Authors: Joseph Macarthy and Abu Conteh, SLURC
A multidisciplinary research project has been launched at the College of Medicine and Allied Health Sciences (COMAHS) Hall, New England in Freetown to foster conversation among communities and policy stakeholders about improving equity, health and wellbeing in Freetown’s informal settlements. ARISE (Accountability and Responsiveness in Informal Settlements for Equity) is a five-year consortium led by the Liverpool School of Tropical Medicine (LSTM) in partnership with institutions in the global south - Sierra Leone, Kenya, Bangladesh and India - and UK based universities, including the Institute of Development Studies, University of Sussex, University of York and University of Glasgow.
The Sierra Leone hub is being run jointly by the Sierra Leone Urban Research Centre (SLURC), College of Medicine and Allied Health Sciences (COMAHS) and affiliates of Slum/Shack Dwellers International (SDI) in Sierra Leone – the Federation of Urban and Rural Poor (FEDURP) and Centre of Dialogue on Human Settlement and Poverty Alleviation (CODOHSAPA). The partners will draw from their multidisciplinary skills and experiences in epidemiology and health systems strengthening, urban development, participatory research, community engagement etc. The partners will explore social identities, intersectionality and governance as measures for understanding the determinants of health in informal settlements and build capacities to enhance equity and access to improved healthcare services.
Group photo at ARISE Sierra Leone stakeholder engagement and launch
The event itself brought together stakeholders from the project’s three research sites (Dworzark, Moyiba and Cockle Bay), policy stakeholders from various government departments and non-state actors working on health systems research and advocacy. The event was launched by the Director of Research and Evaluation from Focus 1000  Mr. Paul Sengeh who made a reflection on overcrowding as one of the key challenges that triggers ill health and poor living conditions in informal settlements in Freetown. He also spoke about the need to reflect on accountability as a dual process wherein the state provides services for communities, while communities themselves protect such vital services as water installations and pipes to ensure safety and improved quality of life.
The ARISE Consortium
The two principal investigators for the ARISE consortium in Sierra Leone Dr. Joseph Macarthy (SLURC) and Dr. Haja Ramatulai Wurie (COMAHS) made presentations on the unique partnership in Sierra Leone, where COMAHS focuses on health systems research, SLURC deals with urban development challenges, while CODOHSAPA and FEDURP specialize in community engagement and participatory planning.
Dr. Wurie, in her presentation summarised the vision of ARISE, which aims to enhance change by supporting informal settlement residents to amplify their voices, many of whom she said are often made vulnerable to complex socio-economic challenges, fragile ecosystems and political violence. She highlighted the country’s weak health system and the need for timely and disaggregated data on the state of health of vulnerable people, especially those living in informal settlements, and that the coming of ARISE is useful in filling that gap. She said the research work to be undertaken by ARISE not only aspires to provide useful evidence, but will improve links between communities and policy stakeholders.
The Exective Director of SLURC Dr. Joseph Macarthy who presented on ARISE’s scope of work and aspirations in Sierra Leone, said the research work to be undertaken by ARISE has links to previous work by SLURC in informal setlements, and that most informal settlements have commonalities in terms of health needs, inequity, and precarious environmental conditions which require further evidence and broad based collaboration to tackle. He spoke about the need to build accountability systems around public health service provision in informal settlements, by first recognizing the current state of health and building the capacity of service providers and policy makers to respond appropriately.
He explained the scope of work through the various work packages which relate to 1) understanding social identities, and how they shape access to healthcare services; 2) exploring governance systems and how they shape inequity and 3) analysing secondary data hosted by national/international organizations to draw comparisons with empirical field data to further understand health needs of vulnerable people in the urban context. He said the work packages will be logically rolled out between communities and shared among partners within the project’s five-year cycle.
Community Grown Solutions
The second session of the event was a stakeholder engagement facilitated by Mr. Francis Reffell, Director of CODOHSAPA, in which participants discussed accountability and how it impacts on improvements to health and wellbeing in Freetown’s informal settlements. Participants generally expressed need for communities to be empowered to understand how to address their own social needs, given that they consider themselves somewhat abandoned by political leaders. Sentiments about communities being abandoned by political leaders were expressed passionately by community chiefs, who believe that generating knowledge and resources from within are important in solving their local problems.
Issues of empowerment through knowledge co-production were reiterated by several speakers during the discussion, as communities believe that they have enough enlightenment to understand their own health and social needs. However, what is critically needed according to a community member from Moyiba, is a strong commitment to action in searching for community grown solutions.
