CAPACITY BUILDING IN METAP COUNTRIES FOR

THE COST OF ENVIRONMENTAL DEGRADATION

POLICY PAPER 2

SOCIO-ECONOMIC COST OF WATER POLLUTION

AT THE OUM-ER-RBIA BASIN, MOROCCO

Submitted to

The World Bank

Sponsored by

September 2008

i

ACKNOWLEDGEMENT This paper is based on the data and methodologies presented in the study conducted by IRAM

développement (Institut de Recherches et d’Applications des Méthodes de Développements) and

sponsored by the World Bank, on the sanitary and economic impact of pollution reduction in ground

and surface water resources in the Oum Er Rbia basin in Morocco, in June 2007. The study and

associated data were made available by the World Bank.

Special thanks are extended to Dr. Dahlia Lotayef, Senior Environmental Specialist at the World Bank

and METAP Coordinator for the Middle East and North Africa Region, and Ms. Saliha Dobardzic,

METAP Operations Officer at The World Bank, as well as Mr. Fadi Doumani, Consultant at the World

Bank for their support and assistance during the implementation of this project.

ii

CONTENTS

ACKNOWLEDGEMENT ..................................................................................................................i

CONTENTS ..................................................................................................................................ii

TABLES ....................................................................................................................................... iii

FIGURES ..................................................................................................................................... iii

ACRONYMS ................................................................................................................................ iii

EXECUTIVE SUMMARY ............................................................................................................... iv

1 BACKGROUND......................................................................................................................... 1

2 STUDY AREA CHARACTERIZATION ........................................................................................... 3

3 METHODOLOGY ...................................................................................................................... 7

4 RESULTS .................................................................................................................................. 8

4.1 Damage Assessment.......................................................................................................... 8

4.2 Premature Mortality.........................................................................................................10

4.2.1 Human Capital Approach ......................................................................................11

4.2.2 Willingness to pay approach .................................................................................11

4.3 Morbidity .........................................................................................................................11

4.3.1 Cost of illness approach ........................................................................................11

4.3.2 Cost of pain and suffering (DALY) ..........................................................................15

4.4 Benefits ............................................................................................................................15

5 PRIORITIZATION OF INVESTMENT OPTIONS ...........................................................................15

6 CONCLUSION AND LIMITATIONS ............................................................................................17

BIBLIOGRAPHY ..........................................................................................................................17 ANNEX A- Location of Planned Sanitation Investments in the Oum Er Rbia Basin ......................19

iii

TABLES Table

1. Reduction in diarrheal disease morbidity by type of intervention based on meta-analysis

(Fewtrell et al., 2005) .....................................................................................................................2

2. Levels of Fecal Coliform (CFU/100 ml) in the Oum Er Rbia River water measured during 1999

and 2002 (adapted from IRAM développement, 2007) ..................................................................5

3. Pollutant levels in water samples from selected wells in 2004.......................................................6

4. Economic data .................................................................................................................................8

5. Incidence of water-related diseases in 2005 in the provinces of Settat, Safi, Al Jadida,

Khounifra, and Khourbiga ................................................................................................................8

6. Incidence of water-related diseases in 2005 in the Beni Mellal Province in the Oum Er Rbia basin ..........................................................................................................................9

7. Main inputs for the COI estimation by province ...........................................................................10

8. Calculation of DALYs due to child mortality in the Oum Er Rbia basin..........................................11

9. Cost of outpatient treatment and hospitalization in the provinces of Settat, Safi, Al Jadida,

Khounifra, and Khourbiga ..............................................................................................................12

10. Cost of Illness for non-hospitalized cases in 2005 in USD .............................................................13

11. Cost of hospitalization due to water-related diseases in the Beni-Mellal Province in USD ..........14

12. Cost of lost work days due to water-related diseases in the Oum Er Rbia Basin..........................14

13 Summary of estimated damage cost from morbidity associated with inadequate water and

wastewater management..............................................................................................................15

FIGURES

Figure

1. Population density distribution in the Oum Er Rbia basin (IRAM développement, 2007)..............4

2. Prioritization of investments based on reduction in the burden of disease .................................16

3. Prioritization of investments based on reduction in socio-economic costs..................................16

ACRONYMS

DALY = Disability Adjusted Life Years

GDP = Gross Domestic Product

HCA = Human Capital Approach

IRAM = Institut de Recherches et d’Applications des Méthodes de Développements

USD = United States Dollars

USEPA = United States Environmental Protection Agency WHO = World Health Organization

WTP = Willingness To Pay

iv

EXECUTIVE SUMMARY Domestic water supplies and environmental sanitation contribute to livelihoods in a wide range of

ways. They have important roles in promoting food security, health and household maintenance,

and water-based livelihoods. Poor water quality coupled with inadequate water and sanitation

services and hygiene practices has long been associated with higher water-borne diseases resulting

in a serious cost to society in the form of cost of illness and forgone earnings directly related to

increased morbidity and premature mortality, as well as cost of protective measures. In the Oum Er

Rbia basin, the uncontrolled discharge of untreated domestic and industrial wastewater along the

river and its tributaries, as well as agricultural runoff has caused significant degradation of surface

and ground water quality in the area. This has been associated with adverse health impacts on the

population in the basin, which manifested itself in terms of high incidence of waterborne diseases and infant mortality due to diarrheal diseases. Accordingly, this report assesses the socio-economic

costs of water pollution in the Oum Er Rbia river basin, based to a great extent on the outcome of

the study conducted in 2007 by IRAM développement and sponsored by the World Bank.

Methodology

As a first step, data collected from seven provinces by IRAM développement via field surveys and

secondary sources were analyzed. The surveys were conducted to estimate the number of water-

related morbidity cases, namely diarrhea, acute gastroenteritis, typhoid hepatitis, and dysentery,

recorded at medical facilities within the study area for one complete year (2005) as well as the

associated treatment costs. Mortality cases were not available so they were estimated indirectly. This was followed by the application of 1) the human capital and the willingness to pay approaches

for mortality valuation and 2) the cost of illness, pain and suffering approach for morbidity valuation.

