Hilary Standing and Sally Theobald have reviewed Sabina Rashid’s book ‘Poverty, gender and health in the slums of Bangladesh: Children of Crows’ for the PLOS journal’s Speaking of Medicine and Health blog.
“This is an unusual book. It inverts the usual academic conventions. It doesn’t foreground theory or give us a lot of statistics. Instead, it gives us an utterly absorbing set of narratives of women and their families living in slum settlements over two time periods, each marked by crisis and uncertainty. Here, it’s the details that count – the worn and patched clothing, the missed meals, the constant resort to loans, the stories told to hide the fact that the family has been reduced to begging. The small but telling details that give us the warp and weft of urban poverty.” Read more on the PLOS Speaking of Medicine and Health blog.
Authors: BRAC James P Grant School of Public Health, BRAC University, Bangladesh with the ARISE Consortium
In four informal settlements in Dhaka, Khulna and Satkhira cities of Bangladesh, ARISE partners BRAC Urban Development Programme and BRAC JPGSPH facilitated community action plans (CAPs) led by community members that led to increased ownership and empowerment of communities to advocate for their needs, as well as improvements to the water, sanitation and hygiene (WASH) infrastructure.
Background
Informal urban settlements in Bangladesh are characterised by unsafe water supply, inadequate environmental health services and substandard sanitation. Marginalised and vulnerable groups – such as children, young and adolescent girls, pregnant women, the elderly and people living with disabilities (PWDs) – face substantially more challenges. Despite universal access to basic water sources and over 80% access to shared improved sanitation in informal urban settlements, residents complained about foul smell/colour/taste, bacterial contamination, frequent unavailability, and sharing toilets (with on average 70 people) and long waiting times, along with a lack of accountability mechanisms.
To address these issues, the BRAC UDP, as a part of an ARISE Responsive Fund project, applied the CAP tool to support and facilitate the co-production of community-led WASH interventions in four informal urban settlements – Kallyanpur and Shyampur (in Dhaka), Greenland (in Khulna) and Itagacha (in Satkhira).
CAP is a participatory strategic planning tool that allows communities to actively take part in decision-making – identifying and prioritising problems and needs and deciding on a set of actions to address those issues.
CDO members present their Community Action Plan (CAP)
What happened
In each settlement, BRAC UDP worked with local community development organisations to implement the CAP process. Each community development organisation had 21 members, including influential community leaders, women, people with disabilities and young adults. community development organisation members played a key role in mobilising residents and represented their informal settlements as the voices of their community in meetings and forums with diverse stakeholders (i.e. formal and informal service providers, elected Ward Councillors (WCs), and Non-Governmental Organisations (NGOs) working in the communities).
Initially, several rounds of leadership training were held with community development organisation members, followed by consultation workshops with the community and stakeholders. Between May and July 2023, BRAC UDP and BRAC JPGSPH jointly arranged four CAP sessions with the community development organisation members, one each in Kallyanpur (Dhaka), Shyampur (Dhaka), Greenland (Khulna) and Itagacha (Satkhira) along with four validation sessions with key stakeholders, including the WCs.
In the CAP sessions, with BRAC UDP and BRAC JPGSPH facilitation and support, community development organisation members collectively identified the problems and possible solutions. Discussions revealed several socio-economic issues (unemployment, drug misuse, gender-based violence, child marriage and disease prevalence) and infrastructural issues (lack of reliable water sources, inadequate hygienic toilet facilities, waterlogging, inadequate waste disposal systems and lack of daycare facilities) in the informal settlements. The participants then prioritised their needs by voting, and BRAC UDP and communities jointly agreed on what areas of the WASH infrastructure needed improving and created a list of actions required.
The final CAPs were presented to the respective WCs to get their buy-in and support. Informal settlement residents seldom have the opportunity to articulate their needs to WCs, so these meetings marked a shift in power dynamics and established a conducive environment for them to assert their demands. With the support of the BRAC UDP and BRAC JPGSPH teams and BRAC’s legitimacy, WCs agreed to support them in solving these problems, approved the action plans and signed written endorsements in all areas, as a sign of their commitment and accountability to the community.
Additionally, WCs in all four sites committed to raising the issues in different relevant meetings and forums with Mayors, police, the Water Supply and Sewerage Authority and other NGOs.
Once approved, BRAC UDP assisted in implementing the identified prioritised WASH interventions through the ARISE Responsive Fund and created an enabling environment for the active participation of the community. Community members contributed 10% of the total cost needed for the WASH interventions in their area, and community development organisation members decided on suitable places for the infrastructure establishment, formed small committees to actively monitor and were involved in each step of implementation – from buying bricks and monitoring the construction workers to inaugurating the infrastructure with the WCs.
