Poverty, Health and Poverty, Health and Sanitation –Sanitation –

The Case for More Investment The Case for More Investment in Sanitationin Sanitation

Norman Hicks/Derko KopitopoulosNorman Hicks/Derko KopitopoulosFebruary 2006February 2006

Poverty, Health and SanitationPoverty, Health and Sanitation

Millennium Development Goals– improved health Millennium Development Goals– improved health is integral part of poverty reduction:is integral part of poverty reduction: Reduce child mortality—Reduce child mortality—

• Target 5: Reduce by 2/3rds the child mortality rate (between Target 5: Reduce by 2/3rds the child mortality rate (between 1990-2015) 1990-2015)

Improve maternal healthImprove maternal health• Target 6: Reduce by 3/4ths the maternal mortality rate Target 6: Reduce by 3/4ths the maternal mortality rate

Combat AIDS, malaria and other diseasesCombat AIDS, malaria and other diseases• Targets 7 & 8: Halt and begin to reverse spread of AIDS, Targets 7 & 8: Halt and begin to reverse spread of AIDS,

malaria and other diseases by 2015malaria and other diseases by 2015

MDG for Water and SanitationMDG for Water and Sanitation

Halve, by 2015, the proportion of people Halve, by 2015, the proportion of people without access to safe drinking water and without access to safe drinking water and sanitation (Target 10)sanitation (Target 10) Indicator: proportion of population with access Indicator: proportion of population with access

to improved water source and improved to improved water source and improved sanitation, urban and rural.sanitation, urban and rural.

What is the connection between the health What is the connection between the health goals and the water/sanitation goals?goals and the water/sanitation goals? What is the objective of improving water and What is the objective of improving water and

sanitation if not for health improvements?sanitation if not for health improvements?

DefinitionsDefinitions SanitationSanitation:: refers to the infrastructure and refers to the infrastructure and

service provision required for the safe service provision required for the safe management of human excreta, for example management of human excreta, for example latrines, sewers, and wastewater treatment. latrines, sewers, and wastewater treatment.

Hygiene:Hygiene: refers to the set of behaviors related to refers to the set of behaviors related to safe management of excreta, such as washing safe management of excreta, such as washing hands with soap at appropriate times, the safe hands with soap at appropriate times, the safe disposal of child feces, and so on. disposal of child feces, and so on.

Solid Waste Management:Solid Waste Management: refers to the refers to the handling of non-liquid and non-excreta handling of non-liquid and non-excreta household and industrial waste.household and industrial waste.

Drainage:Drainage: Refers to the removal of surface Refers to the removal of surface water from rain or flooding.water from rain or flooding.

What is Improved Sanitation?What is Improved Sanitation?

Quantifing Benefits of reaching Quantifing Benefits of reaching MDGs in sanitationMDGs in sanitation

Benefits quantified:Benefits quantified: Health costs avoidedHealth costs avoided Patient health seeking costs avoidedPatient health seeking costs avoided Value of time saved (work, school)Value of time saved (work, school)

Results show:Results show: 80% of benefits come from time saved80% of benefits come from time saved Assumes value of time at minimum wage, including Assumes value of time at minimum wage, including

school children.school children. Nevertheless, the regional cost-benefit ratios (CBRs) Nevertheless, the regional cost-benefit ratios (CBRs)

are high (average 6.6; range 3.0 to 28.5)are high (average 6.6; range 3.0 to 28.5)• Source: Evans, Hutton and Haller “Closing the Sanitation Gap” OECD March 2004.Source: Evans, Hutton and Haller “Closing the Sanitation Gap” OECD March 2004.

World RegionWorld Region

PopPop(m)(m)

Meeting sanitation MDG (annual figures, in US$ Meeting sanitation MDG (annual figures, in US$ million)million)

Cost-Cost-BenefitBenefitratio*ratio*

HealthHealthsectorsector

TreatmentTreatmentCostsCosts

avoidedavoided

PatientPatientHealthHealth

SeekingSeekingCostsCosts

avoidedavoided

AnnualAnnualvalue ofvalue of

TimeTimegaingain

TotalTotalbenefits*benefits*

Sub-Saharan AfricaSub-Saharan Africa 968968 1,1301,130 7272 12,87312,873 16,18316,183 10.610.6

Latin AmericaLatin America 624624 514514 1616 5,6955,695 7,3257,325 11.911.9

East Mediterranean & East Mediterranean & North AfricaNorth Africa 373373 148148 66 5,1575,157 5,8655,865 28.528.5

Central & Eastern Central & Eastern EuropeEurope 460460 6060 22 2,3812,381 2,5082,508 12.712.7

