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Domestic Water and Sanitation
May 1982
>> This Is USAID >> USAID Policy Papers >> Domestic Water and Sanitation
[Download original document] III. Current Situation in Developing Countries and the Role of International Donors
In recent years there has been relatively little improvement in the proportion of people in LDCs who have access to adequate supplies of safe water and basic sanitation, in large part because continued rapid population growth has outpaced the expansion of basic health-related services. Even a vigorous and well coordinated effort by LDCs and developed countries is unlikely to result in safe water and adequate sanitation for all the world's population by 1990, the goal of the International Drinking Water Supply and Sanitation Decade. The U.N. estimates that the cost of achieving universal access to adequate water and sanitation will be $300 billion over the decade. This estimate probably falls short of actual requirements, because the total cost of providing water to all rural areas, where the bulk of LDC populations live, is very high. But the estimated $300 billion far exceeds the resources that are likely to be available over the decade for drinking water and sanitation programs.
A. The U.S. Commitment to Supporting Water and Sanitation Programs in Developing Countries
The United States has voiced strong support for water supply and sanitation programs in developing countries in numerous international fora in recent years. The U.S. has supported resolutions endorsing the provision of safe water supplies and hygienic means of waste disposal at the U.N. Conference on Human Settlements (Habitat) in 1976; at the U.N. Water Conference in 1977, which proposed that the U.N. establish the 1981-1990 International Drinking Water and Sanitation Decade; at the International Conference on Primary Health Care (Alma Ata) in 1978; at the U.N. World Health Assembly; and, most recently, at the convocation of the U.N. General Assembly inaugurating the International Drinking Water and Sanitation Decade.
B. USAID and Other International Donors
USAID is one of the leading international donors providing financial support and technical assistance for water supply and sanitation programs in developing countries. (See Table 1). Compared with the aggregate contribution of other donors, however, the level of USAID financing for such activities is small. The World Bank (including IDA), by far the largest donor in developing countries, lent nearly $900 million for water supply and sanitation programs in 1979, primarily in urban areas. UNICEF devotes one-quarter of its budget ($53 million in 1979) to water supply and sanitation activities. Other bilateral, multilateral, and private voluntary donors in this area include the Inter-American Development Bank, UNDP ($698 million in 1979), the Asian Development Bank, the various Arab development banks, and the bilateral agencies of the OECD countries. While there is an impressive number of organizations involved in development assistance in this sector, it should be noted that at least 75 percent of the roughly $10 billion expended annually on improving domestic water supply and sanitation, comes from the LDCs (both governments and consumers) themselves.
USAID FUNDING, WATER SUPPLY AND SANITATION (1978-82)
($000)Asia LAC NE Africa S&T/H HG TOTALS
DA/ESFAnnual
Totals1 Development Assistance Funds.
2 Economic Support Funds.
*82 = EstimatedC. USAID's Role in Water Supply and Sanitation in Developing Countries
Many of the water supply and sanitation programs supported by major donors other than USAID have traditionally been urban-oriented and have generally employed relatively sophisticated levels of technology. However, the majority of LDC populations lives in rural areas and in villages and market towns, and it is in these areas that access to safe water and sanitation is most limited.1 Another residential grouping that has largely been bypassed by traditional water and sanitation systems is the recent immigrants living in the slums, squatter settlements and fringe areas of burgeoning LDC cities. Their poverty, their illegal or squatter status, and their lack of familiarity with urban life all tend to deny them the basic services more likely to be available to other urban residents. The neediest groups in developing countries include not only rural households but also those in cities and, in particular, in high density urban slums, and it is USAID's policy to assist in providing water supply and sanitation to both.
The cost-effectiveness of alternative technologies in various settings therefore becomes of paramount concern in USAID's investment decisions. For instance, providing domestic water and sanitation to people who live in extremely isolated regions or in widely dispersed households is likely to be more costly on a per capita basis than providing the same technology and services to settlements that are somewhat more densely populated and more readily accessible. But less costly technology and related design factors can narrow considerably if not close this gap. In certain regions the minimum community size for provision of improved water supply and sanitation at a reasonable cost will be 2,000-10,000, whereas in others, as a result of less costly technologies and other factors, it may be as low as 500.2 Providing improved sanitation in rural areas does not necessarily involve a large capital investment in construction; sanitation in urban areas, on the other hand, tends to be more costly on a per capita basis, because relatively sophisticated technology is frequently required.3
In the selection of technologies for water supply and sanitation programs, planners should also pay attention to "software" components. These might include training, technical assistance, the development of host country institutions, hygiene education, the promotion of community participation, the support of complementary nutrition and health activities, and the development of national and regional water and sanitation policies and plans. USAID does not and should not support water supply and sanitation programs where these essential software elements have not been adequately considered in the design of the project.
