Safer Water, Better Health

The World Health Organization has just published Safer Water, Better Health: Costs, Benefits and Sustainability of Interventions to Protect and Promote Health by Annette Prüss-Üstün, Robert Bos, Fiona Gore and Jamie Bartram. It’s a good read – but also disturbing as “Almost one tenth of the global disease burden could be prevented by improving water supply, sanitation, hygiene and management of water resources”.

Table 1 on page 12 (pdf page 16) in Safer Water, Better Health gives a summary of the situation in 2002 (country-by-country information is given in Annex I). In developing countries there were 2.4 million deaths in that year due to inadequate domestic water supplies, sanitation and hygiene (5.5% of total deaths). This is in huge contrast to the number in industrialized countries where there were only 24,000 deaths due to inadequate domestic WSH (0.2% of total deaths).

Globally children under 15 suffer most, with just over 2.2 million deaths in 2002 due to inadequate domestic WSH (nearly 19% of all U15 deaths). This really means that governments that don’t invest in WSH for all their citizens are effectively killing nearly one in five of their children under the age of 15 – every year. I think bald statements like this are becoming necessary to kick-start some governments into action − you always have to talk louder to those who are deaf or choose not to hear.

Sanitation governance

First of all, what is ‘governance’? This seems to be a valid question, especially if you read the new World Bank blog on the subject − one of the first postings was essentially an answer to this question: What we talk about when we talk about governance. The World Bank also has a helpful Knowledge in Development Note on Governance (2007) and a very informative Governance and Anticorruption website.

The UK Department for International Development (DFID) in its 2006 White Paper Eliminating World Poverty: Making Governance Work for the Poor is a little more specific (page 22):

So what is good governance? Good governance is not just about government. It is also about political parties, parliament, the judiciary, the media, and civil society. It is about how citizens, leaders and public institutions relate to each other in order to make change happen. Elections and democracy are an important part of the equation, but equally important is the way government goes about the business of governing. Good governance requires three things:
• State capability – the extent to which leaders and governments are able to get things done.
• Responsiveness – whether public policies and institutions respond to the needs of citizens and uphold their rights.
• Accountability – the ability of citizens, civil society and the private sector to scrutinise public institutions and governments and hold them to account. This includes, ultimately, the opportunity to change leaders by democratic means.

So how does all this relate to sanitation? Democracy is good for your health (see 2004 article in the British Medical Journal here), but we know that even in good democracies (Tanzania, for instance) there’s not 100% sanitation coverage. Has anyone done any work on sanitation coverage in democracies and non-democracies in Sub-Saharan Africa, for example? Now we have the JMP report A Snapshot of Sanitation in Africa, this shouldn’t be too difficult. I’ll try to find time to have a go over the next few weeks.

The DFID White Paper also has this to say (page 21):

Effective states and better governance are essential to combat poverty. States which respect civil liberties and are accountable to their citizens are more stable, which in turn means they are more likely to attract investment and generate long term economic growth. They can also cope better with calamities. Famines, for example, are less likely where there is a free media, because the press creates pressure on governments to provide relief. Unless governance improves, poor people will continue to suffer from a lack of security, public services and economic opportunities.

So could a free press and free radio/television improve sanitation coverage by shaming the government into action? Well, if it was a really sustained attack on the lack of sanitation coverage, it might, just might. But this would take a committed journalist to champion the cause and a supportive editor. I wonder what success rates vigorous environmental organizations, like the Centre for Science and Environment in India, have had in influencing and changing government policies.

The Water Research Group at the University of Bradford, UK, works on water governance in developing countries (see, for example, Water Governance and Poverty: What Works for the Poor?), but there’s not a lot on sanitation on their website. Maybe what’s good for water governance is also good for sanitation governance?

And what can be done in the ‘bottom billion’ countries? [See The Bottom Billion: Why the Poorest Countries are Failing and What Can Be Done About It (by Professor Paul Collier of the University of Oxford, OUP, 2007) – one of the best books you’ll ever read.]

