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Trends in Causes of Adult Deaths among the Urban Poor: Evidence from Nairobi Urban Health and Demographic Surveillance System, 2003–2012

23 March 2015 11:34 (America/New_York)

Trends in Causes of Adult Deaths among the Urban Poor: Evidence from Nairobi Urban Health and Demographic Surveillance System, 2003–2012. Journal of Urban Health, March 2015.

Authors: Blessing Mberu, Marylene Wamukoya, Samuel Oti, and Catherine Kyobutung

In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3 % of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73 % of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66 % in 2003 to 53 % in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5 % in 2003 to 21.3 % in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11 % in 2003 to 22 % in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets.

Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh

23 March 2015 11:27 (America/New_York)

Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh. Health Policy Plan. (2015) 30 (suppl 1): i32-i45. doi: 10.1093/heapol/czu094.

Authors: Alayne M Adams, Rubana Islam and Tanvir Ahmed

In Bangladesh, the health risks of unplanned urbanization are disproportionately shouldered by the urban poor. At the same time, affordable formal primary care services are scarce, and what exists is almost exclusively provided by non-government organizations (NGOs) working on a project basis. So where do the poor go for health care? A health facility mapping of six urban slum settlements in Dhaka was undertaken to explore the configuration of healthcare services proximate to where the poor reside.

Three methods were employed: (1) Social mapping and listing of all Health Service Delivery Points (HSDPs); (2) Creation of a geospatial map including Global Positioning System (GPS) co-ordinates of all HSPDs in the six study areas and (3) Implementation of a facility survey of all HSDPs within six study areas. Descriptive statistics are used to examine the number, type and concentration of service provider types, as well as indicators of their accessibility in terms of location and hours of service. A total of 1041 HSDPs were mapped, of which 80% are privately operated and the rest by NGOs and the public sector. Phamacies and non-formal or traditional doctors make up 75% of the private sector while consultation chambers account for 20%.

Most NGO and Urban Primary Health Care Project (UPHCP) static clinics are open 5–6 days/week, but close by 4–5 pm in the afternoon. Evening services are almost exclusively offered by private HSDPs; however, only 37% of private sector health staff possess some kind of formal medical qualification. This spatial analysis of health service supply in poor urban settlements emphasizes the importance of taking the informal private sector into account in efforts to increase effective coverage of quality services. Features of informal private sector service provision that have facilitated market penetration may be relevant in designing formal services that better meet the needs of the urban poor.

Sharing reflections on inclusive sanitation

23 March 2015 11:22 (America/New_York)

Sharing reflections on inclusive sanitation. Environment & Urbanization, Feb 2015.

Authors: Evans Banana, Patrick Chikoti, Chisomo Harawa, Gordon Mcgranahan, Diana Mitlin, Stella Stephen, Noah Schermbrucker, Farirai Shumba, Anna Walnycki

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.

Co-producing inclusive city-wide sanitation strategies: lessons from Chinhoyi, Zimbabwe

23 March 2015 11:17 (America/New_York)

Co-producing inclusive city-wide sanitation strategies: lessons from Chinhoyi, Zimbabwe. Environment & Urbanization, Mar 2015.

Authors: Evans Banana, Beth Chitekwe-Biti, Anna Walnycki

This paper explores how communities in Chinhoyi, Zimbabwe have used community-led mapping and enumerations(1) to build partnerships with local government to support the development and co-production of innovative pro-poor city-wide sanitation strategies as part of the SHARE City-Wide Sanitation Project. This action research project is being conducted in four cities across sub-Saharan Africa: Chinhoyi (Zimbabwe), Kitwe (Zambia), Blantyre (Malawi) and Dar es Salaam (Tanzania).

This programme of work responds to the failure of conventional approaches to urban sanitation to meet the needs of low-income urban communities in sub-Saharan Africa. Over three years it has supported Shack/Slum Dwellers International affiliates to develop and test pro-poor sanitation strategies that can be adopted and driven by networks of community organizations and residents’ associations, and supported by public authorities and private providers.

Gender-Responsive Sanitation Solutions in Urban India

23 March 2015 11:12 (America/New_York)

Gender-Responsive Sanitation Solutions in Urban India, 2015.

Authors: Miriam Hartmann, Suneeta Krishnan, Brent Rowe, Anushah Hossain, and Myles Elledge. RTI International.