In general, USAID's increasingly scarce and limited levels of funding in many countries are not likely to be sufficient to support the capital investment costs of major urban water supply and sanitation programs.4 The Agency will finance "software" components of programs in urban and urban fringe areas. This policy is based on several considerations, not the least of which is expense. More substantial resources for major capital investment in water supply and sanitation tend to be available from other donors and lending institutions such as the World Bank; these funds are less often available for the technical assistance elements of such projects. Furthermore, in fine with growing U.S. concern for assuring the long-term viability of LDC institutions, USAID is placing strong and increasing emphasis on the "software" and technical assistance components mentioned above.
D. The Linkages Between Domestic Water Supply, Sanitation, and Health
What priority should water supply and sanitation programs have in USAID's overall health objectives? There is a strong temptation to compare health improvements that result from water and sanitation programs with those from other health activities, especially interventions such as immunizations or oral rehydration that appear to achieve comparable health objectives at lower per capita cost.
Although improvements in water supply and sanitation are generally linked to improvements in life expectancy and decreases in mortality and morbidity,5 water and sanitation programs tend to be relatively costly per capita compared with other health interventions.6 While per capita costs of establishing and operating water and sanitation systems are important considerations, and in many cases will be the most important factor determining investment strategies in health, other factors should also be considered. For instance, water and sanitation systems, depending on the type of system, water source, storage and treatment (if any), may not require heavy involvement of highly skilled manpower. In settings where the absence of such skilled personnel is a major constraint, water and sanitation projects can be competitive alternatives to other health programs designed to combat diarrheal and other water-related diseases.7
In addition, in any assessment of water and sanitation benefits, effects other than health must be taken into account.8 Thus while an analysis of the relative cost-effectiveness of water programs in improving health might discourage investments in domestic water supply and sanitation programs in favor of simpler or "more direct" health interventions (immunizations, etc.), a cost-benefit analysis (of all benefits, not only health) might argue strongly in favor of investments in water projects.
The Agency's past experience has resulted in a fairly thorough appreciation of what is needed to keep water supply and sanitation systems functioning in the developing countries in which USAID typically works. Unfortunately, there is much less certainty about the precise characteristics of water and sanitation systems that have the greatest impact on improving health. Will more convenient, reliable, and safe water supplies necessarily improve health in all communities, or must an area have achieved a certain level of socioeconomic development (whether measured in terms of educational level, level of agricultural or industrial production, or family income) before health improvements result?9 What types of health improvements can be expected in given settings and what is the best means of bringing about the behavioral changes necessary to translate improved water and sanitation into improved health?
While USAID continues to support economic and social research on these important questions, it has developed some general guidelines, listed below, for its support of improved domestic water supply and sanitation programs. More specifically, USAID will consider funding projects for improvements in domestic water supply and sanitation where:
- A clear need exists, as indicated by high prevalence of disease caused by (a) insufficient water, (b) consumption of highly contaminated water, and/or (c) inadequate or inappropriate sanitation systems; and demand for services is indicated by a willingness on the part of users to W support recurrent costs through some combination of fees, taxes or labor contributions, and (b) cover some portion of the investment costs to improve traditional systems or build new ones; or
- The absence of basic water and sanitation services poses a public health hazard for the community at large and the national government demonstrates a commitment to shoulder a substantial portion of investment costs where demand is insufficient to generate the revenue necessary to cover these costs10 ; and
- The local or national institution responsible for water and sanitation programs has the personnel and budgetary resources to assist in the construction, operation, and maintenance of the improved systems, or, with modest outside support, can be strengthened to the point where it has that capacity; and
- Infrastructure (both roads and other means of communication) is developed enough to permit routine contacts for supervision, technical assistance, maintenance, and the delivery of fuel or spare parts; or where the technology adopted is such that the system can be sustained by the community itself.