Earlier, the welcome statement was made by the Deputy Vice Chancellor of COMAHS, University of Sierra Leone, Professor Mohamed Samai. He highlighted numerous planning challenges such as poor construction of houses and drainage, which make people vulnerable to flooding and health problems in informal settlements, and gave assurance of the university’s support for ARISE in providing evidence to aid policy processes to improve the wellbeing of people living in informal settlements.
Participants discussing accountability and health
Dr. Braima Gogra who spoke on behalf of the School of Environmental Sciences at Njala University said the university has had a good working relationship with SLURC since its inception, and that they will continue to provide support to make research evidence useful to policy processes, especially those related to environmental management. Other speakers from the Ministries of Health and Sanitation, and Planning and Economic Development spoke about the need for disaggregated data on informal settlements, the lack of which often causes misinformed planning.
The first session for the launch of the event was facilitated by the Director of Research and Training at SLURC, Braima Koroma, who also emphasised the need for integrating community knowledge and experiences with those of policy stakeholders to enhance informed policy processes to improve conditions in informal settlements.
Improving health and wellbeing in Freetown’s informal settlements is a truly multidisciplinary challenge, which is reflected in the diverse range of stakeholders involved in the ARISE launch event in Freetown.
 Focus 1000 is a local organization engaged in health systems research and policy advocacy in Sierra Leone. Its formative research during the Ebola period helped shape communication and community engagement strategies aimed at disrupting the chain of infections.
Author: Hawanatu Bangura, SLURC
SLURC is part of a major new research project called AT 2030: Community-led solutions: Assistive Technologies in Informal Settlements, led by The Bartlett Development Planning Unit, University College London, in collaboration with Leonard Cheshire Disability (UK). The sub-programme focuses on Life Changing Assistive Technology for All by learning directly from communities living in informal settlements in Freetown, Sierra Leone and Banjarmasin, Indonesia. SLURC is the local research partner in Freetown, and the Indonesian NGO Kota Kita (“Our City”) in Banjarmasin which seeks to answer the question “How can collective, and community led responses, enable disabled people to access better life outcomes through increasing the relevance and uptake of Assistive Technology (AT)?”. The SLURC collaboration is one sub-programme of a larger project, led by the Global Disability Innovation Hub (GDI Hub) and funded by the UK Department for International Development (DFID), seeking to lay the foundations for global AT access and reach 3 million people worldwide.
Above: At an event for people with disabilities organised by the Mayor of Banjarmasin
A pilot workshop on Assistive Technology (AT2030) Project for All in Banjarmasin
A two week workshop was held in Banjarmasin in May 2019 with a team from UCL (UK), Kota Kita and Kaki Kota (Indonesia), and SLURC (Sierra Leone) as part of the project. The workshop started with site visits to the two communities (Pelambuan and Kelayan) in Banjarmasin where the AT2030 would be implemented. Participants then introduced useful presentations on the wider AT2030 project, disability, AT and informality between the two countries (Indonesia and Sierra Leone).
The workshop focused on understanding the phases of the project by agreeing timelines, milestones, outputs and agreeing the research methods. This included testing a new tool developed by the World Health Organisation (WHO) called the “rapid Assistive Technology Assessment tool” (rATA). We discussed how to apply it locally and how we will feedback on the implementation of the tool to WHO. We also discussed how the research will engage with persons with disability and AT users, as well as the inclusion of local participants, such as community members, community leaders, disabled people’s organisations (DPOs), community-based organisations (CBOs), and relevant NGOs for the data collection and the research.
The tool was tested within the community of Kelayan in selected households. These included people with disabilities and representatives of local CBOs. This testing led to a mutual learning which identified how the tool could be further improved to support the effective data collection process for the project.
We also met with community leaders of the two informal settlements where the Indonesian team will be working (Pelambuan and Kelayan) to present the project, clarify the process, earn their support - especially during the data collection process in their respective communities - and to identify the gaps in the community for intervention.
Above: Meeting with Pelambuan community stakeholders on AT 2030
Following the agreed timelines, the rATA tool will be conducted during the months of August and September 2019 by trained data collectors, many of whom will be part of the communities, in both countries. The survey will give us an initial understanding of the access and use of AT in the four communities, following this process we will explore more in depth the aspirations of people with disabilities and their communities through a selection of participatory methods.
