Amar Razaq, Muhammad Asad ur Rehman Naseer, Muhammad Naseer, Saher Jabeen
Decentralization has become one of the main governance reforms through which developing economies try to make food security policy more responsive to local conditions. The reform promise is straightforward: subnational governments and community institutions may know local agroecological conditions, household vulnerability, market constraints, and social exclusion better than central ministries. Yet decentralization can also reproduce weak service delivery when authority is transferred without finance, staff, data systems, accountability, or coordination. This chapter argues that local food governance should be assessed as a design problem rather than as a general reform ideal. Effective devolution links clear functional assignments, predictable finance, capable local administration, public participation, and national standards. The chapter develops a multilevel framework for food governance, compares fiscal and institutional patterns in selected developing economies, and uses case boxes from Pakistan, India, Brazil, Kenya, Indonesia, and Ethiopia. It concludes that decentralized governance can strengthen inclusion and responsiveness, but only when local discretion is embedded in transparent institutions and coherent intergovernmental systems.
Arbee Mae L. Castro, Chanelie B. Tabliga, Patricia Antonette Merecido, Anthony Vince P. Bongo ¡ 5 authors
Wastewater disposal and treatment are critical, under-recognized components of public health and environmental protection in the Philippines. This systematic review synthesized evidence on wastewater system types, treatment technologies, assessment approaches, and population-level implications from January 1982 to 11 February 2026. Following PRISMA 2020, we searched Scopus, Web of Science, PubMed, ScienceDirect, Philippine E-Journals, and Google Scholar, plus 17 gray/institutional sources. From 717 records identified, 582 were screened and 120 full texts assessed; 57 sources (39 academic studies and 18 operational/regulatory documents) were included. Across four decades, wastewater management was constrained by fragmented governance, limited financing, weak local capacity, and low sewerage coverage, with most households relying on septic systems that often provide inadequate treatment. Evidence linked untreated or poorly treated wastewater to river and lake degradation, groundwater contamination, heavy metal bioaccumulation, eutrophication, and persistent chemical markers, while industrial case studies showed high removal efficiencies where compliant treatment was implemented. Decentralized and nature-based options (constructed wetlands, DHS, MSL, MBBR and hybrids) showed promising pollutant removal and community acceptability, and recent studies highlighted resource recovery and greenhouse-gas mitigation via sludge management. Overall, stronger coordination, investment, monitoring, septage management, and scalable decentralized solutions are essential for climate-aligned wastewater sustainability and public health protection.
Purpose: This study examines the potential of on-site water reuse (OSWR) systems as sustainable solutions to Nigeriaâs growing urban water challenges, assessing technological, socio-cultural, economic, and regulatory dimensions to determine their role in improving resilience and equity. Methodology: A Systematic Literature Review (SLR) was conducted using Scopus, Web of Science, and Google Scholar databases, covering studies from 2015 to 2025. From over 400 initially identified publications, 100 were retained after applying the inclusion criteria. Thematic analysis was employed to evaluate the technological options, financial models, socio-cultural perceptions, and governance structures that influence OSWR adoption. Findings: Evidence suggests that low-cost technologies, such as biosand and ceramic filtration, ultraviolet disinfection, and modular greywater systems, are technically feasible and locally adaptable. Economic assessments highlight long-term cost savings; however, the upfront capital intensity requires innovative financing mechanisms. Socio-cultural barriersâincluding mistrust, hygiene concerns, and low awarenessâremain significant, while regulatory frameworks are fragmented and lack explicit guidelines for decentralized reuse. Case studies in Lagos and Abuja confirm feasibility but reveal gaps in policy enforcement and sustained investment. Unique Contribution to Theory, Practice and Policy: OSWR systems are a viable pathway to strengthen urban water security, reduce reliance on centralized supply, and enhance resilience in Nigeria. Success requires governance reforms, participatory community engagement, targeted subsidies, and innovative financing (e.g., climate funds, PPPs). Embedding OSWR into national policy and urban planning frameworks is essential for long-term sustainability.
Ronald Sakaya, Charles B. Niwagaba, A.Y. Katukiza, Christoph LĂźthi
ABSTRACT This study reviews the status of access to water supply, sanitation, and solid waste management (SWM) services in Uganda, examining the influence of national government policies, institutional frameworks, and financing mechanisms. It employs a mixedâmethods approach, combining qualitative analysis of primary data from key informant interviews with secondary data from systematically reviewed literature, including performance reports, project data from ministries, development partner websites, and peerâreviewed journal articles. The findings reveal persistent challenges related to intersectoral coordination, overlapping roles, policy inconsistencies, stakeholder conflicts, and funding inefficiencies. Water services receive a disproportionately high percentage of funding (over 80%), whereas sanitation and SWM receive significantly less (approximately 5% and 10%, respectively). Regulations advocate for sustainability, but their implementation in small towns remains weak. Policy analysis at the local level suggests a misalignment that prioritizes SWM over individual water and sanitation services. Decentralization empowers local authorities, but successful service delivery depends on robust enforcement of available policies. The analysis of funding and service delivery gaps underscores the need for equitable resource allocation and integrated approaches. The study concludes by emphasizing the need for active engagement by governments, development partners, local communities, and the private sector to achieve equitable access to basic services.
