WATER AND SANITATION PROGRAM: RESEARCH BRIEF Scaling Up Rural Sanitation Investing in the Next Generation Children grow taller, and smarter, in rural, mountainous villages of Vietnam where community members use improved sanitation December 2014 INTRODUCTION Widespread lack of improved sanitation in rural areas of Viet- nam leads to stunting, i.e. children being too short for their e The use of unimproved latrines in rural villages in age. It is not the water that makes children sick and mal- mountainous regions of Vietnam leads to five-year-old nourished, it is the feces: sanitation is the primary barrier to children being 3.7 cm shorter than healthy children stop the ingestion of human feces. Stunted children are not living in villages where everybody practices improved sanitation. This difference in height is irreversible and only short for their age, but also more likely to have poorer matters a great deal for a child's cognitive development and cognitive and educational outcomes in later childhood and future productive potential. adolescence.' They are more likely to become less produc- A child remains at risk of stunting if community tive adults, and be less able to contribute to their nation's members use unimproved sanitation facilities, growth.2 In addition to the mother's and child's dietary diver- even when the child's family uses improved latrines sity, health care and hand washing and hygiene practices, themselves. Universal usage of improved sanitation is improved sanitation determines a child's health. Improved sanitation serves as a primary barrier to stop a child from di- To improve stunting outcomes rural sanitation needs gesting feces that causes disease and reduces the uptake of prioritization, especially after the foreseen ending of the National Target Program for Rural Water Supply and vital nutrients. Thus, the elimination of open defecation and Sanitation in 2015. unimproved sanitation should be a priority issue for policy makes wo ar cocered wth aximzin th curentand * Future rural sanitation policy and incentives need to aim makers who are concerned with maximizing the current andsanitation, future human capital of their country. In simple terms: invest- promote collective behavior change and include ing in sanitation means investing in a future generation of targeted support for the poor. smart and productive adults. e A national rural sanitation program beyond 2015 is required to accelerate progress towards the Post 2015 Sustainable Development Goals of eliminating open defecation, progressive elimination of inequality and universal access to improved sanitation by 2030. * Community-wide sanitation interventions should be considered for integration into nutrition and poverty Grantham-McGregor, S., Cheung, YB., Cueto, S., Glewwe, P., Richter, L. and 3. Strupp (2007) programs to support stunting prevention. Developmental potential in the first 5 yearn for children in developing countries. The Lancet Vol. 369, Issue 9555, pp. 60-70. 2 Vogi, T (2012) Height, Skills, and Labour Market Outcomes in Mexico. Department of Economics, Princeton University. WS WORLD BANKGROUP fuur prociv potntiL 2 Investing in the Next Generation Scaling Up Rural Sanitation Box 1. LACK OF IMPROVED SANITATION AND STUNTING The p ul T EM Ema There is a growing body of evidence that links open defecation to poor child health through at least two mechanisms. The first 2011, 62 million people (70% of the overall population) were and most commonly recognized mechanism is diarrhea from living in rural areas. The strong economic growth that occurred digesting feces. The second, which is only recently becoming over the past two decades, combined with government pro- understood, is a disorder of the intestine caused by continued grams that address sanitation, have contributed to a dramatic fecal exposure. This condition called chronic environmental decline in the prevalence of open defecation between 1990 enteropathy prevents absorption of nutrients, even without (44%) and 2012 (3%) in rural areas. However, the percent- the child getting diarrhea and appearing ill.3 age of people using unimproved sanitation has increased from 26% to 30% over the period (including 4% sharers) .4 Figure 1. Rural Sanitation Coverage (1990-2012) The rural poorest are five times more likely to open defecate or Rural sanitation trends in Vietnam, use unimproved facilities (58%) than the richest (11%)7. Rural 1990 and 2012 poverty and lack of improved sanitation are mainly found in 100 -Vietnam's highland regions: the Central Highlands, the North- ern Midlands and Mountain Areas and the