In this research brief, we provide an overview of recent literature on women and sanitation in urban India. In particular, we consider possible improvements to the design and location of toilet facilities based on articulated needs and current solutions. We also highlight the need for further research evaluating the potential benefits of female-targeted interventions for women and their communities.

The issues we consider are context specific, because women’s preferences vary across caste, religion, and region. Furthermore, the improvements we discuss respond primarily to existing gender norms. Broader efforts are needed to transform gender norms and meet the dual goals of higher sanitation adoption and better outcomes for women.

Urbanisation, the Peri-urban Growth and Zoonotic Disease

4 March 2015 11:20 (America/New_York)

Urbanisation, the Peri-urban Growth and Zoonotic Disease. IDS Practice Paper in Brief, Feb 2015.

Author: L. Waldman.

Ebola has had significant, negative effects in the rapidly expanding, unregulated areas of peri-urban and urban West Africa. The residents of these areas maintain vital connections with rural populations while intermingling with and living in close proximity to urban and elite populations. These interconnections fuel the spread of Ebola. The degradation of natural resources, temporary housing, inadequate water supplies, hazardous conditions and dense concentrations of people in peri-urban areas exacerbate the potential for zoonotic disease spread.

Yet the peri-urban remains largely unacknowledged and under addressed in development. In considering the intersections between Ebola, peri-urban settlements and urbanisation, we must recognise that: basic hygiene and isolation of the sick are frequently impossible; disease control through quarantine often ignores poor people’s patterns of movement and immediate
material needs; quarantine can reinforce the political exclusion of peri-urban residents; and there exists the potential for future zoonotic disease emergence in peri-urban contexts.

Development must acknowledge these ever-burgeoning settlements and address the ability of the poor to live safely. This
includes the provision of decent hygiene and sanitation, context-appropriate forms of disease containment, the recognition of the peri-urban poor as legitimate citizens, and improved understandings of human/animal interactions.

Pit Latrine Emptying Behavior and Demand for Sanitation Services in Dar Es Salaam, Tanzania

4 March 2015 11:10 (America/New_York)

Pit Latrine Emptying Behavior and Demand for Sanitation Services in Dar Es Salaam, Tanzania. Int. J. Environ. Res. Public Health, Feb 2015.

Authors: Marion W. Jenkins, Oliver Cumming and Sandy Cairncross

Pit latrines are the main form of sanitation in unplanned areas in many rapidly growing developing cities. Understanding demand for pit latrine fecal sludge management (FSM) services in these communities is important for designing demand-responsive sanitation services and policies to improve public health. We examine latrine emptying knowledge, attitudes, behavior, trends and rates of safe/unsafe emptying, and measure demand for a new hygienic latrine emptying service in unplanned communities in Dar Es Salaam (Dar), Tanzania, using data from a cross-sectional survey at 662 residential properties in 35 unplanned sub-wards across Dar, where 97% had pit latrines.

A picture emerges of expensive and poor FSM service options for latrine owners, resulting in widespread fecal sludge exposure that is likely to increase unless addressed. Households delay emptying as long as possible, use full pits beyond what is safe, face high costs even for unhygienic emptying, and resort to unsafe practices like ‘flooding out’. We measured strong interest in and willingness to pay (WTP) for the new pit emptying service at 96% of residences; 57% were WTP ≥U.S. $17 to remove ≥200 L of sludge. Emerging policy recommendations for safe FSM in unplanned urban communities in Dar and elsewhere are discussed.

Lancet editorial: Urban health post-2015

27 February 2015 11:04 (America/New_York)

Editorial – Urban health post-2015. Lancet, Feb 28, 2015.

An excerpt: There are three opportunities to address urban health post-2015. First, governments committed to improving urban health must prioritise equitable access and adapted delivery of health and related services to the urban poor— including to non-legal residents. Slum dwellers make up the informal employment sector of cities, and are often not present in slums during regular clinic hours. Health services must adapt delivery to reach them.

Correspondence: Urban health in the post-2015 agenda

Authors: Shamim Talukderemail, Anthony Capon, Dhiraj Nath, Anthony Kolb, Selmin Jahan, Jo Boufford

An excerpt: The transformative approach stated in the post-2015 development agenda necessitates innovative and strong partnerships between civil society and private sectors, institutions that can work in an integrated manner, transfer of technology, capacity building, and greater attention than previously given to information access, monitoring, and reporting for accountability. A worldwide shared ambition should be to bring health to the centre of sustainable urban development.