Marc Bosonkie, Benito Kazenza, Rawlance Ndejjo, MarieâClaire Muyer ¡ 10 authors
Background: The rapid spread of COVID-19 forced governments to urgently implement non-pharmaceutical measures to stop the surge. These restrictions disrupted the provision of nutrition services. This study identified challenges faced by nutrition services using the six components of the health system and preventive strategies that can strengthen nutrition interventions during future outbreaks. Methods: A multiple-case qualitative study was carried out. Purposive sampling was used for recruitment of participants. 57 key informants were selected based on their role in the Nutrition sector at different levels of the health pyramid. The interview guide incorporated nutrition leadership, financing, workforce, infrastructure and commodities, service delivery and information system. Each topic had subtopics on challenges and adaptations. All transcripts were exported to Atlas Ti v22, and thematic analysis was conducted. Results: Initially excluded from the national COVID-19 response, nutrition services were later integrated through advocacy by the National Nutrition Program. Despite limited funding, the government maintained support, and health workers adapted with flexible staffing approaches. Commodity shortages, including Ready-to-Use Therapeutic Food, led to the use of locally produced substitutes. Movement restrictions and fear of infection disrupted essential services such as growth monitoring and immunization. To sustain access, mitigation strategies were implemented, including tailored education, modified weighing methods, and decentralized care. Key innovations included rapid registration with anthropometric protocols, additional service points for child health activities, double-weighing scales to reduce contact, crowd control during Growth Monitoring Promotion, community-based service delivery, and improved digital integration. Conclusions: COVID-19 disrupted all pillars of nutrition services in the DRC but also spurred innovation. Institutionalizing adaptive strategies, securing sustainable funding, and supporting local Ready-to-Use Therapeutic Food production are essential to strengthen resilience and ensure continuity of nutrition services in future health emergencies.
Access to safe drinking water remains a pressing global issue, with over 2.2 billion people still lacking safely managed water services. In Indonesia, rural communities often face disparities in access, relying on decentralized systems with limited sustainability. This study investigates financing mechanisms for community-based rural water utilities (RWS) in Piyungan Subdistrict, Bantul Regency, to identify suitable models that support long-term service sustainability. By employing Analytical Hierarchy Process (AHP) method, this research analyzes social, economic, and environmental criteria and sub-criteria influencing financing preferences from the RWS. Primary data were collected through structured interviews and questionnaires with eight RWS entities meeting specific performance and operational criteria. The results show that social factors, particularly community-based management and participation, are the most influential in sustaining RWS. Among four financing alternatives, community financing emerged as the most preferred (62%), followed by private financing and grants, with debt financing receiving the lowest priority. These findings highlight the critical role of local engagement, institutional capacity, and adaptive financial strategies in ensuring service continuity. The study proposes a phased, blended financing approach, tailored to each stage of RWS development, emphasizing that long-term sustainability must be supported by institutional reforms, improved financial management, and environmental risk governance.
Mohammad Tabieh, Tala Qtaishat, Khaleda M Al Ghazawi, Ahmad Jamrah ¡ 7 authors
Expanding centralized wastewater services to all regions in Jordan is constrained by economic, topographical, and engineering challenges. As a result, decentralized wastewater treatment systems (DEWATS) are increasingly recognized as a complementary solution, particularly for rural and peri-urban areas where centralized connectivity is unfeasible. This study aims to design a sustainable and scalable business model for DEWATS in Jordan, with a focus on overcoming the institutional, financial, and regulatory barriers that have historically hindered their adoption. The research integrates spatial diagnostics, stakeholder consultations, institutional analysis, and a comprehensive financial and economic evaluation of three nature-based DEWATS configurations designed for settlements of up to 5,000 population equivalent (PE). Indicators such as average incremental cost (AIC), net present value (NPV), internal rate of return (IRR), and benefit-cost (B/C) ratios were used to evaluate technical and operational viability under both private and public investment scenarios. While all configurations demonstrated strong economic performance (IRRs > 27%, B/C > 3.7), financial feasibility remains weak without public capital support due to high per capita costs and limited revenue collection in small communities. The study identifies critical challenges, including undefined institutional mandates, lack of certified operators and regulators, insufficient cost-recovery mechanisms, and underdeveloped markets for private sector participation in O&M. Furthermore, existing tariff structures and bylaws do not adequately support capital investment or full operational cost recovery by private service providers. To address these gaps, the paper proposes a hybrid public-private-community business model incorporating performance-based service contracts, revised regulatory standards, and blended financing instruments. The model emphasizes the integration of DEWATS into spatial water safety planning, climate-resilient system design, and resource recovery to enhance environmental, social, and financial sustainability.
Silvia Landa, Elisha Y. Sanoussi, Ezechiel Mahamane, Kairou Oudou Bilo Mahamadou ¡ 6 authors
Water, sanitation, hygiene, waste management, and other environmental health services are critical for safe health systems, but global access is lacking. Adequate financing is a key barrier, and understanding resource allocation can help identify solutions in resource-limited contexts. We conducted a qualitative case examining resource allocation in rural Niger. Our objectives were to understand resource allocation processes, key actors and their roles, and contextual factors that influenced resource allocation. We interviewed thirty-three healthcare workers, community leaders, and government officials. We found that resource allocation followed formal and informal processes. Formal processes encompassed annual budgets and monthly supplies through government channels, while informal processes depended on healthcare workers' out-of-pocket expenses, unpaid labor, in-kind community support, healthcare facility revenue, and contributions from non-governmental and United Nations agencies, and the diaspora. Informal resource allocation was critical to fill the gap when formal processes were slow or insufficient. Resource allocation was highly decentralized with minimal influence of national policies and legal frameworks at the local level. Key contextual factors influencing resource allocation included politicization of budgets at the commune level, sometimes leading to inefficiency or inequity. We observed that healthcare facility actors who were most knowledgeable of needs often held the least decision-making power. We concluded that informal processes were complementary to formal processes, not conflicting. In contexts where government funding is severely limited, informal mechanisms may be the only viable short-term option to ensure the availability of services, demonstrating greater flexibility and adaptability. However, ultimately informal processes are an interim solution that should be explored to ensure service delivery without undermining long-term government systems strengthening. We recommend that funders commit to long-term initiatives promoting local government democratic decision-making, account for local actors' capacities and incentives, and acknowledge dynamic formal and informal resource allocations to optimize investments and trade-offs.
