Gade Pi lwen pase Livrezon Sèvis Dlo ak Sanitasyon Gouvènman an Ap Dirije: Chwa Mache ak Pratik Pèp Ayiti ki pi Frajil la

Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services The Market Choices and Practices of Haiti’s Most Vulnerable People Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized This work was financed by the World Bank Water and Sanitation Program and the Swedish International Development Cooperation Agency and was a multi-Global Practice initiative led by Water and Poverty with significant support from Governance and Health, Nutrition, and Population. Looking Beyond Government- Led Delivery of Water Supply and Sanitation Services The Market Choices and Practices of Haiti’s Most Vulnerable People © 2018 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Please cite the work as follows: World Bank. 2018. Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services: The Market Choices and Practices of Haiti’s Most Vulnerable People. WASH Poverty Diagnostic. World Bank, Washington, DC. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522- 2625; e-mail: pubrights @­worldbank.org. Cover design: Bill Pragluski, Critical Stages LLC. Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services iii Contents Acknowledgments vii Executive Summary ix Abbreviations xvii Chapter 1 Introduction 1 Background and Conte xt 1 Objectives of the Haiti W ASH Poverty Diagnostic 1 Sources of Data 2 Quantitative Data 2 Administrative Data and Qualitative Information 2 Notes 3 Reference 3 Chapter 2 Poverty, Vulnerability, and Health in Haiti 5 Notes 9 References 9 Chapter 3 Water Supply, Sanitation, and Hygiene in Haiti 11 Access to Water Supply and Sanitation at the Household Le vel 11 Community-Lev el Environmental Health Conditions and WSS in Public Spaces 19 Notes 24 References 24 Chapter 4 Improving Health Outcomes through WASH Interventions 25 Nutritional Benefits of Inv esting in Water Supply, Sanitation, and Hygiene 25 Quantifying the Health Benefits of Improved Household Water Supply and Sanitation 28 Notes 32 References 32 Chapter 5 The Challenges of Government-Led Water and Sanitation Service Delivery 33 Quality and Financial Sustainability of Gover nment-Led Service Delivery 33 Failing to Cope with Urban Population Gro wth: The Case of Utility of Port-au-Prince 36 Notes 39 References 40 Chapter 6 The Response of the Private Sector: The Case of the Port-au-Prince Metropolitan Area 41 The Metropolitan Water Mar ket 42 The Household Water Mix: Alternatives and Choices Made by the Metr opolitan Poor 42 Understanding Alternative Service-Delivery Chains 46 The Operating Environment of Private Water Service Pr oviders 48 Fecal W aste Management in the Metropolitan Area 51 Mechanical Emptying: Servicing Institutional and Commercial Clients 54 iv Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services Manual Emptying: Stigmatized and Unaffordable for the Poorest 58 A Potential Solution for the Poor: The EkoLakay Business Model 58 Public Sector Collaboration with the Fecal Sludge Management Services Industry 59 Notes 61 References 61 Chapter 7 Conclusions and Recommendations 63 Improve the Geog raphical Targeting and Increase the Public Funding Channeled to Areas where WSS Are Crucially Needed 64 Work across Sectors to Impro ve Health Outcomes of WASH Interventions 64 Recognize and T ake Advantage of the Predominance of the Private Sector in WSS Service Delivery in Urban Areas, Adjusting the Role of State Accordingly 65 Appendix A Data and Methods 67 Appendix B Correlates of Cholera and Diarrhea in Haiti 73 Appendix C UNICEF Framework of Analysis of Malnutrition 75 Appendix D WASH Poverty Risks Model (WASH-PRM) 81 Box Box 3.1: Barriers to Adopting Improved Hygiene Practices in the Centre Department 19 Figures Figure 2.1: Poverty and Extreme Poverty—National, by Region and Department, 2012 5 Figure 2.2: Urbanization in Haiti, 1970–2014 6 Figure 2.3: Vulnerability to Poverty, 2012 7 Figure 2.4: Mortality Rates in Infants and Children under Five, per Quintile, 2005–06 and 2012 8 Figure 3.1: Progress Experienced in Access to Drinking Water and Sanitation, 1990–2015 11 Figure 3.2: Access to Water, 1990–2015 (Thousands of People) 12 Figure 3.3: Access to Sanitation, 1990–2015 (Thousands of People) 13 Figure 3.4: Access to Water, by Department and Type of Water Source 13 Figure 3.5: Access to Sanitation, by Department and Type of Sanitation Facility 14 Figure 3.6: Progress in Access to Drinking Water and Sanitation by Type of Access as Defined by the MDGs, Geographical Area, and Wealth Quintile, 1995–2012 15 Figure 3.7: Likelihood of Access to the Port-au-Prince Public Water Network and Drinking Water Choices among the Population with Access, by Wealth Quintile 16 Figure 3.8: Access to Water, by Type of Management and Geographical Area 16 Figure 3.9: Water Expenditures, by Poverty Status, 2012 17 Figure 3.10: Access to Improved Water Sources in Percentage of Population, 2002, 2006, and 2012 17 Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services v Figure 3.11: Water Fetching Time, by Type of Water Source and Socioeconomic Level 18 Figure 3.12: Water Fetching Time, by Type of Water Source and Geographical Area, 2006 and 2012 18 Figure 3.13: Rates of Community Improved Sanitation and Water Coverage, by Wealth Quintile 21 Figure 3.14: Health Centers with Access to Improved Water Sources and Sanitation Facilities 22 Figure 3.15: Percentage of Schools with Access to Water (Any Type) and Sanitation Facilities 23 Figure 4.1: Stunting in Children 0–23 months, by Region and Welfare Quintile, 2012 26 Figure 4.2: UNICEF’s Framework of Analysis 26 Figure 4.3: Adequacy Status of Factors Underlying Malnutrition, by Region, Wealth Quintile, and Age 27 Figure 4.4: Households with At