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Article

Behavioral Interventions as Policy Instruments to Manage Household Water Use  

Leong Ching and Swee Kiat Tay

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

Brasília’s Experience With Wastewater Treatment Systems: A Case Study  

Klaus Dieter Neder

Brasília is one of the few large cities in the developing world that provides full coverage of sanitation services for its population, including the collection of wastewater and adequate wastewater treatment. Caesb, the local water and sanitation utility, has developed a lot of experience in the planning, design, construction, and operation of sanitation systems, with a special emphasis on the need to use appropriate treatment technologies. Today, serving a population of more than three million people, Caesb runs 16 wastewater treatment plants, using technologies from very simple natural treatment processes, such as stabilization ponds and overland flow processes, to very sophisticated units, including tertiary activated sludge plants, with flotation as an effluent-polishing treatment step. During the development of the several different sanitation solutions, Caesb has found that it has been best to use simple, natural, low-cost treatment processes to achieve feasible and sustainable solutions even when, in specific circumstances, more sophisticated processes are required. The desire to increase the sustainability of the treatment plants has also stimulated Caesb to improve the performance of the applied treatment processes, which was achieved by the implementation of several modifications aimed at reducing costs and improving the efficiency of the plants. Today, the treatment of all wastewater produced in the city guarantees the quality of the discharge to the point that water bodies located downstream of wastewater treatment plants are used as resources for water supply for the city.

Article

Case Study of the Federal District of Brasília: CAESB’s Experience With Condominial Sewerage  

Maria Martinele Feitosa Martins and César Augusto Rissoli

Brasília, the capital of Brazil, which is located in the Federal District, has one of the highest sanitary sewerage connection rates in the country. More than 92% of its more than 3 million inhabitants are served by sewage collection and treatment systems, and Companhia de Saneamento Ambiental do Distrito Federal (CAESB), the local public sanitation company, is firmly committed to reaching universal coverage. A condominial sewerage system has been used by CAESB as a powerful tool to make universal coverage possible. The system offers advantages in reduced costs and guaranteed connections and a close partnership with the community. Installed throughout the Federal District beginning in the early 1990s, this system has provided effective service to more than 1.6 million inhabitants of all social classes, which has contributed to the resurgence of civic participation and improved the population’s quality of life.

Article

Community Directed Approaches for Health Improvement  

William R. Brieger and Bright C. Orji

The community-directed intervention (CDI) strategy is an approach in which communities themselves direct the planning and implementation of intervention delivery fostered with support from the Special Programme for Research and Training in Tropical Diseases of the World Health Organization and partners. This approach grew out of the onchocerciasis control effort in Africa and has been piloted in several African countries, such as Nigeria and Kenya. The approach would become a stimulus for developing primary health care (PHC) services in remote and previously unreached rural villages. Empirical works across countries indicated that CDI is an accepted and effective strategy in the mass treatment of schistosomiasis and soil transmitted helminths (STH) infections. That will further support technical skill and institutional knowledge on mass treatment across countries using a standard approach. Staff orientation and training were needed to get programs off the ground since few staff had basic training in the benefits and procedures of organizing community participation. However, technical training to perform these health tasks did not guarantee that services would reach communities where participation was not the underlying value of the system. The team aimed to trace the development and evolution of CDI from community-directed treatment with ivermectin (CDTI), a focused disease control effort for onchocerciasis/river blindness; adapt the approach to address other health and development needs; and examine the challenges CDI has faced, which are not unlike those experienced by PHCs.

Article

Conceptual and Practical Aspects of Water Regulation in Developing Countries  

Sanford V. Berg

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

Disability and Rural Health  

Rayna Sage, Genna Mashinchi, and Craig Ravesloot

The ways in which disability impacts people and their health in rural places are a result of the interaction between the person and the rural environment in which they live. Disability is defined as ongoing difficulties engaging in daily activities and social roles due to physical or mental conditions. The United Nations Convention on the Rights of People with Disabilities (UN-CRPD) implemented policy in 2008 that recognized that disabled people are worthy of autonomy and dignity. The social and physical environment are constructed in ableist ways that make it difficult for people with disabilities to realize their independence and this is particularly true in many rural places. Person–environment fit and urbanormativity (the favoring of urban spaces at the expense of rural ones) are important concepts in understanding the experiences of rural disabled people. There is little existing research regarding the epidemiology of disability and rural health, but rural people report higher and earlier rates of disability than urban people and rural places have higher rates of older adults with higher rates of disability. Furthermore, rural people with disabilities experience various secondary health conditions and higher rates of mortality compared to urban people with disabilties. The lack of access to health care and advocacy help explain some of the differences in health outcomes when comparing rural and urban people. The disability rights movement led to the creation of different types of advocacy and service organizations across the globe to address these disparities. An important way to improve the experiences and health of rural people with disabilities is to ensure they have access to quality and dependable in-home services and community-based rehabilitation, which currently tend to be under-funded with dramatic worker shortages in many rural places. A final promising approach to improving the health of rural disabled people is through evidence-based health promotion programming that targets early indicators of health problemsand recovery and health-sustaining efforts following a health problem.

