Water, Sanitation and Hygiene in Developing Countries: an HWTS perspective Jamie Bartram Water Institute University of North Carolina at Chapel Hill
Water, Sanitation and Hygiene in Developing Countrieshwts.web.unc.edu/files/2014/09/Keynote-Bartram-Water-Sanitation-and... · Water, Sanitation and Hygiene in Developing Countries:
Water, Sanitation and Hygiene in Developing Countries:
an HWTS perspective
Jamie Bartram
Water Institute
University of North Carolina at Chapel Hill
Outline
HWTS
• Context
• Why we need it
• Where we need it
• Some history
• Future outlook
Presenter
Presentation Notes
* Water = drinking water supply and quality, hygiene behaviors, sanitation, water resources … Global burden of disease - 9% of morbidity and 6% of mortality (Pruss-Ustun et al, 2008) Huge economic impact – an estimated 1-4 trillion dollars (2 – 7% of GDP). Water and sanitation interventions are cost effective across all world regions. These interventions were demonstrated to produce economic benefits ranging from US$ 5 to US$ 46 per US$ 1 invested (5). Drains health resources and reduces effectiveness of care – HIV, malaria, and increasing chronic disease burden Impact most felt by children – 90% of diarrheal disease is borne by children under five Philosophical approach: water as a human right; empowerment angle Major public health challenge for 21st century Historical perspective: The impact of clean water technologies on public health in the U.S is estimated to have had a rate of return of 23 to 1 for investments in water filtration and chlorination during the first half of the 20th century (4).
Annual cost of not dealing with water, sanitation and hygieneLives lost
• 1.6 million annually due to diarrhoea alone
• Especially children also malnutrition
Health care costs:
• USD7 billion per year to health agencies
• USD340 million to individuals
Value of time lost
• USD 63 billion per year
Economic impact
• estimated 1-4 trillion dollars (2 – 7% of GDP).
Presenter
Presentation Notes
Lets start with the punch line: Not dealing with water and sanitation costs. Worldwide: It costs millions of lives, * it costs billions of unnecessary dollars to hard stretched health care systems * it costs hundreds of millions to the individuals and families who can least afford it * and it costs time lost to economy and education that can be valued at tens of billions of dollars.
WaSH = disease and poverty ?
• Inadequate water supply
• Unsafe water resources
• Inequitable access
• Time, financial cost
• Disease burden
• Health care costs
POVERTY
Presenter
Presentation Notes
When I began working in this field I recall well a 'lecture' that I received in different forms on many occasions. It was almost a 'dominant paradigm'. In this the poor are forced to use distant and/or expensive sources of poor quality water, losing time and suffering ill health as a consequence; they eke out a meagre living often over-exploiting natural resources to which they have inadequate access and which by nature of their contamination and degradation undermine further the scant likelihood of the poor, and these factors are presented as trapping the poor in a vicious cycle. Science underpinned this paradigm. Scientific studies showed that the poor paid more for less access to water of inferior quality than the rich, did not benefit from regulatory systems which targeted the maintenance and improvement of the water supplies of the more privileged and the ill health itself and its effect on domestic economy were more severe for the poor which lacked resilience and had recourse to fewer coping mechanisms
Trends in use of an improved drinking-water source 1990 – 2008 and projections to 2015
Source: WHO and UNICEF, 2010. Progress on Sanitation and Drinking-water 2010 Update
199023% un-served
1.2 billion
2015 (projected)9% un-served
672 millionOut-perform target (12%)
Presenter
Presentation Notes
Turning to drinking-water, our indicators tell us that the world is ‘on track’ to meet the target In fact it is projected in 2015 there will be less than 700 million people without Represents 9% unserved - far better than 12% target
Drinking-water: on track Sanitation: off track
0,0
0,5
1,0
1,5
2,0
2,5
3,0
1990 2002 2015
Popu
latio
n (in
bill
ions
)
If on track to reach the MDG targetCurrent trend
1.9 bn
2.4 bn
2.7 bn
MDG goals: on or off-track?
Presenter
Presentation Notes
We all know the numbers: WATER: Currently 884 million people are still without access to an improved source of water. If we meet the target (and we are on track), 672 million will still be without an improved source of water. SANITATION: Even if we meet the MDG target, there will still be 1.7 billion people without access to basic sanitation. If the trend remains as currently projected, an additional billion people who should have benefited from MDG progress will miss out, and by 2015 there will be 2.7 billion people without access to basic sanitation.
