Sanitation MDG is badly off track, but a community-led approach could fix that
Vast sums are wasted on programmes for free toilets, but the community-led total sanitation approach has helped millions avoid often fatal, faecally related infections.
Community-led total sanitation (CLTS) does not sound such a big deal, but it is revolutionary. We have so many “revolutions” in development that only last a year or two and then fade into history. But this one is different. In all the years I have worked in development this is as thrilling and transformative as anything I have been involved in. Let me explain.
Firstly, sanitation and scale: 2.6 billion people need improved sanitation and 1.1 billion defecate in the open. The millennium development goal (MDG) for sanitation is badly off track in most countries, which affects all the other MDGs.
Secondly, sanitation and hygiene matter much more than most people realise. Where they are lacking, the effects are horrendous. Faecally related infections are many. Everyone feels outrage because more than 2 million children are killed by diarrhoea each year. We hear about cholera outbreaks. But who hears about the guts of 1.5 billion people hosting greedy, parasitic, ascaris worms, about 740 million with hookworm voraciously devouring their blood, 200 million with debilitating schistosomiasis or up to 70 million with liver fluke? And what about dysentery, hepatitis, giardia, tapeworms, typhoid, polio, trachoma…?
May 19, 2011 – India’s cabinet has approved a proposal for a survey to identify people living below the poverty line, which also redefines what constitutes poverty.
It will classify the rural poor into “destitutes, manual scavengers and primitive tribal groups”.
Urban poor will be defined as those in vulnerable shelters, low-paid jobs and homes headed by women or children.
The survey, to be conducted alongside a caste census later this year, will help identify those who need state aid.
There are various estimates on the exact number of poor in India.
Officially, 37% of India’s 1.21bn people live below the poverty line. But one estimate suggests this figure could be as high as 77%.
The last poverty survey was conducted in 2002, but this is the first time that details about caste and religion will be included. The last caste census in India was in 1931.
AN ALTERNATIVE TO CONVENTIONAL PUBLIC WATER SERVICE : “USER GROUP NETWORKS” IN A MUMBAI SLUM, 2011.
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Rémi de BERCEGOL, Adeline DESFEUX. Centre for Human Sciences.
Providing universal access to drinking water remains a formidable challenge in the cities of developing countries and all potential technical and institutional solutions need to be taken into account. By looking at the specific example of “user group networks” set up in a poor neighbourhood in the North-East of Mumbai, this article aims to highlight the ability of local communities to design and run functional systems that compensate for shortcomings in the public service.
We will analyse the effective role that users play in regulating these groups at local level as well as the political-territorial implications of this type of management. After providing a clear overview of the systems that have emerged and their modus operandi, we will describe and assess them from a critical technical/economic perspective in order to suggest possible improvements. More generally, our research is part of a broader attempt to study the different ways of providing access to urban water and the legitimacy of local communities in taking the process in hand. We wish to contribute to the debate that focuses on providing a differentiated service to the inhabitants of the same city.
April 22, 2011 – While other industrial designers merely tweak the appearance of the latest electronic gadget to make minor improvements to trivial point-of-sale appeal, Israel’s Noa Lerner, a Berlin-based industrial engineer, is developing a much more crucial necessity: a mobile public toilet for third world urban slum dwellers.
The design that she created at her company Morph Design, involves a top that resembles the familiar toilet bowl, placed over a removable container covered with a plastic layer with odor-repellant and anti-bacterial substances. A very small amount of water is used to rinse the top bowl.
These nearly waterless green toilets could be emptied like chamber pots, but with a difference. About once a week, these could be rolled (securely closed of course!) to a neighborhood collection facility.
Each of these toilet barrels is sealed and nano-coated in a way that allows them to be used for a week at a time without emptying or cleaning.
Once it’s time to empty, the barrel is brought by an individual or a multi-barrel servce to the local Biogas Plant. Once there, waste is traded for energy in the form of cooking gas, warm water for showers, or electricity. All of these forms of energy are generated by processing the human waste at the Biogas Plant.
Once the contents collected at a neighborhood facility, where the secretions could be farmed to create methane gas through composting, which can then be used as an energy source or fertilizer.
Working with the Indian non-profit: Sulabh, which is already operating various ways of serving the needs of slum dwellers in India, Lerner will create a pilot project to be launched in India’s capital.
