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The Progress of Nations 1997

The day will come  when nations will be judged  not by their
military or economic strength,  nor by the splendour of
their capital  cities and public buildings,  but by the
well-being of their peoples:  by their levels of health,
nutrition and education; by their opportunities to earn a
fair reward for their labours; by their ability to
participate in the decisions that affect their lives; by the
respect that is shown for their civil and political
liberties;  by the provision that is made for those who are
vulnerable and disadvantaged;  and by the protection that is
afforded to the  growing minds and bodies of their children.
The Progress of Nations, published annually  by the United
Nations Childrens Fund, is  a contribution towards that day.

                           * * * *
1. Foreword by Kofi A. Anan, Secretary-General United Nations

2. Charting progress for children:  Introduction by Carol Bellamy,
   UNICEF Executive Director

3. Water and Sanitation
   Commentary - The Sanitation gap: Development's deadly menace
   3.1 Sanitation League Table
   3.2 Water/sanitation gap widening
   3.3 79% of all guinea worm cases occurring in Sudan
   3.4 Grading school sanitation: Few high marks
   3.5 Making ORT a household habit

4. Nutrition 
   Commentary - Putting babies before business
   4.1 Nutrition League Table
   4.2 Exclusive breastfeeding: A chance for survival
   4.3 One in five babies too small at birth
   4.4 Stunting: A scar and a wound
   4.5 Slow starters catching up in salt iodization

5. Health
   Commentary - Fighting AIDS together
   5.1 Gauging AIDS' terrible toll
   5.2 Health League Table
   5.3 Pneumonia: K=Little progress on a big killer
   5.4 52 countries falling short on immunization goal for DPT
   5.5 Neonatal deaths: 5 million each year
   5.6 Malaria's death toll: A child every 30 seconds

6. Education
   Commentary - Quality education: One answer for many
   6.1 Doing more with less
   6.2 Girls' education: Commitment or neglect?
   6.3 Maths and science: Some developing countries score high
   6.4 Do teachers make the grade?
   6.5 Rural kids short-changed

7. Women
   Commentary - The intolerable status quo: Violence against
                women and girls
   7.1 Women's League Table
   7.2 Outlawing violence against women: A first step
   7.3 Risk of death in childbirth can be as high as 1 in 7
   7.4 A bill of rights for women, but with reservations
   7.5 Help wanted: Skilled birth attendants

8. Special Protections
   Commentary - No age of innocence: Justice for children
   8.1 Old enough to be a criminal?
   8.2 Over 7 million children are refugees
   8.3 Hidden killers
   8.4 The cost of war: Billions for development diverted to

9. Industrialized Countries
   Commentary - Healthy cities, healthy children
   9.1 Youth unemployment rate highest in Spain, lowest in Austria
       and Switzerland
   9.2 Teens at risk: Drinking and bullying
   9.3 Sharing the wealth? Aid at lowest level in 45 years

10 Statistical Tables
    Social Indicators for Less Populous Countries

   Statistical Profiles for 149 countries
    The age of the data
    Statistical tables are available at the UNICEF website
                                 * * * *

Water and Sanitation

The sanitation gap: Development's deadly menace

Akhtar Hameed Khan*

Adequate sanitation is the foundation of development - but a
decent toilet or latrine is an unknown luxury to half the
people on earth. The percentage of those with access to
hygienic sanitation facilities has declined slightly over the
1990s, as construction has fallen behind population growth.
The main result can be summed up in one deadly word:
diarrhoea. It kills 2.2 million children a year and
consumes precious funds in health care costs, preventing
families and nations from climbing the ladder of development.

On the brink of the 21st century, half the worlds people are
enduring a medieval level of sanitation. Almost 3 billion
individuals do not have access to a decent toilet, and many of
them are forced to defecate on the bare ground or queue up to
pay for the use of a filthy latrine. This unconscionable
degradation continues despite a fundamental truth: Access to
safe water and adequate sanitation is the foundation of
development. For when you have a medieval level of sanitation,
you have a medieval level of disease, and no country can
advance without a healthy population.

In many developing countries, the plagues of old are
revisiting, taking their strength from teeming urban squatter
settlements and shanty towns, from streets and waterways awash
in excrement and garbage. The recent cholera epidemic in Peru
and outbreaks of bubonic and pneumonic plague in India are but
three examples.

