Since the early 1990s, health policy in Latin America has focused on reform in most countries with the explicit purpose to increase access, decrease inequity, and provide financial protection. Basically, two different and opposed models of reform have been implemented: the Universal Health Coverage (UHC) model and the Single Universal Health System model. The essential characteristics of Latin American UHC are that health care is commodified by the introduction of competition that depends, in turn, on the payer/provider split, free choice, and pre-priced health service plans. In this framework, insurance, be it public or private, is crucial to assuring market solvency, because health needs not backed by purchasing power do not constitute a market that is particularly important in the Latin American region, the most unequal in the world. The Single Universal Health System (in Spanish, Sistema Universal de Salud, SUS) model is a model inspired by the principles of social justice and egalitarian, universal social rights. Characteristically funded by tax revenues, it makes provision of health services to the whole population a responsibility of the State and a universal citizens’ entitlement, independent of individual ability to pay or prior contributions. It considers health to be a public good that, for reasons of efficiency and equity, the market cannot provide. Everyone is entitled, as a right, to free care financed by the State.
Given that health system reform occurs in specific historical contexts, these models have had different results in each country. In order to highlight the concrete reform outcomes, the following issues need be addressed: the political scenario and the stakeholders involved; the previous health system and the relative strength of the public and private sectors; coverage achieved by public institutions or insurance, public or private; the different health packages existing within each country; the institutional (re)organization; and the relative importance of public health actions. An analysis is needed of the UHC reforms in Chile, Colombia, and Mexico, on the one hand; and the Single Universal Health System in Brazil, Venezuela, and Cuba on the other.
The UHC model in practice tends to increase inequity in access, create new bureaucratic barriers to timely care, fail to provide financial protection, and leads to deteriorated public health measures. It has also created new powerful private sector stakeholders, particularly in Chile and Colombia, while in Mexico the predominance of a strong public sector has “crowed-out” the private one. The Single Universal Health System has significantly increased access for millions that before reform had almost no access and has also strengthened public health actions. However, the strong preexisting private sector providers have profited from the public-sector purchases of complex medical services. Private health insurance has also increased among the upper middle class and workers belonging to strong labor unions.
Article
Health Policies and Systems in Latin America
Asa Cristina Laurell and Ligia Giovanella
Article
History of Public Health in Latin America
Marcos Cueto and Steven Palmer
From the late 19th to the late 20th century, Latin America was a developing region of the world in which public and private health discourses, practices, and a network of agencies were consolidated. Many organizations appeared as a response to pandemics, such as yellow fever, that attacked the main ports and cities, and they interacted with global agencies such as the Rockefeller Foundation. Frequently, single-disease-focused and technocratic approaches were promoted in a pattern that can be defined as the “culture of survival.” However, some practitioners believed in public health programs as a tool to improve the living conditions of the poor, the most important being comprehensive primary health care, which emerged in the late 1970s. Toward the end of the Cold War (ca. 1980s), neo-liberal reformers supported a restrictive idea of primary care health that overemphasized cost-effectiveness and efficiency.
Article
The Implications of Informal Settlement Upgrading Programs for Access to Water, Sanitation, and Public Health
David Satterthwaite and Alice Sverdlik
Most cities in low- and middle-income countries have substantial proportions of their population living in informal settlements—sometimes up to 60% or more. These also house much of the city’s low-income workforce; many informal settlements also concentrate informal economic activities. These settlements usually lack good provision for water, sanitation, and other essential services.
The conventional government responses were to bulldoze them or ignore them. But from the 1960s, another approach became common—upgrading settlements to provide missing infrastructure (e.g., water pipes, sewers, drains). In the last 20 years, community-driven upgrading has become increasingly common. Upgrading initiatives are very diverse. At their best, they produce high-quality and healthy living conditions and services that would be expected to greatly reduce illness, injury or disablement, and premature death. But at their worst, upgrading schemes provide a limited range of improvements do nothing to reduce the inhabitants’ exclusion from public services.
There is surprisingly little research on upgrading’s impact on health. One reason is the very large number of health determinants at play. Another is the lack of data on informal settlement populations.
Much of the innovation in upgrading is in partnerships between local governments and organizations formed by informal settlement residents, including slum/shack dweller federations that are active in over 30 nations.
Community-driven processes can deal with issues that are more difficult for professionals to resolve—including mapping and enumerations. Meanwhile, local government can provide the connections to all-weather roads, water mains, sewers, and storm drains into which communities can connect.
