Webinar review: An intersectional and gendered approach to health and wellbeing in informal settlements
Lynda Keeru, Hayley Stewart and Kate Hawkins report back on an ARISE and CHORUS consortia hosted webinar, ‘An intersectional and gendered approach to health and wellbeing in informal settlements.’
Informal settlements are now a widespread reality in cities globally and particularly common in low- and middle-income countries, housing millions of people. The residents of these spaces face multiple issues that impact on their health and wellbeing. This webinar took a specific focus on intersectional and gendered approaches. Both consortia took attendees through the frameworks that underpinned their work. This was followed by a rich panel discussion that dug deeper into the implementation of the frameworks in the different settings across both projects. The webinar was well attended with valuable contributions from participants through the online questions and answers.
Laura Dean from LSTM began her presentation by challenging participants to reflect on when they last noticed the existing structural and social inequities that exist around them. She pointed out that they are all around us, with some more visible than others. As cities continue to become even more divided, ARISE is focused on recognising these inequities and working with organisations of slum dwellers and other institutions to change and challenge them. ARISE uses a social determinants approach which aims to unpack dimensions beyond the biological and draw attention to the political, environmental and structural factors that underlie health and illness.
Heightened health challenges experienced by those living in informal settlements include infectious diseases, non-communicable diseases and mental distress. These illnesses are exacerbated by a lack of access to healthcare. The lack of entitlement and denial of the human right to health is fundamentally a problem of unequal power relations. And an absence of formal government institutions creates multiple interlinking systems of informal governance.
To this end, ARISE employs intersectional theory, that is inherently gendered, to help understand these challenges. It uncovers the underlying inequalities within informal spaces that shape the challenges faced by residents. ARISE merges multiple social and anthropological theories to create its equity analysis framework. It uses the theory of structural violence to consider how political, economic and social inequalities can be a cause and consequence of poor mental and physical health, and considers how both symbolic violence (e.g. classism, ethnocentrism) and everyday violence (e.g. physical violence) become mediating processes of structural inequality. Merging these theories of violence with intersectionality theory is essential to allow for academic theory to be operationalized and to promote social change. By taking this approach, ARISE can consider how varying forms of violence interact and are mediated by different characteristics to create nuanced experiences at the individual level.
Sushama Kanan, from ARK Foundation in Bangladesh introduced attendees to the gender and intersectionality framework used by CHORUS researchers in the cities in Nepal, Bangladesh, Ghana and Nigeria. The consortium aims to strengthen health systems in urban areas by developing and testing interventions to strengthen health systems. While the interventions vary according to city context, they focus on linking across the plurality of providers, encouraging multi-sectoral collaboration, responding to the urban burden of non-communicable disease and communicable disease and identifying, reaching and engaging the urban poor. Within all the CHORUS focus cities, researchers have used qualitative and quantitative methods to understand practices around health and have found that individual and community identities determine the health outcomes and behaviours. Inequities are a key feature of all the cities where CHORUS works and identifying and addressing urban inequities fundamental to improving urban health systems.
To ensure that gender and equity is addressed, CHORUS is using a framework based on work by Rosemary Morgan and colleagues, as well as an action learning group. CHORUS has also developed a gender and intersectionality guide to assist researchers in understanding and applying these concepts to their work. The gender framework has been useful in all stages of the research process, including in conceptualizing and designing projects, sampling and disaggregating data and in analysis. The framework has also been used to reflect on the internal dynamics of country teams and the workings of CHORUS as a whole.
It uncovers how gender and other social stratifiers, such as socioeconomic status, ethnicity, and education levels work as a power relation and driver of inequity in health systems. This focus has allowed the team to ask important questions about the division of labour, access to resources, social norms, ideologies, beliefs and perceptions, and formal and informal rules and decision making. Through these reflections, teams have been able to better identify how power relations are constituted and negotiated in urban settings as well as how they could be shifted positively in the contexts where CHORUS works.
How gender shapes health in different contexts
Speaking about Nepal, Abriti Arjyal from HERD International explained that the gender influenced the experiences, opportunities, constraints and power to seek health care among the urban poor. There is a clear intersection between gender and occupation within the context of the urban poor. Most of the urban poor are daily wage workers and they have limited time to visit any healthcare facility and access services. This means the availability and accessibility of the health services is one of the important factors that determines the health seeking behavior of the urban poor. Participants noted while most government health facilities services are available for free or at a minimum cost, they are often at odds with their working schedules. Additionally, women face the dual responsibility of taking care of household chores while also having to earn. Owing to this, they prefer seeking medical attention in facilities closer to them in order to make their lives easier.
