Cambodia: Poverty Cambodia: Poverty Reduction and Reduction and SanitationSanitation

Norman Hicks/Derko KopitopoulosNorman Hicks/Derko KopitopoulosDRAFT—Dec. 6, 2005DRAFT—Dec. 6, 2005

Poverty and HealthPoverty and Health

National Strategic Development National Strategic Development Plan(draft)Plan(draft)– ““poverty reduction in the fastest possible poverty reduction in the fastest possible

manner is RGC’s foremost priority”manner is RGC’s foremost priority” Poverty is seen as a lack of good Poverty is seen as a lack of good

health--Cambodian Millennium health--Cambodian Millennium Development Goals:Development Goals:– Reduce child mortality Reduce child mortality – Improve maternal health Improve maternal health – Combat AIDS, malaria and other diseasesCombat AIDS, malaria and other diseases

Goals—Child and Infant Goals—Child and Infant MortalityMortality Under 5 mortality infant mortalityUnder 5 mortality infant mortality

– 1998 – 1998 – 124 95124 95– 2005 -- 2005 -- 82 (est.) 66 (est.) 82 (est.) 66 (est.)– 2015 -- 2015 -- 65 (proj.) 50 (proj.) 65 (proj.) 50 (proj.)

[World Bank data[World Bank data– 2000 --2000 -- 134 134 9595– 2003 --2003 -- 140 140 97 ]97 ]

– Source: National Development Strategic Source: National Development Strategic Plan (draft, 8 Nov 2005) Annex I and World Plan (draft, 8 Nov 2005) Annex I and World Bank, World Development Indicators, 2005Bank, World Development Indicators, 2005

Goals – water and Goals – water and sanitationsanitation

YearYear RuralRural UrbanUrban

Access to Safe Water(% Access to Safe Water(% pop.)pop.)

19981998 2424 6060

20052005 4242 7676

20152015 5050 8080Access to Improved Access to Improved SanitationSanitation

19981998 99 4949

20052005 1616 5555

20152015 3030 7474

--Good progress in coverage of water;

-- Reaching sanitation target is more doubtful

-- Sanitation – where is the plan or strategy to reach these goals (not discussed in Strategy)?

What is “Safe” Water?What is “Safe” Water?

What is Improved What is Improved Sanitation?Sanitation?

Cross Country Evidence: Cross Country Evidence: Child mortality declines Child mortality declines as sanitation improves…as sanitation improves…

Data from World Development Indicators for 107 developing countries; most data is 2002 or 2003

Child mortality declines Child mortality declines as access to water as access to water improves…improves…

Child mortality is also Child mortality is also related to education…related to education…

Cambodia compared to Cambodia compared to all LDCsall LDCs CambodiaCambodia All LDCsAll LDCs

– Child MortalityChild Mortality 140 140 7676– Water accessWater access 34 34 7878– Sanitation accessSanitation access 16 16 6060– Secondary EducationSecondary Education 25 25 6262– GNI PPPGNI PPP 20502050 4557 4557

– Source: World Bank, World Development Source: World Bank, World Development Indicators, 2005. Data for 2002-2003. “All LDCs” Indicators, 2005. Data for 2002-2003. “All LDCs” is average of 107 countries with data.is average of 107 countries with data.

Cambodia underperforms Cambodia underperforms on child mortality on child mortality compared to similar compared to similar countries…countries… Given its income, Given its income,

Cambodia should Cambodia should have a child have a child mortality of 104 mortality of 104 instead of 140.instead of 140.

Graph shows child Graph shows child mortality against log mortality against log GNI per capita; GNI per capita; Cambodia is above the Cambodia is above the regression line showing regression line showing that its predicted value that its predicted value is lower than actual is lower than actual value;value;

Cambodia Cambodia underperforms on underperforms on sanitationsanitation A country with its A country with its

per capita income per capita income should have should have sanitation sanitation coverage of about coverage of about 49%, not 16% 49%, not 16%

Graph shows log GNI and Graph shows log GNI and sanitation coverage; sanitation coverage; Cambodia is below Cambodia is below predicted coverage levelpredicted coverage level

Cross Country Regression Cross Country Regression results:results:Child Mort = f(water, san, sec Child Mort = f(water, san, sec ed)ed) Regression results show that for a Regression results show that for a

10 percentage point change in 10 percentage point change in coverage…coverage…– improved water supply reduces child improved water supply reduces child

mortality by 9.7%mortality by 9.7%– Improved access to sanitation reduces Improved access to sanitation reduces

child mortality by 7.9%child mortality by 7.9%– Increased secondary school enrollment Increased secondary school enrollment

reduces child mortality by 12.6%reduces child mortality by 12.6%

What is “Sanitation”?What is “Sanitation”?

