As of 2017, the urban access rate to safe water sources in 2017 stood at 84% while rural access was still around 45%. The rates for sanitation were 44% and 22%, respectively. Since the 1980s many high-profile reforms supported by international organizations have been implemented in the region in an attempt to close the access gaps in the water and sanitation sector (WSS). Two recommendations with high international exposure were an increased role for large-scale private sector participation in the management and financing of national or regional utilities and the creation of separate sector regulatory agencies to increase the independence of regulation. Both reforms seemed to contribute to improved water access rates, at least for the urban population, but not enough to catch up with the demands of a fast-growing population; and both failed to deliver on sanitation. The progress these initiatives allowed was correlated with improvements in the average health outcomes for some indicators (i.e., under-five mortality associated to diarrhea) but once again, it was not enough and was not fairly distributed. Indeed, improvements seem to have mostly benefited upper- and middle-income groups. Unfortunately, an evaluation of the health effects of these two reforms have not yet been fully established empirically, which is why it seems prudent to talk about correlations rather than causal effects. Most of the statistically robust evidence on the impact of utilities and regulatory reforms on health is incomplete because details of several dimensions of these reforms and their context are not measured consistently across countries or within countries. In addition, the small amount of econometric evidence available is based on pre-2010 data for SSA. The imperfect data is however solid enough to suggest that without further governance changes in the region, the health risks are likely to increase. This is because due to the high population growth rate of the region, closing the access gaps is likely to get tougher considering current investment levels and technological choices. The necessary changes require improving the match between policy and technological choices, including service delivery technologies that are consistent with the ability to pay and the tariff and subsidy levels adopted to ensure cost recovery without excluding any category of users.
Article
The Health Impact of Water and Sanitation Utilities Privatization and Regulation in Sub-Saharan Africa
Lisa Bagnoli, Salvador Bertomeu-Sanchez, and Antonio Estache
Article
The Politics of Primary Health Care
David Sanders and Louis Reynolds
The global project to achieve Health for All through Primary Health Care (PHC) is a profoundly political one. In seeking to address both universal access to health care and the social determinants of health (SDH) it challenges power blocs which have material vested interests in technical approaches to health and development.
The forces that have shaped PHC include Community Oriented Primary Care and the Health Centre Movement, the “basic health services approach,” and nongovernmental and national initiatives that exemplified comprehensive and participatory approaches to health development. The 1978 Alma-Ata Declaration codified these experiences and advocated Health for All by the year 2000 through PHC. It emphasized equitable and appropriate community and primary-level health care as well as intersectoral actions and community participation to address the social and environmental determinants of health. This would need the support of a new international economic order.
The concept of “Selective Primary Health Care” emerged soon after Alma-Ata, privileging a limited set of technical interventions directed at selected groups, notably young children. This was soon operationalized as UNICEF’s Child Survival Revolution. The visionary and comprehensive policy of PHC was further eroded by the 1970s debt crisis and subsequent economic policies including structural adjustment and accelerated neoliberal globalization that deregulated markets and financial flows and reduced state expenditure on public services. This translated, in many countries, as “health sector reform” with a dominant focus on cost efficiency to the detriment of broad developmental approaches to health. More recently this selective approach has been aggravated by the financing of global health through public-private partnerships that fund specific interventions for selected diseases. They have also spawned many “service delivery” NGOs whose activities have often reinforced a biomedical emphasis, supported by large philanthropic funding such as that of the Gates Foundation.
Educational institutions have largely failed to transform their curricula to incorporate the philosophy and application of PHC to inform the practice of students and graduates, perpetuating weakness in its implementation.
Revitalizing PHC requires at least three key steps: improved equity in access to services, a strong focus on intersectoral action (ISA) to address SDH and prioritization of community-based approaches. The third sustainable development goal (SDGs) focuses on health, with universal health coverage (UHC) at its center. While UHC has the potential to enhance equitable access to comprehensive health care with financial protection, realizing this will require public financing based on social solidarity. Groups with vested interests such as private insurance schemes and corporate service providers have already organized against this approach in some countries. The SDGs also provide an opportunity to enhance ISA, since they include social and environmental goals that could also support the scaling up of Community Health Worker programs and enhanced community participation.
However, SDG-8, which proposes high economic growth based substantially on an extractivist model, contradicts the goals for environmental sustainability. Human-induced environmental degradation, climate change, and global warming have emerged as a major threat to health. As presciently observed at Alma-Ata, the success of PHC, and Health for All requires the establishment of a new, ecologically sustainable, economic order.
