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Article

Ndola Prata and Karen Weidert

Adolescence, spanning 10 to 19 years of age, begins with biological changes while transitioning from a social status of a child to an adult. For millions of adolescents in low- and middle-income countries (LMICs), this is a period of exposure to vulnerabilities and risks related to sexual and reproductive health (SRH), compounded by challenges in having their SHR needs met. Globally, adolescent sexual and reproductive ill-health disease burden is concentrated in LMICs, with sexually transmitted infections and complications from pregnancy and childbirth accounting for the majority of the burden. Adolescents around the world are using their voices to champion access to high-quality, comprehensive SRH information and services. Thus, it is imperative that adolescents’ SRH and rights be reinforced and that investments in services be prioritized.

Article

The design of municipal water tariffs requires balancing multiple criteria such as financial self-sufficiency for the service provider, equity among customers, and economic efficiency for society. Globally, various forms of water tariffs are in use (e.g., tariffs based on fixed or volumetric charges, single and two-part tariffs, and increasing or decreasing block tariffs) but increasing block tariffs (IBTs) have become popular worldwide over the last few decades for two main reasons. Apart from the fact that IBTs incentivize households to save water by charging large volumes at a higher price, there is a widespread belief that IBTs are pro-poor. The latter would be the consequence of providing all households with a minimum amount of water at a low (subsidized) price while large water users pay higher prices. However cross-subsidization between wealthy and poor households will occur only if poor households’ consumption falls in the low (subsidized) block and if rich households consume in the higher block and pay a price that is above the average cost of supply. These two conditions are rarely met in reality and IBTs often fail to allocate subsidies to the poor effectively. There are a few examples of water utilities making adjustments to the tariff to take into account that poor households with large families are likely to be adversely affected by IBTs. However, the provision of a minimum amount of water for free (as in South Africa), the design of household-specific low-cost water allowances (as in California), or tariffs being adjusted based on household size do not usually improve the targeting of subsidies to the poorest households. The widespread use of IBTs is difficult to rationalize, in particular while knowing that the use of a (simple) uniform volumetric tariff where water provision is charged at its full cost could improve social welfare by removing price distortions and would be easier for households to understand than IBTs. This simple tariff could be combined with some consumer assistance programs to help the poorest households pay their bills.

Article

Water planners and policy analysts need to pay closer attention to the behavioral aspects of water use, including the use of nonprice measures such as norms, public communications, and intrinsic motivations. Empirical research has shown that people are motivated by normative as well as economic incentives when it comes to water. In fact, this research finds that after exposure to feedback about water use, adding an economic incentive (rebate) for reducing water use holds no additional power. In other cases, nonprice measures can be a way to increase the salience, and subsequently, effectiveness of any adopted pricing mechanisms. We review these empirical findings and locate them within more general literature on normative incentives for behavioral change. Given increasing water scarcity and decreasing water security in cities, policy planners need to make more room for normative incentives when designing rules for proenvironmental behavior.

Article

Lillian Abracinskas and Santiago Puyol

As time goes by, the world experiences advances and setbacks in the field of sexual and reproductive health and rights. But new challenges appear in terms of professional performance and implementation of services created by newer laws and policies. The development of new ethical frames in dialogue with disputed value systems is one of the main obstacles to ensuring universal access and comprehensive services to guarantee the exercise of these rights. Since 2002, Uruguay has been one of the few countries in Latin America and the Caribbean that has achieved significant advances regarding sexual and reproductive rights by recognizing them as human rights. The passage of several laws has resulted in the implementation of programs in SRHS and legal abortion as being considered mandatory for the National Health System. The follow-up and monitoring of this process by the Observatory of Mujer y Salud en Uruguay (MYSU) has demonstrated how changes in the legal framework led to a new stage for health-care providers, politicians, and decision makers and also for the social movement that has historically advocated for this agenda, all now facing new problems and challenges—some of which are completely unexpected. The high prevalence of conscientious objection exercised by physicians and OB/GYNs in refusing the provision of care in SRHS is one of the ethical dilemmas that needs to be discussed to innovate solutions to the problems and promote best practices from a gender equity and human rights paradigm.

Article

Célia Landmann Szwarcwald, Maria do Carmo Leal, Wanessa da Silva de Almeida, Mauricio Lima Barreto, Paulo Germano de Frias, Mariza Miranda Theme Filha, Rosa Maria Soares Madeira Domingues, Elisabeth Barboza Franca, Silvana Granado Nogueira da Gama, Cristiano Sigueira Boccolini, and Cesar Victora

Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis. Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.