Least One Member Sick with Cholera, by Department, 2010–12 28 Figure 4.5: Incidence of Diarrhea among Children under Five, by Socioeconomic Level and Type of Drinking Water and Sanitation, Haiti 29 Figure 4.6: Total and WASH-Related Burden of Enteric Diseases, by Region and Wealth Quintile 29 Figure 4.7: Conceptual Framework of the Poverty Risk Model 30 Figure 4.8: Enteric Diseases, Exposure, Susceptibility, and Risk Indexes for Children under Five, by Quintile 30 Figure 5.1: Institutional Structure of the Haitian WSS Sector 34 Figure 5.2: CTE Operating Ratios, Fiscal Year 2015/16 35 Figure 5.3: DINEPA’s Budgeted and Executed Incomes and Expenses, Fiscal Year 2014/15 36 Figure 5.4: Main Sources of Drinking Water in the Port-au-Prince Metropolitan Area, 2006 and 2012 37 Figure 5.5: Share of the Port-au-Prince Population, by Source of Drinking Water Used, 1994, 2006, and 2012 38 Figure 5.6: Water Flows Managed by CTE RMPP, 2015 38 Figure 5.7: Accumulated Household Water Expenditures, by Source of Water, Port-au-Prince, 2012 39 Figure 6.1: Prevalent Household “Water Mix” Decisions across Consumption Quintiles 42 Figure 6.2: Detailed Data on Water Choices, Citywide and for the Bottom 40 43 Figure 6.3: Average Age of Private Kiosks, 2013 44 Figure 6.4: Scoring of Service Options on Key Parameters by Female Focus Group Participants 45 Figure 6.5: Twenty-Liter Bokit Price per Source of Water 45 Figure 6.6: Port-au-Prince Water Flow Diagram 46 Figure 6.7: Relationships among Stakeholders with Responsibilities for or Interest in the Port-au-Prince WSS Market 49 Figure 6.8: Trends in Use of Sanitation in Port-au-Prince between 2006 and 2012 52 Figure 6.9: Use of Sanitation in Port-au-Prince, by Wealth Quintile, 2012 52 Fig ure 6.10: The Fecal Waste Diagram of the Port-au-Prince Metropolitan Area 55 Figure 6.11: Average Monthly Volumes of Septage and Fecal Sludge Discharges per Company in Morne-à-Cabrit 56 Figure 6.12: Number of Trucks Arriving at Treatment Plant, by Month and Type 57 Figure 6.13: Monthly EkoLakay Service Costs per Household Toilet 59 vi Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services Maps Map 4.1: Regional Exposure Index and Susceptibility Index, by Department 31 Ma p 4.2: Potential Enteric Disease Risk Reduction Associated with Improved Access to Sanitation and Drinking Water, by Department 31 Map 6.1: Location of the Tianyen and Morne-à-Cabrit Fecal Waste Treatment Plants 54 Map D.1: Regional Exposure Index and Susceptibility Index for Children in B40 82 Tables Table 5.1: Kiosks and Standpipes Servicing Rural Areas of Haiti 34 Table 6.1: Trucked Water Prices per Neighborhood 47 Table B .1: Regression Results on Correlates of Diarrhea and Choler a in Haiti 73 Table C .1: Factors of Malnutrition in Haiti, 2012 77 Table C .2: Percent of Children in Haiti with Adequate Food, Care, Environment, and Health Care, 2012 79 Table C .3: Factors of Stunting in Haitian Children 0–23 Months 79 Table D .1: Relative Risks Associated with Various Water and Sanitation Scenarios 82 Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services vii Acknowledgments The WASH Poverty Diagnostic for the Republic of Haiti (P150705) is led by Emilie Perge (Economist, Poverty Global Practice), Zael Sanz Uriarte (Water and Sanitation Specialist, Water Global Practice), and Christian Jacobsen (Senior Water and Sanitation Specialist, Water Global Practice). The team includes Helene Grandvoinnet (Lead Governance Specialist, Governance Global Practice), Anil Silwal (Consultant), Katja Vinha (Consultant), Ian Ross at Oxford Policy Management, Pierre-Yves Rochat (Consultant), Beatrice Mosello (Consultant), Rosemary Rop (Consultant), Gina Fleurantin (Consultant), and Felipe Jacome (Consultant). The team would like to thank the Government of the Republic of Haiti for its support, in particular the National Directorate for Drinking Water and Sanitation (DINEPA) and the Observation Unit on Poverty and Social Exclusion (UOPES). The team is particularly grateful to all Haitian individuals who participated in the interviews and focus-group discussions. The team is grateful for feedback and discussions with Pierre-Xavier Bonneau (Program Leader SD, Haiti), David Michaud (Practice Manager, Water Global Practice), Oscar Calvo-Gonzalez (Practice Manager, Poverty Global Practice), Craig Kullmann (Senior Water Supply and Sanitation Specialist, Water Global Practice), Emmanuel Skoufias (Lead Economist, Poverty Global Practice), Vivek Srivastava (Lead Public Sector Development Specialist, Governance Global Practice), Jean-Martin Brault (Senior Water and Sanitation Specialist, Water Global Practice), Luis Andres (Lead Economist, Water Global Practice), and Kinnon Scott (Senior Economist, Poverty Global Practice). The team also thanks Berenice Flores (Consultant, Water Global Practice), Carolina Delgadillo (Program Assistant, Water Global Practice), and Eunice Flores (Program Assistant, Water Global Practice) for their support. The peer-reviewers for the Quality Enhancement Review (QER) stage of this work were: Sergio Olivieri (Senior Economist, Poverty Global Practice), Glenn Pearce-Oroz (Lead Water Supply and Sanitation Specialist, Water Global Practice), and Abel Bove (Governance Specialist, Governance Global Practice). Eleonora Cavagnero (Senior Economist, Health Global Practice) gave additional comments at the completion stage. Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services ix Executive Summary Poverty in Haiti remains endemic. Haiti is the poorest country in the Latin America and Caribbean region and among the poorest in the world. Its growth performance over the past four decades has been very low, averaging 1 percent per year, with gross domestic product (GDP) per capita falling by 0.7 percent a year on average between 1971 and 2013. As a result, the overall poverty headcount in 2012 was about 58.5 percent of the population and extreme poverty 23.8 percent, 1 meaning that almost 6.3 out of 10.4 million Haitians could not meet their basic overall needs and 2.5 million cannot even cover their food needs. Furthermore, with a Gini coefficient of 0.6, Haiti’s income inequality ranks the highest in the region and among the most unequal in the world. Poor macroeconomic performance and a limited fiscal space restrict government expenditures on public goods. Despite recent improvements in tax collection, Haiti collects less domestic revenue than comparable countries in the region. Of tax revenue, much comes from indirect taxes that affect consumers independent of their income level. In the absence of sufficient public expenditures, the private sector has become the main provider of basic services, placing a substantial financial burden on households and delivering achievements closely linked with income. Nongovernmental organizations (NGOs) are responsible for about 50 percent of total health expenditures, which for the most part are dedicated to deliver primary health-care services. In Education, NGOs or private for-profit institutions run over 80 percent of all primary and secondary schools. Drinking water supply and sanitation (WSS) services are no exception to this trend. Financial resources channeled to the WSS sector fall short of what is needed. In 2014, budget transfers and tariff revenues directed to the WSS sector accounted for US$69 million, equivalent to 0.8 percent of GDP (in comparison, fuel subsidies accounted for 2 percent of GDP during said year). Because of insufficient public investments and poor quality of government-led WSS services, the percentage of Haitians who resorted to the private sector for drinking water increased from 10.9 to 25.8 percent between 2006 and 2012. In urban areas, this percentage was even higher: 57.1 percent in the Port-au-Prince metropolitan area in 2012 and 45.5 percent in other cities of the country. The Haiti WASH Poverty Diagnostic seeks to inform how to maximize the socioeconomic impact of the scarce fiscal resources channeled to the sector. The study assesses the linkages between improved access to water supply, sanitation, and hygiene (WASH) services, poverty, and health outcomes. The diagnostic also provides convincing evidence of the linkages between improved access to WSS and other dimensions affecting the adequate development of children in Haiti, with a focus on stunting. The diagnostic also analyzes the functioning of WSS markets to identify ways to ensure that services delivered by the private sector are both of good quality and affordable. In particular, it focuses on water supply and fecal waste collection, transportation, and treatment services in the Port-au-Prince metropolitan area. This is the largest and most sophisticated WSS market in Haiti, although not the fastest growing. Understanding how this market functions may aid stakeholders in addressing issues and opportunities that may arise in other urban areas in the future, and in structuring successful public-private partnerships to serve rural communities. x Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services Poverty, Vulnerability to Shocks, and Health: How Is Haiti Faring? Poverty and extreme poverty are significantly higher in rural areas and in departments far from the capital city of Port-au-Prince than in urban centers. In 2012, 75 percent of rural Haitians were poor, and 40 percent were extremely poor. In that same year, 67 percent of the nation’s poor and 83 percent of its extremely poor resided in rural areas. The departments of Nord- Ouest, Nord-Est, and Grand’Anse were particularly affected: 80 percent of their populations were poor. Rural poor seeking a better life in cities face a harsh reality. The endemic poverty, lack of access to basic services, and limited job options seen in rural areas have prompted many Haitians to migrate to urban areas in search of job opportunities and a better quality of life. Between 1970 and 2014, the share of the urban population grew from 20 to 58 percent of Haiti’s total population. The nation’s cities have struggled with this rapid growth; migrants from rural areas often encounter poverty, unemployment, political and social marginalization, and limited access to services. A million Haitians now living above the poverty line are vulnerable to falling back into poverty because of shocks. A typical Haitian household faces multiple shocks each year—among them hurricanes, floods, disease, death, and unemployment and other economic shocks. For more than 60 percent of Haitian households, health shocks are the most severe shocks to negatively impact their income, keeping the poor in a poverty trap and pushing vulnerable Haitians into poverty. Therefore, improving access to WASH services could significantly contribute to alleviating poverty and the vulnerability of the Haitian population. Diarrhea and stunting are important issues affecting infants and children in Haiti and impairing cognitive function and long-term productivity. Such health outcomes are conditioned by access to improved WASH, among other factors. Water Supply, Sanitation, and Hygiene: How Do They Correlate with Poverty? A decline in access to improved drinking water over the past 25 years hit the poorest hardest. Although the percentage of Haitians who rely on surface water for drinking decreased from 17 to 3 percent between 1990 and 2015, access to improved drinking water sources decreased by 4 percentage points (that is, the share of the population with improved or piped water declined from 62 to 58 percent). During the same period access to