Policies, institutions, and regulations: PIRs of a stormwater management system.

Urban services, like stormwater management, are complex tasks that depend on many actors and involve activities that fall within several fields of knowledge, but infrastructure solutions have been known for a long time. Recently, the view that urban water should be treated in an integrated way has become more pronounced, breaking the pathway dependency that treated it in isolation. Since the last decade, the perception that policies, institutions, and regulations (PIRs) condition good results has become more pronounced. The key question lies in incentives capable of mobilizing actors to produce aligned PIRs in a governance system. Better results can come from transformations in the incentives that currently exist for PIRs. The compatibility between incentives, which are not always identical for all involved, aligning them toward results, is the main objective. Based on these premises, aspects related to the necessary ideological change are analyzed here, that is, at the level of ideas and conceptions, which reflect the perception of objective, involving all actors, public and private, attracting them to solve the challenges posed, for example, the delivery of services according to sustainable development goals (SDGs). Examples of this in-progress transformation, a paradigm shift, are presented as support for reflection and experimentation.

Institutional paradigm shift: transitions in stormwater management principles.

In most cities, stormwater systems are part of the invisible and expensive urban infrastructure that plays a vital role in the urban environment but depends on weak institutional and organizational structures. Based on the evidence that solving the issues only from a technological point of view is not sufficient for the provision of stormwater services, in several countries, sustainable drainage systems (SuDS) structures are being implemented, but a new paradigm shift involving a new socio-institutional mentality that meets not only the old but also the new demands of climate and territorial changes, migratory issues, and participatory management is required.

Aedes Aegypti-Insights on the Impact of Water Services.

Epidemics in general and dengue in particular surcharge the health services and the economy. However, the fighting actions are circumscribed to the health sector despite the known positive economic impacts that the investments in water supply and sanitation services (WSS) may cause on society and public health. Besides the fact that urban WSS infrastructure is closely linked to disease prevention, in Brazil, the user's perception and demand are very few and many institutional aspects, like the integration between local WSS, health, environment, and development of city councils, need to be improved and better aligned. In this way, disease control and vector density reduction remain challenges to be overcome. This article addresses the need for greater institutionalization of urban WSS relating them to health aspects from official data. It concludes that the negative impacts of lacking universal access to WSS on dengue and other mosquito diseases are dispersed in all cities, regions, and populations regardless of their degree of development. Furthermore, contrary to what is normally emphasized, the analysis carried out shows that the lack of urban stormwater management systems may be an important component of WSS in preventing the proliferation of dengue disease.

A network Data Envelopment Analysis to estimate nations' efficiency in the fight against SARS-CoV-2.

The ongoing outbreak of SARS-CoV-2 has been deeply impacting health systems worldwide. In this context, it is pivotal to measure the efficiency of different nations' response to the pandemic, whose insights can be used by governments and health authorities worldwide to improve their national COVID-19 strategies. Hence, we propose a network Data Envelopment Analysis (DEA) to estimate the efficiencies of fifty-five countries in the current crisis, including the thirty-seven Organisation for Economic Co-operation and Development (OECD) member countries, six OECD prospective members, four OECD key partners, and eight other countries. The network DEA model is designed as a general series structure with five single-division stages - population, contagion, triage, hospitalisation, and intensive care unit admission -, and considers an output maximisation orientation, denoting a social perspective, and an input minimisation orientation, denoting a financial perspective. It includes inputs related to health costs, desirable and undesirable intermediate products related to the use of personal protective equipment and infected population, respectively, and desirable and undesirable outputs regarding COVID-19 recoveries and deaths, respectively. To the best of the authors' knowledge, this is the first study proposing a cross-country efficiency measurement using a network DEA within the context of the COVID-19 crisis. The study concludes that Estonia, Iceland, Latvia, Luxembourg, the Netherlands, and New Zealand are the countries exhibiting higher mean system efficiencies. Their national COVID-19 strategies should be studied, adapted, and used by countries exhibiting worse performances. In addition, the observation of countries with large populations presenting worse mean efficiency scores is statistically significant.

