Examination of Witnesses (Questions 60
- 70)
TUESDAY 2 JUNE 2009
MR ANDY
RUTHERFORD, MR
GORDON MCGRANAHAN
AND MS
LOUISE MEINCKE
Q60 Hugh Bayley:
It is clear from your answer that you cannot plan cities in Africa
as if you were planning downtown Düsseldorf, but it does
seem to me when I visit slums that it is so common that the health
facilities are eight miles away and completely inaccessible. I
remember going by train out of Delhi at walking pace for an hour
through slums with no public toilets, everybody defecating on
the lines. You do not need rocket science, although India has
got rocket science, to put a pit latrine every 50 metres through
a slum, or to ensure that there is a school, that you regulate
a slum enough to set land aside for a school and to accept you
will have a school in a slum. There could be some basic town planning
rules that you could apply. Should not the African Development
Bank, for instance, or UNDP or UN-Habitat develop these packages
of minimalist town planning that stop you having to evict hundreds
of people later to provide a school or a road?
Mr Rutherford: One of the key
challenges is resources. There are lots of plans and they are
very interesting and there are again a number of countries we
work in. There are interesting training centres and colleges for
urban administrators and town planners and there is a good interface
and work between some of the citizens' organisations we talked
about earlier on, some of the local level officials who are already
in post and the people who are going through the training colleges,
even in Angola. It happens, and it is interesting. As we were
saying, the exchanges can be very rich. We have facilitated exchanges
between Cape Verde and Angola, between Mozambique, Angola and
Brazil, and that sort of sharing of experience really makes a
difference. UNDP and the African Development Bank are probably
not going to provide the revenues for the local authorities to
implement the plans as they exist, even in a participatory way,
so the resource and the revenue challenge becomes key, how the
local authorities then develop their resources in a way which
does not perpetuate poverty and exclusion becomes the key question,
so it is planning and resources together which is the key challenge.
That is why I refer back to the resource-poor nature of many of
the local authorities that we are working with, and therefore
they are saying, "What can we do?". They have the equivalent
of school fetes, bring-and-buy events to generate resources at
the local level. That is not sustainable.
Hugh Bayley: The point is well made.
Q61 Richard Burden:
Perhaps we could have a word about health because I guess it is
one of those areas where some of the challenges of urbanisation
are at their most stark but it is not an issue of distance from
facilities; it is an issue of the exclusion an inequality and
so on. I suppose the first question is, what do you think specifically
donors such as DFID could do to try to support and deliver better
and more equitable health systems in urban areas?
Mr McGranahan: If you think of
health systems as the systems that support health and things like
water and sanitation and housing in themselves as being part of
healthcare—
Q62 Richard Burden:
I am going to ask you about water and sanitation in a minute.
Mr McGranahan: So just health
services, you mean? You mean health services in the sense of healthcare?
Q63 Richard Burden:
Access to healthcare, issues around HIV/AIDS.
Mr Rutherford: We have worked
on urban community health programmes in Bangladesh with some EC
support and again the issue is appropriate forms of outreach,
so gender-sensitive participatory programmes—all my key
themes again. You have to work with paramedics who have come up
from the community, so who have been trained in appropriate approaches
to the community as opposed to coming down from the colleges,
and develop very localised centres within slums as opposed to
people having to pay large amounts to go to a hospital where their
access chances are very slim. At source you have to develop networks
of primary healthcare centres which are supported by paramedics
but are also rooted in the community and in appropriate and gender-sensitive
approaches to healthcare so that they are relevant. It may not
be with the whole range of healthcare facilities, but it will
be what is most appropriate to the community and still will have
a referral mechanism to health centre units which become more
accessible, so that two-tier approach, which is going back to
the "health for all" primary healthcare approaches that
have been proven to work, at least in Bangladesh and in parts
of India, and linking that to private healthcare schemes for the
slum dwellers which are low-level access at the beginning means
that people can get access to broader levels of care. There is
a lot of work on that which has been very interesting and some
of it supported by DFID in Dhaka as well.
Ms Meincke: Just on the issue
of health in regards to street children, I think we can all agree
that slum dwellers need more healthcare. What donors need to be
aware of is that even if you have healthcare in a community or
in a slum area children living on the street are unlikely to be
able to access it because of stigma and discrimination. Lack of
documentation is a major issue as well. You do not have a birth
certificate so you cannot access healthcare. If you are a street
child with HIV you can suffer from double discrimination because
you are perceived as "dirty" and you live on the street
and because you have got HIV/AIDS as well, so it is very difficult.