Urban WASH in Emergencies

27 February 2015 10:51 (America/New_York)

Urban WASH in Emergencies, 2014.

From the 24 – 28 March 2014, RedR held a pilot course for 24 WASH experts on the subject of addressing the social, institutional and technical gaps that currently exist for water, sanitation and hygiene provision in the urban emergency context. This document, produced as a partnership between ALNAP and RedR, captures the key messages, lessons and experiences of both course facilitators and participants on the topic of WASH in urban emergency response.

Many specific lessons for the WASH sector in the urban context can be drawn from this discussion, including:

• Solid waste management can be of particular importance and there are multiple new technologies that can assist in this sector. • Vector control is more complex but just as essential in the urban environment, especially when considering dengue fever, which is on the rise across the developing world and particularly a threat to urban populations.
• Hygiene promotion remains a critical part of the WASH response but is potentially far more complicated, owing to the diverse target groups in urban settings. Schools are a particular asset for hygiene promotion.
• Diverse target groups may also mean a more responsive and greater range of WASH options may be needed to ensure effective service provision.

A recurring lesson from this discussion has been the emphasis on the interconnected and dynamic nature of the urban setting, and how this challenges ‘silo’-based, sector-structured responses. Recognising this characteristic, many lessons have wider applicability for humanitarian response more generally. Vector control, solid waste management and drainage are key examples of where success or failure in one area could greatly determine results in other sectors. These specialist and technical areas also clearly demonstrate the need for humanitarian agencies to ‘ know their limits and utilise external expertise – including potentially the private sector



Review of Results-Based Financing (RBF) schemes in WASH

27 February 2015 10:44 (America/New_York)

Review of Results-Based Financing (RBF) schemes in WASH: A report to the Bill and Melinda Gates Foundation, 2015.

Results-Based Financing (RBF) is an alternative to conventional funding mechanisms for Water, Sanitation, and Hygiene (WASH) projects. As the name suggests, Results Based Financing (RBF) provides funding for an initiative after results have been delivered. This is in contrast to the conventional approach of providing the finance upfront. RBF was developed in an attempt to improve aid effectiveness by increasing accountability, efficiency, and private participation.

Given the massive need to improve WASH services globally, donors have been trying RBF in WASH since at least the mid-1990s. However, until now, there have been no comprehensive evaluations of RBF in WASH. This report summarizes findings from an investigation into whether RBF works in WASH, in what circumstances, how, and why.

The report was prepared by Castalia Advisers, on behalf of a group of WASH donors interested in better understanding RBF in WASH (including DGIS, DfID, USAID, GPOBA, SIDA and others). The study was managed and financed by the Bill & Melinda Gates Foundation.

CityLinks – Water and Sanitation

27 February 2015 10:38 (America/New_York)

What is CityLinks

The CityLinks™ model was designed by ICMA as a way to enable municipal officials in developing and decentralizing countries to draw on the resources of their U.S. counterparts to find sustainable solutions tailored to the real needs of their cities. It was formalized in collaboration with the U.S. Agency for International Development (USAID) in 1997 with the launch of a funded program, known at the time as Resource Cities.

Based on the success of Resource Cities, USAID awarded ICMA a new program with the CityLinks name in 2003 and the current five-year City-to-City Partnerships cooperative agreement—now known as CityLinks—in 2011.

This website is for the most recent program: CityLinks 2011-2016. CityLinks leverages the experience and expertise of ICMA’s membership of 9,000 local government chief administrators and their professional staffs. It is based on the premise that well-managed cities are the key to efficient service delivery, economic growth, sound management of resources, and political stability.

U.S. cities offer a great many models for provision of sound water supply and sanitation services, and CityLinks facilitates partnerships between professionals from these cities and their counterparts who are seeking solutions for cities in developing countries.

The CityLinks Knowledge Network is a platform for sharing information on news, events, publications and job postings.

Financing sanitation for cities and towns: learning paper

25 February 2015 11:08 (America/New_York)

Financing sanitation for cities and towns: learning paper, 2014. Institute for Sustainable Futures; SNV.

