The health of women and girls in urban areas with a focus on Kenya and South Africa: a review

This thematic review examines the literature focuses on a range of health challenges faced in particular by women and girls living in low-income urban settlements in expanding cities in Kenya and South Africa. The authors examine specific health issues that affect vulnerable women and girls in the most marginal urban areas, including: sexual, reproductive, maternal and child health; communicable diseases; violence and mental distress; non-communicable diseases, nutrition and the food environment; and sanitation. The review also identifies: contextual factors and conditions that impact upon the health of women and girls in urban areas; interventions that have aimed to address the health challenges of women and girls in urban areas; and gaps in knowledge.

Findings from the review include:

• evidence consistently shows that poor people living in informal settlements in urban areas face a disproportionate health challenge, but studies contributing a gendered analysis are still limited 
• there is little research which focuses on the distribution of health outcomes within an urban area, and the literature overlooks the broader social and environmental health risks that exist in most urban settlements 
• inequity and inequality are conceptually central to the urban health challenge 
  interventions that aim to improve urban health are not necessarily implemented with a gendered lens 
•  interventions with a broad multisectoral focus, and those based on community leadership and participation that acknowledge power relations and governance, are given prominence in the literature 
• the urban health literature calls for interventions which go beyond health sector responses to also address the social determinants of ill health, such as cash transfers, equity-focused urban planning, income redistribution and law and policy reform.

The review makes the following recommendations:

• advocate for interventions that address health problems in a holistic way, and that attempt to consider the underlying structural factors that go beyond narrowly defined notions of health 
• infrastructural reform and accessibility of basic services are key, as are cross-sectoral approaches that can appropriately support change on the ground 
• interventions should focus on community involvement, including engaging men, and see the urban poor as change agents, not just passive recipients of interventions and policy pronouncements 
• campaigning and advocacy at national and sub-national levels is necessary to identify gaps in implementation and to inform international action to avoid uncritical blueprint solutions 
• women living in ‘slum’ areas are not a homogenous group. While they require the provision of integrated services, careful targeting might be needed to avoid marginalisation 
• it is important to generate robust evidence and evaluate existing interventions rather than encourage a constant proliferation of standalone projects. This evidence should include the voices of women themselves and their experience of life in settlements and what they consider to be interventions that have ‘impact’ on their conditions of life
• there is a need to communicate issues in new ways and to seek accounts that also highlight the potentially positive features of urban living for women and girls.