South and SE AsiaSouth and SE Asia 2,1622,162 1,3781,378 8484 8,1128,112 11,10411,104 3.03.0

West Pacific (LDCs)West Pacific (LDCs) 1,6731,673 1,6451,645 6464 8,9058,905 11,61911,619 3.83.8

All regionsAll regions 7,1837,183 4,9554,955 244244 51,52551,525 63,26963,269 6.66.6

Cost-Benefits and Economic Rates Cost-Benefits and Economic Rates of Returnof Return

CBRs are equivalent CBRs are equivalent to high internal rates to high internal rates of returnof return

A Cost-benefit ratio of A Cost-benefit ratio of 6.6 is equivalent 6.6 is equivalent (roughly) to an (roughly) to an internal rate of return internal rate of return of 50%--higher than of 50%--higher than most other projectsmost other projects

Source: CBRs: by G. Hutton in Evans, Source: CBRs: by G. Hutton in Evans, Hutton and Haller, “Closing the Sanitation Hutton and Haller, “Closing the Sanitation Gap” OECD, March 2004, IRRs calculated Gap” OECD, March 2004, IRRs calculated by authors, assuming 14 yr. amortization, 3% by authors, assuming 14 yr. amortization, 3% real interest rate.real interest rate.

CBRsCBRs IRRsIRRs

3.03.0 28%28%

6.66.6 50%50%

12.012.0 64%64%

Benefits from sanitation go Benefits from sanitation go beyond health…beyond health…

Environment

Health Economy Community

SanitationNo visual, no adverse odorNatural resources preserved No fecal contaminationLess ponding water

Less diarrhea (90%)Less aneamia, blindnessLess dengue, malaria

Time availabilityLess medical costs

EducationInfrastructure

Tourism Fisheries Reuse

Less treatmentLess maintenance

Less gritLess erosionLess WS pollution

Privacy - Security Gender sensitivity Religious, cultural

Social Cohesion

Collective action

Girls at school

Other community activities

SocialOperations

Diseases arising from poor Diseases arising from poor sanitationsanitation

Diarrhea: main indicator of various diseasesDiarrhea: main indicator of various diseases Excreted infections includeExcreted infections include

Non-bacterial fecal-oral:Non-bacterial fecal-oral: • Hepatitis, viruses, amoebiasis,…Hepatitis, viruses, amoebiasis,…

Bacterial fecal-oralBacterial fecal-oral• E.Coli infection, Cholera, Typhoid, …E.Coli infection, Cholera, Typhoid, …

HelminthsHelminths• Ascariasis, taenia, schistosomiasis,…Ascariasis, taenia, schistosomiasis,…

–Source: WHO 1992Source: WHO 1992

Sanitation and Diarrhea…the linksSanitation and Diarrhea…the links1.1. Diarrhea accounts for 1.8 million deaths per year; 90% are Diarrhea accounts for 1.8 million deaths per year; 90% are

children (WHO).children (WHO).2.2. 88% of diarrheal disease is attributed to unsafe water supply, 88% of diarrheal disease is attributed to unsafe water supply,

inadequate sanitation and hygiene (WHO)inadequate sanitation and hygiene (WHO)3.3. Improved sanitation brings about:Improved sanitation brings about:

a 38% reduction in diarrheal diseases; anda 38% reduction in diarrheal diseases; and a 32% reduction in diarrheal mortality, on average.a 32% reduction in diarrheal mortality, on average.

4.4. Hygiene interventions – including hygiene education and Hygiene interventions – including hygiene education and promotion of handwashing can lead to reduction of diarrheal promotion of handwashing can lead to reduction of diarrheal cases by up to 45% .cases by up to 45% .

5.5. Improvements in water quality through household water Improvements in water quality through household water treatment can lead to a reduction in diarrhea of between 35 treatment can lead to a reduction in diarrhea of between 35 and 39%.and 39%. Sources: #1-2: WHOSources: #1-2: WHO “Water, Sanitation and Hygiene Links to Health – FACTS AND “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. FIGURES, March 2004; #3-5 based on research by Esrey and Fewtrell, as cited in Evans, et. al. “Securing Sanitation” SIWI, 2005, p. 7“Securing Sanitation” SIWI, 2005, p. 7

Reducing Diarrhea a function of Reducing Diarrhea a function of both sanitation and hygiene…both sanitation and hygiene…

Improved Sanitation (safe disposal of feces) – Improved Sanitation (safe disposal of feces) – blocks path between feces and food, flies, fields.blocks path between feces and food, flies, fields.

