WATER AND SANITATION PROGRAM: RESEARCH BRIEF 93724 Scaling Up Rural Sanitation Investing in the Next Generation Children grow taller, and smarter, in rural villages of Lao PDR where all community members use improved sanitation December 2014 KEY FINDINGS • Children living in rural villages of Lao PDR where community members defecate in the open and/or use unimproved latrines are 1.1 cm shorter than healthy children living in rural villages where everybody uses improved sanitation. This small difference in height is irreversible and matters a great deal for a child’s cognitive development and future productive potential. • Children are at risk of stunting even when their families use improved sanitation facilities, but other households in the rural villages where they live do not. Universal usage of improved sanitation is needed to adequately address stunting. • What happens today in terms of sanitation behaviors will affect the country’s future. Improving sanitation in rural communities of Lao PDR is thus a development priority that requires resources for a National Rural Sanitation Program. • Future policy, targets and incentives need to be aligned to promote community-wide behavior change, going beyond individual household interventions. • Criteria for Lao PDR’s Model Healthy Villages, now set at INTRODUCTION 60-70% access to sanitation, would best be harmonized One of the underlying causes of child malnutrition—in addi- with the Ministry of Health's Open Defecation Free tion to the mother’s and child’s dietary diversity and health village status that requires every household to have care situation—is unsafe water, inadequate sanitation and improved access. poor hygiene practices that lead to increased exposure to hu- • Targeted support for the poor, especially in ethnic man feces.1 When feces are ingested by young children living and remote areas, is needed to accelerate progress towards the post 2015 Sustainable Development in unhygienic conditions, their bodies are unable to properly Goals of eliminating open defecation, progressive absorb nutrients. Children then become undernourished and elimination of inequality and universal access to improved stunted. Stunting makes children more vulnerable to infectious sanitation by 2030. 1 UNICEF, 1990. Conceptual Framework, http://www.unicef.org/nutrition/ training/2.5/4.html (ac- cessed December 2013). 2 Investing in the Next Generation Scaling Up Rural Sanitation Key Facts Box 1. OPEN DEFECATION AND STUNTING • While urban sanitation access in Lao PDR is 90%, 50% of There is a growing body of evidence that links open defecation rural households are still practicing open defecation to poor child health through at least two mechanisms. The first and most commonly recognized mechanism is diarrhea from and/or using unimproved sanitation as of 2012. This is digesting feces. The second, which is only recently becoming far below the average for rural sanitation access in Eastern understood, is a disorder of the intestine caused by continued Asia (excluding China) of 83%. fecal exposure. This condition called chronic environmental • Remote and poor rural areas are even worse off and enteropathy prevents absorption of nutrients, even without only 13% of the poorest households are using im- the child getting diarrhea and appearing ill.2,3 proved sanitation. • Inequalities along ethnic groups are persistent, with 74% of Lao-Tai families using improved sanitation and only 30% of Mon Khmer, 46% of Hmong-Mien and 30% of Chi- diseases and more likely to die from them.4 Stunted children nese-Tibetan. are more likely to have poorer cognitive and educational out- • During the last decade child malnutrition has improved very comes in later childhood and adolescence.5 They are more marginally and almost 49% of rural children were stunt- likely to become less productive adults, and be less able to ed in 2011 [27% of urban children]. contribute to their nation’s growth.6 The elimination of open • Stunting has a permanent impact on the life of a child. defecation and unimproved sanitation should be a priority is- It does not only affect the child’s height, but also her/his sue for policy makers who are concerned with maximizing cognitive abilities. Stunted children are likely to become less the potential of the current and future human capital of their productive adults, and be less able to contribute to their countries. country’s growth and prosperity. 2 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. 3 Humphrey, Jean H. 2009. Child undernutrition, tropical enteropathy, toilets, and hand-washing." The Lancet, 374: 1032 - 35. 4 Black, Robert E., Cesar G. Victora, Susan P. Walker, Zulfiqar A. Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, Sally Grantham-McGregor, Joanne Katz, Reynaldo Martorell, and Ricardo Uauy. “Mater- nal and child under nutrition and overweight in low-income and middle-income countries”. The Lancet 2013; 382 (9890): 427-451. 5 Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L,Strupp B. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369: 60-70. 6 Vogl T. 2012. Height, Skills, and Labor Market Outcomes in Mexico. Department of Economic, Princeton University. www.wsp.org Scaling Up Rural Sanitation Investing in the Next Generation 3 PROBLEM STATEMENT Lao PDR has made progress in expanding sanitation ser- and that were born from the poorest households are more vices during the last decade, especially in urban areas. at risk of being stunted. Almost 49% of rural children (27% However, access to improved sanitation remains low in ru- of urban children) and 61% of the poorest children (20% of ral areas: while 90% of the urban population used improved the richest children) were stunted in 2011.8 facilities, only 50% of the rural population did likewise in 2012.7 Widespread open defecation and unimproved sanitation in rural Lao PDR and high levels of stunting make us question The poorest segments of the population are suffering most whether poor sanitation in a rural community is associated from the lack of improved sanitation facilities: in 2011, only with stunting. If it does, could a family protect her/his child 13% of the poorest households (100% of the richest house- from the risk of stunting by using improved facilities? Would holds) were using improved sanitation. Similar patterns are neighbors’ poor sanitation still be associated with stunting found for stunting prevalence: children living in rural areas of the child’s growth? And what can be done about this? Sanitation Figure 1. Sanitation and Stunting Disparities and Stunting Disparities 100 100 100 88 80 80 61 Percentage Percentage 60 60 48 49 40 40 27 20 20 20 13 0 0 Poorest Richest Rural Urban Income Area Improved facilities Stunting prevalence 7 JMP, 2014. Joint Monitoring Programme of WHO/UNICEF. Progress on Drinking Water and Sanitation – Update 2012. 8 LSIS, 2011. Lao People’s Democratic Republic Ministry of Health and Lao Statistics Bureau, Lao Social Indicator Survey LSIS (MICS/DHS), 2011/12. www.wsp.org 4 Investing in the Next Generation Scaling Up Rural Sanitation research first examines whether open defecation and unim- Box 2. DEFINITION OF OPEN DEFECATION AND UNIM- proved sanitation in a rural community are related to stunted PROVED SANITATION children of different age groups across Lao PDR using 2011 Open defecation is the lack of any facility, and/or defecation in LSIS data. Secondly, the analysis uses regression analysis, the bush, field or forest. which looks at the relationship between a child’s height and all the other factors that may potentially impact stunting, includ- Unimproved sanitation is the use of pit latrines without slab/ open pit, bucket toilets, hanging toilets/latrines and toilets that ing sanitation. By using data sets from two years (2006 and flush to somewhere other than a septic tank or sewer (based on 2011), the analysis examines the change in children’s height Joint Monitoring Programme of UNICEF/WHO). over time and taking into account systematic differences across the country’s regions (for example, weather-related characteristics).12 METHODOLOGY An improved sanitation facility hygienically separates hu- man excreta from human contact. This rules out both open defecation and unimproved sanitation. Stunting can be as- sessed by comparing the height of children younger than five to that of a reference population of healthy and well- nourished children. Children are stunted when a statistical measure called ‘height-for-age Z score’ is less than -2. This means that children are stunted if they are more than two standard deviations shorter than the mean of the healthy reference population. Stunting depends on socio-economic characteristics of the child household (asset ownership and gender of the house- hold head), child’s characteristics (gender, age in months, month of birth, feeding practices, access to health services and illness) and environmental factors [sources of drinking water, water treatment method, and use of improved sanita- tion by the child household and by community members, crowding (number of household’s and community’s mem- bers) and local area electrification].9 This research makes use of the Multiple Indicator Cluster Survey (MICS3) 2006,10 and the Lao Social Indicator Survey (LSIS)11 2011 databases to statistically estimate the impact of (lack of) sanitation on stunting in rural villages of Lao PDR. The 9 Because of data unavailability, the following variables could not be included in the regression analysis for Lao PDR: mother’s age, height, body mass index, education and employment status in the 12 months preceding the survey date, information on whether the child is twin and size of the child at birth, information on whether the child was given iron supplementation, place of delivery, and distance to health facility. 