Article

Ensuring the Public Value of Long-Term Care Services  

Joseph E. Ibrahim

Many seniors needing social and clinical care come from vulnerable populations that have difficulty accessing services, a great need for those services, and/or potentially impaired decision-making skills. At the same time, when seniors use services on a routine basis, they become increasingly dependent on the individual service provider. The aged care sector has a duty to provide “public value”—that is, to provide a valuable contribution to society within existing resource constraints. This requires more than simply addressing the basic individual needs of care recipients. Ethical factors must be considered in policies around services to vulnerable seniors and potential issues in addressing suboptimal quality of care, neglect, and abuse of seniors, as demonstrated by continuing public news of poor care provided to seniors in nursing homes, social care, and residential care settings.

Article

Health Care Access for Migrants in Europe  

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 Health Economic-Industrial Complex (HEIC) and a New Public Health Perspective  

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

Health for All and Primary Health Care, 1978–2018: A Historical Perspective on Policies and Programs Over 40 Years  

Susan B. Rifkin

In 1978, at an international conference in Kazakhstan, the World Health Organization (WHO) and the United Nations Children’s Fund put forward a policy proposal entitled “Primary Health Care” (PHC). Adopted by all the World Health Organization member states, the proposal catalyzed ideas and experiences by which governments and people began to change their views about how good health was obtained and sustained. The Declaration of Alma-Ata (as it is known, after the city in which the conference was held) committed member states to take action to achieve the WHO definition of health as “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Arguing that good health was not merely the result of biomedical advances, health-services provision, and professional care, the declaration stated that health was a human right, that the inequality of health status among the world’s populations was unacceptable, and that people had a right and duty to become involved in the planning and implementation of their own healthcare. It proposed that this policy be supported through collaboration with other government sectors to ensure that health was recognized as a key to development planning. Under the banner call “Health for All by the Year 2000,” WHO and the United Nations Children’s Fund set out to turn their vision for improving health into practice. They confronted a number of critical challenges. These included defining PHC and translating PHC into practice, developing frameworks to translate equity into action, experiencing both the potential and the limitations of community participation in helping to achieve the WHO definition of health, and seeking the necessary financing to support the transformation of health systems. These challenges were taken up by global, national, and nongovernmental organization programs in efforts to balance the PHC vision with the realities of health-service delivery. The implementation of these programs had varying degrees of success and failure. In the future, PHC will need to address to critical concerns, the first of which is how to address the pressing health issues of the early 21st century, including climate change, control of noncommunicable diseases, global health emergencies, and the cost and effectiveness of humanitarian aid in the light of increasing violent disturbances and issues around global governance. The second is how PHC will influence policies emerging from the increasing understanding that health interventions should be implemented in the context of complexity rather than as linear, predictable solutions.

Article

Health Status of Refugees and Asylum Seekers in Europe  

Rachel Humphris and Hannah Bradby

The health status of refugees and asylum seekers varies significantly across the European region. Differences are attributed to the political nature of the legal categories of “asylum seeker” and “refugee”; the wide disparities in national health services; and the diversity in individual characteristics of this population including age, gender, socioeconomic background, country of origin, ethnicity, language proficiency, migration trajectory, and legal status. Refugees are considered to be at risk of being or becoming relatively “unhealthy migrants” compared to those migrating on the basis of economic motives, who are characterized by the “healthy migrant effect.” Refugees and asylum seekers are at risk to the drivers of declining health associated with settlement such as poor diet and housing. Restricted access to health care whether from legal, economic, cultural, or language barriers is another likely cause of declining health status. There is also evidence to suggest that the “embodiment” of the experience of exclusion and marginalization that refugee and asylum seekers face in countries of resettlement significantly drives decrements in the health status of this population.

Article

The Intersections of Resistance and Health  

Ryan Essex

Resistance refers to a range of actions such as marches, strikes, and civil disobedience. It also refers to less visible and even hidden acts like sabotage. Perhaps more subtly, it refers to discourse and knowledge; how issues are thought or spoken about could be an act of resistance. While the concept of resistance is far from settled, it is a concept that has broad applications and has been applied to better understand a range of actions and struggles. Its relationship to health, however, has often been overlooked or taken for granted. This is despite resistance having an influential role in securing a number of important health related gains and pushing back against powers that would otherwise harm health. Resistance has also been triggered by concerns about health, or framed around issues related to health. The intersections of resistance and health, however, are far more complex. Resistance has challenged and shaped health related knowledge and practice, and health in itself has been used as an act of resistance. Charting the intersections of health and resistance is not only important in itself; it also sheds light on how disruption, dispute, and opposition can shape health and well-being.