 Plagues make headlines, but in human terms, the price of
neglecting sanitation is both more prosaic and more profound.
It can be summed up in one word: diarrhoea. It thrives in the
absence of hygienic conditions and is tied with pneumonia as
the biggest child-killer on earth, taking the lives of 2.2
million children each year. Diarrhoeal episodes leave millions
more children underweight, mentally and physically stunted,
easy prey for deadly diseases and so drained of energy that
they are ill equipped for the primary task of childhood:

How can any nation hope to advance if its people - its main
resource - are so diminished from the beginning of their
lives? How can leaders ignore the fact that their citizens are
diminished not by an implacable enemy or an incurable disease
but by something as mundane and easily preventable as
diarrhoea? And how can a civilized world tolerate the status
quo when it could be fixed with an investment equal to 1 per
cent of yearly world military expenditures?

To deny people basic sanitation is not just inhumane - it also
kicks the first step out from a country's ladder of
development. History has taught that a safe means to dispose
of bodily wastes is not a luxury that can wait for better
economic times but a key element in creating them.   In the
late 19th century, life expectancy in the industrial city of
Liverpool (UK) was about 35, lower than in any developing
country today. A key reason for the abbreviation of those
lives was the lack of safe water and sanitation, and providing
these services was a decisive turning point in reducing infant
death rates. Epidemiologists studying historical records
realize that there has been a tendency to underestimate the
impact of water and sanitation on peoples health.

Considering the state of the infrastructure in the developing
world, it is no surprise that diarrhoea still holds sway in
the 1990s. As population has increased, so too has the number
of people lacking access to sanitation. Just since 1990, an
additional 300 million individuals are making do without
decent sanitation, an ominous indication that the world
community is failing in its efforts to provide services where
they are most needed.

Many large cities are still without central sewage systems
for their millions of residents. In New Delhi, for example,
less than 40 per cent of households are connected to sewers.
In Ibadan (Nigeria), a city of more than 1 million people,
less than 1 per cent of households have sewer connections.

Though latrines are available to some city dwellers in
developing countries, more than a third lack adequate
sanitation. In such conditions, many of these residents,
particularly the very poor, are forced to defecate in open
spaces or to dispose of their waste in nearby gullies and
streams. Have we become so inured to the disparity between
rich and poor that we fail to notice the dreadful irony of
people defecating in vacant lots in the shadows of high-tech
office buildings?

Such de facto latrines become breeding grounds for bacteria,
ripe to contaminate the children who play in these open spaces
and the families who wash and fetch drinking water from
streams near them. These sites also encourage the growth of
virulent strains of typhoid, typhus and dysentery and
infestation by disease-ridden carriers such as insects and
vermin. The water that collects in urban detritus, such as
discarded vehicle tyres, nurtures mosquitoes, which spread
deadly malaria, yellow fever and dengue fever - the latter a
relatively modern disease. Rats, coexisting with people in
this fragile environment, thrive on the mountains of waste
that accumulate around squatter settlements and are the
principal carriers of bubonic and pneumonic plague.

Since 1990, an additional 300 million people are making do
without decent sanitation. 
Declining access

Even where sanitation facilities are available, they are often
woefully inadequate. In Kampala in the 1980s, for example, as
many as 40 people were using each city latrine. Given the
volume of use, inevitably such public latrines are filthy,
attracting swarms of disease-bearing insects and frequently
overflowing, particularly during storms.

I try to take comfort from what good news there is, and the
success in expanding access to safe water stands in stark
contrast to the shameful failure in sanitation. By 1994, three
quarters of the worlds people had access to safe water, up
from 61 per cent just four years earlier. This is crucial, as
safe water is a key part of the sanitation equation. But
during the same period, the proportion of people who had a
sanitary means of excreta disposal declined from 36 to 34 per

This decline should set off an alarm. It tells me that the
world community is far off track and, just three years before
the millennium, has no hope of achieving its goal of providing
adequate sanitation to everyone on earth by the year 2000.
Access rates are low partly because some countries have
tightened their definitions of what constitutes adequate
sanitation. While it is good news that standards are being
raised, the fact that the minimum standard is now a notch
higher does not excuse governments for their failure to
provide such a fundamental human necessity to all their people
at the end of the 20th century.

Hopes for increasing access to sanitation began to erode in the
1980s, years that many have called the lost decade of development,
when many poor countries found their budgets stretched thin from
making payments on enormous international loans.