Once completed, the communities inaugurated the WASH infrastructures inviting the stakeholders to the events and in the presence of the WCs. BRAC UDP field colleagues also shared the CAP in the NGO coordination meeting.
The councillor signs the CAP as a symbol of acknowledgement after the validation session
Impacts
Throughout the CAP process, ARISE played the role of a catalyst between the community and stakeholders, in line with ARISE’s goals to enhance accountability and responsiveness. Impacts from the process include:
Development of an advocacy tool: The CAP report acted as a reference of evidence for the community and local councillors to present the findings in City Corporation meetings, pursue NGOs and other duty bearers and advocate for their communities.
Community ownership and sustainability: Joint implementation of need-based, context-specific WASH interventions through partnership between communities and service providers, active participation and co-financing by communities helped to ensure community ownership and long-term sustainability.
Building trust: Interactions between the communities and the councillors established a sense of accountability and enhanced the relationship between community members and councillors.
Empowerment of community members: A crucial accomplishment of this implementation activity was the empowerment and capacity development of marginalised communities to participate in decision-making processes and articulate their demands. “We are the guardians of this area, it’s our responsibility to prepare this plan correctly.” [CAP Participant, Kallyanpur]
Improved inclusion: Active involvement of marginalised and vulnerable groups ensured their voices and priorities were reflected in the process. While overall there was an increased inclusion in the process, in some areas and on occasions, powerful men continued to dominate the conversation.
Lessons learned
Co-production promotes an equitable approach: Involving community residents in the self-assessment of their needs and in decision-making represents a pioneering, meaningful and equitable approach. It allows feasible and context-specific solutions based on the knowledge and active engagement of community, NGO implementers and Government actors.
The CAP process strengthens relationships: Periodic session-based collective activities (like CAP) by an organised platform (like community development organisations) proves to be mutually beneficial. When councillors endorse a plan, communities feel assured that their problems will be solved, and when councillors observe genuine community participation in the proposed plan, they feel a sense of accountability and satisfaction in taking action to meet the community’s needs. It also encourages community cohesion, allowing them to demand accountability from service providers and governance actors.
Empowering the community is crucial: Empowering communities in decision-making enables them to articulate their demands, which is crucial for addressing their needs. It recognises that their rights and voices are acknowledged, considered, and incorporated when decisions are made in programmes and when shaping policies.
The community discuss and plan their WASH-based intervention with local leaders
What’s next
CAP reports continue to be used to seek support and accountability from key stakeholders. In Kallyanpur, the CAP identified the need for drains and roads in some areas. Through the ARISE project, two roads with drains were built, but more were needed. Community development organisation members have since used the CAP to approach a local NGO working in their community to build these additional drains and roads.
It is hoped that community members and key stakeholders will continue to develop their strengthened relationships to work together to address the challenges of their communities in an equitable and inclusive way.
Thank you to Nazia Islam, Louise Clark, Sweta Dash, Kate Hawkins, Jiban Karki, Leah Murphy, Anthony Mwaniki, Hayley Stewart, Joe Taylor and Sia Tengbe for developing and editing this output.
Please note, due to ongoing protests in Bangladesh the conference dates have been moved, and will now be taking place from 27th to 29th of August.
Taking place between the 27th and 29th of August, this conference is a joint collaboration between ARISE, BRAC James P. Grant School of Public Health, BRAC University, and the International Society of Urban Health (ISUH). The conference is designed with a primary focus on spotlighting urban health and equity in the Global South. The conference will see 100+ speakers from the South Asian region, Kenya, Sierra Leone, UK and USA, as well as hybrid representation from European countries.
The objective of this conference is to establish a collaborative forum for the discussion of evidence, challenges, innovations, and priorities concerning urban health and equity in the Global South. It seeks to foster critical learning and dialogue across diverse contexts and issues. We will examine and discuss evidence on implementation practices, obstacles, innovations, and research methodologies within various contexts. The emphasis will be on the lived experiences of communities and insights from practitioners and organizations, with a commitment to contextualising and localising knowledge to ensure its relevance and applicability within the Global South. Additionally, the conference will highlight the current leadership of key stakeholders to inform the development of effective policies, programmes, and community-centered designs for urbanisation, urban health, and equity, with a view towards sustainability.
There is an urgent imperative to decolonise knowledge, amplify voices and perspectives from the Global South, and address both current and emerging issues in urban health and equity across low- and middle-income countries. Policy and practice should not be driven by a top-down approach and avoid being solely driven by Northern-led priorities and understandings. Recognising the need for meaningful and transparent partnerships, there is a call for equitable research and collaborative implementation models. This requires a paradigm shift towards learning and capacity sharing from the South to the North, as well as among countries within the Global South. This conference and its partnerships embody the principles of collaborative and equitable engagement.