10 The Multiple Indicator Cluster Survey 2006 (MICS 2006) is the third Multiple Indicator Cluster Survey undertaken by the Department of Statistics (Former NSC) of the Ministry of Planning and Investment in close collaboration with the Hygiene and Prevention Department of Ministry of Health. The Lao PDR Multiple Indicator Survey is a nationally representative sample survey which was conducted between March and June 2006. The final sample size was calculated at 6,000 households (100 clusters * 3 regions * 20 households per cluster). It was known in advance that one village only had 15 households; therefore, the total expected number of households was eventually 5,995. In each region, the clusters (villages or collection of villages) were distributed to urban and rural with road access and without road access domains. 11 The Lao Social Indicator Survey LSIS (MICS/DHS) was carried by the Ministry of Health (MoH) and Lao Statistics Bureau (LSB) in collaboration with line ministries. LSIS is a household-based survey that ap- plied the technical frameworks of the Multiple Indicator Cluster Survey (MICS) and Demographic and Health Survey (DHS). The data was collected from September 2011 to February 2012 in 20,000 households in 1,000 villages around the country. 12 For further details, see M. Quattri and S. Smets, ‘Lack of community-level improved sanitation is associated with stunting in rural villages of Lao PDR and Vietnam,’ submitted for the 37th WEDC International Conference ‘Sustainable 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. Children in rural villages of Lao PDR are likely 2. Open defecation and/or unimproved sanitation to be stunted at every age, even when only in rural villages of Lao PDR is associated with a small proportion of villagers do not use shorter children living in those villages improved latrines The regression analysis suggests that, because of open defe- The following figure shows the relationship between a child’s cation and/or unimproved sanitation in a rural village, an aver- height and the sanitation status of a child’s rural community. age five year old child that lives in a village where no one uses The figure illustrates that, as the percentage of community improved sanitation is 1.1 cm shorter than a child who lives in members that open defecate and/or use unimproved latrines a village where everybody uses improved facilities. This value moves from 0% to 100%, children are on average shorter. is found after taking account of (‘controlling for’) all the above Children grow shorter even when less than 50% of all com- mentioned factors that may affect stunting, the passage of munity members open defecate or use unimproved. Once a time and fixed differences among regions within the country. child’s height becomes shorter than average, it remains short- This seemingly small difference in height is irreversible and er than average at every age and even falls below the critical matters a lot for a child’s cognitive development and future measure of stunting (Z score of -2). productive potential. Figure 2. Growth faltering (height for age z-score) of rural children under five for different ages 0.0 -0.5 height-for-age z-score -1.0 -1.5 -2.0 -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% 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 3. Open defecation and/or use of unimproved 4. Lack of improved sanitation has a permanent latrines by neighbors are associated with negative impact on a child health and stunting even when the child’s family uses development improved facilities. Once the lack of community sanitation—as well as other fac- The analysis found that the use of improved facilities by a child’s tors that are associated with stunting—takes its toll on chil- household has in itself no beneficial impact on that child’s height dren’s height, there is no way back and this effect is irrevers- if other households in the village open defecate and/or use unim- ible. If at a very early age children are shorter than average, by proved facilities. Because of the community’s lack of improved the age of five they are likely to be stunted. In villages where sanitation, the child is still exposed to contact with human feces community members open defecate and/or use unimproved and fecal bacteria. To reduce