policies and services that meet adolescents’ unique needs within urban informal settlements. This study explored policy makers, community health service providers and community’s perceptions about access to, and delivery of, sexual reproductive health services for pregnant adolescents in one informal urban settlement in Nairobi. We employed qualitative methods with respondents throughout the health system, purposively sampled by gender and diversity of roles.

Authors: Linet Okoth, LVCT Health; Rosie Steege, Liverpool School of Tropical Medicine; Anne Ngunjiri, LVCT Health; Sally Theobald, Liverpool School of Tropical Medicine; Lilian Otiso, LVCT Health

ARISE presentation as part of Healthcare II session

Negotiation for Healthcare by People Living in Informal Urban Settlements in Dhaka City: Strategies, Drivers and Barriers

Tuesday, 7 November, 2023 • 3.00pm – 4.15pm

Room: Kirkwood

Availability and access do not always ensure receiving healthcare services, especially for poor people living in cities’ informal settlements. They have to constantly negotiate with different actors to claim their health rights. More than seven million people live in more than 5000 informal settlements in Dhaka city, the capital of Bangladesh and one of the most crowded megacities in the world. In Bangladesh’s complex, fragmented and pluralistic urban health systems, the urban poor face difficulty in accessing affordable healthcare from formal health systems. This PhD research tried to understand how informal settlement dwellers negotiate to receive healthcare from formal health systems.

Author: Bachera Aktar, BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh; Liverpool School of Tropical Medicine, Liverpool, United Kingdom

ARISE presentation as part of WASH session

Intersecting Systems of Power Shaping Health and Wellbeing of Urban Waste Workers in the Context of COVID‐19 in Vijayawada and Guntur, Andhra Pradesh, India

Thursday, 9 November, 2023 • 12.00pm – 1.00pm

Room: Sweet Auburn

Waste work in India is an undervalued role relegated to historically marginalised communities. The informal nature of their work coupled with lack of state regulation keeps waste workers trapped in poverty. This presentation explores how intersecting systems and relations of power impact the agency of waste workers to shape their health and wellbeing. The ability of communities to exercise agency is constrained by the power exercised on their lives by the state and society. NGOs play a supportive role for the realisation of rights, but the ability of waste workers to organize and effect change is limited to coping strategies.

Author: Inayat Singh Kakar, The George Institute for Global Health India; Apeksha Mallya, Liverpool School of Tropical Medicine, UK; Lana Whittaker, Liverpool School of Tropical Medicine, UK; Rachel Tolhurst, Liverpool School of Tropical Medicine, UK; Surekha Garimella, The George Institute for Global Health India

ARISE presentation as part of Community session

The Critical Need for Community-Based Committees (CBC) for Improving Health and Well-being in Urban Informal Settlements: Evidence from Bangladesh

Thursday, 9 November, 2023 • 3.00pm – 4.15pm

Room: Buchkead

Urban informal settlements, also known as “slums,” are a rapidly developing phenomenon, in low- and middle-income countries with over one billion residents. This rapidly growing population is underrepresented in cities’ health and development planning.  The formation of Community-Based Committees (CBC) in urban slums comprising marginalised populations, community leaders and major public, private, and community-level stakeholders can improve voice, collective action, and agency.

This presentation presents data from a large community-based participatory action research project and focuses on the contributions of local CBCs on improving the health and well-being of informal urban settlement residents and the ability of those committees to increase the accountability and responsiveness of service providers within the settlements.

Author: Bachera Aktar, BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh; Liverpool School of Tropical Medicine, Liverpool, United Kingdom

ARISE poster presentation

Identifying Spatial Inequities and their Impacts on Health and Wellbeing through Participatory GIS Mapping: Experience from Bangladesh

Wednesday, 8 November, 2023 • 2.00pm – 3.00pm

Venue: Midtown combined

People living in informal urban settlements face spatial inequities in the distribution of resources and service availability.  Participatory Geographic Information System (PGIS) mapping is a great tool to visually present spatial inequities, especially in a data-scarce context like Bangladesh. ARISE in Bangladesh used PGIS mapping to identify spatial inequities in informal urban settlements and their impacts on the health and wellbeing of the dwellers. Using PGIS mapping from April 2020 to December 2021, ARISE Bangladesh co-produced three interactive GIS maps of three informal settlements in Dhaka city. This poster presents findings from two informal settlements.