Environment and Urbanization, April 2011
Indian cities, sanitation and the state: the politics of the failure to provide
Susan E Chaplin, School of Public Health, La Trobe University, Melbourne VIC 3086, Australia, firstname.lastname@example.org
The environmental problems confronting Indian cities today have arisen because millions of people have been forced to live in illegal settlements that lack adequate sanitation and other basic urban services. This is the result of two factors. The first is the legacy of the colonial city characterized by inequitable access to sanitation services, a failure to manage urban growth and the proliferation of slums, and the inadequate funding of urban governments. The second is the nature of the post-colonial state, which, instead of being an instrument for socioeconomic change, has been dominated by coalitions of interests accommodated by the use of public funds to provide private goods.
This has enabled the middle class to monopolize what sanitation services the state has provided because the urban poor, despite their political participation, have not been able to exert sufficient pressure to force governments to effectively implement policies designed to improve their living conditions. The consequence is that public health and environmental policies have frequently become exercises in crisis intervention rather than preventive measures that benefit the health and well-being of the whole urban population.
Environment and Urbanization, April 2011
The state of urban health in India; comparing the poorest quartile to the rest of the urban population in selected states and cities
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India has the world’s second largest urban population (after China). This paper shows the large disparities within this urban population in health-related indicators. It shows the disparities for child and maternal health, provision for health care and housing conditions between the poorest quartile and the rest of the urban population for India and for several of its most populous states. In the poorest quartile of India’s urban population, only 40 per cent of 12 to 23 month-old children were completely immunized in 2004—2005, 54 per cent of under-five year-olds were stunted, 82 per cent did not have access to piped water at home and 53 per cent were not using a sanitary flush or pit toilet.
The paper also shows the large disparities in eight cities between the poorest population (the population in the city that is within the poorest quartile for India’s urban areas), the population living in settlements classified as “slums” and the non-slum population. It also highlights the poor performance in some health-related indicators for the population that is not part of the poorest quartile in several states — for instance in under-five mortality rates, in the proportion of stunted children and in the proportion of households with no piped water supply to their home.
Rapid Assessment Scorecard to Identify Informal Settlements at Higher Maternal and Child Health Risk in Mumbai
J Urban Health. 2011 Apr 13.
A Rapid Assessment Scorecard to Identify Informal Settlements at Higher Maternal and Child Health Risk in Mumbai.
Osrin D, Das S, Bapat U, Alcock GA, Joshi W, More NS. UCL Centre for International Health and Development, Institute of Child Health, 30 Guilford St, London, WC1N 1EH, UK, email@example.com.
The communities who live in urban informal settlements are diverse, as are their environmental conditions. Characteristics include inadequate access to safe water and sanitation, poor quality of housing, overcrowding, and insecure residential
status. Interventions to improve health should be equity-driven and target those at higher risk, but it is not clear how to prioritise informal settlements for health action.
In implementing a maternal and child health programme in Mumbai, India, we had conducted a detailed vulnerability assessment which, though important, was time-consuming and may have included collection of redundant information. Subsequent data collection allowed us to examine three issues: whether community environmental characteristics were associated with maternal and newborn healthcare and outcomes; whether it was possible to develop a triage scorecard to rank the health vulnerability of informal settlements based on a few rapidly observable characteristics; and whether the scorecard might be useful for future prioritisation.
The City Initiative for Newborn Health documented births in 48 urban slum areas over 2 years. Information was collected on maternal and newborn care and mortality, and also on household and community environment. We selected three outcomes-less than three antenatal care visits, home delivery, and neonatal mortality-and used logistic regression and classification and regression tree analysis to test their association with rapidly observable environmental characteristics.
We developed a simple triage scorecard and tested its utility as a means of assessing maternal and newborn health risk. In analyses on a sample of 10,754 births, we found associations of health vulnerability with inadequate access to water, toilets, and electricity; non-durable housing; hazardous location; and rental tenancy. A simple scorecard based on these had limited sensitivity and positive predictive value, but relatively high specificity and negative predictive value. The scorecard needs further testing in a range of urban contexts, but we intend to use it to identify informal settlements in particular need of family health interventions in a subsequent program.
The Lancet, Volume 377, Issue 9766, Pages 627 – 628, 19 February 2011
Health care for urban poor falls through the gap
While governments and donors focus on health care for those living in rural poverty in developing countries, the residents of the world’s slums are being neglected, writes Priya Shetty.