In Africa, for example, 22 per cent of the total value of
exports in 1990 went to debt repayment. In addition, many
economies underwent the shock therapy of structural adjustment
programmes called for by the Bretton Woods institutions and
donor nations. Public expenditures, and often basic services,
were cut.

The numbers show what happened. In Nairobi, capital
expenditures for water and sewerage fell by a factor of 10,
from $27.78 per capita in 1981 to $2.47 in 1987, and per
capita maintenance expenditures declined by two thirds. In
Zimbabwe, close to one quarter of village water pumps fell
into disrepair when the Government slashed maintenance funds
from $12 per water site in 1988 to $5.30 in 1990. The
incidence of cholera and dysentery surged in Kinshasa for
several months in 1995 when funds for water chlorination ran

Growing cities

In terms of simple numbers, the need for sanitation is
greatest in rural areas. United Nations statistics show that
only 18 per cent of rural residents in developing countries
have access, compared with 63 per cent in urban communities.
However, the urban figures in some cases do not include
squatter communities, home to 30 to 60 per cent of a city's
population in many developing countries.

Whatever the numbers, though, lack of sanitation is far more
worrisome in urban areas than in rural regions, mainly because
of population density. Simply put, the more people in a given
space, the greater the potential for contact with human waste.

And the world is on a relentless path towards increasing
urbanization. Almost half the people on earth will live in
urban areas by the year 2000, growing to 61 per cent by 2025.
The population of my country, Pakistan, is about 70 per cent
rural now, but within 30 years that will shrink to less than
45 per cent.

Public authorities are not helping to find homes for urban
migrants, so they take matters into their own hands: After the
rich build their homes and offices and shops, the enterprising
poor improvise their own communities on what is left over the
most undesirable and marginal land, adjacent to garbage dumps,
on hillsides, in gullies and ravines, on soil that is either
too rocky or too sandy or lies in a flood plain.

These crowded informal settlements remain largely unserved by
public utilities, mostly because of governments unwillingness
to acknowledge that they even exist. It is no surprise, then,
that these communities are places of poor hygiene and rampant
disease. In some cases, the urban poor suffer infant death
rates 1.5 to 3 times higher than people who are better off,
partly due to lack of safe water and sanitation.

The price of poverty

The poor also pay a high tax for their poverty, and
entrepreneurs always seem to find a creative way to extort it
- such as by charging exorbitant prices for use of public

In Kumasi (Ghana), for example, where the poorest pay for each
visit to the neighbourhood latrine, they spend more on
sanitation services each year than do residents with toilet
facilities in their homes. Residents of some impoverished
communities spend 20 per cent or more of their income for
small quantities of water of questionable purity, while their
neighbours in wealthier, established neighbourhoods receive
government-subsidized piped water.

And then there is the health tax. In a study in Karachi, we
found that people living in areas without sanitation or
hygiene education spend 6 times more on medical bills than do
people in areas with sanitation and hygiene knowledge.

These are staggering, and unnecessary, expenses. Think what it
would mean for a family if that money were available to spend
on other essentials: healthier food and more of it, school
books and pencils, investment in business.

But such outlays do reveal a critical fact: Poor people are
prepared to pay for access to safe water and hygienic
sanitation. In one Brazilian city, residents were asked how
much they were willing to pay for installation and maintenance
of water and sewage services. The figures they cited were 4
times above the actual cost for water and more than 2 times
for sewage.

Providing sanitation systems is a daunting and expensive task,
but it is not impossible. It requires political will and a
clear-headed understanding of the implications of failing to
act. So far in this decade, governments in Africa, Asia and
Latin America have invested roughly $2.1 billion a year in
water and sanitation services for rural and undeserved urban
areas - and still they fell behind. The cost of achieving
universal coverage would be an additional $4.7 billion a year
(in 1994 dollars) for a decade, or a total of $6.8 billion per

The figure also includes $300 million a year for hygiene
education programmes, which are just as important as latrines,
given that they teach people the importance of such basic
activities as washing their hands after defecating. Operating
and maintaining sanitation systems would add another 5-20 per
cent to the bill.

A bill of $68 billion over 10 years may sound high. But it is
only about 1 per cent of what the world will spend on military
expenditures in this decade. Given the cost to human health of
failing to provide sanitation, it is hard to understand how a
humane society can say no. Given the payback in terms of
development, I cannot think of a more lucrative investment.

