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Womens leadership is built through federation saving schemes in Kenya

01 12 2020

Leadership by women: Perspectives of grass root leaders

In this blog by Jackline Waithaka and Jane Wairutu the issue of women’s leadership is explored through the identification of women making change in the informal settlements of of Nairobi, Kenya.

The world has witnessed the emergence of women leaders most of whom have rose to break the traditional glass ceilings that barred them from taking up leadership positions despite possessing the necessary skills. Over time, women have constantly evolved realizing new roles. Their progress within the society has proven substantial yet uneven as women all around continue to be vastly underrepresented in decision making as well as community set-ups. These are the facts, and they tell a story. A story of resilience and enthusiasm to lead despite the setbacks encountered.

When supported and empowered to take up leadership positions, women have exhibited the ability to lead. They have successfully demonstrated the ability to lead through organizing around issues that are fundamental to them and in the long run advance their interests for overall well-being of a community.

The Kenya movement of Slum Dwellers demonstrates that facilitating women’s leadership builds a culture of self-confidence and empowerment thereby inspiring continuous wave of female grass root leaders interested in carving out a different narrative for their communities. Paving way for emergence women to become leaders is no mean feat, however, for over 20 years, the federation has sought to support women leaders who make a large number of leaders even with the alliance, and are always seeking ways to uphold this practice in a bid to build on its vision of sustainable and inclusive communities.

Gender barriers in leadership and solutions

Being a woman, they saw as though we had no power. But because there were many of us, we combined our forces together. We did not shy, nor did we back down.

Anastacia Wairimu, Kahawa Soweto

To date, women face limited access to leadership positions despite the strides undertaken in creating positions of power for women. Anastacia Wairimu, a national federation leader who has served as a leader within the federation for fifteen years admits to having faced opposition from male counterparts. As a means to navigate through opposition from the men, Anastacia explains on importance of leveraging on their numbers in order to claim their spaces as equally competent leaders in their community.

Anastacia Wairimu leading community discussions in Mukuru

Women leaders all around the globe are still a minority as men continue to outpace women in leadership roles in most sectors. Inclusivity in leadership remains a significant gap to address as a means to ensure achievement of gender balance within positions of power.

Nancy Njoki, also a national federation leader within the slum dweller grass root movement in Kenya, also explains, women leaders are often held to higher standards than men and many occasions, they require to do more than their male counterparts including sharing testimonials in a bid to prove one’s leadership ability.

Such preferences act as biased gate keeping factors hence the growing need for women to proactively communicate their desires to serve in leadership positions. Drawing from federation experiences, providing a supportive space for women to take up minor leadership responsibilities then advance to major responsibilities enables understanding on the importance of promoting gender inclusivity in leadership.

Family and leadership, balancing it all

It comes with its fair share of challenges. This is because even as a woman serving in a leadership position, one still needs to perform their duties as a wife and a mother. This therefore calls for one to work extra hard.

Nancy Njoki, Mathare

Family is the foundation of communities and in many settings women who double up as mothers and wives within the family setup, play a vital role in the wellbeing of a family. Women who have overtime actively claimed leadership positions within the society while taking on their family duties have demonstrated what women can do. Determining how best to align family and leadership requires consideration of both sides.

Nancy Njoki who doubles up as a mother of four, and has served as a national federation leader for ten years, explains it requires double effort to successfully juggle between the roles.

Over time women leaders have had to confidently grow into their leadership positions in order to address issues that in the past, they were unable to. In some cases, this has resulted to conflict at home or with society as Nancy Njoki further notes. It is therefore critical for women leaders to communicate with their families to ensure they understand their participation in federation activities which are geared to create positive change within the community.

In order to strike a balance, it requires carefully structuring and planning one’s activities in a bid to achieve the balance.

Navigating through the roles and leading change

It requires commitment and may take up most of your time. Commitment to other social issues can easily be overridden by leadership duties.

Emily Wangare, Mathare

Emily (pictured second from the left) participating in peaceful demonstrations in Nairobi, calling an end to forceful evictions

Women have steadily emerged in leadership roles bringing to the exercise of leadership an arsenal of strengths.

Through volunteerism, and helping to amplify issues of the most marginalized, leaders such as Emily have taken up exceptional roles thereby contributing substantively to the development of their communities. Through her leadership role in Mathare, Emily has capitalized on her position to participate in matters community organizing through mobilizing community self-help groups in Mathare among other organized groups, and has mentored them through the essentials appertaining loan application for livelihood. Over time, the federation’s savings model mainly has given rise to the emergence of more female leaders within grass root communities as has evolved as a tool that has largely increased women’s participation in the federation.

Additionally, when community has faced eviction threats, Emily emerged at the forefront to carry out advocacy around the issued threats, a move that enabled the formation of cooperatives and as a means to lobby for community land. As a result of frequent confrontations with authorities and leading collective advocacy efforts, evictions were avoided. Despite the challenges that existed, leaders like Emily have been at the fore front of land eviction struggles in Mathare through activism further highlighting impact of women’s leadership presence on the frontline of resistance to evictions.

Further reflections from Christine Mwelu, also a national federation leader from Mukuru Viwandani, explains how her leadership role also positioned her at the forefront of major community processes. Earlier in March 2017, Mukuru was declared a Special Planning Area effectively freezing development in order to pave way for development of an integrated development plan. For over five years, Christine along with other community leaders took up central role in supporting to mobilize community to participate at every stage of the planning process. Her participation in the process seeks to depict at scale the contribution of women in matters community development if provided a platform.

To sustain the present and future tire of impactful women leaders from low income communities, it is critical to invest in women and set the agenda for continuously nurturing a wave of upcoming female grass root leaders to deliver the envisioned change.

After all, why not women?

01 11 2020

What’s health got to do with World Habitat Day?

Epidemics are a window into society. They reveal our social relationships and circumstances. The global pandemic has brought to the fore the inequalities that persist within our towns and cities. The spread and the impacts of the disease have not been even. As the world continues to grapple with the fallout from the pandemic, this year’s World Habitat Day is an important, if not urgent moment to reflect on the interaction between pandemics, health and cities.

At the beginning of the pandemic, in my neighbourhood in London, there was a sense that we were all in it together. Yet, underlying this good spirit, the inequalities across cities and within cities have been undeniable. Across cities, there are differing health system capacities, economies, and infrastructure. While London had less acute care bed space than Berlin or Rome, it had more than many cities in the Global South; and the UK government was able to provide more economic support to the residents of London than was possible in Kampala or Dhaka.

