October 19, 2022

Informal networks as sources of healthcare support

Informal networks as sources of healthcare support: How slum dwellers cope with health challenges by talking to each other

Informal health support

Photo by Sheyi Owolabi on Unsplash

Blog written by Chinwe Onuegbu

Access to quality healthcare is a fundamental human right, but this remains a struggle for people living in slums in low and middle-income countries. The term “slum” can be controversial but it is used in this article, in line with a larger project under which the research described in this article is based, to describe poor urban settlements characterised by overcrowding, poor housing structures and an overall shortage of social and health amenities. Globally, one in eight people reside in slums or poor urban settings, and in many African countries, including Nigeria, about 60% or city dwellers live in slums. Public health services in urban cities do not sufficiently cater to people living in the slums, and many are unable to obtain the comprehensive formal healthcare they need.

Staying healthy and fit is particularly essential for people living in slums. Many engage in informal jobs with daily wages, and maintaining health is crucial for maintaining daily household income.

In the face of inadequate formal healthcare services, slum dwellers turn to alternative healthcare options. It is important that we begin to understand these alternatives in order to mitigate any negative consequences and to amplify potential synergies.

My PhD study within the NIHR-funded slum health project

My PhD project was nested within the NIHR funded slum health unit at Warwick Medical School. The unit worked collaboratively with universities in Asia and Africa to map and understand use of health services in slums across both continents.

With my background in Sociology, I recognised the untapped opportunity to explore how health was managed beyond formal medical settings in the slums. My thesis explored a phenomenon known as lay consultation: how people manage illnesses and health challenges by talking to informal network members (e.g. family, friends and neighbours) or other informal online forums or resources (e.g., Facebook friends) beyond medical settings. My study population were the working-age adults in slums in Ibadan (Oyo state), Nigeria, and they were chosen because they were more likely to migrate in and out of the slums, be engaged in work that make them unable to seek care when needed and are likely to own and use mobile devices. These dynamics can shape lay consultation behaviours and network composition. The project adopted a mixed method approach. First, a survey to map how common lay consultation was, which network members were contacted and how influential were informal network members in determining people’s treatment behaviours. Next, interviews were conducted to understand in more depth the connections between speaking to others about a medical problem and actions taken afterwards. The study was done in collaboration with partners from the University of Ibadan, Nigeria.

The study found that most people experiencing illnesses consulted 1-3 network members including family, friends and neighbours. People navigated through the complexities of social life in slums such as having fewer networks due to busy life and difficulties in having trusted or dependable sources of support, to find people they could talk to. Participants rarely used online informal networks, mainly because many did not have access to such devices, had limited digital literacy, or preferred physical networks. The informal consultations were largely unplanned and taken-for-granted as they were ingrained in everyday life. Yet, within those informal conversations, were exchanges of advice and support- some useful and some not, that shaped how people managed illness experiences.

A striking finding from this study was that, despite living in the slums where the harsh conditions may drive over-reliance on informal networks for health maintenance, slum dwellers were highly agentic in using advice or support from others. People had strategies for coping with health challenges which included ability to assess the relevance of advice they received. Occasionally, they consulted other informal health providers such as local medicine vendors (known locally as ‘chemists’) and traditional healers to confirm advice they received from their network members.

So what?

We now know from this study that lay consultation, that is talking to informal network members, is a common way of managing illnesses in slums. The conversations- whether intended or unintended- contribute to management of personal health. There is a potential to leverage on informal networks to improve knowledge about health conditions and health care access, thereby contributing to strengthening of the health system in poor urban settings. Informal networks, including those existing online, should be recognised as an integral part of the overall health system, and incorporated into health policies and programmes as a means of increasing the coverage and effectiveness of health interventions.

Next steps:

The next step involves working with collaborators at the University of Ibadan, Nigeria on an intervention around lay consultation for slum communities in Ibadan, Nigeria. Our initial idea is to co-design an online health-resource that would provide formal, verified and accessible health advice for people living in the slums. People feeling ill or having health challenges can consult the online resource as part of steps taken to inform their health-seeking decisions. We will work with policy makers, community members and concerned organisations such as NGOs to co-design and promote the resource.