Sustainable water and sanitation for all: Are we there yet?

The lack of access to water and sanitation services (WSS) of a considerable share of the world population has been challenging the international community for decades. The proposal of the Millennium Development Goals and, later on, the Sustainable Development Goals (SDGs) by the United Nations (UN) intended to act as a blueprint to achieve a more equitable future for all and, in the case of WSS, "Ensure the availability and sustainable management of water and sanitation for all" (SDG 6). However, the current global pandemic further emphasised the importance of WSS, given the increasing asymmetries faced by billions worldwide, and the gaps between high-income and low- and middle-income nations. For this reason, understanding whether low- and middle-income countries have been approximating towards or deviating from the SDG 6 is crucial to derive and communicate key information for the sake of improved public governance and political decision-making. In this paper, we extend a state-of-the-art methodology based on data envelopment analysis for assessing the convergence of the low- and middle-income UN Member States regarding the SDG 6 between 2016 and 2017. We find that, on average, not only did the Member States converge by decreasing the performance spread and the gap between the best and worst practice frontiers, but also the Level of water stress: freshwater withdrawal as a proportion of available freshwater resources was the indicator in which the majority exhibited the worst performances. In the end, we derive possible policy implications, which, as our results show, are aligned with the recent UN reports on the subject.

An Incentive-Based Framework for Analyzing the Alignment of Institutional Interventions in the Public Primary Healthcare Sector: The Portuguese Case.

Over the years, the Portuguese National Health Service has undergone several reforms to face the challenges posed by internal and external factors on the access to and quality of its health services. One of its most recent reforms addressed the primary healthcare sector, where understanding the incentives behind the actors of the inherent institutional interventions and how they are aligned with the governing health policies is paramount for reformative success. With the purpose of acknowledging the alignment of the primary healthcare sector's institutional interventions from an incentive-based perspective, we propose a framework resting on a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, which was built in cooperation with a panel of decision-making actors from the Portuguese Ministry of Health. In the end, we derive possible policy implications and strategies. This holistic approach highlighted the positive impact of the primary healthcare reform in the upgrade of physical resources and human capital but stressed the geosocial asymmetries and the lack of intra- and inter-sectorial coordination. The proposed framework serves also as a guideline for future primary healthcare reforms, both national- and internationally.

Investment in drinking water and sanitation infrastructure and its impact on waterborne diseases dissemination: The Brazilian case.

Investment in sanitation and drinking water infrastructure is essential for universal access to these services in developing countries. Universal coverage of water and sanitation services (WSS) can prevent the dissemination of waterborne diseases and mitigate their adverse effects. These diseases are responsible for many deaths worldwide, especially among the disadvantaged population and children. A causal effect can be established between WSS investment and hospital admissions due to waterborne diseases. Therefore, we considered an innovative network-DEA approach that models the link between serially connected subsystems (upstream investment and downstream hospitalizations). This approach allowed us: to measure the efficiency of both subsystems; estimate the amount of (efficient) investment necessary to universalize the access to proper WSS infrastructure; and mitigate hospital admissions due to waterborne diseases. We used the Brazil case study to test our model. On average, Brazilian states could increase the number of people not requiring hospitalizations due to waterborne diseases by 157 thousand per R$100 million invested in sanitation and 26 thousand per R$100 million invested in drinking water. Our results suggest that relatively small (efficient) investment in those two infrastructure types has a massive impact on hospitalizations. This impact would be more significant than the investment in WSS coverage. Therefore, if safely managed, WSS would cover all citizens, and Brazil would come closer to developed countries.

Waste services' performance assessment: The case of Tuscany, Italy.

