Yvonne Magawa (ESAWAS), Batsirai Majuru (WHO), Bisi Agberemi (UNICEF), Jan-Willem Rosenboom
& Alyse Schrecongost (BMGF)Faecal sludge transport workers in Kenya - UNICEF/UN0348903/Modola
This blog is part of a series for World Toilet Day highlighting issues within the WHO-UNICEF State of the World’s Sanitation report. The topic of sanitation regulation is also covered in 'Catalysing Citywide Sanitation For All Through Regulating Service Providers' by IWA's Regulation for Citywide Inclusive Sanitation initiative's advisory and taskforce members - Yvonne Magawa (ESAWAS), Diego Polania (CRA), and Gustavo Saltiel (World Bank).
For too long sanitation, specifically on-site sanitation systems such as septic tanks and pit latrines, have been left in the realm of household responsibility.
The scant investments available for urban sanitation gravitate towards sewered infrastructure, reaching small proportions of large urban areas, primarily wealthier populations. Urban populations continue to grow rapidly, often in dense settlements with limited basic public services or infrastructure. Particularly for sanitation, households are forced to make do, covering the costs of basic access for themselves. The very nature of safe sanitation, however, means that the decisions and priorities of individuals are largely decoupled from what would be required to protect public health, the environment, and reach the poorest. Services for safely containing, emptying, transporting and treating human waste, and preventing pits and septic tanks from contaminating groundwater and open drains are needed, but without regulation, investments will not prioritize public health outcomes.
This situation is both unfair to the households and ineffective in achieving a primary purpose of sanitation: protecting public health. Sanitation is fundamentally a public good. Individuals’ decisions maximize their own best interest – they do not necessarily serve the best interests of society at large.
Investments in sanitation need to be planned, regulated and financed to align the priorities of individual households with those of service providers. This alignment is required to address the broader social goals of public health protection, cleaner environments, and stronger economies. Among the countries that have made extraordinary gains in a generation, a common factor among them has been strong political leadership that clarified public goals, gave clear mandates to the responsible authorities to achieve those goals, regulated authorities’ delivery of services, and mobilized the corresponding investments needed.
Where utilities manage sewers, generally those utilities have a defined, public service-oriented mandate, performance accountability, and financing strategies. Over two thirds of countries have environmental standards for wastewater treatment.
Beyond sewered areas, urban sanitation remains a public good, but it is largely delivered by unorganized and unregulated private or informal actors. Few countries have standards for faecal sludge treatment or safe reuse of wastewater or sludge. Individual providers of emptying and transport services may or may not be subject to a smattering of on-paper regulatory codes or standards. Where standards exist, they are almost universally decoupled from efforts to monitor, incentivize or enforce compliance. As a result, less than a third of mandated oversight agencies are able to carry out the basic functions of monitoring and enforcement.
Robust regulatory systems can address the market failures of urban sanitation to protect public health and incentivize delivery of safe, inclusive, and viable services. We highlight three issues critical to pursuit of this outcome that merit case studies, discussion, and sector learning and evolution.
First, regulations can help to better link sanitation services to public health protections. Simple statement but not a simple task. Regulation of sanitation services has long lagged behind that of water services: only 1 in 5 countries have any indicators for sanitation service quality. If sanitation services are to protect public health, then public health-aligned guidance and oversight must become the expected norm in all countries, for sewered and non-sewered sanitation systems alike. Health outcomes must be designed into simple, transparent and effective by-laws, codes and standards; actionable and funded monitoring and enforcement systems are required to make those standards meaningful. To achieve this, systems must be designed in collaboration with public health authorities. Public health risk assessment and risk management priorities must underpin product and service standards along the full sanitation service chain. This includes measures to address the specific health risks, stigma and marginalization faced by sanitation workers in unregulated settings.
Second, as with public health regulation, the focus of economic and performance regulation of sanitation services must be on safe, inclusive services, irrespective of the infrastructure used. Failure to focus mandates and regulatory frameworks on service outcomes instead of infrastructure inputs exacerbates systemic inequity and exclusion. In most cases, providers of non-sewered products and services remain unregulated and unorganized retail actors. They deliver services with wide variability in price and quality, with little accountability for the quality of their service to households or for public health. Market structuring – particularly economic and performance regulation of services – is required if public or private providers are to be incentivized to protect public health, to reach low income communities, and to mobilize investment and innovation. Economic regulatory tools can help align customer inclusion and affordability goals with providers’ financial interests.
