Roles and institutional arrangements for economic regulation of urban water services in sub-Saharan Africa

This research focused on determining the roles and institutional arrangements for economic regulation of urban water services in Sub- Saharan Africa. Urban water service delivery mainly supplied by state owned utilities is constrained due to many factors one of which is related to insufficient or lack of a clear economic regulatory framework. The research used a multiple case study approach and systematically analysed the roles and institutional arrangements of economic regulation of urban water services in three countries of Ghana, Mozambique and Zambia. Based on literature as the source of information, the research developed the existing political and socio-economic environment in the different countries which can affect the design and determination of the roles and institutional arrangements for economic regulation. A further analysis was made of the perceptions on the roles and institutional arrangements of the regulatory framework in the Sub-Saharan African context through a questionnaire distributed beyond the three case countries. The study obtained primary data from focus group discussions, key informant interviews, official documents and observations. Lessons obtained through literature from regulatory institutions in other continents have also been included and these are Jamaica, Latvia, Jakarta in Indonesia, and England and Wales. The factors which can affect the roles and institutional arrangements of economic regulation of urban water services were divided into three groups as: including country governance, socioeconomic and sectoral factors. Country governance factors, which include political stability and fragility, are a key factor in the decision of whether to establish a regulatory agency. On the other hand, socio-economic factors influence the focus or areas which must not be ignored by economic regulation. The third type of factors which include the robustness of a policy framework, and performance levels of utilities, affect the effectiveness and efficiency of an economic regulator. Based on the evidence from the research, economic regulation in Sub-Saharan Africa should address five key roles, which are [i] approval of tariffs that will lead to service providers achieving commercial viability, [ii] "consumer protection" [iii] monitoring and enforcing performance standards, [iv] setting up of a knowledge bank on urban water services, and [v] ensuring that the poor gain sustained access to water services. There are a number of specific regulatory functions within each role. Sub-Saharan African countries are in a unique situation where the urban poor comprise as much as 60% of the urban population and so cannot be ignored in the design of a regulatory framework. The conclusion from this research is that in order to achieve the perceived benefits of economic regulation of urban water services in Sub-Saharan Africa, and subject to conducive and appropriate political and socio-economic environment, the more appropriate institutional arrangements is an autonomous regulatory agency. The autonomy of the regulatory agency will be enhanced if it has its own legal status, and is able to develop, manage and control its own budget financed from a regulatory fee charged on the regulated water providers. Governments should be willing to relinquish regulatory decision making powers to this non-political and non-governmental body. The reporting and appointing mechanisms for the board could also have an influence on the autonomy of the regulator. The research further concludes that economic regulation of urban water services is a necessary but perhaps not sufficient condition for efficient and effective delivery of urban water services. It is not a panacea to the enormous problems of urban water services but can play a very effective role. The research has further found that it is too early to determine the impact of utility regulation on the performance levels of utilities in those countries that have a clearly defined regulatory framework. Utility regulation is still in its infancy in Sub-Saharan Africa and its impact is therefore a subject for further research

Water and sanitation services to the urban poor

Africa has the lowest water supply and sanitation coverage of any region in the world. More than 1 in 3 Africans have no access to improved water supply or to sanitation facilities. Coverage levels in 2000 for both water supply (62%) and sanitation (60%) are about the same. The sad reality is that the total number of people without these services is increasing; unless we act now, the absolute number will double by 2020 from 200 million to 400 million1. The majority of these people will be those living in informal or peri-urban areas and rural communities

Impact of Dual Gauge Railway Tracks on Traffic Load Induced Permanent Deformation of Low Embankments

