Open Access Publications from the World Bank: Introduction (Resources Series No. 1)

This post is the first in a series on open access resources from the World Bank that could be useful to Rotarians as well as others involved in service work and development projects around the world. Probably more than any other development organization, the World Bank is making available a wealth of resources on topics related to development, including a large number of books and reports. The focus of most World Bank open access knowledge resources is on developing countries, but data and publications are also available for developed countries, and often lessons learned from the developing world have implications for service projects and social policy in developed countries as well.

In coming weeks, this blog will feature selections of recently published World Bank books and reports by topic, considering in priority the areas of focus of the Rotary Foundation (TRF), namely promoting peace, fighting disease, providing clean water, saving mothers and children, supporting education, and growing local economies apart from eradicating polio. The hope is that the featured publications will be beneficial not only to researchers, but also to practitioners and policy makers.

Why a Focus on Open Access Resources?

The inspiration for this series of posts on open access resources came in part from the fact that Rotary is organizing between January and March 2016 five conferences on the core areas of focus of the Rotary Foundation. The first will be the Rotary Presidential Conference on Peace and Conflict Prevention/Resolution or “World Peace Conference” to be held in January 2016 in Ontario, California. The other conferences are on disease prevention and treatment in Cannes, economic development in Cape Town, literacy and WASH (water, sanitation, hygiene) in schools in Kolkata, and WASH in schools in Manila. The dates of the five conferences are listed in the table below together with their websites.

Dates Topic Location Website
15-16 January Peace and conflict prevention/resolution Ontario, California, USA Click here
19-20 February Disease prevention & treatment Cannes, France Click here
27 February Economic development Cape Town, South Africa Click here
12-13 March Literacy & WASH in Schools Kolkata, India Click here
18-19 March WASH in Schools Pasay City, Philippines Click here

The conferences are sponsored jointly by Rotary International President K.R. Ravindran and TRF Trustee Chair Ray Klinginsmith. Each conference will be led by local Rotary districts and are open to all, whether Rotarians or not. The conferences will feature plenary sessions with world class speakers as well as parallel sessions on topics of interest and hands-on workshops.

The hope for this series of posts on open access resources is that selecting relevant publications on the topics to be discussed at the above five conferences could be useful not only to conference participants, but also to many others working or implementing service projects in those fields.

Why Focusing on World Bank Resources?

Only resources available from the World Bank will be included in this series even though many other organizations provide highly valuable open access resources. Restricting the focus on resources provided by the World Bank is driven by practicality. Including other organizations would yield a rather unwieldy list of relevant publications due to the scope of what would need to be included. At the same time, focusing on the World Bank has the advantage of being able to go global with a single organization, since the World Bank is engaged with the developing world as a whole. By contrast, many other organizations, including regional development banks, tend to have more of a regional focus.

In order to keep the list of publications and other resources highlighted through this series manageable, the focus in most cases will be on open access books and reports as opposed to other publications such as working papers, articles, and briefs. Even when restricting resources to books, a large number of World Bank publications directly relevant to the topics of the five Rotary conferences can be listed. In the case of the first conference on promoting peace for example, several dozen recent books and reports published since 2010 that relate closely to the topics of the conference can be listed.

Topics for Consideration

To keep things simple, the series of posts will consider in priority the six areas of focus of TRF, which also correspond to the topics selected for the five Rotary Presidential conferences (to a large extent, the conference on disease prevention and treatment also implicitly covers the area of focus of TRF devoted to saving mothers and children).

But the series will also feature a few cross-sectoral topics that are highly relevant to multiple areas of focus of TRF. One example is that of early childhood development, for which interventions are needed from virtually all six areas of focus of TRF. The series could also cover some topics in more depth than others, for example allocating more than one post to a single area of focus of TRF if this appears to be warranted.

So please, do not hesitate to share your views as to what should be covered by providing a comment on this post, so that your views can inform the final selection of topics and open access resources to be provided.

Providing Water and Sanitation in Uganda (Partnerships Series No. 3)

As in other low income African countries, access to water and sanitation remains limited in Uganda, especially for the poor. This third post in a series on partnerships, innovation, and evaluation tells the story of how Rotary is playing an important role in helping to meet some of the water and sanitation needs of Uganda’s population.