Article
Indigenous Health and Connection to Country
Alister Thorpe, Aryati Yashadhana, Brett Biles, Emily Munro-Harrison, and Jonathan Kingsley
There are an estimated 370 million Indigenous peoples living in more than 70 countries. Indigenous populations are defined as the First Peoples occupying countries or regions at times of colonization, with distinct cultural, religious, and social practices that distinguish them from other populations. Indigenous peoples across the globe have deep, intimate, holistic, localized, and reciprocal relationships and connections to their “Country” (as it is known in Australia), which includes elements of the land, sea, waterways, sky, stars, and living and nonliving entities. This relationship is largely unacknowledged through Western biomedical models of health, which tend to focus on individual risk behaviors and disease outcomes, thereby situating Indigenous health inequities in terms of deficiency and ignoring the ongoing impacts and trauma of colonization. Indigenous concepts of health are holistic, encompassing emotional, physical, cultural, and spiritual health. Country is central to health and is steeped in the harmonized interrelationships that constitute cultural well-being. Models for measuring and understanding health outcomes for Indigenous peoples need to respectfully incorporate the full range of determinants that are relevant to their health that understand the importance of connection to Country.
Article
Inequalities and Inequities in the Health of People With Intellectual Disabilities
Eric Emerson
Children and adults with intellectual disabilities have poorer health and are more likely to die sooner than their non–intellectually disabled peers. There is growing evidence that some of these inequalities in health are avoidable, unjust, and unfair, given that they are driven by the higher rates of exposure of people with intellectual disabilities to well-established social determinants of poor health. People with intellectual disabilities are more likely than their peers to: live in poverty, not be employed (or if employed to work under precarious conditions), be exposed to discrimination and violence, face significant barriers in accessing effective health care, and be less resilient when exposed to adversities. In other words, they are examples of health inequities that arise from “the societal conditions in which people are born, grow, live, work and age, referred to as social determinants of health. These include early years’ experiences, education, economic status, employment and decent work, housing and environment, and effective systems of preventing and treating ill health” (World Health Organization).
Future research needs to address three key issues. First, most of the existing evidence is based on the experiences of people with intellectual disabilities in the world’s high-income countries. In contrast, the vast majority of the world’s population live in middle- and low-income countries. The limited evidence available suggests that children with intellectual disabilities growing up in middle- and low-income countries are much more likely than their peers to be growing up in poverty and to be exposed to specific social determinants of poorer health associated with poverty such as undernutrition, poor sanitation, low levels of parental stimulation, violent parental discipline, and hazardous forms of child labor. Second, little research has focused on health inequalities and inequities among two important groups of people with intellectual disabilities: people with intellectual disabilities from minority ethnic communities and people with mild intellectual disabilities. Third, very little research has attempted to test the proposition that people with intellectual disabilities may be more or less resilient than their peers when exposed to social determinants of health.
While much remains to be learned about the inequalities and inequities faced by people with intellectual disabilities, the existing knowledge is sufficient to guide and drive changes in policy and practice that could reduce the health inequities faced by people with intellectual disabilities. These include: improving the visibility of people with intellectual disabilities in local, national, and international health surveillance systems; making “reasonable accommodations” to the operation of health care systems (e.g., introducing annual health checks into primary care services, making “easy read” materials available, employing intellectual disabilities liaison nurses in acute hospitals) to ensure that people with intellectual disabilities are not exposed to systemic discrimination; and ensuring that people with intellectual disabilities (along with all other people with disabilities) are included in and benefit equally from local and national strategies to reduce population levels of exposure to well-established social determinants of poor health.
