January 2014 Investing in improved Sanitation: key to achieving the MDGs?

Outline Impact of Sanitation on development indicators Current status of sanitation in Tanzania Programs and approaches to address the problem

2 Sanitation matters because it’s more than toilets MGD 7c: Access to improved basic sanitation and water MDG1: Poverty Up to 7% of annual GDP loss in lagging countries results from poor sanitation, driven by health costs and lost productivity with poor households bearing the burden MDG4: Reduction of child mortality Diarrhea is the 3rd leading cause of death in children under 5 MDG2: Education 443 million school days are lost every year due to WASH related diseases. Girls are disproportionately affected by lack of privacy and cleanliness during their period MDG3: Gender equity Improving sanitation impacts on reduction of violence against women during open defecation MDG4: Reduction of child mortality 1,800 children under 5 die every day from fecal related diarrheal disease MDG4: Reduction of child mortality 50% of childhood malnutrition is associated with repeated diarrhea and nematode infections Poor sanitation costs Tanzania US$ 206 million each year….. equivalent of US$ 5 per person in Tanzania per year or 1% of the national GDP.

Feces Fluids Fingers Flies Fields/Flo ors Food Sanitation Clean water Handwashing/hygiene 3 It’s not the water that makes children sick and malnourished, it’s the feces - sanitation is the primary barrier to stopping the consumption of human feces Sanitation

UNICEF: “The first two years are forever” Indian children, 2005 DHS height relative to healthy norms

as we all know, there are germs in feces, which get onto children’s fingers and feet, into water and foods, and wherever flies go  even in rural places, open defecation is not always far from homes  diarrhea  direct loss of food  enteropathy  no aborption  energy consumption fighting disease

small kids? big deal!  Height is not the only thing developing in the first few years life  The same early life health that helps bodies grow tall also helps brains grow smart  Height predicts (on average):  Cognitive achievement  Adult occupation class, employment, wages  Adult health, mortality, and happiness  Promotion of people in large organizations (!)

change over time in Bangladesh

height and cognitive achievement

merely wealth? wealth within India

Short and Long-term outcomes from stunting In Eastern and Southern Africa, 24 million children under five or 39% suffer from stunted growth (UNICEF, Nutrition Profile).  More likely to die from diarrhoea, pneumonia, measles and other infectious diseases (Black, 2013)  Are more likely to have poorer cognitive and educational outcomes in later childhood and adolescence (Walker et al., 2011, Grantham- McGregor et al., 2007). Making another generation less productive than they would otherwise be (Black, 2013)  Have higher levels of depression and anxiety and lower self-esteem (Walter et al., 2007), increased risk of suicidal ideation (Cheung et al., 2009), and higher levels of hyperactivity in late adolescence and attention deficit in adults (Galler, 2012).

Evidence of WASH on stunting  Lin (2013) Markers of environmental enteropathy in children are associated with a decrease in height for age Z score supporting the hypothesis that environmental contamination causes growth  Based on a randomized field experiment in Maharashtra, India, Hammer and Spears (2013) found that children living in villages randomly assigned to receive sanitation motivation and subsidized latrine construction grew taller than children in control villages.  Spears (2013) found that the differences in child height between India and Africa are explained by differences in sanitation.  Cameron et al (2013) found that a Total Sanitation and Sanitation Marketing project in Indonesia increased average height of children living in households without access to sanitation at baseline.

0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000, billion Defecating in the open - 90% occurring in rural areas 754 million using Unimproved Sanitation – 75% occurring in rural areas 761 million using Shared sanitation – 61% occurring in urban areas 4 Because of service delivery failure in both urban and rural areas, 2.5 billion people lack access to sanitation– resulting in one of the most off-track MDGs

 Government led 1970’s Mtu ni Afya Campaign, helped reduce OD and achieve high coverage of traditional pit latrines – from 5-20% in 1973 to over 80% in 1978 THE SANITATION STATUS

Sanitation practices are getting worse in rural Tanzania 5.1 million people 24 million people

Sanitation access is not drastically different across expenditure quintiles Source: Analysis by K. Mdadila using income/expenditure data from National Panel Survey

Stunting is worse off in children that are poor and who live rural areas of Tanzania Source: UNICEF Nutrition Profile

Childhood stunting varies by level of local area open defecation and unimproved sanitation Tanzania (2010) – Height-for-age z-score by age and local area open defecation and unimproved sanitation

Open defecation is becoming more prevalent in the north over time Souce: Ending Open Defecation in Rural Tanzania, Which Factors Facilitate Latrine Adoption. J Graham, S. Sara

NATIONAL SANITATION CAMPAIGN Campaign conducted across the country Campaign conducted across the country Knowledge Sharing Forum What works at scale? Distilling critical success factors for scaling-up rural sanitation

WSP Theory of change Improve health and socio economic conditions for poor rural households and communities (Vision 2025) Increase access to, and use of improved sanitation (Draft National S&H Policy, MKUKUTA II) Increase demand at community level to stop open defecation and increase the supply and demand of household sanitation solutions Strengthen the enabling environment needed to sustain improved sanitation at scale

WSP Theory of Action Positive Impact on health, economy and education Local Governments (Districts, Wards, Villages) Implement and Monitor National Sanitation Program, Regulates Private Sector National Government Supervises and Monitors National Sanitation Program Implements Activities with National Scope (Core concepts, Media), Improves Enabling Environment Households install and use improved sanitation facilities Local Private Sector offers sanitation goods and services Regional Authorities Monitor and Supervise Local National Sanitation Program Activities Communities (sub villages) ignite and commit to 100% coverage and usage (ODF) WSP Support: Programmatic approaches for supply and demand Performance reviews With related support to enable:  Policy  Leadership  Donor coordination  Financing  Capacity development

Thank you, open for discussion!!