There have been important inequalities between residents within cities. Facing lockdown in London was very different depending on whether you had a garden, could work from home and have your food delivered, compared to if you lived in a tower block, with limited space and perhaps had insecure work delivering food. Likewise, in cities like Mumbai, some people were able to protect themselves in private gated homes while others living in informal settlements could not socially distance or wash hands and found their livelihoods suddenly curtailed. Studies have found that 57 per cent of people living in ‘slum’ neighbourhoods in Mumbai had antibodies to COVID-19 compared to 16 per cent in ‘non-slum’ areas.

Cities on the frontline – but overlooked and misunderstood

With COVID19, most of the spread has been in urban settings – reflecting issues around space, connections, and density. Yet, COVID is not the only major epidemic the world has faced in recent years, and it continues a long list of outbreaks which have had urban dimensions for example Ebola in West Africa, Zika, Yellow Fever in Angola, or Cholera in Zimbabwe.

The major challenge is that our understanding of urban health has not kept up with patterns of urban development. The world is urbanising dramatically. The global population is now majority urban and the proportion of urban residents is increasing. Urban populations are growing fastest in the Global South. We know that inequality and poverty have a range of negative impacts on health but we do not clearly understand the social determinants of health in many of these rapidly growing urban settings. Urban-health interactions are overlooked and misunderstood; we know least about the most vulnerable settings and people, in particular, the one billion people living in informal settlements.

However, despite these very evident trends, spending on and attention to urban development is limited. Often there is a lack of urban policy, both at the national level and within key sectors e.g. in health or pandemic preparedness policies. While health receives significant aid funding, the urban development receives comparatively little. Another problem is that health experts are often disconnected from urban experts and planners. We are left with siloed health and urban activities. In addition, local expertise is too often ignored.

Most importantly, there is a politics of neglect when it comes to informal urban settlements. There is a severe lack of data and evidence on informal settlements in part because governments do not collect it out of the fear that it would validate the existence of settlements they deem to be illegal. Exclusionary policy and practice are evident in the way poorer and marginal residents are not routinely included in planning processes. All of this follows a long history of blaming the poor for their problems and treating them as vectors of disease, not as victims.

Clearly, there is an urgent need to better consider the characteristics of this urban growth and implications for health. Highest up on the ‘urban/health’ priorities should be informal settlements.

Improving our understandings of health in informal settlements

The first thing to note is that we cannot generalise about urban settings in the global south. Cities, settlements, and people are all very different, whether you are in Salvador in Brazil, Wuhan in China, or if you are a male migrant worker in India or a female low caste waste picker.

Informal settlements also look very different from one another. A case in point is in Freetown, Sierra Leone, where there is a dense settlement in downtown area on the coast built out of rubbish, and another is a hillside settlement on the outskirts of the city and much more spacious. They both have infrastructural challenges, but they are different.

A starting point is that heterogeneous social, political and economic relations shape urban spaces. Drivers of health and well-being comprise intersections between environmental deprivations and hazards as well as social marginalisation, stigma, violence. Ambiguous governance also shapes health. Cities have complex governance arrangements across sectoral, administrative and spatial scales, much of which is invisible and informal; as a result, accountability is unclear. It is a challenge to identify drivers of multiple, intersecting inequities in health and wellbeing and routes for redress.

So how do we address these challenges? Certainly, we need increased investment and attention to urban settings, and improved data. But perspective is also vital.

We need to do four things:

Learn to ‘see like a city’ – we need to understand systems and interactions, and especially informal dynamics
Learn to ‘see like a citizen’ – understand how people are expressing and understanding rights and entitlements, how they are claiming accountability and from who
Consider invisibility – who and what is not seen, or not easily counted? For example displaced or migrant populations who cannot claim rights
Focus on social infrastructures as much as the technical and medical, recognising that learning, dialogue, and collaboration are the key to progressive change.

It may feel hard to look to the future when we are still navigating our way through this global crisis. But what happens next depends on how we can diagnose and influence the power relations which have shaped urban development trends towards inequality and exclusion.

A key long-term response must be to marshal interdisciplinary, intersectoral and intersectional approaches, which pay attention to power dynamics, and most importantly, are inclusive of the most marginalised.
—
This blog by Annie Wilkinson and based on the author’s presentation for UN-Habitat Norway ‘World Habitat Day’ Webinar on Pandemics and Future Cities. It was first published on the IDS website and is repeated here with permission.

industrial waste in the informal settlement

30 10 2020

Secondary impacts of COVID-19 on informal urban settlements

This blog was written for World Cities Day, 31 October 2020. The theme this year is Valuing Our Communities and Cities. People in informal urban settlements deserve our support and solidarity. In the blog we explore how they are experiencing some of the secondary effects of COVID-19 and mechanisms that could strengthen the ways that they are involved in the pandemic response.

Current upheavals highlight longstanding socioeconomic inequities that continue to raise difficult policy and accountability questions. Some forms of vulnerability are more discernible than others. Nearly one billion people live and work in informal, under-serviced, and precarious urban conditions. Before COVID-19, these communities occupied a peripheral and precarious space, both physically and in the imaginations of those in power. Such spaces are often rendered invisible and excluded from city-wide processes of development, at other times hyper-visible as sites of chaos or calamity.

Non-COVID-19 related health care

Our colleagues in Sierra Leone have argued that people living in informal urban settlements are more pre-disposed the chronic conditions which affect COVID-19 but that this is under-explored.

“The ‘slow violence’ of informal settlements includes everyday exposure to poorly managed waste, dust, smoke, fires, floods, disease vectors, long journeys across cities on overcrowded shared transport which can spread infections, occupational hazards, crime, but also insecurity, stress, lack of accountability, discrimination, abuse, invisibility, exclusion from economic and political power, and an inability to claim and maintain basic rights or services.”

In all contexts we work in lockdown has led to mental health strains and greater stress and anxiety are reported as precarious existences deepen with continued containment. Lockdown itself is troubling but also the loss of income that comes with it. In Sierra Leone we have documented detrimental psychosocial effects on health care workers as well as interventions from the Ebola epidemic that may help alleviate some of this burden. In Kenya as in other settings, access to healthcare has been disrupted. This has impacted particularly on mothers and children, residents with chronic conditions and the elderly.

