Improving the Health and Lives of People Living in Slums

Authors


Address for correspondence: Shaaban A. Sheuya, Ardhi University (formerly the University College of Lands and Architectural Studies), Dar es Salaam, Tanzania. Address: P.O. Box 35176, Dar es Salaam, Tanzania. Fax: 255-022-2775391.
 sheuya@yahoo.com

Abstract

Urban poverty, ill health, and living in slums are intrinsically interwoven. Poverty is multidimensional and there is no agreement on a universal definition. UN-HABITAT has introduced an operational definition of slums that is restricted to legal aspects and excludes the more difficult social dimensions. The World Health Organization definition is more comprehensive and uses a health and social determinants approach that is strongly based on the social conditions in which people live and work. Health and improving the lives of people living in slums is at the top of international development agenda. Proactive strategies to contain new urban populations and slum upgrading are the two key approaches. Regarding the latter, participatory upgrading that most often involves the provision of basic infrastructure is currently the most acceptable intervention in developing countries. In urbanization of poverty, participatory slum upgrading is a necessary but not sufficient condition to reduce poverty and improve the lives of slum dwellers. Empowering interventions that target capacity development and skill transfer of both individuals and community groups—as well as meaningful negotiations with institutions, such as municipal governments, which can affect slum dwellers' lives—appear to be the most promising strategies to improve the slum dwellers' asset bases and health. Non-governmental organizations, training institutions, and international development partners are best placed to facilitate horizontal relationships between individuals, community groups, and vertical relationships with more powerful institutions that affect the slum dwellers' lives. The main challenge appears to be lack of commitment from the key stakeholders to upgrade interventions citywide.

Introduction

In 2005, the world population was 6.45 billion, of which 3.17 billion (49.15%) were living in urban areas.1 It is estimated that by 2008, and for the first time in human history, 3.3 billion people, half of the world population, will be urbanites.2 The number of urban dwellers will continue increasing, and projections show that by 2030, 5 billion people will live in urban areas. Of these, 4 billion (80%) will be living in the developing countries of Asia and Africa.

Urbanization, the increase in the urban share of total population, is not a new phenomenon. It started in the developed world more than 200 years ago. In these countries, industrialization triggered urbanization, which has since then continued to be associated with high economic growth rates. In the developing countries, however, urbanization has not been associated with industrialization. It is characterized by, among other things, low to medium economic growth rates, urban poverty, and the mushrooming of slums.

Poverty is a multidimensional concept. However, considering poverty just as defined by income, half of the world's population lives on less than US$1 a day.3

In the cities of the developing world, urbanization has become virtually synonymous with slum formation.1 In 2005, about 1 billion people—a third of the world urban population—lived in slums: Asia was leading with 518 million people, followed by sub-Saharan Africa with 199 million, and Latin America and the Caribbean with 134 million. If the current trend continues, 1.4 billion people will live in slums by 2020.

Living in slums and under conditions of urban poverty is a major cause of ill health. As defined by the 1946 World Health Organization (WHO) constitution, health is a “state of complete physical, mental and social well being”4 (emphasis added). On the basis of this definition, the Ottawa Charter for Health Promotion, in 1986, declared that health is “created and lived by people within the settings of their everyday life; where they learn, work, play, and love.”5 The approach to health through the conditions in which people live and work is popularly known as social determinants of health (SDH). WHO has classified the SDH into two major blocks: structural and intermediate. The structural factors comprise poverty, gender, ethnicity, education, and health, whereas the intermediate factors include living and working conditions, social and political exclusion, social capital, access to quality health care, violence and crime, transportation, and the physical environment.6

Today, health and improving the lives of people living in slums are priority goals for international development. Three of the Millennium Development Goals (MDGs) directly focus on health: goal 4 (reduce mortality of children younger than 5 years), goal 5 (improve maternal health), and goal 6 (combat diseases, including HIV/AIDS, malaria, and other diseases). Goal 7 focuses on ensuring environmental sustainability. Targets 10 and 11 of the goal focus on halving the proportion of people without sustainable access to safe drinking water and sanitation and improving the lives of people living in slums, respectively. Goal 1 (eradicate extreme poverty) is cross-cutting: It determines and is at the same time determined by the success of the other goals, including goal 2 (achieve universal primary education) and goal 3 (promote gender equality and empower women).