And if we look at progress in access to drinking-water at household level we see a different story. In fact using this benchmark drinking-water is also badly off-track
Water lags sanitationSanitation Drinking-water
Current benchmarks Improved sanitation at home
61% servedMDG off track
Collect water from an improved source
87% servedMDG on-track
Household level benchmarks
Improved sanitation at home
61% served MDG off-track
Improved water at home
57% served MDG off track
Safe water at homeEven more off track!
Presenter
Presentation Notes
And if we look at progress in access to drinking-water at household level we see a different story. In fact using this benchmark drinking-water is also badly off-track
Wait in line?• Even the MDG target of ‘halving the unserved’
will leave large populations un- or under-served
• Because the numbers of un- or under-served are stagnant, the global burden of disease remains high
• The human right to water creates an imperative to directly tackle the circumstances of un- and under-served populations in all countries
• HWTS provides a tool to tackle both
WaSH = motor of development• Improved water supply
• Safe water resources
• Universal access
•HWTS where needed
• Time, financial savings
• Averted disease costs
• Health & education
Development
Presenter
Presentation Notes
I would like to look again at this figure and maybe turn it around a little. Investments in water and sanitation reduce disease and free time for productive activity and education. A healthier and more educated workforce benefits from time savings, reduced healthcare costs and contributes not only to household prosperity but also to national economy. Science also underpins this paradigm: We know that at household level improving water and sanitation improves health and increases the availability of time for school, work and leisure. And at macroeconomic level if we look at poor countries at comparable levels of per capita income, those with improved water supply and sanitation are reported to enjoy annual GDP growth of 3.7% compared to 0.1% in those without. Chinese authorities estimate that 1.3% of China's GDP is lost because of an average loss of 6.5 IQ points amongst 7 million children due to heavy metal contamination of water Historical perspective: The impact of clean water technologies on public health in the U.S is estimated to have had a rate of return of 23 to 1 for investments in water filtration and chlorination during the first half of the 20th century (4). Apart from seeing investing in water and sanitation as a motor for development, WHO interest arises especially because of the large impact of water, through health, on poverty and prosperity.
Who are the targets of HWTS?
The un-served, no?
Urban supplies +
strong regulation
Urban piped
supplies + weak
regulation
Rural piped
supplies
Rural poor Urban poorUnserved
(developed countries)
Water piped into house/onto plot; supply may be irregular, quality may be compromised
NB most (1.04M) in the developing world
Collect water from protected sources away from home
Collect water from protected sources away from home
Collect water from unprotected sources
0.75 billion people
1.77 billion1.24 billion people
1.59 billion people
0.58 billion people
0.87 billion people
Looking closer
Presenter
Presentation Notes
Let’s look a little closer at the breakdown. The majority of people who use HWT are not the ones who need it most (unserved). But if we can’t deliver watsan infrastructure, how can we deliver HWTS? It will take a significant amount of time to fill the infrastructure gap for all concerned. Where can HWTS best meet the current need?
Urban supplies + strong regulatio
n
0.75 billion people
Urban piped
supplies + weak
regulation
1.77 billion
Rural piped
supplies
1.24 billion people
Rural poor
1.59 billion people
Urban poor
0.58 billion people
Unserved
0.87 billion people
Improved system reliability, safety
Facilitating access to higher levels of service for households
Interim Household water Treatment and Safe Storage
Who are the Targets of HWTS?
Urban supplies + strong
reg’n
0.75 billion people
Urban piped
supplies + weak
regulation
1.77 billion
Rural piped
supplies
1.24 billion people
Rural poor
1.59 billion people
Urban poor
0.58 billion people
Unserved
0.87 billion people
Household Water Treatment and Safe StorageTarget group: 6 billion?
Organizing HWTS as a response
Early 2000s
§ Fragmented
§ Gaps in the knowledge
§ Lack of awareness of HWTS as interim response
§ HWTS Network created in 2003
Presenter
Presentation Notes
Multiple effective technologies and methods but no single “silver bullet” Lack of awareness of HWTS as interim solution and no way to disseminate HWTS Network created in 2003 to consolidate the movement and achieve greater gains and momentum
Some successes
2003-2009 – “Phase 1”
§ HWTS identity
§ Widespread international awareness
§ Acceptance of HWTS "potential"
§ Emergence of wide body of HWTS-related research
§ Development of national action plans
Region Total % Rural % Urban %
Western Pacific 66.8% 65.8% 68.0%
Southeast Asia 45.4% 42.2% 56.0%
Latin America & Caribbean 40.0% 36.8% 42.1%
Central and Eastern Europe 39.4% 33.4% 43.0%
Eastern Mediterranean 13.6% 10.4% 18.1%
Africa 18.2% 17.0% 21.0%
Use of HWT in developing regions
Source: Rosa & Clasen, 2010.
