Part 1 IWRM and Health

1. Part 1IWRM and Health Water management practices and health economics

2. The legacy of the Brundtland years • Health high on the international political agenda, with a consistent focus on ill-health-poverty links • WHO Commission on Macro-economics and Health: safe water and adequate sanitation among the most cost-effective interventions for lasting health gains • Combined GDP of countries in sub-Saharan Africa would be US$100 billion more had malaria been effectively controlled 40 years ago

3. Some perspectives on water, poverty and health Africa South of the Sahara has 10% of the global population, yet 24% of the global burden of disease linked to environmental health determinants Water supply and sanitation coverage reaches just over half the population; 60% of the rural population lacks both In 2000, communicable diseases constitute the single largest category in terms of DALYs lost: 73.2% up from 65.9 in 1990

4. Some perspectives on water, poverty and health The 2000 Burden of Disease estimates related to Environmental Health determinants stand at 103 million DALYs lost (29% of total) Further analysis by income group suggests that 55% of this burden affects the poorest fifth of the population, and that of this segment, 81% accrues to the rural poor

5. A clustered approach to reducing the environmental health risks to which the poor are exposed can accelerate a reduction in their burden of disease The Top Three Environmental Health-related Burden of Disease clusters are Total EH BoD in Mn of DALYs lost Total pop. Poorest 1/5 Vector-borne diseases 40.9 25.1 Water-related diseases 25.8 14.3 Respiratory infections 24.6 13.5

6. A clustered approach to reducing the environmental health risks to which the poor are exposed can accelerate a reduction in their burden of disease The challenges: • To effectively include health as a parameter in decision making in IWRM • To strengthen environmental health component of health sector programmes so they have capacity to respond to the needs in IWRM • To establish cross-sectoral compatibility in terms of boundaries, scale and level of decision-making • For professionals to learn to understand each other’s language and to trust and respect professionals from other disciplinary backgrounds in an open dialogue

7. A combination of Burden of Disease estimates and cost-effectiveness analyses can differentiate those water supply and sanitation interventions that give poor largest incremental health gains for least possible costs. Recent WHO analyses to attribute a disease burden to water, sanitation and hygiene risk factors show they account for: • 2.1 million deaths each year (3.9% of total) • 76 million DALYs lost each year (5.3% of total)

8. A combination of Burden of Disease estimates and cost-effectiveness analyses can differentiate those water supply and sanitation interventions that give the poor largest incremental health gains for least possible costs. Maximum health gains in absolute terms: • provide the most basic water supply services to those who have no access at all • provide water supply and sewage connection to individual households Most cost-effective interventions: • Disinfection at point-of-use through chlorine treatment and safe storage vessels combined with limited hygiene education • Targeting key behavioural change (hand washing)

9. Annual funding per intervention world-wide (billions of US$)

10. Costs of interventions versus healthy life years gained

11. A combination of Burden of Disease estimates and cost-effectiveness analyses can differentiate those water supply and sanitation interventions that give the poor largest incremental health gains for least possible costs. The challenges: • IWRM should always have a Water Supply and Sanitation component • Burden of Disease and Cost-effectiveness criteria need to be included in the decision-making about water supply and sanitation and in IWRM • Water supply and sanitation projects need to have a component that documents Burden of Disease reduction and health gains

12. A significant part of the burden of disease of poor, vulnerable communities can be attributed to the way we develop water resources and manage them.

13. A significant part of the burden of disease of poor, vulnerable communities can be attributed to the way we develop water resources and manage them. • Ethiopia, Tigray: micro dams cause a seven-fold intensification of malaria transmission intensity • Senegal, Richard Toll: irrigated rice and sugar cane schemes cause the intestinal schistosomiasis prevalence rate to explode from 0 to 90% • Sri Lanka, Mahaweli System H: Japanese encephalitis outbreaks due to irrigation extension combined with pig rearing

14. A significant part of the burden of disease of poor, vulnerable communities can be attributed to the way we develop water resources and manage them. • Environmental management measures for health protection and promotion are a cost-effective option provided they are included at the planning and design stage • Environmental modification capital intensive, lasting infrastructure works • Environmental manipulation recurrent environmental management activities with a potential for community participation

15. A significant part of the burden of disease of poor, vulnerable communities can be attributed to the way we develop water resources and manage them. Environmental management: • design options at zero extra costs (e.g. larger diameter of outlets in dams) • operational options at zero extra costs (e.g. flushing, reservoir management) • options with dual benefits (e.g. alternate wetting and drying as part of rice irrigation practice: improved yields, less vectors, less methane) • capital investment in structural improvements (e.g. self-draining hydraulic structures, canal-lining, double spillways for dams)

16. A significant part of the burden of disease of poor, vulnerable communities can be attributed to the way we develop water resources and manage them. The challenges: • Include training on environmental management for health in curricula of water professionals • Promote best practice in integrated planning and management of water resources (cf. World Commission on Dams) • Convince finance ministries that including health safeguards in water resources development projects is sound economics • Mobilise NGOs to adopt similar procedures strategically into their development activities

17. A review of water resources sector policies and programmes can help identify opportunities to improve the health status of vulnerable communities.

18. A review of water resources sector policies and programmes can help identify opportunities to improve health status of vulnerable communities. Ethiopia’s Water Sector Development Programme – By 2016: Water supply : Urban coverage increase 74 to 98% Rural water supply coverage from 23 to 71%. Irrigation : Small scale irrigation adds ~ 127,000 ha. to current 200,000 ha. Remaining expansion ~ 147,000 ha. will be medium and large scale. Hydropower : Six medium-scale, 15 small-scale hydropower plants completed; 63 medium-scale, 67 small-scale hydropower plants under development.

19. A review of water resources sector policies and programmes can help identify opportunities to improve the health status of vulnerable communities. Ethiopia’s Water Sector Development Programme An estimated US$7.5 billion will be needed over the next 15 years to achieve the objectives contained in the programme. The breakdown by sub-sector is : water supply and sewerage extension 39% hydropower capacity development 26% irrigation development 23% water resources management 9% institution/capacity building 3%

20. A review of water resources sector policies and programmes can help identify opportunities to improve the health status of vulnerable communities. The challenges: • Use policy and programme development in the water sector as an opportunity for capacity building in integrated thinking • Educate sectoral ministries that time invested in policy reviews for health is time well-invested

21. Part 3IWRM and Health End – Part 3