Díaz, JJ and Andrade, R, 2015, An exploration of the impact of water and sanitation on child health in Peru, 3ie Grantee Final Report. New Delhi: International Initiative for Impact Evaluation (3ie)
Achieving access to clean water for sanitation and hygiene is marked as an important goal to improve health – especially of children – and development, including as one of the Millennium Development Goals. Figures of access to improved water and sanitation for 2012 taken from WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation indicate that Peru is still lagging in the Latin American and Caribbean region despite progress over the last decades. Access to improved water was 96 per cent on average in Latin American and Caribbean countries but 87 per cent in Peru, while access to improved sanitation was 89 per cent in Latin American and Caribbean countries and 73 per cent in Peru. Wide urban-rural disparities in access are also present across Latin American and Caribbean countries and Peru is no exception. By 2012 about 91 per cent of Peru’s population had access to improved water in urban areas in contrast to 72 per cent in rural areas while 81 per cent had access to improved sanitation in urban areas in contrast to just 45 per cent in rural areas.
In response to such challenges, the Peruvian government has made large investments in improving community access to water, including constructing approximately 500,000 new communal water taps between 2006 and 2011, under the aegis of its Programa Agua para Todos (PAPT). The government also implemented Programa Nacional de Agua y Saneamiento Rural (PRONASAR), currently under Programa Nacional de Saneamiento Rural (PNSR), to increase the sustainable use of new and rehabilitated water supply and sanitation facilities in rural areas and small towns. Overall, access to improved water and sanitation had increased in Peru from 1986 to 2010 and has presumably increased further because of PAPT and PRONASAR. The percentage of children with access to piped water increased from 38 per cent in 1986 to 69 per cent in 2010 among children under the age of 5 years, which a particularly dramatic increase in rural areas. National access to flush toilets increased from 23 per cent to 47 per cent while access to latrines increased from 9 per cent to 36 per cent. Over the same time, rates of child diarrhea, malnutrition, and stunting fell.
In this study, the authors sought to make causal claims about whether improving access to sanitation and hygiene led to these improvements in child health outcomes.
The authors utilised the seven waves of Demographic and Health Survey (DHS) data collected in Peru between 1986 and 2010. These data were independently pooled cross-sections, accounting for geo-political changes that have taken place over the years represented. This allows for the analysis of 77,000 individual child records from over these 24 years. To assess the effects of water on child health outcomes, the authors looked reported household access to water and sanitation and several child health indicators, including prevalence of diarrhoea, anthropometric indicators of present health, and indicators of malnutrition. DHS data allow to measure household’s access to piped water from the public network (the type of connections pursued under PAPT and PRONASAR) as opposed to water from wells and public taps or other sources. These data also allow to measure access to sanitary facilities connected to the sewage system as opposed to latrines and pit toilets and other types of sanitation (including defecation in open spaces).
The authors use regression analyses to examine these outcomes in a way that accounts for the similarities in a district over time (using a district fixed-effects model). They find that access to piped water for drinking and flush toilets or latrines, reduce the prevalence of diarrhoea. In particular, they find that having access to piped water reduces the reported prevalence of diarrhoea by 10 per cent, while access to flush toilet facilities reduces it by 18 per cent and access to a latrine reduces it by 6 per cent. They also find that access to piped water for drinking reduces the prevalence of wasting by 12 per cent but has no effects on the prevalence of stunting or underweight while flush toilets and latrines reduce wasting by 14 and 15 per cent and stunting by 21 and 7 per cent respectively. These results are in accord with evidence provided by cross-country studies such as Fink et al. (2010), as well as meta-analysis on high quality impact evaluations across the developing world by Waddington et al. (2009) in particular for evaluations conducted over periods longer than 12 months.
Implications for policy and practice
Efforts are still required to increase the coverage of piped water and improved sanitation, especially in rural areas. DHS data for 2010 show that 4 out of 10 children under five do not have access to piped water in rural areas, while 3 out of 10 children do not have access to improved sanitation. Access to flush toilets is particularly limited in rural areas, where only 1 in 10 children have access. Investments aimed at expanding access to safe water should consider that, at least based on the available evidence from this study, water from public taps show no protective effect against diarrhea or malnutrition. Such investment could be complemented by mechanisms for monitoring water quality at the point of use in order to achieve the populations have access to safe water in areas where public piped water systems are difficult to implement.