Isabel Günther

The effect of water and sanitation on child health: evidence from the demographic and health surveys 1986–2007

BACKGROUND Despite continued national and international efforts, access to improved water and sanitation remains limited in many developing countries. The health consequences of lacking access to water and sanitation are severe, and particularly important for child development. METHODS To investigate the associations between child health and access to water and sanitation, we merged all available Demographic and Health Surveys (DHS) with complete birth histories and water and sanitation information. The merged data set of 171 surveys includes information on 1.1 million children under the age of 5 years in 70 low- and middle-income countries over the period 1986-2007. We used logistic models to estimate the effect of water and sanitation access on infant and child mortality, diarrhoea and stunting. RESULTS Access to improved sanitation was associated with lower mortality (OR = 0.77, 95% CI 0.68-0.86), a lower risk of child diarorhea (OR = 0.87, 95% CI 0.85-0.90) and a lower risk of mild or severe stunting (OR = 0.73, 95% CI 0.71-0.75). Access to improved water was associated with a lower risk of diarrhoea (OR = 0.91, 95% CI 0.88-0.94) and a lower risk of mild or severe stunting (OR = 0.92, 95% CI 0.89-0.94), but did not show any association with non-infant child mortality (OR = 0.97, 95% CI 0.88-1.04). CONCLUSIONS Although our point estimates indicate somewhat smaller protective effects than some of the estimates reported in the existing literature, the results presented in this article strongly underline the large health consequences of lacking access to water and sanitation for children aged <5 years in low- and middle-income countries.

Water, sanitation and children's health : evidence from 172 DHS surveys

This paper combines 172 Demography and Health Survey data sets from 70 countries to estimate the effect of water and sanitation on child mortality and morbidity. The results show a robust association between access to water and sanitation technologies and both child morbidity and child mortality. The point estimates imply, depending on the technology level and the sub-region chosen, that water and sanitation infrastructure lowers the odds of children to suffering from diarrhea by 7-17 percent, and reduces the mortality risk for children under the age of five by about 5-20 percent. The effects seem largest for modern sanitation technologies and least significant for basic water supply. The authors also find evidence for the Mills-Reincke Multiplier for both water and sanitation access as well as positive health externalities for sanitation investments. The overall magnitude of the estimated effects appears smaller than coefficients reported in meta-studies based on randomized field trials, suggesting limits to the scalability and sustainability of the health benefits associated with water and sanitation interventions.

Measuring Chronic Non-Income Poverty

An increasing interest in poverty dynamics has lately also led to an extensive literature on the analysis of chronic poverty. Based on Amartya Sen?s groundbreaking work on capabilities and functionings static poverty measures have long used non-income indicators. In contrast, measures of poverty dynamics - including chronic poverty – have in general conceptualised poverty only in an income dimension. Hence, this paper first critically discusses the conceptual and empirical potentials and limitations of analysing chronic poverty from a nonincome perspective. Second, it proposes methods to empirically measure chronic nonincome poverty, with an exploratory application to panel data from Vietnam from 1992 and 1997, which demonstrates that a range of useful insights can be generated from such an analysis. In particular, we find that the correlation between chronic income and non-income poverty is rather low which is mostly due to a low correlation between income and nonincome poverty in each period, while both move relatively closely over time. We also find a surprising amount of heterogeneity in static and dynamic non-income poverty within households.

Slum Residence and Child Health in Developing Countries

Continued population growth and increasing urbanization have led to the formation of large informal urban settlements in many developing countries in recent decades. The high prevalence of poverty, overcrowding, and poor sanitation observed in these settlements—commonly referred to as “slums”—suggests that slum residence constitutes a major health risk for children. In this article, we use data from 191 Demographic and Health Surveys (DHS) across 73 developing countries to investigate this concern empirically. Our results indicate that children in slums have better health outcomes than children living in rural areas yet fare worse than children in better-off neighborhoods of the same urban settlements. A large fraction of the observed health differences appears to be explained by pronounced differences in maternal education, household wealth, and access to health services across residential areas. After we control for these characteristics, children growing up in the slums and better-off neighborhoods of towns show levels of morbidity and mortality that are not statistically different from those of children living in rural areas. Compared with rural children, children living in cities (irrespective of slum or formal residence) fare better with respect to mortality and stunting but not with respect to recent illness episodes.