Objectives of the Conference
Amplify voices and perspectives from the Global South addressing current and emerging health risks and issues in urban health equity across low- and middle-income countries.
Promote the sharing of evidence from the Global South, enhancing the development of localised effective, equitable, and context-specific policies and practice in global health and development initiatives.
Highlight innovative and contextually relevant methodological approaches, such as intersectionality, grounded empirical research, and social science methods, in data collection, analysis, and implementation research for action. This aims to advance more representative knowledge production from the Global South.
Examine the impact of emerging issues to develop strategies for building resilient cities through addressing environmental challenges (such as heat, water, sanitation, hygiene (WASH), and air quality); gender-specific challenges and solutions in sexual and reproductive health and rights (SRHR); and emerging infectious diseases.
Expand beyond the biomedical (disease centric) model of health, to integrate social, economic, political, cultural, spiritual, and psychosocial dimensions of health equity and well-being.
Showcase powerful narratives and artworks presenting lived experiences and innovative solutions emerging from communities to foster a deeper understanding of urban health and equity issues.
We’re excited to announce that our ARISE colleague Wafa Alam, from BRAC James P Grant School of Public Health in Bangladesh, will be attending the Prince Mahidol Award Conference (PMAC 2024) later this month. Taking place in Bangkok, Thailand, from 22 to 27 January, this international conference focuses on geopolitics, human security and health equity in an era of polycrises.
Wafa will be presenting two posters from ARISE at the international health conference in Thailand:
Co-production requires dismantling existing power hierarchies. As such, it can support decolonising knowledge generation and fostering inclusive and equitable relationships with diverse (and at times) marginalised actors participating in health governance, research and decision-making. Decolonising knowledge production recognises that expertise lies with those communities directly affected by health inequities and challenges as well as other key actors.
ARISE uses community based participatory research (CBPR) to build the capacities of urban marginalised people to generate contextually grounded evidence to incite action and strengthen relationships with governance actors. In this poster, prepared for the Prince Mahidol Award Conference we demonstrate the range of participatory methods used by ARISE. Fostering equitable research partnerships requires an openness to learn from communities, and a foundation of humility, trust and respect.
Decolonising health research requires a shift to inclusive processes, and actively engaging with communities. Community-based participatory research (CBPR) fosters collaboration among communities, researchers, and implementers to produce contextual knowledge for action. Enhancing co-production skills and competencies has been shown to improve research quality and validity, while CBPR principles have been developed, limited guidance exists on the skills needed to adhere to these. There is a need for frameworks to guide equitable and meaningful contributions from both community and external partners. This poster, prepared for the Prince Mahidol Award Conference, explores the competencies necessary to foster high quality research partnerships with community-based organisations and co-researchers.
We’re really excited about this opportunity to share our work with an international audience, and meet like minded colleagues from different contexts. See you there!
Informal settlements are not a one-dimensional box.
Dr. Hossain Zillur Rahman, BRAC Chairperson
At a recent workshop, stakeholders discussed the health, well being, housing and water and sanitation related challenges faced by the residents and the governance systems in urban informal settlements. They talked about important issues such as migration and urbanization in Dhaka city (Bangladesh) and accountability mechanisms for service providers and community residents. While there are many problems, there is no comprehensive national urban policy which addresses these issues.
Key messages
Urban informal settlements in Dhaka are complex.
Multi-sectoral coordination is required to address these complexities.
Research on these complexities are needed to inform policy makers.
Rural-urban migration
Thousands of migrants come to Dhaka city every day. This shift from rural to urban areas of Bangladesh is attributable to natural disasters like river or land erosion, lack of job opportunities and a general slow rural economy. However, as identified by Brig. Gen. Dr. Md. Sharif Ahmed, Chief Health Officer, Dhaka North City Corporation, poor income generating opportunities are not the sole reason for this shift. Poor access to quality services also drive people to move out of rural areas. He added that strengthening the quality of education and providing employment opportunities by supporting agriculture and cottage industries in rural areas are vital.
On the issue of rural to urban migration in Dhaka city, Dr. Zillur Rahman said,
We need incentive-based thinking to reduce migration.
He talked about multiple pathways to address migration such as making secondary cities more attractive, improving villages and developing commuter satellite cities around Dhaka.
