WATER AND SANITATION PROGRAM: TECHNICAL PAPER 82606 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China A six-country study conducted in Cambodia, China, Indonesia, Lao PDR, the Philippines and Vietnam under the Economics of Sanitation Initiative (ESI) September 2012 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. THE WORLD BANK Water and Sanitation Program East Asia & the Pacific Regional Office Indonesia Stock Exchange Building Tower II, 13th Fl. Jl. Jend. Sudirman Kav. 52-53 Jakarta 12190 Indonesia Tel: (62-21) 5299 3003 Fax: (62 21) 5299 3004 Water and Sanitation Program (WSP) reports are published to communicate the results of WSP’s work to the development community. Some sources cited may be informal documents that are not readily available. 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Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China A six-country study conducted in Cambodia, China, Indonesia, Lao PDR, the Philippines and Vietnam under the Economics of Sanitation Initiative (ESI) Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China Executive Summary A. INTRODUCTION The “Economics of Sanitation Initiative” (ESI) in Yunnan, associated with sanitation, particularly in the less developed China, is part of a study conducted by the World Bank’s and rural parts of China such as Yunnan Province, and the Water and Sanitation Program in East Asia. As one of the importance of sanitation in promoting economic develop- underdeveloped western provinces of China, Yunnan has ment. By providing decision makers at national and pro- achieved huge progress in sanitation improvement. Since vincial levels with comprehensive information to support the early 1990s, the Chinese government has set sanitation policies on public sanitation investment, the goal of this improvement as one of the top priorities in the national study is to increase the efficiency of sanitation investments. development plan. As a result, the access to sanitary latrines and toilets in both rural and urban areas has increased B. STUDY AIMS AND METHODS rapidly. In rural areas of Yunnan, access to improved sani- This study evaluates the costs and benefits of technical sani- tary latrines has increased from 2.4% in 1990 to 53.7% tation options and sanitation programs in Yunnan Province. in 2008. In urban areas of China, coverage with improved Sanitation options evaluated in the study include the facili- private facilities has increased by 10 percentage points from ties to collect and convey human excreta, household waste- 48% to 58% since 1990, and a further 30% of the urban water treatment and related hygiene practices. The benefits population using shared facilities in 2008. of sanitation evaluated include health, water quality, time to access sanitation facilities, external environment, reuse Still, in comparison with the rest of China, Yunnan lags of human excreta, quality of life improvement and other in access to improved sanitation and faces significant chal- intangible benefits such as privacy, cleanliness and com- lenges in catching up with the pace of development in east- fort. The costs of sanitation measured include investment ern provinces. The average national coverage with improved costs and recurrent costs (operations and maintenance). sanitary latrines (including shared) was 59.7% for rural ar- The study compares the costs and benefits of alternative eas in 2008, while Yunnan reached only 53.7%. In the year improved sanitation options over the expected life of each 2007, only 30% of urban areas in Yunnan were equipped technology, to estimate efficiency of alternative sanitation with sewerage systems, in comparison with 70% nationally. options. The “optimal” performance of technologies as- In Yunnan Province, 6.4% of the total population of 45 sumes 100% adoption rates and correct utilization by the million is living under the poverty line, which mostly lacks beneficiaries, while the “actual” performance is adjusted access to safe and sanitary latrines. downwards based on adoption rates observed in the field. The main barrier to achieving the national sanitation targets C. DATA SOURCES AND STUDY SITES lies in the efficiency and effectiveness of sanitation invest- This study focuses on recent sanitation programs in Yun- ments. This study aims to provide evidence for decision nan Province, implemented and co-financed by the govern- making on future options for sustainable sanitation devel- ment and other partners. For the study, sanitation options opment, focusing on the selection of economically viable in eight different sites throughout Yunnan Province were technology options, as well as efficient delivery modes. In selected, representing urban, peri-urban and rural areas as doing so, the study attempts to demonstrate the benefits well as different socio-economic levels and cultural settings. www.wsp.org iii Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary The three rural sites include: a) villages in Luquan county’s sentation, the benefit-cost ratio (BCR) is the cost-benefit mountainous rural villages (R1), located near Yunlong res- indicator presented in this executive summary, while cost ervoir, wich supplies drinking water to Kunming city and per disability-adjusted life-year (DALY) is the main cost- where Yi and MIao are the dominant ethinic groups; b) effectiveness indicator presented. The reader is referred to Dali Shangguan (R2) lakeside plain, with the Bai ethnic Chapter 8 for a full presentation of the efficiency indicators. group; and c) villages in Qiubei county (R3) which are both laekside and mountainous, and where the dominantt ethnic In rural areas, all the sanitation options have very high BCR groups are Zhuang, Miao and Yi. Shared and pit latrines are as follows: UDDT (9.4), private pit latrines (8.5), 3-in-1 widely used in rural areas together with improved sanita- biogas units (6.9), shared toilets (6.0), and private septic tion options like biogas units, septic tanks and urine-divert- tanks (4.7). The cost-effectiveness of these measures range ing dehydration toilets (UDDT). Open defecation is still from US$272 per DALY averted for UDDT to US$479 commonly practiced in mountainous rural villages. per DALY averted for septic tanks. As a health intervention, these results indicate sanitation as a highly cost-effective The three urban sites represent different classes of urbaniza- intervention, represented by the cost per DALY being less tion: a) Kunming (U1), the provincial capital of Yunnan than the GDP per capita (see Figure D)1. However, there is located in the center of the province, with high population a significant loss of efficiency between ideal and actual per- density and water scarcity challenges; b) Dali (U2), a pre- formance of each sanitation option, as shown in Figure A. fectural capital, located on Erhai Lake in western Yunnan Province. Flush toilets with sewerage are the main sanita- In urban areas, the BCR of sanitation options are as follows: tion option in these two cities; c) Qiubei (U3), a county public toilets (4.5), septic tanks (2.8), and sewerage (1.9). capital, is located in the Karst area by Puzhehe Lake in Other less commonly applied options in urban areas – pit southern Yunnan Province. Public and private flush toilets latrines and UDDT – have higher economic returns, but with septic tanks and pit latrines are Qiubei’s main sanita- are generally less relevant for the majority of urban areas tion options. in China. Cost-effectiveness ratios are US$558 per DALY averted for public toilets, US$886 per DALY averted for The two peri-urban sites include a) Kunyang town of Jin- septic tanks, and US$1,385 per DALY averted for sewer- ning County (PU1), a small town located on the southern age. While these figures represent a higher cost than that of side of Dianchi Lake and part of the wider urban agglom- rural areas for the same health return, they are still under eration of Kunming city; and b) Dali Zhoucheng (PU2), the benchmark for a cost-effective intervention. As in rural a rapidly urbanizing rural area, located on Erhai Lake near areas, there is a significant loss of efficiency between ideal Dali, with Bai as the dominant ethnic group. Public dry toi- and actual program performance in urban areas, as shown lets, pit latrines, shared latrines, UDDTs, and septic tanks in Figure B. are widely used in these peri-urban areas. In peri-urban areas, the BCR of sanitation options are low- D. RESULTS er compared with rural areas, but still significant, as fol- lows: UDDT (8.7), private latrines (7.6), septic tanks (6.1) D1. COST-BENEFIT ANALYSIS RESULTS and shared latrines (4.2). As in urban and rural areas, The economic returns on all improved sanitation options there is a significant loss of efficiency between ideal are significant in all the sites evaluated, when compared and actual program performance in peri-urban areas with no access to basic sanitation. To simplify the pre- (see Figure C). 1 World Health Organization iv Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary FIGURE A: IDEAL AND ACTUAL BENEFIT-COST RATIOS OF RURAL SANITATION OPTIONS Shared Pit latrine UDDT Biogas Septic tank 0 3 6 9 12 15 ideal actual benefit-cost ratio FIGURE B: IDEAL AND ACTUAL BENEFIT-COST RATIOS OF URBAN SANITATION OPTIONS Shared Public toilet Pit latrine UDDT Septic tank Sewerage 0 3 6 9 12 15 ideal actual benefit-cost ratio Note: “Ideal” ratios reflect the scenario where all sanitation options delivered are fully and correctly utilized by households, according to their function. “Actual” ratios reflect the observed utilization rates from the survey data. FIGURE C: IDEAL AND ACTUAL BENEFIT-COST RATIOS OF PERI-URBAN SANITATION OPTIONS Shared Pit latrine UDDT Septic tank 0 3 6 9 12 15 ideal actual benefit-cost ratio www.wsp.org v Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary FIGURE D: COST PER DALY AVERTED OF SANITATION OPTIONS IN RURAL SITES (US$) Shared Pit latrine UDDT Biogas Septic tank 0 500 1,000 1,500 2,000 2,500 3,000 3,500 ideal actual cost per DALY averted (US$) Note: “Ideal” ratios reflect the scenario where all sanitation options delivered are fully and correctly utilized by households, according to their function. “Actual” ratios reflect the observed utilization rates from the survey data. As an example of the efficiency of moving up the sanitation ranges from US$135 to US$185. The average cost of the ladder from one improved option to another, results from 3-in-1 biogas units is US$361, and the average cost of rural Qiubei site are presented in Table A. The ideal scenario septic tanks is US$507. Average annual recurrent costs per is compared. The efficiency of improved sanitation moving household are US$15 for hygiene and US$16 to US$43 from shared toilet to private pit latrine, UDDT and biogas for the different sanitation options. Total equivalent annual are 3.8, 4.5 and 7.3, respectively. The incremental efficiency costs per household (thus annualizing investment costs and of improved pit latrines is significant in comparison with including annual recurrent costs) averages between US$29 the “shared toilet.” Moving from pit latrine to options with and US$68 per household. higher health benefits and reuse benefits leads to a BCR of 4.5 (UDDT), 5.0 (biogas) and 2.1 (septic tank). Cost- In urban areas, average investment cost per household for effectiveness ratios range from US$230 per DALY averted hygiene is US$41. The cost for shared and public toilets, for moving from shared toilet to biogas, to US$557 per pit latrines and UDDT ranges from US$138 to US$189 DALY averted for moving from pit latrine to septic tank. per household. Septic tanks (with septage management) and sewerage range from US$522 to US$685. Average an- D2. COSTS nual recurrent cost per household ranges from US$16 for A summary of sanitation option costs is provided in shared toilets to US$72 for sewerage. Average annual cost Table B. In rural areas, the average investment cost per per household calculated for the whole life period ranges rural household for shared toilet, pit latrine and UDDT from US$27 for hygiene to US$105 for sewerage. Capital vi Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary TABLE A: RURAL AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER (QIUBEI RURAL SITE) Moving from shared toilet to Moving from pit latrine to Efficiency measures Pit latrine EcoSan UDDT Biogas EcoSan UDDT Biogas Septic tank + STF COST-BENEFIT MEASURES Benefits per US$ input 3.8 4.5 7.3 4.5 5.0 2.1 Internal rate of return (%) >100% >100% >100% >100% >100% 40% Payback period (years) 1.2 <1.0 <1.0 <1.0 1.6 3.9 Net present value ($) 164 270 339 270 315 142 COST-EFFECTIVENESS MEASURES Cost per DALY averted ($) na 325 230 325 335 557 Cost per case averted ($) na 3.1 2.2 3.1 3.2 5.3 Cost per death averted ($) na 5,840 4,139 5,840 6,026 10,010 Note: na: not calculated due to improved pit latrine assumed to have the same health impact as improved shared latrine. STF - septage treatment facility. TABLE B: COSTS PER HOUSEHOLD IN RURAL AND URBAN AREAS – INVESTMENT AND RECURRENT (US$) Shared Public Septic Septic tank+ Cost Item Pit latrine EcoSan Biogas Sewerage toilet toilet tank STF Capital investment 134.7 - 159.1 165.7 336.0 484.0 - - Program investment 0.0 - 0.0 19.0 25.5 23.3 - - Rural Recurrent (O&M) 15.7 - 19.3 24.7 31.6 42.6 - - Average annual 29.2 - 35.3 43.2 67.8 68.0 - - Capital 133.2 187.4 164.0 168.3 - 497.9 537.2 629.8 Program 4.4 13.9 0.0 20.5 - 24.2 27.8 29.5 Urban Recurrent 16.1 28.5 19.5 29.3 - 46.0 60.0 72.3 Average annual 29.9 48.7 35.9 48.2 - 72.1 88.3 105.2 “-“ no data investment accounts for between 24 and 45% of the total some or all of the existing hardware. For example, moving cost, program cost a maximum of 4%, and the percentage from a shared toilet to a private pit latrine, or from a pit of recurrent cost ranges from 54 to 74%. latrine to a UDDT, will need the full investment cost. Mov- ing from a pit latrine to biogas can use some of the existing In peri-urban areas (not presented in the table), average in- facilities, thus costing less than US$200 in rural areas. Mov- vestment cost per household is around US$145 for shared ing from septic tank to sewerage also involves a partial cost toilet, pit latrine and UDDT; rising to US$520 for septic saving as the toilet does not need to be replaced – hence re- tank with septage treatment. The average recurrent cost per quiring an investment cost of US$769 instead of US$2,170. peri-urban household averages US$45 for a septic tank. Av- erage annual cost calculated for the whole life period of a D3. HEALTH BENEFITS septic tank is US$72, assuming a 20-year life span. To estimate health benefits, the study determined the health costs of illnesses, health treatment, and loss of pro- The costs of moving up the sanitation ladder depend on the ductivity, and estimated the total avoided costs by apply- starting option, and whether an entirely new facility needs ing risk reduction proportions from international scientific to be built, or whether the “higher” ladder option can utilize literature. www.wsp.org vii Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary The disease burden of diarrhea and helminthes is high in ease is highest among the rural population, followed by the China, with a heavier burden in rural areas than in peri-ur- peri-urban and urban population, respectively (see Figure ban and urban areas. From international research, the links E). between environmental risk factors and malnutrition, and diseases resulting from malnutrition, have been made. The Premature mortality costs are calculated based on the mor- most important of these, acute lower respiratory infections tality rate and cost per premature death. Children under (ALRI) in children under five, were among those included five have the highest premature mortality cost. Diarrheal in this study. In rural sites, it is estimated there are 1.9 cases disease causes the highest premature mortality cost. For the of disease per person per year, 16 DALYs per 1,000 people, total value of premature mortality cost caused by the diseas- and an annual risk of death of 0.92 per 1,000 people due es, the 0-4 age group in rural areas has the highest average to poor sanitation and hygiene. In urban areas the rates mortality cost per person per year at US$280, compared to are lower, at 1.4 cases of disease per person, 13 DALYs per urban areas (US$254) and peri-urban areas (US$166). 1,000 people, and an annual risk of death of 0.67 per 1,000 people. In peri-urban areas the rate is more similar to urban The total health costs of poor sanitation include medi- than to rural areas, at 1.5 cases of disease per person, 12 cal, productivity, and premature mortality costs. The re- DALYs per 1,000 people, and an annual risk of death of duction in health risks and costs has been documented 0.69 per 1,000 people. A high proportion of disease cases internationally with each step up the sanitation ladder, and disease burden overall is in the under five population; with pit latrines (with partial isolation) reducing diarrheal hence households with one or more young children will disease incidences by 36% from open defecation (OD), have higher health returns from improved sanitation and and sanitation options with full isolation or treat- hygiene practices than households with no young children. ment of excreta reduces diarrheal disease incidence by 56%. Hygiene interventions carried out alongside these The majority of people seek care from public providers and sanitation improvements add further to the health risk re- private clinics, depending on the costs of travel and treat- duction. ment, and the proximity of public hospitals. According to the ESI survey, 20% of rural households choose public Each step up the sanitation ladder results in an avoided providers, 30% private clinics, 20% informal care, and 9% cost. The avoided cost of moving from OD to basic sanita- self-treatment. In comparison, 40% of urban households tion for rural households averages US$280 per household choose public providers and 20% self-treatment. per year. In urban areas, moving from OD to sewerage sys- tems may avert an average US$277 per household, while Health-related productivity cost is calculated based on dis- moving from basic sanitation to sewerage averts an average ease incidence (disease cases per person per year), the time US$106 per household. In peri-urban areas, moving from of inactivity due to disease, and the opportunity cost of OD to basic sanitation may avert an average US$195 per time. The result shows that the productivity loss due to dis- household (refer to Table C). TABLE C: AVERTED HEALTH COSTS OF IMPROVED SANITATION (US$) Costs averted (US$) Cost items Rural (OD to Urban (OD to Urban (OD to Urban (Step 1 to Peri-urban (OD to Step 1) Step 2) Step 1) Step 2) Step 1) Health care 33.9 36.4 23.0 13.4 26.7 Productivity 38.4 33.8 20.8 13.0 25.1 Premature mortality 207.5 206.3 126.9 79.3 143.7 Total 279.8 276.5 169.7 105.7 195.5 Source: ESI study. Step 1: partial isolation or treatment of excreta; Step 2: full isolation or treatment of excreta. viii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary FIGURE E: COMPARISON OF THE PRODUCTIVITY COST BETWEEN STUDY SITES OF ACUTE LOWER RESPIRATORY INFECTIONS (ALRI) AND DIARRHEAL DISEASE 2008 (US$ PER HOUSEHOLD PER YEAR) 0 - 4 years Rural 5 - 14 years 15+ years 0 - 4 years Urban 5 - 14 years 15+ years 0 - 4 years Peri-urban 5 - 14 years 15+ years 0 3 6 9 12 15 diarrheal ALRI US$ per household per year D4. WATER BENEFITS Some water bodies in Yunnan Province have been seriously Although Yunnan Province is rich in water resources, the affected by poor sanitation practices, including the lack of geographic distribution of water resources is uneven. In the latrines, latrine options that lead to pollution of ground most populated and economically developed regions, such and surface waters, and the release of untreated wastewa- as the center of the province, the average water resource per ter into water bodies. Drinking water quality in both ur- capita is 700m3, while in Dianchi watershed, it is 276m3 per ban areas and rural sites is not up to the drinking water capita. The source of drinking water also differs by region. standard, as measured by various water quality indicators. In Dali, 87% of drinking water comes from ground water Water samples collected for the ESI survey from rural and while in Qiubei ground water comprises only 9% of the urban field sites in Qiubei, as well as water quality data total. collected from government sources, indicate high values www.wsp.org ix Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary for E.coli (Escherichiacoli), NH3-N (Ammonia-nitrogen), more in urban sites, as shown in Table E. Under a high cov- TN (Total Nitrogen) and TP (Total phosphorus), which erage of sanitation and hence water protection, some house- indicate a high influent loading from domestic sources. holds can be assumed to stop household treatment, while Related to that, the turbidity, conductivity, and chemical others may use cheaper or more environmentally friendly oxygen demand (COD) values are also high. The level of home treatment methods. Table E shows the predicted annu- ammonium nitrogen in rural shallow wells is higher than al costs averted due to the improved quality of water sources. that in urban shallow wells, pointing to the greater impact of human and animal wastes in rural areas on ground water. D5. ACCESS TIME SAVINGS In villages where animal husbandry is a common practice, The average rural household without a private latrine or toi- the influence of animal waste on ground water might be let has to spend the equivalent of 37.6 days to access sanita- even more serious than human excreta. tion (travel plus waiting time) while urban and peri-urban households without a toilet spend 24.0 and 36.6 days av- The field survey results show that full isolation of excreta erage per year, respectively, using shared or public toilets. (or a high degree of isolation, according to Chinese stan- Owning their own toilet averts these access times, which dards, such as septic tanks) is high in all sites, as of 67% of when valued at 30% of the average wage rate for adults and the total investigated households (see Figure F). However, 15% for children leads to equivalent economic savings of pollution from poor household management of sewage US$60 in urban, US$64 in peri-urban, and US$44 in rural (i.e. draining untreated, or inadequately treated, into the households every year. ground or surface water bodies) is high in rural areas R2 and R3 and peri-urban area PRU2. D6. EXCRETA REUSE BENEFITS Human excreta collected from latrines or septic tanks and As well as human excreta, draining of general household treated before being reused as fertilizer to improve soil qual- wastewater (gray water) into the ground or water bodies ity and promote growth of crops is common practice in is a relatively common practice in all rural, peri-urban and rural areas of Yunnan Province. This study has evaluated urban sites, and is practiced by an average of 43% of house- the economic value of safely reusing human excreta as fertil- holds investigated. Also, not all treated wastewater is treated izer through UDDT and producing gas from human and to high standards, so some pollution is originating from animal excreta through biogas units. The result of ESI’s wastewater treatment plants. household surveys shows that reuse of human excreta can save an average US$47 annually per household if excreta The annual costs of water access, as well as the dominant is reused as fertilizer, and an average US$77 annually per sources of drinking water, are shown in Table D. On aver- household if excreta is processed through 8 cubic meter bio- age, rural, urban and peri-urban sites all have high access to gas units and used for lighting and cooking energy. In the piped water, at 66%, 86% and 93% respectively. Average latter case, animal manure is commonly collected and fed annual cost per household for water sources ranges from into the biogas digester, and provides a significant propor- US$11 for accessing unprotected sources in rural areas to tion of the raw materials needed for successful functioning US$52 for piped water in peri-urban sites. The figures in- of the digester. clude tariffs and the opportunity cost of time spent collect- ing water from off-plot sources. D7. INTANGIBLE BENEFITS OF SANITATION OPTIONS While drinking water sources can often be exposed to pollu- The study conducted 24 focus group discussions (FGDs), tion risks, the widespread cultural practice of treating drink- involving over 100 participants of whom 60% were wom- ing water, regardless of its quality, significantly reduces the en. The topics for FGDs include the population’s under- risks of waterborne diseases. Boiling is the dominant practice standing of sanitation; factors explaining current sanitation for treating water at home, while some households use filtra- practices; preferences for selection of different sanitation tion. There is little difference among the water source access options; and decision making processes for current and of rural, peri-urban and urban sites. Water treatment costs future sanitation options. Results are also presented from x Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary FIGURE F: ISOLATION LEVEL OF SANITATION OPTIONS THROUGH THE FIELD SITES R1 R2 R3 U1 U2 U3 PRU1 PRU2 0 20 40 60 80 100 proportion of households (%) not isolated (open defecation) partial isolation (dry pit) full isolation not isolated (flush to water) partial isolation (wet pit) TABLE D: WATER ACCESS AND TREATMENT COST Water source Indicator Rural sites Urban sites Peri-urban sites % access 66% 86% 93% Piped water Average annual access cost (US$) 29 29 52 Non-piped % access 20% 11% 4% protected Average annual access cost (US$) 34 20 16 % access 14% 3% 3% Unprotected Average annual access cost (US$) 11 41 32 TABLE E: WATER ACCESS AND HOUSEHOLD TREATMENT COSTS INCURRED AND AVERTED (US$, 2009) Annual average costs averted per household Annual average costs per household (US$) Variable following 100% sanitation coverage (US$) Rural Peri-urban Urban Rural Peri-urban Urban Water source access 84 76 83 2.1 1.7 1.8 Water treatment 27 32 50 7.3 7.0 6.7 questions in the household survey that focused on these in- without their own toilets to get a toilet are “comfort” and tangible aspects of sanitation. “proximity,” cited by 83% and 82% of survey respondents, respectively. “Privacy” is important for 77% of households, The main reasons some households did not possess toilets “cleanliness” for 70% of households, “non-pollution” for are lack of investment capital, lack of a proper site for con- 58% of households, and “not having to share” for 53% of struction, and the need for a radical behavior change in us- households. Figure G shows the average scores (out of a ing and maintaining the new sanitation facility. As shown maximum of 5) for the importance of different features of in Figure G, the two most important factors for households improved sanitation. www.wsp.org xi Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary FIGURE G: PROPORTION OF IMPORTANT AND VERY IMPORTANT REASONS TO GET A LATRINE FOR THOSE CURRENTLY WITHOUT (%) (1 = NOT IMPORTANT; 5 = VERY IMPORTANT) comfortable clean not sharing privacy proximity non-pollution 0 1 2 3 4 5 In rural areas, most respondents consider improved private All environmental quality average scores range between 2.4 pit latrines to be most appropriate for them as it can collect and 3.6 (out of a maximum of 5) for all sites, suggesting excreta and is easy to clean, with the 3-in-1 biogas unit the poor to moderate environmental quality. Among the rea- option of second choice. UDDT is not widely accepted by sons for the spoiled environment, open sewage and rubbish most households and is ranked in third place because of are ranked as the worst performing with an average score of poor quality and the requirement for a change of habits in below 3. using and maintaining it. Urban households with private flush toilets, such as those in Kunming and Qiubei, have Perceptions can, however, vary. For example, the survey in a high level of satisfaction with their toilet options (over 4 Dali Old Town suggests that women are much more sensi- out of 5). Among the urban households using public toi- tive to a poor environment, citing the presence of human lets, most of them believe that ownership of their own toilet and animal excrement, domestic garbage and urine in the would be more comfortable and they would expect to have back streets of the town. Female respondents think that a flush toilet. Peri-urban households using public toilets the poor external environment affects the health of the prefer flush toilets connected to septic tanks or sewerage, residents as well as the reputation of Dali Old Town as a and desire to build such a toilet if conditions permit. Those famous tourist site. On the other hand, male respondents using public toilets in Kunming peri-urban and Dali city think the environment is reasonably clean. However, both have the least satisfaction for their current sanitation op- men and women say they are willing to pay for better public tion, at less than 3 out of a maximum score of 5 . waste management. D8. EXTERNAL ENVIRONMENT D9. SUMMARY “External” environment refers to the area outside the toilet Table F shows the summary breakdown of benefits. In rural and is not related to toilet-going itself. It includes living areas, households could save an average of US$331 annu- areas, public areas, and private land, which can all be af- ally for health, water and access time benefits of improved fected by open defecation practices and unimproved toilet basic sanitation, with an additional reuse value of US$47 options. from UDDT or US$77 for biogas. Reuse of human excreta from pit latrines and septic tanks, and sludge from treat- Figure H shows the ranking of different factors that poten- ment plants, also has a net positive economic value – if tially affect the quality of life related to the environment. handled properly and fully treated to avoid transmission xii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary of disease. In urban areas, the savings are US$344, com- off-site sanitation options become more necessary and pared with US$303 in peri-urban areas. Using the criterion with the proper implementation lead to the best environ- of the benefit-cost ratio to reflect efficiency, the UDDT mental as well as health performance. However, due to has the best performance. However, taking into account user the high costs of septic tanks and wastewater manage- preferences and the actual performance efficiency (the ment, the benefit-cost ratios are less favorable, but non-use of UDDTs), normal latrines are the most effective still economically viable (with benefit-cost ratio greater option in rural areas. In urban and peri-urban areas, than 1.0). TABLE F: SUMMARY OF LOCAL IMPACTS OF SANITATION IMPROVEMENT Benefits of improved sanitation and hygiene Quantitative benefit Benefit (US$/household, annual) Qualitative or Other Benefit Rural Urban Peri-urban HEALTH Health burden/quality of life • Avoided pain and discomfort from illness (captured partially in the • Cases/person 1.93 1.43 1.47 DALY losses) • Mortality/1000 population 0.92 0.67 0.69 • Avoided costs from other diseases associated with poor sanitation • DALYs/1000 population 16.0 13.0 12.0 Health costs averted 280 277 196 Health care OD to Basic 34 27 OD to Sewerage 36 Productivity costs averted Refer to Tables 7 to 12 and Figures 10 to 13. OD to Basic 38 25 OD to Sewerage 34 Mortality costs averted OD to Basic 207 144 OD to Sewerage 206 WATER Access cost savings 2 2 2 Improved water quality (smell, appearance, less contaminants) for drinking, domestic purposes, recreation and other. Refer to Figure 16 Treatment cost savings 7 7 7 Access time 44 60 88 • Avoided discomfort from having to queue • Households without toilets mostly consider “comfort” and “proximity” the most important reasons to get a toilet • Time loss associated with urination is excluded Refer to Table 18, Table 19 and Figure 28 Intangibles nc nc nc • Comfort associated with use of clean toilets • Pride in having a toilet, especially if expensive • Privacy and not being seen going to the toilet • Safety of women and children • Confidence to invite guests to the house Refer to Figure 31 and Table 25 External environment - - - • Cleaner surrounding areas • Less exposure to insects and rodents Refer to Annex Table F5 Reuse: composting 47 - - • Cleaner surroundings and averted water pollution Reuse: biogas unit 77 - - www.wsp.org xiii Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary FIGURE H: PERCEPTIONS OF ENVIRONMENTAL SANITATION STATE, BY TYPE (1= VERY BAD; 5 = VERY GOOD) rubbish sewage standing water smoke smell dirt outside dirt inside rodents insects 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 R1 U2 R2 U3 R3 PRU1 U1 PRU2 xiv Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary The most important contributor to the quantified benefits crucial for the success of the sanitation and hygiene pro- is related to health improvements of improved sanitation. gram (see Table G). Benefits of improved sanitation and hygiene can avoid the health burden by reducing disease cases, mortality, and The program approach used to deliver sanitation interven- DALYs, and averting annual health cost per household tions is an important determinant of the effectiveness of of US$280 in rural areas, US$277 in urban and US$196 the interventions. In rural areas of China, the promotion in peri-urban areas. This includes financial gains related of improved sanitation facilities is conducted mainly by to less health care seeking, gained productive time due to the government, using a supply-driven approach with little improved health, and saved lives. The latter contrib- consideration of local preference. As a result, the actual ef- utes most significantly to overall health economic gains. ficiency results presented in this study suggest the interven- Improved sanitation can increase water quality, and tions are not reaching their potential, as many households thus can save water access costs and treatment costs rang- do not utilize their toilets correctly or all the time. In ru- ing from US$8.5 per household in urban site to US$9.3 ral areas, there are cases of “demand-led” sanitation where per household annually in rural areas. Improved sanita- households voluntarily invest in their own toilet, with little tion can release time for productive activities, with an av- outside influence. For this reason, the economic efficiency erage value of US$44, US$60 and US$88 per household of pit latrines is high. Also, the technology is simple, and annually in rural, urban and peri-urban areas, respectively. the human excreta is commonly reused in the fields. The Other intangible benefits are also perceived by the users. reuse value has not been added to the pit latrine option, as Reuse of the products of improved sanitation also save there are concerns about whether households are knowl- US$47 annually per household by composting and US$77 edgeable about good practice in relation to safe handling annually per household by using biogas, in rural areas. and treatment of human excreta. These benefits are summarized in Table F. In urban areas, the original “technology planning” ap- D10. PROGRAM PERFORMANCE proach is commonly utilized, with property developers hav- The main indicators of program efficiency include usage rate ing a major influence over the choice and design of sani- of improved sanitation, cleanliness of the latrine or toilets, tation options. Flush toilets with connection to sewerage access time to toilets, reuse of human excreta, satisfaction are most commonly chosen. However, the household often toward improved sanitation and the quality of the external has the option of choosing the actual toilet type. As most environment. Public participation and good governance are urban households have little choice but to use their own TABLE G: SELECTED KEY INDICATORS FOR PROGRAM EFFECTIVENESS (FROM A HOUSEHOLD SURVEY) Impact Indicator area FOR QUANTITATIVE COST-BENEFIT ANALYSIS TO ESTIMATE ACTUAL EFFICIENCY Health (sanitation) 78% household members using improved toilet instead of previous unimproved option Health (hygiene) 75% households answered “yes” to washing hands after defecation 16% improved latrines in which