By Vinodkumar Rao, Puja Solanki & Sheela Patel

Traditionally, medical camps by non-governmental organisations (NGOs), corporate sponsors, foundations, and other charitable institutions are seen as acts of charity. The communities that the camps support also see them as short, solidarity events. Weak public health systems, particularly those in preventive health, necessitate such acts of charity.

Such camps continue to play a crucial role in helping individuals access better health primarily because the demand for decent and affordable healthcare outstrips its supply. In our experience, however, apart from fulfilling the immediate, short-term needs of individual citizens, medical camps can also become an important research tool, aimed at strengthening the larger public health system.

ARISE partner Society for Promotion of Area Resource Centers (SPARC) India works with the National Slum Dwellers Federation and Mahila Milan, a women’s collective. Together, we have over three decades of experience working on tenure security, access to sanitation, housing, etc. for the urban poor, which is aligned with the larger goal of improving health, dignity, quality of life and wellbeing of poor urban residents across the country. However, working directly with the public health system is a first for the alliance.

At first, the engagement of resident communities in conversations around health and health systems could, at best, be described as passive. We then experimented with using medical camps as icebreakers with our resident slum and slum relocation communities to generate conversations about their personal and community health. In our experience, these camps proved to be far more consequential than we expected – they did a lot more than simply ‘break the ice’.

Understanding the reality

The experience of arranging the logistics around a medical camp, along with the actual execution of a camp, was an important learning. Each participant was weighed, their height measured and noted, their blood pressure and random blood sugar levels checked with portable devices, and then referred to the doctor to help demystify these numbers. Participants then had a one-on-one conversation with the doctor about how they feel, and any challenges they are facing. Accordingly, everyone was advised to access a few basic free medicines that were dispensed by a staff member.

Since staff members were themselves involved in these activities, everyone developed an understanding of what it takes to run a health centre, similar to a clinic. While a regular local clinic may not see such high patient loads, such an understanding helps in gauging the types of activities, along with the cost of screening for and treating minor illnesses.

Deeper and evidence-based understanding of the problem

The data from the camps gave us deeper evidence-based understanding of the extent of specific challenges within the communities. In particular, it revealed a surprisingly high prevalence of both hypertension and elevated blood sugar levels across all age groups, including the young. For instance, 87 per cent of all individuals screened in the age group of 20-29 in Ahmedabad were prediabetic or diabetic. This was starkly different from what we found in Mumbai – while younger individuals seem comparatively less likely to have high blood sugar, this problem peaks in the age group of 50-59, with 45 per cent of all tested diagnosed as prediabetic or diabetic.

These numbers correlate well with body mass index (BMI) for these age groups, calculated using the collected height and weight information. Rampant malnourishment was prevalent among communities in one city, as was the consumption of tobacco by boys as young as eight and nine years old. Almost a quarter of all adults screened in Ahmedabad were underweight.

While screening at any camp does not provide conclusive evidence of the underlying conditions, these results provide us with a ballpark understanding of the reality of hypertension and diabetes prevalence among the urban poor. In the absence of regular screening, which should be an essential feature of public health that has focus on these non-communicable diseases (NCDs), people usually get diagnosed after the secondary effects of underlying condition become visible, increasing the likelihood of incurring catastrophic health expenditures. Such data-based findings from medical camps can serve two equally vital purposes – promote and provide direction to relevant health-based conversations within our underserved communities and compel our municipal health systems to undertake necessary action steps.

Uncovering new areas of action

Most women participants in the medical camp brought their children with them, while the men usually came alone. Women openly shared their problems around menstrual health, mental stress, and visible signs of physical abuse from domestic violence. We draw two lessons from it: –

1. Public health action needs to prioritise and accord specific focus to women’s issues and recognise the role of women as central knowledge providers for engagement and action around family health.
2. Action against domestic violence and violence against women in all forms needs to be an essential part of public health.

Trust and cooperation – Essentials for a strong public health system

In all camps, turnout was at least 100 people each day and across all ages, received by a team with one doctor. Women participated more than men, often bringing their children along. Participants willingly shared their health problems with the doctor and sought his advice. Observations like these indicate a clear willingness among people to actively use primary preventive healthcare systems when available, to improve health outcomes for themselves and their communities.  