Finally, if the public sector is well-structured and regulated, it can increase business opportunity, available finance, and incentivize investment in innovation to meet health and inclusivity goals. Recognizing sanitation as a public good does not imply that the public sector has sole responsibility for delivering public services. Indeed, without structuring sanitation as a public service, opportunities for private sector engagement are more restricted, higher risk, less effective, less profitable, and less aligned with the public good. Tools and business models that align public, customer, and provider interests have not always been clear, but promising innovations are emerging in urban markets in Kenya, Malaysia, Zambia, and other countries. In these areas, regulators are insisting on improved sector outcomes. They are also supporting utilities and the private sector to learn and grow as the sector transforms and more is expected of everyone.
Significant challenges remain. In many countries sanitation is entirely managed by municipalities. Municipal service systems tend to be subject to individuals’ short term political interests, missing accountability mechanisms, and with limited flexibility to generate or ringfence revenue effectively. Treatment compliance or the relationship between customer-based revenue mechanisms and service quality can be opaque.
We have good reason to believe that well-designed regulatory systems can accelerate global progress toward SDG 6.2 and 6.3, and improve public health. The WHO Guidelines on Sanitation and Health provide a useful point of departure in addressing public health criteria in sanitation regulations, and articulating the role of the health sector in sanitation authorities’ service provision.
In addition, a new publication – the WHO-UNICEF State of the World’s Sanitation – launching today draws attention to the role of regulators in solving the sanitation crisis. The report brings together lessons from high-achieving countries, and presents a vision of what is needed to deliver universal access to safe sanitation. It calls for urgent action around five areas: governance; financing; capacity development; data; and innovation, and highlights leadership, effective coordination and regulation as effective pathways for achieving safe sanitation for all. Building on the directions outlined in the report, WHO and other partners working with regulators’ networks such as the East and Southern Africa Water and Sanitation (ESAWAS) Regulators Association and the WHO International Network of Drinking-water and Sanitation Regulators (RegNet), will work to create concrete and contextualized changes in regulation of sanitation services that can inform future updates of the report.
Antimicrobial resistance and consumption remains high in the EU/EEA and the UK, according to new ECDC data
Health is a human right, and tactics learned from the human rights movement can help ensure every person access to the highest standard of sexual and reproductive health.
WHO, HRP and partners present a new documentary series about the power of people to change the world.
Every individual on the planet has the right to the highest standard of health and well-being in all aspects of their sexuality, their body and their reproductive choices – but there is no ‘one size fits all’ strategy for making this a reality.
Right To A Better World is a documentary video series produced by WHO and HRP, in partnership with UN Human Rights (OHCHR) and the Oxford Human Rights Hub (OxHRH). It explores how tactics developed by the human rights movement can be used to achieve sexual and reproductive health rights, and drive meaningful progress towards the fulfillment of the 2030 Agenda for Sustainable Development.
“A human rights-based approach to health is essential to achieving my top priority as DG – universal health coverage,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus, when he signed the 2017 WHO-OHCHR Framework of Cooperation.
Right To A Better World builds on this major milestone for health and human rights, affirming that rights holders and their experiences belong at the centre of every discussion and decision affecting them.
“The achievement of the 2030 Agenda for Sustainable Development hinges on the realization of human rights, which necessitates action across sectors and disciplines,” said Veronica Birga, Chief of Women's Human Rights and Gender Section of UN Human Rights. “The lessons in this series created through a multi-disciplinary partnership are invaluable and make it clear that securing rights for all, is not only the right way, but the smart way to achieve truly sustainable development.”
There are four 20-minute thematic episodes in Right To A Better World, all free to access: contraception , comprehensive sexuality education maternal mortality and morbidity , and violence against women .
“This powerful series creates a unique synergy between academic and practical human rights approaches, vividly demonstrating the key role human rights can play when advocating for sexual and reproductive health rights in political, legal, and international forums,” said Professor Sandra Fredman, Director of OxHRH.
