Sewerage

Works
Public
investment
in sewers
saves lives
David Hall and Emanuele Lobina

Public Services
International
Research Unit
Contents

Foreword 1

1_Summary 2

2_Sewers and sanitation 4

2.1_The greatest medical milestone in the last 167 years 4

3_The Millennium Development Goals (MDGs) for sanitation 6

3.1_MDG targets and policies 6

4_Death, sewers and cities 8

4.1_Cholera and diarrhoea 8
4.2_The impact on children 8
4.3_The need for sewers in cities 10
4.4_A new target for urban sewer connections 12

5_The need for public finance 15

5.1_Cost recovery and the private sector 15
5.2_The problems of cost recovery 16
5.3_The solution of public finance 17
5.4_The illusion of private sector investment 19
5.5_Development in the south: public sector and public finance 26
5.6_Taxation needed 30

6_Costs, benefits and affordability 31

6.1_Costs 31
6.2_Cost benefit analysis 32
6.3_Economic capacity 33
6.4_What can be afforded: comparative spending and revenue decisions 40

7_Conclusion 42
Analytical conclusions 42
Policy conclusions 42

8_Further reading 44

9_Annex: Calculation of tables on needs and affordability 46

Endnotes 52
Foreword
Sewerage Works
Public investment in sewers
saves lives

Using the toilet is something we take for granted in the West. We pay little
attention to what happens to the waste when we flush it away and we
assume the sanitation services will always be available when we need them.

This is not the case for people living in developing countries, where 2.6
billion people have no access to even the most basic toilet facilities. The
situation is worst in sub Saharan Africa where 62% of the population have
no access to municipal sanitation services. Thousands suffer waterborne
diseases every day, caused in part by improper, or non-existent removal and
treatment of human excreta. Many children, especially girls, are unable to
attend schools for lack of sanitation facilities. The impact of lack of sanitation
services on human health and economic development is staggering.

Public services are essential for sustainable pro-poor development. For

many years, public sector solutions to water and sanitation crises for
the poorest people have been dismissed as unaffordable and idealistic.
This report argues that public sewerage systems will make a significant
difference to urban sanitation by saving 326,000 infant deaths every year.
Against conventional wisdom, the report finds that the cost of implementing
urban public sewerage systems is affordable and can be met through
taxation for most countries. For a limited number of low-income countries,
only $7.9 billion of aid is needed to meet the shortfall.

The report calls for an end to the demands for full cost recovery as a pre-
condition of investment in water and sanitation services. Full cost recovery will
never enable countries to tackle the needs of the urban poor. Investment in
sewerage must be seen by donors and governments alike as a public good that
will benefit many generations to come. This was the justification for municipal
sanitation in Western Europe when a similar need for investment existed in
the 19th Century. Crucially, the report argues that we must fund the public
sector to deliver the necessary sewerage systems because, as the evidence
shows, the private sector cannot be relied upon to meet this need. It has
failed to deliver any significant investments in sewerage in the last 15 years.

UNISON, the UK’s largest public service trade union, and PSI, the global union
federation for public sector trade unions, have researched and campaigned
for many years on public sector solutions to water and sanitation problems
in poor countries. We represent thousands of public service workers who
deliver water and sanitation services in the UK and around the world. Their
first-hand experience informs our campaigning and policy work.

We hope the report will stimulate debate on the role of public sewerage
systems in dealing with sanitation in urban areas. Sewerage works.

Dave Prentis Peter Waldorff

General secretary, UNISON General secretary, PSI

1
1_Summary

This report focuses on a particular aspect because faeces from unconnected households
of sanitation, the importance of sewerage increases the health risks of all households.
systems. The introduction of the ‘sanitatary
system’ of household connections to sewers The problem is acute in some major
flushed by water has been voted as the cities, such as Jakarta, Indonesia, with a
greatest medical milestone since 1840. population of 12 million, but with only 1%
But although this system is universal in the of households connected to a sewer. Urban
north, developing countries continue to lack sewers are not a northern invention but
urban sewerage systems (Section 2). a traditional urban technology developed
in south Asia 4,000 years ago. The
The UN estimates that nearly 1.5 billion benefits can be delivered by conventional
people need access to improved sanitation sewerage systems or other systems such
by 2015. But the Millennium Development as condominial sewerage (Section 4.3).
Goals (MDGs) definitions only specify
‘improved sanitation’, do not require sewerage The MDGs should include a specific target
connections, and emphasise the use of for urban sewerage: “To halve by 2015 the
‘lowest-cost’ solutions. As a result, they fail proportion of the urban population without
to address the needs of city dwellers for household connections to a sewerage system”.
sewerage connections and so fail to give This entails connecting a further 1.14 billion
proper weight to the enormous public health people by 2015. Half of this need for urban
benefits of sewerage connections (Section 3). sewerage connections is concentrated in
four countries: China, India, Indonesia and
Cholera and diarrhoeal diseases are the Brazil; and 90% of the global need for urban
major health problems in the absence of sewerage connections is in just 24 countries
sanitation, especially for children. They kill with some combination of high economic
about two million children a year in low and growth, high urban populations, or low
middle-income countries – more than malaria, existing levels of sewerage (Section 4.4).
measles and HIV/Aids combined. With sewers,
infant mortality rates are lower. Achieving Donors and international institutions are
universal coverage could save 326,000 infant wrongly emphasising full cost recovery from
lives per year – the equivalent of eliminating users and privatisation as a way of developing
infant deaths from HIV/Aids. Children in sanitation systems. They also argue that
homes without sewers are shorter, and their sewers are unaffordable. This is misleading
educational achievements lower, than children and unhelpful. Sewerage is a public good,
in households connected to sewers. Toilets and leaving it to individual spending choices
and piped water alone do not make up for does not deliver the coverage needed for
the lack of sewerage (Section 4.1-4.2). full public benefits. Full cost recovery makes
sewerage unaffordable to the poor.
The problem of ignoring sewers is greatest All existing urban sewerage systems in
in urban areas, where world population is high-income countries – in Europe, North
growing fastest. Hygienic practices such America, and Japan – were developed
as hand washing and household toilets through taxation and the public sector, not
help, but the problem of disposal of faeces through full cost recovery from user charges
remains. Cess pits and septic tanks do not by the private sector. Connection was made
provide the same benefits due to leakage and compulsory as a matter of public policy
contamination; recycling onto fields is not an and not subject to consumer choices to opt
option in cities. Universal coverage matters in or out. The European Union continues
2
 Sewerage Works
Public investment in sewers
saves lives

to provide high levels of subsidies from countries, especially in Africa, notably Nigeria
taxation for countries in eastern Europe to and the Democratic Republic of Congo. This
develop water and sanitation systems. would require a redistribution of the present
pattern of aid, which is too concentrated in
The private sector has failed to deliver any countries with relatively low needs are target
significant investments in sewerage (or markets for multinational water companies. The
other urban infrastructure) in the south in total amount of aid required is also affordable
the last 15 years. By contrast, some major for developed countries. It represents a fraction
developing countries are already achieving of the cost of the war in Iraq, for example, and
significant extensions of sewers in cities the UK government support for the troubled
through public finance. In China for example, bank Northern Rock alone would cover half
the urban sewerage connection rate rose the total global needs for sewers (Section 6).
from 30% in 1990 to 50% in 2002, and is still
rising. In Brazil, the connection rate in the Developing countries should continue to adopt
city of Salvador (2.5 million) was increased policies of extending sewerage systems using
from 26% to 80% in just eight years. public finance and concentrate on raising tax
These national efforts can be supported by revenues to finance them. They should resist
donors, for example Japan provides training advice to raise user charges and introduce the
support through a series of public-public private sector. Donors should stop giving this
partnerships. Since public finance is the advice, and instead concentrate on providing
key mechanism, the issue is not increasing aid to those countries most in need of it, along
user charges but whether countries are with capacity building and training (Section 7).
raising sufficient taxation (Section 5).

The costs of meeting the MDGs in full, and

extending urban sewerage connections,
are affordable. Even using the highest cost
estimates from WHO and World Bank officials,
the economic and public health benefits of
investing in sewers far outweigh the costs,
as demonstrated by recent cost-benefit
analyses. The actual spending required
represents an affordable proportion of gross
national income (GNI) in countries with the
majority of those needing connection.

Donor arguments that sewers are unaffordable

are based on a misleading assumption
that they should be financed by personal
consumption. If taxation is used, then the
question is about the capacity of the national
economy. For 14 of the 20 countries with the
greatest need, urban sewerage connection
targets can be achieved at a cost of less than
1% of GDP per annum. Where the cost is
above 1%, countries may need aid. This need
is concentrated in a number of low-income
3
2_Sewers and sanitation

“The sewer is the conscience of the city” people killed by infectious diseases. The
Victor Hugo, Les Misérables motive was not just humanitarian: the
from UN World Water Development diseases were killing off male breadwinners
Report (WWDR), 2006 and pressure was being put on the state
to carry the cost of supporting the families.
“Urban poverty is not merely a simple The removal of sewage was crucial to
problem brought on by low incomes: it is curb the diseases, and the main reason
more of a matter of poor quality of life as for connecting every house to clean
characterised by very limited access to water was to flush away the sewage. All
clean water and sanitation, health care, households, rich and poor, were connected
education, and economic activities.” 1 to water supply and sewers. The system
was financed and run by the public sector.
This report is about the sewerage systems of
cities. It argues that the health benefits of such This solution included four key features:
systems are too great for them to be treated as — the technology to develop a network of
an optional extra, especially in cities. The view sewers throughout the city, flushed by water
that sewers have to be financed by charges to — public administrative structures to finance,
households, and that the private sector might build and manage these expensive works
provide the necessary investment, is shown to — the recognition that sewers were a public
be mistaken: public finance needs to be the environmental measure, rather than an
basis of developing sewerage systems. When attempt to alter individual behaviour
the costs of urban sewerage are measured — a recognition that the sewers were a
against national economies, the sums are universal public measure applied to
affordable, and some countries are already everyone, not selectively targeted. 3
investing the necessary amounts to deliver
these systems. The amount of aid required to These same principles have been applied
support national programmes is also affordable in every high income country in the world.
for high income donor countries, and needs England achieved near-universal coverage
to be targeted at countries most in need of before the Second World War, but others,
assistance; not those where the private sector such as France, did not do so until much later
sees the opportunity for profitable markets. in the 20th century. It was very expensive
to develop the system (as it is today in
developing countries) and it was financed
2.1_The greatest medical from taxation or massive cross-subsidies. 4
milestone in the last 167 years
The same principles were used for the
In January 2007, over 11,000 readers of the development of sanitation in cities across
British Medical Journal (BMJ) chose “the sanitary the USA. Cities, towns and even villages
revolution” – connecting people’s homes both in these countries have piped water and
to clean piped water and to sewers to dispose sewerage connections to all houses. In
of their waste – as the most important medical Europe, every village with a population
milestone since 1840. They thought it was of 2,000 or more must have a sewer
more important than antibiotics, vaccination system collecting household waste. 5
or the discovery of the structure of DNA. 2
The extension of systems to the villages
The system was first introduced in London of Europe has taken a long time. But in
in the 19th century to reduce the number of developing countries, many cities and towns
4
 Sewerage Works
Public investment in sewers
saves lives

are still waiting for the sanitary revolution costs by cost-benefit analysis and their
to reach them. They lack the sewerage affordability for national economies
systems, which protect the northern cities. — the potential requirements for assistance
The rate of death and disease in developing from international aid, and comparison
countries continues to reflect this. with other expenditure choices
— the conclusion, with recommendations
Through the Millennium Development for country and donor policies.
Goals (MDGs), the countries of the world
are committed to improving sanitation
in developing countries. However, the
current policy of donors and development
banks implementing these goals are often
at odds with the key principles of the
sanitary revolution. This is because they:
— avoid commitment to the expensive works
of building sewers flushed by water
— are failing to support public sector finance
and public sector organisations to introduce
these systems, preferring to plan on the
basis of cost “recovery” from users
— do not prioritise public
environmental measures
— prefer “targeted”solutions to
a universal approach.

This report addresses these issues

and argues that sewerage systems are
necessary, achievable and affordable.
It consists of the following:
— a critical account of the
limitations of the MDGs
— a presentation of the compelling
public health case for sewers
and their necessity in cities
— an account of the central role of public
finance in developing sewerage systems
— the failure of the system to recover
costs through user charges
— the risks of relying upon private
sector investment
— a review of past and present programmes
of public investment which have succeeded
in developing urban sewerage systems
— a discussion of the costs of achieving
the MDGs and the extra costs of a target
for urban sewerage connections
— an assessment of the affordability of these
5
3_The Millennium Development Goals (MDGs)
for sanitation

3.1_MDG targets and policies The numbers needing improved sanitation

are greatest in rural areas, especially in South
Improved sanitation was adopted by the and East Asia, and the existing standards
United Nations as the seventh Millennium are also lower in rural areas: in 2004 only
Development Goal (MDG), which addresses 33% of the rural population of developing
environmental sustainability, with a further countries had access to improved sanitation,
target (no.10) to “halve by 2015 the proportion compared with 73% of the urban population. 9
of people without sustainable access to
safe drinking water and basic sanitation”. The MDGs have undoubtedly helped attract
publicity and policy attention to the need for
The UN Millennium Task Force produced a developing water and sanitation in developing
report on achieving the goals for water and countries, but in respect of sanitation there
sanitation in 2005 (UN Millennium Project).6 are a number of serious limitations:
Progress towards the targets is monitored — the targets do not give sufficient weight to
by the Joint Monitoring Programme (JMP) the urgent public health reasons for sewerage
of the World Health Organization (WHO) — the MDGs do not recognise the very specific
and the United Nations Children’s Fund importance of sewerage systems in cities
(UNICEF)).7 It is also the subject of reports — too much emphasis is given to misleading
every three years, which are entitled the World assumptions about affordability.
Water Development Reports (WWDR). 8
The Task Force and the JMP have
Since then, the original estimates of the introduced modifications to the definitions
improvements needed to achieve the MDGs of the MDG. These modifications emphasise
have been updated. The JMP now estimates that solutions that cost less than sewers
that nearly 1.5 billion people will need to are both acceptable and preferable.
be given access to improved water and
sanitation to meet the targets in 2015. 3.1.1_What is “improved”?

Table 1: Although the MDG refers to “safe” drinking

Millions of people needing access water and sanitation, the JMP measures
between 2005 and 2015 for MDG targets progress, according to the percentage of
people using “improved” facilities. The JMP
Region Water Sanitation defines “improved” sanitation facilities as
Northern Africa 33 33 those which “are more likely to prevent human
Sub-Saharan Africa 288 345 contact with human excreta than unimproved
Latin America and Caribbean 80 104 facilities”, and lists these as including any
East Asia 184 288 of: “flush or pour-flush to a piped sewer
South Asia 247 508 system, septic tank, or pit latrine; ventilated,
South East Asia 98 102 improved pit latrine (pit latrine with slab or
West Asia 48 56 composting toilet)” but only if these facilities
Oceania 4 3 “are not shared or are not public”. 10
CIS (former Soviet Union) 5 18
All developing regions 1,002 1,463 This means that urban households can be
counted as having “improved’”sanitation,
Source: JMP 2006 p.40 (see Annex). Note: regional figures do not sum even without a sewer connection. It also
precisely to overall totals in original. means that the health benefits of achieving the
MDG on sanitation are much reduced. Even
6
 Sewerage Works
Public investment in sewers
saves lives

if the MDGs are met, it has been estimated having a sewerage connection in 2004 — far
that 76 million people will die by 2020 of lower than any other region. And at a country
preventable water-related diseases. 11 level, Pakistan is considered “on track” to meet
its overall MDG sanitation goals, and to have
3.1.2_What is “sustainable”? increased the proportion of its urban population
with improved sanitation from around 80%
The UN task force has also refined the definition in 1990 to over 90% by 2004. This is despite
of safe sanitation as follows: “the lowest-cost the fact that over the same period, the urban
option for securing sustainable access to safe, percentage with sewerage connections actually
hygienic, and convenient facilities and services for fell, from around 45% to under 40%.14
excreta and sullage disposal that provide privacy
and dignity, while at the same time ensuring a The following table shows the gap between
clean and healthful living environment both at the MDG definitions and actual sewerage
home and in the neighbourhood of users.” 12 connections for urban populations. In 2004, 73%
of the urban population in developing countries
The most striking feature of this definition is had access to improved sanitation, but only
that it introduces “lowest cost” as part of the 42% had sewerage connections. The gaps were
target itself. Sewers are not ruled out, but they especially wide in Sub-Saharan Africa, South
are clearly not the ”lowest cost” solution. Asia and South East Asia. By contrast, in the
developed countries of Western Asia (roughly
It also explains that “sustainable” in this the Middle East) and the former Soviet Union the
definition, includes the economic sustainability level of sewerage connections are over 80%.
of the service, which is defined as requiring:
“credible arrangements to ensure a regular Table 2:
and reliable flow of adequate performance- Urban population with
determining resources – human, financial, (a) access to “improved” sanitation
institutional, and technical know-how, (b) sewer connections 2004
among others – needed to ensure proper
functioning and satisfactory operation and Region
Urban
population
% with
improved
% with
sewer
(billions) sanitation connection
maintenance of service infrastructure.” 13
Sub-Saharan Africa 0.27 53 19
East Asia 0.58 69 50
While this is an important aspiration, it South Asia 0.46 63 24
also makes public improvements, such South East Asia 0.24 81 9
as sewers, look even more costly. Latin America and Caribbean 0.43 86 62
Oceania 0.02 81 32
3.1.3_The limitations of the MDG Northern Africa 0.08 91 73
definitions: no sewers necessary Western Asia 0.13 96 83
CIS (former Soviet Union) 0.18 92 82
The MDG definition of “improved” sanitation Developed countries 0.76 100 93
does not require household connection World total 3.11 80 56
to sewerage. This makes a significant
difference to the assessment of the problem, Source: JMP online data (see Annex)
and of the extent to which the MDGs
indicate a solution, especially in cities. These modifications and policies fail to
For example, South East Asia is considered give sufficient weight to the enormous
”on track” for meeting the MDG sanitation public health benefits of sewerage
goal, despite only 9% of urban households connections, especially in cities.
7
4_Death, sewers and cities