there were signs of feces around toilet Access time 78% household members using own toilet instead of off-plot options Reuse 71% households with UDDT or biogas use the bi-products (fertilizer or biogas) FOR QUALITATIVE ANALYSIS Intangibles Average score of 3.6 (out of maximum score of 5) for all relevant satisfaction questions External environment Average score of 3.0 (out of maximum score of 5) for 2 external environment questions relating to sewage (visibility and smell) www.wsp.org xv Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary toilet when they are at home, the effectiveness of sanitation mate and a minimum amount of excreta to generate meth- options in urban areas is correspondingly high, and “actual” ane. The UDDT is more suitable for the areas with a economic performance is reasonable. dry climate and low temperatures. The three-grid sep- tic tank is not suitable for the areas with a high water ta- Program design and implementation modality play an ble. Centralized wastewater treatment technology is not important role in the overall effectiveness and impact on appropriate to extend in the sparsely populated rural and households and hence efficiency. The project design is cru- mountainous areas. The high construction and operation cial for site and technology selection, considering the scarci- costs of centralized wastewater treatment leads to a less favor- ty of land, the preferences and cultural habits of the inhabit- able economic performance compared to on-site sanitation. ants, and the environmental conditions. Whether the target groups have the opportunity to choose and make decisions E. RECOMMENDATIONS on the sanitation option is crucial in affecting the participa- This study has shown that all sanitation options have a tion of the users in construction, use and maintenance. In highly favorable economic return, but they all experience the field sites, most of the households have little say over the a drop in performance under actual program conditions. sanitation options chosen. Programs should also consider Since improved sanitation options have been shown to be the users’ ability to pay. As most of the projects need some highly efficient in economic terms, populations without matching funds from households, the poorer households access to basic sanitation should be prioritized by sanita- are unable to invest in their own toilet facility. As a result, tion and hygiene programs. Comparison of economic per- some of them gave up participating in the projects. formance among different sanitation options should form part of the decision on which sanitation type to choose. Each sanitation option has its own advantages as well Government subsidies should be first allocated to ensure as limitations for wide-scale adoption, summarized in populations, especially the poor and disadvantaged, receive Table H. Three-in-one biogas toilets require a mild cli- basic access. TABLE H: ADVANTAGES AND DISADVANTAGES OF SANITATION OPTIONS FOR SCALING UP Sanitation types Advantages Disadvantages • Hygiene status of the toilet is often poor • Low construction cost • Often pollutes the environment, especially in the • Simple technology Pit latrine rainy season • Human excreta commonly extracted from the pit • Human excreta is not safely treated, causing a and reused as fertilizer higher health risk Biogas • Saves energy for lighting and cooking • High construction cost • Provides highly efficient and safe organic • Occupies space in homestead fertilizers • Limited by availability of animal manure • Saves money • Not suitable for cold climates • Reduces pollution to the environment • Needs good post-phase management, including • Convenient, safe and healthy maintenance UDDT • Provides highly efficient and safe organic • Not seen as convenient by users fertilizers • Smells if not properly maintained • Reduces pollution to the environment • Needs time input of household and resources (such as rice husk/sawdust) • Higher investment and recurrent cost than simple pit latrine Water flushing toilet (with • Clean • High construction cost and operational cost septic tank or sewerage) • Hygienic • Needs a large amount of water • Convenient • Needs off-site wastewater treatment systems, and if not, black water released to the environment pollutes water bodies xvi Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Executive Summary Movements up the sanitation ladder have been shown to be There is no systematic and comprehensive publicly-avail- economically viable, such as from shared toilet to private able database on the approaches, locations and coverage toilet, and from private pit latrine to septic tank. Hence achieved of different sanitation and hygiene programs. where households are able to contribute financially to the Therefore to ensure a coordinated and efficient scaling up intervention, programs should shift these populations fur- of services, it is important to set up and share an integrated ther up the sanitation ladder. database to support decision makers. The detailed evidence on economic performance can be Evidence-based sanitation decision making should be used by program staff to support demand promotion cam- promoted. Variations in economic performance of options paigns, to actively participate in sanitation programs and to suggest a careful consideration of site conditions is need- contribute to financing. ed to select the most appropriate sanitation options and delivery approaches. Decisions should take into account In many municipalities and counties of Yunnan Province, not only the measurable economic costs and benefits, funds are adequate to deliver more sustained and quality but also other key factors, including intangible impacts services – that is, going beyond basic sanitation provision. and socio-cultural issues that influence demand and behav- These quality services better capture the full environmental ior change, availability of suppliers and private financing, and health benefits of better sanitation, and respond to the and actual household willingness and ability to pay for ser- population’s wish for a clean, livable environment. vices. Further health advancements can be achieved with im- proved sanitation and hygiene in Yunnan Province; hence sanitation programs should put health among their top pri- orities. Insufficient financial support for sanitation programs threatens their sustainability and impact, and a financing strategy is recommended to secure funds from multiple sources. The many agencies involved in sanitation provision suggest that efficiency gains be made from improved cross-sectoral coordination and cooperation, which will lead to improved planning and choice of technologies, strengthened mutual learning and resource saving. It is therefore advised to cre- ate a coordination mechanism to establish effective and sus- tainable cooperation across departments. Users’ voluntary participation in sanitation and hygiene programs is low, so people-centered implementation approaches are advised to improve participation of us- ers and thus increase effectiveness and sustainability of selected options. Since most of the programs lack gender- sensitivity, women should be encouraged to partici- pate in decision making and implementation as well as monitoring. www.wsp.org xvii Foreword In the recognition of sanitation as a key aspect of human Phase 1 of the Economics of Sanitation Initiative in 2007- development, target 10 of the Millennium Development 8 conducted and published a “sanitation impact” study, Goals includes access to safe sanitation: “to reduce by half which estimated the economic and social impacts of un- between 1990 and 2015 the proportion of people without improved sanitation on the populations and economies of access to improved sanitation.” This reflects the fact that other countries of Southeast Asia1. This study showed that access to improved sanitation is a basic need: at home as the economic impacts of poor sanitation averaged US$22 well as at the workplace or school, people appreciate and per capita per year among five Southeast Asian countries, value a clean, safe, private and convenient place to urinate or 2% of annual GDP.2 Although the country-specific eco- and defecate. Good sanitation also contributes importantly nomic impact as a proportion of GDP ranges from 1% in to achieving other development goals such as child mortal- Vietnam to 7% in Cambodia, the likely impact in Yunnan ity reduction, school enrollment, nutritional status, gender Province is the regional average of 2% - which is close to the equality, clean drinking water, environmental sustainability figure in Indonesia, which has similar GDP per capita and and quality of life of slum dwellers. sanitation coverage levels as Yunnan Province. Despite its recognized importance, sanitation continues to The current volume reports the second major activity of lose ground to other development targets when it comes ESI, which examines in greater depth the costs and benefits to priority setting by governments, households, the private of specific sanitation interventions in a range of field set- sector and donors. This fact is hardly surprising given that tings in Yunnan Province in the People’s Republic of China. sanitation remains a largely taboo subject in societies, nei- The purpose is to provide information to decision makers ther is it an “attractive” subject for media or politicians to on the impact of their decisions relating to sanitation – to promote as a worthy cause. Furthermore, limited data exist understand the costs and benefits of improved sanitation on the tangible development benefits for decision makers to in selected rural and urban locations, as well as to enable a justify making sanitation a priority in government or pri- better understanding of the overall national level impacts of vate spending plans. improving sanitation coverage in China. On the cost side, decision makers and stakeholders need to understand more Based on this premise, the World Bank’s Water and Sanita- about the timing and size of costs (e.g. investment, opera- tion Program (WSP) is leading the “Economics of Sani- tion, maintenance), as well as financial versus non-financial tation Initiative” (ESI) to compile existing evidence and costs, in order to make the appropriate investment decision to generate new evidence on the socio-economic aspects that increases intervention effectiveness and sustainability. of sanitation. The aim of ESI is to assist decision makers On the benefit side, the monetary as well as non-monetary at different levels to make informed choices on sanitation impacts need to be more fully understood in advocating for policies and resource allocations. improved sanitation as well as making the optimal sanita- 1 The study was not conducted in China. 2 Hutton G, Rodriguez UE, Napitupulu L, Thang P, Kov P. Economic impacts of sanitation in Southeast Asia. World Bank, Water and Sanitation Program. 2008.. xviii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Foreword tion choice. For cost-benefit estimations, a sample of sites representing different contexts of Yunnan Province was se- lected to assess the efficiency of sanitation interventions, and thus illustrate the range and sizes of sanitation costs and benefits. The ESI research is being conducted in Cambodia, China, Indonesia, Lao PDR, the Philippines and Vietnam. Similar studies are also ongoing in selected South Asian, African and Latin American countries. While WSP has supported the development of this study, it is an “initiative” in the broadest sense, which includes the active contribution of many people and institutions (see Acknowledgment). www.wsp.org xix Abbreviations and Acronyms ADB Asian Development Bank ALRI Acute Lower Respiratory Infection BCR Benefit-cost ratio BOD Biochemical oxygen demand CBA Cost-benefit analysis COD Chemical oxygen demand DHS Demographic and Health Survey DO Dissolved oxygen EAP East Asia and the Pacific Ecosan Ecological sanitation ESI Economics of Sanitation Initiative FAO Food and Agriculture Organization FGD Focus Group Discussion FY Financial Year GDP Gross Domestic Product GNP Gross National Product HCA Human capital approach I.E. Income elasticity IRR Internal rate of return JMP Joint Monitoring Programme of WHO/UNICEF Kg Kilograms xx Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Abbreviations and Acronyms MDG Millennium Development Goals Mg/l Milligrams per liter NGO Non-governmental organization NPV Net present value OECD Organization for Economic Cooperation and Development OER Official Exchange Rate PBP Payback period PEM Protein energy malnutrition SEAR-B WHO Southeast Asia region epidemiological strata B UDDT Urine Diversion Dehydration Toilet UNICEF United Nations Children’s Fund USAID United States Agency for International Development VOSL Value of a statistical life WB World Bank WHO World Health Organization W&S Water Supply and Sanitation WPR-B WHO Western-Pacific Region epidemiological strata B WSP Water and Sanitation Program WTP Willingness to pay YEPD Yunnan Environmental Protection Department www.wsp.org xxi Glossary of Terms Benefit-cost ratio (BCR): the ratio of the present value of the stream of benefits to the present value of the stream of costs. The higher the BCR is, the more efficient the intervention. Cost per case averted: the discounted value of the costs for each case of a disease that is avoided because of an intervention. Cost per DALY averted: the discounted value of the costs for each DALY that is avoided because of an intervention. Cost per death averted: the discounted value of the costs for each death that is avoided because of an intervention. Cost-effectiveness ratio (CER): the ratio of the present value of the future costs to the present value of the future health benefits in non-monetary units (cases, deaths, disability-adjusted life-years). The lower the CER the more efficient the intervention. Disability-Adjusted Life-Year (DALY): a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. One DALY can be thought of as one lost year of “healthy” life (WHO, 2010). Ecological sanitation (Ecosan): a new paradigm in sanitation that recognizes human excreta and water from households not as waste but as resources that can be recovered, treated where necessary and safely used again. It is based on the systematic implementation of reuse and recycling of nutrients and water as a hygienically safe, closed-loop and holistic alternative to conventional sanitation solutions (GTZ, 2009). Improved sanitation: the use of the following facilities in home compounds: flush/pour-flush to piped sewer system/septic tank/pit latrine, ventilated improved pit (VIP) latrine, pit latrine with slab, or composting toilet (JMP, 2008). Shared sanitation facilities: sanitation facilities of an otherwise acceptable type shared between two or more households. Only facilities that are not shared or not public are considered improved (JMP, 2008). Open defecation: the practice of disposing human feces in fields, forests, bushes, open bodies of water, beaches or other open spaces or disposed of with solid waste (JMP, 2008). Intangible benefits: Benefits of improved sanitation which are difficult to quantify. These include impacts on the quality of life, comfort, security, dignity, personal and cultural preferences, among others. Internal rate of return (IRR): the discount rate for which the present value of the stream of net benefits is zero. In other words, the IRR is the discount rate for which the BCR equals unit (1). xxii Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Glossary of Terms Net benefit: the difference between the present value of the stream of benefits to the present value of the stream of costs. Net present value (NPV): the discounted value of the current and future stream of net benefits from a project. Payback period (PBB): represents the number of periods (e.g. years) that are necessary to recover the costs incurred to that time point (investment plus recurrent costs). Unimproved sanitation: the use of the following facilities anywhere: flush/pour flush without isolation or treatment, pit latrine without slab/open pit, bucket, hanging toilet/hanging latrine, use of a public facility or sharing any improved facility, no facilities, bush or field (open defecation) (JMP, 2008). www.wsp.org xxiii Acknowledgments The Economics of Sanitation Initiative was conducted in Cambodia, China (Yunnan Province), Indonesia, Lao PDR, the Philippines and Vietnam. The study was led by the World Bank’s Water and Sanitation Program (WSP), with the contribution of WSP teams and consultants in each of the participating countries. The research team in Yunnan Province was financially and technically supported by USAID’s ECO-Asia Program. The study took two years to complete, and has undergone several major peer review processes. Guy Hutton (WSP Senior Water and Sanitation Economist and Task Team Leader) led the development of the concept and methodology for the ESI at regional level, the management and coordination of the country teams, and technical assistance. For all countries, report writing and data analysis was assisted by detailed tools and templates, and continual guidance on data input values, data interpretation and writing of reports. BjÖrn Larsen contributed to the development of generic data collection tools and the health methodology. The study benefited from the continuous support of other WSP staff: Almud Weitz, Isabel Blackett, Yosa Yuliarsa, Irvan Tjondronegoro and WSP support staff. In Yunnan Province, ESI has been supported by the Environmental Protection Department (EPD) of Yunnan Province. Zhou Bo led project preparation and coordination of field studies. Liang Chuan, associate professor at Yunnan Academy of Social Sciences, led and managed the research team, supervised data collection, data analysis and report writing, and played a major role in writing the study report. The research team was composed of multi-disciplinary researchers: Fang Jinmin (program approach analysis and health data collection); Dong Di and Dong Lin (cost-benefit and cost-effectiveness analysis); Luo Ronghuai (focus group discussions); associate researchers Zhang Tiwei, Zou Yahui and Wang Jing (subgroup leaders of field survey and data set management); Zhouzheng Yuxiao (team member); and Yang Liqiong and Zhang Pu from YEPD (management of water quality survey, the external environment survey and policy issues). The research team also appreciates the assistance of doctors and health researchers from the Associated Hospital of Yunnan University in providing health data. Special thanks are also given to the graduate students from Southwest Forestry College, Yunnan Normal University and Yunnan Ethnological University, who worked hard in the field to conduct the household survey. The contribution of peer reviews of the Yunnan report is gratefully acknowledged. Paul Kriss (World Bank, Beijing) and Linda Shi (ECO-Asia) provided valuable comments. Peer reviewers of other country reports also fed into the final version of this report, whose contribution is acknowledged in the specific country report they contributed to. It is also acknowledged that many governmental agencies and institutes including Yunnan Provincial Development and Reform Committee, Rural Energy Station, Yunnan Provincial Health and Disease Control Center, Women’s Federation, Urban Construction Bureau of Kunming Municipal City, Yunnan Provincial Forestry Department, and the Poverty Alleviation Office of Yunnan Provincial Government have all provided peer reviews to validate the research results and policy recommendations. Special thanks are given to those local community organizations and local agencies which supported the field surveys. xxiv Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Acknowledgments The ESI has been financed by WSP’s regional multi-donor trust fund for East Asia funded by the Swedish International Development Agency and AusAID. The Asian Development Bank co-financed the consultant teams in Indonesia, the Philippines and Vietnam. The study in Yunnan Province was co-financed by the ECO-Asia program supported by USAID. WSP and the report authors are grateful to the funding agencies for their support. Reference for citation: Economic assessment of sanitation interventions in Yunnan Province, People’s Republic of China. Liang Chuan, Guy Hutton, Yang Liqiong, Fang Jinmin, Zhang Tiwei, Dong Lin, Zhang Pu, Luo Ronghuai. World Bank, Water and Sanitation Program. 2012. Other country and synthesis reports: Economic assessment of sanitation interventions in Cambodia. Sam Sok Heng, Guy Hutton, Poch Kongchheng, Phyrum Kov. World Bank, Water and Sanitation Program. 2012. Economic assessment of sanitation interventions in Indonesia. Asep Winara, Guy Hutton, Oktarinda, Edi Purnomo, Koderi Hadiwardoyo, Indon Merdykasari, Takdir Nurmadi, Bert Bruinsma, Dedek Gunawan, Dadang Fadilah, Martin Albrecht. World Bank, Water and Sanitation Program. 2011. Economic assessment of sanitation interventions in Lao People’s Democratic Republic. U-Primo Rodriguez, Guy Hutton, Alan Boatman. World Bank, Water and Sanitation Program. 2012. Economic assessment of sanitation interventions in the Philippines. U-Primo Rodriguez, Guy Hutton, Nelissa Jamora, Dieldre Harder, Jeremy Ockelford and EdKarl Galing. World Bank, Water and Sanitation Program. 2011. Economic assessment of sanitation interventions in Vietnam. Nguyen Viet Anh, Guy Hutton, Hoang Thuy Lan, Phan Huyen Dan, Le Thu Hoa, Bui Thi Nhung. World Bank, Water and Sanitation Program. 2012. Economic assessment of sanitation interventions in Southeast Asia. Guy Hutton, U-Primo Rodriguez, Asep Winara, Nguyen Viet Anh, Sam Sok Heng, Kov Phyrum, Liang Chuan. World Bank, Water and Sanitation Program. 2012. Full research reports as well as summary reports are available for each country, in both English and in local languages. All country reports are accessible from http://www.wsp.org www.wsp.org xxv Content Executive Summary ................................................................................................................................ iii A. Introduction.................................................................................................................................. iii B. Study Aims and Methods . ........................................................................................................... iii C. Data Sources and Study Sites ..................................................................................................... iii D. Results ........................................................................................................................................ iv E. Recommendations . .................................................................................................................... xvi Foreword . .............................................................................................................................................. xviii Abbreviations and Acronyms . ............................................................................................................... xx Glossary of Terms . .................................................................................................................................xxii Acknowledgments . ............................................................................................................................... xxiv Content ..................................................................................................................................................xxvii Development Indicators for PR China and Yunnan Province . ........................................................... xxxvi I. Introduction....................................................................................................................................... 1 1.1 Risks of Poor Management and Isolation of Human Excreta......................................................... 1 1.2 Sanitation Options and Definitions. ............................................................................................... 1 1.3 Sanitation and Hygiene Improvement In Yunnan Province............................................................. 2 1.4 Institutions and Programs ............................................................................................................ 4 1.5 Funding Mechanism. ..................................................................................................................... 5 1.6 Scaling Up Sanitation in China and the Millennium Development Goals......................................... 6 1.7 ESI Study and Structure of the Report.......................................................................................... 8 II. Study Aims . ...................................................................................................................................... 9 2.1 Overall Purpose ........................................................................................................................... 9 2.2 Study Aims .................................................................................................................................. 9 2.3 Specific Study Uses ..................................................................................................................... 9 2.4 Research Questions . ................................................................................................................... 9 III. Methods ........................................................................................................................................... 12 3.1 Technical Sanitation Interventions Evaluated ............................................................................... 12 3.2 Costs and Benefits Evaluated ..................................................................................................... 15 3.3 Field Studies ............................................................................................................................... 16 3.4 Program Approach Analysis ........................................................................................................ 24 3.5 Steering Collaboration . ............................................................................................................... 25 IV. Local Benefits of Improved Sanitation and Hygiene ..................................................................... 26 4.1 Health ......................................................................................................................................... 26 4.2 Water . ........................................................................................................................................ 33 4.3 Access Time ............................................................................................................................... 43 4.4 Reuse of Human Exreta .............................................................................................................. 47 4.5 Intangible Sanitation Preferences ................................................................................................ 49 4.6 External Environment .................................................................................................................. 55 4.7 Summary of Local Benefits ......................................................................................................... 59 xxvi Economic Assessment of Sanitation Interventions V. Costs of Improved Sanitation and Hygiene ................................................................................... 61 5.1 Cost Summaries ......................................................................................................................... 61 5.2 Economic Versus Financial Costs . .............................................................................................. 65 5.3 Sources of Financing for Sanitation and Hygiene . ....................................................................... 65 5.4 Costs of Moving up the Ladder.................................................................................................... 68 VI. Sanitation Program Design and Scaling Up . ................................................................................. 69 6.1 Program Approach Analysis from Field Sites ............................................................................... 69 6.2 Program Approach Analysis from a Broader Analysis .................................................................. 76 6.3 Analysis of Program Approaches ................................................................................................ 79 VII. Efficiency of Improved Sanitation and Hygiene ............................................................................. 82 7.1 Efficiency of Sanitation and Hygiene Improvements Compared to No Facility .............................. 82 7.2 Efficiency of Alternatives for Moving up the Sanitation and Hygiene Ladder . ............................... 86 7.3 Scaling Up Results for National Policy Making . ........................................................................... 88 7.4 Overall Cost-Benefit Assessment ................................................................................................ 90 VIII. Discussion ....................................................................................................................................... 92 8.1 Study Messages and Interpretation . ........................................................................................... 92 8.2 Potential Uses of Results ............................................................................................................ 94 8.3 Integrating Economic Considerations into the Decision Making Process ..................................... 95 X. Recommendations .......................................................................................................................... 96 Annex A: Study Methods ....................................................................................................................... 99 Annex B: Health Impact ........................................................................................................................ 108 Annex C: Water Quality Impact............................................................................................................. 111 Annex D: Access Time .......................................................................................................................... 116 Annex E: Intangible User Preferences for Sanitation .......................................................................... 119 Annex F: External Environment............................................................................................................. 122 Annex G: Cost Tables . .......................................................................................................................... 125 Annex H: Program Approach Analysis ................................................................................................. 129 Annex I: CBA and CEA Results ............................................................................................................ 131 www.wsp.org xxvii List of Tables Table 1 Basic sanitation coverage in Yunnan - 2008......................................................................... 3 Table 2 Classification of sanitation options and sub-options. ........................................................... 14 Table 3 Benefits of improved sanitation included in this study.......................................................... 15 Table 4 Background information on the eight selected field sites in Yunnan Province....................... 17 Table 5 Average unit values for economic cost of time per day and of loss of life (US$, 2009).......... 20 Table 6 Annual disease morbidity and mortality attributable to poor sanitation and hygiene, 2008... 27 Table 7 First health provider visited for treatment, for selected diseases (all age groups).................. 28 Table 8 Unit costs associated with treatment of severe diarrhea (US$, 2009)................................... 28 Table 9 Annual costs per person (by age group) attributed to poor sanitation and hygiene in Yunnan (US$, 2009)............................................................................................................ 29 Table 10 Average productivity cost per person per year in field sites, by disease, age group and rural/urban location (US$, 2009)................................................................................... 29 Table 11 Average mortality cost per person per year in field sites, by disease, age group and rural/urban location (US$, 2009).......................................................................................... 31 Table 12 Perceived difference in diarrhea incidence since improved sanitation, in all field sites........... 33 Table 13 Annual costs per household of poor sanitation and hygiene, and annual costs averted of improved sanitation ((US$, 2009)........................................................................ 33 Table 14 Overview of water resources of three selected study sites................................................... 34 Table 15 Drinking water sources in ESI study sites. ............................................................................ 34 Table 16 Water access and treatment cost for three categories of drinking water source................... 40 Table 17 Water access and household treatment costs incurred and averted (US$, 2009)................. 43 Table 18 Proportion of population satisfied with toilet convenience.................................................... 46 Table 19 Opportunity cost of time – how many respondents would spend an extra 30 minutes a day doing different activities (%)........................................................................................ 46 Table 20 Sanitation coverage and households reusing excreta in eight different field sites. ................ 48 Table 21 Value associated with reuse of human excreta (US$, 2009)................................................. 49 Table 22 Respondents’ understanding of sanitation (the top three answers)...................................... 49 Table 23 Perception of the urban population towards institutional toilets - Liangyuan Community, Kunming City................................................................................................... 50 Table 24 Concerns of people who practice open defecation.............................................................. 52 Table 25 Reasons for current sanitation coverage – top five ranked responses per site. .................... 53 Table 26 Scoring of different types of living areas from a household survey........................................ 59 Table 27 Summary of local impacts of sanitation improvement (2009)................................................. 60 Table 28 Average rural cost per household for different sanitation and hygiene options, using full (economic) cost (US$, year 2009). .................................................................................. 61 Table 29 Summary of average cost per urban household for different sanitation and hygiene options, using full (economic) cost (US$, year 2009)............................................................ 63 Table 30 Summary of average cost of a peri-urban household for different sanitation and hygiene options, using full (economic) cost (US$, year 2009)............................................... 65 Table 31 Marginal costs of climbing the sanitation ladder (average all sites) (US$, year 2009)............ 68 Table 32 Sanitation coverage information per field site....................................................................... 69 xxviii Economic Assessment of Sanitation Interventions Table 33 Basic features of field site sanitation programs.................................................................... 70 Table 34 Indicators of overall program effectiveness in field sites....................................................... 74 Table 35 Selected key indicators for program effectiveness averagely calculated for all the sites........ 75 Table 36 Key information on sanitation programs. .............................................................................. 