Descending the sanitation ladder in urban Uganda: evidence from Kampala Slums

BackgroundWhile the sanitation ladder is useful in analysing progressive improvements in sanitation, studies in Uganda have not indicated the sanitation barriers faced by the urban poor. There are various challenges in shared latrine use, cleaning and maintenance. Results from Kampala city indicate that, failure to clean and maintain sanitation infrastructure can lead to a reversal of the potential benefits that come with various sanitation facilities.MethodsA cross sectional qualitative study was conducted between March and May 2013. Data were collected through 18 focus group discussions (FGDs) held separately; one with women, men and youth respectively. We also used pictorial methods; in addition, 16 key informant interviews were conducted. Data were analysed using content thematic approach. Relevant quotations per thematic area were identified and have been used in the presentation of the results.ResultsWhether a shared sanitation facility was improved or not, it was abandoned once it was not properly used and cleaned. The problem of using shared latrines began with the lack of proper latrine training when people do not know how to squat on the latrine hole. The constrained access and security concerns, obscure paths that were filthy especially at night, lack of light in the latrine cubicle, raised latrines sometimes up to two metres above the ground, coupled with lack of cleaning and emptying the shared facilities only made a bad situation worse. In this way, open defecation gradually substituted use of the available sanitation facilities. This paper argues that, filthy latrines have the same net effect as crude open defection.ConclusionWhereas most sanitation campaigns are geared towards provision of improved sanitation infrastructure, these findings show that mere provision of infrastructure (improved or not) without adequate emphasis on proper use, cleaning and maintenance triggers an involuntary descent off the sanitation ladder. Understanding this reversal movement is critical in sustainable sanitation services and should be a concern for all actors.

Gender variations in access, choice to use and cleaning of shared latrines; experiences from Kampala Slums, Uganda

BackgroundSanitation is one of the most intimate issues that affect women, especially in slums of developing countries. There are few studies that have paid attention to the gender variations in access, choice to use and cleaning of shared latrines in slums.MethodsThis paper draws on qualitative data from a cross sectional study conducted between 2012 and 2013 in six slums of Kampala City, Uganda. The study involved both women and men. Data were collected from 12 Focus Group Discussions (FGDs), 15 Key informant interviews; community transects and photographs of shared latrines.ResultsLocation of a shared latrine facility, distance, filthy, narrow and irregular paths; the time when a facility is visited (day or night), privacy and steep inclines were gender ‘filters’ to accessing shared latrines. A full latrine pit was more likely to inhibit access to and choice of a facility for women than men. Results indicate that the available coping mechanisms turned out to be gendered, with fewer options available for women than men. On the whole, women sought for privacy, easy reach, self-respect and esteem, cleanliness and privacy than men. While men like women also wanted clean facilities for use; they (men) were not keen on cleaning these facilities. The cleaning of shared latrines was seen by both women and men as a role for women.ConclusionThe presence of sanitation facilities as the first step in the access, choice, use, and cleaning by both women and men has distinct motivations and limitations along gender lines. The study confirms that the use and cleaning of latrines is regulated by gender in daily living. Using a latrine for women was much more than relieving oneself: it involved security, intimacy and health concerns.

Why do households invest in sanitation in rural Benin: Health, wealth, or prestige?

Seventy percent of the rural population in sub-Saharan Africa does not use adequate sanitation facilities. In rural Benin, as much as 95% of the population does not use improved sanitation. By analyzing a representative sample of 2000 rural households, this paper explores why households remain without latrines. Our results show that wealth and latrine prices play the most decisive role for sanitation demand and ownership. At current income levels, sanitation coverage will only increase to 50% if costs for construction are reduced from currently

Desired Fertility and Number of Children Born Across Time and Space

190 USD to

Urban Mortality Transitions: The Role of Slums

50 USD per latrine. Our analysis also suggests that previous sanitation campaigns, which were based on prestige and the allure of a modern lifestyle as motives for latrine construction, have had no success in increasing sanitation coverage. Moreover, improved public health, which is the objective of public policies promoting sanitation, will not be effective at low sanitation coverage rates. Fear at night, especially of animals, and personal harassment, are stated as the most important motivational factors for latrine ownership and the intention to build one. We therefore suggest changing the message of sanitation projects and introduce new low-cost technologies into rural markets; otherwise, marketing strategies will continue to fail in increasing sanitation demand.

Attracting Attentive Academics: Paper, Person or Place?

Economists have often argued that high fertility rates are mainly driven by women’s demand for children (and not by family planning efforts) with low levels of unwanted fertility across countries (and hence with little room for family planning efforts to reduce population growth). We study the relationship between wanted fertility and number of children born in a panel of 200 country-years controlling for country fixed effects and global time trends. In general, we find a close relationship between wanted and actual fertility, with one desired child leading to one additional birth. However, our results also indicate that in the last 20 years, the level of unwanted births has stayed at 2 across African countries but has, on average, decreased from 1 to close to 0 in other developing countries. Hence, women in African countries are less able to translate child preferences into birth outcomes than women in other developing countries, and forces other than fertility demand have been important for previous fertility declines in many developing countries. Family planning efforts only partially explain the observed temporal and spatial differences in achieving desired fertility levels.