A holistic approach to health
Ensuring quality health and well being related services in the complex landscape of the urban informal settlements is a major challenge. Multiple actors including government departments, the private sector and NGOs work simultaneously to provide services for the urban poor. Dr. Rahman emphasized the need to identify and map the roles of the stakeholders working in urban Dhaka as a strategy to improve the health outcomes of the vulnerable and marginalized urban communities. The complexities of urban informal settlements need to be looked at with a holistic approach, where humanitarian and development approaches come together, and become part of policy thinking.
Brig. Ahmed talked about the importance of coordinated efforts between stakeholders working in urban areas, and the need for better coordination between the Ministry of Health and Family Welfare, Ministry of Local Government, Rural Development and Cooperatives, private sectors and NGOs.
A lack of coordination between NGOs, donor agencies and government bodies gives rise to problems such as disparity in service concentration, duplication of services and poor referral mechanisms; making it more challenging to improve the well being of the residents of urban informal settlements.
Remodeling existing services
Brig. Ahmed identified poor housing conditions, limited access to safe water, drainage and sanitation facilities and lack of access to quality health services as some of the major challenges faced by the urban poor in Dhaka. While the City Corporation is working to improve the condition of the urban poor, their contribution is not enough to support the growing number of people in need.
Also, as urban informal settlements are not recognized as legal lands, the residents lack access to basic public services. These residents rely on NGOs for basic health and well being related services. NGOs often have to close down their programmes as donors wrap up. That’s when these people are left with no choice but to pay high prices for services and face extortion at the hands of the local mastaans. Often, these mastaans are local leaders who are affiliated and have patronage from political leaders, government and law enforcement agencies.
Dr. Rahman recognized urban centers as being extremely land scarce and said that in such settings giving access to land to solve daily problems like housing may not be feasible. This means we need to come up with innovative solutions or revamp existing services. He gave the example of ‘evening clinics’ as a solution that may be able to meet the need of the urban poor women who are unable to access health centres during the day, when they are busy earning a living by working as domestic aides or in the ready made garments industry.
Two-way accountability is important
Often the residents of informal settlements in Dhaka are paying higher prices for access to basic services like water and electricity. This is the result of poor governance and accountability in those settlements which allow local mastaans in the communities to take control of the facilities and sell to the residents at a higher cost. This issue of accountability needs to be explored from the horizontal and vertical aspects, that is, the accountability of the service provider, as well as that of the user, according to Dr. Rahman.
Generating new knowledge for Bangladesh
Knowledge is an important vehicle through which overall objectives of improving well being can be achieved
Dr. Rahman
Dr. Rahman stressed that new knowledge should be disseminated downwards to communities being researched and upwards to policy makers in Bangladesh. This will help communities understand and improve their current state. When research findings flow into policy thinking, it will also help generate new types of projects.
Research to understand the complexities in informal settlements, such as the ecological and locational diversities that exists between informal settlements, is vital.
The workshop ‘Working Together Towards Health Equity in Urban Informal Settlements’ was held on the 5 September 2019 in Dhaka, Bangladesh. It was jointly hosted by the ARISE Hub Bangladesh and Pathways to Equitable Healthy Cities under the Center of Excellence for Urban Equity and Health, BRAC James P Grant School of Public Health, BRAC University. The workshop was attended by stakeholders from government departments, NGOs and research institutions, who shared information about their work in urban informal settlements and their suggestions for improving urban health.
Everyday many young men and women migrate to Dhaka city from rural areas of Bangladesh in search of work and in hope of a better life. Many of these people end up in informal settlements where they live in unhealthy and unsafe conditions, often subjected to harassment.
According to the Bangladesh Bureau of Statistics 2015, there are more than 3,000 informal settlements in Dhaka, with over 1 million households. Unfortunately, people living in those informal settlements are exposed to higher degree of violence and crime. Traditional gender roles often make adolescent girls and young women more prone to different forms of harassment, be it at home, in the community and on the streets.
What harassment do women face?
The types of harassment faced by young women in the slums of Dhaka ranges from name calling and bad comments to giving perverse looks, inappropriate touching, physical abuse and sexual harassment. School and college going girls, women living away from their husbands, and female garment workers are particularly vulnerable to such abuse.
The ‘mastaans’ (local goons), local shopkeepers and sometimes the unemployed boys tease girls and young women in the streets. During one of our visits to a slum in Dhaka, an adolescent boy said:
These powerful men (mastaans) tease girls and they know no one will protest because of their strong political backup.
These practices are often so normalized and socially perpetuated that people don’t even protest, let alone report incidents.