Apac

Water Projects

A first important initiative is the Uganda Rotary Water Plus (URWP) program. URWP coordinates work on water and sanitation done by 78 Rotary clubs (virtually all the clubs in Uganda). The program was launched by the Ugandan Minister for Water and Environment in October 2011. It promotes effective service delivery to rural and less privileged communities.

Clubs develop projects for the communities they wish to serve. For this purpose, they must first build strong relationships with the community and develop a needs assessment. Having identified needs, clubs then select partners to meet those needs, including other Rotary clubs for fund raising, non-profits and/or business partners for implementations, and local authorities. Co-funding is typically provided by the Rotary Foundation (TRF) and in some cases other funding agencies.

The design of projects must be based on adequate technologies for the community context, with attention paid to gender and environmental issues. Clubs are encouraged to link the projects to other areas of focus of TRF, for example by providing water and sanitation to schools or health clinics.

The idea is that water and sanitation alone can’t transform a community; the “Plus” in URWP refers to other areas of focus of TRF such as supporting education or fighting disease.

The model also encourages local management committees to oversee facilities cost recovery through tariffs so that funds are available for maintenance.

URWP aims to raise $7 million for more than 30 projects. Rotary International is also partnering in Uganda with USAID to invest $4 million over four years through additional projects, following previous successful similar collaborations in the Dominican Republic, Ghana, and the Philippines (this broader partnership is referred to as the International H20 Collaboration).

Beyond the mobilization of funds, the URWP initiative has also succeeded in uniting 4,000 Ugandan Rotarians, more than 3,000 Rotaractors and many members of Rotary Community Corps (RCCs) behind countrywide water and sanitation initiatives. Many have volunteered their time and financial resources to support the projects.

Community Needs Assessments

Another interesting initiative that is part of URWP has been the implementation of a detailed diagnostic of water and sanitation facilities in communities of Apac District located 250 kilometers north of Kampala.

The idea behind the water and sanitation community needs assessment was to prepare an inventory of resources as well as gaps to be used by the Ministry of Water and the Environment as well as Rotary and other funders for the prioritization of investments. Teams visited communities. After an initial meeting in each community, data collection involved implementing a survey, conducting interviews and focus groups, establishing an inventory of all water and sanitation assets in the community, and conducting community mapping exercise.

Data were collected using the FLOW (Field Level Operations Watch) system developed by Water for People. The application relies on Android cell phones together with GPS data and Google Earth software to document water and sanitation infrastructure as well as its functionality.

The community needs assessments was implemented with support from the Apac government and 16 organizations. Rotaractors served as field enumerators. Data were collected for communities as well as public institutions such as schools and health centers, with ratings provided on the quality of facilities and the satisfaction of users. Tests of water quality have also been conducted in some of the areas.

Conclusion

URWP represents a prime example of efforts by Rotary to invest in projects that have a larger impact through partnerships, innovation, and monitoring and evaluation.

The URWP team has established partnerships with multiple NGOs as well as USAID and Ministry of Water and the Environment. It has been innovative in project design to ensure a higher likelihood of sustainability. Evaluations of the projects are not yet available (many projects are still at the design or implementation stage), but monitoring systems are being put in place.

Finally, in the case of Apac district, extensive data collection has been conducted on water and sanitation assets and gaps at the level of communities in order to inform prioritization of future investments. This should also help in achieving higher impact through targeted interventions.

A brief on the URWP initiative as well as the water and sanitation context in Uganda is available here.

“We Love You Gringos!” Serving Remote Communities in Honduras

by Quentin Wodon

Every year, many Rotarians, Rotaractors, and Interactors travel internationally to participate in hands-on community service projects in developing countries. What does it take to implement such projects? Are the projects sustainable? Do travelling teams do useful work? Do the projects make sense or are they costly? What are their main benefits?

Honduras

A new Rotarian Economist Brief by Bill Phillips suggests answers to these questions. The brief is based on a decade-long commitment by Tennessee Rotarians to support families in remote communities near Choluteca in Honduras, among others through access to electricity and water. As for other posts showcasing briefs from this blog’s series, rather than summarizing the brief, I encourage you to read it in full here.

If you would like to submit a brief about your project, please send me an email through the Contact Me page of this blog.

