COMMUNITY ENGAGEMENT, CO-PRODUCTION OR CITIZEN ACTION? LESSONS FROM COVID-19 RESPONSES IN INDIA AND BANGLADESH'S INFORMAL URBAN SETTLEMENTS.

• Author: Rao, Vinodkumar

INTRODUCTION

Epidemic diseases are public health emergencies and controlling them is primarily the responsibility of state institutions. The COVID-19 pandemic has highlighted longstanding tensions between "biosecurity-focused, authoritarian and sometimes militarized approaches to public health, and in contrast, comprehensive, social determinants, participatory and rightsbased approaches." (1) From the latter perspective, disease prevalence and mortality reduction alone cannot be considered as adequate markers of successful disease control. (2) In October 2020, the World Bank predicted that between 71 and 100 million people would be pushed into extreme poverty as a result of the pandemic and the indirect effects of pandemic response. (3) In much of the Global South, a large number of urban residents live precarious lives in informality, and strict disease control measures can have serious negative impacts on the lives and livelihoods of the poor.

Informal settlements now house a third of the world's urban population, (4) and their residents suffer disproportionately from substandard health throughout their lifetimes. (5) Inadequate housing, crowded spaces, limited or nonexistent access to basic services (including health services), precarious livelihoods, and limited ability to furnish identity documents necessary to access services are longstanding issues for the urban poor. The COVID-19 crisis has only accentuated these inequities. Epidemic control measures in most countries in the Global South do not take into account these deficits, resulting in negative consequences for most urban informal residents. Failing to attend to these socioeconomic realities, which determine these residents' ability to follow public health advice and measures such as lockdown, can impede a country's overall pandemic response. (6)

Epidemic disease control measures, particularly those developed within the "biosecurity-focused" model, tend to follow a one-size-fits-all approach. Standardized approaches are not only inequitable in their immediate impact but are likely to increase inequalities in the long term. (7) While addressing public health emergencies such as the COVID-19 pandemic requires resources at scale that are mainly available to governments, effective and equitable public health approaches rely on multidirectional flows of information, as well as trust and cooperation between different sectors of society, in line with the comprehensive public health model. (8) Inequalities in cities, however, pose significant barriers to development of cooperation and trust. The vast numbers of urban residents engaged in informal work and residing in informal settlements already face multiple exclusions, and they may lack trust in government or constructive relations with local authorities. Meaningful community participation is required to build and enhance trust and engage with deep-seated challenges around food security, stigma, and fear of epidemics. Examples documented across a range of countries in the Global South have demonstrated the important contributions of community participation and civil society responses in shaping effective disease control measures, primarily using existing local support structures. (9)

Meaningful engagement, participation, and co-production with communities has been identified as essential to identifying, acknowledging, preventing, and responding to the risks and unintended consequences that control measures can produce, particularly those shaped by intersecting inequities. (10) Co-production is most commonly defined according to Elinor Ostrom's definition as "the process through which inputs used to provide a good or service are contributed by individuals who are not 'in' the same organization." (11) However, with regard to citizen-state co-production in cities in the Global South, there are a plethora of definitions available. We find Kate Lines and Jack Mackau's definition to be relevant to the COVID-19 pandemic: "a situation in which the state and citizens come together to find a solution to a challenge, with both parties going beyond their normal processes and building an altogether new solution based on their synergy." (12) However, it is important to acknowledge that epidemic responses emerge within existing social relations and political economies, which must be strategically navigated to pursue equitable outcomes. Current literature lacks exploration of the specific political, economic, and social circumstances in which community engagement, participation, or co-production emerges. (13) It also neglects the ways that engagement is shaped by multiple intersecting inequities. (14) We address this gap by reflecting on empirical evidence from case studies in cities across India and Bangladesh. We highlight how community responses to the pandemic in urban informal settlements emerged to cope with the inadequacy of state support and as such, could not be categorized as community engagement or co-production. We argue that mere community engagement is no panacea for government failings; in order to improve the equity, effectiveness, and sensitivity of pandemic response, a multi-scalar approach grounded in a comprehensive public health model is required. This requires health systems to meaningfully engage with, and be accountable to, communities to co-produce appropriate response measures to meet the unique needs of the vast population living in informal settlements.

METHODS

Study Setting

In both Bangladesh and India, lockdown was the main measure used by the governments to control the spread of the virus. On March 25, 2020, the federal government of India announced a lockdown across the country with only a four-hour notice, and Bangladesh announced its lockdown on March 26, 2020, leading to closure of most institutions and businesses. The effects of the lockdown, and citizen responses to it, are therefore the main subject of the case study analyses.

Data Collection

We aimed to explore the different governance aspects of COVID-19 control and its impact on people living and working in urban informal settlements. Information for the case studies comes from preliminary thematic analysis of in-depth interviews from ongoing research conducted by the ARISE consortium. ARISE, which stands for Accountability and Responsiveness in Informal Settlements for Equity, is a five-year participatory action research program supported by the UK Research and Innovation's Global Challenges Research Fund across India, Bangladesh, Kenya, and Sierra Leone. We conducted qualitative interviews in three Indian cities: Mumbai, Guntur, and Vijayawada, and in the Bangladeshi capital, Dhaka. All interviews were conducted from April 2020 to February 2021.

Sampling

* Mumbai (India): The selection of respondents was carried out by local federation partners of the Society for Promotion of Area Resource Centres (SPARC). SPARC is an NGO working with two community-based organizations in India, the National Slum Dwellers Federation (NSDF) and Mahila Milan, which means "women together" in Hindi. To obtain a fair representation of these communities, SPARC'S partners selected respondents living in slums and slum relocation colonies based on such factors as their age group, their participation in relief work, and their personal experience with COVID-19 infection and treatment. The respondents were selected from the Bainganwadi, Shivaji Nagar, and Airport informal settlements as well as three "relocation colonies" in Mumbai: the Natwar Parikh compound, PGMP colony, and Lallubhai compound. (15) SPARC staff experienced in qualitative interviewing conducted the interviews with men (n=9) and women (n= 16) aged 20-65.

* Guntur and Vijayawada (India): Experienced researchers from the George Institute (TGI) and the Dalit Bahujan Resource Centre (DBRC) conducted qualitative interviews with key informants purposively selected by gender (n = 2, one man and one woman) and waste pickers (n=7, four women and three men). (16)

* Dhaka (Bangladesh): Experienced qualitative researchers from the James P. Grant School of Public Health (JPGSPH) conducted longitudinal case study interviews with young adults and adolescents (n= 12, six female and six male). Respondents came from the Moddho Badda low-income housing area in Ghudaragat; Korail Basti, one of the largest slums in Dhaka; and the low-income housing in Moghbazar, an area near a railway crossing. Two of the respondents in Dhaka have since relocated and now reside in a village.

All interview data were analyzed using a thematic analysis approach. Data were repeatedly read and codes assigned, allowing for the development of common themes across the study sites. (17) This approach also helped in identifying rich individual stories that illustrated one or many of the identified themes. All names included in the case studies are pseudonyms.

The Mumbai case study focuses on issues faced by people living in slum relocation colonies during the pandemic, and it highlights a few small yet impactful actions taken by the residents themselves. The Dhaka case study focuses on the loss of livelihoods due to lockdowns among those who were already living on the margins before COVID-19. Finally, the experience of waste pickers in Guntur and Vijayawada point to the specific precarity of...