The choice of valuation methods adopted was largely based on the availability of data concerning

each impact.

Findings

The surveys revealed a total of 44,106 cases of water-related diseases in the Oum Er Rbia Basin,

recorded during 2005, with 98 percent of the cases being diarrhea and acute gastroenteritis. Tables I

and II present the distribution of recorded cases in the provinces within the Oum Er Rbia basin by

type of case. The surveys also revealed the average duration of each illness under study, the average

duration of hospitalization, and the cost of hospitalization and outpatient treatment per province, as

detailed in Table III.

Table I. Incidence of water-related diseases in 2005 in the provinces of

Settat, Safi, Al Jadida, Khounifra, and Khourbiga

Diarrhea and acute

gastroenteritis

Amoebic

dysentery

Typhoid Viral Hepatitis Provinces Population

n Per

100,000

n Per

100,000

n Per

100,000

n Per

100,000

Settat 336,635 5,687 1689.4 8 2.38 1 0.30 1 0.30

Safi 890,752a - 0.0 - - 26 19

El Jadida 1,129,776 19,513 1727.2 79 6.99 3 0.27 0 0.00

Khénifra 413,708 3,189 770.8 - 0.00 206 49.79 13 3.14

Khouribga 493,000 1,016 206.1 - 0.00 64 12.98 3 0.61

Total 3,263,871 29,405 87 300 36 a

Adapted from Wikipedia for 2004 and projected using the population growth rate of 1.1 % reported by the

WHO Statistical Information System (WHOSIS)

v

Table II. Incidence of water-related diseases in 2005 in the

Beni Mellal Province in the Oum Er Rbia basin

Disease Number of cases Incidence per

100,000

Typhoid 87 9.2

Viral Hepatitis 61 6.4

Acute gastroenteritis 3,174 335.5

Diarrhea (< 5yrs)-

Mild dehydration

5,984

632.6

Diarrhea (< 5yrs)-

Moderate dehydration

105

11.1

Diarrhea (> 5yrs) 4,812 508.6

Dysentery 38 4.0

Persistent Diarrhea 17 1.8

Total 14,278 1509.3

vi

Table III. Main inputs for the COI estimation by province

Diseases Province Average

duration of

illness

Average

duration of

hospitalizatio

n

Daily cost of

hospitalization

Average cost

of outpatient

treatment

Diarrhea and acute gastroenteritis

Settat 5 4 25.5 22.6

Safi 0.0

El Jadida 5 4 25.5 22.6

Khénifra 5 4 25.5 22.6

Khouribga 12 7 10.4 16.9

Diarrhea (> 5yrs) 5 3 25.5 (158.2 a) 30.7

Gastroenteritis

Beni Mellal

5 4 25.5 (95.0 a

) 29.3

Settat 5 3 25 22.6

Safi 0.0

El Jadida 5 3 25 22.6

Khénifra 0.0

Amoebic dysentery

Khouribga 0.0

Settat 5 4 25.5 22.6

Safi 15 12 35.9 1.6

El Jadida 15 12 35.9 1.6

Khénifra 15 12 35.9 1.6

Khouribga 10 7 10.4 7.9

Typhoid

Beni Mellal 21 12 35.9 (424.2 a) 87.3

Settat 30 8 25.9 22.6

Safi 30 5 25.9 1.1

El Jadida 30 5 25.9 1.1

Khénifra 30 5 25.9 1.1

Khouribga 15 5 25.9 1.1

Beni Mellal 15 5 25.9 (332.8 a) 12.4

Viral Hepatitis

- - - 14.7

- - - 18.0

- - - 175.9

Dia

rrh

ea

(< 5

yrs)

Mild dehydration

Moderate

dehydration

Persistent diarrhea

Dysentery

Beni Mellal

- - - 23.7 a Reported average cost per case

Using the valuation approaches mentioned above, the total cost of water-related mortality and

morbidity was estimated to range between 52.4 million and 170.1 million USD/year, with an average

of 111.27 million USD/year (0.69-2.25 percent of the GDP in the Oum Er Rbia Basin for the year

2004).

vii

Table IV. Estimated incurred damage costs associated with water pollution and uncontrolled

wastewater discharge in the Oum Er Rbia basin

Impact Methodology Total damage cost in

million USD

Total damage cost in percent of

GDP1(%)

Mortality HCA 46.2

WTP 163.9

Subtotal 46.2-163.9 0.6-2.2

Morbidity COI 6.17

DALY 0.047

Subtotal 6.22 0.09

Total 52.4-170.1 0.69-2.29

Finally, the annual benefits accrued from improved water supply and sanitation in the Oum Er Rbia

basin are estimated to range between 31.4 and 102.1 million USD per year, constituting 0.42 to 1.35

percent of the GDP in the Oum Er Rbia Basin for the year 2004. Using a social discount rate of 4%,

the present value of the flow of damage costs associated with pollution over a time span of 16 years

(till 2020) ranges between 366 million USD and 1,190 million USD with an average of 778 million

USD, which exceeds significantly the estimated cost of investment in water supply and sanitation in

the basin, amounting to 300 million USD.

1

1 BACKGROUND

Domestic water supplies and environmental sanitation contribute to livelihoods in a wide range of

ways. They have important roles in promoting food security, health and household maintenance,

and water-based livelihoods. In addition, the management of water supply and sanitation systems

has important effects on ecosystems that support livelihoods (Butterworth and Soussan, 2001). In

fact, polluted water, water shortages, and unsanitary living conditions, which are commonly

associated with increased waterborne illnesses and premature mortality, are one of the most

important global risk factors (WHO, 2004a; Esrey et al., 1991), whereby the burden created by this

risk factor has been reported to exceed many major diseases such as malaria or tuberculosis (Pruss

et al., 2002). With nearly 3 billion people lacking safe drinking water and adequate sanitation facilities (IRC 2007), water-related diseases have become a human tragedy, resulting in millions of

deaths each year, preventing millions more from leading healthy lives, and undermining global

development efforts. In 2004, an estimated 1.8 million deaths were attributed to unsafe water and

sanitation, including lack of hygiene, whereby 90 percent of this burden falls on children under five,

mostly in developing countries (WHO, 2004). Other vulnerable groups include the elderly and

pregnant women. In most countries the main risks to human health associated with the

consumption of polluted water are microbiological in nature. Waterborne and other water-related

diseases consist mainly of infectious diarrhea, typhoid and paratyphoid, cholera, salmonellosis,

shigellosis, amoebiasis, and other protozoan and viral intestinal infections. Some pathogens causing

these diseases are transmitted by water, but other forms of transmission do occur such as person-to-person contact, animal-to-human contact, and food and aerosols (Hunter, 1998). In addition to

water pollution by biological agents, chemical contamination should not be underestimated.

