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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.


Theory of Change in Sports-Based Urban Youth Programs: Lessons from Creating Chances  

Rachel Baffsky, Lynn Kemp, and Anne Bunde-Birouste

Sports-based positive youth development (SB-PYD) programs are health promotion programs that intentionally use sports to build life skills and leadership capacity among young people at risk of social exclusion. The defining characteristics of SB-PYD programs are that they are strengths-based, holistic, and use sports as a vehicle to maximize young people’s health, social, and educational outcomes. SB-PYD programs aim to enhance modifiable social determinants of health (such as social inclusion) by explicitly addressing three Ottawa charter action areas; strengthening community action, developing personal skills, and creating supportive environments. These programs have been increasingly implemented since the early 2000s to address the United Nations’ sustainable development goals. Despite their growth, research indicates that SB-PYD programs are often designed, implemented, and evaluated without evidence-based theories of change. An evidence-based theory of change is a visual depiction of a program’s assumptions, activities, contextual factors, and outcomes supported by scientific findings. A lack of evidence-based theory of change becomes problematic at the implementation phase when practitioners are trying to determine if their programs should be adapted or fixed. Without an evidence-based theory of change, practitioners are making changes based on their intuition, which limits program outcomes. However, the process of developing a theory of change is time-consuming and resource intensive. Multiple calls to action have been made for SB-PYD practitioners who have successfully developed evidence-based theories of change to share their process with others in the field. This will provide a blueprint for other SB-PYD practitioners to develop and articulate their own theories of change to optimize program development and adaptation. Traditional translational research models assume the development of an evidence-based theory of change is the first step in a linear process of developing a sustainable health promotion program. However, in the 2010s, researchers started to observe that the development and adaptation of health promotion programs was rarely a linear process in reality, and that case studies are needed to provide empirical support for this claim. It is valuable for SB-PYD practitioners to consider the benefits of using translational research to develop and revise evidence-based theories of change for programs at any stage of implementation to maximize their public health impact.


Child Health in Latin America  

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.


Child Development, Major Disruptive Events—Public Health Implications  

Tracy Vaillancourt and Peter Szatmari

The COVID-19 pandemic has upended nearly all the safeguarding systems in the lives of children and youth, such as family life, school, extracurricular activities, sports, unstructured social opportunities, health care, and church. With many of the typical promotive and protective factors disrupted all at once, and for so long, the mental health of children and youth has deteriorated in many areas, but not all, and for many children and youth, but not all. It is important to acknowledge, however, that the mental health of children and youth was in crisis before the pandemic, with 1 in 7 children and youth worldwide having a mental disorder. Given the continued decline in this area of health, children and youth may well be on the cusp of a “generational catastrophe” that could involve lasting harms if immediate action is not taken. Of particular concern are marginalized and vulnerable children and youth—they are the ones unduly enduring the brunt of this global crisis. Accordingly, child and youth mental health recovery must be prioritized, along with the reduction of inequity within and across countries. A commitment to public health strategies that never include harming children and youth as a tolerated side effect must also be made.


Where Is Disability in Global Public Health?  

Gloria Krahn

Accounting for about 15% of the world’s population, persons with disabilities constitute a critical population. Despite a substantial knowledge base in disability and public health, persons with disabilities have been remarkably invisible within general global public health. Public health’s view of disability is shifting from regarding disability only as an outcome to prevent, to using disability as a demographic characteristic that identifies a population experiencing a range of inequities. Alternative models of disability reflect how disability has been viewed over time. These models vary in their underlying values and assumptions, whether the locus of disability is the individual or the environment or their interaction, who designates “disability,” and the focus of intervention outcomes. The United Nations flagship report on Disability and Sustainable Development Goals, 2018 documents that, as a group, the lives of persons with disabilities are marked by large disparities in Sustainable Development Goal indicators. These include increased likelihood of experiencing poverty, hunger, poor health, and unemployment, and greater likelihood of encountering barriers to education and literacy, clean water and sanitation, energy, and information technology. Overall, persons with disabilities experience greater inequalities, and this is particularly experienced by women and girls with disabilities. The COVID-19 pandemic and other disasters have highlighted the gaps in equality and consequent vulnerability of this population. Global disability data have improved dramatically during the decade from 2010 to 2020 with the advent of standardized disability question sets (Washington Group) and model surveys (Model Disability Survey). New studies from the Global South and North identify areas and strategies for interventions that can effectively advance the Sustainable Development Goals. This call-to-action outlines strategies for increasing visibility and improving wellbeing of persons with disabilities, particularly in the Global South. Increased visibility of the disability population within the global public health community can be achieved through active engagement of persons with disabilities. Improved collection of disability data and routine analysis by disability status can provide information vital to planning and policies. A twin-track approach can provide direction for interventions—inclusion in mainstream programs where possible, use of disability-specific and rehabilitation approaches where necessary. The article ends by outlining ways that multiple roles can increase the inclusion of persons with disabilities in global public health.