This paper aims to emphasize the significance of creating subnational nutrition action plans in regions with high variation in nutrition challenges and evaluates their projected return on investment in Kenya. Despite steady progress, undernutrition in Kenya remains high, costing the country an estimated US$ 4.2 billion or 7% of its GDP annually. Under Kenya's decentralized government system, numerous counties developed sectoral County Nutrition Action Plans (CNAPs) in 2018 to identify and prioritize essential nutrition actions to target undernutrition at the subnational level. In this paper, the authors present findings from county investment cases (CICs) in five counties - Nandi, Busia, Makueni, Vihiga, and Elgeyo Marakwet-including the costs, health impacts, and benefit to cost ratios of implementing high-impact nutrition interventions. Data was collected on the target coverage and cost of interventions prioritized in each county's CNAPs for the 2018 to 2022 period. A monetized DALY approach, using the value of a statistical life methodology was used for cost-benefit analysis and the Optima Nutrition tool was used for cost-effectiveness analysis. The estimated cumulative impact of the five CNAPs was projected as 1,800 child and 115 maternal deaths averted; preventing and treating 19,000 cases of stunting and 4,700 cases of wasting in children under five and averting 67,000 cases of anaemia in pregnant women and adolescent girls. The county-level benefit-cost ratios range from $5:1 to $14:1 (at a default 3% discount rate). This analysis demonstrates that localized subnational plans can be advantageous for policymaking and prioritization to better address subnational disparities in undernutrition and offer a high return on investment.
This review paper aims to examine the key challenges associated with wastewater management in major cities of the East African region and explore the emerging opportunities for addressing this crisis. An extensive database search identified 100 peer-reviewed publications related to wastewater crisis in East Africa. The reviewed literature was analysed and synthesized to develop an understanding of the topic. The findings from this review have shown that less than 55% of the East African population (30% in Tanzania, 40% in Uganda, 50% in Kenya, 40% in Rwanda, 20% in Burundi, 30% in Ethiopia, 50% in Sudan, and 15% in Somalia) is connected to sewers systems. Additionally, the study has revealed the following issues as the main challenges facing wastewater management in East Africa; poor infrastructure, regulatory and institutional deficiencies, poor financing and cost recovery mechanism, and poor community participation and utility management, which in turn results to potential environmental and public health implications. This paper has also identified possible innovative strategies and emerging opportunities for sustainable wastewater management. These include; decentralized wastewater treatment systems, resource recovery and reuse, publicâprivate partnerships, policy and governance reforms and the use of modern technologies such as membrane filtration, advanced oxidation processes, and electrochemical treatment methods. In addition, the role of policy and governance reforms in enabling sustainable wastewater management in East Africa has also been emphasized, in this paper. The findings of this review emphasize the urgent need for comprehensive policies, investments, and collaborative efforts to address the wastewater crisis and harness the potential benefits of wastewater as a resource.
While maternal mortality decreased during the Millennium Development Goals era, it remains unacceptably high, with stagnation in reductions possible due to shocks such as COVID-19. Most women in low- and middle-income countries already receive antenatal care and over half give birth in health facilities. In cities, use of health facilities for childbirth is near universal (>90%). Cities present complex challenges in ensuring pregnant women receive equitable, high-quality care. The UrbanBirth Collective is a portfolio of projects in sub-Saharan African cities seeking to address an important knowledge gap: how to adapt urban healthcare systems and lived environments to improve maternal and perinatal well-being? Its key focus is care during labour, childbirth, and the early postnatal period, when most poor maternal and perinatal outcomes occur. Our starting projects focus on harnessing open source data to examine and compare cities on the continent, including in-depth case studies of three cities: Grand Conakry (Guinea), Grand NokouĂŠ metropolitan area (Benin), and Lubumbashi (Democratic Republic of the Congo), where we will capture and analyse three main dimensions of the dynamics: maternal health service provision; maternal healthcare use by women; and the complex, nonlinear interactions between the provision and use of care within the spatial, social, and political ecosystem of a city. By comparing these three cities, we shall propose a generalisable model which can be validated and applied in other cities in sub-Saharan Africa. The growth of cities demands increasing attention on future-proofing them with the capacity to develop, implement, and continuously adapt a coherent strategy for the provision of equitable maternal and newborn care. Our ambition is to contribute to reaching zero preventable maternal deaths in cities. To achieve these goals through understanding specific contexts and facilitating the adoption and application of research findings and recommendations, we will collaborate closely with local stakeholders, including healthcare workers, community leaders, and policymakers.
