Ana Hardoy

Integrated approaches to address the social determinants of health for reducing health inequity.

The social and physical environments have long since been recognized as important determinants of health. People in urban settings are exposed to a variety of health hazards that are interconnected with their health effects. The Millennium Development Goals (MDGs) have underlined the multidimensional nature of poverty and the connections between health and social conditions and present an opportunity to move beyond narrow sectoral interventions and to develop comprehensive social responses and participatory processes that address the root causes of health inequity. Considering the complexity and magnitude of health, poverty, and environmental issues in cities, it is clear that improvements in health and health equity demand not only changes in the physical and social environment of cities, but also an integrated approach that takes into account the wider socioeconomic and contextual factors affecting health. Integrated or multilevel approaches should address not only the immediate, but also the underlying and particularly the fundamental causes at societal level of related health issues. The political and legal organization of the policy-making process has been identified as a major determinant of urban and global health, as a result of the role it plays in creating possibilities for participation, empowerment, and its influence on the content of public policies and the distribution of scarce resources. This paper argues that it is essential to adopt a long-term multisectoral approach to address the social determinants of health in urban settings. For comprehensive approaches to address the social determinants of health effectively and at multiple levels, they need explicitly to tackle issues of participation, governance, and the politics of power, decision making, and empowerment.

Reducing urban poverty; some lessons from experience

Many donor agencies are recognizing the need to address the growing levels of urban poverty in Africa, Latin America and much of Asia. Many also acknowledge that they had under-estimated the scale of urban poverty. As they develop or expand programmes on poverty reduction in urban areas, there are many remarkable initiatives on whose experience they can draw. This paper reflects on the lessons from seven of these: three from Asia, three from Latin America and one from Africa. All these initiatives combined direct action by low-income groups themselves, working with local NGOs, with some support negotiated from one or more external agency in order to improve housing and living conditions, basic services and livelihoods. Each initiative sought to make limited funding go as far as possible-and most achieved partial or total cost recovery for some (or all) of their interventions. All used credit to allow low-income groups to spread the cost of capital investment over a number of years. These initiatives also changed the relationship between poor urban groups and local authorities, bringing about major benefits. However, official donors may find it difficult to fund initiatives such as these, especially through conventional project-cycle oriented funding for capital projects that is channelled through recipient governments. They may also find it difficult to fund initiatives that aim to change the policies and practices of local (or national) governments; also to support initiatives that are multisectoral, relatively cheap and require long-term support because they are long-term processes rather than discrete projects. Initiatives that generate cost recovery may also present them with difficulties. Most official donors will need to develop new channels to support such initiatives-for instance through support for intermediary funds for community projects located within these cities.

New models for the privatization of water and sanitation for the urban poor

This paper draws on the authors’ experience working in informal settlements in Buenos Aires and with the privatized utility (Aguas Argentinas) to consider how privatized provision for water and sanitation can best meet the needs of low-income groups, especially those living in informal settlements. It includes a discussion of the key issues that should be taken into account when government agencies responsible for privatization design the bid, and an elaboration of the different organizational models through which private utilities can provide water and sanitation in informal or otherwise unserved low-income settlements.

Governance for water and sanitation services in low-income settlements: experiences with partnership-based management in Moreno, Buenos Aires

Over the last 10–15 years, there has been a heated debate about the ability of private companies to provide adequate water and sanitation services to low-income households and their neighbourhoods. There have been a few successful examples of private provision to low-income areas but it has generally not proved possible to replicate these. This paper considers how sparsely populated, low-income and largely unserved urban settlements might obtain full coverage of formal water and sanitation networks under a private concession contract, drawing on the case study of Moreno municipality in Buenos Aires Metropolitan Area. The paper describes an initiative implemented by IIED–América Latina that seeks to address deficiencies in water and sanitation provision through partnership-based management, a participatory process whereby different types of actors collaborate with each other, bringing their own particular strengths. Through awareness-raising and a participatory assessment of water and sanitation provision in the municipality, a local partnership-based management unit was formed. It is hoped that this will be institutionalized into a local water authority. Given that extending conventional water and sewerage services to the many unserved settlements is unrealistic in the short term, the paper suggests that providing both water and sanitation services to the poorest areas like Moreno is likely to happen only if all the actors involved – the public sector, private company, regulator, NGOs and communities – are committed to working together towards a solution.