An internal seed fund grant has been obtained from the Warwick International Partnership fund (IPF) to kick start this project. The funding will be used to:

  • Disseminate findings from the PhD to study participants, key stakeholders and the general public,
  • Engage representatives of slum communities and public health policy makers at the state level in Nigeria to assess the value of lay consultation as an intervention to improve health outcomes
  • Build a multidisciplinary collaborative research team from across public health, information technology and social science and other stakeholders (such as Non-Governmental Organizations) for future research on leveraging lay consultation for health benefits in the slums.

In conclusion, interventions that are bottom-up, innovative and interdisciplinary approaches have the potential to tackle the complex issues in slums. The PhD project and planned intervention discussed in this blog exemplify how the intersection between social science and health science can improve health in slums.

Author Bio:

Chinwe Onuegbu is a Research Fellow at the Division of Health Sciences, Warwick Medical School, University of Warwick, UK. She recently completed her PhD in Health Sciences at Warwick Medical School. Her research interests include the social determinants of health in resource-constraint settings, and the role of information and communication technology (ICT) in healthcare in low- and middle-income countries. She is also interested in research communication and hosts a Research chat show on YouTube in her free time.

September 21, 2022

Colonial legacies, race and the labour market in Trinidad and Tobago

colonial legacies blog

Photo by Rashmi Mathur [The Trinidad & Tobago flag at sunrise]

Colonial Legacies, Race and the Labour Market in Trinidad and Tobago

Written by: Jamelia Harrisand Gianluc Robinson

Recent years have seen increased calls for equality and social justice. In many so-called developed countries, the movement has manifested in efforts to renameplaces, remove/replacestatues and decolonisethe curriculum. In former colonial countries, the renaming, replacing and re-writing is not new, and for some started decades ago. For example, there has been a Caribbean flavour to the syllabus, pedagogy and assessment in the English-speaking Caribbean since the establishment of the Caribbean Examination Council(CXC) in 1972; and the South African curriculum has gone through a plethora of changessince 1994. Several countries reclaimedtheir names post-independence – among them are Belize, St Kitts and Nevis, Sri Lanka and Zimbabwe, and most recently Eswatini. We no longer speak of Bombay, but Mumbai; and Kolkata rather than Calcutta.

These examples highlight that the ‘decolonisation’ movement is not new in former-colonial states. These countries have long tried to shake the colonial chains and reclaim their identities. Many efforts have been successful as indicated above. Some are more challenging, especially those that are built on deep-rooted institutions.

Institutionsare the rules of the game with respect to how social, political and economic systems are organised and function. They are influenced by social interactions, and oftentimes formalised by laws and regulations. As expected, early institutions shape contemporary ones, and ultimately affect current outcomes. They determinehow a country, its economy and society, prospers (or not). This is true in Trinidad and Tobago – a small island nation in the Caribbean, and former British colony. Although sugar plantations (and agriculture in general) play a limited role in Trinidad and Tobago’s economy sixty years after independence(in 1962), race relations/tensions that were bred and nurtured doing the colonial period continue today, and rears its head in the labour market (among other aspects of society).

The ‘origin’ story

British colonialism in the West Indies used a model of division to control, which “fragments, divides, marginalizes, alienates, and represses certain groups”. These divisions were often institutionalised in laws and policies, and have a high probability of shaping contemporary institutions and development prospects. In Trinidad and Tobago, one of these divisions lay between the Afro- and Indo- Trinidadian communities.

From 1845, seven years after ‘Apprenticeship’ ended in 1838, East Indians (from India) were “imported into Trinidad” to work on sugar plantations as indentured labourers. Remuneration of the indentured labourers undercut that of the former enslaved, and the indentured labourers were offered the promise of land in exchange for relinquishing their free passage home. This, understandably, created tensions between the two groups – which played out in a society already “pervaded by the racist ideology of local and metropolitan whites.”