Progress at the MDG midpoint suggests that some progress is being made: The proportion of people living in extreme poverty has decreased; the number of extremely poor people in sub-Saharan Africa has leveled off; more children in the developing world are now going to school; women's political participation has been growing; globally, child mortality has declined; key interventions to control malaria have been expanded; and the tuberculosis epidemic seems to be declining.7

With specific reference to goal 7, target 11, of the MDGs, the UN report notes, “… the rapid expansion of cities is making slum improvement even more daunting” (emphasis added). The report further notes that to meet goal 7, target 10 (on sanitation), an estimated 1.6 million people will need access to improved sanitation in 2005–2015. To this end, the report cautions, “… if trends since 1990 continue, the world is likely to miss the target by almost 600 billion people.”

Current discussions on improving the lives of people living in slums focus on a two-pronged approach: forward-looking proactive strategies to contain new urban populations and slum upgrading to address the needs of the people currently living in slums. With specific reference to health, WHO adds three other strategies: improving access to quality health care; targeted health promotion; and integration of health, welfare, and education services.6

On the basis of the above criteria, this article focuses on slum upgrading. Previous work has argued that participatory slum upgrading that is holistic and takes into account health, education, housing, livelihood, and gender is currently the accepted best practice intervention for developing countries.3 And most often, the holistic approaches involve the provision of basic infrastructure and community facilities. Although participation in slum upgrading is crucial, participation alone is a necessary but not sufficient condition to reduce poverty and improve health in slums. Whereas the provision of safe water, solid-waste management, and sanitation in Europe some 200 years ago paved the way for the dramatic reductions in mortality arising from infectious diseases, the same interventions are unlikely to be effective under the prevailing conditions of urban poverty in most of the developing countries.

Some argue that under these conditions the issue is not to provide basic infrastructure alone (the hardware) but rather to use empowerment strategies in the provision of infrastructure (the software). Empowerment is born of participatory processes. However, the processes alone do not necessarily (1) facilitate capacity development and asset building of the individuals and communities and (2) aim at influencing the efficiency of institutions that, in many ways, govern the growth and development of individual and community assets.

Empowerment is also context specific. To obtain an insight of the potentials of empowerment in poverty reduction and improving health of people living in slums, I first clarify the concepts of urban poverty and slums. Thereafter, I document the most important evidence and causal factors that exist between living conditions in slums and health. Then I define empowerment. I use a project carried out in Dar es Salaam, Tanzania, in the mid-1990s to illustrate how one can put in place empowerment.

Poverty: More than Lack of Money

Households whose incomes or consumption level are less than that required to meet certain defined physical needs, such as adequate diet, quality housing (with basic services), health care, and education, are considered poor.8 According to the World Bank, people whose per capita income is below US$370 per year (in 1985 dollars) are deemed poor, whereas those with less than US$275 per year are extremely poor.9 Chambers uses the term “income-poverty” to describe poverty defined through the use of income or consumption.10

However, there has been increasing criticism on poverty defined in terms of income only from many angles because it fails to

  • • consider the role of assets;
  • • take into account intrahousehold differences;
  • • distinguish between different-sized households;
  • • account for nonmonetary income sources; and
  • • allow for the large variations in living costs within and between nations.11

Also, such a definition fails to consider the differences in expenditures between rural and urban areas. Many empirical studies have shown that, unlike their rural counterparts, urban households spend much of their incomes on urban transport, housing, access to water for hygiene, health care, energy, and child care.12

Therefore, and to overcome the deficiencies outlined by many people, Satterthwaite12 developed a comprehensive list that shows the various dimensions of urban poverty:

  • 1Poor quality and often insecure, hazardous and overcrowded housing
  • 2Inadequate provision for infrastructure and services
  • 3Inadequate protection or poorer groups' rights through the operation of the law
  • 4Poor groups' voicelessness and powerlessness
  • 5Inadequate income
  • 6Inadequate, unstable, or risky asset base
  • 7Limited or no safety net

In spatial terms, the first two dimensions of urban poverty are the major defining characteristics of housing poverty; that is, “the individuals and households who lack safe, secure and healthy shelter with basic infrastructure such as piped water and adequate provision for sanitation, drainage and the removal of household wastes.”11

This richer understanding of poverty highlights the importance of considering poverty reduction strategies other than income. It provides more entry points and multiple strategies to effectively address urban poverty. In this article the multiple strategies focus on slum upgrading (points 1 and 2) through empowerment (points 3 and 4) to improve the asset base of individuals as well as community groups (points 5, 6, and 7). Also, the richer definition of poverty comprises some social aspects of poverty that are not easily measurable.

