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Improving Access to Safe Water and Sanitation Improving access to safe water, sanitation, and basic health services is crucial for the absorption of nutrients that are consumed. Thus it is crucial that efforts to improve diets are combined with improvements in access to safe water, sanitation, and health care. Since issues of access to health care are complex and need to be treated separately, we focus here on outlining the nature of the gaps in access to safe water and sanitation, and the policy priorities for closing these gaps.
Impact of access to safe water and sanitation on malnutrition Unsafe water and unhygienic sanitation practices result in several infectious diseases, most notably diarrhoea and soil-transmitted helminths (STH, worms). Compounded by the lack of access to basic health services, diarrhoea and STH severely reduce the absorption of nutrients that are consumed. Unsafe water and poor sanitation cause a number of other infectious diseases which increase the need for nutrients and diminish appetites. In the worst situations, malnutrition and diarrhoea can form a vicious cycle as a malnourished person becomes more susceptible to infections and the diseases become more persistent.
There is strong empirical evidence of the adverse impacts of lack of access to safe water and sanitation on health and malnutrition. Pruss-Ustun et al. (2004) estimated that, in 2000, unsafe water, sanitation, and hygiene accounted for 1.73 million deaths and 88 percent of the total burden of infectious diarrhoea. In a systematic review of studies of the impact of improvement in access to safe water and sanitation on the morbidity of different diseases, Esrey et al. (1991) found that improvement in access to water and sanitation accounted for a median of 26 percent reduction
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in the incidence of diarrhoea. In a detailed study of eight Sub-Saharan countries, Esrey (1996) found that improvements in access to safe sanitation resulted in taller and heavier children. Interestingly, Esrey (1996) found that improvements in water supply influenced the incidence of diarrhoea and nutritional outcomes only when accompanied by improvements in sanitation and when safe water was available from a source on the household premises. Smith and Haddad (2015), in a detailed econometric assessment of the determinants of decline in child stunting using data for 116 developing countries for a forty-two-year period between 1970 and 2012, found that improvements in access to safe water and sanitation accounted for about 38 percent of the decline in prevalence of child stunting during that period.
Gaps in access to safe water and sanitation Gaps in safe water supply to household premises and access to improved sanitation are large. Globally, expansion of access to improved sanitation – which often goes hand in hand with expansion of the availability of water on household premises – remains the more widespread problem of the two.
According to the latest statistics available from the WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation, for 2012, about 2.5 billion people all over the world did not have access to improved sanitation practices (Table 5.2), while 750 million persons did not have piped water on the premises of their homes (Table 5.1). Expanding access to safe drinking water and improved sanitation has been much more difficult for rural populations. In 2012, over 80 percent of the people who did not have access to safe water supply in their household premises, and over 70 percent of those who did not have access to improved sanitation lived in rural areas.
A total of 325 million persons or over 40 percent of the population of Sub-Saharan Africa did not have access to piped water on their premises.
The region is expected to miss the MDG target of halving the proportion of people without access to safe drinking water. About 150 million people in South Asia, 114 million in East Asia, and 67 million in Southeast Asia lacked piped water supply to home premises (Figure 5.1). Of the global population who did not have access to improved sanitation, about 67 percent lived in Asia and about 26 percent in Sub-Saharan Africa (Table 5.2 and Figure 5.2). South Asia, and in particular India, has made very slow progress in expanding sanitation (Box 5.1).
Access to Safe Water and Sanitation 75 Table 5.1 Number of persons and proportion of population not having access to piped water on premises, by region, 2012 (million and percent)
Box 5.1 Sanitation and Malnutrition in India Lack of safe sanitation is a problem of enormous proportions in India.
According to the latest statistics from the WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation, India alone accounted for 31 percent of the world’s population without access to improved sanitation.
According to the 2011 Census of India, only 44 percent of Indian households had improved sanitation facilities. Among rural households, this proportion was a dismal 28 percent. With lack of toilets and water on household premises, open defecation is widely prevalent in India (Table 5.3).
The availability of sanitation facilities in public spaces is also very poor. In 2013–14, about 13 percent of India’s schools had no toilets (NUEPA, 2014).
Lack of sanitation has important gender and social dimensions. Lack of sanitation facilities at home specifically inconveniences women, exposes them to the worst forms of sexual violence, and harms their health even more than for men (Kulkarni, O’Reilly, and Bhat, 2014; Sharma, Aasaavari, and Anand, 2015). National statistics also show continued disparities in access to sanitation across caste and social groups (Chawla, 2014; Singh, 2014;
Swaminathan and Singh, 2014; Thorat, 2009). In a detailed sociological study of determinants of access to basic amenities in rural India, Singh (2014) shows that social exclusion in rural India, particularly as seen in the segregation of residential areas among different social groups, and continued economic differences contribute to continued social and caste disparities in access to sanitation, safe drinking water, and other basic amenities.
Statistical evidence shows that poor access to safe water, sanitation, and hygiene are major determinants of nutritional outcomes in India. Detailed statistical analysis by Spears (2013) showed that “open defecation can account for much or all of excess stunting” among children in India.
There is also a huge gap in the access to safe drinking water. According to data from the 2011 Census of India, only 32 percent of Indian households had access to tap water from a treated source. Lack of a safe water source on household premises is a major factor behind the large proportion of Indian households not being able to use safe sanitation facilities. As shown in Figure 5.4, there is a large overlap in regions that have performed poorly in terms of access to sanitation and water.