The first phase of the research project will conclude in a synthesis workshop at the beginning of next year in London (UK) where researchers from Indonesia, Sierra Leone and the UK will come together again to learn from both countries experiences, analyse the initial findings and plan phase 2 of the research.
Author: Julia Wesley (UCL DPU / Urban KNOW)
We are delighted to start the second year of fieldwork in Freetown, Sierra Leone, as part of the SLURC/DPU learning alliance for transformative action. Building upon last year’s work under the leadership of Adriana Allen and Rita Lambert, the practice module of the MSc Environment and Sustainable Development (ESD), the Sierra Leone Urban Research Centre (SLURC) and partners on the ground continue their work as a co-learning alliance.
This years’ research focuses on disrupting urban risk traps in the following seven settlements: Moyiba, Dworzark, Cockle Bay, Susan’s Bay, Colbot, Crab Town-Kolleh Town-Gray Bush (CKG), and Portee-Rokupa. The ESD students have intensely prepared themselves for this fieldwork over the past months and developed conceptual and methodological frameworks to gather and analyse data in their study areas. Each of the seven groups consists of ESD students and tutors, community mobilisers and facilitators from the settlements, as well as local interns, who are young professionals and advanced students from Freetown. In total, we are a team of 75 people from 35 countries.
The seven interns were selected by SLURC following an open call that attracted 24 applicants. During the fieldtrip, they are sharing their local experiences and knowledge and becoming important team members, who support the grounding of approaches and the stimulation and facilitation of debates. The interns and facilitators are also integral to the educational work of the Knowledge in Action for Urban Equality (KNOW) project, which aims to support them in their capacity building and learning experience.
A warm welcome to our fieldwork team!
Above: CKG group (Crab Town-Kolleh Town-Gray Bush) (Students: Stephania Spitale, Lucie Tavernier, Yvonne Wang, Pilar Caceres, Lokman Hadji, Lucinda Auden, Yuki Cui; SLURC tutor: Sudie Austina Sellu; DPU tutors: Qurratulain Faheem, Donald Brown; Intern: Vanessa Scott; Community Facilitators: John AG Elliott, Daniel B Jones, Isatu S Kamara, Sabatu Marrie, Mohamed Turay)
Vanessa Scott is working as an intern with the CKG group. She has an MSc in Development Studies and a work experience with the National Commission for Social Action (NaCSA) on issues of cash transfers with Open Data Kit (ODK) as well as with the Community Integrated Development Organisation in their work during the Ebola emergency. Her motivation to join the learning alliance is to gain knowledge from interactions with the students, learn about training and student exchange programmes, and enhance her facilitation skills. She is keen to implement some of the methodologies acquired during the fieldwork into her professional life to make a difference to the urban livelihoods and resilience of people living in Freetown.
Above: Cockle Bay group (Students: Julian Reingold, Ambika Misra, Ji Yoon Yang, Chen Kou, Pingzhang Luo, Gaetan Laforge, Achilleas Vryniotis; SLURC tutor: Joana Kaine; DPU tutor: Adriana Allen; Intern: Rita Jimmy-kay; Community Facilitators: Joana Kain, Morland D Kamara, Osman Momoh, Abu M Sesay, Kadiatu Turay)
Rita Jimmy-kay is part of the Cockle Bay group for the second year as well. She is a graduate of Fourah Bay College University of Sierra Leone with Honours in Bachelor of Science in Physics 2017.
She writes short stories and believes in the power of words to induce individual and collective change. She has work experience as data entry clerk, enumerator in the Population Housing Census 2015, ballot box controller in the National Electoral Commission 2012, and as office assistant at the Forum for African Women Educationalist (FAWE) printing press. She also has experience working in issues of child protection, gender-based violence, disability/elderly and nutrition.
Above: Colbot group (Students: Daniella Hu, Lucie Long, Costanza De Stefani, Jihoon Yoo, Ellie Ma, Maksalina Abueva, Amy Smith; SLURC tutor: Mary Kamara; DPU tutor: Rita Lambert; Intern: Hawanatu Yanka; Community Facilitators: Fatmata O Bangura, Gibrilla K Bangura, Momoh Bangura, Patrick Conteh, Isatu Dumbaya)
Hawanatu Yanka is joining the research in the Colbot settlement. She has a BSc in Sociology and History and previous work experience as Community Led Total Sanitation Survey Enumerator, where she was tasked with administering questionnaires on housing, water, sanitation and hygiene in informal settlements. She has also been a recent trainee in a course on Data Collection for Informal Settlement Profiling, which was conducted by SLURC, and took part in the Participatory Spatial Research Methods Workshop facilitated by ASF-UK and the Urban KNOW project.