The cost would be less if governments mounted an attack on
waste within existing water and sanitation systems. High
costs, low efficiency and unreliabilitythese are the
characteristics of many public utilities in developing
countries. Maintenance does not make for good photo

Water systems are notoriously leaky in developing countries,
where 30 to 60 per cent of the water treated and pumped never
makes it to the consumer at the end of the pipe because of
leaks and illegal tapping. Such losses cost Latin Americans
between $1 billion and $1.5 billion each yearthe amount needed
annually to provide water and sanitation services to all the
regions currently unserved citizens by the year 2000.

Using the right technology for the job is another affordable
way to provide modern sanitationand I am not suggesting
second-rate systems for the poor. Designers and engineers,
wedded to traditional construction methods and often caught in
a tangle of questionable bidding practices, insist on using
large-width piping and installing it deep in the ground. These
are costly procedures appropriate for intensively developed
areas with heavy vehicular traffic. But in communities where
structures are small and most traffic is on foot, narrow pipes
laid just under the surface of lots, fields and footpaths
usually suffice, at a small fraction of the price.

With a very small customer base, most sanitation utilities
remain largely unaccountable to the community at large, and
often they make little effort to go after customers who fail
to pay their bills. Most government sanitation funds end up
subsidizing services to the middle class and the rich in
established neighbourhoods, ignoring those who can least
afford it. This is unjust and, given the price it extracts
from the countrys development, foolish. 

But I do not expect any sudden shifts in public policy. One
thing I have learned during many years of working both inside
and outside government is that the authorities do not act
until forced by the people.

Marginalized communities are invisible to bureaucrats, who
often do not view the poor as part of their constituency.
Unrepresented communities must organize themselves to demand
the attention they deserve. And they will organize, once they
understand what is needed and how to go about it. But they
will need help.

When the people lead

Experience shows how much change can be generated by a little
help. In the Dharavi slum of Bombay, pavement dwellers were
forced to use wretched public toilets, each of which served as
many as 800 people. Working with local and international NGOs,
female construction workers living in the slum were taught how
to build latrines. The project had a dual benefit: They
learned skills that more than doubled their income, and they
got modern latrines. Construction costs were only 40 per cent
of those charged by private contractors. The pavement dwellers
each pay 2 to 5 rupees (less than 15 cents) per month for
cleaning and maintaining the new facilities. The Bombay
Municipal Corporation recently pledged to support construction
of 2,000 latrine blocks, each with five latrines.

The residents of Lemba, a poor neighbourhood of Kinshasa,
endured huge mounds of rotting garbage that blocked sewage
canals and drew armies of ratsuntil they had the idea to hold
a cleanliness contest. Now they cart the waste to a central
dump where it is separated. Glass, plastic and paper are sold;
organic waste is composted, to be sold later as fertilizer.
Revenue from the operation supports community improvement

The city I know best is Karachi. Like many cities in
developing countries, about 40 per cent of Karachis population
lives in squatter communities, called katchi abadis. These are
not decaying slums in the urban centre but dynamic new
neighbourhoods developed on the edge of the city over the past
25 years by enterprising migrants from rural areas. For rich
people living in established neighbourhoods, Karachi has
modern sanitation, with flush latrines in the homes and
underground sewers. But most of the poor living in the katchi
abadis had only bucket latrines and open sewers.

In the 1970s, the municipal government made a major shift in
policy: The authorities accepted the fact that the katchi
abadis were here to stay. This was a key step, because it
enabled people to buy title to their homesites, giving them a
sense of permanency and the incentive to invest in
improvements. The city dug water lines to the katchi abadis,
but they still lacked sewage service. The streets were filled
with excrement and other waste. People, especially children,
paid with their health. This in turn meant that families were
spending an enormous percentage of their income on medical

In 1980, we formed an organization called Orangi Pilot Project
to work with one of these communities. Orangi is home to about
1 million working-class peopleskilled labourers, clerks,
shopkeeperswith family incomes averaging about 1,000 rupees
($30) per month. The residents had formed numerous community
associations that relentlessly pressed their demands with the
authorities, but they were getting nowhere. Sanitation was
their most urgent need, above health care, schools and jobs.
They wanted the government to install a modern sewage system.
This seemed unlikely to happen. Orangi Pilot Project set about
helping them to develop it on their own.

Seventeen years later, virtually every home in Orangi has a
pour-flush toilet connected to an underground sewage line, all
paid for by the residents. Orangi Pilot Project provided
technical advice and plans for a simplified design, which
reduced the cost by almost a factor of 10, but the
organization did not contribute one rupee for construction.
Each family invested about a months income to buy materials
and hire labour. We avoided government contractors, who often
pad costs and include kickbacks for officials.