Even if the healthcare is there it is very difficult for certain
groups of children to access that healthcare, so it is something
that needs to be taken into consideration. Just on another point,
I know we have moved on but I just wanted to say that the Consortium
is currently running a project in Tanzania; I think I alluded
to it before. It was funded by the Baring Foundation and when
we initially applied for funding for this project they came back
to us and said, "This is not what we normally do but it is
so interesting that we will do it". This was about the participatory
approach, working both with street children and the community
in which they live. We would like to see DFID and other funders
going a little bit beyond the normal parameters of funding and
take that step further and fund projects like the ones that we
have been running in Tanzania which works with communities and
street children.
Q64 Richard Burden:
I suppose this may be particularly relevant to street children
but perhaps also more widely, there will be some health issues
that maybe should be more obvious, certainly more prevalent, that
would have increased incidence in urban areas compared to others.
A classic example may be mental health problems. Looking at that
specifically, are there any areas like that which you think donors
could be doing more to try to improve access or is it much the
same as you were saying before in terms of the basic components
and what needs to be done?
Mr Rutherford: In Nicaragua there
is a very interesting law where the coalitions of disabled people's
organisations, building on issues of mental health but also broader
issues of access, provide an obligation on local authorities in
Nicaragua for scrutiny of issues around access, including around
health issues. It is not always fulfilled but for some of our
partner organisations it provides a benchmark to be able to say,
"This is your obligation. You should take this forward".
That is a law which relates specifically to local authorities
and local health authorities, the point being that in addressing
some of the challenges that you are highlighting it is very important
to go back to the legal basis for responsibility of the state
or the local state or the service provider to have to respond
to the needs of the community, how that is drafted and becomes
a key process.
Mr McGranahan: You raised the
issue of HIV/AIDS where prevalences are higher in urban areas
of Africa than in rural areas of Africa and at the moment I gather
they are still higher in wealthier groups than in poorer groups.
It is a bit like water and sanitation used to be. Urban areas
play a critical role not just in and of themselves but in terms
of the spread of diseases and it is not just urban. You have to
understand urban/rural relations and the movement of people in
different parts when they get the disease. Do they move into the
rural areas or not, and what types of services are needed in urban
versus rural areas? What you would expect to see occurring, which
is what basically happened with water and sanitation, is that
over time disease becomes less a disease of the affluent and more
and more a disease of poverty. It becomes more spatially circumscribed
and that could be what we are seeing occurring over time, and
hopefully not just DFID but donor organisations can help prevent
that transition happening.
Q65 Richard Burden:
This is my last question but it is in two parts. The first picks
up a little on that and I guess what I was saying about mental
health services as well. In looking at the development of initiatives
and support around the challenges of urbanisation does there need
to be more specific focus on rural/urban migrants as well as those
that have lived there for some time, and, if so, how? The second
part is, could there be any positives here? In most of our evidence
sessions we are looking at the challenges and the problems of
urbanisation. In terms of delivering healthcare could there be
some plus points there if we get it right?
Mr McGranahan: I think there could
be. I do not really feel all that comfortable making strong claims
about that but on the issue of rural/urban migrants I was on an
advisory board for a group in Nairobi that does health studies.
They monitored a couple of very large slums over time and of the
people who entered the slum one year 25% would be gone the next
year because there is an awful lot of movement of people around
these places, and the notion that you have got people stuck in
one place that need to be treated and that will be there consistently
is clearly wrong. At the moment people certainly would move into
those settlements so as to get health services but on the other
hand as a possibility in a somewhat more ideal world I think there
are opportunities there.
Mr Rutherford: Potentially yes,
but the challenge is the issue of mobility. It is the same in
London. The mobility within each borough each year is quite significant.
In the urban context in Africa or south east Asia the mobility
is enormous and therefore from the point of view of service delivery
you have a higher percentage of the population captive in a potentially
more serviceable area. It will require a major rethink on issues
of access and entitlement to services to be able to track and
ensure people do not, as we were saying earlier on, become de
facto excluded from services by the sheer nature of their
mobility and the fact that they are not seen to be part of the
planning process, symbolised by a group. I have not already mentioned
Cape Verde. We worked with an organisation there whose key success
was to go to the capital municipal authorities when they were
trying to advocate for some services and then found out that they
were not even on the map; they did not exist. It is a symbol of
the reality of many urban dwellers in Africa and Asia that the
lack of visibility becomes a key challenge and therefore makes
it probably even more difficult to respond positively to your
question if that rethinking does not take place.
