Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities

Safe environmental conditions and the availability of standard precaution items are important to prevent and treat infection in health care facilities (HCFs) and to achieve Sustainable Development Goal (SDG) targets for health and water, sanitation, and hygiene. Baseline coverage estimates for HCFs have yet to be formed for the SDGs; and there is little evidence describing inequalities in coverage. To address this, we produced the first coverage estimates of environmental conditions and standard precaution items in HCFs in low- and middle-income countries (LMICs); and explored factors associated with low coverage. Data from monitoring reports and peer-reviewed literature were systematically compiled; and information on conditions, service levels, and inequalities tabulated. We used logistic regression to identify factors associated with low coverage. Data for 21 indicators of environmental conditions and standard precaution items were compiled from 78 LMICs which were representative of 129,557 HCFs. 50% of HCFs lack piped water, 33% lack improved sanitation, 39% lack handwashing soap, 39% lack adequate infectious waste disposal, 73% lack sterilization equipment, and 59% lack reliable energy services. Using nationally representative data from six countries, 2% of HCFs provide all four of water, sanitation, hygiene, and waste management services. Statistically significant inequalities in coverage exist between HCFs by: urban-rural setting, managing authority, facility type, and sub-national administrative unit. We identified important, previously undocumented inequalities and environmental health challenges faced by HCFs in LMICs. The information and analyses provide evidence for those engaged in improving HCF conditions to develop evidence-based policies and efficient programs, enhance service delivery systems, and make better use of available resources.     

Use of focus groups for the environmental health researcher

Qualitative research techniques, such as focus groups, are often underutilized by the environmental health researcher. Researchers can use the data from focus groups for study planning and implementation, as well as the interpretation of study results. Focus group data can also be used to understand community risk perceptions and potential barriers to co munity acceptance of programs and policies. This paper describes the value of focus groups for the environmental health researcher. Examples from the literature are inccorporated to demonstrate the effective use of focus groups in a variety of environmental health research settings. A brief review of data analysis approaches, including commercially available software, is provided. The authors encourage increased application of this and other qualitative research methods in environmental health research.     

The critical need for WASH in emergency preparedness in health settings,the case of COVID-19 pandemic in Kisumu Kenya

The devastating effects of inadequate basic utilities such as water, sanitation, hygiene, waste management and environmental cleaning (WASH) is underscored by the current global pandemic declared on March 11, 2020. This paper explores the experiences of key informants (n = 15) ie government and non-government organization officials on the impacts of the COVID-19 pandemic in health care facilities (HCFs) and the role of WASH in emergency preparedness in health settings and the communities they serve using Kisumu, Kenya as a case study. The results from interviews with the key informants indicate socioecological challenges shaping access to hygiene services in HCFs and related disparities in social determinants of health such as WASH that serve as barriers to the pandemic response. All participants indicated the healthcare system was ill-prepared for the pandemic. Health care workers experienced such severe psychosocial impacts due to the lack of preparedness that they subsequently embarked on strikes in protest. These situations influenced citizens' perceptions of the COVID-19 pandemic as a hoax and resulted in a surge in other population health indicators (e.g., increased maternal mortality; decreased vaccination rates for other illnesses such as measles). We recommend authentic partnerships among all stakeholders to develop and implement context-driven sustainable solutions that integrate WASH and emergency preparedness in HCFs and the communities they serve across all spatial scales, from the global to the local.     

An implementation model for health system reform

Health system reform in post-industrial countries has become a dominant problem facing national governments. This problem is aggravated by the pace of social and technological changes and continued economic pressures. In order to accomplish health system reform, governments must develop new policies to redirect or change the present course of the system. Health system reform involves broad based change in behaviors of consumers, providers and the government itself. The direction of the change requires nothing less than shifting the focus of the system and its actors from its predominant emphasis on sickness treatment (negative-health focus) towards an emphasis on maintaining and promoting the highest possible standards of personal health (positive-health focus). This paper introduces an implementation model for health system reform. The model was developed based on major supports and constraints presently operating in the United States health policy context. Major support is provided by the existence of both theoretical and structural frameworks upon which the policy shift can be built. The structural framework includes four laws and their associated activities which outline national health goals and objectives. A major constraint is the implementation conundrum. Policy is government's primary tool to achieve system reform. However, while government is strong in creating policies, it is extremely weak in implementing the very policies it creates. This implementation conundrum consists of three barriers. These barriers are: a universal fear of change; early stage in development of the technology of social change; and the failure of government to plan for implementation of the very policies it creates. The implementation model for health system reform is introduced to aid policy makers and analysts in overcoming this implementation conundrum. The model recognizes policy as a process of change and provides two stages for use in translating theory and aims of policy into a formula for action. Stage one is used to identify the factors of change necessary in achieving policy reform. Stage two identifies the appropriate process of change to achieve successful outcomes. The model can be used in planning for both national and local levels of health system reform by both public and private sector players in the health arena.     

