How do Water and Sanitation Look from a Child Health Perspective?John BorrazzoU.S. Agency for International Development

World Water Forum VIstanbul, TurkeyMarch 20, 2009

The child health problem - targetingRelevant programmatic strategies focusingOutcomes and impact - measuring

90% preventable

Undernutrition implicated in 50% of child deaths, and is also associated with diarrhea9.2 million child (

Source: Safer Water, Better Health, WHO 2008

Diarrhea Real Progress in Reducing Mortality1990 World Summit for Children Goal met by 2000(reduce under-five diarrheal deaths by half)

Almost 3 million child deaths/year averted by 2005But -

Estimated 1.5 billion child diarrhea episodes/year (in developing countries)

Still over 1.5 million child deaths/year

Where do child deaths from diarrhea occur?

Chart6

643

631

201

66

46

Sheet1

19902001reduction 1990-2001

ECA6112ECA80.3sub-Saharan Africa643

LAC10846LAC57.4South Asia631

MENA14466MENA54.2East Asia201

SA991631SA36.3Middle East66

EAP274201EAP26.6LAC46

SSA784643SSA18.0

Sheet1

6112

10846

14466

991631

274201

784643

1990

2001

DD deaths in '000s

Sheet2

reduction 1990-2001

DD deaths reduction 1990-2001 (%)

Sheet3

11 countries account for over 70% of the annual deaths globally from diarrhea

Deaths from Diarrhea have declined in all regionsSource: WHO, 2002; ECA=Europe and Central Asia, LAC=Latin America and the Caribbean, MENA=Middle East and North Africa, SA=South Asia, EAP=East Asia and the Pacific, SSA=sub-Saharan Africa

Chart4

6112

10846

14466

991631

274201

784643

1990

2001

DD deaths in '000s

Sheet1

19902001reduction 1990-2001

ECA6112ECA80.3

LAC10846LAC57.4

MENA14466MENA54.2

SA991631SA36.3

EAP274201EAP26.6

SSA784643SSA18.0

Sheet1

1990

2001

DD deaths in '000s

Sheet2

reduction 1990-2001

DD deaths reduction 1990-2001 (%)

Sheet3

Chart5

80.3278688525

57.4074074074

54.1666666667

36.3269424823

26.6423357664

17.9846938776

reduction 1990-2001

DD deaths reduction 1990-2001 (%)

Sheet1

19902001reduction 1990-2001

ECA6112ECA80.3

LAC10846LAC57.4

MENA14466MENA54.2

SA991631SA36.3

EAP274201EAP26.6

SSA784643SSA18.0

Sheet1

1990

2001

DD deaths in '000s

Sheet2

reduction 1990-2001

DD deaths reduction 1990-2001 (%)

Sheet3

Under-five mortality rate from diarrhea (deaths per thousand live births)Source: The Lancet Child Survival Series, 2003

Chart3

55.7460876187

49.6238861612

48.46041346

42.041674179

40.7136811208

40.1739342049

37.466553672

37.0032475265

34.5281531783

31.6397002315

30.8906030868

28.7749927068

25.9991180143

25.6133447084

25.0893641306

23.7536468163

23.4053392523

23.3395662592

21.1178486784

20.9297632052

20.8053999906

19.7761864052

Sheet1

U5MRU5 deaths%DDU5 DD DeathsDDMRpriority (if USAID)imp water (urban)imp water (rural)imp water (total)imp san (urban)imp san (rural)imp san (total)U5 DD DeathsDDMR

Sierra Leone28369,00019.713,59255.7****754657533039Nigeria130,800Sierra Leone55.7

Angola260169,00019.132,25649.6****704050561630DR Congo87,400Angola49.6

Afghanistan257251,00018.947,32948.5****1911131658Ethiopia81,800Somalia48.5

Somalia225100,00018.718,68542.0****322729471425Tanzania37,400Liberia42.0

Liberia235n/a17.3n/a40.7****72526249726Angola32,300Mali40.7

Mali219128,00018.323,48140.2****763548593845Niger30,900Rwanda40.2

Rwanda20354,00018.59,96637.5***926973563841Mozambique25,600DR Congo37.5

Democratic Republic of the Congo205484,00018.187,36437.0***832946432329Uganda25,000Burundi37.0

Burundi19050,00018.29,08634.5***907879473536Mali23,500Zambia34.5

Zambia18288,00017.515,37031.8***903655683245Kenya20,600Malawi31.6

Malawi17596,00018.117,35731.6***966267664246Nigeria30.9

Nigeria197834,00015.7130,77530.9***724960483038Burkina Faso19,600Ethiopia28.8

Ethiopia166472,00017.381,81828.8**8111...194...Somalia18,700Benin26.0

Benin15250,00017.18,55226.0**796068581232Malawi17,400Guinea25.6

Guinea15562,00016.510,24525.6**78385125613Madagascar15,700Mozambique25.1

Mozambique152155,00016.525,58525.1**762442511427Zambia15,400Uganda23.8

Uganda138145,00017.224,95923.8**875256533941Cameroon14,400Senegal23.4

Senegal13750,00017.18,54223.4**905472703452Sierra Leone13,600Cambodia23.3

Cambodia14163,00016.610,42823.3**58293453816Chad13,200Tanzania21.1

United Republic of Tanzania126223,00016.837,37521.1**926273544146Guinea-Bissau11,500Djibouti20.9

