While health programming has helped reduce the severity and fatality of diarrhoea among children below the age of five, the percentage of children affected by diarrhoea in Nepal has not budged in almost a decade, remaining at a stubbornly high 14 percent.
A major cholera epidemic in 2009 affected over 70,000 people in 27 of the country’s 75 districts, killing almost 380. Since then, an average 3,500 under-five children are hit by diarrhoea outbreaks every year, resulting in some 50 deaths (1.4 percent fatality rate), according to government statistics.
Some nine out of 10 deaths due to diarrhoea worldwide are traced to unsafe water, inadequate sanitation and poor hygiene, according to the UN Children’s Fund (UNICEF), all of which are lacking in Nepal.
According to the most recent census in 2011, almost 40 percent of households nationwide did not have any safe way to dispose of faeces, and while 85 percent had access to an “improved” water source, it was still not necessarily safe, said Madhav Pahari, water, sanitation and hygiene (WASH) specialist at UNICEF’s office in Kathmandu. Less than half the population had access to soap and clean water for hand-washing.
A recent self-assessment by the WASH sector in Nepal, including both governmental and non-governmental groups, blamed insufficient funding, as well as inefficient spending.
In order to achieve its targets of universal toilet coverage by 2017 and basic water and sanitation services for all, Nepal will need to double its current annual investment in the sector from US$43 million to some $85 million, concluded the 2011 assessment.
But it is not only about more money, but also more “rational” spending, said Nanda Bahadur Khanal, senior divisional engineer at the water supply and sanitation Sector Efficiency Improvement Unit of the Ministry of Urban Development (MoUD).
Lack of coordination between the many actors has hampered effective use of funds, said Pahari.
“We have too many government entities implementing water and sanitation projects.” For rural WASH activities alone, there are three key agencies, all functioning under separate ministries and through different local bodies.
“Whose responsibility is sanitation at the broader national level?” asked Sudha Shrestha, acting chief technical adviser at the UN Human Settlements Programme (UN-HABITAT) in Nepal. “Is it the Ministry of Urban Development? Is it the Ministry of Local Development? Or is it the Ministry of Physical Planning, Works, and Transport Management? And for hygiene, is it the Ministry of Health and Population? The roles and responsibility are not explicitly defined.”
Officials have only recently identified that in addition to last year’s $43.3 million WASH budget, another $19 million was funnelled by donors to water and sanitation projects, but not in collaboration with any government agencies and, therefore, did not appear on any official expense statements.
“Externally channelled money makes up about 30 percent of investment in the sector, but its geographical coverage is not even 5 percent,” calculated Khanal at the MoUD. “That money has not been used effectively.”
Fragmentation has often led to duplication of efforts on the ground, he added. If a water tap built by one agency stops running, instead of repairing it, locals will request a different agency to build a new water supply system.
As a result, some village development committees (VDCs) are saturated with water supply schemes, while others have none, said UNICEF’s Pahari.
Water and sanitation projects too often target communities most easily reached by road or air, which are already better-off, said Shrestha at UN-HABITAT. “If I go to a district for an intervention, I will choose a place where I can get quick results.”
Even with a national sanitation average hovering around 60 percent, around 10 districts have less than 30 percent of their population accessing “improved” sanitation.
“There is a poor culture and practice of evidence-based resource allocation,” according to the government’s Water Supply, Sanitation and Hygiene, Sector Status Report 2011.
“Our funding needs to prioritize unreached populations - deprived communities, remote communities, and those with weak political access,” said Khanal. “That is what we are advocating for now.”
Attention should be paid to the “sanitation-dark” stretch of districts along the central-eastern Terai flatlands bordering India from the districts of Parsa to Saptari, where over 20 percent of the country’s population resides, said Pahari. Investment for water and sanitation in these districts needs to increase at least five-fold, as estimated in the 2011 sector report.
There are also concentrated pockets of recurring diarrhoeal outbreaks in the country, particularly in the mid- and far-western hill districts of Accham, Doti, Dialekh, Bajhang, Jajarkot, and Rukum that require constant and improved disease surveillance, explained Sameer Dixit, country director of the scientific NGO Centre for Molecular Dynamics.
