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USAID/India – Launch of “Strengthening Water and Sanitation in Urban Settings” project in Kolkata

25 August 2015 13:35 (America/New_York)

Launch of “Strengthening Water and Sanitation in Urban Settings” project in Kolkata.

Kolkata, 12 August 2015: TERI University and the U.S. Agency for International Development (USAID) in association with Coca Cola and The Energy and Resources Institute (TERI) today launched the ‘Strengthening Water and Sanitation in Urban Settings” initiative in Kolkata. The WASH programmes (Water, Sanitation and Hygiene) aim to reach 50,000 beneficiaries in low-income settlements and over 300 professionals through WASH governance studies. It will also reach out to 2,500 students through 20 municipal schools across India.

The goal is to help achieve the Government of India’s sanitation targets by conducting a WASH risk analysis in slums of Kolkata and Chennai. As first steps, two urban neighbourhoods – Kannagi Nagar and Nedunchelliyan Nagar in Chennai, and areas in KMC wards 57 and 58 (Khayari basti, Arupota and Dhapa) in Kolkata – have been chosen for household surveys.

The project will assist in developing participatory intervention strategies in urban areas, and in building the capacity of faculty and students through a model sanitation curriculum.\

Read the complete article.

Urban Malaria: Understanding its Epidemiology, Ecology, and Transmission Across Seven Diverse ICEMR Network Sites

25 August 2015 13:25 (America/New_York)

Urban Malaria: Understanding its Epidemiology, Ecology, and TransmissionAcross Seven Diverse ICEMR Network Sites. Am Jnl Trop Med Hyg, Aug 2015.

Authors: Mark L. Wilson, Donald J. Krogstad, et al.

A major public health question is whether urbanization will transform malaria from a rural to an urban disease. However, differences about definitions of urban settings, urban malaria, and whether malaria control should differ between rural and urban areas complicate both the analysis of available data and the development of intervention strategies. This report examines the approach of the International Centers of Excellence for Malaria Research (ICEMR) to urban malaria in Brazil, Colombia, India (Chennai and Goa), Malawi, Senegal, and Uganda. Its major theme is the need to determine whether cases diagnosed in urban areas were imported from surrounding rural areas or resulted from transmission within the urban area.

If infections are being acquired within urban areas, malaria control measures must be targeted within those urban areas to be effective. Conversely, if malaria cases are being imported from rural areas, control measures must be directed at vectors, breeding sites, and infected humans in those rural areas. Similar interventions must be directed differently if infections were acquired within urban areas. The hypothesis underlying the ICEMR approach to urban malaria is that optimal control of urban malaria depends on accurate epidemiologic and entomologic information about transmission

 

Entering the city : emerging evidence and practices with safety nets in urban areas

25 August 2015 13:16 (America/New_York)

Entering the city: emerging evidence and practices with safety nets in urban areas, 2015.

Author: Ugo Gentilini, World Bank.

Most safety net programs in low and middle-income countries have hitherto been conceived for rural areas. Yet as the global urban population increases and poverty urbanizes, it becomes of utmost importance to understand how to make safety nets work in urban settings. This paper discusses the process of urbanization, the peculiar features of urban poverty, and emerging experiences with urban safety net programs in dozens of countries. It does so by reviewing multidisciplinary literature, examining household survey data, and presenting a compilation of case studies from a first generation of programs.

The paper finds that urban areas pose fundamentally different sets of opportunities and challenges for social protection, and that safety net programs are at the very beginning of a process of urban adaptation. The mixed-performance and preliminary nature of the experiences suggest to put a premium on learning and evidence-generation. This may include revisiting some key design choices and better connecting safety nets to spatial, economic, and social services agendas compelling to urban areas.

Interpersonal communication as an agent of normative influence: a mixed method study among the urban poor in India

25 August 2015 13:12 (America/New_York)

Interpersonal communication as an agent of normative influence: a mixed method study among the urban poor in IndiaReprod Health. 2015; 12: 71.

Authors: Rajiv N. Rimal, Pooja Sripad, et al.

Background - Although social norms are thought to play an important role in couples’ reproductive decisions, only limited theoretical or empirical guidance exists on how the underlying process works. Using the theory of normative social behavior (TNSB), through a mixed-method design, we investigated the role played by injunctive norms and interpersonal discussion in the relationship between descriptive norms and use of modern contraceptive methods among the urban poor in India.