North Central and Central Coast Area. 80 - Key Facts 0d In rural Vietnam, the prevalence of open defecation has dramatically declined from 44% in 1990 to 3% in 2012. Yet the percentage of households using unimproved 0 latrines increased from 26 to 30% over the same _FU period.5 2 40 T The poorest households living in Vietnam's mountainous regions are the most affected by the lack of improved sanitation facilities (Central Highlands, Northern Midlands and Mountain Areas and North Central and Central Coastal Area). *Children are more at risk of stunting if they live in 0 rural areas in those same mountainous regions and 1990 2012 if they were born from the poorest households. The prevalence of stunted children in all rural areas decreased 0 Improved sanitation I(%) from 42% in 2000 to around 25% in 2010/11 . Yet, stunting Unimrovd snitaion(%)prevalence in the mountainous regions remains high UNOpnmdoed sniation (%) in the range of 28 to 31 %.1 Checkley, William, Gillian Buckley, Robert H Gilman, Ana MO Assis, Richard L Guerrant, Saul S Morris, KareMolbak, PalleValentiner-Branth, Claudio F Lanata, Robert E Black, and The Childhood Malnutrition and Infection Network.2008. Multi-country analysis of the effects of diarrhoea on childhood stunting." International Journal of Epidemiology, 37; 816-830. 4The Government of Vietnam sets a nigher standard for improved sanitation than the WHO/UNICEF Joint Monitoring Programme. In fact, the Government classifies as 'hygienic' sanitation only water flush, composting and ventilated improved pit (VIP) latrines. The simple pit latrine with a slab and cover, but witnout a vent pipe, is not considered 'hygienic'. Tnis research brief distinguishes between improved and unimproved sanitation. See the box on 'Definition of sanitary means of excreta disposal in tne research' for furtner details. "JMP, 2014. Joint Monitoring Programme of WHO/UNICEF Progress on Sanitation and Drinking Water - Update 2012. "UNICEF (2010-11) MICS4 - Multiple Indicator Cluster Survey 2010-2011 for Vietnam. www.wsp.org Scaling Up Rural Sanitation Investing in the Next Generation 3 Similar patterns are found for stunting prevalence: children Thus, this research brief aims to answer the question: 'Is are more at risk of being stunted if they live in rural areas community level unimproved sanitation associated with child and in mountainous regions and were born from the poorest height in rural Vietnam?' While addressing this question and households. Stunting prevalence among children under five for the reasons explained above, the research zoomed in on years old in these regions is in the range of 28 to 31 %.8These a subset of the national data that looks at rural mountainous similarities suggest that there may be a correlation between a regions. Based on the research findings, and considering the lack of improved sanitation and stunting in rural communities ongoing government's efforts, a number of policy recommen- in the mountainous regions of Vietnam, especially among the dations and suggestions are presented to tackle the sanita- poorest communities, as can be observed in Figure 2. tion challenge. Figure 2. Overview maps of Vietnam poverty, sanitation access and stunting rates Percentage of rural poverty rate Percentage of rural households Stunting prevalence - without a toilet Nutrition surveillance 2010 North East Northe North West Red River Delta Red River Detta Poverty rate ()North =0- 10 Central 10 - 20 Central Coast Coast 20 -30 % households 30*40 without latrine Stunting Prevalence 40 -.50 0 10 Nutrton SUelance 2010 50-60 10-20 . 40 -45 (2) 60-70 20-30 *35 -40 (8) 70-8 otaIMIhl 040 Ceta 30- 35 (21) 70-80 Highrllaindls 25 -30 (27) L 40 -50 20-25 (2) 90-100 15 -20 (1) S No data | 0 -70 .51 South Eas 70 o-0 South East go9 - 100 Mekong . River Delta Source: 2009 Census for Sanitation Maps; Source: 2009 Census for Sanitation Maps; Source: National Institute of Nutrition and Poverty Map based on 2009 Census and Poverty Map based on 2009 Census and Alive and Thrive Vietnam, 'National nutrition 2010 VHLSS; Nguyen Viet Cuong 2010 VHLSS; Nguyen Viet Cuong monitoring survey'2010 Based on quintile analysis of the Viet Nam Multiple Indicator Cluster Survey (MICS4) which was conducted from December 2010 to January 2011 by the General Statistics Office in collaboration with the Ministry of Health (MOH) and the Ministry of Labour, Invalids and Social Affairs (MOLISA). Financial and technical support for the survey was provided by the United Nations Children's Fund (UNICEF) and financial support by the United Nations Population Fund (UNFPA). MICS4 is based