Report The sanitation problem: What can and should the health sector do? Report Summary Summary recommendations: 1. Global health institutions should acknowledge and address the impact of sanitation on the global disease burden, the contribution of improved sanitation to reducing that disease burden and the potential benefits for public health outcomes. 2. International donors should prioritise support for programmes in countries with low sanitation coverage and high burden of sanitation-related disease and invest in research and evaluation to understand the relative health impacts and additive effects of different types of sanitation intervention. 3. Developing country governments should ensure that sanitation is addressed within all relevant health policies, regulations, guidelines and procedures and establish targets and indicators for monitoring improvements in sanitation related diseases. 4. Developing country governments should strengthen public health legal and regulatory frameworks to improve inter-sectoral coordination between ministries and agencies responsible for sanitation at different levels and enhance accountability for results. 5. National and sub-national health programme priorities should take account of sanitation-related disease burden and ensure that sanitation and hygiene are fully integrated within disease specific and national health programmes. Half of the people living in developing in reducing the burden of sanitation- countries do not have access to even a related diseases borne by poor people basic toilet.1 This presents a major risk in developing countries remains slow to public health. Diseases attributable and is holding back progress on all to poor sanitation currently kill more other development outcomes. children globally than AIDS, malaria and measles put together, and diarrhoea The wider problem of political and is the single biggest killer of children financial neglect of sanitation issues in Africa.2 Safe sanitation is widely has already been well documented3 acknowledged to be an essential and the 2008 International Year of foundation for better health, welfare Sanitation signalled a concerted and economic productivity, but progress effort to try and address the sanitation Report problem. But WaterAid’s experience are primarily focused on treatment on the ground in Africa and Asia has and patient-based interventions while shown that the enduring challenge is preventive and public health aspects tend not just how to provide infrastructure, to receive less attention.5 In developing but also how to promote uptake countries the majority of investment in and use of facilities. Infrastructure sanitation is currently channelled through is necessary but not sufficient for infrastructure ministries where it is mainly better health. There is a critical need to focused on providing new facilities. develop better integrated approaches Meanwhile, budget allocations to in order to maximise the health gains health ministries for sanitation tend to associated with sanitation interventions be less clearly defined and allocation in support of the ongoing drive to of health system resources for related achieve ‘Sanitation and Water for All’.4 activities is often diffuse, making it difficult to monitor results. The health sector has an important role to play in promoting sanitation. There is relatively little research on Creating demand and changing appropriate health sector roles and behaviours are both areas where responsibilities in promoting sanitation the health sector has a strong track but after reviewing existing theory and record and recognised comparative practice the study focuses on four key advantage. However, there is a lack of ‘functional deficits’ that characterise consensus regarding institutional roles existing institutional responses to and responsibilities for sanitation in sanitation and health: developing countries, and the degree of health sector involvement in promoting 1. norms and regulations safe sanitation varies significantly. This 2. inter-sectoral policy and coordination report draws upon recent WaterAid- 3. delivery of scaleable funded research into the different sanitation programmes roles played by the health sector 4. collection and use of data in developing countries and makes recommendations for accelerating This report explores the role of the progress on sanitation and securing health sector in addressing each of the related health outcomes. functional deficits identified, drawing on examples from the four country The report reviews recent trends in case studies. health sector policy and programmes in developing countries, confirms the The study concludes that improved inadequate nature of existing institutional collaboration between WASH and health responses to the sanitation problem sectors is key to improving sanitation- in these countries, and highlights the related health outcomes. It shows that absence of strong political leadership health systems have a critical role to and lack of clearly-defined institutional play in promoting sanitation but that roles and responsibilities. It further existing health sector involvement is notes that health sector planning and frequently sub-optimal. It makes a series funding allocations frequently do not of recommendations for health sector reflect the burden of disease attributable stakeholders interested in accelerating to sanitation in developing countries progress on sanitation and securing related and that contemporary health systems health gains in developing countries. Report A WaterAid report, May 2011. Written by Yael Velleman and Tom Slaymaker. Acknowledgements: This policy report draws upon the findings of WaterAid-funded research conducted in collaboration with the Water Institute (WI) at the Gillings School of Public Health, University of North Carolina, during 2010. The views expressed here are those of WaterAid and do not necessarily reflect those of the Water Institute. With particular thanks to WaterAid country programme staff in Malawi, Nepal and Uganda for their support and contributions to this report. This paper should be cited as WaterAid (2011) The sanitation problem: What can and should the health sector do? A soft copy of this and all other WaterAid papers can be found at www.wateraid.org/publications. Front cover image of children in Malawi: WaterAid/Layton Thompson Report Table of contents 1. Introduction 2 2. The critical role of sanitation in health 4 3. The inadequacy of existing institutional responses 9 4. Functional deficits and the role of the health sector in addressing them 12 4.1. Core functional deficits in securing progress on sanitation and related health gains 12 4.1.a Functional deficit 1: Norms and regulations 13 4.1.b Functional deficit 2: Inter-sectoral policy and coordination 15 4.1.c Functional deficit 3: Delivery of scalable sanitation programmes 20 4.1.d Functional deficit 4: Collection and use of data 26 5. Facilitators and barriers to health sector addressing functional deficits 28 5.1.a Leadership 28 5.1.b Community participation 29 5.1.c Human resources 29 5.1.d Financing 30 6. Recommendations for health sector stakeholders 31 6.1. International health policy and donor policy 31 6.2. National development policy and resource allocation 32 6.3. National health policy and sanitation programme design 32 6.4. Other stakeholders 34 1 Report 1. Introduction WaterAid’s vision is of a world where everyone has access to safe water and sanitation. This vision can only be achieved by working in collaboration with others. This report is part of an ongoing programme of work which seeks to reach out beyond the water, sanitation and hygiene (WASH) sector to engage with actors and agencies from other sectors, particularly health and education, as part of a concerted joint effort to address the lack of access to WASH and the profound impact it has on health, welfare and economic growth in the world’s poorest countries and communities. Box 1: Health ‘sector’ or health ‘system’? The terms ‘health sector’ and ‘health system’ are often used interchangeably and are rarely defined. For the purposes of this paper the term ‘health sector’ is used to refer to the various different actors and agencies that play a role in improving health (whether political, financial, technical or administrative), whereas the term health system is used to refer to the system for delivery of healthcare services (mostly understood as curative or palliative services). According to the World Health Organization (WHO): “A well functioning health system responds in a balanced way to a population’s needs and expectations by: • Improving the health status of individuals, families and communities. • Defending the population against what threatens its health. • Protecting people against the financial consequences of ill-health. • Providing equitable access to people-centred care. • Making it possible for people to participate in decisions affecting their health and health system.”6 2 Report The report argues that the scale of coverage provided the context for more the financial and human costs of the detailed case studies: Malawi, Nepal, neglect of sanitation cannot be ignored; Sri Lanka and Uganda.7 Extensive in- and that joint, cross-sector efforts that country support was provided by local make better use of existing resources WaterAid staff and partners. are critical to building on the gains achieved so far in improving global A triangulation approach was health. Progress on global health, in used to gain a fuller