Chemicals such as nitrates, fluoride or arsenic in water can have long-term toxic effects.

There is significant evidence that the provision of improved water and sanitation to communities

lacking basic sanitation and using vulnerable and contaminated water can lead to a considerable

reduction in mortality and morbidity from water-related infectious disease. Fewtrell et al. (2005)

conducted a systematic review and meta-analysis to compare the effectiveness of these and similar

interventions. The examined interventions were reported to reduce the risks of diarrheal illness

significantly. Most interventions had a similar degree of impact on diarrhea illness, with the relative

risk estimates from the overall meta-analyses ranging between 0·63 and 0·75. Furthermore, multiple

interventions (consisting of combined water, sanitation, and hygiene measures) were not more

effective than interventions with a single focus (Table 1).

2

Table 1. Reduction in diarrheal disease morbidity by type of intervention

based on meta-analysis (Fewtrell et al., 2005)

Intervention Number of studies Relative risk

(95% Cl)

Hygiene 11 0·63 (0·52–0·77)

Excluding poor quality studies 8 0·55 (0·40–0·75)

Handwashing 5 0·56 (0·33–0·93)

Education 6 0·72 (0·63–0·83)

Sanitation 2 0·68 (0·53–0·87)

Water supply 6 0·75 (0·62–0·91)

Diarrhoea only 4 1·03 (0·73–1·46)

Household connection 2 0·90 (0·43–1·93)

Standpipe or community connection 3 0·94 (0·65–1·35)

Water quality 15 0·69 (0·53–0·89)

Source treatment only 3 0·89 (0·42–1·90)

Household treatment only 12 0·65 (0·48–0·88)

Household treatment

• excluding poor quality studies 8 0·61 (0·46–0·81)

• rural location 6 0·61 (0·39–0·94)

• urban/periurban 4 0·74 (0·65–0·85)

Multiple 5 0·67 (0·59–0·76)

Valuing the socio-economic benefits of such interventions requires a valuation of the cost of water

pollution and inadequate sanitation and hygiene, in the form of cost of illness and forgone earnings

associated with increased morbidity and premature mortality or cost of protective measures

referred to as averting expenditures such as purchasing bottled water or the incremental cost paid

to transport cleaner water from other sources (Esrey et al., 1991; Muller and Morera, 1994; WHO,

1996; 1998). Valuing the health impacts of water pollution faces many difficulties, including the

actual identification and measurement of health impacts and the estimation of monetary values for

associated mortality and morbidity. Generally, the economic valuation of health impacts proceeds by

conducting epidemiological studies in order to establish dose-response relationships (DRRs) linking environmental variables with observable health effects. However, in the case of water pollution,

establishing dose-response functions (DRFs) is complicated and less advanced than is the case of

evaluating health impacts from air pollution, for instance. Lately, efforts have concentrated on

quantifying this cost through the environmental burden of disease approach (Fewtrell et al., 2007;

Pruss et al., 2002), which adopted the Disability Adjusted Life Years (DALYs) as a unit measurement.

Pruss et al. (2002) calculated the burden of disease associated with water sanitation and hygiene

and estimated that globally these factors are responsible for 4 percent (2,213,000 cases) of all

deaths and 5.7% of disease burden. The authors also reported that the disease burden can be up to

240 times higher in developing regions when compared with a developed region. Yet, it should be

noted that the quantification of the disease burden due to water, sanitation, and hygiene is a complex task because of a) the numerous interrelated causes leading to transmission of water-

related diseases (source factors, pathway factors, behavioral factors); b) the complex exposure

patterns at the household and community level; and c) the scarce information on the risk factor–

disease relationship (Pruss et al. 2002).

Using various economic valuation approaches, this study examines the damage cost of water

pollution in the Oum Er Rbia Basin in Morocco where surface and groundwater water pollution

3

coupled with the lack of proper environmental service provisions are suspected to contribute to

significant health and other socio-economic impacts. An analysis is then conducted to prioritize

planned infrastructure interventions in the area, based on the results of the socio-economic

assessment. This paper is based on the study conducted by IRAM développement (2007) in the basin

of Oum Er Rbia. The data on the incidence of water-related morbidity and mortality and on the costs of treatment reported in the IRAM study were used without field ascertainment. The methodologies

adopted and calculations reported by IRAM développement were followed closely, and revised

when necessary. Mortality valuation methodologies were added to complement the existing

calculations. Not all data and valuation results were adopted, particularly when the methodology

followed in IRAM développement (2007) was not clear.

It is important to highlight the weaknesses of the data used in this assessment. First, no data on

mortality was available, and therefore, as reasonable as possible, assumptions were made to fill in

this gap. Second, the morbidity data collected were not clear with respect to the age distribution of

the cases and the percentage of the cases that were hospitalized. Third, there was no clear distinction between the characteristics of hospitalized and non-hospitalized cases. Fourth, the type

of data collected was not uniform across the various provinces in the Oum Er Rbia basin. As a result,

uncertainties in the calculations of the cost of illness are expected. In addition, the methodology for

the prioritization of the investment options was not explained in the study documents. Evidently, the

case provides guidelines and lessons about the need to clearly define data inputs at the onset of a

socio-economic assessment study to ensure that uniform data are collected all throughout and

minimize the assumptions that have to be made to bring the assessment to completion. Despite

these limitations which were addressed through relatively conservative assumption, it is clear that

the socio-economic cost of water pollution and inadequate sanitation in the Oum Er Rbia basin is

significant and that the planned investments are likely to be economically justified.

