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.
Ty Bereskie, Ianis Delpla, Manuel J. RodrĂguez, Rehan Sadiq
Abstract Drinking-water management systems (DWMSs) represent the primary means for preventative management of a drinking-water supply and are defined as a system of policies, procedures and administrative/behavioral controls designed to ensure safe drinking water from source to tap. With influence and inspiration ranging from safe food handling to industrial quality management, DWMSs can take, and have taken, many different forms throughout the world. This variability is especially true in Canada, a country with a decentralized governance structure, where provincial and territorial governments are mostly autonomous in regard to drinking-water governance and management. While this has resulted in comprehensive DWMSs in provinces such as Ontario, less-proactive provinces and territories have fallen behind and may be exposing consumers to under-protected and vulnerable drinking-water supplies. This paper includes a review and comparison of the existing Canadian national, provincial and territorial approaches to drinking-water management, the World Health Organization Water Safety Plan Recommendations, national DWMSs from Australia and New Zealand, and also includes widely applied, generic quality management systems. This information is then used to gauge the comprehensiveness of DWMSs in Canada and highlight potential management gaps and policy recommendations for the development of new, or improving existing, DWMSs.
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.
Manfred van Afferden, Jaime Cardona, Mi-Yong Lee, Ali Subah · 5 authors
Planners and decision-makers in the wastewater sector are often confronted with the problem of identifying adequate development strategies and most suitable finance schemes for decentralized wastewater infrastructure. This paper research has focused on providing an approach in support of such decision-making. It is based on basic principles that stand for an integrated perspective towards sustainable wastewater management. We operationalize these principles by means of a geographic information system (GIS)-based approach 'Assessment of Local Lowest-Cost Wastewater Solutions'--ALLOWS. The main product of ALLOWS is the identification of cost-effective local wastewater management solutions for any given demographic and physical context. By using universally available input data the tool allows decision-makers to compare different wastewater solutions for any given wastewater situation. This paper introduces the ALLOWS-GIS tool. Its application and functionality are illustrated by assessing different wastewater solutions for two neighboring communities in rural Jordan.
This briefing paper has been prepared based on the basis of field level experiences. It highlights the emerging decentralized leadership in the WASH sector in light of the Master Plan and ODF movement in Nepal. The Master Plan has introduced innovative institutional arrangement of inclusive WASH Coordination Committees to lead ODF movement. These committees leadership of such committees hashave come up with several innovations in planning, financing, implementation and monitoring, and promoting inclusive and participatory governance process in sanitation development. Nepal's sanitation campaign has visibly scaled up ODF status despite some shortcomings. Mobilization of local resources is possible through local leadership, sustainability requires equal emphasis on behavioural and facility aspects and advocacy for health benefits of the improved sanitation are the prime drivers for changes. Similarly, cross-learning are vital for innovations in the sector and integration of sanitation with other development sector activities enhances synergy. The post-ODF intervention is leading the sanitation sector towards livelihood promotion and social wellbeing aspect too.
Investments for basic rural sanitation programs should not only focus on the construction of new installations, but also on the necessity of implementing proper management models that guarantee the operational and financial sustainability of the investments. The integrated rural sanitation system (SISAR) is based on the idea of creating a confederation of local user groups which come together on a regional basis, and through an adequate institutional setup, are responsible for managing SISAR and assuring the adequate provision of water supply and in some cases, wastewater services. Financial sustainability is achieved by the implementation of tariffs for water consumption and provision of wastewater services generating revenue which is redistributed among all systems in order to cover all operational, maintenance and administration costs. Important stakeholders in the model include, besides the users, local and state government and international financing institutions responsible for financing the investments in the construction of rural water supply and wastewater systems. This document focuses on the experience and results achieved by SISAR in the Brazilian state of CearĂĄ. In 2001 eight SISARs began providing improved water supply services in 66 settlements. Today, more than 560 settlements (more than 330,000 inhabitants) are supplied by SISARs.
