This blog is the third of the health in urban development blog series. View also:

Health in secondary urban centres: Insights from Karonga, Malawi
By Don Brown

Gaza: Cage Politics, Violence and Health
By Haim Yacobi

If you are interested in DPU’s new MSc in Health in Urban Development, more information can be found on our website.

In Dar es Salaam, Tanzania’s main economic and administrative centre, high population densities, the accumulation of informal lower-income residents, lack of access to clean water and poor sanitary conditions have been associated with a range of water and sanitation-related diseases. Cholera outbreaks are a frequent occurrence during the rainy season and some settlements in the city are among the worst affected in the country. In this context, I argue that urban water poverty needs to be tackled using a proactive rather than reactive approach at the local level to yield long-lasting health benefits.

Main access road in an informal settlement in Dar es Salaam after an episode of heavy rainfall (Photo © P. Hofmann, 2015)

Tackling urban water poverty and community health promotion

Internationally, the link between urban water poverty – i.e. inadequate access to water supply and sanitation facilities, and public health – is widely recognised whereby improvements in accessing water and sanitation are deemed crucial in tackling a diverse range of diseases and improving the lives of the poor.

Such thinking calls for integrated and consistent approaches, which, as emphasised by a UNICEF WASH specialist in Tanzania are evidently lacking in most policy-driven practices on the ground.

“Hygiene and sanitation awareness, behaviour change, communication and empowerment are maybe done in urban areas but erratically, not systematically. When the rains are coming and there is threat of cholera etc. then you will find people will announce:  ‘food vendors cover properly your food and make sure it is hot and whatever, please clean your surroundings, no solid waste should be seen and liquid waste, please drain it out completely’ etc. […] or there is a cholera outbreak in a certain locality in Dar es Salaam and it is feared that it might spread, so that happens but on a regular basis there is not a lot done” (quote from UNICEF WASH specialist).

During the recent cholera outbreak in 2015 government spending increased significantly to treat the affected population. While curative measures are vital, efforts to improve water supply and sanitation constitute essential steps towards future outbreaks. Similarly, some municipalities in Dar es Salaam have put continuous support into household fumigation programmes to impede the spread of malaria but fall short of investing in preventative measures to keep people healthy – i.e. reduce mosquito breeding sites through the provision of safe drinking water, improved sanitation and hygiene. Currently, the onus is predominantly on residents themselves to be pre-emptive in their everyday practices with regards to potential health implications but not everybody is equally aware or shares the same ability to act. In the absence of sufficient government action, those who can have invested in better access to water, improved sanitation facilities and even flood defences.

Drainage channel built by two neighbouring households to divert water from the Msimbazi river, which carries wastewater from nearby wastewater stabilisation ponds (Photo © P. Hofmann, 2015)

“In 2011 there was flooding and we lost our livestock and we had to start afresh. What actually happened is there has been increased silt in the Msimbazi river. At the same time, there is wastewater that comes from the ponds and where these meet, that impact pushes the water towards our land. […] we constructed this drainage channel jointly with my neighbour after the flooding to try and divert the water from coming in” (quote from a resident in an informal settlement in Dar es Salaam).

The need for a proactive, decentralised approach

Ward health officers are officially tasked with preventing water-related diseases and promoting environmental health in their jurisdiction through regular water quality tests at local water supply schemes and inspections of businesses and households with no equivalent paid staff at sub-ward level. However, with limited resources at ward level much of the action regarding water supply, sanitation and environmental health depends on voluntary efforts in the communities by residents themselves and facilitated through sub-ward committees, water committees and community representatives. Many health officers at the ward level understand the importance of sanitation, drainage and safely-managed water supply but struggle to influence the agenda at higher levels of government. The Decentralisation by Devolution Policy introduced in the 1990s transferred responsibilities to local government for service improvements but without fiscal decentralisation or devolution of decision-making power. Decentralisation should pave the way for bottom-up participatory planning processes but municipalities in Dar es Salaam focus on central government priorities while continuing to disregard lower levels of government and their efforts to address local challenges. Decentralised decision-making structures are therefore not a guarantee for more democratic processes.

The importance of engaging urban poor communities

To lower the burden of water and sanitation-related diseases, engagement of communities with the authorities (utility and municipal government) is crucial but often limited and slow. Until recently, one of Dar es Salaam’s municipalities prohibited low-income communities living near wastewater stabilisation ponds to use them for safe sewage disposal. A lengthy period of continuous interaction between the local community, the municipality and the utility, facilitated by a local NGO, eventually led to a pilot initiative that connects household toilets to the nearby ponds using simplified technology. This has reduced the number of pits being informally emptied during the rainy season and led to a safer and healthier environment for residents.

Inspection chambers of the simplified sewerage pilot in an informal settlement of Dar es Salaam (Photo © P. Hofmann, 2015)

The utility seems keen to replicate the scheme elsewhere in the city, which shows potential that policy-driven practices can be transformed, scaled up and institutionalised in ways that are more integrated and sensitive towards the needs of the urban poor if sufficient consideration is given to the scope for scaling up and sharing the benefits more equally within a settlement.

