Equity implications for sanitation from recent health and nutrition evidence
Cronin et al. International Journal for Equity in Health
Equity implications for sanitation from recent health and nutrition evidence
A. A. Cronin 0
M. E. Gnilo 2
M. Odagiri 1
S. Wijesekera 3
0 Chief Water, Sanitation and Hygiene (WASH) program, UNICEF, World Trade Centre Block 6 (10th Floor) , Jalan Jenderal Sudirman Kav. 31, Jakarta 12920 , Indonesia
1 Water and Sanitation Officer, UNICEF, World Trade Centre Block 6 (10th Floor) , Jalan Jenderal Sudirman Kav. 31, Jakarta 12920 , Indonesia
2 Sanitation and Hygiene Specialist, Water, Sanitation and Hygiene Section , UNICEF, 3 UN Plaza, New York, NY 10017 , USA
3 Associate Director, Water, Sanitation and Hygiene Section , UNICEF, 3 UN Plaza, New York, NY 10017 , USA
Recent evidence points to the possible underestimation of the health and nutrition impact of sanitation. Community sanitation coverage may first need to reach thresholds in the order of 60% or higher, to optimize health and nutrition gains. Increasing coverage of sanitation to levels below 60% of community coverage may not result in substantial gains. For example, moving Indonesia from 60% to 100% improved sanitation coverage could significantly reduce diarrhoea in children under 5 years old (by an estimated 24% reduction in odds ratio for child diarrhoea morbidity) with gains split equally by reaching underserved communities and the unserved within communities. We review the implications of these results across three levels of program implementation - from micro level approaches (that support communities to achieve open defecation-free status), to meso level (sub-national implementation) to macro level approaches for the national enabling environment and the global push to the Sustainable Development Goals. We found significant equity implications and recommend that future studies focus more extensively on community coverage levels and verified community open defecation free status rather than household access alone. Sanitation practitioners may consider developing phased approaches to improving water, sanitation and hygiene in communities while prioritizing the unserved or underserved.
Sanitation; Health impact; Equity; SDG target 6; Wash; Indonesia
Background
Several recent studies [
1–3
] examine the impact of
sanitation on health and nutrition and increasingly
highlight the importance of achieving minimum levels
of community improved sanitation coverage, i.e.
critical thresholds, for achieving health and nutrition
outcomes. A common finding is that the health and
nutrition benefits of improved sanitation are only
seen once a threshold of approximately 60% coverage
or higher is achieved; exact threshold values may vary
across studies. An impact on child stunting was found
once a threshold of 75% community sanitation
coverage was reached [
4
] while a similar value was
suggested for health gains [
5
] while there are calls for
further research into these threshold community
sanitation coverage values [
6
].
This growing evidence is important for the design of
sanitation programs. Sanitation practitioners remain
puzzled by the previous underwhelming estimates of
health impact from sanitation. These were based on
cross-sectional regression analyses not considering the
potential effects brought about by poor sanitation of a
few households to the entire community, e.g. [
7
], or the
small number of randomized control trials undertaken
to date on this subject e.g. [
8–10
]. The new findings
matter to those who deliver sanitation programs – from
one side of the debate that questions whether
communities might be better off focusing on interventions
around water, handwashing, vaccination and clinical
management of diarrhoea [
11
] to the other side flagging
the inherent difficulties of measuring impact in water
and sanitation interventions and the need to end open
defecation in any case based on the best available
evidence given that it is a basic human right [
12
]. The
equity implications are clear, given the vast majority of
the burden of poor water and sanitation still falls on
the poorest [
13
]. These implications are further
examined below at three levels (global, national and
subnational) and put into a sample country context with
recommendations made for future work.
Implications at the macro, meso and micro levels
Sanitation practitioners have tended to get on with the
‘how’ of accelerating sanitation rather than the ‘why’ but
this debate on the health impact of sanitation matters on
many levels and here we examine three such levels – from
the macro level (global to national) to the micro level (at
the community) and the critically important, but often
overlooked, meso level in between – by meso we refer to
the sub-national administrative units (Province or District
level) where national policy is often expected to be
implemented but without full understanding, capacity or
resources being put into place to achieve this.
Multiple recent and complementary research f (...truncated)