The city has plans to build a treatment plant, but for now, as
in the rest of Karachi, Orangis sewage lines empty into

From an initial desire for better sanitation, these stalwart 
people have gone on to develop a whole series of services to
improve their lives and futures. They have organized mothers'
classes on disease prevention and hygiene - for which the
women pay - as well as group discussions about family
planning. Now, more than half of Orangi women plan the births
of their children, compared to 7 per cent in other

The children fill the rooms of over 500 private schools.
Parents are willing to pay the extra fees for the private
schools because they are better than the government schools.
There is also a revolving loan fund for small businesses,
which are thriving in every lane of Orangi. It is a community
transformed. The people have been strengthened by their role
in solving their most fundamental problem, and their pride is

The Orangi experience reinforces an essential lesson: Adequate
sanitation is fundamental to improving living standards. In
its absence, diarrhoea and other illnesses prevail, leading to
high death rates and forcing families to spend their scarce
savings on medical care. No matter how hard they work, the
poor are then left with little hope of accumulating the means
to start up the ladder of development. But when this
fundamental problem is solved, especially when the people play
a leading role in solving it, they are strengthened, and the
stage is set for advance.

The experience teaches another lesson as well. Through their
massive collective effort, the people of Orangi pushed aside
the roadblocks the bureaucrats had erected in their path.
However, the roadblocks should not be there in the first
place. It is inhuman to expect the many to endure medieval
sanitation while the few enjoy modern facilities. As
government policy  or lack of policy  it is economically
suicidal. With enough pressure from their citizens as well as
the international community, governments will learn that they
cannot remain indifferent to the most fundamental human needs. 

                           # # # # #

*Akhtar Hameed Khan has been involved in development work for
more than 40 years. Since 1980, he has been Director of the
Orangi Pilot Project in Karachi (Pakistan), which has brought
modern sanitation to a squatter community of 1 million people.
Previously he organized farmers' cooperatives and rural
training centres and served as an adviser to various
development projects in Pakistan. He has been a research
fellow and visiting professor of Michigan State University
(US), Director of the Pakistan Academy of Rural Development
and Principal of Victoria College(Bangladesh).

Sanitation League Table

Access to Sanitation

Sanitation is fundamental to development. Public health
officials have long known that epidemics of communicable
diseases cannot be stopped without safe water and sanitation
and widespread public health measures. But the percentage of
people with access to sanitation has actually fallen in the
developing world since 1990,  as funding has declined and
population has increased.

Sanitation access: Data dilemmas

What type of facility is sanitary? What is convenient
access? Each country has its own definition, or more than
one  often different for urban and rural areas.

The sanitation league table does not provide exact rates of
access to sanitation, nor does it rank countries on this
basis. Rather, the table groups countries in broad
categories by percentage of people with access to sanitation
according to the national definition. These definitions vary
both in type of toilet facility and in its distance from the
home. Because of these differences in definitions and also
in data reporting methods and the quality of data, direct
comparisons of countries achievements are difficult.

Definitions may reflect countries level of economic
development, urbanization and resources available for
sanitation. Rapid urbanization increases population
densities and puts greater demands on sanitation facilities.

Some countries count ordinary pit latrines as adequate
sanitation, while others count only ventilated improved pit
(VIP) latrines and/or flush toilets connected to a septic
tank or a sewerage system. In Uganda, for example, pit
latrines are counted as sanitary, and the latest Demographic
and Health Survey (DHS) shows 80% of households with access.
But if pit latrines are not counted, the level of access
shrinks to a mere 3%. Because of this discrepancy, the table
uses data from Uganda's sanitation surveillance system,
which reported access of 57%.

Differences behind the data must be explained to understand
why, for example, Tanzania, one of the least developed
countries, has a rate of access to adequate sanitation above
75%, while Brazil, far wealthier and more developed, has an
access rate below 50%.

Pit latrines may be adequate for rural communities but may
not be appropriate for urban areas. Therefore, more
urbanized countries, such as Argentina and Brazil, record
only flush toilets as adequate and report lower rates of
access than poorer countries, such as Kenya and Tanzania.