Developing Policies Responsive to Barriers to Health Care Among Rural Residents: WhatDo We Need to Know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies hove grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.     

Toward a national health risk management approach in Australia

There has been increasing international consensus about the importance of competition for achieving national growth and community well-being. The Australian government accordingly has introduced policies to promote such competition. Major legislative review and many public inquiries have assisted implementation of national competition policy and the development of national goals and standards related to international agreements to promote health and sustainable development. Since the 1980s, Australia has had legislation that requires the identification and control of health risks arising at work. The management structures necessary for coordinated delivery of national programs designed for effective identification and control of health risks arising in communities to achieve national health and development goals are still being developed, however. Major difficulties related to this development are discussed. National health development programs should be approached primarily through establishment of regional partnerships between bodies responsible for managing community health, local government, and employment placement, in consultation with other relevant organizations and the community. Related research and evaluation programs are required.     

Policy and environmental change: new directions for public health

Solving major, persistent public health problems requires new policies and more aggressive, sweeping interventions that affect large populations. We need well-conceived health policies and effective interventions for environmental change, but are we likely to get them? To find out, the Directors of Health Promotion and Education and the U.S. Centers for Disease Control and Prevention initiated a study of state and local public health agencies in the United States from 1996 through 1999. Data were collected by peer- and non-peer-reviewed literature searches, key informant interviews, reviews of Internet sites, and a nationwide survey. Study conclusions found confusion about the legitimacy of advocacy, lack of priority and funding for interventions that take more time versus quick fixes, variable leadership, reluctance to take risks, and a political climate that often discourages government agencies to take on these interventions. There are successes, yet more can be done.     

Implementation of public policy on alcohol and other drugs in Brazilian municipalities: comparative studies

One of the challenges with respect to public health and the abuse of alcohol and other drugs is to implement policies in support of greater co‐ordination among various levels of government. In Brazil, policies are formulated by the Secretaria Nacional de Políticas sobre Drogas (SENAD – State Department for Policies on Drugs) and the Ministério da Saúde (MS – Ministry of Health). This study aims to compare implementation of policies adopted by SENAD and MS at the municipal level. Three municipalities were intentionally selected: Juiz de Fora having a larger network of treatment services for alcohol and drug users; Lima Duarte, a small municipality, which promotes the political participation of local actors (COMAD – Municipal Council on Alcohol and Drugs); and São João Nepomuceno, also a small municipality, chosen because it has neither public services specialised to assist alcohol and other drugs users, nor COMAD. Data collection was conducted through interviews with key informants (n = 19) and a review of key documents concerned with municipal policies. Data analysis was performed using content analysis. In Juiz de Fora, there are obstacles regarding the integration of the service network for alcohol and other drug users and also the articulation of local actors, who are predominant in the mental health sector. In Lima Duarte, while there is a link between local actors through COMAD, their actions within the local service network have not been effective. In São João Nepomuceno, there were no public actions in the area of alcohol and drugs, and consequently insufficient local debate. However, some voluntary, non‐governmental work has been undertaken. There were weaknesses in the implementation of national‐level policies by SENAD and the MS, due to the limited supply of available treatment, assistance and the lack of integration among local actors.     

Understanding the central-local relationship in health care: a new approach

One of the basic assumptions of governmental health planning policy is that the government can effectively take final responsibility for the development of the health care system. Failure to reach policy goals is explained in terms of inadequate planning technology and instruments to control implementation. In this article an alternative explanation is offered, based on the theory of strategic organizational behavior. According to this theory, the government must be seen as but one actor in a complex interorganizational network. From this, a different perspective on effective health planning policy is developed. Policies will fail if they are not based on a valid analysis of the policy space of health care institutions and the interdependencies between government and health care organizations. This article starts with an outline of the nature of the central-local relationship as seen from the perspective of strategic organizational behavior theory. Next, this theory is used to frame two cases in which Dutch health care institutions successfully pursued their own strategies that ran counter to the existing health planning policies. The article ends with a discussion of the implications of the theory of strategic organizational behavior for the development of effective central health care policies. This development starts with a thorough analysis of the policy space and interdependencies of all relevant actors in the health system, the government included. Following, policy makers can set the governmental goals and then have to start negotiations with health care institutions about mutual adaptation of their strategies and the governmental goals. The result is a negotiated health care order.     

