Implementation issues in sanitation and water for health

Transcription

1 Implementation issues in sanitation and water for health Forum on Microbial Threats Institute of Medicine Washington, DC September Vahid Alavian and Pete Kolsky The World Bank

2 Outline Water, sanitation, health the investment dimension World Bank operations and context Implementation challenges How to make more health smart investments Closing Remarks

3 Implications of running dry Decreasing per-capita water availability Degrading water quality Increasing tension urban vs. rural upstream vs. downstream national vs. international Widening rich and poor gap Increasing competition/conflict with the environment Increasing cost of next generation of options

4 WSS in context water withdrawal Limited resource with rapidly increasing demand Direct link to poverty Cause of economic shock to many client countries Many dimensions: people, food, energy, environment, transport, etc. Agriculture 78% Municipal 6% Industrial 4% Environ. Flows 10% Open water evap. 2% World Bank Strategy Today s focus Economy-wide Our interventions Poverty targeted Resource development & management Delivery of services Broad water resource interventions WSS service delivery reforms Targeted water resource interventions Targeted improved WSS service delivery

5 Gaps in access and financing compounded by policy gaps Access Gap: Large proportion of population in low income countries still lack access to basic infrastructure services 100% 75% 50% 25% 0% Access to Electricity Access to Water (Rural) Access to Water (Urban) Rural Transport Index AFR EAP ECA LCR MNA SAR Financing Gap Current spending on infrastructure: 3-4% GDP; Required spending: 7-9% of GDP Estimates could exceed $750 billion/ year, including electricity transmission/distribution, wastewater treatment, urban transport, ports & airports, oil & gas infrastructure Policy and Institutional Gap More effective spending on infrastructure possible with improvements in policy and institutions. Source: World Bank & OECD-DAC

6 Key challenge financing Annual investment required to meet the MDGs: $25 30 billion Currently: $15 billion (Public: ~ 75%; Private: ~11%; ODA: ~14%) Investment in WSS is less than 1% GDP on average. Current private sector investment level is $1 to 2 billion per year - primarily focused on specific markets (e.g. China, treatment facilities) Official Development Assistance to the water sector has declined since the mid 1990s. OECD figures show that the share of aid allocated to WSS dropped from 8% in to 6% in And holding steady. US share??

7 The Bank investment in WSS The portfolio IBRD/IDA Historical lending for WSS Currently $11 billion for 132 active projects. 35 million people have gained access. (27 million -water, 8 million - sanitation) between 2000 and US$million 2,500 2,000 1,500 1, IBRD IDA (underestimate) FY93 FY94 FY95 FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07* IDA share of total donor financing in the last five years has increased from 7% to 21% relative to other sources. It s more than just taps and toilets sustainability and quality matter. Scale up investment Extend and expand WSS services Strengthen governance and institutions Ensure financial sustainability of utilities

8 Emerging challenges and new areas Traditional areas of activity Areas for growth Power Renewable energy Oil and gas District heating Mining Energy 4 core business lines equally compelling going forward Pursue Investment Framework for clean energy development access agenda; climate change Information & Communication Technologies Telecommunications Postal services Information technologies / E-agenda Media / broadcasting Transport Roads, highways and railways Urban and rural transport Ports and shipping Aviation Trade transport infrastructure Water Supply & Sanitation Water supply Sanitation and sewerage Flood protection Greater focus on addressing rural urban divide; expanding backbone access; addressing next generation regulatory issues; developing local IT industry; technical and financial assistance for enhancing public service delivery Expand scope to incorporate egovt, IT development, municipal networks, IT parks, backbone networks and open access policies Sustainability (performance & affordability) of transport infrastructure Environmental sustainability of all transport interventions & improving rural and urban access & mobility Use combination of subnational financing instruments, demand management and targeted incentives Transport and key component of regional trade facilitation Expand services to rural, urban, and peri-urban areas Opportunities for integrated approach, including water security, efficiency in water management, climate change & adaptation, health Increasing support for sanitation

9 Water Investments Irrigation and Drainage Water Services Urban Water & Sanitation Rural Water & Sanitation Water Investment Infrastructure & Institution Flood Control Water Resources Watershed Management Water Resources Mgt. Multi-purpose facilities

10 World Bank Water Investments (Fiscal Year ) 5,000 4, FY06/FY07 Actual Lending FY08/FY09 Projected Lending , US$million 3,500 3,000 2,500 2,000 1, Service Delivery 32 1, Irrigation and Drainage Urban WSS Rural WSS Flood Control Agriculture Water Management Watershed Management Water Resources Management Multipurpose Facilities Resource Management No. of Projects

11 Senegal: Improved WSS access and services Early 90s: The setting National water utility almost bankrupt Widespread water shortages in Dakar Low access to WSS services Bank intervention in 1996 Strong Bank involvement in sector reform and capacity building Large Bank financing, catalytic role in leveraging other donors Public asset holding company for planning and financing investments Private operator for water supply services Focus on Sanitation in Dakar National sanitation agency as part of sector reform Balance of water-borne and on-site sanitation Sanitation marketing approach, (simple technologies, small scale providers, and involving civil society) Rapid uptake, 57% in 2002 to 78% in 2005; over 63,000 on-site facilities for about 450,000 persons, largely financed by the families themselves