“The obvious benefits to poor people of a year in low and middle income countries.
increased provision of sewerage facilities The incidence of diarrhoeal diseases has not
should serve as the mandate for greater decreased significantly in recent decades. 19 20
investment by all levels of government
and civil society in tackling one of the There have been great advances and efforts
greatest scourges to communities made to reduce child deaths from diarrhoea
in developing countries — infectious by improved healthcare, but their impact
diarrhoea due to poor sanitation.” has been much lower than hoped for. In the
David Durrheim, writing in the 1980s it was estimated that two thirds of
Lancet, 10 November 2007. 15 deaths from diarrhoea could be avoided if all
children suffering from diarrhoeal diseases
were treated with water containing a sugar/
4.1_Cholera and diarrhoea salt solution – known as oral rehydration
therapy (ORT). The WHO and the UN Childrens’
Cholera and diarrhoeal diseases, both Fund (UNICEF) led a major programme of
transmitted through contaminated food training and the production of suitable kits.
and water, are the major health problems However by 2003, still only about 40% of
in the absence of sanitation. Outbreaks of children were being treated with ORT. 21
cholera are most likely in countries with
high infant mortality rates which, in turn, This emphasises the importance of public
are strongly linked to diarrhoeal diseases. health measures. A recent WHO editorial
The common factor is the absence of estimated that over 9% of the global disease
adequate sanitation systems.16 burden could be prevented by improved
water supply, sanitation and hygiene, with
Cholera epidemics in the 19th century led the greatest impact coming from reductions
to the creation of sewerage systems in in diarrhoeal disease. “The slow progress in
London and New York, and subsequently the extending basic services leaves a billion people
rest of Europe and north America. Cholera waiting in line for services to reach them.”22
epidemics no longer affect London and New
York, but they continue to be major killers in
developing countries. In 2006 the World Health 4.2_The impact on children
Organization (WHO) recorded 236,896 cases
of cholera with 6,311 deaths in 52 countries. 4.2.1_Infant mortality and sewers
This was a 79% increase in cases since 2005,
and was a return to the levels of the 1990s.17 The greatest impact of inadequate sanitation
and sewerage is on children. More than 10
The sanitary revolution brought about through million children under the age of five years
sewerage systems could curb cholera in die each year, most from preventable causes.
the south as it has in north. According to Three hundred and sixteen out of every 1,000
a global medical review: “The longterm children die before they are five. Almost all
prevention of cholera will require improved these deaths are in poor countries: three
water and sanitation facilities, but these quarters of them are in Sub-Saharan Africa
improvements are not happening rapidly in and South Asia. Diarrhoea and pneumonia
most regions where cholera is prevalent.”18 are the biggest two killers, each responsible
for over two million deaths each year.
Diarrhoeal diseases, including dysentery,
continue to kill around two million children
8
 Sewerage Works
Public investment in sewers
saves lives

Table 3: holding other factors, such as income,

Causes of death of children constant.27 As the household sewerage
under five, globally connection increases, the infant mortality rate
drops. If the level of sewerage connection is
Millions of child deaths, annually as low as 15%, (this is the average for most
Neonatal 3.9 African countries), then infant mortality is 95
Pneumonia 2.0 per 1,000. If sewerage connections rise to
Diarrhoea 1.9 80%, infant mortality falls to 65 per 1,000.
Malaria 0.8
Measles 0.4 These massive health gains from sewers
HIV/Aids 0.3 in cities have been demonstrated in the
Injuries 0.3 city of Salvador, Brazil, where diarrhoeal
Other 1.0 diseases fell by over 20% as a result of
Total 10.6 installing sewers (see Section 5.5.2).

Source: Bryce et al. 2005 23 Chart A:

Infant mortality and sewerage connections
The risk of dying from these diseases is strongly
increased by the absence of water and sanitation: 100

“Unhygienic and unsafe environments place

children at risk of death.” 24 Simply because of
80
its effectiveness in curbing diarrhoeal
diseases, universal water and sanitation
provision could save 326,000 infant lives per
60
year. This is the equivalent of eliminating all
infant deaths from AIDS.25 Infant mortality rate per thousand

40
Table 4:
Under fives’ deaths that could be
prevented by universal coverage of most
20
effective preventative interventions

Number of under fives’ deaths preventable

0
10 20 30 40 50 60 70 80 90 95 100
Breast-feeding 1,301,000
Sewerage connections % of households
Insecticide-treated materials 691,000
Complementary feeding 587,000 Source: Shi 2000 Table 4. 28
Zinc 459,000
Clean delivery 411,000
Hib vaccine 403,000
Water, sanitation, hygiene 326,000

Source: Jones et al. 2003 26

A World Bank study of 92 major cities

demonstrated the clear relationship between
sewerage connections and child mortality
9
4_Death, sewers and cities

4.2.2_Children’s growth and education most without sewerage systems. There are
three features which make urban sewerage
A lack of sewers not only leads to more infant systems of particular importance:
deaths through higher rates of diarrhoeal
disease. The higher rates of disease also — urban populations are growing fast
cause long term damage to the physical — a significant proportion of urban dwellings
growth and the educational progress of are in slums, where the health problems
children who survive. Children in homes of diarrhoeal diseases are most acute
without sewerage and water connections — the safe collection and disposal of
have more episodes of diarrhoea. This human faeces is much harder in
damage to their health stunts their growth. densely populated areas which do not
Diarrhoea in childhood is also clearly linked have easy access to countryside.
to lower scores in non-verbal intelligence
tests and worse performance at school. Programmes to improve sanitation in
developing countries include a range of
A study in Peru 29 demonstrated these initiatives. Many are concerned with the
remorseless links between sewerage systems, creation of toilet facilities, which are an integral
disease and disability. Children in households part of a comprehensive sanitation system. The
without sewers had a 54% higher rate of disposal of faeces also has to be addressed,
diarrhoeal disease. Children in households and in a rural context this may involve various
without a sewage connection were 0·9 cm forms of septic tank, for example. Hygienic
shorter at two years of age than children from practices are also necessary in order to obtain
households with sewerage connections. the health benefits of improved sanitation, for
example hand-washing after defecation. All of
Toilets alone, without sewerage connections, these initiatives are important and valuable.
made much less difference: by the age of two,
the children in these households had the same But in an urban context, the benefits of toilets
rate of diarrhoeal diseases as those with no and hygienic practices are much more limited
latrine/toilet at all, and were not significantly taller. without a sewerage system to ensure safe
disposal of excreta.31 Attempting to dispose
Sewerage connections also make a greater of human waste without sewers, through the
difference than a piped water connection use of soak-pits or septic tanks, does not
alone. Children in houses with piped water, remove the waste from the urban environment.
but no sewerage connection, were shorter These solutions do not provide the same
than those in households with sewerage health benefits as sewers. A survey in Pakistan
connection as well as piped water. 30 found that infants in households with soak-
pits were 60% more likely to die than those
with toilets connected to sewers.32 Household
4.3_The need for sewers in cities toilets without a sewerage connection may
actually increase the contamination of the
There is a need for sanitation in all areas, neighbourhood, and thus endanger other
rural and urban and the benefits of sewerage households. 33 In rural areas it may be feasible
systems apply in all human settlements, even to recycle excreta as a fertiliser on fields, but
at village level. The needs of rural populations this becomes uneconomic as cities grow and
must be met by public policies, supported by absorb farming land and it is common for water
aid, as much as the needs of urban populations. borne diseases, such as typhoid, to become
However it is urban populations who suffer more prevalent in these conditions.34 However
10
 Sewerage Works
Public investment in sewers
saves lives

a household with a sewerage connection neighbour’s well. Many tanks leak too. Some
still has a higher risk of disease if the streets are more like pits, because the base of the
are contaminated with sewage from other tank is not sealed and some have walls made
households which are not connected. 35 Even the of ordinary bricks or are too small. Some have
disposal of wastewater from household activities inlet pipes that are not functioning properly.
such as washing and laundry – known as ”grey
water” – “is a major problem in low income The contents of these septic tanks are often
settlements without sewerage and represents a dumped by sewage trucks straight into rivers.
significant health and environmental threat”. 36
Many urban people still use river water for
As the UN’s World Water Development washing and bathing and, collectively, these
Report (WWDR) 2006 states: millions of septic tanks have polluted 70% of the
groundwater in cities with bacteria. Yet half of city
“While household solutions may be sufficient dwellers use this groundwater for their daily needs.
in a rural environment or in a dispersed
settlement, they would be woefully inadequate 4.3.2_The ancient South Asian
in an urban area, especially in urban slum tradition of urban sewers
areas or in congested urban areas and
megacities. For such situations, we would Some argue that sewers and wastewater
need to go beyond access at the household treatment plants are an inappropriate northern
level to provide proper collection systems, technology, at odds with the environment
such as an appropriate form of sewerage, and traditional wisdom. A paper published
together with facilities for treatment and by the German aid agency GTZ in 2006, for
disposal of the collected sewage.” 37 example, argued that end-of-pipe sanitation
systems are “expensive to build, operate
4.3.1_Case study – Indonesia and maintain, and out of step with traditional
wastewater management philosophy”,
The need for sewers in cities is well which was based on the principle of
illustrated by the example of Indonesia. 38 re-use and recycling of human waste. 39

The great majority of people in Indonesian It is important to respect and use local traditions
cities live without a sewerage connection. and knowledge in all countries, but this is
In the capital city, Jakarta, which has a not a reason for avoiding the development of
population of 12 million people, only 1% sewerage systems. In urban environments,
of houses are connected to a sewer. sewers are the traditional technology – a
technology that was first developed in the
Around 12% of the urban population have no ancient cities of South Asia 4,000 years ago.
access to latrines, so they defecate outdoors. The first urban sewerage systems were built
Some of the houses with latrines empty their around 2,000 BC by the inhabitants of the
contents directly into streams or rivers. great cities of the Indus Valley civilisation
The majority, around 65% of houses in urban at Mohenjo-Daro (now in Pakistan).
areas, use septic tanks. In Jakarta alone,
there are more than one million septic tanks. They installed universal systems: almost
every house was connected. “Wastewater
More than 60% of homes have septic tanks was conveyed in baked clay conduits to
that are less than 10 metres apart from their covered gutters, then through canals dug
wells and they are often too close to their under the streets and covered with bricks,
11
4_Death, sewers and cities

and finally to larger collectors. Settling tanks sewers throughout the city, including the
existed in this network to prevent clogging”. slums: “OPP’s proposal for sewage disposal
The main sewer was 1.5 metres deep.40 for Karachi is now the KWSB’s [Karachi Water
and Sewerage Board] plan for the city costing
Other ancient urban civilisations also used Rs.8.85 billion (about US$121 million). The
sewers. In Ancient Rome, there was even a plan has been approved by the provincial
shrine to a goddess of sewers, Cloacina. 41 and federal government for its financing.” 44

4.3.3_Sewers, slums and Public authorities in Brazil developed

condominial sewerage “condominial” sewerage systems as a
cheaper method for providing sewerage,
A large part of the urban population in using narrower pipes installed at shallower
developing countries lives in informal depths under back alleys or pavements, rather
settlements in slum areas. Here, the health than under streets. Condominial systems, or
benefits of sewerage may be twice as high simplified sewerage, are not an alternative to
as in other urban settlements, because of the sewers – they are sewers, built using cheaper
combination of living conditions and poverty. 42 construction techniques. The system has
been adopted by some public authorities as
Therefore, some major initiatives have a standard. For example, the sewerage board
focused upon improving conditions for of Brasilia, the capital city, use condominial
slum dwellers. Here are some examples: systems throughout the city, not just for poor
areas. However the installation of condominial
In the slums of Indore City, India, a sewerage sewers requires skilled workers and a “lack of
network was constructed in the roads and trained engineers is a major constraint to the
side paths of city slums, paving the streets implementation of condominial sewerage.”.45
and redeveloping the riversides. This was
funded by the public authorities, and supported
by aid from the UK. Residents were given 4.4_A new target for urban
official long-term land leases by the public sewer connections
authorities, effectively legalising their tenure. 43
Because of the above factors, the MDGs
The Orangi pilot project (OPP), in Karachi, should be revised so that the target for
Pakistan, was created by a community urban sanitation, at least, is specifically for
organisation who planned and developed a household sewerage connections – not merely
sewerage network throughout the area. It was “improved” sanitation. It would then read:
constructed by paving the lanes over sewers,
following natural drainage channels. It was “To halve by 2015 the proportion of the
built using local labour and micro finance. The urban population without household
municipal authority built large mains sewers in connections to a sewerage system.”
the settlements to support the development.
The same principles have been applied in other The following table illustrates the number of
towns and cities in Pakistan, with investments people in cities in developing countries needing
financed by the Government and development household connections to sewers, in order
banks. The project has successfully to achieve this goal. It is based on JMP data
campaigned for the principles of this approach for urban sewerage connections, and the UN
to be adopted by the Karachi Water and urban population forecasts for 2015. The JMP
Sewerage Board, as the basis for developing data on household connections to sewers
12
 Sewerage Works
Public investment in sewers
saves lives

is not certain enough for exact conclusions, in these regions to rise from an average
but the results can be used to indicate the of 41% in 2004 to an average of 71% in
differences between the existing and 2015. Based upon World Bank estimates
proposed goals. measuring the relation between sewerage
connections and infant mortality (see Table
The total figure is higher than the comparable 4), this could be expected to reduce infant
number in the existing MDG target for mortality in relevant urban areas from about
urban improved sanitation. The regional 84 children per thousand to about 70 per
distribution also differs from the MDG thousand. Moreover, the needs are highly
targets for “improved” sanitation, with a concentrated in relatively few countries.
much higher concentration of needs in
East, South and South East Asia. North This target is quite feasible. For all regions,
Africa and West Asia are already close including South East Asia, which requires
to the level of high income countries. the greatest leap, it is less demanding
than the achievement in Salvador, Brazil,
The target would require the levels of which moved sewerage connections
urban household sewerage connections from 26% to 80% in eight years.

Table 5:
Millions needing connections to halve proportion of urban
population without sewerage connection by 2015

Millions %
Numbers of people needing 2004 % urban household 2015 % urban household
connection to achieve target sewerage connection sewerage connection after
achieving target
Northern Africa 46 73 87
Sub-Saharan Africa 179 19 60
Latin America and Caribbean 146 62 81
East Asia 273 50 75
South Asia 277 24 62
South East Asia 157 9 55
West Asia 50 83 92
Oceania 1 32 66
Total above 1,141 41 71

Source: calculated from JMP data and UN ESA population data 46

(see Annex for more details)

13
4_Death, sewers and cities

The next table shows that half of all the new involved. Some of the countries at the top of
sewerage connections needed to meet this the list are there because of their size and rapid
target are in just four countries: India, China, growth and urbanisation (China, India). Some
Indonesia, and Brazil. Three-quarters of all the are included mainly because of an existing large
connections needed are in just 20 countries. urban population (eg Brazil). Some are included
mainly because of a very low level of sewerage
This concentration helps make the discussions connection (eg Indonesia and the Philippines);
of needs and affordability concrete, instead of and some because of very high levels of forecast
an abstract debate about billions of people in urban population growth coupled with low levels
unspecified places, and the billions of dollars of sewerage connection (eg Nigeria, Bangladesh).

