Community, voice and participation

Voice, participation and community engagement are essential to ensuring delivery of appropriate and effective health services for women and girls in low-income urban settlements. There are numerous examples from the case studies where participatory engagement has been integral to improving health services and delivery. The Philani Mentor Mothers Programme – a maternal mental health intervention in low-income urban settlements in Cape Town, South Africa – recruited mentor mothers, acknowledging that resident women with thriving children are best placed to be trained to deliver services to other women in their community. Similarly, in the intervention to address NCDs in Khayelitsha, the community were involved from conception through to delivery. CHWs and the wider community requested the intervention, informed it (through a community mapping exercise) and participated in activities (fun walks, health club, etc.). As part of the Community Led Total Sanitation (CLTS) initiative in Kalyani, India, women living in low-income urban settlements played a lead role in making Kalyani open defecation-free (ODF). This was the first time they were included in decision-making processes both at home and in the community, and they felt that they had finally found their voice. 

Before CLTS was implemented in Kalyani, the municipality played a limited role in the welfare of low-income urban settlements and provided no institutional commitment or resources. However, the municipality chairperson played a key role in driving the process and supporting the community to successfully make their town ODF. As a result of the community’s success in improving their sanitation status, the municipality received national recognition and now pays more attention to the needs of those living in the low-income urban settlements. Engagement with and buy-in of local community leaders was an important element that strengthened the impact of the Philani, NCD and CLTS interventions. 

Local women were active agents of change in these community interventions. But more often, voices of women living in low-income urban settlements are silenced and there exist many barriers to their participation in high level health-decision-making. Despite inheritance and marital homestead being determined by the maternal line in Khasi society in Meghalaya, India, women are excluded from political participation in many ways. There are limited, if any, procedural mechanisms for community participation in policy development and the prioritisation of health needs. This, coupled with the culture of silence around SRHR in Kahasi society, makes it challenging for women to discuss or inform decision-making on SRH. 

Where official channels for political engagement do exist and where governments recognise the importance of public participation in informing policy, this does not always translate to women being able to engage in decision-making around issues that affect their health. In Kenya, the new constitution encourages and emphasises public participation, and devolution (introduced in 2013) should support this, with appropriate civic education programmes for citizens. However, so far there has been low public engagement in decision-making and governance, and, as one health-care professional stated, ‘here in Kenya, policies are made by leaders, and not beneficiaries. Leaders make policies that favour them.’ Women and girls living in low-income urban settlements face both internal and external barriers to political participation through not knowing how the political systems works, a lack of confidence and knowledge about how to engage policymakers, a lack of time and income, and other competing priorities. 

Policy recommendations

The active involvement of communities, the buy-in of local leaders and the genuine ability of women to engage and participate in decision-making processes are essential to ensuring women’s and girls’ access to appropriate and effective health services in low-income urban settlements. 

Policymakers, governments and others involved in the implementation of interventions should:

  • Focus on community involvement in interventions, including engaging men, and should see the urban poor as change agents and not just passive recipients of interventions and policy pronouncements.
  • Learn from and build on the many successful community-based approaches that exist. Care should be taken to ensure genuine gender inclusivity and to avoid tokenistic references to women’s participation within government and state policy processes.