1. Look as shit as an asset, the beginning of a whole sanitation value chain 2. Emphasize the role of the private sector in sanitation, in particular small scale private enterprises 3. Pay attention to the economics of investing in sanitation 4. Increase the efficiency of the sanitation value chain 5. Look at advantages of small scale decentralized versus large scale centralized waste water treatment (WWT) plants 6. Considering sanitation as a multi-governance challenge 7. Consider the economics of different technological options for sanitation 8. Incorporating informality in the sanitation sector 9. Tap alternative sources of finance for sanitation 10. Be aware of the politics of sanitation
Over the past 50 years, both financing and socio-economic considerations in South India have shifted heavily towards improving urban infrastructure, causing rural services to be left behind. A recent report released by WHO and UNICEF states that over 884 million people, 84% of whom live in rural areas, use âunimproved water sourcesâ for domestic purposes. This paper considers the case study of Nalgonda, a district to the east of Hyderabad, India. Nalgonda struggles with three main issues concerning domestic water: high fluoride levels in groundwater have caused thousands of cases of dental and skeletal fluorosis; second, over two-thirds of Nalgonda does not meet the WHO-requirement of 40 liters per capita daily of domestic water supply; third, poor management and maintenance have increased the risk of failure of existing water infrastructure. The state has been pursuing these issues in conjunction with a multi-district irrigation project that taps the regional Nagarjuna Sagar Dam. Centralized water supply, treatment, and distribution services are appropriate for high population density areas; however, geographical expanse and sparse populations lead to onerous access to improved water sources and inhibit the success of a similar centralized framework in rural areas. This is compounded by a lack of ownership at the habitation and socio-cultural levels. Further, the current water network and its problems - including inconsistent service, corruption, and general distrust of the treated Sagar water - have emboldened wealthier citizens to build private, unregulated groundwater defluoridation plants and commercialize small-scale water businesses. Inequitable services and uncertainty of shared water resources have caused a âtragedy of the commons,â leading to growing disparity and a severely receding water table. This research proposes the Louis-Ostrom Comprehensive Capacity Assessment (LOCCA) tool - an integration of the quantitative Capacity Factors Analysis risk methodology and the qualitative Ostrom's framework for assessing socio-ecological systems (SESs). The new framework is used to provide a sample assessment of the Vaillapally habitation in Narayanpur Mandal, Nalgonda. Preliminary results indicate that the institutional, technical, and socio-cultural capacity factors must progress to meet the policymakers' current projects technical capacity. Alternatively, decentralized systems, such as rainwater harvesting technology, better serve rural areas with low capacity and demand, while increasing collective investment in village-scale systems.
Failure is the norm for urban sanitation infrastructure in Ghana: of the rather substantial number of wastewater and faecal sludge treatment plants, with about 70 mostly decentralized systems throughout the country, less than 10 are operating effectively. This research presents an overview of the related sanitation situation in Ghana, and compares the few successful facilities with their failed counterparts in order to decipher the factors that enable the former to prevail. The research reveals important differences in the operation and maintenance (O&M) strategies, financing schemes and incentive structures in the successful versus unsuccessful facilities, which are probably not unique to Ghana. Based on the findings, we suggest a set of guiding questions for incorporation into the existing planning, funding or general decision-making framework in order to avoid commonly observed traps, which not only undermine progress in the delivery of sanitation services but also harshly affect environmental and public health.
While large centralized sanitation projects are not affordable for most cases in urban and rural areas, the only way to increase sanitation coverage, especially for the poor, is to implement low-cost alternatives with decentralized sanitation management schemes where local community, administrative authorities and private sectors are involved in the decision making as well as in the exploitation process. Despite of that, there are some reasons discussed why decentralized wastewater management concept and its application is still not widely disseminated throughout Vietnam. Among institutional and managerial aspects there are weaknesses of environmental pollution control capacity at different, especially local levels, limitations of existing Vietnamese environmental standard system, and lacking of incentive measures to encourage consultants to go for the decentralized wastewater concept, as well as to force polluters to improve their situation. In term of finance, discussed pints are low wastewater fee, and limited participation of private sector in the business. In technical aspects, there are limited information of appropriate and proven technical options for different contexts, lessons on their performance and system setting up. Besides, difficulties in the household connection and in collection network are among factors. The paper also provides some examples of decentralized alternatives implemented in different sanitation projects at different scales in Vietnam.