Authors: Bachera Aktar, BRAC James P Grant School of Public Health, BRAC University, Bangladesh and Liverpool School of Tropical Medicine, United Kingdom; Proloy Barua, BRAC Institute of Governance and Development (BIGD), BRAC University, Bangladesh; Sadaf Khan, Institute of Development Studies, United Kingdom; Sabina Rashid, BRAC James P Grant School of Public Health, BRAC University, Bangladesh.

ARISE poster presentation

The Fault in our Social Safety Schemes: Tales of missing accountability and its impact on the health of informal settlers in Dhaka

Wednesday, 8 November, 2023 • 2.00pm – 3.00pm

Venue: Midtown combined

About 16.6% of Bangladesh’s urban population resides in challenging informal urban settlements. The Government of Bangladesh’s Social SafetyNet Programs (SSNP) includes 145 programs under 23 ministries. Access to SSNPs has a huge impact on the overall health and well-being of the urban poor – SSNPs help poor people access healthcare, nutritious food and education. Informal settlement residents face governance complexities and neglect from state institutions, limiting their capacity to access SSNPs. ARISE project in Bangladesh documented experiences of informal settlement dwellers in accessing four SSNPs (table below). This poster presents findings on the challenges experienced by people residing in informal settlements in accessing SSNPs, and how their ability or inability to access SSNPs affects their health and overall well-being.

Authors: Adrita Rahman, BRAC James P Grant School of Public Health, BRAC University, Bangladesh; Md Sohrab Hossen, BRAC James P Grant School of Public Health, BRAC University, Bangladesh; Farha Musharrat Noor, BRAC James P Grant School of Public Health, BRAC University, Bangladesh; Bachera Aktar, BRAC James P Grant School of Public Health, BRAC University, Bangladesh and Liverpool School of Tropical Medicine, UK

ARISE poster presentation

Power of light: How art and light can support the health and wellbeing of people in urban informal settlements

Thursday, 9 November, 2023 • 2.30pm – 3.00pm

Venue: Midtown combined

Poorly lit public spaces, roads and alleyways in informal settlements in Freetown increase the risk of injury, violence and pickpocketing, negatively impacting the health and wellbeing, and quality of life of dwellers. Children, women and vulnerable groups are most affected. Multiple partnerships driven by ARISE and LSTM united to improve the wellbeing of people in informal settlements in Freetown through the use of art and light.

Authors: Motto Nganda, Liverpool School of Tropical Medicine, UK; Samuel Saidu, College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Sierra Leone; Ibrahim Sesay, Sierra Leone Urban Research Centre (SLURC), Sierra Leone; Samira Sesay, College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Sierra Leone; Ibrahim Gandi, Centre for Dialogues on Human Settlement and Poverty Alleviation (CODOHSAPA), Sierra Leone; Bintu Mansaray, College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Sierra Leone; Luke Jerram, International artist, United Kingdom; Kate Hawkins, Pamoja Communications, United Kingdom; Sally Theobald, Liverpool School of Tropical Medicine (LSTM), United Kingdom

In this blog ARISE colleagues in Nepal, Saugat Joshi, Alisha Karki, Barsha Rijal, Rudra Neupane and Jiban Karki, discuss the challenges of building trust and gaining access to informal settler communities, in order to undertake research and intervention activities.

In Nepal, the term sukumbasi is frequently used in a derogatory manner to describe slum dwellers. For the majority of people in Kathmandu, the term evokes images of ‘land grabbers’ and ‘river polluters’. Several reports indicate that in Kathmandu alone, there are nearly 50 squatter settlements with 2,800 households. A national report published by the Ministry of Urban Development in Nepal, indicates that around ten percent of the urban population lives in informal settlements, and they are mushrooming in major cities like Kathmandu and Pokhara.