A partial reason for the high turnout at these camps was the trust that resident communities have in the federation network. For each camp, organised resident groups made local arrangements, such as sourcing a location and communicating to ensure residents were aware of the camps. Their direct involvement added to the trust among the people. This indicates that investing in trust-building between public health systems and communities has had a positive impact, and further justifies the need to create a formal role for organised or federated local community networks in the fight to strengthen local public health systems.

Medical camps: a tool for research

In our experience, these medical camps have worked as a ‘research tool’, offering insights and learning around health issues in particular localities, and knowledge on areas of intervention to strengthen public health more broadly. It has worked as a diagnostic tool in understanding local health challenges and, in the process, built further conviction among residents in working with us towards strengthening our health systems. It has also helped to shape conversations around improving prevention, early detection, and management of NCDs and other stigmatised illnesses, like tuberculosis. Lastly, medical camps provide avenues that helps knowledge building and curiosity among resident groups, who begin to look at gaps in health care within their neighbourhood and seek accountability from the duty bearers in filling them.

Alongside other interventions, medical camps can become tools to promoting health and health service challenges as a collective problem that neighbourhood groups will see value in investing time and collective effort into.

The International Society for Urban Health (ISUH) is the only global non-governmental organization solely focused on advancing urban health and health equity by addressing the broader determinants of health. Through its annual global conference and program activities, the ISUH serves as a platform for interdisciplinary academic researchers and educators, practitioners and policymakers from multiple sectors in government and the private sector – NGOs and businesses to learn from each other and advance evidence and action that improves urban health.

We are delighted to join our colleagues at the 2022 International Conference on Urban Health 24-27 October – flying the flag for ARISE research. We are holding a mix of in-person and virtual sessions so whether you are travelling or attending from the comfort of your own home there is something for everyone! Check the agenda below and attend our sessions.

Monday, October 24, 2022 Parallel Session 1: 11:30 – 13:00 CET

The economics of health-care access in low- and middle-income countries: A scoping review and evidence map on the economic impact of health-care access for urban populations

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). The lack of good quality public services and reliance on the private sector result in high costs and catastrophic health expenditures (CHE). We undertook this scoping review to document the economic impact of access to care and to identify inequalities in health-care expenditure and CHE across urban populations. This review was developed as part of the ARISE research consortium which aims to enhance accountability and improve the equitable health and wellbeing of marginalised populations living in slums in LMICs.  This is a collaborative study developed by representatives from the ARISE partner organisations in the UK, India, Bangladesh, Sierra Leone and Kenya. 

This scoping review presents a narrative synthesis of cost studies conducted in urban areas of LMICs.  We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in slums and non-slums settlements.  The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We combined three quality assessment checklists (patient costs, health economics, and observational and cross-sectional studies). We calculated the costs of accessing health care, concentration curves, index and incidence of CHE of acute, chronic and unspecified health conditions. We developed an evidence map to identify research gaps in the domains of the total number of studies, health interests and country. The review had a strong capacity strengthening element and all reviewers completed the Cochrane interactive learning modules on systematic reviews. The review team met regularly to develop skills and ensure quality and consistency throughout the review.

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). None of the definitions of slums used covered all characteristics proposed by UN-Habitat. We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Health-care expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. The evidence map showed that city-wide studies reached a higher number of studies and sample size in almost all domains, but most of the evidence was classified as poor quality.

Our findings indicated severe, but different patterns of the economic burden of accessing health care for slum dwellers and residents across LMIC cities. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs. We are currently using our findings to develop policy briefs and recommendations to decision-makers in ARISE countries and advocate for improvements in health care access for vulnerable slum-dwellers.

Room: Aula Cavanilles

By: Noemia Siqueira Filha, Jinshuo Li, Penelope Phillips-Howard, et al.

Wednesday, October 26, 2022 Virtual Session 7: 10.30-12.00 CET

Urban poor, city development and vulnerabilities: Learning from the ARISE project in Bangladesh

The rapid urban growth of Bangladesh is driven by rural-urban migration for better employment opportunities. Most migrants cannot afford proper accommodation in the cities and start living in densely populated informal urban settlements, which are built-in low-lying areas vulnerable to frequent inundation arising from poor drainage systems and other natural calamities. About 1.5% of the total urban population lives in informal urban settlements in Bangladesh, and the greatest concentration is in Dhaka, the capital of Bangladesh. This abstract presents the findings of the ARISE project on the vulnerabilities induced by improper urban planning among poor people
living in informal urban settlements in Dhaka city.