ASKNet − The African Sanitation Knowledge Network

This should be a really good idea as the goal of ASKNet is “To enhance the ability of academics and professionals across the disciplines to contribute to the mainstreaming and up-scaling of sustainable sanitation in Sub-Saharan Africa, to the benefit of livelihoods, health, and the environment.” Although ASKNet was launched at AfricaSan2008 in February (see blog of 21 February), the ASKNet website is virtually empty. I don’t know why this is – but you might get an inkling of the reason(s) if you read the rather complex ASKNet by-laws (and you’ll see you have to pay to join). Then, if you read the small print, you’ll notice that the website is maintained by EcoSanRes and the by-laws emanate from WASTE – both EcoSan-oriented organizations. A cynic might wonder if ASKNet is just meant to be another way of promoting EcoSan in Africa ...

Well, I reckon a better way of getting knowledge on low-cost sanitation alternatives to ‘academics and professionals’ is through free websites like mine! Of course, there’s the ‘digital divide’ to consider and I admit I haven’t solved this yet. Maybe via the eGranary Digital Library (School of Library and Information Science at the University of Iowa). I’ll have to look into this.

The African Union and WatSan targets

The ‘Eleventh Ordinary Session of the Assembly of the African Union’ is going to take place in Sharm El-Sheikh, Egypt, on 30 June and 1 July and its theme is ‘Meeting the Millennium Development Goals on Water and Sanitation’. The draft Assembly Agenda for this includes (a) introductory remarks by the Commissioner for Rural Economy and Agriculture (it doesn’t say who this is and the AU website doesn’t tell you either); (b) remarks by the Chair of the United Nations Secretary General’s Advisory Board on Water and sanitation (again it doesn’t say who this is, but we all know it’s HRH the Prince of Orange); (iii) presentation of the Theme by H.E. President Mubarak of Egypt (let’s hope he’s properly briefed!); and (iv) a presentation by an unidentified representative of Civil Society – all followed by a debate. So, all in all, a very good agenda item. Will it bring results? Let’s hope it does as Africa definitely needs results, especially sanitation results. Watch this space for the outcome of this AU meeting.

FAO & IFAD: Water for the Rural Poor

The joint FAO/IFAD report Water and the Rural Poor: Interventions for Improving Livelihoods in Sub-Saharan Africa has just been published. Sanitation is mentioned a few times and the report does say that “improvements in water supply alone are unlikely to have positive health impacts unless sanitation practices are also improved. Optimal intervention programmes include improvements in water volume, water quality, and sanitation practices” (page 57), but nowhere in the report is there mention of any specific sanitation system(s). I thought this was a bit odd, especially given the success of Arborloos in parts of Sub-Saharan Africa and IFAD’s enthusiasm for agroforestry (see blog 1 and blog 2 of 6 April), so at least a Box on Arborloos would have been helpful. Time, I think, for these good agencies to wake up to Arborloos!

Why WatSan projects fail

I’m in Cali, Colombia, for a few days before going to Bogotá next week to lecture. So I’m working with colleagues at the Instituto Cinara, Universidad del Valle, and this reminded me of a finding by Dr Ines Restrepo when she was doing her Leeds PhD (her thesis is here). She found that the two main reasons why WatSan projects fail were that (1) local government engineers simply don’t have sufficient technical knowledge about available WatSan options for the poor; and (2) that, because they’re not well paid, they commonly have a second job and as a result they don’t pay as much attention as they should to their local government job − the consequence of this is that they often don’t spend their budget allocation till late in the financial year, so they spend it badly. All sound familiar?

I’ve said it before and I’ll say it again: how are we going to get the knowledge needed to those who need it? If we don’t, then there’s very little chance that the MDG sanitation target will be met. It’s time knowledge transfer was taken much more seriously – the theme of the April 2008 issue of Waterlines (also here) is ‘Knowledge Sharing’, so this is a good start, but much more needs to be done. When will the agencies with all the money finally wake up to this? (A cynic might reply ‘on 1 January 2016’.)

