Published on Investing in Health

Water and Sanitation for Health: Why Is Progress Slow?

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Today is World Habitat Day. Created almost 30 years ago, the day promotes adequate shelter for all. Why should this be mentioned in a blog on investing in health? Because adequate shelter, including access to safe water and sanitation, is essential for health. Several million people, many of them chidren, die from diarrheal diseases every year. Many of these deaths can be attributed to unsafe water, poor sanitation and poor hygiene.

Hand washing in practice

Given the importance of water and sanitation for well-being and health, one would hope to see rapid progress in access, but this is not the case. Trends in coverage of piped water and sanitation prepared for a World Bank study on Africa's infrastructure a few years ago suggest stagnant rates (more progress is being achieved for electricity, and course, cell phones). Water networks are expanding, and latrines are being built, but too often this only enables countries to keep up with pressure of population growth and the reduction in household size (the smaller the average household is, the more households need to be served for any given population).

Uganda is a good example. Despite rapid growth in the water network in recent years, on a small minority (7%) of households had access to piped water in the latest survey for 2012/13. Under usual definitions from the Joint Monitoring Program of the World Health Organization (WHO), three in four households have access to an improved water source, but some of the sources imply out-of-pocket costs or opportunity costs for the time needed to reach the source. The situation is similar in many other low-income countries.

Why is progress slow? Apart from increasing demand, findings from qualitative fieldwork suggest that supply factors are also at play. In the case of water, these include lack of infrastructure functionality(facilities may notbe working properly, even shortly after being installed), lack of local responsibility (poor leadership may hinder investments in water supply or leadto lack of maintenance) and scarcity (in some communities, water is simply not easily available).These factors tend to be organizational in nature, or physical in the case of water scarcity. But in addition, one should not underestimate the role of culture, tradition, and behaviors.

For example, households know that boiling water is one of the best ways to make it safe. But a minority (less than 40%, according to the latest survey) do it. A few quotes from qualitative fieldwork illustrate why: “We do not have time to boil this water because of the demanding household chores. We feel it is a waste of time since this water looks clean.”“We are aware this water is bad, but it takes a long time to bring the water to boil and firewood has become scarce.”“I am about 57 years old and I have been living on un-boiled water without falling sick. What matters to us is for the government to expandthe availability of water points, not to tell us to boil the water.”

Adequate sanitation is also essential for health. Yet again, in many low-income countries, only a small minority of households has access to improved sanitation. Part of this may be due to a low priority assigned to sanitation in terms of public funding. But part of it is also due to cultural and traditional norms, as well as lack of income or time. Poor terrain or soil type and a lack of land to build latrines also play a role in some areas.

When public latrines are available, there is often a consensus on charginguser fees to ensure maintenance, but enforcement is weak. The same is true for by-laws in areasrequiring households to build their own latrines, which are often expensive to build, at least for the poor.

Focus group participants were asked why they pay for cell phones but not for latrines. They responded that latrines have a much larger one-time cost, but also that having a cell phone is a sign of modernity and important for one’s status in communities. Clearly, more needs to be done to convince households of the importance of latrines, for example through sanitation marketing campaigns.

Finally, in terms of health benefits, there is perhaps no more cost-effective intervention that the promotion of hand washing, but only a small minority of Uganda’s households (less than one in ten) has a facility to wash hands with both soap and water. Information campaigns are held, but, as aparticipant in focus groups noted, “many of the community members do not attend them, saying that these trainings are a waste of time.”

Sometimes even children contribute to low uptake of the practice: “We used to have hand washing utensils, but the children would play with them and waste the water, so we gave up”. More fundamentally, local leadershipappears to be one of the keys: “Local leaders have campaigned, but there is poor adoption, because hand washing is viewed as a very strange practice to the local culture. Local leaders themselves are not visibly seen practicing hand washing... You cannot simply continue telling people about what they should do, but do not see you doing!”

Studies from the Bank’s Water and Sanitation Program suggest that the cost of lack of sanitation is high. As in other low-income countries, Uganda has invested over the years in safe water and sanitation. But the constraints faced by households and communities are complex. The qualitative work implemented in 14 districts suggests that solutions often must be context- and community-specific. This may not lead to cookie-cutter solutions, but it is important to document precisely because of the variety of local circumstances.

Follow the World Bank health team on Twitter: @worldbankhealth
Follow the World Bank water team on Twitter: @worldbankwater


Report: Africa's Infrastructure: A Time for Transformation

Study: Economic Impacts of Poor Sanitation in Africa

World Habitat Day

World Bank and Water

World Bank and Health

World Bank Sanitation Resource Guide

Sanitation Marketing Toolkit: Uganda

Report: Assessment of Eight African Cities Explores Limitations and Possibilities of Prepaid Meter Systems


Quentin Wodon

Lead Economist, Education Sector, World Bank

Clarence Tsimpo Nkengne

Economist, Poverty Global Practice, World Bank Group

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