Above: Dworzark group (Students: Gideon Mensah-Commey, Shuyi Liu, Adrian Pang, Marwa, Amina Ismail, Judy Cerqueira Moura, Su-Yuan Yang, Candida Villa-Lobos; SLURC tutor: Yirah Conteh; DPU tutor: Julia Wesely; Intern: Henry David Bayoh; Community Facilitators: Margaret Bayoh, Mohamed Mansaray, Jusu Saffa. Braima B Samura, Mustapha Sankoh)
Henry David Bayoh is working as an intern with the Dworzark group for the second time. He has an MA in Sustainable Development (Environmental Sustainability) from the University of Makeni, holds an Executive MBA, BSc. (Hons.) Environmental Sciences (Environment and Development), Advanced Professional Certificate in Conservation and NRM; Certificate in Project Management, M&E and a Certificate in Climate Change. He is a scientific member of Conservation Society of Sierra Leone (CSSL), member of YOUNGO, and Citizens’ Climate Lobby (CCL) Africa. Henry has over ten years professional work experience in environment and development, with a passion for the environment. He is the Planning and Development Officer at the National Tourist Board (NTB) and serves as National Coordinator/Focal Point for Pan African Climate Justice Alliance (PACJA).
Above: Moyiba group (Students: Sarah-Jane McGaw, Alexandra Brandl, Hind Al-Ali, Erhu Deng, Donna Sit, Yanna Sun, Samira Orudzheva; SLURC tutor: Ibrahim Bangura; DPU tutor: Kate Goh; Intern: Musa Wullarie; Community Facilitators: Fatmata Bangura, Joseph Conteh, Memunatu Lambat, Zainab Sesay, Issa Turay)
After working as a community facilitator in Cockle Bay last year, Musa Wullarie is now joining the Moyiba group as an intern. He is a community youth leader in Mafengbeh, the largest community in the Cockle Bay informal settlement, where he has helped to found an education syndicate for underprivileged local children. He has worked with SLURC over the past few years as a community liaison on a range of research projects and has vast experience facilitating workshops with SLURC, ASF-UK and also the DPU. Currently, he is conducting data collection in Cockle Bay and Dworzark as part of the UrbanKNOW project.
His motivation to join the learning alliance are to help build his knowledge of development processes in Freetown's informal settlements. He is keen to ensure that the outcomes of the action research project are used to benefit the community beyond the length of the research project itself.
Above: Portee-Rokupa group (Students: Vivian Rangel, Kelly Mumford, Giulia Hallqvist, Tom Hartmann, Ning Sun, Samita Tangsunawan, Nata Tavonvunchai, Juliette Ma; SLURC tutor: Sulaiman Kamara; DPU tutor: Zeremariam Fre; Intern: Amadu Labor; Community Facilitators: Abdulia Kanu, Isatu Y Koroma, Ibrahim Kamara, Joseph King, Sallay Turay)
Amadu Labor is working with the group researching Portee-Rokupa. He has a BA in Development Studies, and is presently pursuing a BSc in Agricultural Education at Ernest Bai Koroma University of Science and Technology. He has been working with informal communities on Malaria protection in the role as Malaria Faith Champion, where his role has been to sensitise communities for the protection and control of Malaria. He also has work experience as a case investigator and surveillance officer for the District Ebola Response Centre (DERC) in Bombali District, and in community-led data collection and informal settlement surveys in Freetown. He is presently a member of FEDURP. Amadu is looking forward to share his ideas of community development and to learn with and from the students.
Above: Susan’s Bay group (Students: Mona Ackholm, Connor Muesen, Yuna Chang, Claudia Nicolini, Cristian Tolvett, Thomas Jennings, Jehan Bhikoo, Kendra Haven; SLURC tutor: Thomas Doughty; DPU tutor: Pascale Hofmann; Intern: Fatima Kabba; Community Facilitators: Joseph T Conteh, Alpha Kabba, Sorie M Kanu, Adikalie Kargbo, Nancy Sesay)
Fatima Kabba is doing her intership with the Susan’s Bay group. She is a volunteer at the Center of Dialogue on Human Settlement and Poverty Alleviation (CODOHSAPA). Her background is in social work and she has been working with informal settlements since February 2018, gathering valuable skills in community work. She is motivated to expand her skills and professional expertise in community-based action research through this co-learning alliance.