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
Time in Health Promotion and Public Health
Lyndall Strazdins
Being physically active and eating fresh foods could reduce the growing burdens of cardiovascular disease, cognitive decline, obesity, some cancers, diabetes type II, depression, and anxiety. Increasing these health behaviors has been a public health focus for decades, yet over one half of adults around the world remain insufficiently physically active and four in ten are overweight or obese. When people are asked why they don’t exercise more or eat healthy food, the most common reason they give is lack of time. Everyone has 24 hours in a day, so why do so many people say they lack time to be healthy?
Time is a challenging (and intriguing) concept. Usually, time is thought about in terms of hours and minutes which evenly divide a day, and its lack a consequence of misguided priorities. This assumes that all hours are equal and available for use and that every person has agency over their time. Although having sufficient time is fundamental to health (exercising, preparing healthy food, resting, accessing services, and maintaining social bonds all take time), other dimensions such as control, flexibility, intensity, and timing are essential for understanding how time and health are connected. Like income, time is exchanged and given within households, so it can be fruitful to view time as a household resource rather than an individual’s resource. In the labor market, time is exchanged for payment, and this underscores time’s potency as a social and economic resource.
Historically, research on the social determinants of health and health equity have focused on the harms linked to work hours, including the length and timing of the work day and flexible hours. Yet this research missed the importance of time outside the labor market, which alters the health consequence of work hours, delivering only a partial analysis of how time shapes health. Research since the early 2000s is supplying new evidence of the interplay between work, care, and other non-market time, allowing a more accurate insight into how time shapes health and how this relationship connects to social and gender equity. Debates remain, however, and these include the extent to which time pressure and time scarcity are problems of motivation and perception and whether time scarcity is a problem of only the affluent.
There are precedents to address time costs and inequities. A first step for health prevention and health promotion practitioners is to value time in ways comparable to how the field values money. This would mean limiting the time costs of health interventions and services, including the requirement to “find time” outside of work or care roles to be healthy. The field also needs to challenge the idea that the income-poor are time-rich since this is rarely the case if they are caregivers. As well as minimizing time burdens, policies to address the social determinants of time from urban planning, transport systems, and work-hour regulations will be critical to achieving a fairer and healthier world.
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
Urban Health in Latin America and the Caribbean
Luiz Galvão, Waleska Teixeira Caiaffa, Solimar Carnavalli Rocha, and Bernhard Liese
Urbanization can enhance the quality of life in cities and promote healthy living conditions. Unfortunately, according to the World Health Organization, 24% of urban populations live in unhealthy slums, making early intervention and public policies imperative. While urban areas have the advantage of access to essential services like transportation and healthcare, inadequate planning can lead to health issues.
Rural populations also face challenges accessing safe drinking water and sanitation, leading to unequal distribution of drinking-water quality. Climate change exacerbates these issues, resulting in conflicts, social and economic instability, and adverse environmental and public health effects. Additionally, population growth and improved water access have intensified wastewater treatment problems, and waste generation remains a significant issue in Latin America. Homeless communities in urban areas are particularly vulnerable to crises like COVID-19 and climate change. Access to healthcare is crucial for urban health, but half of the population lacks this access, leading to poverty due to healthcare expenses. Promoting social equity through healthcare access is vital.
The United Nations recognizes the devastating impact of COVID-19 and calls for a transformative approach to rebuild economies that prioritize social equity and environmental sustainability. Sustainable development policies can combat poverty, hunger, climate change, and environmental degradation. The Barcelona Institute for Global Health has developed a framework that connects healthy urban development to the sustainable development goals, emphasizing intersectoral work, health equity, and data quality. However, COVID-19 has severely affected the implementation of the 2030 Agenda.
Research in Brazil and Latin America reveals that economic segregation and inequality contribute to higher homicide rates and lower life expectancy. Effective urban policies can improve population health, and understanding the factors that impact elderly health can lead to better planning for active aging and reducing health disparities.
Successful approaches to research and addressing urban health issues involve interdisciplinary collaboration among academia, public and private sectors, and communities. Policies that impact health, with particular attention to the social, economic, and urban determinants of health in urban areas, are essential. The aim of the authors of this article, as public health researchers, is to identify targets for large-scale policy interventions in these areas.
The Belo Horizonte Observatory for Urban Health was founded in 2002 through a process led by the local university and health services to bring together academics and public sector services as part of a broader agenda to strengthen local and national health systems. This model could be a modern approach to Urban Health and play a central role in the current global health challenges.