We extracted and analyzed data from the photo diaries method conducted by the ARISE project in Bangladesh from April to August 2021. Six community peer researchers, recruited from three informal urban settlements (Kollayanpur, Nama Shyampur and Dholpur)of the ARISE project in Bangladesh, collected photos of different challenges their respective communities face. They captured pictures by themselves and shared voice notes with the academic researchers explaining the images. In online reflexivity sessions, both academic (we) and community peer researchers co-analyzed the photos and narratives. We recorded the reflexivity sessions, prepared transcripts,
and did the content analysis. Then we triangulated findings from the co-analysis and content analysis.

Improper solid waste management and flawed drainage system are the main reason behind waterlogging – a common problem the informal settlement residents suffer throughout the year, which hampers their daily lives and puts them at risk of waterborne diseases. Most of the toilets are also connected to the drainage system resulting in solid waste blocking the drains, which ultimately causes waterlogging. Nama Shyampur informal settlement is surrounded by mills and factories where industrial wastewater is dumped into the low area, which causes regular waterlogging and flooding. One NGO built a drainage system in Kollayanpur informal settlement about 19 years ago, connecting the drains to the Mirpur canal, which has been blocked over the years due to the
development of the Mirpur area. But the area development plan did not include the Kollayanpur settlement. Co-researchers from Kollayanpur also shared that one government agency has taken over one-third of their settlement lands in the name of development. That government agency was reconstructing roads surrounding the Kollayanpur settlement during data collection. There was a fear among the residents that they would be evicted once the road construction was completed as that government agency owns the land. Waste disposal was a great concern for the Dholpur informal settlement residents, although most of them are city corporation cleaners. There is a dustbin beside the ten-story reallocation building of the city corporation workers. But no city corporation’s waste collection truck collects waste from that dustbin. As a result, there is always an overflow of garbage on the street, causing environmental pollution.

Informal settlements are excluded from the city development plans, creating new vulnerabilities and intensifying existing ones. The city authorities have never taken any initiatives for permanent solutions to the problems.

By: Bachera Aktar

Wednesday, October 26, 2022 Parallel Session 7: 16:30 – 18:00 CET

Informal social accountability mechanisms for water, sanitation and hygiene in informal settlements

Despite many institutions gaining access to improved water sanitation and hygiene (WASH) services, childcare centres in informal settlements have low access and poor condition of WASH services. It is imperative to understand how existing actors and social networks operate in the WASH sector in childcare centres in Nairobi’s informal settlements. Our objective was to empirically map and understand how different actors within informal settlements influence the provision of adequate and quality water, sanitation and hygiene services within childcare centres in Nairobi’s informal settlements.

This was a qualitative study. We conducted an ethnographic study using governance diaries with 24 participants from Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved conducting bi-weekly governance in-depth interviews (IDIs) with study participants for four months, complemented with observations, reflections, participant diaries and informal discussions. We used a framework analysis which is partly deductive, informed by the governance framework and stakeholder framework.

Social accountability actors were individuals or groups involved in WASH service provision in childcare centres. The actors included both key actors (actors who are primary to meeting the day-to-day WASH service needs of children) and non-key actors (actors operating in the WASH sector but not always present for day-to-day provision in childcare centres). The key actors were unanimously identified as childcare centre owners/teachers and parents/guardians as they had a more direct role in the provision of WASH services in childcare centres. The actors had direct, possible or desired networks, with the direct networks portrayed more by the parents and childcare centre owners, whose roles included acting as a voice and responding to the WASH service needs of children as it relates to access and quality. Centre owners had more power/authority over WASH services for children in childcare centres than the parents. Key actors derived power by their discretion depending on whether a decision was beneficial to children or not. Lastly, the interest of key actors were diverse ranging from income generation, access to WASH services by children, compliance with government regulations, and promotion of child health, to the prevention of the spread of diseases.