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
Intervention Approaches for Osteoarthritis
Susan Hughes, Cheryl Der Ananian, and Andrew DeMott
Osteoarthritis (OA) currently affects 32.5 million people in the United States at a cost of $136.8 billion. The available literature on the epidemiology of OA shows that the number of people affected will increase exponentially by the year 2040, affecting 78.4 million people. There is an abundance of evidence that self-management and physical activity (PA) approaches improve multiple outcomes for individuals with arthritis. However, these programs are not widely accessible to the population that can benefit from them across the United States. Two national organizations—the arthritis program of the Centers for Disease Control and Prevention (CDC) and the Administration on Community Living (ACL)—have established similar, but distinct, criteria for the review of evidence-based programs and seek to promote their dissemination. The CDC arthritis program has reviewed the evidence bases of arthritis-appropriate, evidence-based intervention programs and classified them as self-management or PA approaches. These “recognized” programs are recommended for national dissemination by the CDC. The ACL has also recognized several of the same programs by using its own criteria and classified them as Self-Management or Falls Prevention approaches. The different review criteria used by these two national public organizations present significant challenges for investigators who design interventions. The situation is further compounded by an investment in funding that hugely supports the discovery of interventions as opposed to the dissemination of interventions that have demonstrated efficacy. The National Public Health Agenda for Osteoarthritis: 2020 Update presents a blueprint that includes nine strategies for improving public health outcomes among persons with OA. These recommendations should be considered by interventionists in the future when developing programs. Other areas that can substantially benefit from further research include weight management and weight loss, injury prevention, technology-based interventions, addressing comorbid conditions, and understanding program mechanisms of action. Finally, underscoring all of these approaches and common to them is the need to enroll underserved populations to improve health equity. Underserved populations disproportionately include African Americans, Hispanics, persons with low socioeconomic status, and persons who live in rural areas of the United States. Policy recommendations to render future approaches to improving health outcomes for persons with OA are (a) to increase funding for the dissemination of programs that demonstrated efficacy and effectiveness, (b) to increase the transparency of the review and funding processes across public agencies, and (c) to nurture, broker, and provide sustainable funding streams to maintain evidence-based programming for all persons with OA across the United States.
Article
Legal, Regulatory, and Institutional Framework of Water and Sanitation Services in the Eastern and Southern Africa Region
Yvonne Magawa
Deteriorating quality of service provision and disease outbreaks (such as cholera) led to the institution of water supply and sanitation (WSS) sector reforms in Eastern and Southern Africa region in the 1990s. The realization of the urgent need to improve the performance of the sector, especially as related to health impacts, resulted in the formulation of new policy and legal and institutional frameworks to reorganize the sector and establish regulators who could address networked and nonnetworked WSS systems.
Regulators as policy implementers have the delicate role of balancing the interests of government, service providers, and consumers. Decision- makers continue to design, implement, and evaluate the outcomes associated with new frameworks. Regional regulatory cooperation can accelerate improvements in service provision to meet the United Nations Sustainable Development Goals through development of common frameworks and approaches for WSS that can be adapted to unique country situations.
Article
Migrant Health in Refugee Camps: A Neglected Public Health Issue
Manuela Valenti
There are 1 billion migrants in the world today, which means that one in seven of the world’s population are migrants. Of these, 272 million are international migrants and 763 million are internal migrants. It is estimated that around 70 million of the world’s migrants, both internal and international, have been forcibly displaced.
Many things force people to leave their homes in search of a better future: war, poverty, persecution, climate change, desertification, urbanization, globalization, inequality, and lack of job prospects. Migrants remain among the most vulnerable members of society even when their living conditions improve after migration.
Migrant women and children are a particularly vulnerable group and have a great need for basic and preventive health care.
Many refugees and migrants are young and in good health, but hard living conditions and difficulty accessing basic health care can affect their state of health. Many of them face inhuman journeys during migration and live in refugee camps with very low standards of hygiene; when they find a job, they are often exploited. All these things can also affect their mental health.
Migrants struggle with similar challenges as other marginalized groups when it comes to access to health care, but they face the additional barriers of mobility, language barriers, cultural differences, lack of familiarity with local health care services, and limited eligibility for publicly and privately funded health care.
Governments should provide affordable preventive and basic health care to refugees and migrants not only because it is a human right but also because in the long term it can lower the costs of the whole health care system.
Article
Migration, Migrants, and Health in Latin America and the Caribbean
Deisy Ventura, Jameson Martins da Silva, Leticia Calderón, and Itzel Eguiluz
The World Health Organization has recognized health as a right of migrants and refugees, who are entitled to responsive healthcare policies, due to their particular social determinants of health. Migrants’ and refugees’ health is not only related to transmissible diseases but also to mental health, sexual and reproductive health, and non-communicable diseases, such as diabetes. Historically, however, migration has been linked to the spread of diseases and has often artificially served as a scapegoat to local shortcomings, feeding on the xenophobic rhetoric of extremist groups and political leaders. This approach fosters the criminalization of migrants, which has led to unacceptable violations of human rights, as demonstrated by the massive incarceration and deportation policies in developed countries, for example, the United States under the Trump administration.