What is the potential of Massive Open Online Courses (MOOCs) for redressing inequalities in the education of urban practitioners?
Author: Julia Wesley (Knowledge in Action for Urban Equality: Urban KNOW)
The workshop was kicked off with presentations by Geetha Krishnan and Garima Jain from the IIHS Digital Blended Learning team. They discussed their experience with a MOOC on Sustainable Cities that was co-developed with the SDG Academy. This course has been fundamental and timely to promote advocacy for SDG 11 amongst its more than 19.000 learners. Following this, Diana Laurillard from the UCL Knowledge Hub gave fascinating insights into the potential of MOOCs as a form of research collaboration. Based on recent experience with the RELIEF Centre and its MOOC “Community Based Research", she and colleagues Eileen Kennedy and Mustafa Ismail explored how MOOCs can act as platforms to facilitate knowledge exchange and crowdsource local data at a global scale.
Both presentations drew attention to several key issues in the co-design, delivery and evaluation of MOOCs. These included the role of quality assurance; the distribution of recognition, ownership and responsibilities especially in collaboratively developed courses; the sustainability of institutional and financial resourcing; and harnessing the potential of a diverse classroom with mostly professional learners through learner-centred pedagogies.
Image above: Location of active participants in the 'Development and Planning in African Cities' MOOC. Source: SLURC and UCL, 2019. Leading image: Freetown. Source: Emmanuel Osuteye, 2017.
KNOW Freetown city partner SLURC has twice run a MOOC called “Development and Planning in African Cities”. Joseph Macarthy, Braima Koroma, Thomas Doughty and Andrea Klingel (SLURC), Alexandre Apsan Frediani and Andrea Rigon (DPU-UCL) and Jo Stroud (UCL Digital Education) shared their critical reflections on learning agents, the learning environment, learning intent and learning outcomes in this MOOC and touched upon several of the above-mentioned key issues. They further highlighted that “Development and Planning in African Cities” has already been a critical contributor to expanding knowledge about urban planning and practice particularly in the context of Sierra Leone and Sub-Saharan Africa. Amongst other achievements, the course became the most-downloaded resource on the UCL Open Education repository and has recently been awarded a UCL Faculty Education award.
Based on a thorough evaluation of the two iterations of this course, the WP5 team and SLURC will work together over the coming months to align the MOOC with a wider learning and educational strategy of SLURC that builds the capacities of urban practitioners to foster pathways to urban equality.
MOOC links discussed:
This article was originally posted on Knowledge in Action for Urban Equality (Urban KNOW)'s blog
Author: Thomas Doughty, SLURC
Waste management problems, poor quality of shelter, precarious livelihood options and limited healthcare access drive the poor living conditions in informal settlements that directly impact residents’ health outcomes. Women, children and the aged are thought to be more vulnerable than men, and in the event of sickness or injury most residents administer self-treatment or consult informal providers as a first option, and tend to use formal care if and when that fails.
SLURC and FHS research
Up to now there had been a significant research gap in the understanding of social and environmental determinants of health in informal settlements in Sierra Leone. It is in this context that SLURC has undertaken a two year research study in partnership with Future Health Systems (FHS), investigating how living conditions in four of Freetown’s informal settlements relate to the health concerns of their communities. The findings and recommendations are now available, following a launch event in Freetown in January 2019.
Following a scoping study which established the evidence gaps surrounding urban health in Sierra Leone, SLURC launched its research project in Freetown, exploring the links between human health and the living conditions in informal settlements. The findings of the scoping study provided a roadmap for the main research.
Using a mixed methods approach (qualitative and quantitative) in four informal settlements - Cockle Bay, Portee-Rokupa, Dwarzack and Moyiba. The research drew on focus group discussions and individual interviews with policy makers, community leaders, civic leaders, traditional birth attendants, traditional healers and health facility providers, as well as an investigation into patterns of service utilization at local Freetown health facilities.
Participants from across the different stakeholder groups came together for a validation workshop in November, to discuss and corroborate the research findings. There was lively discussion between stakeholders, particularly about the barriers and deterrents people face to accessing healthcare. For example, many perceive a lack of confidentiality from formal healthcare workers. Also apparent were the commonalities in experiences across different settlements, yet also the place-specific aspects to many issues.
