Provided for non-commercial research and educational use only. Not for reproduction or distribution or commercial use. This article was originally published by IWA Publishing. IWA Publishing recognizes the retention of the right by the author(s) to photocopy or make single electronic copies of the paper for their own personal use, including for their own classroom use, or the personal use of colleagues, provided the copies are not offered for sale and are not distributed in a systematic way outside of their employing institution. Please note that you are not permitted to post the IWA Publishing PDF version of your paper on your own website or your institution’s website or repository. Please direct any queries regarding use or permissions to [email protected] 240 © IWA Publishing 2013 Journal of Water, Sanitation and Hygiene for Development | 03.2 | 2013 Sanitation coverage in Bangladesh since the millennium: consistency matters Y. Zheng, S. A. I. Hakim, Q. Nahar, A. van Agthoven and S. V. Flanagan ABSTRACT Household surveys in Bangladesh between 1994 and 2009 assessed sanitation access using Y. Zheng (corresponding author) S. A. I. Hakim questions that differed significantly over time, resulting in apparently inconsistent findings. Q. Nahar A. van Agthoven Applying the WHO and UNICEF Joint Monitoring Programme’s 2008 definition for open defecation and S. V. Flanagan Water and Environmental Sanitation Section, improved sanitation facilities excluding shared facilities to the compiled data set, sensible sanitation UNICEF Bangladesh, coverage trends emerge. The percentage of households openly defecating declined at a rate of 1 Minto Road, Dhaka 1000, about 1.8% per year from 30% in 1994 to 6.8% in 2009, primarily due to changes in rural areas. Bangladesh E-mail: [email protected]; Access to individual improved sanitation facilities nearly doubled from about 30% in 2006 to 57% in [email protected] 2009, with both rural and urban areas showing impressive progress. Access to shared improved Y. Zheng School of Earth and Environmental Sciences, latrines also nearly doubled from about 13% in 2006 to 24% in 2009, with the urban slums recording Queens College, the greatest gain from 17% in 2006 to 65% in 2009. Shared improved latrines are only slightly less City University of New York, Flushing, NY 11367 and clean than individual ones. Dependence on shared improved latrines increases with population Lamont-Doherty Earth Observatory of Columbia University, density. In 2007, 20% of the poorest households still openly defecated, although more of them (38%) Palisades, NY 10964, shared a latrine of any type. A poverty reduction program is recommended to address this USA equity issue, although applying consistent definitions is crucial to documenting progress. Key words | Bangladesh, demographic and health survey, multiple indicator cluster survey, population density, sanitation, wealth INTRODUCTION Globally, improving water, sanitation and hygiene (WASH) Goals (MDG) sanitation target, with 2.5 billion people lack- has the potential to prevent at least 9.1% of the disease ing access to improved sanitation, including 1.1 billion who burden in disability-adjusted life years (DALYs), or 6.3% of have no facilities at all as of 2010. all deaths (Prüss-Üstün et al. ). Water and sanitation Slow progress in sanitation in sub-Saharan Africa and interventions are cost effective and have demonstrated econ- South Asia perpetuates a poverty cycle. In Bangladesh, omic benefits ranging from US$ 5 to US$ 46 per US$ 1 inadequate sanitation was shown to cost US$ 4.2 billion invested (Hutton et al. ). The Joint Monitoring (109), equivalent to 6.3 per cent of the gross domestic pro- Programme (JMP) of the World Health Organization and duct (GDP) in 2007, with the largest contributor, diarrhea, the United Nations Children’s Fund (WHO and UNICEF accounting for two-thirds of the health-related economic ) reckons that improving sanitation coverage offers impacts primarily due to premature deaths of young the opportunity to save the lives of 1.5 million children a children (Water and Sanitation Program [WSP] ). More- year who would otherwise succumb to diarrheal diseases. over, 71% of the impacts were borne by the poor. Since Access to sanitation facilities protects women’s dignity and 2000, Bangladesh has emerged as a global leader in innova- is fundamental to gender equity. However, the most recent tive approaches to rural sanitation. Community Led Total JMP update (WHO and UNICEF ) shows that the Sanitation (CLTS), which began in Bangladesh and was world is off track to meet the Millennium Development credited for improving rural sanitation coverage, has now doi: 10.2166/washdev.2013.154 241 Y. Zheng et al. | Progress of sanitation access in Bangladesh Journal of Water, Sanitation and Hygiene for Development | 03.2 | 2013 been adopted in many developing countries. However, with design (UNICEF ). In addition, a MICS tends to have the