Methods - Data from a household survey (N = 11,811) were used to test the underlying theoretical propositions, and focus group interviews among men and women were then conducted to obtain more in-depth knowledge about decision-making processes related to modern contraceptive use.

Results - Spousal influence and interpersonal communication emerged as key factors in decision-making, waning in the later years of marriage, and they also moderated the influence of descriptive norms on behaviors. Norms around contraceptive use, which varied by parity, are rapidly changing with the country’s urbanization and increased access to health information.

Conclusion - Open interpersonal discussion, community norms, and perspectives are integral in enabling women and couples to use modern family planning to meet their current fertility desires and warrant sensitivity in the design of family planning policy and programs.

Life in a landfill slum, children’s health, and the Millennium Development Goals

25 August 2015 13:03 (America/New_York)

Life in a landfill slum, children’s health, and the Millennium Development Goals. Sci Total Env, Dec 2015.

Authors: Tomoyuki Shibata, et al.

Highlights
• Waste-pickers and the health and well-being of their children are examined
• Landfill slum (LS) residents do not have a share in improving economies
• LSs illustrate the interrelationship of Millennium Development Goals
• LS mothers and children are exposed to toxic chemicals and pathogens
• MDGs directly and indirectly addresses issues affecting LS children’s health
• Improved solid waste management will benefit LS resident health and well-being

People living in slums can be considered left behind with regard to national successes in achieving Millennium Development Goals (MDGs). The objective of this study was to evaluate the living and working conditions of waste pickers and their children in a landfill slum located in the largest city in eastern Indonesia. A total of 113 people from the landfill slum and 1184 people from the general population participated in face-to-face interviews. Municipal solid waste (MSW) was analyzed for metals, metalloids and fecal indicator bacteria. Ambient air quality including particulate matter was measured in the landfill. Households in the landfill slum were 5.73 (p = 0.04) times more likely to be below the international poverty line (MDG 1: Poverty) and 15.6 times (p < 0.01) more likely to have no one in the household possessing a primary education (MDG 2: Universal Education), and 107 times (p < 0.01) more likely not to have improved sanitation facilities (MDG 7: Environmental Sustainability) when compared to the general population. Diarrhea is one of the leading causes of death in children under five in Indonesia. Young children living in the landfill slum were 2.87 times (p = 0.02) more likely to develop diarrhea than their general population counterparts. Other survey results and environmental measurements suggest that landfill slum children have additional adverse health effects (e.g. infections and poisoning). Poverty underlies several MDG issues that directly or indirectly affect child health. Therefore, eradicating extreme poverty will continue to be the most critical challenge for the MDGs beyond 2015.

Current state and trends of access to sanitation in Ethiopia and the need to revise indicators to monitor progress in the Post-2015 era

25 August 2015 12:58 (America/New_York)

Current state and trends of access to sanitation in Ethiopia and the need to revise indicators to monitor progress in the Post-2015 eraBMC Public Health. 2015; 15: 451.

Abebe Beyene,corresponding author Tamene Hailu, Kebede Faris, and Helmut KloosAuthor information ► Article notes ► Copyright and License information ►Go

Background - Investigating the current level and trends of access and identifying the underlying challenges to sanitation system development will be useful in determining directions developing countries are heading as they plan to promote sustainable development goals (post 2015 agenda). This research investigates the status and trends of access to improved sanitation coverage (ISC) in relation to the MDG target in Ethiopia with the aim of identifying prevailing constraints and suggesting the way forward in the post-MDG era.

Method - We examined data from a nationwide inventory conducted in accordance with the sanitation ladder at the national level and from a household survey in randomly selected urban slums in Addis Ababa. The inventory data were analyzed and interpreted using the conceptual model of the sanitation ladder. We used administrative reports and survey results to plot the time trend of the ISC.

Results - The data from the nationwide inventory of sanitation facilities, which are presented along the sanitation ladder reveal that more than half of the Ethiopian population (52.1%) still used unimproved sanitation facilities in 2014. The majority (35.6%) practiced open defecation, implying that the country is far from the MDG target for access to improved sanitation (56%). Most people in urban slums (88.6%) used unimproved sanitation facilities, indicating that the urban poor did not receive adequate sanitation services. Trend analysis shows that access to ISC has increased, but Central Statistical Authority (CSA) data reveal a decline. This discrepancy is due to differences in data collection methods and tools. Dry pit latrines are the most widely used toilet facilities in Ethiopia, accounting for about 97.5% of the ISC.