Honoratha Mushi, K. Mullei, J. Macha, Francis Wafula · 7 authors
Health worker training is a key component of the integrated management of childhood illness (IMCI). However, training coverage remains low in many countries. We conducted in-depth case studies in two East African countries to examine the factors underlying low training coverage 10 years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007-08. Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitization and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. In Tanzania, districts could not spend more than 10% of their budgets on training. In Kenya, limited financial decentralization meant that district managers had to rely on donors for financial support. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and donor support for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI. Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally.
Abstract In recent decades, many changes have occurred in the approach to financing and operating water services in developing countries. The demandâresponsive approach is now adopted in many countries in a context of donorâsupported decentralization processes, which gives more responsibility to end users. However, the government's responsibility at different levels is enforced by the international recognition of the human right to water. This paper examines specific actions that build the role of local government authorities in this scenario. A collaboration between an international NGO and a rural district in Tanzania from 2006 to 2009 is used as an action research case study that is representative of local capacityâbuilding needs in decentralized contexts and rural areas. Three main challenges were detected: i) lack of reliable information; ii) poor allocation of resources in terms of equity; and iii) lack of longâterm community management support from the district. Two mechanisms were established: i) water point mapping as a tool for information and planning; and ii) a District Water and Sanitation Unit Support (DWUS) for community management. The results show how the framework provided by the goal of human right to water helps to define useful strategies for equityâoriented planning and postâproject support at the local level.
Neonatal mortality in the country continues to be unacceptably high and unrelenting with wide variations across states. Six high population states account for 60% burden of neonatal deaths. Most of the evidence-based interventions are reflected in the programs, but the coverage levels are low due to poor implementation resulting from missed opportunities and weak health systems. Action is required at the home and community level, as well as at the outreach and facility levels in rural and urban settings. ASHAs must be engaged in home care of neonates. Private sector needs to be involved for providing care to neonates of poor families. Demand side financing and incentives could be game-changers in enhancing care seeking and service uptake. Effective programming would require still higher budgets, decentralized planning, managerial support, proper monitoring and a massive human resources capacity development. Community mobilization is essential for which panchayati raj institutions can play an important role. Advoa.cy efforts should not be diluted because there still is a long way to attain an acceptable level of newborn survival.
OBJECTIVE: To summarize the expectations held by World Health Organization programme personnel about how the introduction of the Integrated Management of Childhood Illness (IMCI) strategy would lead to improvements in child health and nutrition, to compare these expectations with what was learned from the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE-IMCI), and to discuss the implications of these findings for child survival policies and programmes. DESIGN: The MCE-IMCI study designs were based on an impact model developed in 1999-2000 to define how IMCI would be implemented at country level and below, and the outcomes and impact it would have on child health and survival. MCE-IMCI studies included: feasibility assessments documenting IMCI implementation in 12 countries (1999-2001); in-depth studies using compatible designs in Bangladesh, Brazil, Peru, Tanzania and Uganda; and cross-site analyses addressing the effectiveness of specific subsets of IMCI activities. RESULTS: The IMCI strategy was successfully introduced in the great majority of countries with moderate to high levels of child mortality in the period from 1996 to 2001. Seven years of country-based evaluation, however, indicates that some of the basic expectations underlying the development of IMCI were not met. Four of the five countries (the exception is Tanzania) had difficulties in expanding the strategy at national level while maintaining adequate intervention quality. Technical guidelines on delivering interventions at family and community levels were slow to appear, and in their absence countries stalled in their efforts to increase population coverage with essential interventions related to care-seeking, nutrition, and correct care of the sick child at home. The full weight of health system limitations on IMCI implementation was not appreciated at the outset, and only now is it clear that solutions to larger problems in political commitment, human resources, financing, integrated or at least coordinated programme management, and effective decentralization are essential underpinnings of successful efforts to reduce child mortality. CONCLUSIONS: This analysis highlights the need for a shift if child survival efforts are to be successful. Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches. The focus on process within child health programmes must change to include greater accountability for intervention coverage at population level. Global strategies that expect countries to make massive adaptations must be complemented by country-level implementation guidelines that begin with local epidemiology and rely on tools developed for specific epidemiological profiles.
