Water privatisation: looking at Mali

Throughout the world, there are various approaches towards managing the provision of water. Since the 1990s, private sector participation has been heavily promoted by the IMF and World Bank to reduce the burden of providing water on the state. Like everything, privatisation comes with its costs and benefits; in this post I will explore the success of the privatisation of the water supply in Mali.

Privatisation entails a huge variety of ‘contractual arrangements between the government and the private sector’ (Bayliss 2003). These may include:

• management contracts – agreement between owner and a company that will oversee the project operating the enterprise for a fixed payment
• leases – government owns assets and private actor operates these; government is responsible for investing in infrastructure
• concessions – distinction from leases is obscure, difference is usually that the private investor is responsible for investing in infrastructure
• divestiture – partial or full sale of a unit to another party (i.e. transfer of ownership of water infrastructure)

Mali, a country I have focused on previously, is located in Western Africa. According to Water Aid, 3.7 million people in the country do not have access to safe water – about 22% of the population. The water supply in main cities falls under the responsibility of Energie du Mali (EDM), traditionally a public enterprise. Regulation, sector support and policy are carried out by the central government (Estache and Grifell-Tatje 2012). With an extremely low GDP of $36 billion in 2015, foreign direct investment (FDI) can have huge macroeconomic impacts on the country (CIA World Factbook).

Map of Mali and surrounding countries. Source: Michigan State University Museum 

In recent decades, Mali has tried to augment private sector participation in water provision. In 2000 the Malian government transferred operations of the main electricity and water company EDM to the French group Saur, signing a 20 year lease with the intention of improving accessibility and performance in provision (both technical and financial). The result was a rise in output quantity; total water supplied and sold increased by over 40% in the period 2001-04 (from 30.1 to 43.2 million metres cubed). About half of this went to residential subscribers, two fifths to industry and the rest to public fountains. In real terms, consumers actually faced a reduction in prices by 11.5% (Estache and Grifell-Tatje 2012).

These demonstrate some clear benefits for consumers, but does that mean all consumers? While revenues increased by over a third, practically all income came from industry and residential subscribers. In Bamako, the capital, 13% of water was sold in public fountains, yet in many other urban areas, less than 5% of water went to these (Estache andGrifell-Tatje 2012). Public fountains are a key source of safe water for the poorest who lack the ability to pay for a private tap or for the costly water infrastructure. The fact that rural areas (which are difficult and expensive for any enterprise or operator to connect for water delivery) tend to be home to the poorest means that there is virtually no financial incentive to increase access to clean water for Mali’s poor.

Other than spatial and socio-economic disparities in distribution, there were other issues with the privatisation of water in Mali. In theory, privatisation would reduce the economic burden of supplying water on the state. However, the Malian government gave the private actor subsidies to avoid a significant increase of 26% in water and electricity prices (that would make these unaffordable for much of the population), meaning this service was still a drain for government funds (Mainguy and Jeppesen 2009). From 2001-03, one-off subsidies of over one billion CFA francs (in real terms, i.e. not taking into account inflation) were given to EDM.

Post-2000, EDM was regulated by the Regulation Commission of Water and Energy (CREE), the objective of which is to protect consumer interest and coordinate private sector participation. According to Estache andGrifell-Tatje (2012), the ‘insistence of the regulator to collect data needed fuelled the tension between the regulator and the operator and contributed to end the privatisation experience’. The lease, initially signed for 20 years, lasted a quarter of its life. ‘Multiple mistakes and inaccuracies’ in terms of tariffs, price indices and valuations were recognised later on, and were also blamed for the failure of privatisation in the country. After Saur withdrew from the lease contract, ownership of EDM was split, with the State of Mali taking the highest percentage, followed by Saur.

As can be observed from Mali’s experience, private sector participation is complex and can face an array of issues, both economic and social. The impacts of privatisation of water provision are beneficial for some people in some areas, but not others.  In countries where privatisation has been unsuccessful in serving the general population or more isolated communities, there has been much resentment towards it. In Mali, anti-privatisation protests that broke out in Bamako left one dead and more injured in 2008 (IRIN News 2013). One thing seems clear: if the government cannot provide access to piped clean water for rural marginalised communities because of limited financial capacity and incentives, a private actor that is profit-oriented is most likely not the solution — providing water for the poorest is not seen as financially viable, let alone profitable.