Discrepancies can also arise depending on whether data are
gathered by routine government reporting or by surveys -
both of which were used in preparing the table. The rate of
access to adequate sanitation is usually determined by
dividing the number of sanitation facilities in a community
by the number of inhabitants. Routine reporting may,
however, rely on outdated census data or fail to take into
account squatter communities or public sanitation facilities
that fall into disrepair. It may also not include privately
built latrines.

Household surveys, on the other hand, can provide data on
actual availability of sanitation facilities - rather than
simply on what facilities have been provided - and have the
advantage of providing direct, timely information from the
field. Surveys can therefore point to problems in data
obtained from routine reporting. They are, however, much
more expensive than routine government reporting, may use
different definitions and are subject to sampling errors and

The WHO/UNICEF Joint Monitoring Programme was established in
1990 to help countries strengthen water and sanitation data
collection and evaluation. Generally, countries' definitions
have since become more restrictive and realistic, resulting
in reports of lower rates of access. Just as many countries
need to step up efforts to improve access to sanitation,
greater standardization of definitions is needed to allow
for more accurate global comparisons of progress.

What the table ranks

Percentage of population with access to a sanitary means of
excreta disposal

What the rankings mean

1 75 - 100% Access
2 50 -  74% Access
3 25 -  49% Access
4  0 -  24% Access

The definition of access varies by country and refers to a
means of sanitation either in the dwelling or at a
convenient distance (See  Sanitation access: Data

Note: Comparable sanitation data do not exist for Europe

Kenya                        1
Mauritius                    1
Tanzania                     1
Botswana                     2
Burundi                      2
Cameroon                     2
Central African Rep.         2
Congo                        2
Ghana                        2
Guinea                       2
Mozambique                   2
Nigeria                      2
Rwanda                       2
South Africa                 2
Uganda                       2
Zambia                       2
Zimbabwe                     2
Burkina Faso                 3
Cote d'Ivoire                3
Gambia                       3
Guinea-Bissau                3
Lesotho                      3
Madagascar                   3
Mali                         3
Mauritania                   3
Namibia                      3
Senegal                      3
Togo                         3
Angola                       4
Benin                        4
Chad                         4
Congo, Dem. Rep.             4
Ethiopia                     4
Liberia                      4
Malawi                       4
Niger                        4
Sierra Leone                 4
Somalia                      4
Eritrea                      No data
Gabon                        No data

Algeria                     1
Iran                        1
Jordan                      1
Libya                       1
Oman                        1
Saudi Arabia                1
Tunisia                     1
U. Arab Emirates            1
Iraq                        2
Lebanon                     2
Morocco                     2
Syria                       2
Turkey                      2
Egypt                       3
Sudan                       4
Yemen                       4
Israel                      No data
Kuwait                      No data

Kazakstan                   1
Kyrgyzstan                  1
Turkmenistan                1
Afghanistan                 4
Armenia                     No data
Azerbaijan                  No data
Georgia                     No data
Tajikistan                  No data
Uzbekistan                  No data

Australia                   1
Korea, Rep.                 1
Malaysia                    1
Philippines                 1
Singapore                   1
Thailand                    1
Bhutan                      2
Indonesia                   2
Mongolia                    2
Sri Lanka                   2
Bangladesh                  3
India                       3
Lao Rep.                    3
Myanmar                     3
Pakistan                    3
Cambodia                    4
China                       4
Nepal                       4
Papua New Guinea            4
Viet Nam                    4
Japan                       No data
Korea, Dem.                 No data
New Zealand                 No data
Costa Rica                  1
Dominican Rep.              1
El Salvador                 1
Guatemala                   1
Honduras                    1
Jamaica                     1
Panama                      1
Trinidad/Tobago             1
Argentina                   2
Bolivia                     2
Colombia                    2
Cuba                        2
Ecuador                     2
Mexico                      2
Uruguay                     2
Venezuela                   2
Brazil                      3
Nicaragua                   3
Paraguay                    3
Peru                        3
Haiti                       4
Canada                      No data
Chile                       No data
United States               No data
Sources: WHO, Water Supply and Sanitation Collaborative
Council and UNICEF, Water Supply and Sanitation Sector
Monitoring Report: 1996; other government reports; MICS and

Water and Sanitation
Progress and Disparity

Water/sanitation gap widening

An estimated 2.9 billion people lack access to adequate
sanitation, up from 2.6 billion in 1990. But access to safe
water is improving. Today, almost 800 million more people
can count on safe water supplies than could in 1990. The
number with access increased from 2.5 billion to 3.3

Most governments and communities have placed a higher
priority on safe water, but that in itself is not a panacea
for all ills. Without a stronger commitment to sanitation,
it will be difficult to reduce the incidence of diarrhoea, a
leading child killer, and other diseases that flourish in
unsanitary conditions. Among steps to combat disease and
malnutrition, the Convention on the Rights of the Child
calls on countries to ensure provision of clean drinking
water and sanitation.

