{"id":2043,"date":"2020-05-05T11:04:00","date_gmt":"2020-05-05T11:04:00","guid":{"rendered":"https:\/\/urbanbetter.science\/?p=2043"},"modified":"2022-12-20T15:53:33","modified_gmt":"2022-12-20T15:53:33","slug":"a-participatory-approach-to-building-a-coalition-of-health-and-planning-sector-urban-actors-in-africa-a-douala-case-study","status":"publish","type":"post","link":"https:\/\/urbanbetter.science\/archive\/a-participatory-approach-to-building-a-coalition-of-health-and-planning-sector-urban-actors-in-africa-a-douala-case-study\/","title":{"rendered":"A participatory approach to building a coalition of health and planning sector urban actors in Africa-a Douala case-study"},"content":{"rendered":"\n

Abstract<\/h3>\n\n\n\n
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Africa is undergoing rapid urbanisation with migration into informal settlements. Exposure to these environments is associated with a rise in infectious and non-communicable diseases. Addressing these urban health challenges will require collaboration across sectors that influence health. However, the siloed nature of policymaking means that little is known about the barriers and facilitators of integrated intersectoral policy approaches for improving health through urban planning and development. Furthermore, the transdisciplinary research methodological approaches to establishing intersectoral collaboration are not well documented in Africa. We utilised participatory methods to engage a variety of stakeholders in the co-design and conduct of a transdisciplinary workshop. Through co-development processes, this workshop was designed to explore stakeholder perspectives on urban health priorities in Douala municipalities and experiences of intersectoral collaboration. We describe the process and experience of co-creation of the workshop agenda between academic, policy, private and civil society partners. We further present stakeholder experiences of intersectoral collaboration prior to the workshop, convey their understanding of the urban drivers of ill health, and discuss perspectives on strategies to mitigate these health risks through human settlement intervention. This study documents the development of a participatory transdisciplinary approach to urban health in rapidly urbanising Africa.<\/p>\n\n\n\n

KEYWORDS: Africa<\/a>, transdisciplinary<\/a>, urban<\/a>, health<\/a>, planning<\/a><\/p>\n\n\n\n

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Introduction<\/h3>\n\n\n\n
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Africa\u2019s rapid urbanisation is contributing to the growth in informality, as many people migrate into urban slums and informal settlements (UN-Habitat 2015<\/a>). This includes both sub-Saharan as well as some North African countries such as Algeria (from 59.9% to 72.6%; 2000\u20132018) and Morocco (53.3% to 62.4%; 2000\u20132018) experiencing rapid urbanisation, largely due to rural-urban migration (TheWorld Bank 2019<\/a>). Informal settlements, evident across all regions of Africa (UN-Habitat 2018<\/a>) are characterised by high poverty rates, overcrowding, and poor housing conditions, including poor waste removal, sanitation and ventilation (United Nations Human Settlements Programme 2013<\/a>). These conditions have been linked to the persisting presence of infectious diseases, and increasing burden of chronic illnesses, injuries, mental disorders and poor nutrition (World Health Organization\/UN-Habitat 2010<\/a>). Despite the importance of health and wellbeing in sustainable urban development strategies, health is largely not considered within the housing policy agenda. This is partly due to the siloed vertical nature of policy making, which results in a lack of policy coherence between the housing and health sectors (Leppo et al<\/em>. 2013<\/a>, Rudolph et al<\/em>. 2013<\/a>). Addressing the current high burden of infectious diseases in Africa and the growing prevalence of chronic multimorbidities urgently requires new thinking around housing and human settlement strategies.<\/p>\n\n\n\n