Abu Conteh from SLURC, Sierra Leone discussed how the ARISE framework has contributed to understanding intersectionality and gender differences within the context of the slums in Freetown. In Sierra Leone the framework revealed how structural violence shapes health outcomes and the choices that people make. It has guided questions around health outcomes by revealing why certain groups of people are continuously excluded from healthcare services or why some people are much more susceptible to certain health issues than others. Living in informal settlements continues to be deeply stigmatised. Women carry an additional burden of stigmitisation, as they are considered inferior members of society. Many women living with chronic diseases, are denied access to education while their male counterparts are allowed to go to school. Consequently, this denies them opportunities in life and affects their economic opportunities heightening difficulties in accessing healthcare, reinforcing a pattern of exclusion for certain groups of people.
Speaking about experiences in Dhaka, Adrita Rahman from the BRAC University, JPG School of Public Health in Bangladesh described how female headed households in informal settlements are impacted by poverty, power relations and gender dynamics that result in women experiencing high levels of vulnerability. They are solely responsible for making money and taking care of the households and as a result, they often prioritise their family’s needs, and ignore their own healthcare requirements. The long waiting periods in health facilities mean that to seek health care women must take time off work, without sick leave, and are under the constant threat of losing their jobs.
Chineyere Mbachu from the University of Nigeria presented a preliminary analysis, from qualitative interviews carried out among informal providers in urban slums. Through the interaction with the providers, they teased out a pattern influenced by gender and intersectionality. The patent medicine vendors in the settlements are mostly men while the traditional birth attendants are female. Men tended to have higher levels of education and had access to more networks in comparison to the traditional birth attendants. The project aims to avoid propagating any gender differences and imbalances in access to resources, particularly for the providers.
Ivy Chumo from APHRC in Kenya discussed child headed households. She described poor, uneducated children expected to head households. Emergencies such as COVID-19 further exacerbate their vulnerabilities and marginality. They face many challenges including access to health care services. Many of their biological and physical needs are unmet. These children lack a voice and are institutionally invisible. The lack of representation leads to a lack policy inclusion. There is a need to treat these children as the children they are and not adults. The majority of child headed households in informal settlements are female and are more likely to experience sexual violence compared to boys, and may have to trade sex for basic needs like food, water and education. Notably, girls were highly susceptible to structural violence due to community social structures that favored boys while seeking to meet their basic needs. Consequently, female child-headed households went through a lot of physical abuse as a result of a lack of adults to support them and inability to escape from a scene of physical violence.
Lauren Wallace from the School of Public Health at the University of Ghana spoke about the gendered perceptions of the Community-based Health Planning and Services (CHPS) program in urban communities in Accra. CHPS is a national programme that places nurses in communities where they provide basic primary healthcare. Nurses are supported by volunteers who liaise between the health workers and community members and support activities such as community outreach and home visits. CHPS was initially piloted in rural areas with particular emphasis on improving maternal, reproductive and child health indicators. Initial findings show that in urban areas, there are challenges in implementing the program including the limited number of nurses, logistics, limited understanding of the program and difficulties motivating volunteers. Owing to these challenges, the CHPS programme as it is implemented in these urban settings mostly caters to MCH and SRH activities. The community’s perception is that it is a program meant for women and their children hence there is need to find ways to engage other populations including men.
Partho Mukherjee from The George Institute in India works with waste workers. They are often denied health services despite the fact that their occupation is hazardous due to frequent exposure to toxic materials. In attempting to shift gender norms and promote gender inclusion, researchers realised that the system is often not ready to work with these very marginalized groups of people because migrants rarely have local political power and it is difficult for them to hold local governance structures accountable. Discrimination faced by migrants, cutting across gender, limits access to public health care. Policy makers should address strengthening the primary health care system in both rural and urban areas. Partho highlighted the need for a longstanding funding commitment to implement this.
Sushama Kanan, from the ARK Foundation who conducted their research with the transgender community in Dhaka, said that there was a clear difference in male, female and third gender experiences in terms of accessing and providing care. Research findings reveal that the trans population faces discrimination in health centres when accessing services. Trans people reported being told by healthcare providers not to go to the health centres because it will offend other patients. She recommended that service providers need to be trained to show more empathy to trans people and the creation of formal policies to address stigma and bias.
The webinar concluded with chair Helen Elsey from the University of York thanked participants and attendees for their time, and commenting that the session had made it clear just how valuable this kind of analysis can be in unearthing and understanding the inequities that are being seen in urban contexts, particularly informal settlements. She highlighted how as gender and social norms continue to transform in these settings, there is room for optimism and progress on these issues and insights like the ones shared at the webinar can really help us move towards great urban equity.