Presenter
Presentation Notes
Estimated 1.1 billion people from these middle- and low-income countries reported treating their water to make it safer to drink. However, not all used “adequate” methods to treat their water: Adequate methods: Boiling Chlorination Filtration Solar-driven Inadequate methods: Straining Settling The most popular methods were boiling, chlorination or straining.
Recent Network developments
The Network in 2010/ 2011
§ Recent JMP data estimate 1.1 billion people using HWT
§ New strategy developed with WHO/UNICEF as co-hosts
§ New resources focusing on direction, activities, comms
§ 90 organizations worldwide have recommitted
§ Upcoming meetings: Uganda, Cambodia, USA
Presenter
Presentation Notes
1st bullet - Recent JMP data estimate 1.1 billion people using HWT : based on Rosa & Clasen (2010) study, see more detailed results on previous slide.
Looking ahead
2011-2016 – “Network Phase 2”
§ Continue strengthening evidence base
§ Tangible results in the scaling up of HWTS globally
§ Policy advocacy and integrated environmental health focus
§ Dissemination and evaluation of best practice
Presenter
Presentation Notes
3rd bullet - Policy advocacy and integrated environmental health focus: --- this point refers to integration of HWTS with other household-level interventions such as solar cooking to improve indoor air quality and insecticide treated bed nets.
Challenges to scaling up
§ Belief that diarrhea is not a disease
§ Scepticism about effectiveness
§ Need for sustained behavior change
§ Public health suspicion of commercial agenda
§ Nay-sayers
§ Orphan status of HWTS at public sector level
§ Perceived conflict with public water supply
Presenter
Presentation Notes
These are selected from the new WHO/LSHTM/Clasen paper: Scaling Up Household Water Treatment Among Low-Income Populations, 2009 public health interventions among low-income populations—creating awareness, securing acceptance, ensuring access and affordability, establishing political commitment, addressing sustainability, etc. However, there are at least a few special constraints that HWTS must overcome before it can achieve scale. These include 1) the persistent belief that diarrhoea is not a disease; 2) scepticism about the effectiveness of water quality interventions; 3) special challenges associated with uptake, including low aesthetic appeal for consumables, high up-front cost, the need to replace components for durables and the need to continuously use the product, even in the face of disease through other transmission pathways; 4) public health suspicion of the agenda of commercial products and strategies; 5) the orphan status of HWTS at the public sector level, with neither the water sector nor the health sector willing and able to assume ownership of the intervention; 6) minimal public sector participation in the promotion of HWTS; 7) a lack of focused international effort and commitment to advance HWTS; and 8) perceived policy conflict with efforts to promote piped-in water supplies.
Who?
• WaSH intervention
or
• Health intervention?
• Right to Water and Right to health change perspective
Health Sector Involvement in WaSH
S Health professionals see WaSH as importantS 2007 BMJ survey participants hailed sanitation as
the most important medical milestone since 1840
S BUT do not see relevance to day-to-day workS (informal but consistent feedback)
S Key Questions:SWhat roles can health systems play to effectively
advance WaSH? S Does HWTS offer a natural entry point for greater
health sector engagement?
Sources: Ferriman, 2007; Bartram and Platt, i2010
Health Sector Functions in WaSH
Rehfuess, Bruce and Bartram, 2009
Five Key Capacities for Health
Sector Functions
Source: Bartram and Platt, i2010
… and beyond?
Success factor Status Remarks
Accepted and validated?
+/-Continue strengthening
evidence base (RCTs and more)
Regulated? ûWHO Guidelines in progress
(Sobsey & Brown)
Monitored? ûMore M&E needed
especially at grassroots
Adopted? ~ Post-MDG policy integrationNational policies for scale-up
Presenter
Presentation Notes
2015 is “tomorrow” For HWTS to mature, the following needs to happen. Other issues / talking points: HWTS should be part of a comprehensive WASH response Promote products / approaches that work in each country, no global standardization Work with experienced HWTS organizations / government / private sector No subsidies for individual households Stimulate demand and market response
UNC
• HWTS Network communications
• New Journal to help overcome fragmentation of evidence on WaSH, Health and Development
• Annual Conference ‘Where Science meets Policy’
WaSH and Development Research
• Cooperating with the International Water Association in publishing a new Journal of Water, Sanitation and Development (launch April 2011).
Presenter
Presentation Notes
“... ensure that UNC responds effectively when people turn to it for balanced, objective and relevant information on water, health and development, and assist concerned individuals and organizations to network and communicate with one another. ” National (USEPA, AWWA) Global (Australia, UK) Global (WHO, developing nations) Common Better focus health protection, asset management. costs
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