In Latin America and the Caribbean, in particular, there have been legal developments, such as pioneering national legislation in Argentina in 2004 and Brazil in 2017, which suggest some progress in the direction of human rights, although in practice drawbacks abound in the form of countless barriers for migrants to access and benefit from healthcare services in the context of political turmoil and severe socioeconomic inequality. The COVID-19 pandemic has exposed and enhanced the effects of such inequality in the already frail health conditions of the most disenfranchised, including low-income migrants and refugees; it has both caused governments in Latin America to handle the crisis in a fragmented and unilateral fashion, ignoring opportunities to cooperate and shield the livelihoods of the most vulnerable, and served as a pretext to sharpen the restrictions to cross-border movement and, ultimately, undermine the obligation to protect the dignity of migrants, as the cases of Venezuela and the U.S.-Mexico border illustrate. Still, it could represent an opportunity to integrate the health of migrants to the public health agenda as well as restore cooperation mechanisms building on previous experiences and the existing framework of human rights organizations.
Article
NGO Contributions to Community Health and Primary Health Care: Case Studies on BRAC (Bangladesh) and the Comprehensive Rural Health Project, Jamkhed (India)
A. Mushtaque R. Chowdhury and Henry B. Perry
Non-governmental organizations (NGOs) working in developing countries are chiefly a post-World War II phenomenon. Though they have made important contributions to health and development among impoverished people throughout the world, the documentation of these contributions has been limited. Even though BRAC and the Jamkhed Comprehensive Rural Health Project (CRHP) are but two of 9.7 million NGOs registered around the world, they are unique. Established in 1972 in Bangladesh, BRAC is now the largest NGO in the world in terms of population served—now reaching 130 million people in 11 different countries. Its programs are multi-sectoral but focus on empowering women and improving the health of mothers and children. Through its unique scheme of generating income through its own social enterprises, BRAC is able to cover 85% of its $1 billion budget from self-generated funds. This innovative approach to funding has enabled BRAC to grow and to sustain that growth as its social enterprises have also prospered. The Jamkhed CRHP, founded in 1970 and located in the Indian state of Maharashtra, is notable for its remarkable national and global influence. It is one of the world’s early examples of empowering communities to address their health problems and the social determinants of those problems, in part by training illiterate women to serve as community health workers. The Jamkhed CRHP served as a major influence on the vision of primary health care that emerged at the 1978 International Conference on Primary Health Care at Alma-Ata, Kazakhstan. Its Institute for Training and Research in Community Health and Population has provided on-site training in community health for 45,000 people from 100 different countries. The book written by the founders entitled Jamkhed: A Comprehensive Rural Health Project, describing its pioneering approach, has been translated into five languages beyond English and is one of the most widely read books on global health. These two exemplary NGOs provide a glimpse of the breadth and depth of NGO contributions to improving the health and well-being of impoverished people throughout the world.
Article
Operationalizing Human Rights in Sexual and Reproductive Health and Rights Programming: An Example from a Global Family Planning Partnership
Karen Hardee
The International Conference on Population and Development (ICPD), which has guided programming on sexual reproductive health and rights (SRHR) for 25 years, reinforced that governments have a role to play in addressing population issues but in ways that respect human rights and address social and gender inequities. The shift at ICPD was partly in response to excesses that had occurred in some family planning programs, resulting in human rights abuses. The 2012 London Summit on Family Planning refocused attention on family planning as a crucial component of SRHR and, in part due to significant pushback on the announcement of a goal of reaching an additional 120 million women and girls with contraception by 2020 in the world’s poorest countries, ignited work to ensure that programming to achieve this ambitious goal would be grounded in respecting, protecting, and fulfilling human rights. This attention to human rights has been maintained in Family Planning 2030 (FP2030), the follow on to Family Planning 2020 (FP2020). While challenges remain, particularly in light of pushback on reproductive rights, widespread work over the past decade to identify human rights principles and standards related to family planning, integrate them into programming, strengthen accountability, and incorporate rights into monitoring and evaluation has improved family planning programs.