If Africa\u2019s rapidly growing urban population is to enjoy living in safe and sustainable cities by 2030, policy strategies need to measurably improve living conditions and, subsequently, the health of the population, particularly the urban poor. The opportunities for intersectoral approaches through the coordination of health-enhancing housing, urban planning and environmental health regulation in African cities, are particularly important for contributing towards efforts to meet Sustainable Development Goal (SDG) 11, which seeks to \u2018make cities and human settlements inclusive, safe, resilient and sustainable\u2019<\/em> (United Nations 2017<\/a>). Urban planning \u2013 as an inclusive, integrated decision-making process \u2013 can give a voice to those who often do not participate in urban and territorial decision-making and respond to the needs and vulnerabilities of different population groups (particularly the urban poor, women, children, older adults, informal sector workers and migrants). Thus, applying a health \u2018lens\u2019 in urban and territorial planning (UN-Habitat 2017<\/a>) can reveal synergies to achieve environmental, economic, health and social targets, to ensure that the New Urban Agenda (NUA) \u2013 a global agenda for sustainable urban development and management that compliments the implementation of the SDGs (UN-Habitat 2016<\/a>) \u2013 delivers healthy, safe, inclusive, and equitable cities. Cities can play vital roles in addressing health and social inequity; and greater policy coordination on housing and urban planning could contribute to improving health outcomes, as well as reducing neighbourhood crime and increasing economic development (Rudolph et al<\/em>. 2013<\/a>).<\/p>\n\n\n\n

The population of Douala, the economic capital of Cameroon, is projected to triple by 2035 with an average annual rate of population growth estimated at 5% over the past 30 years, well above the national rate of 2.8% (Priso 2017<\/a>). This population increase has not been matched by increased availability of affordable housing. Currently, over 70% of the population live in informal settlements (Mbaha et al<\/em>. 2013<\/a>), with both urban poor and middle-class residents living under conditions of informality due to poor housing and tenure policies. Douala metropolis is made up of six municipalities, with each headed by a Mayor duly elected by the municipal councillors. Municipalities\u2019 responsibilities are to improve the living conditions of their citizens by making sure they have access to basic socio-urban infrastructures (Presidency of the Republlic of Cameroon 2009<\/a>). However, these municipalities are under the authority of a Government Delegate appointed by the President of the Republic. It is this Government Delegate who administers the city. The local Agenda 21 for Douala, developed in 2010 by the Douala City Council (DCC), identifies development of urban planning and sustainable housing as a priority. However, the agenda has a poor focus on health outcomes and the health impact assessment of human settlement policies. Given the unhealthy and unsafe environment of informal settlements, inhabitants are exposed to a range of risk exposures which contribute to a growing burden of infectious and non-communicable diseases (Sanou et al<\/em>. 2015<\/a>). The DCC have expressed the need to address urban challenges related to informal settlements in Douala. In addition, the paucity of data on the health of Douala informal settlement residents, and the weak collaboration between health and housing sectors in the urban planning represent a knowledge gap and opportunities for the development of innovative integrated approaches to address health and human settlement challenges.<\/p>\n\n\n\n

A transdisciplinary research approach, which seeks to link scientific inquiry with context-specific societal challenges identified by non-academic stakeholders, can assist in guiding the co-production of new useable knowledge for addressing complex urban health challenges in cities (Pohl et al<\/em>. 2017<\/a>). The co-production of knowledge process should not be driven by academic agendas, but should give particular attention to the needs of non-academic stakeholders who will need to act on the new knowledge, for example, through urban planning interventions (Clark et al<\/em>. 2016<\/a>). The process provides important opportunities for mutual-learning around key societal and urban problems identified (Cornell et al<\/em>. 2013<\/a>) and enabling new and relevant knowledge to be produced for the local context. The aim of this paper is to document the knowledge co-production process as a model for implementing transdisciplinary research approaches for collaboration.<\/p>\n\n\n\n

As part of a larger multi-country research study exploring strategies and opportunities for intersectoral collaboration between human settlements and health sectors, we utilised participatory methods to engage a variety of relevant stakeholders in the co-design and conduct of a transdisciplinary workshop to explore perspectives on urban health priorities in Douala municipalities and experiences of intersectoral collaboration. A key component of this engagement was convening a workshop in Doula with stakeholders.<\/p>\n\n\n\n

In this paper, we describe the process and experience of co-creation of a transdisciplinary workshop agenda between academic and policy partners. We further present experiences of intersectoral collaboration by stakeholders prior to the workshop, perceptions of multisectoral stakeholders on human settlement priorities across Douala municipalities, their understanding of the urban drivers of ill health, and perspectives on strategies to mitigate these health risks through human settlement intervention.<\/p>\n\n\n\n

