Improving access to safe water, sanitation, and basic health services is crucial for the absorption of nutrients that are consumed. Thus it is crucial that efforts to improve diets are combined with improvements in access to safe water, sanitation, and health care. Since issues of access to health care are complex and need to be treated separately, we focus here on outlining the nature of the gaps in access to safe water and sanitation, and the policy priorities for closing these gaps.
Impact of access to safe water and sanitation on malnutrition Unsafe water and unhygienic sanitation practices result in several infectious diseases, most notably diarrhoea and soil-transmitted helminths (STH, worms). Compounded by the lack of access to basic health services, diarrhoea and STH severely reduce the absorption of nutrients that are consumed. Unsafe water and poor sanitation cause a number of other infectious diseases which increase the need for nutrients and diminish appetites. In the worst situations, malnutrition and diarrhoea can form a vicious cycle as a malnourished person becomes more susceptible to infections and the diseases become more persistent.
There is strong empirical evidence of the adverse impacts of lack of access to safe water and sanitation on health and malnutrition. Pruss-Ustun et al. (2004) estimated that, in 2000, unsafe water, sanitation, and hygiene accounted for 1.73 million deaths and 88 percent of the total burden of infectious diarrhoea. In a systematic review of studies of the impact of improvement in access to safe water and sanitation on the morbidity of different diseases, Esrey et al. (1991) found that improvement in access to water and sanitation accounted for a median of 26 percent reduction
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in the incidence of diarrhoea. In a detailed study of eight Sub-Saharan countries, Esrey (1996) found that improvements in access to safe sanitation resulted in taller and heavier children. Interestingly, Esrey (1996) found that improvements in water supply influenced the incidence of diarrhoea and nutritional outcomes only when accompanied by improvements in sanitation and when safe water was available from a source on the household premises. Smith and Haddad (2015), in a detailed econometric assessment of the determinants of decline in child stunting using data for 116 developing countries for a forty-two-year period between 1970 and 2012, found that improvements in access to safe water and sanitation accounted for about 38 percent of the decline in prevalence of child stunting during that period.
Gaps in access to safe water and sanitation
Gaps in safe water supply to household premises and access to improved sanitation are large. Globally, expansion of access to improved sanitation – which often goes hand in hand with expansion of the availability of water on household premises – remains the more widespread problem of the two.
According to the latest statistics available from the WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation, for 2012, about 2.5 billion people all over the world did not have access to improved sanitation practices (Table 5.2), while 750 million persons did not have piped water on the premises of their homes (Table 5.1). Expanding access to safe drinking water and improved sanitation has been much more difficult for rural populations. In 2012, over 80 percent of the people who did not have access to safe water supply in their household premises, and over 70 percent of those who did not have access to improved sanitation lived in rural areas.
A total of 325 million persons or over 40 percent of the population of Sub-Saharan Africa did not have access to piped water on their premises.
The region is expected to miss the MDG target of halving the proportion of people without access to safe drinking water. About 150 million people in South Asia, 114 million in East Asia, and 67 million in Southeast Asia lacked piped water supply to home premises (Figure 5.1). Of the global population who did not have access to improved sanitation, about 67 percent lived in Asia and about 26 percent in Sub-Saharan Africa (Table 5.2 and Figure 5.2). South Asia, and in particular India, has made very slow progress in expanding sanitation (Box 5.1).
