By Ummekulsoom Lalani (Johns Hopkins University), Daniela Rodriguez (Johns Hopkins University), Elizabeth Ekirapa (Makerere University), Freddie Ssengooba (Makerere University), Eric Ssegujja (Makerere University), Martha Akulume (Makerere University), and Ligia Paina (Johns Hopkins University)
In resource poor settings, health system accountability for quality services is weak and represents an important barrier to achieving Universal Health Coverage and the Sustainable Development Goals. Social accountability – the mechanisms and strategies through which citizens participate in decision-making and hold public and/or private sector actors accountable for the services rendered and their performance – has been the target of systems strengthening efforts aiming to foster and sustain reliable and transparent accountability structures. However, most of the demonstration and experimentation thus far has been in rural areas, and with mixed results (1, 2, 3, 4, 5). Understanding and transforming social accountability in urban, informal settlements is many times more complex.
Informal settlements are often characterized by limited access to basic infrastructure and social services, such as running water, proper drainage, and solid waste management. Residents in informal settlements are poor, marginalized, transient, and regularly rely on the private, informal health sector, whose services are unregulated and often lack quality. A long history of structural inequities and social injustice has left residents of informal settlements and local authorities in conflict. In Kampala, remnants of its colonial legacies impact urban planning, as land and planning policies along with administrative practices continue to serve the interests of elites.
Between 1991 and 2014, Kampala’s resident population doubled. Rapid urbanization has overwhelmed existing structures and led to the emergence of informal settlements, which house approximately 60 percent of Kampala’s population. They are believed to grow at a yearly rate of five to nine percent. Many of these are slums found in low-lying and flood prone areas not zoned for human settlement. In Kampala and elsewhere, Covid-19 has only exacerbated growing inequities in urban informal settlements and increased the need for innovative and responsive research methods.
We recently explored the feasibility of social accountability initiatives to improve health services for residents of informal settlements in Kampala, Uganda. The insights from stakeholder interviews provide a snapshot of priorities and accountability dynamics of providing health services to informal settlement residents.
What is the social accountability landscape in Kampala?
Three main types of actors are active in addressing the needs of informal settlements: (1) government city authorities, (2) non-governmental organizations (NGOs) and civil society organizations (CSOs), and (3) community health clinics and providers. Figure 1, below, summarizes their respective and most common existing urban social accountability channels.
Figure 1. Overview of existing urban social accountability channels, by actor type
How do these stakeholders coordinate and engage?
While governmental and non-governmental stakeholders aim to improve access to services for populations in informal settlements, there is a lack of coordination and strategies between health and non-health sectors. Mechanisms to include the priorities of residents of informal settlements in decision-making are either inactive, non-health sector specific or not sufficiently mainstreamed to be institutionalized. Limited funding also hampers service delivery and implementation of existing accountability channels, especially within the public sector. The government uses the private sector, which is often fragmented and uncoordinated, to provide access to services where government services are lacking. These existing mechanisms do not account for the transient nature of urban populations in informal settlements; more contextually adaptable models are needed.
Inadequate social services further exacerbate the vulnerabilities of populations in informal settlements. In many cases, residents of informal settlements need to negotiate access to limited public services through actors such as politicians and local government authorities. In Kampala, elected officials’ demand for specific services impacts how governmental entities are engaged in planning.
What can be done differently in the future?
More knowledge and practice are needed to improve outcomes for residents in urban informal settlements. We have outlined some initial questions to understand how to design social accountability initiatives to improve health service access for urban informal settlements.
Enhancing community engagement and participation:
- How can existing social accountability mechanisms be strengthened to engage more effectively with residents in informal settlements?
- What strategies can improve social cohesion in urban settings?
- Given overlapping vulnerabilities, what types of strategies can be developed to ensure equity and intersectional inclusion for programming and accountability (e.g. gender, poverty, employment status, age)?
Supporting policy and program transformation:
- What are barriers and facilitators for municipal governments to consistently engage in informal settlements, across sectors, so as to enhance health services?
- Who are the champions for social accountability for health for residents in informal settlements and how can their capacity to act in such a role be strengthened?
Existing social accountability interventions need significant adaptation to work within informal settlements, such as those found in Kampala. Planning for urban health services should better account for high mobility and low social cohesion among city residents, and for the vast number of stakeholders and often uncoordinated efforts. Strengthening existing accountability structures while exploring innovative approaches that are context specific will be crucial if the needs of urban informal settlements are to be met.
Image: Martha Akulume (Makerere University)