Infrastructure and Poverty: Part 3 – What Can Be Done?

by Quentin Wodon

Infrastructure matters for poverty and development (first post in this series), but the needs of the poor are not being met (second post). In this third post, the discussion shifts to what can be done to improve infrastructure services for the poor, considering first reforms and subsidies, and next projects including those by service organizations.

Water fountain (Photo: C. Tsimpo)
Water fountain (Photo: C. Tsimpo)

Reforms and Subsidies

PPIs (private participation in infrastructure) and IRAs (independent regulatory agencies) have been among the most important reforms implemented in the past two decades. The empirical evidence reviewed in my   book with Antonio Estache suggests that these reforms have improved investment and service quality (as well as reduced corruption in the case of IRAs), but there are differences in these impacts between sectors and the effects have been relatively modest. In addition, while these reforms have helped some households, they probably have helped mostly households among better off groups since the poor simply have no access to basic infrastructure countries in low income countries.

Another area of concern is that of subsidies. Many countries have (often large) consumption subsidies for basic infrastructure services such as electricity and piped water. These subsidies prevent cost recovery by the utilities and this reduces the incentives for them to expand the networks. But in addition, while the subsidies are justified in theory by the aim to make services affordable to the poor, they are in practice very poorly targeted to the poor. In most countries the average subsidy received by a poor person is only a third (or less) of the average subsidy received by a person randomly chosen in the population as a whole.

Most existing subsidies are consumption subsidies implemented through the inverted block tariff (IBTs) structures. With IBTs the unit cost per kWh or cubic meter of water is lower for the first few blocks of consumption for all those connected to the network, and often below cost recovery levels. In low income countries, these subsidies are poorly targeted to the poor simply because most of the poor are not connected to the networks.

The targeting performance of those subsidies could be improved by reducing the lower bands of the IBTs so that only those who consume very low amounts of water or electricity benefit from the largest subsidies. Another option is to shift to Volume Differentiated Tariffs, whereby only those consuming in a tariff band receive the subsidy for that bans (under IBTs, all clients receive the subsidies in the lower bands for the part of their consumption in those bands). Both approaches tend to have a limited positive impact on targeting performance, but they help in reducing the cost of the subsidies.

Another alternative is to shift from consumption to connection subsidies. Instead of subsidizing the consumption of those already connected to the water network or the electricity grid, the idea is to subsidize the connection of new and typically poorer households to the network. Still another alternative is to target subsidies to those in need more purposefully (this can be done among others through geographic targeting or proxy means- testing). In those cases, targeting performance to the poor can under some conditions be improved significantly. These are all high priorities that governments and utilities should implement, as argued for example here.

Projects

What about the role of the nonprofit community, including NGOs and service clubs? Precisely because so many among the poor do not have access to basic infrastructure services, the role of nonprofit organizations is important to fill part of the gap in coverage of basic infrastructure services. It is important however for nonprofits, including service clubs, to operate in a highly professional and sustainable manner.

Providing access to electricity, water, sanitation, or other basic infrastructure services in poor areas is hard. Many projects are implemented in an unsustainable way, so that they ultimately fail. Research I am doing with Clarence Tsimpo on Uganda suggests that many small water projects fail in large part because of lack of infrastructure functionality (facilities stop to work properly, even shortly after being installed) or lack of local responsibility (poor local leadership or lack of proper community arrangements hinder maintenance, thereby yielding a slower but often irreversible damage in the infrastructure).

Sometimes, expensive technologies are put in place that communities have simply no way to keep up because of the high cost of parts for repairs. Training for proper maintenance may not be provided at all, or provided in a haphazard way, to beneficiary communities. These and other factors lead to the failure of many projects despite the best of intentions. So what are NGOs and especially service clubs to do? They need to get professional advice. In the Rotary family, the good news is that advice may be available from Rotarian Action Groups (RAGs). In the case of water and sanitation WASRAG is ready to help.

My Rotary club was recently considering a promising water harvesting and sanitation project in India. We got detailed specifications ready and they looked good.  But we asked for a professional review by a district Rotarian expert in the field. He raised concerns and suggested we contact WASRAG for advice. We did, and in the end we decided to subsume our own small individual project and funds into a much larger project run by WASRAG. This gave us piece of mind that the project would benefit from the professional expertise it needed.