Article

Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta

Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings. Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.

Article

Ine Vanwesenbeeck

Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.

Article

Organizations regulating the water sector have major impacts on public health and the sustainability of supply to households, industry, power generation, agriculture, and the environment. Access to affordable water is a human right, but it is costly to produce, as is wastewater treatment. Capital investments required for water supply and sanitation are substantial, and operating costs are significant as well. That means that there are trade-offs among access, affordability, and cost recovery. Political leaders prioritize goals and implement policy through a number of organizations: government ministries, municipalities, sector regulators, health agencies, and environmental regulators. The economic regulators of the water sector set targets and quality standards for water operators and determine prices that promote the financial sustainability of those operators. Their decisions affect drinking water safety and sanitation. In developing countries with large rural populations, centralized water networks may not be feasible. Sector regulators often oversee how local organizations ensure water supply to citizens and address wastewater transport, treatment, and disposal, including non-networked sanitation systems. Both rural and urban situations present challenges for sector regulators. The theoretical rationale for water-sector regulation address operator monopoly power (restricting output) and transparency, so customers have information regarding service quality and operator efficiency. Externalities (like pollution) are especially problematic in the water sector. In addition, water and sanitation enhance community health and personal dignity: they promote cohesion within a community. Regulatory systems attempt to address those issues. Of course, government intervention can actually be problematic if short-term political objectives dominate public policy or rules are established to benefit politically powerful groups. In such situations, the fair and efficient provision of water and sanitation services is not given priority. Note that the governance of economic regulators (their organizational design, values or principles, functions, and processes) creates incentives (and disincentives) for operators to improve performance. Related ministries that provide oversight of the environment, health and safety, urban and housing issues, and water resource management also influence the long-term sustainability of the water sector and associated health impacts. Ministries formulate public policy for those areas under their jurisdiction and monitor its implementation by designated authorities. Ideally, water-sector regulators are somewhat insulated from day-to-day political pressures and have the expertise (and authority) to implement public policy and address emerging sector issues. Many health issues related to water are caused or aggravated by lack of clean water supply or lack of effective sanitation. These problems can be attributed to lack of access or to lack of quality supplied if there is access. The economic regulation of utilities has an effect on public health through the setting of quality standards for water supply and sanitation, the incentives provided for productive efficiency (encouraging least-cost provision of quality services), setting tariffs to provide cash flows to fund supply and network expansion, and providing incentives and monitoring so that investments translate into system expansion and better quality service. Thus, although water-sector regulators tend not to focus directly on health outcomes, their regulatory decisions determine access to safe water and sanitation.

Article

For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations. Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health. It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.

Article

Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water. Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries. A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries. Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.

Article

R. Quentin Grafton, Long Chu, and Paul Wyrwoll

Water insecurity poses threats to both human welfare and ecological systems. Global water abstractions (extractions) have increased threefold over the period 1960–2010, and an increasing trend in abstractions is expected to continue. Rising water use is placing significant pressure on water resources, leading to depletion of surface and underground water systems, and exposing up to 4 billion people to high levels of seasonal or persistent water insecurity. Climate change is deepening the risks of water scarcity by increasing rainfall variability. By the 2050s, the water–climate change challenge could cause an additional 620 million people to live with chronic water shortage and increase by 75% the proportion of cropland exposed to drought. While there is no single solution to water scarcity or water justice, increasing the benefits of water use through better planning and incentives can help. Pricing is an effective tool to regulate water consumption for irrigation, for residential uses, and especially in response to droughts. For a water allocation to be efficient, the water price paid by users should be equal to the marginal economic cost of water supply. Accounting for all costs of supply is important even though, in practice, water prices are typically set to meet a range of social and political objectives. Dynamic water pricing provides a tool for increasing allocative efficiency in short-term water allocation and the long-term planning of water resources. A dynamic relationship exists between water consumption at a point in time and water scarcity in the future. Thus, dynamic water pricing schemes may take into account the benefit of consuming water at that time and also the water availability that could be used should a drought occur in the future. Dynamic water pricing can be applied with the risk-adjusted user cost (RAUC), which measures the risk impact of current water consumption on the welfare of future water users.

