Co-author:Sophie Durrans, Research Uptake Officer at London School of Hygiene & Tropical Medicine
A child who is stunted early in life – who fails to grow as tall as expected for their age – often has reduced physical and mental development. Water supply, sanitation, and hygiene (WASH) influences a child's growth in multiple ways. Evidence across low and middle-income countries demonstrates that higher open defecation rates are associated with stunting and higher overall incidence of poverty.
Two years ago, I visited a village in Rudaki, a hilly district located to the south of Dushanbe, Tajikistan. It lies about forty kilometres from the capital, but it feels like a thousand kilometres away. On our drive up a hill, we saw women carrying buckets of water from a nearby spring. Moving further up, we saw children bathing and animals drinking from the same river. Once in the village, it was clear that life is largely shaped by water scarcity—the backyards were filled with pots and buckets, fuel and stoves for boiling water, and pit latrines that were no longer used because of lack of water. Although we could spot remnants of a once-functional water supply network, people living there had not had access to piped water for at least two decades. Without it, they were only able to practice the most basic forms of sanitation and hygiene.
The conditions we witnessed in Rudaki were harsh, but not rare. Located on the western tip of the Himalayas, Tajikistan is a country blessed with large fresh water resources in its lakes, rivers, and glaciers. Yet, access to safe drinking water and sanitation connected to a functioning sewer system is lacking, particularly for rural residents and the poor. Much of the existing infrastructure was built during the Soviet era and has not been upgraded for decades. Tajikistan is one of the few countries outside Africa that did not meet the Millennium Development Goal on drinking water and basic sanitation. Because poor water and sanitation conditions, together with poor nutrition and care, are key determinants of childhood stunting, Tajikistan’s childhood stunting rates remain high. Recent estimates indicate that in Tajikistan more than one in five children under the age of five are stunted and will not reach their full potential as adults.
In a new report, Glass Half Full: Poverty Diagnostic of Water Supply, Sanitation and Hygiene (WASH) Conditions in Tajikistan, we document the realities of Tajikistan’s WASH-deprived population. Our analysis builds on one of the largest data collection efforts of its kind – including national surveys of households and schools, water quality tests, ethnographic work, and case studies of existing WASH projects. It also includes poverty mapping and analysis of other secondary data, including a UNICEF nutrition survey that shared a subsample with our WASH survey.
This blogpost is part of a series of thematic blogs for the World Bank's Water Supply, Sanitation, and Hygiene (WASH) Poverty Diagnostic.
Addressing gender and sex inequalities in WASH is not only recognized in Sustainable Development Goals (SDGs) 4 and 6, it is central to the entire ambition of the SDGs themselves. Some water, sanitation, and hygiene issues are faced only by women because of their biological sex, whereas others are more influenced by gendered societal norms. To truly leave no one behind, we need to be mindful of and work against gender and sex inequalities in all development work.
It was inspiring to see so many committed water practitioners at World Water Week in Stockholm the last week of August, coming together to share experiences and advance global action to achieve the Sustainable Development Goal of safe and accessible water and sanitation for all (SDG6) by 2030. As we know, access to water and sanitation is key to thriving communities. It determines whether poor girls are educated, whether cities are healthy places to live, whether industries grow, and whether framers can withstand the impacts of floods and droughts.
Without it, we are limiting our full potential. In fact, today we face a “silent emergency”, with stunted grown affecting more than a third of all children under five in countries such as Bangladesh, Indonesia, Niger and Guatemala. This was presented in the new World Bank report WASH Poverty Diagnostics, provides new data on water, sanitation and hygiene (WASH) for 18 countries and finds that we get the biggest bang for the buck when we attack childhood stunting and mortality from many angles simultaneously, in a coordinated way. While improving water and sanitation alone does improve a child’s well-being, the impacts on child height are multiplied when water, sanitation, health, and nutrition interventions are combined. The report also pinpoints the geographical areas in a country where access to services are low or missing completely, and suggests that to move the needle on improving poverty indicators, policies need to be implemented and resources have to be better targeted to reach the most vulnerable.
“What’s wrong with this picture?” Louisa Gosling of WaterAid asked the participants at her training on Disability-inclusive Water Operations at the World Bank Water Week in March 2017. She pointed to a photo of a woman standing on the wall of a well. It was round and high, the ground around it muddy, and there was no lifting mechanism in sight.
More pictures followed… latrines and water sources with steep steps, narrow doorways, unstable construction without handles or rails. The more pictures we saw, the clearer it became what was wrong - all the facilities shown were inaccessible and dangerous, quite likely impossible to use for many people.
While the share of poor people in Sub-Saharan Africa decreased from 56 percent in 1990 to 43 percent in 2012, the region’s rapid population growth outpaced the decrease in poverty, resulting in higher number of poor people than before. More specifically, Africa’s urban population is expected to triple in size in the next half century, which is putting pressure on scarce resources in cities, exacerbated by capacity, budget and governance bottlenecks. The densely-populated areas with low levels of water and sanitation services pose a serious threat to public health – cholera epidemics have broken out in urban areas in several African countries in recent years.
Crowded slums, poor sanitation and unhealthy diets. It’s a potent cocktail and for too many families across the world, a daily reality. Right now, an estimated one billion people live in slums and that number is expected to double by 2030. Slums are where the many deprivations facing the urban poor collide, including lack of access to clean drinking water, sanitation, safe and nutritious foods, sufficient living space, durable housing and secure tenure (UN Habitat). They’re where human waste is routinely emptied into streets, canals, and garbage dumps. And where overcrowding and low rates of immunization and breastfeeding combine to exacerbate the already perilous problems children face.
Children growing up in these surroundings are at a higher risk of death and disease and are more likely to be chronically malnourished (Ezeh et al. 2017). For example, forthcoming World Bank research from Bangladesh shows that children living in slums are 50 percent more likely to be stunted than children living in other urban areas. This doesn’t just have implications for today - children who are stunted early in life go on to learn and earn less, and face a higher risk of chronic disease as they grow older. Tragically, these effects are often passed on to offspring, trapping families in poverty and malnutrition for generations, as per findings in a forthcoming World Bank report called Uncharted Waters.
Water investments are lumpy and costly: financing is essential to spread the costs of these investments out over time. For water, development finance institutions still provide the bulk of such financing. It can no longer be the only one, however. The costs of extending universal access to safe water and sanitation has been estimated at US$ 114bn per year, which is a substantial increase compared to what was invested to reach the Millenium Development Goals. In contrast, in 2014 total official development finance for water, including grants and loans with varying degrees of concessionality, reached a mere US$18 bn per year, three times more than in 2003 but still woefully insufficient to meet all investment needs.
To meet the Sustainable Development Goals, governments will need to better target their investments and leverage more financing from private sources, including from households that can afford it (via more realistic and fair tariff policies and incentives to invest in things like toilets) and from commercial finance providers, including microfinance institutions, commercial banks, bond investors or venture capitalists.
Have you ever wondered how your life chances are affected by where you were born? Odds of being born at all are already miraculously small, but only one in ten of us is born into the relative security of a high-income country. What if you are born in Niger or in the Democratic Republic of the Congo (DRC)? Before you could even walk or talk, your challenges would be daunting. That's because, despite progress, deaths of children under five years old are more than twenty times higher than in the EU and nearly ten times higher than in China.
Even if you survived, you would confront another major risk to your development: malnutrition. In Niger and DRC, almost one out of every two children is stunted. Stunting has significant and long-lasting negative effects on early childhood development, impeding physiological and mental development, and making small children more vulnerable to disease. Starting off in life stunted is akin to starting a marathon with a broken ankle.