In Rotary, on average (there are of course exceptions), larger projects are likely to be better designed than small ones. They also tend to be better managed because the stakes are higher. This means that they probably  have (again on average) more impact, and are more likely to be sustainable. Larger projects also require less administrative work than multiple smaller ones. Not all Rotary service projects need to be large projects where many clubs and districts pool resources together with professional advise from RAGs. But in some cases, when the expertise of RAGs is available, it is a good idea to work with them and pool resources.

 

Infrastructure and Poverty: Part 2 – Are Household Needs Being Met?

by Quentin Wodon

The first post in this series asked whether infrastructure matters for poverty reduction and other development outcomes. It does. This second post asks whether the infrastructure needs of households are being met. They are not. Part of the analysis relies on my new  book with Antonio Estache on infrastructure and poverty in Africa.

Solar panels in Karamoja, Uganda (Photo: C. Tsimpo)
Solar panels in Karamoja, Uganda (Photo: C. Tsimpo)

Challenges in Low Income Countries

Infrastructure does matter for growth and poverty reduction, but there is probably a difference in that relationship between low and middle or high income countries. In low income countries, there is no guarantee that investments in infrastructure will benefit the poor in a straightforward way, unless the investments are designed from the start to do so.

Consider it this way. The priorities of private investors and households in poverty are likely to differ in low income countries. In the African context especially, the number of the poor is rather large, with many living in rural areas and having no access to basic infrastructure services. Only the better off tend to have access to those services, and even at the margin, new investments in infrastructure may not necessarily benefit the poor, simply because they live too far away from the electricity grid or the piped water network. Incentives for private utilities to reach the poor are limited.

What about the links between infrastructure and employment? There is no doubt that lack of infrastructure is an obstacle for firms to operate. In enterprise surveys, close to half of firms declare that lack of electricity is a constraint for them, and one fourth cites lack of telecom and transportation services. This compares to 40 percent of firms citing corruption as a major obstacle to doing business. These rates are high, suggesting that lack of infrastructure is indeed a major constraint to investments and growth. But at the same time, in low income countries only a small minority of workers is engaged in the formal sector where these firms operate. Even if the firms would do better, this still may not have a direct immediate impact on the poor, apart from trickle down effects.

Another challenge relates to the cost and quality of service provision – such as the generation, transmission, and distribution of electricity. In part because the networks are small in many countries, operating costs tend to be higher in Africa than in other regions of the world. In some cases high costs result from over-engineering of projects. As for quality, in part due to capacity constraints, service is often provided only intermittently. These and other challenges make it difficult to serve the poor, especially in Africa.

Gains in Coverage?

 Organizations such as NGOs and service clubs are not engaged in large infrastructure projects. But they can play an important role in meeting household demand for basic infrastructure – including for off-grid electricity, water, and sanitation. In the case of Rotary for example, the Water and Sanitation Rotarian Action Group (WASRAG) is actively involved in providing access to water and sanitation in local communities. The question of whether household demand for basic services is being met is thus important not only for governments and utilities, but also for nonprofit organizations.

Progress in meeting household demand has unfortunately been very slow, especially in Africa. In telecoms there has been dramatic progress thanks to the mobile cell phone revolution. But in other sectors, with the exception of gains in rural electrification in some countries, coverage rates have not improved much (see this paper). For piped water, coverage rates have remained below 20 percent on average across countries with no clear gain over time. For electricity, there has been an increase in coverage rates from a fourth of households to about a third thanks as just mentioned to gains in rural areas. For flush toilets as for piped water, access has also remained flat with only about one in ten household being served. Even when gains in coverage are being achieved, these tend to benefit mostly better off households.

Cost, Affordability, and Supply

In urban and peri-urban areas small-scale providers are filling some of the gaps left by national or regional utilities, but they often have high costs and substantial margins, and are thus expensive for households. In Niger, a study suggests that the cost of water per liter from street vendors could be up to five times higher than the cost from the piped network.

Is the lack of coverage of infrastructure in the population a demand or supply issue? Lack of affordability of modern infrastructure services is an issue for the poor, and it may reduce the demand for those services. Yet the main constraint is lack of supply, not lack of demand (see this paper). The fact is that it is often more expensive for households to meet infrastructure needs through small scale providers or alternative sources than through the networks. For electricity and lighting, the cost of batteries, candles, or kerosene lamps is often higher, at least per unit of efficient energy, than the cost of an electricity bill.