78 Table 37 Approach of selected project. .............................................................................................. 79 Table 38 Advantages and disadvantages of different sanitation options............................................. 80 Table 39 Rural area efficiency measures for main groupings of sanitation interventions, compared to “no toilet” (cost data in US$, year 2009)......................................................... 82 Table 40 Urban area efficiency measures for main groupings of sanitation interventions, compared to “no toilet” (cost data in US$, year 2009)......................................................... 85 Table 41 Peri-urban efficiency measures for main groupings of sanitation interventions, compared to “no toilet” (cost data in US$, year 2009)......................................................... 87 Table 42 Rural area efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder (Qiubei rural site)................................... 88 Table 43 Urban area efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder . ........................................................... 89 Table 44 Characteristics of field sites selected in the ESI study.......................................................... 90 www.wsp.org xxix List of Figures Figure 1 Distribution of sanitation options – comparing Yunnan Province with PR China, 2009....... 3 Figure 2 Sanitation progress in Yunnan Province, 2002 to 2009. ..................................................... 3 Figure 3 Organizational structure and programs related to water resources, water supply, and sanitation................................................................................................................... 4 Figure 4 Use of improved sanitation facilities in China, according to the Joint Monitoring Programme (latest data 2008) .......................................................................................... 7 Figure 5 Flow of data collected (inputs) and eventual cost-benefit assessments (outputs).............. 12 Figure 6 Representation of the sanitation “ladder”. ......................................................................... 13 Figure 7 Overview of methods for estimating field-level benefits of improved sanitation. ................ 19 Figure 8 Diagram of collaboration of ESI team with stakeholder agencies in Yunnan, China........... 25 Figure 9 Comparison between study sites of diarrheal disease incidence for under fives, 2008. .... 27 Figure 10 Comparison of the productivity cost between study sites of ALRI and diarrheal disease 2009................................................................................................................... 30 Figure 11 Comparison of premature mortality cost between study sites of helminthes and diarrheal disease 2009..................................................................................................... 31 Figure 12 Relative risk of fecal-oral diseases and helminthes of different risk exposure scenarios. .... 32 Figure 13 Health costs averted of improved sanitation options (US$, 2009)..................................... 33 Figure 14 Water quality of main lakes and reservoirs by quality classifications.................................. 35 Figure 15 Water quality of urban river sections under monitoring..................................................... 36 Figure 16 Evolution of water quality in key rivers from 1995 to 2008................................................ 36 Figure 17 Development in wastewater treatment capacity from 1999 to 2008 (Source: YEPD, 2009)...................................................................................................... 37 Figure 18 E.coli readings, by water sampling point in Qiubei field sites. ........................................... 38 Figure 19 Extent of isolation of human excreta in field sites. ............................................................ 39 Figure 20 Pollution from poor sanitation and wastewater management (% of households)............... 39 Figure 21 Households citing poor water quality from their principal drinking water source. ............... 41 Figure 22 Cited reasons for using water sources – rural versus urban.............................................. 41 Figure 23 Cited reasons for using water sources............................................................................. 42 Figure 24 Household water treatment practices. .............................................................................. 42 Figure 25 Places of defecation for households with no “own” toilet (%)............................................ 44 Figure 26 Average time per trip and waiting times per day spent accessing toilet for those with no toilet in different sites........................................................................................... 45 Figure 27 Average cited preferences in different sites (%). ................................................................ 45 Figure 28 Average time saved per year per household member (days)............................................. 47 Figure 29 Average annual value of time savings per household (US$, 2009).................................... 48 Figure 30 Average level of satisfaction with current toilet option (1 = not satisfied; 5 = very satisfied)................................................................................. 51 Figure 31 Households stating reasons to get a latrine for those currently without (1 = not important; 5 = very important).......................................................................................... 52 Figure 32 Scoring of different types of living areas—private plots..................................................... 55 xxx Economic Assessment of Sanitation Interventions Figure 33 Scoring of different types of living areas—community living areas . .................................. 56 Figure 34 Proportion of households with unimproved sanitation practice......................................... 57 Figure 35 Proportion of households without toilets who see children defecating in external environment near living quarters (sometimes or regularly)................................................. 57 Figure 36 Perceptions of environmental sanitation state, by option type (1 = very bad; 5 = very good). ....................................................................................................................... 58 Figure 37 Economic costs per rural household for major items (US$, year 2009)............................. 62 Figure 38 Economic costs per urban household for major items (US$, year 2009)........................... 64 Figure 39 Economic costs per peri-urban household for major items (US$, year 2009).................... 64 Figure 40 Proportion of total (economic) costs which are financial, across all field sites.................... 66 Figure 41 Proportion of rural sanitation costs financed from different sources (%)............................ 66 Figure 42 Proportion of urban sanitation costs financed from different sources (%).......................... 69 Figure 43 Proportion of peri-urban sanitation costs financed from different sources (%)................... 69 Figure 44 Household who stated they had a choice whether to participate or not. ........................... 71 Figure 45 More than one sanitation option was given to households. ............................................... 72 Figure 46 Appropriate Technology – Households with insufficient water for flushing toilets............... 72 Figure 47 Financial inputs from household versus project sources (US$, 2009). ............................... 73 Figure 48 Satisfaction level to sanitation options (5 = very satisfied; 0 = dissatisfied)........................ 75 Figure 49 The satisfaction level towards the external environment (5 = very satisfied; 0 = dissatisfied)................................................................................... 76 Figure 50 Proportion of households with members who sometimes or regularly urinate or defecate in open areas, per site (%)................................................................................. 76 Figure 51 The sanitation status inside and around the toilet building/room....................................... 77 Figure 52 Proportion of households with pit often overflowing during rainy season (%).................... 77 Figure 53 Proportion of households reusing human excreta (%)....................................................... 77 Figure 54 Ideal and actual benefit-cost ratio of rural sanitation options............................................ 83 Figure 55 Benefit-cost ratio of pit latrine in three rural sites.............................................................. 83 Figure 56 Cost per DALY averted for rural sanitation options (US$, year 2009). ................................ 84 Figure 57 Benefit-cost ratio of sanitation options in urban areas...................................................... 85 Figure 58 Cost per DALY averted for urban sanitation options (US$, year 2009 )............................. 86 Figure 59 Benefit-cost ratio of peri-urban sanitation options............................................................ 87 Figure 60 Cost per DALY averted of peri-urban sanitation options (US$, year 2009)........................ 87 www.wsp.org xxxi List of Annex Tables Annex Table A 1. Selection of field sites for economic study . ........................................................... 99 Annex Table A 2. Assessment of advantages and limitations of different design options . ................ 100 Annex Table A 3. Methodology for benefit estimation (calculations, data sources, explanations) . .... 101 Annex Table A 4. Diseases linked to poor sanitation and hygiene, and primary transmission routes and vehicles .............................................................................................. 104 Annex Table A 5. Water quality measurement parameters per location, and test method ................ 105 Annex Table A 6. Households sampled versus total households per village/community . ................. 106 Annex Table A 7. Sample sizes of other surveys in study sites ........................................................ 107 Annex Table B 1. Rates per population for cases of diseases .......................................................... 108 Annex Table B 1. Rates per 1000 population for deaths .................................................................. 108 Annex Table B 2. Rates per 1000 population for DALYs................................................................... 109 Annex Table B 3. Evidence on treatment seeking behavior for other diseases.................................. 109 Annex Table B 4. Unit costs associated with treatment of severe diarrhea (US$,2008) .................... 110 Annex Table C 1. Full water quality measurement results . ............................................................... 111 Annex Table C 2. Water quality measurement results of ground water ............................................. 112 Annex Table C 3. Pollution from poor sanitation and wastewater management (% of households) . . 112 Annex Table C 4. Water access and costs ...................................................................................... 113 Annex Table C 5. Households citing poor water quality from their principal drinking water source ... 113 Annex Table C 6. Households responses to polluted water – reasons for using water sources ........ 114 Annex Table C 7. Treatment practices.............................................................................................. 114 Annex Table C 8. Treatment costs.................................................................................................... 115 Annex Table C 9. Water access and household treatment costs incurred and averted. ..................... 115 Annex Table D 1. Place of defecation of households with no “own” toilet ........................................ 116 Annex Table D 2. Daily time spent accessing toilet for those with no toilet........................................ 116 Annex Table D 3. Practices related to young children ...................................................................... 117 Annex Table D 4. Preferences related to toilet convenience, from household questionnaire.............. 117 Annex Table D 5. Opportunity cost of time – what respondents would spend an extra 30 mins a day doing (%)..................................................................................................... 118 Annex Table D 6. Average time savings per year, by household member ......................................... 118 Annex Table D 7. Average annual value of time savings . ................................................................. 118 xxxii Economic Assessment of Sanitation Interventions Annex Table E 1. Respondents’ understanding of sanitation - top 3 ranked responses per site . ..... 119 Annex Table E 2. Reasons for current sanitation coverage - top 3 ranked responses per site . ........ 120 Annex Table E 3. Level of satisfaction with current toilet option, by option type (1 = not satisfied; 5 = very satisfied) .................................................................................. 121 Annex Table E 4. Important characteristics of a toilet for those currently without (1 = not important; 5 = very important) . ............................................................................ 121 Annex Table F 1. Scoring of different types of living area (1 = clean; 2 = minor soiling; 3 = moderate soiling; 4 = major soiling; 5 = extreme soiling) ...................................... 122 Annex Table F 2. Proportion of households with and without toilet with unimproved sanitation practice................................................................................................................ 122 Annex Table F 3. Implication of current toilet option for external environment (1 = not satisfied; 5 = very satisfied). ................................................................................................ 123 Annex Table F 4. Perceptions of environmental sanitation state, by option type (1 = very bad; 5 = very good)...................................................................................................... 123 Annex Table F 5. Ranking the importance of environmental sanitation, by option type (1 = not important; 5 = very important). ............................................................................. 124 Annex Table G 1. Average rural cost per household for different sanitation and hygiene options, using full (economic) cost (US$, year 2009) ............................................ 125 Annex Table G 2. Average urban cost per household for different sanitation and hygiene options, using full (economic) cost (US$, year 2009)........................................................... 126 Annex Table G 3. Average peri-urban cost per household for different sanitation and hygiene options, using full (economic) cost (US$, year 2009) ............................................ 127 Annex Table G 4. Proportion of total (economic) costs which are financial (US$, year 2009) ............ 128 Annex Table G 5. Incremental costs of moving up the sanitation ladder (US$, 2009) ....................... 128 Annex Table H 1. Household choices and other interventions . ........................................................ 129 Annex Table H 2. Financing from household and project sources..................................................... 129 Annex Table H 3. Appropriate technology......................................................................................... 130 Annex Table H 2. Actual program performance in relation to key selected indicators for program effectiveness. .......................................................................................... 130 www.wsp.org xxxiii Annex Table I 1. Site 6 - Rural Luquan efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 131 Annex Table I 2. Site 7 - Rural Dali efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 132 Annex Table I 3. Site 8 - Rural Qiubei efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 132 Annex Table I 4. Site 1 - Urban Kunming efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 133 Annex Table I 5. Site 2 - rural Luquan efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 133 Annex Table I 6. Site 3 - Urban Dali efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 134 Annex Table I 7. Site 4 - Urban Qiubei efficiency measures for main groupings of sanitation interventions, compared to “no toilet”................................................................... 134 Annex Table I 8. Site 5 - Peri-urban Kunming efficiency measures for main groupings of sanitation interventions, compared to “no toilet”. ................................................... 135 Annex Table I 9. Site 8 - Rural Quibei area efficiency measures for main groupings of sanitation interventions, comparing different points on the sanitation ladder (US$, year 2009). .................................................................................................. 135 xxxiv Economic Assessment of Sanitation Interventions Development Indicators for PR China and Yunnan Province Variables China Yunnan Province Population Total population (2008) 1,328 million1 45.4 million9 Rural population (%) 54.3 %1 76.6%9 Urban population (%) 45.7 %1 23.4%9 Annual population growth (%) (year 2008) 0.51 %1 0.63%9 Proportion of population under 14 years of age (% of total) 19%1 26%16 (2008) Under 5 mortality rate (deaths per 1000) 2414 74.913 Female population (% of total) (2008) 48.5%1 48.0%9 Population below poverty line (%) (2006) 3.7 %8 6.4%12 Economic Currency name Renminbi Yuan (RMB) Year of cost data presented 2009 Currency exchange with US$ (average 2009) 6.832 GDP per capita (US$) (2009) US$ 3,6033 US$ 2,0031 GDP per capita adjusted for purchasing power (2009) I$ 6,00017 I$ 3,336 Sanitation Improved total (%) (2004) 40.1 %6 n.a. Improved rural (%) (2007) 59.7% (2008) 6 51% (2006) Rural with road access (2008) 86.4% 4 70.5%10 Rural without road access (2008) 13.6%4 29.5%10 Improved urban (%) (2004) 86.55 %6 n.a. Sewerage connection (urban areas, 2008) (%) 70.4% 5 30% Note: n.a.- not available Sources: 1 China population information web http://www.cpirc.org.cn/tjsj/tjsj_cy_detail.asp?id=10410 2 http://www.pbc.gov.cn/diaochatongji/tongjishuju/gofile.asp?file=2009S08.htm 3 http://zhidao.baidu.com/question/134290928.html 4 Perspective on legal protection of the plight of China’s rural roads. http://mcxjtj.smx.gov.cn/n42513.aspx 5 http://hzs.ndrc.gov.cn/newhjyzyjb/t20090703_289320.htm 6 http://wwwold.bjmu.edu.cn/extra/col19/1225161462.pdf 7 2008 Chinese Environment Status Report 8 http://news.xinhuanet.com/politics/2006-10/30/content_5266164.htm 9 http://news.yninfo.com/yn/zhxw/200902/t20090218_773538.htm 10 http://yunnan.stis.cn/ynjj/jingctj/dfjj/200908/t20090812_264314.html 11 http://www.yn.gov.cn/yunnan,china/74600764432973824/20090415/1189980.html 12 http://www.china.com.cn/chinese/pinkun/956567.htm 13 WANG Xing-tian; GUO Guang-ping; ZHOU Hong; et al. Tendency and Evaluation of the Deaths among Children under 5 Years in Yunnan from 1975 to 2005. Chinese Journal of Natural Medicine.2007,9(2). (2000 data) 14 http://www.cnr.cn/news/200709/t20070914_504569460.html (2006 data) 15 http://www.chinacitywater.org/rdzt/chshp/10684.shtml 16 Yunnan Statistical Yearbook 2009. Compiled by the Statistical Bureau of Yunnan Province and Survey Office of the National Bureau of Statistics in Yunnan.2009. This statistic reflects data from the year 2000. 17 http://www.photius.com/rankings/economy/gdp_per_capita_2009_0.html I. Introduction 1.1 RISKS OF POOR MANAGEMENT AND Widespread reuse of untreated human and animal excreta ISOLATION OF HUMAN EXCRETA as agricultural fertilizer in China’s rural areas is an impor- Poor sanitation has many negative impacts. A first phase tant contributor to polluting water sources and spreads in- study of the Economics of Sanitation Initiative (ESI) in fectious diseases. A survey of rural households from 2006 five countries of Southeast Asia found that poor sanitation to 2007 conducted by the National Patriotic Health Cam- causes considerable financial and economic losses. Financial paign Committee, the Ministry of Health, revealed that losses – including direct monetary costs – average 0.44% 84% of households use excreta in agricultural production, of annual GDP, while overall population welfare (i.e. eco- and most of these were using non-sanitary latrines as op- nomic) losses average 2% of GDP. The majority of econom- posed to sanitary latrines. Hence the risk of transmitting ic losses are shared between health (54%), water resources fecal-oral diseases due to reuse of untreated manure is high2. (25%) and time spent accessing open defecation sites or public sanitation facilities (15%)1. 1.2 SANITATION OPTIONS AND DEFINITIONS Improved sanitation facilities are defined in terms of the Like in other developing countries, water contamination types of technology and levels of services that are more has become the greatest challenge for environmental pro- likely to be sanitary than unimproved technologies. Hav- tection and sustainable development in China. In Yunnan, ing access to improved sanitation is seen as one of the basic the contamination of surface water bodies, including the human needs and identified as one indicator of the Mil- province’s major lakes and rivers, has been caused by hu- lennium Development Goals. Improved sanitation includes man activities: agriculture, industry, deforestation and land connection to public sewers, connection to septic systems, reclamation, as well as household wastewater and human pour-flush latrines, simple pit latrines and ventilated im- excreta. Poor household wastewater and excreta manage- proved pit latrines. Not considered as improved sanitation ment – made worse by continued population growth – are service or bucket latrines (where excreta is manually re- has become major threats to water resources protection in moved), public latrines and open latrines3. Yunnan Province. For example, water quality in the Dian- chi Lake deteriorated from the quality of drinking water In China, a distinction is made between sanitary latrines to the bottom (5th) grade of water quality, due partly to and sanitary latrines with safe excreta disposal. Sanitary la- poor household wastewater and excreta management, caus- trines are latrines with wall, roof and door, closed non-leak- ing eutrophication in sections of the lake. Protecting lim- ing storage tank, with slab, no worms, no bad odors, excreta ited water resources, particularly lakes and drinking water emptied in a timely manner, and safe disposal of excreta sources, from contamination of human and animal waste is separately, and sanitary latrines with safe excreta disposal one of the priority issues for environmental agencies. are sanitary latrines that, in addition, enable reduction, re- 1 Source: “Economic Impacts of Sanitation in Southeast Asia.” Hutton G, Rodriguez UE, Napitupulu L, Thang P, Kov P. World Bank, Water and Sanitation Program. 2008. 2 http://cn.chinagate.cn/health/2008-02/18/content_10079458.htm 3 According to the WHO / UNICEF Joint Monitoring Programme. www.wsp.org 1 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction moval of or killing pathogens in human excreta, therefore Flush toilets to sewer are flush toilets connected to a sewer avoiding infections4. By definition, a sanitary latrine in the system and toilet wastewater is then purified in centralized Chinese context is equivalent to improved sanitation ac- or decentralized treatment facilities. cepted internationally. A double (alternating) pit latrine is a type of dehydration Six main sanitary latrines with safe excreta disposal recom- toilet with water flushing. Its two pits are used in shifts: mended by governmental sanitation programs include a while one pit is used the other one will be closed to allow three grid septic tank, a double-urn funnel-type lavatory, a excreta to dehydrate, and allow safe disposal of the excreta 3-in-1 biogas digesters toilet, a urine diversion dehydration after six months. toilet (UDDT), a flush toilet to sewer, and double (alternat- ing) pit latrine. Figure 1 shows that among all these six types of sanitation option, flush toilets to sewers, the three grid septic tank and The three grid septic tank provides minimal on-site treat- 3-in-1 biogas digester toilets are the dominant technologies ment for toilet wastewater through a concrete structure adopted in both Yunnan Province and China. Many fac- composed of three tandem connected chambers, where tors: economic, social, cultural, climatic, and geographical, wastewater flows in, stays and gradually leaves and get determine the type of technology to be chosen. cleaned via simple settlement and digestion processes. 1.3 SANITATION AND HYGIENE The double-urn funnel-type lavatory is composed of two IMPROVEMENT IN YUNNAN PROVINCE connected urns and a funnel-type squatting pan. The urn, In rural Yunnan Province the coverage of sanitary latrines which is placed directly under the pan is used for storage has remained low, compared to the majority of the prov- and settling, its overflow flows into the second urn where inces and municipalities in China, despite a big leap having organic matters are decomposed and pathogens are killed been achieved within the province in the last two decades. over a period of time. The digested liquid is rich in nutri- As shown in Figure 2, by the end of 2009 its sanitary latrine ents and is a good fertilizer. The pan is flushed by a mini- coverage was 54% and the share of sanitary latrines with mum amount of water. safe excreta disposal was 27%, lower than the national aver- age of 63.2% and 40.5% respectively, ranking 19th out of The 3-in-1 biogas digester toilet is a structure integrated 30 provinces and municipalities of the country5. The dia- with a latrine where human and animal excreta, kitchen gram below illustrates the continuous sanitation develop- waste, agricultural waste are disposed of through a fermen- ment in Yunnan in the last eight years. The sharp decline tation process and biogas is produced for household use. of sanitation coverage and number of rural households in the diagram in 2006 is caused by changing statistical meth- Urine-diverting dry toilets (UDDT) do not mix urine odology. and feces at the point of collection and do not use water for flushing. In China the function of this type of latrine The basic sanitation coverage of the three study areas, is largely achieved through a reversible squatting method namely Kunming, Dai and Wenshan is shown in Table 1. allowing the separation of urine and feces placed on two excreta/fecal vaults being used alternatively. Urine is chan- Access to sanitary latrines in rural areas of Yunnan is tar- neled to a bucket or storage tank which is convenient for geted to have reached 60% by the end of 2010, and access urine reuse. After dehydration for an appropriate period of to sanitary latrines with safe excreta disposal is targeted to time, the fecal matter can be applied as safe organic fertil- have reached 35%. While the data are not yet available to izer to farmland. report on whether the target has been reached or not, the 4 Technical Guidelines for Rural Latrine Improvement (provisional), NPHCC, May 2009. 5 Health Yearbook of China 2010. 2 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction FIGURE 1: DISTRIBUTION OF SANITATION OPTIONS – COMPARING YUNNAN PROVINCE WITH PR CHINA, 2009 2% 1% China 47% 10% 24% 17% 1% 1% Yunnan 21% 65% 4% 8% 0 20 40 60 80 100 three grid septic tank double-urn funnel-type lavatory 3-in-1 biogas digesters toilet UDDT flush toilet to sewer double (alternating) pit latrine FIGURE 2: RURAL SANITATION PROGRESS IN YUNNAN PROVINCE, 2002 TO 2009 10,000 100% 9,000 90% 8,000 80% 7,000 70% 6,000 60% 5,000 50% 4,000 40% 3,000 30% 2,000 20% 1,000 10% 0 0% 2002 2003 2004 2005 2006 2007 2008 2009 number of rural households total sanitary latrines by end of the year households sharing public sanitary latrines newly constructed sanitary latrines of the year percentage of sanitary latrine percentage of sanitary latrine with safe disposal TABLE 1: BASIC SANITATION COVERAGE IN YUNNAN - 2008 Coverage of sanitary latrines with safe Locality Coverage of sanitary latrines (%) excretal disposal (%) Kunming Municipal City 64% 32% Dali Prefecture 50% 27% Wenshan Prefecture 49% 25% Yunnan Province 54% 27% Source: Yunnan PHHC www.wsp.org 3 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction development trends indicated in Figure 1 suggest the sani- years, and this mechanism allows the general public includ- tation targets set out in the 11th five-year plan of Yunnan ing civil societies, enterprises, and individuals to contribute are unlikely to happen. to full basic sanitation access in China. For urban sanita- tion the Ministry of Housing and Urban-Rural Develop- 1.4 INSTITUTIONS AND PROGRAMS ment (MHURD) is taking the lead, while in rural areas The national government aimed to improve sanitation cov- the Ministry of Health (MoH) takes on a coordination and erage to 65% (Eastern China), 55% (Central China) and key implementation role through the National Patriotic 35% (Western China) during 2001-2010. For 2009 and Health Campaign Committee (NPHCC) which has other 2010 it budgeted 2.86 billion RMB (US$0.43 billion) for governmental agencies and institutions as its members. At constructing 7.58 million improved latrines with safe ex- provincial and lower levels the organizational structure cor- creta disposal in rural China6. responds to the national one. For such a huge and continuous investment program, a Among the sectoral governmental agencies contributing to mechanism with multiple governmental agencies’ partici- sanitation improvement, the housing and urban-rural de- pation for sanitation development has been in place for velopment department and health department have a di- FIGURE 3: ORGANIZATIONAL STRUCTURE AND PROGRAMS RELATED TO WATER RESOURCES, WATER SUPPLY, AND SANITATION sewerage system and sewage treatment Housing and Urban Pollution facilities urban sanitation Urban-rural Control Developmant Dept. water resource sewer system and Programme (UPCP)/ conservation sewage treatment Watershed Pollution facilities Prevention and Environmental Control Programme Protection Dept. (WPPCP) solid waste colection Reform and and disposal Development Committee PHCC/ providing basic six types of improved Water supply and Finance Dept. sanitation latrines latrine improvement Health Dept. infrastructure programme (WSIP) energy provision, biogas digester Rural Energy Agriculture water and forest latrine Programme Dept. conservation, (REneP) resource reuse energy provision, biogas digester Rural Energy Forestry water and forest latrine Programme Dept. conservation, (REP) rural sanitation resource reuse water and forest biogas digester Rural environmental conservation, latrine/UDDT/Three programme (REnvP)/ Environmental resource reuse grid septic Watershed pollution Protection Dept. tank/sewage prevention and control treatment facilities programme (WPPCP) Financing and planning dept. water resource rural sewage Watershed pollution Leading govt. dept. Housing and conservation treatment facilities prevention and Urban-rural control programme Contributing govt. dept. Developmant Dept. (WPPCP) Area of responsibility improvement of rural sewage Whole-village- Sanitation option applied Poverty Alleviation housing condition treatment facilities improvement Office programme (WVIP) Key sectoral programme 6 China’s Progress towards the Millennium Development Goals 2010 Report. 4 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction rect mandate to provide basic sanitation infrastructure and wastewater treatment facility similar to a standard septic increase access to improved sanitation, while other depart- tank but composed of five grids is being tested in villages ments such as agriculture, forestry and environmental pro- close to Erhai lake. tection departments contribute to sanitation improvements via their energy, security and natural resources saving. Fig- Apart from the three dominant sanitation options (three ure 3 provides an overall picture of the governmental struc- grid septic latrines, biogas toilets, and toilets connected to ture for sanitation in China. sewer) about 93,000 UDDT units11 were constructed main- ly in Daichi watershed and some in Erhai watershed from The household biogas digesters, supported by the relevant 2002 to 2007, considering the prominent environmental governmental agencies in Yunnan, successfully scaled up to benefit of this technology. Its planned roll-out however, was cover 2.5 million households by September 2010 at a steady not carried forward further due to a generally low utiliza- increase of 200,000 households each year7. By the end of 2010, tion rate. However, examples of successful use of UDDT the total biogas households amounts to 3 million, accounting can also be found in some localities of Yunnan. for 35.9% of the total rural households of the province8. Building on the existing 4,829,000 improved latrines that By 2009 there were 42 centralized sewage treatment plants covered 53.74% of rural households, Yunnan was supposed in place, posing a treatment capacity of 1,342,000 m3/d, and to have achieved 56.5% access to improved sanitation in achieving a domestic wastewater treatment rate of 67.1%9. 2010, which implies that 247,000 new sanitary latrines According to the Yunnan urban sewerage treatment plan, with safe excreta disposal shall be newly built12. by the year 2012, 143 centralized domestic waste water treatment projects to cover all the districts, municipalities 1.5 FUNDING MECHANISM and county seats in Yunnan (129 in total) will have been Upgrading the sanitation state in China needs a robust co- constructed. By then the urban domestic wastewater collec- financing mechanism, despite a big share of the investment tion rate will reach 85% and treatment rate 80%10. The tar- being provided by different levels of government. Sanita- geted treatment capacity is 90% of urban households, 70% tion, as one of the public services, has been continuously of households in peri-urban areas, and 40% in rural areas. subsidized by the central government, provincial and lower levels of government. Funds for sanitation provided by the Focusing on villages located around the nine key lakes in central to local governments vary in volume and mechanism. Yunnan, the Environmental Control Program for Lake- They can be funds exclusively for water supply and latrine shore and Lake-adjacent Villages of Nine Plateau Lakes improvement programs or funds for urban environmental in Yunnan (2009-2011) addresses drinking water safety, infrastructure only. They can also be part of the funds for domestic wastewater pollution, animal waste and rural general uses, for instance, poverty alleviation and forest con- industrial pollution prevention and control. The program servation. To a large extent sanitation construction plans covers 494 lakeshore and lake-adjacent villages with a total and financing plans of different governmental departments investment of 1.2 billion RMB (US$179 million), aiming are coordinated by the reform and development committee to achieve 70% of domestic wastewater treatment coverage and the finance ministry/department. Governmental invest- and 90% access to improved sanitation of these villages. ment for the implementation of a sectoral program, such as Currently, decentralized village domestic wastewater treat- WSIP, often comes from multiple sources. The central gov- ment facilities using biological methods are being piloted in ernment requires local governments (provincial, prefectural, Lake Dianchi and Erhai watersheds, and a new household county, and township governments) to provide counterpart 7 http://www.greentimes.com/green/news/yaowen/zhxw/content/2010-09/16/content_104237.htm 8 Yunnan Rural Energy Development Plan (2003-2010). 9 Environmental Status Report of Yunnan 2009. 