SanitationSanitation– ““Collection and treatment of excreta and Collection and treatment of excreta and

community liquid wastes in a hygienic way community liquid wastes in a hygienic way so as not to endanger the health of so as not to endanger the health of individuals and the community as a wholeindividuals and the community as a whole””

– It relates to:It relates to: DrainageDrainage Housing conditionsHousing conditions Solid waste collection and disposalSolid waste collection and disposal

–Source: WHO 1987Source: WHO 1987

Benefits provided by Benefits provided by sanitation sanitation improvementsimprovements

Environment

Health Economy Community

SanitationNo visual, no olfactive impactsNatural resources preserved No fecal contaminationNo industrial pollutionLess ponding water

Less diarrhea (90%)Less aneamia, blindnessLess dengue, malaria

Time availabilityLess medical costs

EducationInfrastructure

Tourism Fisheries Reuse

Less treatmentLess maintenance

Less gritLess erosionLess WS pollution

Privacy - Security Gender sensitivity Religious, cultural

Social Cohesion

Collective action

Girls at school

Other community activities

SocialOperations

Water borne diseasesWater borne diseases

Diarrhoea: main indicatorDiarrhoea: main indicator

Excreted infectionsExcreted infections– Non-bacterial faeco-oralNon-bacterial faeco-oral

Hepatitis, viruses, amoebiasis,…Hepatitis, viruses, amoebiasis,…

– Bacterial faeco-oralBacterial faeco-oral E.Coli infection, Cholera, Typhoid, …E.Coli infection, Cholera, Typhoid, …

– HelminthsHelminths Ascariasis, taenia, schistosomiasis,…Ascariasis, taenia, schistosomiasis,…

–Source: WHO 1992Source: WHO 1992

Other diseases related Other diseases related to inadequate to inadequate sanitationsanitation Vector diseasesVector diseases

– FliesFlies Hepatitis, viruses,..Hepatitis, viruses,..

– MosquitoesMosquitoes Dengue, malaria,…Dengue, malaria,…

– RodentsRodents Leptospirosis,…Leptospirosis,…

–Source: D.Mara 1996Source: D.Mara 1996

Environmental hazards Environmental hazards associated with water...associated with water...

Health hazardsHealth hazards– Human non-industrial activitiesHuman non-industrial activities

Nitrates (fertilizers)Nitrates (fertilizers) Detergents (cleaning)Detergents (cleaning)

– IndustriesIndustries Heavy metalsHeavy metals ToxicsToxics

–Source: D.Mara 1996Source: D.Mara 1996

Diarrhea…Some factsDiarrhea…Some facts Diarrhea accounts for 1.8 million deaths per Diarrhea accounts for 1.8 million deaths per

year; 90% are children.year; 90% are children. 88% of diarrheal disease is attributed to unsafe 88% of diarrheal disease is attributed to unsafe

water supply, inadequate sanitation and water supply, inadequate sanitation and hygienehygiene

A 30-50% reduction in diarrheal diseases can A 30-50% reduction in diarrheal diseases can be achieved through feasible prevention –be achieved through feasible prevention –improvements in water supply, sanitation and improvements in water supply, sanitation and hygiene.hygiene.

Controlled field trials – point of use water Controlled field trials – point of use water treatment and safe water storage leads to 42% treatment and safe water storage leads to 42% reduction in diarrheareduction in diarrhea

Handwashing with soap produces 40% Handwashing with soap produces 40% reduction in diarrhea, and other intestinal reduction in diarrhea, and other intestinal infections by over 50%infections by over 50%

Source: “The Hygiene Improvement Framework” UNICEF/World Source: “The Hygiene Improvement Framework” UNICEF/World Bank/USAID EHP Joint Publication No 8 May 2004Bank/USAID EHP Joint Publication No 8 May 2004

Fecal contamination is the main source of Fecal contamination is the main source of diarrhea infections ….diarrhea infections ….

Feces Future Victim

Fluids

Fingers

Flies

Fields/Floors

Sanitation

Food

Hygiene

Water supply

Water contamination…Water contamination…an example….an example….