Defining Slums

Slums are multidimensional. Comprehensively, they are characterized by the following3:

  • • A lack of basic services
  • • Substandard housing or illegal and inadequate building structures
  • • Overcrowding and high density
  • • Unhealthful living conditions and hazardous locations
  • • Insecure tenure
  • • Irregular or informal settlements
  • • Poverty and social exclusion
  • • Minimum settlement size

Some of these characteristics can be clearly defined, whereas others cannot. Owing to their diversity and the need to have a quantitative and objective definition that can be used to measure slums globally, a 2002 United Nations Expert Group Meeting came up with an operational definition that “combines, to various extents, the following characteristics (restricted to the physical and legal characteristics of the settlement, and excluding the more difficult social dimensions[emphasis added]):

  • • Inadequate access to safe water
  • • Inadequate access to sanitation and other infrastructure
  • • Poor structural quality of housing
  • • Overcrowding
  • • Insecure residential status.”

The State of the World's Cities Report 2006/2007 slightly modifies the wording of these deficiencies to sharpen their meanings. According to the report, “a slum household is a group of individuals living under the same roof in an urban area who lack one or more of the following five conditions: access to improved water, access to sanitation, durable housing, sufficient living area, and secure tenure”1 (original emphasis).

To better understand the problems facing the more than 1 billion people living in slums today in terms of health, I highlight the extent of each defining characteristic, followed by the evidence showing its association with ill health.

Extent of Deprivation and Associations Between Slum Conditions and Health

Improved Water

The delivery of clean water, removal of wastewater, and improving sanitation are three of the most basic foundations for human development.13 Accordingly, when people are denied access to clean water for domestic hygiene and productive purposes, their choices and freedoms are constrained by ill health, poverty, and vulnerability. Although this is the case, some 1.1 billion people in the developing countries do not have access to clean water. They use about 5 L a day against the minimum average of 20 L. In Europe and the United States, the average daily consumption per capita is 200 L and 400 L, respectively.

Lack or inadequate supply of clean water for domestic hygiene is associated with such diseases as dysentery, cholera, eye infections including trachoma, worm infections, and diarrhea. Studies have shown that diarrhea and pneumonia are prevalent among children living in slums and are known to kill 2 million children in the developing world each year.1

Access to Sanitation

Sanitation is a broad concept that encompasses the safe removal, disposal, and management of, for example, household solid waste, wastewater, and industrial waste. Access to improved sanitation in urban areas, on the other hand, is defined as the direct connection to a public piped sewer, direct connection to a septic system, or access to pour-flush or ventilated improved pit latrines. Today, an estimated 2.6 billion people lack improved sanitation.

People without access to improved sanitation are 1.6 times more likely to experience diarrhea, as well as higher rates of morbidity and mortality.1 Lack of improved sanitation is also associated with intestinal worms, such as hookworms, roundworms, and tapeworms. Open defecation, poor hygiene, and lack of safe drinking water together contribute to about 88% (1.5 billion) of deaths due to diarrheal diseases in children younger than 5 years.7 Intestinal worms can also lead to anemia, which for girls increases the risks later of complications in childbirth. The inability to remove storm water from the slums creates pools of contaminated standing water, which in turn provide breeding grounds for mosquitoes that spread malaria.

Put together, poor sanitation and lack of clean water are the world's second biggest killer of children.13 Also, at any given time, nearly half of the people living in developing countries are suffering from diseases caused by lack of water and/or sanitation. Thus, providing adequate clean water with sanitation is one of the most important instruments to improve health in slums.