Article

Unconventional natural gas development (UNGD), which includes the processes of horizontal drilling and hydraulic fracturing to extract natural gas from unconventional reservoirs such as shale, has dramatically expanded since 2000. In parallel, concern over environmental and community impacts has increased along with the threats they pose for health. Shale gas reservoirs are present on all continents, but only a small proportion of global reserves has been extracted through 2016. Natural gas production from UNGD is highest in the United States in Pennsylvania, Texas, Louisiana, Oklahoma, and Arkansas. But unconventional production is also in practice elsewhere, including in eighteen other U.S. states, Canada, and China. Given the rapid development of the industry coupled with its likelihood of further growth and public concern about potential cumulative and long-term environmental and health impacts, it is important to review what is currently known about these topics. The environmental impacts from UNGD include chemical, physical, and psychosocial hazards as well as more general community impacts. Chemical hazards commonly include detection of chemical odors; volatile organic compounds (including BTEX chemicals [benzene, toluene, ethylbenzene, and xylene], and several that have been implicated in endocrine disruption) in air, soil, and surface and groundwater; particulate matter, ozone, and oxides of nitrogen (NOx) in air; and inorganic compounds, including heavy metals, in soil and water, particularly near wastewater disposal sites. Physical hazards include noise, light, vibration, and ionizing radiation (including technologically enhanced naturally occurring radioactive materials [TENORMs] in air and water), which can affect health directly or through stress pathways. Psychosocial hazards can also operate through stress pathways and include exposure to increases in traffic accidents, heavy truck traffic, transient workforces, rapid industrialization of previously rural areas, increased crime rates, and changes in employment opportunities as well as land and home values. In addition, the deep-well injection of wastewater from UNGD has been associated with increased seismic activity. These environmental and community impacts have generated considerable concern about potential health effects and corresponding political debate over whether UNGD should be promoted, regulated, or banned. For several years after the expansion of the industry, there were no well-designed, population-based studies that objectively measured UNGD activity or associated exposures in relation to health outcomes. This delay is inherent after the introduction of new industries, but hundreds of thousands of wells were drilled before any health studies were completed. By 2017, there were a number of important, peer-reviewed studies published in the scientific literature that raised concern about potential ongoing health impacts. These studies have reported associations between proximity to UNGD and pregnancy and birth outcomes; migraine headache, chronic rhinosinusitis, severe fatigue, and other symptoms; asthma exacerbations; and psychological and stress-related concerns. Beyond its direct health impacts, UNGD may be substantially contributing to climate change (due to fugitive emissions of methane, a powerful greenhouse gas), which has further health impacts. Certain health outcomes, such as cancer and neurodegenerative diseases, cannot yet be studied because insufficient time has passed in most regions since the expansion of UNGD to allow for latency considerations. With the potential for tens of thousands of additional wells across large geographic areas, these early health studies should give pause about whether and how UNGD should proceed. Citing health concerns, several U.S. states and nations in Europe have already decided to not allow UNGD.

Article

Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss

The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions. The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.

Article

Since the 1970s, global goal setting to increase access to safe drinking water has taken a number of different approaches to whether water should be primarily understood as a “human right” or a “human need.” In the Mar del Plata declaration of 1977, states both recognized a human right to water and committed themselves to achieving universal access by 1990. By the 1990 New Delhi Statement, with universal access still out of reach, the goal was renewed with a new deadline of 2000, but water was described as a human need rather than a human right. This approach was coupled with an emphasis on water’s economic values and the need for increased cost recovery, which in turn increased the focus on, and uptake of, private-sector participation in the delivery of water and sanitation services across the Global South. A similar needs-based approach was adopted at the start of the new millennium in Target 7 of the Millennium Development Goals (MDGs), but during this decade a consensus on the recognition of the human right to water also emerged in international law. As the normative status and content of this right came to be better articulated and understood, it began to influence the practice of providing water and sanitation services, and by the end of the MDG process a rights-based approach featured more prominently in the Sustainable Development Goals (SDGs) of 2015. While the provision of water and sanitation services is multifaceted, the evidence of global achievements from the 1970s onward indicates that a rights-based approach increases the priority given to the social values of such services and focuses attention on the need to go beyond technical solutions to address the structural issues at the heart of water inequality. Going forward, approaches to the provision of water and sanitation services and the human right to water will need to continue to adapt to new challenges and to changing conceptualizations of water, including the growing recognition that all living things have a right to water and that water itself can have rights.