“Individuals with chronic illness suffer a lot as they need specific medical attention, yet …we lack timely and adequate information on treatment of chronic illness…. Sometimes when they access the information, we lack money to buy drugs during this outbreak as many people have lost jobs…”

In India the heightened cost of transport to facilities and of services is having a troubling effect. Fear of infection is leading some to rely more on private pharmacies.

Economy and food security

COVID-19 has pushed previously financially stable people across informal settlements into poverty. For example in Dhaka, Bangladesh, the pandemic led multinational companies to cancel orders to garment factories plunging this workforce, who mainly live in informal settlements, into precarity. There is risk of malnutrition and starvation as day labourers are prevented from earning an income. COVID-19 has disrupted traditional networks of support. People are resorting to loan sharks as rent and food are hard to buy on credit. They are relying on community/family members, collecting cash from friends. Local crime rates have also risen. How long can this go on for?

When people are in ‘obhab’ (scarcity), people tend to fight more, they tend to resort to stealing. There is a chance of increasing crime in this community. I am worried that theft and crime will increase in our community.

In India, as elsewhere the work of ‘waste pickers’ and other sanitation workers is vital to the cities they work in, particularly now when the need for a sanitary environment is at its greatest and there has been an increase in biomedical waste. Yet, they remain ‘invisible’. Despite their key role, the provisions put in place to ensure their safety in the pandemic are inadequate. For example, aid meant for vulnerable populations, is often based on certificates of citizenship which denies these communities eligibility for many forms of relief, leaving them no resort but philanthropy and luck.

“We are Indians! I have all the documents like you have, to prove that I am an Indian: voter ID, ration card, Aadhar card…But we do not get rations since the ration cards are based at our homes, which we moved from six years ago. I transferred my Aadhar card because we cannot get jobs here without an Aadhar card and PAN card.”

This has been exacerbated by brutality in policing of lockdowns, targeted as informal communities, a troubling pattern that has been seen in many countries including Kenya. A community member in India said:

When we tried to resume work after the lockdown, we were troubled by the police. They said we give rations and all that, then why do you need to get out? But rations are not much. If the NGO had not supported us then, we don’t know what we would have done. We would have died of starvation before corona hit us.

The health system alone cannot solve these issues which require multi-sectoral approaches to address the structural, economic, patriarchal and social inequalities poor people face.

In Bangladesh, as elsewhere, we have seen stigma and discrimination against households affected by COVID-19. The coronavirus is seen as contagious and fatal disease. As a result, there are fears of quarantine and isolation or being locked up and never seeing one’s family again. Red flags are placed in homes of infected people and the media pictures of death, and bodies being thrown in separate burial grounds stokes fears that people will be buried without the appropriate religious ceremony. Fears of getting the virus have resulted in surveillance of others, under-reporting, harassment of family members with spouses returning from abroad, harassment of people with flu-like symptoms and suspicions about outsiders.

Treatment of women and children

In Kenya and elsewhere there have been increases in reports of Gender Based Violence (GBV) in informal settlements since COVID-19 began, and lockdowns and curfews were put in place.

Women are the hardest hit by COVID-19, they are primary caregivers of individuals who are ill during COVID-19 pandemic… Women are not the decision makers in most families and as such, the money they make in a day to day activity ends up in the hands of men in the family.

In Kenya, people with disabilities make up 10 percent of the population, an average of 4.4 million people. 66 percent of these people live in rural areas while 44 percent are in urban settlements, mostly for work purposes. Due to the rise of sexual harassment and domestic violence, disabled people have been majorly affected and abused by a spouses, parents or caregivers. The frustrations of lack and mental stress makes them among the more vulnerable victims. This causes unwanted pregnancies and contracting sexually transmitted diseases.

Conclusion

We need to address the situation of the urban poor through context-specific policies and action in the COVID-19 response. We should not think of the urban poor as a homogenous group, so data must be disaggregated (by gender, age, occupation, ethnicity and other axes of inequity). Longitudinal qualitative research is critical to capture impact now and post-pandemic. We must also reframe health beyond a biomedical (disease model) approach and put in place socially just models with the well-being of communities and people at the centre. Health decisions and policies must be balanced with social and economic interventions.

Communities have the potential to mobilise and take action to address life-threatening experiences. For example in Sierra Leone, FEDURP members’ action in Thompson Bay supported quarantined homes with drinking water while government support was delayed. In Funkia FEDURP members used the fund generated from the public toilet they manage to give out revolving loans to their members to revitalise their livelihood sources.

There is an urgent need to bridge the gap between formality and informality through recognition and inclusive participation so that the needs and aspirations of informal settlements can be addressed. There is a growing need to recognise and draw on community knowledge, creativity and capacities, which is the basis of first responses during pandemic. Governments should place communities at the centre of development aspirations and actions and work with them to develop appropriate support.

This blog draws on the work of Kate Hawkins, Sabina Rashid, Joseph Etyang, Janice Cooper, Bintu Mansaray, Rosie Steege, Caroline Kabaria, Sally Theobald, Blessing Mberu, Laura Dean, Haja Wurie, JK Lakshmi, Joseph Macarthy, Hayley Macgregor, Karsor Kollie, Joanna Raven, Lilian Otiso, Rachel Tolhurst, Annie Wilkinson, Abu Conteh, Beate Ringwald and Francis Anthony Reffell.

27 10 2020

Webinar: The effects of COVID-19 on vulnerable urban populations and strategies for mitigation

A webinar on 5 November 2020, 10:00-11:30am CET (Geneva) organised by the Alliance for Health Policy and Systems Research, bringing together findings from six countries featuring our colleague Francis Reffell.

COVID-19 has a disproportionately large impact on vulnerable populations globally, including but not limited to slum dwellers and migrant workers. These populations often have limited access to basic water, sanitation and hygiene (WASH) facilities, live in cramped conditions where it is difficult to socially distance and are more likely to be dependent on a daily wage. Vulnerability to loss of income also makes it difficult to meet basic nutritional needs. Therefore, implementation of potential government recommendations such as social distancing and WASH to slow the transmission of COVID-19 becomes extremely difficult.

Both the effects of COVID-19 and the strategies to mitigate these effects must be context-specific, taking into account the needs of these populations. While considering individual contexts, bringing together learning from a wide range of socio-economically, culturally and geographically vulnerable populations will help us learn from experiences that may be more widely applicable.