Table 6:
The 20 countries needing most urban sewerage connections

Millions % %
Numbers of people needing 2004 % urban 2015 % urban household
connection to achieve target household sewerage sewerage connection
(millions) connection after achieving target
China 251 50 75
India 184 25 63
Indonesia 73 2 51
Brazil 60 53 77
Nigeria 43 23 62
Philippines 34 7 54
Pakistan 32 40 70
Bangladesh 27 7 54
Iran 25 19 60
Democratic Republic of Congo 15 4 52
Vietnam 14 14 57
Argentina 13 48 74
Thailand 12 0 50
Sudan 11 1 51
Egypt 11 68 84
Venezuela 10 61 81
Ethiopia 10 2 51
Malaysia 10 41 71
Myanmar 9 10 55
Korea Rep 9 65 83
Total of top 4 (China, India, Indonesia, Brazil) 568
Total of 20 countries with greatest needs 851
Total connections needed in all developing countries* 1,141

*from Table 5
Source: calculated from JMP data and UN ESA population data 47
(see Annex for more details)

14
5_The need for public finance
Sewerage Works
Public investment in sewers
saves lives

5.1_Cost recovery and “The use of self-provision, informal provision,

the private sector public provision, or private-sector provision
determines, in part, the scale of service.
There are many who still believe that the This, in turn, determines what type of
necessary investment in water and sanitation infrastructure or technological option would
should come through the private sector be appropriate. Thus, sewerage is not a
investing in commercially viable operations. technology of choice for private provision.” 49
For most of the 1990s, and up to 2003, this
was the mainstream view of the major donors The Organisation for Economic Co-operation
and development banks. The World Bank and Development (OECD) is currently
in particular promoted the private sector as contributing to the process by conducting three
the key to delivering water and sanitation. large studies on water and sanitation finance.
One study is on pricing and cost recovery; one
The main policy advice of donors and focuses upon the role of the private sector;
development banks emphasised three key and the third is researching financial strategies
policy positions: to incorporate the other two pillars. Angel
— the insistence on the need to finance Gurria, its general secretary, told an OECD
developments through cost recovery from users forum in 2007 that, although there may be a
— the preference for a central role for the temporary need for some use of public finance:
private sector
— the assumption that sewer systems were “The first requirement is to make better use
too expensive and so unaffordable. of market mechanisms, both to ensure the
most efficient use of water supplies and to
For example, the UN World Water Development help finance water infrastructure to encourage
Report (WWDR) 2006 report states: greater supply. This means pricing water so
“Population growth and burgeoning water that there is full cost recovery and capacity
demand have convinced most policymakers for reinvestment. … True pricing of water also
that the cost of water system development provides an incentive for the development of
will increasingly have to be met by users, new technologies and for greater participation
especially if the Millennium Development by private investors in helping to build
Goals are to be achieved. Meeting the and operate water supply systems.” 50
financial challenge of water supply means
the involvement of all stakeholders, with The same ideology and the same approach
funds from governments, financial markets, recur in many other policy documents. One
international aid and users. However, with example is the African Development Bank’s
private sector participation – ranging from (AfDB) current strategy document for Nigeria,
small water vendors to large private utilities – whose cities have the greatest need in Africa
projected to increase in the next decades, the for sewerage connections. Previous attempts at
issue of pricing is critical, not only to improve water privatisation were rejected by companies
access and quality of service and discourage as insufficiently profitable. Nevertheless, the
theft and wasteful use, but to ensure AfDB repeatedly refers to the need to develop
affordability and fairness to all customers.” 48 policies which attract the private sector. It:

The UNWP Task Force report even suggests “foresees the implementation of interventions
that by choosing to use the private sector, that will contribute to a more conducive
as the most fundamental choice, this then environment for private sector activity through
determines whether sewers are appropriate: improved water supply and sanitation,
15
5_The need for public finance

power supply and enhanced road transport sewerage systems in the south also use
and mobility.…. Priority will be given to public finance. The current policy advice is
projects that will attract public and private in itself an obstacle to the development of
participation and lead to immediate capital sewerage and sanitation in the south, because
investments. …… Support activities will focus it directs aid and government efforts into
on preparatory activities to make a project developing schemes which will not deliver
attractive (short term studies, execution the investment needed for sanitation.
studies, Public Private Partnership, tender
documents, etc.). …Private sector participation
(PSP) in the water sector has great potential in 5.2_The problems of cost recovery
several areas of African Water Facility (AWF)
interventions. The AWF would provide the Insisting on full cost recovery means that
necessary support to attract private sector sanitation programmes are only worth doing if
participation, whenever possible, in line with people are willing and able to pay the full cost
the Country policy and regulatory framework.”51 themselves. There are two flaws in this approach.

The problem extends beyond the operation Firstly, the benefits of sewerage connections
of water supply and sewerage. Donors have are public. The improvements in health and the
encouraged the development of public environment are benefits to the community as
toilets by local groups on a private enterprise a whole, not just the households connected,
basis. But these commercial ventures create and so should be financed collectively.
similar problems of affordability and service The UN task force report notes that many
delivery. The Wateraid representative in India households are reluctant to pay for the health
has stated that: “Public toilets are being benefits of sanitation: “among the reasons
viewed as profitable sub contracted works that people invest in improved [sanitation]
and are being increasingly contracted out services, health does not figure particularly
resulting in both unaffordable and badly prominently”. But, as they also note, this
maintained infrastructure for the urban poor. was exactly the same in the countries of
…. The trend to privatise and contract out the north in the 19th century: the citizens of
public infrastructure in slums and even Boston, Massachusetts, in 1850 were also:
in mixed areas (commercial and slums), “unable or unwilling to take on personal
needs to be curtailed.”.52 In Ghana, the responsibility to conduct their lives in accord
policy of contracting out the management with recommended sanitary principles”. 54
of public toilets to “community businesses”
led to local political elites creating “front” The second problem with user charges is
businesses to run these lucrative contracts, affordability. The poorest, who usually are in
as a prime source of funding which they greatest need of connections, will be least
would not easily give up – thus creating an likely to afford them. An insistence on cost
obstacle to developing better services.53 recovery from users of the system becomes
an obstacle to achieving improvements in
This emphasis on the private sector and cost sanitation: “If international donors wish to
recovery is contrary to the experience of high pursue a policy of universal access, they
income countries, all of which developed should acknowledge that the costs of
sewerage systems using public finance. improved services are far beyond the reach
It ignores the failure of privatisation in the of many households.”55 Even low levels of
south to deliver any significant investment; connection charges act as deterrents for poor
and the fact that successful extensions of households, who suffer most from the disease
16
 Sewerage Works
Public investment in sewers
saves lives

consequences of poor sanitation, because of urbanisation and industrialisation process that

unequal resources. The death rate within the took place after 1945 … investment in sewage
same city varies according to the income of treatment led to the creation of the Agences de
residents: a study found that infant mortality l’Eau … levying water pollution and abstraction
rates in seven different areas of Karachi charges from water bills at river basin level,
varied from 33 to 209 per 1000 live births.56 through a mutualisation of investment needs.” 58

Japan expanded sewerage coverage from

5.3_The solution of public finance 8% in 1965 to 69% in 2006 using public
finance, public operations and domestic
The core reasons are listed above as to public-public partnerships (PUPs), mainly
why, in all developed countries, the idea of technical and financial assistance provided
financing sanitation through cost recovery by a central governmental agency to
from users was abandoned. The sewerage local authorities. Sewerage coverage is
systems in Europe, the USA and Japan projected to reach 72% in 2007.59
were not developed through full cost
recovery from users – they were paid for by The problems of affordability and people’s
distributing the costs amongst the public, reluctance to pay are addressed when a
using taxation and cross-subsidy. Connection redistribution through taxation is adopted.
was not a matter of individual choice, but This redistribution is key, as individuals
required as a matter of public policy: contribute what they can afford with the
“Public financing of sanitation infrastructure wealthy contributing the most. By contrast,
was seen as the only option for ensuring policies based on full cost recovery from
investment adequate to protect public health.” 57 users are more likely to favour the rich. The
same principle is applied in Europe at a
The example of Toronto (see 5.3.1) shows how transnational level. The EU raises taxes across
little progress was made in extending sewerage all the countries of Europe to support the
connections in the 19th century by waiting for cost of water and sanitation improvements
private demand from individual householders. in the poorer countries. This cost is the
The system only grew significantly when the equivalent of €20 per person per year. 60
cost of connections was publicly financed and
the sewer connections were made compulsory. However, the key donor publications
avoid mentioning public finance. The UN
France was no exception, even though private Task Force report, for example, explained
water companies have continued to operate clearly that households cannot be expected
there since the 19th century. The development to pay for sanitation, but urged public
of sewers was financed through local taxation, authorities to “broaden their focus toward
subsidies from central government taxation, an emphasis on influencing citizen/
and cross-subsidies through special taxes consumer behaviour, as well as toward
at regional river basin level. Sewerage was engaging community-level institutions in
a matter of public health policy and so: planning appropriate interventions”. 61

“Connection to a main sewer was compulsory

for households, and therefore it was covered
by local taxes (as in Germany) … It required
an intense effort, supported by government
subsidies, to catch up with the rapid
17
5_The need for public finance

5.3.1 Case study – Toronto sewers for public health reasons, whether
householders asked for it or not, financed by
Before the 1870s, the city of Toronto was the municipality. The benefits were immense:
mainly dependent on private contractors for
water supply. Sewers were not automatically “This unprecedented power…led to
laid in new streets. Instead, householders had tremendous sewer development in the
to petition the local council for connections, 1880s…..The effects of the typhoid fever
and then pay the cost themselves. Neither epidemic were greatly reduced by the
water nor sewerage connections grew presence of a complete, clean sewage
fast enough and deaths from water-borne system. At the beginning of the 20th
diseases, especially typhoid, were common. century, most of the streets in the city had
been serviced and the operational costs
In 1872 the Toronto Globe newspaper wrote: were met through direct taxation.” 63

“We have neither the quantity nor the quality The same approach was taken up across
[of water] necessary to secure the health and the province of Ontario, where public water
comfort of the citizens, and we are equally systems were growing rapidly by the turn of the
destitute of what is indispensable for the century. The Public Health Act 1912 enshrined
safety of our houses from fire; the flushing the Toronto principles of public finance
of our common sewer; and the watering and compulsory connection, by giving the
and cleaning of our streets. No city of the provincial board of health the right not only to
size and pretensions of Toronto can be decide when a water or sewerage system was
mentioned where the sanitary arrangements necessary “in the interest of the public health”,
are so inadequate, and where consequently but also to require local councils to finance it. 64
preventable disease is so common.” 62
The water and sanitation system of
Over the next five years, despite an Toronto has continued to be publicly
economic recession, the city council not run and financed. As a proportion of the
only municipalised the water service, it household incomes of Toronto, there
authorised the city engineer to install new is a long-term downward trend. 65

18
 Sewerage Works
Public investment in sewers
saves lives

Chart B: The cost of water and chooses to operate in and only one third of
sanitation in Toronto (1935-95) developing countries have received any kind
of private investment in water and sanitation.
Therefore governments have frequently had
to revise contracts and provide guarantees,
creating fiscal risks for governments in the
shape of unexpected liabilities. As a result,
private companies have been unable to get
the necessary rate of return, due at least
in part to public resistance to paying the
prices required to deliver this rate of return.
Therefore governments have retreated, even
Figure 9. Ratio of total water and sewer expenditures from those areas where they have invested.
(capital and operating) to total income Even in middle income countries where the
Source: Pharasi and Kennedy 200266 private sector presence has been greater,
the private sector investment is very small
in comparison to investment by the state.
5.4_The illusion of private In South Africa, for example, total private
sector investment investment in urban infrastructure over
the entire 20 year period “has been quite
The idea that the private sector can or insignificant … much less than 1% of one
will invest significant money in developing year’s local government spending.” 67
sanitation or sewerage systems is equally
misleading. It is contradicted by the evidence A World Bank research paper in 2006, reviewing
on investment in sanitation in developed actual private investment in a 22 year period
countries; by the evidence of private from 1983 to 2004, concluded bluntly that:
sector failure to invest in infrastructure in “PPI [private participation in infrastructure] has
general in developing countries; and by the disappointed – playing a far less significant
evidence of the lack of private investment role in financing infrastructure in cities
in sanitation in developing countries. than was hoped for, and which might be
expected given the attention it has received
In developed countries, the private sector and continues to receive in strategies to
played almost no role in financing the mobilize financing for infrastructure…
sanitation systems. The constant donor
advice to involve the private sector is thus “...PPI is inherently limited in scope for
contrary to all the experience of successful financing urban infrastructure for the wide array
development of sanitation and sewerage. of non-commercial infrastructure services cities
need. Even for commercial services like water
In developing countries, despite all the supply, subsidies are prevalent all over the
encouragement and support from donors and world…Local governments need good sources
development banks, the private sector has of public finance to fund those services,
contributed only a trivial amount to investment and some form of government borrowing is
in urban infrastructure in the last 20 years. needed for major investments in these areas
A key problem has been that the private to avoid inter-generational inequities.”
sector has to make profits that cover the
cost of its capital and the associated risks. This failure is confirmed by reviewing the
It is therefore selective about the countries it actual cases of private sector involvement in
19
5_The need for public finance

sanitation in developing countries. The record zone. Both concessions included responsibility
of the private sector in water was described for water and sanitation, including targets for
in the earlier World Development Movement’s new sanitation concessions. The regulator,
report called Pipe Dreams.” 68 This section the Manila Water Company (MWSS-RO),
does not repeat the material in that report, assessed that Maynilad increased sewerage
but supplements it with details specific to coverage from pre-privatisation levels of 7%
sewerage connections and sanitation policies. to 11% in 2001 (compared to a target of 16%
for the same year) and 10% in 2002. Manila
5.4.1_Asia Water achieved coverage of 3% in 2001
(meeting its target of 3% for the same year)
In Asia, there have been few attempts to and 3% in 2002, from pre-privatisation levels
use the private sector to finance investment of 7%. 70 A Maynilad executive admitted that
in water supply and sanitation. Asia needs the company had fallen short in achieving
about one billion sewerage connections to sewerage and sanitation targets. 71
achieve 80% urban coverage, but the great
majority of cities have received no sewerage According to an Asian Development Bank
extensions from the international or local (ADB) report in 2007, less than 4% of Manila’s
private sector. There have been private water total population is connected to the sewer
concessions in the capital cities of Indonesia network: “It is estimated that there are more
and the Philippines; Malaysia set up a private than one million septic tanks in Manila.
concession for developing sewerage; and a However, sludge treatment and disposal
project in Tamil Nadu, India, used a private facilities are rare, resulting in indiscriminate
company as a construction contractor in disposal of untreated or poorly treated
building a sewerage system. In China, as of effluent into the Pasig River. Some 10 million
2002, there were a number of private Bank of people discharge untreated waste into the
Thailand (BOT) concessions for waste water Pasig, which, combined with the 35 tons of
treatment plants, but no private concessions solid waste also deposited in it annually by
for extending sewerage connections.69 squatters living in makeshift shelters on the
river bank, makes it one of the world’s most
This includes only two cases where the polluted rivers, with human waste accounting
private sector actually invested in sewerage for 70% of the pollution load.” The limits of
coverage (Malaysia and Philippines). the Millennium Development Goal definitions
However, one example was later nationalised are also highlighted by the fact that the
and the other has delivered very little. Philippines is regarded as on-track to meet
its target for urban sanitation: in 2004, 80%
In Jakarta, where only 1% of the population of the urban population were assessed as
is connected to a sewer, the concessions do having ”improved” sanitation facilities, although
not cover sanitation at all. They have thus only 7% had sewerage connections. 72
contributed nothing to improved sanitation.
In Malaysia, a concession for developing
In Manila, both water supply and sanitation sewerage and sanitation throughout the
were privatised in January 1997 to two company was awarded to a private company
private groupings: a Lyonnaise des Eaux-led Indah Water Konsortium, in 1993. The
consortium to operate Maynilad, involving concession was based on the principle of
the multinational Suez group, in the western financing investment through consumer
zone of the city; and Manila Water, led by the charges. However, consumers objected to the
British company United Utilities in the eastern tariffs, so its structure was revised, and then
20
 Sewerage Works
Public investment in sewers
saves lives

investment needs were found to be higher fee: “when located relatively close to the
than anticipated. As a result, the Government sewerage network, the toilets are connected
had to provide substantial financial support in to it, otherwise septic tanks are used.”76
the form of long term soft loans. In 2000, the There is also a BOT contract for a wastewater
Malaysian Government nationalised Indah, thus treatment plant, which will be financed
ending the experiment with private sewerage. 73 through a combination of user charges
and tax revenues of public authorities.77
In India, a sewerage project was set up in
2001 to build a sewerage network for the city Table 7:
of Alandur, Tamil Nadu, with a population of Asia: private concession contracts
145,000 in 2001. The construction contract covering sanitation
was issued to an Indian construction company.
However operation was not included, and the Country City Private Sewerage Results
sector aspect
company made no contribution to the financing involvement
of the project. The project was financed by
Philippines Manila Concession Yes, targets Coverage
the public authorities through grants and contracts only 4% after
10 years
loans, with advanced consumer contributions
expected to provide 20-25% as a kind of Malaysia National Concession Sewerage Nationalised
contract extension in 2000
equity investment. The household tariff was
reduced following consumer complaints, and
the Tamil Nadu state government increased 5.4.2_Africa
its contribution. Despite the fact that Alandur
residents were relatively well off, the chair The contribution of the private sector to
of the municipality commented that: “In investment in urban sewerage in Africa is
Alandur, we were able to raise a substantial limited to five concessions or lease contracts
amount from the beneficiaries because of which covered sanitation as well as water.
their paying capacity. In other areas, this may
not work, given the economic conditions of The two contracts in South Africa, at Nelspruit
the people. So, the state government has to and Dolphin Coast, were concessions requiring
support such schemes by giving grants”. 74 investment in new extensions. In Nelspruit, the
company laid 35 kilometres of sewer mains and
The works were delayed, and there was most residents gained access to waterborne
confusion over whether the company or the sanitation.78 The company reported 5,000
municipality was responsible for maintaining new household connections, but no precise
and operating the pumping station element figures for sewerage connections. As with
of the project, and there were problems with water, therefore, despite various problems
sewage flooding due to design problems with finances and public resistance, these
with the pumping station.75 By 2005, nearly are the only two cities in Africa where some
8,350 of the 23,000 households that had paid new household sewerage connections may
for the service in advance were connected, have been made by private investment.
including 500 of the 7,000 slum households,
43% of whom opted for individual sewerage It is worth examining the situation of sanitation
connections. For the poor households that in three other countries, one where a lease
could not afford to pay for the sewerage did not cover sanitation; one where it did;
service, public toilets were provided as an and one where the private sector decided
alternative, but families were expected to join that neither water nor sanitation was an
a membership register and pay a monthly attractive commercial proposition.
21
5_The need for public finance