Conclusion - The sanitation coverage is far from the MDG target and the majority of the population, mainly the urban poor, are living in a polluted environment, exposed to water and sanitation-related diseases. The sanitation coverage estimates might be even lower if proper utilization, regular emptying, and fecal sludge management (FSM) of dry pit latrines were considered as indicators. In order to enhance sanitation services for all in the post-MDG era, urgent action is required that will establish proper monitoring and evaluation systems that can measure real access to ISC.

Sharing reflections on inclusive sanitation

5 August 2015 13:00 (America/New_York)

Sharing reflections on inclusive sanitation. Env & Urbanization, March 2015.

Authors: E Banana, et al.

This paper draws on sanitation innovations in  Blantyre (Malawi), Chinhoyi (Zimbabwe), Dar es Salaam (Tanzania) and Kitwe (Zambia) driven by slum(1)/shack dweller federations to consider what an inclusive approach to sanitation would involve. This includes what is possible for low-income households when there is little or no external support, no piped water supply and no city sewers to connect to.

The paper discusses low-income households’ choices in situations where households can only afford US$ 3–4 per month for sanitation (for instance between communal, shared and household provision). It also considers the routes to both spatial and social inclusion (including the role of loan finance in the four cities) and its political underpinnings. In each of the four cities, the community engagement in sanitation intended from the outset to get the engagement and support of local authorities for city-wide sanitation provision

Shared Sanitation Versus Individual Household Latrines in Urban Slums: A Cross-Sectional Study in Orissa, India

5 August 2015 12:45 (America/New_York)

Shared Sanitation Versus Individual Household Latrines in Urban Slums: A Cross-Sectional Study in Orissa, IndiaAm J Trop Med Hyg. 2015 Jun.

Authors: Heijnen M, Routray P, Torondel B, Clasen T.

A large and growing proportion of the global population rely on shared sanitation facilities despite evidence of a potential increased risk of adverse health outcomes compared with individual household latrines (IHLs). We sought to explore differences between households relying on shared sanitation versus IHLs in terms of demographics, sanitation facilities, and fecal exposure. We surveyed 570 households from 30 slums in Orissa, India, to obtain data on demographics, water, sanitation, and hygiene.

Latrine spot-checks were conducted to collect data on indicators of use, privacy, and cleanliness. We collected samples of drinking water and hand rinses to assess fecal contamination. Households relying on shared sanitation were poorer and less educated than those accessing IHLs. Individuals in sharing households were more likely to practice open defecation. Shared facilities were less likely to be functional, less clean, and more likely to have feces and flies.

No differences in fecal contamination of drinking water or hand-rinse samples were found. Important differences exist among households accessing shared facilities versus IHLs that may partly explain the apparent adverse health outcomes associated with shared sanitation. As these factors may capture differences in risk and promote sanitary improvements, they should be considered in future policy.

Redefining shared sanitation

5 August 2015 12:31 (America/New_York)

Redefining shared sanitation. WHO Bulletin, July 2015.

Authors: Thilde Rheinländer, Flemming Konradsen, Bernard Keraita, Patrick Apoya, and Margaret Gyapong

The proportion of people depending on shared toilets is higher in the least developed countries (16%) and highest in sub-Saharan Africa, where 19% of the population depends on shared sanitation. In the same region, a staggering 33% of the urban population depends on shared sanitation, and in 17 sub-Saharan countries the rates of people using shared sanitation is on the increase. In four Asian countries, Bangladesh, China, Mongolia and the Philippines, over 15% of the population depend on shared sanitation – a number that increases daily.

Current definitions do not account for the diversity of shared sanitation: all shared toilet facilities are by default classified as unimproved by JMP because of the tendency for shared toilets to be poorly managed and unhygienic. However, we argue that shared sanitation should not be automatically assumed to be unimproved.