Health in All Policies: Perspectives From the Region of the Americas  

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.


Global Goal Setting and the Human Right to Water  

Cristy Clark

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.


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.


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.


Ten Lessons From a Career in Global Health: Guidance to Those Considering a Life Working With the Poor Countries of the World  

Jon Rohde

Global health, defined by the World Health Organization as “priority on improving health and achieving equity in health for all people worldwide,” is an expanded view of traditional public health. While utilizing many of the tools widely taught in schools of public health, its emphasis is both on reaching the poorest and most isolated populations and transferring knowledge and skills for their benefit. Extensive and continuous field interactions and collaboration with the populations for whom health interventions are intended to benefit are very important. Thus, immersion in local culture and society, language skills, and active listening are key attributes for a global health professional to acquire. These apply to local health workers as well as expatriates. A broad array of disciplinary insights, ranging from clinical medicine to social sciences, communication strategies, and team building, are often more valuable than a single technocentric expertise, enabling a more holistic approach to health problems. The ability to simplify suggested techniques and interventions and especially the ability to create a culturally understood logic behind biomedical explanations go a long way to establishing acceptance of health messages and advice. Introducing new ideas, habits, and procedures incrementally rather than in one large dose of instructions or training has more lasting impact on both trainees and the targeted population. Invariably, delegating both authority and responsibility to “lower-level” workers—that is, those closer to the people through tradition, familiarity, and geographic access—results in greater acceptability and uptake of desired behaviors. Learning in the field is best accomplished from observing and emulating mentor figures—those who best exemplify the attributes of a widely accepted and respected health leader. In time, one’s own role as a mentor for new recruits facilitates the transfer of attitudes and approaches that embody these important principles of global health work. In the end, one’s impact on communities will be measured by the people and institutions that one inspires and leaves to carry on the work into the future.


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.


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

José Gomes Temporão and Carlos Augusto Grabois Gadelha

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


Environmental Health in Latin American Countries  

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.


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.


Changing Open Defecation Behavior  

Mark Radin

Open defecation (OD) remains a persistent problem in many low-income countries. The international community, through the Sustainable Development Goals (SDGs), has committed itself to eliminating OD by 2030. While access to and use of latrines has steadily increased, much is unknown on how to eliminate OD. The history of the elimination of OD in high-income countries offers potential lessons for achieving the sanitation targets of the SDGs. A desk review of sanitation literature revealed a well-documented effort to eliminate OD in the United States, which faced many of the same obstacles as those encountered in low-income countries in the 21st century. One of the important lessons is that eliminating OD takes sustained efforts over decades and substantial resources. The international efforts to eliminate OD have evolved through numerous phases within the global development agenda. To eliminate OD will require continued investment in new and ongoing programs, which are often led by national governments in partnership with international organizations, civil society, and the private sector. Many successful programs have utilized numerous approaches for eliminating OD as the barriers to sanitation use are different across societies and for each individual. Access to sanitation in institutions such as schools and health care facilities as well as public facilities remains a problem in both high- and low-income countries. Finally, the international community will need to deploy more resources and develop effective approaches for ensuring that latrine adoption and use is sustainable.


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.