In Senegal, water distribution was privatised, than most other African cities, but these were
following World Bank pressure, under a lease financed, not by the multinational company
contract. Therefore the private company had no involved (Bouygues), but by World Bank loans
responsibility for new investments, which were and other public finance. The slum areas,
all made by the state and the World Bank.79 such as Yopougon, do not have sewerage
But responsibility for urban sanitation and connections: “Plans for further large investments
sewerage was excluded from the privatisation, to improve the sanitation of Abidjan, including
and was given to a new government agency, Yopougon, exist but have not yet been
the Office National d’Assainissement (ONAS). implemented.”84 At the end of February 2008,
According to a World Bank report, the reason there were problems with the performance of the
was as follows: “It was decided that including private company: “A third of Abidjan’s inhabitants
the sanitation sector in the responsibilities have had no drinking water for over a month”. 85
of the private operator would be too
burdensome, given its poor state. However, Nigeria has the second highest number of
ONAS was not completely ignored…” 80 under fives’ deaths in the world (834,000).
The infant mortality rate is 184/1000, worse
Unrelated to the water privatisation, between than Ethiopia (174) or Haiti (125). Two thirds of
1998 and 2007 the World Bank helped finance childhood disease is attributable to inadequate
new sewerage connections for 212,250 additional access to safe drinking water. 86 Less than
people in Senegal. However the current World 1% of the population of Lagos, the largest
Bank country assistance strategy for Senegal city, with a population of over 11 million, is
ignores ONAS completely and forgets that it connected to a sewerage system. 87 Lagos
was not privatised. It refers to the success of has suffered from a lack of sewerage and the
privatisation “in water and sanitation”.81 Health associated health problems for a long time.
problems remain: in 2005 a cholera epidemic In the 1920s, colonial administrators decided
killed 1,295 people of 76,881 cases in West that modern sewers could not be afforded,
Africa, according to the World Health Organization even after a series of outbreaks of bubonic
(WHO), more than a third of them in Senegal. In plague.. A further proposal to build sewers
the first 10 months of 2007, there were 12 deaths was later dropped in 1956, because of a lack
and 2,231 cases of cholera in the country. 82 of capital and opposition from politicians who
were benefiting from private waste-removal
In Cote d’Ivoire, the nationwide water privatisation, contractors. 88 After independence, Nigeria’s
which covers sewerage, as well as water, is also own plan for a sewerage system was also
a lease contract not a concession. The private frustrated: “The extraordinary Lagos master
company, Les Actionnaires de la Société de plan of 1980… envisaged that within the
Distribution d’Eau de la Côte d’Ivoire (SODECI), space of two decades all households would
owned by the French multinational construction be connected to a water supply and sewerage
company Bouygues, is thus responsible only for system…but the programme of works was
maintenance and renewal, not for new extensions. curtailed by a combination of economic crises,
The concession was awarded without competition externally imposed structural adjustment
in 1960, and renewed in 1987 for a further 20 policies and the return of military rule”89
years: “In these renegotiations, [Bouygues]
was not prepared to take on responsibility for In 1999 the International Finance Corporation (IFC)
investment because the company did not want made privatisation a condition of a loan for water
to take the risk that future revenue would cover in Lagos, claiming that investment of $1billion
debt service requirements.” 83 Abidjan, the capital, was needed, and that this should be: “largely
has a higher level of sewerage connections financed by tariffs generated by the expanded
22
 Sewerage Works
Public investment in sewers
saves lives

system.” This plan failed when the multinational of the original target. In the other concessions
companies refused to consider investing money. in Buenos Aires province, the connection rates
The current plan of the Lagos State Water did not improve. The Salta concession did
Company envisages outsourcing of operations, achieve a significant increase in connection
but there is no coherent plan for financing rates, but this was largely due to public
investment.90 However, another World Bank finance rather than private investment.
project for development and governance of Lagos
metropolitan area is encouraging higher property Brazil illustrates the illusions of private sector
taxes, through higher rates and better collection, investment. In the affluent suburb of Limeira,
to support infrastructure: “In most cities, property sewerage connection levels reached 80%
taxes are a substantial part of general revenues. under public control, even before privatisation.
In Lagos, however, property tax rates have been Since then, private companies have claimed to
historically very low.” Increasing the yield from this increase this coverage to 100%, but the figures
source of revenue, therefore, is critical for Lagos are not credible. In the city of Manaus, sewerage
State Government (LASG) to sustain benefits connection was at just 3% when the concession
from investments in drainage and solid waste.” 91 started: by 2005, the company had increased
this to just 12%, compared with a target of
Table 8: 31%. This compares badly with the progress
Private concession and lease contracts in the comparable city of Salvador, which in
covering sanitation in Africa almost the same time period, under the public
sector, increased connection levels to 80%.
Country Location Company MNC Type
involved
In Chile, the high levels of coverage were
Cote d’Ivoire National SODECI Saur Lease achieved under public ownership before
privatisation took place. In the three cases
South Africa Dolphin Siza Water Biwater Concession noted below, the private operators inherited
Coast
levels of sewerage connection of 86%,
South Africa Nelspruit GNUC Biwater Concession 87%, and 97% – more typical of European
and North American cities. The coverage in
Tanzania Dar es City Water Biwater Lease Chile is therefore another tribute to the use
Salaam (terminated)
of public finance for developing sewers.

5.4.3_Latin America In Colombia, there have been significant

sewerage extensions in Cartagena, where
Privatisation has been most extensive in official levels of coverage are 95%. Once
Latin America, with a significant number of again, however, these extensions have been
concessions and leases being issued which overwhelmingly financed by public finance from
have included targets for the extension of the World Bank and the Government, with the
sewers. Very few achieved these targets. private company contributing little. Also, the
In some cities the levels of sewerage damaging impact of connection charges can
connections are high, but this is due to public be seen here too. Around 40,000 homes in a
investment, not to the private concessions. poor neighbourhood remained unconnected
to the sewerage network in 2006, which was
In Argentina, the flagship concession in Buenos partly due to the level of connection charges.
Aires managed to increase a pre-existing
connection level of 58% to only 63% in nine The concessions in Bolivia, Ecuador and Peru
years – around one million connections short also fell short of targets by varying amounts.
23
5_The need for public finance

Table 9:
Water privatisations and sewerage extensions in Latin America

Country Concession Company Performance on sewerage – other issues (and sources)

Argentina Aguas Argentinas Suez In the nine years from 1993 to December 2001 – prior to the breakout of the
(Buenos Aires) Argentine crisis – Aguas Argentinas expanded sewerage service coverage
from 58% to 63%, compared with the original contractual target of 72%.
Aguas Argentinas’ failure to reach the original contractual goals meant that
by December 2001 more than one million Buenos Aires dwellers had not
been connected to the sewerage network.
Argentina OSBA (Buenos Aires Azurix In 1999 – when privatisation took place – 47% of the urban population had
province) access to sanitation. By 2005, only 45% of households were connected.
Argentina AGBA (Buenos Aires Aguas de Bilbao; Urbaser In July 2006 the contract with AGBA was terminated, claiming that the
province) concessionaire had failed to achieve its targets in terms of investments and
expansion of services. Of the 1.8 million inhabitants covered by the AGBA
concession, 80% were not connected to sewerage.
Argentina Aguas de Salta Latinaguas Sewerage connections under the Salta concession increased from 54%
to 84%, partly thanks to public subsidies directly subsidising low-income
consumers.
Bolivia AISA (La Paz/El Alto) Suez AISA increased sewerage connections, but these fell 33% short of its
contractual target.
Brazil Aguas de Limeira Suez Sewerage coverage was 80% at the start of the contracts. The company
claimed to have reached 100% connections by 2005, but a 2003 report
stated that “There was also a small improvement in services expansion,
whose rates were already high, and a broad investment in sewage treatment
… On the other hand, there are strong suspicions … of manipulation on
data about the investments made and the contract goals.”
Brazil Aguas do Amazonas Agbar The concession contract emphasised sewerage and sanitation, with 65% of
investment expected to be concentrated in this area. From an initial level of
3% in 1999, the company was expected to increase connections to 31% by
2005 and 90% by 2029. However, actual coverage for sewerage in 2005
was only 12%.
Brazil Aguas de Guariroba Agbar Awarded in July 2000, the concession aimed at achieving 50% coverage for
sewerage in 10 years and 70% coverage in 30 years (from an initial level of
22%). In 2005, sewerage coverage was 32%. 92
Brazil Sanepar Veolia In 1998 SANEPAR achieved 32.67% coverage in sewerage, and in 2005 coverage
(minority stake, reached 42.02% ( 50.95% in urban areas). However in November 2007, urban
1998-2007) coverage was said to be only 48.7%. Sanepar president Stênio Jacob wanted to
achieve 60% coverage in urban areas by 2010, and said that the only way to meet
this target was through state control of the company: “It is important that the state
control the company because aggressively trying to make profits would not leave
room for making water and sewage access universal, serving small communities or
keeping the social and environmental commitment of the company.” 93

Chile ESSBIO Thames Water Under public ownership, Chilean water supply and sanitation company
ESSBIO increased sewerage coverage from 69.2% in 1990 to 86.1% in
2000. Thames Water took control of ESSBIO in September 2000, after which
ESSBIO increased sewerage coverage by 2.1% in five years, from 86.1% in
2000 to 89% in 2005: ESSBIO failed to meet targets, including targets on
expanding the sewerage network. 94

24
 Sewerage Works
Public investment in sewers
saves lives

Country Concession Company Performance on sewerage – other issues (and sources)

Chile ESVAL Anglian Water Under public ownership, Chilean water supply and sanitation company
ESVAL increased sewerage coverage from 81.0% in 1990 to 87.4% in 1998.
Overall, under private operations, coverage for sewerage increased from
87.4% in 1998 to 91.2% in 2005.

Chile EMOS/Aguas Andinas Suez/Agbar Under public ownership, in 1980 EMOS provided sewerage to 90% of the
urban population with the exclusion of informal settlements. Coverage
reached 97% in the early 1990s, including poor peri-urban areas. In June
1999, a Suez/Agbar consortium took control of EMOS (then renamed Aguas
Andinas): according to Ducci (2007: 142), Aguas Andinas has achieved
98.3% coverage in sewerage.
Colombia ACUACAR Agbar The World Bank (2006) estimates that by 2005 ACUACAR had extended
access to sewerage to 95% of the population, 56% in 1994 (ARD, 2005:
63). However, ACUACAR’s claimed achievements in terms of extending
sanitation coverage from 1995 to 1999, at a growth rate of 5 to 8%, are not
remarkable given the scale of external investment ($157.7m). In June 2006,
40,000 buildings in the La Boquilla neighbourhood were not connected yet to
the sewerage network. A number of families referred to the high connection
costs as the impediment to accessing the service. 95
Colombia Monteria Proactiva/Veolia In May 2003, Proactiva was criticised for low investment levels and failing
to reach contractual targets in the first three years of operations (Lobina and
Hall, 2007: 40) 96 Proactiva was reported as halting planned investments
due to financial difficulties, “meaning the city may lose 600 million pesos
($202,000) in promised sewerage upgrades.” 97

Ecuador Interagua IWL In July 2007, the regulator fined Interagua for failing to comply with
contractual targets for the first five-year period of operations. Interagua was
supposed to have reached a total of 55,000 water and sewerage connections
during its first five years of operations, but only installed 27,733. In terms of
sewerage networks, the utility reached 62% of the goals set out. 98
Peru Aguas de Tumbes Latinaguas Despite generous support from public funds, Peruvian regulator Sunass
reportedly found that in the first year of operations Aguas de Tumbes had
failed to extend water supply and sanitation networks and only achieved 5%
of the contractually established operational targets. 99

Source: Lobina and Hall 2007 and others

25
5_The need for public finance

5.5_Development in the south: Brazil to meet its MDG targets in full and the
public sector and public finance urban sewerage connections target (see below).

The continuing importance of public finance The development of sewerage connections in

for the development of sanitation can be the city of Salvador provide an outstanding
seen in the actual policies being pursued by illustration of the benefits obtained from
the four countries which are of the greatest expansion of urban sewerage connections.
importance for connecting urban populations:
Brazil, China, India and Indonesia. Table 10:
Financing sanitation investment
Three of these – Brazil, China, and India – are in Brazil 2007-11
investing in sanitation, including sewerage
connections, using public finance. As a US$ billion
result, Brazil and China are investing enough
to achieve the MDGs in full and 80% urban Federal government 5.6
sewerage connections by 2015. India may
need further investment, but is actively Regional state and municipal budgets and 3.7
increasing its tax revenues, which will permit operating surpluses
this. The fourth country, Indonesia, has no Workers’ savings fund (FGTS) & federal workers 9.4
national programme of investment in sewers protection fund (FAT)
using public finance, despite having very TOTAL 18.7
healthy government finances, with growing
tax revenues. It is being advised by the
World Bank to focus on increasing user Source: Business News Americas April 27, 2007101
charges. If it does so, Indonesia will fail to
improve its urban sewerage connections to
anywhere near the proposed target level.

5.5.1_Brazil

In January 2007 Brazil announced a new four

year programme for economic growth, the
Programa de Aceleração do Crescimento
(PAC), based on investment of $236
billion (504 billion reais) in infrastructure,
especially in roads and electricity, but
also water, sanitation and housing.100

The sanitation investment programme aims to

greatly increase the proportion of households
connected to sewerage systems. It is half
financed by federal and regional state finance,
and half by loan finance from the savings funds
and pension funds. The total budget of $18.7
billion represents an annual rate of $4.7 billion
investment, which is 0.53% of Brazil’s gross
national income (GNI) – which is sufficient for
26
 Sewerage Works
Public investment in sewers
saves lives

5.5.2_Case study – Salvador, Brazil: behaviour, and the installation of household

saving children by building sewers toilets, but found they had relatively little, or
no, effect. Like another study of diarrhoea
The experience of the sewerage system in North East Brazil, which found that
in Salvador at the start of the 21st century there was no statistically significant benefit
demonstrates the same lessons evident associated with having a flush toilet alone103,
from the introduction of the sewerage the Salvador analysis “also found that an
system in London in the mid 19th century. indoor toilet did not explain the reduction in
A public system, publicly financed, delivers diarrhoea”. It was the connection to sewerage
health benefits, especially to the poorest. which delivered the gains in child health.