Our study highlights that parents and childcare owners play an important role in WASH service provision. While service providers and other players may be statutorily given primary responsibilities for WASH provision, and more visible in official standing, among study participants they are not seen as primary actors but secondary players with ancillary responsibilities. We conclude that WASH service provision in child care centres may be realised when key actors have a voice and work within networks to demand WASH services from desired networks including the government. We also conclude that developing more direct networks and converting desired and potential networks into direct networks in WASH service provision is critical for the success of WASH service delivery. Lastly, actors in WASH services in childcare centres may need to collaborate in identifying potential avenues for strengthening existing networks that enhance access and quality of WASH services in childcare centres

Room: Salón de Actos

By: Ivy Chumo

Thursday, October 27: Virtual: 9:00 – 10:30 CET

PANEL! Intersectoral collaboration and integrative governance on the road to urban health: Lessons from CUSSH, ARISE & SISTARs projects

Adaptive co-management systems are flexible community-based systems of resource management tailored to specific places and situations, and they are supported by and work with various organizations at different levels. The flexible structure allows for learning and ways to respond to and shape change. We present lessons, results and an integration of bottom up and top-down approaches. We criticize tactical approaches that rely on bounded interventions, neglect diverse actors, and rest on flawed assumptions. We describe adaptive governance of four projects implemented in the urbanization and wellbeing unit at APHRC. 

Complex Urban Systems for Sustainability and Health (CUSSH) aims to understand complex and adaptive connections between urban development actors and health within city systems. CUSSH utilizes multidisciplinary methods to achieve the transformations that cities need to address the environmental challenges of the 21st century. In addition, it provides transferable evidence on how to accelerate actions essential to achieving large-scale changes in sectors such as energy, transport, water, sanitation, and housing.

Accountability for Informal Urban Equity (ARISE) aims to understand the role of social accountability in addressing the socioeconomic, health and wellbeing inequities of vulnerable populations living and working in urban slums in Nairobi, Kenya. Rapid urbanization has been a characteristic feature of the development process. While urbanization presents opportunities for social and economic development, it also demonstrates the world’s most obvious socio-economic, health and wellbeing disparities. Vulnerabilities and inequities are often invisible in urban planning, health and socio-economic indicators and are usually poorly addressed in formal service provision, more so during COVID-19 pandemic. Vulnerable groups (persons with disability, older persons and children headed families) in Nairobi’s informal settlements face disproportionate socio-economic, health and wellbeing burdens and are disadvantaged in access to services.

Social accountability for water, sanitation and hygiene (SWASH) project aims to co-produce adaptive social accountability mechanisms for WASH in childcare centers during COVID-19 pandemic. Despite the existence of discrete social accountability mechanisms (SAMs) in informal settlements, Adaptive SAMs rarely form a part of strategic approach to addressing social accountability challenges in access to WASH services in childcare centres. Children attending childcare centers in informal urban settlements disproportionately experience ill-health and socio-economic burdens and yet routine government data rarely cover informal settlements and are usually insufficiently disaggregated.

TranSforming InsTitutions to Advance women leadeRS in Science Technology Engineering and Mathematics (SISTARS) project aims to contribute to advancing women in STEM in industry and academia through the development of adaptive governance strategies that will promote women to leadership positions, more so during the COVID-19 pandemic. Using Ghana and Kenya as case studies, the project seeks to understand why women found it difficult to rise to leadership positions in their STEM careers during the COVID-19 pandemic. This will enhance institutional efforts at gender mainstreaming in STEM and has contributed to innovative strategies to promote institutional advancement and protection of women in leadership positions in academia and industry.

Effective health research is built upon equitable partnerships between researchers and communities. In Connecting Citizens to Science, Dr. Kim Ozano and Robinson Karuga, interview expert researchers from across the globe who engage with communities in their research. 

Series 4: Research for social change within urban informal communities

Series 4 of Connecting Citizens to Science is supported by ARISE. The ARISE consortium is all about promoting social change for improved health and wellbeing with communities and people living and working within urban informal spaces.  Together, across ten partners in four countries – Bangladesh, India, Kenya and Sierra Leone- they are co-developing solutions with communities to health and wellbeing challenges. However, co-production of knowledge for action is challenging due to the many and intersecting inequalities and power relations between researchers, development professionals, activists and communities. The podcast will explore how ARISE is working to overcome these, in partnership with people in urban informal settlements or slums, to stimulate change. 