Using marketing methods in sanitation

Marketing is not just about advertising. It is fundamentally about understanding a target audience, what customers want, and how to alter perceptions to successfully sell a product. The unprecedented power of marketing can determine whether a business or industry succeeds or fails. Sanitation marketing, a relatively new concept within the field, seeks to use marketing techniques to encourage hygienic practices or boost demands for sanitation facilities (e.g. a new flush toilet). The four well-known elements within marketing are: price, place, product and promotion. In this blog entry, I will outline the importance of the four Ps and how they can be relevant to water and sanitation solutions in Africa. 

There is no official definition for sanitation marketing. Whilst some see it as selling sanitation using commercial marketing methods to encourage communities to build facilities, other define it as strengthening supply by building the capacity of the private sector locally (Water and Sanitation Program 2012).

PRICE AND PLACE
Price can refer to money or a non-monetary payment for sanitary products. Households must be willing and able to pay, meaning that paying for a resource must be deemed acceptable and that people must have money or access to credit to pay for it. Willingness to pay for water in developing countries is very high, though calculating this in the first place may be controversial in itself. Depending on location and stakeholder, water can be considered an indicator of a strong government, a basic necessity, a gift or blessing, power and security, or an environmental resource. If governments and development organisations wrongly estimate the willingness to pay of a community, water supply projects fail (Littlefair 1998). For instance, in Guinea in 1987, water collection rates were very low and only about 15% of those billed paid, a reflection of the country's economic state (Bayliss 2003). Place and price are closely interlinked; cost of living varies from country to country, for example, or from rural areas to urban areas. Where a product or service is sold determines how it can be priced and whether or not it will sell.

The Community Cleaning Services (CCS) scheme in Nairobi, Kenya, employed a handful of youths in Mathare (an informal settlement) to clean over 100 toilets and improve sanitation conditions, as well as prospects for young people there (Thieme and DeKoszmovszky 2012). The programme had to be officially drawn to a close in 2013 after running for several years. This was largely a result of unforeseen financial issues; it was not difficult to convince people that CCS was valuable, but rather to persuade them that it was worth that price. It failed to break even and SC Johnson could no longer justify investing in it. There were problems related to payment habits. For instance, in the month of February demand fell for the service, as children were on school holiday and some parents did not see the point of paying for cleaning if the children were going to quickly dirty the toilet again. In addition, parents were more financially strained around this time because school fees were due (Thieme 2015). Better marketing - a fuller understanding of the people, habits, social norms and perceptions particular to that place - would have improved the design and success of the project.

PRODUCT AND PROMOTION
As we can see from the example above, a product can be a material good or a service. A key question marketeers must ask themselves is: what does the population want? In Mathare, a major attraction of the CCS was the 'whiteness of the bowl' and 'sweet smell' which were a matter of social and personal pride. Customers wanted a toilet that family and guests could use without shame or discomfort (Thieme 2015). No product will see a successful uptake without appropriate promotion, which is essentially communication and brings together all the Ps. It can take many forms, from a demonstration to social media to  posters or adverts. In the case of CCS, the team's uniform was a symbol of its professional image. They would walk through the settlement during the busiest time of the day to their first toilet wearing their uniform and carrying their equipment as a form of advertising to pedestrians.

Promotion is the pathway by which a behaviour or perception can be 'targeted for modification' (Water and Sanitation Program 2012). The act of hand washing has been heavily promoted to improve sanitation. Projects such as School Led Total Sanitation (SLTS) have educated children in schools to wash their hands regularly and not practise open defecation (Joshi et al. 2016). Similarly, Unilever's Lifebuoy 'Help a child reach 5' was a campaign to teach millions of children in developing countries the importance of hand  washing, reducing infant mortality rates in many areas. The company collaborated with UNICEF, USAid, London School of Hygiene and Tropical Medicine, and various NGOs to deliver the project (Financial Times 2007).

Overall, it is clear that the four marketing Ps are 'at the core' of any sanitation initiative and must be taken into account seriously, not just in Africa but worldwide (Water and Sanitation Program 2012).  In order for schemes to successfully improve water and sanitation conditions they need to understand people's needs, perceptions and communication methods, as well as how these vary spatially.