In 1996 the city of Salvador, in Brazil, with The authors of the study concluded:
a population of 2.5 million, started on a “Our findings contradict those who claim that,
major sanitation programme. Only 26% of ‘there appears to be little prospect of further
the city’s households were connected to a reducing diarrhoea morbidity rates by investing
safe sewerage system, mainly the upper and further in sanitation’… Sanitation contributes
middle classes in the oldest part of the city. to many of the Millennium Development Goals,
The primary objective of the new programme but our results show that urban sanitation, as a
was to extend the sewerage system to 80% highly effective health measure, can no longer
of households. This involved laying over 2,000 be ignored… Because sewerage is mainly
kilometres of new sewers, building 86 pumping external to houses and the fact that it prevents
stations, and making new connections to disease transmission in the public domain,
300,000 households. This was completed public responsibility is to ensure that sewerage
in eight years, involving 140 construction is installed. At a typical cost per person of
companies. The total cost of the project was $160, investment in sewerage is too large to be
$440m, of which $264m came from a loan left to cash-strapped municipalities, and needs
by the Inter American Development Bank the involvement of international organisations,
(IADB). The development of the sewerage and central government and its agencies.” 104
system cost about $220 million, half the total
project costs. The IADB loan included $20m
for maintenance equipment and training. 102

A major study examined the health of children

before and after the extension of the sewerage
system. The overall reduction in diarrhoea
was 22%, and 43% in the highest risk areas
inhabited by the poorest. The effect would
have been even greater if the coverage had
been improved even further into the poorest
areas. The study is the largest ever conducted
on a city-wide sewerage programme and
its impact on child health. The results are
broadly similar to other smaller scale studies
which found reductions of 36% and 32%.
The study tested for the impact of many
other factors, including changes in hygiene

27
5_The need for public finance

5.5.3_China crucial sectors. ….The Bank can regain its

relevance only if it becomes practical once
The urban sewerage connection rate in China again, by returning its focus to financing public
rose from 30% in 1990, to 50% in 2002. 105 investments in priority sectors, just as the
Public spending on infrastructure has not only Chinese leadership is prepared to do.” 110
kept pace with the growth of the Chinese
economy, it has increased twice as fast: 5.5.4_India
“Since 1995, China’s GNI has almost tripled
while overall annual municipal infrastructure India is developing new plans for investment
spending, including roads, has increased six- in water and sanitation as part of the current
fold.”.106 The total length of urban sewerage five year plan for the economy. Water and
networks increased by nearly 225% between sanitation has been given priority in its urban
1991 and 1998, but less than 4% of all the infrastructure programme, and the new plans
investment in water and sanitation was propose to nearly double the previous finance
financed through the private sector.107 from central and state governments. The new
plans amount to $31.75 billion, about $6.4
China is now investing over $10 billion per billion per year, which is the equivalent of 0.7%
year (0.4 percent of GNI) and spending another of GNI. This could be sufficient to achieve
0.6%of GNI in operating costs in water and the MDGs and the urban sewerage target.
sanitation. This combined total of 1% of GNI Over 90% of this is to be financed by central
($25bn.) is sufficient not only to achieve the and state governments and national financial
MDGs, but also the urban sewerage target (see institutions, with only 8% funded by aid
below). The contribution from development and only 1.5% from the private sector.
banks and aid has been large in absolute terms
but small as a proportion of total cost. Between Table 11:
1992 and 2013, the World Bank will lend about Financing of water and
$7 billion, an average of $0.3 billion per year, sanitation plans of India
which is just over 1% of the current level of
China’s spending on water and sanitation. 108 Financed by R crore $ billion %
Central government 70,000 17.50 55
Furthermore, under the 11th Five-Year State governments 35,000 8.75 28
Wastewater Sector Plan (2006–2010), the National banks 10,000 2.50 8
Chinese government is putting greater emphasis Aid 10,000 2.50 8
than in the past on drainage networks, FDI/private sector 2,025 0.50 1.5
consisting of sewer-only pipelines, combined Total 1,27,025 31.75 100
sewer and storm water drainage. Projected
investments in drainage alone amount to a Currency converted at R40=$1
total of RMB 188 billion (US$ 23.81 billion). 109 Source: Planning Commission of India 111

China’s approach has been favourably 5.5.5_Indonesia

compared to that of the World Bank by
economist Jeffrey Sachs: “Unlike the Chinese, Indonesia has no comparable national
the Bank has too often forgotten the most programme for water and sanitation.
basic lessons of development, preferring to
lecture the poor and force them to privatise A World Bank analysis of Indonesia’s public
basic infrastructure, rather than to help the finances in 2007 estimated that Indonesia
poor to invest in infrastructure and other could spend an extra $15 billion per year,
28
 Sewerage Works
Public investment in sewers
saves lives

and that there is a particular need to do areas, ie the training of engineers in designing,
so in infrastructure spending. This is partly operation and maintenance of sewage treatment
because it has fallen to low levels, and partly plants; strengthening of the administrative
because of the refusal of the World Bank capacity of local government in order to keep
to lend further money to public authorities book-keeping of the basic data and records
already in arrears – which includes most of the on sewer networks and house connections;
country’s water and sewerage authorities. 112 strengthening of the administrative capacity
of the central government in creating
The report’s main suggestion is that Indonesia regulatory frameworks for house connections,
should charge higher prices to users of water and industrial water, aquatic water quality
sanitation. But the lack of a public investment control; and in creating financial support
programme is not being compensated for by systems for sewerage development, and the
private sector investment: the World Bank environment and sanitation education.” 114
itself shows clearly that the private sector is
not investing in infrastructure in Indonesia. Public-public partnerships (Pups) have been
used to enhance local capacity building in the
5.5.6_Japan: donor funding and training design and operation of sanitation systems.
to support sewerage development A twinning arrangement between Tokyo
Metropolitan Sewerage Bureau and Beijing
The experience with sanitation in Asia also Municipal Design and Research Institute was
illustrates the potential for a supportive role instrumental to the design of the Gabi Dian
by donors. wastewater treatment plant, but was then
extended to include a sewerage component.
The Japan Bank for International Cooperation
(JBIC) has acquired considerable experience “The first-phase of construction work had
in assisting developing countries to develop started in 1990, and Beijing City itself
sewerage systems.113 On the basis of this executed the entire work under its direct
experience, JBIC highlights the importance management. In March 1993, when the work
of raising public finance through central was almost 80% completed, Beijing City
governments, and for donors to provide capacity- requested Tokyo Metropolitan Sewerage
building and training, including the use of Bureau to provide them with training for
public-public partnerships. JBIC recommends: sewerage operation and management.”
The training was funded by JBIC.115
“Since sewerage systems are very expensive
and are sometimes not affordable for the Furthermore, Osaka and other municipalities
majority of residents, financial support of have run training courses in sanitation for
the central government is indispensable. public authorities in other Asian countries.
Economic externality of sewerage, the The sewerage operator in Osaka, Japan, is
necessity of preserving the water quality of the municipal department for public works.
public water bodies, would justify the financial The municipal department boasts 100%
support by the central government.” sewerage coverage (ADB, 2004a: 3, 19), and
“investments in sewerage and sanitation
With regards to capacity development, during 1997–2001 amounted to ¥336.4 billion
JBIC recommends the following: ($2.71 million)”. Osaka Public Works Bureau
has offered training programmes in a number
“In order for sewerage systems to work of sewerage-related areas to staff from
effectively, capacity development in various developing countries. Such programmes were
29
5_The need for public finance

funded by Japan’s governmental agency JICA taxes enough to make a difference. In China,
(Japan International Cooperation Agency). The economic growth is producing a growth in
duration of the typical training programme is 90 personal incomes, which means that income
days and sessions cover the following topics: tax can start to grow; China may be able to
finance; renovation of combined sewers; collect 4.5% of GNI in income tax by 2010,
sludge treatment; waste water treatment plant with total taxes worth over 18% of GNI. This
design; history of Osaka sewerage works; asset would reflect a similar process in northern
management; electrical equipment and sewers countries in the first half of the 20th century,
maintenance; water quality management; the same period when much of the investment
storm water drainage. From 2003 to 2007, the in sewerage systems was made. In those
department trained a total of 51 staff from 29 countries: “moving from an elite income tax
countries, mostly Asian, including India and raising less than 1% of GNI to a mass income
China, but also from the Middle East, Africa tax raising around 4-5% of GNI is exactly
and Latin America. It should be noted that the kind of process through which western
other Japanese municipal sewerage operators, countries went during the 1914-50 period.” 121
including Sapporo city, East Hiroshima city and
Kitakyusyu, run similar training programmes.116 Similar growth in taxable personal incomes
is expected in India. 122 The present Indian
government is already increasing tax revenue:
5.6_Taxation needed between 2006 and 2008 tax revenues have
increased by around 50%, with special
As emphasised by JBIC and the experiences attention to increased taxation of multinational
detailed above, raising taxes is central to finance company profits and capital gains.123
public spending on sewerage connections, or Indonesia is also experiencing an increase
other investment in infrastructure and public in tax revenues: the World Bank forecasts
services: “Small government and low taxes are that non-oil tax revenues will rise from 13%
not the answer for reaching the MDGs.”117 of GNI in 2005 to 14.5% in 2010. 124

Higher levels of taxation are associated with

higher levels of economic performance: tax
revenue as a share of GNI is about 14% in
low income countries, 19% in lower-middle
income countries, 23% in upper-middle income
countries and 38% in high income countries.118
The most unequal societies have tended to
resist proposals for higher taxation, because
the rich would have to pay most. This is one
reason why developing countries have not
made enough public investment in education,
health or water and sanitation.119 Some of
the countries with greatest need for urban
sewerage connections have very low taxation
levels. In 2002, India only raised 9.9% of GNI
in taxes, Bangladesh only 7% of GNI.120

A combination of economic growth and more

active public investment policies can raise
30
6_Costs, benefits and affordability
Sewerage Works
Public investment in sewers
saves lives

6.1_Costs WHO methodology. Firstly, the inclusion of

operation and maintenance costs obscures
There have been a series of estimates of the an important distinction between capital
costs of delivering the water and sanitation investment in new systems and current
improvements necessary for the Millennium expenditure on those systems. This is relevant
Development Goals (MDGs).125 The most recent in discussing the role of borrowing, for
estimates were published in a report by the example. Secondly, it is hard to justify the
World Health Organization in 2008 and were inclusion of the continuing costs of existing
much higher than previous estimates.126 facilities in a costing of future needs to attain
This was principally because of two the MDGs – especially as these costs represent
methodological approaches adopted in the over 60% of the total costs of the MDGs, as
report. The first was that, in addition to the presented by the WHO. It means that these
costs of building new facilities, the estimated figures cover, in effect, the total annual budget
annual recurrent costs for hygiene education, of running water and sanitation services in
operation and maintenance, and capital developing countries. Thirdly, the estimates
replacement for these new facilities were are presented as if there was a single global
added to the figures. In addition, the costs of corporation carrying out the work. For example,
existing systems in place before the MDGs it assumes that all the expenditure will have
(including the costs of continuing to operate, an overhead of 10–30% -30% to cover
maintain and replace the existing stock “programme costs”. However it is important to
of water and sanitation provision in these remember that these are water and sanitation
developing countries) were also included. systems of many sovereign countries.

The WHO presented water and sanitation The table below shows the costs both
costs separately. However, household including and excluding existing systems.
sewerage connections require household water A target to provide household connections
connections to flush the sewage, and so it is increases costs of new elements
not meaningful to cost sewerage connections significantly; and the urban sewerage
in isolation from water connections. target increases these costs still more.

The WHO estimated total costs for a “base”

case of low-cost improvements, but also
estimated the costs of providing household
connections – in the case of sanitation, to
sewers. This increased the overall costs of
meeting the sanitation targets by about one
third. However it did not fully reflect the costs
of meeting the proposed target for urban
sewerage, as this requires connection of about
250 million more people than are covered by
the existing MDG targets. The proposed target
would thus require approximately an extra
$60 billion in addition to the WHO “household
connections” case (using the upper end of
the WHO estimate of the additional cost
of sewerage connections of $193-258).
A number of comments can be made on the
31
6_Costs, benefits and affordability

Table 12: (2) Patient expenses avoided

Costs of meeting MDGs and proposed due to avoided illness
urban sewerage target by 2015 (3) Value of deaths avoided
(4) Value of time savings due to
Urban and rural ($billion), Total costs to achieve Average annual cost access to water and sanitation
2005 prices MDG targets 2015 over 10 years
(5) Value of productive days gained
Sanitation Water and Sanitation Water and of those with avoided illness
sanitation sanitation
(6) Value of days of school attendance
gained of those with avoided illness
Costs of existing facilities, 216 538 22 54
operation and maintenance (7) Value of child days gained of
(O&M) those with avoided illness
WHO base case: low-cost
improvements
It concluded that in all regions studied, and for
Costs of new coverage 142 184 14 18
inc O&M all levels of investment – including sewerage
Including costs of existing 358 722 36 72 connections which are the most expensive
facilities – the cost benefit ratio (CBR) is positive.
WHO ‘household
connections’
128
More recent reviews have confirmed this
Extra cost of household 114 143 11 15 assessment. A Wateraid study estimated the
connections: $bn. economic value of the health benefits alone
Total costs of new 256 327 26 33 to be of the order of $9 for every $1 spent,
coverage
inc O&M with higher returns for universal coverage. 129
Including costs of existing 472 865 47 87 A recent WHO editorial quotes benefits falling
facilities
between $3 to $34 dollars per dollar invested.130
WHO ‘household
connections’ + proposed
urban sewerage target Table 13: Positive cost benefit ratios for
Extra cost of proposed 22 22 2 2 water and sanitation spending (WHO, 2004)
urban sewerage target
Total costs of coverage 278 349 28 35
inc O&M Intervention 5
Including costs of existing 494 887 50 82
facilities WHO Part of region Pop. m. Full household
region connections
Source: WHO 2008, PSIRU calculations (see Annex)
AFR-E Africa 481 4.8 x

SEAR-D South Asia 1689 2.9 x

6.2_Cost benefit analysis
WPR-B1 East and 1488 1.9 x
Cost benefit analysis attempts to decide South East Asia
whether the costs of a policy, such Source: Hutton and Haller 2004
as universal water and sanitation, are
greater than the benefits. The results of Another economic benefit not included in the
such analyses of spending on water and above calculations, would be the creation of large
sanitation have been invariably positive. scale employment opportunities in developing
countries for the necessary construction,
A detailed cost benefit analysis published maintenance and operations. This in itself is a
by the WHO in 2004 127 analysed the major contribution to pro-poor development:
benefits under the following headings: “Employ­ment generation is a particularly
salient linchpin between economic growth
(1) Health sector benefit due to avoided illness on the one hand, and poverty reduction and
32
 Sewerage Works
Public investment in sewers
saves lives

development on the other. Policies that augment supply cannot and will not be financed: “In
the demand for labour are therefore likely to many nations, at least in the next five to 10
produce desirable social-impact outcomes for years, it will not be possible for the provision
developing economies.” 131 The health benefits deficiencies in most urban areas to be addressed
are substantial, whether or not they are reduced by the conventional model of a (public or
to economic terms. The UN World Water private) water utility extending piped water
Development Report (WWDR), 2006, noted that supplies and sewers to individual households.”
the greatest benefits for health are derived from
sewerage connections: “The scenario scoring It offers the following three reasons for this:
highest in actually reducing the burden of water- — the cost of achieving these gains is “above
related disease to nearly zero is that where income levels in developing countries”
universal access to piped water and sewerage — “population growth and burgeoning water
connections is provided.”132 Commenting on demand have convinced most policymakers
the results of the Salvador sewerage study, an that the cost of water system development
article in the Lancet urged that: “The obvious will increasingly have to be met by users”
benefits to poor people of increased provision of — “there is not enough capital to finance the
sewerage facilities should serve as the mandate high costs of expanding and extending
for greater investment by all levels of government provision of household water and sewer
and civil society in tackling one of the greatest connections and of building the institutional
scourges to communities in developing countries capacity to undertake this – and manage
– infectious diarrhoea due to poor sanitation.” 133 the systems once they are constructed
whether publicly or privately.”134

6.3_Economic capacity The first point is not supported by any evidence

of what countries can or will afford and implies
In one sense, the cost benefit analyses that developing countries cannot expect any
answer the question of whether full sewerage international assistance. The second implies that
connections can be afforded. Since the the costs have to be met by users – through full
economic and health benefits clearly exceed cost recovery – and so nothing can be financed
the costs, then it is clearly worth spending the that users cannot afford to pay for. This denies
necessary money. As the WHO analysis points the possibility of redistribution through taxation,
out, the cost benefit analysis itself does not the core traditional technique for financing
answer the question of who should pay, and sewerage extensions – or through international
whether they can afford to pay. Affordability aid. The third point, that ‘there is not enough
is relative to the ability to pay – whether capital’, is simply incorrect. As already noted,
countries, donors, or individuals have sufficient middle income countries such as China, and
income to afford the expenditure needed. Brazil have already committed substantial
amounts of public capital to investment in water
6.3.1_The donor view: too expensive supply and sewerage, and continue to do so.
for the poor Also there is $167 trillion – that is $167,000
billion – of global financial assets managed by
The explicit or implicit position of most of the pension funds, insurance companies, sovereign
official donor publications is that in this sense, wealth funds, private investment banks and
household sewerage connections cannot be others.135 Most of these invest a significant
afforded. The WWDR can be taken as typical proportion of their assets in government-
of this position. It argues that the option of full guaranteed bonds to fund public investment
household connections to sewers and water in utilities such as water and sanitation.
33
6_Costs, benefits and affordability