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Methodology<\/h3>\n\n\n\n
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This study used participatory methods to engage a variety of stakeholders in the co-design and conduct of a transdisciplinary workshop. Twenty-four stakeholders participated in the 3-day workshop, held at the Douala City Council building 12\u201314 March 2019, representing policymakers, academia, practitioners, private sector, and civil society.<\/p>\n\n\n\n

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Pre-workshop<\/h4>\n\n\n\n
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Prior to the workshop, we sought to engage key stakeholders to co-develop the workshop. The stakeholders were generally grouped along the proposed Stakeholders groups of the International Guidelines on Urban and Territorial planning (IG-UTP) (United Nations Human Settlement Programme (UN-Habitat) 2015<\/a>), namely representatives from National government, local government, civil society and their associations, and planning professionals and their associations. The following three-step process was used: <\/p>\n\n\n\n

  1. Identifying stakeholders:<\/strong><\/em> We began by building a collaboration with the Douala City Council (DCC). A formal meeting was then organised at the city hall, to which actors active in the management of the city were invited by the DCC. After presenting the proposed project on integration of health and human settlement policies, we sought to jointly identify stakeholders best suited to engage in the transdisciplinary workshop. Through this process, we identified five categories of stakeholders across a variety of sectors: policymakers, planning practitioners, territorial governance actors, academia, and civil society.<\/li>
  2. Engaging with identified stakeholders:<\/em> <\/strong>In total, fifteen stakeholders were identified and formally invited to attend a large stakeholder engagement meeting. Two stakeholders formally declined, and six stakeholders confirmed their participation in the meeting. These attendees represented the Douala Urban Community, the University of Douala, Delegate Public Health, Delegate Housing and Town Planning, Delegate Urban and Rural Planning and Development Mission, and a private non-government organisation. The meeting was held from 16 to 18 October 2018. The first step in engaging stakeholders identified was to provide an opportunity for stakeholders to reflect on and share with others their experience in city management and practice. Next, the DCC team shared the city\u2019s vision for town planning. Thirdly, the research team shared the aims of the project and the overall goal to contribute towards making Douala a healthy and sustainable city. At this point, invited stakeholders were asked to reflect on whether they shared the vision of the city as presented by the DCC and the goal of the research programme; and to share their thoughts on this. Agreement was collectively recognised as an indication of the desire to proactively engage with the workshop and subsequent research collaboration. These engaged stakeholders, as well as the original list of identified stakeholders, were subsequently invited to attend the transdisciplinary workshop with members of the DCC and the wider research team. The typology of stakeholders who were identified for engagement is represented in Table 1.<\/li><\/ol>\n\n\n\n
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    Stakeholders<\/th>Organization<\/th><\/tr><\/thead>
     National Policymakers<\/td>Ministry of Housing and Urban Development<\/td><\/tr>
     <\/td>Ministry of Public Health<\/td><\/tr>
     <\/td>Ministry of Environment<\/td><\/tr>
     <\/td>Ministry of Water and Power Resources<\/td><\/tr>
     <\/td>Ministry of Home Affairs<\/td><\/tr>
    Professions and Practitioners<\/td>Real Estate and Land use<\/td><\/tr>
     <\/td>Planners<\/td><\/tr>
     <\/td>Architect Professionals Organisation<\/td><\/tr>
     <\/td>Social housing<\/td><\/tr>
    Local authorities \/ Technocrats<\/td>Douala Urban Council<\/td><\/tr>
     <\/td>Ministry in charge of Decentralization<\/td><\/tr>
     <\/td>Municipalities<\/td><\/tr>
     <\/td>Land management<\/td><\/tr>
    Academia<\/td>University of Douala (Geography)<\/td><\/tr>
     <\/td>University of Yaound\u00e9 I (Geography)<\/td><\/tr>
     <\/td>University of Yaound\u00e9 II (Law and Political Sciences)<\/td><\/tr>
    Non-governmental Organisations<\/td>Land use<\/td><\/tr>
     <\/td>Waste recycling<\/td><\/tr>
    Private sector<\/td>Waste management<\/td><\/tr><\/tbody><\/table>
    Table 1: A summary of practical strategies, proposed by local stakeholders through groupwork activity, to address identified urban health risks through urban planning in Douala, Cameroon.<\/figcaption><\/figure>\n\n\n\n
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    1. Co-designing the workshop:<\/strong><\/em> In recognition of the vital role that workshop delegates would play in research partnership and as implementers and advocates of healthy public policies, we sought to ensure the workshop programme addressed their needs and knowledge gaps to engender stronger partnerships. Following the engagement step (Step 2), the research team drafted an initial agenda, and invited engaged stakeholders to review and propose edits to the agenda. The process of designing the workshop was interactive and participatory at all levels (Figure 1<\/a>). This process included engaged stakeholders, the DCC team and the research team. Initial comments on the draft workshop agenda were incorporated into a second version which was then revisited in subsequent consultation meetings with the stakeholders until consensus was achieved. This co-developed agenda was then reviewed by the research team in a consolidation meeting that sought to ensure the key objectives of the research were covered by the workshop, and to ensure that the required logistics were feasible.<\/li><\/ol>\n\n\n\n
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      Figure 1. Process of co-designing the workshop within the framework of a transdisciplinary research.<\/figcaption><\/figure><\/div>\n\n\n\n
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      Workshop structure design<\/h4>\n\n\n\n
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      In planning the structure of the workshop, we utilised three approaches to ensure the workshop was interactive. <\/p>\n\n\n\n