Article

Mental Health of Migrant Children  

Saida M. Abdi

The psychosocial well-being of migrant children has become an urgent issue facing many Western countries as the number of migrant children in the population increases rapidly and health-care systems struggle to support them. Often, these children arrive with extensive exposure to trauma and loss before facing additional stressors in the host country. Yet, these children do not access mental health support even when available due to multiple barriers. These barriers include cultural and linguistic barriers, the primacy of resettlement needs, and the stigma attached to mental health illness. In order to improve mental health services for migrant children, there is a need to move away from focusing on trauma and mental health symptoms and to look instead at migrant children’s well-being across multiple domains, including activities that can promote or diminish psychological well-being. Trauma Systems Therapy for Refugees (TST-R) is an example of an approach that has succeeded in overcoming these barriers by adopting a culturally relevant and comprehensive approach to mental health care.

Article

Preventing Falls Through Service Innovations: Institutional and Hospital Settings  

Keith Hill

Falls in hospital and residential care settings are common events that can have major impacts for the older person, their families, and staff and also at an organizational level. They are a major trigger event for those with chronic health problems to advance to greater levels of care because they often result in traumatic injuries while they provide a signal event for declining health that may have gone unobserved before injury. Falls among older people in hospital and residential care settings are often caused by a complex mix of risk factors and have proved difficult to prevent. There is growing research evidence that a mix of universal falls prevention interventions that are applied to all patients or residents, as well as targeted interventions addressing one or more identified personal and environmental falls risk factors (often based on a falls risk factor assessment and environmental assessment) can help to reduce risk of future falls in hospitals and residential care. Preventing falls among older people in hospitals and residential care settings requires a complete staff and organizational focus.

Article

Public Health and the UN Sustainable Development Goals  

Claire E. Brolan

The COVID-19 crisis—the most catastrophic international public health emergency since the Spanish influenza 100 years ago—provides impetus to review the significance of public and global health in the context of Sustainable Development Goal (SDG) achievement. When countries unanimously adopted the 17 SDGs in September 2015, stakeholders had mixed views on global health goal SDG 3 (Good Health and Well-Being). Concern arose over the feasibility of achieving SDG 3 by 2030 when countries pursued its nine targets and four means of implementation with sixteen other ambitious global goals. Nonetheless, health surely cuts across the SDG framework: for instance, the underlying health determinants are expressed in many goals as is urban and planetary health. Although health (and its different constructions) is central to overall SDG achievement, SDG success depends on a paradigm shift toward whole-of-government policy and planning. Indeed, the 2030 Agenda echoes calls for a Health in All Policies (HiAP) approach to public health programming. This depends on another paradigm shift in public health tertiary education, practitioner training, and policy skills development within and beyond ministries of health. Added to this are the underlying problematics around SDG health financing, human resources for health, health target and indicator localization for equitable country responses that leave no one behind, strengthening civil registration and vital statistics systems for inclusive and accountable health implementation, and the sidelining of human rights from SDG metrics. While COVID-19 has derailed SDG efforts, it could also be the ultimate game changer for intergenerational human and environmental health transformation. Yet strong global health governance and rights-based approaches remain key.

Article

Public Sector Participation in the Water Sector: Opportunities and Pitfalls  

Sebastian Galiani

Water is one the most indispensable human needs. Although pumped wells, bottled water, or public faucets are used in many parts of the world as means to obtain this crucial good, piped water services are considered the gold standard to ensure wide, regular, and secure access. At first glance, piped water services have all the characteristics of a natural monopoly in which the government is better positioned for provision than the private sector: high sunk costs and economies of scale are present, and the quality of the service is costly to supervise. However, in that first intuition, there is one missing block: government behavior. In countries with low state capacity and accountability, weak checks and balances, and institutional dysfunction, public companies are frequently used to fulfill political goals instead of their stated objectives. In those cases, privatization coupled with the creation of an independent regulatory agency can limit the predatory capacity of the government, displace the service to the sphere of private incentives, and provide the opportunity to extend coverage and improve quality. There is, nonetheless, a fragile side to this solution. If the same institutional vulnerabilities that create poor public companies’ management persist, incentives for predatory government behavior remain latent and can emerge when circumstances facilitate it. This whole parable was observed with the privatization of Obras Sanitarias de la Nación in Argentina. First, a paralyzed and overstaffed public company was replaced by a dynamic private company. During this period, more than 2 million people gained access to the water service and 1.2 million people gained access to the sewage networks, which substantially improved health outcomes for the newly incorporated groups. Then a big economic crisis hit the contractual relationship between the government and the company, and renationalization took place. This change was paired with a return of previously observed predatory practices such as unsustainable pricing policy and non-meritocratic appointments.

