Sustainable Development and Health Equity Technical Report Series 1 Environmental Gradients and Health Inequalities in the Americas Access to Water and Sanitation as Determinants of Health This report shows that, while the Region of the Americas as a whole was on track to meet the targets of MDG 7 in water and sanitation, large, pervasive, and growing inequalities between and within countries remain hidden behind the regional averages. Tackling these environmentally determined health inequities should be the highest priority in the post-2015 development agenda: inequality is a growing threat to both global health governance and sustainability. The first step is to document, measure, and monitor these inequalities. This report could serve as a benchmark for assessing the impact of actions taken toward health equity under new and existing policies and comparing the results over time. Sustainable Development and Health Equity Technical Report Series 1 Environmental Gradients and Health Inequalities in the Americas Access to Water and Sanitation as Determinants of Health Special Program on Sustainable Development and Health Equity Washington, D.C. 2016 PAHO HQ Library Cataloguing-in-Publication Data **************************************************************************************** Pan American Health Organization Environmental Gradients and Health Inequalities in the Americas. Access to Water and Sanitation as Determinants of Health. Washington, DC : PAHO, 2016. 1. Social Determinants of Health. 2. Environmental Health. 3. Water Value. 4. Water Supply. 5. Sanitation. 6. Health Inequalities. 7. Equity in Access. 8. Gradient. 9. Americas. I. Title. ISBN: 978-92-75-11913-6 (NLM Classification: WA 30.5) © Pan American Health Organization, 2016. All rights reserved. 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In no event shall the Pan American Health Organization be liable for damages arising from its use. •• ii •• Contents Foreword .................................................................................................................................................. vii Acknowledgements ................................................................................................................................. ix Acronyms .................................................................................................................................................. xi Executive summary .................................................................................................................................. xiii Introduction: the Region is on track, but… ......................................................................................... 1 The global and regional paths toward Millennium Development Goal 7 ............................................. 1 The need to look through the equity lens ........................................................................................... 1 Rationale of the Report ...................................................................................................................... 1 Background: context and concepts ........................................................................................................ 3 Situation and trends in access to water and sanitation in the Region .................................................. 3 Access to water and sanitation as environmental determinants of health ........................................... 5 Methods: data, metrics, and analyses .................................................................................................... 7 Definitions and data acquisition ......................................................................................................... 7 Summary measures of environmental health inequalities .................................................................... 7 Methodological restrictions ................................................................................................................ 8 Findings: inequalities in health by access to water and sanitation ..................................................... 9 Descriptive findings ............................................................................................................................ 9 Demographic transition and access to water and sanitation ........................................................... 9 Geospatial distribution of access to water and sanitation ............................................................... 10 Analytical findings ............................................................................................................................. 12 Access to water and sanitation and their gradients as proxies of social position .............................. 12 Inequalities in health by access to water and sanitation .................................................................. 16 Inequalities in the burden of disease attributable to unimproved water and sanitation ................... 25 Country case-studies .......................................................................................................................... 28 The way forward: policy implications .................................................................................................... 33 Main findings .................................................................................................................................... 33 Priorities for action: access to water and sanitation in the post-2015 development agenda ................ 34 Annex: summary tables .......................................................................................................................... 37 References ................................................................................................................................................ 41 •• iii •• Figures Figure 1 Twenty-year progress in access to water (left) and sanitation (right). The World and Latin America and the Caribbean; 1990, 2000, and 2010. ................................................... 3 Figure 2 National coverage of access to improved sources of drinking water (left) and sanitation (right). Countries of the Americas; 1990, 2000, and 2010 ...................................................................................... 4 Figure 3 National progress toward MDG 7 in drinking water (left) and sanitation (right). Countries of the Americas; 1990-2010 ....................................................................................................... 4 Figure 4 Weighted correlation of access to drinking (left) and piped (right) water on access to sanitation. Countries of the Americas; 1990, 2000, and 2010 ...................................................................................... 5 Figure 5 The Dahlgren and Whitehead model of health determinants ....................................................................... 6 Figure 6 Schematic representation of the social determinants of health conceptual model (modified) ....................... 6 Figure 7 Demographic distribution by age and sex according to country terciles of access to piped water (upper panel) and sanitation (lower panel). Region of the Americas; 1990 and 2010 ................................... 10 Figure 8 National coverage of access to improved sources of drinking water in urban (left) and rural (right) scenarios. Countries of the Americas; 1990, 2000, and 2010 ............................................. 10 Figure 9 National coverage of access to improved sanitation facilities in urban (left) and rural (right) scenarios. Countries of the Americas; 1990, 2000, and 2010 ...................................................................................... 11 Figure 10 Weighted correlation of access to drinking water on access to sanitation in urban (left)