Durable Housing

For a house to be durable, it must be built on a nonhazardous site and must be made of a permanent structure that can protect its inhabitants from such elements as rain, heat, cold, noise pollution, dampness, and mold. The nondurability of housing affects an estimated 117 million people living in the cities of the developing world, more than half of whom live in Asia.7

Low and high indoor temperatures have been associated with cardiovascular and respiratory conditions in old and young people.14 Noise pollution, access to little daylight, and the absence of views out of windows in the European cities have been linked to depression. Dampness is linked with respiratory infections, including coughs and asthma symptoms. And poorly maintained houses provide breeding grounds for such pests as rats, mice, flies, and cockroaches, which spread infectious diseases and cause allergens.14

As far as site location of slums, it is estimated that between three and four in every 10 nonpermanent houses in the developing world are located in dangerous sites that are prone to floods, landslides, and other natural disasters.1 Hazardous waste landfill sites in developing countries are located near slums. The landfills may be associated with risks of low birth weight, birth defects, infectious diseases, and cancers.15

Sufficient Living Area

For a house to have sufficient living area for household members, not more than three people should share the same room.1 On the basis of this definition, about 20% of the world's 2003 urban population was residing in inadequate dwellings. Two-thirds were found in Asia. Africa ranked second with 75 million people and Latin America and the Caribbean ranked third with 49 million people.1

Living in a house with insufficient living area is associated with respiratory infectious due to lack of ventilation, lack of hygiene, and exposure to environmental contaminants. Diseases, such as pneumonia, account for 18% of deaths among children younger than 5 years. Lack of ventilation and exposure to high levels of indoor air pollution caused by incomplete combustion of biomass fuel for cooking, boiling water, and heating is also a major cause of deaths in developing countries: An estimated 1.6 million people die from exposure to indoor air pollution, of whom 1 million are children. Indoor smoke can also increase chronic obstructive pulmonary diseases in women and double the risk of lung cancer if the smoke comes from the use of coal fuel for cooking.16 A study conducted in São Paulo, Brazil, has demonstrated strong relationships between tuberculosis and household overcrowding, particularly in smaller housing units.1

Overcrowding in inadequate dwellings has also been linked to increases related to negative social behaviors such as domestic violence and child abuse. Lack of space for doing homework may also directly affect children's education.

The dwelling in a slum is not used for living purposes only. As observed by Laquian (cited in United Nations Centre for Human Settlements 1989):

If there is one lesson for planners in the massive literature on slums and squatter community life, it is the finding that housing in these areas is not for home life alone. A house is a production place, market place, entertainment centre, financial institution and also a retreat.17

Informal sector activities occupy important spaces in and around houses. Kellett and Tipple argue that the enterprises appear to have a symbiotic relationship with the housing in which they take place. They argue that “many households would not have a dwelling without their home-based enterprises and many enterprises would not exist without the use of a dwelling.”18

In a study on urban livelihoods in two informal settlements in Dar es Salaam, Tanzania, several households were engaged in such activities as charcoal selling, carpentry workshops, preparation of food for sale, metal welding, and maize milling, without using protective gear.19 Most of these activities are likely to cause occupational health hazards, such as dust, high temperatures, impairment of vision, and impairment of hearing.

The use of lead in paint on houses or in contaminated water is associated with lead poisoning. Ingesting lead can irreversibly damage intellectual growth and cause increased behavior problems.14 Asbestos and radon are also associated with various kinds of cancer.

Secure Tenure

Unlike the first four defining characteristics of slums, which are quantitative, secure tenure does not render itself easily to measurements. In view of this, UN-HABITAT defines secure tenure as the right of all individuals and groups to effective protection from the state against forced eviction.1 To measure secure tenure, two indicators are proposed: proof of documentation (e.g., utility bills, voter registration forms, municipal tax receipts) and perceived security. In 2003, the World Bank estimated that between 30% and 50% of urban residents in the developing world had no legal documentation to show that they have tenure security.1

People who own houses enjoy better health than people who rent.14 Insecurity of tenure, on the other hand, is associated with injuries, respiratory problems, infectious diseases, and mental health problems.15

