1. Cambodia: Poverty Reduction and Sanitation Norman Hicks/Derko Kopitopoulos DRAFT—Dec. 6, 2005

2. Poverty and Health National Strategic Development Plan(draft) National Strategic Development Plan(draft) –“poverty reduction in the fastest possible manner is RGC’s foremost priority” Poverty is seen as a lack of good health-- Cambodian Millennium Development Goals: Poverty is seen as a lack of good health-- Cambodian Millennium Development Goals: –Reduce child mortality –Improve maternal health –Combat AIDS, malaria and other diseases

3. Goals—Child and Infant Mortality Under 5 mortality infant mortality Under 5 mortality infant mortality –1998 – 124 95 –2005 -- 82 (est.) 66 (est.) –2015 -- 65 (proj.) 50 (proj.) [World Bank data [World Bank data –2000 -- 13495 –2003 -- 14097 ] –Source: National Development Strategic Plan (draft, 8 Nov 2005) Annex I and World Bank, World Development Indicators, 2005

4. Goals – water and sanitation YearRuralUrban Access to Safe Water(% pop.) 19982460 20054276 20155080 Access to Improved Sanitation 1998949 20051655 20153074 -- 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)?

5. What is “Safe” Water?

6. What is Improved Sanitation?

7. Cross Country Evidence: Child mortality declines as sanitation improves… Data from World Development Indicators for 107 developing countries; most data is 2002 or 2003

8. Child mortality declines as access to water improves…

9. Child mortality is also related to education…

10. Cambodia compared to all LDCs Cambodia All LDCs Cambodia All LDCs –Child Mortality 14076 –Water access 3478 –Sanitation access 1660 –Secondary Education 2562 –GNI PPP2050 4557 –Source: World Bank, World Development Indicators, 2005. Data for 2002-2003. “All LDCs” is average of 107 countries with data.

11. Cambodia underperforms on child mortality compared to similar countries… Given its income, Cambodia should have a child mortality of 104 instead of 140. Given its income, Cambodia should have a child mortality of 104 instead of 140. Graph shows child mortality against log GNI per capita; Cambodia is above the regression line showing that its predicted value is lower than actual value; Graph shows child mortality against log GNI per capita; Cambodia is above the regression line showing that its predicted value is lower than actual value;

12. Cambodia underperforms on sanitation A country with its per capita income should have sanitation coverage of about 49%, not 16% A country with its per capita income should have sanitation coverage of about 49%, not 16% Graph shows log GNI and sanitation coverage; Cambodia is below predicted coverage level Graph shows log GNI and sanitation coverage; Cambodia is below predicted coverage level

13. Cross Country Regression results: Child Mort = f(water, san, sec ed) Regression results show that for a 10 percentage point change in coverage… Regression results show that for a 10 percentage point change in coverage… – improved water supply reduces child mortality by 9.7% –Improved access to sanitation reduces child mortality by 7.9% –Increased secondary school enrollment reduces child mortality by 12.6%

14. What is “Sanitation”? Sanitation Sanitation –“Collection and treatment of excreta and community liquid wastes in a hygienic way so as not to endanger the health of individuals and the community as a whole” –It relates to: Drainage Drainage Housing conditions Housing conditions Solid waste collection and disposal Solid waste collection and disposal –Source: WHO 1987

15. Benefits provided by sanitation improvements Environment HealthEconomyCommunity Sanitation No visual, no olfactive impacts Natural resources preserved No fecal contamination No industrial pollution Less ponding water Less diarrhea (90%) Less aneamia, blindness Less dengue, malaria Time availability Less medical costs Education Infrastructure Tourism Fisheries Reuse Less treatment Less maintenance Less grit Less erosion Less WS pollution Privacy - Security Gender sensitivity Religious, cultural Social Cohesion Collective action Girls at school Other community activities SocialOperations

16. Water borne diseases Diarrhoea: main indicator Excreted infections –Non-bacterial faeco-oral Hepatitis, viruses, amoebiasis,… Hepatitis, viruses, amoebiasis,… –Bacterial faeco-oral E.Coli infection, Cholera, Typhoid, … E.Coli infection, Cholera, Typhoid, … –Helminths Ascariasis, taenia, schistosomiasis,… Ascariasis, taenia, schistosomiasis,… –Source: WHO 1992

17. Other diseases related to inadequate sanitation Vector diseases Vector diseases –Flies Hepatitis, viruses,.. Hepatitis, viruses,.. –Mosquitoes Dengue, malaria,… Dengue, malaria,… –Rodents Leptospirosis,… Leptospirosis,… –Source: D.Mara 1996

18. Environmental hazards associated with water... Health hazards Health hazards –Human non-industrial activities Nitrates (fertilizers) Nitrates (fertilizers) Detergents (cleaning) Detergents (cleaning) –Industries Heavy metals Heavy metals Toxics Toxics –Source: D.Mara 1996

19. Diarrhea…Some facts Diarrhea accounts for 1.8 million deaths per year; 90% are children. Diarrhea accounts for 1.8 million deaths per year; 90% are children. 88% of diarrheal disease is attributed to unsafe water supply, inadequate sanitation and hygiene 88% of diarrheal disease is attributed to unsafe water supply, inadequate sanitation and hygiene A 30-50% reduction in diarrheal diseases can be achieved through feasible prevention – improvements in water supply, sanitation and hygiene. A 30-50% reduction in diarrheal diseases can be achieved through feasible prevention – improvements in water supply, sanitation and hygiene. Controlled field trials – point of use water treatment and safe water storage leads to 42% reduction in diarrhea Controlled field trials – point of use water treatment and safe water storage leads to 42% reduction in diarrhea Handwashing with soap produces 40% reduction in diarrhea, and other intestinal infections by over 50% Handwashing with soap produces 40% reduction in diarrhea, and other intestinal infections by over 50% Source: “The Hygiene Improvement Framework” UNICEF/World Bank/USAID EHP Joint Publication No 8 May 2004 Source: “The Hygiene Improvement Framework” UNICEF/World Bank/USAID EHP Joint Publication No 8 May 2004