Table 5.1 Number of persons and proportion of population not having access to piped water on premises, by region, 2012 (million and percent)
Country Persons (million) Prevalence (percent)
Urban Rural Total Urban Rural Total
East Asia 12 102 114 2 15 8
Southeast Asia 15 51 67 6 15 11
South Asia 25 124 149 4 11 9
Caucasus and Central Asia 1 10 11 4 22 14
West Asia 6 14 20 4 21 9
North Africa 5 8 13 5 11 8
Sub-Saharan Africa 51 274 325 15 48 36
Latin America and Caribbean 14 22 36 3 18 6
Oceania 0 4 5 6 56 44
Developed countries 4 6 9 0 2 1
Total 132 615 748 4 18 11
Source: Based on data from WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
Table 5.2 Number of persons and proportion of population not having access to improved sanitation, by region, 2012 (million and percent)
Country Persons (million) Prevalence (percent)
Urban Rural Total Urban Rural Total
East Asia 190 296 485 24.3 43.4 33.2
Southeast Asia 55 124 179 20 37 29.3
South Asia 205 796 1001 35.9 68.8 58
Oceania 1 6 7 24.3 76.4 64.7
Caucasus and Central Asia 1 2 4 4.1 4.8 4.5
West Asia 6 18 24 4.1 27.3 11.3
North Africa 5 10 14 4.9 13.1 8.5
Sub-Saharan Africa 198 446 644 58.7 77.3 70.4
Latin America and Caribbean 64 46 110 13.2 36.9 18.1
Developed countries 32 22 54 3.3 7.9 4.3
Total 756 1767 2523 20.4 52.8 35.8
Source: Based on data from WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
EndingMalnutrition Figure 5.1 Proportion of population having access to piped water on premises, 2012 (percent)
Note: Map plotted using Gall-Peters projection.
Source: Based on data from WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
toSafeWaterandSanitation77
Note: Map plotted using Gall-Peters projection.
Source: Based on data from WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
Box 5.1 Sanitation and Malnutrition in India
Lack of safe sanitation is a problem of enormous proportions in India.
According to the latest statistics from the WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation, India alone accounted for 31 percent of the world’s population without access to improved sanitation.
According to the 2011 Census of India, only 44 percent of Indian households had improved sanitation facilities. Among rural households, this proportion was a dismal 28 percent. With lack of toilets and water on household premises, open defecation is widely prevalent in India (Table 5.3).
The availability of sanitation facilities in public spaces is also very poor. In 2013–14, about 13 percent of India’s schools had no toilets (NUEPA, 2014).
Lack of sanitation has important gender and social dimensions. Lack of sanitation facilities at home specifically inconveniences women, exposes them to the worst forms of sexual violence, and harms their health even more than for men (Kulkarni, O’Reilly, and Bhat, 2014; Sharma, Aasaavari, and Anand, 2015). National statistics also show continued disparities in access to sanitation across caste and social groups (Chawla, 2014; Singh, 2014;
Swaminathan and Singh, 2014; Thorat, 2009). In a detailed sociological study of determinants of access to basic amenities in rural India, Singh (2014) shows that social exclusion in rural India, particularly as seen in the segregation of residential areas among different social groups, and continued economic differences contribute to continued social and caste disparities in access to sanitation, safe drinking water, and other basic amenities.
Statistical evidence shows that poor access to safe water, sanitation, and hygiene are major determinants of nutritional outcomes in India. Detailed statistical analysis by Spears (2013) showed that “open defecation can account for much or all of excess stunting” among children in India.
There is also a huge gap in the access to safe drinking water. According to data from the 2011 Census of India, only 32 percent of Indian households had access to tap water from a treated source. Lack of a safe water source on household premises is a major factor behind the large proportion of Indian households not being able to use safe sanitation facilities. As shown in Figure 5.4, there is a large overlap in regions that have performed poorly in terms of access to sanitation and water.
The national government in India has introduced specific programmes to tackle the problem of sanitation since the mid-1980s. These programmes have mainly focused on providing financial support for the construction of toilets and activities to raise public awareness. Despite a significant increase in public expenditure (Figure 5.3), these programmes have only had limited success in expanding access to safe sanitation. A recent study shows that a significant proportion of toilets constructed under the Total Sanitation Programme, a flagship programme of the national government in the area of sanitation, have ceased to exist and are not in use (Kumar, 2015). In a review of the Total Sanitation Programme, Hueso and Bell (2013) found that “only one in five latrines reportedly constructed since 2001 were in place in 2011. The rest either had become unusable due to bad construction quality and lack of maintenance, or were not fully built in the first place.” Lack of synergy
inadequate emphasis on awareness-building and hygiene education, and lack of community participation have been identified as the main reasons for the lack of success of public sanitation programmes in India.