Q66 Hugh Bayley:
What are the principal constraints that prevent children getting
to school in urban areas? Are they supply side problems—lack
of teachers, lack of land, lack of schools—or are they demand
problems, that children and their families need the children working
rather than in school, and if you want to get those children into
school how would you do it and how would you recompense the families
for the lost labour?
Ms Meincke: You can talk about
lack of schools and lack of teachers and school fees, lack of
books, et cetera. From a street children point of view one of
the main obstacles is that you have to work. You would be working
in a market during the day. If you are a street child and you
have no family contact you are very unlikely to attend school,
for obvious reasons. What we did again in Tanzania was work with
the community which identified the issue of schooling. There is
no education for children who are working and living on the street.
We were working in partnership with the Faraja Trust which initially
set up a street-side school where they would literally go with
their teachers to the pavements during the day and they would
meet the children in the market where they were working and they
would sit down and have a lesson on the pavement. We have got
another organisation working in Kenya. They have got a bus and
they will drive into the market and open up the bus so that the
children, when they have time, will come into the bus and have
lessons when it suits them, but most importantly the school that
is being set up in a slum in Morogoro in Tanzania works with local
schools as well and the national system. What happens is that
if you are a street child, which is the same in this country,
you have often been out of school for a long time which makes
it very difficult to get back into it and you might even find
that you are too old to get back into the level where you should
be, so the school in Tanzania takes in street children for a couple
of years, gets them up to the level where they should be, and
then they have an agreement with the local school where they are
re-integrated into the school at the right level with the right
qualifications, and I think this is really significant. What we
do not want to do is create two school systems that sit next to
each other, the informal school system and the formal school system,
and NGOs have got very innovative ways of doing this, of linking
the formal and informal education systems.
Q67 Hugh Bayley:
Can I ask one other question which does not appear in our brief.
From what I know of slum cities crime is always a major problem.
People have things stolen, racketeers force you to pay much more
rent than you should be paying, there are drugs. Surely to goodness
security and policing and accountability of police forces and
other officials to slum dwellers are really important issues.
Should we not be looking at that?
Mr Rutherford: Totally, absolutely,
on the street children level but also on the general level. Again,
back to where we began, in El Salvador the key interface was a
restructuring of the relationship between citizens and the police
and developing women's police committees and citizens' groups
that could work with the police in a completely different way,
coming from the slums, not from the middle classes. It is an enormous
challenge, it does not necessarily bring instant results, but
you have to seize it full on.
Ms Meincke: Street children are
often seen as the people who are doing the robberies and the stealing,
but what we have got as well is that street children are exposed
to a huge variety of violence and theft themselves, so again innovative
approaches by NGOs working on the ground, such as having street
children banks where children from the market can go at the end
of the day and deposit their earnings, which means that they can
save, they can become entrepreneurial.
Q68 Hugh Bayley:
I saw that in your evidence.
Ms Meincke: It is a very good
initiative. Also, with the violence, you mentioned accountability
in policing. Often street children find themselves exposed to
a huge variety of violence from the people who should be protecting
them.
Mr McGranahan: One thing to keep
in mind is that there is enormous variation in violence between
different communities and between different countries in terms
of slum communities. I remember I was doing a study that was looking
at violence as one of a number of different issues. When you go
up to São Paulo in certain areas that is what people care
about. It was tearing the families apart. They could not stop
talking about it; it was one of those things where you just could
not stop them, whereas in other places it was a much less significant
issue and not a major concern. You really need to look at the
local context but it should be in the brief as one of the many
areas that also links up with why these communities have trouble
engaging politically, co-operating and forming good associations
to do with a lot of their other problems.
Q69 Chairman:
Can I address the issue of water provision and sanitation because
you, Mr McGranahan, have said that neither the public sector nor
the private sector are very good at delivering it. This Committee
did a report on sanitation and water a couple of years ago and
the general convention at that time was that privatisation was
an issue of delivery and it was marginal, it was a red herring;
it had been a distraction, so I think we can agree with you on
that. The point is, what would work? These are challenges. In
one sense you would like to think that if you have got a lot of
people in a confined space it ought to be easier to provide water
and sanitation. In some ways, at least physically, the infrastructure
has not had to travel huge distances, so what are the challenges
and how can they be overcome?
