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.

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.

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’.