Findings and recommendations were also taken out into the four communities studied (Cockle Bay, Dworzark, Moyiba and Portee-Rokupa) in order to obtain as wide a range of feedback as possible.
As well as the scoping study, research report and policy brief, SLURC worked with FHS to create shorter ‘issue briefs’ on three of the key issues that emerged from the research – water and sanitation, waste management and healthcare accessibility. Findings and recommendations were presented to community members, health workers and policy makers at January’s launch event, where copies of the publications were also distributed. Everyone was given the opportunity to respond to the findings, and representatives of the Federation of the Urban and Rural Poor (FEDURP), Freetown City Council (FCC) and the Ministry of Water Resources all discussed opportunities for creating synergies between what each is doing to improve environmental conditions.
SLURC has also trialled dissemination of compressed versions of the outputs via Whatsapp for this project. Freetonians are heavy Whatsapp users, for sharing and disseminating of all kinds of content through their multiple networks. This is an important channel that we will seek to utilise more in the dissemination of SLURC outputs.
Future Health Systems is a global research project led by the Bloomberg School of Public Health, Johns Hopkins University (JHU), USA and the Institute of Development Studies (IDS), University of Sussex, UK. SLURC, a member of this consortium, has carried out two research projects in Sierra Leone.
Authors: Sophie Morley, Louisa Orchard and Niki Sole (ASF-UK)
A five day workshop was held between the 21st - 25th January 2019 in Freetown by SLURC and Architecture Sans Frontrieres-UK (ASF-UK) as part of the KNOW project. The workshop introduced participatory spatial research methods and explored how they can be used in Freetown to develop Informal Settlement Profiles. This workshop followed the completion of two Community Action Area Plans for the communities of Dworzark and Cockle Bay. Informal Settlement Profiles will be mobilised in order to provide a robust evidence base to support the principles set out in these Plans.
More specifically, the focus of this workshop was to explore how participatory spatial research methods could be utilised to collect data, with the help of a diverse mix of over 30 local participants including community members, community leaders, students and representatives from local NGOs and CBOs.
The workshop opened with symposium consisting of different city stakeholders drawn from the City Learning Platform and Community Learning Platform who discussed the needs and aspirations for informal settlement profiles and how they can contribute to better understanding of city-wide urban development processes to inform entry points for interventions that support urban equality for informal communities in Freetown. This event explored the approaches to community-led data collection for informal settlement profiles and concluded with reflections on the challenges and opportunities around the process.
Following the symposium the workshop participants were introduced to the concept of participatory spatial research methods, and explored how data collection using these methods for informal settlement profiling could be undertaken within an ethical framework. This resulted in participants producing a code of conduct for data collection. Five different tools for participatory spatial data collection were introduced; transect walks, mapping, timelines, photo diary and ranking/prioritising.
With data standardisation and consistency in mind, each tool proposed to utilise a ‘digital’ and ‘manual’ component. Digital components included Ramblr, a phone app for ramblers and hikers to share routes, to support transect walks, in addition to GPS and WhatsApp which were used to record photographs and identify locations. The potential ways these digital platforms could be adapted to support the participatory collection of spatial data were set out and discussed by participants.
The tools were then tested by participants in groups within the communities of Dworzark and Cockle Bay. This testing, in addition to feedback by participants, led to a mutual learning process which helped to identify how the tools could be further developed to aid effective participatory spatial data collection.
Following the data collection period which will begin in the next few weeks, a further workshop is to be held in the summer by ASF-UK and SLURC as part of the KNOW project. This workshop will see local and international participants come together to process and visualise the data collected in the Cockle Bay and Dworzark communities.
Author: Thomas Doughty
The poor health of those living in informal settlements across Freetown is a direct consequence of their living conditions, but often in locally specific ways. This is further exacerbated by unequal access to healthcare, meaning such communities face a double burden on their health due to the environmental conditions in which they live.
These are some of the findings of a research study, led by SLURC in collaboration with Future Health Systems, seeking to explore relationships between living conditions in informal settlements and common health problems, and to explore whether the socioeconomic backgrounds of people living in informal settlements affect their access to health care services.