      1. Knowledge sharing:<\/em> We recognised that stakeholders came to the workshop with different levels of knowledge on global and local trends in urban planning, health, and the interaction between these; as well as the global frameworks and resources that exist to guide development of healthy planning policies. As such, a key component of the workshop involved talks by the research team, UN-Habitat representatives, and Douala policymakers and academics. These sessions covered essential dimensions of urban and territorial planning. These included providing information on global urban trends and global frameworks, i.e. SDG, NUA, World Health Organization (WHO) (World Health Organization\/UN-Habitat 2010<\/a>) and UN-Habitat (2017<\/a>) frameworks; as well as grounded experiences and case studies of the implementation of these frameworks. One case study was presented for Cape Town, where a similar study integrating health in human settlements policies was being conducted by the members of the project team. Case-studies relevant to the Douala urban development context were selected to illustrate the implementation of global frameworks into its specific context. In addition, local academic and policy stakeholders shared their local knowledge on the challenges of urbanisation in Douala, and strategies being implemented to address these.<\/li>
      2. Interactive assessments:<\/em> We utilised real-time surveys, to engage participants and facilitate interaction. The tool, Mentimeter<\/a>, was used to conduct surveys that enabled participants to see in real time the response of all participants on screen. A pre-workshop survey was conducted at the start of the workshop to take a measure of participants\u2019 perceptions on the role of health in urban planning, their experiences of intersectoral collaboration and their perspectives on challenges and opportunities for integrating health into urban planning policy. The survey explored participant perceptions using response scales. Participant responses to questions exploring perceptions on the role of health in urban planning were measured on a 5-point Likert scale with categories of \u2018strongly agree\u2019, \u2018agree\u2019, \u2018undecided\u2019, \u2018disagree\u2019 and \u2018strongly disagree\u2019. A 0\u201310 response scale (0 = not relevant; 10 = very relevant) was used for the questions exploring experiences of intersectoral collaboration and perspectives on challenges and opportunities for integration. <\/li>
      3. Participants could indicate the degree to which they felt the statement was relevant to their work or situation. The results of the survey were automatically recorded in an Excel spreadsheet and were analysed using frequency distributions for the categorical data.<\/li><\/ol>\n\n\n\n
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        The second interactive survey was conducted at the start of the second day of the workshop and engaged participants to share their perspectives of Douala\u2019s planning system; in particular assessing ongoing multistakeholder, multisector involvement in planning policies, and the ways in which the governance, accountability mechanisms of planning policies are aligned for health creation. This survey operationalised the 12 planning principles of urban and territorial planning (United Nations Human Settlement Programme (UN-Habitat) 2015<\/a>) and helped to identify the opportunities and challenges at the local level.<\/p>\n\n\n\n