Episode 4: Participatory action research: from community collected data to action and change  

In this episode we hear from our co-host Robinson Karuga on his role as a Research, Evaluation and Learning Manager at LVCT. Robinson has been part of a team implementing a participatory action research approach to improve health and wellbeing in two informal settlements in Nairobi. Robinson shares with us: 

• How data collected with community co-researchers using photovoice (see S4E1) was presented to key stakeholders like chiefs, village elders, civil society organisations and community volunteers so they could identify and prioritise key health and wellbeing issues  
• The development of work improvement teams that were responsible for driving actions for change together with key decision makers, government bodies and those who held power such as police 
• The journey from data collection to problem identification, root cause analysis, developing actions and implementing them within the system 
• The role of researchers as facilitators, coaches, and moral support, as well as assessing and navigating power dynamics through reflexivity 

Episode 3: Covid-19 research and relationships with communities in informal settings for policy response

In this episode we talk about COVID-19 and how travel and public health restrictions presented challenges to ensuring that urban marginalised voices were heard by researchers and policy makers in India and Bangladesh. Our impressive guests Professor Sabina Faiz Rashid and Senior Research Fellow Dr Surekha Garimella discuss the importance of having established long-term relationships with people, communities and supporting organisations which enabled research to continue and ensured that the needs of people in urban spaces were reaching decision makers. Our guests share;

• What happened when COVID-19 hit urban informal communities in India and Bangladesh
• The personal and professional passion of researchers to work with communities, not only for research purposes but in solidarity for the struggles faced
• Their own career journeys of humility, unlearning, connectedness and shared humanity that shaped their lives and relationships with communities

Episode 2: Intersections between research and activism

In this week’s episode we will be discussing the intersections between research and activism for social change. With our guests Vinodkumar Rao and Joseph Kimani, we will be seeking to understand how lessons from activist approaches can be applied within research and vice versa. We will also explore how power, participation and social justice fits within the wider research agenda when seeking to engage communities in informal settings. Key points we hear from Kimani and Vinod include:

• How slum federations in India and Kenya lead data collection with support from NGOs and researchers so they can demand rights and ensure they have a ‘seat ‘at the decision-making table 
• The role that researchers play within activist organisations to support knowledge generation, understand government policies and to decipher academic evidence so that communities can develop solutions or ask for resources from the state.
• The organic growth of ‘movement’ building – when one community takes action another will follow and have an example to build upon
• The importance of collecting data about slums, challenging government data, and producing evidence to ‘prove their existence, to prove their requirements and to prove the value that they bring to the city by inhabiting in the city.’
• How dominance and power within community structures is considered and managed within activism to promote inclusion

Episode 1: Storytelling and visual methods with people living in informal settlements 

In this week’s episode we are talking to Inviolata Njoroge from LVCT Health in Kenya and Shrutika Murthy from The George Institute for Global Health (TGI), India. They shared their experiences of using visual methods and storytelling to bridge the power-laden distances between the lived realities of waste pickers, child headed households, the elderly and people with disabilities in urban informal communities and research and policy. We hear about: 

• Methods that have been used to connect with the most marginalised and often hidden people in urban informal communities 
• How different intersecting identities and inequities add new layers of vulnerability in urban informal settlements  
• The use of participant shadowing as an activity to capture experience and context of vulnerable people and what needs to be considered before using this as a method to connect with people 
• How the photovoice method has brought out silent voices and stories that are often left unheard  
• The importance of considering researcher and community mental health when using these in-depth exploratory and creative methods with vulnerable populations 

Lynda Keeru documents discussions in the ARISE panel of the Gobeshona Global Conference on Research into Action. Speakers included Vinod Rao, Shrutika Murthy, Inayat Kakkar, Wafa Alam, Dr Aditya Pradyumna and Smruti Jukur.

Vinod introduced the session and explained to the participants some of the issues and themes that the presenters would be addressing – urban marginal living and work. They would particularly focus on the romanticization of resilience and whether actions based on limited choices can be termed resilient. The COVID-19 pandemic created large disruptions but many in the margins survived and we ought to ask ourselves if that is being resilient. People sadly survive in spite of poor public health access –  is that too a marker of resilience?

