Why has water treatment been historically neglected by governments and donors given the significant short- and long-term benefits of clean water provision and use? How can we design interventions to ensure households have access to and use clean water?
This podcast is the first of a series in collaboration with J-PAL, covering their policy insights which highlight evidence on important topics in development. Read “Pairing insights from engineering, public health, and behavioral science to improve access to and use of clean water” on J-PAL's website.
The sixth goal of the UN’s Sustainable Development Goals is to ‘ensure the availability and sustainable management of water and sanitation for all.’ In 2022, 2.2 billion people lacked safely managed drinking water (UN 2022). In this episode of VoxDevTalks, Tim Phillips speaks to Pascaline Dupas about the pressing need to ensure this goal is reached and the cost-effective interventions that are available to policymakers.
‘Water treatment has just been neglected, not just by governments but also by donors. The consequence of this is that in rural areas of low- and middle-income countries, water delivered from tanks or standpipes is typically untreated.’
The human cost of unsafe drinking water
Unsafe drinking water has a significant human cost, as contaminants and germs may enter the water supply causing disease and diarrhoea. Among the weak and vulnerable, as well as children, diarrhoea can cause death. A lack of access to clean water has knock-on effects for children’s educational attendance and attainment. Children may be forced to remain at home due to illness, to look after other ill family members or due to limited resources that have already been spent on medication. Unclean water therefore has serious long-term consequences.
Pascaline Dupas comments that we lack experimental evidence on this topic, partly because the issue sits in the intersection between health and education. This means that interventions focusing on how water quality affects educational outcomes fall through the research gap.
Why has clean water been neglected?
‘Unlike vaccinations or bed nets, most households are not able to access free point of use water treatment through the health system.’
If ensuring households have access to and use clean water has the potential to drive significant short- and long-term benefits, why has there been relatively little focus on this development goal, relative to other interventions like bed nets or vaccinations? Pascaline notes that governments may be slow to mobilise as the problem lies in the remit of both water and health departments.
Water is commonly treated using chlorine. Chlorine offers a two-pronged solution by providing disinfection and residual protection – preventing recontamination for approximately up to two days following its initial use. Furthermore, as chlorine is easy to use and very cheap it offers a highly cost-effective solution. Pascaline Dupas points to Kremer et al. (2023)’s recent meta-analysis on water treatment and child mortality – reporting that treating water with chlorine averts 1 in 4 child deaths.
Barriers to boosting the use of chlorine?
The availability of chlorine does not ensure it will be used. A range of research has looked at how chlorine is provided and its usage in different contexts. For example, although chlorine dispensers may be provided next to where people get their water, and be free at the point of use, there still may not be 100% take-up. Dupas highlights several behavioural explanations:
Preferences over water taste.
Fears that children might put too much chlorine in the water when sent to collect it.
Individuals simply forgetting (in high disease burden areas individuals often must remember a long list of preventative measures).
Even with reduced take-up, interventions providing chlorine are still impactful, especially given that non-use does not have a cost.
In many rural settings, households may not visit a communal water spot to collect water. Or the risk of contamination between source and consumption is high (e.g. dirty containers). This presents challenges in how to ensure chlorination of water at the point of consumption.
How can policy increase the use of chlorine?
Pascaline Dupas shares the potential advantages of a voucher programme where households are given vouchers that can be redeemed to collect a bottle of purifier, given it may have a relatively limited shelf-life (i.e. not last for five years). Furthermore, such a programme gives agency to individuals and households - particularly important given the historical context in sub-Saharan Africa and colonial medical campaigns. New programmes and interventions must be careful not to generate further mistrust.
The importance of context for clean water interventions
‘This is coming to the forefront...people are paying attention. This could be because the other sources of mortality have gone down...but with climate change coming into the picture, we do not have a choice, it just has to happen.’
Water treatment has been historically neglected, and climate change is exacerbating the challenge and poses a growing threat to water safety and health. Pascaline Dupas finishes the podcast by describing how the appropriateness of interventions critically depends on the context.
In rural settings where people visit one communal space to collect their water, implementing a dispenser right by this source or space is a powerful tool. In rural settings that lack access to a common water source, Pascaline argues that we should incorporate safe water treatment into maternal and child health standards alongside the norms that already exist (e.g. free bed nets, vaccinations, folic acid). Importantly all three of these strategies can be and should be pursued simultaneously.
In urban areas, building pipe infrastructure and ensuring full chlorination can lead to 100% take-up of clean and safe water. Pascaline comments that such programmes should be forward-looking, responding to how rural-urban migration will occur as a country develops.
References
United Nations (2022), “The Sustainable Development Goals Report 2022", https://sdgs.un.org/goals/goal6.
Kremer, M, S P Luby, R Maertens, B Tan, and W Więcek (2023), “Water Treatment and Child Mortality: A Meta-Analysis and Cost-effectiveness Analysis,” National Bureau of Economic Research Working Paper Series, No 30835. https://doi.org/10.3386/w30835. https://www.nber.org/system/files/working_papers/w30835/w30835.pdf