on an actual sample of 11,614 households in 600 communes/wards of 440 districts in all 63 provinces/cities in the country, and it is representative of Vietnam's six regions. I JMP (2013) estimates for the year 2011 are used in this brief as MICS (2010/11) data have been used for the regression analysis. www.wsp.org 4 Investing in the Next Generation Scaling Up Rural Sanitation METHODOLOGY The research uses regression analysis, which looks at the re- for the mountainous regions to investigate whether the use lationship between a child's height and household, social and of unimproved latrines by a large proportion of households in environmental variables that may impact on a child's height, the community is associated with stunting.10 In this part of the including sanitation. Data that were used are from a nation- analysis, the research controls for all factors that may impact ally representative household survey conducted by UNICEF in a child's height, such as lack of improved sanitation in a rural 2010/11 called the Multiple Indicator Cluster Survey (MICS4).9 community and in the child' household, level of poverty of the child's family, their ethnic origin, the mother's education, Children are stunted when a statistical measure called 'height- the gender of the household's head, access to safe water and for-age Z score' is less than -2. This means their height is 2 (or health services, hand washing and hygiene practices, child' more) standard deviations below the mean height of children sex, age and month of birth, child's illness, feeding practices of a well-nourished and healthy reference population. and dietary diversity, size of the child's household and popula- tion density at the region level, and availability of electricity and The research first examines whether open defecation and road access in the community. The research finds similar re- unimproved sanitation in a rural community are related to suits for all regions of Vietnam and for the subset of mountain- stunting among children of different age groups across entire ous regions where unimproved sanitation and stunting prevail. Vietnam. The analysis then zooms into a subset of the data This policy brief presents results for the subset of regions ,Based on quintile analysis of the Viet Nam Multiple Indicator Cluster Survey (MICS4) which was conducted from December 2010 to January 2011 by the General Statistics Office in collaboration with the Ministry of Health (MCH) and the Ministry of Labour, Invalids and Social Affairs (MOLISA). Financial and technical support for tne survey was provided by the United Nations Children's Fund (UNICEF) and financial su pport by the United Nations Populatoon Fund (UNFPA). MICS4 is based on an actual sample of 1614 households in 600 communes/wards of 440 districts in all 63 provinces/cities in the country, and t is representative of Vietnam's six regions. A community in the survey refers to villages or cluster of nearby villages (primary sampling unit), but not to administrative communes. The term villages or communities is used throughout the brief to indicat e this primary sampling unit. For further details, see M. Qattri and S. Smets, 'Lack of community-level improved sanitation is associated with stunting in rural villages of Lao PDR and Vietnam,' submitted for the 37t WEDC International Conference 'Shstainable Water and Sanitation Services for All in a Fast Changing World', Hanoi, Vietnam, 2014. www.wsp.org Scaling Up Rural Sanitation Investing in the Next Generation 5 KEY LESSONS 1. Lack of improved sanitation in rural villages of munity members to 100%, children are on average shorter Vietnam is associated with increasing stunting than healthy children. Children grow shorter even when only at every age a small proportion of villagers (less than 50%) do not use im- The following figure shows the relationship between a child's proved latrines. Once a child's height becomes shorter than height and the sanitation status in the child's rural community. average, it remains shorter at every age. By the age of five, on As poor sanitation status (meaning combined unimproved average, a child in communities where no one uses improved sanitation and open defecation) moves from 0% of the com- sanitation reaches the critical level of stunting (Z-score of -2). Figure 3. Growth faltering (height for age z-score) of rural children under five years old for different ages 0.0 - -0.5 - 0 N -2.5- 0 20 40 60 age in months - Community level open defecation and unimproved sanitation = 0% Community level open defecation and unimproved sanitation between 0% and 50% C - - Community level open defecation and unimproved sanitation between 50% and 99% - Community level open defecation and unimproved sanitation = 100% www.wsp.org 6 Investing in the Next Generation Scaling Up Rural Sanitation 2. Unimproved sanitation is associated with village where community members use unimproved sanita- stunting in rural villages of mountainous tion is 3.7 cm shorter than a child who lives in a rural village regions of Vietnam where everybody uses improved facilities. This seemingly In the regression analysis, the brief focuses on the subset of small difference in height is irreversible and matters a lot for a rural areas in the mountainous regions of Vietnam: the Central child's cognitive development and future productive potential. Highlands, the Northern Midlands and Mountain Areas and the North Central and Central Coast Area. The research also 3. Community members' unimproved sanitation controls for all the above mentioned socio-economic, demo- negatively affects a child's height even when graphic and health variables and environmental factors that the child's family uses improved facilities may influence a child's height,12 which means that possible Surprisingly, while the relationship between height and com- factors that impact the height of a child are taken into ac- munity level sanitation is statistically significant, this is not the count. If the sanitation status in the community remains to case for the child' household sanitation practices. After con- have an effect on the child height after consideration of all trolling for community members' use of unimproved sanitation, these factors, it can be safely concluded that this effect is real a child' household use of improved sanitation does not help and not by chance. Indeed, the regression analysis shows to reduce the risk of stunting for this child. The child is still ex- that the height of a child decreases in a significant way when posed to contact with human feces and fecal bacteria due to community-level unimproved sanitation increases. The analy- neighbors' lack of improved sanitation and thus remains at risk sis finds that an average five-year-old child that lives in a rural of stunting if not all community members use improved latrines. Because of data unavailaility, tne following variables could not be included in the regression analysis for Vetnam: mother's age, height, BMI, and employment status in the 12 months preceding the survey date, information on whether the child is twin and swze of the child at birth, nformation on whether the cni[d was given ron supplementaheon, place of delivery, and distance to health fanlit. www.wsp.org Scaling Up Rural Sanitation Investing in the Next Generation 7 Box 2. DEFINITION OF SANITARY MEANS OF EXCRETA DISPOSAL IN THE RESEARCH * Improved sanitation includes water flush latrine (that is, flush to piped sewer system, septic tank, pit latrine or unknown place), pit latrine with a slab and cover, ventilated improved pit (VIP) latrine, composting toilet and, for rural areas, hang- ing toilets/latrines. * Unimproved sanitation is the use of pit latrines without slab/ open pit, bucket toilets, and flush or pour-flush to elsewhere (that is, street, yard or plot, open sewer, a ditch, a drainage way or other location). * Open defecation refers to defecation in the bush, field or forest. The research excludes hanging toilets/latrines (mainly found in the Mekong River Delta region) from the definition of 'unimproved sanita- tion'. The reason is that children are less likely to be exposed to fecal contamination from feces from fish-pond latrines, as the feces are 'water sealed' and not exposed to flies. Further regression analysis indicates that the use of hanging toilets by community members has no significant negative impact on stunting. CONCLUSION Poor sanitation and stunting are prevalent particularly among in improved sanitation. Government targets and incentives the poorest rural villages in the mountainous regions of Vietnam. need to go beyond open defecation-free status and focus on Stunted children are not only shorter than average, but they are community-level universal access to improved sanitation. also more likely to have poor cognitive abilities and become less productive adults. A lack of improved sanitation throughout the At present, community-wide targets and a programmatic ap- community is associated with stunting of children in rural vil- proach that focuses on village-level improved sanitation out- lages of Vietnam. It is also shown that unimproved sanitation in comes are still to be adopted at scale under Vietnam's Third the community affects every child in the community: also those National Target Program for Rural Water Supply and Sanita- children whose families use an improved sanitation facility them- tion (RWSS-NTP3). While the RWSS-NTP3 aims to provide selves. Thus, policies and interventions should focus on com- 65% of rural households with hygienic latrines, the research munity-wide behavioral change and outcomes for improved suggests that universal use of improved sanitation is needed sanitation, rather than only on individual household investments to adequately reduce stunting 13. 