2 STUDY AREA CHARACTERIZATION

The Oum Er Rbia River is a main river in central Morocco and the longest in the country. The 550-km

long river has an average water debit of about 105 m3/s. It originates from the Middle Atlas at an

altitude of 1,800 m ASL, passes through the city of Khénifra in the Tadla plain and ends in the

Atlantic Ocean in Azemmour, 16 kms from the city of El Jadida. Oum Er-Rbia River has six dams, the

most important of which is Almassira Dam. Its main tributaries are El-Abid River, Tessaoute River,

and Lakhdar River (INECO Morocco, 2008; Wikipedia, 2008).

The Oum Er Rbia Basin has a population of around 4.5 million (19% of the total population) spread

over eight provinces, namely Beni Mellal, Khouribga, Settat, Khenifra, Azilal, El Kalaa of Sraghna, El

Jadida and Safi (Figure 1). Around 65 percent of the population in the basin lives in rural areas. The

economic activity in the basin is quite varied, including irrigated and rain-fed agriculture, agro-food

industries, mining industries, and numerous large transformation industries. In fact, the Oum Er Rbia

basin encompasses half of Morocco’s large scale irrigated areas and it produces 60 percent of the

country’s sugar beet, 40 percent of olives and 40 percent of the milk production.

4

Figure 1. Population density distribution in the Oum Er Rbia basin (IRAM développement, 2007)

Surface and ground water resources in the Oum Er Rbia basin are subject to significant pollution

from source and non-point sources. Given the intensive agricultural activity in the basin, agricultural

runoff laden with chemical fertilizers, pesticides, and herbicides is considered a major non-point

source of pollution, particularly nitrogen and phosphate. Another source of pollution in the basin is

domestic wastewater, which is discharged in an uncontrolled manner and without prior treatment

into the River. The daily discharge of raw wastewater into the river is estimated at 65,000 m3/d

(adapted from UNEP, 1995). Pollution from domestic wastewater discharge is more pronounced

during the dry season in downstream areas, particularly in Khenifra, Kasba Tadla, Beni Mellal, and

Azemmour. Polluted water from the River is often used for irrigation, which poses a risk to public

health. Table 2 shows fecal coliform levels in water samples from six stations along the Oum Er Rbia

River at various times of the year for the period 1999 to 2001. The reported concentrations ascertain the presence of significant microbiological pollution in the river water and thus the urgent need for

intervention. Groundwater aquifers were found to be equally vulnerable to domestic wastewater

pollution, whereby most local wells tested in 1995 showed bacteriological contamination, in addition

to elevated nitrate levels (Table 3). A third major source of water pollution in the Oum Er Rbia basin

is industrial in nature. Sugar refineries in Beni Mellal, Soul Sebti, and Oulad Ayyad, tanneries in

Khenifra and Beni Mellal, and olive presses in Afourer, Boujaad, and Fquih Ben Saleh, discharge their

industrial effluent into the environment without prior treatment. Levels of cadmium and arsenic,

slightly exceeding international water quality standards were detected in groundwater wells (Table

3). Finally, while the available data on water quality in the Oum Er Rbia basin are relatively old,

sporadic and incomplete, they are still indicative of the level of pollution in the basin with potential adverse impact on public health in the area.

5

Table 2. Levels of Fecal Coliform (CFU/100 ml) in the Oum Er Rbia River water

measured during 1999 and 2002 (adapted from IRAM développement, 2007)

Summer Winter Sampling station

Range Average Range Average

AC Oued Day 100-820 340 30-170 100

Ouled Zidouh 10-20,000 6,930 80-6,700 2510

Douwnstream of Tadla

discharge - 3,500,000 5,600-760,000 245,150

K. Zidania 12-1,700 590 0-7,200 2,570

Tadla reservoir 24-2,200 760 640-4,000 2,080

Mashraa 0-1,200 180 0-1,200 217

Ouled Sidi Driss 0-6,800 450 0-5,900 1,160

6

Table 3. Pollutant levels in water samples from selected wells in 2004

Province Parameter Arsenic (As)

(mg/l)

Cadmium (Cd)

(mg/l)

Chromium (Cr)

(mg/l)

Lead (Pb)

(mg/l)

Selenium (Se)

(mg/l)

Ammonium (NH4+)

(mg/l)

Nitrates (NO3-)

(mg/l)

Floride (F-)

(mg/l)

FC

(CFU/100 ml)

TC

(CFU/100 ml)

SC

(CFU/100 ml)

Min - - - - - 0.002 35.7 - 196 - -

Max - - - - - 0.89 35.7 - 4,716 - - Beni Mellal

Avg - - - - - 0.2900429 35.7 - 1931 - -

Min 0 0 0 0 0 0 0.626 0.12 0 0 0

Max 0.012 0.003 0.001 0.009 0.029 0.000 8,655 0.21 114 249 124 Khenifra

Avg 0.003 0.000 0.000 0.002 0.008 0.000 964.9 0.16 10 25 12

Min 0 0 0 0 0 0.0005 0.3 0.22 - - -

Max 0.005 0 0.002 0.002 0.001 0.060 65.9 1.20 - - - Azilal

Avg 0.003 0 0.002 0.002 0.001 0.032 26.6 0.50 - - -

Min 0.00225 0.00083 0.0037 0.004 0.002 0.00025 3.4 0.19 - - -

Max 0.004 0.001 0.014 0.036 0.007 0.220 2,758 1.32 - - - Khouribga

Avg 0.003 0.001 0.006 0.008 0.003 0.038 148.4 0.48 - - -

USEPA MAL 0.05 0.005 0.1 0.015 NA NA 10 4 0 0 NA Drinking water

Standards WHO GV 0.01 0.003 0.05 0.01 NA NA NA NA 0 0 NA

7

3 METHODOLOGY

In order to assess the impact of water pollution on health in the Oum Er Rbia basin, a field survey

was conducted to collect data from 13 centers in the province of Beni Mellal where investment

projects in water and sanitation are proposed. Accordingly concerned districts and municipalities

were visited. Data were collected on four waterborne diseases, namely typhoid, viral hepatitis, acute

gastroenteritis, and diarrhea. The data included the existing conditions of drinking water supply and

sanitation provision, incidence of diseases, the total population and the population under five. In addition, data on the costs of diseases, including out-patient consultation, hospitalization, and

treatment outside the hospital were provided by the Regional Hospital Center of Beni Mellal, the

Sanitary Division of Beni Mellal, and the French Agency for Development (through a study performed

on the profitability of the Wastewater Treatment Plant in Fez). Similar data were collected from

secondary sources for the provinces of Settat, Safi, Al Jadida, Khounifra, and Khourbiga. The data

were compiled and analyzed and then used to calculate the incidence of water-related diseases in

the basin and to estimate the cost of illness incurred by the society.