the risk and severity of stunting, all latrines, children will not only be stunted, but their cognitive community members need to use improved sanitation. abilities will also be damaged permanently. www.wsp.org Scaling Up Rural Sanitation Investing in the Next Generation 7 CONCLUSION Children are likely to be stunted if they live in rural, remote and ethnic villages of Lao PDR where community members prac- tice open defecation and/or unimproved sanitation. Stunting is not just a measure of how tall children are: it is an indica- tor of children’s cognitive abilities and life potential. Stunted children are more likely to have poor cognitive skills, to per- form badly at school, get low-paid jobs and be less able to contribute to the country’s development. Lack of improved sanitation and stunting still prevails among the poorest, and often ethnic, households in the rural villages of Lao PDR, and did not show any significant improvement in the past decade. Policies, programs and incentives should be aligned to focus on community-wide behavioral change and outcomes, go- ing beyond interventions that focus on individual household improvements. The National Plan for Action 2015 for Rural Water Supply and Sanitation aims to achieve 65% access to rural sanitation and Lao PDR’s ‘Model Healthy Village Program’ sets the bar for a healthy village in terms of sanitation at 60% for villages without road access and 70% for villages with road access. The Lao PDR Government has successfully implemented Community- Led Total Sanitation in several regions of Lao PDR and has issued a Guideline for Open Defecation Free Village Status, which is defined by 100% of households using improved facili- ties. The National Plan of Action also recognizes the importance of community mobilization and behavioral change to promote a new social norm within communities, supported by a strong local supply chain of affordable, accessible and aspirational toi- lets. This research suggests that sanitation criteria under the Model Healthy Village Program would best be harmonized with the Ministry of Health’s Guideline for Open Defecation Free Vil- lage Status to adequately address stunting. www.wsp.org 8 Investing in the Next Generation Scaling Up Rural Sanitation Envisioning Lao PDR’s intended gradu- pro-poor outcomes. This would en- ation as a Least Developed Country by sure further progress towards the post Acknowledgments 2020, a national rural sanitation program 2015 Sustainable Development Goals of This research brief was prepared by Maria Quattri, needs to be put in place with adequate eliminating open defecation, progressive Susanna Smets, and Viengsompasong Inthavong (WSP). Valuable contributions and support were funding to ultimately achieve universal elimination of inequality and universal ac- received from Viengsamay Vongkhamsao, Emily usage of improved sanitation. Future cess to improved sanitation by 2030.13 Rand, Craig Kullman, Eduardo Perez, Almud policies, targets and incentives for ru- Weitz (WSP), and Dean Spears (Research Institute ral sanitation should be aligned to pro- Finally, Lao PDR’s National Nutrition for Compassionate Economics). Editing support mote village-wide behavior change and Strategy and Plan of Action 2010-2015, was provided by Yosa Yuliarsa (WSP). would need to be adopted by the Model which recognizes sanitation as a nutri- Healthy Village Program. A national ru- tion sensitive intervention, offers oppor- ral sanitation program would need to include targeted support for the poor, tunities for multi-sectoral responses in order to overcome persistent stunting Scaling Up especially in Lao PDR’s ethnic, moun- tainous and remote regions to ensure and to achieve community-wide im- proved sanitation. Rural Sanitation Today, 2.5 billion people live without access to improved sanitation. Of these, 71% live in rural communities. To address this challenge, WSP is working with governments and local private sectors to build capacity and strengthen performance monitoring, policy, financing, and other components needed to develop and institutionalize large-scale, sustainable rural 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 13 WSSC, 2014. Water Supply and Sanitation Collaborative Council. Water Supply, Sanitation and Hygiene Targets and Indicators Post- For more information please visit 2015. Fact sheet: Comprehensive recommendations – updated April 2014. www.wsp.org or email wspeap@worldbank.org. The Water and Sanitation Program is a multi-donor partnership, part of the World Bank Group's Water Global Practice, supporting poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. © 2014 International Bank for Reconstruction and Development/The World Bank