Article

The end of the Cold War brought far-reaching world changes in many areas, including the health field. A number of “new” terms emerged (such as global health, global governance, and global health governance or global governance for health), among them global health diplomacy (or health diplomacy). There is no single, consensual definition of this term, and still less are there theoretical and analytical frameworks or empirical data to help understand its meaning and practice more clearly. Global health diplomacy is a sociopolitical practice involving the global health policy community, which promotes the interrelationship between health and foreign policy both at the national level, through cooperation projects or international actions and, in international arenas, by acting in global political space in the widest range of spheres, whether health-sector-related or otherwise.

Article

Emily Q. Ahonen, Sherry L. Baron, Lisa M. Brosseau, and Alejandra Vives

Standard employment arrangements—where the relationship between employers and employees is clear and employment is full-time, understood to be lasting, and with full protections—coexist with nonstandard employment (NSE) relationships. A variety of terms have been used to describe specific types of NSE including temporary, contingent, contract, freelance, on-call, gig, and app-based employment. These forms of employment, in combination with larger social and economic forces, structural power dynamics, and advances in technology, can work together to limit the ways in which employment supports health, and undermine workplace health protections. Nonstandard employment brings with it particular concerns for health and safety related to work, and in a broader public health sense. Health can be protected in NSE through intervention at national, state and province, and local levels to proactively shape the quality of employment arrangements.

Article

Catherine A. O'Donnell

Migration is a reality of today’s world, with over one billion migrants worldwide. While many choose to move voluntarily, others are forced to migrate due to economic reasons or to flee war, conflict, or persecution. Such migrants often find themselves in precarious and marginalized situations—particularly asylum seekers, refugees, and undocumented or irregular migrants. While often viewed as a single group, the legal status and entitlements of these three groups are different. This has implications for their ability to access health care; in addition, rights and entitlements vary across the 28 countries of the European Union and across different parts of national health systems. The lack of entitlement to receive care, including primary and secondary care, is a significant barrier for many asylum seekers and refugees and an even greater barrier for undocumented migrants. Other barriers include different health profiles and awareness of chronic disease risk amongst migrants; awareness of the organization of health systems in host countries; and language and communication. The use of professional interpreters can help to overcome communication barriers, but entitlement to free interpreting services is highly variable. Host countries need to consider how to ensure their health systems are “migrant-friendly”: solutions include provision of professional interpreters; ensuring that health care staff are aware of migrants’ rights to access health care; and increasing knowledge of migrants in relation to the organization of the health care system in their host country and how to access care, for example through the use of patient navigators. However, perhaps one of the greatest facilitators for migrants will be a more favorable political situation, which stops demonizing people who are forced to migrate due to situations out of their control.

Article

The construction of the concepts of diplomacy and health diplomacy must consider their conceptions and practices, at both the global and regional levels. Health diplomacy is vitally important in a global context, where health problems cross national borders and more new stakeholders appear every day, both within and outside the health sector. On the other hand, regional integration processes provide excellent opportunities for collective actions and solutions to many of the health challenges at the global level. In the current global context, the best conditions for dealing with many health challenges are found at the global level, but the regional and subregional spheres also play essential roles. The region of Latin America and the Caribbean (LAC) consists of 26 countries or territories that occupy a territory of 7,412,000 square miles—almost 13% of the Earth’s land surface area; it extends from Mexico to Patagonia, where about 621 million people live (as of 2015), distributed among different ethnic groups. Geographically, it is divided into Mexico and Central America, the Caribbean, and South America, but it presents subregions with populations and cultures that are a little more homogenous, like the subregions of the Andes and the English Caribbean. By its characteristics, LAC has acquired increasing global political and economic importance. In the 1960s, integration processes began in the region, including the creation of the Union of South American Nations (UNASUR), Mercosur, the Andean Community, the Caribbean Community (CARICOM), the Central American System, the Bolivarian Alliance for the Peoples of Our America (ALBA), the Amazon Cooperation Treaty Organization (ACTO), the Sistema Económico Latinoamericano y del Caribe (SELA), the Asociación Latinoamericana de Integración (ALADI), and finally, since 2010, the Community of Latin American and Caribbean States (Comunidad de Estados Latinoamericanos y Caribeños, or CELAC), which is the most comprehensive integrative organization. While originally a mechanism for political and economic integration, health is now an important component of all the abovementioned integration processes, with growing social, political, and economic importance in each country and in the region, currently integrating the most important regional and global negotiations. Joint protection against endemic diseases and epidemics, as well as noncommunicable diseases, coordination of border health care, joint action on the international scene (particularly in multilateral organizations such as the United Nations and its main agencies), and the sectoral economic importance of health are among the main situations and initiatives related to health diplomacy in these integration processes. The effectiveness of integration actions—and health within those actions—varies according to the political orientations of the national governments in each conjuncture, amplifying or reducing the spectrum of activities performed. The complexity of both the present and future of this rich political process of regional health diplomacy is also very important for global health governance (GHG).