Cholera, the disease of the poor

Cholera is an infectious disease caused by the ingestion of the Vibrio cholerae strain of bacteria that affects the small intestine. Transmission can occur via faecal-oral contamination or consumption of contaminated food or water. The symptoms include diarrhoea, vomiting and muscle cramps, resulting in severe dehydration and organ failure. Diarrhoea causes 11% of child deaths globally – more than AIDS, measles and malaria combined (Liu et al. 2012). The disease ‘no longer poses a menace to countries with minimum standards of hygiene’, but continues to be problematic in places that lack clean water and sanitation coverage (Talavera and Perez 2009: 408). While rich countries face practically no cases at present, serious outbreaks in less economically developed countries are still occurring regularly. Is the prevalence of cholera determined by economic prosperity (i.e. GDP per capita)?

Outbreaks of cholera can be seen throughout the past centuries across the world. In London during the 1850s there was a cholera outbreak in Soho, which was found by Dr John Snow to be an issue of the interconnected wells which provided people with contaminated water. Today, cholera has been eradicated in the UK, yet African countries reported 3,221,050 suspected cases from 1970-2011, and worldwide (excluding Haiti) in 2011 sub-Saharan Africa accounted for 86% of cases and 99% of the deaths from the disease (Mengel et al. 2014). Mali, with a GDP per capita of $2200 in 2015 (CIA World Factbook), has seen thousands of cases and deaths in the past decades (Figure 1) – and these are just the ones recorded and reported to the World Health Organisation (WHO). According to Talavera and Perez (2009), nearly all low income countries experience cholera outbreaks, whereas the proportion of the high income countries group was 30 times lower (see Figure 2). In these countries, the high rates of poverty indicate a lack of financial capacity, both by the state and by individuals, to provide safe water, waste management infrastructure and other sanitary resources, which are the main causes of easy spread of the disease.These features in fact act as preventative measures against cholera. The authors found that the variable that contributes most to the sudden incidences of cholera is the proportion of households without tap water; other factors that correlated positively with cholera were low household incomes and lack of sewerage systems. In Mali, 3.7 million people do not have access to safe water (Water Aid 2016). 

Fig.1 Officially notified cases & deaths to WHO 1970-2008. Source:WHO

Widespread poverty means that cholera in some countries is often fatal, a much more severe and dramatic result than those in high income countries. Cholera mortality, which is non-existent in the latter group, is 2.3% in low income countries (Talavera and Perez 2009). In Mali, for example, during the outbreak in 2005, 158 cases were reported from 20^th June to 24^th July, including 20 deaths, which signifies a case fatality rate of 13% (WHO 2005). GDP per capita here is also clearly linked in the sense that patients would be able to afford (better) medication or education that would have improved their health literacy.

Fig. 2 Percentage of countries reporting indigenous cholera cases in each group (income per habitant). Source: Talavera and Perez 2009

So far I have practically assumed that it is down to individuals to implement measures to control the prevalence of cholera. Yet, the state has a role to play when it comes to such an important matter of public health; one cannot simply expect individuals to have access to the credit needed to pay for large water or sewerage infrastructure projects. The Malian government spends under 7% of its GDP on health, and GDP is just $36 billion (CIA World Factbook). To give this some perspective: the UK spends the equivalent of 325% of Mali’s total GDP on the NHS (King’s Fund 2016). There are 8 doctors per 100,000 people. This demonstrates that medical attention is very difficult to access, particularly in rural areas, and simple cholera treatments like oral rehydration solutions (ORS), which prevent serious dehydration and electrolyte imbalances in the body, are not distributed quickly to those who need it.

In some of the worst cases, much of the governance and policies on cholera control are acted upon by international bodies and non-governmental organisations (NGOs) instead of the state. The WHO, UNICEF, Doctors Without Borders and other NGOs have extensive operations in Mali, particularly in the more neglected northern regions. In the Gao region, Doctors Without Borders staff work in health centres in rural areas to arrange medical referrals, and support hospitals with outpatients, maternal health and surgery. In 2012, to curb yet another cholera outbreak, over 70 tonnes of relief supplies were flown to Mali, including water purification supplies for over 28,000 people, emergency medical kits for 25,000 people and ORS to help 2 million people. This list consists of just UNICEF and AmeriCare’s contribution (InterAction 2012).