Health enhancing physical activity in all policies? Comparison of national public actors between France and Belgium

Despite evidence on the benefits of health enhancing physical activity (HEPA), only few countries have developed “health in all policies” and specifically integrated HEPA policies. Paucity of studies have questioned the role of public national actors in PA policies enactment and delivery, the barriers and levers for adopting cross-sectoral HEPA. The present work seeks at comparing France and Belgium in regard to their competencies of ministries promoting HEPA, the presence of leadership and coordination in HEPA policies implementation, their key public legal entities working on HEPA. Expert interviews and document analysis were realized to complete the HEPA policy audit tool in each country. Results have shown that HEPA cross-sectoral policies are at their early stage. A broad diversity of sectors was implicated in HEPA policies: sport, health, transport, environment, and education, but often with weak activity. No leadership or coordination exist to implement HEPA policies, although different public legal entities could work on this aim. Ministries relationships were principally coming from formal co-interventions mandated by national public plans in France, where in Belgium relationships were punctual. Lobbying within each sector and in key public legal entities to promote HEPA is needed, and the development of official national coordination is essential.     

Linking public health, housing, and indoor environmental policy: successes and challenges at local and federal agencies in the United States

We describe the successes and challenges faced by federal and local government agencies in the United States as they have attempted in recent years to connect public and environmental health, housing, community development, and building design with environmental, housing, and building laws, codes, and policies. These policies can either contribute to or adversely affect human physical and mental health, with important implications for economic viability, research, policy development, and overall social stability and progress. Policy impediments include tension between housing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built environment. We contrast this with other environmental frameworks such as ambient air and water quality statutes where the concept of "shared commons" and the "polluter pays" is more robust. The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful policy insights. Local programs can effectively build healthy homes capacity through local laws and housing codes. The experience of coordinating remediation for mold, asthma triggers, weatherization, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multi-disciplinary approach at all levels of government to prevent unhealthy buildings, houses, and communities.     

The Chinese government's response to drug use and HIV/AIDS: A review of policies and programs

Illicit drug use has become popular in China. Acknowledging the challenge of illicit drug use, China has adopted several new policies on the management of illicit drug use in recent years. This study reviews the current policies on drug use and assesses the harm reduction interventions among drug users in China. The review documents that the new policies on drug use provide a variety of choices of detoxification treatment for drug users. The methadone maintenance treatment and needle exchange programs have been adopted as harm reduction models in China. Most of the reviewed harm reduction programs have been successfully implemented and yielded positive effects in reducing drug related risk behaviors among drug users. Although there remain barriers to the effective implementation of policies on drug use and harm reduction programs, Chinese government has shown their commitment to support the expansion of harm reduction interventions for drug users throughout the country.     

Preparing racially and ethnically diverse communities for public health emergencies

The tragedy of Hurricane Katrina in New Orleans confirmed that effective implementation of public health preparedness programs and policies will require compliance from all racial and ethnic populations. This study reviews current resources and limitations and suggests future directions for integrating diverse communities into related strategies. It documents research and interventions, including promising models and practices that address preparedness for minorities. However, findings reveal a general lack of focus on diversity and suggest that future preparedness efforts need to fully integrate factors related to race, culture, and language into risk communication, public health training, measurement, coordination, and policy at all levels.     

Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.     

Key challenges to achieving health for all in an inequitable society: the case of South Africa

The health inequalities in South Africa are rapidly worsening. Since 1994, the new democratic government has initiated a number of large-scale policies and programs with explicit pro-equity objectives that have improved access to health care and other social resources. However, these policies and programs have been constrained by macroeconomic policies that dictate fiscal restraint and give priority to technical rather than developmental considerations.We propose an approach to improving health for all that focuses on equity in the allocation of health resources. The implementation of pro-equity policies requires, in addition to technically efficacious interventions, both advocacy initiatives and communication with, and the involvement of, affected communities. The Cape Town Equity Gauge project is presented as one example of a response to the challenge of inequity.     

Insurance + access not equal to health care: typology of barriers to health care access for low-income families

PURPOSE Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.     

The present role of the local health department in environmental toxicology.

Environmental health concerns are focusing sharply on health risks associated with exposure to toxic substances. The local health department role in responding to these concerns is becoming more crucial as well as more difficult. Commercial production of toxic chemicals is increasing rapidly. Individuals are being exposed to these substances in their residential communities as well as in their workplaces. Over two dozen major federal laws exercise some control over toxic substances, but much responsibility for implementation rests at the local level. Local health department responsibility is primarily in the areas of education, services, and regulation. Education must be provided for local government officials and for those who render and receive local environmental services. Services must include surveillance to identify environmental causes of disease, documentation of disease and dysfunctions possibly related to toxic substances, and coordination of environmental toxicology services with related community activities. Regulatory activities call for careful risk assessment and risk management, accomplished in cooperation with other government agencies, universities, and industry.