Urban water provision sits at the intersection of public administration, infrastructure policy, and social equity. In the Philippines, high aggregate access to drinking water coexists with uneven service reliability, coverage gaps, and persistent inefficiencyâpatterns that point to governance constraints rather than hydrological scarcity alone. This study examines how institutional structures and incentive systems shape urban water governance outcomes across five cities in the Zamboanga Peninsula (Region IX): Zamboanga City, Pagadian City, Dipolog City, Dapitan City, and Isabela City. The analysis applies a multi-level governance and institutional-incentive framework to trace how authority, resources, and accountability are distributed among national regulators and sector agencies (notably the National Water Resources Board and the Local Water Utilities Administration), local government units, and city water providers. The study adopts a comparative case design using publicly verifiable secondary data from 2022â2024, including utility performance reports and administrative records on service delivery and operational efficiency. Key indicators include service coverage, continuity of supply, and non-revenue water, alongside governance features such as tariff-setting influence, access to national financing, technical capacity, and the presence of cross-agency coordination mechanisms. Findings show persistent intra-regional disparities under a common national legal framework. Zamboanga City reports the highest coverage and continuity, but also the highest system losses, while smaller systems demonstrate lower coverage and more intermittent supply with only marginally better efficiency. Across cases, outcomes align less with formal decentralization than with fragmented mandates, weak regulatory enforcement, politically constrained tariff governance, and limited performance-linked fundingâconditions that weaken accountability and dilute responsibility for results. The study proposes reforms focused on (1) tighter regulatory and planning coordination across levels, (2) performance-conditioned financing tied to measurable service and efficiency targets, and (3) transparent, insulated tariff review with structured stakeholder engagement to improve equity, reliability, and sustainability in regional urban water services.
Urban water services in secondary cities across Southeast Asia are frequently shaped less by engineering constraints than by institutional design: overlapping mandates, weak regulatory leverage, and misaligned incentives across levels of government. This study analyzes the governance of urban water services in Zamboanga City, Philippines, using a multi-level institutional approach that integrates Multi-Level Governance theory with the Institutional Analysis and Development (IAD) framework. Drawing on documentary and policy analysis, administrative and performance data from 2018â2023, and a review of the rules-in-use governing planning, regulation, and financing, the study maps how national agencies, the local government unit, sector regulators, and the Zamboanga City Water District interact in practice. Findings indicate persistent gaps between formal authority and operational control. Service coverage remains limited (approximately 48% of households), non-revenue water is high (exceeding 39%), and tariff recovery is insufficient to sustain capital investment for network expansion and system rehabilitation. Governance outcomes are driven by (1) regulatory overlap and unclear accountability for enforcement, (2) policy mandates that compete with local political authority over priorities and resource allocation, and (3) weak coordination mechanisms that fail to align incentives for performance, investment, and demand management across institutions. The study contributes evidence on how decentralization can reproduce fragmentation without credible coordination and accountability instruments. It identifies reform directions centered on clarifying regulatory authority, strengthening performance-based accountability, and improving the financial architecture for investmentâaimed at enabling service expansion, reducing losses, and enhancing the sustainability of urban water provision in decentralized settings.
Urban populations in Asia, Africa, and Latin America are confronted with significant difficulties in accessing water due to inadequate infrastructure, limited governance capabilities, and the exacerbating effects of climate change, which further exacerbate water scarcity. This article investigates the physiological, environmental, and economic hardships that arise from insufficient access to quality water and sanitation infrastructure in cities of the Global South. Available evidence suggests that more than two billion individuals living in urban areas do not have access to water sources that are appropriately maintained. This lack of access has led to the widespread occurrence of diarrhoea diseases, particularly in marginalized informal settlements. There is a cumulative impact on households, municipal authorities, and national budgets due to economic losses resulting from healthcare expenses, decreased productivity, and limitations in the industrial sector. Reports also demonstrate severe water shortages caused by distinct local circumstances while also highlighting shared challenges of contamination, intermittent supply, and affordability problems that worsen inequality. While there are promising decentralized options available, as well as water efficiency and reuse advancements, there are still significant gaps in financing. It is estimated that an annual amount of $114 billion is needed to ensure access to safe water and sanitation for the increasing urban populations in the developing nations. Effective collaboration on a global scale and local administrative changes are crucial for addressing these deficiencies in infrastructure and enhancing the ability of mega cities in the Global South to withstand the escalating hazards posed by climate change.
Urban Flooding stems from the torrential spells of rainfall overwhelming the capacity of drainage systems in an area of dense population leading to global concerns for economic and social damages. Recent meteorological conditions in Pakistan have resulted in surplus rainfall across the Sindh province inundating it most populous and financial capital, Karachi due to downpour [1]. The Provincial Disaster Management Authority PDMA reported 26 deaths from June 20 to 10 July [1]. With devastating damages to both public and private infrastructure and property, urban flooding has also evoked serious concerns for health and sanitation in the metropolitan setup. Direct contact with drainage and rainwater augmented the threats to vector-borne diseases such as malaria, dengue, Hepatitis A, leptospirosis, and water-borne such as typhoid, diarrhea, cholera, and other gastrointestinal infections, particularly in a low - middle-income country with poor hygiene and sanitation control [2]. After the havoc burdened by the COVID-19 pandemic exposing the vulnerability of the healthcare system worldwide, a new outbreak of Cholera was reported by WHO in Sindh, Karachi after 234 confirmed cases from 15 January to May 27, 2022 [3]. Cholera is an acute infection caused by the bacterium Vibrio Cholera upon contact with contaminated food or water. It is associated with episodes of watery diarrhea and is virulent with high