improved water sources among the rural bottom 40 (B40) decreased by 7 percent. Gains in access to improved sanitation were unequally distributed, with access to improved sanitation decreasing among the B40. Between 1990 and 2015 the percentage of people practicing open defecation dropped from 48 percent to 19 percent, and the share of the population with access to improved sanitation facilities increased by 10 percentage points at the national level, 8 percentage points in rural areas, and 1 percentage point in cities. However, during the same period, access to improved sanitation increased just by 1 percentage point among the rural B40 and decreased by 3 points for the urban B40. The increase in access to improved sanitation facilities in rural areas is mainly due to a sharp reduction in the size of the rural population owing to urbanization. The number of rural households with access to improved water sources and sanitation facilities has been declining in absolute terms, suggesting that infrastructure is collapsing. Access to piped water on premises and access to other improved water sources is increasing for the rural Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services xi top 20 (T20)—most of which live in small towns that can be served through piped schemes— but decreases for the rest of the rural population, many of which live in disperse and small communities. Likewise, access to improved sanitation remained stagnant among the rural B40 both in relative and absolute terms. Urban water utilities are struggling to cope with urban population growth. However, the decrease of the share of the urban population using piped water to satisfy their drinking water needs is also due to the lack of trust on the quality of water delivered by the public sector. In 2012, around 55 percent of the Port-au-Prince metropolitan population had access to the public water network but just 28 percent used this water source as the main source of drinking water. During that year, 67 percent of the overall metropolitan population and 59 percent of the B40 had recourse to the private sector to satisfy their drinking water needs, domestic water needs or both. Households report not using public water for drinking because they fear that public water is of low quality. Access to improved WSS in institutions and public spaces is poor. In 2011, 41 percent of primary schools and 30 percent of secondary schools had access to water, and 53 percent of secondary schools had toilets. In 2013, 79 percent of health centers offered their patients access to improved water and 46 percent offered toilets. In the Grand’Anse, Nord-Ouest, and Sud-Est departments, less than 30 percent of health centers had sanitation facilities. In the 36 communes with the highest incidence of cholera, just 44 percent of the 187 existing health centers had access to an improved water source; 40 percent of the centers routinely suffered severe water shortages. WASH Services and Health: How Can Interventions Improve Health Outcomes? The rural poor suffer most from cholera and other waterborne diseases. Diarrhea is the third- leading cause of death among children under five, and the annual burden of enteric diseases 2 associated with inadequate or unsafe WASH services is 13,278 DALYs 3 per 100,000 children— about three-quarters of Haiti’s estimated burden of enteric disease. Nationally, the WASH- related diarrheal burden borne by the poorest quintile is about 2.7 times greater than that of the richest quintile. Cholera—a major concern in Haiti in the aftermath of the 2010 earthquake— is twice more likely to strike poor households than richer ones. Access to improved WSS services is critical to preventing diarrheal diseases and improving nutrition. Among children with similar diets and care, those with access to improved services have better nutritional outcomes than those without. In addition, although children from all quintiles are equally likely to suffer from diarrhea, children without access to improved services are much more likely to die from it. Investing in WSS and hygiene, therefore, could lower the mortality risk for children. The positive health impacts of WASH investments are likely to be highest in the Artibonite, Nord, and Grand’Anse departments. These are the departments where a greater reduction of enteric disease risk could be achieved among children under five if every household with unimproved water and sanitation gained access to improved water and sanitation services. Hygiene and community-level environmental conditions affect health outcomes as much as households’ access to water and sanitation. This is evident from the persistence of cholera in households with access to piped water and by the even distribution of diarrheal disease prevalence across quintiles. Disparities in improved community-level sanitation coverage are noticeable just between the highest quintile and the rest of the population in urban areas, and between the two highest quintiles and all others in rural areas. Regarding hygiene practices, half of households in  the lowest two quintiles reported treating their water. Fifty-nine percent of the poor had handwashing facilities in their dwellings in 2012, although more than half of these facilities did not have water. Only a quarter of the B40 used soap or detergent to wash their hands. xii Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services Government-Led Water and Sanitation Services: What Are the Challenges? The quality of government-led water supply services is low. A substantial proportion of rural water systems managed by local water committees (Comité d’Approvisionnement en Eau Potable et Assainissement [CAEPA]) are not operational, and less than 10 percent are equipped with chlorination