AbstractThere is a growing interest in recent years of many African countries to revamp their neglected railways in order to promote regional trade and transportation integration. Investors are faced with problems of railway track gauge conversions to promote railway inter operability. The objective of the work documented here was to numerically evaluate the impact of track gauge conversions on traffic load induced permanent deformation (PD) of low embankment on soft sub-grade. A method to predict the traffic load induced settlement of low embankment on soft sub-grade is proposed. Using the user-defined material subroutines (UMAT) in ABAQUS, a 2-D finite element (FE) model was formulated. These models are converted into a numerical formulation for implementation in FE analysis and the traffic load induced dynamic stress in the sub grade are calculated by using the multi-layer elastic theory. Then the plastic vertical strain in the sub-grade is calculated by an empirical equation, whose constants are related to the physical and mechanical properties of the sub-grade soil. The method was applied to analyze a 700m long section of a low embankment on the soft black cotton soil of Nakuru plains in Kenya. Corresponding results showed that the application of traffic loads on alternate rail tracks due to gauge conversions have a significant effect on the permanent deformation of the sub grade soil. The depth significantly influenced by traffic loading was found to be close to 6 m below the base of the embankment. The analysis also shows that increasing the thickness and stiffness of the sub grade is a very effective way of reducing the traffic load induced permanent deformation of soft sub grade soil. The proposed method can be used for settlement analysis on low embankments as well as a useful tool for making decisions on railway track gauge conversions

Design Method and Cost-Benefit Analysis of Hybrid Fiber Used in Asphalt Concrete

Fiber, as an additive, can improve the performance of asphalt concrete and be widely studied, but only a few works have been done for hybrid fiber. This paper presents a new and convenient method to design hybrid fiber and verifies hybrid fiber’s superiority in asphalt pavement engineering. Firstly, this paper expounds the design method used as its applied example with the hybrid fiber composed of lignin, polyester, and polypropylene fibers. In this method, a direct shear device (DSD) is used to measure the shear damage energy density (SDED) of hybrid fiber modified asphalts, and range and variance statistical analysis are applied to determine the composition proportion of hybrid fiber. Then, the engineering property of hybrid fiber reinforced asphalt concrete (AC-13) is investigated. Finally, a cost-benefit model is developed to analyze the advantage of hybrid fiber compared to single fibers. The results show that the design method employed in this paper can offer a beneficial reference. A combination of 1.8% of lignin fiber and 2.4% of polyester fiber plus 3.0% polypropylene fiber presented the best reinforcement of the hybrid fiber. The cost-benefit model verifies that the hybrid fiber can bring about comprehensive pavement performance and good economy

Key issues in the persistence of poliomyelitis in Nigeria: a case-control study

Background The completion of poliomyelitis eradication is a global emergency for public health. In 2012, more than 50% of the world’s cases occurred in Nigeria following an unanticipated surge in incidence. We aimed to quantitatively analyse the key factors sustaining transmission of poliomyelitis in Nigeria and to calculate clinical effi cacy estimates for the oral poliovirus vaccines (OPV) currently in use. Methods We used acute fl accid paralysis (AFP) surveillance data from Nigeria collected between January, 2001, and December, 2012, to estimate the clinical effi cacies of all four OPVs in use and combined this with vaccination coverage to estimate the eff ect of the introduction of monovalent and bivalent OPV on vaccine-induced serotype-specifi c population immunity. Vaccine effi cacy was determined using a case-control study with CIs based on bootstrap resampling. Vaccine effi cacy was also estimated separately for north and south Nigeria, by age of the children, and by year. Detailed 60-day follow-up data were collected from children with confi rmed poliomyelitis and were used to assess correlates of vaccine status. We also quantitatively assessed the epidemiology of poliomyelitis and programme performance and considered the reasons for the high vaccine refusal rate along with risk factors for a given local government area reporting a case. Findings Against serotype 1, both monovalent OPV (median 32·1%, 95% CI 26·1–38·1) and bivalent OPV (29·5%, 20·1–38·4) had higher clinical effi cacy than trivalent OPV (19·4%, 16·1–22·8). Corresponding data for serotype 3 were 43·2% (23·1–61·1) and 23·8% (5·3–44·9) compared with 18·0% (14·1–22·1). Combined with increases in coverage, this factor has boosted population immunity in children younger than age 36 months to a record high (64–69% against serotypes 1 and 3). Vaccine effi cacy in northern states was estimated to be signifi cantly lower than in southern states (p≤0·05). The proportion of cases refusing vaccination decreased from 37–72% in 2008 to 21–51% in 2012 for routine and supplementary immunisation, and most caregivers cited ignorance of either vaccine importance or availability as the main reason for missing routine vaccinations (32·1% and 29·6% of cases, respectively). Multiple regression analyses highlighted associations between the age of the mother, availability of OPV at health facilities, and the primary source of health information and the probability of receiving OPV (all p<0·05). Interpretation Although high refusal rates, low OPV campaign awareness, and heterogeneous population immunity continued to support poliomyelitis transmission in Nigeria at the end of 2012, overall population immunity had improved due to new OPV formulations and improvements in programme delivery.Funding Bill & Melinda Gates Foundation Vaccine Modeling Initiative, Royal Society.Introduction In May, 2012, after more than 20 years of mass vaccination campaigns, the 65t