rates of mortality if untreated [2,3]. Climate changes such as heavy rain, followed by floods and damage to sanitary infrastructure accelerates cholera surge due to expediting contact of contaminated water with human activities [4]. Thus, the current situation of urban flooding in Karachi favors the occurrence, growth, and transmission of Cholera. About 70% public and household water sources of Karachi was found be contaminated with Cholera including E. coli (55%), Coliform (90%), and Shigella on testing, making 91% of the water supply unsafe for drinking [5]. Unsuitable sanitary and hygiene (WASH) practices, improper waste disposal, close-quarter residence in more than 600 slums [6], and millions of people with no awareness, resources, or even motivation have been predisposed to the risk of an intensified outbreak. Together with casualties and the spread of vector and water-borne diseases, flood water has imposed a threat to lives and is quite alarming as similar patterns of infection including diarrheal diseases and dengue were reported in 2020 after record-breaking rainfall in Karachi as a result of inadequate sewage treatments and contaminated water supply [7]. Considering an already burdened economy and weakened health setting in low-middle income countries any neglect of preventive measures and efficient control strategies may cause a sharp rise in disease progression jeopardizing millions of individuals at stake. The cases reported so far suggest a possible outbreak, hence, strategies to efficiently counter Cholera must be devised. The combination of prevention and adequate measure for control can refrain from the increasing risk of widespread infections including Cholera and could limit the existing burden of floodwater calamities to a reasonable extent. Thus, to combat the current alarming condition in Sindh and Karachi, this article made some recommendations: Awareness campaigns for management using advertisement and pamphlets emphasizing primary health and hygiene: frequent washing of hands, use of boiled drinking water, thoroughly washing of fruits and vegetables, covering food from flies, ensuring fully cooked home-made food with clean hands and utensils, use of disinfectants to clean floors and distancing from the crowd and avoid using public toilets could be effective to limit the transmission. Advertisements demonstrate steps to boil water or teach household treatment of unclean water with chlorine products (granules and tablets) or household bleach [8]. WASH interventions and health surveillance programs are to be initiated by the government. Discard food that comes in contact with floodwater or rainwater. Also, avoid eating food with unusual odor or color and refrain use of any perishable food that has not been frozen or adequately refrigerated for at least 4 h given the power cutoff during a rainstorm [9]. Avoiding street food that possibly gets contaminated with direct flood water or flies could give positive outcomes in restricting the advancement of the number of cases. Safe Water treatment interventions to be made and monitoring of quality water supply amongst the households and public settings including tertiary clinics and hospitals. Installation of filters and water cleaning plants by the government. Doorstep supplies of sealed mineral water, soaps, hand wash, sanitizers, and disinfectants particularly in slum areas to increase access to basic hygiene kits. Refraining direct contact with floodwater and dispose of any clothing that comes in direct contact with it to minimize the possibility of flu, fever, skin rash, cholera, dengue, and other infectious diseases. Diarrheal death are much more prevalent among infants younger than 5 years [10] thus, maternal guidance should be provided to protect infants from cholera through regular baths, hand washing, wipes, clean drinking water, boil bottles, and appropriate feeding. For already infected children who acquire diarrhea immediate ORS and ample water intake to be regulated to prevent severe dehydration. Material support should provide by government to ensure the availability of supplies including ORS, zinc, selected antibiotics for case management. Earlier diagnosis, antibiotics, vaccination, oral hydrating solution therapy, and online consultations to be provided to the affected individuals. Oral Cholera Vaccine (OCV) administration [3] that significantly reduces the incidence of Cholera [11] and large-scale disinfectant programs are to be introduced. Hospital staff to be alerted and trained to combat the surge of cases. Guidelines should be laid and resources to be accumulated to counter the aggravating situation. The government must also take steps to provide safety kits to front-line staff and workers indulged in restraining efforts against natural calamities. Crisis and case management training and treatment outlines to be deduced in Tertiary Care Centers and hospitals to address the alarming situation of Cholera and other diseases whose epidemic risks are amplified by flooding [5]. Crisis management team to be formed and trained to counter the casualties and disasters of floods and spells of the thunderstorm. Special measures were taken to access the situation and launch a volunteer force to enable access to help and hospital facility in case of emergencies. Rescue teams to be mobilized to operate in areas submerged in flood water. Government to accommodate inhabitants with shelter, food supply, and safe water. Ethical approval N/A. Sources of funding None. Author contribution Shafaq Taseen conceived the idea, Shafaq Taseen and Sara Jawed retrieved the data and did write up of an article; and Aqleema Mohammad Ameen did the proof-reading and submission. All authors approve final version of the article. Registration of research studies N/A. 1. Name of the registry: N/A. 2. Unique Identifying number or registration ID: N/A. 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A. Guarantor N/A. Consent N/A. Declaration of competing interest None. Acknowledgment The authors would like to sincerely thank executive council of KMRC for motivating and imparting us with adequate knowledge.
Jennifer McConville, Elisabeth KvarnstrĂśm, Marcus AhlstrĂśm, Charles B. Niwagaba
Pressure is growing to develop innovative decentralized sanitation systems that protect public health and recover resources. This study evaluates the opportunities for niche technologies focusing on nutrient resource recovery to enter the market in Greater Kampala, Uganda. It applies methodology from sustainability transition studies in a novel way to provide new insights into possibilities for change in the on-site sanitation sector. The study 1) characterizes the existing socio-technical regime for on-site sanitation, 2) identify stress points in the regime and 3) possible advantages for the niches. Assessment of the regime covers technology, epistemic practice, sector values, organisational modes, policy and financing. The niches include urine diversion toilets, on-site resource recovery, and container-based models. The on-site sanitation regime is under performing and the niches all offer advantages for improved service and resource use. However, it will be difficult for the niches to break into a sector in which epistemic practice, organisational modes and financing are heavily dominated by the sewage regime. Recommendations for creating a more open environment for innovation are provided for specific stakeholders.