This webinar will bring together country teams from Ghana, Vietnam, India, Sierra Leone, Guinea-Bissau and Kenya, all of whom have been engaging in responding to COVID-19 in the context of vulnerable populations in their settings. The webinar seeks to draw lessons learned from these teams. The Alliance hopes that such lessons will be useful for those working on similar issues in other settings, including policymakers tasked with responding to COVID-19 and health systems researchers keen to better understand the added value of HPSR in such a response.

Moderators

Dr Zubin Shroff, Alliance for Health Policy and Systems Research, WHO, Switzerland
Dr Geetanjali Lamba, Alliance for Health Policy and Systems Research, WHO, Switzerland

Panellists

Dr Matilda Aberese-Ako, University of Health and Allied Sciences, Ghana
Prof. Bui Thi Thu Ha, Hanoi University of Public Health, Vietnam
Mr Francis Reffell, Centre of Dialogue on Human Settlement and Poverty Alleviation (CODOHSAPA), Sierra Leone
Ms Niloufer Memon, Bridgespan Group, India
Mr Yussuf Sane, Tostan, Guinea-Bissau
Mr Kennedy Odede, Shining Hope For Communities, Kenya

Register for webinar

Doing Community Based Participatory Research in Kenya

27 10 2020

“It puts value on the people” Community Based Participatory Research in Kenya

Faith Munyao, Veronicah Mwania and Beate Ringwald conduct a community based participatory research (CBPR) study on prevention of intimate partner violence and HIV in Gitathuru, Korogocho, Nairobi, Kenya. In this blog they share their experience of conducting this ARISE-affiliated project together.

Beate: After working from home for five months, I was excited about the restart of the study (my PhD research project) in August. It has already been a great learning journey for me, and I am grateful that you have joined me. I have been exposed to participatory group work since my time as a youth leader in my local parish. Since then, I have used it a lot in my work. But this is the first time that you have used a participatory approach to research. How do you like it?

Faith: It is a unique kind of research, because the community is fully engaged.

Veronicah: I love it. To me, this is the best approach that I have experienced so far. The participatory research approach puts value on the people. The community is involved in the research and drives the process. It gives people the time to digest information. It does not impose foreign ideas on the community, is very inclusive, and empowers the community.

Faith: This is an opportunity to learn how research with communities can be done differently. I like about the participatory approach to see how eager community co-researchers are to learn and come up with ideas on how to do things. For example, they came up with a name for themselves. The community co-researchers are involved in all steps of the study, unlike in other studies where they are mainly engaged as informants during data collection or involved as data collectors. I like the formation of the local research team and the capacity building of the community co-researchers. When discussing their tasks with them, they were free to say what they want and what they do not want to do.

Veronicah: The participatory approach creates partnerships between community members, national and international researchers. For this long-term engagement, ethical considerations become an ongoing process throughout the study and are not a one-off exercise.

Beate: It sounds like you see great potential in participatory research. What are its benefits?

Veronicah: Participatory research, especially the visual methods that we use, offers unique learning about the study topic. It also gives us as researchers time to learn as we go and adjust. Regular debriefing has proven to be very useful.

Faith: Researchers are likely to get more information, because visual methods offer new ways of seeing. They do not restrict participants on what to say and not to say. I also see that the community co-researchers feel appreciated. They are given the opportunity to share the problems at the community. The weekly meetings and reflections give them also the time to digest information.

Veronicah: I agree. The community is fully engaged in identifying the problem and seeking solutions. In the process, capacity of community co-researchers is built. I hope by the end of the study we will be leaving the community impacted.

Beate: As you mentioned, participatory research involves long-term engagement with the community. This is different from many other studies whereby community members are met once for a short period of time. What challenges do you foresee, and how could we mitigate them?

Faith: So far, time has been a challenge. Everything takes longer than anticipated, including time for tea breaks, an important time for bonding and socialising.

Beate: True, we often have ambitious time plans. Time indicated in guidelines for methods is usually underestimated. I am learning how to make more feasible plans for our meetings and give room for in-depth discussions.

Veronicah: The study requires commitment of community co-researchers over a long period of time, with regular meetings on Saturday mornings. It is challenging if co-researchers are missing meetings due to other commitments. Being flexible and adjusting meeting times to dates when many are available has been useful.

Beate: We are still at the beginning of the study. I am looking forward to the joined data collection and analysis with co-researchers. What are you looking forward to?

Veronicah: I look forward to finalizing the definition of intimate partner violence and to discussions on power dynamics in the community that influence HIV and intimate partner violence risk. I also want to see us achieving the study objectives. I can’t wait to see the impact of the study on the community.

Faith: I am curious to explore with the community how intimate partner violence and HIV intersect and the solutions that they will come up with. Also, I am looking forward to seeing sustainability and ownership of the project by the community.

Beate: This is awesome. Thank you very much, Faith and Vero for sharing your experiences and reflections on community based participatory research with me and the ARISE family.

About us

Faith Munyao is a Kenyan researcher with four years of experience in HIV and Gender Based Violence-related qualitative research.

Veronicah Mwania is a Kenyan researcher with 17 years of experience in market research and health research.

Beate Ringwald has five years of experience in desk-based global health research and over ten years of experience in participatory work with youth, women and communities.

Within the ARISE Hub, this research project is a partnership between LSTM, LVCT Health and Gitathuru village. The study seeks to strengthen community capacity to prevent intimate partner violence and HIV in Gitathuru, Korogocho, Nairobi, Kenya. It is guided by the ALIV[H]E framework, which stands for Action Linking Initiatives on Violence against women and HIV Everywhere. Locally the study is known as the Korogocho ALIV[H]E study.

26 10 2020

Join us at the Global Symposium on Health Systems Research

The Global Symposium on Health Systems Research is held every couple of years and this year, due to COVID-19, will be held remotely. We’re delighted that we successfully secured a panel session at the conference on COVID-19 and a range of oral and poster presentations. We hope that if you are attending you will pop along to find out more about our work. You are very welcome.

Symposium panel sessions

Establishing a socially just response to Covid-19 from the vantage point of urban informal settlements

Monday 13:15 – 14:30, Gulf Standard Time (GST)

It is now almost a cliché to announce that COVID-19 has highlighted the fault lines in societal structures that perpetuate inequity – from the heavy burden borne by poorly paid key workers, to the rising rates of violence against women and children seen all over the world.

