DISPARITIES IN ACCESS TO IMPROVED SANITATION

PUBLIC FINANCE, SOCIAL POLICIES AND CHILDREN DISCUSSION PAPER East Asia & Pacific WATER AND SANITATION THE RIGHT INVESTEMENTS IN CHILDREN DISPARITIES IN ACCESS TO IMPROVED SANITATION CORE ISSUES Reducing disparities in sanitation and water must be a priority, with special attention to countries showing limited or no progress. Unsafe water, inadequate sanitation and poor hygiene can lead to chronic undernutrition (stunting) Open defecation the most extreme manifestation of poor sanitation must end. 1 The East Asia and Pacific (EAP) region has seen extraordinary gains in sanitation and water supply over the past two decades. Some 35 per cent more people had access to improved sanitation facilities in 10 than in 1990. That translates into 823 million additional adults and children, with China alone accounting for nearly 593 million (UNICEF and WHO, 12). But the work is far from finished. 671 million people in this region remain without access to improved sanitation more than in sub-saharan Africa. Seven countries are not on track to meet the MDG sanitation target (Papua New Guinea,, Nauru,, Timor-Leste, and Samoa). Large urban-rural divide. Rural households have lower access levels than urban dwellers. Although the region-wide sanitation gap between rural and urban areas shrunk to 19% in 10 from 36% in 1990 (77% urban, 58% rural), there are still wide differentials in several countries. As Figure 1 shows, the gap between urban and rural coverage tops 50% in, and is only slightly less in, Timor-Leste and. Rich-Poor gaps are significant. Figure 2, the equity tree of the Philippines, shows that although the country s national sanitation coverage is above the regional and world average, access for the poorest rural quintile is not much higher than the rural national average for. The disparities in sanitation are mirrored in other related indicators, such as hand washing with soap, a critical action that can significantly reduce the risk of diarrhoea. In, for instance, just 30% of the poorest quintile of households practice hand washing with soap compared to 85% in the richest quintile (Figure 3). In East Asia and the Pacific, as globally, the MDG targets for water supply have been met, according to the 12 Joint Monitoring Programme report. Region-wide, 677 million more people have access to Figure 1: Rural-urban disparities in sanitation coverage in 10 China DPRK Malaysia Myanmar PNG Philippines Thailand Timor-Leste Tuvalu Viet Nam Rural 0 Coverage (%) Urban Source: UNICEF and WHO, 12 Prepared for the Public Finance for Children Conference, Ha Noi, Viet Nam, September 12 For more information please visit: http://www.unicef.org/eapro/activities_138.html

Figure 2: Rural sanitation coverage, regional and country estimates (%), with subnational disparities in the Philippines 98 Samoa 96 Malaysia 93 Tokelu Richest % Urban Richest % Rural 85 CEE/CIS 74 Philippines 79 Urban 75 Poorest % Urban 63 World 67 East Asia & the Pacific 64 China 69 Rural 38 South Asia 30 Sub Africa Source: UNICEF and WHO, 12 57 Vanuatu 51 47 Timor-Leste 45 Papua New Guinea 31 39 Poorest % Rural Figure 3: Hand washing with soap and water by wealth quintile in Households (%) 0 Poorest Quintile Source: DHS, 10 Source: MICS, 06; DHS, 07 Richest Quintile Quintile Figure 3: Use of piped or other improved water facilities by wealth quintiles in Households (%) 0 Poorest Quintile Improved water coverage Richest Quintile Unimproved improved drinking water compared with years ago. But once again, this great progress masks serious problems. Almost 0 million people in the region are still unable to attain satisfactory water, with by far the lowest coverage in Papua New Guinea (see Figure 5). Inequalities in access to clean water persist, both among countries and at sub-national levels. While the urban-rural gap in improved water coverage fell sharply to 13% in 10 from 37% in 1990, disparities are still significant in Papua New Guinea,, Timor-Leste and. Generally, few people in rural areas have access to piped water. Similarly, the poorest households have less access to improved water than the richest. In, more than 90% of the richest quintile can access improved water sources, compared with just about % of the poorest quintile, as shown in Figure 4. Other ongoing challenges Water quality: High levels of arsenic contamination in water supplies have been found in, China, Myanmar and Viet Nam. Less widespread occurrences have been documented or are probable in other countries (Amini et al., 08). Individual studies suggest that both bacterial and chemical contamination of drinking water supplies is a serious problem in the region. 2

