Title: NIHR Global Health Research Group on From surviving to thriving: Assessing and responding to occupational and public health risks in informal settlements and for informal workers and the effects of climate change on these risks: Building learning from India and Zimbabwe at the IIED
Funder: Department of Health and Social Care

Abstract: This project will build on the partners’ strategic objectives to fill key gaps in knowledge on the health of informal workers, with findings that can foster inclusive interventions and generate world-leading health research. It resonates with IIED, UHRC, and TARSC’s missions to build a fairer, more sustainable world using evidence, action and influence in close collaboration with LMIC partners. A focus on urban poverty, informal settlements, and well-being is fundamental to IIED’s extensive work on inclusive shelter and accountable local governance (Mitlin & Satterthwaite 2012). IIED’s strategies to promote inclusive urbanisation operate at multiple scales by partnering with grassroots organisations, researchers, local and national governments, and international agencies. For instance, during the programme Urban Africa: Risk Knowledge (Urban-ARK), IIED researchers have worked with the University of Ibadan, the African Population and Health Research Centre (APHRC), and Kings College London to assess risks in informal settlements (Satterthwaite & Bartlett 2017). IIED also has longstanding relations with federations of slum/shack dwellers in LMICs to document their living conditions and key health risks (see Director’s track record). This proposal neatly aligns with IIED’s strategic focus areas of promoting inclusive urbanisation, climate change adaptation, and the well-being of low-income residents in LMICs. To achieve these aims, IIED engages in rigorous action-research, strategic communications, and monitoring and evaluation (M&E). IIED’s Human Settlements Group has 10 staff, including 7 researchers with doctorates and 2 with professorial status (Satterthwaite at University College London, Mitlin at Manchester University). Along with experienced urban researchers, this project will benefit from input by IIED’s communications team and an M&E specialist. Communications staff will work closely with local partners to develop outputs, which can raise the profile of informal workers and share promising interventions to improve their health outcomes (see pathways to impact). IIED’s researchers and communications team have experience developing outputs to reach multiple audiences including blogs, journal articles, and policy briefs. The proposed research was developed to reflect the priorities, existing partnerships, and expertise of UHRC and TARSC in India and Zimbabwe, respectively. Although this is a new partnership, IIED has long recognised both organisations’ high-quality research, and the director of UHRC has already published with IIED (Agarwal 2011). Both TARSC and UHRC are committed to researching urban health equity and working closely with low-income residents to promote well-being (see team expertise below). These organisations are highly experienced with community-based and participatory action research methods, including with informal workers and residents of informal settlements (Loewensen et al. 2014, Agarwal 2016a). For instance, TARSC regularly conducts short courses on public health and participatory action research; conducts capacity-building activities for specific research programmes; and has in-house facilitators with expertise in public health, health systems, statistics, and related fields (Loewenson et al. 2016). UHRC’s director Siddharth Agarwal (co-PI) works full-time in a 100% non-remunerative role and is an internationally-recognised urban health researcher (see team expertise). UHRC has 10 other full-time staff and 5-6 part-time members. The project will benefit significantly from well-established links between TARSC and informal workers’ organisations in Zimbabwe. TARSC has previously worked with the Zimbabwe Congress of Trade Unions (ZCTU) and Zimbabwe Chamber of the Informal Economy Associations (ZCIEA). Formed in 1981 and registered under Zimbabwe’s Labour Act, ZCTU has had a vibrant occupational health and safety department since the early 1990s. It has trained occupational health and safety officers in its affiliate unions and its shop-floor health and safety representatives, in line with the Factories and Works Act. It has also conducted research surveys on occupational health and participated in trainings by ILO and TARSC on occupational hygiene, environmental health, and environmental policy. ZCTU is represented in the national Zimbabwe Occupational Health and Safety Council and has been involved in national-level negotiations on reforming OHS law and practice, including to cover the informal economy. ZCTU’s lead for this proposal, Nathan Banda, is the head of its health and social welfare department. ZCIEA is an affiliate of the ZCTU and organises Zimbabwe’s informal workforce, estimated at over 3 million people. Founded in 2002, ZCIEA is a national membership driven organisation representing Zimbabwe’s informal workers, covering the self-employed, informal workers in small enterprises, and undeclared workers. It has 265 chapters with a total membership of 198,466 (60% women, 25% men, 15% youth). ZCIEA’s lead for this proposal, Wisborn Malaya, serves as its Secretary General. With longstanding links to health officials, government, and community residents, UHRC’s partnerships will be expanded and strengthened during the project to incorporate issues of occupational health. Past research by UHRC has already analysed the shelter provision, healthcare utilisation, and social exclusion among Indore’s migrants, including informal workers at brick kilns and construction sites (Agarwal 2016). Additionally, UHRC has trained 60 women’s groups in informal settlements, who will help to implement the proposed action-research, and UHRC has mobilised slum youths into networks. Informal workers will be incorporated into these organisations, and UHRC will build the capacities of existing groups to ensure they support these labourers’ well-being. Nearly 800 women volunteers are currently affiliated with UHRC and active in Indore’s informal settlements; they will form key pillars of sustainability, as they will ensure that outreach to workers and advocacy activities will continue after the project ends. Furthermore, UHRC has long-term ties with Indore’s health department and government hospitals; local government officials; utilities agencies; and multiple service providers. Such links will foster meaningful dialogue and health-promoting interventions with informal workers and other relevant stakeholders in Indian cities. We will combine our action-research expertise; create opportunities for North-South, South-South, and South-North learning; and generate high-quality interdisciplinary research. The partners will also build upon their far-flung local, regional, and global networks to ensure that findings reach several audiences (see pathways to impact). This project will create multiple opportunities for learning and capacity-building in LMICs while also contributing to the emerging interest in ‘slum health’ (Lilford et al. 2017, Corburn and Riley 2016). We aim to address the paucity of research on informal workers’ health needs and to develop multifaceted strategies that can promote well-being (whether in informal settlements or other informal worksites). To date, “there is a huge knowledge gap about the health of urban informal workers, even when it is clear that they have unique exposures to risk at home and work, with poor access to health services” (Rockefeller Foundation 2014, p. 12). The proposed project seeks to fill this research gap by a multifaceted, rigorous analysis of informal workers’ occupational health, environmental risks, and climate change impacts. We will utilise an expert panel to support rigorous review and will target the leading health, climate change, and urban development journals, as well as engaging in vigorous outreach to policymakers. In turn, this partnership will create pathbreaking research that can enhance the well-being, livelihoods, and climate resilience of informal workers in other LMICs.