On 22 November 2018, a group of 30 community stakeholders, health professionals and policy makers came together at the Sierra Leone Urban Research Centre office in Freetown to validate the initial findings. This was an opportunity for participants from the four communities involved to discuss and validate the research findings, include any additional information that may not have been covered so far, and provide a platform for dialogue between community stakeholders and local and national government representatives around the issues raised and the ways in which these might be addressed going forwards. Following initial presentations by SLURC’s Dr Joseph Macarthy, Abu Conteh and Sudie A. Sellu, consolidating findings from focus groups and interviews, participants broke into groups to discuss and record their feedback and further ideas, before sharing these with the whole group. This was the first time all stakeholders had come together in such a way.
We have also held a similar validation exercise within the four communities of research, to get further views on what has come out the research so far. These included members of the wider community who had not yet participated in the research.
Many health issues in informal settlements are place-specific
It was clear from the initial research findings that there are many crosscutting issues affecting health across all the informal settlements included in the study, such as toilets, water, housing and energy use. Yet, within each of these issues, place is instrumental in driving the specific health conditions affecting each community. In Portee-Rokupa, residents travel huge distances to obtain water; in Cockle Bay, water is relatively available, yet some of the sources are contaminated by saltwater.
In discussion, the groups added other specific examples of the specificity of health conditions in their communities. In the hillside settlements of Dwarzark and Moyiba, accidental falls are a concern due to the terrain. Blindness is more of a concern in the seaside settlements (though causes are differentiated by gender roles - among women it is attributable to excessive smoke exposure through drying fish, while fishermen are exposed to salt water while fishing. A gender perspective has been crucial to the project – the research has found that men are more likely to use informal healthcare than women, for example. Participants shared other issues affecting all communities alike, such as strokes - believed to be prevalent due to physical strains, stress and irregular medical check-ups – and fistula - due to forced or obstructed labour caused by some inexperienced Traditional Birth Attendants.
People face multiple barriers to healthcare when they get ill or injured
When it comes to seeking treatment for ill health, findings from the focus groups established a range of barriers that those in Freetown’s informal settlements face when accessing healthcare, which the research team grouped into five main categories: long distances, difficult terrains, poor roads, long wait times, and the main factor - high costs. These were all corroborated by participants, and explain many of the decisions people make in how they access healthcare.
“Some men stop their women from going to family planning services at the health centre because they believe that their religion says that women should be able to give birth and not be stopped” (health worker)
“Most men will not come to the health facilities if the health facilities are staffed by women, because of the men’s links to secret societies” (health worker)
There was much discussion of social barriers, for example the role of religious and cultural beliefs, coupled with gender imbalances in health facilities in preventing some from accessing formal care. Healthworkers breaching confidentiality is another significant barrier – for example, to young women seeking family planning services.
“The attitude of some nurses are very negative towards women who have given birth to more than five or six children – they can be shouted down in hospital” (community member)
Nurses’ attitudes were perceived by many to be negative, putting people off seeking their care – though it was acknowledged that this might sometimes be due to high workload, lack of formal enrolment and thus low motivation.
Overcoming these barriers requires greater accountability
“Healthworkers are taught on the ethics of nursing on the issue of confidentiality, but there is a need for refresher training so that nurses stick to the ethics of their profession. If nurses refuse, it should result in retrieval of their licence” (health worker)
The range of participants present together in the room provided the opportunity to productively establish concrete steps towards addressing some of these barriers. Health worker recruitment should consider gender balance, ensuring that women and men are not reluctant to visit health facilities. All healthworkers should receive ethics training, ensuring patient confidentiality for people seeking care – and this could perhaps be accompanied by strict penalties for those who breach confidentiality. Greater recruitment of trained health workers would reduce the workload and thus boost motivation among those already working. Finally, inclusion of religious leaders in health sensitization activities is suggested as a positive step. In short, along with addressing the environmental factors, priority must be given to boosting accountability across all healthcare services accessed by “Freetonians” to make it more accessible and responsive to their needs.
The full report is due for publication in December.
(Quotes are all translated from Krio)
Authors: Matilda Leong, Son Nam Vo, Hayeon Kim, Paul Korsi Simpson, Peter Korsi Simpson and Adriana Allen
(Cockle Bay Group from the ESD MSc practice module)
In the early hours of Wednesday, 25 April 2018, the residents of Kola Tree in Cockle Bay were awakened to the shouts of fire. The blaze took place in the informal settlement located in the Western coast of Freetown and affected 97 people. Although there were no casualties reported, rampant loss of property, possessions and livelihoods were claimed by the incident.