In these settlements, the everyday exhortations to physically distance, wash hands frequently, and shelter in place are highly impractical. Thissession will highlight the COVID-19 experiences and recommendations of people in urban informal settlements in relation to:
• Public and private provision of care
• Marginalisation, gendered discrimination and violence
• Community systems
• Accountability and governance
• Power and politics
• Research and information

The session includes presentations with a focus on Kenya, Sierra Leone, Bangladesh and India.

An effective global COVID-19 strategy requires the full participation of colleagues in urban informal settlements. This session should be of interest to all health systems researchers and decision-makers.

Symposium oral presentations

Understanding challenges and complex dynamics of urban informal settlements in Bangladesh: Learning from ARISE project

In: Urban informality and life at the margin
Thursday, Nov 12, 2020
11:45 – 13:00

Bachera Aktar, Nadia Farnaz, Wafa Alam, Abdul Awal, Sabina Faiz Rashid

Informal settlements in urban areas, especially in Dhaka city growing rapidly and are bringing huge challenges for the cities throughout the country in terms of ensuring the health and wellbeing of the residents. Inequity in service provision and resource distribution in informal settlements is very much evident in Bangladesh. The need of equity is not only a social agenda but also a must need for making a healthy and liveable city for everyone.

ARISE is a multi-country research consortium focusing on inequity in the health and wellbeing of the people residing in the informal settlements in the cities in four countries – Bangladesh, India, Sierra Leone, and Kenya. ARISE Bangladesh partner, BRAC James P Gant School of Public Health at BRAC University, conducted an initial scoping exercise to understand the dynamics of informal settlements in Dhaka city. A series of informal discussions with city authorities and urban experts along with a stakeholder consultation workshop, and data scoping review were conducted from January to December 2019. This abstract highlighted the key findings from the initial scoping exercise.

The health and wellbeing of people living in urban informal settlements is a burning issue that is mostly neglected in Bangladesh. Geographical or locational differences, ecological vulnerability, diversity within settlements, focusing dominantly on primary healthcare while secondary or tertiary level healthcare is absent, poor infrastructure and functionality, lack of Government services and stewardship, inequitable distribution of services, less access basic services like sanitation, pure drinking water, housing etc. are existing challenges of informal settlements. Multiple actors are working for improving the condition of the informal settlement dwellers. However, the programs are working vertically with lots of overlapping services. At the same time, there are some areas still not covered by any program. Coordination between different stakeholders is one of the key challenges of working in informal settlements. City Corporation is working to improve the condition but the contribution is very low. The NGOs have the main role in changing the condition but unfortunately, the NGOs lack coordination within themselves. Lack of timely, accurate and quality data from reliable sources is another challenge that affects evidence-based decision making.

Considering the resource constraints, it’s very important to strengthen the coordination to work together in order to bring positive change in slum dwellers’ lives. Both humanitarian approaches and development approaches need to come together to address the complexities of urban informal settlements.

Symposium posters

Embodiment of ‘othering’ on health and well-being among waste picking communities – impact of discrimination and erasure of social voices

Shrutika Murthy, J K Lakshmi, Prasanna S Saligram, Varun Sai, Ramanamurthi Botlagunta, Surekha Garimella

Much of the interest in waste management in the past two decades has been geared towards ‘managing waste’ and thereby ‘managing’ waste pickers, by integrating them into municipal solid waste management. Knowledge and evidence that internalises waste pickers as ‘people’ is hard to find. Hence, we wish to explore the lesser known/researched aspects of the lives of waste pickers.

Waste picking as an occupation, is deeply embedded with symbolic and practical manifestations of caste and gender, with a majority of waste pickers belonging to the most disadvantaged socio–economic groups in India. Consequently, they experience several layers of discrimination in their daily lives and are often viewed with distrust and suspicion. We seek to understand how their experiences of discrimination and the embodiment of ‘othering’ manifests in their lives and affects their overall health and well–being and influences their capacity to demand accountability.

Through a narrative review, policy landscaping exercise and key–informant interviews, we seek to understand the context in which waste picking and waste pickers are discussed, identify the gaps in the literature and erasures in the policy world. We have also interacted with diverse stakeholders, particularly waste picking communities, in order to get a holistic understanding of the issues that are most important to them – especially their priorities for improving their health and well-being and the accountability processes in place to facilitate these.

‘Zones of invisibility’: in addition to the high degree of conflation of terms and concepts, the language used to describe the waste pickers and their work is highly condescending, thereby reinforcing the adverse perceptions/prejudices about them.

Waste pickers in urban spaces are ‘marginalised by design’: processes of urban development and planning systematically exclude these communities by neither envisioning a space for them nor acknowledging their ‘voice’.

The understandings around the health of waste pickers has been restricted to their ‘occupational health’.

Waste pickers have argued that securing ‘housing’ will be the key to improving their health and well–being.

Discrimination in India needs to be explored and examined through an intersectional lens, where different identities intensify different levels of oppression, injustices, power relations and inequalities. Without an understanding of this system of oppression, current knowledge around these communities on their health and well–being will remain incomplete. Efforts to improve this situation will remain acontextual, affecting their design and practice, especially in relation to responsiveness of health systems.

Safeguarding: Power, vulnerability, and accountability in research and action

Josyula K. Lakshmi, Prasanna S. Saligram, Shrutika Murthy, Varun Sai, Botlagunta Ramanamurthi, and Surekha Garimella

Protection of human subjects of research is embedded in regulation. However, policies for the protection of participants, researchers, and implementers in health and development programmes are not as well articulated. Recent exposes of harm in research, humanitarian, and private enterprises have brought safeguarding to the fore, and highlight the need to expand its scope.

ARISE, a participatory action research consortium across five countries and eleven institutions emphasises safeguarding in its work, and also participated in a consultation to explore perspectives of safeguarding in LMICs.

The ARISE consortium held a workshop to deliberate risks to various stakeholders in research and practice; enumerate existing policies and procedures, and gaps thereof, in the partner organisations to identify, report, and redress breaches; and advance safeguarding. The consultation on safeguarding in India involved five key informant interviews.