Lay abstract: Informal settlements are often sites of vibrant livelihoods and grassroots organisations (World Bank 2006, Mitlin & Satterthwaite 2012), but there is limited understanding of the overlapping health risks in these areas. Few studies examine the multiple health risks facing residents of informal settlements and other informal workers due to occupational hazards, meagre shelter, and inadequate services. ‘Informal’ livelihoods lack regulations to protect wages, working conditions, or occupational health and safety (Benach et al. 2008). Most informal workers have lower incomes and less training than formal workers, as well as poorer access to healthcare and protective equipment (Chen 2016). Annually, over 1 million deaths occur globally due to occupational risks, but limited data make such estimates uncertain, especially for often-invisible informal workers (Rushton 2017, Forouzanfar et al. 2016, Takala et al. 2014). Informal jobs are widespread in cities of LMICs. For those in non-agricultural employment, 66% of women and 43% of men in Zimbabwe were in informal employment; in India, 85% of women and 83% of men were in informal employment (ILO 2013). This study will offer a holistic assessment of the occupational health risks to which urban informal workers are exposed in Zimbabwe and India, including consideration of climate-related risks. Informal settlements often face high risks from extreme weather because of low-quality housing, lack of infrastructure, and locations upon flood-plains or steep slopes (Revi et al. 2014, Scovronick et al. 2015). This makes them particularly vulnerable to the more intense storms associated with climate change. Climate change may also imperil informal workers’ homes, health and livelihoods due to more frequent or extreme heatwaves, flooding or water scarcity (Kjellstrom et al. 2016). Using document review, community-based, and participatory action-research in Zimbabwe and India, this project will assess and promote the health of informal workers, including those who work and live in informal settlements (hereafter ‘informal workers’). It will analyse the following research questions: 1. What are the key health determinants and health outcomes for informal workers and those living in informal settlements? 2. What is the interaction between these in relation to public health, occupational health and environmental health? 3. How do the current and projected impacts of climate change affect this interaction? 4. What approaches are being used by informal workers to mitigate risks and enhance benefits? Findings will be used to identify the priority interventions to address risks, strengthen assets, and promote public, environmental, and occupational health while also enhancing informal workers’ resilience to climate change. We will argue that responses must be informed by an understanding of the full spectrum of health risks facing informal workers and residents of informal settlements. Our analysis will build upon past action-research by all partners, including IIED’s work on risks in African informal settlements (Satterthwaite & Bartlett 2017), TARSC’s analyses of health equity in East and Southern Africa (Loewenson et al. 2016), and UHRC’s health research in Indian cities (Agarwal 2011). Such findings can promote workers’ well-being and will complement the rising interest in slum health (Lilford et al. 2017, Ezeh et al. 2017), occupational health (Rockefeller Foundation 2014), and resilient urban development.

Research activity codes: 2.2 FACTORS RELATING TO PHYSICAL ENVIRONMENT;2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: GENERIC HEALTH RELEVANCE