The aim of this paper is to provide a starting point for such planning for the service chain and life cycle to occur. It is a synthesis of key literature on financing for the water services sector seeking to achieve the millennium development goals (MDGs) and its post-2015 successor, the sustainable development goals (SDGs). The findings from the literature review are complemented by key insights from an online ‘DGroup’ discussion organised by SNV on the topic of ‘financing for urban sanitation investment’.

The focus of this paper is on access to the upfront finance and other ‘lumpy’ finance needs, for initial investment and for rehabilitation/replacement as physical systems approach their end of life. The upfront investment is the main determinant as to whether there is service at all, and the decisions made upfront have a profound influence on the performance of the entire service chain.

This focus is not a denial of the utmost importance of the relatively smaller and ongoingfunding required on a day-to-day and short-term basis, but rather, a recognition that theirfinancing is qualitatively different. Regular sources of revenue might be more readily available forthe smaller ongoing requirements, whereas the ‘lumpy’ investments require finance upfront.

Trémolet Consulting – Toilets on Credit

19 February 2015 10:02 (America/New_York)

Toilets on Credit, 2015. Trémolet Consulting.

Can microfinance help increase access to sanitation? Today, 2.5 billion people do not use proper sanitation facilities. Essential services for maintaining latrines and treating faecal sludge are also underdeveloped. In many places, toilets can cost up to one year of income for poor households. Private operators of sanitation services do not have enough capital to acquire more equipment and respond to growing demand.

Since 2010, Trémolet Consulting and research partners based in Kenya MicroSave have been exploring the potential of microfinance for helping sanitation markets to develop. The research, funded by SHARE/DFID, culminated with an action-research in Tanzania in which financial institutions were trained to provide financial services for sanitation.

This film explains why microfinance should be explored further, and potentially, included in sanitation programmes. The film also presents what has been done in Tanzania under the action-research and takes the views of households, sanitation entrepreneurs, microfinance institutions and researchers.

WSUP – Stand-Alone Unit or Mainstreamed Responsibility: How Can Water Utilities Serve Low-Income Communities

19 February 2015 9:56 (America/New_York)

Stand-Alone Unit or Mainstreamed Responsibility: How Can Water Utilities Serve Low-Income Communities, 2015. Water and Sanitation for the Urban Poor.

Urban utilities throughout the developing world face the challenge of extending services to low-income communities (LICs). This paper draws on current best practice to explore a question that is core to addressing this challenge: how can utilities effectively structure their organisation to extend services to LICs?

Our review of ten utilities reveals three candidate approaches:

  • Dedicated, stand-alone LIC unit with operational function;
  • Dedicated, stand-alone LIC unit with advisory function;
  • ‘Mainstreaming’ approach in which responsibilities for serving LICs are distributed throughout the utility’s operational units.

Urban Opportunities: Perspectives on Climate Change, Resilience, Inclusion, and the Informal Economy

19 February 2015 9:49 (America/New_York)

Urban Opportunities: Perspectives on Climate Change, Resilience, Inclusion, and the Informal Economy, 2015. Wilson Center; USAID.

To encourage a new generation of urban scholars, practitioners, and policymakers, and to disseminate their innovative ideas, the Wilson Center’s Urban Sustainability Laboratory, together with Cities Alliance, the International Housing Coalition, USAID, and the World Bank, sponsors an annual paper competition for advanced graduate students working on issues related to urban poverty. The competition is designed to promote the early career development of young urban researchers as well as to strengthen ties between urban policymaking and academia.

This publication marks the fifth year of the “Reducing Urban Poverty” competition and includes a range of perspectives on urban challenges and policy solutions. The 2014 competition called for papers linked to one of the following subtopics: cities and climate change; urban resiliency; inclusive
cities; and the impacts of the informal economy. Each chapter in this volume critically examines existing urban policies and projects, offering original, solutions-oriented research and strategies.

USAID/Ethiopia – Urban Gardens Help Women with HIV

17 February 2015 12:15 (America/New_York)

USAID/Ethiopia – Urban Gardens Help Women with HIV, 2015.

USAID supports an Urban Gardens program in Ethiopia to provide vulnerable and HIV-infected women with the tools, land, and knowledge to plant vegetable gardens, feed their families, and sell the produce to increase household income. The program trains women in nutrition, composting, vegetable growing, irrigation, proper hygiene, and HIV/AIDS awareness, and workers with degrees in agriculture assist the women in planting and maintaining their gardens.