Article
The Political Determinants of Health: A Global Panacea for Health Inequities
Daniel E. Dawes, Christian M. Amador, and Nelson J. Dunlap
The political determinants of health create the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health. Globally, recurring examples of the role that these political determinants—through government action or inaction, and policy—are playing in health outcomes and life expectancy, particularly in under-resourced communities, can be observed currently as well as historically. Most notably, the political determinants of health are more than merely separate and distinct from social determinants of health: they serve as the instigators of the social determinants of health with which many people are already well acquainted. They involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities. Focusing on the political determinants of health homes in on the fundamental causes that give rise to, sustain, and exacerbate the social determinants of health that create and worsen the persistent and devastating health inequities that are observed, experienced, researched, and reported. By employing both a theoretical and practical lens to the amelioration of health inequities that continue to pervade communities across the globe, the article contextualizes many of the historic harms that have occurred throughout history, providing a unique perspective on the current state of affairs, and offering a tangible path forward toward a more equitable future. Furthermore, consideration of this new framework at all levels of government as it relates to improving health outcomes for any nation is imperative in order to eliminate existential threats for any and all populations.
Article
Post-Disaster Recovery and Social Capital
Suzanne Vallance and Ashley Rudkevitch
Disaster scholarship has resurrected interest in social capital, and it has become well established that strong social ties—bonding capital—can also help individuals and communities to survive in times of crisis, as well as provide substantial and wide-ranging benefits on the long road to recovery. The theoretical tripartite of bonding capital generated in “close ties,” bridging capital developed through “associations,” and linking capital from possibly cool but nonetheless “civil” encounters is also reasonably well established. So too are the currencies of trust and reciprocity. Social capital is noted to be a potent resource capable of facilitating many benefits in terms of health and well-being, and it is considered fundamental to post-disaster attempts to Build Back Better in the Sendai Framework for Disaster Risk Reduction. Indeed, the idea of social capital has become almost synonymous with resilience.
Nonetheless, it is also acknowledged that there may be disadvantages associated with social capital, such as tribalism, neoptism, and marginalization. Scholarship therefore paints a rather complex picture, and there is still considerable debate about what social capital is: what it does, where it comes from and where it goes, and for what purpose. Without denying the value of a celebratory approach that focuses on the benefits, it is concluded that there is a need for more attention to be given to the broader ideological contexts that may shape the generative and distributional effects of social capital, particularly as these underscore health and well-being outcomes post-disaster.
Article
Prevention of Suicide
Danuta Wasserman
Around 700,000 people take their lives each year worldwide. Suicide accounts for approximately 1.3% of all deaths and therefore represents a major public health problem. The global age-standardized suicide rate is 9 per 100,000 population, yet there are large variations among genders, ages, countries, and world regions. The stress–vulnerability model of suicidal behaviors has been proposed to explain how a diathesis, developed through the influence of genetic and neurodevelopmental factors in relation to perinatal, postnatal, and life experiences, interacts with different risk and protective factors that either decrease or enhance the individual’s level of resilience to stress and suicidal risk. Public health suicide prevention strategies include suicide means restriction, reducing harmful substance use, promoting responsible media reporting, public-awareness campaigns, gatekeeper trainings, school-based interventions, crisis helplines, and postvention. Mental health strategies comprise identification, treatment, and rehabilitation of persons in distress and at risk for suicide. Multicomponent strategies that use a combination of evidence-based methods from public and mental health sectors are recommended. Future work should aim at enhancing the quality of epidemiological data, improving the research on protective and ideation-to-action factors, expanding the quantity and quality of data coming from low- and middle-income countries, and evaluating the cost-effectiveness of different suicide prevention strategies.
Article
Priming Healthcare for Health Equity Management
Ebbin D. Dotson, Kimson E. Johnson, and Jada Irving
Health equity management (HEM) is defined as an actionable framework that supports the development of an industry-defining position for healthcare organizations and senior leaders to guide their business practices for investments in and financial gains from health equity. As healthcare leaders confront the disparate racial and ethnic burdens caused by the nation’s racialized societal history, making investments that increase health equity can help eliminate health disparities. To achieve health equity, leaders must cultivate a sense of interdependence among stakeholders and community members to effectively communicate the importance of collaboration, which is a shared understanding of the necessary actions that engage stakeholders around a central purpose. Achieving health equity forces healthcare systems to consider the notion that creating an equitable environment, where the costs of health inequity and barriers to achieving community and population health are shared with stakeholders and community members, might be addressed by the modification of certain management practices.