This paper assesses the performance of waste services in the region of Tuscany in Italy. It adopts non-parametric techniques for this purpose. Furthermore, it investigates the influence of the operational environment on the estimated performance by using the robust order-m technique. Meaningful levels of inefficiency were found in the Italian waste services. A specification of the ownership of the operator entrusted with waste management by municipalities and the formal adoption of the zero-waste strategy are included as environmental variables. The study concludes that the influence of the operational environment is a determinant of performance. The income per capita is negatively associated with efficiency, while population density is positively associated. Furthermore, efficiency levels are lower for municipalities with higher mixed waste per capita produced. Improving good pro-environmental behaviours is likely to improve efficiency and, thus, tariffs. The empirical results support the idea that it is necessary to make relevant organizational decisions that imply higher costs to increase the refuse collection rate. An increase in the separate collection rate beyond 50% is associated with the reduction of the efficiency level reached. Efficiency analysis does not consider the additional costs and the opportunities for municipalities to get revenues by selling them as secondary raw materials. Besides, the adoption of a zero-waste strategy is related to higher efficiency in MSW service provision. Finally, results about the ownership issue support the idea that privatization is not necessarily associated with the performance improvement of the waste services.

Transnational resource generativity: Efficiency analysis and target setting of water, energy, land, and food nexus for OECD countries.

Depletion of natural resources needs quantification and efficiency analysis of the use of resources to improve sustainability. This paper evaluates the efficiency of Organization for Economic Co-Operation and Development (OECD) countries in terms of Water-Energy-Land-Food (WELF-Nexus) to ensure sustainability and environmental viability for both present and future generations. An input-output index system is built at a transnational level. Composite and intrinsic indicators are introduced to incorporate the interconnections and tradeoffs between sectors of the nexus and outcomes of the nexus. The nonparametric benchmarking order-α model, resulting from Data Envelopment Analysis (DEA) is used to estimate WELF-Nexus efficiency of each country, and to alleviate the intricacies of using composite and intrinsic indicators. To ensure resource generativity, an output target setting model that accommodates predefined input is proposed. Results show variation in performance among OECD members, with an annual average efficiency score of 68%, 69% and 78% in 2007, 2012, and 2016. Sensitivity analysis was performed to measure the effect of drought on WELF efficiency, a decrease of about 13% on average WELF efficiency was observed. Outputs improvement was recommended for each country: Lithuania (14%), Mexico (10%) and 11% for Hungary, Latvia, and Turkey due to their high inefficiency. The study provides a robust framework for policy making and shows that a win-win strategy for the nexus must be implemented to achieve WELF-Nexus efficiency, given the trade-offs within its sectors. Furthermore, it highlights that innovative-driven policies will enhance WELF-Nexus efficiency and sustainability.

An analytical review of the efficiency of water and sanitation utilities in developing countries.

Due to the importance of analyzing the efficiency of water utilities and the large number of publications in this area, at least five reviews have already been carried out to identify patterns and trends. These reviews aimed to cover worldwide studies, and the results may not correspond to the reality in developing countries. Therefore, this review provides a literature update on the quantitative studies of water and sanitation services, focusing on studies carried out in developing countries. This overview mainly examines the economies of scale and scope, public versus private ownership, and the impact of regulation. As expected, our results show patterns that differ from those found in worldwide reviews (e.g., the influence of regulatory incentives on operator efficiency and economies of scope). In addition, this paper presents patterns regarding the quantitative methods adopted, as well as some trends and areas for possible future research.

The impact of household connection to public network wastewater systems: regulatory impact assessment.

Brazil faces a severe lack of wastewater coverage. Even in urban areas, wastewater is directly disposed of in watercourses without any treatment for a large part of the population. Although the federal, state, and local governments have invested in water and wastewater services (WWS), the expected results have not been achieved. To overcome this problem, the present paper provides an opportunity to observe an ex-ante regulatory impact assessment (RIA) as a policy tool in Brazil. The regulatory policy options will be appraised through the multiple criteria decision analysis (MCDA) according to the following objectives: (i) protect the customers with respect to social aspects; (ii) safeguard the economic, operational and infrastructure sustainability; and (iii) protect the environment. The results show that by making decisions based on evidence, policy makers should reduce the households not connected to wastewater services by 75% and for that they should incur BRL 33 million to the year 2023. Hence, the extra revenues to be obtained with these new connections are capable of making a surplus estimated as BRL 42 million for the same period. This study promotes the use of RIA as a rational, robust and transparent decision framework by the regulatory agencies worldwide.