The 20-year sanitation partnership of Mumbai and the Indian Alliance

17 February 2015 11:40 (America/New_York)

The 20-year sanitation partnership of Mumbai and the Indian Alliance. Environment & Urbanization, Feb 2015.

Author: Sheela Patel, The Sparc Team. e-mail: sparcssns@gmail.com

Mumbai is well-known for the scale of the community toilet programme supported by local government, much of it undertaken in partnership with community-based organizations, including the National Slum Dwellers Federation, Mahila Milan (a federation of women’s savings groups) and SPARC (a local NGO), together known as the Alliance.

After describing how this community toilet programme developed over the last 20 years and sought city-wide scale, this paper focuses on the Alliance’s co-development with the municipal corporation of a system to monitor conditions in the hundreds of community toilet blocks built. This monitoring system supports government officials in each ward and the communities served by the toilet blocks in identifying and addressing faults. It also helps develop good working relationships between communities and ward and municipal officials, which can allow other key issues to be addressed.

HDSS Profile: The Nairobi Urban Health and Demographic Surveillance System

17 February 2015 11:27 (America/New_York)

HDSS Profile: The Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Int. J. Epidemiol. (2015)
doi: 10.1093/ije/dyu251

Authors: Donatien Beguy, Patricia Elung’ata, et al.

The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was the first urban-based longitudinal health and demographic surveillance platform in sub-Saharan Africa (SSA). The NUHDSS was established in 2002 to provide a platform to investigate the long-term social, economic and health consequences of urban residence, and to serve as a primary research tool for intervention and impact evaluation studies focusing on the needs of the urban poor in SSA. Since its inception, the NUHDSS has successfully followed every year a population of about 65 000 individuals in 24 000 households in two slum communities—Korogocho and Viwandani—in Nairobi, Kenya.

Data collected include key demographic and health information (births, deaths including verbal autopsy, in- and out-migration, immunization) and other information that characterizes living conditions in the slums (livelihood opportunities, household amenities and possessions, type of housing etc.). In addition to the routine data, it has provided a robust platform for nesting several studies examining the challenges of rapid urbanization in SSA and associated health and poverty dynamics. NUHDSS data are shared through internal and external collaborations, in accordance with the Centre’s guidelines for publications, data sharing.

CityLinks WASH App2Action Challenge to develop phone or web based tools

17 February 2015 11:02 (America/New_York)

Housed under the USAID-funded, ICMA CityLinks program, the App2Action Challenge brings together software developers, designers, and subject-matter experts to develop phone- or web- based tools that help address WASH challenges in a local community.

CityLinks is releasing a Call for Interest for Missions who would be interested in an App2Action Challenge in their communities either to  enhance an existing water/sanitation projects or serve as a stand-alone event in support of local development and improved services.

It is fully funded by the CityLinks Leader, and therefore comes at no cost to the field missions. Rather, the Mission’s role can include

a) identifying a sub-national entity (city, province, department, etc.) that would be interested in and benefit from the App2Action Challenge;
b) assistance in defining the WASH challenge;
c) participating on the judge’s panel; and
d) connecting CityLinks with in-country resources and knowledge.

We really envision this model to drive civic engagement and innovation. In the past, there have been international projects similar to this, but on a larger scale. Because we are working with one Mission and a specific sub-national entity , this project structure can be very flexible to their needs and capacity. We ask for an email indicating interest by February 25, 2015.


Water For People – Strengthening public sector enabling environments to support sanitation enterprises, 2014.

20 January 2015 14:21 (America/New_York)

Strengthening public sector enabling environments to support sanitation enterprises, 2014. Water For People.

Water For People is piloting sanitation business approaches and seeks to discover under what conditions these approaches are successful. Public sector influence is one condition that has the potential to facilitate or hinder private sector sanitation endeavors.

This study aims to understand: (1) how the public sector enabling environment can facilitate or hinder low-cost sanitation enterprises; and (2) how NGOs can effectively engage the public sector to support sanitation businesses. Data were collected from Water For People staff and partners in nine countries and summary case studies were coded to discover prevailing themes.


fhi360 care Winrock International

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