WASH Poor in a Water-Rich Country Poor in a Water-Rich WASH WASH Poor in a Public Disclosure Authorized Water-Rich Country A Diagnostic of Water, Sanitation, Hygiene, and Poverty in the Democratic Republic of Congo A Diagnostic of Water, Sanitation, Hygiene, and Poverty in the Democratic Republic of Congo A Diagnostic of Water, Public Disclosure Authorized DEMOCRATIC REPUBLIC OF CONGO Public Disclosure Authorized Public Disclosure Authorized About the Water Global Practice Launched in 2014, the Word Bank Group's Water Global Practice brings together financing, knowledge, and implementation in one platform. By combining the Bank's global knowledge with country investments, this model generates more firepower for transformational solutions to help countries grow sustainably. Please visit us at www.worldbank.org/water or follow us on Twitter at @WorldBankWater. WASH Poor in a Water-Rich Country A Diagnostic of Water, Sanitation, Hygiene, and Poverty in the Democratic Republic of Congo © 2017 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Please cite the work as follows: World Bank. 2017. WASH Poor in a Water-Rich Country: A Diagnostic of Water, Sanitation, Hygiene, and Poverty in the Democratic Republic of Congo. World Bank, Washington, DC. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522- 2625; e-mail: pubrights @ worldbank.org. Cover design: Bill Pragluski, Critical Stages LLC Contents Acknowledgments ix Executive Summary xi Abbreviations xxi Chapter 1 Introduction 1 Reference 2 Chapter 2 Poverty in the Democratic Republic of Congo: The Heart of the Challenge 3 Evolution of Poverty in the Democratic Republic of Congo Since 2005: The Scope of the Challenge 4 Spatial Distribution of Poverty in the Democratic Republic of Congo 7 Notes 9 References 10 Chapter 3 Level and Quality of Water and Sanitation Access for the Poor 11 The Democratic Republic of Congo’s Hydrological Resources: Water Rich but Service Poor 12 The Evolution of WASH Services: Modest Access Improvements Overpowered by Population Growth 13 The New Sustainable Development Goals: Access Plus and the Water Quality Problem 18 WASH Access and Poverty 23 Conclusion 28 Notes 29 References 30 Chapter 4 WASH, Nutrition, and Health: The Foundations of Long-Term Development 33 Malnutrition: A Silent Emergency 34 The Link Between WASH, Health, and Malnutrition 35 Cross-Sectoral Interventions to Target the WASH–Malnutrition–Health Nexus 40 Implications of the WASH–Nutrition Nexus for Policy Makers 42 Notes 44 References 46 Chapter 5 WASH Service-Delivery Constraints and Potential Solutions 51 The Legal Framework: A New Water Law 52 The Present Institutional Structure and Its Major Weaknesses 53 Urban Water: In the Shadow of REGIDESO 59 Urban Sanitation: Where to Begin? 68 Rural Water and Sanitation: Struggling to Scale 75 Conclusion 81 Notes 83 References 83 WASH Poor in a Water-Rich Country iii Appendix A Activities and Delivery Package for Democratic Republic of Congo WPD 87 Appendix B A Regional Perspective on Metropolitan, Urban, and Country WASH Access Gaps 89 Appendix C Democratic Republic of Congo WPD Household Survey Design and Methodology 91 Appendix D Household Surveys Data Available for the Democratic Republic of Congo 97 Appendix E Joint Monitoring Program Indicators 99 Appendix F Determinants of Household Access 105 Appendix G Water, Sanitation, and Nutrition Pathways 111 Appendix H Stunting, Anthropometric Failures, and Unimproved Access 113 Appendix I Stunting, Improved Sanitation, and Water Versus Open Defecation 115 Appendix J Improved WASH Access, CIAF, and Under-Five Children (0–59 Months) 117 Appendix K Improved WASH Access, CIAF, and Younger Children (0–24 Months) 121 Appendix L Improved WASH Access, CIAF, and Older Children (25–59 Months) 125 Appendix M Anemia and WASH Access of Children (6–59 Months) 129 Appendix N Malaria and WASH Access of Children (6–59 Months) 131 Appendix O Stunting, Improved Sanitation, and Water in Kinshasa 133 Appendix P Improved WASH Access and Stunting of Under- Five Children (0–59 Months) in Kinshasa 135 Appendix Q Anemia, Malaria, Stunting, WASH Access, and Conflict (Children 6–59 Months) 139 Appendix R Anemia, Malaria, Stunting, WASH Access, and