devices. The services delivered by urban water operating centers (centres techniques d’exploitation [CTE]), part of the National Directorate for Drinking Water and Sanitation (Direction Nationale de l’Eau Potable et de l’Assainissement [DINEPA]), are also poor. In the Port-au-Prince metropolitan area, for example, the CTE’s clients are serviced 26 hours a week on average, and 20 percent of water-quality test results do not meet applicable standards. Public water supply is far from being financially sustainable, even in urban areas. Nineteen of Haiti’s 24 CTE 4 do not generate enough revenue to cover their operating costs, let alone preventive maintenance. Neglect of preventive maintenance translates into a further deterioration of the quality of service and an increased need for investments in corrective maintenance, resulting in an inefficient use of scarce fiscal resources. The CTE of the Port-au- Prince metropolitan area, which has been receiving technical and financial support from the donor community, only recently managed to cover its staff costs with tariff revenues. Its billed volume represents just 39 percent of its total production, and just 44 percent of the bills it sends are paid. Dependency on donor financing makes public WSS highly vulnerable to the continued availability of donor resources. In fiscal year 2015, tariffs and transfers from the national treasury respectively covered just 20 percent and 3 percent of DINEPA’s expenditures, 53 percent of which corresponded to operating expenditures and 47 percent to invesments. In other words, the donor community finances all WSS investments and 30 percent of the sector operating expenditures. Utilities prioritize service delivery to the most profitable clients to improve their financial situation, to the detriment of the poorest residential consumers. In Port-au-Prince, only 14 percent of the volume of water distributed (15,000 cubic meters per day [m 3 /day]) reaches disadvantaged neighborhoods (equivalent to 15 liters per person per day [lpd]), where the population is serviced by poorly managed public kiosks and stand post. In comparison, 42,000 m 3 /day are distributed to other residential areas (equivalent to 35 lpd) and 14,000 m 3 /day are sold to industrial and major commercial establishments. Responses from the Private Sector: How Do Markets for Water Supply and Sanitation Work? In this context, the private sector has developed a very profitable urban water market and an incipient market for the removal of fecal waste. It is estimated that the metropolitan water market in 2016—including water for both residential and commercial consumption—was worth US$66.3 million. Forty-seven percent of this value came in sales of untreated water delivered by truck, 30 percent in sales of bagged water, 13 percent in sales from private kiosks, and just 10 percent in sales by the water utility. The metropolitan market for fecal sludge management is evaluated to be worth US$7.3 million. Revenues generated by the treatment facility run by the regional bureau of water and sanitation (Office Régional de l’Eau Potable et de l’Assainissement [OREPA]) OREPA Ouest represent less than 1 percent of the market value. Despite prohibitive prices, 59 percent of the metropolitan B40 resort to the private sector for drinking water, for water for other household needs, or both. Moreover, while around 55 percent of the metropolitan B40 had access to the public water network, just 38 percent used it for Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services xiii drinking purposes. The metropolitan poor lacking access to piped water usually buy water treated by reverse osmosis 5 (RO) and sold by private water kiosks to satisfy their drinking water needs; and untreated water from the Cul-de-Sac aquifer distributed by trucking companies (which is often resold to neighbors by households possessing a tank or cistern) for other domestic purposes. RO-treated water and truck water are on average 27 and 10 times more expensive than the water distributed by the utility, respectively. In 2012, the average metropolitan household dedicated 15 percent of its total expenditures to water—an extraordinarily high percentage. A few big companies dominate the water market while a myriad of small retailers adapt. Three major companies supply more than 75 percent of the RO-treated water sold in private kiosks. These kiosks—there are about two thousand of them in Port-au-Prince—are franchised by water-treatment companies, with the revenues shared 50:50. The bagged-water market is also very concentrated, with an atomized distribution. Bagging companies sell to wholesalers who sell on to large or small retailers, and finally to street-sellers. It is estimated that the livelihood of approximately 24,500 families in Port-au-Prince depends on the water market (that is, around 4.4 percent of the population in the metropolitan area), despite the fact that just 830 people are employed by the utility. Demand for pit-emptying and fecal waste transportation services is low and provided exclusively by the private sector. Although all households in the Port-au-Prince metropolitan area rely on non-network sanitation, with about 6 percent of households practicing open defecation, only 5.4 percent of the latrines in low-income areas have ever been emptied. In most cases, households report that their latrines have never filled up. When they do fill up, households often prefer to dig a new pit because it is cheaper than paying an emptier or because emptiers cannot get access to the existing pit. One company dominates the fecal waste removal market and offers services to the richest, while the poor must do without services. Various manual, mechanical, and hybrid service options are available