Empowerment: A Promising Strategy to Improve Health in Slums

Defining and Contextualizing Empowerment

Empowerment is a widely debated concept. Over time it has acquired a variety of meanings and definitions depending on different socioeconomic contexts. In the context of this article, Narayan and the World Bank provide two related but important definitions. According to Narayan, empowerment is the “expansion of assets and capabilities of poor people to participate in, negotiate with, influence, control, and hold accountable institutions that affect their lives.”20 The World Bank defines empowerment as “the process of increasing capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes” to build “individual and collective assets, and to improve the efficiency and fairness of the organizational and institutional context which govern the use of these assets.”21

Three cross-cutting issues emerge from the two definitions of empowerment. First, the unit of analysis for empowerment is at multiple levels—that is, individual (including household), group, and community and, by implication, neighborhood. And beyond the neighborhood level we have the municipal and city level. Most of the institutions that affect people's lives are found at these levels, particularly for slums, local authorities are closest to people.

Operating at different levels, empowering strategies provide room to formulate interventions to improve health that strengthen individual and/or community capacities. Strengthening individuals and communities are two (of the four) actions that are considered important to tackle social inequalities in health.22 The remaining two are promoting healthful macropolicies and improving living and working conditions.

The interventions at the individual level are aimed at strengthening individual abilities by using person-based strategies. Such interventions address a perceived personal deficit in an individual's knowledge, beliefs, self-esteem, practical competence in life skills, or powerlessness.22 The solution in these kinds of situations is personal education and skills to make up for the deficiencies.

Interventions to strengthen communities aim at building social cohesion and mutual support. The problems being addressed at the community level stem from social exclusion and powerlessness in disadvantaged groups. According to Whitehead,22 the interventions at this level fall in two groups: horizontal and vertical. The former aims to foster horizontal social interactions between members of the same community. The latter focuses on creating vertical bonds between different groups from the top, as well as the bottom, of the social scale and institutions.

Fostering horizontal and vertical solidarity aims to produce a less divided society, which can eventually enable groups to bargain as a unit to access resources, such as those related to health. Although education and skill transfer are equally important at the community level, the art of community organizing works best at this level.

So far, there is no single recipe for empowering interventions. However, most successful interventions are based on group dialogue, collective action, advocacy and leadership training, organizational development, and transfer of power to participants.21 In slums, locally recruited and trained community animators using the Chinese famous model of “barefoot doctors” could carry out awareness creation and training activities. Community animators are usually local and dynamic volunteers who are specifically trained to become change agents in their settlements. National and international non-governmental organizations (NGOs) are best placed to equip the community animators with the necessary skills.

Second, the purpose of empowerment is to increase the capacities of individuals and communities in decision making and advocacy to expand their assets. Expanding individual and community assets is an equally important attribute of empowerment because the individuals and community groups have for a long time and under difficult conditions managed to mobilize their assets to provide, among other things, the housing in which they live. Besides housing as a physical asset, other assets that individuals and communities normally command are human, financial, natural, and social capital23 (Table 1). Interventions that promote or augment any of these assets are likely to improve the health and living conditions of slum dwellers.

Table 1.  Households' major capital assets
Type of capitalExplanation
  1. Source: Own construct based on Rakodi and Lloyd- Jones, 2002.23

HumanIdentified as the most important asset of poor people. It depends on the number of people available to work, their health status, and skills and education they possess.
PhysicalIncludes housing, water, energy, and transport. For poor urban households, housing is often the most important. Physical capital also includes production equipment that enables people to pursue their livelihoods.
FinancialIncludes savings, remittances, access to credit, and pension.
NaturalIncludes land, water, and other common pool environmental resources. Natural capital is said to be less significant in urban areas except where urban agriculture is practiced.
SocialReciprocity within communities and between households on the basis of trusts deriving from social ties.

Third, one of the definitions of poverty described earlier is voicelessness and powerlessness. Providing space where institutions and organizations participate and negotiate with individuals and communities on matters that affect the latter's lives not only increases their ability to reduce poverty but also removes formal or informal barriers among them and provides room for each to exercise power. The World Development Report of 2000/2001 captures this aspect of empowerment, defining it as the process of “enhancing the capacity of poor people to influence the state institutions that affect their lives, by strengthening their participation in political processes and local decision making. And it also means removing the political, legal, and social barriers that work against particular groups and building the assets of poor people to enable them to engage effectively in markets.”9

Thus, facilitating integrated and collaborative partnerships horizontally among individuals and community members and vertically with local government institutions and national governments is likely to give voice to the people and therefore reduce powerlessness. Also, through their diversity and exposure to different contexts worldwide and commitment to the MDGs, international development partners—including the UN agencies, multilateral funding agencies, and bilateral donors—have a key role to play in facilitating horizontal as well as vertical collaborative partnerships.