Stigma and blame
There is widespread stigma associated with harassment which means that it is often young girls, and not the abuser who is held responsible. This also means that families stop girls and women from seeking justice for fear of having their reputation tarnished. A young girl residing in Korail slum said:
My mother thinks that if I act (dress and behave) properly, then everything will be fine, but if I don’t, then boys will definitely say things.
She also said that when boys teased her on the streets, her mother told her not to give an ear to such comments. Her mother always tells her:
You are born as a girl, and you should behave like one. You don’t have to show that you are brave.
A survey conducted by Save the Children showed that around 80% of the girls living in informal settlements in Dhaka are married off before the age of 18 and one of the reasons for early marriage was also found to be fear of sexual harassment. Young girls are restricted from going out alone, or going out at night due to safety concerns in the community. Together with all the issues explained above, the long existing practices of child marriage and other issues are perpetuated when a girl reports an incident of harassment, further depriving them of their basic human rights like education. This is aggravated by the lack of support from community and law enforcement.
Imperfect justice
In the few cases of harassment that are actually reported, police are either reluctant to get involved, or are in favor of the accused. There have been cases were the police coerced the victims to settle the matter out of court, or fix marriage between the victim and the accused, as they receive financial benefits from doing so.
Parents of the victims also seek help from local community leaders. The local leaders hold ‘shalish’ (informal court) where the accused may be beaten or charged a fine, if found guilty, or even forced into marriage. However, there are incidents where these local leaders also seem to only take strict action in case of influential people, and in other instances they victimize people who do not have important connections in the community. The consequences are often, if not always, faced by the girls and their families. If the families try to protest, they may be forced to vacate their house and move to another area.
However, over the years, communities have become more responsive towards incidents of harassment in their slums. Slum chairman, club presidents and members hold regular meetings where they talk to family members, men and women, and help them solve such problems. Women are now more concerned about their own safety due to awareness campaigns, rallies and the influence of the media.
These measures still do not consider that incidents of harassment are heavily under-reported. Moreover, while the situation has largely improved, there is still a long way to go before the communities transform into conducive support networks for the victims and harassment is indiscriminately eliminated.
Walking along the narrow spaces in between two, two-storey tin shed houses of the Korail slum in Dhaka, signs of community development were all around us. Korail is the largest slum in Dhaka with over 200,000 households, and about 534 houses.
In December 2016 the community was devasted by a fire that destroyed many houses. But with the help of BRAC Urban Development Program, Disaster Management and Climate Change, residents were able to rebuild households based on a community needs assessment. As we drove through, we realized the new roads were the most striking improvements for easy access to the residents in the slums, in case of any more fires or other emergencies. Measures are now in place for fire prevention, detection and firefighting, as we observed the installation of fire bells, alarms and extinguishers in every household in the community and we also learned that the people were trained on how to use them.
After the tragic event, a project was developed by engaging multi-sectoral partners to create opportunities, improve the well-being of residents and support the realization of rights for the urban poor. We met with the Community Development Organisation and saw their wall display of mapping systems and well being analysis map to enable them to easily identify households or target groups who require assistance. This was a great demonstration of organization and contextual understanding.
The Community Development Organisation helps manage problems through advocacy, learning and empowerment. There are 4500 households per Community Development Organisation and they have supported proper road development and socio-economic work. This is undertaken in partnership with BRAC with the community providing contributions either by cash, kind or by the labour provided. The roads have changed lives in terms of livelihood, sanitation and waste/sewage system, access to health providers and the medical centre.
BRAC Maternity Center in Korail is clean and well maintained and a calm environment. There we were told about the great work of the Community Health Workers and how it is made much easier with the help of trained Community Health Volunteers. These volunteers visit 10 households per day to identify people in need of health services and provide basic care, they give advice to visit the health centers. Encouraging people to take proper health counselling like pregnant women and adolescent girls. Providing personal hygiene packages to encourage proper sanitary measures and husbands are being encouraged to also help remind their wives to not deliver at home. These Community Health Workers expressed so much joy as they shared their achievements. As we spoke with the health workers in the Maternity Center, we asked how they would evaluate their maternal health impacts. In response, they said so far the home deliveries had dropped down to 10% from an initial 85% with an average of 30-40 deliveries per month, which were very exciting numbers to learn about.
Complex health systems in the urban areas depend on local government and NGOs like BRAC to manage their health payments. At risk groups have been identified using the mapping system and the poor are being charged less or provided services for free. Even though much progress has been made in Korail, more needs to be done. When I saw the gas burners for cooking, as we climbed up the stairs to the second storey, I was concerned about the safety of children moving around those open burners, plastic pipes and GI gas connections. I believe our countries need to learn from developments in Dhaka and implement these initiatives with our own urban poor populations.