The problem is not that households do not want to connect to networks. It is that even though households would benefit from a connection to existing networks, the opportunity to do so is often not available. This may be because households live too far from the networks. But it may also be because connection costs requested by utilities are often high, especially for the poor and when the costs have to be paid in a single installment.

This quick diagnostic suggests that a lot of work remains to be done to provide basic infrastructure services to the poor in Africa and many other developing countries. In the third post of this series, the record of the reforms and policies of the past two decades will be discussed, together with their implications for projects by organizations such as Rotary.

Infrastructure and Poverty: Part 1 – Does Infrastructure Matter for Poverty Reduction?

by Quentin Wodon

World Toilet Day will be celebrated in a few days on November 19. Some 2.5 billion people do not have access to proper sanitation, including toilets and latrines. Lack of sanitation has dramatic consequences for health. Several million people, many of them children, die from diarrheal diseases every year. Many of these deaths are attributed to unsafe water, poor sanitation including lack of toilets, and poor hygiene. Access to basic infrastructure services – not only for sanitation, but also electricity, piped water, and transport – remains low in many countries.

Women in Uganda carry water (photo: C. Tsimpo)
Women in Uganda carry water (photo: C. Tsimpo)

This 3-part post series discusses the relationship between infrastructure and poverty. The focus is on Africa (the region discussed in my book with Antonio Estache published this week), but the lessons apply more broadly. I will ask three questions: (1) Does infrastructure matter and is funding sufficient? (2) Are household infrastructure needs being met?; and (3) Have reforms succeeded, and what does it mean for us?

Infrastructure Matters

Infrastructure has long been recognized as essential for growth, and growth in turn is empirically proven to be the best way to reduce poverty in the long run (reducing inequality also helps, but has a much lower impact, especially in very poor countries where there is not much to redistribute). Estimates suggest that the elasticity of GDP to infrastructure is in the 0.4 to 1.5 range. This is large – better infrastructure has a major impact on growth.

Infrastructure also matters for other development outcomes at the individual and household level. As mentioned above, many child deaths could be adverted with access to improved water sources and better sanitation. Infrastructure also helps households shift time from domestic chores to productive work.

This has gender implications. In the developing world women work on average longer hours than men. They are involved, as men are, in farm and labor market work, but in addition they have the responsibility to fetch firewood and water. This responsibility can be time consuming. As a villager from Uganda explains: “They are few public taps available here and there is a lot of congestion, making it hard to access water without waiting for a period of one to two hours”.

In work I am doing with Clarence Tsimpo on Uganda, regression analysis with the latest household survey suggests that in areas where the electricity grid or the piped water network is available, a connection to the grid or piped water network for those households not yet connected could enable women to decrease their domestic working time, and correspondingly increase their market working time by about two hours per week.

The additional earnings that could be generated through this shift could reduce the share of the population in poverty by about one percentage point for each of the two basic infrastructure services. While this would not by itself eradicate poverty in the country, it would help beneficiary households, and especially rural women, fairly substantially.

Infrastructure as a New Priority

Throughout much of the last two decades, funding allocated to infrastructure by governments fell in proportion of available budgets. It has also been said that transport was one of the forgotten MDGs (Millennium Development Goals). Today, the situation has changed and the crucial role of infrastructure is widely recognized. Yet funding remains a challenge.

According to the World Bank, private infrastructure investment in emerging markets and developing economies dropped from US$186 billion in 2012 to $150 billion last year. At its annual meetings last month, the World Bank announced the launch of a new global infrastructure facility. While developing countries invest US$1 trillion per year on infrastructure, this would need to be doubled to maintain current growth rates and meet future demand for infrastructure from firms, households, and regions.

The private sector will play a key role in future infrastructure investments, but governments will need to invest more as well. For this, they will need to rely on both their own tax revenues and the availability of foreign aid. For low income countries, concessional financing (grants or very low interest loans) will remain crucial.

When increasing funding for infrastructure, governments and donors will need to be careful to assess fiscal and institutional capacity – not all countries have the same absorptive and implementation capacity. The worst that could happen would be to have large investments in sub-optimal infrastructure projects. The risk of an increase in debt to unsustainable levels must also be managed. But many countries do have the capacity to absorb more funding for infrastructure.

