NEWS
IN FOCUS
Flagging global sanitation target threatens other Millennium Development Goals
Sarah Jane Marshall
Bulletin
The global target of halving the proportion of people without access to basic sanitation by 2015 is currently out of reach for many countries, said Børge Brende, Chair of the 12th Session of the UN Commission for Sustainable Development (UNCSD), in a special interview with the Bulletin. The Commission is to meet in New York on 1430 April 2004 to review progress on achieving the Millennium Development Goals relating to water, sanitation and human settlements.
"There are major differences in how much progress has been made, both across [the water and sanitation-related] goals and across countries. The least progress has been made on sanitation," said Brende. "This affects not only other health-related goals but also some non-health-related goals such as poverty reduction and education," he added.
A report on the status of progress towards the implementation of the targets relating to sanitation will be submitted by UN Secretary-General, Kofi Annan, to the UNCSD in April and will be the first review of sanitation as a stand-alone topic by an intergovernmental body.
In 2000, 2.4 billion people lacked access to basic sanitation and 1.1 billion people did not have access to safe water supply, according to a report by WHO and UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Whilst progress was made during the 1990s over one billion people acquired access to improved sanitation and over 900 million people acquired access to improved water supply population growth has left the gains looking modest when compared with total global coverage.
WHO projections suggest that continuing the rates of progress maintained in the 1990's could lead to the achievement of the Millennium Development Goal for water to halve the proportion of the population without access to safe drinking-water by 2015.
For the sanitation target, however, the picture is bleaker. Projections indicate that globally the targets will not be achieved and over 2 billion people will still not have access to any type of improved sanitation facility by 2015. In sub-Saharan Africa, for example, if rates of progress from the 1990's are maintained, the nu mber of people without sanitation coverage will almost double by 2015.
"Even if the target is achieved, 1. 7 billion people almost a quarter of humanity would be left without access to even a simple improved latrine in 2015," said Dr James Bartram, Coordinator of the Water, Sanitation and Health programme, who is leading input to the UN Secretary-General's report to be submitted to the UNCSD in April.
Achieving the sanitation target requires extending coverage to an additional 1.9 billion people between 2000 and 2015, taking into account projected population expansion in urban areas. The regions that pose the biggest challenge are South-Central Asia and East Asia where an additional one billion people require access to basic sanitation over the same period. Sub-Saharan African countries, where roughly one in two people do not have access to improved sanitation, will need to extend coverage between 2000 and 2015 to an additional 355 million people.
For all regions, access to sanitation in rural areas is much worse than in urban areas. In 2000, only 15% of India's rural population of 730 million had sanitation coverage whilst in the same year 600 million people living in rural China had no access to basic sanitation.
Urban areas, on the other hand, are faced with the challenge of extending sanitation coverage to slum settlements. Currently 930 million people live in slums and this figure is growing at an accelerated rate. UN Habitat recently reported that 83 per cent of the population in 43 African cities live without connection to a sewerage system.
Insufficient progress in meeting the sanitation target is holding up other health-related Millennium Development Goals including access to clean drinking water. Water supplies are unlikely to remain safe for drinking without attention to sanitation since human excreta remain one of the most serious sources of drinking-water contamination.
According to WHO, at any given time nearly half the people in the developing world are suffering from one or more of the main diseases associated with inadequate provision of water and sanitation such as diarrhoea, ascaris, guinea worm, hook worm, schistosomiasis and trachoma.
This in turn has an impact on the child mortality goal. "Water and sanitation-related diseases remain one of the biggest causes of deaths among children," said Bartram. Diarrhoea alone causes the deaths of 1.8 million people every year, 90% of which occurs in children less than five years old.
Achieving universal primary education, the second Millennium Development Goal, is also likely to be affected by access to sanitation. A joint WHO/UNICEF report showed that the most common single cause of girls dropping out of school in Africa is lack of adequate sanitation.
