The economic burden of inadequate water and sanitation in South Tarawa, Kiribati: Who bears the cost?

May 25th, 2015

Dr. Padma Narsey Lal, CSIRO, Australia

Pacific island countries face significant challenges in meeting their Millennium Development Goals, including MDG 7c of halving the proportion of people without access to safe drinking water and safe sanitation by 2015. Kiribati is no different. Kiribati is one of three countries in the Pacific assessed to be off track to achieve their MDG Target 7c, and the situation is expected to get worse with climate change. This is despite decades of aid from development partners to help improve water and sanitation services, which generally were not sustainable1.

Pacific island countries also have difficulty in adopting a more effective charging policy for the supply of water and sanitation services due to concerns about the adverse impact of higher charges on household welfare and/or public resistance to increased utility charges. Drawing on a recent study from the Asian Development Bank (ADB)2, this article illustrates the nature and distribution of the economic burden associated with inadequate water and sanitation services in South Tarawa, information that could be used to encourage behavioural changes by government, development partners and households alike.

Background

The Republic of Kiribati (Kiribati) comprises 33 low lying atolls in the Central Pacific. Almost half of the country’s population of 105,000 reside in South Tarawa. Almost two thirds of residents of South Tarawa currently live in ‘unsafe’ conditions (involving members of the household using unimproved toilet and water systems), as compared with 32 percent in 2010 (Figure 1). This is despite decades of investments in water and sanitation. In 2013 more than 60 per cent of households on South Tarawa used beach for defecation, with 35 per cent using the beach even when they had access to improved toilet facilities. The use of the beach is common across all villages, largely because a single improved toilet is often insufficient to meet the needs and cultural practices of extended families living together.

Further, even where government supplied water is accessed, most households use a range of ‘unsafe’ water storage facilities, such as open ’44 gallon drums’, pots and buckets, which are easily contaminated through poor hygiene. Many households also access water from neighbours’ water systems, which also may involve unimproved water sources and poor water storage practices. There is also contamination of water supplies from animal waste, primarily family pigs that run freely in the villages.

Poor water and sanitation has serious impacts on human health with related diseases, transmitted through multiple pathways3, contributing to the burden of disease a country faces4,5. Kiribati is assessed to be amongst the Pacific countries with a very high burden of disease across many of the indicators. Kiribati has, for example, a WASH related death rate of 25 deaths per 100,000 population per year as compared with 11.47 for other Micronesian countries6.

The economic burden of poor water and sanitation

The economic burden of poor water and sanitation is usually defined in terms of health-related economic costs and economic costs borne by other parts of the economy7. These costs are not only financial, but also include the ‘hidden’ costs that could have been saved and/or avoided had there been adequate water and sanitation services7 (i.e., loss in wages, opportunity costs of carer’s time, opportunity costs of lost lives, transportation costs and loss of tourist dollars).

The total quantifiable economic burden of poor water and sanitation on South Tarawa is conservatively (i.e., not all impacts have been quantified) estimated to be about $6.4 million a year (with a range of $4.3-9.1 million, depending on assumptions made and parameter estimates used to determine different cost-items). Of this, health related costs borne by the government and households account for almost 83 per cent. Impact on tourism is estimated to be about 17 per cent.

Who bears the economic burden?

There are both public and private costs of poor water and sanitation, borne directly or indirectly by individuals and households as well as the government.

The majority of the quantifiable economic costs of poor water and sanitation is borne by households, reflecting opportunity costs associated with lost wages and value of time lost by patients and their care-givers (35%). If the economic value of lost lives were considered, the cost would be equivalent to almost two-thirds of the total economic burden of poor water and sanitation.

In comparison, government borne preventative and treatment costs in the health sector only make up 19 per cent of the total costs (Figure 2). Of this, identifiable medicine costs paid for by the Government account for a little less than half. The majority of the preventative and treatment costs borne by the Government is ‘hidden’ because overhead costs of running hospitals and clinics are not differentiated across categories of diseases treated by the clinics and hospitals.

Household and village characteristics, sex and age are found to be important determinants of who in the community is likely to bear higher economic burden associated with the incidence of diarrhoea and dysentery (the key WASH related diseases). The ADB study2 revealed that the incidence of diarrhoea and dysentery are most likely (statistically significant) to be associated with:

Individuals living in households with no latrine.

Households that use open well water, as well as neighbours’ water.

Where household members live in traditional and mixed houses, reflecting either poor economic conditions or the practice of households constructing additional traditional houses, to accommodate extended family members, but rarely additional toilets.