“The “Right to a Better World” series bridge the communicative divide between health and human rights practitioners, throwing the spotlight on the importance of addressing not only health outcomes but the underlying gender inequalities, stereotypes and structures,” adds Dr Meghan Campbell, Deputy Director at OxHRH.
Although health outcomes and the achievement of rights have improved for many across these core components of sexual and reproductive health, progress overall remains fragile and uneven.
In each episode across the series, experts in health and human rights share their professional struggles and successes working on the frontline of communities worldwide. As advocates and activists, they represent a broad range of professional fields, ages, levels and backgrounds.
The episodes can be watched at home, in groups and in classroom settings. Viewers are encouraged to learn from the experiences shared, and consider how tactics could be adapted to their own contexts.
“Human rights are the key to ensuring every person has access to comprehensive sexual and reproductive health care, and WHO and HRP are committed to mainstreaming human rights into health policies and programmes. Our partnership with UN Human Rights and OxHRH affirms that in the changing landscape of sexual and reproductive health, human rights must be heard as loudly as clinical and scientific research,” said Ian Askew, Director of the WHO Department of Sexual and Reproductive Health and Research including HRP.
Join the conversation at #RightToABetterWorld.
Right To A Better World VIDEOS Comprehensive sexuality education (episode 1 of 4)
Building support and understanding of every young person’s right to education, health and well-being, in an inclusive and gender equal society.Contraception (episode 2 of 4)
Ensuring each woman's and adolescent’s right to make decisions about their reproductive health and future.Maternal mortality and morbidity (episode 3 of 4)
Ensuring every woman's and adolescent’s right to not only survive pregnancy and childbirth, but have a positive experience of this profound life event.
Violence against women (episode 4 of 4)
Building a world in which women and girls are free from all forms of violence and discrimination.
WHO launches new roadmap on human resource strategies to ensure that all newborns survive and thrive
Every year, an estimated 15 million babies are born preterm – before 37 weeks of pregnancy. That is more than 1 in 10 live births. Approximately 1 million children die each year worldwide due to complications from their early birth. Those that survive often face a lifetime of ill-health including disability, learning difficulties, and visual and hearing problems.
Half of the babies born at or below 32 weeks (2 months early) die in low-income settings, due to a lack of feasible, cost-effective care, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties. In high-income countries, almost all these babies survive.
Today, on World Prematurity Day, WHO launched a new Roadmap on human resource strategies to improve newborn care in health facilities in low- and middle-income countries, aimed at improving quality of care for newborns, including small and sick babies, and supporting countries to achieve the SDG target to reduce neonatal mortality to less than 12 per 1000 live births by 2030.
As the COVID-19 pandemic overburdens already weak health systems in many countries, it is expected to increase the number of newborn deaths, particularly among babies born too soon. Disrupted essential health services, like family planning or antenatal check-ups, will leave women more at risk of preterm birth and vulnerable infants without the services they need.
“We have the power to prevent, diagnose and treat preterm birth, and save babies lives, if we invest in competent and specialized nurses and health workers to care for them,” Dr Anshu Banerjee, WHO Director for the Department of Maternal, Newborn, Child and Adolescent Health and Ageing. “As more pregnant women give birth in health facilities, we must also strengthen our health workforce to provide a positive pregnancy experience for each of them.”
Survival and health outcomes of preterm newborns can be enhanced by increasing access to interventions provided to the mother shortly before or during birth as well as interventions for the newborn baby. However, the highest burden of preterm birth, death and disability is concentrated in low- and middle-income countries, where competent and specialized health workers are in short supply.
Of the 30 million newborns who require inpatient care every year, approximately half do not have access to neonatal care services and those who have access often receive care of suboptimal quality. Skilled birth attendants, including medical doctors and midwives, are critical to the provision of high-quality newborn care and to improving newborn outcomes, not only at the time of birth and for routine postnatal care but also in health facilities to which mothers and newborns with complications are referred.
The new WHO roadmap consists of 10 strategies to guide countries in developing their policies to improve the number and competence of health workers to deliver high-quality essential care for all newborns and specialized care for small and sick newborns. It also aims to fill the gap in the numbers of health workers with specialized neonatal skills in low- and middle-income countries required to provide high-quality inpatient care for small and sick newborns.
