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Global Health Diplomacy: A Theoretical and Analytical Review  

Celia Almeida

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.


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.


Urban Guerrilla Gardening and Health  

Alec Thornton

The benefits of gardening for mental and physical health are well known. Gardening is also recognized as a local-level or grassroots response to the negative effects of climate change and global warming. In urban areas, dense neighborhoods, limited green spaces, contaminated brownfield sites, and, at times, restrictive council regulations on the public use of parks and verges can act as barriers to gardening. In the 1970s, guerrilla gardening emerged as a clandestine, environmentally conscious, grassroots activity to reclaim and transform neglected or derelict urban spaces into healthy green spaces. Although not as subversive since its inception, guerrilla gardening in cities is as much a recreational activity as it is an ecological statement of urban activism, which effectively provides urban dwellers an entry point to engage with the outdoors for the planting of edible and nonedible plants in artificial places and spaces where natural life struggles to exist. Guerilla gardening has been impactful to city life through its contributions and controversies in improving urban ecosystems, educating neighbors on nutrition and food production where gardens crop up, and broadly to the health of humans (and other creatures) who live there.


Health Diplomacy in the Political Process of Integration in Latin America and the Caribbean  

Paulo Buss and Sebastián Tobar

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).


Digital Solutions to Public Health Issues  

Si Ying Tan and Jeremy Fung Yen Lim

Digital health technology has been adopted rapidly by countries as tools to promote good public health outcomes over the last decade. The COVID-19 pandemic that occurred since November 2019 has further accelerated the salience and relevance of digital health technology in tackling public health issues as countries start to implement movement restriction policies that pose a challenge to the physical delivery of healthcare services. Unarguably, the pandemic has elevated the significances of digital solutions to public health issues, which include improving access to an increased range of health services and the potential of cost-saving, maximizing population-wide health impacts through behavioral modifications, and controlling and managing public health emergencies. In general, digital technology in public health has three major applications—monitoring, decision support, and education. Monitoring is especially relevant in the context of effective disease screening and pandemic surveillance, decision support applies to the promotion of behavior modifications and resource optimization, while education serves to improve population-level health awareness and knowledge. Despite the promises of digital solutions to address various public health issues, there are unintended consequences that could arise consequent to their widespread applications, resulting in governance challenges and ethical issues in their applications, such as data privacy and erosion of trust, safety, cybersecurity, algorithmic bias, liability, autonomy, and social justice. To reap tangible benefits and positive impacts from large-scale deployment of various digital health solutions, countries need to anchor their national digital health policies or strategies by considering not only their benefits and applications, but also various governance challenges and ethical issues that could ensue during their implementations.


Conceptual and Practical Aspects of Water Regulation in Developing Countries  

Sanford V. Berg

Organizations regulating the water sector have major impacts on public health and the sustainability of supply to households, industry, power generation, agriculture, and the environment. Access to affordable water is a human right, but it is costly to produce, as is wastewater treatment. Capital investments required for water supply and sanitation are substantial, and operating costs are significant as well. That means that there are trade-offs among access, affordability, and cost recovery. Political leaders prioritize goals and implement policy through a number of organizations: government ministries, municipalities, sector regulators, health agencies, and environmental regulators. The economic regulators of the water sector set targets and quality standards for water operators and determine prices that promote the financial sustainability of those operators. Their decisions affect drinking water safety and sanitation. In developing countries with large rural populations, centralized water networks may not be feasible. Sector regulators often oversee how local organizations ensure water supply to citizens and address wastewater transport, treatment, and disposal, including non-networked sanitation systems. Both rural and urban situations present challenges for sector regulators. The theoretical rationale for water-sector regulation address operator monopoly power (restricting output) and transparency, so customers have information regarding service quality and operator efficiency. Externalities (like pollution) are especially problematic in the water sector. In addition, water and sanitation enhance community health and personal dignity: they promote cohesion within a community. Regulatory systems attempt to address those issues. Of course, government intervention can actually be problematic if short-term political objectives dominate public policy or rules are established to benefit politically powerful groups. In such situations, the fair and efficient provision of water and sanitation services is not given priority. Note that the governance of economic regulators (their organizational design, values or principles, functions, and processes) creates incentives (and disincentives) for operators to improve performance. Related ministries that provide oversight of the environment, health and safety, urban and housing issues, and water resource management also influence the long-term sustainability of the water sector and associated health impacts. Ministries formulate public policy for those areas under their jurisdiction and monitor its implementation by designated authorities. Ideally, water-sector regulators are somewhat insulated from day-to-day political pressures and have the expertise (and authority) to implement public policy and address emerging sector issues. Many health issues related to water are caused or aggravated by lack of clean water supply or lack of effective sanitation. These problems can be attributed to lack of access or to lack of quality supplied if there is access. The economic regulation of utilities has an effect on public health through the setting of quality standards for water supply and sanitation, the incentives provided for productive efficiency (encouraging least-cost provision of quality services), setting tariffs to provide cash flows to fund supply and network expansion, and providing incentives and monitoring so that investments translate into system expansion and better quality service. Thus, although water-sector regulators tend not to focus directly on health outcomes, their regulatory decisions determine access to safe water and sanitation.


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.