When the team from Development Planning Unit (DPU) at University College London (UCL) and Sierra Leone Urban Research Centre (SLURC) arrived at the site, they were met with chaos. A crowd of residents were still dealing with the aftermath of the fire over the rubbles of their corrugated metal sheet homes. Despite all effort to mitigate damages, the flames had been eventually extinguished by burying them under the collapsing building structures.
It was soon established that the Cockle Bay community was left on its own to undertake responsive actions. There were minimal external interventions save for the fire brigade who attempted to extinguish the fire alongside the residents. The DPU/SLURC team quickly came to the support of the residents by conducting an enumeration process to determine who was affected and what was the impact of the fire. This information was subsequently handed to the local leader of the Federation of the Urban and Rural Poor (FEDURP) and of the Community Based Disaster Risk Management Committee to facilitate the provision of relief for victims and temporary shelter for the night. While the source of the fire was yet to be determined, the rapid assessment conducted by partners on the ground speculated the possibility of an electrical fault. The Office of National Security (ONS) responded hours after the event and is reportedly conducting a more detailed assessment to identify the origin of the fire.
DPU team supporting the enumeration of those affected by fire in Cockle Bay. Photo by A. Allen.
The absence of external support during small-scale disasters is not unusual for informal settlements. In most circumstances, external actors such as governmental institutions and non-governmental organisations have to conserve their limited resources. Consequently, they can only respond to severe incidents. For example, a prominent local NGO was only able to support 144 of the 2,048 victims during the 2015 fire in Susan’s Bay due to the lack of funding. Minor disasters such as that in Cockle Bay accordingly tend to be overlooked and underreported. Moreover, dismal planning characterised by limited road access and dispersed and insufficient water sources also hinder evacuation and relief efforts and exacerbate the everyday risks facing local communities. Moreover, although preliminary relief is given to the victims of disasters, this is often insufficient to ensure that those affected can recover from such events, let alone to escape risk accumulation and poverty cycles.
It is estimated that about 547 fires outbreaks affected those living in informal settlements in Freetown between 2011 to 2015 (Di Marino et al, 2018). Fires are only one of the multiple hazards facing poor and impoverished women and men in the city on a regular basis. Other hazards include floods, mudslides, landslides, waterborne diseases, and occupational hazards, amongst others. Each of these disasters, small and large-scale, disproportionately impact the urban poor – destroying their housing, disrupting their education and in some case, even terminating their sources of livelihood.
Photo by N. Vo.
The fire outbreak in Cockle Bay brings to light the broader issue of prolonged systematic oversight of informal settlements and the invisibility of certain segments of the city population, such as tenants. As the fire was confined to a mere 8 compounds within a small area of about 100m2, initial estimates speculated that about 20 people had being affected. However, the enumeration process conducted by the team in collaboration with local residents revealed that it was in fact a total of 97 people, a third of whom were children. About 80% of the victims were tenants. This yields an abrupt indication of how vulnerable groups such as tenants and the youth in households are often inadvertently not accounted for, leaving them virtually invisible by the community themselves in times of disasters.
Lacking the means to enter the housing and land markets elsewhere in the city, many women in men are forced to reside in informal settlements like Cockle Bay. Therefore, these areas have experienced consistent densification and land reclamation over the years, particularly since the Civil War. Aside from high housing densities, most informal settlements also face scarce provision of basic services. Communities are forced to utilise improvised infrastructures, causing overloading of electrical points. In the area affected by the blaze, all 34 families relied on two metered connections for electricity.
Everyday life in Cockle Bay. Photo by: A. Allen
Some might posit that informal settlements are hazards in themselves and ought to be eradicated. However, these settlements house a sizeable proportion of Freetown’s population, with no alternative dwelling options. Moreover, their residents perform jobs that support the daily functioning of Freetown; quietly they run the city. Demolishing their living quarters as a ‘protective measure’ against risk simply displaces the issue - disrupting lives, livelihoods, family ties and social organisations - making poor women and men even more invisible. Events like the fire in Cockle Bay remind us of the need to stop blaming the victims and victimising the poor, the need to acknowledge that they live at risk not as an exception but as a common reality, the need to seek pathways for more inclusive urbanisation beyond risk.
Di Marino, Marco; Lacroix, Lea; Nastoulas, Illias; Simpson, Paul; Trintafillides, Georgina; Williams, Cai Anwyl ; and Yang, Deyu. (2018) Urban Risk Trap: Fire Dynamics in Freetown’s Informal Settlements. Policy Brief No. 2. SLURC/DPU Action-Learning Alliance.
Author: Alexander Stone