The term ‘safeguarding’ is poorly understood, and finds little or no usage in policy documents, or people’s conceptualisation of protection of persons in research, healthcare, and practice. Concepts of safeguarding overlap with concepts of ethics, professional regulations, and organisational and national laws. Organisations articulate the particular risks faced by their members and stakeholders, and delineate procedures for identification, reporting, and redressal of harm, principally to participants in research and programmes. Extreme harms, as defined in legislation, are addressed through legal means. Subtler harms, and harm to stakeholders other than research or programme participants, regarded as power politics, are largely left to individuals to resolve.

Respondents were wary about how safeguarding requirements would play out in multi-country partnerships between the Global North and Global South, especially in relation to country legal requirements and sovereignty, and their impact on confidentiality, roles, and power differentials in these partnerships. They also contemplated the paths that safeguarding requirements could take – punitive mechanism versus facilitator of ethical practice.

Safeguarding is not articulated, although implicit in the conceptions of researchers, activists, and programme implementers. Protection of research participants from the effects of the research is the component of safeguarding clearly expressed in regulatory deliberations. Other aspects of safeguarding, as well as other stakeholders in research, health systems, and programmes (e.g., frontline workers), may or may not be covered under diverse policies of the organisation, or the country. A substantial proportion of safeguarding rests on personal initiative, organisational culture, and social support. Safeguarding merits foregrounding, especially in power-unequal societies, to assure protection and voice to all, particularly the most vulnerable.

Visible policies, invisible workers, and distant health systems

Barathi Nakkeeran, Prasanna Saligram, Azim Premji, Surekha Garimella

Solid waste management (SWM) has received lot of traction in India recently in the context of Swachh Bharat (clean India) Mission (SBM). India produces around 62 million-tonnes of waste annually, an estimated twenty percent of which informal waste workers contribute towards recycling. Waste workers’ labour is barely recognised and is lowest in hierarchy of urban informal occupations. Waste workers come from most marginalized castes, classes, and are predominantly women. Does ‘clean India’ mean including the rights to a dignified life and well-being of these workers?

Where does the waste worker emerge in policy and legal discourse? Is it only with respect to segregation and management of waste? Waste is a deeply caste issue and waste workers face tremendous stigma which the discourse on health does not address. The study looked at the legal and policy landscape in terms of the health and well-being of waste workers.

This study undertook a policy landscaping exercise to review various legal, policy documents pertaining to waste workers on their health and well-being. A policy matrix was drawn up. A discourse analysis was applied to understand the socio-cultural meanings of waste as elicited in the policies.

SWM and plastic waste management legislations mention responsibilities and duties of waste workers but only instrumentally with respect to their contribution as recyclers to waste economy and silent regarding their health and well-being. Health ministry policies are largely silent on waste pickers. The NULM highlights social protection measures for informal workers but does not include waste workers explicitly. Even the NULM-SBM convergence document which provides for organising Self Help Groups for “ragpickers and wastepickers” is silent on their health protection benefits.

In India waste is deeply embedded in the socio-cultural dimensions like caste, gender, and class and this is where policies’ silences are intensely heard. This erasure in policy spaces have their snowballing effect on lack of responsive services from the state for the marginalised and a misrepresentation of what constitutes the last mile. The SWM discourse is largely neo-liberal in its outlook stressing more on stop-gap mechanisms like provision of gloves, identification cards, etc. The state and the municipal corporations thrive on this informality and hence these provisions do not address why only certain marginalised sections collect, pick, and sort waste, this then blocks any aspiration of a genuinely inclusive ‘clean India’.

The health and wellbeing of waste pickers survey

21 10 2020

Planning the India health and well-being survey

In this blog J. K. Lakshmi, Vinodkumar Rao, Smruti Jukur, Prasanna Saligram and Surekha Garimella describe how the ARISE India team members met virtually to brainstorm the design, content, development, and administration of a survey to help understand the perceptions of health, well-being and associated concepts and experiences in communities. They detail the process that was followed, areas of contestation and disagreement, and the importance of the survey.

The goal of the survey we are developing is to elicit perceptions and concerns related to health and well-being, which will help our community partners shape their work to address those issues. While the survey instrument will collect quantitative data, it will be informed by, and supplemented with, in-depth discussions with community members and our civil society partners. The process of thinking through the tool was far from straightforward. The preliminary discussion planned for an hour took twice that time with each of us proffering and defending different points of view on health, well-being, the determinants thereof; the optimal research method to achieve the objective; and then the optimal way to put the method into practice.

An instrument developed in a previous study was the launch pad for our deliberations. We went over the domains of health and well-being addressed by the instrument, discussed the administration of the survey, in particular the shortcomings thereof, and debated the relative merits of the components of the instrument in eliciting the information that would aid an understanding of the perceptions of the communities we are focusing on. We realised that we were not constrained to use this instrument, and to administer it as it had been in the previous study. We decided to develop an instrument to meet our particular needs, and plan its administration using lessons from previous studies and the advice of community representatives in this study.

The crux was – what is it we are aiming for through this survey? We are looking for a granular and deep understanding of the communities’ conceptualisations, and experiences of health and well-being, including determinants, access, agency, and needs, met and unmet, and how their individual, family, and community histories and struggles have a bearing on, and feed into these.

We did not know of any existing instrument that met our needs. The nuance required of the instrument to explore circumstances frequently encountered in the communities in our project, e.g., exposure to occupational hazards among waste pickers, became clear. We also recognised that standardising the instrument for use across communities and settings posed the risk of neglect of important issues in some communities, and delving into matters of low relevance in others.

We spent some time arguing about our individual inclinations towards different research methods, and different designs of instruments, and kept placing our arguments against our objectives to establish good fit. A vital discussion point was the difference between open-ended discussions and objective surveys in aims, execution, and outcomes. We also conferred on the best sequence of activities to elicit the information that we seek, in the most ethical and efficient manner, and provisionally decided on:

Interviews with community representatives, and focus group discussions with co-researchers (community members engaging in data-collection and analysis with the research team) to compile a comprehensive list of domains and items to include in the survey, as well as the terminology and articulation called for in each community and language, to inform the development of our survey;
Designing the instrument in consultation with our statistician colleagues, to ensure that the items are articulated and scored as intended, suitable to analysis and interpretation;
Planning the administration of the survey to assure standard data-collection technique within and across communities; and
Envisioning the use that the findings would be put to by the research team, the civil society partners, and the communities.