20. Fecal contamination is the main source of diarrhea infections …. Feces Future Victim Fluids Fingers Flies Fields/ Floors Sanitation Food HygieneWater supply

21. Water contamination…an example….

22. Health Improvement Framework Access to Hardware Water supply systems Improved sanitation facilities Household technologies ● Soap ● Safe water containers Hygiene Promotion Communication Social mobilization Community participation Social marketing Advocacy Enabling Environment Policy improvement Institutional strengthening Community organization Financing and cost recovery Crosssector & PP partnerships Diarrheal Disease Prevention

23. Urban Cambodia: Mixed drainage/sewerage

24. Typical Septic Tank

25. Mixed problems of solid waste, drainage, sewerage

26. Alternative approaches Improvement Investment cost USD/capita Recurrent cost USD/capita Recurrent cost source Sewerage450 Very high Fees + household Sewer connection 150High Fees + household Small bore 60Medium Fees + household Septic tank 100HighHousehold Pour-flush50 Medium / Low Household VIP50LowHousehold Pit latrine 25LowHousehold Hygiene education 10LowHousehold –Source: SIWI, 2000

27. Meeting the Demand Criteria convenience health economy regulation authorities support incentives DemandConditions education infrastructure Offer operation

28. Responsibilities— Collective vs. Individuals Responsibility share for urban sanitation IndividualCollective HouseholdBlocksCommunityAuthority Latrines Construction O&M Construction O&M Construction O&M Promotion Regulation Septic tanks Construction Emptying Construction Emptying Disposal Emptying Disposal Simplified sewerage Connections Construction O&M Construction O&M Small bore sewerage Septic tank construction Septic tank construction Construction O&M Construction O&M Conventional sewerage Connections Construction O&M

29. A Possible Strategy… Focus on Education – Raise Awareness Focus on Education – Raise Awareness –Raising awareness at all levels: household, community and national leaders of sanitation’s importance –Improve household practices Water treatment – boiling, chlorination, in the home for untreated water Water treatment – boiling, chlorination, in the home for untreated water Hand washing (with soap), personal hygiene, food handling Hand washing (with soap), personal hygiene, food handling

30. Strategy (p.2) Institutions and Strategy: Institutions and Strategy: –Develop a national sanitation plan outlining role of national and local govt., private sector, and households. Focus on low cost improvements Focus on low cost improvements Include drainage (often a higher priority in low lying areas). Include drainage (often a higher priority in low lying areas).

31. Strategy (p. 3) Hardware: Limit heavy investments Hardware: Limit heavy investments –Modest facility improvements with public support, regulation, with subsidies for poor. Improved septic tanks, latrines Improved septic tanks, latrines In dense urban areas, develop community/block based simple sewer systems with heavy community involvement (condominium approach) In dense urban areas, develop community/block based simple sewer systems with heavy community involvement (condominium approach)

32. The End

33. Benefits Reductions in diarrhoea risk from improvements –Source: DFID, 2003

34. Benefits Impact on diarrhoea in young children of sanitation infrastructure –Source: DFID, 2003

35. Health Improvement Framework Improved Sanitation (safe disposal of feces) – blocks path between feces and food, flies, fields. Improved Sanitation (safe disposal of feces) – blocks path between feces and food, flies, fields. Improved water quality blocks link to drinking water IF water is properly handled—does not block other paths Improved water quality blocks link to drinking water IF water is properly handled—does not block other paths Increased quantity of water improves hygiene via improved food preparation and personal hygiene Increased quantity of water improves hygiene via improved food preparation and personal hygiene Increased handwashing (with soap) blocks link to food and direct contacts. Increased handwashing (with soap) blocks link to food and direct contacts.

36. Health Improvement Framework Improved Sanitation (safe disposal of feces) – blocks path between feces and food, flies, fields. Improved Sanitation (safe disposal of feces) – blocks path between feces and food, flies, fields. Improved water quality blocks link to drinking water IF water is properly handled—does not block other paths Improved water quality blocks link to drinking water IF water is properly handled—does not block other paths Increased quantity of water improves hygiene via improved food preparation and personal hygiene Increased quantity of water improves hygiene via improved food preparation and personal hygiene Increased handwashing (with soap) blocks link to food and direct contacts. Increased handwashing (with soap) blocks link to food and direct contacts.

37. Collective and Individual Responsibilities IndividualCollective Excreta Latrine/ Septic Tank Sullage sewerage + drainage Rain water Soak pit + run-off Drainage - Sewerage/ Septic Tank regulation

38. Cross Country Regression results: Child Mort = f(water, san, sec ed) Dependent Variable: child mortality R R2 F Prob.>F DF1 DF2 0.828 0.686 75.009 0.000 3 103 Adjusted 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 0.401 sec school -0.458 -0.950 0.179 -5.317 0.000 2.431 0.411 Constant = 227.282

39. For Cambodia …(based on regression equation extrapolations) If water supply coverage was 100%, but sanitation coverage was zero.. If water supply coverage was 100%, but sanitation coverage was zero.. –The child mortality rate would still be 102 (instead of 140; assuming no change in GNI, education) –If sanitation was raised to 100%, child mortality would drop to 42.