 

Usage and Barriers to Use of Latrines in a Ghanaian Peri-Urban Community

5 August 2015 12:20 (America/New_York)

Usage and Barriers to Use of Latrines in a Ghanaian Peri-Urban CommunityEnvironmental Processes, March 2015

Authors: Peter A. Obeng, Bernard Keraita, Sampson Oduro-Kwarteng, Henrik Bregnhøj, Robert C. Abaidoo, Esi Awuah, Flemming Konradsen

This study was conducted in a Ghanaian peri-urban setting to understand the factors that influence the usage of household and communal latrines and to discuss potential interventions to address existing barriers to regular usage. Data was collected using household survey questionnaires orally administered to 189 and 283 respondents with access to private and communal latrines respectively, five focus group discussions with gender and age groups, as well as observations at latrines. It was found that only 15 % of households had access to latrines at home while the rest depended on communal latrines or practised open defecation.

The ventilated improved pit latrine was the commonest technology used by 47 % of households with private latrines. The residents ranked safety and privacy as the most important factors that influenced their decision to use any latrine. For private latrines, desludging challenges (14 %) and intense odour (7 %) were the most significant technical barriers while the most significant non-technical barriers were lack of immediate access when the latrine is locked or busy (28 %).

For communal latrines, the major technical barrier was intense odour (23 %) while the major non-technical barriers were distance to latrines (28 %), user fees (21 %) and unhygienic conditions (7 %). Regular latrine usage in the study setting may be enhanced by technical support to address desludging challenges and control odour in latrines, as well as social interventions to make communal latrines affordable and more hygienic.

 

Is it possible to reach low-income urban dwellers with good-quality sanitation?

5 August 2015 12:16 (America/New_York)

Is it possible to reach low-income urban dwellers with good-quality sanitation? Env & Urbanization, Apr 2015.

Authors: David Satterthwaite, Diana Mitlin, Sheridan Bartlett

Before public or shared toilets are dismissed as appropriate solutions, is it not worth asking their users what their needs are, what is deficient, what should be done to address this, by whom and with what funding? Where there isn’t universal provision for high-quality sanitation, it is only by engagement with those needing solutions in each location that effective, appropriate solutions will be developed.

The Sanitation Ladder, What Constitutes an Improved Form of Sanitation?

5 August 2015 12:11 (America/New_York)

The Sanitation Ladder, What Constitutes an Improved Form of Sanitation? Env Sci Tech, Dec 2014.

Authors: Josephine L. R. Exley, Bernard Liseka, Oliver Cumming, and Jeroen H. J Ensink

This study aimed to assess whether the MDG classifications and JMP sanitation ladder corresponded to hygienic proxies. Latrines were purposefully sampled in urban and rural Tanzania. Three hygienic proxies were measured: E. coli on points of hand contact, helminth at point of foot contact, and number of flies. Additionally, samples were collected from comparable surfaces in the household, and a questionnaire on management and use, combined with a visual inspection of the latrine’s design was conducted. In total, 341 latrines were sampled.

The MDG classifications “improved” vs “unimproved” did not describe the observed differences in E. coli concentrations. Disaggregating the data into the JMP sanitation ladder, on average “shared” facilities were the least contaminated: 9.2 vs 17.7 (“improved”) and 137 E. coli/100 mL (“unimproved”) (p = 0.04, p < 0.001). Logistic regression analysis suggests that both the presence of a slab and sharing a facility is protective against faecal-oral exposure (OR 0.18 95% CI 0.10, 0.34 and OR 0.52, 95% CI 0.29, 0.92). The findings do not support the current assumption that shared facilities of an adequate technology should be classified for MDG purposes as “unimproved”.

 

Shared Sanitation Versus Individual Household Latrines in Urban Slums: A Cross-Sectional Study in Orissa, India

5 August 2015 12:05 (America/New_York)

Shared Sanitation Versus Individual Household Latrines in Urban Slums: A Cross-Sectional Study in Orissa, India. Am Jnl Trop Med Hyg, June 2015.

Authors: Marieke Heijnen, Parimita Routray, Belen Torondel and Thomas Clasen

A large and growing proportion of the global population rely on shared sanitation facilities despite evidence of a potential increased risk of adverse health outcomes compared with individual household latrines (IHLs). We sought to explore differences between households relying on shared sanitation versus IHLs in terms of demographics, sanitation facilities, and fecal exposure. We surveyed 570 households from 30 slums in Orissa, India, to obtain data on demographics, water, sanitation, and hygiene. Latrine spot-checks were conducted to collect data on indicators of use, privacy, and cleanliness. We collected samples of drinking water and hand rinses to assess fecal contamination.