to consumers. Service quality depends to a large degree on consumers’ willingness and ability to pay. In Port-au-Prince, although seven trucking companies regularly discharge wastewater or sludge in DINEPA’s treatment facilities, one dominates the market. These providers serve rich households and institutional clients. Manual emptying is a cheaper option but remains unaffordable for the poorest. Both mechanical and manual emptiers illegally dump fecal waste outside the Morne-à-Cabrit treatment facility. An NGO is piloting a container- based sanitation management model covering the entire chain of fecal sludge management. This management could be a good solution to serve the urban poor. DINEPA interprets its regulatory role to its strictest definition and lacks resources to operationalize it. Most DINEPA officials seem to believe that the regulatory authority of the institution is limited to water service providers managing piped systems. This narrow interpretation of the water law is mainly because DINEPA is still de facto an executing agency and an operator of WSS infrastructure. At the same time, it shares regulatory responsibilities over private WSS service providers with the Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population [MSPP]), the Ministry of Environment (Ministère de l’Environnement [MDE]), the Ministry of Commerce and Industry (Ministère du Commerce et de l’Industrie [MCI]), and local governments. In practice, none of these authorities, including municipal governments, is active in sanitation or has the capacity or resources to operationalize these responsibilities. Priorities and Recommendations The Haiti WASH Poverty Diagnostic concludes that there is an urgency to shift the paradigm of how the Haitian government operates in the WASH sector. Between 2006 and 2012, the situation with respect to access to WASH has not improved and even worsened in some areas. Reaching SDG 6 by 2030 requires an adaptation on how WASH interventions and investments xiv Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services are implemented. The Haiti WASH Poverty Diagnostic offers three entry points to maximize the socioeconomic impact of the scarce fiscal resources channeled to the WSS sector: 1. Improve the geographical targeting and increase the public funding channeled to areas where WSS are crucially needed. a. Dedicate greater efforts to improving access to WASH services in dispersed rural communities in which access to improved water and sanitation is actually decreasing (both in relative and absolute terms), poverty levels and the burden of waterborne diseases are high, and nutritional outcomes are low. b. Prioritize geographical areas and communities where WASH initiatives are likely to have the greatest effect on reducing the risk of enteric diseases. 2. Work across sectors to improve health outcomes of WASH interventions. a. Adopt communitywide approaches for all WSS and hygiene-related interventions, focusing not only on increasing access to improved water and sanitation facilities at the household level, but also on improving environmental health conditions and providing access to safely managed WASH services in public spaces and institutions. b. Develop WASH investments as part of multidimensional interventions to maximize health and nutritional outcomes, which depend as much on WASH variables as they do on other factors related to diet, parental care, and access to health care. 3. Recognize and take advantage of the predominance of the private sector in WSS service delivery in urban areas, adjusting the role of State accordingly. This requires a coordinated effort of multiple public institutions, spanning beyond the water sector. a. MSPP could focus on developing a water-quality-control system, building on the interest of large water companies facing unfair competition from smaller players applying lax water-quality standards. b. MCI could promote competition among large water companies and help water retailers develop collective bargaining mechanisms to purchase bulk water to bring down water price. c. DINEPA could transform its organizational culture, since today many of its officials see private water service providers more as competitors than as entities to be regulated. In addition, sector governance and regulation responsibilities could be separated from infrastructure development and management responsibilities. d. CTE could adopt public-private partnership (PPP) approaches for the development of more water-loading stations across the city to reduce transportation costs and water prices. CTE could analyze the possibility of adopting PPP approaches with local companies to improve utility efficiency. e. OREPA could enter into direct agreements with large institutional and commercial currently served by fecal waste trucking companies for the payment of the tipping fees. This in turn could (a) facilitate the control of illegal dumping activities, (b) eliminate an important economic disincentive affecting the willingness of service providers to properly dispose collected fecal waste, and (c) allow DINEPA to introduce cross-subsidies to make fecal sludge management services more affordable for the poor. Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services xv f. OREPA could also collaborate with NGOs running container-based sanitation management models co vering the entire fecal sludge service chain. This management model has been proven successful in similar contexts like Nairobi (Kenya) and Dar- es-Salaam (Tanzania) and may offer a good solution to serve the urban poor. Coupling their composting facility with fecal waste treatment plants run by OREPA may help to achieve sustainability. Notes 1. Throughout this report, “poverty” refers to the national definition; a household is deemed poor if household consumption per capita is lower than Haitian gourde (HTG) 81 per day (2011 purchasing power parity of US$3.64), and extremely poor if consumption is lower than HTG 42 per day (2011 purchasing power parity of US$1.86). 