Households that use piped water supplied by the public water utility. This is contrary to normal expectation, which is likely to be attributed to improper water storage at the household level that exposes water supplies to contamination; contamination of piped water supplies due to system leakages and illegal connections.

Households living in villages with high rates of open defecation, contributing to village-wide ‘unsafe’ conditions.

While children generally have higher incidence of water related diseases, in South Tarawa, female children have a higher likelihood of suffering from diarrhoea and dysentery than male children. This is not surprising given gender inequality in practices evident in traditional I-Kiribati social structures, including discriminatory feeding practices between boy and girl-child and access to health services8. With age the chances of individuals suffering from these diseases decreases, although men have higher chance of suffering as they get older, which could be attributable to the consumption of kava in kava bars where hygiene standards may be low.

Using economic burden information to underpin targeted responses

While improving WASH conditions in a country is everyone’s business, governments can play a decisive role in focussing on creating favourable conditions targeting the vulnerable in society. Currently, Public Utilities Board (PUB), a statutory agency, supplies centralised water and sanitation services to residents in South Tarawa. Seventy per cent of households have access to PUB water while only 22 per cent of households are connected to PUB sanitation system.

The government and development partners can improve centralised water and sanitation services, which would undoubtedly help improve access to improved water and sanitation. They could be encouraged to increase their financial contributions by highlighting the potential increase in the country’s Gross Domestic Product expected from improved water and sanitation; the current economic burden is equivalent to 2-4 per cent of the Kiribati’s GDP, or about $550-1083 per household per year.

The PUB charges $10 per household for water supply, which many households do not pay. Sanitation services are supplied for free. The revenue raised is not sufficient to cover even the costs of current services, with regular demands for government subsidy.

The many public benefits of improved water and sanitation warrant increased attention from the government and development partners. Women, children and elderly, who bear a disproportionate share of the economic burden of inadequate water and sanitation services in South Tarawa, would benefit the most.

Households could also be encouraged to accept higher utility fees by highlighting that households already bear a large share of hidden health-related costs of $45-90 per month, four to nine times the current utility charges per household per month. By emphasising the ‘hidden costs,’ households could also be encouraged to change their behaviour to reduce their disease risks, particularly in changing their traditional sanitation practices, water storage practices and human hygiene.

References:

Clarke, M., S. Feeny and J. Donnelly (2014). “Water, Sanitation and Hygiene Interventions in the Pacific: Defining, Assessing and Improving ‘Sustainability’.” European Journal of Development Research 26: 692-706. ADB (2014). Economic costs of inadequate water and sanitation, South Tarawa, Kiribati. Pacific Studies Series. Mandaluyong City, Philippines, Asian Development Bank: 74. Campbell, O. M. R., L. Benova, G. Gon, K. Afsana, et al. (2015). “Getting the basic rights – the role of water, sanitation and hygiene in material and reproductive health: a conceptual framework.” The European Journal of Tropical Medicine and International Health 20(3): 252-267. WHO (2008). Global Burden of diseases 2008 – Summary. Geneva, WHO. IHME (2010). Disability Weights_1990_2010. Seattle, USA, Global health data Exchange, Institute of Health Metrics and Evaluation (IHME). WHO (2004). Global Burden of diseases 2004. Geneva, WHO. WHO (2009). WHO guide to identifying the economic consequences of disease and injury. Geneva, Switzerland, World Health Organisation. Rasanathan, J. J. K. and A. Bhusan (2011). Measuring and responding to gender-based violence in the Pacific: Action on gender inequality as a social determinant of health, Republic of Kiribati – a Background Paper. World Conference on Social Determinants of Health. 19-21 October, 2011. Rio de Janeiro, World Health Organisation, Regional Office for the Western Pacific. Draft Background Paper 4. Government of the Republic of Kiribati (2010). Kiribati 2010 Census of Population and Housing: Volume 1- Basic Information and Tables. Republic of Kiribati Census. Tarawa, Kiribati, National Statistics Office, Ministry of Finance.

Dr Padma Narsey Lal has over 35 years’ of professional experience in Oceania, including as the Sustainable Development Adviser to the intergovernmental agency, Pacific Islands Forum Secretariat and Chief Technical Adviser to IUCN. She also served as co-coordinating author of Chapter 5 of the IPCC’s Special Report on Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation. She currently works as freelance consultant in the Pacific region, focussing on action research for development, adopting interdisciplinary and ecological economic analytical approaches. Her research and development work has covered a range of sectors and themes, including water and sanitation, and disaster risk management and climate change adaptation.