The persistent urban challenges of migration and informal settlements in the context of HIV: towards the development of a framework to guide the appropriate and equity promoting urban health and developmental responses of local government within Johannesburg, South Africa

Vearey, Joanna Louise
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Rationale Understanding how to ensure and sustain the health and health equity of urban populations is of increasing importance as over half of the world population is now urban (UNFPA, 2007). Urbanisation is taking place rapidly across Africa, with fifty percent of the continent expected to be residing in urban areas by 2030 (UNFPA, 2007). South Africa has experienced a faster rate of urbanisation compared to neighbouring countries, with almost sixty percent of the population estimated to be urban (Kok & Collinson, 2006). This process of urban growth is accompanied by in-migration from within the country and across borders. Urban growth places pressure on limited, well-located and appropriate housing, resulting in the development of informal settlements within and on the periphery of urban areas. In addition to the multiple exposures to a variety of health hazards in informal settlements, HIV presents a contextual challenge, particularly in South Africa where the highest HIV prevalence is found within urban informal settlements (Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005). South African local government has a ‘developmental mandate’ which calls for government to work with citizens to develop sustainable interventions to address their social, economic and material needs (The Republic of South Africa, 1998a). This requires local government to address the challenges of urban growth, migration, informal settlements and HIV, as outlined above (Bocquier, 2008; Landau & Singh, 2008; Landau, 2007). The current (2007 – 2011) South African National Strategic Plan (NSP) for HIV signalled a welcome shift in HIV policy, with recognition of the role of government in ensuring that (1) internal and cross-border migrant groups and (2) residents of informal settlements are able to access the continuum of HIV-related services, which includes prevention, testing, support, treatment, and access to basic services. However, guidelines are lacking to assist local government in addressing HIV-related concerns with migrant groups and in informal settlements at the local level. As a result, migrant groups and residents of informal settlements struggle to access HIV-related services, including healthcare, adequate housing, and basic services such as water, sanitation and refuse removal. Given the developmental mandate of local government in South Africa (The Republic of South Africa, 1998a), this raises the question: how should local government respond to the urban challenges of migration and informal settlements in the context of high HIV prevalence? This thesis explores how the challenges of migration and informal settlements – within a context of high HIV prevalence – interact to generate a specific urban reality that requires an appropriate urban health response at the local government level. The question of how to address the gap between discourse, theory and action is tackled. Various frameworks for urban health have been developed that aim to assist in understanding the impact of city living on urban health, several of which draw on the concept of the social determinants of urban health (SDUH) (for example Galea, Freudenberg, & Vlahov, 2005; WHO, 2008b, 2008a). However, as I will go on to argue, none of the existing urban health frameworks deal adequately with the specific complexities of developing country urban environments. In particular, the frameworks have failed to adequately account for guiding local government in responding to the challenges identified above, namely: urban growth and informal settlements; internal and cross-border migration; high HIV prevalence; and, the responsibilities of a developmental local government. Aim Based on the findings from four studies, this PhD research aims to generate a revised urban health framework that will address the following specific challenges that I argue are associated with developing country contexts: (1) urban growth and informal settlements; (2) internal and cross-border migration; (3) high HIV prevalence; and, (4) the responsibilities of developmental local government. It is proposed that this revised framework will assist local government in responding to the interlinked challenges of informal settlements and migration in a context of high HIV prevalence. Methods A series of four studies were undertaken in Johannesburg. A review of international and local literature – including existing policy – was undertaken. In order to engage with the complexity of the urban environment, the four studies draw on both quantitative and qualitative methods. These include: a cross-sectional household survey across Johannesburg inner-city and one urban informal settlement (n = 487); a cross-sectional survey with ART clients at four ART sites in the inner-city (n = 449); and semi-structured interviews with community health worker volunteers, healthcare providers, local level policy makers and programmers involved with urban health and HIV in Johannesburg. By reflecting on involvement in participatory photography and film projects, the experiences of rural migrants who enter the city through ‘hidden spaces’ are examined; the concept of ‘being hidden’ is explored as a tactic employed by marginalised groups so that they are able to find a way to enter and participate in the city. Through the four studies, a series of four central themes were identified: (1) rights to the urban social determinants of health; (2) urban livelihoods; (3) policy and governance; and (4) urban methodologies. These four themes assist in synthesising the study findings and generating a revised approach to guide local government in responding to urban health challenges in a developmental way. Key findings The developmental mandate of local government is evolving very slowly (Paper I, V). Local level responses to the interlinked urban health challenges of migration, informal settlements and HIV are lacking (Paper I, V). Where they do exist, HIV is not viewed as an intersectoral developmental challenge and vertical HIV programmes prevail (Paper V). It will be argued that informal settlements require integrated local developmental responses (Paper V). In general, policies and guidelines that outline the right to basic healthcare and ART for crossborder migrants are not implemented at the local level (Papers I and III). In addition, residents of informal settlements struggle to access adequate housing and basic services (Papers IV and V). Some internal migrant groups, who reside in ‘hidden spaces’ of the innercity, are found to employ deliberate tactics in order to evade the state, whilst others are marginalised through a lack of state intervention (Paper II). The research shows that innovative methods are required to engage with urban populations, both for research and intervention purposes. Participatory approaches are found to be useful methods for engaging with urban migrant groups and this research draws on participatory photography and film projects as examples (Paper II, V). It is essential that urban public health practitioners and other development professionals learn how to engage with the complexities of the urban environment. A review of existing urban health frameworks finds that whilst these frameworks are themselves complex, and include the multiple levels and determinants that ultimately impact health outcomes, they result in generalised and static models of urban health. I argue that these existing frameworks are unable to inform responses to the specific complexities present within a particular urban context. Through the synthesis of the four study findings, an alternative approach to assist local government and other stakeholders in responding to urban health challenges is proposed. The idea of ‘concept mapping’ is suggested as a way to vii enable local government, and other actors, to engage with the complexities of the urban context in a participatory way. A core set of components have been identified that can be used to guide the creation of city-specific ‘concept maps’, that are able to work towards identifying and addressing the specific urban health needs associated with different areas within a city. A recommitment to intersectoral action, ‘healthy urban governance’ and public health advocacy is considered critical to the effectiveness of such an approach. It is suggested that the resultant ‘concept map’ will assist local government in responding in a developmental way to the interlinked challenges of migration and informal settlements in a context of high HIV prevalence. Implications Based on the findings of the PhD research, a new approach to urban health is suggested. ‘Concept mapping’ is presented as a new tool to assist local government in achieving its developmental mandate and address urban health. Whilst developed to address the challenges faced by urban migrants and residents of informal settlements in a context of high HIV prevalence, the concept map approach is likely to be a useful tool for considering the health and development needs of other urban groups. Future research is needed to evaluate the effectiveness of the application of participatory ‘concept mapping’ to assisting local level urban health policy makers, planners, and other stakeholders respond to the interlinked challenges of migration and informal settlements in a context of HIV.
PhD, Unversity of the Witwatersrand, Faculty of Health, School of Public Health
HIV, local government, informal settlements, urban health, migration, health access, governance, National Strategic Plan, framework, concept mapping, participation