The subsequent institutionalisation of the Westminster system of government in Trinidad and Tobago hosted, and arguably perpetuated, one contemporary manifestation of this division in the area of race and politics, with one main party predominantly supported by the Afro-Trinidadian population, and the other supported by the Indo-Trinidadian population. Race and politics often enterthe labour market, and debates around these issues emerge most strongly in the lead up to general elections.

Contemporary manifestations

There is a high level of perceived racism in employment. Both the Afro and Indo populations claim to experience levels of racism in hiring and treatment in the workplace. Most studies acknowledge that this may be driven by perceptions on disparities in position, education, access to credit or resources such as loans. Perceptions on racial discrimination interplay with perceived political affiliation as politicians are suspected of providing their supporters and constituents with access to more opportunities and resources than the opposing side.

Recorded historical evidence on differences in positions between Afro, Indo and other races have influenced perceptions. In the immediate post-independence years, mixed, white, Chinese and Syrian populations tended to occupy higher levels of management and business ownership despite comparative or less training or education. Into the 2000s, Afro-Trinidadians weremore likely to be employed in government positions; while the Indo population became more entrepreneurial and were more represented in the private sector and enterprise. However, no major differences in earnings between Indo and Afro populations were reported at the time. Afro-Trinidadians have the lowest self- employmentrates in the country. This may be because they have higher denial rates for business loans, even when accounting for similar factors to other groups. This may hint at some level of discrimination towards Afro-Trinidadians in financial markets. It may also be a result from historical factors, differences in inheritance and cultural/ family differences.

Relatively recent stories in the media have only served to fuel these perceptions. The former Prime Minister, Kamla Persad Bissessar, publicly apologisedafter being accused of appointing a junior civil servant to a director position, suggesting patronage ahead of merit. Allegations have not been limited to the public sector, but have also been madein the private sector. These perceptions enter formal channels. A studyusing data from the Equal Opportunities Commission between 2008 and 2013 notes that race/ethnicity was the largest named reason for raising a complaint of workplace discrimination to the Commission.

Addressing the issue

On a more positive note, a 2018 studyargues that racial differences in employment outcomes is relatively low (seven percent on the Karmel-Maclachlan index) and have generally improved over the 1999 to 2015 period. The authors suggestthat when race-based differences exists in labour market outcomes, it is often a result of prior educational differences. These findings indicate some positive change, but also point to the complexities inherent in changing institutions – those interactions and practices deep-rooted in history.

First, perceptions matter. And information is important in shaping perceptions. The 2018 study suggests that labour market outcomes by race may not be as large as perceived. Yet, perceptions held are different. And perceptions matter for racial cohesion. One way of shifting perceptions is through information. The Trinidad and Tobago Central Statistical Office (CSO) monitors and reports on labour market data on a quarterly basis. Data is publicly availableby sex, age, educational attainment, type of worker, occupation group, and industry. This data is easy to download and analyse. However, one important variable is absent from the publicly available data – racial/ethnic background. It begs the question, should such data be publicly available given such high public interest in the issue? Arguably, routine monitoring of differences, if/where they exist, is the first step in correcting imbalances.

Second, if it is indeed the case that differences in labour market outcomes by racial groups result from differences in education outcomes, this warrants its own area of enquiry. If some racial/ethnic groups perform better than others, what drives these differences in the Trinidad and Tobago context? And, subsequently, how can policy tackle these issues? Would addressing educational differences highlight other disparities along racial lines?

The first Prime Minister of Trinidad and Tobago and reputed historian, Dr Eric Williams, famously remarked and used the slogan ‘Massa Day Done’ – the day of the colonial masters is finished. This sentiment informedmuch of the ideology in independent Trinidad and Tobago, and many other Caribbean islands. Indeed, countries like Trinidad and Tobago are free to choose their path and shape their destiny. It remains that breaking the chains of some colonial legacies, like race relations, is an ever-present challenge.