Health Improvement Health Improvement FrameworkFrameworkAccess to HardwareWater supply systemsImproved sanitation facilitiesHousehold technologies ● Soap● Safe water containers

Hygiene PromotionCommunicationSocial mobilizationCommunity participationSocial marketingAdvocacy

Enabling EnvironmentPolicy improvementInstitutional strengtheningCommunity organizationFinancing and cost recoveryCrosssector & PP partnerships

Diarrheal Disease Prevention

Urban Cambodia: Urban Cambodia: Mixed Mixed drainage/seweragedrainage/sewerage

Typical Septic TankTypical Septic Tank

Mixed problems of solid Mixed problems of solid waste, drainage, waste, drainage, seweragesewerage

Alternative Alternative approachesapproachesImprovementImprovement Investment cost Investment cost

USD/capitaUSD/capitaRecurrent cost Recurrent cost

USD/capitaUSD/capitaRecurrent cost Recurrent cost

sourcesource

SewerageSewerage 450450 Very highVery high Fees + Fees + householdhousehold

Sewer Sewer connectionconnection

150150 HighHigh Fees + Fees + householdhousehold

Small boreSmall bore 6060 MediumMedium Fees + Fees + householdhousehold

Septic tankSeptic tank 100100 HighHigh HouseholdHousehold

Pour-flushPour-flush 5050 Medium / LowMedium / Low HouseholdHousehold

VIPVIP 5050 LowLow HouseholdHousehold

Pit latrinePit latrine 2525 Low Low HouseholdHousehold

Hygiene Hygiene educationeducation

1010 LowLow HouseholdHousehold

–Source: SIWI, 2000Source: SIWI, 2000

Meeting the Demand Meeting the Demand CriteriaCriteria

convenience

health

economy

regulation

authorities support

incentives

Demand Conditions

education

infrastructure

Offer

operation

Responsibilities—Responsibilities—Collective vs. Collective vs. IndividualsIndividuals

Responsibility share for

urban sanitation

Individual Collective

Household Blocks Community Authority

LatrinesConstruction

O&MConstruction

O&MConstruction

O&MPromotion Regulation

Septic tanksConstruction

EmptyingConstruction

EmptyingEmptying Disposal

Emptying Disposal

Simplified sewerage

ConnectionsConstruction

O&MConstruction

O&MSmall bore sewerage

Septic tank construction

Septic tank construction

Construction O&M

Construction O&M

Conventional sewerage

ConnectionsConstruction

O&M

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A Possible Strategy…A Possible Strategy…

Focus on Education – Raise Focus on Education – Raise AwarenessAwareness– Raising awareness at all levels: Raising awareness at all levels:

household, community and national household, community and national leaders of sanitation’s importanceleaders of sanitation’s importance

– Improve household practices Improve household practices Water treatment – boiling, chlorination, in Water treatment – boiling, chlorination, in

the home for untreated waterthe home for untreated water Hand washing (with soap), personal Hand washing (with soap), personal

hygiene, food handlinghygiene, food handling

Strategy (p.2)Strategy (p.2)

Institutions and Strategy:Institutions and Strategy:– Develop a national sanitation plan Develop a national sanitation plan

outlining role of national and local outlining role of national and local govt., private sector, and govt., private sector, and households. households. Focus on low cost improvementsFocus on low cost improvements Include drainage (often a higher priority Include drainage (often a higher priority

in low lying areas).in low lying areas).

Strategy (p. 3)Strategy (p. 3)

Hardware: Limit heavy investmentsHardware: Limit heavy investments– Modest facility improvements with Modest facility improvements with

public support, regulation, with public support, regulation, with subsidies for poor. subsidies for poor. Improved septic tanks, latrinesImproved septic tanks, latrines In dense urban areas, develop In dense urban areas, develop

community/block based simple sewer community/block based simple sewer systems with heavy community systems with heavy community involvement (condominium approach)involvement (condominium approach)

The EndThe End

BenefitsBenefits

Reductions in diarrhoea risk from improvements

–Source: DFID, 2003Source: DFID, 2003

BenefitsBenefits

Impact on diarrhoea in young children of sanitation infrastructure

–Source: DFID, 2003Source: DFID, 2003

Cross Country Regression Cross Country Regression results:results:Child Mort = f(water, san, sec Child Mort = f(water, san, sec ed)ed)

Dependent Variable: child mortality

R R2 F Prob.>F DF1 DF2 0.828 0.686 75.009 0.000 3 103Adjusted R Squared = 0.677

Std. Error of Estimate = 36.436

Variable Beta B Std.Error t Prob.>t VIF TOL san -0.247 -0.602 0.227 -2.652 0.009 2.855 0.350 water -0.206 -0.729 0.309 -2.359 0.020 2.493 0.401sec school -0.458 -0.950 0.179 -5.317 0.000 2.431 0.411

Constant = 227.282