6.3.2_What can be afforded: data on coverage and costings. One feature of

national affordability the results is that the cost of urban sewerage
represents a high proportion of the total
National affordability is the most important MDG costs with household connections.
issue. In practice, the great majority of the
resources for extending water and sanitation The costings allow the discussion of affordability
come from national resources. Especially in in terms of the country’s own economy, by
the larger countries, such as India and China, reference to the percentage of GNI needed.
aid can only meet a small proportion of needs. And then some discussion of what aid may be
Private sector investment contributes little, and needed, by calculating what is needed to finance
so government revenues are the key source each country’s needs beyond 1% of its own GNI.
for financing developments. There is a political
reason for this too. The countries concerned Table 14 shows that 14 out of these 20 countries
are all sovereign states, and so decisions can achieve the urban sewerage target, and
are – or should be – taken by governments of the full MDGs for sanitation and water, rural
those states. The key decisions are taken in and urban, with full household connections, for
Beijing, Delhi, Brasilia, Jakarta and other capital less than 1% of GNI per year. For many of the
cities, not in Washington, London or Paris. middle income countries the cost is less than
half of one per cent of GNI per annum. China,
The table overleaf estimates the costs facing Brazil and India are already planning to spend as
countries. It sets out estimates of the annual much on development of water and sanitation
costs for the 20 countries needing the greatest as these estimates suggest is needed for the
number of urban sewerage extensions (as shown MDGs with household connections and the urban
in Table 6) as these countries cover nearly 90% sewerage target (see above). Even including
of the need for urban sewerage connection. the running and depreciation costs of existing
services, which effectively includes the running
It estimates costs for the urban sewerage costs of all water and sanitation services, only
target alone; and for the full cost of the MDGs half of these countries would need to spend more
(with household connections, urban and rural than 1% of GNI (see extended table in Annex).
and the extra needed for the proposed urban
sewerage target). For each of these two It is not credible to dismiss this level of
definitions, it then expresses these costs as a commitment as “unaffordable”. When a number
percentage of each country’s economy (GNI), of developing countries have clearly decided that
and calculates the amount needed in excess they are prepared to invest on this scale, it is
of 1% of GNI, as an indicator of how much inappropriate for international financial institutions
international aid might be needed. The urban to declare that they “cannot” afford it.
sewerage targets are calculated by reference
to the connections needed in each country (as These levels of spending are affordable
shown in Table 6), and a global average cost elements of public investment in relation to
for new connections derived from the WHO the size of economies, especially in view of
estimates. The full costings for the MDGs, plus recent growth rates. The average level of
urban sewerage targets, are then calculated public investment in developing countries on
by grossing up the figure for urban sewerage all infrastructure has varied between 7% and
connections in line with the global relationship 10% of GNI over the last 35 years, and is
between this figure and the full cost of the generally considered to be too low.136 Therefore
MDGs. The estimates illustrate the likely scale spending 1% on new investment in water
of national needs, subject to the limitations of and sanitation is not an excessive burden.
34
 Sewerage Works
Public investment in sewers
saves lives

Most of these countries have experienced demands on the taxation systems of

sustained economic growth in recent years. countries. The taxation collected by some
Between 2001 and 2006 China averaged countries is adequate for these levels of
growth of 9.7% per annum, India 7.6%; public spending, but others need to increase
but other much poorer countries have also the tax collected. India collected only 12.5%
grown, including Mozambique (average annual of GNI as tax in 2004, Bangladesh 10%,
growth rate of 8.6% between 2001 and 2006), the Democratic Republic of Congo 8%,
Vietnam (7.6%), Tanzania (6.4%), Bangladesh, Pakistan 13% and the Philippines 15%; while
Iran, Nigeria (5.6%), Ghana, Pakistan (5.2%), other low income countries collect more,
Indonesia (4.9%), Philippines (4.6%), the for example Ghana 24%. 138 Establishing
Democratic Republic of Congo (4.2%), and sustainable public revenues, and building
Brazil (2.9%).137 Spending an extra 1% of the capacity of public authorities, are
GNI on investment in water and sanitation is important elements in development. Water
thus allocating part of this growth. It is not and sanitation investments can drive these
a claim on other uses of existing income. developments as they did in European and
This level of spending makes greater North American countries a century ago.139

Table 14: National affordability: costs as percentage of national income

National GNI 2006 Urban sewer Annual cost %GNI Annual cost % GNI
income group ($ billion) target of urban of MDG HC +
(millions) sewer target urban sewer
($ million) target
($ million)
China ML 2641.6 251 6275 0.24 7878 0.30
India L 906.5 184 4591 0.51 5764 0.64
Indonesia ML 315.8 73 1825 0.58 2291 0.73
Brazil ML 892.8 60 1498 0.17 1881 0.21
Nigeria L 92.4 43 1086 1.18 1364 1.48
Philippines ML 120.2 34 852 0.71 1069 0.89
Pakistan L 122.3 32 797 0.65 1000 0.82
Bangladesh L 69.9 27 681 0.97 855 1.22
Iran ML 207.6 25 630 0.30 790 0.38
Democratic Republic of Congo L 7.7 15 386 5.01 485 6.29
Vietnam L 58.1 14 358 0.62 450 0.77
Argentina MU 201.4 13 321 0.16 403 0.20
Thailand ML 193.7 12 302 0.16 379 0.20
Sudan L 29.9 11 281 0.94 352 1.18
Egypt ML 101.7 11 270 0.27 340 0.33
Venezuela MU 164.0 10 247 0.15 310 0.19
Ethiopia L 12.9 10 243 1.89 306 2.37
Malaysia MU 141.4 10 238 0.17 299 0.21
Myanmar L 9 230 288
Korea Rep H 856.6 9 214 0.03 269 0.03
Total of above 21,325 26,773
Total for all developing countries 27,800 34,900

Source: PSIRU calculations from World Bank, JMP, UN ESA and WHO data (see Annex)
Income groups: L=low income; ML=lower middle; MU=upper middle; H=high.
35
6_Costs, benefits and affordability

6.3.3_What can be afforded: show what would be needed to cover

global affordability and aid the costs of sewerage and the MDGs in
excess of 1%, 0.75%, or 0.5% of GNI.
One way of addressing the global affordability
question is whether the world economy as a On any such rule, aid should be concentrated
whole has capacity for this level of spending. on a few countries. Under the 1% threshold,
Tested against the capacity of the global the aid required would be heavily concentrated
economy, achieving the MDG targets, plus in two countries – Nigeria and the Democratic
urban sewerage connections, costs 0.08% Republic of Congo – followed by Ethiopia and
per annum of global GNI. This is modest for Bangladesh. These four countries account
a key public investment in infrastructure, with for half of all the aid required at this level. A
very high economic returns and major gains in number of African countries, including Sudan,
public health. If full existing costs of the water Ghana, Tanzania, Mozambique, Madagascar,
and sanitation systems are added in, so that together with Haiti, would also require
the figures represent total costs of investment significant aid at this level (see Annex for
and operation of water and sanitation for details on other countries). At the 0.75% level,
most people on earth, the total comes to Nigeria, the Democratic Republic of Congo,
only 0.2% of global GNI. In light of the actual Ethiopia, Bangladesh, Philippines, Sudan, and
spending levels noted above, this seems a Pakistan account for over half of all the aid
quite feasible level of global resources. required. Middle income countries only start
receiving significant aid if it covers costs above
This is an abstract exercise, however, because 0.5% of GNI. Indonesia and the Philippines
there is no global government and taxation both require significant aid, because the
system to redistribute the income of the global current level of sewerage connections is
economy. The only mechanisms which attempt so poor. India and Pakistan would also
this task are the aid programmes of the rich receive large amounts of aid at this level.
countries, and the investment programmes
of the development banks. So the real test is
whether this amount of aid required can be
afforded, realistically by the richer nations.

It needs to be emphasised again that

developing countries are sovereign states
which decide how much should be invested
in water and sanitation. It is inaccurate and
unnecessary to assume that the entire cost of
achieving the targets must be carried by aid.
As noted above, many countries are getting
on with financing sanitation and sewerage
programmes from their own national taxation,
and aid plays only a marginal role. So the first
question to be established is how much of the
required money might be provided by aid?

The table overleaf calculates aid on the

basis that it is meant to reduce the burden
on a country’s economy. So the figures
36
 Sewerage Works
Public investment in sewers
saves lives

Table 15:
Global affordability: the need for aid

Income Annual cost of MDG Aid needed to cover Aid needed to cover Aid needed to cover
group HC + urban sewers spending >1% of spending >0.75% of spending >0.5% of
%GNI GNI ($million) GNI ($million) GNI ($million)
China ML 0.30
India L 0.64 1232
Indonesia ML 0.73 712
Brazil ML 0.21
Nigeria L 1.48 440 671 902
Philippines ML 0.89 168 468
Pakistan L 0.82 83 389
Bangladesh L 1.22 156 331 505
Iran ML 0.38
Democratic Republic of Congo L 6.29 408 427 446
Vietnam L 0.77 14 159
Argentina MU 0.20
Thailand ML 0.20
Sudan L 1.18 53 128 203
Egypt ML 0.33
Venezuela MU 0.19
Ethiopia L 2.37 177 209 241
Malaysia MU 0.21
Myanmar L n/a
Korea Rep H 0.03
TOTAL for all developing countries 2236 3603 7919

Source: PSIRU calculations from World Bank, JMP, UN ESA and WHO data (see Annex)
Income groups: L=low income; ML=lower middle; MU=upper middle; H=high.

37
 6_Costs, benefits and affordability

The total amount of aid required to support Table 16:

spending on the combined targets over 0.5% Aid: going to the wrong countries?
of GNI is $7.9 billion. This compares with actual
aid for water and sanitation of $5.9 billion in Country Income Aid needed to Annual average aid
group cover spending for water received
2005 ($4.5 billion from donors and $1.4 billion >0.5% of GNI from donors
from development banks).140 This implies an ($ million) 2001-2005
increase, but a feasible increase: aid for water Iraq 343
and sanitation increased by $0.9 billion per China 287
year from 2002 to 2005, and a continuation India L 1232 210
of this upward trend is a possibility. So even Malaysia 151
this high level of aid is a realistic target. Palestinian 129
admin areas

A redistribution of existing aid would be Indonesia ML 712

appropriate, however. Ten per cent of aid for Nigeria L 902
water and sanitation in 2001-2005 was spent Bangladesh L 505
by the USA in Iraq. Of the 10 countries which Philippines ML 468
appear to need most aid on our estimates, Democratic L 446
Republic of
only two (India and Vietnam) were amongst Congo
the top ten recipients of water and sanitation Pakistan L 389
aid. Instead, five of the top ten recipients Sudan L 203
were North African countries, and the largest Ghana L 167
was China. This pattern of spending reflects Vietnam L 159 114
the target markets of the multinational Tanzania L 149
companies, but not the pattern of needs. 141 Egypt 84
Jordan 93
Tunisia 71
Morocco 91

Source: OECD 2007 http://www.oecd.org/dataoecd/20/61/40162562.pdf

and PSIRU calculations

The figure of $7.9 billion is also a fairly low

burden on the incomes of the richer countries.
It represents 0.02% of the combined GNI
of high income countries. This is equivalent
to about $6.50 per capita per year in high
income countries, or 12 cents per week. It
seems quite disproportionate to describe
such levels of finance as “unaffordable”.

If funded through borrowing, the combined

targets would require only 0.03% of the global
finance capital of pension funds, insurance
companies, sovereign wealth funds and
banks, all of whom may be expected to be
interested in such long term investments.

38
 Sewerage Works
Public investment in sewers
saves lives

This is a very different conclusion from that 6.3.4_Case study – Stone Cross, England
reached by the WHO study on costs, which
concluded that “there is an enormous overall A group of 32 houses in Stone Cross, a
financing gap at the global level”.142 The key village in the countryside of Sussex, in
difference is that this paper takes account southern England, are being connected
of the capacity of countries to finance for the first time to a sewerage system.
expenditure through public finance; treats The work is needed because the
aid as a supportive supplement, not the existing septic tanks and cesspits
implicit source of all wealth; and recognises were polluting the environment, and so
that the development of water and sanitation posed a danger to public health.143
infrastructure, including sewers, has to be based
on public finance, not consumer spending. The water company, Southern Water, is
charging the villagers the standard connection
Table 17: fee of £276.81 per household.144 But these
Affordability in relation to global economy charges only cover 0.6% of the cost, which
and aid from high income countries is £1.5 million. The other £1,491,142.08 is
being spread between all the customers of
$ billion Annual Annual Annual Annual Southern Water, about four million people.
cost of cost of cost of cost of aid
total MDGs aid to to support This adds less than 40p per person to the
MDGs HC + urban support cost of annual water and sewerage bill (equivalent
+ urban sewerage cost of MDGs
sewerage target + MDGs + urban to about 80 cents in US currency).
target existing + urban sewerage
costs sewerage over 0.5%
over 1% of GNI The Stone Cross sewers show two things:
of GNI
Firstly, the need for cross-subsidy to achieve
34.9 88.7 3.6 7.9 the public benefits of sewerage. If the
principle of full cost recovery was applied,
Global GNI 48482 0.08% 0.20% 0.007% 0.016% the Stone Cross villagers would have to
2006 pay a connection charge of £46,875 per
High income 37529 0.01% 0.02% household. Instead, the capital expenditure
GNI 2006 is paid for collectively, by all users.
Global finance 167100 0.03% 0.11%
capital Secondly, if the same principle of cross-
subsidy was applied internationally through
Source: calculated from World Bank GNI stats, McKinsey 2007, table 11 aid, the cost of the target for the MDGs
with urban sewer connections in all the
cities in developing countries would be
remarkably low. The total annual aid
required to support all spending over 0.5%
of GNI is $7.9 billion – but spread across
Europe, the USA and the other high income
countries, with a population of 1.223 billion,
this would cost $6.46 per person per year.

That is only eight times the per capita

cost of the Stone Cross sewers.

39
6_Costs, benefits and affordability

6.4_What can be afforded: comparative Northern Rock has now been consolidated
spending and revenue decisions in a nationalisation which is estimated
to cost £100 billion ($200 billion).
6.4.1_Demand stimuli
This amount would be sufficient to
The global banking crisis that emerged in 2007 finance more than half the entire costs
has reduced global economic growth. The of the MDGs and the urban sewerage
USA government has announced a reflationary target in every city on earth.
package worth $150 billion in a single year.
The purpose of this is to provide an economic The purchase of Northern Rock is an
stimulus to help avoid a world recession. investment made for economic and social
The managing director of the International reasons, and is expected to produce some
Monetary Fund, Dominique Strauss-Kahn, has returns, although with significant risk of losses.
called for global reflationary measures: “This A similar amount invested through loans for
has become a global problem that requires a sewerage and water in developing countries
global solution …. Emerging markets need to would also provide economic and social
join industrial countries in the macroeconomic returns, though also with some degree of risk.
and regulatory policy response.”145 Private
sector borrowing through bond issues in 6.4.3_Company profits
developing countries fell sharply at the end
of 2007, and “emerging market economies The profits recorded by Exxon, Shell and BP
that are heavily dependent on capital in 2007 amount to $40.6 billion, $27.6 billion
inflows could be particularly affected”. 146 and $17.2 billion respectively, a total in a
single year of $85.4 billion.147 Much of this
A programme of sewer construction would profit was made from activities in oil-rich,
provide a very good economic stimulus. but sewer-poor, countries such as Nigeria.
The annual total of $34.9 billion needed for
the MDGs, plus the urban sewerage target, A 10% windfall tax on these profits would
could be financed through increased public be sufficient to finance all the aid needed
borrowing by national or international bond in one year to support the achievement
issues, for example. The boost to demand in full of the MDGs, plus urban sewerage
would be about 0.3% of developing country targets, throughout the world.
GNI, more modest than the USA package,
which represents about 1% of USA GNI. 6.4.4_Arms spending

It would have an additional major economic Total global military expenditure in 2006
benefit by creating hundreds of thousands was about $1,200 billion. The biggest
of jobs in southern countries. This would three spenders accounted for more than
provide a boost to employment incomes and half of this: USA ($529 billion), UK ($59
so reduce poverty, and create more taxable billion) and France ($53 billion).148
earnings and spending power which could
help finance further public investment. Half of the amount spent by these three
countries on arms in one year would
6.4.2_Northern Rock pay for almost the entire ten year cost
of achieving the MDGs in full, plus the
The support from the UK Government for urban sewerage connections target.

40
 Sewerage Works
Public investment in sewers
saves lives

6.4.5_Iraq

Recent calculations of the costs of the war in

Iraq and Afghanistan show that the monthly
expenditure by the USA on these wars is around
$16 billion, an annual total of £192 billion dollars.