2. Enteric diseases are diseases of the intestine caused by any infection. These diseases are typically caused by pathogens such as Campylobacter, Salmonella, and E. coli. and enteric diseases are characterized by diarrhea, abdominal discomfort, nausea and vomiting, and anorexia. 3. The disability-adjusted life year (DALY) is a measure of the overall disease burden, expressed as the number of years lost due to ill health, disability, or early death. 4. There are 25 CTE in Haiti but one of these is not functioning; 24 CTE were retained for t he present study. 5. Reverse osmosis (RO) is a water purification technology that uses a semipermeable membrane to remove ions, molecules, and larger particles from drinking water. RO systems have very high effectiveness in removing protozoa, bacteria viruses, and common chemical contaminants. Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services xvii Abbreviations AEPA sanitation and drinking water distribution (ad duction d’eau potable et d’assainissement) B20 bottom 20 (lowest income quintile of population) B40 bottom 40 (two lowest income quintiles of population) BMI body mass index CAEPA community-based organizations local water committees (comité d’appro visionnement en eau potable et assainissement) CDC Centers for Disease Control and Prevention (United States) CIA T Inter-Ministerial Committee for Territorial Development (Comité Interministériel d’Aménagement du Territoire) CLTS community-led total sanitation CTE urban water operating center (centr e technique d’exploitation) CTE RMPP Port-au-Prince metropolitan water utility (centre technique d’exploitation de la région métropolitaine de Port-au-Prince) DALY disability-adjusted life year DGI General Direction of Taxes (Dir ection Générale des Impôts) DHS Demographic Health Survey DINEP A National Directorate for Drinking Water and Sanitation (Dir ection Nationale de l’Eau Potable et de l’Assainissement) ECVMAS Post-Earthquake Survey of Household Living Conditions (Enquête sur les Conditions de Vie des Ménages Après le Séisme) EMMUS Mortality, Morbidity and Service Usage Survey (Enquête Mortalité, Morbidité et Utilisation des Services) FGD focus group discussion FSM fecal sludge management GDP gross domestic product IDB Inter-American Development Bank IDP Internally displaced person HTG Haitian gourde xviii Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services IHSI Haitian Institute for Statistics and Informatics (Institut Haitien de Statistique et d’Informatique ) JMP Joint Monitoring Programme lpd liter per person per day MARNDR Ministry of Agriculture, Natural Resources and Rural Development (Ministère de l’Agriculture, des Ressources Naturelles et du Développement Rural) MCI Ministry of Commerce and Industry (Ministère du Commerce et de l’Industrie) MDE Ministry of Environment (Ministère de l’Environnement) MDG Millennium Development Goal MEF Ministry of Economy and Finance (Ministère de l’Economie et des Finances) MENFP Ministry of Education (Ministèr e de l’Education Nationale et de la Formation Professionnelle) MINUSTAH United Nations Stabilizaiton Mission in Haiti (Mission des Nations Unies pour la Stabilisation d’Haiti ) MSPP Ministry of Population and Public Health (Ministère de la Santé Publique et de la Population) MTPTC Ministry of Public Works, Transport and Communication (Ministère des Travaux Publics, du Transport, et de la Communication) m 3 /day cubic meters per day NGO nongovernmental organization OREP A regional bureau of water and sanitation (office r égional de l’eau potable et de l’assainissement) PPPs public-private partnerships PRM poverty risk model RMPP Port-au-Prince metropolitan area (région métropolitaine de Port-au-Prince) RO reverse osmosis SAEP drinking water supply system (système d’alimentation en eau potable ) SDG Sustainable Development Goal T20 top 20 (highest wealth quintile of population) TEPA C community water and sanitation technicians TDS turbidity and total dissolved solids TEPA C community water and sanitation technicians (techniciens en eau potable et assainissement communaux) [... middle sections omitted for long document ...] Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services 79 Table C.2: Percent of Children in Haiti with Adequate Food, Care, Environment, and Health Care, 2012 Factor National Bottom 40% Top 60% None 50 59 42 Food 9 10 7 Care 11 14 9 Environment 7 2 12 Health care 7 6 8 Food and care 4 5 3 Food and environment 1 0 1 Food and health care 2 2 2 Care and environment 2 1 4 Care and health care 1 0 2 Environment and health care 3 0 5 Food, care, and environment 1 0 1 Food, care, and health care 1 1 2 Care, environment, and health care 0 0 1 Food, environment, and health care 1 0 1 All four 0 0 1 Source: Vinha 2016. Note: Based on data from EMMUS 2012. EMMUS = Mortality, Morbidity and Service Usage Survey. Table C.3: Factors of Stunting in Haitian Children 0–23 Months Item National Rural Urban Bottom 40% Top 60% Adequate food 0.129 0.166 0.036 0.29 −0.077 Adequate care 0.125 0.114 0.18 0.056 0.236 Adequate WASH 0.331** 0.208 0.439** −0.275 0.335** Adequate health care 0.703*** 0.897*** 0.384 0.604 0.708** Adequate in food and care 0.268 0.163 0.905** 0.249 0.327 Adequate in food and WASH 0.108 0.252 −0.05 0.024 0.039 Adequate in food and health care 0.398 0.294 0.438 0.29 0.477 Adequate in care and WASH 0.088 0.015 0.093 −0.36 0.129 Adequate in care and health care 0.303 0.196 0.47 0.508 0.17 Adequate in WASH and health care 0.743*** 1.127*** 