Abstract
Informal urban settlements in the Global South are sites of acute governance challenges, where the absence of formal infrastructure collides with complex socio-political dynamics to shape access to essential services. This thesis investigates the governance of public health service delivery in informal urban settlements in Dhaka, the capital city of Bangladesh, one of the world’s most densely populated and rapidly growing cities. Despite increasing attention to urban health systems, the everyday realities of how the diverse population in informal urban settlements access healthcare remain poorly understood. To address this gap, this PhD research aims to examine how formal and informal governance actors operate, interact, and how residents navigate governance within informal urban settlements.The study employed qualitative, multi-method community-based participatory research approaches and methods to address three integrated objectives: (1) to map health governance actors and networks, (2) to document residents lived experiences of navigating governance to access services, and (3) to explore governance arrangements for public health service delivery and access. Data was collected in two informal urban settlements in Dhaka city between December 2020 and February 2023. Qualitative participatory methods included four stakeholder workshops (two community-level and two city-level), ten governance network mapping sessions (five in each site, small group discussions with 68 diverse community participants), governance diaries (repeated in-depth interviews and small group discussions) with 16 families (eight from each site), key informant interviews with local government and City Corporation representatives, and informal discussions with residents, service providers, community leaders and city officials. Thematic framework analysis was guided by three frameworks: the Urban Political Ecology (UPE) framework as an overarching theoretical framework, and contextualised versions of the Multi-Level Governance (MLG) framework, and Hybrid Governance theory to analyse the interactions among formal and informal actors, power dynamics, and internal governance system of public health service delivery and access.
This thesis identifies a fragmented yet dynamic constellation of governance actors operating at three interconnected levels: Constitutional (elected local government representatives, NGOs and private service providers), Collective (community-based committees, such as local mosque committees, market committees, and different NGO-formed committees), and Operational (informal actors - community leaders, local elites, youth leaders, landlords, house managers, and individual community members). Operational-level actors can move to the Collective Level by joining committees. While NGOs remain the primary health service providers, their ability to operate is highly contingent on local political structures and powerful gatekeepers. Politically affiliated informal actors often act as “network navigators”, controlling access to services through clientelist ties. The mapping reveals that power is exercised not through hierarchical institutions, but via negotiated relationships embedded in local socio-political contexts. Patronage relationships play a pivotal role in mediating service access, creating a highly localised and unequal governance ecosystem. These findings addressed the first objective of this research and are presented in Chapter 5 in this thesis.
Analysis of the participants’ lived experiences of navigating everyday governance to access urban public health services, revealed that service access is determined by a family’s ability to mobilise three critical and interconnected resources: financial (income, savings, external borrowing), social (ties to community leaders, political patrons, NGO workers), and personal (negotiation skills, civic knowledge, confidence). These resources are unevenly distributed and deeply influenced by factors such as gender, tenure status, political affiliation, and socioeconomic background. Men had better access to the men-dominated political spaces, while long-term residents were more likely to be included in decision-making structures. Those without connections, such as new migrants or poorer tenants, were often excluded from health interventions and community aid lists. The findings suggest that rather than being passive recipients of governance, many residents are active agents navigating a dense landscape of informal authority and institutional opacity. However, this navigation often reinforces existing hierarchies, as those with better resources or networks continue to benefit disproportionately. These results address the second objective and are detailed in Chapter 6.
A Multi-layered Hybrid Governance (MHG) framework was developed by synthesising research findings to conceptualise urban health governance, which is a dynamic interplay between formal state institutions, non-state actors, and informal community networks. It helps in analysing how governance functions through fluid and negotiated arrangements. At the macro level, government Ward Councillors exert intermittent authority. At the meso level, NGOs and non-state service providers serve as intermediaries, balancing bureaucratic mandates with community expectations. At the micro level, residents mobilise personal, social and financial resources to engage in these governance processes. The findings revealed that actors’ positionality in local governance is fluid; residents shift between being clients, patrons, or gatekeepers depending on their power at the time, their ability to influence key networks, and the specific context. Trust within these networks is instrumental and transactional, where actors collaborate due to mutually beneficial incentives. The MHG framework offers an analytical tool for understanding this hybridity, not as a breakdown of governance, but rather as its operational logic in informal settings. These findings address the third objective of this research and are discussed in Chapter 7.
This thesis makes important contributions, both empirically and theoretically, to the fields of Urban Political Ecology (UPE), Health Policy and Systems Research (HPSR), and hybrid governance. Firstly, it expands UPE to the context of health service delivery, demonstrating that access to health services is shaped more by the local socio-political environments than by technocratic planning. Health infrastructure in informal settlements is produced and distributed through power relations that systematically benefit certain groups while marginalising others. Secondly, this research advances HPSR by highlighting governance as a central health determinant. Thirdly, this thesis further refines the concept of hybrid governance as resilient governance by identifying key characteristics, such as positional fluidity, mutual dependence, and instrumental trust. Lastly, it contributes to the decolonising discourse by prioritising community voices and recognising the complex realities of informal governance, while challenging the prevailing deficit narratives of urban health governance. Although challenges persist, informal governance has emerged as an alternative solution to address the injustices that informal settlement residents face in accessing urban public health services.
In conclusion, this thesis provides a context-sensitive and grounded understanding of how health services are accessed, governed, and experienced in informal urban settlements. Public health services in those settlements are delivered through a complex, multi-layered hybrid system characterised by continual negotiations, resource mobilisation, and strategic interactions that are intricately political and deeply embedded in the local context. Therefore, this research advocates for urban health governance strategies that are community-specific, prioritise equity, and facilitate structural transformation.
| Date of Award | 7 Nov 2025 |
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| Original language | English |
| Awarding Institution |
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| Sponsors | UK Research and Innovation |
| Supervisor | Kimberley Ozano (Supervisor), Sally Theobald (Supervisor), Sabina Rashid (Supervisor) & Linda Waldman (Supervisor) |