Dollars for Diarrhoea

Jan 09, 2013

Insufficient, fragmented and misdirected investment in the water and sanitation sector hinders the fight against diarrhoea.

1287 An abandoned arsenic water filter turned planter. PHOTO: Marcus Benigno/IRINNew 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”.