It is important at this juncture to make a clear distinction between participation and empowerment. Whereas participation can be passive or, indeed, manipulative, empowerment is an active process that is characterized by the presence of four key elements: access to information, inclusion and participation, accountability, and local organizational capacity.21 Thus, although participation forms the basis for empowerment, it is only part of the overall concept of empowerment.

Drawing on a wide range of literature, Wallerstein has documented the outcomes of empowerment. These include social capital, neighborhood cohesion, neighborhood influence, sense of community, and community capacities or assets.21 Furthermore, Wallerstein has documented evidence to show that empowerment improves health:

  • • Increased community participation in water supply projects is correlated with improved child health strategies.
  • • Organized youth-to-youth activities and linking them to institutions improves, among other things, mental health and academic performance.
  • • Empowering HIV/AIDS strategies that are targeted at gender inequities increase condom use and hence reduce HIV infection.
  • • Improved education for women and empowerment has been associated with improved child health.

Empowerment is context specific. In view of this, Wallerstein cautions that successful empowerment interventions cannot be easily transferred across multiple populations. This limitation makes standardizing empowerment interventions on a global scale difficult.

Empowerment in the Hanna Nassif Community Managed Settlement Upgrading Project, Dar es Salaam, Tanzania

Hanna Nassif is one of the 54 major informal settlements in the city of Dar es Salaam, Tanzania. It is located about 4 km from the city center and covers an area of 50 ha. In 1998, the settlement had an estimated population of 20,000.14

Prioritizing Environmental Issues

Through structured interviews and focus group discussions, the residents prioritized three key environmental problems in the settlement: lack of storm water drainage channels, which made much of the settlement water logged for a longer period during the rainy season; lack of safe drinking water; and impassable access roads. Other problems, which were not mentioned as priorities but existed in the settlement, included uncollected solid wastes and insecure tenure due to lack of legal documents.

Community Organizing

Faced with these problems, local leaders from the settlement approached municipal authorities to find out the best solutions. The municipal authorities in turn linked the community leaders with UN agencies and different donors. Key participants in the project formulation were community leaders, municipal authorities, a local university (University College of Lands and Architectural Studies), UN agencies (ILO, UNCHS, and UN Volunteers), and international donors (UNDP and the Ford Foundation). Participants then drafted a joint project proposal to upgrade the settlement. One of the project objectives was to build and expand the capacities of the community and the municipal council to respond effectively to community-based upgrading proposals. Awareness creation and community mobilization started in mid-1993, and the project officially came to an end in 2000.

Community animators raised awareness in the settlement. Through, for example, individual, group, and community meetings, discussions, and workshops, community members formed and legally registered a gender-balanced and democratically elected community development association (CDA). After registration, the CDA became the official body representing the Hanna Nassif community in all discussions concerned with the community upgrading project.

Project Design and Implementation

During the project design, the project team consisting of planners, architects, engineers, and community animators worked together with CDA leaders to decide on the best approaches to address the environmental problems facing the community members. Meeting participants agreed that labor-based technology and community contracting contracts should be used as the main vehicles through which storm water drainage channels, water supply, and access roads were provided.

Project Implementation and Skill Transfer

During the project execution, the joint project team provided on-the-job training for individuals and group members from the settlement. This training included the different technical and nontechnical skills needed to implement the project. At the end of the project in 2000, people who 7 years ago were unskilled laborers had become semiskilled or skilled laborers; construction activities generated 30,500 worker days of employment, and the microcredit facility scheme generated another 262,700 worker days.24

Water supply. The provision of water supply in the settlement was accompanied by the installation of water vending kiosks, jointly owned between individual plot holders and the CDA. The individuals provided the land on which the kiosks were built, and the CDA built the physical structures, including the water reserve tanks. Even today, individual plot holder and the CDA equally share profit made from the sale of water. The former use it as a livelihood strategy and the latter for maintenance of the water reticulation network, access roads, and storm water drainage channels.