Conflict (Number of Events Year Prior to Survey, Children 6–59 Months) 141 Appendix S Anemia, Malaria, Stunting, WASH Access, and Conflict (Causalities, Children 6–59 Months) 143 Appendix T WASH Access, Mining, and Stunting 147 Appendix U Stunting and Correlates with WASH and Environmental Context, 2007 149 iv WASH Poor in a Water-Rich Country Appendix V Multi-Sectoral Nutrition Framework (Synergy Analysis) 151 Appendix W Notes on WASH Variables Processing Across Surveys 159 Appendix X Overview of Poverty Risk Model (PRM) 163 Appendix Y Participants in Democratic Republic of Congo WASH Poverty Diagnostic Review in Kinshasa, November 23, 2016 177 Appendix Z Key Extracts from Report on Public Hygiene by the Belgian Colonial Government 179 Appendix AA Restructuring of the CNAEHA - Summary of the Most Important Changes 185 Boxes Box 3.1: Summary of Access Definitions 19 Box 4.1: The Complex Influences on WASH Quality and Nutrition: Fragility and Mining 43 Box 5.1: Urban Sanitation in Kinshasa: A Case Study 73 Box X.1: Relative Risk and the WASH Risk Index 165 Box X.2: Use of National, Urban, and Rural Wealth Quintiles 174 Figures Figure ES.1: Access to Improved Facilities, by Poverty Status, for Kinshasa, Other Major Cities, Minor Towns, and Rural Zones xiii Figure ES.2: Current Improved Access to Water and Sanitation Compared with SDG Water and Sanitation Access Tiers xiii Figure ES.3: Pervasive Malnutrition in Democratic Republic of Congo xiv Figure ES.4: External Funding for WASH, by Urban or Rural Area and Subsector (Disbursements and Commitments, 2005–20) xv Figure ES.5: Cross-Sectoral and Sector-Specific Institutional Constraints and Key Resulting Service Gaps xvi Figure 2.1: Poverty Rates, Selected Countries, 2016 4 Figure 2.2: Poverty and Inequality in Democratic Republic of Congo across Space and Time (National Poverty Line with Spatially Adjusted Price Levels) 5 Figure 2.3: Poverty in Urban Areas 8 Figure 3.1: JMP Estimates of Access to Improved Water and Sanitation vs. National Survey Results 14 Figure 3.2: Access to Improved Water and Piped Water for Urban–Rural Spectrum 15 Figure 3.3: Access to Improved and Unimproved Sanitation for Urban–Rural Spectrum 16 Figure 3.4: Current Improved Access to Water and Sanitation Compared with SDG Water and Sanitation Access Tiers 18 Figure 3.5: Improved, Basic, and Safely Managed Water Access (and Intermediate Steps) across the Urban–Rural Spectrum 20 Figure 3.6: Access to Water, by Service Type 20 WASH Poor in a Water-Rich Country v Figure 3.7: “Access Plus”: Time to Access Water 22 Figure 3.8: Access to Sanitation, by Service Type 22 Figure 3.9: “Access Plus”: Handwashing Facilities in Households 23 Figure 3.10: Access to Improved Water and Sanitation, by Decile, 2005–12 25 Figure 3.11: Access, by Poverty Status, for Kinshasa, Other Major Cities, Minor Towns, and Rural Zones 26 Figure 3.12: Change in Improved Water Access since 2001 27 Figure 3.13: Change in Improved Sanitation Access since 2001 27 Figure 3.14: Who Gets Water? Water-Fetching Responsibilities, by Gender 28 Figure 3.15: Population Currently Lacking Water Access and Expected Population Requiring Access for Universal Water Supply, by SDG Tier 29 Figure 4.1: Pervasive Malnutrition in Democratic Republic of Congo 34 Figure 4.2: Stunting in Children Under Five, by Wealth Quintile and Location Type 34 Figure 4.3: Years Lost Due to Disability (YLD) for People Living with a Health Condition or its Consequences in Democratic Republic of Congo 37 Figure 4.4: Composite Index of Anthropometric Failures (CIAF) and Water Contamination with E. coli 38 Figure 4.5: Water Treatment across Settings in Democratic Republic of Congo 39 Figure 5.1: Overview of WASH Sector Hierarchies in Context of Partially Completed Decentralization 57 Figure 5.2: External Funding for WASH, by Urban or Rural Area and Subsector (Disbursements and Commitments, 2005–20) 58 Figure 5.3: Number of Autonomous Water Supply Schemes Built in the Democratic Republic of Congo 65 Figure 5.4: Sanitation Service Chain 72 Figure 5.5: Core Service Gaps in Water and Sanitation and Underlying Institutional Weaknesses 82 Figure B.1: Access to Improved Water in the Country Compared with Capital Areas 89 Figure B.2: