Arsenic in Bangladesh

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					“Fighting arsenic poisoning in Bangladesh
 through partnerships, research and
 education – the World Bank perspective”

                                             Carter Brandon
                               Lead Economist, World Bank
Prepared for presentation at “Arsenic in Drinking Water: An
          International Conference at Columbia University”,
                              New York, November 27, 2001
History of World Bank Involvement in
        Arsenic in Bangladesh
 • No World Bank involvement in rural water supply until
   the late 1990s.
 • Bangladesh Arsenic Mitigation Water Supply Project
   (BAMWSP), approved in 1998 and co-financed with the
   Swiss Development Corporation.
 • Project design uncertainties included:
    – Prevalence and distribution of Arsenic
    – Field testing methods
    – Methods for providing safe water
       BAMWSP – Components

• Testing and Mitigation
  – Screening of tubewells
  – Provision of safe water sources.
• Improving Understanding
  – Assessment of technologies;
  – Hydrogeological investigation;
  – Patient identification and management.
• Strengthening Capacity
  – Awareness raising in affected communities;
  – Local Government Arsenic Committees;
  – Training of health personnel.
   BAMWSP Status - Testing
• 249 subdistricts (thanas or
  upazilas) known affected
• 3 phases under BAMWSP
   1 - 6 upazilas (~1999-2000)
   2 - 35 upazilas (~1999-2001)
   3 - 147 upazilas (~2001-2002)
   (Total of 188, or 75% of total)
• Project will cover a total
  of 188 subdistricts, or
  75% of those affected
• 3rd phase complete in 2002
• Remaining upazilas
  covered by other programs
   BAMWSP Status - Mitigation
• Offered where > 40%
  tubewells affected
• Community chooses:
   –   Deep tubewell (in coastal areas);
   –   Dug well;
   –   Pond sand filter;
   –   Rainwater harvesting;
   –   Removal technologies on
       experimental basis (to be
       expanded after verification)
• Mitigation already underway
  in phase 1 subdistricts
• All subdistricts completed
  mid 2002
             BAMWSP Status –
          Improving Understanding
• Assessment of test kits and household
  arsenic removal technologies:
   – Rapid Assessment – completed
   – Technology Verification Program at the
     Bangladesh Centre of Scientific and
     Industrial Research, by mid-2002
• Hydrogeological investigation –
  Groundwater Task Force developing
  strategy for implementation in 2002
• Arsenic patient identification and
  management – international
  conference in January, 2002
            BAMWSP Status –
          Strengthening Capacity
• Awareness raising during
  screening and through
  electronic media
• Building capacity of local
  government arsenic
• Training of health
• Support for technology
  verification program
              BAMWSP Status –
          Institutional Arrangements
• National level:
   – Inter-ministerial Task Force and Secretaries’ Committee guides multi-
     sector response
   – Arsenic Policy Support Unit in Local Government Division coordinates
     programmatic approach
   – Arsenic Donor Coordination Unit coordinates development partners’
• Local level:
   – NGOs acting as training and support organizations to build local capacity
   – Local Government Arsenic Committees coordinating local response
   – Community-Based Organizations being assisted to develop action plans
     responsive to local requirements
     BAMWSP Issues and Lessons
• A common problem in many projects in Bangladesh is slow or poor
• BAMWSP is no exception. It has disbursed less than 25%, while it’s
  more than 75% into the project period. Why?
   – Many unknowns: little consensus on what to do.
   – Lack of test kits of an appropriate design.
   – NGOs and local government institutions were not sufficiently involved from
     the outset.
   – The independent project management Unit (PMU) did not get broad support.
   – Some corruption-related delays.
   – Inter-agency turf problems, reducing bureaucratic motivation and
   – Constrained role of private sector in addressing mitigation.
             BAMWSP – Mid-Course
• In response, the government of Bangladesh has:
   – restructured project management, including appointment of a
     new authority to assess quickly arsenic removal technologies.
   – strengthened inter-agency and donor coordination.
   – broadened its partnerships with local government, community
     organizations, and NGOs – particularly larger NGOs who were
     less involved early on in BAMWSP.
   – improved communication with the general public.
   – Initiated a new Bank-financed project on the health aspects of
  World Bank Arsenic Public
  Health Project (proposed)