There are numerous complementary programs, in the areas of education, nutrition, primary health care, housing, irrigation, cottage industries, and rural development with which domestic water supply and sanitation programs can be combined to improve the impact of the program; such integrated approaches should be adopted wherever technically and financially feasible. For instance, where improved water supply and sanitation systems have been introduced in a community to improve health conditions, especially among young children, high priority should be given to constructing latrines and providing adequate water supplies in the local schools, and to including hygiene in the curriculum. In some settings, the school environments are so unhealthy that parents are reluctant to allow their children to attend. Furthermore, having appropriate sanitation facilities in the schools is a powerful way of reinforcing the hygiene lessons being taught in the classroom. Where provision of more convenient water in greater quantity is designed to lessen diarrheal disease, simultaneous introduction of oral rehydration (teaching women to mix solutions hygienically) can enhance the health impact of the new water supply, thus further diminishing mortality.
Among the benefits generally thought to flow from investments in water are: (1) improved health, (2) more cash income, (3) increased food production or diversification of crops, (4) more employment, and (5) more leisure.11 The extent to which any one of these benefits is realized or sustained varies considerably from setting to setting. 12 In subsequent sections of this paper, the factors that tend to lead to sustained health improvements and ancillary benefits are discussed in greater detail. Except in unusual circumstances, USAID programs will be expected to adhere to the guidance contained below.
1It may be extremely costly to provide these services for the poorest, most widely dispersed groups (who are the least able to pay for them) but USAID is committed to the search for low-cost technologies that lower the cost of serving the poorest population in LDCs (see pp. 21-24 below).
[return to text]2Saunders and Warford, op. cit. Total costs depends on the quality and quantity of the water available, the type of "hardware" selected, the related training, administrative, and other costs, and much more.
[return to text]3"Water Supply and Waste Disposal," Poverty and Basic Needs Series, The World Bank, Washington, D.C., 1980.
[return to text]4Housing Guaranty and Economic Support Fund Programs which operate primarily in urban areas are exceptions.
[return to text]5Barnum, Howard, et. al., A Resource Allocation Model for Child Survival, Cambridge, Ma: Oelgeschlager
[return to text]6See, for instance, Grosse, Robert N., "International Between Health and Population: Observations Derived from Field Experience," Social Science and Medicine, Vol. 14C No. 2, pp. 99-120, 1980.;
[return to text]7Barnum, op. cit. p. 4
[return to text]8See, for instance, the studies cited in footnote 8 of Section II. See also Hollister, Arthur C., Jr., et. al., "Influence of Water Availability on Shigella Prevalence in Children of Farm Labor Families," American Journal of Public Health, 45 (3):354-362, 1995; Moore Helen, et. al. "Diarrheal Disease Studies in Costa Rica. Iv. The Influence of Sanitation Upon the Prevalence of Intestinal Infection and Diarrheal Disease." American Journal of Epidemiology, 82(2): 162-184, 1965: Schliessman, DE.J., et. al., "Relation of Environmental Factors to be Occurrence of Enteric Diseases in Areas of Eastern Kentucky," Public Health Monograph No. 54 (Issued concurrently in Public Health Reports, 73 (11).), Washington, 1958.
Section 611(b) of the Foreign Assistance Act requires "...a computation of benefits and costs made insofar as practical in accordance with the procedures set forth in the Principles and Standards for Planning Water and Related Land Resources, dated October 25, 1973, with respect to such computations." [return to text]9Shuval, Hillel, et. al., "The Effect of Water Supply and Sanitation Investments in Health Status: A Threshold-Saturation Theory," in press, 1981.
[return to text]10In situations where the public need is compelling, host government subsidization of recurrent costs may be necessary on an interim basis, with the expectation that consumers will eventually assume the costs.
[return to text]11Carruthers, I.D., "Impact and Economics of Community Water Supply: A Study of Rural Water Investments in Kenya" (Kent, England: Agrarian Development Studies Report No. 6), 1973, p. 30.
[return to text]12Warner, Dennis, "Social and Economic Preconditions for Water and Sanitation Programs," Washington, D.C.: U.S.USAID, 1981.
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