10 Construction Plan for Urban Sewage Treatment and Reuse Facilities in Yunnan (2008 to2012) 11 Yunnan PHCC. 12 http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohjbyfkzj/s5898/200912/44928.htm. www.wsp.org 5 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction funds for projects. Shares among tiers of government largely the central government for biogas digester latrines is 1,000 depend on the source/nature of subsidies and their financing yuan/unit and in Yunnan another 1,000 yuan is added on capacities. Subsidies of the state government often favor less by the provincial government. The rest is shared by govern- developed over more developed regions. ments and households at lower levels. WSIP specific funds from the central government subsidize In addition to government financing, village communities components such as the septic tank, bowl, and the plat- and individuals are required to bear part of the construc- form (made from prefabricated board), at different rates tion costs where their contribution can be either in kind for different regions (e.g. 400 yuan per household in the or cash. Local societies, organizations and individuals are midwest, 300 yuan per household in the eastern region). encouraged to shoulder part of the financial burden as well. Local matching funds shall be equal to the central govern- For urban sanitation infrastructure, even more diversified ment’s funds. For central and western provinces, funds pro- financing sources and mechanisms exist. vided by the provincial government should not be less than half of the total matching fund. Meanwhile, the provincial 1.6 SCALING UP SANITATION IN CHINA AND government needs to provide a sufficient budget for tech- THE MILLENNIUM DEVELOPMENT GOALS nical guidance, training, health education monitoring and The Chinese government puts the improvement of sanita- inspection. tion facilities and scaling up of sanitary latrines as one of the top priorities for water conservation and improvement For urban wastewater treatment plants, the Development of sanitary conditions and health. During the early 1990s, and Reform Commission, MEP and MHURD jointly co- China began a long-term and sustained scaling up of sani- finance the initial capital for wastewater treatment plants, tary latrines, providing both policy support and technical with a maximum co-financing of 70% of capital costs, and assistance for implementation of programs. Significant the provincial government is expected to finance the rest of progress in China towards the realization of the Millen- the initial capital outlay. nium Development Goal (MDG) Target 7 has been made, which seeks to reduce by half the proportion of the popula- To upgrade urban sanitation, the central government pro- tion without sustained access to basic sanitation. Statistics vides exclusive funds and general subsidies. Urban wastewa- of the Joint Monitoring Programme (JMP) evaluation re- ter treatment projects listed in the national 11th five-year port from the United Nations Children’s Fund and World plan for urban sewage treatment and reuse of infrastructure Health Organization indicated that in both rural and urban construction receive a subsidy in the form of a reward fund areas, sanitation coverage in China is increasing, but the av- at 40 RMB/m3 of treatment capacity and 200 RMB/m of erage rate in rural areas is far behind that in urban areas (see a sewage pipe system. In Yunnan, besides the abovemen- Figure 4). By the end of 2009, China had reached 63.2% tioned funding opportunities from the national govern- coverage of improved latrines and 40.5% of improved la- ment, the provincial financial budget will allocate 0.4 bil- trines with safe excreta disposal14. JMP estimates show cov- lion RMB (US$149 million) for urban sewage treatment erage of improved sanitation in urban areas of 74% and projects each year from 2008 to 201213. The operation and rural areas of 56%. Based on progress since 1990, projec- maintenance costs are to be recovered by a wastewater dis- tions of sanitation coverage to 2015 suggest that the MDG charge fee at a price of 1.0 yuan per cubic meter. sanitation target will be achieved in China. When UDDTs were constructed in Dianchi catchment, However, sanitation improvement in China still faces big construction costs of some of the units were fully covered challenges. First, the urban-rural disparity in terms of access by the Kunming municipal government and for some units to improved sanitation remains large; and the gap between households contributed 100 to 180 yuan. A subsidy from western and eastern parts of China is unlikely to be closed 13 Construction Plan for Urban Sewage Treatment and Reuse Facilities in Yunnan (2008-2012). 14 Health Yearbook of China 2010. 6 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction FIGURE 4: USE OF IMPROVED SANITATION FACILITIES IN CHINA, ACCORDING TO THE JOINT MONITORING PROGRAMME (LATEST DATA 2010) China - urban China - rural Use of improved sanitation facilities Use of improved sanitation facilities in % in % 100 100 NHSS08 NHSS03 90 90 80 80 NHSS93 NHSS98 70 NMICS92 PSS99 70 NHSS08 AC06 CEN91 60 60 Coverage Coverage NHSS03 50 50 40 40 NHSS98 NHSS93 30 30 CEN91 NMICS92 PSS99 20 20 10 10 0 0 1980 1985 1990 1995 2000 2005 2010 2015 1980 1985 1990 1995 2000 2005 2010 2015 JMP-estimated survey findings JMP-estimated coverage Improved + shared Improved + shared Improved Estimated coverage 2012 update Estimated coverage 2012 update Open Open Year Improved Shared Unimproved Year Improved Shared Unimproved defecation defecation 1990 48% 15% 34% 3% 1990 15% 4% 72% 9% 1995 54% 18% 26% 2% 1995 25% 6% 62% 7% 2000 61% 20% 18% 1% 2000 35% 9% 51% 5% 2005 68% 22% 9% 1% 2005 46% 11% 40% 3% 2010 74% 24% 2% 0% 2010 56% 14% 28% 2% Shared facilities : The proportion of the population using a shared improved sanitation facility is based on the CEN91and SAGE08 anytime soon. Areas with low access coverage normally are In most places in China insufficient budgets for laying cor- remote and less economically developed provinces. Finan- responding sewer pipes also caused the sewage treatment cial constraints do not give them much chance to inject plants to operate at under-capacity. A survey report of MEP sufficient funds into sanitation, and sanitation investment revealed that among 1,178 sewage plants which have been has to rely mainly on central government support. In many in operation longer than one year, 32% of them are oper- cases, even local financing cannot meet the counterpart ated at less than 60% of designed load and 7% of them run fund requirements. at lower than 30% of designed load15. 15 http://news.163.com/09/0702/08/5D73OJVC000125LI.html. www.wsp.org 7 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Introduction 1.7 ESI STUDY AND STRUCTURE OF THE REPORT field sites, including the total investment and recurrent The present study is part of a second phase of the Econom- costs per sanitation option, broken down by financial and ics of Sanitation Initiative. This is the first study in China economic costs, and the marginal costs of moving up the that conducts a comprehensive economic assessment in a sanitation ladder. Chapter 6 compares sanitation program range of geographical locations – rural, peri-urban and ur- performance in the field sites using simple performance in- ban areas – and comparing several different sanitation op- dicators, and cites examples of program design that enhance tions per field site. performance from selected programs. Chapter 7 presents the cost-benefit analysis, comparing efficiency indicators This report contains a further eight chapters, as follows. for ideal and actual performance of sanitation programs, Chapter 2 presents the study aims, objectives and research including the marginal efficiencies of moving up the sanita- questions. Chapter 3 introduces the research methodol- tion ladder. Chapter 8 discusses the results in the light of ogy and data sources. Chapter 4 presents the results on the the main findings, the current and future sanitation poli- benefits of improved sanitation options, including health, cies, and the research methodologies of the study. Chapter water source access and treatment, access time, reuse of ex- 9 proposes policy recommendations to the relevant govern- creta, intangible preferences and the external environment. mental agencies and sector stakeholders for improved sani- Chapter 5 presents the costs of improved sanitation in the tation decision making. 8 Economic Assessment of Sanitation Interventions II. Study Aims 2.1 OVERALL PURPOSE The purpose of the Economics of Sanitation Initiative (ESI) This study also contributes to the debate on approaches to is to promote evidence-based decision making using im- sanitation financing and ways of scaling up sanitation im- proved methodologies and data sets, thus increasing the provements to meet national targets. effectiveness and sustainability of public and private sanita- tion spending. 2.3 SPECIFIC STUDY USES By providing hard evidence on the costs and benefits of im- Better decision making techniques and economic evidence proved sanitation, the study will: themselves are also expected to stimulate additional spend- • Provide advocacy material for increased spending ing on sanitation to meet and surpass national coverage tar- on sanitation, and to prompt greater attention of gets. sector stakeholders to efficient implementation and scaling up of improved sanitation. 2.2 STUDY AIMS • Enable the inclusion of efficiency criteria in the The aim of this current study is to generate robust evidence selection of sanitation options in government and on the costs and benefits of sanitation improvements in donor strategic planning documents, and in specific different programmatic and geographic contexts in China, sanitation projects and programs. leading to the selection of the most efficient and sustain- • Bring greater focus on appropriate technology able sanitation interventions and programs. Basic hygiene through increased understanding of the marginal aspects are also included, insofar as they affect health out- costs and benefits of moving up the “sanitation lad- comes. der” in different geophysical, socio-economic and demographic contexts. The range of evidence is presented in a few selected effi- • Provide the empirical basis for improved estimates ciency indicators and distilled into key recommendations of the total costs and benefits of meeting sanitation to increase uptake by a range of sanitation financiers and targets (e.g. MDG or other national target), and implementers, including different levels of government and contribute to provincial and national strategic plans sanitation sector partners, as well as households and the pri- for meeting and surpassing these targets. vate sector. • Contribute to the design of feasible financing op- tions through identification of the beneficiaries as Standard outputs of cost-benefit analysis include benefit- well as cost incidence of sanitation programs. cost ratios, internal rate of return, payback period, and net benefits (see Glossary). Cost-effectiveness measures relevant 2.4 RESEARCH QUESTIONS to health impacts will provide information on the costs of In order to fulfill the overall purpose of the study, research achieving health improvements. In addition, intangible questions were defined that have direct bearing on sanita- aspects of sanitation not quantified in monetary units are tion policies and decisions, distinguished for overall effi- highlighted as being crucial to the optimal choice of sanita- ciency questions (i.e. cost versus benefit), and for costs and tion interventions. benefits separately16. 16 “Costs” and “benefits” refer simultaneously to financial and economic costs, unless otherwise specified. www.wsp.org 9 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Study Aims The major concern in economic evaluation is to understand competitive compared with other uses of the same health economic and/or financial efficiency – in terms of return on budget. investment and recurrent expenditure. Hence the focus of economic evaluation is on what it costs to deliver an inter- As well as overall efficiency questions, it is useful from deci- vention and what the returns are. Several different efficiency sion making, planning and advocacy perspectives to better measures allow examination of the question from different understand the nature and timing of costs and benefits, as angles, such as number of times by which benefits exceed well as how non-economic aspects (such as socio-cultural costs, the annual equivalent returns, and the time to repay considerations) affect the implementation of sanitation in- costs and start generating net benefits (see Box 1). Also, terventions (see boxes 2 and 3). Furthermore, given that as sanitation and hygiene improvement also fall within the several impacts of improved sanitation cannot easily be health domain, economic arguments can be made for in- quantified in monetary terms, this study attempts to give vestment in sanitation and hygiene interventions with the greater emphasis to these “intangible” impacts in the overall health budget, if the health return per unit cost invested is cost-benefit assessment. BOX 1. RESEARCH QUESTIONS ON SANITATION EFFICIENCY i. Are benefits greater than the costs of sanitation interventions? By what proportion do benefits exceed costs (benefit-cost ratio – BCR)? ii. What is the annual internal rate of return (IRR)? How does the IRR compare to national or international standards for investments of public and private funds? How does the IRR compare to other non- sanitation development interventions? iii. How long does it take for a household to recover its initial investment costs, at different levels of cost sharing (payback period – PBP)? iv. What is the net gain of each sanitation intervention (net present value – NPV)? What is the potential interest of sanitation for business opportunities ? v. What is the cost of achieving standard health gains such as averted death, cases and disability-adjusted life-year (DALY)? vi. How does economic performance vary across sanitation options, program approaches, locations, and countries? What factors explain performance? BOX 2. RESEARCH QUESTIONS ON SANITATION COSTS i. What is the range of costs for each technology option in different field settings? What factors determine cost levels (e.g. quality, duration of hardware and software services)? ii. What proportion of costs are capital, program and recurrent costs, for different interventions? What are necessary maintenance and repair interventions, and costs, to extend the life of hardware and increase sustainability? iii. What proportion of total (economic) cost is financial in nature? How are financial and economic costs financed in each field location? iv. What are the incremental costs of moving from one sanitation improvement to another - i.e. up the sanitation ladder – for specified populations to meet sanitation targets? 10 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Study Aims In addition, other research questions are crucial to an ap- is paying for the interventions and who is benefiting from propriate interpretation and use of information on sanita- the interventions (and who thus may be willing to pay). tion costs and benefits. Most importantly, the full benefits Given that scale-up cannot be achieved with full subsidi- of a sanitation intervention may not be received due to zation of sanitation interventions by government or other implementation issues that affect the uptake and compli- sector partners, it will be key to better understanding how ance with the intervention. These factors need to be bet- public money and subsidies can be used to leverage further ter understood to advise future program design. Also, the investments from the private sector and from households ESI study touches on many financing issues, related to who themselves (see Box 4). BOX 3. RESEARCH QUESTIONS ON SANITATION BENEFITS i. What local evidence exists for the links between sanitation and the following impacts: health impact, water quality and water users, land use, time use, and welfare? ii. What are the size of financial and economic benefits related to health expenditure, health-related productivity and premature mortality; household water uses; time savings; property value; and other welfare impacts? iii. What proportion of the benefits are pecuniary benefits (financial gains) and what proportion are non- pecuniary benefits? iv. What proportion of each benefit accrues to households who invest in sanitation and what proportion is external to the household? v. What is the actual or likely willingness to pay of households and other agencies for improved sanitation? vi. How do benefits accrue or vary over time? vii. How is improved sanitation – and the related costs and benefits – tangibly linked with poverty reduction? viii. What is the overall household and community demand (expressed and latent demand) for improved sanitation? BOX 4. OTHER RESEARCH QUESTIONS i. How do program design and program implementation affect costs and benefits? In practice, (how) can sanitation programs be delivered more efficiently – i.e. reducing costs without reducing benefits? ii. How to leverage grants to incentivize investments in sanitation? iii. What factors determine program performance? What are the key factors of success and constraint, covering contextual, institutional, financial, social and technical aspects? iv. Which program approaches are best suited to which technical options? v. What is the acceptability of different sanitation options and program approaches? vi. What other issues determine intervention choice and program design in relation to local constraints: energy use, water use, polluting substance discharge, and option robustness/durability/maintenance requirements? vii. Based on research findings, what other key issues enter into sanitation option decisions? www.wsp.org 11 III. Methods The study methodology in Yunnan follows the same stan- provements as well as other benefits that may accrue outside dard methodology developed at the regional level reflect- the sanitation improvement site. Hence Output 3, overall ing established cost-benefit techniques, which have been cost-benefit assessment, takes these into account. adapted to the specific sanitation interventions and research needs in Yunnan. As shown in Figure 5, the study comprises 3.1 TECHNICAL SANITATION INTERVENTIONS field research on the quantitative cost-benefit estimates, as EVALUATED well as an in-depth study of the qualitative aspects of sanita- The type of sanitation evaluated in this study is household tion. Two types of field-level cost-benefit performance are human excreta management. Interventions to improve hu- presented: Output 1 reflects ideal performance assuming man excreta management in households focus on both the intervention is delivered, maintained and used appro- on-site and off-site sanitation options. One of the key aims priately, and Output 2 reflects actual performance based of this study, where possible, is to compare the relative ef- on observed levels of intervention effectiveness in the field ficiency of different sanitation technologies. Basic hygiene sites. However, both these analyses are partial, given that aspects of sanitation are also included, insofar as they affect the study excludes intangible benefits of sanitation im- health outcomes and intangible aspects. FIGURE 5: FLOW OF DATA COLLECTED (INPUTS) AND EVENTUAL COST-BENEFIT ASSESSMENTS (OUTPUTS) CHAPTER 4 Field-Level CHAPTER 7 Input 1: Monetary Benefit Estimates Ideal Cost-Benefit Output 1: Field Performance CHAPTER 7 Actual CHAPTER 5 Output 2: Cost-Benefit CHAPTER 6 Field Performance Field-Level Field-Level Program Input 4: Input 2: Monetary Cost Approach Analysis Estimates CHAPTER 4 CHAPTER 7 Intangible Overall (Non-Monetized) Input 3: Output 3: Cost-Benefit Field-Level Assessment Costs and Benefits 12 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods As well as human excreta management, interventions are bring benefits. Figure 6 presents a generalized sanitation considered that jointly address human waste with domes- ladder. The upward slope of the ladder reflects the assump- tic wastewater management (especially in urban areas) and tion of greater benefits as you climb the ladder, but (gener- with animal waste management (in the case of biogas gen- ally) with higher costs. The progression shown in Figure eration). 6 is not necessarily true in all settings and hence needs to be altered based on setting-specific features (e.g. rural or To qualify as an economic evaluation study, a cost-benefit urban, different physical/climatic environments such as soil analysis compares at least two alternative intervention op- type or water scarcity). tions. It usually includes comparison with the baseline of “do nothing.” However, comparing two sanitation options While the study proposes to conduct analyses of the costs will rarely be enough: ideally the analysis should compare and benefits of achieving the MDG targets and beyond, all sanitation options that are feasible for each setting – in sanitation options will not be restricted by “unimproved” terms of affordable, technically feasible, and culturally ac- and “improved” sanitation as defined by the WHO/UNI- ceptable options – so that a clear policy recommendation CEF JMP. For example, some households will be interested can be made based on efficiency of a range of sanitation in upgrading from one type of improved sanitation to an- options, among other factors. other type, such as from pit latrine to septic tank, or from septic tank to sewerage. Other households are faced with a Technical sanitation options include all those interventions decision whether to replace a facility that has reached the that move households up the sanitation ladder and thus end of its useful life. FIGURE 6: REPRESENTATION OF THE SANITATION “LADDER” Costs per household Pour or mechanical flush with sewerage Pour or mechanical flush with septic tank Pour or mechanical flush latrine with pit Improved dry pit latrine with appropriate excreta management or reuse Improved public or shared latrine Unimproved pit latrine Water Quality Intangibles Public or unimproved shared latrine Health Status Open defecation Access Time (to land or water) Benefits per household Cautionary note: versions and interpretations of the sanitation ladder vary. This Figure is for illustrative purposes only. www.wsp.org 13 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods Based on the ladder in Figure 6 as a starting point, a framework for interpretation of the specific options Table 2 shows different types of intervention (sub-cat- evaluated in the field settings (shown in 3.2.2), given egory) within the more broadly defined sanitation op- that option sub-categories may have different associ- tions. This classification provides an overview to allow ated costs and benefits. TABLE 2: CLASSIFICATION OF SANITATION OPTIONS AND SUB-OPTIONS Categories (JMP definition) Sub-categories 0 Open defecation 0.1 On plot or on land/in water outside plot 0.2 On plot 0.3 On land outside plot 0.4 Next to or directly in waterway/body 1 Shared/community/public latrine, 1.1 Public toilet (with community) unimproved 1.2 Shared toilet (with limited no. of other households) 2 Private latrine, unimproved 3 Shared/community/public latrine, improved 3.1 Public toilet (with community) 5 Private dry latrine, improved 5.1 Simple dry pit 5.2 Ventilated improved pit latrine (VIP) 5.3 Single vault composting toilet (UDDT) 5.4 2-3 vault composting toilet (UDDT) 6 Private wet latrine, improved 6.1 Pour-flush toilet + non-watertight pit and/or dumping of sludge and/or flow directly to waterway/body 6.2 Sealed pit with sludge removal & septage treatment facility 6.3 Biogas digester (human, animal) 6.4 Wastewater reuse (garden, domestic) 7 Private toilet, septic tank 7.1 Non-watertight septic tank and/or dumping of sludge and/or flow directly to waterway/body 7.2 Improved septic tank with sludge removal & septage treatment facility 7.3 Improved septic tank with sludge removal & sludge drying bed & constructed wetland 7.4 Improved septic tank with safe sludge use in agriculture or fish feeding 8 Private toilet, separate sewerage 1 8.1 Decentralized conventional treatment2 8.2 Decentralized natural treatment 8.3 Centralized conventional treatment2 8.4 Centralized natural treatment 8.5 Combined conventional and natural2 9 Private toilet, combined sewerage1 9.1 Decentralized conventional treatment2 9.2 Decentralized natural treatment 9.3 Centralized conventional treatment2 9.4 Centralized natural treatment 9.5 Combined conventional and natural2 1 Can be simplified or normal sewerage 2 Includes primary, secondary and tertiary treatment options 14 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods 3.2 COSTS AND BENEFITS EVALUATED stantial until a critical mass of households has im- Sanitation costs are the denominator in the calculation to proved their sanitation. These benefits may include: estimate the cost-benefit ratio and the numerator in the es- health impacts related to environmental exposure to timation of cost-effectiveness ratio. Thus costs are crucial pathogens (e.g. water sources, open defecation prac- to the evaluation of sanitation option efficiency. Summary tices on land), aesthetics of environmental quality, cost measures include the total annual and lifetime costs, and usability of local water sources for productive cost per household and cost per capita. For financing and activities. Given the challenges in designing studies planning purposes, this study disaggregates costs for each to distinguish these benefits from household direct sanitation option by capital, program and recurrent costs; benefits (in point 1.) this study groups local level ex- by financial and economic costs; by financier; and by wealth ternal benefits together with household direct ben- quintile. The incremental costs of moving up the sanitation efits. ladder are assessed. 3. Wider scale external benefits: these result from im- proved sanitation at the macro-level. Benefits may To maximize the usefulness of economic analysis for diverse include: water quality for productive uses, tourism, audiences, the benefits of improved sanitation and hygiene local business impact, and foreign direct investment. are divided into three categories: They can either be linked to coverage in specific areas 1. Household direct benefits: these are enjoyed by the or zones (e.g. tourist area or industrial zone), or the households who are making the sanitation improve- country generally (e.g. investment climate). As well ment. These actual or perceived benefits will drive as improved management of human excreta, other the decision by the household to invest in sanitation, contributors to environmental improvement such as and will also guide the type of sanitation improve- solid waste management and wastewater treatment ment chosen. These benefits may include: health im- need to be considered. While tourism and business pacts related to household sanitation and hygiene, surveys were conducted in other ESI countries in local water resource impacts, access time, intangible Southeast Asia, these surveys were not within the impacts, house prices, and the value of human ex- scope of the ESI study in Yunnan Province. creta reuse. 2. Local level external benefits: these are potentially Table 3 shows the impacts included in the current study, incurred by all households living in the environ- distinguishing between those impacts that are expressed in ment where households improve their sanitation. monetary units and those that are expressed in non-mone- However, some of these benefits may not be sub- tary units. TABLE 3: BENEFITS OF IMPROVED SANITATION INCLUDED IN THIS STUDY Socio-economic impacts evaluated in Impact Monetary terms ($ values) Non-monetary terms (non-$) Health • Health care costs • Disease and mortality rates • Health-related productivity • Quality of life impacts • Premature death • Gender impacts Domestic • Water sourcing • Link poor sanitation, water quality and water treatment practices water • Household treatment Other welfare • Time use • Convenience, comfort, privacy, status, security, gender issues Environmental • Aesthetics of household and community environment quality Output reuse • Fertilizer or biogas generated • Preferences for UDDT and biogas, and handling/reusing human excreta Key: UDDT – Urine Diversion Dehydration Toilet www.wsp.org 15 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods While the focus of this study is on household sanitation, ects, and how they perform in relation to the three criteria. the importance of institutional sanitation also needs to be The final eight sites selected are presented below. Table 4 highlighted. For example, improved school sanitation af- shows the sanitation coverage in the selected field sites com- fects decisions for children (especially girls) to start or stay pared with the national coverage. in school until the end of the secondary level, and work- place sanitation affects decisions of the workforce (espe- Site 1 (R1): The villages in Luquan County in the greater cially women) to take or continue work with a particular Kunming metropolitan area are located in a cool mountain- employer. These benefits are incremental over and above the ous area near Yunlong reservoir, the drinking water source three cited above. However, these impacts are outside the for Kunming. For protection of the reservoir, UDDTs and scope of this present study. biogas are being heavily promoted by the government. Yi and Miao are the dominant ethnic groups. Four villages The next sections describe the study methods for the three were sampled for the ESI survey, each with around 200 to major study components: the field level cost-benefit assess- 500 residents. These are poverty-stricken areas with an av- ment (3.3), and the assessment of program effectiveness erage annual income of around 1,632 yuan (US$240) per (3.4). Section 3.5 describes process aspects of the research capita, and the sanitation coverage is around 30%. such as study steering and collaboration. Site 2 (R2): Dali Shangguan is a rural site on a lakeside 3.3 FIELD STUDIES plain. Septic tanks, UDDTs and biogas are being heavily promoted by the government. Bai is the dominant ethnic 3.3.1 FIELD SITE SELECTION AND group, and the area has a total population of around 10,000 DESCRIPTION residents with an average annual income of 3,480 yuan According to good economic evaluation practice, interven- (US$510) per capita. Sanitation coverage is around 45%. tions evaluated should reflect the options faced by house- holds, communities and policy makers. Therefore, locations Site 3 (R3): The villages in Qiubei County are located in should be selected that contain a range of sanitation options mountainous areas or by the lake, which are often flooded which are typically available in Yunnan Province, covering in the rainy season. Zhuang, Miao and Yi are the domi- both urban and rural sites. By sampling a range of represen- nant ethnic groups in these villages, which have around tative locations, the study results can be generalized outside 200 to 500 residents each, with an average annual income the study settings, and hence be more useful for national, of less than 1,500 yuan (US$220) per capita. The sani- provincial and local level planning purposes. tation coverage is 46%, and four villages were sampled for the ESI survey. Unimproved shared and pit latrines The principal criterion for site selection applied in this are widely used in rural areas together with improved study is that there has been a sanitation project or program sanitation options such as biogas units, septic tanks, and implemented in the past five years, and at some level of UDDT. Open defecation in mountainous rural areas is scale that allows minimum sample sizes of 30 households still being practiced. to be collected per sanitation option per site. Once this list of projects and programs has been established, a further set Site 4 (U1): Kunming City is the provincial capital of of criteria was applied in order to reduce the short-list to Yunnan Province located in the center of the province. It eight locations or projects (based on the available budget). is characterized by a low altitude upland monsoon climate These criteria include (i) logistical feasibility for research to with scarce water resources. The total population is 3.2 mil- be conducted; (ii) potential for collaboration with project/ lion urban residents with permanent registration and 6.08 program; (iii) being representative of Yunnan in terms of million including rural residents. Han is the dominant eth- geophysical, climatic, demographic and socio-economic nic group. The annual income per capita is 16,495 yuan characteristics. Annex Table A1 shows the long list of proj- (US$2,420), and sanitation coverage is estimated at 87% 17 Data source: local statistics and Yunnan provincial sanitation survey results. 