Mr McGranahan: It is easier in
urban than in rural areas and if you get it right it is less costly.
A lot of the issues we have already been talking about are some
of the reasons why it ends up being much more difficult to deliver
water and, even more, sanitation and hygiene improvements in urban
areas, because on the one extreme you have many cases where the
utility is not even allowed to go into the slum because it is
not really supposed to be there. That is, I guess, one of my points
in terms of private versus public. It is a big deal if you are
in the water sector but it does not affect that phenomenon. You
have to deal with issues to do with land and rights as part of
providing water and sanitation. There are all sorts of different
paths into this but the groups that we have worked with that have
been most successful have not been from the water and sanitation
sector. They have been people that have been working in low income
communities and have picked up water or sanitation as a means
of improving conditions in these settlements and they have done
it in rather different ways in different parts of the world. I
do not know whether you are familiar with this but in Karachi
you have the Orangi pilot project, which is one of the best known
examples. What they did was to give up on the idea that the government
was going to provide sewers. Technical assistance provided two
lanes to put in much simpler, affordable devices and they really
emphasised affordability. They were very much against the high
cost, donor-driven improvement projects and went instead for something
that these communities could build, at least up to a point. That
did cause problems because they basically used the natural contours
of the land which meant that they were dumping sewage sometimes
into the streams that were not exactly where they should be, but
basically over time and through negotiations you got the planners
becoming involved and doing their part of hooking up those community
systems, and that then became the basis over a long period of
time but they kept with it and, based on certain principles, they
pushed for many years until eventually now the government has
responded and a number of the principles have been adopted. If
you go into a government office there you will see the maps that
were originally drawn often by children that were helping with
these maps of all the different canals and systems that were being
built. I think one of the key things that that example provides,
and most of the other examples we have, particularly in relation
to sanitation, is that at the local level it is a collective problem,
something nobody can deal with individually. It is too costly
to bring in the sewers to most of these settlements, and particularly
it is too costly to bring in sewers up to the standard which you
would really like there to be, and so in effect one of the key
questions is how can these communities get together and organise
around solving their sanitation problem. In rural areas now one
of the more popular approaches is community-led total sanitation,
which may be a bit oversold at the moment but it is centred around
stopping open defecation and going for an affordable solution
by getting everybody to see how awful the situation is. You do
a transact walk through the community and point out faeces at
various points and, depending on how it is done, there are various
ways through. The point is that it is creating a community demand
for that sanitation. Even political groups have often, when trying
to organise in poor urban areas, come up with sanitation as a
means of becoming popular, so once you create that collective
the demand is there. The problem is that you often have all sorts
of barriers to overcome if the people are considered to be living
in areas where there is not supposed to be a settlement, or if
you want to achieve standards that most of us, or most politicians
in the country, would consider acceptable. I think that is one
of the ones which is the hardest to deal with. Sometimes the best
way to improve these conditions is to make improvements which,
in effect, people should not have to live with still. Again, I
would say that is particularly why it is important this is done
through a process which engages with the local communities because
they are the only ones who can make that decision in terms of
accepting what are not necessarily acceptable standards. You have
seen in most of the groups we work with which deal with housing
and land problems, they also come around to deal with water and
sanitation problems. Sanitation in India, Mumbai and Puna, developing
these toilet blocks is almost part of the process of engaging
with the community and creating savings groups, to the extent
when people get organised, if they can solve their sanitation
problems and water, they have not dealt with that already.
Q70 Chairman:
It seems from what you have all said in answer to a number of
our questions, you want community-led initiatives which are then
responded to by municipal and national authorities. You think
DFID could do more and national governments could do more. Presumably
the Poverty Reduction Strategy should incorporate these things
as part of the process, allowing that community groups may well
take the lead when they have to be responded to. That seems to
be a general theme of your answers.
Mr McGranahan: That is rather
difficult for a donor to do. The traditional donor route is through
a delivery chain where by the time it reaches a low income household
in a slum, it has gone through, it has had all of its requirements
added to it and then all of these little bits of money taken out
of it and there is very little there. You do have to deal with
issues like sovereignty, you cannot have donors going around doing
things which national governments do not accept, so this has to
be built on principles of sovereignty. You have to have horizontal
networks which are then funded going quickly down rather than
through a traditional delivery chain.
Chairman: Thank you very much indeed
for coming in and giving us your written evidence. It has been
very welcome.
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