One fifth of this amount would be sufficient to

finance the total annual cost of achieving the
MDGs, plus the urban sewerage connections
target, for every city in the world.

Table 18: Affordability comparisons

US$ billions $ per capita

Global annual cost of full MDGs and urban sewerage target 35
USA reflationary package 150
UK nationalisation of Northern Rock 200
Global military expenditure 2006 1200
Annual USA current spending on Iraq and Afghanistan wars 192
Exxon + Shell + BP profits 2007 87
Global annual cost of aid needed for full MDGs and urban sewerage target 7.9 $6.46
Cost of Stone Cross sewers $0.80

41
7_Conclusion

Analytical conclusions Policy conclusions

There are four key analytical Three broad policy conclusions can
conclusions to be drawn from the also be drawn from this report.
evidence presented in this report:
1. In analysing affordability, the starting
1. The health benefits of household sewerage point must be national policies and
connections are so certain and so great economies. Aid is only a marginal element
that they should be incorporated as central in this process, and so it is misleading
to the Millennium Development Goals to see donors as the key policy-makers
(MDGs), not dismissed as an expensive or aid as the key economic resource.
‘extra’. The need for sewerage in cities, in When analysed at national level, it is
particular, is so fundamental that it should clear that the financial requirements are
be incorporated as a new target in the affordable for most countries. The need
MDGs: “To halve by 2015 the proportion for aid should be assessed in relation
of the urban population without household to national needs and affordability, not
connections to a sewerage system.” by reference to the total global cost of
developing water and sanitation systems,
2. The finance for developing sewerage most of which will be met nationally.
systems has to come from public finance,
as it has done in the north. It will not 2. Developing countries should make urban
be successfully delivered by the private sewerage as great a priority as high-income
sector, and it will not be affordable countries did in the past, and continue to
for the poor on this basis. The private plan for development of household water
sector’s failure to extend sewerage and sewerage connections. A number of
systems in the south demonstrates countries are already doing so, led by those
the need to abandon this ideology. that are most independent of pressures from
international financial institutions or donor
3. The costs of sewerage systems countries, notably China, Brazil and India.
is justified by the health and
economic benefits achievable. Countries that are more inclined to follow
the policies of the international bodies,
Sewerage programmes are affordable such as Indonesia and the Philippines, are
for the national economies of countries failing to do so. The important financial
with the great majority of people needing issue is to ensure that sufficient taxes are
connections. The additional benefits in terms raised to finance urban sewerage systems.
of employment and stimulus to the global Attempts to finance them through user
economy are important additional benefits charges to recover costs, or attempts to
of a programme of sewer extensions. involve the private sector in investment, are
likely to be expensive irrelevances that will
4. The aid required is affordable for slow down achievements. Countries such
donor countries and should be as Indonesia and the Philippines need to
targeted at the countries with greatest develop major public spending programmes
need. The requirements are modest to develop urban sewer systems.
when compared with other items of
expenditure by high-income countries.

42
 Sewerage Works
Public investment in sewers
saves lives

3. The major donor countries and development

agencies are currently pursuing policies
that undermine what is needed for the
development of urban sewerage systems.
Donors should stop encouraging countries
to try and finance development of sewerage
systems through cost recovery from users,
and stop encouraging countries to believe
that the private sector will make any
significant contribution to investment in
sanitation. They should instead encourage
countries to build the taxation capacity
needed to finance this investment, and
provide support and training for capacity
building through public-public partnerships,
following the model of Japan. Aid should
be focused on the countries in greatest
need of assistance to meet the costs of
urban sanitation, in particular low-income
African countries, led by Nigeria and
the Democratic Republic of Congo.

43
8_Further reading

ADB 2007 Asian Water Development Gandy, Matthew 2006 ‘Planning, anti-planning
Outlook www.adb.org/Documents/ and the infrastructure crisis facing Metropolitan
Books/AWDO/2007/AWDO.pdf Lagos’, Urban Studies, 43:2, 371–396 http://
dx.doi.org/10.1080/00420980500406751
Annez P.C. 2006. Urban Infrastructure
Finance From Private Operators: Hall D. and Lobina E. 2006 Pipe Dreams
What Have We Learned From Recent www.wdm.org.uk/resources/briefings/
Experience? World Bank Policy Research water/pipedreamsbriefing01022006.pdf
Working Paper 4045, November 2006
Hall D. and Lobina E. 2007 Water as a
Barreto et al 2007. Barreto M., Genser B., Public Service. PSIRU www.psiru.org
Strina A., Teixeira M., Assis A., Rego R.,
Teles C., Prado M., Matos S., Santos D., Indonesia 2006 It’s Not A Private Matter
dos Santos L., Cairncross S. Effect of city- Anymore! Urban Sanitation: Portraits,
wide sanitation programme on reduction Expectations, And Opportunities. Government
in rate of childhood diarrhoea in northeast of Indonesia September 2006 http://esa.
Brazil: assessment by two cohort studies. un.org/iys/docs/san_lib_docs/Not%20
Lancet 2007; 370: 1622–28 November 10, a%20Private%20Matter%20Anymore.pdf
2007 www.thelancet.com/journals/lancet/
article/PIIS0140673607616389/fulltext JMP 2006 Meeting the MDG drinking water
and sanitation target: the urban and rural
Bartlett, Sheridan. 2005. “Water, Sanitation challenge of the decade. WHO and Unicef
and Urban Children: The Need to Go Beyond 2006 www.who.int/water_sanitation_health/
“Improved” Provision.” Children, Youth and monitoring/jmp2006/en/index.html
Environments 15(1): 115-137. www.colorado.
edu/journals/cye/15_1/a6_Sanitation.pdf Lobina E. and Hall D. Water privatisation and
restructuring in Latin America, 2007 www.
Black RE, Morris SS, Bryce J. 2003 Where psiru.org/reports/2007-09-W-Latam.doc
and why are 10 million children dying
each year? Lancet 2003;361:2226-34. Mara D.D. 2003 Water, sanitation and
hygiene for the health of developing nations.
Checkley W., Robert H Gilman, Robert E Public Health (2003) 117, 452–456
Black, Leonardo D Epstein, Lilia Cabrera,
Charles R Sterling and Lawrence H Orangi Pilot Project Research And Training
Moulton Effect of water and sanitation on Institute (OPP-RTI) www.oppinstitutions.
childhood health in a poor Peruvian peri- org/creplicationofspnd.htm
urban community The Lancet, Volume 363,
Issue 9403, 10 January 2004, 112-118 Shi, Anqing, “How Access to Urban Potable
Water and Sewerage Connections Affects
Comparative Analysis, Obstacles and Child Mortality” (January 2000). World Bank
Recommendations. World Water Council Policy Research Working Paper No. 2274.
March 2006 www.financingwaterforall. http://wbln0018.worldbank.org/Research/
org/fileadmin/Financing_water_for_all/ workpapers.nsf/2b412592eac839e28525
Reports/FullTextCover_MDG.pdf 67e50050df1c/deb83a3c607e359c85256
86600521ddd/$FILE/wps2274.prn.pdf

44
 Sewerage Works
Public investment in sewers
saves lives

UNHAB-FUS 2005 Financing Urban Shelter.

UN-Habitat Global Report On Human
Settlements 2005 www.unhabitat.org/global_
report_on_human_settlements_2005.asp

UNMP 2005. UN Millennium Project.

Health, Dignity, and Development: What
Will it Take? Task Force on Water and
Sanitation. 2005 www.unmillenniumproject.
org/reports/tf_watersanitation.htm

WHO 2004. Guy Hutton and Laurence

Haller. Evaluation of the Costs and Benefits
of Water and Sanitation Improvements at
the Global Level. WHO 2004. www.who.
int/water_sanitation_health/wsh0404.pdf

WHO 2008 Hutton G. and Bartram J. 2008

Global costs of attaining the Millennium
Development Goal for water supply and
sanitation. Bulletin of the World Health
Organization January 2008, 86 (1) www.
who.int/entity/bulletin/volumes/86/1/07-
046045-ab/en/index.html

World Bank 2007. Spending for Development:

Making the Most of Indonesia’s New
Opportunities. Indonesia Public Expenditure
Review 2007. http://siteresources.
worldbank.org/INTINDONESIA/Resources/
Publication/280016-1168483675167/
PEReport.pdf

WWC 2006 Tubkiss J. Costing MDG

Target 10 on Water Supply and
Sanitation. www.worldwatercouncil.org/
fileadmin/wwc/Library/Publications_
and_reports/FullTextCover_MDG.pdf

WWDR 2006. Water – a shared

responsibility. The UN World Water
Development Report 2. 2006 www.unesco.
org/water/wwap/wwdr2/index.shtml

45
9_Annex: Calculation of tables on needs and affordability

Table 1

Data is taken from the report of the joint

monitoring programme: JMP 2006 Meeting
the MDG drinking water and sanitation
target: the urban and rural challenge of the
decade. WHO and Unicef 2006 www.who.
int/water_sanitation_health/monitoring/
jmp2006/en/index.html. The data is taken
from the final table on page 40: the figures
for annual connections needed have been
multiplied by ten to generate totals over the
whole 10 year period. The JMP notes that
“Regional values do not add up to totals.”

Table 2

All data – on 2004 urban populations, improved

sanitation and and sewerage connection levels
– is taken from the JMP website on sanitation
at: www.wssinfo.org/en/31_san_intro.html.
Although the JMP collects this data on household
sewerage connections, it did not publish any of
it in the 2006 mid-term assessment, which only
presented information on “improved” sanitation.

46
 Sewerage Works
Public investment in sewers
saves lives

Table 5

2004 Household Numbers Numbers with 2015 Extra connections Target

urban sewer with sewer no sewer urban needed by household
Population connection % connection connection population 2015 to halve sewer
(millions) coverage in 2004 2004 forecast unconnected connection
2004 (millions) (millions) (millions) (millions) % in 2015
North Africa 80 73 58 21 121 46 87

Sub-Saharan 268 19 51 217 386 179 60

Africa
Latin America 428 62 265 163 508 146 81
and Caribbean

East Asia 579 50 289 289 750 273 75

South Asia 459 24 110 349 624 277 62

South East Asia 235 9 21 214 327 157 55

West Asia 129 83 107 22 171 50 92

Oceania 2 32 1 1 3 1 66

Total of above 2179 41 903 1277 2890 1141 71

World total 3113 56 1744 1369.89 3845 1255 78

This has been calculated from the data in because the countries in the region are
Table 2, plus the urban population forecasts grouped very differently in the UN and JMP
for 2015 in World Urbanisation prospects: 2007 data. The connection rate is already very high.
revision http://esa.un.org/unpp/. The forecasts
use slightly different regional definitions
from the JMP, and so they have been
adjusted to exclude Japan from Eastern Asia;
exclude Kazakhstan, Kyrgystan, Tajikistan,
Turkmenistan, and Uzbekistan from Southern
and Central Asia; and creating a forecast
for Oceania by adding the urban population
forecasts for Melanesia, Micronesia, and
Polynesia. The numbers needing connection
have then been calculated by halving the
numbers unconnected in 2004; subtracting
the result from the population for 2015; and
from this total subtracting the population
already connected in 2004. The resulting
connection rate in 2015 is then calculated.
The CIS has been omitted from the table
47
9_Annex

Table 6

2004 urban Household Numbers Numbers with 2015 urban Extra connections Target
Population sewer with sewer no sewer population needed by household
(millions) connection % connection connection forecast 2015 to halve sewer
coverage in 2004 (millions) 2004 (millions) (millions) unconnected connection %
2004 (millions) in 2015
China 683 523 50 262 262 251 75
India 416 304 25 76 228 184 63
Indonesia 147 103 2 2 101 73 51
Brazil 185 154 53 82 73 60 77
Nigeria 94 62 23 14 48 43 62
Philippines 70 51 7 4 47 34 54
Pakistan 76 53 40 21 32 32 70
Bangladesh 55 35 7 2 32 27 54
Iran 57 46 19 9 37 25 60
DR Congo 31 18 4 1 17 15 52
Vietnam 30 22 14 3 19 14 57
Argentina 40 35 48 17 18 13 74
Thailand 24 20 0 0 20 12 50
Sudan 23 14 1 0 14 11 51
Egypt 38 31 68 21 10 11 84
Venezuela 30 23 61 14 9 10 81
Ethiopia 20 12 2 0 12 10 51
Malaysia 23 16 41 7 9 10 71
Myanmar 19 15 10 2 14 9 55
Korea Rep 41 39 65 25 14 9 83
South Africa 32 27 70 19 8 9 85
Korea DPR 16 14 12 2 12 7 56
Ghana 15 10 13 1 9 7 57
Tanzania 14 14 3 0 13 7 52
Angola 13 6 19 1 5 7 60
Côte d’Ivoire 12 8 18 1 7 6 59
Mozambique 10 7 4 0 7 5 52
Peru 22 20 67 14 7 5 84
Kenya 11 14 9 1 12 5 55
Yemen 10 5 44 2 3 5 72
Afghanistan 10 7 6 0 6 5 53
Morocco 20 18 70 13 5 5 85

48
 Sewerage Works
Public investment in sewers
saves lives

This has been calculated from the urban

population and sanitation data on the JMP
website at www.wssinfo.org/en/31_san_intro.
html, plus the urban population forecasts for
2015 in World Urbanisation prospects: 2007
revision. The numbers needing connection
have then been calculated by halving the
proportion unconnected in 2004; subtracting
the result from the population for 2015; and
from this total subtracting the population
already connected in 2004. The resulting
connection rate in 2015 is calculated by
halving the proportion unconnected in 2004.
The detailed table reproduced here covers all
32 countries where more than 5 million new
connections are required. These countries
require 1,119 million new connections, 83%
of the total estimated for all regions.

49
9_Annex

Tables 15 and 16

Group GNI Urban Annual % GNI Grossed % GNI Possible Possible Possible MDG HC %GNI
2006 ($ sewer cost ($ up to aid need aid need aid need + urban
billion) target million) MDG HC >1% of >0.75% >0.5% of sewers
(millions) + urban GNI ($ of GNI ($ GNI $m $m +
sewers ($ million) million) existing
million) costs
China ml 2641.6 251 6275 0.24 7878 0.30 20022 0.76
India l 906.5 184 4591 0.51 5764 0.64 1232 14650 1.62
Indonesia ml 315.8 73 1825 0.58 2291 0.73 712 5823 1.84
Brazil ml 892.8 60 1498 0.17 1881 0.21 4779 0.54
Nigeria l 92.4 43 1086 1.18 1364 1.48 440 671 902 3466 3.75
Philippines ml 120.2 34 852 0.71 1069 0.89 168 468 2718 2.26
Pakistan l 122.3 32 797 0.65 1000 0.82 83 389 2542 2.08
Bangladesh l 69.9 27 681 0.97 855 1.22 156 331 505 2173 3.11
Iran ml 207.6 25 630 0.30 790 0.38 2009 0.97
DR Congo l 7.7 15 386 5.01 485 6.29 408 427 446 1232 16.00
Vietnam l 58.1 14 358 0.62 450 0.77 14 159 1143 1.97
Argentina mu 201.4 13 321 0.16 403 0.20 1025 0.51
Thailand ml 193.7 12 302 0.16 379 0.20 963 0.50
Sudan l 29.9 11 281 0.94 352 1.18 53 128 203 896 3.00
Egypt ml 101.7 11 270 0.27 340 0.33 863 0.85
Venezuela mu 164.0 10 247 0.15 310 0.19 787 0.48
Ethiopia l 12.9 10 243 1.89 306 2.37 177 209 241 777 6.02
Malaysia mu 141.4 10 238 0.17 299 0.21 759 0.54
Myanmar l 9 230 288 0 0 0 733
Korea Rep h 856.6 9 214 0.03 269 0.03 684 0.08
South Africa mu 255.3 9 214 0.08 269 0.11 683 0.27
Korea DPR l 7 183 230 0 0 0 583
Ghana l 11.8 7 180 1.52 226 1.91 108 137 167 574 4.86
Tanzania l 13.4 7 172 1.28 216 1.61 82 116 149 549 4.10
Angola ml 32.4 7 171 0.53 215 0.66 53 546 1.68
Côte d’Ivoire l 16.0 6 140 0.87 176 1.10 16 56 96 446 2.79
Mozambique l 6.9 5 129 1.87 162 2.34 93 110 127 411 5.96
Peru ml 82.7 5 124 0.15 155 0.19 395 0.48
Kenya l 20.5 5 121 0.59 152 0.74 49 385 1.88
Yemen l 16.4 5 120 0.73 150 0.91 27 68 381 2.33
Afghanistan l 8.1 5 117 1.45 147 1.82 66 87 107 374 4.62
Morocco ml 58.0 5 114 0.20 143 0.25 363 0.63
Madagascar l 5.3 4 96 1.80 120 2.26 67 80 93 305 5.75
Nepal l 8.0 3 83 1.03 104 1.30 24 44 64 263 3.29
Ecuador ml 38.1 3 81 0.21 102 0.27 260 0.68
Haiti l 4.1 3 75 1.84 94 2.30 53 64 74 240 5.86
Bolivia ml 10.3 3 74 0.71 92 0.90 15 41 235 2.28
Senegal l 8.9 3 72 0.81 90 1.02 1 24 46 230 2.58
Uganda l 8.9 3 71 0.80 89 1.00 0 22 44 226 2.54
Mali l 6.1 3 70 1.15 88 1.44 27 42 57 223 3.66
Benin l 4.7 3 63 1.34 79 1.68 32 44 56 201 4.27
50
 Sewerage Works
Public investment in sewers
saves lives