Water and sanitation in schools: In most countries, sanitation facilities in primary schools are not up to par. Of the eleven countries shown in Figure 6, only three have adequate sanitation in more than around 65% of primary schools. Already-served populations risk slipping back. A new global WHO (12) study states that the costs of keeping safe water flowing to populations that currently have access to it will exceed the costs of additional coverage to meet the MDG water target a staggering 50 times for water and six times for sanitation. Clearly, resources for the operation, maintenance and replacement of water supply infrastructure need to be guaranteed to prevent slippage. Assuming that aid money will not increase significantly in the next five years, governments and households will have to meet a large proportion of the funding gap. Households (%) Figure 5: Access to improved drinking water in rural areas 0 Piped Timor-Leste Myanmar China Philippines Viet Nam Thailand DPRK Source: UNICEF and WHO, 12 Other Improved PNG Vanuatu Fiji Palau Samoa Figure 6: Estimated proportion of primary schools with adequate sanitation facilities Source: UNICEF and WHO, 12 Amini, M., Abbaspour, K.C., Berg, M., Winkel, L., Hug, S. J., Hoehn, E., Yang, H. and Johnson, C.A., 08. Statistical modelling of global geogenic arsenic contamination in groundwater. Environmental Science and Technology, 42(10), pp.3669-3675. UNICEF and WHO, 12. Progress on Drinking Water and Sanitation, 12 update. Joint Monitoring Programme Report. WHO, 12. Global costs and benefits of drinking water supply and sanitation interventions to reach the MDG target and universal coverage. Primary Schools (%) Malaysia Myanmar Palau Philippiens Solomon Regional Average Islands Thailand Timor-Leste 3

East Asia & Pacific PUBLIC FINANCE, SOCIAL POLICIES AND CHILDREN DISCUSSION PAPER WATER AND SANITATION THE RIGHT INVESTEMENTS IN CHILDREN ECONOMIC BENEFITS OF INVESTING IN WATER AND SANITATION CORE ISSUES Investing in water supply and sanitation yields far-reaching economic benefits and is a spring-board for growth. One dollar spent on sanitation provides an average economic return of $5.50. The ramifications of not spending on sanitation include costs for health and other vital measures of human well-being. Better targeting of resource is needed to ensure the poorest and most vulnerable are served with improved sanitation. Investing in sanitation is cost-effective The economic costs of poor sanitation and hygiene in East Asia and the Pacific run into the billions of dollars, affecting everything from health to tourism and, ultimately, even threatening development. Starting in 07, The World Bank Economics of Sanitation Initiative (ESI) undertook studies in,,, the Philippines, and Viet Nam, looking at the quantitative and qualitative impact of poor sanitation on health, water, tourism and other welfare impacts such as value of life, time use, environmental and social benefits. For these five East Asian and Pacific countries as a whole, the lack of adequate sanitation is estimated by ESI to cost over US$9.2 billion a year (in 05 prices) (World Bank, 07-11). Figure 1: Cost of not investing in improved sanitation as percentage of GDP Viet Nam Philippines 0% 2% 4% 6% 8% Proportion of annual GDP Source: World Bank, 07-11 We realize that deficiency in water and sanitation development could lead to economic losses. The cost of doing nothing to pre-empt poor sanitation is estimated to reach US$ 6.3 billion, or equivalent to 2.3 per centof s GDP Amida Alisjahbana s Minister of Planning, speaking at the Sanitation and Water For All Ministerial Conference in April 12. Other economic studies conducted by the World Bank over the past 15 years have shown that poor sanitation and hygiene cost EAP countries between 0.5% () and 7.2% () of annual Gross Domestic Product (see Figure 1). These impacts reflect: a) the adverse health effects associated with poor sanitation (premature mortality, health care costs and loss of productivity when individuals are sick and others have to care for them), b) time spent to access services, c) the pollution of water resources, and d) adverse impacts on tourism. For many countries in the region, tourism is a major service industry and a robust driver of economic 4 Prepared for the Public Finance for Children Conference, Ha Noi, Viet Nam, September 12 For more information please visit: http://www.unicef.org/eapro/activities_138.html