Table 5.3India: Proportion of households by different types of sanitation facility, 2011 (percent)
Type of sanitation facility Rural Urban Total Improved sanitation within premises 28 79 44
Water closet 20 73 36
Other types of improved facility 8 6 8
Unimproved sanitation within 3 2 3
premises
Use of public toilets 2 6 3
Open defecation 67 13 50
All households 100 100 100
Source: Census of India, 2011.
Figure 5.3 India: Per capita public expenditure on water and sanitation, 1992–93 to 2010–11 (ppp US$)
Policy lessons from past experiences
Access to improved sanitation is closely related to the development of public infrastructure for drainage, waste treatment, and waste disposal. In most developing countries, rural sanitation programmes have focused on promoting solutions based on safe on-site sewage disposal because of the impracticality of centralized effluent sewage disposal. Further, the need to
Figure 5.4 India: Proportion of houses without access to a water source and toilet on premises, 2011 (percent)
Note: Map plotted using Gall-Peters projection.
Source: Based on data from the Census of India, 2011.
keep costs low has meant the use of low-cost materials that typically are difficult to maintain and clean, thus frustrating the adoption of improved sanitation. Although several technical solutions have been proposed and attempted, the difficulties in maintaining and cleaning low-cost toilets remain an important barrier to widespread adoption of improved sanitation.
In addition, as shown in Figure 5.5, access to improved sanitation is also closely related to supply of piped water to household premises. In general, the existence of piped water supply is a prerequisite for improved household sanitation. Some countries, however, have managed to break this barrier. As shown in Figure 5.5, Sri Lanka, Vietnam, Myanmar, Marshall Islands, Rwanda, and Bangladesh are particularly noteworthy for having achieved significantly above-average levels of access to improved sanitation despite relatively limited access to piped water supply. The figure also shows that, while most high-income countries have good access to piped water on household premises and improved sanitation, several countries have made significant progress in providing access to piped water and improved sanitation despite low per capita income levels.
Figure 5.5 Relationship between proportion of population having access to piped water on premises, proportion of population having access to improved sanitation, and per capita income across countries, 2012
Note: Points for different countries have been sized according to the per capita GDP of the country.
Source: Based on 2012 data from WHO–UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
A large body of empirical literature from across the world has found a significant positive impact of education, in particular women’s, on the adoption of improved sanitation. Policymakers, civil society activists and researchers have all highlighted the importance of building awareness for improving sanitation.
In recent years, an alternative approach called Community-led Total Sanitation (CLTS) has been implemented in many countries. Having its origin in a micro-level programme in Bangladesh, CLTS was mainstreamed by the Water and Sanitation Programme (WSP) led by the World Bank, and
implemented in twenty-five countries across Asia and Africa. Since the early 1990s, the WSP started to move away from supporting public programmes that provided subsidized toilets to households without toilets. It started supporting CLTS programmes since the early 2000s, and adopted CLTS as the main approach for sanitation programmes by the end of the decade.
CLTS is based on the idea that lack of adoption of improved sanitation in a community is not due to economic deprivation or exclusion from public services, but because of the unwillingness of people to stop defecating in the open. Proponents of CLTS have argued that public support for providing toilets is ineffective and should be substituted by community-level interventions to bring about behavioural change, while putting the onus of mobilizing resources for constructing sanitation facilities on the households themselves (Kar and Chambers, 2008; Kar and Pasteur, 2005; Robinson, 2005; Sanan and Moulik, 2007). In a major study on why progress in adoption of improved sanitation in India has been slow, Coffey et al. (2014) claimed that people prefer open defecation because they find it “pleasurable”.
There are two aspects of the strategy adopted by the CLTS programmes implemented in various countries. First, under these programmes, be-havioural change is brought about by exposing persons practising open defecation to shame, public humiliation, and various kinds of punishment.
Monetary fines and humiliating punishments like forcing the offenders to clean public places are imposed on those who engage in open defecation.
These are expected to humiliate and coerce people to build toilet facilities, and to stop defecating in the open. Secondly, it is argued that people value and use toilets only if they pay for building them. Toilets built with public subsidies lie unused because people do not value them and see no benefit in using them (Sanan and Moulik, 2007). Thus, no public support is provided for the construction of toilets, existing programmes that provide financial support are to be discontinued, and households are to mobilize their own resources for the construction of toilets. In sum, under CLTS, the focus of intervention is on preventing the practice of open defecation, so that people are left with no choice but to find resources to build toilets for themselves.