The scoping research undertaken for this blog was funded by the Warwick Interdisciplinary Centre for International Development (WICID). The authors thank WICID for this generous support.

Authors Bio:

Jamelia Harrisis a Research Economist at Fiscus and Visiting Research Fellow at the Politics and International Studies Department, University of Warwick. Her research spans a range of topics and includes foreign aid and the labour market, political patronage, and government finances.

Gianluc Robinsonis an MPhil Candidate at the University of Trinidad and Tobago. His research is mainly in environmental and marine sciences, though he has an interest in social sciences and data analytics.

August 17, 2022

The KazAID Story

The KazAID Story

Written by: Prachi Agarwal

The ongoing Russian aggression in Ukraine has captured the world’s attention. Conversations focusing on the fragility of countries’ sovereignty and security are growing, especially among former soviet republics. Despite threats to sovereignty and security, Kazakhstan, the largest country in central Asia and a former member of the USSR, aspires to be a global superpower. However, the primary challenge to this aspiration lies in ‘promoting increased connectivity while maintaining a freedom of action’. The solution to this challenge may require using foreign aid as an instrument of foreign policy.

Thus, the primary aim of this blog is to describe and highlight pertinent issues for Kazakhstan’s foreign aid practices in the context of using foreign aid. The rationale behind such an endeavour is that KazAID (Kazakhstan’s foreign aid body) remains an under-researched area. KazAID’s establishment was driven by fulfilling Kazakhstan’s security needs and economic aspirations. While the role of foreign aid as a foreign policy instrument of the rich countries may be widely known, KazAID’s story shows that other developing nations could also challenge the existing western hegemony through strategic aid foreign practices.

Contextualising Kazakhstan

Kazakhstan has been carefully trying to maintain relations with its largest trading partners - Russia, the United States and China. Kazakhstan believes that Eurasian connectivity could benefit its economic and security interests. Simultaneously, Kazakhstan maintains close ties with Russia and China. Earlier in 2022, when protests broke out against the Russian invasion of Ukraine, Kazakhstan sought assistance from Russia to quell the growing protests. These protests were guided by the fear that Kazakhstan, too, may be invaded by Russia. These fears are not misguided as being a member of Russia’s Eurasian Economic Union (EaEU) is getting increasingly costly for Kazakhstan. Critics suggest that while the EaEU mimics the EU’s institutional framework, in practice it is an agency for Russia’s geopolitical interests. Being a member of the EaEU constrains Kazakhstan’s sovereignty and weakens its economy and it may want to leave the EaEu, thus inviting Putin’s wrath. China, too, pursues economic interests in Kazakhstan as its largest trading partner and an emerging source of Foreign Direct Investment (FDI). Such close ties with China and Russia may invite sanctions from the West. Therefore, Kazakhstan maintains a multivectoral foreign policy and foreign aid is a crucial, yet overlooked, aspect Kazakhstan’s foreign policy.

From Aid Recipient to Aid Donor

Kazakhstan delivers foreign aid through its agency, KazAID. However, Kazakhstan used to be a prominent aid recipient rather than a donor. Previously, Kazakhstan received aid under the OECD’s Official Development Assistance (ODA) banner. Figure 1 captures the trends in aid receipt amongst the Central Asian countries to show that until 2007, Kazakhstan received aid in the same proportion as most countries in the region, but post 2007, the amount of aid received drastically decreased. Simultaneously, the demand for aid among other countries in the region (barring Turkmenistan) continued to increase.

new kaz aid image

Figure 1: Trends in Aid Receipts (Source: Author’s Own; Data: QWIDS)

Some argue that this pivot may be due to the oil industry. In figure 1, the increasing trend (till 2007) occurred as Kazakhstan (and other Central Asian countries) needed assistance in transitioning to a market-based economy post their disintegration from the USSR. Simultaneously, due to its export policies for Uranium, wheat, and other natural resources, Kazakhstan experienced massive increases in its GDP.