Over the past three decades countries that have invested in their nursing and midwifery workforces have achieved sustained reductions in maternal and newborn mortality. With continued investments in universal access to high-quality newborn care an estimated 1.7 million newborns could be saved each year. Almost half of the effect would result from providing special and intensive hospital care for preterm, low-birth-weight or sick newborns.Link to new roadmap
Over US$ 2 billion raised to support equitable access to COVID vaccines with additional US$ 5 billion needed in 2021
WHO-commissioned global systematic review finds high HCV prevalence and incidence among men who have sex with men
WHO has developed the assistive technology capacity assessment (ATA-C) tool, a system-level tool to evaluate a country’s capacity to finance, regulate, procure and provide assistive technology. The ATA-C tool enables countries to better understand the current status and identify key actions to improve access to assistive technology: it can be used for awareness raising, policy and programme design and ongoing monitoring and evaluation. The ATA-C implementation process can also serve to bring diverse stakeholders together and build momentum for action.
The tool was developed by WHO, in collaboration with the Clinton Health Access Initiative and with support of many other in-country partners. Its development has been informed by implementation in Bahrain, Bolivia (Plurinational State of), Ethiopia, Indonesia, Iraq, Liberia, Malawi, Mongolia, Nigeria, Rwanda, Sierra Leone, Tajikistan, Uganda and Viet Nam. The tool development and country assessments were funded by UK aid under the AT2030 programme led by the Global Disability Innovation Hub, with contributions from the United States Agency for International Development.
To access the tool and supporting documents, WHO has created a dedicated portal. Through this portal, WHO will provide technical support and facilitate coordination and connections between the diverse stakeholders in countries. Click here to access the ATA-C portal.
The ATA-C is part of the WHO Assistive Technology Assessment (ATA) Toolkit, helping countries to collect effective and relevant data on assistive technology. For more information on the toolkit, visit the ATA Toolkit webpage.
WHA73 endorses resolutions on meningitis control and epilepsy, roadmap on neglected tropical diseases
Member States recommended the adoption of two resolutions on meningitis control and epilepsy at the 73rd World Health Assembly on Thursday (November 12).
Committee A, which focuses on programme and budget matters, decided to recommend the adoption of the first-ever resolution on meningitis, which would approve a global roadmap to defeat meningitis by 2030 – a disease that kills 300,000 people annually and leaves one in five of those affected with devastating long-term consequences.
The Committee also recommended the adoption of a resolution calling for scaled-up and integrated action on epilepsy and other neurological disorders such as stroke, migraine and dementia. Neurological disorders are the leading cause of disability and the second leading cause of death worldwide.
The Committee further decided to recommend the adoption of a decision endorsing the new roadmap for neglected tropical diseases. The roadmap aims to achieve these targets by 2030: reduce by 90% the number of people requiring treatment for NTDs, eliminate at least one NTD in 100 countries, eradicate two diseases (dracunculiasis and yaws), and reduce by 75% the disability-adjusted life years (DALYs) related to NTDs.
Committee A noted the Operational Framework for Primary Health Care, which aligns with the Declaration of Astana and resolution WHA72.2 (2019). WHO has established a Special Programme on Primary Health Care to roll out the Operational Framework – supporting Member States to build people-centred, resilient and sustainable primary health care-based health systems.
Committee B – which deals predominantly with administrative, financial and legal matters – reviewed the Director-General’s report on “Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan”. The Committee also decided, by vote, to recommend the adoption of a decision requesting the Director-General, amongst others, to report on progress in the implementation of its recommendations to the next World Health Assembly.
All resolutions and decisions recommended by the Committees for adoption by the 73rd World Health Assembly will be included in the Committees’ reports to the Plenary and considered on Friday.
The World Health Organization has announced a new Council on the Economics of Health for All, staffed by leading economists and health experts, to put “Health for All” at the centre of how we think about value creation and economic growth.
“The COVID-19 pandemic has demonstrated the consequences of chronic under-investment in public health. But we don’t just need more investment; we must also rethink how we value health,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus, as he made the announcement on the final day of the resumed 73rd World Health Assembly on Friday.
