**4. The Land Tenure Security and Health Nexus: Pathways of Association**

The review identified four pathways through which land tenure security and health are connected—physical space and basic infrastructure, environmental conditions and stewardship, psycho-ontological security, and social cohesion. Our findings demonstrate that land tenure security, or the deprivation of it, fosters or hinders the above pathways and influences the severity or mildness of health burdens and health outcomes of individuals and urban neighborhoods.

#### *4.1. Land Tenure Security, Physical Space, and Basic Infrastructure*

One way to improve the living conditions and health of urban dwellers is the provision of affordable and secure shelter with access to basic services and amenities. Yet, literature shows that over one billion people are living in urban (mostly informal) areas that lack access to space and basic infrastructure and services [38]. Several scholars have simply attributed health outcomes in these areas to the provision of water, sanitation, and hygiene facilities through physical planning [96,97]. On the contrary, the solutions to poor health, material deprivation, lack of access to health care, clean water, and sanitation are not merely in the provision of these resources but in the access to these resources and the social milieu within which they are provided [98]. One such context to view the provision of infrastructure and basic services is land tenure. There is a connection between a person's land tenure status and health, which is mediated by the link between tenure and access to infrastructure and basic services [99]. Lack of secure tenure either leaves people with no other options but to settle on hazardous lands, deprives them access to basic amenities in cities, or disincentivizes people from undertaking private investment in infrastructure to improve their living conditions. Unsatisfactory land tenure relations and insecurity can impede investment in housing improvement, water, sanitation, and other services [100]. Moreover, viewed differently, the provision of these infrastructure by central government can lead to dispossessions and exposure to harsh living conditions where there is no security of tenure [101]. Merely providing infrastructure in urban neighborhoods is not enough to improve the living conditions and health of the inhabitants. Instead, people need secure tenure to access and enjoy these infrastructure and services. The lack of land tenure security means that people end up occupying high-risk land on which infrastructure and service provision are less attractive or not feasible at all. Another way in which insecure tenure affects the provision of infrastructure and services is the revenue leakages that are also associated with areas characterized by undefined and secure property rights. Low government revenues from these areas also mean low budgetary allocations for the provision of health and other infrastructure and services [102]. From a data perspective, the instability of persons and neighborhoods without secure tenure also presents a data problem, which is required for undertaking infrastructural and service interventions to improve health or reduce health burdens [103]. Beyond governments providing infrastructure and services, self-help provision, investment, and improvement of basic infrastructure and services are inhibited by the absence of secure tenure. This makes a difference in livelihood and health outcomes as it, for example, limits private provision of sanitation in deprived urban neighborhoods [100]. Neighborhoods with ample physical infrastructure and amenities such as housing, water supply, sanitation, basic drainage, and public space are less prone to poor health and disease contagion. Bhardwaj et al. [104] debunked claims of urban density rendering cities vulnerable to diseases and posit that density is not the problem but infrastructure. To leverage the health benefit of infrastructure however requires that people have secure tenure to access physical infrastructure and amenities to lower their health risks. Giving people secure tenure rights not only enables access to state provided infrastructure but can unleash investment in private infrastructure [105–107], which is an incremental

and pro-poor approach to meeting infrastructure needs of urban neighborhoods, given that it is expensive to implement all the infrastructure needs of urban areas. Thus, when people have secure tenure, they can improve their living conditions and health through undertaking self-supportive basic infrastructural investment and improvement. According to Gomes et al. [108], land tenure insecurity inhibits the construction of definitive houses, which in their view makes homes vulnerable to Chagas diseases.