16 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods for urban areas and 60% for the overall rural17, peri-urban toilets with septic tanks and sewerage are the main sanita- and urban areas . Public and private flush toilets with septic tion options in the city. tanks and sewerage are the main sanitation options in the city. Site 6 (U3): Qiubei City, a county capital, is located in the karst region by Puzhehe Lake in southern Yunnan Province. Site 5 (U2): Dali City is a prefectural capital, located on It is characterized by a mountanious monsoon climate with the bank of Erhai Lake, west of Yunnan Province. It is flooding during the rainy season. Zhuang, Yi and Miao are characterized by a mountanious monsoon climate. Bai is the dominant ethnic groups in the city, which has a total the dominant ethnic group in the city, which has 610,000 population of less than 100,000. The average annual in- urban residents with an annual income of 14,100 yuan come is less than 3,500 yuan (US$515) per capita, and (US$2,070) per capita. Sanitation coverage in urban areas sanitation coverage is 46%. Public and private flush toilets is proximately 60%, and 45% for Dali prefecture including with septic tanks and pit latrines are the main sanitation rural and peri-urban populations. Public and private flush options in the city. TABLE 4: BACKGROUND INFORMATION ON THE EIGHT SELECTED FIELD SITES IN YUNNAN PROVINCE Dali Rural Kunming Rural Qiubei Rural Xinyi and Villages in Villages: Puzehei Kunming Qiubei Dayingcun Kunming Peri-urban Luquan County Administrative, Urban Dali Urban Urban Variable Administrative Peri-urban Zhoucheng, (Yizi,Huoqi, Xianrendong, (Kunming (Dali City) (Qiubei Villages, (Jinning) Xizhou Lianhe and Xialeshao, City) Town) Shangguan Puzhong) and Xiangshui. Town Label R1 R2 R3 U1 U2 U3 PU1 PU2 Location & setting Mountainous, Lakeshore, Lakeshore, rural Provincial Prefectural Country Small town Urbanizing rural Miao and Yi ethnic rural area, area, shallow capital – city, densely town, less Han, area, Bai ethnic groups, upstream Bai ethnic ground water densely populated densely urbanizing group, by Erhai rural area groups Zhuang, Maio populated city Tourism populated town lakeside and Yi ethnic attraction groups Bai ethnic group Baseline options OD, shared or Shared or OD, Shared Public wet or Public dry Pit latrine Pit latrine, Public dry pit, (pre-program) private pit latrine private pit or private pit dry latrine latrine, pit shared pit private pit latrine latrine latrine latrine latrine Improved UDDT, biogas Septic tank, UDDT, biogas, Private flush Public flush Flush toilet Public dry Wet latrine, options (program biogas, UDDT wet pit latrine toilet with toilet, private to septic latrine, septic septic tank intervention) septic tank to flush toilet with tank tank, UDDT sewerage septic tank to sewerage Average household 4 4 3 4 4 4 4 size PROJECT INFORMATION Start-end date 2005-2008 2005-2008 2004-2008 1995-2000 2000-2004 2002-2007 2006-2007 2005-2008 Financing agent Yunnan Forestry Yunnan EPD German Kunming Dali Tourism Qiubei Kunming Dali Tourism Department Embassy Municipal Administration County Municipal Administration Government Office Government. Government Office Implementing Yunlong Township Erhai Lake YEDI & Qiubei Urban Urban Qiubei Kunming Erhai Nature agent Government & Management EPB Construction Construction Construction EPB, Reserve Energy Extension Institute Bureau Bureau Bureau Township Management Station Government Station Start of project 21.8% 72.3% 69.1% 78.2% 66.7% 74.1% 74.3% 85.2% improved sanitation coverage (%) End of project 94.0% 75.1% 94.5% 83.0% 81.5% 77.8% 78.5% 82.5% improved sanitation coverage (%) Key: EPD – Environmental Protection Department; YEDI – Yunnan Environment Development Institute; OD - open defecation Data source: local statistics and project documents. www.wsp.org 17 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods Site 7 (PU1): Kunyang Town of Jinning County, located of impact is crucial, requiring a robust study design. Annex in the greater Kunming metropolitan area, is a small town Table A2 presents alternative study designs for conducting on the southern bank of Dianchi Lake. It has a monsoon economic evaluation studies, starting at the top with the climate. Han is the dominant population group, and the most valid scientific approaches, down to the least valid at total population is less than 50,000 residents with an aver- the bottom. Given that the most valid scientific approach age annual income of around 9,000 yuan (US$1,320) per (a randomized time-series intervention study) was not pos- capita. Sanitation coverage is estimated at around 60%. sible within the time frame and resources of this study, the Public dry latrines, septic tanks, and UDDT are all used in most valid remaining option was to construct an economic this peri-urban area. model for a cost-benefit assessment of providing sanitation interventions and of moving from one sanitation coverage Site 8 (PU2): Dali Zhoucheng is an urbanizing rural area category to the next. A range of data was used in this mod- near Dali City. It is located by Erhai Lake, with Bai as the el, reflecting both households with and without improved dominant ethnic group. The total population is around sanitation, to ensure that before and after intervention 10,000 residents with an average annual income of 5,135 scenarios were most appropriately captured. This included yuan (US$750) per capita, and sanitation coverage is capturing the current situation in each type of household around 45%. Public dry toilets, pit latrines, shared, UDDT, (e.g. health status and health seeking, water practices, time and septic tanks are all used in this peri-urban area. use), as well as understanding attitudes towards improved and unimproved sanitation, and the factors influencing 3.3.3 COST ESTIMATION METHODOLOGY sanitation decisions. These data were supplemented with This study estimates comprehensive costs of different sani- evidence from other local, national and international sur- tation options, including program management costs as veys and data sets on variables that could not be scientifi- well as on-site and off-site costs. Cost estimation was based cally captured in the field surveys (e.g. behavior and risk on information from three data sources (sanitation program factors for health assessment). or project documents, the provider or supplier of sanitation services, and the ESI household questionnaire, described in Figure 7 shows an overview of the methods for estimating 3.3.4). Data from these three sources were compiled, com- the benefits of moving up the sanitation ladder. The actual pared, adjusted, and entered into standardized cost tabula- size of the benefit will depend on the specific sub-type of tion sheets. Annual equivalent costs of different sanitation sanitation intervention implemented. options were calculated based on an annualized investment cost (taking into account the estimated length of life of The specific methods for the sanitation benefits are de- hardware and software components) and adding annual scribed below. For further details, refer to Annex Table A3. maintenance and operational costs. For data analysis and interpretation, financial costs were distinguished from non- Health: For the purposes of cost-benefit and cost-effective- financial costs, and costs were broken down by financiers. ness analysis, three types of disease burden are evaluated: Information from documents of sanitation projects and numbers of cases (incidence or prevalence), numbers of providers as well as market prices was supplemented with deaths, and disability-adjusted life-years (DALYs). Diseas- interviews with key resource people to ensure correctness of es included are all types of diarrheal disease, helminthes, interpretation, and to enable adjustment where necessary. scabies, malnutrition and diseases related to malnutrition (malaria, acute lower respiratory infection, measles) (see 3.3.4 BENEFIT ESTIMATION METHODOLOGY Annex Table A4). Health costs averted through improved To be credible to decision makers, economic evaluation of sanitation are calculated by multiplying overall health costs sanitation interventions should be based on sufficient evi- per household by the relative risk to health reduction from dence of impact, thus giving unbiased estimates of econom- improved sanitation and/or hygiene measures. Health costs ic efficiency. Hence the appropriate attribution of causality are made up of disease treatment costs, productivity losses 18 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods FIGURE 7: OVERVIEW OF METHODS FOR ESTIMATING FIELD-LEVEL BENEFITS OF IMPROVED SANITATION BENEFIT POPULATION WITH POPULATION WITH BENEFIT CATEGORY UNIMPROVED SANITATION IMPROVED SANITATION ESTIMATED Data on health risk per person, Generic risk reduction, Averted health care costs, HEALTH by age category & socioeconomic using international literature reduced productivity loss, status reduce deaths Data on water source and Observed changes Reduced water sourcing WATER treatment practices in practices in populations and water treatment costs with improved sanitation Data on time to access toilet Observed reductions in time Opportunity cost of time ACCESS TIME per person per day to access toilet applied to time gains Attitudes and preferences Benefits cited of improved Strength of preferences for INTANGIBLES of householders to sanitation sanitation different sanitation aspects and willingness to pay Practices related Value gained, based on REUSE to excreta reuse sales or own use and premature mortality losses. For a cost-effectiveness patient travel and sundry costs are applied based on analysis, DALYs are calculated by combining the morbid- treatment seeking. ity element (made up of disease rate, disability weight and • Health-related productivity costs are calculated by illness duration) and the mortality element (mortality rate applying time off work or school to the disease rates, and life expectancy). Standard weights and disease duration per population age group. The economic cost of time are sourced from the Global Burden of Disease study, and lost due to illness reflects an opportunity cost of time average life expectancy at birth for China of 62 years is used or an actual financial loss for adults with paid work. (WHO, 2000). The unit cost values are based on the average income rates per location. For adults a rate of 30% of the • Rates of morbidity and mortality are sourced from average income is applied, reflecting a conservative various data sets for three age groups (0-4 years, 5-14 estimate of the value of time lost. For children 5-14 years, 15+ years), and compared and adjusted to re- years, sick time reflects lost time at school that has an flect local variations in those rates. National disease opportunity cost, valued at 15% of the average in- and mortality rates were adjusted to rates used for the come. For children under five, the time of the child field sites based on socio-economic characteristics of carer is applied at 15% of the average income. Values sampled populations. As not all fecal-oral diseases are provided in Table 5. have a pathway from human excreta, an attribution • Premature death costs are calculated by multiply- fraction of 0.88 is applied for these diseases. Meth- ing the mortality rate by the unit value of a death. ods for the estimation of disease and mortality rates Although premature death imposes many costs on from indirect diseases via malnutrition are provided societies, it is difficult to value precisely. The method in the ESI Impact Study report (Hutton et al 2008). employed by this study – the human capital ap- • Health care costs are calculated by applying treat- proach (HCA) – approximates economic loss by es- ment seeking rates for different health care providers timating the future discounted income stream from to the disease rates, per population age group. The a productive person, from the time of death until the calculations also take into account hospital admis- end of (what would have been) their productive life. sion rates for severe cases. Unit costs of services and In a sensitivity analysis, the value-of-statistical-life www.wsp.org 19 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods (VOSL)18 was estimated by adjusting by difference tation alone (50%), basic sanitation with hygiene in GDP per capita levels to China from developed (70%), basic sanitation + wastewater management country studies. Values are provided in Table 5. (80%), basic sanitation + wastewater management • Risk reductions of illness and death associated with with hygiene (100%). improved sanitation and hygiene interventions are assessed from the international literature, and are ap- Water: While water has many uses at the community level plied and adjusted to reflect risk reduction in local as well as for larger-scale productive purposes (e.g. industry), settings based on baseline health risks and interven- the focus of the field study is use for domestic purposes, in tions applied. Risk reductions depended on whether particular drinking water. The most specific link between the intervention provided a safe place to defecate poor management of human excreta and water quality is without full isolation or treatment (basic sanitation), the safety aspect, which causes communities to take mitiga- or whether a high degree of isolation and/or treat- tive actions to avoid consuming unsafe water. These include ment was achieved (basic sanitation + wastewater reducing reliance on surface water and greater use of wells management). The reductions in diarrheal disease, or treated piped water supply. It even involves the need to other fecal-oral diseases and diseases related to result- rely less on shallow dug wells, which are more easily con- ing malnutrition are as follows: basic sanitation alone taminated with pathogens, and to drill deeper wells. Water (36%19), basic sanitation with hygiene (50%20), ba- sources that communities traditionally relied on for their sic sanitation + wastewater management (56%21), other domestic needs (such as cooking, washing, shower- and basic sanitation + wastewater management with ing) are changed in favor of cleaner, but more expensive, hygiene (65%22). For soil-transmitted helminthes, water sources. Water quality measurement is conducted as fewer primary studies were available to estimate risk part of this study in representative locations in Qiubei field reductions; the following was assumed: basic sani- site, to enable a detailed analysis of the impacts of improved TABLE 5: AVERAGE UNIT VALUES FOR ECONOMIC COST OF TIME PER DAY AND OF LOSS OF LIFE (US$, 2009) Daily value of time Value of life Technique 0-4 years 5-14 years 15+ years 0-4 years 5-14 years 15+ years RURAL SITES Human capital approach1 1.77 1.77 3.54 21,376 33,453 35,058 VOSL2 123,999 123,999 123,999 URBAN SITES Human capital approach1 1.87 1.87 3.73 22,546 35,285 36,977 VOSL 2 130,789 130,789 130,789 1 2% real GDP or wage growth per year, discount rate = 8% 2 The VOSL of US$2 million is transferred to the study countries by adjusting downwards by the ratio of GDP per capita in each country to GDP per capita in the USA. The calculation is made using official exchange rates, assuming an income elasticity of 1.0. Direct exchange from higher to lower income countries implies an income elasticity assumption of 1.0, which may not be true in practice. 18 VOSL studies attempt to value what individuals are willing to pay to reduce the risk of death (e.g. safety measures) or willing to accept for an increase in the risk of death. These values are extracted either from observations of actual market and individual behavior (“hedonic pricing”) or from what individuals stated in relation to their preferences from interviews or written tests (“contingent valuation”). Both these approaches estimate directly the willingness to pay of individuals, or society, for a reduction in the risk of death, and hence are more closely associated with actual welfare loss compared with the HCA. 19 Thirty-six percent reflects the average of Waddington 2009, Fewtrell 2005, Esrey 1991 and Esrey 1996. 20 Fifty percent reflects the sanitation interventions alone of 36% plus 14% add-on for hygiene. 21 Fifty-six percent reflects the average for the two Brazilian studies which found a 43% and 69% risk reduction for high risk populations, and also is close to the 57% which is the half way risk reduction from scenario IV (or Vb) to scenario II (Prüss, 2002) 22 Sixty-five percent reflects a 56% reduction from sanitation plus hygiene add-on which brings a 9% marginal impact. 20 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods sanitation on local water quality (see Annex Table A5). This as children, men, women, and the elderly all have different study measures the actual or potential economic impacts of sanitation preferences and practices. Therefore, this study improving sanitation on two sets of mitigation measures: calculates the time savings for different population groups of improving sanitation, based on observations of house- • Accessing water from the source. Because households holds both with and without improved sanitation. The val- pay more or walk further to access water from clean- ue of time is based on the same values as health-related time er sources such as drilled wells, or they pay more for savings (see above). piped water, it would in theory reduce these costs if sanitation was improved. For example, traditionally Excreta reuse: Human excreta, if handled properly, can be people prefer the taste of water from shallow wells to a safe source of fertilizer, wastewater for irrigation or aqua- deeper wells, and hence would likely return to the culture, or biogas. In four of the eight sites (three rural and use of shallow wells if they could guarantee cleaner, one peri-urban), UDDTs have been provided, and biogas safer water. Also, providers of piped water have to units were evaluated in three sites (all rural). The value of treat water less if it is less contaminated, thus saving excreta reuse is measured through the assessment of the costs. Hence, expected percentage cost reductions nonmarket value (when used by the household, given that are applied to current costs of clean water access to the by-products are rarely sold or traded in the field sites). estimate cost savings from improved sanitation. This enables calculation of an average value per household • Household treatment of water. Traditionally, in Chi- practicing human excreta reuse. In the case of combined na many households treat their water due to con- human and animal excreta reuse (as with biogas), both the cerns about safety and appearance. This is common- full cost and benefit of the biogas digester are included. ly true even for piped, treated water supplies. Boiling is the most popular method because it is perceived to Intangibles: Intangibles are major determinants of per- guarantee water to be safe for drinking, and it is used sonal and community welfare such as comfort, privacy, for making tea. However, boiling water can require convenience, safety, status and prestige. Due to their often considerable cash outlays or it consumes their time very private nature, intangibles are difficult to elicit reliable for collecting fuel. Furthermore, boiling water for responses from individuals, and some may vary consider- drinking purposes is more costly to the environment ably from one individual and social group to another. In- due to the use of wood, charcoal or electricity, with tangibles are therefore difficult to quantify and summarize correspondingly higher carbon dioxide (CO2) emis- from a population perspective, and are even more diffi- sions than other treatment methods. If sanitation cult to value in monetary terms for a cost-benefit analy- is improved and the pathogens in the environment sis. Economic tools do exist for a quantitative assessment reduced to low levels, then households would feel of intangible benefits such as contingent valuation method, more ready to use a simple and less costly household and willingness to pay surveys are commonly used to value treatment method such as filtration or chlorination. environmental goods. However, there are many challenges Hence, based on observations and expected future to the application of these methods in field settings which household treatment practices under a situation of affect their reliability and validity, and ultimately appro- improved sanitation, the cost savings associated with priate interpretation of quantitative results. Furthermore, alternative water treatment practices are calculated. willingness to pay often captures more than just the intan- gible variables being examined, but also will capture pref- Access time: When households have their own private la- erences that have been valued elsewhere (e.g. health and trine, many of them will save time every day, compared to water benefits). This current study therefore attempts only the alternative of going to the bush or using a shared fa- to understand and measure sanitation knowledge, practices cility. The time used for each sanitation option will vary and preferences in terms of ranking scales, on a simple scor- from household to household, and from person to person, ing system of key characteristics between 1 (very poor) and www.wsp.org 21 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods 5 (very good), sourced from household surveys and focus of interview), while the second was a shorter observational group discussions. This enables a separate set of results to be component covering physical water, sanitation and hygiene provided alongside the monetary-based efficiency measures. features of the household. The oral interview consisted of questions on: External environment: Likewise, the impacts of poor • Socio-economic and demographic information, and sanitation practices on the external environment are also household features difficult to quantify in monetary terms. Hence, this study • Current and past household sanitation options and attempts only to understand and measure practices and practices, and mode of receipt preferences in relation to the broader environment, in terms • Perceived benefits of sanitation, and preferences re- of ranking scales (see description in above paragraph). Giv- lated to the external environment en human-related sanitation is only one of several factors • Household water supply sources, treatment and stor- in environmental quality, other aspects – sources of water age practices pollution, solid waste management, and animal waste – are • Health events and health treatment seeking also addressed to understand human excreta management • Hygiene practices within the overall picture of environmental quality. • Household solid waste practices 3.3.4 DATA SOURCES The household questionnaire was applied to a total of 909 Given the range of costs and benefits estimated in this study, households over the eight sites, or roughly 114 households different data sources were identified including survey evi- per site. In most locations, control sites were also estab- dence from the field sites collected within the ESI study as lished for comparison with project intervention sites. An- well as evidence from other databases or studies. Due to nex Table A6 presents the sample sizes per sanitation option certain limitations of the field study, elements of some ben- and per field site. The sample size has a minimum of 30 efits needed to be sourced from other more reliable sources. households for each sanitation option, and there are a total Routinely collected data such as the health information sys- of eight sanitation options across all field sites. Considering tem are often of poor quality and incomplete, and hence the comparison of the same sanitation option among dif- were supplemented with evidence provided byWHO. ferent sites, around 110 samples for each sanitation option are needed for the calculations. The option of “no sanita- Data collection in field sites was conducted from 26 May to tion” (open defecation) served as the control for each of the 28 June in 2009 in the eight sites. Sixteen graduate students sanitation options – i.e. enabling comparison of indicators, under the direction of three researchers from Yunnan Acad- conditions and preferences between with versus without emy of Social Sciences (YASS) formed the team. A training sanitation scenarios. This sample was gathered from the workshop on the questionnaire and household interviews field sites by calling a meeting of local community organiza- was held for the interviewers, and field testing was conduct- tions and interviewing them individually. In both rural and ed in Kunming. The research team benefited from the for- urban areas, conducting face-to-face interviews was found mer contacts and relationships with most of the sanitation to be challenging. In rural areas, heads of households were projects in Yunnan, and the Yunnan Environmental Protec- often hard to find or unavailable during the daytime, and tion Department played an important role in coordinating in urban areas, some households refused to participate due with sanitation projects at different levels for the study. to mistrust of strangers. The contents of the field tools used are briefly introduced Field tool 2: Focus group discussion. The purpose of the below. focus group discussion (FGD) was to elicit behavior and preferences in relation to water, sanitation and hygiene from Field tool 1: Household questionnaire. Household ques- different population groups, with the main distinctions by tionnaires consisted of two main parts: the first was asked sanitation coverage (with versus without) and gender (male to household representatives (the senior male and/or fe- and female). The topics covered in the FGDs followed a ge- male household member, based on availability at the time neric template of discussion topics, but the depth of discus- 22 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods sion was dictated by the readiness of the participants to dis- the type of test and location per parameter, and the num- cuss the topics. The added advantage of the FGD approach ber and type of water sources tested. Parameters measured is to discuss aspects of sanitation and hygiene that may not varied per water source, but generally included biological otherwise be revealed by face-to-face household interviews, oxygen demand (BOD), chemical oxygen demand (COD), and to either arrive at a consensus or otherwise to reflect dissolved oxygen (DO), E.coli (Escherichiacoli), Total Co- the diversity of opinions and preferences for sanitation and liform, pH, turbidity, NH3-N (Ammonia-nitrogen), TN hygiene among the population. Annex Table A7 shows the (Total Nitrogen) and TP (Total Phosphorus). number of FGDs held per group per location – with a total of 190 participants distributed across 24 FGDs. Each FGD Field tool 5: Market survey. For economic evaluation, local took approximately one hour. prices are required to value the impacts of improved sani- tation and hygiene. Selected resource prices, and in some Field tool 3: Physical location survey. A survey of the phys- cases resource quantities, were recorded from the most ap- ical environment was conducted in 14 field locations across propriate local source: labor prices (average wage, mini- eight sites. The main purpose was to identify important mum wage) and employment rate, water prices by differ- variables in relation to water, sanitation and hygiene in the ent sources, water treatment filters, fuel prices, sanitation general environment, covering land use, water sources, and improvement costs, soap costs, fertilizer costs (when excreta environmental quality. This information was triangulated is used for fertilizer) and pharmacy drug costs. with the household surveys and FGDs, as well as the water quality measurement survey, to enable appropriate conclu- Field tool 6: Health facility survey. Given the importance sions about the extent of poor sanitation and links to other of health impacts, a separate survey was conducted in two impact variables. This survey was conducted by an envi- to three health facilities serving each field site. Variables col- ronmental engineer from the Yunnan Environment Science lected included numbers of patients with different types of Institute. water-related disease, and the types and cost of treatment provided by the facility. Data were supplemented by those Field tool 4: Water quality measurement. Given that one of collected or compiled at higher levels of the health system, the major impacts of poor sanitation is the impact on sur- such as the district or provincial levels. face and ground water quality, special attention was paid in this study to identify the relationship between the type and Other data sources: As well as collection of data from coverage of toilets in the selected field sites, and the quality field sites, data and information were collected from other of local water bodies. Due to the time frame of the present sources to support the field-level cost-benefit study, such as study, it was not possible to measure water quality variables reports, interviews, and data sets. These include: before the project or program was implemented; neither • China Health Yearbook 2009 was it possible to compare wet season and dry season mea- • Published papers in journals. surements. For reasons of cost and lack of available labora- tories, water testing was only conducted in the sites of Qiu- 3.3.5 DATA ANALYSIS bei City and Qiubei Rural. The water quality measurement The types of costs and benefits included in the study are survey was contracted to Wenshan Prefectural Hydrological listed in Section 3.2. This section describes how costs, ben- Laboratory and carried out in July 2009. The study enabled efits and other relevant data are analyzed to arrive at overall the assessment of the impact of specific local sanitation estimates of cost-benefits. features on water quality. It also enabled a broader com- parison of water quality between study sites with different The field-level cost-benefit analysis generates a set of ef- sanitation coverage levels. Water sources tested in both sites ficiency measures from site-specific field studies, focusing included ground water (dug shallow wells, deeper drilled on actual implemented sanitation improvements, includ- wells), standing water (ponds, lakes, canals), and flowing ing household and community costs and benefits. The costs water (rivers, wastewater channels). Annex Table A5 shows and benefits are estimated in economic terms for a 20-year www.wsp.org 23 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods period for each field site, using average values based on the 3.4 PROGRAM APPROACH ANALYSIS field surveys and supplemented with other data or assump- The aim of the program approach analysis (PAA) is to show tions. Five major efficiency measures are presented: the levels and determinants of performance of sanitation programs. It evaluates the link between different program 1. The benefit-cost ratio (BCR) is the present value of approaches and the eventual efficiency and impact of the the future benefits divided by the present value of sanitation interventions. It is also used as the basis for ad- the future costs, for a 20-year period. Future costs justing ideal intervention efficiency to estimate actual in- and benefits (i.e. beyond year one) are discounted to tervention efficiency. The PAA also shows current practices present a value using a discount rate of 8% (sensitiv- in relation to sanitation program evaluation, and provides ity analysis: low 3%, high 10%). recommendations for improved monitoring and evaluation 2. The cost-effectiveness ratio (CER) is the present of sanitation programs. value of the future health benefits in non-monetary units (cases, deaths, disability-adjusted life-years) di- The PAA is essentially a desk study assessment of sanitation vided by the present value of the future costs, for a program documents, with additional information gained 20-year period. Future costs and health benefits (i.e. through interviews with sanitation program managers and beyond year one) are discounted to present a value implementers. More in-depth studies and data were pos- using a discount rate (see above). sible using the field sites for the cost-benefit analysis (see 3. The internal rate of return (IRR) is the discount rate Section 3.3). The PAA has four main steps: at which the present value equals zero – that is, the 1. Listing of in-country sanitation programs and their costs equal the benefits – for a 20-year period. characteristics, followed by a selection of sanitation 4. The payback period (PBP) is the time after which programs to include in the PAA. Chapter 7.2 shows benefits have been paid back, assuming initial costs the selected programs and their main characteristics. exceed benefits (due to capital cost) and over time 2. Assessment of specific types of program “approach” benefits exceed costs, thus leading to a point that is to be compared. The supply-driven approach, stra- break even. tegic planning approach and demand-led approach 5. The net present value (NPV) is the net discounted are compared in the study in order to identify the benefits minus the net discounted costs. effectiveness of the different program approaches. 3. Evaluation of selected sanitation programs in terms Results are presented by field site and for each sanitation of their programming approach and measures of out- improvement option compared with no sanitation option put and success (e.g. unit costs, coverage, uptake). (i.e. open defecation). Also, selected steps up the sanitation For the assessment of actual efficiency, key indicators ladder are presented, such as from shared latrine to private of program effectiveness are selected. latrine, from dry pit latrine to wet pit latrine, or from wet 4. Analysis of factors determining program perfor- pit latrine to sewerage. The efficiency ratios are presented mance, focusing on economic variables. both under conditions of well-delivered sanitation pro- grams which lead to well-functioning sustainable sanitation The PAA is constrained by a lack of data on inputs, outputs systems, as well as sanitation systems and practices under and outcomes available from programs evaluated, which actual conditions, observed from the program approach limits the number of programs that could be included in analysis (Section 3.4). Given that not all sanitation benefits the study. The results of the analysis are interpreted taking have been valued in monetary units, these benefits are de- into account setting-specific conditions which are partially scribed and presented in non-monetary units alongside the responsible for the performance results; hence findings are efficiency measures. not definitive, but instead illustrative and instructive. 24 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Methods 3.5 STEERING AND COLLABORATION Involving sector stakeholders is important in evaluating The multi-sectoral focus, innovative methods and skill alternative policy options from an early stage. The joint mix required made this research study very challenging. evaluation with the sector stakeholders on the policies and The overall management structure includes four levels: co- implementation mechanisms has consolidated the study re- ordination support by the Yunnan Environmental Protec- sult, and promoted the awareness among sector stakehold- tion Department (YEPD), organization and implementa- ers on the importance of public investment in sanitation tion by YASS, collaboration with and among the sectors as well as the need for efficiency improvement. YEPD also of the governments as stakeholders of the study, and the played an important role in selecting field sites. The Hu- internal coordination of the research team (see Figure 8). man and Environmental Action Research Office at YASS YEPD coordinated multi-sectoral collaboration among the played a leading role in the formulation of study outputs. different governmental agencies, and was responsible for The role of YEPD was to coordinate inputs from the differ- disseminating the study results. Through formal consulta- ent government agencies. Workshops were held to conduct tions to different agencies, YEPD helped contribute to the joint discussions and to share field study results with the research design, provide data, and interpret and use the stakeholders, producing policy recommendations to the study results. governments. FIGURE 8: DIAGRAM OF COLLABORATION OF ESI TEAM WITH STAKEHOLDER AGENCIES IN YUNNAN, CHINA Yunnan Environment Protection Department Poverty Alleviation Office Yunnan Institute of Environment Sciences Yunnan Water Resources Department Academy of Social Science Study Team Rural Energy Office, Forestry Bureau Yunnan Patriotic Health Campaign Committee, Health Bureau Kunming Urban Construction Bureau Kunming Institute for Environment Sciences Women’s Federation of Yunnan Province For direct relationship For parallel relationship www.wsp.org 25 IV. Local Benefits of Improved Sanitation and Hygiene This chapter presents the following community- and house- Five million people can avoid trachoma, 200 million can hold-level impacts of improved sanitation and hygiene: avoid schistosomiasis infection, and malaria incidence can be reduced by 40%24. • Health (Section 4.1) • Water (Section 4.2) In China, there are more than 50 diseases related to unsafe • Access time (Section 4.3) drinking water, and the rural residents are more prone than • Reuse of human excreta (Section 4.4) urban residents to these diseases due to the poorer quality • Intangibles Sanitation Preferences (Section 4.5) of drinking water and inadequate sanitation and hygiene25. • External environment (Section 4.6) In general, the incidence of these diseases is lower in China in comparison with other developing countries in Asia. Ac- 4.1 HEALTH cording to the available data, 1.5% of deaths and 3% of disease burden (including diarrhea, Hepatitis A, Hepatitis 4.1.1 DISEASE BURDEN OF POOR SANITATION E, trachoma, and Helminthes) were directly related to poor AND HYGIENE water supply and sanitation in 199026. According to the WHO, water, sanitation and hygiene- related diseases lead to more than five million premature Annually, in rural sites, it is estimated that there are 1.9 deaths globally every year. Fecal-oral diseases are one major cases of disease per person, 16 DALYs per 1,000 popula- set of water-related disease, and intestinal nematodes (or tion and an annual risk of death of 0.92 per 1,000 people helminthes) are another. It is increasingly recognized that due to poor sanitation and hygiene (see Table 6). In urban these water-related diseases are a major cause of malnutri- areas the rates are lower, at 1.4 cases of disease per person, tion worldwide, being responsible for 50% of malnutrition 13 DALYs per 1,000 people, and an annual risk of death (WHO), which leads to a higher incidence or fatality rate of of 0.67 in 1,000 people. In peri-urban areas, the rate is 1.5 diseases which are not traditionally linked to fecal-oral dis- cases of disease per person, 12 DALYs per 1,000 people, ease. According to WHO 88% of diarrhea incidence is due and an annual risk of death of 0.69 per 1,000 people. Site- to unsafe drinking water, poor hygiene practice and sanita- specific rates used are in Annex Table B1. tion facilities, causing one and a half million annual deaths globally. The number of children dying before their fifth To some extent, quality of life impacts associated with mor- birthday is 860,000 every year globally. It is estimated that bidity are reflected in the DALY calculations above27, and in approximately two billion people suffer from helminthes the estimates of health care and productivity costs (see later including schistosomiasis, ascariasis and ancylostomiasis. sections). These diseases affect people’s health, and cause Twenty-five million people are seriously disabled due to pain and mental suffering. Some patients lose their ability lymphatic filariasis (LF), and two thirds of LF cases are due to work, have to borrow money to pay treatment costs, and to a lack of safe water, improved sanitation and hygiene23. risk falling into the poverty trap. Some infectious diseases 23 http://www.un.org/chinese/News/fullstorynews.asp?newsID=10025 24 http://www.yigan1.com/ygzz/ygzz_20090427095132.html 25 http://news.xinhuanet.com/politics/2006-09/04/content_5046923.htm 26 http://www.stuln.com/huanbaozhichuang/hbjy/hbgs/2009-3-13/Article_29681.shtml 27 DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for incident cases of the health condition. 