Each year, up to three million deaths due to malaria and close to five billion episodes of clinical illness possibly meriting antimalarial therapy occur throughout the world, with Africa having more than 90% of this burden. Almost 3% of disability adjusted life years are due to malaria mortality globally, 10% in Africa. New information is presented in this supplement on malaria-related perinatal mortality, occurrence of human immunodeficiency virus in pregnancy, undernutrition, and neurologic, cognitive, and developmental sequelae. The entomologic determinants of transmission and uses of modeling for program planning and disease prediction and prevention are discussed. New data are presented from the Democratic Republic of the Congo, Tanzania, Ethiopia, and Zimbabwe on the increasing urban malaria problem and on epidemic malaria. Between 6% and 28% of the malaria burden may occur in cities, which comprise less than 2% of the African surface. Macroeconomic projections show that the costs are far greater than the costs of individual cases, with a substantial deleterious impact of malaria on schooling of patients, external investments into endemic countries, and tourism. Poor populations are at greatest risk; 58% of the cases occur in the poorest 20% of the world's population and these patients receive the worst care and have catastrophic economic consequences from their illness. This social vulnerability requires better understanding for improving deployment, access, quality, and use of effective interventions. Studies from Ghana and elsewhere indicate that for every patient with febrile illness assumed to be malaria seen in health facilities, 4-5 episodes occur in the community. Effective actions for malaria control mandate rational public policies; market forces, which often drive sales and use of drugs and other interventions, are unlikely to guarantee their use. Artemisinin-based combination therapy (ACT) for malaria is rapidly gaining acceptance as an effective approach for countering the spread and intensity of Plasmodium falciparum resistance to chloroquine, sulfadoxine/pyrimethamine, and other antimalarial drugs. Although costly, ACT ($1.20-2.50 per adult treatment) becomes more cost-effective as resistance to alternative drugs increases; early use of ACT may delay development of resistance to these drugs and prevent the medical toll associated with use of ineffective drugs. The burden of malaria in one district in Tanzania has not decreased since the primary health care approach replaced the vertical malaria control efforts of the 1960s. Despite decentralization, this situation resulted, in part, from weak district management capacity, poor coordination, inadequate monitoring, and lack of training of key staff. Experience in the Solomon Islands showed that spraying with DDT, use of insecticide-treated bed nets (ITNs), and health education were all associated with disease reduction. The use of nets permitted a reduction in DDT spraying, but could not replace it without an increased malaria incidence. Baseline data and reliable monitoring of key outcome indicators are needed to measure whether the ambitious goals for the control of malaria and other diseases has occurred. Such systems are being used for evidence-based decision making in Tanzania and several other countries. Baseline cluster sampling surveys in several countries across Africa indicate that only 53% of the children with febrile illness in malarious areas are being treated; chloroquine (CQ) is used 84% of the time, even where the drug may be ineffective. Insecticide-treated bed nets were used only 2% of the time by children less than five years of age. Progress in malaria vaccine research has been substantial over the past five years; 35 candidate malaria vaccines are in development, many of which are in clinical trials. Development of new vaccines and drugs has been the result of increased investments and formation of public-private partnerships. Before malaria vaccine becomes deployed, consideration must be given to disease burden, cost-effectiveness, financing, delivery systems, and approval by regulatory agencies. Key to evaluation of vaccine effectiveness will be collection and prompt analysis of epidemiologic information. Training of persons in every aspect of malaria research and control is essential for programs to succeed. The Multilateral Initiative on Malaria (MIM) is actively promoting research capacity strengthening and has established networks of institutions and scientists throughout the African continent, most of whom are now linked by modern information-sharing networks. Evidence over the past century is that successful control malaria programs have been linked to strong research activities. To ensure effective coordination and cooperation between the growing number of research and control coalitions forming in support of malaria activities, an umbrella group is needed. With continued support for scientists and control workers globally, particularly in low-income malarious countries, the long-deferred dream of malaria elimination can become a reality.