HEM encompasses an applied management model to help healthcare organizations maximize their efforts to increase health equity for vulnerable populations. It provides a stepwise approach to help frame the social, economic, and educational changes necessary for leaders to invest in health equity initiatives. The HEM involves the following actions: (a) redefining health equity, (b) identifying upstream inequalities, (c) realigning fiscal investments, and (d) leveraging community partnerships. Establishing and sustaining health equity initiatives through HEM ensures that both economic and social criteria are systematically considered, and financial investments are prioritized for sustained impact. Without addressing all four, the efforts of healthcare organizations will fall short of what it will take to effect lasting change.
Redefining health equity requires incorporating upstream and downstream inequities to offer a lens to align mission, assess capacity, and leverage profitable partnerships. The systematic approach to HEM goals and principles can be integrated at various organizational levels as a tool to successfully address health inequalities and social determinants of health.
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
Regulating Quality in the Water Sector: A Theoretical Perspective
Emmanuelle Auriol
Regulating quality is challenging because in public utilities such as water and sanitation, quality is multidimensional, is not always objectively measurable, and can be hard to verify, both ex ante and ex post. It is therefore useful to review the main insights from the New Economics of Regulation theoretical literature on quality provision to guide public policy. Focusing on formal utilities, this normative approach emphasizes the asymmetry of information between a regulator and the regulated companies. The analysis shows that when quality is verifiable, it can be included in a contract exactly like a quantity variable. Its provision, however, will be distorted as a result of regulated quantities also being distorted due to asymmetric information. When quality and quantity are complements, service quality ends up being lower because in the optimal regulatory contract, quantities are distorted downward for rent extraction. If quality is not verifiable but is observable by the users, the operator freely chooses its quality investment. It tends to underprovide quality when an improvement in quality raises the gross consumer surplus more than it increases the gross profit of sales because it does not take into account the nonmonetary benefit generated by its investment. It tends to overprovide quality otherwise. In order to correct these distortions, the regulator has to use a production allocation rule to simultaneously lower the informational rent and boost quality. The regulator has a single instrument to achieve the conflicting goals of rent extraction and quality provision. Quantities can be higher or lower than the first-best optimal levels depending on the correction needed to control quality. Finally, when quality is neither verifiable nor observable by consumers, as is typically the case with credence attributes such as those concerning process of production impacting security or pollution, the optimal level of quality investment from the firm’s perspective is zero. In this case, the easiest solution is often to impose a minimum standard and either rely on certification agencies to ensure that this minimum target is met or directly audit the quality investments made by the regulator. Finally, when improving the quality of water and sanitation services requires the creation of new infrastructure or institution, the high opportunity cost of public funds in developing countries raises the question of whether it is optimal to commit public funds for such investments. The analysis illuminates the trade-off between financing those investments with private funds and protecting consumer surplus.
Article
Religion, Aging, and Public Health
Jeff Levin and Ellen Idler
Religion, in both its personal and institutional forms, is a significant force influencing the health of populations across the life course. Decades of research have documented that expressions of faith and the practice of spiritual pursuits exhibit significantly protective effects for physical and mental health, psychological well-being, and population rates of morbidity, mortality, and disability. This finding has been observed across sociodemographic categories, across nations and cultures, across specific disease outcomes, and regardless of one’s religious affiliation. A salutary religious effect on health and well-being is especially apparent among older adults, but is also observed across generations and age cohorts. Moreover, this association has been persistently found for various religious indicators, including attendance at worship services, prayer and other private practices, subjective feelings of religiosity, and numerous measures of religious behaviors, attitudes, beliefs, and experiences. Finally, a protective or primary preventive effect of religion has been observed in clinical, epidemiologic, social, and behavioral studies, regardless of research design or methodology.
Faith-based organizations also have contributed to the health of populations, in partnerships or alliances with medical institutions and public health agencies, many of these dating back many decades. Examples include congregational health promotion and disease prevention programs and community-wide interventions, especially targeting the health and well-being of older congregants and those in less well-resourced communities, as well as faith–health partnerships in healthcare delivery, public health policymaking, and legislative advocacy for healthcare reform. Religious denominations and institutions also play a substantial role in global health development throughout the world, individually and in partnership with national health ministries, transnational medical mission organizations, and established nongovernmental agencies. These efforts focus on a wide range of goals and objectives, including building public health infrastructure, addressing ongoing environmental health needs, and responding to acute public health challenges and crises, such as infectious disease outbreaks. Constituencies include at-risk populations and cohorts throughout the life course, and programming ranges from perinatal care to maternal and child healthcare to geriatric medicine.
Article
Street Science: Community Knowledge for Global Health Equity
Jason Corburn
Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.