26 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 6: ANNUAL DISEASE MORBIDITY AND MORTALITY ATTRIBUTABLE TO POOR SANITATION AND HYGIENE, 2008 Rural Urban Peri-urban Disease Cases/ Mortality/ DALYs/ Cases/ Mortality/ DALYs/ Cases/ Mortality/ DALYs/ person 1,000 pop. 1,000 pop. person 1,000 pop. 1,000 pop. person 1,000 pop. 1,000 pop. Mild diarrhea 0.767 0.01 1.1 1.033 0.01 1.5 0.800 0.01 1. 2 Severe diarrhea 0.133 0.13 2.2 0.200 0.20 3.3 0.150 0.15 2.4 Helminthes 0.373 0.37 6.6 0.387 0.39 6.4 0.360 0.36 5.9 Scabies 0.001 0.00 0.01 0.001 0.00 0.01 0.001 0.00 0.01 Trachoma 0.100 0.10 1.1 0.100 0.10 1.1 0.100 0.10 1. 1 Hepatitis A,E 0.001 0.00 0.6 0.001 0.00 0.6 0.001 0.00 0.6. Malnutrition 0.010 0.01 0.1 0.010 0.01 0.1 0.010 0.01 0.1 Malaria 0.002 0.00 0. 0.100 0.10 1. 3 0.001 0.00 0.01 ALRI 0.040 0.03 1.4 0.100 0.10 1.4 0.050 0.05 0.7 Measles - 0.01 0.1 - 0.01 0.1 - 0.01 0.1 Other indirect - 0.01 0. 1 - 0.01 0.1 - 0.01 0.1 Total 1.427 0.67 13.2 1.932 0.92 16.8 1.473 0.69 12.2 Data source: ESI and World Bank, see Annex table B1, B2 and B3. Pop - population can be transmitted to animal stocks, which when affected FIGURE 9: COMPARISON BETWEEN STUDY SITES OF can risk household income and social stability. Households DIARRHEAL DISEASE INCIDENCE FOR UNDER FIVES, 2008 therefore take disease preventive measures they know about. For example, the survey found that 95% of the respondents boil water for drinking and clean containers to feed infants. 1.2 Figure 9 shows that the rate of diarrheal incidence in rural areas is the highest. 1.0 4.1.2 HEALTH CARE COST Health care costs are estimated based on disease cases, the diarrhea incidence proportion of illnesses treated by each provider, and the 0.8 unit costs associated with each provider. Table 7 shows a summary of treatment seeking rates from different data sources. The evidence from both the ESI survey and the 0.6 Health Statistic Yearbook suggests that the majority of the population seeks care from public providers and private for- 0.4 mal clinics. However, in some cases they differ since the data from the Yearbook is province-wide, while ESI data draw on the surveys of the field sites. For instance, the ESI 0.2 survey shows that 10% of patients choose pharmacies, in comparison to 1% from the Health Statistic Yearbook. In these cases, the Yearbook’s statistics were used as the source 0.0 of data for treatment seeking, given they better reflect the province-wide situation. The tables in Annex Table B7 show severe diarrhea mild diarrhea treatment seeking behavior for other diseases. Data Source: ESI. See health data sets and Annex Table B1 www.wsp.org 27 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 7: FIRST HEALTH PROVIDER VISITED FOR TREATMENT, FOR SELECTED DISEASES (ALL AGE GROUPS) % seeking treatment from No Data source Obs. Public Private Informal Pharmacy Self- Total treatment provider formal clinic care treatment RURAL AREAS ESI sites (diarrheal disease only)1 215 20 30 20 20 9 1 100 Yunnan Province (all diseases) 2 - 41 30 10 10 9 1 100 URBAN AREAS ESI sites (diarrheal disease only)1 185 40 10 20 10 20 0 100 Yunnan Province (all diseases) 2 - 49 17 16 1 15 2 100 PERI-URBAN AREAS ESI sites (diarrheal disease only)1 150 38 12 20 10 20 0 100 Data source: 1ESI survey (2009) and 2China Health Statistic Yearbook (2009). Obs. - observations TABLE 8: UNIT COSTS ASSOCIATED WITH TREATMENT OF SEVERE DIARRHEA (US$, 2009) Outpatient cost Inpatient cost Health provider Health care Incidentals 1 ALOS 2 Health care (per day) Incidentals1 (per case) PUBLIC/NGO Rural 15.62 0.29 0.44 34.11 5.86 Peri-urban 15.62 0.73 0.44 39.23 4.68 Urban 15.62 0.73 0.44 39.23 2.93 PRIVATE FORMAL Rural 7.76 0.29 0.44 23.42 4.39 Peri-urban 11.71 0.73 0.44 26.35 2.93 Urban 13.61 0.73 0.44 26.35 2.20 PHARMACY Rural 4.39 0.73 - - - Peri-urban 4.39 0.59 - - - Urban 4.39 0.29 - - - 1 Incidentals: non-health patient costs such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay; ALOS: average length of 2 stay; 3Inpatient health care costs are presented per stay Data source:“2009 China Health Statistic Yearbook,” and supplemented by interviews with doctors and patients, and annex table B8, B9 and B10. Table 7 shows that there are disparities between the ESI sur- from rural areas are much more likely to seek treatment vey and the 2009 Health Statistic Yearbook. The proportion from private clinics and other informal types of treatment seeking treatment from public providers in rural areas from than people from urban and peri-urban areas. In particular, ESI is much less than that from the Health Statistic Year- the rural population will not go to public health providers book. However, the rate of the ESI survey is much higher for inpatient treatment until the diseases get severe. Accord- than that of the 2009 China Health Statistic Yearbook for ing to the ESI survey, 20% of the rural population choose seeking treatment from informal care, pharmacies and self public providers, which is half that of urban populations treatment. In this study, the treatment seeking rate is from (40%). This is due to travel costs, proximity of public hos- the 2009 China Health Statistic Yearbook, as the field sur- pitals, and cost of treatment. Thirty percent of the rural vey data are not sufficient for other diseases except diar- population chooses private formal clinics for treatment, rhea. It is illustrated by a statistical analysis that the differ- 20% informal care and 9% self-treatment. Twenty percent ence between the rural population and urban population in of the urban population choose self-treatment. The average treatment seeking behavior is significant (P<0.001). People rate of inpatient care is around 1% of the sick persons when 28 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene their conditions reach severe stages, according to the 2009 for different providers correspond with treatment seeking China Health Statistic Yearbook. behavior. For the same disease, the pharmacy cost is similar. But for different diseases, the pharmacy cost varies a lot, as Unit costs for treatment of severe diarrheal disease are pro- some of the diseases have a long duration. For example, the vided in Table 8 by health care providers. Health care costs pharmacy cost of treating Hepatitis is around US$500. for public providers of outpatient care have little difference among the different sites, but formal treatment costs vary Annual costs per person vary by age group, and are esti- among urban, peri-urban and rural areas. Private formal mated to range from US$22 to US$52 in rural areas, from treatment in urban areas is the most expensive, followed by US$17 to US$39 in urban areas and US$14 to US$37 in peri-urban areas and rural areas. Health care costs for public peri-urban areas. On average, the cost per person is highest providers are more expensive than private formal treatment, in rural areas, and among the under-five age group. Inter- partly explaining why the rural population often opts for estingly, one of the most expensive diseases is ALRI – which private treatment first. The incidental costs vary between is an indirect disease whose risks are increased through mal- locations, as the transportation in urban and peri-urban ar- nutrition, but whose unit costs of treatment are higher than eas is more convenient and cheaper. The health care costs the direct and more common diarrheal disease. TABLE 9: ANNUAL COSTS PER PERSON (BY AGE GROUP) ATTRIBUTED TO POOR SANITATION AND HYGIENE IN YUNNAN (US$, 2009) Rural Urban Peri-urban Disease 0-4 yrs 5-14 yrs 15+ yrs 0-4 yrs 5-14 yrs 15+ yrs 0-4 yrs 5-14 yrs 15+ yrs Diarrheal disease mild 13.17 8.91 6.74 9.45 8.49 5.44 8.42 4.63 3.74 Diarrheal disease severe 8.51 6.58 2.33 8.16 5.59 1.72 6.46 4.83 2.41 Helminthes 5.64 6.77 4.37 5.69 6.79 5.38 3.90 4.68 2.96 Hepatitis A, E 0.42 0.34 0.34 0.45 0.36 0.36 0.29 0.29 0.29 Scabies 0.72 0.84 0.84 0.71 0.85 0.85 0.48 0.48 0.48 Trachoma 0.01 0.01 0.01 0.01 0.01 0.01 0.00 0.00 0.00 Malnutrition 2.93 0.72 0.36 2.99 0.71 0.36 1.92 0.55 0.27 Malaria 2.83 1.16 1.16 0.84 0.06 0.02 1.74 0.36 0.35 ALRI 18.13 9.46 5.66 10.68 4.99 2.62 13.33 6.54 3.27 Total 52.37 34.80 21.80 38.99 27.85 16.76 36.55 22.37 13.78 Data source: health data sheets of rural, peri-urban and urban areas of ESI. TABLE 10: AVERAGE PRODUCTIVITY COST PER PERSON PER YEAR IN FIELD SITES, BY DISEASE, AGE GROUP AND RURAL/ URBAN LOCATION (US$, 2009) Rural Urban Peri-urban Disease 0-4 yrs 5-14 yrs 15+ yrs 0-4 yrs 5-14 yrs 15+ yrs 0-4 yrs 5-14 yrs 15+ yrs Diarrheal disease mild 8.72 4.93 7.25 6.50 4.44 5.61 5.03 2.75 3.85 Diarrheal disease severe 3.82 2.94 2.01 3.49 2.34 1.44 1.98 1.44 1.09 Helminthes 3.54 4.24 5.46 3.45 4.11 6.38 2.39 2.87 3.44 Hepatitis A, E 0.02 0.03 0.06 0.02 0.03 0.06 0.01 0.02 0.04 Scabies 0.71 0.71 1.41 0.75 0.75 1.49 0.48 0.48 0.96 Trachoma 0.01 0.01 0.01 0.01 0.01 0.01 0.00 0.00 0.01 Malnutrition 0.50 0.14 0.14 0.52 0.15 0.15 0.33 0.10 0.10 Malaria 2.16 0.81 1.63 0.69 0.04 0.03 0.84 0.03 0.01 ALRI 10.93 6.02 7.29 5.57 2.85 2.96 6.22 2.46 2.46 Total 30.39 19.83 25.26 20.99 14.71 18.14 17.29 10.14 11.96 www.wsp.org 29 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene 4.1.3 HEALTH-RELATED PRODUCTIVITY COST 4.1.4 PREMATURE MORTALITY COST Table 10 shows average productivity cost per person Table 11 shows the average mortality cost per person per year, per year in the field sites, by disease, age group and calculated as the annual risk of mortality per field location locations. The value is calculated based on disease in- and age group multiplied by the estimated value of life. The cidence (disease cases per person per year), time off average value varies significantly across age groups, with chil- productive activity due to disease, and opportunity dren under five having the highest premature mortality cost. cost of time. The result shows that productivity lost Diarrheal disease and helminthes have the highest premature of rural populations due to the disease is the highest mortality cost. For a total value of the premature mortality followed by peri-urban populations. Figure 10 shows cost caused by the diseases, the 0-4 age group in rural areas that productivity costs of ALRI and diarrheal disease has the highest average mortality cost per person per year at are similar. US$280, urban areas have a lower cost at US$254, and peri- urban areas at US$166. FIGURE 10: COMPARISON OF THE PRODUCTIVITY COST BETWEEN STUDY SITES OF ALRI AND DIARRHEAL DISEASE, 2009 0 - 4 years 5 - 14 years Rural 15+ years 0 - 4 years Urban 5 - 14 years 15+ years 0 - 4 years Peri-urban 5 - 14 years 15+ years 0 3 6 9 12 15 diarrheal disease ALRI US$ per household per year Data source: see Table 11 30 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 11: AVERAGE MORTALITY COST PER PERSON PER YEAR IN FIELD SITES, BY DISEASE, AGE GROUP AND RURAL/URBAN LOCATION (US$, 2009) Rural Urban Peri-urban Disease 0-4 yrs 5-14 yrs 15+ yrs 0-4 yrs 5-14 yrs 15+ yrs 0-4 yrs 5-14 yrs 15+ yrs Diarrheal disease mild 57.93 0.79 0.79 61.11 0.83 0.83 39.18 0.53 0.53 Diarrheal disease severe 89.16 68.75 23.47 81.47 54.69 16.77 46.32 33.55 12.77 Helminthes 62.00 74.40 47.85 60.39 71.97 48.56 41.93 50.32 30.19 Hepatitis A, E 0.12 0.12 0.12 0.13 0.13 0.13 0.08 0.08 0.08 Scabies 12.40 12.40 12.40 13.08 13.08 13.08 8.39 8.39 8.39 Trachoma 0.12 0.12 0.12 0.13 0.13 0.13 0.08 0.08 0.08 Malnutrition 8.68 2.48 1.24 9.16 2.62 1.31 5.87 1.68 0.84 Malaria 32.87 12.40 12.40 10.58 0.65 0.26 12.77 0.42 0.04 ALRI 10.38 20.47 12.40 10.94 9.70 14.27 7.02 8.39 4.19 Measles 0.84 0.62 0.62 0.89 0.65 0.65 0.57 0.42 0.42 Others 5.38 3.72 0.62 5.68 3.92 0.65 3.64 2.52 0.42 Total 279.90 196.27 112.03 253.55 158.38 96.64 165.85 106.37 57.96 Data source: Data sheets of cost of health impacts in ESI. FIGURE 11: COMPARISON OF PREMATURE MORTALITY COST BETWEEN STUDY SITES OF HELMINTHES AND DIARRHEAL DISEASE 2009 0 - 4 years Rural 5 - 14 years 15+ years 0 - 4 years Urban 5 - 14 years 15+ years 0 - 4 years Peri-urban 5 - 14 years 15+ years 0 30 60 90 120 150 diarrheal disease ALRI US$ per household per year Data source: see Table 12 www.wsp.org 31 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 12: RELATIVE RISK OF FECAL-ORAL DISEASES AND HELMINTHES OF DIFFERENT RISK EXPOSURE SCENARIOS Open Defecation Basic Sanitation Basic Sanitation with Handwashing Sewerage Sewerage with Handwashing 0.0 0.2 0.4 0.6 0.8 1.0 relative risk, compared with open defecation fecal-oral disease helminthes hygiene-related disease 4.1.5 AVOIDED HEALTH COST basic sanitation with hygiene can reduce it by 50%. It has Central to the arguments of improving sanitation and hy- been proved that improved sanitation and hygiene are cru- giene are the health effects. Limited evidence exists on the cial to improved human health. actual impact of sanitation or hygiene programs on health outcomes in China and this study draws on international Table 12 presents results from a question in the household evidence (see Methods Section). Figure 12 shows the dif- survey “have you noticed an observable change in diarrhea ferent risk exposure scenarios being compared in this study, disease rates in any household members since you received and the relative risk of fecal-oral disease and helminthes the new latrine?” The response shows that 29% to 59% of infection associated with each scenario. The left-hand side households answered “yes”. The effect appears to be larger scenarios (basic improved sanitation) are relevant mainly for those receiving shared or public latrines, possibly be- for rural areas, while the right-hand side scenarios (moving cause they did not have toilets before, whereas those re- to treatment of sewage and wastewater) are relevant mainly ceiving new septic tanks or sewerage connections are more for urban areas. likely to have had basic sanitation already. Figure 12 shows the different risk exposures to fecal-oral Table 13 summarizes the total costs per household of im- disease, to helminthes and to other hygiene-related diseases proved sanitation and hygiene in Yunnan for rural, peri- according to sanitation and hygiene coverage. Sewerage and urban and urban field sites. The averted costs are calculated hygiene measures can together reduce helminthes incidence by multiplying the total costs of disease by the proportional significantly (90% reduction selected in this study), while reduction, per disease. 32 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 12: PERCEIVED DIFFERENCE IN DIARRHEA INCIDENCE SINCE IMPROVED SANITATION, IN ALL FIELD SITES Answer to question “have you noticed an observable change in diarrhea disease rates Households in any household members since you received the new latrine?” Sanitation coverage in sample Yes No Don’t know Shared/public 118 58.5% 11.9% 4.2% Pit latrine 203 25.6% 18.2% 1% Septic tank 242 28.9% 23.6% 1.7% Flush to Sewerage 93 31.2% 22.6% 2.2% TABLE 13: ANNUAL COSTS PER HOUSEHOLD OF POOR SANITATION AND HYGIENE, AND ANNUAL COSTS AVERTED OF IMPROVED SANITATION (US$, 2009) Costs averted Costs (US$) Rural (OD to basic Urban (OD to Urban (OD to Urban (basic Peri-urban (OD to sanitation) sewerage) basic) sanitation to basic sanitation) sewerage) Health care 33.94 36.44 23.03 13.42 26.74 Productivity 38.36 33.81 20.84 12.97 25.14 Premature mortality 207.47 206.25 126.91 79.34 143.66 Total 280. 277 171 106 196 FIGURE 13: HEALTH COSTS AVERTED OF IMPROVED Table 13 shows that the averted cost from OD to basic sani- SANITATION OPTIONS (US$, 2009) tation for rural households is US$280 per year. In urban areas, moving from OD to a sewerage system may avert 300 US$277 per year for an average household, while moving Premature mortality from basic sanitation to sewerage may avert US$106. In peri-urban areas, moving from OD to basic sanitation may 250 Productivity avert US$196 per year. It has shown that the living stan- Health care dards and health level can be highly improved by moving 200 from open defecation to basic sanitation. US$ 4.2 WATER 150 This section provides an overview of water resources in Yun- nan Province, including rivers, lakes and ground water. It 100 draws on government data28, and focuses on urban areas. Information collected from ESI surveys enables estimation of costs associated with water pollution at household level 50 in the eight field sites, and estimates costs avoided through improved sanitation. 0 28 2008 Yunnan Annual Environmental Status Briefing Report, Yunnan Environmental Protection Department, June 2009; Yunnan Infrastructure Construction Plan for Urban Domestic Wastewater Treatment and Reuse (2008 -2012), Yunnan Housing, Urban and Rural Development Department, 2006; 11th-Five Year Plan for Water Pollution Prevention and Control in Dianchi Watershed, Ministry of Environmental Protection, May 2003; Rural Water Supply and Sanitation Survey Report – Yunnan, Yunnan Patriotic Health Campaign Committee (YPHCC), October 2007; Yunnan Water Resources in Brief, Yunnan Water Resources Department, December 2008 www.wsp.org 33 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene 4.2.1 WATER RESOURCES IN YUNNAN per capita (Yunnan Water Resource Department, Decem- PROVINCE ber 2008). Yunnan Province is a relatively “water rich” province in China. In 2008, internal freshwater resources per capi- Among these three study sites, Kunming and Dali are the ta per year were 5,059 m3, which is significantly higher more economically developed areas in Yunnan, but water than the average across China of 2,200 m3. In Yunnan resources available there are less than in Wenshan Prefec- Province, 908 rivers, comprising a catchment area larger ture, to which Qiubei County belongs. A comparison of than 100 km2, drain into the Yangtze, Pearl, Red River, water sources at these sites is given in Table 14. Per capita Mekong, Salween, and Irrawaddy water basins. There are and by total volume, Kunming is now the most water scarce more than 40 lakes in Yunnan with a total storage capac- area of Yunnan. Water pollution is placing additional pres- ity of 29 billion m3, including the nine most important sure on the water shortage to this region. lakes - Dianchi, Erhai, Fuxian, Chenghai, Lugu, Yilong, Qilu, Yangzong and Xingyun, each having a surface area In rural areas of Yunnan, available drinking water sources larger than 30 km2. differ from region to region. In general, surface water is al- most as important as ground water as a source of drinking The average water resource per capita in Yunnan is gen- water in the province. However, in Dali, 87% of drinking erally high, but it is unevenly distributed. In the most water comes from ground water while in Qiubei it accounts populated and economically developed regions, such as for only 9% of the total drinking water share. Table 15 the center of the province, the average water resource per provides an overview of different drinking water sources in capita is 700 m3, while in Dianchi watershed it is 276 m3 three regions. TABLE 14: OVERVIEW OF WATER RESOURCES OF THREE SELECTED STUDY SITES Administrative Water resources by region (billion m3) Water resources per capita (m3) Kunming 6.9 1,114 Wenshan Prefecture 1 18.2 5,304 Dali Prefecture 2 12.2 3,484 Yunnan Province 231.4 5,095 1 Where Qiubei County belongs to. 2 Where Dali City/Municipality belongs to. TABLE 15: DRINKING WATER SOURCES IN ESI STUDY SITES Surface water (%) Ground water (%) Population Region River Lake Reser- Pond Cistern Sub- Bore Spring Dug Sub- (’000) voir total hole well total Kunming– Anning 137 0 0 36.3 5.1 0 41.4 12.9 45.7 0 58.6 City Kunming– 312 0 0 44.9 8.7 0 53.5 6.9 25.7 13.8 46.5 Songming County Qiubei County 425 3.25 0 3.0 62.4 22.42 91.1 0.8 0 8.1 8.9 Dali City 379 0 13.1 0 0 0 13.1 0.6 41.4 44.9 86.9 Yunnan Province 8,940 3.58 0.73 17.9 21.0 5.39 48.6 2.4 25.8 23.2 51.4 Notes: 1) Source: Rural Water Supply and Sanitation Survey Report – Yunnan, YPHCC, October 2007 2) In Kunming two study sites: Anning City and Songming County were surveyed, therefore data collected there were used to represent the greater Kunming region. 3) Data were collected between August and October 2006. 4)Population given in the table reflects the total population of the corresponding site. Be aware that the percentage by type of water source was extrapolated according to the survey results of sample localities. 34 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene 4.2.2 WATER QUALITY FROM PROVINCIAL LEVEL DATA diversion and supply project alone cost four billion RMB Poor sanitation has been recognized as an important fac- (US$590 million). In addition, the fishery, irrigation and tor for water body deterioration, and has received a high recreational functions of Lake Dianchi have been seriously public profile for this reason. In the last two decades, rapid affected. In Yunnan Province, other lakes, such as Xingyun urbanization and population growth have together imposed and Qilu, face similar problems. tremendous pressures on the environment in Yunnan, and in particular on water resources. Many lakes and rivers have Among the 63 lakes and reservoirs in the province that been degraded due to pollutants brought on by human ac- have water quality monitoring, 68% have grade III or bet- tivities. Domestic waste is the largest source contributing to ter water quality, 32% have water quality at grade IV, V or water pollution. Despite increased investment in sanitation worse than V29 (see Figure 14). The water quality of 40% of infrastructure and software development, the condition of lakes and reservoirs satisfy their corresponding functional most lakes and rivers in Yunnan have not been improved requirements, thus leaving 60% of water resources below very much. the quality standards required for their current uses. Lakes close to the cities, such as Dianchi, Xingyun, Qilu and One example is Lake Dianchi, which used to be a clear lake Yilong, are seriously polluted. For example, the permanga- and an important resource for drinking water, fishery, ir- nate index of many of these inland water resources is high, rigation and recreation. However, largely due to a massive indicating strong contamination by oxidizable pollutants discharge of untreated wastewater, Lake Dianchi became so from agricultural, industrial and domestic sources. Dianchi, polluted that it is no longer suitable for drinking, there- Yilong, Qilu and Xingyun Lakes suffer from severe eutro- by requiring high-cost water diversion works. Among the phication, caused largely by domestic wastewater and agri- water supply projects, the largest one, the Zhengjiu water cultural runoff. In 2008, 19,000 tons of ammonia-nitrogen FIGURE 14: WATER QUALITY OF MAIN LAKES AND RESERVOIRS BY QUALITY CLASSIFICATIONS I II III IV V worse than V 0 5 10 15 20 number of lakes/reservoirs lakes reservoir 29 The surface water quality standard classifies surface water quality into five categories according to a set of indicators. Grade-I surface water is the best, suitable for drinking purposes, while Grade V is the worst, normally used for irrigation. www.wsp.org 35 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 15: WATER QUALITY OF URBAN RIVER SECTIONS were released into lakes around Yunnan, of which 3,200 UNDER MONITORING tons was industrial contribution (YEPD, 2009). 7.16% Nevertheless, due to the sustained efforts made in water 5.11% pollution control since 2000, the pollution trend has been reversed. As illustrated in Figure 16, the number of key river sections with Grade-III or better water quality by 2008 has more than doubled since 1995. However, due to devel- 10.23% opment activities, achieving full sanitation for the whole society and maintaining a healthy ecological environment remains a great challenge. According to environmental statistics, in 2008 there were 552 million tons (equivalent to 1.34 million tons per day) of domestic wastewater produced, and the nitrogen dis- 15.34% charged amounted to 1.58 thousand tons, and COD 187.8 5.11% thousand tons. Urban sewage (domestic wastewater plus 2.5% rainwater) receiving treatment in 2008 was about 398 mil- lion tons, equivalent to a treatment rate of 72% of the total grade I grade IV domestic wastewater generated (YEPD, 2009). grade II grade V As seen in Figure 17, in the last ten years, the domestic grade III worse than grade V wastewater treatment capacity has been tripled (YEPD, FIGURE 16: EVOLUTION OF WATER QUALITY IN KEY RIVERS FROM 1995 TO 2008 70% 60% 50% river water quality 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 river sections with water river sections with water river sections with water quality worse than Grade V quality at Grade IV to Grade V quality at Grade I to Grade III 36 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 17: DEVELOPMENT IN WASTEWATER TREATMENT CAPACITY FROM 1999 TO 2008 (SOURCE: YEPD, 2009) 150 50 number of wastewater treatment plants (unit) treatment capacity (10,000 tons/day) 120 40 90 30 60 20 30 10 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 treatment capacity number of waste water (10,000t/d) treatment plants 2009). And according to plans, by 2012 all of the 129 cities COD values are also in the highest range. Although down- and county-level towns will be equipped with centralized stream results show a reduction in pollutants, environmen- domestic wastewater treatment plants (YHURDP, 2008). tal and health risks from human waste remains. 4.2.3 WATER QUALITY AND ITS Drinking water quality in both urban areas and rural sites DETERMINANTS AT STUDY SITES is poor, indicating a wide range of E.coli value. From the The results of water quality measurements carried out in readings, it is difficult to correlate these readings with lo- Qiubei town and villages are presented here. Full data tabu- cal sanitation practices. But a general trend does show that lations can be found in Annex Table C 1. The results indi- the mean NH3-N value (0.002mg/l) of urban shallow well cate that sewage in urban areas was transferred untreated to water is lower than the average of rural sites (0.004mg/l), water courses, causing high levels of E.coli and the deple- which means human/animal waste has a more severe impact tion of dissolved oxygen downstream. Similar problems on the ground water in rural sites, which people reply on were found in Xianrendong village, where intensive tour- as a drinking water source. It can be concluded that rural ism activities, especially around the lake, are leading to the people are more at risk for digestive infectious diseases due direct discharge of domestic wastewater to water bodies. to unsafe water, and lower rates of centralized water treat- When comparing the water quality measurement results ment and distribution. in Qiubei county-town and Xianrendong where flush toi- lets are prevalent with that of other rural sites, pollution of Besides the aforementioned reason, another factor might be the water bodies there was found to be even worse. E.coli, that some dug wells are not protected/covered. In rural vil- NH3-N, TN and TP values of samples taken at the points lages, household animal farming is a common practice, so where the sewage discharges into the water body are all very the impact of animal waste on ground water might even high, indicating a heavy influence of excreta from domestic be more serious in comparison to that of human waste, if sources. Related to that, their turbidity, conductivity, and animal waste is not properly handled. www.wsp.org 37 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 18: E.COLI READINGS, BY WATER SAMPLING POINTS IN QIUBEI FIELD SITES UR UR UR UR UR UDW UDW UDW UDW UDW UDW UDW UP-W UP-W RS-C RS-C RS-C RS-C RS-C RS-C RS-C RS-D RS-D RS-D RDW RDW RDW RDW RDW RSP RSP RSP RSP 0 5,000 10,000 15,000 20,000 25,000 coliform forming units per liter Key: UR - urban river; UDW - urban dug well; UP-W - urban piped from well; RS-C - rural surface water close to dwelling; RS-D - rural surface water distant from dwelling; RDW - rural dug well; RSP - rural spring water To increase drinking water safety, sanitation improvement of three sites, the lowest percentage of not-isolated-sani- is essential and critical. However, when considering mov- tation of 0% was found at Dali urban site (U2) and the ing to a higher level up the sanitation ladder, safe disposal highest of 27.9% was found at rural Qiubei (R3). Even must be taken into account. Upgrading the physical struc- the improved latrine, in this case, water flush toilets, can ture alone will not help, unless human waste is treated and cause serious pollution to the water body if the waste is safely disposed of. not properly disposed of. Not-isolated or partially isolated human excreta and The field survey results suggest that the majority (67.4%) household wastewater drain to ground are major determi- of surveyed households fully isolate their excreta, and that nants of water quality. Figure 19 shows the extent of isola- more households fully isolate their waste in urban areas tion of human excreta and wastewater respectively. Full than in rural or peri-urban areas. Unlike other sites, the isolation normally is achieved through flush toilets con- percentage of open defecation in rural Qiubei (R3) is high necting to sewage treatment, while partial isolation refers (28%). And the second highest is found in the urban area to dry pit, wet pit and other sanitation options requiring of Qiubei (U3). Even in the urban sites where centralized handling of waste by users. The extent of full isolation at wastewater treatment and septic tanks are placed, there are all the field sites ranged from 49.1% to 89.7%, with an incomplete collecting systems and/or mixed rainwater and average of 66.4%. Among the eight different categories wastewater collecting systems. 38 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 19: EXTENT OF ISOLATION OF HUMAN EXCRETA IN FIELD SITES R1 R2 R3 U1 U2 U3 PRU1 PRU2 0 20 40 60 80 100 proportion of households (%) not isolated OD partial isolation dry pit full isolation not isolated flush to water partial isolation wet pit FIGURE 20: POLLUTION FROM POOR SANITATION AND WASTEWATER MANAGEMENT (% OF HOUSEHOLDS) R1 R2 R3 U1 U2 U3 PRU1 PRU2 0 20 40 60 80 100 proportion of households (%) human excreta management - full isolation (%) household wastewater - drain to ground (%) www.wsp.org 39 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene Draining household wastewater to the ground is very com- that they were using at the time of the survey. It seems that mon at all rural, peri-urban or urban sites, and is practiced contamination of solids in the water is the general con- by an average of 43% of households investigated. In com- cern at all three sites. For piped water, users complained parison to the rural sites (54%), the percentage in urban about the bad appearance, taste and dregs, while users of sites is much lower (34%). All the results from study sites untreated or unprotected water complained about a bad revealed that more households are without household smell and dregs. As shown in Table C5, there were more wastewater management than those without fully isolating complaints from urban piped water users than rural and sanitation facilities. Urban Qiubei has 82% of full isolation peri-urban users. However, in reality, the majority of the of waste but 75% of wastewater is discharged to ground, piped-water users are located in urban areas, so the com- making it likely that contamination of human waste will plaints from those urban users are likely to be more than take place downstream while in the rural areas with low from rural sites. It cannot be concluded that the water isolation of human waste, the community’s surroundings quality of piped water in rural sites is better than that in will be affected directly. urban sites. The cited bad taste or smell in piped water by the urban respondents may be related to the disinfec- 4.2.4 HOUSEHOLD WATER ACCESS AND tant agent used for centralized treatment. For non-piped TREATMENT COSTS (protected or unprotected) water, urban and peri-urban One of the major implications of polluted wells, springs, riv- residents generally have higher hygiene awareness and are ers and lakes is that households and/or water supply utilities seeking better living standards than rural dwellers, which will have to treat water, or treat water more intensively, for could also be one of the reasons to explain this phenom- safe human use. Alternatively, households and water supply enon. The cited bad taste or smell in piped water by the utilities can access cleaner water from different and more urban respondents may be related to chlorine residue used distant sources, thus increasing access costs. Those who do for centralized treatment. not take precautionary measures are exposed to a higher risk of infectious disease, or poisoning due to chemical content. In dealing with polluted traditional water sources, house- Table 16 shows the percentages of households by different holds may react differently: purchasing bottled water, walk- categories of primary sources for drinking water, and the ing further to haul free water, having water treatment at average annual cost per household. Except in Qiubei, ac- home, connecting to a piped water source (if available and cess to piped water with standardized or simple treatment affordable), or harvesting rainwater. is generally high in other rural, peri-urban and urban ar- eas, ranging from 81% to 98%, while in rural Qiubei only Figure 22 shows that whether at rural, peri-urban or urban 29% of households have access. One reason might lie in sites the users of all three water sources (piped water, non- the rather high dependence on surface water as a drinking piped protected source and non-piped and unprotected source there. More details can be found in Annex Table C 1. source) see water quality as the most important factor, then available quantity as the second most important, while cost Figure 21 shows the summary of householders’ responses is the least important factor for the respondents in deciding to the question on characteristics of poor quality water to use the current water source. TABLE 16: WATER ACCESS AND TREATMENT COST FOR THREE CATEGORIES OF DRINKING WATER SOURCE Water source Indicator Rural sites Urban sites Peri-urban sites % access 66% 86% 93% Piped water Average Annual Cost US$29 US$29 US$52 % access 20% 11% 4% Non-piped protected Average Annual Cost US$34 US$20 US$16 % access 14% 3% 3% Unprotected Average Annual Cost US$11 US$41 US$32 40 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 21: HOUSEHOLDS CITING POOR WATER QUALITY FROM THEIR PRINCIPAL DRINKING WATER SOURCE bad appearance bad smell piped bad taste water contains solids any bad appearance bad smell non-piped bad taste protected contains solids any bad appearance bad smell unprotected bad taste contains solids any 0 2 4 6 8 10 12 proportion of households responding (%) peri-urban urban rural FIGURE 22: CITED REASONS FOR USING WATER SOURCES – RURAL VERSUS URBAN quality piped quantity cost quality protected quantity cost quality unprotected quantity cost 0 20 40 60 80 100 proportion of households responding (%) peri-urban urban rural www.wsp.org 41 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene They may change the source of hauled water, or introduce gienic importance of water is apparently not well recog- new sources (e.g. drill a household well or buy bottled wa- nized by the users. ter). In addition, as well as in isolation, they may treat wa- ter at home. Particularly in urban areas/cities, many house- As seen in Figure 24, boiling is the dominant practice for holds are sourcing their drinking water from bottled water treating water at home; only a few applied filtration or or buying extra filters for home use. stand-and-settle, while many people do nothing to treat the water. Because boiling water for drinks is a common As illustrated in Figure 23, when we look into the specific practice in China, it is impossible to separate the amount quality-related reasons for using the existing water source, of water boiled for the purposes of killing bacteria. It is also generally those who have responded at all sites perceive that hard to foresee whether this practice will be reduced once good taste and good color are mostly important, followed water quality is improved, based on the data collected from by a reduction in solids and being safer for health. The hy- the field study. FIGURE 23: CITED REASONS FOR USING WATER SOURCES R1 R2 R3 U1 U2 U3 PRU1 PRU2 0 20 40 60 80 100 proportion of households responding (%) safer for health good color/clarity less or no solids good taste FIGURE 24: HOUSEHOLD WATER TREATMENT PRACTICES boiling filtration settling nothing 0 20 40 60 80 100 proportion of households responding (%) rural peri-urban urban 42 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 17: WATER ACCESS AND HOUSEHOLD TREATMENT COSTS INCURRED AND AVERTED (US$, 2009) Annual average costs averted per household Annual average costs per household (US$) Variable following 100% sanitation coverage (US$) Rural Peri-urban Urban Rural Peri-urban Urban Water source access 84 76 83 2.1 1.7 1.8 Water treatment 27 32 50 7.3 7.0 6.7 4.2.5 HOUSEHOLD WATER COSTS AVERTED defecate in a “neighbor’s plot” or in their “own plot”, indi- FROM IMPROVED SANITATION cating shared toilets and toilets outside houses are popular Table 17 shows that water access cost is roughly US$80 per there. However, in Qiubei, most men and women choose household per year. Although in most rural villages water their “neighbor’s plot” or an “outside plot”, showing shared fees do not fully recover provision costs, as in most cases, toilets and public toilets are relatively popular there. customers do need to contribute to the construction and maintenance of the waterworks. In cities, where the cost of In rural areas, most peasants from Luquan, Kunming a centralized water supply is shared by a large population, choose to use their “own plot”, with average value close to the average cost per capita is lower than that in villages. Un- 90%, while peasants (male and female adults ) from Dali like the water source access cost, water treatment cost varies and Qiubei prefer to use their “own plot”, with an average in these three types of areas, of which that of the peri-urban value greater than 90%. One-hundred percent of rural chil- area is the highest. dren choose to use a “neighbor’s plot.” Households with unsecured drinking water sources tend Over 70% of male and female adults on the urban-rural to buy bottled water, if it is available and affordable, or in fringe choose to use an “outside plot”, while the rest use most cases treat water at home by boiling, settling and de- their “own plot”. Almost every child has made the same composition and other means. Boiling is the most prevalent option with some tiny differences. One-hundred percent home treatment method, with an average cost of US$27 to of rural children in Jinning (site PU1) choose to use an US$50 per household depending on area. If water supply “outside plot” and 75% of rural children in suburban Dali and sanitation are improved, for example, a well regulated choose to use an “outside plot”, with 25% using the other piped water supply can provide pathogen-free water, then two options. perhaps the household boiling will be reduced, despite the fact that the Chinese tradition of boiling water to make hot For the households with no own toilet, it is normal to make tea will remain the norm. As a result, household water treat- a round trip from home to toilet several times a day. How- ment costs will only be partially averted, with cost reduc- ever, no previous research has ever calculated how much tions of an estimated US$7 per household per year. time they spend on this. The data can provide much useful information directly or indirectly for researchers, such as For water source access costs, when water is sanitized by land utilization, community scale, situation of local health centralized water treatment, it can be done much more development, etc. So far, no research has been made on this cheaply than household boiling. As Table 17 shows, an- subject. Therefore, studies and data of ESI projects may fill nual average water treatment costs per household can be the gap. Access time includes urination and defecation and reduced dramatically following 100% sanitation coverage the same travel time is assumed for each. Figure 26 shows and change in household behavior. average time per trip and waiting times per day spent ac- cessing toilets for those with no toilet in different sites. 