Djibouti126n/a16.6n/a20.9**826780552750Guinea10,200Madagascar20.8

Madagascar12393,00016.915,73120.8**753445492733Rwanda10,000Kenya19.8

Kenya120125,00016.520,60019.8*894662564348Burundi9,100

Tajikistan118n/a16.4n/a19.3*934758714753Benin8,600

Haiti11745,00016.57,42319.3*915971522334Senegal8,500

Yemen11197,00016.115,63417.9*746869761430

Timor-Leste80n/a21.9n/a17.5*735152653033

India852,402,00020.3487,57417.3*968286581830

Turkmenistan103n/a15.6n/a16.1*935471775062

Nepal7676,00020.515,56115.6*938284682027

Bangladesh77343,00020.068,71615.4*827275753948

Azerbaijan90n/a15.3n/a13.8*955977733655

Niger259156,00019.830,92751.380364643412

Guinea-Bissau20362,00018.611,53537.8794959572334

Chad20073,00018.113,17836.14032343008

Burkina Faso192104,00018.819,55136.182445145512

Cameroon14983,00017.314,36625.8844163633348

Myanmar105132,00021.127,90422.2957480966373

Mauritania125n/a16.2n/a20.263455664942

Sao Tome and Principe118n/a16.0n/a18.9897379322024

Bhutan80n/a20.9n/a16.7866062657070

Papua New Guinea93n/a15.3n/a14.3883239674145

Lao People's Democratic Republic83n/a15.6n/a12.9663843611424

Eritrea82n/a15.6n/a12.87254573439

Sheet1

Sheet2

Sheet3

Median Age-specific Incidences for Diarrheal Episodes per Child per Year from Three Reviews of Prospective Studies in Developing Areas, 1955-2000

Source: Disease Control Priorities in Developing Countries, Second Edition; 2006

Full coverage with proven interventions could reduce under-five mortality by 66%, equivalent to 6 million child deaths/year.Lancet Child Survival Series

Focus on the evidence-based interventions with greatest potential for reducing morbidity and mortalityPOU water treatment & safe storage approximately 30-50% reduction in DD prevalence (Cochrane Review, Clasen et al., 2006)Optimal handwashing (meta-analysis showed 43% reduction in diarrhea prevalence, April 2003, Lancet)Sanitation basic, low-cost systems can reduce DD by 30% or moreIncreasing quantities of water used impact on general hygiene and specifically facilitates handwashing

Costs vs. impact of various WSH program strategies (WHO 2007)

Chart1

0.16722.6

0.5324.6

0.69136.5

DD Reduction (%)

Annual Cost (B$)

Sheet1

4%$1.8 B2.22

10%6%$11.3 B$9.5 B0.88

16.70%10.70%$22.6 B$11.3 B0.71

53%36.30%$24.6 B$2.0 B2.15

69%16%$136.5 B$111.9 B0.51

36.3$1.78

$11.30$9.52

$22.60$11.30

$24.60$2.00

$136.50$111.90

Sheet2

41.8

10$11.30

17$22.60

53$24.60

69$136.50

Sheet2

41.8

1011.3

16.722.6

5324.6

69136.5

&A

Page &P

Sheet3

Sheet2 (2)

Annual Cost (B$)DD Reduction (%)

MDG Standard Water and Sanitation$2317%

MDG Standard + Improved POU Quality$2553%

Piped water and sewerage$13769%

Sheet2 (2)

&A

Page &P

DD Reduction (%)

Annual Cost (B$)

Use of Appropriate Technologies: Tippy Tap

Impact of Key Interventions on Diarrhea

Take-home messagesTARGET - Countries with high DD burden (severity, magnitude), children ages 6-24 months, newborns (caregiver handwashing)

FOCUS - On key behavioral outcomes water use, water quality (at POU), feces disposal, and handwashing

MEASURE - Behaviors, not diarrhea

*Please express my sincere regrets - JB.

Id give serious thought to dropping the and Friends business. I think that it risks sounding like well only do business with friendly implementing partners and friendly governments, but thats not true.*Diarrhea 2 million child deaths88% preventable

*DD deaths have declined everywhere, but are not declining in sub-Saharan Africa as quickly as in other regions*Certainly improving health and increasing survival is one of the paramount reasons for USAID investment in WSH. To achieve that, one needs to work on three fundamental contributions etc, etc.This Hygiene Improvement Framework has also been adopted and adapted by other leading organizations, including UNICEF and the Water and Sanitation Program.*Currently, our major emphasis is on various household chlorination products, although we are also starting to look at various filtration options as well.

In order, these are the Safe Water System (SWS), developed by Rob Quick and his colleagues at CDC, working with other partners, working closely with PSI, a major non-profit social marketing NGO.combined flocculent and disinfection products, which are especially useful and suitable when dealing with turbid water. We work closely with Procter & Gamble on applications for their product, PuR, shown here. and we are beginning work with Medentech, an Irish manufactuer of chlorine-based (dichloroisocyanurate) tablets for water disinfection. The tablets have advantages over chlorine solution in terms of transportability and shelf life. However, current implementation models rely on importation, not local production as for SWS, so that may be a concern in some settings.*which were subsequently adapted for use in branded advertising.