Comparison of vertical cup-to-disc ratio estimates using stereoscopic and monoscopic cameras

Background: The use of monoscopic cameras for glaucoma screening is increasing due to their portability, lower cost, and non-mydriatic capabilities. However, it is important to compare the accuracy of such devices with stereoscopic cameras that are used clinically and are considered the gold standard in optic disc assessment. The aim of this study is to compare vertical cup-to-disc ratio (VCDR) estimates obtained using images taken with a monoscopic and stereoscopic camera. Methods: Participants were selected from the Tema Eye Survey. Eligible subjects had images of at least one eye taken with two cameras. They were classified as meeting the glaucoma threshold if an eye had a VCDR estimate >97.5th percentile, corresponding to >0.725 for this population. Hence, we used 0.725 as the cutoff to group eyes into two categories: positive and negative. We calculated sensitivity, specificity, and predictive values of VCDR assessed by expert readers at a reading center for monoscopic photos using stereoscopic photos as the gold standard. Results: Three hundred and seventy-nine eyes of 206 participants were included in the study. Most participants were female (60.2%) and the most common age group was 50–59 years (36.4%). Sixteen eyes met the glaucoma threshold (VCDR > 0.725). Of these, the VCDR estimates of 14 eyes (87.5%) disagreed on the glaucoma threshold from the two cameras. The sensitivity to detect glaucoma with the monoscopic camera was 14.3% (95% CI: 4.0, 40.3). Conclusions: The low sensitivity of monoscopic photos suggests that stereoscopic photos are more useful in the diagnosis of glaucoma

Improving quality of medical certification of causes of death in health facilities in Tanzania 2014-2019

BACKGROUND: Monitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data. METHODS: We used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death. RESULTS: 9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%. CONCLUSION: Data from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses

Hypertension management in rural primary care facilities in Zambia: a mixed methods study

Abstract Background Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening, monitoring, treatment and control of high blood pressure. Methods Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content. Results From January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89.1% overall (range: 70.1–100%), but decreased to 62.1% (range: 0–100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were <10% and did not improve with time. In in-depth interviews, antihypertensive medication shortages were common, with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts. Principal challenges in hypertension management included 1) equipment and personnel shortages, 2) provider belief that multiple visits were needed before official management, 3) medication stock-outs, leading to improper prescriptions and 4) poor patient visit attendance. Conclusions Our findings suggest that numerous barriers stand in the way of hypertension diagnosis and management in Zambian primary health facilities. Future work should focus on performance indicator development and validation in low resource contexts, to facilitate regular and systematic data review to improve patient outcomes. Trial registration ClinicalTrials.gov, Identifier NCT01942278 . Date of Registration: September 2013

Retinal nerve fibre layer thickness floor and corresponding functional loss in glaucoma

To estimate the floor of retinal nerve fibre layer (RNFL) thickness measurements and the corresponding retinal sensitivity loss in glaucoma