Pascale is a Lecturer at the Development Planning Unit, UCL, where she leads the MSc in Environment and Sustainable Development Programme. Her current research is particularly concerned with the dialectics of urban water poverty, examining different policy-driven and everyday practices and their impact on everyday trajectories of the urban water poor. She is interested in generating knowledge towards developing feasible pathways out of urban water poverty.

This blog is the first of the health in urban development blog series. View also:
Gaza: Cage Politics, Violence and Health

If you are interested in DPU’s new MSc in Health in Urban Development, more information can be found on our website.

They may be small, but don’t let their size mislead you. Secondary centres form a significant—though underappreciated—part of the global urban landscape. Drawing on my doctoral research in Karonga, a small town in Malawi, I explain why achieving a healthy urban future will depend increasingly on how urban growth occurs outside the largest cities.

Haphazard densification of a previously planned settlement, Karonga Town, Malawi. Photo credit: Donald Brown (2017)

It is widely proclaimed that we now live in an urban age, with more than half of the world’s population living in ‘cities’. While impressive, this statistic does not tell the whole story. It is widely assumed that most of the world’s urban population live in the largest cities and that they are the fastest growing. But there are relatively few mega cities (with more than 10 million residents) and they account for less than 10% of the world’s urban population. Many are also not growing especially fast.

Far more urban dwellers live in small and intermediate centres (with less than 1 million inhabitants), many in Asia and Africa. These ‘secondary’ centres constitute the bottom and middle of the urban hierarchy, where a large and typically growing share of the world’s future urban growth is expected to occur. But this is also where the capacity to plan and manage urban growth, provide services, and reduce environmental risks is so often lacking.

If the growth of secondary centres in Malawi and other sub-Saharan African countries is to contribute to a healthy urban future, research and action is required on several fronts:

The dynamics of in situ urbanisation

Most accounts of Africa’s urban transition have focused on the causes and patterns of urbanisation and peri-urbanisation. Much less attention has been paid to in situ urbanisation—the placed-based transition from a rural area into an urban one. These dynamics are of growing importance in sub-Saharan Africa given its low urbanisation level and moderate urbanisation rate, meaning that many small settlements have yet to emerge.

Karonga exemplifies the process of in situ urbanisation: it grew from a small trading post in the colonial era into a sub-regional service centre under the current national planning framework. The town’s population increased nearly four-fold from around 11,000 in 1966 (the first census year) to over 40,000 in 2008 (the last census year). Karonga is now the second largest centre in the Northern Region following Mzuzu.

Despite its size and growth, Karonga has no local government and so lacks the capacity to effectively plan and manage its growth. Numerous environmental hazards have subsequently emerged, ranging from poor sanitation, to seasonal floods, to large-scale disasters, posing major health risks.

Flooding in and around the central market, Karonga Town, Malawi. Photo credit: Wisdom Bwanali (2017)

The need for disaggregated urban data

Most demographic and health data is aggregated to provide averages for urban populations, obscuring widespread health disparities within and between urban populations. Basic health data is especially limited in sub-Saharan Africa in the absence of vital registration systems, disease surveillance sites and electronic health records, even though the region bears the brunt of the world’s deadliest epidemics, including HIV/AIDS, malaria and tuberculosis.

Where available, local information sources can be used to generate disaggregated data at the urban scale. Among the most valuable sources are hospital records, which provide information on the causes of disease in populations. To generate this information for Karonga, nearly 3,000 inpatient records from Karonga District Hospital (located in the town) were collected over a 12-month period (August 2016 to July 2017) to produces estimates of the prevalence of environmental disease.

While the sample is not completely representative of the town’s population, the findings reveal alarming patterns:

• 63% of all recorded diseases were environmental (i.e. related to factors in the physical environment);
• 64% of environmental diseases were infectious and parasitic; and
• cholera outbreaks during the rainy season are recurrent in areas with the poorest sanitation.

These observations support the longstanding suspicion that smaller settlements with limited capacities can be among the most hazardous places to live, highlighting the need for urban environments far more capable of preventing disease.

The dynamics of rural governance regime change

As in situ urbanisation unfolds, villages will grow into towns, towns will be reclassified as urban (raising the urbanisation level), and modern institutions will attempt to intervene in rural governance regimes that may be resistant to change. This process is creating new governance challenges for planning authorities attempting to intervene in towns once they have already emerged.

These challenges are heightened in Karonga in the absence of a local government, meaning the balance of power has not shifted from traditional to modern institutions in much the same way the planning system has not resulted in formal urban development. Instead, customary and modern institutions have intertwined in hybridised governance arrangements in which the authority and legitimacy of the state is contested.

A chief holds a meeting in a village in Karonga Town, Malawi. Photo credit: Donald Brown (2017)

Understanding the place-based dynamics of rural governance regime change in emerging towns such as Karonga is at the forefront of planning research on in situ urbanisation. Case studies of this kind have significant potential to reveal the possibilities and obstacles for planning healthy towns at the bottom of the urban hierarchy. This is where many of the future challenges facing public health will be increasingly concentrated, but where little scholarly or practical attention has been paid to this and other important urban development issues.

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Donald Brown is an urban planner and researcher interested in the nexus between urban development planning, public health and (disaster) risk reduction in sub-Saharan Africa and other urbanising regions. His doctoral research focused on environmental health in smaller African urban centres as increasingly important to overall urban population health.