Cambodia: Poverty Reduction and Sanitation

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

2. Poverty and Health • 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: • Reduce child mortality • Improve maternal health • Combat AIDS, malaria and other diseases

3. Goals—Child and Infant Mortality • Under 5 mortality infant mortality • 1998 – 124 95 • 2005 -- 82 (est.) 66 (est.) • 2015 -- 65 (proj.) 50 (proj.) • [World Bank data • 2000 -- 134 95 • 2003 -- 140 97 ] • Source: National Development Strategic Plan (draft, 8 Nov 2005) Annex I and World Bank, World Development Indicators, 2005

4. Goals – water and sanitation • -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. CambodiaAll LDCs Child Mortality 140 76 Water access 34 78 Sanitation access 16 60 Secondary Education 25 62 GNI PPP 2050 4557 Source: World Bank, World Development Indicators, 2005. Data for 2002-2003. “All LDCs” is average of 107 countries with data. Cambodia compared to all LDCs

11. Cambodia underperforms on child mortality compared to similar countries… • 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;

12. Cambodia underperforms on sanitation • 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

13. Cross Country Regression results:Child Mort = f(water, san, sec ed) • 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 • “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 • Housing conditions • Solid waste collection and disposal • Source: WHO 1987

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

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

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

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

19. Diarrhea…Some facts • 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 • 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 • 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

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

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 Diarrheal Disease Prevention Enabling Environment Policy improvement Institutional strengthening Community organization Financing and cost recovery Crosssector & PP partnerships

23. Urban Cambodia: Mixed drainage/sewerage

24. Typical Septic Tank

25. Mixed problems of solid waste, drainage, sewerage

26. Alternative approaches • Source: SIWI, 2000

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

28. Responsibility share for < ---------------- > Individual Collective urban sanitation Household Blocks Community Authority Construction Construction Construction Promotion Latrines O&M O&M O&M Regulation Construction Construction Emptying Emptying Septic tanks Emptying Emptying Disposal Disposal Simplified Construction Construction Connections sewerage O&M O&M Small bore Septic tank Septic tank Construction Construction sewerage construction construction O&M O&M Conventional Construction Connections sewerage O&M Responsibilities—Collective vs. Individuals

29. A Possible Strategy… • 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 • Hand washing (with soap), personal hygiene, food handling

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

31. Strategy (p. 3) • Hardware: Limit heavy investments • Modest facility improvements with public support, regulation, with subsidies for poor. • Improved septic tanks, latrines • 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. 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