Households relying on shared sanitation were poorer and less educated than those accessing IHLs. Individuals in sharing households were more likely to practice open defecation. Shared facilities were less likely to be functional, less clean, and more likely to have feces and flies. No differences in fecal contamination of drinking water or hand-rinse samples were found. Important differences exist among households accessing shared facilities versus IHLs that may partly explain the apparent adverse health outcomes associated with shared sanitation. As these factors may capture differences in risk and promote sanitary improvements, they should be considered in future policy.

Container-based sanitation: assessing costs and effectiveness of excreta management in Cap Haitien, Haiti

5 August 2015 12:01 (America/New_York)

Container-based sanitation: assessing costs and effectiveness of excreta management in Cap Haitien, Haiti. Env & Urbanization, Apr 2015.

Authors: S Tilman.

Container-based sanitation (CBS) – in which wastes are captured in sealable containers that are then transported to treatment facilities – is an alternative sanitation option in urban areas where on-site sanitation and sewerage are infeasible. This paper presents the results of a pilot household CBS service in Cap Haitien, Haiti. We quantify the excreta generated weekly in a dense urban slum,(1) the proportion safely removed via container-based public and household toilets, and the costs associated with these systems.

The CBS service yielded an approximately 3.5-fold decrease in the unmanaged share of faeces produced, and nearly eliminated the reported use of open defecation and “flying toilets” among service recipients. The costs of this pilot small-scale service were higher than those of large-scale waterborne sewerage, but economies of scale have the potential to reduce CBS costs over time. The paper concludes with a discussion of planning and policy implications of incorporating CBS into the menu of sanitation options for rapidly growing cities.

A controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children: research protocol for the Maputo Sanitation (MapSan) study, Mozambique

5 August 2015 11:55 (America/New_York)

A controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children: research protocol for the Maputo Sanitation (MapSan) study, MozambiqueBMJ Open 2015;5:e008215 doi:10.1136/bmjopen-2015-008215.

Authors: Joe Brown, Oliver Cumming, Jamie Bartram, et al.

Introduction – Access to safe sanitation in low-income, informal settlements of Sub-Saharan Africa has not significantly improved since 1990. The combination of a high faecal-related disease burden and inadequate infrastructure suggests that investment in expanding sanitation access in densely populated urban slums can yield important public health gains. No rigorous, controlled intervention studies have evaluated the health effects of decentralised (non-sewerage) sanitation in an informal urban setting, despite the role that such technologies will likely play in scaling up access.

Methods and analysis – We have designed a controlled, before-and-after (CBA) trial to estimate the health impacts of an urban sanitation intervention in informal neighbourhoods of Maputo, Mozambique, including an assessment of whether exposures and health outcomes vary by localised population density. The intervention consists of private pour-flush latrines (to septic tank) shared by multiple households in compounds or household clusters. We will measure objective health outcomes in approximately 760 children (380 children with household access to interventions, 380 matched controls using existing shared private latrines in poor sanitary conditions), at 2 time points: immediately before the intervention and at follow-up after 12 months. The primary outcome is combined prevalence of selected enteric infections among children under 5 years of age. Secondary outcome measures include soil-transmitted helminth (STH) reinfection in children following baseline deworming and prevalence of reported diarrhoeal disease. We will use exposure assessment, faecal source tracking, and microbial transmission modelling to examine whether and how routes of exposure for diarrhoeagenic pathogens and STHs change following introduction of effective sanitation.

 

The MAPSAN Trial: A Controlled Before and After Study of Shared Sanitation in Maputo

5 August 2015 11:46 (America/New_York)

WSUP – The MAPSAN Trial: A Controlled Before and After Study of Shared Sanitation in Maputo, 2015.

This major study, funded by USAID, is being led by the London School of Hygiene and Tropical Medicine (LSHTM). The research is looking at a number of related questions: will this communal toilet intervention have an effect on health, and more specifically, will any effects be dependent on population density? (We would expect the positive effect on health to be stronger in areas with higher population density)

It’s a fascinating and innovative study in many respects, not least because of the wide range of health metrics being measured: not just self-reported diarrhoea incidence (the common measure, widely suspected to be unreliable), but also a bunch of other metrics including child height and weight, parasites in child stools, and biochemical markers of viral and parasite infection. Plus at the same time other researchers will be applying the Gates-supported SaniPath approach to get a measure of degree of faecal contamination of the local environment.