Article
Urban Homelessness Policy in OECD Nations
Charley E. Willison and Amanda I. Mauri
Homelessness is a public health challenge for modern governments. Homelessness emerged as a formal policy problem for rich nations in the mid- to late 20th century as nations developed stable economies and democracies, including housing and job markets, and social welfare mechanisms to protect citizens from disenfranchisement. In early 21st-century Organisation for Economic Co-operation and Development (OECD) nations, homelessness arises most often among at-risk or vulnerable populations, such as historically marginalized groups and/or persons with constrained access to welfare state mechanisms, such as immigrants or refugees. Thus, homelessness in OECD nations is very different from informal housing or mass poverty in poor nations and/or non-democratic regimes.
Homelessness affects individual and population health, requiring complex policy solutions across multiple domains of health, as well as intergovernmental coordination. Policy responses to homelessness vary across OECD nations in their approach and efficacy. There are four key factors influencing how OECD nations respond to homelessness: (a) the strength and inclusivity of the welfare state; (b) degrees of decentralization in homeless policy governance; (c) the strength, capacity, and inclusivity of the health and behavioral healthcare systems; and (d) the role of federated structures in health and welfare state policy. Overall, nations with weaker welfare states and health/behavioral healthcare systems face greater risks of homelessness. The inclusivity of these systems also shapes who may be eligible for protection or experience homelessness. Local governments, especially those in large metropolitan areas, are the frontline providers of homelessness services. Yet local governments are constrained at both ends: Policies designed, delivered, and funded at larger units of government—such as welfare state provisions—influence many of the determinants of homelessness, such as housing, and the resources available to subnational actors to combat homelessness. Local actors are also constrained by the degree of decentralization. Devolution of homelessness policy to smaller units of government or even solely to nongovernmental actors, through federated mechanisms or decentralization, may create barriers to locally tailored solutions by perpetuating disparities across jurisdictions and/or constraining authority and resources necessary to design or deliver homeless policy.
Article
Urban Water Regulation and Health: The Case of Chile
Michael Hantke-Domas and Ronaldo Bruna
In 50 years, Chile achieved nearly full urban water and sanitation coverage—even higher than some developed countries. Furthermore, in just a decade, the country obtained full urban wastewater treatment, making it probably the only developing country that will successfully meet the Sustainable Development Goals (SDGs) in this matter. These achievements can be attributed to policies oriented towards the incremental or gradual improvement of the water and sanitation sector sustained for more than 50 years. This policy was mainly focused on (a) increasing public investment in expanding coverage levels, both for potable water and sewerage; (b) reducing enteric diseases and infant mortality; (c) improving child nutrition; (d) streamlining public utilities; (e) establishing a legal framework for economic regulation applied by an independent body applicable to all utilities; (f) building efficient institutions; (g) a full cost recovery tariff policy; (h) bringing private capital into the industry; (i) subsidizing those who need it most; and (j) de-politicizing the sector. The Chilean experience is not well documented or, at least, there are few references regarding its success story, which reinforces the motivation to understand its history.
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
Wastewater Tariffs in Spain
Marián García-Valiñas and Fernando Arbués
Urban water cycle services culminate in wastewater services; that is, with the collection, transport, and treatment of wastewater. Wastewater management in Spain is not a straightforward issue. In fact, the European Commission has initiated infringement procedures against Spain for not fully complying with the Urban Waste Water Treatment Directive. Yet, appropriate collection and treatment would require a large monetary investment that is increasingly difficult to carve out of existing government revenues. In this context, wastewater pricing emerges as a significant tool for achieving cost recovery and environmental protection aims.
In Spain, local governments are responsible for providing wastewater services in urban areas and for setting the prices for those services. Spanish regional governments are in charge of specific pollution taxes on wastewater, which are included in the individual users’ water bills. Moreover, in most Spanish cities, the urban water tariffs for wastewater services (like water supply tariffs) are different for different users, representing the most common distinction between residential and nonresidential users. Additionally, specific tariffs are frequently imposed for different customer groups within both categories. In this respect, it is common to include pollution charges for industrial users, increasing their water prices according to the environmental impact of their wastewater discharges. The result is a very complex map of water-pricing and taxing in Spain.