• Duration: 2002 – 2006
• Components:
  1. Public education
  2. Provider education
  3. Epidemiological
  4. Case management
    Arsenic Public Health Project:
    Public Education Component
•   National in scope
•   Use all media sources
•   Parallel to BAMWSP program
•   Educate about:
    –   Testing and color coding
    –   Health effects
    –   Treatments
    –   Water alternatives
    –   NOT contagious
    –   NOT treatable with folk remedies
• Coordinate with water testing
   Arsenic Public Health Project:
  Provider Education Component
• National in scope
• Education to
  providers at all levels
• Add to medical school
• Patient counseling
Arsenic Public Health Project:
    Research Component

• Expert steering committee
• Foster rapid research and
  dissemination without excessive
• Topics of interest:
   –   Incidence, prevalence,
   –   latency, dose-response
   –   Predictive value of skin lesions
   –   Risk factors
   –   Treatment, reversibility
    Arsenic Public Health Project:
    Case Management Component
• Scope undetermined
• Must be consonant with the ongoing Health and Population Sector
  Program (multi-donor)
• Arsenic objectives will be kept in perspective with all other health
  threats and public health programs. (For example, annual health
  expenditure = $3.47 per capita per year. Arsenic programs will be
  scaled commensurate with incidence and risk.
• Arsenic programs to be integrated with other MoHFW programs by
  end of project.
     Policies and institutions must work
     despite lack of crucial information
Unknowns related to WATER Unknowns related to HEALTH

1. prevalence of contamination      1. prevalence and distribution of
2. changes over time                cases
3. methods of removing arsenic      2. latency periods and incidence
from well water                     rates
4. potential for contamination of   3. predictive value of skin lesions
deep aquifer                        4. dose-response relationship
5. safety of irrigated crops        5. factors affecting susceptibility
6. safe disposal of arsenic-rich    6. effective treatments and role of
sludge                              nutrition
                                    7. reversibility of disease with safe
Conclusions and Lessons Learned (1)
1. Priority-setting. Adaptive management is essential in the face of
   uncertainties: and the need to use research, learning and
   dissemination to constantly shape priorities.
2. The centrality of education. Prevention is key – which requires
   education of both the general population and service providers.
3. Coordination matters. Proper sequence of awareness and
   availability of alternatives to limit panic/frustration under control.
4. The media. The media has played an important and constructive
   role in keeping arsenic in the forefront of public concern.
Conclusions and Lessons Learned (2)
5. Financial flows: look at cost recovery, demand-responsive
   approaches, and the mandate of government vs. NGO vs. private
   sector agencies involved in testing and mitigation.
6. Balance “community-driven development” with local skills:
   “The arsenic problem will serve as a major driving force for the
   administrative decentralization program of the government.”
   But this has also slowed down the arsenic response mechanism.
   The right balance between expediency and optimality may differ
   by region, depending on local circumstances.
7. Technology: gaining the socio-economic acceptance of new
   technologies is harder than developing the technology itself.
Conclusions and Lessons Learned (3)
8. NGOs and Community Based Organizations: involvement of
   local CBOs is essential, and must be built up over time through
   partnerships with national NGOs and others. Government should
   not try to build up local organizations by itself.
9. Sustainability: Local institutions must pick up when outside
   financing dries up. “Ultimately, it is up to the communities
    Final note: the role of the World Bank
1. Provider of financing – necessary but not sufficient.
2. Can help broaden the scope of arsenic programs – involving not just
   Water Supply and Health agencies, but Ministries of Finance,
   Planning, Education and Information.
3. Facilitator of process to develop a national arsenic strategy.
4. Can offer expertise in economics, capacity-building, and
   international experience.
5. Can help leverage NGO, donor, or international partnerships.

•   Bottom line for the World Bank: “Fighting arsenic poisoning
    through partnerships, research and education” and not simply
    “Fighting arsenic poisoning through more financing.”