4.3 ACCESS TIME The following conclusion is drawn by means of data analy- 4.3.1 ACCESS TIME AND TIME SAVED sis of different groups in three different sites: On average, in In Kunming, most urban households without their own toi- Yunnan, rural women go to the toilet 4.2 times a day and lets use public toilets nearby. In Dali, most people choose to spend 6.3 minutes per time, urban women go 4 times a day www.wsp.org 43 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene and 3 minutes per time, and suburban women 4 times a most important determinant for 50% of rural households day and 4 minutes per time. The figures for rural women, and 75% of suburban households is to save time. All the urban women and peri-urban women are the same as those interviewed urban households in Qiubei agree on “proxim- for rural men, urban men and peri-urban men. On average, ity/distance” as the most important reason for them to get/ rural children go to the toilet 6 times a day and spend 8.4 build a toilet. Furthermore, 73% of rural households also minutes per time, urban children go 4.7 times a day and consider time saving as the top reason to get a toilet. 5.8 minutes per time, and peri-urban children 5 times a day and 9.6 minutes per time. Among the households with their own toilets, 54% of ru- ral interviewees, 62% of urban interviewees and 56% of 4.3.2 PREFERENCE FOR TIME SAVING AND suburban interviewees are satisfied with locations of toi- UNIT VALUE OF TIME lets (distance). The overwhelming majority (over 98%) of When the households with no own toilets choose a toilet households without their own toilets are not satisfied with type or make decisions for getting/building a toilet, the locations of toilets. FIGURE 25: PLACES OF DEFECATION FOR HOUSEHOLDS WITH NO “OWN” TOILET (%) neighbor women own plot outside plot neighbor men own plot outside plot neighbor children own plot outside plot 0 20 40 60 80 100 av. PRU av. urban av. rural proportion of households with no toilet (%) 44 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 26: AVERAGE TIME PER TRIP AND WAITING TIMES PER DAY SPENT ACCESSING TOILET FOR THOSE WITH NO TOILET IN DIFFERENT SITES average rural women average urban average peri-urban average rural men average urban average peri-urban average rural children average urban average peri-urban 0 2 4 6 8 10 time per trip times per day number of minutes (for time per trip) and number of times per day FIGURE 27: AVERAGE CITED PREFERENCES IN DIFFERENT SITES (%) those with toilet proximity cited as satisfied or very satisfied those without toilet saves time those without toilet: reasons to get a toilet (important or very important) proximity important 0 20 40 60 80 100 av. PRU av. urban av. rural average proportion responding with “yes” to questions (%) www.wsp.org 45 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene Saving time is a major reason as a household decides to toilets is perceived to be an issue by peri-urban dwellers. build a toilet. Therefore, distance is crucial. On average, Most rural villagers with their own toilets, especially those 80% of rural households, 78% of peri-urban households with 3-in-1 biogas units, are very satisfied with convenience and 83% of urban households agree that saving time is an of toilets. They consider that 3-in-1 biogas units not only important reason. All the interviewed urban and peri-urban are safe and convenient, but also can protect the environ- households agree on “proximity/distance” as one of the rea- ment, improve sanitary conditions and save time, energy sons for them to get/build a toilet. Furthermore, 88% of and labor. Villagers that use public toilets are not so satis- rural households agree with this viewpoint. fied. They wish to improve their own living circumstances and enhance their quality of life. Analysis on results of the group discussion has supported results of door-to-door questionnaire interviews. Men and women hold different attitudes toward conve- nience and time saving of toilets. Women are more con- Findings from the focus group discussion on the satisfac- cerned about, and sensitive to safety, privacy and conve- tion with toilet convenience in different sites are summa- nience of toilets than men, especially the women without rized in Table 18. their own toilets. Urban women think about safety, con- venience and time of toilets when going out (for business Most urban households with flush toilets are satisfied with trips, travel etc), while rural women pay special attention to convenience and time saving of private flush toilets. The a type of a toilet from which more manure can be obtained, tenants and the residents in urban areas who use public toi- besides safety, convenience and time of toilets. lets complain about time wasted in using public toilets and the inconvenience. In peri-urban areas, households that use According to results of the group discussion, generally, if public toilets have reflected difficulties and problems con- 30 minutes can be saved per day, 70% of men will spend cerning convenience and time saving. The poor quality of it on rest and recreation, 20% on economic activities and TABLE 18: PROPORTION OF POPULATION SATISFIED WITH TOILET CONVENIENCE Type of Toilet (%) Site Flush toilet 3-in-1 biogas unit UDDT Improved pit-latrine Men Women All Men Women All Men Women All Men Women All Rural 22 24 46 24 24 48 10 10 20 30 30 60 Urban 20 25 45 0 0 0 2 3 5 0 0 0 Peri-urban 8 10 18 2 3 5 6 6 12 18 17 35 TABLE 19: OPPORTUNITY COST OF TIME – HOW MANY RESPONDENTS WOULD SPEND AN EXTRA 30 MINUTES A DAY DOING DIFFERENT ACTIVITIES (%) Ranking Respondents with toilet (% ) Respondents with no toilet (% ) RURAL SITES Ranking 1 Leisure 34.5% Work/help to generate income/output/economic practice - 5.7% Ranking 2 Work/help to generate income/output/economic practice Leisure - 2.0% - 31.0% Ranking 3 Cleaning room, washing clothes, cleaning yard - 21.5% Sleeping - 1.5% URBAN SITES Ranking 1 Leisure 41.5% Leisure - 1.2% Ranking 2 Cleaning room, washing clothes, cleaning yard - 19.4% Work/help to generate income/output/economic practice - 0.8% Ranking 3 Sleeping - 17.0% Cleaning room, washing clothes, cleaning yard - 0.8% 46 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene 10% on cleaning (rooms, clothes and courtyard etc). Sixty children 6.9 days, adults that accompany children 6.9 percent of women will spend it on cleaning (rooms, clothes days and each urban household 24.0 days. In peri-urban and courtyard etc), 30% on production and economic ac- areas, the average time saved per year for women and tivities and 10% on rest and recreation. Men and women men is 6.1 days, children 12.2 days and each peri-urban differ in how they allocate and use the extra 30 minutes. household 36.6 days. The overwhelming majority of women would like to spend it on house cleaning. Therefore, women should be the main Average time value per year saved by each household mem- target group of environmental and sanitary infrastructure ber is shown in Figure 29. For the opportunity cost for ac- construction projects. Women’s involvement in planning, cess to toilets, 30% of hourly wage for adults and 15% for design, implementation and monitoring of environmental children are assumed in this study. Working days per year is and sanitary infrastructure promotion projects is an essen- 230 days for the daily rate calculation of the average wage in tial element to improve project benefits and realize the sus- the different sites. The average annual value of time savings tainability of projects and social development. per household in rural sites is 298 yuan, 410 yuan in urban sites, and 439 yuan in peri-urban sites. 4.3.3 TOTAL VALUE OF SAVED TIME Saved time is different between urban and rural areas due to 4.4 REUSE OF HUMAN EXCRETA locations of toilets. Figure 28 shows the average time saved Data in Table 20 show reuse of human excrement of per year per household member. households with different types of toilets in different sites. Among the interviewed households with unimproved toi- The average data of Yunnan Province is obtained by lets, 56 households defecate outdoors, accounting for 6.3% means of the summarization of data in three different of the total number of households. One hundred and eigh- sites. In rural areas, the average time saved per year for teen households use shared toilets, 14.5% of the total, and women and men is six days, children 12.8 days and each 13.6% of the 118 households reuse excreta. Although ex- rural household 37.6 days. In urban areas, the average creta is reused from pit latrines, it is not included in the time saved per year for women and men is 5.1 days, CBA calculations as this reuse is not safe. FIGURE 28: AVERAGE TIME SAVED PER YEAR PER HOUSEHOLD MEMBER (DAYS) women men children young children per household 0 5 10 15 20 25 30 35 40 av. PRU av. urban av. rural number of days Source:Annex tabel D www.wsp.org 47 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 29: AVERAGE ANNUAL VALUE OF TIME SAVINGS PER HOUSEHOLD (US$, 2009) women men children young children per household 0 20 40 60 80 100 av. PRU av. urban av. rural annual value (US$) TABLE 20: SANITATION COVERAGE AND HOUSEHOLDS REUSING EXCRETA IN EIGHT DIFFERENT FIELD SITES Field sites Number of households % Of which reuse (%) UNIMPROVED OD 51 6.3 0 Private pit 2 0.2 0 Shared 118 14.5 13.6 IMPROVED Simple pit 174 21.4 33.0 Wet pit 276 34.0 23.2 UDDT 67 8.3 40.3 Biogas 56 6.9 19.6 Septic tank 68 8.4 0 Among the interviewed households with improved toi- 8.4% of the total, and none of them reuse the waste from lets, 174 households use single-pit latrines, 21.4% of the flush toilets. total number of households, and 33% of them reuse the single-pit latrines. Two hundred and seventy six house- The results of a group discussion concerning safety for re- holds use wet pit latrines, 34% of the total, and 23.2% use of human excrement show that over 98% of people of them reuse the waste from wet pit latrines. Sixty seven think flush toilets connected to septic tank and sewerage households use UDDTs, 8.3% of the total, and 40.3% is safe, sanitary and environmentally friendly. Of the op- of them reuse the UDDTs. Fifty six households use 3-in- tions, the perceived safety (in descending order of safety) 1 biogas units, 6.9% of the total, and 19.63% of them is as follows: flush toilet, improved pit latrine, unimproved reuse the 3-in-1 biogas units. Sixty eight households use outdoor pit latrine, pail-closet, digging a hole, and open flush toilets (connected to septic tank and sewerage), defecation. 48 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 21: VALUE ASSOCIATED WITH REUSE OF HUMAN EXCRETA (US$, 2009) % households Average value (US$) Variable Own use Selling Own use Composting (fertilizer) 100 0 46.8 Biogas generation (with animal excreta) 100 0 77.3 TABLE 22: RESPONDENTS’ UNDERSTANDING OF SANITATION (THE TOP THREE ANSWERS) Focus Group Discussions Household interview With sanitation Without sanitation Men Women Men Women Average 1. flush toilet connected 1. improved pit-latrine 1. improved pit-latrine 1. shared toilet 4.3% 1. shared toilet 5.7% rural to sewerage 17% 18.3% 19.7% 2. improved pit latrine 2. improved pit latrine 2. private toilet 7% 2. 3-in-1 biogas unit 2. 3-in-1 biogas unit 3% 3.3% 3. toilet built in yard or 11.3% 18.6% 3. flush toilet with 3. UDDT 0.7% near the residence 3. UDDT 10% 3. UDDT 10.3% septic tank or 4% sewerage 1.3% Average 1. flush toilet connected 1. flush toilet 1. flush toilet connected 1. flush toilet 1. flush toilet urban to sewerage 6% (connected to to septic tank and connected to septic connected to septic 2. improved public toilet septic tank and sewerage 26.7% tank and sewerage tank and sewerage 2.3% sewerage) 20.3% 2. public toilet 8.7% 22.7% 27.6% 3. toilet building near 2. public toilet 7.3% 3. improved pit latrine 2. public toilet 9.7% 2. public toilet 10% the yard or house 3. improved pit-latrine 6.3% 3. improved pit- 3. flush toilet 10.3% 1.7% 1.7% . latrine7.3% Average 1. improved flush toilet 1. flush toilet 1. flush toilet connected 1. flush toilet 1. flush toilet Peri- 9% connected to septic to septic tank and connected to septic connected to septic urban 2. improved public toilet tank and sewerage sewerage 19% tank and sewerage tank 22% 6.5% 20% 2. public flush toilet 12% 19% 2. public flush toilet 3. toilet installed in the 2. public flush toilet 3. UDDT 5.5% 2. public flush toilet 11.5% house 5% 10% 4. 3-in-1 biogas unit 10% 3. UDD 10% 3. UDDT 4% 5.5% 3. UDDT 4% Table 21 shows analysis on values of reuse of human ex- peri-urban sites. The topics covered in the FGDs included crement. According to the table, 219 households use com- understanding of sanitation and attitudes to school and post only for private use. Since total money saved from workplace sanitation, factors explaining current sanitation, the use of compost is RMB70,109 yuan, it is RMB320 satisfaction with current sanitation options and worries of yuan for each household. There are 34 households using people without sanitation options on the dangers of open 3-in-1 biogas units. Since total money for energy saving is defecation, preferences for sanitation options, and decision RMB17,960 yuan, it is RMB528 yuan for each household. making on sanitation choices. Data from the household The unsafe handling of excreta may result in having health survey are also used to cross check with the FGD findings. costs. Therefore, the value of excreta use from pit latrines is not included in the CBA. Only the value of reuse from 4.5.1 UNDERSTANDING OF SANITATION AND UDDTs and biogas is included. ATTITUDES TO SCHOOL AND WORKPLACE SANITATION 4.5 INTANGIBLE SANITATION PREFERENCES According to FGD results, most people’s understand- Over 100 people participated in a total of 24 focus group ing of sanitation reflects the sanitation devices, location, discussions (FGDs), of whom 60% were women. Find- and household and community waste treatment facilities, ings were compared between groups consisting of women’s shown in Table 22. Sanitation should include improved toi- and men’s groups, between households with improved let bowls located in houses, or nearby yards. Septic tanks or and unimproved sanitation, and between rural, urban and pits and public toilets must be non-leaking. In rural areas, www.wsp.org 49 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene the household survey shows that the most preferable sanita- 4.5.2 WHAT FACTORS EXPLAIN CURRENT tion option is flush toilets with sewerage, while the FGD SANITATION OPTIONS? shows that men and women with sanitation generally prefer In urban sites, it is usual for urban households to be improved pit-latrines. equipped with either an indoor private flush toilet built indoors or a public flush toilet connected to either a septic The FGDs also investigated the experience of public toilets tank or sewerage. Most urban households do not change and institutional sanitation in work places. Most of the re- their toilets. All apartments are installed with flush toilets spondents thought that public toilets were very important equipped with cheap devices by the property developer. In except that a few rural villagers were less concerned about the case of new apartments, the first owner may be given public toilets. Table 23 shows an example of the perceived the choice of bathroom hardware to install. At present, importance of school, work place and public toilets in an most apartments are only installed with washroom trunks urban area. connected to a septic tank and sewerage system, so the TABLE 23: PERCEPTION OF THE URBAN POPULATION TOWARDS INSTITUTIONAL TOILETS - LIANGYUAN COMMUNITY, KUNMING CITY What is the perceived importance of toilets in school? Very important! Children spend quite a long time in school, which is vital for Why? their futures. It saves time and is also safe. The school should build more toilets with larger spaces and that are of better quality. What is the perceived importance of toilets in the It is convenient for our work! We can save time, and work more efficiently. This working area? Why? is one of the reflections of a people-centered policy. What is the perceived importance of toilets in public Public toilets can protect the environment, provide convenience to the people. places? Why? They are beneficial in controlling transmission of diseases. What is the perceived importance of well protection? It is important to protect wells in order to prevent disease BOX 1. CASE STUDIES OF HOUSEHOLDS WITH NO TOILETS Dali Old Town: Lack of adequate land space for sanitation options Dali Old Town, with its Bai ethnic population and unique architecture and culture, is a famous tourism attraction. It has been rebuilt on the site of the previous old town with a municipal sewerage system connected to a wastewater treat- ment plant. But there are some residents using public toilets due to a lack of private sanitation options. A lack of a proper land area to build private toilets is one of the main reasons that some households living in old com- munities of Dali Old Town do not have private toilets. If a household wants to build a toilet, he or she first has to build a private septic tank to connect to the municipal sewerage system. Therefore, the cost is very high. On the other hand, to protect the architectural style in the old town, private construction permits are strictly controlled. Xiangshui Miao ethnic village: Sanitation in a poor, disadvantaged, and difficult to access village Xiangshui Miao ethnic village, located in Qiubei County, is difficult to access from the town center. As of 2008, the vil- lage had 75 households, with an estimated 400 people. The village is poverty-stricken with poor physical infrastructure and living conditions. The average annual net income per capita of the village is less than RMB500. For drinking water and domestic use water, the villagers have to fetch water from the hill gully by oxcarts or manual la- bor. There are only two shared pit latrines in the village constructed by the school and by a relatively wealthy household. It is the poverty and the lack of development opportunities that are the main reasons for not having toilets. The radical behavior changes required by UDDT results in low acceptance The village of Huichangcun, located on the banks of Dianchi Lake within Jingning County territory, has built UDDTs with government subsidies, but only around 20% were actually used. The reasons for the low acceptance of UDDT are mainly because of their poor quality and the need for dramatic change in the living habits. In addition, the project performance — such as lack of sufficient promotion of users’ awareness on the new sanitation options and their func- tions — is also a main factor in affecting users’ acceptance. 50 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene owners of apartments could choose different kinds of sani- construction, resistance to changing habits related to toi- tation furnishings and options according to their prefer- let-going and the required maintenance of new sanitation ences and the affordability of the sanitation options. options. The two cases in Box 1 serve as examples of why households lack private sanitation options. Across the peri-urban and rural sites, the households mostly use traditional pit latrines and shared pit latrines that are Also, the FGDs revealed that some male villagers have poor built outdoors and in communal places. In addition, 3-in-1 awareness of the importance of toilets and sanitation. The biogas units and UDDT are also used widely due to the pro- men claimed it is convenient to defecate in the open, be- motion of governmental projects and other donors. A lack cause they do not need a fixed location and they feel unre- of a public sewerage system is the main constraint for the stricted. What they need is a relatively concealed place. Fur- peri-urban and rural population in choosing flush toilets. thermore, they do not have to clean the place up. Therefore, cropland, bushes, the place beside a ditch and even spaces The main reasons why some households lack toilets include in front of and in back of a house are used for urinating or a lack of investment capital, a lack of a proper land site for defecating. FIGURE 30: AVERAGE LEVEL OF SATISFACTION WITH CURRENT TOILET OPTION (1 = NOT SATISFIED; 5 = VERY SATISFIED) toilet position cleanliness status visitors maintaining health conflict avoidance convenience for children convenience for elderly night use of toilet avoid rain showering dangerous animals 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 improved unimproved www.wsp.org 51 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene 4.5.3 SATISFACTION WITH CURRENT TOILET ately. In short, the usage rate of UDDTs in many places OPTION AND CONCERN OF PEOPLE WITHOUT is low. Some UDDTs have been turned into the villagers’ TOILET OF DANGER OF OPEN DEFECATION “storehouse”. Figure 30 shows 13 indicators for household satisfaction to- wards current toilet options: toilet position, cleanliness, sta- Figure 31 shows the five reasons households without toilets tus, visitors, maintaining, health, conflict, convenience for cited as being very important or important for getting a children, convenience for elders, night use of toilet, avoid- toilet (see Annex Table E4 for the complete ranking). ing rain, showering and dangerous animals. Across the 13 indicators, households with improved sanitation scored on People without toilets clearly indicated their concerns about average 3.5 in satisfaction, while households without im- safety, children’s safety and animal attacks during defecation proved sanitation scored 1.5 points lower, at 2.0. in the open (see Table 24). Answers to these concerns make up 40% of the total. Many people also have shown their Group discussions on satisfaction with use of toilets has concerns and worries during group discussions. In particu- supported the results of the above analysis from the ESI lar, women have shown a stronger sense of worry about the household interviews. When considered overall, the accu- dangers for themselves and children during open defecation. mulated opportunity cost is high. 4.5.4 PREFERENCES FOR TOILET OPTIONS In the discussions, one sanitation option – the UDDT – Reasons why households build private toilets focus on safety, did not fare as well as the other conventional options. Use privacy, convenience, environmental protection and com- of UDDT has failed to achieve the anticipated goal due to fort. During group discussions, many participants counted dissatisfaction with this option, such as low quality building toilet construction as one of the signs of social status and materials and poor construction. Doors of some UDDTs dignity. Table 25 presents the top five ranked reasons for have been broken before they are put to use. It is hard to sanitation coverage of households, segregated results from change traditional toilet habits of users, so maintenance is men and women, and comparing results of the household not carried out and UDDTs are often not used appropri- survey with the FGD. FIGURE 31: HOUSEHOLDS STATING REASONS TO GET A LATRINE FOR THOSE CURRENTLY WITHOUT (1 = NOT IMPORTANT; 5 = VERY IMPORTANT) comfortable clean not sharing privacy proximity non-pollution 0 1 2 3 4 5 TABLE 24: CONCERNS OF PEOPLE WHO PRACTICE OPEN DEFECATION Number of Answers (%) Worry respondents never sometimes often Do you feel danger during OD? 56 32 23 1 Have you ever worried about the safety of children? 53 22 26 5 Have you ever heard about people being attacked by wild animals during OD? 58 34 21 3 52 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene TABLE 25: REASONS FOR CURRENT SANITATION COVERAGE – TOP FIVE RANKED RESPONSES PER SITE Focus Group Discussions Why families without toilet do not have a Why families with toilet have a toilet toilet Household interview Men (accounting Women Men (accounting Women for heads) (accounting for for heads) (accounting for heads) heads) Average 1. Privacy of toilet 1. clean19% 1. clean 22% 1. high cost 1% 1. high cost 5.7% rural 44% 2. convenient and 2. convenient and 2. no space 0.7% 2. no space 2.7% 2. Proximity to the safe19% safe 15.3% 3. incapable 0.7% 3. incapable 1.3% house 34% 3. protect the 3. protect the 4. never considered 4. never considered 3. use toilet on rainy headwater 18.3% headwater 21.7% this 0.7% this 3.3% days 17% 4. alone and not 4. health 13.3% 5. no one provided 5. no one provided 4. Comfortable being disturbed 6% 5. save energy 8.3% facility 3.3% facility 2.6% location 10% 5. health 3% 5. avoid snakes and pests 8% Average 1. Privacy of toilet 1. convenience, 1. safety 10.7% 1. limited by location 1. limited by location urban 27% sanitary 8.3% 2. convenience, 8% 12% 2. Avoid snakes and 2. environment sanitary 10% 2. limited by money 2. limited by money pests 26% protection 8.3% 3. environment 8% 12% 3. convenient for 3. safety 5.7% protection 7.3% 3. limited by city 3. limited by city using on rainy days 4. health 3% 4. health 7.3% planning 8% planning 12% 23% 5. civilized 2% 5. civilized 3% 4. Proximity to house 18% 5. comfortable location 11% Average 1. privacy of toilet 1. convenience 8.5% 1. convenience 10% 1. no space 10% 1. no space 11% Peri-urban 33% 2. sanitary 8.5% 2. sanitary 10% 2. incapable 10% 2. incapable 11% 2. avoid snakes and 3. environment 3. environment 3. use public toilet 3. use public toilet pests 19% protection 8.5% protection 10% 10% 11% 3. showering in the 4. safety 8% 4. safety 10% 4. live in rented room 4. live in rented room toilet 19% 5. comfort 7% 5. comfort 6% 10% 11% 4. comfortable 5. not necessary 10% 5. not necessary 10% location 7% 5. proximity to the house 6% Most villagers think an improved private pit latrine is more using public toilets prefer flush toilets connected to septic applicable as it can collect manure and is easy to clean, with tanks or sewerage, and desire to build such a toilet if condi- the 3-in-1 biogas unit in second place. UDDT is not accept- tions permit. The following are questions asked during an ed widely by most households and is ranked in third place FGD regarding people’s choices and preferences. because of being of poor quality and requiring a change of habits in using and maintaining it. Rural households with- Selection of toilet: If you decide to get a toilet, which out own toilets expect to use public toilets in the commu- toilet do you prefer? Among the interviewees in rural and nity, or improved pit latrines. Urban households with flush peri-urban areas, most of them prefer improved pit latrines, toilets have a high level of satisfaction. Among the urban from which they can collect manure. Some desire a 3-in- households using public toilets, most of them believe that 1 biogas unit. A few prefer UDDT and for some a flush use of their own toilets is more comfortable and they expect toilet is the least preferred due to lack of a public sewerage to have a toilet bowl or flush toilet. Peri-urban households system. In urban areas, households can afford apartments www.wsp.org 53 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene that are equipped with private flush toilets connected to apartments when they move in. Some households can im- a public sewerage system. People renting rooms or living prove the existing sanitation devices to meet their require- in older buildings without sewerage branches have to use ments according to their ability to pay. public toilets. 4.5.6 HEALTH IMPACTS “What will be the most important feature of your toi- Through FGDs, the study found that urban residents have let?” We hope to use a private toilet with privacy. The toilet a lower exposure to risks of water-based diseases due to must be built nearest to the house, odorless and comfort- good hygiene and sanitation options as well as a cleaner able without flies and insects. external environment. “What is the major reason for you to get a toilet?” A pri- In contrast, rural populations are exposed to much higher vate toilet is safe and convenient for household members. health risks, due to endemic diseases such as schistosomiasis We hope that we can use the toilet as needed at any time and lithiasis in Dali, as well as adult diseases, such as rheu- and have privacy. We can save time when having our own matism, diarrhea, tummy bugs, colds, high blood pressure, toilet. On the other hand, if other households have built a schistosomiasis and lithiasis. From the FGDs, participants toilet, we feel embarrassed if we don’t have one. An impor- estimated that it costs each rural household around US$150 tant reason for most households to have private toilets is to (1,000 yuan) to treat less acute diseases, and a multiple of save time. five to ten times this value for inpatient treatment, with an additional US$75 (500 yuan) income loss from time off 4.5.5 DECISION MAKING FOR SANITATION productive activities. OPTIONS In rural areas, the choice of sanitation options is largely The impact of unimproved sanitation and hygiene on chil- supplier-driven. Across the rural sites, the households use dren’s health is very significant in rural areas. The children mostly traditional pit latrines or do not have their own in rural areas often have fever, diarrhea, and colds which toilets before building new toilets. Building new toilets in often occur simultaneously. For a child’s severe diarrheal rural areas depends on governmental support via different case, it costs US$60 to US$150 (400-1,000 yuan) to use a projects (environmental protection projects, poverty alle- public health facility and an additional opportunity cost of viation projects, energy-saving projects) and some receive US$45 to US$90 (300-600 yuan) for parents accompany- partial support from donors and NGOs. The type of toilet ing children. received depends on the option selected by the project or suppliers, so rural people are in a passive situation in most The reasons for the disease burden, according to the FGD of the external projects. However, some rural households participants, are poor hygiene and food borne infections. make their own decisions for toilet construction. For exam- They think that the diseases are indirectly related to water ple, some households in Xianrendong Village in Puzhehei quality: diseases are perceived in some rural communities to of Qiubei have built flush toilets and some have improved be directly related to polluted water. traditional pit latrines when they engage in farm-based tourism (agritainment). The case of Puzhangkang village, Luquan county, indi- cates that villagers suspect that a poorly functioning water The decision making for current and future sanitation supply facility is responsible for diseases including hepati- options in urban areas is decided by the urban sanitation tis, pneumonia, and diarrhea. The reasons for this disease program approach, the so called “strategic urban sanita- prevalence and incidence are mainly because of a lack of tion.” The government, with an urban development plan, protected piped water. The water source is located far away, has invested and built public sewerage systems and septic which is diverted to the village through open ditches. The tanks. Improvement and construction of sanitary options water source is often polluted in the course of the delivery, inside the apartments for urban households are decided on particularly during the rainy season and by garbage that is by themselves. For most households, toilets are available in thrown in the ditches. 