Article

The Role of Service User Preferences and User-Centered Approaches in Adult Social Care  

Helen Dickinson and Robin Miller

In recent years we have seen growing interest in a range of countries around how service user preferences can be accommodated in adult social care and how these services might be oriented to be more user-centered. There is a diverse array of different initiatives that might be classified as creating more user-centered approaches. Those at the strategic (macro) and organizational (meso) levels typically have greater amounts of evidence available than those at the individual (micro) level. However, many of these struggle to significantly disrupt power relations and clearly demonstrate an impact on service users. Those at the micro level more readily demonstrate impact, although the very local nature of these interventions means that they are not always well evaluated, and lessons may not be easy to transfer from one context to another. Overall, there is no system that has managed to reorient its adult social care system in a wholesale way; this is an issue that requires both technical and cultural change. Such changes take time to achieve, but there is much that can be learned from the existing evidence base.

Article

Urban Health and Disaster Resilience  

David Sanderson, Ronak Patel, and Kelsey Gleason

As cities and towns across the world continue to grow to accommodate most of the world’s population increase, so too are they increasingly and often disproportionately exposed to the threat of natural hazards—including those worsened by climate change—such as floods, earthquakes, windstorms, and fires. Efforts that aim to enhance and safeguard urban health are those that seek to build the resilience of people and systems before, during, and after disasters. Yet where these efforts fail or fail to exist, components of vulnerability and urban diversity inform disaster risk. Taking a systems approach is especially essential to recognize the interconnected, complex, and dynamic issues that include and impact on the spectrum of urban health.

Article

Violence and Health  

Maria Cecília de Souza Minayo and Saul Franco

Violence is a problem that accompanies the trajectory of humanity, but it presents itself in different ways in each society and throughout its historical development. Despite having different meanings according to the field of knowledge from which it is addressed and the institutions that tackle it, there are some common elements in the definition of this phenomenon. It is acknowledged as the intentional use of force and power by individuals, groups, classes, or countries to impose themselves on others, causing harm and limiting or denying rights. Its most frequent and visible forms include homicides, suicides, war, and terrorism, but violence is also articulated and manifested in less visible forms, such as gender violence, domestic violence, and enforced disappearances. Although attention to the consequences of different forms of violence has always been part of health services, its formal and global inclusion in health sector policies and guidelines is very recent. It was only in 1996 that the World Health Organization acknowledged it as a priority in the health programs of all countries. Violence affects individual and collective health; causes deaths, injuries, and physical and mental trauma; decreases the quality of life; and impairs the well-being of people, communities, and nations. At the same time, violence poses problems for health researchers trying to understand the complexity of its causes, its dynamics, and the different ways of dealing with it. It also poses serious challenges to health systems and services for the care of victims and perpetrators and the formulation of interdisciplinary, multi-professional, inter-sectoral, and socially articulated confrontation and prevention policies and programs.

Article

Water Tariffs in Spain  

Fernando Arbués and Marián García-Valiñas

In the current context of climate change, water scarcity has become the center of an intense debate in recent years. Spain is a country affected by strong regional differences in terms of weather; thus, the quality and availability of water resources vary widely depending on the area, and the country is plagued by droughts and problems with water quality. Nevertheless, urban water prices in Spain are among the lowest in the European Union. Moreover, it is a federal country where subcentral governments (regional and local) are autonomous entities with different responsibilities in the design of water policies. The extremely atomized local panorama and the strong power of the regional governments have led to a highly complex system with a wide range of water price levels and structures. Since the heterogeneity is so great, this article focuses on the tariffs related to the water supply service in the 15 largest Spanish cities. In general, urban water tariffs commonly distinguish between residential and non-residential users. Additionally, there are usually specific tariffs for different customer categories within both residential and non-residential users, which are not always justified in terms of the equity principle. It is important to note that in most cities the eligibility criteria for these special tariffs usually add more complexity to the tariff system and adversely affect horizontal equity. All these factors contribute to the great complexity of Spain’s water-pricing map. The heterogeneous tariff system found in most Spanish cities runs counter to equity principles and can send the wrong signal to users about water scarcity, thereby hindering compliance with the resource sustainability objective. Thus, most Spanish cities require a simplification of the tariff system.