The national government in India has introduced specific programmes to tackle the problem of sanitation since the mid-1980s. These programmes have mainly focused on providing financial support for the construction of toilets and activities to raise public awareness. Despite a significant increase in public expenditure (Figure 5.3), these programmes have only had limited success in expanding access to safe sanitation. A recent study shows that a significant proportion of toilets constructed under the Total Sanitation Programme, a flagship programme of the national government in the area of sanitation, have ceased to exist and are not in use (Kumar, 2015). In a review of the Total Sanitation Programme, Hueso and Bell (2013) found that “only one in five latrines reportedly constructed since 2001 were in place in 2011. The rest either had become unusable due to bad construction quality and lack of maintenance, or were not fully built in the first place.” Lack of synergy Access to Safe Water and Sanitation 79 between rural water supply programmes and rural sanitation programmes, inadequate emphasis on awareness-building and hygiene education, and lack of community participation have been identified as the main reasons for the lack of success of public sanitation programmes in India.
Table 5.3 India: Proportion of households by different types of sanitation facility, 2011 (percent)
Figure 5.3 India: Per capita public expenditure on water and sanitation, 1992–93 to 2010–11 (ppp US$) Policy lessons from past experiences Access to improved sanitation is closely related to the development of public infrastructure for drainage, waste treatment, and waste disposal.
In most developing countries, rural sanitation programmes have focused on promoting solutions based on safe on-site sewage disposal because of the impracticality of centralized effluent sewage disposal. Further, the need to 80 Ending Malnutrition Figure 5.4 India: Proportion of houses without access to a water source and toilet on premises, 2011 (percent) Note: Map plotted using Gall-Peters projection.
Source: Based on data from the Census of India, 2011.
keep costs low has meant the use of low-cost materials that typically are difficult to maintain and clean, thus frustrating the adoption of improved sanitation. Although several technical solutions have been proposed and attempted, the difficulties in maintaining and cleaning low-cost toilets remain an important barrier to widespread adoption of improved sanitation.
In addition, as shown in Figure 5.5, access to improved sanitation is also closely related to supply of piped water to household premises. In general, the existence of piped water supply is a prerequisite for improved household sanitation. Some countries, however, have managed to break this barrier. As shown in Figure 5.5, Sri Lanka, Vietnam, Myanmar, Marshall Islands, Rwanda, and Bangladesh are particularly noteworthy for having achieved significantly above-average levels of access to improved sanitation despite relatively limited access to piped water supply. The figure also shows that, while most high-income countries have good access to piped water on household premises and improved sanitation, several countries have made significant progress in providing access to piped water and improved sanitation despite low per capita income levels.
Access to Safe Water and Sanitation 81 Figure 5.5 Relationship between proportion of population having access to piped water on premises, proportion of population having access to improved sanitation, and per capita income across countries, 2012 Note: Points for different countries have been sized according to the per capita GDP of the country.
Source: Based on 2012 data from WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
A large body of empirical literature from across the world has found a significant positive impact of education, in particular women’s, on the adoption of improved sanitation. Policymakers, civil society activists and researchers have all highlighted the importance of building awareness for improving sanitation.
In recent years, an alternative approach called Community-led Total Sanitation (CLTS) has been implemented in many countries. Having its origin in a micro-level programme in Bangladesh, CLTS was mainstreamed by the Water and Sanitation Programme (WSP) led by the World Bank, and 82 Ending Malnutrition implemented in twenty-five countries across Asia and Africa. Since the early 1990s, the WSP started to move away from supporting public programmes that provided subsidized toilets to households without toilets. It started supporting CLTS programmes since the early 2000s, and adopted CLTS as the main approach for sanitation programmes by the end of the decade.
CLTS is based on the idea that lack of adoption of improved sanitation in a community is not due to economic deprivation or exclusion from public services, but because of the unwillingness of people to stop defecating in the open. Proponents of CLTS have argued that public support for providing toilets is ineffective and should be substituted by community-level interventions to bring about behavioural change, while putting the onus of mobilizing resources for constructing sanitation facilities on the households themselves (Kar and Chambers, 2008; Kar and Pasteur, 2005; Robinson, 2005; Sanan and Moulik, 2007). In a major study on why progress in adoption of improved sanitation in India has been slow, Coffey et al. (2014) claimed that people prefer open defecation because they find it “pleasurable”.
There are two aspects of the strategy adopted by the CLTS programmes implemented in various countries. First, under these programmes, behavioural change is brought about by exposing persons practising open defecation to shame, public humiliation, and various kinds of punishment.
Monetary fines and humiliating punishments like forcing the offenders to clean public places are imposed on those who engage in open defecation.
These are expected to humiliate and coerce people to build toilet facilities, and to stop defecating in the open. Secondly, it is argued that people value and use toilets only if they pay for building them. Toilets built with public subsidies lie unused because people do not value them and see no benefit in using them (Sanan and Moulik, 2007). Thus, no public support is provided for the construction of toilets, existing programmes that provide financial support are to be discontinued, and households are to mobilize their own resources for the construction of toilets. In sum, under CLTS, the focus of intervention is on preventing the practice of open defecation, so that people are left with no choice but to find resources to build toilets for themselves.
Evidence suggests that economic progress does not automatically translate into improved sanitation. Experience from sanitation programmes across the world shows that mere provision of funds for the construction of low-cost toilets is not sufficient for the adoption of improved sanitation.
However, the fact remains that the vast majority of those who lack improved sanitation are poor, have low levels of educational attainment, and do not have access to public infrastructure for water and drainage on their household premises. Hence, their inability to have or to use a toilet has to be seen as a deprivation and a failure of entitlements rather than as an exercise of freedom.