Another obstacle that makes governance and cholera control more challenging is its prevalence in neighbouring countries. Lack of sanitation in adjacent states can mean spread of cholera through contaminated surface water that flows downstream in trans-boundary rivers, as well as via movement of people or trade. In Ghana, another West African country, cases of cholera incidence rates are highest along the coast (where most trade with neighbouring countries arrives) and in the north near the border with Burkina Faso (which also borders Mali). UNICEF recommends ‘strengthening early detection’, ‘coordination mechanisms across the sectors and borders’ and ‘building capacity on outbreak management’ (UNICEF 2016). This means that cooperation between states – e.g. disclosing information about outbreaks and their geographical distribution immediately – and collaboration on preventative measures is needed to effectively control cholera. The management of cholera outbreaks in reality is not confined to national boundaries and must be an international effort.

For Mali, the prospects of tackling cholera look grim; long term solutions seem difficult given the current financial constraints of the government and violent conflicts in parts of the country. With average adult literacy below 40%, achieving widespread health literacy and awareness of hygienic practices that will reduce the severity of cholera incidents is extremely challenging (CIA World Factbook). Large infrastructure projects to provide clean water and dispose of waste are costly, while security issues and high poverty rates (translating to low ability to pay) act as deterrents for the private sector to enter the water and sanitation industry. It may not be the case that cholera is a disease of the poor, but rather a disease of poor governance. 

Perceptions of sanitation

Sanitation has for hundreds of years been perceived as something very personal and unspeakable. It is clear that topics such as human excreta or toilet habits are, even today, uncomfortable for the majority of the world to discuss. This silence around sanitation is problematic when it comes to carrying out research, educating communities and implementing large scale policies. In this post, I will briefly explore some colonial perceptions of sanitation, and current views and interventions.

In Western Europe, images of hygiene, cleanliness and beauty increased during the 19^th century.  Hygienic practices were seen as socially progressive, the essence or “primary art of civilisation” (Burke 1996: 32). According to Ramanna (2004:205), the self-assumed duty to ‘civilise’ and ‘sanitise’ was primarily founded on the perception of superiority of western medicine and ideas of sanitation. Much colonial discourse demonstrated an inextricable relationship between disease, sanitation and racist perceptions (de Barros 2003: 68). During the 20th century, powerful images and imaginaries portrayed Africans as dirty and diseased. Poor sanitary conditions were seen as contributing to high death tolls and as being a major threat to the health of European settlers, something which they very much feared (see Frenkel and Western 1988). Such sentiments were unique in 'physicality', influencing whites to act with revulsion towards the African population. Soap was essentially the poster child for hygiene in 19^th century colonial times. It was not used in interior southern Africa but was used in European settlements. Instead, in Zimbabwe, for example, ruredzo (a ground vine with powdered leaves) and chitupatupa (root plant pounded into soap-like cake) plants were used for washing by the 'natives' (Burke 1996: 24). Burke gives examples of records and diaries kept by travellers and settlers in Zimbabwe during the colonial era. These accounts associate Africans with words such as ‘unwashed’, ‘smelly’ and ‘nasty microbes’, indicating the strong perceptions of dirtiness and inferiority colonial subjects experienced.

Taboos surrounding sanitation vary significantly across space and time. In some places or communities the subject is practically taboo and often associated with the poor or low classes. In Ghana, cultural attitudes towards faeces in the Akan community demonstrate severe contradictions: getting rid of dirt from the body is important, but avoiding dirt is also vital. This results in the Akan people having ‘extremely inefficient systems of dealing with faeces’. Their unhygienic practices vary from using dirty crowded and overflowing toilets, to defecating in the open or plastic bags that they throw in a bush or out with their household rubbish (Jewitt 2011). In recent years, politicians and investors have turned their eyes towards the sector of sanitation; the year 2008 was declared by the UN as the International Year of Sanitation to highlight the fact that one third of the world’s population lack access to ‘improved sanitation'. For instance, Joshi et al. (2016) discuss the School Led Total Sanitation (SLTS) programme in Ghana, a project that consisted of teaching children in schools the risks of open defecation and the advantages of hygienic practices (e.g. hand washing). These children would not only change their own sanitary behaviours but also influence their wider community, teaching their families, or acting as watchdogs and confronting open defecators. However, the effectiveness of the SLTS is hindered by the unevenness in access and quality of clean toilets and hand-washing facilities. Flush systems are not likely to be inexpensive or sustainable in Ghana and many countries of the global South, with investments in these totalling US$30billion and access to clean water posing a major problem for progress in the area (Jewitt 2011). Ultimately, perceptions of sanitation can only do so much to improve conditions.