Doctors, nurses, and the optimal scale size in the Portuguese public hospitals.

This study analyses the scale efficiency, optimal scale for hospital clinical staff, and the exogenous dimensions that can be associated with them. They offer useful insights for health policy design, particularly when human resources need to be reallocated across the country due to uneven distributions. Initial data considered a sample of 27 Portuguese general/acute-care public hospitals belonging to the National Health Service, observed between 2013 and 2016. This resulted into a sample of 108 hospitals-year. Data Envelopment Analysis was employed to assess scale efficiency and optimal scale associated with the workforce and at the overall hospital level. Quality and access to health care services adjusted the measures of scale efficiency and optimal size. A multiple regression analysis was carried out to associate optimal scale and scale efficiency to demographics. Optimal scale centred on 274 full-time equivalent (FTE) doctors and 475 FTE nurses. Overall, there is an excess of FTE doctors and FTE nurses, even after potential reallocations. There is an uneven distribution of health workforce, with excess of staff located in urban areas. Hospitals productivity would increase if they reduced their operational scale. Drivers of potential change include population size, childhood mortality rate, birth rate, and purchasing power parity. Health policies are required, not to hire more staff, but rather to promote the reallocation of employees to deprived regions.

Identifying congestion levels, sources and determinants on intensive care units: the Portuguese case.

Healthcare systems are facing a resources scarcity so they must be efficiently managed. On the other hand, it is commonly accepted that the higher the consumed resources, the higher the hospital production, although this is not true in practice. Congestion on inputs is an economic concept dealing with such situation and it is defined as the decreasing of outputs due to some resources overuse. This scenario gets worse when inpatients' high severity requires a strict and effective resources management, as happens in Intensive Care Units (ICU). The present paper employs a set of nonparametric models to evaluate congestion levels, sources and determinants in Portuguese Intensive Care Units. Nonparametric models based on Data Envelopment Analysis are employed to assess both radial and non-radial (in)efficiency levels and sources. The environment adjustment models and bootstrapping are used to correct possible bias, to remove the deterministic nature of nonparametric models and to get a statistical background on results. Considerable inefficiency and congestion levels were identified, as well as the congestion determinants, including the ICU specialty and complexity, the hospital differentiation degree and population demography. Both the costs associated with staff and the length of stay are the main sources of (weak) congestion in ICUs. ICUs management shall make some efforts towards resource allocation to prevent the congestion effect. Those efforts shall, in general, be focused on costs with staff and hospital days, although these congestion sources may vary across hospitals and ICU services, once several congestion determinants were identified.

Tariff regulation in the waste sector: An unavoidable future.

Waste management and other services of general economic interest are normally out of market. Therefore, regulation may be required to provide sustainable services with the desired quality of service at affordable and fair prices. Some countries have created regulatory authorities to supervise service levels and tariffs. However, the implementation of such entities is still a novelty being relevant to open the discussion about the explicit regulation of the waste sector. This study addresses the waste sector in Portugal and the regulator's role in setting prices and providing proper incentives to ensure efficiency and added value. In this context, regulation was proposed to implement a tariff setting mechanism based on a productivity-related X factor linked to revenue caps. This innovative application (in the waste sector) calculates the X factor through a catch-up factor (static efficiency determined by Data Envelopment Analysis) and a production technology change or frontier shift (dynamic efficiency calculated by a Törnqvist index). Besides targeting the financial sustainability of waste utilities, there is also a focus to achieve reasonable environmental and quality of service standards. This study argues that economic regulation is required for this sector since it can be prone to the quiet life and inefficiency due to market failures and lack of incentives. Thus, a tariff setting system may be important and, perhaps, unavoidable to prevent these misbehaviors. The results highlight several predicaments and opportunities related to the application of this innovative performance-based approach.