In 1999, former President Nazarbayev had announced the intentions to reduce aid dependency. Following this decision, Kazakhstan took measured steps in reducing its loans and grants. Due to the increases in national income, the World Bank, in 2006, categorised Kazakhstan as an upper-middle-income country. Subsequently, in line with its foreign policy, Kazakhstan aspired to be included in the elite Organisation of Economic Cooperation and Development (OECD). Becoming a donor nation was critical in achieving this aspiration. In 2014, the government implemented the ODA Law which established the tasks, agendas, regulations and organisational matters for the same. This law served as the legal basis for establishing Kaz AID

What is KazAID?

KazAID was established through a presidential decree, under the Ministry of Foreign Affairs of Kazakhstan. It was founded with the aim of building regional cooperation, helping Kazakhstan integrate into regional systems, connecting Europe and Asia, and promoting peace and security in the region. Thus far, major chunks of its aid have been delivered to countries in the region, but KazAID intends to extend aid to Latin American and African countries, too.

With a unilateral aid of USD 2 million, Afghanistan has been KazAID’s largest aid recipient so far. KazAID also supplies aid to Tajikistan. Although Tajikistan didn’t list Kazakhstan as a ‘foreign donor’ in one of its reports, KazAID continued with its initiatives in the region to build ‘brotherly relations’. Such activities resulted in an invitation from the OECD for a conference in Paris in 2018. Subsequently, Kazakhstan’s international image improved considerably, even perhaps establishing Kazakhstan as a regional leader. However, countries in the region are still reluctant to accept this status.

Figure 2 shows the amount of developmental assistance provided as a share of Kazakhstan’s Gross National Income (GNI) to indicate that initially, the aid amounts increased exponentially and then stabilised as it received the OECD Paris Conference invite. This further alludes to Kazakhstan’s strategy of employing foreign aid to aid its own agendas.

image 2 Kazak aid blog

Figure 2: Developmental Assistance provided as a share of GNI (Source: OECD, 2020)

At a conference, the Kazakh Ministry of Foreign Affairs expressed that KazAID is an essential tool for the region’s long-term growth and development which would ensure peace and stability in the region. Indeed, this would directly benefit Kazakhstan’s own security and economic interests, which highlights the importance of foreign aid in Kazakhstan’s multivectoral foreign policy.

Situating KazAID in Kazakhstan’s Foreign Policy & Identity as a Donor

Given Kazakhstan’s proximity, history and economic ties with Russia, Kazakhstan could have invited sanctions from the United States or the NATO countries. However, to avoid this, Kazakhstan has employed its aid agency to partner with the US, the UN and other important nations/ organisations. Through KazAID initiatives and ODA policies, Kazakhstan’s donor identity was built which reaffirmed its authority in the region. But, in doing so, Kazakhstan has contrasted itself against other emerging donors.

Kazakhstan uses a ‘hybrid identity’ as a donor to combine aspects of being a traditional and an emerging donor. Historically, Kazakhstan has always maintained partnership, self-reliance and non-interference in other nations’ internal affairs. This is significantly different from the practices of traditional aid agencies, such as USAID. Yet, the motivations of establishing an aid agency and practices match that of the traditional aid agencies, contrasting it from other emerging donors.

For a landlocked and transcontinental country, like Kazakhstan, the development of foreign policy is crucial. However, to effectively employ the landlocked location, Kazakhstan must diversify its foreign policy approaches to develop its foreign aid practices. To this end, Kazakhstan strategically engages in foreign aid practices to cushion itself from hostile nations while ensuring a dominant role in the region. Thereby presenting itself as a viable ally to Russia rather than a threat, despite maintaining relations with the US.

Author bio:

Prachi Agarwal is an independent researcher and development sector professional, based out of India. Her academic interests include, among others, understanding foreign aid in relation to power and hegemony in a global setting.


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