This is the big picture about the relationship between infrastructure and poverty in Africa and many other parts of the world. The next post in this series will discuss whether household needs are being met, and if not, why not.

Water Conservation in two Indian Villages

by Divya Wodon, Naina Wodon, and Quentin Wodon

“How can the water be conserved sustainably and in the long term?” Every year the summer monsoons in India bring much needed rain to inundate rice fields so that rice can be planted. As the river fills, water reaches into particularly arid parts of India. In Maharashtra the Monsoon season starts in June and tappers of in September, but it is often followed by droughts and much of the water from the monsoon flows into the Arabic See leaving the farmers with virtually no water (the water left is stored in wells but even those dry up rather quickly). The farmers then not only lack water to cultivate their fields, but they also lack drinking water especially in remote villages.

June issue - India

The Rotary club of Mumbai Cuff Parade realized the severity of the situation and partnered with the Rotary club of Rockville to help alleviate water scarcity in the villages of Shilonda and Naroli. Chenguttai Dheenan (CK) from the Rockville club had visited Maharashtra and knew about the monsoon and subsequent droughts. He was the ideal person to help launch a much needed water conservation project.

Two small dams were built so that the villages would have access to water through most of the year. The dams were made of a concrete wall stretching across the stream to create a small reservoir connected to wells. The reservoir can hold up to 15,000 cubic meters of water. As CK explained “Thanks to a pump and conduits the water reaches the villages directly; that way the girls from the village don’t have to spend time fetching the water and they are able to go to school and concentrate on studies.” Another added benefit of the reservoir is that the farmers can now grow two crops instead of one.

Implementing international projects takes time and effort, but the rewards are great and the projects truly make a difference. So “to the Rotarians who are shying away from international projects because they are not able to connect with other clubs in the world,” CK’s advice is simply to “connect with other clubs so that international projects can be achieved and the money from the Rotary Foundation can be used well. DO more international projects!”

Note: This story is reproduced with minor changes from a book published by the authors entitled Membership in Service Clubs: Rotary’s Experience (Palgrave Macmillan, 2014).

Clean Water in India

by Divya Wodon, Naina Wodon, and Quentin Wodon

“I was moved when I saw the first two or three people carry the water units on the back of their bikes to the rest of their families and installing them, they were all very happy.” Water-borne diseases, such as Cholera and Typhoid, kill hundreds of villagers every year in the area of West Bengal, India, where Paul Mahata from the Mt. Airy Rotary Club started to work on an international Rotary project three years ago. The goal of this small project was to provide through water purifiers a source of clean drinking water to a village of 170 families who never had before a source of clean of water unless they went and purchased a bottle of water from a vendor, which was very expensive for them.

KONICA MINOLTA DIGITAL CAMERA

Paul was both the initiator and the director of the project, making sure that it was implemented well and achieved its goals. Paul actually grew up in the village, and when between the ages of eleven and thirteen he got typhoid twice and was very lucky to have survived. “I decided that because I grew up in this village, I wanted to make sure that every person there would get access to clean drinking water.”

Throughout the implementation of the project Paul learned that beyond the initial idea, there needs to be a lot of effort put in to actually make sure that the project succeeds. As he convincingly puts it, “if you do something, you need to make sure that it is sustainable at least for a few years.” For example the villagers need to independently be able to maintain the cleanliness of the water purifiers so that they last longer. To ensure sustainability he engaged the local Rotary Club of Purulia and a local non-profit Trust to act as partners on this project. Although the project was very gratifying, there were challenges. The initial idea for the project was much bigger, but due to higher costs than anticipated, the project had to be narrowed down. But as Paul said, you simply need to “keep pushing for a better idea; even if my first idea was a little different, I liked the fact that the second idea actually became reality.”

Note: This story is reproduced with minor changes from a book published by the authors entitled Membership in Service Clubs: Rotary’s Experience (Palgrave Macmillan, 2014).