Still, taboos and negative perceptions of sanitation-related activities have made it extremely difficult to learn about and tackle these issues. It was not only the colonial rulers that saw cleanliness and purity in sanitation, with hygienic practices (e.g. hand washing, flush latrines) considered a symbol of modernity as part of their “civilising mission”, but it is also currently the case in other places (see the case of the Akan people, Ghana). As Black and Fawcett (2008: 10) state, ‘today’s sanitary crisis requires that we dismantle the last great taboo, and learn to talk about ... shit’. However, perceptions and knowledge of better sanitation practices alone are clearly not sufficient to improve sanitation if resources simply are not provided.

Colonial sanitation infrastructure: issues then and now

The connection between development and colonialism is surrounded by huge controversy; there is a split opinion on whether colonialism benefitted or worsened life in Africa. The European colonisers built a significant amount of sanitation infrastructure in Africa; could this be the reason why there are spatial disparities in sanitation conditions around the continent today?

The construction of public infrastructure during colonial times comprises a ‘strong predictor’ of development in Africa (Njoh 2013). Colonial rulers endeavoured to make life for the Europeans stationed in their respective colonies more comfortable and similar to their environment in Europe, which meant investing and developing ‘modern’ water and sanitation infrastructure. This required not only financial resources, but also significant lengths of time to complete, and therefore were developed only in territories planned for permanent settlement. Countries that have had a longer history of colonial occupation have ‘inherited more pieces of modern infrastructure’ according to Njoh and Akiwumi (2011: 459). Despite the debatable benefits that colonial rule brought to Africa in terms of sanitation infrastructure, there have been countless severe problems, including equity issues and their suitability for conditions of the 21^st century, which I will focus on in this blog entry. 

Post-colonialist scholars such as Rodney (1982) slam European colonialism for Africa’s underdevelopment, discrediting any infrastructure that may have been developed by the colonisers.  Firstly, the objective of building such infrastructure was not necessarily to benefit the lives of the African population, but to protect the health and well-being of colonial officials, troops and civil servants based in colonies. An important element of this mission towards better sanitation was the segregation from the ‘natives’ to avoid contagion of diseases perceived to be carried by them. This was achieved through the physical separation of races, notably by forming residential areas solely for Europeans. A perfect case to illustrate this is the creation of Hill Station in Freetown, Sierra Leone, in 1904. The British Colonial Office used the rationale of needing to protect European residents from tropical diseases (notably malaria and yellow fever) to justify the creation of the enclave on a plateau about 240m above Freetown. The bungalows, equipped with private latrines, were designed around health and comfort, yet nothing was done to improve the health and sanitation of the ‘native’ population (Frenkel and Western 1988). Other similar situations occurred in other countries too. In Lagos, Governor Egerton evicted hundreds of locals from an area of land in the city in order to construct an enclave exclusively for Europeans (Njoh and Akiwumi 2011). These highlight the hugely inequitable nature of sanitation projects in African countries under colonial rule.

Bungalows at Hill Station, 1904-05. Source: Royal Commonwealth Society Library

The manner in which colonial infrastructure was implemented has angered many. Walter Rodney (1982) in How Europe Underdeveloped Africa writes that funds for such projects came from the African continent’s natural riches and labour inputs. The land on which the infrastructure was built was also expropriated from African peoples. Forced labour continued into the middle of the 20^th century under colonial rule. For instance, in Kenya the British used such labour to develop the Mombasa water project from 1911-17, while in the 1930s the French conscripted Africans to work on the scheme to irrigate the Sahara (Njoh and Akiwumi 2011). This again demonstrates a history of injustice when comes to the provision of water and sanitation infrastructure in Africa.