percentage of the population using improved sanitation more PSUs in more strata than a DHS does. For example, at 55% as of 2009 (Bangladesh Bureau of Statistics [BBS] DHS07 had two strata with 227 and 134 PSUs in rural and UNICEF ), Bangladesh is off track to meet the and urban areas, respectively (National Institute of Popu- MDG target of 70% in 2015. Note that improved facilities lation Research and Training [NIPORT] ). On average, shared by more than one household are not counted 30 households were selected to represent each PSU. In com- towards the MDG target in the ‘improved’ category in this parison, MICS06 had five strata with 1,280, 384, 156, 52 and 2009 figure. Here, we examine the progress in sanitation 78 PSUs for rural, municipal, city corporation, slum and first by looking at open defecation because it is the easiest tribal areas, respectively (BBS and UNICEF ). A to measure and reduction in open defecation is a meaningful sample of 35 households was drawn for each of these first step on the sanitation ladder. We then compare several PSUs (clusters). The sampling errors for DHS and MICS data sets by applying a consistent definition for ‘improved are comparable but are smaller for surveys with a higher sanitation facilities’ according to JMP 2008 (WHO and number of total households and smaller clusters such as UNICEF ) in order to properly document progress MICS2009 (Table 1). of sanitation coverage in Bangladesh. The implications are The JMP00, or the Global Water Supply and Sanitation discussed in terms of equitable access to sanitation. Assessment 2000 used a water supply and sanitation sector questionnaire submitted to WHO that presumably used some of the aforementioned surveys (Table 1), and was the METHODS: SANITATION SURVEYS first systematic global effort to report on improved sani- tation. JMP00 defines the improved facilities as connection Sanitation coverage in Bangladesh (Table 1) has been to a public sewer, connection to septic system, pour-flush measured through household surveys (Table 2) such as the latrine, simple pit latrine and ventilated improved pit (VIP) Demographic and Health Survey (DHS) in 1994, 1997, latrine (WHO and UNICEF ). However, it stated that 2000, 2004 and 2007 by Mitra Associates and Macro Inter- the excreta disposal system was considered adequate if it national funded by USAid, the Multiple Indicator Cluster was private or shared (but not public) and if it hygienically Survey (MICS) in 1994, 1995, 1996, 1997, 1998, 1999, separated human excreta from human contact. This left a 2000, 2003, 2006 and 2009 by the Bangladesh Bureau of possibility that some shared facilities would count as Statistics and UNICEF, and additionally the Maternal improved, leading to inaccurate documentation. The not Health Services and Maternal Mortality Survey in 2001 improved category includes service or bucket latrines (MHS01) by Mitra Associates, Associates for Community where excreta are manually removed, public latrines and and Population Research (ACPR), Johns Hopkins, Inter- open latrines. JMP06 made clarifications on the technical national Centre for Diarrhoeal Disease Research definition of improved facilities as flush or pour-flush Bangladesh (ICDDRB) and Macro International funded by toilet/latrine to piped sewer system, septic tank and pit USAid, and the National Sanitation Survey in 2003 latrine, VIP latrine, pit latrine with slab, and composting (NSS03) by the Government of Bangladesh. toilet (WHO and UNICEF ). It also puts pit latrines The sampling designs of DHS and MICS surveys are without a slab or platform, hanging latrines and bucket mostly similar with a two-stage stratification, although latrines into the ‘unimproved’ category. JMP08 further clari- there are also differences. Both DHS and MICS use primary fied and added shared facilities as one step of the four-step sampling units (PSUs) that were the enumeration areas of sanitation ladders (open defecation, unimproved, shared, the Bangladesh Census, comprising around 100 households improved), defined as otherwise improved sanitation facili- for census 2000 for example. The number of households in a ties but are either public or shared between two or more PSU (cluster) is kept the same within each MICS but can be households, and are consequently not considered as different from survey to survey (Table 1). However, this improved (WHO and UNICEF ). JMP08 definitions value can vary in a DHS that uses a standard segment have not been revised and are still in use today. 242 Y. Zheng et al . | Progress of sanitation access in Bangladesh Table 1 | Sanitation coverage and surveys in Bangladesh %HH %HH No. Rural HHs/ Survey Year OD %HH improved shared No. HHs HHs Cluster Survey Period Remarks DHS94 1994 30.0 41.6a N.D. 9174 7798 1993/11–1994/03 DHS97 1997 25.4 45.2a N.D. 8683 7327 1996/11–1997/03 DHS00 2000 19.9 54.1a N.R. 10268 7271 1999/11/10–2000/03/15 First DHS with ‘shared’ question DHS04 2004 13.7 58.6a N.D.