The slums of Mumbai and the favelas of Rio de Janeiro are images of urban poverty so extreme that they are indelibly stamped on the identity of those cities. But urban poverty now goes far beyond these notorious icons.
The world is becoming more urbanised overall. 2008 was a demographic turning point—for the first time, according to the UN Population Fund (UNFPA), more people lived in urban areas than in rural ones. Yet these new urbanites, especially in developing countries, are overwhelming cities that were never designed to have so many inhabitants, and therefore simply do not have the infrastructure to cope.
Link to complete article – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60215-8/fulltext
Determinants of tetanus and sepsis among the last neonatal deaths at household level in a peri-urban area of India
Postgrad Med J. 2011 Apr;87(1026):257-63.
Determinants of tetanus and sepsis among the last neonatal deaths at household level in a peri-urban area of India.
Ghosh R, Sharma AK. Department of Humanities and Social Sciences, Indian Institute of Technology Kanpur, Kanpur 208016, India. firstname.lastname@example.org.
Background – India contributes to one quarter of the total number of newborn deaths in the world. Less explored are the causes of these deaths, and household factors and decision makers for antenatal and postnatal care and their association with neonatal mortality.
Objective – This study estimated neonatal mortality rate due to tetanus and sepsis (TS) and tried to identify the risk factors for TS in a peri-urban area of India characterised by a high level of infant and neonatal mortality rate.
Methods – An intensive cross-sectional study was conducted during January to March 2008. A structured interview schedule was developed, after reviewing major demographic and health studies done in India, to collect data from all women selected in the sample villages, situated at a distance of 3-5 km from a primary health centre.
Results – Of the 894 married women (<50 years of age), 109 reported their last pregnancy outcome as neonatal death, and 84 cases of TS were noted. Using forward conditional stepwise logistic regression the risk factors of TS identified were women’s age, socioeconomic score, antenatal care, pregnancy complications, and treatment after delivery during the neonatal period.
Conclusions – Independent of social class there is high prevalence of neonatal mortality. There is a close association between utilisation of health care services during pregnancy, postnatal period and neonatal deaths due to TS. It is argued that there is a need for a two pronged approach to reduce neonatal mortality due to TS: (1) to train traditional birth
attendants, and expand the reach of existing antenatal care and childbirth facilities; and (2) to empower women to increase their awareness to take decisions about seeking proper medical assistance during pregnancy and
PMID: 21296798 [PubMed - in process]
BMC Public Health. 2011 Mar 8;11:150.
Maternal and neonatal health expenditure in mumbai slums (India): A cross sectional study.
Skordis-Worrall J, et al. UCL Centre for International Health and Development, Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK. email@example.com.
BACKGROUND: The cost of maternity care can be a barrier to access that may increase maternal and neonatal mortality risk. We analyzed spending on maternity care in urban slum communities in Mumbai to better understand the equity of spending and the impact of spending on household poverty.
METHODS: We used expenditure data for maternal and neonatal care, collected during post-partum interviews. Interviews were conducted in 2005-2006, with a sample of 1200 slum residents in Mumbai (India). We analysed expenditure by socio-economic status (SES), calculating a Kakwani Index for a range of spending categories. We also calculated catastrophic health spending both with and without adjustment for coping strategies. This identified the level of catastrophic payments incurred by a household and the prevalence of catastrophic payments in this population. The analysis also gave an understanding of the protection from medical poverty afforded by coping strategies (for example saving and borrowing).
RESULTS: A high proportion of respondents spent catastrophically on care. Lower SES was associated with a higher proportion of informal payments. Indirect health expenditure was found to be (weakly) regressive as the poorest were more likely to use wage income to meet health expenses, while the less poor were more likely to use savings. Overall, the incidence of catastrophic maternity expenditure was 41%, or 15% when controlling for coping strategies. We found no significant difference in the incidence of catastrophic spending across wealth quintiles, nor could we conclude that total expenditure is regressive.
CONCLUSIONS: High expenditure as a proportion of household resources should alert policymakers to the burden of maternal spending in this context. Differences in informal payments, significantly regressive indirect spending and the use of savings versus wages to finance spending, all highlight the heavier burden borne by the most poor. If a policy objective is to increase institutional deliveries without forcing households deeper into poverty, these inequities will need to be addressed. Reducing out-of-pocket payments and better regulating informal payments should have direct benefits for the most poor. Alternatively, targeted schemes aimed at assisting the most poor in coping with maternal spending (including indirect spending) could reduce the household impact of high costs.