Nowadays, regardless of colonial rule, the implementation of infrastructure, water and sanitation is one of the biggest challenges that Africa faces. In many cities in sub-Saharan Africa, clean drinking water and safe sewage removal are largely unavailable to a large proportion of the population, with open defecation and inadequate disposal of waste being common practices. In a recent report published by WaterAid (2016), South Sudan made the top of the list of the world’s worst countries for urban sanitation, with the greatest percentage (84%) living ‘without safe toilets’. The country was also found to be the worst with respect to the percentage of urban dwellers who defecate in the open, at almost 50%. Similarly, in Khartoum, the capital of the neighbouring country Sudan, there are no public toilets and a limited sewerage network serves just 28% of the population (Njoh and Akiwumi 2011). Many households therefore rely on private septic tanks, while those at the very edges of the city dispose of human waste more un-hygienically (e.g. shallow pits that allow faeces to seep into the environment or water system). The septic-tank system was introduced in African countries by colonial authorities in the late 19^th century, involving individual tanks and absorption pits as a form of modern sanitation facilities.

The case of Khartoum is a perfect example of colonial sanitation infrastructure that is insufficient and practically ineffective now. Africa has the most rapid rates of urbanisation and the fastest growing population of any continent. The rudimental colonial infrastructure sometimes implemented up to over a century ago simply does not meet the needs nor the standards of today; it is not adequate to deal with high population density in today's cities. Its outdatedness (and lack of proper maintenance over time) has meant these pose a hazard to the rapidly growing urban populations (Njoh 2013). Moreover, the somewhat better picture we see today of sanitation conditions in both African cities and rural areas is thanks to the work of non-governmental bodies in post-colonial times that have strived to build and improve facilities and access. Today’s infrastructure is not necessarily a legacy of colonisation.

Whilst it has been found that longer colonial rules correlate with more modern sanitation infrastructure, the former may not be the reason why there are spatial discrepancies in sanitation conditions around Africa at present (though it is a factor). From the beginning, there have been many problems related to the nature and means of the construction of such infrastructure that ultimately highlight the inequalities and injustices that stain the colonial era. Furthermore, the construction of these water and sanitation facilities then do not translate directly to benefits now, with much infrastructure unable to provide for large and densely populated urban areas in terms of coverage and quality. Non-governmental entities have since been responsible for bettering sanitation infrastructure on the continent. To conclude this post in the simplest and clearest manner: there was, and still is not, equitable access to sanitation in African cities.

World Toilet Day 2016

Yesterday, Saturday 19^th November, was World Toilet Day. An initiative created by the UN, its purpose is to mark and remember the importance of the ‘oft-neglected global sanitation crisis’ (UN 2016).

The shocking figure of 2.4 billion people living without access to improved sanitation – that is one third of the world’s population – resounded through the media. Over 100,000 people gathered in Mumbai, India, for the Global Citizen Festival which included Jay Z and Coldplay as headliners. I was surprised to find that even the Mirror engaged in publicity for the Day with an article on “genius” funny graffiti in toilets. Scrolling through the tabloid’s pictures of vandalised public loos made me realise how much we take for granted our access to functioning toilets that are free to us in the UK. We take toilets and sanitation for granted much more than we can imagine. We do not expect to pay for such a basic service or encounter faeces outside the sewers – much less see those around us become ill, dropping out of school or work because of inadequate access. Our reality with respect to sanitation is unbelievably different to that of millions of people in other parts of the world.

An unhealthy population makes an unhealthy economy. This year’s theme focuses on ‘toilets and jobs’, highlighting the significant drag that poor sanitation puts on economic development. The UN estimates that in many countries it accounts for a 5% loss in GDP; lack of access to toilets in households and the workplace leads to poor health and increases absenteeism, lowering the overall productivity of the labour force. Improved sanitation is a preventative measure to tackle diseases that burden many low-income countries, and is much cheaper than curing these. To avoid the $260 billion currently lost and huge number of people who die each year as a result of poor sanitation and unsafe water (UN 2016), greater, better and more equitable investments need to be made (Water Aid 2016).

For more information on World Toilet Day, check out the website: www.worldtoiletday.info

Loo Roll art: depiction of Timbuktu, Mali, by artist Anastassia. Source: http://www.wateraid.org/uk/news/news/the-worlds-cities-reimagined-in-toilet-roll

Failure of Water Stress Index as a sanitation indicator

In the previous post I outlined the basis of the Water Stress Index and how it can provide an idea of sanitation levels around the world. However, as I said, there are many components that the Index fails to take into account: spatial and temporal variations, quality and access to water, all of which hugely affect sanitation.