Mathurin François, Marc Arthur Petit-Homme, Eduardo Cohim, SĂlvio Roberto MagalhĂŁes Orrico ¡ 5 authors
Abstract The use of rainwater is a reliable alternative for reducing clean water consumption and water bills. This study assessed the willingness of Haitians to invest in rainwater infrastructure (RWI). A questionnaire with closed and open-ended questions was used for this purpose. For closed-ended questions, â0â and â1â were used for negative and positive answers, respectively. Other numbers were used to encode the open-ended questions. The two-tailed Z-test was used to compare two proportions, where a result was statistically significant when the p-value was less than 0.05. Of 362 rainwater users, 81.2% used it for washing, bathing, cooking, flushing, and drinking. Approximately 73.4% of households with 1â3 people, compared with 84.0% of families with 4â6 people, used rainwater. Of all the respondents, 82.3% would invest in RWI if the government agreed to finance up to 50.0% of the project. More than 73.0% of respondents in each locality would invest in rainwater in RWI under the conditions previously mentioned. It is concluded that the implementation of RWI and decentralization of water systems would be welcomed by the rainwater users in Haiti, but the unwillingness of the Haitian government could be the main barrier to such a transition.
Background: Nigeria piloted decentralized facility financing (DFF) and performance-based financing (PBF) programs under the Nigeria State Health Investment Project (NSHIP), funded by the World Bank. It aimed to increase the utilization and quality of maternal and child health (MCH) services. Although many low- and middle-income countries have launched or piloted DFF and/or PBF like programs and conducted impact evaluation, very few studies related DFF or PBFâs impact to its cost. This study evaluates the incremental cost-effectiveness ratios (ICERs) of facilities with DFF or PBF compared to comparably funded health facilities without it. Methods: This study used a quasi-experimental research design. Local government areas (LGAs) in the three states under NSHIP were randomly assigned to the PBF group, where health facilities received payments based on their performance, and to the DFF group, where payments were not tied to performance. An additional three states served as the control group without additional funding. Reflecting the health system perspective, incremental financial costs were assessed for program implementation and verification, consumables, and donor supervision. Net effectiveness on coverage and quality were assessed through difference-in-differences calculations between baseline and endline facility and household surveys. The Lives Saved Tool and literature were used to convert statistically significant coverage changes to lives saved and quality-adjusted life years (QALYs) gained. Results: Compared to the control group the incremental costs of DFF and PBF were $45.2 million and $87.3 million in 2015 US dollars, respectively. In comparison to the control group, DFF had a major impact on Bacillus CalmetteâGuĂŠrin (BCG) and diphtheria, pertussis and tetanus (DPT)], increasing their coverage by 13.4% (P<0.001) and 9.7% (P<0.05), respectively while PBF increased the rate of skilled birth attendance (SBA) by 9.1% (P<0.05), and use of modern contraceptives by 5.7% (P<0.05). Overall, the quality of care was also improved under the DFF and PBF when compared to the control group. Compared to the control group, DFF and PBF were estimated to save 756 and 1,679 lives per year respectively, with 17,878 and 39,605 QALYs gained. The corresponding ICERs of the DFF and PBF program were $904 and $787 per QALY gained based on the coverage impacts alone. Combined with the improvement of quality of care, the ICERs of the DFF and PBF program were reduced to $224 and $296 per QALY gained when compared to the control group, respectively. Conclusions: Compared to the control group, Nigeriaâs DFF [ICER of $224 per QALY gained or 8.4% of gross domestic product (GDP) per capita] and PBF (ICER of $296 per QALY gained or 11.1% of GDP per capita) program proved cost-effective by the standard of 1.5 times GDP per capita in Nigeria. Whereas PBF is nearly twice as expensive as DFF, it saves many more years of life as compared to DFF during the same periodâPBF is more effective than DFF and DFF more efficient than PBF. These results hold both with and without incorporating quality improvements and suggest that DFF and PBF are among the cost-effective interventions for strengthening MCH services in Nigeria.
Pneumonia, the leading infectious killer of children under five, has been called a âforgotten killer,â âa neglected tragedy,â and a âglobal cause without champions.â1, 2 Despite causing 800 000 child deaths, more than HIV/AIDS, tuberculosis and malaria combined, pneumonia has never attracted the levels of support commensurate with its burden.3 Less than 5% of international Development Assistance for Health and just 3% of all infectious disease research spending, are allocated to pneumonia.4 While the Global Action Plan for Diarrhoea and Pneumonia (GAPPD)5 launched by World Health Organization and UNICEF in 2013 did set a global target of three child pneumonia deaths per 1000 live births by 2025, no government had developed a national strategy to achieve this target by 2019.a The lack of funding and planning have contributed to slow progress meeting the target and just two countriesâBangladesh and Indonesiaâof the 20 with more than 10 000 annual child pneumonia deaths are on track to achieve the GAPPD pneumonia target.6 At current rates of progress, an estimated 6.3 million children will die from pneumonia by 2030 and many low- and middle-income countries (LMICs) will fail to achieve the sustainable development goal for child survival. The solution is not another vertical program channeling billions of dollars to tackle a single disease. There would be little appetite from national governments or the global health and development community for such a mechanism, which might undermine efforts to expand the reach of integrated community case management (iCCM) and integrated management of childhood illness (IMCI) and strengthen primary health care services to deliver Universal Health Coverage (UHC). Experience suggests that further reductions in child mortality in LMICs will require approaches that are sensitive to the complex patterns of comorbidity between pneumonia, diarrhea, malaria and malnutrition, and cognizant of the rising challenges of rapid urbanization, vaccine hesitancy, air pollution, and the double burden of under and overnutrition. The case for harnessing existing mechanisms such as Gavi, the Global Fund, Unitaid, and the Global Financing Facility to better integrate vaccine delivery, nutrition, and community case management is increasingly compelling, and much more work is needed to align the efforts of international agencies engaged in child survival in the high-burden countries.7 The Every Breath Counts Coalition (EBCC; https://stoppneumonia.org/) was officially launched in November 