 

Sites of entitlement: claim, negotiation and struggle in Mumbai. Environment and Urbanization, 2015

30 July 2015 9:48 (America/New_York)

Sites of entitlement: claim, negotiation and struggle in Mumbai. Environment and Urbanization, 2015.

Authors: Colin McFarlane, Renu Desai

This paper develops a conception of “sites of entitlement” as a basis for better understanding how infrastructure and services are perceived and experienced in informal settlements. While legal and policy frameworks are often viewed as the source of entitlements to infrastructure and services, the complexity of provision, access and negotiation in informal settlements demands a conception of entitlement that exceeds those domains. Based on ethnographic research on sanitation and water in informal settlements in Mumbai, we focus on the ways in which people’s everyday experiences, interactions and practices constitute sites of entitlement.

These sites are unevenly produced, contested, often in flux and ambivalent, sometimes made through collective struggle and at other times through quiet individual practice, and always constituted by social relations. Sites of entitlement emerge in close relation to moral economies, and are characterized by often profound and – for research, policy and practice – challenging levels of spatial and temporal variation. We argue that sites of entitlement are vital for thinking through the possibilities of realizing the universal right to sanitation and water.

Urban health indicators and indices—current status

21 July 2015 11:56 (America/New_York)

Urban health indicators and indices—current statusBMC Public Health (2015) 15:494.

Authors: Richard Rothenberg, Christine Stauber, et al.

Over the past 30 years, facilitated by high speed computing and electronics, considerable investment has been made in the collection and analysis of urban health indicators, environmental indicators, and methods for their amalgamation. Much of this work has been characterized by a perceived need for a standard set of indicators. We used publication databases (e.g. Medline) and web searches to identify compilations of health indicators and health metrics. We found 14 long-term large-area compilations of health indicators and determinants and seven compilations of environmental health indicators, comprising hundreds of metrics. Despite the plethora of indicators, these compilations have striking similarities in the domains from which the indicators are drawn—an unappreciated concordance among the major collections.

Research with these databases and other sources has produced a small number of composite indices, and a number of methods for the amalgamation of indicators and the demonstration of disparities. These indices have been primarily used for large-area (nation, region, state) comparisons, with both developing and developed countries, often for purposes of ranking. Small area indices have been less explored, in part perhaps because of the vagaries of data availability, and because idiosyncratic local conditions require flexible approaches as opposed to a fixed format. One result has been advances in the ability to compare large areas, but with a concomitant deficiency in tools for public health workers to assess the status of local health and health disparities. Large area assessments are important, but the need for small area action requires a greater focus on local information and analysis, emphasizing method over prespecified content.

Developing Microfinance for Sanitation in Tanzania

14 July 2015 12:04 (America/New_York)

Developing Microfinance for Sanitation in Tanzania, 2015.

Authors: Sophie Trémolet, Goufrane Mansour, George Muruka

This report presents the findings of a one-year action-research project on sanitation microfinance in Tanzania funded by SHARE. The project took place between December 2013 and January 2015. The project was the culmination of a broader research initiative which investigated how financing for sanitation can be mobilised via the use of microfinance in order to support sustainable access to improved sanitation facilities and/or services.  This report describes the activities carried out under the action-research and extracts emerging lessons on the potential for developing sanitation microfinance through capacity building and networking.

How does urban health relate to the sustainable development agenda?

29 June 2015 15:02 (America/New_York)

How does urban health relate to the sustainable development agenda? African Population and Health Research Centre blog, June 24, 2015.

The inclusion of Sustainable Development Goal 11 in the post-2015 agenda—to make cities and human settlements inclusive, safe, resilient and sustainable—is both a challenge and an opportunity for public health, said a panel of experts at last month’s International Conference on Urban Health in Dhaka. Unabated urbanisation is having a radical effect on urban health, especially because it is widening the divide between the rich and the poor. Among the points that were raised, the panelists emphasised a growing need for multi-sectoral approaches and innovative solutions to delivery of care like public-private partnerships.

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