Can adaptation be resilient?

Is it possible to move beyond arguing just around precarity of livelihoods? Vinod pointed out the need to acknowledge and support people’s processes and invest in people’s universal public health care. Making people’s needs and aspirations central to urban planning is key.

ARISE aims to improve accountability and promote health and wellbeing of urban marginalized people living and working in urban informal settlements. The consortium targets the most marginalized dwellers in urban informal settlements.

The experiences of waste pickers

In all the settings that were presented, waste pickers are more often than not perceived as thieves and not workers. The circumstances in which they work are neglected and very hazardous. They have no protective wear, work long hours and the terrains they cover are usually very hard to traverse. They face a lot of stigma and are discriminated against by state, society and health systems. There are also gendered experiences when seeking care and they encounter many challenges in accessing social security. COVID-19 exacerbated all these pre-existing vulnerabilities and now there is an over-reliance on civil society organizations and philanthropists. They were forgotten in most of the strategies to curb the pandemic as the focus was on providing protective equipment and mass testing.

There are many health disparities in urban areas in India and health vulnerability to climate change is not divorced from general vulnerability. The urban poor experience health vulnerability in the form of poor and precarious living conditions, hazardous occupations and social exclusion from services. There is a general growing prevalence of non-communicable diseases and a big difference in the prevalence between the rich and the poor.

The health care system in India is characterized by multiplicity of providers, inadequate numbers, delay in accessing care, high costs that the vulnerable may not be able to afford out-of-pocket and a lack of dignified care for the vulnerable.

What can be done?

It is the role of the state to ensure availability and access to comprehensive care. There is a lack of Primary Health Care in urban areas and a reliance on secondary and tertiary care facilities including ambulatory care. There is need to create awareness among the general population, which includes the vulnerable, health care providers and policy makers, on the impacts of climate change on human health. The health care system must also be strengthened to reduce illnesses and diseases due to variability in climate. A proactive approach is needed.

The resilience debate

Urban informal settlement residents’ mechanisms for survival are seen as resilience. Resilience is often glorified and this is dangerous as it overshadows lack of accountability among governance actors and service providers. There’s need for thoughtful consideration of the various aspects of urbanization and a better understanding and involvement of urban vulnerable populations in decision-making. Investment in health and equity should be at the core of strengthening public health and not just for the sake of climate change.

Photo credit: “Sujat Nagar slum in Dhaka” by World Bank Photo Collection is marked with CC BY-NC-ND 2.0.

The Gobeshona Global Conference on Research into Action is taking place from the 27 March to the 1 April. GOBESHONA provides an opportunity to bring together multidisciplinary scholars, policy-makers, researchers and practitioners from around the world to share their knowledge, research, and practical experiences on climate change issues with a broad range of themes, focusing on Locally – Led Adaptation Action (LLA) across different geographical regions. ARISE is delighted to host a session on, ‘Urban Marginality and Resilience expectations learning from ARISE – accountability action research in health.’ Please do register for the conference on this link and come to the ARISE session on this link.

31 March 2022, India Time: 10:30 AM – 12:00 Noon, BD Time: 11:00 AM – 12:30 PM, Kenya Time: 08:00 AM – 09:30 AM, SL Time: 05:00 AM – 06:30 AM, UK Time: 05:00 AM – 06:30 AM

Lately there has been a lot of focus on Urban Resilience, which expects actions from duty bearers and policy makers in investing into thinking building resilience among communities, particularly the poor who disproportionately bear the brunt of catastrophic and slowly induced climate related and other urban vulnerabilities. But what does our experience in engagement with poor urban communities tell us about their vulnerabilities, organically developed resilience strategy, and their expectations from others, particularly those that are accountable to their well being in general?

Do we need to look at urban resilience with a new lens and challenge some of the problematic viewpoints that have a potential to reduce the role of governance and accountability and replace them with self-resilience? This session, through examples of community engagement will present and discuss on this crucial but less discussed aspect of Urban Resilience.