Lack of access to water is not necessarily a consequence of a national shortage; in fact, very often significant numbers face inadequate access to clean water despite living in a country that is not water stressed. This is because of economic and physical barriers affecting availability, which vary from place to place. Affordability and infrastructure play a major role, and differences are especially marked between urban and rural areas. For instance, in sub-Saharan Africa only 5% of the rural population has a piped water supply in their homes, in contrast to 35% of urban residents (UNEP 2012). The most important factor that affects urban water usage in East Africa is whether households have access to a functioning piped system. During the 1960s, a person in a piped household consumed eight times as many litres as someone in an unpiped household. In 1997, the latter walked on average about 300m to unprotected sources to obtain water, increasing the risks of poor hygiene and water-borne diseases (Thompson et al. 2000). This demonstrates that although an area may physically have sufficient water (especially when considering water storage and groundwater, not accounted for in the Index calculation), it is not inexpensively, easily and safely available to all. It is access to and quality of water that define sanitation.

Water quantity in a country changes over the course of the year; seasonal differences are not taken into account by the Water Stress Index. As an annual national average, the Index does not take into account that at some times of year there are great quantities of water present, whilst at others there are severe shortages. Rainfall and river flow (especially the upper course) can have strong seasonality in sub-Saharan Africa and is more and more variable between years as a consequence of global climate change. In Namibia, though renewable water resources are plenty (at 45.5km3 per year, or an average of 26,300m3 per year), river flow is extremely seasonal (Taylor 2004). In the month of February rainfall is around 66mm, but in July it is roughly 0.6mm (World Bank – see graph). The changes in water availability force individuals to ‘draw water from a mix of sources through the year’. This is not investigated at all by the Water stress index, suggesting that it cannot represent the ‘spatial and temporal variability in the supply and demand of water’ (Taylor 2004: 14).

Average monthly rainfall for Namibia 1960-1990. Source: World Bank 

A question that must be addressed is: what do we actually mean by ‘water scarcity’? According to Frank Rijsberman (2006: 6), it is when many people in an area are ‘water insecure’ (do not have access to safe, affordable water to meet drinking, washing and livelihood needs) for a ‘significant period of time’. In truth, there is actually no widely accepted definition, since it must be considered very much on a case-by-case basis. What can be deemed “scarcity” depends on how needs are defined, the potential proportion of the resource that could be made available, and temporal and spatial scales. A vital element of good sanitation is full and constant access and use of safe water sources. Nevertheless, in some of the most water scarce countries in North Africa, sanitation levels are high. This is because of other factors also affect sanitation, such as the prevention of food contamination and access to sewage infrastructure or flush toilets. In 2004, Morocco had a coverage of improved drinking water resources of 56% in rural areas, but the improved sanitation rate in these same areas was almost 75% (UNICEF 2006). It is extremely questionable whether there is truly a relationship between water stress and low levels of sanitation.

A measure as one-dimensional as Falkenmark’s Water Stress Index does not capture the essence of water scarcity, let alone what this means for sanitation. To use the Index as a main indicator for sanitation would be to say that sanitation is principally affected by water quantity in a country, without looking at other factors that determine sanitation: affordability, quality, infrastructure for water provision, investments in sanitation facilities, health literacy… The Water Stress Index does not illustrate access to clean water, nor how this varies over time and space, and therefore fails to indicate how sanitation and water truly correlate.

Water & Sanitation: to what extent are they linked?

One of the ways in which the water crisis in Africa has been studied is by looking at where and to what extent water shortages occur. In 1989, Malin Falkenmark published a paper using her very widely used Water Stress Index to emphasise the ‘massive water scarcity’ threatening Africa.  Yet, how does this worrisome issue actually translate to outcomes in sanitation and health? In this blog entry I will look at the foundations of this water index and how it may help assess sanitation-related issues. The backdrop of Falkenmark’s paper is the recurrent and serious droughts in Africa during the latter half of the twentieth century that caused many to lack access to water, especially clean safe water.