Group GNI Urban Annual % GNI Grossed % GNI Possible Possible Possible MDG HC %GNI
2006 ($ sewer cost ($ up to aid need aid need aid need + urban
billion) target million) MDG HC >1% of >0.75% >0.5% of sewers
(millions) + urban GNI ($ of GNI ($ GNI $m $m +
sewers ($ million) million) existing
million) costs
Guinea l 3.7 2 55 1.48 69 1.85 32 41 50 174 4.71
Cuba l 2 54 68 0 0 0 172
Burkina Faso l 6.3 2 53 0.84 66 1.05 3 19 35 168 2.67
Zambia l 7.5 2 53 0.70 66 0.88 10 29 168 2.24
Cambodia l 6.9 2 52 0.75 65 0.94 13 30 165 2.39
Paraguay ml 8.4 2 51 0.61 65 0.77 2 23 164 1.95
Chad l 4.7 2 51 1.09 64 1.36 17 29 41 163 3.46
Malawi l 2.2 2 48 2.17 60 2.73 38 43 49 152 6.93
Togo l 2.2 2 47 2.13 59 2.68 37 42 48 150 6.81
Niger l 3.7 2 41 1.11 52 1.39 15 24 33 131 3.55
Nicaragua l 5.2 2 39 0.76 49 0.95 10 23 126 2.41
Sri Lanka ml 25.7 1 36 0.14 46 0.18 116 0.45
Congo l 3.8 1 35 0.93 44 1.17 6 16 25 113 2.96
Rwanda l 2.3 1 31 1.36 39 1.70 16 22 28 99 4.32
TOTAL group 7835 978 24440 0.31 30681 0.39 1966 3168 6961 77978 1.00
Group as % 85 88 88
of developing
countries
TOTAL 1150 27800 34900 2236 3603 7919 88700
developing
countries

The cost estimates for the MDGs in water new spending for full household sanitation
and sanitation and 80% urban sewerage connection across the 1.052 billion which the
connections are based on the needs WHO paper says are covered by these totals.
assessments in Table 6, the WHO cost The costs for achieving the MDGs as well is
estimates published in Hutton G. and derived by multiplying these estimates for
Bartram J. 2008 Global costs of attaining the costs of urban connections by the ratio
the Millennium Development Goal for water between the total costs of urban sanitation
supply and sanitation. Bulletin of the World connections alone and the full costs of MDGs
Health Organization January 2008, 86 (1) http:// with household connections, for water and
www.who.int/entity/bulletin/volumes/86/1/07- sanitation, in the WHO study. The main
046045-ab/en/index.html, and World Bank columns shown in the body of the report
data on gross national income (GNI) taken do not include the continuing costs of pre-
from World Development Indicators database existing operations; the full table here does
http://go.worldbank.org/3JU2HA60D0. The so, for completeness. The basis of the aid
costs for achieving the connection targets for calculations is as explained in the text.
urban sewerage is calculated by multiplying
(a) the Table 6 estimates of numbers needing
connection, by (b) an approximate average
cost of $250 per person connected, derived
from the WHO study by averaging the total
51
Endnotes

1 Infrastructure In East Asia And The 8 WWDR 2006. Water – a shared

Pacific – The Way Forward. Infrastructure responsibility. The UN World Water
Development And Service Provision Development Report 2. 2006
In The Process Of Urbanization. Final http://www.unesco.org/water/
Report. ADB. 2007. http://www.adb.org/ wwap/wwdr2/index.shtml
Documents/Books/AWDO/2007/AWDO.pdf
9 JMP http://www.wssinfo.org/
2 BMJ readers choose the “sanitary en/35_san_dev.html
revolution” as greatest medical advance
since 1840 Annabel Ferriman BMJ 10 JMP 2006 p.4
2007;334:111 (20 January) http://www.
bmj.com/cgi/content/full/334/7585/111-a 11 Dirty Water: Estimated Deaths from
Water-Related Diseases 2000-2020
3 Sanitation: pragmatism works Pacific Institute Research Report
Johan P Mackenbach BMJ 2007 Peter H. Gleick August 15, 2002
334: 17. file:///P:/Working/Projects/
WDM-sanitation/healthsanitation/ 12 WDDR 2006 p.30
bmj2007-sanitation-hist.htm
13 WDDR 2006 p.32
4 Barraqué, Bernard (2007) “Small
Communes, Centralisation, and 14 JMP 2006 Meeting the MDG drinking
Delegation to Private Companies: water and sanitation target: the urban
The French Experience”, and rural challenge of the decade.
Journal of Comparative Social WHO and Unicef 2006 http://www.
Welfare, 23:2, 121–130 who.int/water_sanitation_health/
monitoring/jmp2006/en/index.html;
5 Council Directive 91/271/EEC of 21 JMP Coverage estimates Improved
May 1991 concerning urban waste- Sanitation Pakistan 2006 http://www.
water treatment, Article 3. http://eur-lex. wssinfo.org/pdf/country/PAK_san.pdf
europa.eu/LexUriServ/LexUriServ.do
?uri=CELEX:31991L0271:EN:HTML 15 David Durrheim. A clarion call for
greater investment in global sanitation
6 UNMP 2005. UN Millennium Project. The Lancet Vol 370 November
Health, Dignity, and Development: 10, 2007 www.thelancet.com
What Will it Take? Task Force on
Water and Sanitation. 2005 http:// 16 Marta-Louise Ackersa, Robert E Quicka,
www.unmillenniumproject.org/ Christopher J Drasbekb, Lori Hutwagnerc
reports/tf_watersanitation.htm and Robert V Tauxea
Are there national risk factors for epidemic
7 JMP 2006 Meeting the MDG drinking cholera? The correlation between
water and sanitation target: the urban socioeconomic and demographic
and rural challenge of the decade. indices and cholera incidence in Latin
WHO and Unicef 2006 http://www. America Int. J. Epidemiol. 1998 April
who.int/water_sanitation_health/ 27 (2): 330-4. http://ije.oxfordjournals.
monitoring/jmp2006/en/index.html org/cgi/content/abstract/27/2/330

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 Sewerage Works
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saves lives

17 David Durrheim A clarion call for 24 Black RE, Morris SS, Bryce J. Where
greater investment in global sanitation and why are 10 million children dying
The Lancet Vol 370 November each year? Lancet 2003;361:2226-34.
10, 2007 www.thelancet.com
25 Jones G, Steketee RW, Black RE,
18 DA Sack, RB Sack, GB Nair and Bhutta ZA, Morris S and the Bellagio
AK Siddique, Cholera, Lancet Child Survival Study Group. How
363 (2004), pp. 223–233. many child deaths can we prevent this
year? The Lancet 2003; 362: 65-71.
19 Kosek M, Bern C, Guerrant RL. The http://www.thelancet.com/journals/lancet/
global burden of diarrhoeal disease, article/PIIS0140673603138111/abstract
as estimated from studies published
between 1992 and 2000. Bull World 26 Jones G, Steketee RW, Black RE,
Health Organ 2003; 81: 197–204., Bhutta ZA, Morris S and the Bellagio
referenced in Barreto et al 2007. Child Survival Study Group. How
many child deaths can we prevent this
20 Birger Carl Forsberg, Max G Petzold, year? The Lancet 2003; 362: 65-71.
Göran Tomsona & Peter Allebeck. http://www.thelancet.com/journals/lancet/
Diarrhoea case management in low- article/PIIS0140673603138111/abstract
and middle-income countries — an
unfinished agenda Bulletin of the 27 Shi, Anqing, “How Access to Urban
World Health Organization | January Potable Water and Sewerage
2007, 85 (1) http://www.who.int/ Connections Affects Child Mortality”
bulletin/volumes/85/1/06-030866.pdf (January 2000). World Bank Policy
Research Working Paper No. 2274. http://
21 Birger Carl Forsberg, Max G Petzold, wbln0018.worldbank.org/Research/
Göran Tomsona & Peter Allebeck. workpapers.nsf/2b412592eac839e28525
Diarrhoea case management in low- 67e50050df1c/deb83a3c607e359c8525
and middle-income countries — an 686600521ddd/$FILE/wps2274.prn.pdf
unfinished agenda Bulletin of the
World Health Organization January 28 Shi, Anqing, “How Access to Urban
2007, 85 (1) http://www.who.int/ Potable Water and Sewerage Connections
bulletin/volumes/85/1/06-030866.pdf Affects Child Mortality” (January 2000).
World Bank Policy Research Working
22 Jamie Bartram Flowing away: water Paper No. 2274. Table 4 http://wbln0018.
and health opportunities Bulletin of the worldbank.org/Research/workpapers.
World Health Organization 86, 1, January nsf/2b412592eac839e2852567e5005
2008, 1-80 http://www.who.int/entity/ 0df1c/deb83a3c607e359c85256866
bulletin/volumes/86/1/07-049619.pdf 00521ddd/$FILE/wps2274.prn.pdf

23 Bryce J., Boschi-Pinto C., Shibuya 29 Effect of water and sanitation on

K., Black R., and WHO Child Health childhood health in a poor Peruvian
Epidemiology Reference Group. .WHO peri-urban community The Lancet,
estimates of the causes of death in 363, 9403, 10 January 2004,
children. The Lancet 365, 9465, 26 112-118 William Checkley, Robert H
March 2005-1 April 2005, 1147-1152 Gilman, Robert E Black, Leonardo

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Endnotes

D Epstein, Lilia Cabrera, Charles R Brazil Environment and Urbanization,

Sterling and Lawrence H Moulton. Vol. 11, No. 1, April 1999 http://eau.
sagepub.com/cgi/reprint/11/1/133.pdf
30 Effect of water and sanitation on
childhood health in a poor Peruvian 36 The use and disposal of greywater in
peri-urban community The Lancet, the non-sewered areas of South Africa:
363, 9403, 10 January 2004, Part 2 – Greywater management options
112-118 William Checkley, Robert H Kirsty Carden, Neil Armitage, Owen
Gilman, Robert E Black, Leonardo Sichone and Kevin Winter Water SA 33,
D Epstein, Lilia Cabrera, Charles R 4 July 2007 http://www.wrc.org.za
Sterling and Lawrence H Moulton.
37 WWDR 2006 p.31
31 Valerie Curtis, Sandy Cairncross,
Raymond Yonli (2000) Review: Domestic 38 Indonesia 2006 It’s Not A Private
hygiene and diarrhoea – pinpointing Matter Anymore! Urban Sanitation:
the problem Tropical Medicine & Portraits, Expectations, And
International Health 5 (1), 22–32. http:// Opportunities. Government of Indonesia
www.blackwell-synergy.com/doi/ September 2006 http://esa.un.org/
pdf/10.1046/j.1365-3156.2000.00512.x iys/docs/san_lib_docs/Not%20a%20
Private%20Matter%20Anymore.pdf
32 Bartlett, Sheridan. (2005). “Water,
Sanitation and Urban Children: The Need 39 The road not taken - how traditional
to Go Beyond “Improved” Provision.” excreta and greywater management
Children, Youth and Environments 15(1): may point the way to a sustainable
115-137. http://www.colorado.edu/ future P. Bracken, A. Wachtler, A.R.
journals/cye/15_1/a6_Sanitation.pdf Panesar, J. Lange http://www2.gtz.de/
Dokumente/oe44/ecosan/en-traditional-
33 Mauricio L Barreto, Bernd Genser, management-sustainable-future-2006.
Agostino Strina, Maria Gloria Teixeira, pdf. Others support similar alternatives
Ana Marlucia O Assis, Rita F Rego, Carlos for being cheaper, involving more local
A Teles, Matildes S Prado, Sheila M A business activity, through “low-cost
Matos, Darci N Santos, Lenaldo A dos household technologies”, and corporate
Santos, Sandy Cairncross. Effect of city- social responsibility, and representing
wide sanitation programme on reduction a leap into the future, e.g. Water and
in rate of childhood diarrhoea in northeast Sanitation in Developing Countries:
Brazil: assessment by two cohort Including Health in the Equation.
studies The Lancet 2007; 370: 1622–28 Maggie A. Montgomery and Menachem
November 10, 2007 www.thelancet.com Elimelech, Yale University. Environmental
Science & Technology. January 1, 2007
34 Takeshi Nagashima. Sewage disposal p.17; Kumudini Abeysuriya, Cynthia
and typhoid fever: The case of Tokyo Mitchell, Stuart White. Can corporate
1912-1940 Annales De Démographie social responsibility resolve the sanitation
Historique 2004 No. 2 p. 105 à 117 question in developing Asian countries?
Ecological Economics 62(2007) 174-183.
35 Heller L. 1999 Who really benefits from
environmental sanitation services in the 40 Jacques W. Delleur 2003. The Evolution of
cities? An intra-urban analysis in Betim, Urban Hydrology: Past, Present, and Future.
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J. Hydr. Engrg., 129, 8, 563-573 47 JMP: http://www.wssinfo.org/

(August 2003) http://link.aip.org/ en/35_san_dev.html ESA: http://esa.
link/?JHEND8/129/563/1 ; M. un.org/unup/index.asp?panel=1
Jansen Water Supply and Sewage
Disposal at Mohenjo-Daro World 48 WWDR 2006. Water – a shared
Archaeology, 21, 2, The Archaeology responsibility. The UN World Water
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41 See http://www.sewerhistory.org/ 49 UNWP 2005 p. 96.

articles/wh_era/cloacina/cloacina.pdf
50 Water: How to Manage a Vital Resource
42 Mauricio L Barreto, Bernd Genser, Angel Gurría, Secretary-General, OECD.
Agostino Strina, Maria Gloria Teixeira, OECD Forum: Innovation,Growth and
Ana Marlucia O Assis, Rita F Rego, Carlos Equity 14-15 May 2007, Paris http://www.
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Santos, Sandy Cairncross. Effect of city- 51 Federal Republic Of Nigeria
wide sanitation programme on reduction Country Strategy Paper 2005-2009
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to Basic Services: Telecommunications, 63 S. Pharasi and C.A. Kennedy (2002)

Water and Sanitation, Financial Services, Reflections On The Financial History Of
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56 Bartlett, Sheridan. (2005). “Water, Congrès Annuel de la Société Canadienne
Sanitation and Urban Children: The Need de Génie Civil Annual Conference of the
to Go Beyond “Improved” Provision.” Canadian Society for Civil Engineering.
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wps/en/contenu/doc/confgen/pdf/
57 UNWP 2005 p.83. GE062-PHARASI-Kennedy.pdf

58 Barraqué, Bernard (2007) ‘Small 64 The Development of Water Supply

Communes, Centralisation, and and Sewage Infrastructure in
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The French Experience’, Institutional Aspects of Public
Journal of Comparative Social Health and Environmental History A
Welfare, 23:2, 121–130 Background Paper for the Walkerton
Inquiry February 2001 http://
59 ADB (2007b) Summary of the Legal tspacetest.library.utoronto.ca:8080/
Framework, Finance, and Institutional bitstream/1778/4019/1/10294043.pdf
Arrangement of Japan’s Sewerage
System, in ADB Asian Water Development 65 S. Pharasi and C.A. Kennedy (2002)
Outlook (http://www.adb.org/Documents/ Reflections On The Financial History Of
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Department of Civil Engineering,
60 Hall D. and Lobina E. 2007 Water as University of Toronto, Ontario, Canada
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of Greenwich. http://www.psiru.org/ de Génie Civil Annual Conference of the
reports/2007-01-W-waaps.pdf Canadian Society for Civil Engineering.
Montréal, Québec, Canada 5-8 juin
61 UNWP 2005 p.83. 2002 / June 5-8, 2002 http://pedago.
cegepoutaouais.qc.ca/media/0358894/
62 The Development of Water Supply wps/en/contenu/doc/confgen/pdf/
and Sewage Infrastructure in GE062-PHARASI-Kennedy.pdf
Ontario, 1880-1990s: Legal and
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Health and Environmental History A Reflections On The Financial History Of
Background Paper for the Walkerton Toronto’s Urban Water Infrastructure
Inquiry February 2001 http:// Department of Civil Engineering,
tspacetest.library.utoronto.ca:8080/ University of Toronto, Ontario, Canada
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