Panel speakers

– Shrutika Murthy and Inayat Kakkar – researchers at The George Insitute for Global health. Shrutika and Inayat have been working with waste picking communities in Shimla and Vijaywada.
– Wafa Alam – is a researcher at BRAC university’s James P Grant School Of Public Health based in Bangladesh. Wafa has been working with slum communities in Dhaka around poverty, health and livelihoods.
– Dr. Aditya Pradyumna teaches at the Azim Premji University is working on Public Health with recent publication on
Health Care inequity in Urban India.
– Smruti Jukur is a trained Architect and Urban Planner by education and a researcher at SPARC. Smruti has been
deeply involved in urban planning and infrastructure development planning in large informal settlements in India and Kenya.

Hope to see you there!

By Noemia Siqueira, Helen Elsey, Jinshuo Li, Penelope A Phillips-Howard, Zahidul Quayyum, Eliud Kibuchi, Md Imran Hossain Mithu, Aishwarya Vidyasagaran, Varun Sai, Farzana Manzoor, Robinson Karuga, Abdul Awal, Ivy Chumo, Vinodkumar Rao,  Blessing Mberu, John Smith, Samuel Saidu, Rachel Tolhurst, Sumit Mazumdar, Laura Rosu, Sureka Garimella

Marginalised urban residents living in slums and other areas of cities face difficulties in accessing healthcare. Frequently, the only healthcare available to these city dwellers are private or informal healthcare providers, where care comes at a high price and quality can be poor.

For low-income city residents, this can lead to people not seeking care due to the financial burden or being driven into deeper poverty to meet the costs of care. This can mean that their health conditions get worse and that they may be vulnerable to additional conditions, leading to spiralling poor health and poverty for the individual and members of their household.

In health economic language, vulnerable urban dwellers can face a severe economic burden when accessing healthcare. This burden can be translated into high out-of-pocket expenditures and a high percentage  of catastrophic health expenditures (CHE), which happen when the patients’ healthcare spending exceeds a specified threshold from the household’s total income.

A group of ARISE researchers came together to investigate the economic burden of healthcare access for slum dwellers and other city residents in low- and middle-income countries (LMICs). To do this, we conducted a scoping review to find out information on this topic in existing literature.

We wanted to know how expenditure on healthcare differed among poor city dwellers and those living in slums in LMIC cities.

In this blog, we show the process of developing the scoping review and the main outcomes of this investigation.

A scoping review to produce evidence

A core activity of ARISE is to produce evidence that can be used to advocate for improvements in the health and wellbeing of marginalised urban residents in LMICs. 

Scoping reviews have a great utility for synthesising research evidence and are often used to group existing literature in a given field. The University Libraries website states that “Scoping reviews are best designed when a body of literature has not yet been comprehensively reviewed or exhibits a large, complex, or heterogeneous nature not amenable to a more precise systematic review”.

Given the complexity and heterogeneity of the literature addressing the economic burden of healthcare access for marginalised urban populations, we agreed that a scoping review would be the appropriate approach to provide evidence on this theme.

The scoping process

We developed a collaborative review process with representatives from ARISE research partners in India, Bangladesh, Sierra Leone, Kenya and the UK. The review team had 21 collaborators from BRAC University in Bangladesh; LVCT Health and African Population and Health Research Center in Kenya; The Society for Promotion of Area Resource Centres and The George Institute for Global Health in India; the University of Sierra Leone in Sierra Leone; University of York, Liverpool School of Tropical Medicine, and the University of Glasgow in the UK.

The process aimed to strengthen research capacity which is one of the core elements of the ARISE Consortium’s work. Some members of the team had little experience with review design, so training at the Cochrane interactive learning platform was offered to provide concepts and methods applied in review studies. They were then able to put their learning into practice in the following review process.

To operationalise the review process, the review team was divided into three groups, core group: researchers with experience in conducting systematic reviews and/or data analysis; new reviewer group: junior researchers with little experience in review methods; and the advisory group: senior researchers with expertise in health economics or urban health. The core and new reviewer teams were responsible for developing all review activities, whilst the advisory team contributed to the interpretation of data.

In July 2020, we had a kick-off meeting to present and discuss the review protocol previously discussed with the review team. Before doing any systematic review of the literature, a detailed protocol that specified every step of the process was produced. In our second meeting, we discussed different review designs and the Cochrane course.