2017 to provide a platform for governments and international health agencies to work together to achieve the GAPPD target. In an acknowledgment of the progress achieved by the Global Fund and Gavi, the 40 member EBCC is a public-private partnership with representation from UN agencies, nongovernmental organizations (NGOs), private foundations, pharmaceutical and medical technology companies, and universities. Each member has made a written commitment to support government efforts to accelerate reductions in child pneumonia deaths according to their capabilities along with the prevention, protection, diagnosis, and treatment continuum. EBCC works with governments to develop data-based pneumonia control strategies, delivered as part of national primary health care strengthening and UHC efforts. The EBCC has prioritized support to four large âtransnationalâ clusters with large populations of children at heightened risk of death from pneumonia including, (a) Chad, Nigeria, Niger, and Mali, (b) Democratic Republic of Congo and Angola, (c) Ethiopia and Somalia, and (d) Pakistan and Afghanistan, the ambition of which is to support the development of bespoke pneumonia control strategies in each country. At the global level, three EBCC teams drive progress towards specific childhood pneumonia âglobal public goodsâ including: The development of routine indicators to measure access to pneumonia diagnosis and treatment; a set of agreed research priorities; and robust advocacy and communications activities. As Nigeria has the largest population of children at greatest risk of death from pneumonia, the EBCC supported the Nigerian Federal Ministry of Health (FMoH) to develop a pneumonia control strategy between January 2019 and 2020. Coalition members including USAID, the Nigerian offices of Dalberg, Save the Children, UNICEF, and the Clinton Health Access Initiative (CHAI) joined forces to support the process. To better understand the barriers preventing faster progress on reducing child pneumonia deaths in Nigeria, the Family Health Department within the FMoH invited 75 participants to a strategy workshop in Abuja in January 2019. Following this workshop, approximately 40 interviews with national and global stakeholders, supplemented by desk research and analysis of state-level policies and data on the burden of pneumonia deaths, were conducted by the strategy firm Dalberg on behalf of the FMoH. By early March 2019, the FMoH and the EBCC had developed a draft pneumonia control strategy, and the FMoH invited 30 partners to meet in Abuja in April 2019 to review the strategy and align the contents with the RMNCAH+N Strategy. EBCC and the FMoH then worked together to develop a more detailed implementation plan and an estimation of the financial resources needed to implement the strategy. Less than 7 months after the process began, a final workshop to validate the strategy took place in Abuja in July 2019. In October 2019, the Minister of Health officially approved the strategy and the strategy was officially launched in Nigeria on January 2020. This strategy development process generated several key lessons. The pneumonia control strategy development process elevated the status of childhood pneumonia as a key public health challenge in Nigeria. Bringing together a range of public (eg, Federal and State Ministries of Health and donor government missions), private (eg, manufacturers of vaccines, medical devices, and antibiotics), faith-based organizations, and civil society actors demonstrated an appetite for a greater focus on pneumonia and drew attention to the gaps and barriers in pneumonia control that were impeding progress to Nigeria's child survival target. Despite many competing priorities in health, stakeholders involved in the process became champions for pneumonia control. Two NGOs, Save the Children and CHAI even decided to integrate parts of the pneumonia control strategy into their own newborn and child health programming. The pneumonia control strategy development process also showed that it is possible to focus on a specific cause of child death, while promoting integrated case management of childhood illnesses at community and facility levels (ie, iCCM and IMCI). By emphasizing that pneumonia should be accorded a level of attention commensurate with its disease burden, the FMoH and EBCC were able to reposition and prioritize pneumonia as a major killer, deserving of at least the same levels of investment as other leading but much better resourced killers (eg, malaria). The process to develop the pneumonia control strategy enhanced cross-sectoral and interministerial collaboration across all levels of government in Nigeria. Effective pneumonia control depends on the coordinated actions of different federal, state, and local government agencies to prevent, diagnose, and treat pneumonia at all levels of the health care system. The Nigerian FMoH had to work closely with the Agriculture, Energy, and Environment Ministries to prevent pneumonia by improving vaccination, nutrition, and clean air. In addition, the FMoH must find ways to influence State and Local Government health actors to improve the diagnosis and treatment of childhood pneumonia in primary health care and hospital services, as these are decentralized responsibilities. The FMoH and EBCC were able to bring these various government actors together for the first time to talk about pneumonia control and offer the support of private and nonprofit sector partners. Lastly, and critically, the experience in Nigeria highlights the importance of taking a data-driven approach that puts the most vulnerable populations of children first. While it is still challenging to map child pneumonia deaths at national and subnational levels, data are improving rapidly and governments have new tools to identify childhood pneumonia âhotspotsâ where deaths concentrate.8 In Nigeria, the subnational child pneumonia maps released by the Institute for Health Metrics and Evaluation in 2019 revealed âhotspotsâ in several northern states. Targeting pneumonia control efforts to these children represents the most cost-effective path to reduce pneumonia deaths and achieve the GAPPD target. The EBCC is committed to sharing these new tools with governments so that they can help direct scarce resources in ways that maximize the number of child pneumonia deaths prevented. These maps not only enable governments to prioritize the most vulnerable children but also to require their international health and development partners to do the same. Nigeria is pioneering a new approach to achieving the GAPPD target. Its pneumonia control strategy will need to be monitored and evaluated over the next 5 years to assess results, to ensure that partners are held accountable for delivering on their commitments and to capture learnings that can inform other governments. If successful, the Nigerian pneumonia control strategy could become a blueprint for other countries struggling with heavy burdens of child pneumonia deaths to achieve the GAPPD target and strengthen integrated newborn and child health policies and programs.