Evidence suggests that economic progress does not automatically trans-late into improved sanitation. Experience from sanitation programmes across the world shows that mere provision of funds for the construction of low-cost toilets is not sufficient for the adoption of improved sanitation.
However, the fact remains that the vast majority of those who lack improved sanitation are poor, have low levels of educational attainment, and do not have access to public infrastructure for water and drainage on their household premises. Hence, their inability to have or to use a toilet has to be seen as a deprivation and a failure of entitlements rather than as an exercise of freedom.
Recent studies, including from the World Bank, doubt that behavioural changes alone can bring about the requisite increase in the use of improved
sanitation. The 2015 World Development Report argued that “a program to change social norms about sanitation in these two countries was important but not sufficient to end open defecation” (World Bank, 2015). It took the position that programmes aiming for behavioural change “can complement, but perhaps not substitute for, programmes that provide resources for building toilets” (World Bank, 2015).
Assessing sanitation programmes in Bangladesh, often cited by pro-ponents of CLTS, Black and Fawcett (2008) point out that progress in Bangladesh is not merely because of CLTS, but has much to do with sustained political commitment at the highest level, sustained efforts of the Department of Public Health Engineering and NGOs, and various specific socio-economic and ecological conditions. A comparative assessment of sanitation outcomes in CLTS and non-CLTS villages in Bangladesh by Hanchett et al. (2011) showed a substantial increase in the adoption of improved sanitation in all areas, and no significant difference between CLTS and non-CLTS villages. The study concluded that “the government’s commitment may have been the cornerstone for influencing the social norms in favor of improved sanitation behaviors and facilities, regardless of the specific approach”. Black and Fawcett (2008) strongly argue against using CLTS as a magic bullet to deal with the problem of sanitation regardless of national contexts.
Given that the inability to have or use toilets fundamentally reflects a failure of entitlements, the ethical underpinnings of using humiliation, policing, punishments, and coercion rather than focusing on provision of sanitation facilities along with education, literacy, and sustained awareness-building are questionable. A detailed study of CLTS programmes in Indonesia found that “it is primarily the poor who are the ‘targets’ of this intervention and that they are, in effect, punished for their poverty and local practices” (Engel and Susilo, 2014). Engel and Susilo (2014) conclude that
“CLTS is clearly a very intrusive process involving facilitators from outside the village inspecting individual households and shaming predominantly poor individuals and households for their circumstances and local practices.”
Experiences from countries that have made significant advances in ac-cess to safe water and improved sanitation suggest that political commitment at the highest level, involvement of all levels of government, sustained fiscal support for the development of common infrastructure and household-level facilities, and a major thrust in awareness-building programmes hold the key to success in the area. Community participation in raising awareness and building a social commitment to sanitation has always been crucial.
It is important to design solutions keeping in mind the local context, including both constraints and resources, rather than imposing one-size-fits-all technical or economic solutions. Improvement in the area of sanitation often goes hand in hand with improvement in access to water on the household premises. This is particularly important for rural areas, where
the gap in access to water supply on household premises is substantial in many countries. In such countries, programmes for development of domestic water supply and sanitation in rural areas should be planned and implemented together.
Box 5.2 ICN2 Framework for Action: Recommended actions on water, sanitation and hygiene
• Recommendation 50: Implement policies and programmes using partici-patory approaches to improve water management in agriculture and food production.a
• Recommendation 51: Invest in and commit to achieve universal access to safe drinking water, with the participation of civil society and the support of international partners, as appropriate.
• Recommendation 52: Implement policies and strategies using participatory approaches to ensure universal access to adequate sanitationb and to promote safe hygiene practices, including hand washing with soap.
a Including by reducing water wastage in irrigation, strategies for multiple use of water (including waste water), and better use of appropriate technology.
b Including by implementing effective risk assessment and management practices on safe waste water use and sanitation.