The next step was to estimate the damage cost of waterborne illnesses whereby health outcomes

were grouped into premature mortality and morbidity. While morbidity data were available through the health survey, mortality data were estimated based on statistics published by the World Bank

and the World Health Organization (WHO). Health outcomes during the year 2005 were considered

in the calculations, since they were the most complete. Mortality was expressed in terms of DALYs, a

methodology developed and applied by WHO and the World Bank in collaboration with international

experts to provide a common measure of the burden of disease for various illnesses and premature

mortality (World Bank, 2004). The DALY is defined as a health gap measure that extends the concept

of potential years of life lost due to premature death to include equivalent years of ‘healthy’ life lost

by virtue of being in states of poor health or disability (Murray and Lopez, 1996). It thus combines in

one measure the time lived with disability and the time lost due to premature mortality. To estimate

the DALY for a particular cause during a particular time period, the number of incident cases in that period is multiplied by the average duration of the disease and a weight factor that reflects the

severity of the disease on a scale from 0 (being in perfect health) to 1 (representing death). A year

lost to premature mortality represents one DALY, and future years lost are discounted at a fixed rate

of 3 percent to account for a social preference for a healthy year now, rather than in the future

(Pruss et al., 2003). Note that age weighting was not applied in the calculations.

In the valuation of mortality, the human capital approach was used to reflect the lower bound of the

estimation. This approach is based on foregone earnings and estimates the production lost from

premature death, accordingly the loss of one statistical year is valued at the level of Gross Domestic

Product (GDP) per capita. The upper bound is given by the willingness to pay approach (WTP), where

one DALY is assessed at the WTP for mortality risk reduction. The WTP approach uses statistical

techniques to record human behavior in trading off risk of dying with a certain amount of money.

Willingness to pay measures reflect the whole range of costs associated with premature death,

including loss of production (as in the human capital approach), suffering, losses imposed on other

family members and society, and other complex attributes associated with a human life.

To assign a monetary value for morbidity, the cost of illness approach (COI) was used to estimate

treatment costs, including medical consultation fees, medications and hospitalizations, as well as the

opportunity cost of the time spent being sick or lost work days. This was complemented by a valuation of DALYs lost to morbidity in relation to GDP per capita to account for the cost of pain and

suffering from illness.

8

Finally the health impact of water pollution and inadequate sanitation was calculated as an annual

value, based on 2004 mortality data and 2005 morbidity data. Other economic data used in the

calculations are summarized in Table 4.

Table 4. Economic data

Parameter Value Reference

Morocco population (2004) 29.8 million World Bank (2006)

Oum Er Rbia population (2004) 4.5 million IRAM développement (2007)

GDP (2004) 50,031 million USD World Bank (2006)

GDP per capita (2004) 1,679 USD World Bank (2006)

Parity (Average for 2004-2005) 8.867 (Dh/USD) CIA World Fact Book (2008)

4 RESULTS

4.1 Damage Assessment

The survey revealed a total of 44,106 cases of water-related diseases in the Oum Er Rbia Basin,

recorded during 2005, with 98 percent of the cases being diarrhea and acute gastroenteritis. Table 5

and Table 6 present the distribution of recorded cases in the provinces within the Oum Er Rbia basin

by type of case. Note that it was not clear whether the reported cases pertained strictly to morbidity

or whether they encompassed mortality cases as well. As such, these cases were considered only

morbidity cases and mortality cases were estimated separately.

Table 5. Incidence of water-related diseases in 2005 in the provinces of

Settat, Safi, Al Jadida, Khounifra, and Khourbiga

Diarrhea and acute

gastroenteritis

Amoebic

dysentery

Typhoid Viral Hepatitis Provinces Population

n Per

100,000

n Per

100,000

n Per

100,000

n Per

100,000

Settat 336,635 5,687 1689.4 8 2.38 1 0.30 1 0.30

Safi 890,752a - 0.0 - - 26 19

El Jadida 1,129,776 19,513 1727.2 79 6.99 3 0.27 0 0.00

Khénifra 413,708 3,189 770.8 - 0.00 206 49.79 13 3.14

Khouribga 493,000 1,016 206.1 - 0.00 64 12.98 3 0.61

Total 3,263,871 29,405 87 300 36 a

Adapted from Wikipedia for 2004 and projected using the population growth rate of 1.1 % reported by the

WHO Statistical Information System (WHOSIS)

9

Table 6. Incidence of water-related diseases in 2005 in the

Beni Mellal Province in the Oum Er Rbia basin

Disease Number of cases Incidence per

100,000

Typhoid 87 9.2

Viral Hepatitis 61 6.4

Acute gastroenteritis 3,174 335.5

Diarrhea (< 5yrs)-

Mild dehydration

5,984

632.6

Diarrhea (< 5yrs)-

Moderate dehydration

105

11.1

Diarrhea (> 5yrs) 4,812 508.6

Dysentery 38 4.0

Persistent Diarrhea 17 1.8

Total 14,278 1509.3

The survey also revealed the average duration of each illness under study, the average duration of

hospitalization, and the cost of hospitalization and outpatient treatment for the provinces under

study, as detailed Table 7. It is important to note that for the province of Beni Mellal, the average duration of illness and average hospitalization was not revealed in IRAM développement (2007). In

addition, the cost of hospitalization was on a per case basis rather than on a daily basis as is the case

for the other provinces. Thus, since data on the actual number of cases that were hospitalized were

not available, the most common daily cost of hospitalization reported in the other provinces was

used in the COI estimations (Table 7).