New data analysis is needed to improve targeting, said Purusotam Shedain, senior integrated medical officer at the Child Health Division of Nepal’s Department of Health Services (DHS). The government has identified hard-to-reach urban poor populations in a number of slum areas in Kathmandu; researchers have only begun to disaggregate national diarrhoea prevalence data by caste. A person’s family background plays a prominent factor in service access. Only with such information can the government tailor and target its services more accurately, he added.
Supply over sanitation
WASH efforts in Nepal have favoured water infrastructure projects over sanitation and hygiene interventions, added Shrestha from UN-HABITAT.
“Diarrhoeal outbreaks are related to the wider perspective of hygiene, water quality, sanitation, and the environment,” said Pahari. “The sector has not been able to address all four parameters in a systematic manner.” Pahari observed that access to improved water has been “significantly improved”, sanitation is “relatively OK”, hygiene awareness is “far from required” and environmental cleanliness is “too far to achieve”.
“Our focus, thus far, has been on getting people to defecate in a toilet,” admitted the MoUD’s Khanal, with issues around the facility’s cleanliness, food hygiene and hand-washing only slowly being addressed.
The government created a separate budget line for national sanitation and hygiene promotion only two years back, but the $3.2 million allotted for 2012 did not fulfil spending requirements of using 10 percent of the total rural water supply budget for national sanitation and hygiene promotion.
The DHS’s National Health Education, Information and Communication Centre initiated water and sanitation outreach work four years ago, Kunj Prasad Joshi, senior health education officer at the centre, told IRIN. It currently spends between $114,000-$228,000 targeting schools in seven districts. Taking the project nationwide requires 10 times more funding, he said.
“With Nepal’s population at 26.8 million, even if you estimate only 10-20 rupees expense per head, you would still need 200 to 250 million [Nepalese rupees, or $2.2-$2.8 million],” calculated Joshi.
No long-term focus
Even where hygiene awareness has spread, most development projects do not run long enough to instil lasting behaviour change, said Shrestha. “Many of our interventions are resource and time bound.” They last an average of three to five years, after which “there are no provisions to return to see how things are going.” Instead, local authorities need to institutionalize behaviour-change interventions, Shrestha added.
The same goes for changing hygiene habits and infrastructure maintenance. Although 20 percent of the water supply budget should go to repair and rehabilitation, according to policy stipulations, less than 1 percent currently does.
Around 80 percent of water supply schemes need repair, rehabilitation, or reconstruction, some of which are completely non-functional, based on the 2011 sector review.
According to the Department of Water Supply and Sewerage’s 2010 assessment, almost 2 percent of the population with toilets did not use them. Of those who did, over 20 percent were poorly managed or dirty and unhygienic.
Coverage statistics are poor indicators of water and sanitation conditions in communities, said the government’s Khanal.
Following the first joint-sector WASH review in 2011, a follow-up consultation was held in 2012, and another national review is planned for 2013. The review initiated formal budget tracking, with a standard format to be in place by next year.
“If we could streamline investment in the sector, there may still not be enough funding, but we would need less investment than is currently demanded,” said Khanal. “We need to consider rational use of our funds. The government needs to develop a roadmap for investment priorities in the sector, and the donors, following the Paris Declaration [on Aid Effectiveness] need to invest where the national government [requests].”
The 2011 review found the WASH sector lacked reliable performance monitoring. “Although more than Rs 22 billion [$250 million] has been allocated to the sector in the past six years [2004-2010], utilization effectiveness is often questioned in the absence of structured monitoring mechanisms.”
A programme document that identifies priority areas to guide WASH practitioners should also be finalized soon, Khanal added.
The Sanitation and Hygiene Master Plan launched in 2011 exposed neglected areas. It set a target year of 2017 for universal toilet coverage, launched a nationwide open defecation-free campaign, and endorsed the creation of district, municipal and village-level coordination committees to oversee WASH interventions.
The crucial question for the sector, said Shestra, is “how to continue and maintain the movement”.
[This report does not necessarily reflect the views of the United Nations]