Improved water quality blocks link to drinking Improved water quality blocks link to drinking water IF water is properly handled—does not water IF water is properly handled—does not block other pathsblock other paths

Increased quantity of water improves hygiene Increased quantity of water improves hygiene via improved food preparation and personal via improved food preparation and personal hygienehygiene

Increased handwashing (with soap) blocks link Increased handwashing (with soap) blocks link to food and direct contacts. to food and direct contacts.

Fecal contamination is the main source of diarrhea Fecal contamination is the main source of diarrhea infections ….infections ….

Feces Future Victim

Fluids

Fingers

Flies

Fields/Floors

Sanitation

Food

Hygiene

Water supply

Health Improvement FrameworkHealth Improvement Framework

Access to HardwareWater supply systemsImproved sanitation facilitiesHousehold technologies ● Soap● Safe water containers

Hygiene PromotionCommunicationSocial mobilizationCommunity participationSocial marketingAdvocacy

Enabling EnvironmentPolicy improvementInstitutional strengtheningCommunity organizationFinancing and cost recoveryCrosssector & PP partnerships

Diarrheal Disease Prevention

Alternative approaches to Alternative approaches to SanitationSanitation

ImprovementImprovement Investment cost Investment cost USD/capitaUSD/capita

Recurrent cost Recurrent cost USD/capitaUSD/capita

Recurrent cost Recurrent cost sourcesource

SewerageSewerage 450450 Very highVery high Fees + householdFees + household

Sewer connectionSewer connection 150150 HighHigh Fees + householdFees + household

Small boreSmall bore 6060 MediumMedium Fees + householdFees + household

Septic tankSeptic tank 100100 HighHigh HouseholdHousehold

Pour-flushPour-flush 5050 Medium / LowMedium / Low HouseholdHousehold

VIPVIP 5050 LowLow HouseholdHousehold

Pit latrinePit latrine 2525 Low Low HouseholdHousehold

Hygiene educationHygiene education 1010 LowLow HouseholdHousehold

–Source: SIWI, 2000Source: SIWI, 2000

Possible Allocation of Possible Allocation of ResponsibilitiesResponsibilities

Responsibility share for

urban sanitation

Individual Collective

Household Blocks Community Authority

LatrinesConstruction

O&MConstruction

O&MConstruction

O&MPromotion Regulation

Septic tanksConstruction

EmptyingConstruction

EmptyingEmptying Disposal

Emptying Disposal

Simplified sewerage

ConnectionsConstruction

O&MConstruction

O&MSmall bore sewerage

Septic tank construction

Septic tank construction

Construction O&M

Construction O&M

Conventional sewerage

ConnectionsConstruction

O&M

< ---------------- >

Key: primary responsibility secondary responsibility

A Possible Strategy…A Possible Strategy…

Focus on Promotion – Raise AwarenessFocus on Promotion – Raise Awareness Raising awareness at all levels: household, Raising awareness at all levels: household,

community and national leaders of community and national leaders of sanitation’s importancesanitation’s importance

Improve household practices Improve household practices • Water treatment – boiling, chlorination, in the home Water treatment – boiling, chlorination, in the home

for untreated waterfor untreated water• Hand washing (with soap), personal hygiene, food Hand washing (with soap), personal hygiene, food

handlinghandling

Strategy….Strategy….

Institutions and Strategy:Institutions and Strategy: Develop a national sanitation plan outlining Develop a national sanitation plan outlining

role of national and local govt., private sector, role of national and local govt., private sector, and households. and households. • Focus on low cost improvements– latrines, septic Focus on low cost improvements– latrines, septic

tanks, small scale seweragetanks, small scale sewerage• Use the private sector– including householdsUse the private sector– including households• Have subsidies for poor householdsHave subsidies for poor households• Include drainage (often a higher priority in low lying Include drainage (often a higher priority in low lying

areas).areas).

Strategy …Strategy …

• In dense urban areas, develop community/block In dense urban areas, develop community/block based simple sewer systems with heavy based simple sewer systems with heavy community involvement (condominium approach)community involvement (condominium approach)

• Improve the regulatory framework – set Improve the regulatory framework – set appropriate standardsappropriate standards

Organize/Coordinate stakeholders--Include Organize/Coordinate stakeholders--Include government and non-government actorsgovernment and non-government actors• Public sector --health, public works, environment, Public sector --health, public works, environment,

water/sanitation institutions, planning, financewater/sanitation institutions, planning, finance• Private sector – NGOs, women’s groups, business Private sector – NGOs, women’s groups, business

groups, householdsgroups, households• International – foreign donors, IFIsInternational – foreign donors, IFIs

The EndThe End