1-20 of 24 Results  for:

  • Public Health Policy and Governance x
Clear all

Article

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

Article

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

Article

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

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

Article

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

Article

Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss

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

Article

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

Article

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

Article

Catherine A. O'Donnell

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

Article

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

Article

José Gomes Temporão and Carlos Augusto Grabois Gadelha

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

Article

Juan Garay, David Chiriboga, and Nefer Kelley

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

Article

Kira Fortune, Francisco Becerra, Paulo Buss, Orielle Solar, Patricia Ribeiro, and Gabriela E. Keahon

There is a broad consensus that the health of an individual or population is not influenced solely by the efforts of the formal health sector; rather, it is also defined by the conditions of daily life as well as the inputs, intentional or not, of various stakeholders and policies. The recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors has led to the emergence of a comprehensive policy perspective known as Health in All Policies (HiAP). Building on earlier concepts and principles outlined in the Alma-Ata Declaration (1978) and the Ottawa Charter for Health Promotion (1986), HiAP is a collaborative approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. Health in All Policies has become particularly relevant in light of the adoption of the 2030 Agenda for Sustainable Development and the 17 Sustainable Development Goals (SDGs), as achieving the goals of the agenda requires policy coherence and collaboration across sectors. Given that local governments are ideally positioned to encourage and galvanize partnerships between a diversity of local stakeholders, the implementation of HiAP at the local level is seen as a powerful approach to advancing health and achieving the SDGs through scaled-up initiatives. As there is no single model for the development and implementation of HiAP, it is critical to examine the different experiences across countries that have garnered success in order to identify best practices. The Region of the Americas has made much progress in advancing the HiAP approach, and as such much can be learned from analyzing implementation at country level thus far. Specific initiatives of the Americas may highlight key examples of local action for HiAP and should be taken into consideration for future implementation. Moving forward, it will be important to consider bottom up approaches that directly address the wider determinants of health and health equity.

Article

Louise Biddle, Kayvan Bozorgmehr, and Rosa Jahn

Ensuring the health of migrants and access to appropriate health services presents a challenge to health systems in the age of global migration. Reliable and timely information is key to decision-making in all sectors of the health system to ensure that health system goals are met. Such information is even more important among a mobile, sometimes rapidly changing, dynamic and heterogeneous migrant population. While health information systems (HIS) are crucial for effective functioning of other health system blocks as well as for evidence-informed decision-making, they are often sidelined in health system policy and development. Looking across the World Health Organization (WHO) European Region, HIS for migrants are deficient both in their overall availability and their integration into regular monitoring structures. Less than half of the 53 member states routinely report health data for refugees and migrants. Most of the routinely collected data on migrant and refugee health can be identified in countries with strong population-based records, with some good practice examples of well-integrated and high-quality health monitoring surveys, disease-specific registries, and “parallel” HIS in migrant-specific settings. Overall, however, HIS in the WHO European Region are not able to provide data of sufficient quality and comparability to be well integrated into regular health monitoring structures. The reasons for this can be highlighted by five key barriers to improved information systems for migrant health: barriers in recording data, standardizing data collection, harmonizing migrant indicators, producing high-quality data, and sharing information. Better integration can be achieved through increased multilateral collaboration for the harmonization of indicators, strengthening of governance frameworks for data-sharing and protection measures, and the increased use of currently underutilized data collection mechanisms, including health monitoring surveys and medical records from refugee reception facilities. These steps will remain essential for the adequate planning and provision of needs-based care for refugees and migrants.

Article

Asa Cristina Laurell and Ligia Giovanella

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

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

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

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

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.

Article

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

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.