Evidence shows that there are numerous socioeconomic and environmental benefits from improved sanitation; conversely, numerous studies have explored the lack of access to basic sanitation and its negative impact on gross domestic product (GDP). This paper establishes the positive impacts on GDP from investment in sanitation and emphasizes how it can regenerate countries. As the backdrop of this idea, this paper combines and analyzes supporting evidence through an extensive literature review to show that a new way of thinking informed by a comprehensive understanding of the historical issues faced must be adopted to address the sanitation challenge. This paper emphasizes decentralization, technological standardization, innovative financing, cost-recovery mechanisms and the potential of socioeconomic spillover effects as tools to revitalize the sanitation sector. It further elaborates on the significance of hybrid governance and institutional mechanisms, including state and non-state actors, to collectively contribute toward achieving total sanitation coverage in developing Asian countries. The paper shares the message that the benefits of wastewater management are far-reaching and conveys the importance of decision makers prioritizing this sector. The paper concludes that achieving replicability and scalability requires dedicated political will and visionary leadership.
Nathaniel Mason, Charles O. Oyaya, Julia Boulenouar
Abstract Motivation Across the Global South, unclear institutional frameworks undermine progress in improving services. Often, ongoing decentralization reforms reduce clarity further. Policy professionals working on institutional reform lack comparative models. Purpose To identify key challenges for the institutional arrangements for urban sanitation in decentralizing contexts, in Kenya and elsewhere, and to propose possible responses. Approach and methods We use key informant interviews and literature review in a problemâdriven analysis, drawing from three comparative case studies: South Africa, Indonesia and Tamil Nadu State. The analysis builds upon research on institutional effectivenessâcoâoperation, collaboration and coâordinationârooted in game theory and elaborated in the 2017 World Development Report. Findings Three key problems in Kenya are identified: overlaps and competition around sector leadership at national and devolved levels; weak incentives for county governments to commit policy attention and finance, despite devolution; and limited regulatory oversight. Policy implications We identify a range of options for urban sanitation policyâmakers: (a) to engage nonâsectoral authorities in coâordinating multiâsectoral issues across all levels of government; (b) to encourage political commitment to proâpoor sanitation services at decentralized levels; and (c) to use incentiveâbased and riskâbased approaches to regulate decentralized entities and strengthen local capacity for monitoring and enforcement.
For countries looking to implement multisectoral nutrition plans, it is critical to understand what works and how programs should be delivered and scaled-up in each context. Programs can learn from each other on how to adapt to new information, evidence and events related to scaling-up and district stakeholders can play important roles in implementation of this multisectoral plan. As part of "Pathways-to-Better Nutrition" (PBN) case study conducted by USAID/SPRING Project, this research set out to explore district leaders' perceptions of the nutrition situation, programs and opportunities for integration. Qualitative data were collected through key-informant interviews and focus group discussions. Thirty-five district and local leaders belonging to district and sub-county multisectoral nutrition committees in Kisoro and Lira were interviewed. Grounded Theory Approach was used to identify themes for coding and key domains included: learning, adoption and evidence of scale-up; adoption of innovations/interventions to local context, financing of nutrition-sensitive activities and long-term planning. Additionally, quantitative data collected by Feed the Future Innovation Lab for Nutrition were analyzed in each of the districts to provide nutrition snapshots. Malnutrition in the study districts was worse than the national average for stunting, anemia and women's underweight. The majority (91%) of respondents were not familiar with these nutrition statistics. Both study areas have formed nutrition multisectoral working groups (District Nutrition Coordinating Committees) and have developed management structures to implement interventions. Government stakeholders from every nutrition-sensitive sector referred to the lack of clear government programs that support nutrition directly in local policy environment. Key agricultural-related programs are focusing on wealth creation, value-addition or increasing agricultural productivity without nutrition lens (not "nutrition sensitive"). Nutrition is not on the 'list' of key priorities of district health departments unlike HIV/AIDS, malaria or sexual reproductive health. About 69% respondents believe they lack operational capacities and soft-power skills to design, implement and manage nutrition interventions such as leveraging of resources and being able to convey evidence. The understanding of "Scaling-up Nutrition" also differed by respondent, and this has resulted in different goals and measurements. Challenges related to nutrition financing were also noted, including fiscal decentralization, use of Output-Based Financing mechanisms, limited flexibility to re-allocate funds for nutrition, and lack of standard reporting procedures or implementation strategy. Efforts to address malnutrition need to be multisectoral, coupled with increased coordination of different sectors and ministries for sustained impact on nutrition outcomes.
Sascha Lamstein, Amanda PomeroyâStevens, Patrick Webb, Eileen Kennedy
Based on the data collected in Uganda, Nepal, and Ethiopia, the papers included in this supplement fill a critical gap in evidence regarding multisectoral National Nutrition Action Plans. The studies offer new data and new thinking on how and why governance, effective financial decentralization, and improved accountability all matter for nutrition actions in low-income countries. This introductory paper offers an overview of the current state of evidence and thinking on the multisectoral nutrition policy cycle, including how governance and financing support that process. It also explores the benefits of applying a systems lens to understand the dynamic, enabling processes of the policy cycle-from research to knowledge and ultimately action-and to provide more dynamic and accurate information for nutrition advocacy and evidence-based decision-making. It concludes with key findings from the 5 country-level studies included. Several important themes emerge: the egregious gap in human resources needed for effective nutrition actions in most low-income settings, the value of research on bottlenecks and successes, and the need for routine monitoring of national policies and plans to measure their effectiveness in achieving both their own stated goals and global sustainable development goals. Reviewing these studies together provides a path forward in building stronger, evidence-based multisectoral nutrition policies and supporting implementation of the nutrition activities included within them.