3 The findings do not mean ihai there is no accrual oi marginal health benefis while moving iuwards the 100% improved saniittion oaut-s. www.wsp.org 8 Investing in the Next Generation Scaling Up Rural Sanitation While Vietnam is clearly making prog- targeting to the poorest segments. Af- ress along the sanitation ladder from fordable, accessible and aspirational A cknow ledgm ents open defecation to unimproved sanita- toilets provided through local private This research brief was prepared by Maria Quattri, tion, this does not seem to be enough suppliers remain needed to move more Susanna Smets, and Minh Thi Hien Nguyen to address the risk of stunting. Stunt- people from open defecation and un- (WSP). Valuable contributions and support were ing impact is expected to be lower if improved sanitation to improved sanita- received from Emily Rand, Craig Kullman, Hang access and use of improved sanitation tion, while community mobilization and Diem Nguyen, Eduardo Perez and Almud Weitz by 100% of community members is behavioral change communications are (WSP), and Dean Spears (Research Institute for achieved. required to support a new social norm within communities. provided by Yosa Yuliarsa (WSP). Once RWSS-NTP3 ends in 2015, a na- tional sanitation program will be needed A national rural sanitation program is re- to achieve universal usage of improved quired to accelerate progress towardn sanitation. Policies, targets and incen- the proposed Post 2015 Sustainable tives under such future program should Development Goals of eliminating open Rural Sanitation be aligned to promote community-wide defecation, progressive elimination of Today, 2.5 billion people live without access behavior change, including targeted inequality and universal access to im- to improved sanitation. Of these, 71% live in support for the poor, such as low-in- proved sanitation by 2030.14 rural communities. To address this challenge, terest household financing and/or tar- WSP is working with governments and local geted output-based subsidies. Such Finally, community-wide sanitation in- private sectors to build capacity and strengthen measures are already introduced un- terventions should be considered for performance monitoring, policy, financing, and der RWSS-NTP3, and deserve further integration into existing nutrition pro- other components needed to develop and scaling beyond 2015, especially to the grams to support stunting prevention in institutionalize large-scale, sustainable rural mountainous regions and with improved Vietnam. sanitation programs. With a focus on building a rigorous evidence base to support replication, WSP combines Community-Led Total Sanitation, behavior change communication, and sanitation marketing to generate sanitation demand and strengthen the supply of sanitation products and services, leading to improved health for people in rural areas. For more information, please visit www.wsp.org/scalingupsanitation. Contact Us A_nationalFor more information please visit 14 WSSC, 2014. Water Supply and Sanitation Collaborative Council. Water Supply, Sanitation and Hygiene Targets and Indicators Post- www.wsp.org or email wspeap@worldbank.org. 2015 Factsheet: Comprehensive recommendations - updated April 2014. The Water and Sanitation Program is a multi-donor partnership, part of the World Bank Group's Water Global Practice, supporting poor WiO RID BAN KGROU P people in obtaining affordable, safe, and sustainable access to waier and sanitation seuvices. WSPs donors include Australia, Ausria, Denmark, Finland, France, the Bill & Melinda Gates FoundaFion, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, Unitea States, ana tne World Bank. The findings, interpretations, and conclusions expressed herein are entirely those of the author and snould not be attributed to the World P Bank or its affiliated organizations, or to members of the Board of Executiye Directors of the World Bank or the governments they represent ( 2014 International Bank for Reconstruction and DeveVopment/The Worcd Bank