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Poverty, Health and
Sanitation –
The Case for More Investment
in Sanitation
Norman Hicks/Derko Kopitopoulos
February 2006
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
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?
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.
What is Improved Sanitation?
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.
Meeting sanitation MDG (annual figures, in US$
million)
Health Patient
sector Health Annual
Pop Treatment Seeking value of Cost-
(m) Costs Costs Time Total Benefit
World Region avoided avoided gain benefits* ratio*
Sub-Saharan Africa 968 1,130 72 12,873 16,183 10.6
Latin America 624 514 16 5,695 7,325 11.9
East Mediterranean &
North Africa 373 148 6 5,157 5,865 28.5
Central & Eastern
Europe 460 60 2 2,381 2,508 12.7
South and SE Asia 2,162 1,378 84 8,112 11,104 3.0
West Pacific (LDCs) 1,673 1,645 64 8,905 11,619 3.8
All regions 7,183 4,955 244 51,525 63,269 6.6
Cost-Benefits and Economic Rates
of Return
CBRs are equivalent
to high internal rates CBRs IRRs
of return
A Cost-benefit ratio of 3.0 28%
6.6 is equivalent
(roughly) to an 6.6 50%
internal rate of return
of 50%--higher than 12.0 64%
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.
Benefits from sanitation go
beyond health…
Education
Sanitation Infrastructure
No visual, no adverse odor
Natural resources preserved
No fecal contamination Privacy - Security
Less ponding water Less grit
Gender sensitivity
Less erosion
Religious, cultural
Less WS pollution
Environment Operations Social
Tourism Less treatment Social
Less diarrhea (90%) Fisheries Less maintenance Girls Cohesion
Less aneamia, blindness Reuse
at school
Less dengue, malaria Collective
action
Time availability
Other community
Less medical costs
activities
Health Economy Community
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
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
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.
Fecal contamination is the main source of diarrhea
infections ….
Water supply
Sanitation Fluids Hygiene
Fingers
Feces Food Future
Victim
Flies
Fields/
Floors
Health Improvement Framework
Access to Hardware Hygiene Promotion
Water supply systems Communication
Improved sanitation facilities Social mobilization
Household technologies Community participation
● Soap Social marketing
● Safe water containers Advocacy
Diarrheal Disease Prevention
Enabling Environment
Policy improvement
Institutional strengthening
Community organization
Financing and cost recovery
Crosssector & PP partnerships
Alternative approaches to
Sanitation
Improvement Investment cost Recurrent cost Recurrent cost
USD/capita USD/capita source
Sewerage 450 Very high Fees + household
Sewer connection 150 High Fees + household
Small bore 60 Medium Fees + household
Septic tank 100 High Household
Pour-flush 50 Medium / Low Household
VIP 50 Low Household
Pit latrine 25 Low Household
Hygiene education 10 Low Household
–Source: SIWI, 2000
Possible Allocation of
Responsibilities
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
Key: primary responsibility secondary responsibility
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
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).
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
The End