As our search of electronic academic databases retrieved many studies (N=5,673), the members of the core and new reviewer teams were reassigned into review sub-groups, each with three researchers including at least one member from the core team.

Each sub-group independently performed the review steps as illustrated in the flowchart below:

Disagreements arise in each step of the process over the inclusion or exclusion of studies, specific data extraction or scoring in the quality assessment of studies. To resolve the disagreements on steps 1 and 2, we had weekly meetings to debate each issue and reach consensus. Disagreements on steps 3 and 4 were resolved by the third reviewer of each sub-group.

Review outcomes

We classified the studies by their settings into:

1. City-wide: urban studies which categorised residents by deprivation level but made no specific reference to whether people lived in slums or not
2. Slum studies: urban studies with data collected only in slums, and
3. Slum and non-slum: urban studies with data collected in slum and non-slum areas

We identified 64 studies for inclusion, 28 were from India, five from Bangladesh and one from Kenya. Our search did not identify any studies conducted in Sierra Leone.

The literature came mainly from city-wide studies, with 37 studies and a total sample of more than 1.5 million people. City-wide studies had more publications including the calculation of CHE, 20 in total. Unspecified and other health conditions (i.e. injuries, acute disease, child health and tuberculosis) were mainly addressed by city-wide studies, while slum studies addressed mainly obstetric and/or neonatal care. For chronic conditions, city-wide studies had more publications, but the total sample size was similar for city-wide and slum studies (~70,000 individuals).

Main findings

We found different expenditure patterns across the study groups. Slum studies reported higher direct costs of accessing healthcare for acute conditions than city-wide studies (Slum: ranged from I$157 poorest quintile to I$408 richest quintile; city-wide: ranged from I$125 poor quintile to I$177 richest quintile); and lower direct costs for chronic conditions (Slum: ranged from I$789 poorest quintile to I$1,695 richest quintile; city-wide: ranged from I$2,552 poorest quintile to I$3,166 richest quintile).

The percentage of individuals incurring CHE across wealth quintiles also differed according to the study group. By using a 10% threshold of the annual household income, we found similar percentages of CHE across wealth quintiles in slum studies (20% on average). However, in city-wide studies, the poorest residents incurred higher percentages of CHE compared with better-off residents (poorest quintile: 46%; richest quintile: 18%).

Process outputs and next steps

We published the review protocol in BMJ Open and the final manuscript has been submitted to the International Journal for Equity in Health.

We completed our scoping review in December 2021 after a huge effort from all team members. The commitment of the review team was crucial during this 1.5-year process as we had to deal with the tight agenda of the researchers and coordination across different time zones. The collaborative process was important to promoting a co-learning environment and a high-standard review. 

Our next step is to translate the scientific findings into country-specific policy briefs with recommendations for action that are relevant to city and country contexts. We can then use the scoping review as a tool for advocacy and changes in policies to promote health and well-being for vulnerable urban residents.

Image credit: Kibera by Stefan Magdalinski is licensed by CC BY 2.0.

The President’s Lecture 2021 webinar hosted by RSTMH brought about some thought provoking conversation and presentations from Professor Sally Theobald and her colleagues, Abriti Arjyal, Bachera Aktar and Zeela Zaizay.

The webinar was a great opportunity to share learning on analysing and addressing intersecting inequities in global health across different contexts, projects and health issues. The presentations demonstrated the power and the potential of social science, participatory process and co-production processes for change.

The event highlighted three different projects that focus on three different types of neglected areas. These are neglected countries: particularly fragile and shock prone contexts, neglected communities in urban informal settlements and neglected health issues or conditions like neglected tropical diseases and stigmatising skin conditions.

Metaphors exert a powerful influence on our daily lives and Sally used a very significant one as she launched her speech. We are all in the same storm, but we are not all in the same boat. COVID-19 has demonstrated that we live in an interconnected but unequal world. We are differentially positioned in terms of our vulnerabilities to the pandemic. COVID-19 has been seen as a spotlight that amplifies the existing inequalities; exposing and often exacerbating these inequities.

In the UK, black and minority ethnic groups and people living in cramped conditions have been particularly adversely affected. The pandemic has also impacted and exacerbated how inequalities play out on a global stage.

Neglected Countries

Neglected communities