Chaired by noted economist Professor Mariana Mazzucato, Professor of the Economics of Innovation and Public Value and Founding Director in the Institute for Innovation and Public Purpose at University College London, the Council will aim to create a body of work that sees investment in local and global health systems as an investment in the future, not as a short-term cost. Designing such investments makes our economies more healthy, inclusive and sustainable.
The COVID-19 pandemic, with 52 million reported cases and 1.3 million deaths, has shown the dire consequences of chronic under-investment in health on the global economy and on the lives and livelihoods of billions worldwide.
Over the past year, the pandemic has ignited a socio-economic crisis like no other; a crisis that has undermined global stability and solidarity. It has stressed how interdependent health and the economy are and served as a reminder that health is a human right.
“We are living through multiple crises: economic, climate and health related. If we continue to patch up the system each time, we will always be one step behind. I am thrilled to work closely with Dr Tedros on a proactive Health for All economic agenda, to shape our economies so they truly have wellbeing and inclusion at the centre of how we create value, measure it and distribute it,” Mazzucato said.
Returning to the status quo following the pandemic will not be enough – we need an innovation-led transformation of our health systems to achieve economic well-being everywhere.
“The time has come for a new narrative that sees health not as a cost, but an investment that is the foundation of productive, resilient and stable economies,” Dr Tedros said.
The Council on the Economics of Health For All is expected to hold its first virtual session in the coming weeks, to discuss its work plan and mode of operation. The Council will produce thought leadership for implementing change, and help to inform the piloting of initiatives at country level.
A new WHO Certification Programme for Trans Fat Elimination aims to recognize countries that have eliminated industrially produced trans-fatty acids (TFA) from their national food supplies. This is the first-ever certification programme that will recognize countries for their efforts to eliminate one of the main risk factors for noncommunicable diseases and protect their populations from premature death.
Increased TFA intake (>1% of total energy intake) is associated with coronary heart disease events and mortality. Industrially produced TFA is used in baked and fried foods, pre-packaged snacks, and certain cooking oils and fats that are used at home, in restaurants or in street food. Replacing it with healthier oils and fats is cost effective, life-saving, and feasible without changing the taste of food or its cost to the consumer.
The new certification programme also aims to accelerate global progress towards achieving WHO’s goal of eliminating industrially produced TFA by 2023, which was set as a priority target to be achieved in 13th General Programme of Work (2019 – 2023). To support countries reach the target and take action, WHO also released the REPLACE action framework in 2018.
A year later, WHO released six REPLACE modules to provide practical, step-by-step implementation guidance to countries. WHO recommends countries to adopt one of two best-practice policy options for eliminating industrially produced TFA from the food supply: (1) limit industrially produced TFA to 2g per 100g of total fat in all fats, oils, and foods, and (2) ban the production and use of partially hydrogenated oils (PHO).
Today, countries are responding to WHO’s call to action and many have passed and implemented best-practice policies. Currently best-practice TFA policies have come into effect in 14 countries (covering 589 million people) and additional 26 countries have passed a best-practice TFA policy that will come into effect in the next two years (covering additional 815 million people). Thus, in two years, approximately 1.4 billion people will be protected from industrially produced TFA.
Similar to other elimination and eradication programmes (e.g. smallpox, poliovirus, malaria and guinea worm), the proposed certification programme for TFA elimination is essential in establishing country accountability and accelerating global progress towards achieving the 2023 elimination target.
To qualify for certification, countries must demonstrate that a best-practice TFA policy has been implemented and that effective monitoring and enforcement systems are in place.
Application requirements and detailed criteria will be made available on the WHO website soon. WHO calls on all countries to take life-saving action by eliminating industrially produced TFA.
 Countries with best-practice policies that are already in effect may meet the criteria for certification and are encouraged to submit expressions of interest: Austria, Canada, Chile, Denmark, Hungary, Iceland, Latvia, Lithuania, Norway, Saudi Arabia, Slovenia, South Africa, Thailand, United States.
Countries with best-practice policies that have passed but have not yet come into effect are encouraged to submit expressions of interest once they meet the criteria for certification: Belgium, Brazil, Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Malta, Netherlands, Peru, Poland, Portugal, Romania, Slovakia, Spain, Sweden, Turkey, United Kingdom, Uruguay.