The Hesperian Foundation

Now here’s a sensible publisher: the Hesperian Foundation (based in Berkeley, California), “a non-profit publisher of books and newsletters for community-based health care”, publishes many of its books in pdf format for free download – visit its Online Library. Have a look at A Community Guide to Environmental Health (by Jeff Conant and Pam Fadem, 2008), especially Chapter 7: Building Toilets, and Sanitation and Cleanliness for a Healthy Environment (by Jeff Conant, 2005). Hesperian also has a good blog here.

Slum Networking in India

‘Slum Networking – Transcending Poverty with Innovative Water and Sanitation Paradigm’ was one of the three winning projects, all from India, announced last month by Changemakers.net. Slum networking is the brainchild of civil engineer Himanshu Parikh; it’s simply fantastic − basically simplified sewerage and more, much more. The cost per household in September 2006 was INR 16,000 (around USD 350) and this paid for individual household sewerage and water supply connections, stormwater drainage, a solid waste bin and landscaping. The sewerage component was INR 6000 − basically a bargain! Invest in the slums and the slums will repay you many times. Well done Himanshu, slum networker par excellence.

Regional Conference on IYS2008, Trinidad

The Regional Conference on IYS2008, organised by the Trinidad & Tobago Water and Sewerage Authority and the Solid Waste Management Company took place in Port of Spain during 2−4 June. Nice conference logo:


Access to ‘improved’ sanitation in Trinidad and Tobago was 100% in both urban and rural areas in 2006, according to the JMP sanitation report for the country. However, in urban areas sewerage coverage is only 19%, with most of the rest on septic tanks and soakaways. Just under a third of the population is served by pit latrines and, while these may represent ‘improved’ sanitation access, it’s likely that many don’t represent ‘adequate’ access (see blog of 14 January). There are also substantial, but not insoluble, problems with wastewater, especially small treatment plants which malfunction either because they’re overloaded or because of inadequate operation and maintenance. So there’s work to be done – but a start has already been made: details here.

Monday 2 June
The opening ceremony dominated the morning. I was invited to give the “feature address” – on sanitation options for the urban and rural poor (a presentation similar to that given in Wageningen). [This was followed by a DVD on endangered animal species – somewhat curious you might think, and you’d be right (but good for jet lag recovery).] In the afternoon there were two presentations – one was an overview of wastewater management in Trinidad & Tobago, the other an economist’s approach to waste management.

Tuesday 3 June
Another opening presentation by me – this time on wastewater management (sewer connection charges, appropriate wastewater treatment, compliance with the Aruba Protocol, reuse). Another DVD – this time on climate change (certainly more relevant than the one shown yesterday). In the afternoon there was a very interesting presentation by Mr David Wilk of the Inter-American Development Bank on IDB’s Sustainable Energy and Climate Change Initiative (applicable to sanitary landfills but also to biogas toilets – see blog of 31 January).

Wednesday 4 June
Two opening addresses: one by the representative of the Minister of Local Government mostly about improved solid waste management, and the other by the Hon. Mustapha Abdul- Hamid, the Minister of Public Utilities, who spoke about the importance of water and wastewater, noting that the government recognises the “great value in wastewater” and that the high-quality treated wastewater from Port of Spain was considered a “NEWater” (rather like in Singapore) which is to be used mostly by local industries but also to a more limited degree in agriculture. The Minister also talked about plans for universal water metering (which should lead to a better charging system for sewerage as well), the need to reduce unaccounted-for water from its current level of ~40% to a target of 25%, and the need to sort out problems with existing septic tank systems and latrines. Overall a really good speech!

Not so much in the late morning or afternoon – at least on sanitation. Conference dinner tonight and fieldvisits tomorrow.

U5 diarrhoeal disease deaths

Just published on-line in the Bulletin of the World Health Organization: Estimating child mortality due to diarrhoea in developing countries: a meta-analysis review. The main findings were “Global deaths from diarrhoea of children aged less than five were estimated at 1.87 million (95% confidence interval, CI: 1.56–2.19), approximately 19% of total child deaths. WHO African and South-East Asia regions combined contain 78% (1.46 million) of all diarrhoea deaths occurring among children in the developing world; 73% of these deaths are concentrated in just 15 developing countries.”