Sanitation (solid-waste management). Through community organizing, different members have formed solid-waste management teams with which the municipal council has contracted to manage solid waste in the settlement. Besides earning income from managing solid waste, the groups also help to keep the settlement clean.

Microcredit facility. With financial support from the Ford Foundation in 1996 and technical assistance from the Presidential Trust Fund, a local NGO, the community established a microcredit facility. The facility issued loans to local entrepreneurs whose collateral was group solidarity involving five members. At the peak of its activities in 2002 (2 years after the project had officially ended), 469 (84%) women and 87 (16%) men had accessed the facility. The facility is now closed because of low repayment rates. It is most likely that the NGO that facilitated the establishment of the facility has not set aside a budget line for backstopping the credit scheme. To this end, there is a need to carry out an in-depth study of the microcredit facility to critically analyze why it closed and propose the best ways to revive it.

Tenure security. Another local NGO, the Human Settlements Trust, formerly the Women Advancement Trust, is currently assisting individual members in whole settlements to carry out cadastral surveys of plots to acquire land titles. Individual members should soon be able to access bank loans for housing improvement or incremental house construction.

Other potentials. Judging from the strong base of community organization in Hanna Nassif, one is tempted to think that, with some additional technical assistance, the community can access quality health services. One way might be through social health insurance schemes such as the Community Health Fund, which is currently being introduced in all urban and rural areas in Tanzania. One can also speculate that if the community wishes to further improve sanitation in the settlement, it can learn from the experience of their colleagues in India who designed, built, and managed toilet blocks.25

The Final Project Report24 of Hanna Nassif highlights some of the project achievements:

  • • Increased vehicular accessibility
  • • Controlled flooding in the entire area
  • • Decline of waterborne disease cases from 4,137 in 1994 to 2,520 in 1998
  • • More registered microenterprises from 296 in 1994 to 340 in 1998
  • • Improved property values, associated with increased property tax collection
  • • Enhanced civil society participation, as shown by an increase in the number of Community-Based Organizations in the settlement

Discussion

Urban poverty and living conditions in slums are intrinsically interwoven. In view of this, my report has provided a richer understanding of poverty than of the recently introduced operational definition of slums. This article does not attempt to resolve definitional limitations and contradictions, which do need to be resolved, but has used the SDH approach, which is strongly based on the social conditions in which people live and work.

After clarifying the two concepts of poverty and slums, I have documented the causal relations between health and living in slums and discussed the need to adopt the concept of empowerment to reduce poverty while improving the health and lives of people living in slums. Here, another problem was encountered. Experience has shown that successful empowering interventions cannot be fully standardized across multiple populations. But the search for the operational definition of slums was made precisely because, among other things, “it would be better for a number of purposes to have a more universal and objective definition—particularly when global measurement and MDG targets are involved”3 (emphasis added).

The above finding appears to suggest that the operational definition of slums is not entirely watertight. Alternatively, empowerment is not a promising strategy to reduce poverty and improve health in slums. I am convinced that the operational definition of slums needs further refinement.

I used the Community Managed Settlement Upgrading project in Hanna Nassif to illustrate how the concept of empowerment was operationalized to reduce poverty and improve health. The community achieved empowerment in the project through making decisions, which led to identifying the priority environmental problems, and by fully participating in the project execution. In so doing, individuals and the community as a whole have gained different technical and nontechnical skills and education (human capital), gained income from water vending and solid-waste management (financial capital), accessed microcredit loans through group solidarity (social capital), and will soon be able to access loans for house improvement.

Besides these achievements at the individual and community levels, the municipal authority and the university as local institutions, as well as the UN agencies and donors, have contributed to the success of the project by providing expertise in their respective areas of competence.

Conclusion

As demonstrated by the Hanna Nassif Community Managed Settlement Upgrading pilot project, empowerment interventions appear to provide more opportunities to reduce urban poverty and improve the lives of people living in slums. The main challenge appears to be lack of commitment from all the key stakeholders—individual households living in the slums, their community associations, local and central government institutions, training institutions, NGOs, and national and international development partners—to scale interventions up to citywide levels.1

Acknowledgment

I thank Professor Philippa Howden-Chapman for her constructive comments.

Ancillary