growth. A poor environment, polluted water and an unhealthy workforce can harm a country s ability to earn foreign exchange, particularly through tourism. In the ESI study, lack of sanitation was mentioned as one of the main complaints by tourists who said they were reluctant to return to the country visited (% of people unwilling to return to the Philippines and, and 13% of those who responded negatively about Viet Nam mentioned sanitation). The new global study by WHO (12) estimates that, between 10 and 15, US$115 billion and US$30 billion will be needed for sanitation and water supply respectively, in order to achieve universal access on both counts. If poor sanitation robs countries of their economic potential, it also has immediate, and often irreversible effects on human potential, at incalculable cost. As Table 1 shows, diarrheal disease, caused by contaminated water and poor sanitation and hygiene, is a major child killer, and contributes to high levels of stunting in the Asia-Pacific region (diarrhoea impairs the absorption of nutrients in the body). Ministerial push on water and sanitation The perils of poor sanitation and water and the payoff in making smart targeted investments was a major theme at the Sanitation and Water for All (SWA) meeting in April 12, attended by ministers responsible for finance, sanitation and hygiene portfolios. Delegations from,,, and Timor-Leste were among the 30 developing countries that attended this meeting on sanitation and water, convened by UNICEF and held at World Bank headquarters in Washington. The main purpose of the gathering was to review the progress on coverage, the outstanding challenges, and agree actions towards ensuring that access to sanitation and safe drinking water becomes a reality for every individual. Major commitments that resulted from the meeting are shown in Box 1. Table 1: Global impacts of poor sanitation and water supply Type of impact Child Mortality from diarrheal disease Malnutrition from poor water and sanitation Stunting in children under five in developing countries Impaired cognitive function and learning capacity*** Extent of impact 1.25 million deaths under 5 and 1.25 million over 5* 1 million children malnourished** Over 30% in low-income countries (UNICEF, 09) Lower school & work productivity; impact: >3% of GDP Source: *Black et al., 10; ** Humphrey, 09; ***Acharya et al, 08 Box 1: Statement of Commitments: Sanitation and Water for All High Level Meeting, April 12 1. Target better and spend smarter a constant theme was that more money in itself is not enough. Urgently identifying and removing finance and management blockages is essential as the 12 GLAAS report demonstrates that many countries are not disbursing the funding that is allocated to water and sanitation; better targeting of available resources is crucial as this report also highlights that sector aid is still disproportionately targeted to i) urban infrastructure even though over 70% of those without basic services reside in rural areas, and ii) drinking water, even though it is sanitation that lags far behind. 2. Better prepare for infrastructure investment effective investment requires better preparation and it was agreed to increase attention to building institutions and capacity and transferring knowledge. 3. Strengthen information systems and track results sector ministers committed to adopt one national sector monitoring system, to produce one annual sector report and to host one annual joint country sector review meeting involving all the main sector and non-sector stakeholders. 4. Increase service access and tackle open defecation and inequity to increase improved sanitation access by 7% and safe drinking water access by 5% over the next two years. The meeting agreed that open defecation more evident among people in the poorest quintile is one of the greatest threats to human health and must be ended, as it addresses disparities in equitable access to adequate sanitation (SWA 12). 5

As a country committed to the MDGs, gives a very high importance to sanitation and water, and it is reflected in our mission of plan. Speaking at the meeting, Hon. Khampheng Phoisena, Minister to the Prime Minister s Office and Chairperson of the National Commission for Mothers and Children,. RECOMMENDATIONS 1. At country level, ensure that adequate resources are available for sanitation and water to meet national targets and regional and global commitments. This involves a review of resource allocation criteria to ensure that significant inequities in access are addressed and that the poorest and most disadvantaged populations targeted. 2. Undertake concrete actions to accelerated to ending open defecation. Three countries in East Asia and the Pacific are among the top 12 countries in the world, accounting for three quarters of the population who practice open defecation, a conduit for the spread of disease-causing bacteria, contributing to high rates of diarrhea and stunting. Acharya, A., Paunio, M. and Ahmed, K., 08 World Bank: Washington DC. 08. Economic productivity effects of 3.8% of GDP in Ghana and 4.7% of GDP in Pakistan. Environmental health and child survival: epidemiology, economics and experience. Black, R.E. et al. 10. Global, regional, and national causes of child mortality in 08. A systematic analysis. Lancet, DOI:10.1016/S01-6736(10)549-1. Humphrey, J.H., 09. Child nutrition, tropical enteropathy, toilets, and handwashing. Lancet, 374, pp.1032-1035. Sanitation and Water for All (SWA), 12. Global overview: Economic impact of water supply and sanitation. World Bank, 07-11. Water and Sanitation Program s Economics of Sanitation Initiative. Economic Assessment of Sanita tion Interventions. Six-country study in,,,. the Philippines and Vietnam. World Health Organization (WHO), 12. Global costs and benefits of drinking-water supply and sanitation interventions to reach the MDG target and universal coverage. 6