10

Table 7. Main inputs for the COI estimation by province

Diseases Province Average

duration of

illness

Average

duration of

hospitalization

Daily cost of

hospitalization

Average cost

of outpatient

treatment

Diarrhea and acute

gastroenteritis

Settat 5 4 25.5 22.6

Safi 0.0

El Jadida 5 4 25.5 22.6

Khénifra 5 4 25.5 22.6

Khouribga 12 7 10.4 16.9

Diarrhea (> 5yrs) 5 3 25.5 (158.2 a) 30.7

Gastroenteritis

Beni Mellal

5 4 25.5 (95.0 a

) 29.3

Settat 5 3 25 22.6

Safi 0.0

El Jadida 5 3 25 22.6

Khénifra 0.0

Amoebic dysentery

Khouribga 0.0

Settat 5 4 25.5 22.6

Safi 15 12 35.9 1.6

El Jadida 15 12 35.9 1.6

Khénifra 15 12 35.9 1.6

Khouribga 10 7 10.4 7.9

Typhoid

Beni Mellal 21 12 35.9 (424.2 a) 87.3

Settat 30 8 25.9 22.6

Safi 30 5 25.9 1.1

El Jadida 30 5 25.9 1.1

Khénifra 30 5 25.9 1.1

Khouribga 15 5 25.9 1.1

Beni Mellal 15 5 25.9 (332.8 a) 12.4

Viral Hepatitis

- - - 14.7

- - - 18.0

- - - 175.9

Dia

rrh

ea

(< 5

yrs)

Mild dehydration

Moderate

dehydration

Persistent diarrhea

Dysentery

Beni Mellal

- - - 23.7 a Reported average cost per case

4.2 Premature Mortality

In the absence of population-based vital registries, mortality rates in the Oum Er Rbia basin due to

diarrhea were estimated from statistical data published by the World Bank and were limited to

children under five. As depicted in Table 8, given a child mortality rate of 38 per 1,000 (World Bank,

11

2006) of which 20 percent are attributable to diarrhea (World Bank, 2003), the annual number of

deaths due to diarrhea among children under five was estimated at 786 cases.

Table 8. Calculation of child mortality in the Oum Er Rbia basin

Parameter Value

Population in Oum Er Rbia Basin 4.5 million

Birth rate in Morocco in 2004 a 23 births per 1,000 population

Live births in Oum Er Rbia Basin in 2004 103,500

Child mortality rate 38 per 1,000 live births

Annual child deaths (all causes) 3,933 per year

Child diarrheal disease deaths b 20.0% of child mortality rate

Annual child diarrheal disease deaths 786

4.2.1 Human Capital Approach

According to the Global Burden of Disease approach (Murray and Lopez, 1996), it is estimated that the death of a child under five represents the loss of 35 DALYs. Thus, the estimated child deaths in

the Oum Er Rbia basin due to diarrhea represent an annual loss of 27,510 DALYs. Using the human

capital approach (HCA), if one year of a person’s life is lost, society loses, at the very least, the

contribution of this person to production, approximated by the GDP per capita, for income during

the ages of 20 to 65 years, at a discount rate of 3 percent. One DALY is assessed at 1,679 USD, which

is the equivalent GDP per capita (World Bank, 2006). Thus, the loss of DALYs due to children

mortality is estimated at 46.2 million USD (0.6 percent of the GDP in the Oum Er Rbia region for the

year 2004).

4.2.2 Willingness to pay approach

While WTP data for Morocco are not available, WTP estimated in Europe and North America can be applied by adjusting for GDP per capita differentials. The adjusted WTP in Morocco for mortality risk

reduction of adults is estimated at 5,957 USD (World Bank, 2003). Accordingly, the loss of DALYs due

to children mortality, based on the willingness to pay approach is estimated at 163.9 million USD. As

such, the damage cost due to infant premature mortality, taking both the HCA and WTP approaches

into account is estimated to range between 46.2 and 163.9 million USD, with an average of 98.3

million USD (0.6-2.2 percent of the GDP in the Oum Er Rbia region for the year 2004).

4.3 Morbidity

Morbidity valuations were conducted based on the available data in each province. Cases that were

considered in the provinces of Settat, Safi, Al Jadida, Khounifra, and Khourbiga pertained to diarrhea,

acute gastroenteritis, viral hepatitis, typhoid, and amoebic dysentery. In the Beni Mellal province, in

addition to the diseases mentioned above, diarrhea cases were categorized according to age and to the severity of the associated dehydration (Table 6).

4.3.1 Cost of illness approach

Based on the inputs obtained via the health survey by IRAM développement (2007) and listed in

Table 7, the cost of outpatient treatment and hospitalization in the Settat, Safi, Al Jadida, Khounifra,

and Khourbiga provinces amounted to 3.83 million USD (Table 9).

12

Table 9. Cost of outpatient treatment and hospitalization in the provinces of

Settat, Safi, Al Jadida, Khounifra, and Khourbiga

Provinces Diseases

Settat Safi El Jadida Khénifra Khouribga

Total

No. of cases 5,687 - 19,513 3,189 1,016 29,405 Diarrhea

Cost (USD) 708,069 - 2,429,497 397,052 90,978 3,625,596

No. of cases 8 - 79 - - 87 Amoebic

dysentery Cost (USD) 792 - 7,822 - - 8,615

No. of cases 1 26 3 206 64 300 Typhoid

Cost (USD) 125 11,230 1,296 88,979 88,979 190,609

No. of cases 1 19 - 13 3 36 Viral Hepatitis

Cost (USD)) 230 2,486 - 1,701 392 4,809

Total (USD) 709,216 13,716 2,438,616 487,732 180,350 3,829,629

Morbidity valuation using the COI approach for the Beni Mellal province was conducted separately

from the other provinces as different input data were available. Accordingly, the cost of outpatient

treatment was estimated separately to be around 0.33 million USD. Around 45 percent of the cost

pertains to diarrhea cases greater than 5 yrs of age and 28 percent of the cost pertains to cases of

acute gastroenteritis (Table 10). As for the cost of hospitalization, and in the absence of the exact

number of cases that were hospitalized, the same methodology that was applied to the other

provinces was applied for Beni Mellal. In other words, each of the reported cases was considered to

have received hospitalized treatment. Accordingly, the cost of hospitalization due to water-related

illnesses in the Beni Mellal province amounted to 1.2 million USD (Table 11). Around 69 percent of

the cost pertains to diarrhea cases and 27 percent pertains to cases of acute gastroenteritis.