In Kathmandu, the Bagmati river bank in particular has been facing a significant rise in the number of slum dwellers. In the past decade, political conflict in Nepal had caused a large number of people to be displaced from their original birth areas to the cities and to these informal settlements. Recently, the situation around the bank of the Bagmati river in the Thapathali area of Kathmandu has become tense due to the eviction informal settlers. Tensions have risen since city officials decided to evict people them from the settlement. The squatters responded by throwing stones and attacking Kathmandu Metropolitan City (KMC) staff with homemade weapons including sickles and khukuri (a type of machete). They also organised a protest in front of the KMC office demanding proper management of the squatters and the resignation of  certain KMC staff.

The challenges of gathering accurate information

When we began our research, we heavily relied on existing literature and reports related to informal settlements in Kathmandu. However, we quickly realised that there were significant discrepancies in the data. Different sources used varying names for the same settlements, and the reported locations often didn’t align with what we found on the ground. This made it challenging to even identify and locate these settlements accurately.

Fieldwork

To address these discrepancies, we decided to visit each of the 32 ward offices in Kathmandu to gather information from local officials. Armed with this data, we embarked on the daunting task of visiting and documenting the conditions of these settlements and visited 55 settlements, but this process included its own set of challenges. As soon as we entered the settlements, residents were curious about the reason for our visit. Given the tense relationship between informal settlers and the Kathmandu metropolis, most settlements had placed bans on outsiders visiting their communities, including journalists, NGOs, and researchers. Residents were concerned with potential negative portrayals in the media, particularly on informal platforms like YouTube, Facebook, as well as in certain newspapers and television channels which had depicted them as landowners and well-to-do people. Gaining the trust and cooperation of residents required time and patience.

Overcoming suspicion

To overcome these initial barriers, we made efforts to clarify our intentions and build trust. We approached the ‘Society for the Preservation of Shelter and Habitation in Nepal,’ an umbrella organisation representing landless people, for support. After extensive discussions, the organisation agreed to back our initiative. However, we had to conduct more than six meetings in each settlement followed by discussions, and presentations to convince individual settlements to allow us to start our research.

Community-based organisations (CBOs) and co-operation

Our breakthrough came when we engaged with community-based organisations (CBOs) within the settlements. After explaining our objectives and intentions, these CBOs gradually allowed us access to their communities. This was a significant turning point in our research, as it enabled us to gather valuable insights directly from the residents.

Unsuccessful attempts

While our research efforts were met with cooperation and understanding in many informal settlements, one notable exception was the Balkhu settlement which is one of the largest informal settlements in Kathmandu. Despite multiple attempts and the presentation of official request letters from relevant authorities, the informal settlers did not allow us to enter their settlement. The resistance and refusal to grant us access to Balkhu was not merely a logistical hurdle. It highlighted the deeper layers of mistrust and scepticism that exist between informal settlers and external stakeholders including researchers.

Conclusion

Conducting a study on informal settlements in Kathmandu, Nepal, posed numerous challenges, including uncovering discrepancies in existing information, suspicion and resistance from settlement residents, and the difficulty in gaining access to certain settlements. The role of community gate keepers, whether they were local representatives of political parties, leaders of community groups or NGOs, were vital to accessing these informal settlements. Without their buy in it was impossible to enter the community. Nevertheless, through collaboration with community-based organisations and transparency in our intentions, we were able to overcome many of these obstacles and gain valuable insights into the lives of those residing in these informal settlements. Our experiences underscore the importance of building trust and understanding the unique dynamics at play when researching such sensitive and marginalised communities.

About ARISE in Nepal

PHASE (Practical Help Achieving Self-Empowerment) Nepal is a non-governmental, working to improve health, education, and livelihood of deprived communities since its inception in 2006. PHASE Nepal’s integrated development projects incorporate healthcare, education, livelihood, disaster risk reduction (DRR) and research components to promote holistic development of disadvantaged and vulnerable populations across the country with support from various national and international partners.

PHASE Nepal is conducting a mixed-method implementation study funded by the ARISE Responsive Fund. The project focuses on assessing living conditions, mental health, and accountability in informal settlements in Kathmandu and Pokhara, Nepal. The research employs participatory methods, including social mapping, transect walks, stakeholder analysis, and photovoice, with active involvement from coresearchers and the community. Additionally, surveys and in-depth interviews are being conducted for a comprehensive understanding. Our intervention strategies involve sensitisation workshops, accountability initiatives and mental health awareness activities tailored to address specific needs identified within the informal settlements.