The table shows the percentage of people with access to safe
drinking water and sanitation in the 15 developing countries
with the largest under-5 populations, along with the
percentage point gap between the two. In Bangladesh, China,
Egypt and India, the gap is greater than 40 percentage
points, with Egypt having the widest - 54 percentage points.
Only in Nigeria is the gap reversed, with 58% of the
population having access to sanitation and 51% with access
to safe drinking water. 

A small gap is not necessarily a sign of success. Ethiopia,
for example, has a small gap, but also the lowest combined
access rate among these countries: 25% for safe water and
19% for sanitation.

        Water and sanitation: Coverage disparities     

        Coverage gaps in developing countries with 
            the highest under-5 population
                % access      % access 
                to safe         to          % pt.
                  water     sanitation      gap
Egypt               83          29          54      
India               81          29          52      
Bangladesh          97          48          49      
China               67          24          43      
Brazil              72          44          28      
Pakistan            74          47          27      
Congo, D. Rep.      42          18          24      
Viet Nam            43          22          21      
Myanmar             60          43          17      
Mexico              83          72          11      
Iran                90          81           9      
Philippines         86          77           9      
Indonesia           61          53           8      
Ethiopia            25          19           6      
Nigeria             51          58          -7

Data from 1993 to 1995, except Brazil and Ethiopia (1991).   
Sources: WHO, Water Supply and Sanitation Collaborative
Council and UNICEF, Water Supply and Sanitation Sector
Monitoring Report: 1996; other government reports; MICS and

Water and Sanitation
Progress and Disparity

78% of all guinea worm cases occurring in Sudan

Conflict in southern Sudan has cast a shadow over remarkable
global progress towards the World Summit for Children goal
of elimination of guinea worm disease (dracunculiasis) by
the year 2000. In 1996, Sudan accounted for 78% of all
guinea worm cases worldwide, up from 32% just two years
before. This reflects both a decline in incidence in other
countries and better reporting of cases in Sudan. 

Guinea worm disease is caused by drinking water contaminated
with a parasite that grows 20 to 30 inches in a patients
body, bringing debilitating pain, ulcers, fever and joint
deformities. Only 10 years ago, it afflicted millions of
people in Africa and Asia. But today, only 10 countries
report more than 1,000 guinea worm cases, and all except
Sudan have shown a decline in cases in the past three years,
nearly conquering the fiery serpent, as the parasite is
known. Pakistan, which has had no reported cases since 1994,
was certified in January as having eliminated the disease,
and Kenya had no reported cases in 1996. India reported nine
cases but verified that the spread of the disease was
contained, thereby increasing the possibility of achieving
elimination in 1997.

In Sudan, armed conflict continues to hamper prevention
efforts, although there is now greater access for health
workers and equipment to southern Sudan where most guinea
worm cases occur. Population upheaval because of the civil
war could retard much of the progress in eradication. Unlike
immunization, which can be accomplished during a few days of
tranquillity agreed to by forces in conflict, eliminating
guinea worm disease takes continuous work for a year

                  War against guinea worm
               Occurrence of guinea worm disease       

                      Guinea worm     % of total      
                       cases, 1996     cases*     

Sudan                    114,772          78     
Nigeria                   10,729           7     
Ghana                      4,877           3     
Burkina Faso               3,199           2     
Niger                      2,978           2     
Cote d'Ivoire              2,785           2
Mali                       2,249           2
Togo                       1,583           1
Uganda                     1,455           1
Benin                      1,204           1
Mauritania                   464           0
Ethiopia                     372           0
Chad                         117           0
Yemen                         62           0
Senegal                       20           0
Cameroon                      13           0
India                          9           0
Kenya                          0           0
Pakistan                       0           0

*Percentages do not add up to 100 due to rounding.

Source: US Centers for Disease Control and Prevention,
Guinea Worm Wrap Up, issue number 64, 7 February 1997.

Water and Sanitation
Progress and Disparity

Grading school sanitation: Few high marks

How sanitary can conditions be when 90 young children in a
school are sharing one toilet? Or when 54% of the toilets
are not functioning? 