Article

José Gomes Temporão and Carlos Augusto Grabois Gadelha

The health economic-industrial complex concept was developed in Brazil in the early 2000s, integrating a structuralist view of the political economy with a public health vision. This perspective advances, in relation to sectoral approaches in health industries and services, toward a systemic approach to the productive environment, focusing on the dimensions of innovation and universal access to health. Health production is seen in an interdependent way, recognizing that the different industrial and service sectors have strong articulations that need to be integrated. The shift toward a universal care model that focuses on human and social needs requires a productive knowledge base that favors promotion, prevention, and local and permanent healthcare, requiring new productive patterns of goods and services and innovation. Therefore, these dimensions are not conceptually apart from each other, considering an analytical and political point of view. The production, care, and sustainability of universal health systems are understood in an integrated and systemic way. Within this vision, a cognitive leap is presented in relation to the traditional health economics, linked to the allocation of scarce resources, to a vision of health political economy that favors the development, expansion, and transformation of the health system and its economic and industrial base. Health is conceived as a moral right of citizenship and a vital space for the development of countries (and for global health), generating social inclusion, equity, innovation, and a possibility for the cooperation between countries and peoples. The Brazilian experience is an exemplary case of association between the development of theoretical conception and its implementation in the national health policy that led to the link between economic development policies and social policies. It was possible to advance both conceptually in terms of a vision of health and social well-being and in contributing to a new paradigm of public policies. This perspective allowed the guidance of guide industrial development and services toward the human needs and universal health systems, considering the challenges brought by the context of an ongoing fourth technological revolution.

Article

Juan Garay, David Chiriboga, and Nefer Kelley

This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Global Public Health. Please check back later for the full article. There is one common health objective by all nations, as stated in the constitution of the World Health Organization of 1947: the progress toward the best feasible level of health for all people. This goal captures the concept of health equity: fair distribution of unequal health. However, 70 years later, this common global objective has never been measured. Most of the available literature focuses on measuring health inequalities, not inequities, and tends to concentrate on comparisons among population subgroups, specific health risks, diseases, or health services, thereby indirectly contributing to the high fragmentation of health policies, actions, and even constituencies and resulting in competition for funds and/or priority. A method to identify standards for the best feasible levels of health through criteria of healthy, replicable, and sustainable (HRS) models is needed. The avoidable death toll has not improved significantly since the 1970s. Younger age groups (though gradually shifting toward older age groups) and women are most affected. Data analysis of smaller sample units (such as provinces, states, counties, or municipalities) increases the sensitivity of measurement and detects higher levels of health inequity. Most of the burden of health inequity takes place in countries with levels of income per capita below the average of the HRS countries, which is called the “dignity threshold” (the economic condition threshold necessary to enjoy the best feasible levels of health). Based on this threshold, it is possible to estimate the necessary distribution of the world’s resources compatible with the universal right to health—“the equity curve.” Income above the upper thresholds, and hence wealth accumulation, prevents others from living in conditions of dignity compatible with the universal right to health, is correlated with a carbon footprint above the ethical sustainable threshold, and does not translate into better health nor well-being. The international redistribution of wealth required to enable all nations to have at least an average per capita income above the dignity threshold would be around 8%, much higher than the present, nonbinding, and volatile levels of international cooperation, which currently lack an equity approach. At subnational levels, the burden of health inequity can be the most sensitive barometer of socioeconomic justice among territories and the population, informing and directing fiscal and territorial equity schemes to enable all people within and between nations to enjoy the universal right to health. HRS models can also inspire lifestyles, political, and economic frameworks that increase efficiency, replicability, and sustainability of ethical well-being without undermining the rights of others in present and future generations.