        A third real-time survey conducted at the end of the workshop assessed whether there were any changes in perceptions of the role of health in planning and vice versa, and any learnings on tools for integrating these sectors. Responses were measured using scale and multiple-choice response formats. <\/p>\n\n\n

        (3) Working group discussion:<\/strong><\/em> Over the course of the workshop, we sought to explore participants\u2019 perceptions of urban challenges in the different Douala municipalities represented; to probe their understanding of health risks associated with these urban challenges, and lastly to collectively develop strategies to mitigate these health risks. These were conducted through working group discussions, which were divided into two sessions.<\/p>\n\n\n

        The first working group session was run after knowledge-sharing talks from the research team on urbanisation challenges in Africa generally, and from a Douala policymaker presenting a local perspective on urbanisation challenges in Douala. In this first session, participants were split into groups with each group representing one of four Douala municipalities represented. The aim was for workshop delegates across sectors to work together to identify and prioritise human settlement challenges experienced in their municipality. The multisectoral distribution of stakeholders in these groups put into practice the concept of intersectoral collaboration as each group comprised representatives from the health and planning\/human settlements sector. The urban priorities were then presented by a rapporteur from each group in plenary.<\/p>\n\n\n\n

        The second working group discussion followed further knowledge-sharing presentations from a Douala policymaker on housing challenges, from a local public health researcher on health needs of the Douala population, and a lecture on the interlinkages between the built environment and health. In this second break out group discussion, the group categories were the top urbanisation challenges identified across all municipalities in the first discussion. Delegates were asked to join a group that best represented their area of interest and were challenged to consider the ways in which the health issues presented are linked to their selected urban human settlement challenge. This session was designed to interactively explore health issues related to the urban challenges previously identified, with each group comprising participants with diverse skills and from across municipalities. Each group was encouraged to brainstorm strategies to be used for mitigating the health risks from the identified urban exposures.<\/p>\n\n\n\n

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        Results<\/h3>\n\n\n\n
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        Pre-workshop motivations, perceptions, and experiences of intersectoral collaboration<\/h4>\n\n\n\n
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        Participants were asked about their primary motivation for attending the workshop on day 1. Of the 20 responses received, the most common motivation (9\/20) was to better understand the relationship between health and planning, and the importance of intersectoral collaboration. A further 20% were primarily motivated to participate in order to learn about case studies on health and human settlements, and to equip themselves with tools and strategies for intersectoral collaboration. When asked about experiences of intersectoral collaboration between health and human settlement sectors prior to the workshop, 53% reported having never worked with the other sector.Perspectives of participants on integration between health and human settlement sectors in Douala are presented in Figure 2<\/a>. Whilst the majority of participants felt that there was poor linkage between planning and health sectors, the majority (10\/18 responses) agreed that the planning system gathered evidence of relevance to health. To explore pre-existing attitudes on the role of health in human settlements planning, using a Likert 0\u201310 scale from not important to very important, participants were asked to express the ways in which they thought health professionals can contribute to urban and territorial planning. Figure 3<\/a> shows that the three most important roles that participants felt health professionals should play are 1) to raise awareness of the importance of integrating health into planning, 2) to provide assistance on health statistics for urban planning, and 3) to develop tools to facilitate this integration. Lastly, when asked about the biggest challenges faced in intersectoral health and planning integration, a \u2018Lack of desire among stakeholders to collaborate\u2019, and \u2018Lack of institutional capacity to foster intersectoral collaboration\u2019 were felt to be most pertinent (Figure 4<\/a>).<\/p>\n\n\n\n

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        Figure 2. Perspectives of participants on integration between health and human settlement sectors in Douala.<\/figcaption><\/figure><\/div>\n\n\n\n
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        Figure 3. Perspectives of roles of health professionals in urban and territorial planning.<\/figcaption><\/figure><\/div>\n\n\n\n
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        Figure 4. Perspectives on challenges to integrating health in urban and territorial planning.<\/figcaption><\/figure><\/div>\n\n\n\n
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        Human settlements priorities across Douala municipalities<\/h4>\n\n\n\n
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        The results from the first working group discussion are summarised in Table 2, highlighting common themes and challenges highlighted across the four municipalities represented. Responses covered across three themes: <\/p>\n\n\n\n