Primary schools in some of the poorest countries have inadequate
sanitation facilities, according to a pilot survey of 14
countries in 1995. The worst findings were in rural schools in
Bangladesh, Maldives and Nepal, where more than 90 pupils on
average are sharing one toilet. By comparison, rural schools in
Burkina Faso, Madagascar and Togo have fewer than 50 students per
toilet. In urban areas, though, these three countries are among
those with the worst record, with more than 50 pupils per toilet
on average. Six countries have fewer than 50 students per toilet
in city schools.

None of the 14 countries has increased the number of school
toilets by more than 8% since 1990, suggesting that they are
barely managing to keep up with the rise in student populations.

The record on toilet conditions is equally dismal. In Bangladesh,
Maldives and Nepal, around half the school toilets are unusable,
meaning they are either unclean (flush toilets) or in need of a
new hole (latrines). Cape Verde rates best in cleanliness, with
91% of toilets being cleaned daily. In Bangladesh, 40% of schools
reported that toilets are cleaned not even once a week.

The 14 countries do somewhat better in providing safe water in
schools. All of them except Ethiopia and Togo provide water to at
least half the primary schools. In Cape Verde all schools have
safe water. Bhutan provides water to 95% of schools and Maldives
to 90% of schools.

Inadequate sanitation and water in schools jeopardize not only
students' health but also  their attendance. Girls in particular
are likely to be kept out of school if there are no sanitation

                    Student access to toilets

                                       % toilets
                  Pupils per toilet         non-
                     rural   urban        usable
Nepal                 92       9           54       
Bangladesh            91       9           48       
Maldives              95       -           48       
Madagascar            45       55          36       
Benin                  -       67          34       
Bhutan                85       15          32       
Burkina Faso          36       64          31       
Tanzania              68       32          29       
Cape Verde             -       90          24       
Uganda                80       20          24       
Togo                  46       54          14       
Ethiopia              77       23          12       
Zambia                85       -            6       
Equatorial Guinea      -       80           -

Source: A. Schleicher, M. Siniscalco and N. Postlethwaite, The
Conditions of Primary Schools: A Pilot Study in the Least
Developed Countries; A Report to UNESCO and UNICEF, September

Water and Sanitation
Progress and Disparity

Making ORT a household habit

Diarrhoeal dehydration is a leading child killer in developing
countries, largely because of inadequate sanitation. It
claimed the lives of an estimated 2.2 million children under
age 5 in 1995 alone. As many as 90% of these deaths could have
been prevented with ORT (oral rehydration therapy).

ORT - defined by WHO in 1993 as an increased volume of fluids,
either oral rehydration salts (ORS) or other recommended home
fluids, along with continued feeding - addresses the
dehydration promptly, by replacing body fluids lost by
diarrhoea at the first sign of the disease. 

Children in the 15 developing countries listed come down with
diarrhoea from 2 to 6 times each year. In 10 of these
countries, more than 80% of children are given ORT; in
Bangladesh, Ethiopia, Indonesia and Pakistan, virtually every
child is treated with ORT.

Yet, while significant progress has been made in recent years,
it is difficult to accurately measure the gains. A previous
definition of ORT simply called for giving the child ORS or
home fluids, without specifying the importance of the volume
of fluids or of continued feeding. Since the definition was
modified only in 1993, most survey data, including those in
this table, are still based on the earlier definition. About
three quarters of the households in developing countries now
use ORT as defined before 1993, up from 38% in 1994. But only
about one third of homes now use ORT following the new
definition, a more effective treatment for diarrhoeal

               Progress in oral rehydration

               Estimated annual      % of diarrhoeal
               diarrhoeal episodes   episodes treated
                   (millions)           by ORS/RHF

China                 360                   85
India                 310                   67
Nigeria               110                   86
Pakistan               90                   97
Bangladesh             70                   96
Brazil                 50                   83
Ethiopia               50                   95
Congo, Dem. Rep.       50                   90
Indonesia              40                   99
Mexico                 30                   81
Philippines            30                   63
Sudan**                30                   35
Tanzania               30                   90
Iran**                 20                   37
Kenya                  20                   76

* Oral rehydration salts/recommended home fluids.
** Excludes RHF.
Note: Estimated diarrhoeal episodes are best estimates from a
variety of sources.

Sources: National household surveys including DHS and MICS
reports, 1993-1996.

                         * * * *

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