0.457* −0.229 0.707*** Adequate in food, care, and WASH −0.154 −0.244 −0.022 −2.117 −0.002 Adequate in food, care, and health care 0.132 0.208 0.035 0.264 −0.004 table continues next page 80 Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services References Skoufias, E. 2016. “Synergies in Child Nutrition: Interactions of Food Security, Health and Environment, and Child Care.” Policy Research Working Paper No. WPS 7794. Washington, DC, World Bank. http://documents.worldbank.org/curated/en/946101 4712 73366462 /Synergies-in-child-nutrition-interactions-of-food-security-health-and -environment-and-child- care. Vinha, K. 2016. “Multisectoral Approach for Nutrition: Haiti.” Background paper for the Haiti WASH Poverty Diagnostic. World Bank, Washington, DC. Table C.3: Continued Item National Rural Urban Bottom 40% Top 60% Adequate in care, WASH, and health care −0.618 −2.112*** −0.052 −0.723 Adequate in food, WASH, and health care 0.931** 0.405*** 1.627*** 0.827* Adequate in all four 0.3 1.158*** −1.499 0.196 Constant −0.722*** −0.748*** −0.657*** −0.803 −0.618*** Observations 1,651 1,143 508 869 782 R-squared 0.025 0.034 0.033 0.017 0.037 Source: Vinha 2016. Note: Tables shows results of ordinary least squares regression using 2012 EMMUS data. Bottom 40% and top 60% were computed using wealth index in EMMUS data. EMMUS = Mortality, Morbidity and Service Usage Survey; WASH = water supply, sanitation, and hygiene. *p<0.10, **p<0.05, ***p<0.01. Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services 81 Appendix D WASH Poverty Risks Model (WASH-PRM) The WASH poverty risk model (WASH-PRM) assesses patterns of disease risk across economic and geographic subpopulations by combining rigorous estimates of the effects of exposure and susceptibility factors on disease with country-specific data on the distribution of these risk factors (Rheingans and others 2016). The primary purpose of the model is to describe how diverse and interrelated risk factors may contribute to the way in which the national diarrheal disease burden is distributed across subpopulation groups (for example, between wealth quintiles). These descriptions are both quantitative (by economic group and setting) and spatial in nature. Understanding of the codistribution of these risk factors is used to identify the most consequential factors or combination of factors that require intervention. The conceptual framework for the WASH-PRM combines key exposure factors and susceptibility factors that are most relevant to diarrhea. Exposure factors include WASH-related elements that influence the risk of diarrheal disease. Relative risks for individual exposure risk factors are combined into a single exposure index. Susceptibility factors address individual risk factors, such as underweight, vitamin A, and oral rehydration therapy. Quantitative risk estimates for each factor are combined into a single susceptibility index. Relative risk is a concept commonly used in public health and epidemiology to quantify how a particular risk factor may increase or decrease the risk of a specific health outcome. A relative risk less than 1 means a factor is protective; a relative risk greater than 1 means a factor increases the risk. The WASH risk index combines quantitative information on household WASH and health to quantify the relative risk of adverse child health outcomes as a result of inadequate WASH practices (table D.1). The index, calculated at the level of the child, combines information on the child’s household WASH characteristics, individual health vulnerabilities, and the relative risk associated with each factor. The relative risks for each factor are multiplied to develop the cumulative risk index. The weight of each is based on the evidence in the literature. The combined relative risk scores are broken into an exposure index (with the WASH variables) and a susceptibility index (with the health-related factors). 82 Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services References Rheingans, R., K. H. Bagamian, J. D. Anderson, S. J. Ryan, L. A. Laytner, K. McNamara, M. P. Amaya, J. Watson, and O. Cumming. 2016. “Poverty Risk Model Assessment: Haiti.” Background paper for the Haiti WASH Poverty Diagnostic. World Bank, Washington, DC. Vinha, K. 2016. “Multisectoral Approach for Nutrition: Haiti.” Background paper for the Haiti WASH Poverty Diagnostic. World Bank, Washington, DC. Wolf, J., A. Prüss-Ustün, O. Cumming, J. Bartram, S. Bonjour, S. Cairncross, et al. 2014. “Systematic Review: Assessing the Impact of Drinking Water and Sanitation on Diarrhoeal Disease in Low- and Middle-Income Settings: Systematic Review and Meta-Regression.” Tropical Medicine & International Health. 19 (8): 928–42. Table D.1: Relative Risks Associated with Various Water and Sanitation Scenarios Scenario Relative risk for water Relative risk for sanitation Combined relative risks 1: No improved water access, no improved sanitation access 1.00 (A) 1.00 (A) 1.00 2: Improved off-plot water access, no improved sanitation access 0.89 (B) 1.00 (A) 0.89 3: No improved water access, improved sanitation access 1.00 (A) 0.84 (B) 0.84 4: Improved off-plot water access, improved sanitation access 0.89 (B) 0.84 (B) 0.75 5: Improved on-premises water access, improved sanitation access 0.77 (C) 0.84 (B) 0.65 6: Improved on-premises water access, sewered sanitation 0.77 (C) 0.31 (C) 0.24 Note: Relative risk values are from Wolf and others 2014. Map D.1: Regional Exposure Index and Susceptibility Index for Children in B40 Source: Rheingans and others 2016. <2.70 2.70–2.74 2.75–2.79 2.80–2.85 >2.85 <0.70 0.70–0.79 0.80–0.89 0.90–1.00 >1.00 a. Regional exposure index b. Susceptibility index W17021 Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services