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— Reduce child mortality— Target 5: Reduce by 2/3rds the child mortality rate (between 1990-2015)Target 5: Reduce by 2/3rds the child mortality rate (between 1990-2015) Improve maternal health Improve maternal health Target 6: Reduce by 3/4ths the maternal mortality rateTarget 6: Reduce by 3/4ths the maternal mortality rate Combat AIDS, malaria and other diseases Combat AIDS, malaria and other diseases Targets 7 & 8: Halt and begin to reverse spread of AIDS, malaria and other diseases by 2015Targets 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. 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? 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 Health costs avoided Patient health seeking costs avoided Patient health seeking costs avoided Value of time saved (work, school) Value of time saved (work, school)  Results show: 80% of benefits come from time saved 80% of benefits come from time saved Assumes value of time at minimum wage, including school children. 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) 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.Source: Evans, Hutton and Haller “Closing the Sanitation Gap” OECD March 2004.

7. World Region Pop(m) Meeting sanitation MDG (annual figures, in US$ million) Cost-Benefitratio* HealthsectorTreatmentCostsavoidedPatientHealthSeekingCostsavoidedAnnual value of TimegainTotalbenefits* Sub-Saharan Africa 9681,1307212,87316,18310.6 Latin America 624514165,6957,32511.9 East Mediterranean & North Africa 37314865,1575,86528.5 Central & Eastern Europe 4606022,3812,50812.7 South and SE Asia 2,1621,378848,11211,1043.0 West Pacific (LDCs) 1,6731,645648,90511,6193.8 All regions 7,1834,95524451,52563,2696.6

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. 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. CBRsIRRs 3.028% 6.650% 12.064%

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

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

11. Sanitation and Diarrhea…the links 1. Diarrhea accounts for 1.8 million deaths per year; 90% are children (WHO). 2. 88% of diarrheal disease is attributed to unsafe water supply, inadequate sanitation and hygiene (WHO) 3. Improved sanitation brings about:  a 38% reduction in diarrheal diseases; and  a 32% reduction in diarrheal mortality, on average. 4. Hygiene interventions – including hygiene education and promotion of handwashing can lead to reduction of diarrheal cases by up to 45%. 5. 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. Fecal contamination is the main source of diarrhea infections …. Feces Future Victim Fluids Fingers Flies Fields/ Floors Sanitation Food HygieneWater supply

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 Enabling Environment Policy improvement Institutional strengthening Community organization Financing and cost recovery Crosssector & PP partnerships Diarrheal Disease Prevention

15. Alternative approaches to Sanitation Improvement Investment cost USD/capita Recurrent cost USD/capita Recurrent cost source Sewerage450 Very high Fees + household Sewer connection 150High Fees + household Small bore 60Medium Fees + household Septic tank 100HighHousehold Pour-flush50 Medium / Low Household VIP50LowHousehold Pit latrine 25LowHousehold Hygiene education 10LowHousehold –Source: SIWI, 2000

16. Possible Allocation of Responsibilities Responsibility share for urban sanitation IndividualCollective HouseholdBlocksCommunityAuthority Latrines Construction O&M Construction O&M Construction O&M Promotion Regulation Septic tanks Construction Emptying Construction Emptying Disposal Emptying Disposal Simplified sewerage Connections Construction O&M Construction O&M Small bore sewerage Septic tank construction Septic tank construction Construction O&M Construction O&M Conventional sewerage Connections Construction O&M 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 Raising awareness at all levels: household, community and national leaders of sanitation’s importance Improve household practices Improve household practices Water treatment – boiling, chlorination, in the home for untreated waterWater treatment – boiling, chlorination, in the home for untreated water Hand washing (with soap), personal hygiene, food handlingHand 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. 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 sewerageFocus on low cost improvements– latrines, septic tanks, 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 areas).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)In dense urban areas, develop community/block based simple sewer systems with heavy community involvement (condominium approach) Improve the regulatory framework – set appropriate standardsImprove the regulatory framework – set appropriate standards Organize/Coordinate stakeholders--Include government and non-government actors Organize/Coordinate stakeholders--Include government and non-government actors Public sector --health, public works, environment, water/sanitation institutions, planning, financePublic sector --health, public works, environment, water/sanitation institutions, planning, finance Private sector – NGOs, women’s groups, business groups, householdsPrivate sector – NGOs, women’s groups, business groups, households International – foreign donors, IFIsInternational – foreign donors, IFIs

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