The involvement of community leaders in healthcare, the environment and sanitation in áreas of social vulnerability.

The main purpose of this article is to identify access to: social assistance inclusion programs; assistance from health agents; public water supply services; and water saving practices, in areas of irregular occupation in Brazil. A stratified random sampling technique by clusters was adopted with a simple sampling strategy. In the universe of 14,079 households, 68 community leaders were identified, representing 6,800 households on average, in a normalized distribution (mean zero, standard deviation 1), deemed to include situations covering 96% of the cases with a margin of error of + or - 1% of the average. The theoretical approach proposes a reflection and verification through questionnaires on the mechanisms of exclusion. Poverty perpetuates the vicious circle of inequality, risks to health and the environment, and it is necessary that these should be considered in the policies and procedures for urban expansion. As a conclusion, various challenges were identified for serving areas of social-environmental vulnerability - the needs to: improve the low quality of health and water services in subnormal agglomerations; modify the behavior of the population accessing the networks in a clandestine manner; and to put inclusive governance mechanisms in place.

Lideranças comunitárias e o cuidado com a saúde, o meio ambiente e o saneamento nas áreas de vulnerabilidade social / The involvement of community leaders in healthcare, the environment and sanitation in áreas of social vulnerability

Resumo O objetivo principal do artigo é identificar o acesso a: programas de inclusão da assistência social, assistência dos agentes de saúde, serviços públicos de abastecimento de água e práticas economizadoras de água, em áreas de ocupação irregular. Adotou-se técnica de amostra aleatória estratificada por conglomerados com estratégia de amostragem simples. No universo de 14.079 domicílios, foram entrevistados 68 líderes, representando 6.800 domicílios em média, numa distribuição normalizada (média 0 e desvio padrão 1) foram englobados as situações que cobrem 96% dos casos com uma margem de erro de + ou – 1% da média. A abordagem teórica propõem uma reflexão e verificação por meio de questionários sobre os mecanismos de exclusão, sendo que a pobreza perpetua o círculo vicioso de desigualdade, riscos para a saúde e meio ambiente, sendo necessário que sejam considerados nas políticas e procedimentos por conta da expansão urbana. Como conclusão, identifica-se diversos desafios para o atendimento às áreas de vulnerabilidade socioambiental: melhorar a baixa qualidade de serviços de saúde e saneamento nos aglomerados subnormais; modificar o comportamento da população acessando as redes de forma clandestina; e implantar mecanismos de governança inclusiva.

Abstract The main purpose of this article is to identify access to: social assistance inclusion programs; assistance from health agents; public water supply services; and water saving practices, in areas of irregular occupation in Brazil. A stratified random sampling technique by clusters was adopted with a simple sampling strategy. In the universe of 14,079 households, 68 community leaders were identified, representing 6,800 households on average, in a normalized distribution (mean zero, standard deviation 1), deemed to include situations covering 96% of the cases with a margin of error of + or – 1% of the average. The theoretical approach proposes a reflection and verification through questionnaires on the mechanisms of exclusion. Poverty perpetuates the vicious circle of inequality, risks to health and the environment, and it is necessary that these should be considered in the policies and procedures for urban expansion. As a conclusion, various challenges were identified for serving areas of social-environmental vulnerability – the needs to: improve the low quality of health and water services in subnormal agglomerations; modify the behavior of the population accessing the networks in a clandestine manner; and to put inclusive governance mechanisms in place.

Estimating size and scope economies in the Portuguese water sector using the Bayesian stochastic frontier analysis.