12 Senegal: MDGs are within reach Impact after more than a decade of engagement Access to water supply increased from 74% to 96% of urban population Water supply service available 24/7 1.6m gained access to water and 830,000 gained access to adequate sanitation Sector has reached financial equilibrium On its way to reach the MDG in urban water supply Investment: Total US$515M, including US$225M from IDA 100% 80% Taux d'accès direct à l'eau potable (% population) Puits BF 84% 9% 96% < 2% 19% 60% BP 64% 19% 18% 40% 76% 20% 35% 57% 0% 10% RURAL VILLES régionales DAKAR Région

13 Water, sanitation, health and the sector Two important, often overlooked truths 1. Water, sanitation and health are not just about drinking water quality, but about the fecal peril 2. People invest in water and sanitation for many reasons, not just for health The challenge we actually face is how can we make investments in WSS as health effective as possible? Will return to this point later

14 The Fecal Peril Water supply Sanitation Fluids Hygiene Faeces Fingers Flies Food Future Victim Fields/ Floors

15 But moving on beyond health Why do people and governments want water and sanitation? Time and work savings Convenience Privacy, dignity (sanitation) Environmental protection The Great Stink in London Save the Bay Health

16 Why do people want sanitation? 5 leading reasons, from a demand study for latrines in Philippines 1. lack of smell and flies 2. cleaner surroundings 3. privacy 4. less embarrassment when friends visit 5. less gastrointestinal disease

17 WSS infrastructure is not built primarily to improve health While often a justification for public sector funding, health outcomes do not determine the perceived success or failure of infrastructure projects Cost and functioning main indicators Epidemics, disasters are the exception A steady contribution to health improvement is not on the radar screen of those who design, build and operate WSS infrastructure

18 The differing agendas for water and sanitation Health Reduce faecal-oral disease ORS/hygiene promotion as well as WSS (overall EH relatively low on agenda) Urban development Water supply and wastewater management for urban economic growth Needs of those NOT on the network Utility Provide a service in accordance with well-defined mandate/contract Manage nuisance of water generated by piped network Environment Water quality standards of rivers, effluent

19 Some governance issues Health Utility Sanitation & Hygiene Environment Urban Development

20 Health What people know How to manage a Ministry of hospitals, health centres, etc. How to take care of the sick as effectively as possible How to manage such programs as vaccine campaigns Urban development Who lives where, and how bad things are for them Utility What service costs, how to build, manage pipes Environment What happens downstream of the sewage outfall The public health of fish

21 Infrastructure wisdom & ignorance Infrastructure wisdom How to manage construction contracts How to manage bricks and mortar How to keep a utility solvent (wish more knew this!!) Infrastructure ignorance We believe health benefits accrue naturally to any project in water, sanitation, and air pollution control which is not true Environmental health specialists flit about, as marginal players in both health and infrastructure camps

22 How people see their city Home Peridomestic Ward (street, school, workplace) City River & Environs

23 An engineering/environment view of sanitation Home Peridomestic Ward (street,school, workplace) City Central Treatment Works Collectors Street Sewers House Connections

24 A public health view Interceptor/ Collector Sewer Mains Home Street Sewer Peridomestic Ward City House Connection River & Environs Treatment Plant/Outfall

25 Challenges for utilities If our current customers have poor service, why should we look for new ones? If we can t break even with the middle class, why would we risk connections for the poor? Why look beyond the network, when the network is so bad? What business are we in? Selling water to the public? Providing WSS services to the entire population?

26 Urban Sanitation Infrastructure Processes Traditional/ ideal process and technologies Real world process experienced by urban poor

27 Designing for Health Designing infrastructure interventions to maximize health benefits need not add much to cost, especially if built in from the start Specialists in both sectors are not evil or lazy often keen to help if they understand the issues, and IF perceived financial, institutional, bureaucratic cost is reasonably low

28 Examples Slum networking concept in Indore, Madhya Pradesh, Ahmedabad elsewhere Infrastructure for powerful passes through the slums lying along the valleys and drains So the incremental cost of serving slums can be low ISSIP(rural sewerage/sanitation) project in Egypt $100 million rural environmental infrastructure Building in hygiene component with health teams support at the start community, schools, household

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30 Closing Remarks Water and health nexus is broader than WSS E.g., agriculture, extreme events, climate change Major scale up in WSS investment is necessary to make a difference Investment in WSS is far below the needed level Investment in WSS is for many reasons, not just health To achieve health benefits from large scale WSS and infrastructure investment, we need to focus on household access by the poor and the institutions which can provide it We need to build in a public health perspective early on in project design We need to think about water and wastes and behaviour

31 Thanks for your attention!