The team parted intending to individually examine the instrument from the previous study, annotate it with descriptions and comments on suitability for use with the communities in this study, comment on essential discussion points in the interviews and focus group discussions, and additional items considered critical for the survey. These thoughts will be compiled and deliberated at our next meeting, after which we will proceed to the first phase of the survey design, i.e., interviews with community representatives, and focus group discussions with co-researchers.

Health and well-being are not easy to conceptualise and articulate, as demonstrated even in our discussion in a small group of supposedly like-minded people. To develop a cogent compilation of objective survey items to be administered to large groups of individuals, while certainly a noble goal, can lead to some challenges to well-being in the run-up. We will be mindful of framing the survey items for ease of understanding, interpretation, and administration by the research team and co-researchers. Our survey findings will be vital for advocacy by the communities and the federated groups.

We now look forward to the fruition of this mighty instrument that we intend to develop. We hope that this exercise will be useful for the communities in focus in the study, stimulating learning, thinking, strategising, and action for improved well-being. We also hope that our well-being and sense of humour survive this process.

10 10 2020

Making the links between cities and health for World Habitat Day

By Lynda Keeru

Unbeknown to many, there are lots of connection between cities and health and this becomes even clearer in the face of pandemics. As has been said over and over again since the COVID-19 debut, epidemics reveal the reality of things. This view was reflected by most of the speakers during the ‘Webinar on Pandemics and Future Cities’ held on 5^th October 2020.

With representation from across the world and all continents, one could not help but feel the sense of solidarity and unity brought about by the pandemic and the willingness to join efforts in its eradication.

In April the United Nations Human Settlement Programme (UN HABITAT) started work on a new flagship report – “The future State of Cities in a World with Pandemics” – to be launched during UN’s “Urban October” campaign 2020. Habitat Norway, in collaboration with UN Habitat and world leading experts, facilitated a presentation and discussion of the reports main findings, conclusions and recommendations. It focused on health, human rights, housing and humanitarian challenges.

A statement from the organisers read,

“The pandemic has triggered unparalleled global action and exposed stark social and economic inequalities and system weaknesses. It has shown that we have to abandon the old, normal way of dealing with global emergencies. It has highlighted that long term complex challenges and short term crisis demand new responses and ways of working. As we look ahead: what do we need to do differently? And what can we learn from the pandemic? What kind of collaboration and action are needed to achieve transformative change and prepare us for a radically different world? Cities will because of demographic and economic development be central.”

Participants from all realms including Civil Society Organizations, academia and government representatives met and discussed the new ways of working and living that need to be developed to tackle present and future crises drawing on lessons learnt from capacity building, advocacy and grassroots’ experiences.

To this end, Annie Wilkinson a member of the ARISE consortium, made a presentation – “Addressing systematic Poverty and inequality in Cities-the health challenge”. She started off by defining the urban health challenge which she said was largely a result of the growing urban population, especially in low- and middle-income countries. Inequality and poverty without a doubt present very negative impacts on health but unfortunately the health determinants in many of these urban settings are unknown to many. Most urban-health interactions are not paid attention to with very little being known on the most vulnerable people and settings especially the one billion people living in informal settlements.

Epidemics are a window into society and they reveal a lot with many wondering if COVID-19 will be a turning point. Annie explained that the way we deal with infectious disease has changed – moving from sanitary and infrastructural reforms to behaviour change and ‘silver bullets’ becoming increasingly disconnected from urban environments.

Drawing on learning from the Ebola epidemic in West Africa, Annie reflected on the challenges that the urban poor faced. She outlined the issue of urban neglect which facilitated spread of the disease, the ill equipped public health teams that could not manage the epidemic response, the histories of structural violence and inequality that led to distrust, violence and resistance. Most noteworthy, locally led control efforts are what eventually bent the curve of the epidemic. Ebola, just like many other pandemics, highlighted the social and political dimensions of health and the need for inclusive responses.

In the case of COVID-19 in informal settlements, people fear the spread of the virus but the greatest challenge is the lack of understanding of vulnerabilities and heterogeneity due to lack of data. Unfortunately, many of the blueprint response guidelines that were prescribed for COVID-19 were not practical and feasible for most populations and people in urban informal settlements. Most of the vulnerable were not reached by state support systems. However, social movements have worked hard and mobilized support networks to plan locally appropriate and inclusive responses. In most cases, this kind of support is made possible by long standing collaboration between residents and local authorities.

A focus on why cities, their inhabitants and urban health interactions are overlooked revealed that the attention and spending on urban development is very limited. The data on the most vulnerable populations and places is sadly very limited and an absence of policy frameworks on national urban policy omitted is from sectoral policies like in health and pandemic preparedness is a huge issue. Siloed expertise and politics of neglect that encompass exclusionary policy and practice and historic blaming of the poor are a huge contributing factor of this misunderstanding.

In order to understand the complex picture of inequality and systematic poverty in cities, we must acknowledge the homogenous social, political and economic relations that shape the urban spaces. Another factor that contributes to this complexity is the fact that drivers of health and wellbeing comprise intersections between environmental deprivations and hazards as well as social marginalization, stigma and violence. The governance in cities is also very complex across different sectors, administrative and spatial scales much of which is unknown and informal to many, making accountability a hard process. People in cities have diverse forms of power and agency and it is quite difficult to identify drivers of multiple, intersecting inequalities in health and wellbeing and routes of redress.

What then is needed to address this challenge? It is vital to increase investment, gather more data and attention to the issue. It is also paramount to have the right perspective; which will mean, as Annie put it, “seeing like a city”, like a citizen and also paying attention to what and who is not visible. Interdisciplinary, intersectoral and intersectional approaches are required, with special attention to power dynamics and the inclusivity of the most marginalized. Finally, there is need to focus on the social context and infrastructures which incorporates processes of learning dialogue and collaboration.

A one size fits all approach and generalization do not work in this case because cities are different, the settlements in them are varied and so are the populations and people.

A colourful mural advocating for an end to teenage pregnancy

28 09 2020

Youth battle against COVID-19

By Jacob Omondi, Jackline Waithaka and Jane Wairutu

Globally, as of September 9, 2020 there have been 27,417,497 confirmed cases of Coronavirus reported to WHO. Efforts to slow the surge in cases and completely flatten the curve continue to be introduced at various scales however, the impacts of the pandemic have severely been experienced all around the globe.