Debate over the achievability of the sanitation target meant that it was only added to the Millennium Development Goals relatively recently in 2002 at the World Summit on Sustainable Development in Johannesburg, South Africa. "There was a big discussion over whether to include sanitation because people knew that it would be a hard target to achieve," said Brende.
A major obstacle to expanding access to sanitation has been funding, in particular at the national level. A 2001 review of Poverty Reduction Strategy Papers found that the poorest countries in Africa do not include sanitation in their national budget recommendations. This despite the fact that past experience has shown that poverty cannot be reduced without improving access to sanitation and safe drinking water: the 1990 cholera outbreak in Peru cost the national economy roughly US$ 1 billion in just 10 weeks more than three times the total national investment in water supply and sanitation improvements during the 1980s.
"We cannot combat poverty, the greatest challenge facing the world today, unless action is also taken within the areas of water, sanitation and human settlements," said Brende.
One reason for the reluctance by governments in some developing countries to invest in sanitation may be due to unrealistic expectations of investment from the private sector. "Sanitation is a less attractive investment proposition than other utility services such as electricity and communication since investment payback periods are often 20 years or more much longer than other utility services such as electricity and communication," said Brende.
Failure to generate demand for sanitation at the community level has been another obstacle. "In most developing countries decisions regarding sanitation are made by individual households," explained Bartram. Previous investments in sanitation have therefore been less effective than they might have been because they failed to generate demand for sanitation services by influencing household-level decision making."
Experiences in Africa, Thailand and India have shown that individual households are willing to invest their own money in low-cost sanitation systems. The Medinipur Intensive Sanitation Project in West Bengal, India, delivered 1.2 million latrines in 10 years, increasing sanitation coverage from almost zero to 80%. Whilst the project involving a multilateral agency, state and district governments, a nongovernmental organization and voluntary grassroots organizations funded technical innovation, research and hygiene education, it did not fund the hardware the householders themselves paid for the construction of on-plot latrines.
Similarly, as part of a World Bank funded programme to expand access to sanitation to 6.7 million slum dwellers in Mumbai, India, each inhabitant paid US$ 2 towards a fund to maintain 320 new toilet blocks. (For details of this project, see Bulletin of the World Health Organization 2002;80:684-5.)
Another problem preventing the expansion of improved sanitation in developing countries is conflict sanitation systems need social stability to function effectively. The failure to integrate sanitation provision with hygiene education has also reduced the impact of previous sanitation programmes.
"Successful urban sanitation projects have certain key principles in common," David Satterthwaite, from the London-based International Institute for Environment and Development, told the Bulletin. "Keep down unit costs to allow limited funding to go further and increase possibilities for cost-recovery; work directly with community organizations, drawing on their priorities thereby ensuring better and more easily maintained designs and their members' capacities to contribute to construction and maintenance; and seek partnerships with municipal governments."
Achieving the sanitation target requires a new division of responsibility, said Satterthwaite: "Get the governments to focus on the 'big pipes' the water, sewer and drainage mains into which the community-municipal schemes ... can integrate."
Brende believes that both the water and sanitation targets are still achievable but only if action is taken immediately. "If we wait until 2010 to implement changes, we will never reach the targets," he told the Bulletin. "We need more comprehensive plans for Integrated Water Resource Management and we must encourage alliances and partnerships among governments, businesses, UN organizations, international financial institutions to drive the implementation process forward."
The UN Millennium Project Task Force on Water and Sanitation, a research team dedicated to identifying means of implementing the water and sanitation targets by 2015, published its interim report in February 2004 (available at http://www.unmillenniumproject.org/html/interim_reports.shtm).
For more information on the twelfth session of UNCSD, visit: http://www.un.org/esa/sustdev/csd/csd12/csd12.htm. 
This month sees the introduction of a second new addition to the News. Every month, In focus will present a feature on a current public health topic. Its objective is to take a closer, more focused look at a particular issue and to place it in context whether this be historical, geographical or theoretical.