Box 2.

Water and sanitation: an analytical lens to examine governance and health equity

Unequal access to water and sanitation has historically been a leading cause of urban health inequalities. Still today, household piped water and sewerage connections are the privilege of a minority in the urban centres of most low and many middle-income cities.38–40 For water, many residents make do with polluted groundwater, distant standpipes, or expensive water sold by local vendors at prices far higher than the official water tariff. For sanitation, open defecation remains common, particularly for children. An important aspect of the link between urban governance and water and sanitation provision lies in the collective nature of the challenge. In economic terms, water and sanitation improvement are quasi-public goods and create the sort of collective action problems conventionally used to justify government action. Indeed, the public health benefits of water and sanitation utilities were used to help justify the creation of public utilities. These utilities performed disappointingly over the course of the 20th century, especially in low-income settings. Governments that are responsive to the needs and health rights of their less well off citizens can overcome many of the barriers to improving their urban water and sanitation. A prerequisite for any government-implemented programme is a viable financial strategy. The same applies when the government is partnering with private suppliers to provide water and sanitation services. This is not just a question of competence, but very much of governance.41 , 42 Getting the financial and institutional aspect right requires constructive and efficient negotiations between government and civil society groups. Private-public partnerships add another governance dimension to this, as they also require negotiation across the public-private divide. In this case, community organization is likely to be critical, thereby involving another dimension of urban governance.