Various reports note the COVID-19 outbreak, has greatly affected the labour market particularly the informal economic sector which harbors a large number of youth who now experience the negative impacts of the outbreak as a result of job losses and pay cuts. The pandemic has greatly devastated the youth, especially in informal settlements such as Mathare, Nairobi. Financial instability caused by contract termination and the evening curfew which affects a retailer’s booming business hours is among the main factors causing hardships for most youth who operate their businesses.

Residents in settlements such as Mathare, who often live from hand to mouth, are used to operating their business in the late-night hours. But they are now required to be home by 21.00 thereby reducing the hours where they would capitalize profits and businesses is at its peak. These businesses include the transport industry where the majority of the drivers and conductors are youths especially men, bar attendees who sell illicit brew (chang’aa) which is the backbone of Mathare’s economy. These jobs created employment for a lot of youths who could otherwise be rendered jobless and has resulted in a higher crime rate.

After the closure of schools as a measure to control COVID-19 there has been increased theft, more cases of teenage pregnancies, greater drug use, and more gang-related activity among youths. The rising trend among such groups has been attributed to the high unemployment rate amongst the youth both students and the ‘hustlers’ increasing social violence such as gender-based violence.

The story of Amos

Amos, a 22-year-old, talented artist and fashion designer from Mathare 4a, sought to sell coffee after the termination of his contract in a fashion firm he worked for. He expressed concern in his new business as it is yet to successfully pick up. A sense of uncertainty lingers as he thinks of his business’s future outcomes due to the low daily’s earning he can carve out. This is due to the low demand for coffee following the introduction of curfew, which has slowed down normal business operations during the booming business hours.

Unemployment has added to the increased rate of insecurity within Mathare. Amos has witnessed several scenes that bring about his fright for the dark. To him, this nightmare began when his and hundreds of other worker’s contracts were promptly terminated. He now has to risk finding customers within the now dangerous streets to earn a living.

The story of Stafford

Stafford Otieno a 28-year-old youth from Mathare said, “Finding a job has been one of my biggest challenges during this difficult pandemic period. I have applied for so many jobs but I have not been successful. Also, most of the jobs require years of experience and I do not have the exposure. I have realized here in Kenya if you don’t have connections or a godfather you can’t find a job.”

The stories of Daniel, Brian and the second Daniel

Many learning institutions around the world remain closed in an attempt to contain the spread of the COVID-19 virus. In Kenya, the education ministry directed the closure of schools in mid-March, three months after the school calendar had commenced. Six months on, various efforts have been channeled towards adapting to a new normal, online learning, as the government-run Kenya Institute of Curriculum Development continues to provide school programmes via the radio, television, and online.

The suspension of school by the government has made some Mathare based university students like Brian Opondo, Daniel Shitanda and Daniel Ongulo among others take up tutoring both primary and secondary candidates. They now have 25 students, whom they tutor within Mathare at a small fee of 100 shillings (KSH) per week to carter for administrative costs e.g. photocopy of the academic past paper for revision. This they do voluntarily while making use of the learning space granted by Canada Mathare Education Trust.

A group of students around a table. They have been affected by school closures

Prompting creative responses

As much as the pandemic has affected many, it has also helped, to an extent, in improving lifestyles as thousands of youth have embraced creativity and innovation, some proceeding to make a living out of it. Sectors such as fine arts by drawing murals, music through composition of inspirational songs, poetry composition and performance, artistic performances are now using social media platforms such as Facebook, twitter and YouTube. Such artistic performances are majorly geared towards attracting audiences and provide entertainment sources as well as educational and awareness creation platforms for the masses.

COVID-19 has impacted negatively on majority of youth, but hasn’t hindered their active brains from being inventive and innovative thereby portraying the possibilities of coping within the pandemic period and going further to also be able to earn a living. And this is only possible if they are empowered to do so by creating co-curriculum training facilities such as vocational and community training institutes. With proper measures, we can manage the drastic economic instability the youth are experiencing currently.

Counselling a client affected by violence

21 09 2020

Supporting people who experience violence during the COVID-19 pandemic

By Joseph Etyang

Cases of gender-based violence have been on the increase during the COVID-19 pandemic. This has not spared anyone including people who are living with a disability. As a deaf counselor, I have received many cases of clients who are going through a difficult time during this pandemic.

During a routine antenatal clinic visit, one of my young female clients approached me. She told me that she was having challenges. I was concerned since she is pregnant.

The young woman was jobless. She planned to join college again after delivering her baby. She would live with her parents who would help her and look after her child. The pandemic, however, increased her uncertainty. As if this was not enough, her boyfriend had lost his job too and was unable to support her at this time. The financial stress created tension between them that even resulted in emotional and physical violence. The conflicts and violence were a threat to their relationship.

At this time, I decided to offer mental health therapy to the young woman. We talked about her current situation, her health and wellbeing as a pregnant woman. After a lengthy discussion, she agreed that she needed to talk with her boyfriend on the importance of taking care of her, the relationship and the unborn baby now more than ever. We planned that I meet both together.

He accepted my invitation, and they came together for a counselling session. Since sexuality education is absent in Kenyan school curricula, I helped the boyfriend understand the partner’s situation and vulnerability as a pregnant woman. His violence against her was a risk to the unborn baby and the expecting mother. Stress could cause her a miscarriage and other complications. Through his violent acts, he put himself at risk of being arrested. During the counselling session, they agreed to look for alternative ways of earning a living. The boyfriend agreed to look for some casual job, while the young woman would follow-up on the funds that have been disbursed by the government in support of vulnerable members of the community during this pandemic.

I am against gender-based violence – it causes a lot of problems psychologically, emotionally, physically and literally affects the well-being of the family. Gender based violence results in self-esteem issues and traumatized individuals and children are mostly affected.

In my experience gender-based violence often results in sexual abuse and exposes the children to the same. Gender based violence prevents economic growth from the couple because of lack of empowerment. In other cases, it might result in untimely deaths, poor environment to the children and sexual diseases. Some women may engage in sex work to be able to economically support their family during these periods; this may exacerbate household tensions and associated violence due to a reliance on sexual relationships outside of the household.

Joseph Etyang is a Kenyan deaf man who works as a counselor with LVCT Health. He is involved in HIV and gender-based violence prevention programmers and supports the Nairobi deaf community through their support groups.