Article
Water Safety Plans
Karen Setty and Giuliana Ferrero
Water safety plans (WSPs) represent a holistic risk assessment and management approach covering all steps in the water supply process from the catchment to the consumer. Since 2004, the World Health Organization (WHO) has formally recommended WSPs as a public health intervention to consistently ensure the safety of drinking water. These risk management programs apply to all water supplies in all countries, including small community supplies and large urban systems in both developed and developing settings. As of 2017, more than 90 countries had adopted various permutations of WSPs at different scales, ranging from limited-scale voluntary pilot programs to nationwide implementation mandated by legislative requirements. Tools to support WSP implementation include primary and supplemental manuals in multiple languages, training resources, assessment tools, and some country-specific guidelines and case studies.
Systems employing the WSP approach seek to incrementally improve water quality and security by reducing risks and increasing resilience over time. To maintain WSP effectiveness, water supply managers periodically update WSPs to integrate knowledge about prior, existing, and potential future risks. Effectively implemented WSPs may translate to positive health and other impacts. Impact evaluation has centered on a logic model developed by the Centers for Disease Control and Prevention (CDC) as well as WHO-refined indicators that compare water system performance to pre-WSP baseline conditions. Potential benefits of WSPs include improved cost efficiency, water quality, water conservation, regulatory compliance, operational performance, and disease reduction. Available research shows outcomes vary depending on site-specific context, and challenges remain in using WSPs to achieve lasting improvements in water safety. Future directions for WSP development include strengthening and sustaining capacity-building to achieve consistent application and quality, refining evaluation indicators to better reveal linked outcomes (including economic impacts), and incorporating social equity and climate change readiness.
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.
Article
Well-Being Economics
Paul Dalziel and Trudi Cameron
A strong social gradient in the experience of health means that a person’s health tends to reflect social position. There is strong evidence that average health outcomes in a country tend to be poorer when income inequality is greater. Consequently, public health policy is influenced by a country’s economic situation. Adopting principles in the Helsinki Statement on Health in All Policies, this means governments should pay attention to the public health implications of its economic policies, moving beyond simple analyses of how policy might support growth in gross domestic product.
Since 2009, a global movement has aimed to shift the emphasis of economic policy evaluation from measuring economic production to measuring people’s well-being. This approach is known as well-being economics. Many countries have engaged with citizens to create their own national well-being framework of statistical indicators. Some countries have passed legislation or designed new institutions to focus specific policy areas on promoting the well-being of current and future generations. A small number of countries are attempting to embed well-being in their core economic policies. Further policy work and research are required for the vision of a well-being economy to be realized.
Article
What Has Emerged From 30 Years of the Orangi Pilot Project
Arif Hasan
The causes of what has emerged from 30 years of the Orangi Pilot Project (OPP) can only be understood through understanding the factors that have shaped its evolution. The OPP was established by Akhtar Hameed Khan whose experience-based thinking and theorization has shaped the project philosophy and methodology. Situated in Orangi Town in Karachi, Pakistan, the project has motivated local communities to finance and build their own neighborhood infrastructure while encouraging the local government to build the off-site infrastructure such as trunk sewers and treatment plants. The project expanded to other areas of Pakistan with the OPP’s Research and Training Institute, training local communities in surveying, estimating materials and labor required for construction works, and motivating communities in building their sanitation systems and negotiating with local government to build the off-site infrastructure. The project methodology has been adopted by local governments and bilateral and international development agencies. The philosophy and methodology have also become a part of universities’ and bureaucratic training institutions’ curriculum. So far, households on over 15,560 lanes all over Pakistan have built their sanitation systems by investing 412 million rupees (Rs). According to the OPP 153rd quarterly report in 2018, the total number of households in these lanes is 272,506. The model shaped the sanitation policy of the government of Pakistan and also influenced policies on housing and informal development, which has results in the upgrade in a much greater number of households in urban areas such as Karachi, Lahore, Faisalabad, Kasur, Narowal, Sargodha, Nowshera, Hyderabad, Sukkur, Rawalpindi, Muzaffargarh, Swat, Lodhran, Kehror Pakka, Dunyapur, Khanpur, Bahawalpur, Khairpur, Jalah Arain, Yazman, Vehari, Uchh, Multan, Alipur, Gujranwala, Jampur, Sanghar, Amanullah, Parhoon, Mithi, and Sinjhoro, as well as 128 villages.
The project suffered a major blow with the assassination of its director and one of its workers and an attempt on the life of its deputy director in 2013. Due to the resulting insecurity, project programs and various linkages with government and international agencies and nongovernmental organizations suffered. However, due to the OPP’s reputation of capability and its roots within the community, the project has survived (against all predictions) and is in the process of expanding its work and expertise.