World Map showing levels of water availability. Source: FAO

To assess water scarcity, information about the gross water available in the country is needed, calculated from measurements of number of flow units as river discharge (equal to 1 million metres cubed per year). This water quantity is compared to the number of people dependent on the water (for food, drink, washing, manufacturing etc) to analyse the degree of water stress. The Water Stress Index states that water scarcity occurs when an area has fewer than 1000m3 of water per person per year. The simple index is useful because it takes into account demography and number of people dependent on a restricted quantity of water in a country each year. This is important to investigate because a higher people-to-water ratio and population density not only means that there is less water to go around (and that, in reality, inequalities of distribution will arise), but also that quality of water used is often compromised. Falkenmark's diagram below illustrates different levels of water scarcity, with each cube representing one flow unit and each dot representing 100 people reliant on that unit. Typical usage in industrialised countries is between 100 and 500 people per flow unit; in temperate zones, beyond 500 people per unit would mean a country is considered water stressed.

In light of this, it is ‘deeply worrying’ that many African countries are seeing numbers higher than these - and which are still rising (Falkenmark 1989: 115). In the period 2005-10, the African continent saw the highest average population growth rate at 2.3% per year (UNFPA 2009). Judging by the Index and the author’s predictions, most of East and some South African countries would be water stressed by 2000 and, 25 years later, some of them would face scarcity. In 1982, Malawi had a population of about 6.6 million and was estimated to increase to over 11.6 million by the year 2000, with level of competition for each flow unit going from 730 to 1300 people (Falkenmark1989:113).  Demand is clearly out-stripping supply – population growth is high and there is a need for greater water quantity to expand agriculture and increase yields.

Water shortage mainly influences sanitation by its effects on quality of drinking water. Africa as a whole did not meet the Millennium Development Goal (MDG) target of halving the proportion of the population without access to safe drinking water and basic sanitation. According to the Africa Water Atlas, water stress or scarcity means that both quantity and quality of water is insufficient to be able to ‘provide safe drinking water, food and hygiene’ (UNEP 2012: 16). Since water is an absolute necessity to live, in areas of high rainfall variability during times of shortage, people may resort to using lower standards of water. For example, if water from an improved water source (e.g. a well) fails or is not enough, households may turn to water collection from unprotected sources, such as rivers or streams. Yet even if they still only used improved water sources, the microbiological quality of the water in these deteriorates when rainfall decline significantly. A major consequence of this is the increased incidence of water-borne diseases, such as cholera and typhoid. The 1991-92 drought in southern Africa left many, especially in rural areas, without access to water. In Malawi, this number reached around 3 million, and the use of unprotected sources which were open to contamination ‘led to outbreaks of diarrhoea, cholera and dysentery’ (Calow etal. 2010: 248). At the end of 1992, the country faced a large cholera outbreak, with over 25,000 cases and 524 deaths reported (WHO 2010). 

This case is a clear example of how a country with high water stress can have low levels of sanitation and poor public health. When it comes to public health, the Water Stress Index may be helpful in painting a general picture of what we might expect to see in a country on average. Nevertheless, like all averages, the Index hides discrepancies and has limitations. I will explore these later on, particularly its failure to show quality, access, and spatial and temporal distributions that immensely affect sanitation.

Introduction: the importance of water

Water is a necessity. It is no wonder that the greatest civilisations on Earth have been based around or near water, which would not only provide drink and irrigation to maintain a population, but also transportation links. Today, water continues to form a central element of countless human activities, such as irrigation, and industrial and domestic uses. Domestic water usage includes drinking, food preparation, bathing and washing, and it is here that the relationship between water and sanitation becomes most obvious.

Sanitation relates to the provision of clean water, sewage infrastructure and prevention of disease. About 884 million people lack access to safe drinking water and over 2.6 billion do not have access to basic sanitation. The United Nations 64^th General Assembly adopted safe drinking water and sanitation as a right, since it is ‘indispensable for leading a life in human dignity’. The Assembly recognises that equitable access to safe water and sanitation is a necessary prerequisite for achieving other human rights (UN 2010: 2). Quality, access and distribution are essential factors that must be taken into account when analysing the issues of water “shortages”; global water quantity in itself is not the issue at stake. In the 21^st century, water shortages will connect some of the most pressing problems on our planet, from poverty reduction and public health to energy production and ecosystem conservation (Vorosmarty et al. 2005).

In this blog, I will discuss multiple issues and literature within the broad topic of water and sanitation, looking specifically at the African continent. According to Tucker et al. (2014), not enough is known about water access, availability and sources, or how these vary over time and space for many households in Africa. Yet, these matters are key to answering health and livelihood questions, not just in Africa but worldwide.