Regarding the cost of lost work days in the Oum Er Rbia basin, and in the absence of age distribution

of cases, it is assumed the 40 percent of the reported diarrhea and gastroenteritis cases are adults. For the remaining diseases, it is assumed that 100 percent of the cases pertain to adults. Based on

the average number of lost work days listed in Table 12 and an average wage rate of 8.23 USD per

day (taking urban and rural wage rates into account), the total cost of lost work days in the Oum Er

Rbia basin due to water-related diseases amounted to 0.8 million USD.

13

Table 10. Cost of Illness for non-hospitalized cases in 2005 in USD

Diarrhea (< 5yrs)

Dehydration

Population center Typhoid Epidemic

Hepatitis

Acute

Gastroenteritis

Diarrhea (> 5yrs)

A B C

Dysentery Persistent

diarrhea

Total

Aghbala 786 0 7,653 2,151 2,170 0 0 0 0 12,760

Beni Mellal 3,928 236 16,274 51,722 27,387 1,895 0 308 2,287 104,036

Bradia 262 12 0 1,905 2,478 0 0 0 0 4,657

Dar Ould Zidouh 0 50 29 17,671 2,419 0 0 308 704 21,181

El Ksiba 524 0 0 1,567 2,097 0 0 0 0 4,188

Fquih Ben Salah 87 335 26,214 11,432 7,096 0 0 0 0 45,165

Kasba Tadla 175 99 31,404 9,220 6,246 0 0 0 0 47,143

Ouled Ayad 87 0 880 22,619 7,404 0 0 0 0 30,990

Ouled M'barek 0 0 0 3,227 1,745 0 0 0 0 4,972

Ouled Yaich 262 0 4,809 3,442 792 0 0 0 0 9,304

Sebt Ouled Nemma 175 25 176 10,787 8,020 0 0 0 0 19,182

Sidi Jaber 0 0 0 2,489 1,041 0 0 0 0 3,530

Zaouiat Echeikh 1,309 0 5,630 9,373 5,337 0 0 284 0 21,933

Total 7,594 757 93,069 147,606 74,229 1,895 0 900 2,991 329,040

Total (%) 2.31 0.23 28.28 44.86 22.56 0.58 0.00 0.27 0.91 100.00

14

Table 11. Cost of hospitalization due to water-related diseases in the Beni-Mellal Province in USD

Parameter Typhoid Viral Hepatitis Acute GA Diarrhea Dysentery Total

Number of cases 87 61 3,174 10,917 38

Hospitalization days/case 12 5 4 3 3

Daily hospitalization cost 35.9 25.9 25.5 25.5 25.5

Total cost of hospitalization 37,441 7,911 323,593 834,779 2,906 1,206,630

Total (%) 3.10 0.66 26.82 69.18 0.24 100.00

Table 12. Cost of lost work days due to water-related diseases in the Oum Er Rbia Basin

Provinces Diseases Number of lost work

days

Parameter

Settat Safi El Jadida Khénifra Khouribga Beni Mellal

Total

No. of cases 2,275 - 7,805 1,276 406 3194 14,956 Diarrhea and

acute GE

3

Cost (USD) 56,184 - 481,938 78,763 25,093 78,895 720,873

No. of cases 8 - 79 - - - 87 Amoebic

dysentery

10

Cost (USD) 659 - 6,514 - - - 7,173

No. of cases 1 26 3 206 64 87 387 Typhoid 21

Cost (USD) 173 4,495 519 35,615 11,065 15,041 66,908

No. of cases 1 19 - 13 3 61 97 Viral Hepatitis 15

Cost (USD) 123 2,346 - 1,605 370 7,533 11,979

TOTAL (USD) 57,139 6,841 488,971 115,983 36,529 101,469 806,932

15

As such the total cost of illness due to water-related diseases in the Oum Er Rbia province amounted to 6.17 million USD.

4.3.2 Cost of pain and suffering (DALY)

For a total of 30,897 reported cases of diarrhea and acute gastroenteritis in the Oum Er Rbia basin,

and based on an average duration of 3 days per diarrhea case and a severity weight of 0.11 (Murray and Lopez, 1996), the total number of DALYs lost because of pain and discomfort resulting from diarrhea is estimated at 28. For a GDP of 1,679 USD/capita (World Bank, 2006), the estimated cost of

years lost due to disability caused by diarrhea is 47,012 USD (number of DALYs × per capita GDP).

DALY calculations were limited to diarrhea and acute gastro-enteritis cases since no severity weight has been reported in the literature for the other water-related diseases. Based on the above estimations, the yearly total cost of morbidity resulting from typhoid, viral

hepatitis, diarrhea, acute gastroenteritis, and amoebic dysentery amounted to 6.22 million USD (0.09 percent of the GDP in the Oum Er Rbia region for the year 2004) (Table 13). The major part of this cost is associated with health treatment (86 %), followed by time (13 %) and discomfort (0.8 %).