Water and Sanitation for Health: Why Is Progress Slow?

by Quentin Wodon and Clarence Tsimpo

Today is World Habitat Day. Created almost 30 years ago, the day promotes adequate shelter for all. Why should this be mentioned in a blog on investing in health? Because adequate shelter, including access to safe water and sanitation, is essential for health. Several million people, many of them chidren, die from diarrheal diseases every year. Many of these deaths can be attributed to unsafe water, poor sanitation and poor hygiene.
Hand washing in practice

Given the importance of water and sanitation for well-being and health, one would hope to see rapid progress in access, but this is not the case. Trends in coverage of piped water and sanitation prepared for a World Bank study on Africa’s infrastructure a few years ago suggest stagnant rates (more progress is being achieved for electricity, and course, cell phones). Water networks are expanding, and latrines are being built, but too often this only enables countries to keep up with pressure of population growth and the reduction in household size (the smaller the average household is, the more households need to be served for any given population).

Uganda is a good example. Despite rapid growth in the water network in recent years, on a small minority (7%) of households had access to piped water in the latest survey for 2012/13. Under usual definitions from the Joint Monitoring Program of the World Health Organization (WHO), three in four households have access to an improved water source, but some of the sources imply out-of-pocket costs or opportunity costs for the time needed to reach the source. The situation is similar in many other low-income countries.

Why is progress slow? Apart from increasing demand, findings from qualitative fieldwork suggest that supply factors are also at play. In the case of water, these include lack of infrastructure functionality(facilities may notbe working properly, even shortly after being installed), lack of local responsibility (poor leadership may hinder investments in water supply or leadto lack of maintenance) and scarcity (in some communities, water is simply not easily available).These factors tend to be organizational in nature, or physical in the case of water scarcity. But in addition, one should not underestimate the role of culture, tradition, and behaviors.

For example, households know that boiling water is one of the best ways to make it safe. But a minority (less than 40%, according to the latest survey) do it. A few quotes from qualitative fieldwork illustrate why: “We do not have time to boil this water because of the demanding household chores. We feel it is a waste of time since this water looks clean.”“We are aware this water is bad, but it takes a long time to bring the water to boil and firewood has become scarce.”“I am about 57 years old and I have been living on un-boiled water without falling sick. What matters to us is for the government to expandthe availability of water points, not to tell us to boil the water.”

Adequate sanitation is also essential for health. Yet again, in many low-income countries, only a small minority of households has access to improved sanitation. Part of this may be due to a low priority assigned to sanitation in terms of public funding. But part of it is also due to cultural and traditional norms, as well as lack of income or time. Poor terrain or soil type and a lack of land to build latrines also play a role in some areas.

When public latrines are available, there is often a consensus on charginguser fees to ensure maintenance, but enforcement is weak. The same is true for by-laws in areasrequiring households to build their own latrines, which are often expensive to build, at least for the poor.

Focus group participants were asked why they pay for cell phones but not for latrines. They responded that latrines have a much larger one-time cost, but also that having a cell phone is a sign of modernity and important for one’s status in communities. Clearly, more needs to be done to convince households of the importance of latrines, for example through sanitation marketing campaigns.

Finally, in terms of health benefits, there is perhaps no more cost-effective intervention that the promotion of hand washing, but only a small minority of Uganda’s households (less than one in ten) has a facility to wash hands with both soap and water. Information campaigns are held, but, as aparticipant in focus groups noted, “many of the community members do not attend them, saying that these trainings are a waste of time.”

Sometimes even children contribute to low uptake of the practice: “We used to have hand washing utensils, but the children would play with them and waste the water, so we gave up”. More fundamentally, local leadershipappears to be one of the keys: “Local leaders have campaigned, but there is poor adoption, because hand washing is viewed as a very strange practice to the local culture. Local leaders themselves are not visibly seen practicing hand washing… You cannot simply continue telling people about what they should do, but do not see you doing!”

Studies from the Bank’s Water and Sanitation Program suggest that the cost of lack of sanitation is high. As in other low-income countries, Uganda has invested over the years in safe water and sanitation. But the constraints faced by households and communities are complex. The qualitative work implemented in 14 districts suggests that solutions often must be context- and community-specific. This may not lead to cookie-cutter solutions, but it is important to document precisely because of the variety of local circumstances.

Note: This post is reproduced with minor modifications from a post in October 2014 on the Investing in Health blog at the World Bank, available at http://blogs.worldbank.org/health/