Accountability in Urban Health
“More than half of the world’s people live in cities, with one in three of those living in low- and middle-income countries doing so in informal settlements, sometimes known colloquially as slums, with inadequate access to services and opportunities to shape decisions about their environment. Our research will support the people in our focal communities to claim their right to health.”
Professor Sally Theobald, Liverpool School of Tropical Medicine, Principal Investigator, ARISE
Around the world, the number of people living in cities is growing rapidly. Transforming the lives of vulnerable people in informal urban settlements is vital to accelerate progress towards the Sustainable Development Goals (SDGs). This entails tackling complex, interrelated challenges of poor health, unequal access to services, insecurity and weak accountability. Rigorous research and evidence, combined with community engagement and ownership, must inform these efforts.
The ARISE Hub – Accountability and Responsiveness in Informal Settlements for Equity – is a new research consortium, set up to enhance accountability and improve the health and wellbeing of marginalised populations living in informal urban settlements in low- and middle-income countries.
COVID-19 response and protracted exclusion of informal residents: why should it matter to city authorities in Freetown, Sierra Leone?
The food situation is bad for residents; I saw a young girl with a plastic bag looking for cooked food to buy for her family. I realized from that point that the girl’s family did not have raw food or rice at home to prepare for that day. I was worried that they might not have something to eat on the first day of the lockdown. At that time, we saw soldiers coming, so we ran away without being able to help to the young girl…As a widow and a single mother myself, it was not easy putting together some food for my children that will last us for three days. People are not happy, and the prices of food items are going up rapidly, so how can you manage to stock up food for a three-day lockdown. And moreover, this is a month of fasting when prices are generally high. (A widow at Moyiba)Owing to the vulnerability of many informal residents, many experienced severe hunger. In Dwarzark for example, many residents including homeless children and people with disability were concerned that their needs are not often considered in planning, so it becomes even more difficult for them during crisis periods. Many of these groups depended on NGO and community support during crisis, but these streams of support were not forthcoming during the lockdown restrictions. During the second lockdown, homeless children had no shelter to live and many were begging in the neighbourhoods for food. Community elders however recognised these challenges and arranged for shelter at the community centre. Community elders also pleaded with residents who had enough food to provide for the homeless children. Water and sanitation Persistent lack of access to water and sanitation services are among the most frequent concerns of informal residents. Most settlements are not connected to the national water grid, so they access water from different sources, some of which are of poor quality. Water tanks supplied by government to communities through the Sierra Leone Water Company (SALWACO) were considered useless by community residents because they have not been refilled since the Ebola period, some five years ago. These access concerns became more challenging during the lockdowns. In their desperate search for water, many people ignored social distancing regulations. Many of them clustered around the few water access points. In Dwarzark (one of the hillside informal communities), most of the wells dried up completely at the peak of the dry season in April, so most residents relied mainly on a solar powered tank to regenerate water. In Moyiba (another hillside community), youths in charge of public taps or ‘‘tap collectors’’ developed a strategy of closing the taps from time to time to control the huge crowds and to enhance even distribution. They devised a way of preventing multiple access by identifying people who had already collected. Those who could not withstand the huge crowds travelled to nearby communities to access water. Children and women were mostly at the centre of water collection since schools had been closed by government to prevent spread of the virus. Children were therefore coming into contact with huge crowds during these interactions. Access to sanitation was also a challenge, since private indoor facilities are less common. Use of shared toilets or open defecation are widespread, which required people to risk leaving their homes or go to the streams or shared spaces. Moreover, outdoor toilets often exposed women and girls to sexual exploitation in informal settlements. Security concerns In addition to health, water and sanitation challenges, communities were also concerned about their security during lockdowns. Police and soldiers were deployed in communities to enhance adherence to response measures. Checkpoints were mounted with frequent patrols. There were incidents of beatings or arrests of people who ventured out to look for food and other basic needs by security personnel. For many residents, the food situation was so dire that they had to plead with their neighbours for food or money to buy basic food items. Women and girls are likely to be particularly vulnerable to public and private violence. This is an area that needs further exploration as recent crime statistics from the Sierra Leone Police reveal high rates of sexual violence and penetration of women and girls in Freetown. Such incidents could be higher in informal settlements where safeguarding awareness is low, coupled with increased risk of gender based violence. Lessons for future health responses Communities, especially informal settlements experience immense pressure to meet their daily needs, including food, water and sanitation services. Yet, they are not well considered in urban policy planning and emergency response by city authorities. In times of crisis, informal residents have shown much intuition to respond appropriately. With little resources, they provide relief support for their counterparts mostly in need of help. They organise fair distribution of scarce resources like water in accordance with social distancing regulations. The current COVID-19 response has shown that limited involvement of informal residents in planning and the response has caused severe hardships. An inclusive process of city planning is imperative for a socially just response that meets the needs of all. Yet, communities feel disempowered because they have not been provided with much support to enhance their local actions in the fight against COVID-19. This account of community agency shows the strong capacity of communities in organizing themselves during emergencies or crisis to promote safe health behaviours and reduce spread of infections. Such actions could be leveraged upon by health professionals and policy makers to improve community surveillance and health promotion. Special thanks to the following co-researchers who provided information and photos for this blog: Abu M. Sesay, Mohamed Bangura, Zakiatu Sesay Suad Kamara.
Shadowing Suvartha on her waste-picking route in Vijayawada
A photo essay by Shrutika Murthy, The George Institute for Global Health India
We have been involved in a number of processes to create guidelines on safeguarding in global health programmes. You can read more in our latest paper in BMJ Global Health.
Or you can read the findings of an international consultation on safeguarding by our colleagues Surekha Garimella and Bintu Mansaray.
We also have advice on safeguarding in the context of the COVID-19 pandemic.