Table 13. Summary of estimated damage cost from morbidity associated with inadequate

water and wastewater management

Cost (million USD) Cost (%)

Cost of treatment 5.36 86.2

Cost of lost work days 0.81 13.0

Cost of years lost due to disability 0.05 0.8

Total morbidity cost (USD) 6.22 100

4.4 Benefits

Based on the valuation presented above, the total cost of water-related mortality and morbidity was

estimated to range between 52.4 million and 170.1 million USD/year, with an average of 111.27 million USD/year (0.69-2.25 percent of the GDP in the Oum Er Rbia Basin for the year 2004). IRAM développement estimated the percentage of the cost attributed to water pollution to be 60 percent, based on Valent et al. (2002) and Spandaro (2002). Accordingly, the annual benefits accrued from improved water supply and sanitation in the Oum Er Rbia basin are estimated to range between 31.4 and 102.1 million USD per year, constituting 0.42 to 1.35 percent of the GDP in the Oum Er Rbia Basin for the year 2004. Using a social discount rate of 4%, the present value of the flow of damage

costs associated with pollution over a time span of 16 years (till 2020) ranges between 366 million USD and 1,190 million USD with an average of 778 million USD.

5 PRIORITIZATION OF INVESTMENT OPTIONS

As part of the National Water Sanitation Plan, fifty-one investments are planned for the Oum Er Rbia basin, which are expected to directly benefit about two million inhabitants, not to mention visitors,

agricultural and fisheries activities (Annex A). The total cost of the planned investments is estimated at 300 million USD for the period 2003-2020, of which 45% is allocated for water treatment.

Given the results of the health valuation, IRAM développement (2007) attempted to prioritize investment options planned for the Oum Er Rbia basin. However, due to the fragmented and

16

insufficient data, as well as budget and time constraints, this prioritization was limited to the province of Beni Mellal, where the IRAM développement research team has been able to collect and review the data in a satisfactory manner. First, projections of the cost of pollution in Beni Mellal until

2015 were made using three scenarios, including (a) constant pollution levels, (b) an annual increase of 5 percent in the pollution levels, and (c) an annual increase of 10 percent in the pollution levels. If pollution levels remained constant, the best estimated cost would be around 112 million USD. With

an annual increase of 5 percent in the pollution level, the best estimated cost would be around 147 million USD and with a 10 percent annual increase in pollution levels, 192 million USD. Then, a ranking of investment options by region was conducted based on two criteria, namely expected reduction in the burden of disease and expected reduction in socio-economic costs incurred, as

depicted in Figure 2 and Figure 3.

0,00%

0,50%

1,00%

1,50%

2,00%

2,50%

3,00%

3,50%

4,00%

4,50%

Dar

Oul

d Zid

ouh

Aghba

la

Ouled

Ayad

Zaouiat E

chei

kh

K. Tad

la

Sidi J

aber

Ouled

Yai

ch

Fquih

Ben S

alah

Ouled

M'bar

ek

Sebt O

uled

Nem

ma

Beni M

ella

l

El Ksib

a

Figure 2. Prioritization of investments based on reduction in the burden of disease

0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

3 000 000

Beni M

ella

l

Oul

ed A

yad

K. T

adla

Fquih B

en S

alah

Zaouiat

Ech

eikh

Dar

Ould

Zidou

h

Seb

t Ouled

Nem

ma

Agh

bala

Oul

ed Y

aich

Oul

ed M

'bar

ek

El K

siba

Sidi J

aber

Figure 3. Prioritization of investments based on reduction in socio-economic costs

This prioritization is simplistic in nature. According to IRAM développement (2007), for a more

accurate prioritization, the causal link between a specific planned investment and its economic and public health impact on an identified population should be well established and quantified. This requires consistent information on (a) the planned investments in water resources or in urban and industrial pollution; (b) the populations benefitting from these investments, which are actually

connected to the water supply sources subject to investments or at which urban industrial pollution mitigation projects are aimed; (c) levels of pollutants measured over several years during which people were exposed; and (d) diseases recorded by the health centers which are visited by the

17

exposed populations. However, the data obtained by the IRAM développement were fragmentary and insufficient to allow spatial analysis and the planned calculations.

6 CONCLUSION AND LIMITATIONS

Inadequate water supply and sanitation in the Oum Er Rbia basin is imposing significant socio-economic costs on the population in the area in terms of water-related mortality and morbidity.

These costs were estimated to range between 52.4 million and 170.1 million USD/year, with an average of about 111 million USD/year (0.69-2.25 percent of the GDP in the Oum Er Rbia Basin for the year 2004). Accordingly, improving the quality of water supply and sanitation is expected to result in considerable economic benefits, estimated to range between 31 and 102 million USD per

year, constituting 0.42 to 1.35 percent of the GDP in the Oum Er Rbia Basin for the year 2004. The present value of the flow of damage costs associated with pollution over a time span of 16 years (till 2020) ranges between 366 million USD and 1,190 million USD with an average of 778 million USD,

which exceeds by far the estimated cost of the planned investment in the Oum Er Rbia basin of 300 million USD. Hence, despite the inadequacy of the prioritization process and the fact that the true relation between the degree of improvement in water supply and sanitation and the expected reduction in disease prevalence and mortality still needs to be ascertained, the present figures are

sufficient to prompt decision-makers to continue investing in implementing the planned National Water Sanitation Plan.

Finally, the estimated figures reflecting the damage cost of sub-standard water quality, inadequate sanitation facilities and sanitary practices, and inadequate personal, food and domestic hygiene, should be regarded as indicative numbers and minimum estimates for the following reasons:

� The causes of morbidity and mortality cases in Morocco are not recorded as systematically as

required for this study. � Health impacts due to chemical pollution of water resources cannot be accounted for due to the

difficulty in linking them to exposure as they are long term in nature. � The exposure approach does not account for all routes, such as exposure to recreational water

or sewage polluted fish/ food. � Data on the number of morbidity cases is limited to the hospitalized ones. Many patients may

visit only dispensaries and may not visit medical facilities at all, especially for mild diarrhea cases. They do simply buy medicaments from pharmacies, without consulting a hospital, a dispensary or a private clinic.

� Water pollution and possible contamination of municipal water in the distribution system has also a cost to society revealed in terms of averting expenditures such as the purchase of bottled water or the incremental cost paid to transporting cleaner water from other sources. However, this issue was not investigated.

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19

ANNEX A

Location of Planned Sanitation Investments in the Oum Er Rbia Basin

20