Poverty, Health and Sanitation – The Case for More Investment in Sanitation

1. Poverty, Health and Sanitation –The Case for More Investment in Sanitation Norman Hicks/Derko Kopitopoulos February 2006

2. Poverty, Health and Sanitation Millennium Development Goals– improved health is integral part of poverty reduction: • Reduce child mortality— • Target 5: Reduce by 2/3rds the child mortality rate (between 1990-2015) • Improve maternal health • Target 6: Reduce by 3/4ths the maternal mortality rate • Combat AIDS, malaria and other diseases • Targets 7 & 8: Halt and begin to reverse spread of AIDS, malaria and other diseases by 2015

3. MDG for Water and Sanitation • Halve, by 2015, the proportion of people without access to safe drinking water and sanitation (Target 10) • Indicator: proportion of population with access to improved water source and improved sanitation, urban and rural. • What is the connection between the health goals and the water/sanitation goals? • What is the objective of improving water and sanitation if not for health improvements?

4. Definitions • Sanitation: refers to the infrastructure and service provision required for the safe management of human excreta, for example latrines, sewers, and wastewater treatment. • Hygiene: refers to the set of behaviors related to safe management of excreta, such as washing hands with soap at appropriate times, the safe disposal of child feces, and so on. • Solid Waste Management: refers to the handling of non-liquid and non-excreta household and industrial waste. • Drainage: Refers to the removal of surface water from rain or flooding.

5. What is Improved Sanitation?

6. Quantifing Benefits of reaching MDGs in sanitation • Benefits quantified: • Health costs avoided • Patient health seeking costs avoided • Value of time saved (work, school) • Results show: • 80% of benefits come from time saved • Assumes value of time at minimum wage, including school children. • Nevertheless, the regional cost-benefit ratios (CBRs) are high (average 6.6; range 3.0 to 28.5) • Source: Evans, Hutton and Haller “Closing the Sanitation Gap” OECD March 2004.

8. Cost-Benefits and Economic Rates of Return • CBRs are equivalent to high internal rates of return • A Cost-benefit ratio of 6.6 is equivalent (roughly) to an internal rate of return of 50%--higher than most other projects • Source: CBRs: by G. Hutton in Evans, Hutton and Haller, “Closing the Sanitation Gap” OECD, March 2004, IRRs calculated by authors, assuming 14 yr. amortization, 3% real interest rate.

9. Benefits from sanitation go beyond health… Sanitation Education Infrastructure No visual, no adverse odor Natural resources preserved No fecal contamination Less ponding water Privacy - Security Gender sensitivity Religious, cultural Less grit Less erosion Less WS pollution Environment Operations Social Tourism Fisheries Reuse Less treatment Less maintenance Social Cohesion Collective action Less diarrhea (90%) Less aneamia, blindness Less dengue, malaria Girls at school Time availability Less medical costs Other community activities Health Economy Community

10. Diseases arising from poor sanitation Diarrhea: main indicator of various diseases • Excreted infections include • Non-bacterial fecal-oral: • Hepatitis, viruses, amoebiasis,… • Bacterial fecal-oral • E.Coli infection, Cholera, Typhoid, … • Helminths • Ascariasis, taenia, schistosomiasis,… • Source: WHO 1992

11. Sanitation and Diarrhea…the links • Diarrhea accounts for 1.8 million deaths per year; 90% are children (WHO). • 88% of diarrheal disease is attributed to unsafe water supply, inadequate sanitation and hygiene (WHO) • Improved sanitation brings about: • a 38% reduction in diarrheal diseases; and • a 32% reduction in diarrheal mortality, on average. • Hygiene interventions – including hygiene education and promotion of handwashing can lead to reduction of diarrheal cases by up to 45% . • Improvements in water quality through household water treatment can lead to a reduction in diarrhea of between 35 and 39%. • Sources: #1-2: WHO “Water, Sanitation and Hygiene Links to Health – FACTS AND FIGURES, March 2004; #3-5 based on research by Esrey and Fewtrell, as cited in Evans, et. al. “Securing Sanitation” SIWI, 2005, p. 7

12. Reducing Diarrhea a function of both sanitation and hygiene… • Improved Sanitation (safe disposal of feces) – blocks path between feces and food, flies, fields. • Improved water quality blocks link to drinking water IF water is properly handled—does not block other paths • Increased quantity of water improves hygiene via improved food preparation and personal hygiene • Increased handwashing (with soap) blocks link to food and direct contacts.

13. Water supply Hygiene Fluids Sanitation Fingers Future Victim Feces Food Flies Fields/Floors Fecal contamination is the main source of diarrhea infections ….

14. Health Improvement Framework Access to Hardware Water supply systems Improved sanitation facilities Household technologies ● Soap ● Safe water containers Hygiene Promotion Communication Social mobilization Community participation Social marketing Advocacy Diarrheal Disease Prevention Enabling Environment Policy improvement Institutional strengthening Community organization Financing and cost recovery Crosssector & PP partnerships

15. Alternative approaches to Sanitation • Source: SIWI, 2000

16. Responsibility share for < ---------------- > Individual Collective urban sanitation Household Blocks Community Authority Construction Construction Construction Promotion Latrines O&M O&M O&M Regulation Construction Construction Emptying Emptying Septic tanks Emptying Emptying Disposal Disposal Simplified Construction Construction Connections sewerage O&M O&M Small bore Septic tank Septic tank Construction Construction sewerage construction construction O&M O&M Conventional Construction Connections sewerage O&M Possible Allocation of Responsibilities Key: primary responsibility secondary responsibility

17. A Possible Strategy… • Focus on Promotion – Raise Awareness • Raising awareness at all levels: household, community and national leaders of sanitation’s importance • Improve household practices • Water treatment – boiling, chlorination, in the home for untreated water • Hand washing (with soap), personal hygiene, food handling

18. Strategy…. • Institutions and Strategy: • Develop a national sanitation plan outlining role of national and local govt., private sector, and households. • Focus on low cost improvements– latrines, septic tanks, small scale sewerage • Use the private sector– including households • Have subsidies for poor households • Include drainage (often a higher priority in low lying areas).

19. Strategy … • In dense urban areas, develop community/block based simple sewer systems with heavy community involvement (condominium approach) • Improve the regulatory framework – set appropriate standards • Organize/Coordinate stakeholders--Include government and non-government actors • Public sector --health, public works, environment, water/sanitation institutions, planning, finance • Private sector – NGOs, women’s groups, business groups, households • International – foreign donors, IFIs

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