This study aims to search for economies of size and scope in the Portuguese water sector applying Bayesian and classical statistics to make inference in stochastic frontier analysis (SFA). This study proves the usefulness and advantages of the application of Bayesian statistics for making inference in SFA over traditional SFA which just uses classical statistics. The resulting Bayesian methods allow overcoming some problems that arise in the application of the traditional SFA, such as the bias in small samples and skewness of residuals. In the present case study of the water sector in Portugal, these Bayesian methods provide more plausible and acceptable results. Based on the results obtained we found that there are important economies of output density, economies of size, economies of vertical integration and economies of scope in the Portuguese water sector, pointing out to the huge advantages in undertaking mergers by joining the retail and wholesale components and by joining the drinking water and wastewater services.

Should inpatients be adjusted by their complexity and severity for efficiency assessment? Evidence from Portugal.

Hospital efficiency analysis depends largely on the model specifications. This study discusses the importance of the case-mix index (CMI) to homogenize the sample of inpatient discharges. It proposes a new index where they are classified by service, since it is usual to have lack of data to compute the CMI and this can influence the credibility of results. Data from the Portuguese national diagnosis-related group (DRG) database was utilized. Three different approaches are developed in this paper, based on locally convex order-m method as well as on translog functions. The first one correlates the efficiency with different inpatients weighting schemes, by using the Nadaraya-Watson method. The second approach compares different frontiers that have been computed using the different weighting schemes. Finally, by using bootstrap, the paper investigates whether the inclusion of severity/ complexity-related variables in the model statistically modifies the results. It has been shown that, under the Portuguese healthcare framework, if the model is environment corrected (which should include epidemiological and main political/ structural health reforms variables), then the severity adjustment of inpatients is pointless. The employment of an inpatient-weighting scheme, such as the CMI, may introduce significant frontier shift, thus its absence is not recommended in productivity evolution analyzes. The CMI shifts the efficiency frontier, but not the relative position of units against it (the last scenario if exogenous variables are present).

Is bigger better? An empirical analysis of waste management in New South Wales.

Across the world, rising demand for municipal solid waste services has seen an ongoing increase in the costs of providing these services. Moreover, municipal waste services have typically been provided through natural or legal monopolies, where few incentives exist to reduce costs. It is thus vital to examine empirically the cost structure of these services in order to develop effective public policies which can make these services more cost efficient. Accordingly, this paper considers economies of size and economies of output density in the municipal waste collection sector in the New South Wales (NSW) local government system in an effort to identify the optimal size of utilities from the perspective of cost efficiency. Our results show that - as presently constituted - NSW municipal waste services are not efficient in terms of costs, thereby demonstrating that 'bigger is not better.' The optimal size of waste utilities is estimated to fall in the range 12,000-20,000 inhabitants. However, significant economies of output density for unsorted (residual) municipal waste collection and recycling waste collection were found, which means it is advantageous to increase the amount of waste collected, but maintaining constant the number of customers and the intervention area.

Did the corporatization of Portuguese hospitals significantly change their productivity?

This paper aims to investigate if the market structure reforms in the Portuguese health system have improved hospital performance and productivity. A robust non-parametric Malmquist index is applied to measure group performance. The significance of the results achieved is examined using a conditional and non-conditional subsampling bootstrapped-based methodology, enhanced by the likelihood cross validation criterion based on the k-nearest neighbors method. The sample contains information about 216 non-corporatized and 176 corporatized Portuguese hospitals for the period 2002­2009. Five models were applied, based on three study dimensions (internment, emergencies and doctor visits). The results show that although corporatized hospitals presented the highest efficiency consistency, they had also the lowest levels of productivity, while the hospitals under the traditional administrative public management system were the ones with the best average performance. However, several best practices were also found in all groups, being the limited companies were often dominated by both noncorporatized and public enterprise entities. Consistent output ranges where all groups present dominance over the others were also identified. It was possible to conclude that the more autonomy the hospital had from the Ministry of Health, the lower was its productivity.