54 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene 4.6 EXTERNAL ENVIRONMENT is located in one of the water reservoir areas of Yunnan, The “external” environment refers to the area outside the and there are several regulations forbidding some activities toilet itself and is not related to toilet-going, and can in- that might result in water pollution, such as using human clude living areas, public areas, and private land, which and animal excreta as the main source of manure. In Qiu- can all be affected by open defecation practices and unim- bei County, there are many breweries that have developed proved toilet options. The consequences of water pollution home-based brewery factories combined with pig breeding have already been covered in Section 4.2. The sources of by using hops to feed pigs. Along with household economic data are mainly the ESI surveys: physical location survey, development, external environmental sanitation is getting household interviews, and focus group discussions. Given worse due to poor management of local sanitation. Table that the external environment is also spoiled from other 26 shows scoring of different types of living areas from a sources of poor sanitation – mainly inadequate solid waste household survey. management practices – these have also been assessed to understand the contribution of each, and relative prefer- Generally speaking, interviewees all think the animal ex- ences regarding their improvement. Households were asked creta incurs more pollution than human excreta. Across to rate the dirtiness – or level of soiling – of their external sites, participant ratings for community areas indicate them environments. to be slightly cleaner than moderate soiling. Animal excre- ta in private plots causes major soiling, especially in rural The survey findings indicate that environmental sanita- areas with an average score of 4.1. The overall community tion is worse in rural areas than in urban areas, especially in living areas rank as moderately soiled. There is little dif- Kunming-Luquan and Qiubei counties. This occurs for two ference in the scores among urban, peri-urban and rural reasons: first, the procedures for human excreta reuse do not areas. Figure 32 and Figure 33 show the quality of envi- meet sanitary requirements; second, along with the exten- ronmental sanitation in private plots and community sion of the local stockbreeding, the management of animal living areas, ranked by interviewees in the household excreta remains unsanitary. For example, Luquan County survey. FIGURE 32: SCORING OF DIFFERENT TYPES OF LIVING AREAS—PRIVATE PLOTS R1 R2 R3 U1 U2 U3 PRU2 PRU1 0 1 2 3 4 5 human excreta animal excreta (1 = clean, 2 = minor soiling, 3 = moderate soiling, 4 = major soiling, 5 = extreme soiling) www.wsp.org 55 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 33: SCORING OF DIFFERENT TYPES OF LIVING AREAS—COMMUNITY LIVING AREAS R1 R2 R3 U1 U2 U3 PRU2 PRU1 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 (1 = clean, 2 = minor soiling, 3 = moderate soiling, 4 = major soiling, 5 = extreme soiling) Figures 34 and 35 show the proportion of households around 4 to 4.4. However, there was little difference among with and without toilets, respectively, with unimproved the options. Treatment and management of rubbish, sew- sanitation practice. The rate of infants of households with age, water, smoke, smell, dirt outside, dirt inside, rodents no sanitation seen defecating in own or other yards var- and insects should all be considered as very important issues ies across sites from 40% to 90%. Regarding households in improving environmental sanitation. It is necessary to with toilets, the proportion of open defecation/urination take comprehensive action instead of doing it piecemeal to is low, but the proportion seeing children defecating in achieve the goal of improving environmental sanitation (see yards is high. annex Table F5). Figure 36 shows the perceptions of environmental sanita- Poor external environment causes diarrhea tion by option types. The option types including rubbish, sewage, water, smoke, smell, dirt outside, dirt inside, ro- Ginghe village of Dali used to drink ground water from dents and insects are generally ranked as bad to normal. tube wells until three years ago. The poor water quality Sewage is considered as a serious factor in incurring a nega- caused diseases among the villagers. After a governmental tive impact on either urban or rural areas, with a score of project to improve the drinking water supply, the villagers 2.8 and 3.0 respectively. Rubbish, dirt outside and insects started to use treated piped water. As a result, disease inci- had an average score of 3.0. Smoke is considered to have dence has decreased in the village. However, the external less environmental impact on both urban and rural areas. environment in the village is still poor although a public Generally, urban areas are perceived to be better than rural garbage collection tank has been built. Due to poor aware- and peri-urban areas. ness on public external environmental protection and bad behavior, garbage is put everywhere and animal excrement Public opinion on the key areas of the importance of envi- is seen everywhere in the public environment. This poor ronmental improvement is surveyed in the study. The results external environment in the village has caused the disease indicated that all factors are important with the score being incidence to increase. 56 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 34: PROPORTION OF HOUSEHOLDS WITH UNIMPROVED SANITATION PRACTICE R1 R2 R3 U1 U2 U3 PRU2 PRU1 0% 20% 40% 60% 80% 100% proportion of households (%) open defecation see children defecating in yard FIGURE 35: PROPORTION OF HOUSEHOLDS WITHOUT TOILETS WHO SEE CHILDREN DEFECATING IN EXTERNAL ENVIRONMENT NEAR LIVING QUARTERS (SOMETIMES OR REGULARLY) R1 R2 R3 U1 U2 U3 PRU2 PRU1 0 20 40 60 80 100 proportion of households (%) www.wsp.org 57 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene FIGURE 36: PERCEPTIONS OF ENVIRONMENTAL SANITATION STATE, BY OPTION TYPE (1= VERY BAD; 5 = VERY GOOD) rubbish sewage standing water smoke smell dirt outside dirt inside rodents insects 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 R1 U2 R2 U3 R3 PRU1 U1 PRU2 58 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene A case in Shangguan Town of Dali Prefecture The ESI survey in Dali Old Town suggests that women are much more sensitive to a poor environment, citing the pres- The children in the town often suffer from bacterial diarrhea ence of human and animal excrement, domestic garbage and and colds, and the adults rank the disease incidence includ- urine in the back streets of the town. Female respondents ing gynecological diseases, appendicitis, diarrhea, gastroen- think that the bad external environment affects the health of teritis disease, and lithiasis. They think that these diseases the residents as well as the reputation of Dali Old Town as a are related to the poor external environment and unsanitary famous tourist site. Male respondents think the environment living habits. Domestic waste, agricultural waste, dust and is reasonably clean. However, both men and women say they other problems co-exist in the town, which are the sources are willing to pay for better public waste management. for air and water pollution. For example, poor water quality in the rainy season is caused by discharged waste in streams Scores provided by villagers from rural areas on the envi- and rivers; in the dry season, lack of sufficient water sources ronment rank worse than those of urban residents. The ex- make water quality poor. Sanitation behavior in private and ternal environments of most villages are very bad, due to public locations is also the main factor in causing disease lack of management of domestic waste and animal excre- incidence. Unsafe food conditions with unsanitary process- ment, causing river and water resource pollution. In addi- ing and use of unsafe material for processed food also cause tion, flies, mosquitos and rats are common in rural com- diarrhea and other diseases. munities, which all contribute towards disease. Although it is necessary to improve the quality of the external environ- The perception of local people on the external environment ment, some villagers are not willing to pay for better waste management due to their poor financial situation. The residents of Liangyuan Community in Kunming city think that the external environment around their commu- 4.7 SUMMARY OF LOCAL BENEFITS nity is very bad with domestic waste and industrial solid Table 26 shows the summary breakdown of benefits. In waste from a car repair factory. Animal excrement is seen rural areas, households could save an average of US$331 in the neighborhood, smelly water canals, flies, mosquitoes, annually for health, water and access time benefits of im- paint smells, noise pollution all disgust the residents. This proved basic sanitation, with an additional US$47 from poor external environment affects the residents quality of UDDT or US$77 for biogas. In urban areas, the savings life. are US$344, compared with US$303 in peri-urban areas. TABLE 26: SCORING OF DIFFERENT TYPES OF LIVING AREAS FROM A HOUSEHOLD SURVEY Site Private plots Community living areas (market, roadside) Human excreta Animal excreta Human excreta, animal excreta & solid waste R1 (Rural-Luquan: Kunming) 2.28 4.02 2.68 R2 (Rural: Dali) 2.59 3.92 3.07 R3 (Rural: Qiubei) 2.79 4.45 3.52 U1 (Urban: Kunming) 2.83 3.47 3.30 U2 (Urban: Dali) 2.39 3.44 2.88 U3 (Urban: Qiubei) 3.30 3.67 2.57 PRU1 (Peri-urban-Jinning: Kunming) 2.34 3.60 2.69 PRU2 (Peri - urban-Zhoucheng: Dali) 3.47 3.64 3.03 Average Rural 2.53 4.13 3.09 Average Urban 2.84 3.52 2.91 Average Peri-urban 2.9 3.6 2.86 Average (All) 2.76 3.75 2.95 (1 = clean, 2 = minor soiling, 3 = moderate soiling, 4 = major soiling, 5 = extreme soiling) www.wsp.org 59 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Local Benefits of Improved Sanitation and Hygiene The most important contributor to the quantified ben- water access costs and treatment costs ranging from efits is related to health improvements of improved US$8.5 to US$9.3 per household annually in ur- sanitation. Benefits of improved sanitation and hygiene ban and rural areas, respectively. Improved sanita- can avoid health costs by reducing disease cases, mortality, tion can save productivity costs of US$44, US$60 and and DALYs, averting an annual health care cost per US$88 per household annually in rural, urban and household of US$280 in rural, US$277 in urban, peri-urban areas, respectively. Other intangible benefits and US$196 in peri-urban areas. Improved sanita- are also perceived by the users. These benefits are sum- tion can improve water quality, and thus can save marized in Table 27. TABLE 27: SUMMARY OF LOCAL IMPACTS OF SANITATION IMPROVEMENT (2009) Benefits of improved sanitation and hygiene Quantitative benefit Benefit (US$/household, annual) Qualitative or Other Benefit Rural Urban Peri-urban HEALTH Health burden/quality of life • Avoided pain and discomfort from illness (captured partially • Cases/person 1.93 1.43 1.47 in the DALY losses) • Mortality/1000 population 0.92 0.67 0.69 • Avoided costs from other diseases associated with poor • DALYs/1000 population 16.0 13.0 12.0 sanitation Health costs averted 280 277 196 Health care OD to Basic 34 - 27 OD to Sewerage - 36 - Productivity costs averted Refer to Tables 7 to 12 and Figures 10 to 13. OD to Basic 38 - 25 OD to Sewerage - 34 - Mortality costs averted OD to Basic 207 - 144 OD to Sewerage - 206 - WATER Access cost savings 2 2 2 Improved water quality (smell, appearance, less contaminants) for drinking, domestic purposes, recreation and other. Treatment cost savings 7 7 7 Refer to Figure 16 Access time 44 60 88 • Avoided discomfort from having to queue • Households without toilets mostly consider “comfort” and “proximity” the most important reasons to get a toilet • Time loss associated with urination is excluded Refer to Table 18, Table 19 and Figure 28 Intangibles - - - • Comfort associated with use of clean toilets • Pride in having a toilet, especially if expensive • Privacy and not being seen going to the toilet • Safety of women and children • Confidence to invite guests to the house Refer to Figure 31 and Table 25 External environment - - - • Cleaner surrounding areas • Less exposure to insects and rodents Refer to Annex Table F5 Reuse: composting 47 - - • Cleaner surroundings and averted water pollution Reuse: biogas unit 77 - - “-“ not calculated 60 Economic Assessment of Sanitation Interventions V. Costs of Improved Sanitation and Hygiene This chapter presents the costs of improved sanitation from 5.1.1 RURAL AREAS different perspectives – investment versus recurrent, eco- In rural areas, the average investment cost per household nomic versus financial, and by financing source (payer). At for shared, pit latrines and UDDTs ranges from US$135 the end, marginal costs of moving up the sanitation ladder to US$185. More than twice this cost is the 3-in-1 biogas are presented. unit, which costs US$361. Rural households invest an aver- age US$507.4 for a septic tank. Average annual recurrent 5.1 COST SUMMARIES cost per households for hygiene is US$15.1 and for the dif- Table 29 to Table 30 show the aggregated costs for each san- ferent sanitation options ranges from US$15.8 to US$42.6. itation option across rural, urban and peri-urban field sites. Total annual costs per household, including both invest- The results show that the investment, recurrent and average ment and recurrent, averages between US$29 and US$68. annual costs of sanitation options are directly related to the level of sanitation improvement. TABLE 28: AVERAGE RURAL COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, YEAR 2009) Cost Item Hygiene Shared Pit UDDT Biogas Septic INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 33.4 134.7 159.1 165.7 336.0 484.0 2. Program 2.9 0.0 0.0 19.0 25.5 23.3 Sub-total 36.3 134.7 159.1 184.7 361.4 507.4 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 5.4 4.4 5.3 5.7 10.4 15.4 4. Maintenance 6.6 11.4 14.1 14.6 16.8 21.2 5. Program 2.9 0.0 0.0 4.4 4.4 6.0 Sub-total 15.1 15.8 19.3 24.7 31.6 42.6 AVERAGE ANNUAL COST CALCULATIONS Duration 5.0 10.0 10.0 10.0 10.0 20.0 Cost/household 22.3 29.2 35.3 43.2 67.8 68.0 Cost/capita 6.4 8.3 10.1 12.3 19.4 19.4 OF WHICH: % capital 0.3 0.5 0.5 0.4 0.5 0.4 % program 0.0 0.0 0.0 0.0 0.0 0.0 % recurrent 0.7 0.5 0.5 0.6 0.5 0.6 Observations 403 14 118 14 43 214 www.wsp.org 61 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene FIGURE 37: ECONOMIC COSTS PER RURAL HOUSEHOLD FOR MAJOR ITEMS (US$, YEAR 2009) hygiene shared pit UDDT biogas septic 0 100 200 300 400 500 capital recurrent (annual) US$ program average (annual) Program costs reflecting software items such as promo- Shared toilet, pit latrine and UDDT have an average tion, education and monitoring contribute a very small pro- annual recurrent cost ranging from US$15.8 to US$24.7. portion of total costs for all the sanitation options, account- The 3-in-1 biogas unit has an average annual recur- ing for a maximum of 4.4% of total costs for UDDT in ru- rent cost of US$31.6. The most advanced sanita- ral areas. Specifically, there was no measured program cost tion options including septic tank have the highest from the governments or any other financiers on shared or recurrent cost ranging from US$46 to US$74.2 an- pit latrines across the field sites, although officially the pro- nually due to more spending on water supply and main- vincial government should allocate funds for the programs tenance. to implement interventions. There is a limited program cost on UDDT in Qiubei from the Swiss Re-insurance Compa- Across all the rural sites, the cumulative recurrent costs ny and the German Embassy in Beijing. Program costs for for a 20-year duration for all the sanitation options are all the sanitation options across the field sites account for higher than the initial investment cost, accounting less than 4.4% of the total cost on an average basis. Limited for more than 50% of total cost, except for the 3-in-1 bio- funds were invested in promotion, education and monitor- gas unit which accounts for 47% of total cost. ing of sanitation options in Yunnan Province. In rural areas, hygiene costs start with an initial one-off Recurrent costs in rural areas are 67% of the overall an- spending of US$36.3 and follow with an annual recurrent nualized cost for hygiene and 47% for biogas units. hygiene cost of US$15.1. 62 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene 5.1.2 URBAN AREAS cost of the centralized treatment facilities. Sewerage refers Table 29 summarizes the average cost per urban household to the flush toilets connected to a sewerage system, and its for different sanitation and hygiene options. The average cost includes household investment on the toilet, sewerage investment cost per household for hygiene is US$40.8. The and discharge of household wastewater. The actual utiliza- cost for shared and public toilets, pit latrines and UDDT tion is lower than the optimal capacity, which is considered ranges from US$137.6 to US$188.8. Septic tanks (with in the cost calculation. septage management) and sewerage range from US$522.2 to US$684.8. Average annual recurrent cost per household 5.1.3 PERI-URBAN AREAS ranges from US$16.1 for shared toilets to US$74.2 for Table 30 summarizes the average cost per peri-urban house- sewerage. Average annual cost per household calculated for hold for different sanitation and hygiene options. Aver- the whole life period ranges from US$26.6 for hygiene to age investment cost per household for hygiene US$40.5, US$108.5 for sewerage. US$145 for shared, pit and UDDT; the average household investment for a septic tank is US$522.9. The average recur- Capital investment accounts for 24% to 45% of the total rent cost per household ranges from US$18.2 for hygiene cost,up to 4.3% on program costs. The percentage of recur- to US$45.4 for a septic tank. Average annual cost calculated rent cost in total cost ranges from 54% to 74%. for the whole life period of sanitation options ranges from US$26.3 for hygiene to US$71.5 for a septic tank. Capital Septage with management refers to centralized sanitiza- (hardware) of the different sanitation options range from tion treatment for wastes from septic tanks, and the cost 29 to 45%, and recurrent (O&M) is 69% of the total cost. includes the toilet itself and the investment and recurrent TABLE 29: SUMMARY OF AVERAGE COST PER URBAN HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, YEAR 2009) Public Septage Septage Sewage Sewerage Cost Item Hygiene Shared Pit UDDT Septic toilet optimal actual optimal actual INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 37.9 133.2 187.4 164.0 168.3 497.9 537.2 571.7 629.9 653.3 2. Program 2.9 4.4 13.9 0.0 20.5 24.2 27.8 30.7 29.4 31.3 Sub-total 40.8 137.6 201.3 164.0 188.8 522.2 565.1 602.4 659.3 684.8 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 6.6 5.9 14.6 5.9 7.3 18.4 24.2 24.6 27.8 28.4 4. Maintenance 9.1 8.1 8.8 13.8 17.6 23.3 31.5 32.2 40.1 41.1 5. Program 2.9 2.2 5.1 0.0 4.4 4.4 4.4 4.8 4.4 4.7 Sub-total 18.4 16.1 28.5 19.6 29.3 46.0 60.0 61.6 72.3 74.2 AVERAGE ANNUAL COST CALCULATIONS Duration 5.0 10.0 10.0 10.0 10.0 20.0 20.0 20.0 20.0 20.0 Cost/household 26.6 29.9 48.7 35.9 48.2 72.1 88.3 91.7 105.2 108.5 Cost/capita 7.6 8.5 13.9 10.3 13.8 20.6 25.2 26.2 30.1 31.0 OF WHICH: % capital 0.3 0.4 0.4 0.5 0.3 0.3 0.3 0.3 0.3 0.3 % program 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 % recurrent 0.7 0.5 0.6 0.5 0.6 0.6 0.7 0.7 0.7 0.7 Observations 257 2 16 26 3 156 10 10 44 44 www.wsp.org 63 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene FIGURE 38: ECONOMIC COSTS PER URBAN HOUSEHOLD FOR MAJOR ITEMS (US$, YEAR 2009) Hygiene Shared Public Toilet Pit Latrine UDDT Septic Tank Septage Optimal Septage Actual Sewage Optimal Sewage Actual 0 100 200 300 400 500 600 700 Capital Recurrent (annual) (US$) Program Average (annual) FIGURE 39: ECONOMIC COSTS PER PERI-URBAN HOUSEHOLD FOR MAJOR ITEMS (US$, YEAR 2009) Hygiene Shared Pit UDDT Septic 0 50 100 150 200 250 300 350 400 450 500 Capital Recurrent (annual) (US$) Program Average (annual) 64 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene TABLE 30: SUMMARY OF AVERAGE COST OF A PERI-URBAN HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, YEAR 2009) Cost Item Hygiene Shared Pit UDDT Septic INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 37.6 135.3 166.7 169.2 498.3 2. Program 2.9 0.0 0.0 17.0 24.6 Sub-total 40.5 135.3 166.7 186.4 522.9 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 6.9 5.9 5.9 7.9 18.3 4. Maintenance 8.3 11.4 14.8 15.8 22.7 5. Program 2.9 0.0 0.0 4.4 4.4 Sub-total 18.2 17.3 20.6 28.3 45.4 AVERAGE ANNUAL COST CALCULATIONS Duration 5.0 10.0 10.0 10.0 20.0 Cost/household 26.3 30.8 37.3 46.8 71.5 Cost/capita 7.5 8.8 10.7 13.4 20.4 OF WHICH: % capital 0.3 0.4 0.4 0.4 0.3 % program 0.0 0.0 0.0 0.0 0.0 % recurrent 69.1 56.0 55.4 60.2 63.5 Observations 199 71 29 24 75 In comparing different settlements, rural households adopt hygiene to 86% for septic tanks. Although the overall eco- similar sanitation options as peri-urban households. There nomic cost for program investment is small, financial costs is little difference between rural and peri-urban households as a proportion of total program cost ranges from 50 to in investment cost, recurrent and average annual cost. The 88%. Financial costs contribute from 44 to 65% of the total cost for sewerage for urban households has a higher invest- recurrent cost. For overall annual equivalent cost, financial ment cost, annual recurrent cost as well as the average an- cost contributes from 54 to 68%. Annex Table G4 provides nual cost. For the same sanitation option, the overall cost more details. in urban areas is higher than that in peri-urban and in rural areas since the urban population tends to invest more in 5.3 SOURCES OF FINANCING FOR hygiene than the rural population due to higher incomes SANITATION AND HYGIENE and consumption level. Figures 41 to 43 show the sources of financing in rural, urban and peri-urban sites, respectively. According to the 5.2 ECONOMIC VERSUS FINANCIAL COST investigation in Dali, Kunming and Qiubei, sanitation and Figure 40 depicts the proportion of financial cost to overall hygiene interventions are largely financed by individual economic cost including capital, program, annual recur- households with contributions also made by different gov- rent, and average annual across all the sanitation options. ernment agencies and NGOs. In rural areas, 3-in-1 biogas The data sources for each sanitation option are based on an units are mostly financed by the forestry bureau and poverty aggregation of the field site implementing each sanitation alleviation office, and improved pit latrines and septic tanks option. The proportion of financial cost for capital invest- are co-financed by the Yunnan Environmental Protection ment for all the sanitation options ranges from 58% for Department (YEPD). www.wsp.org 65 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene FIGURE 40: PROPORTION OF TOTAL (ECONOMIC) COSTS WHICH ARE FINANCIAL, ACROSS ALL FIELD SITES Hygiene Shared Public Toilet Pit Latrine UDDT Biogas Septic Tank Septage Sewage 0 10 20 30 40 50 60 70 80 90 100 Capital Recurrent (%) Program Total Annual FIGURE 41: PROPORTION OF RURAL SANITATION COSTS FINANCED FROM DIFFERENT SOURCES (%) Septic Tank Biogas UDDT Pit Latrine Shared Hygiene Household 0 10 20 30 40 50 60 70 80 90 100 NGO/donor (%) Government 66 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene Shared and pit latrines are commonly built by the users au- In urban or peri-urban areas, the Construction Bureau fi- tonomously without financing from government or other nances the sewerage trunk construction as part of the pub- institutes. Septic tanks, biogas units and UDDT in rural lic infrastructure of the city. Urban households pay for the areas are financed by government agencies. Local and in- flush-toilets, washrooms, septic tanks, sewerage branches ternational NGOs also finance sanitation in rural areas, but and maintenance, which are included in the cost of the at smaller scale in comparison with government agencies. apartment. Public toilets in urban or peri-urban areas are Government funds tend to finance initial capital outlay on mostly financed by the local governments including initial sanitation and hygiene, so when recurrent costs are consid- capital and maintenance, while users pay the operational ered, government financing accounts for roughly 30% of costs. Household flush toilets connected to septic tanks overall sanitation costs. For example, government financing have household financing of 70% and governmental in- of overall cost varies from 22% for septic tanks to 34% for vestment of 30%. The governmental investment funds are biogas units. In some areas, UDDT is financed by interna- used for construction of sewerage and wastewater treatment tional NGOs accounting for 21% of overall cost. In addi- plants. Fifty-eight percent of septage treatment facility costs tion, household financing is partially through non-financial are financed by households and 42% by the government. contributions such as own labor for construction and main- Fifty-one percent of sewerage costs are financed by house- tenance, and locally collected materials. holds and 49% financed by the government. Sewerage FIGURE 42: PROPORTION OF URBAN SANITATION COSTS FINANCED FROM DIFFERENT SOURCES (%) Septage Septic Tank UDDT Pit Latrine Public Toilet Shared Hygiene 0 10 20 30 40 50 60 70 80 90 100 Household NGO/donor Government (%) FIGURE 43: PROPORTION OF PERI-URBAN SANITATION COSTS FINANCED FROM DIFFERENT SOURCES (%) Septic tank UDDT Pit Latrine Shared Hygiene 0 10 20 30 40 50 60 70 80 90 100 Household NGO/donor Government (%) www.wsp.org 67 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Costs of Improved Sanitation and Hygiene In peri-urban areas, shared toilets are co-financed 70% by cost per household of US$677.6. Rural shared pit latrines the government including initial capital and maintenance, and private pit latrines have a total economic cost of US$ and users pay the operational cost. Pit latrines are financed 310.2 and US$357.0. The economic cost of UDDT per totally by households. Fifty-six percent of UDDTs are fi- household is US$456.7, and hygiene is US$129.6. Mov- nanced by households and 44% by the government. Sev- ing up the ladder involves a cost saving when hardware is enty percent of septic tanks are financed by households and reused. 30% by the government. Hygiene interventions receive ap- proximately 80% financing from the households and 20% Table 31 shows that households moving from rural shared from the government across all the field sites. pit latrines, private pit latrines, UDDT, and biogas units to sewerage respectively, have the full cost of the targeted 5.4 COSTS OF MOVING UP THE LADDER sanitation option of sewerage of US$2170, and from septic This section describes the costs of moving up the sanita- tank to sewerage, households will pay an incremental cost tion ladder. The ladder is arranged not by superiority of the of US$769. option performance, but in terms of its cost. These data reflect the weighted average of the field sites – i.e. those Moving up the ladder from pit latrines to biogas units in- field sites with more observations have greater weight in volves a partial cost saving due to the reused hardware. Also, the average result. Septic tanks and sewerage at the top of moving up from septic tanks to sewerage involves a partial the sanitation option cost ladder have a total economic cost saving. All the other sanitation options moving up to cost per household of US$1400.5 and US$ 2169.9 respec- the targeted options need full cost because of the need to tively. Second, 3-in-1 biogas units have a total economic invest in the full hardware costs. TABLE 31: MARGINAL COSTS OF CLIMBING THE SANITATION LADDER (AVERAGE ALL SITES) (US$, YEAR 2009) Public Shared Sewerage Hygiene Pit latrine UDDT Biogas Septic tank toilet with toilet actual sewerage Duration 5.0 10.0 10.0 10.0 10.0 20.0 20.0 20.0 Sub-total 40.8 136.3 161.2 185.9 361.4 515.1 201.3 684.8 investment Sub-total 17.7 17.4 19.6 27.1 31.6 44.2 28.5 74.2 annual recurrent Total economic 129.6 310.2 357.0 456.7 677.6 1,400.5 772.2 2,169.9 costs Shared Pit latrine UDDT Biogas Septic tank Public Sewerage toilet with actual sewerage Shared - 357.0 456.7 677.6 1,400.5 772.2 2,169.9 Pit latrine - - 456.7 200.4 1,400.5 772.2 2,169.9 UDDT - - - 677.6 1,400.5 772.2 2,169.9 Biogas - - - - 1,400.5 772.2 2,169.9 Septic tank - - - - - 772.2 769.3 Public - - - - - - 2,169.9 toilet with sewerage 68 Economic Assessment of Sanitation Interventions VI. Sanitation Program Design and Scaling Up The Program Approach Analysis (PAA) aims to evaluate the specific conditions which are partially responsible for the link between different program approaches and eventual performance results; hence findings are not definitive, but efficiency and impact of the sanitation options. The PAA instead illustrative and instructive. compares indicators of sanitation program performance available from field site questionnaires and program docu- 6.1 PROGRAM APPROACH ANALYSIS FROM ments, and also collects additional information from inter- FIELD SITES views with sanitation program managers and implementers. This section contrasts and compares the different indicators This chapter presents: for assessment of program effectiveness in relation to differ- ent impacts of improved sanitation. The selected indicators • The determinants of performance of sanitation pro- will be used to estimate actual efficiency of sanitation pro- grams from field sites and selected case studies. grams in Chapter 7. • An overview of current practice in relation to sanita- tion program evaluation, to identify major gaps in 6.1.1 BASIC PROGRAM FEATURES FROM FIELD understanding program performance, and to pro- SITES vide recommendations for improved monitoring Table 32 shows basic program information in terms of and evaluation of sanitation programs. starting and finishing coverage, and proportion of house- holds reached by the program. The PAA is constrained by a lack of input data available from programs evaluated: several program reports are not From the collected data, different sites have different sani- available and the information is from forms filled out by tation coverage, and the sanitation coverage has been in- the representatives of the organization or from secondary creased, especially in sites R1, R3 and U2. Different places materials. The lack of information limits the number of have different growth rates, the most significant being Kun- programs that could be included in the study. The results ming rural site R1, where sanitation coverage has increased of the analysis are interpreted taking into account setting- from 22 to 94%. TABLE 32: SANITATION COVERAGE INFORMATION PER FIELD SITE Households Project starting Project ending Site Interviewed in Reached by % coverage(%) coverage (%) ESI survey program R1. Kunming 151 54 35.8% 21.8% 94.0% R2. Dali 133 59 44.4% 72.3% 75.1% R3. Qiubei 171 75 43.9% 69.1% 94.5% U1. Kunming 120 59 49.2% 78.2% 83.0% U2. Dali 61 25 41.0% 66.7% 81.5% U3. Qiubei 72 19 26.4% 74.1% 77.8% PU1. Kunming (Jinning) 141 53 37.6% 74.3% 78.5% PU2. Dali 60 34 56.7% 85.2% 82.5% www.wsp.org 69 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up TABLE 31: BASIC FEATURES OF FIELD SITE SANITATION PROGRAMS Toilet Implementation Site Finance Technical assistance, partnership and coordination types approach Kunming Pit latrine Demand-led Household Household is responsible for construction and management. rural Flush to Traditional technology Household/government Household pays for water bill, sanitation construction cost and (Luquan) septic tank planning maintenance cost. Kunming Flush to Traditional technology Household and government Household pays for water bill, sanitation construction cost and Urban septic tank planning maintenance cost. Flush to Traditional technology Government and household Household pays for water bill, sanitation construction cost and sewerage planning maintenance cost, and local tax will cover the construction cost, and operation cost of WWTP. Kunming Pit latrine Demand-led Household Household is responsible for construction and management. Peri UDDT Supply-driven/project Funds from project and Swedish Royal Institute of Technology funded this project, Kunming City (Jinning) driven matching funds from household Environment Protection Bureau provided the technical support and was responsible for project management. Flush to Traditional technology Household/government Household pays for water bill, sanitation construction cost and septic tank planning maintenance cost. Dali Rural Pit latrine Demand-led Household Household is responsible for construction and management. UDDT Supply-driven/project Funds from project and Dali City Environment Protection Bureau is responsible for technical driven matching funds from household support. The project is contracted to a construction unit, and the household members put in labor and time. Flush to Traditional technology Household/government Household pays for the sanitation construction cost and responsible septic tank planning for sanitation maintenance. The government is responsible for waste management. Biogas Supply-driven/project 66.7% from government and Local forestry bureau provided technical support and financial support, driven 33.3% matching funds from household members put in labor and time. household Pit latrine Demand-led Household/government Household is responsible for construction and management. Dali urban Flush to Demand-led, Household/government Household covers the cost of the toilets, the construction unit is septic tank traditionial technology responsible for construction, the pipeline and other wastewater planning treatment systems are funded by government. Flush to Demand-led, Local government and Household pays for water bill, sanitation construction cost and sewerage traditional technology household maintenance cost, and local tax will cover the construction cost, and planning operation cost of WWTP. Pit latrine Demand-led Household Household is responsible for construction and management. Dali peri- Flush to Demand-led, Household and government Household covers the cost of the toilets, the construction unit is urban septic tank traditional technology responsible for construction, the pipeline and the wastewater treatment planning systems are funded by government. UDDT Supply-driven/project Funds from project and Dali city environmental protection bureau is responsible for building driven matching funds from household UDDT facilities. Pit latrine Demand-led Household Household is responsible for construction and management. Qiubei UDDT Supply-driven/project The project covered 80% Several partners cooperated with each other. The main responsibilities Rural driven of the construction costs; are as follows: Yunnan Environment Development Institute was in charge the voluntarily participating of the project monitoring and inspection, Qiubei County Environment households covered the Protection Bureau, Xianrendong Primary School, Caihuaqing Primary remaining 20%. School were in charge of the implementation. Biogas Supply-driven/project Project funding 66.7%, 33.3% The project was contracted to a construction company, the energy office driven matching funds by households of Qiubei County Forestry Bureau was responsible for checking and accepting. Flush to Traditional technology Household and government Household covered the cost of the toilets, the construction unit was septic tank planning responsible for construction, the pipeline and other wastewater treatment systems were funded by government. Pit latrine Demand-led Household Household was responsible for construction and management. Qiubei UDDT Supply-driven/project 80% funds from project and Swiss Reinsurance Company and German Embassy, Beijing financed Urban driven 20% matching funds from this project, Yunnan Provincial Environment Protection Department household provided the technical support and project monitoring. Traditional technology Household and government Household covered the cost of the toilets, the construction unit was planning responsible for construction, the pipeline and the wastewater treatment systems were funded by government. 70 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up Table 33 shows the main characteristics of different sani- In urban areas, communal systems are a necessity, especially tation programs in eight sites. Program approaches are in densely populated areas or apartments. When houses in assessed from three perspectives: the implementation ap- urban areas are constructed, the sanitation system is de- proach, the financing approach and the partnership ap- signed and constructed by a property developer. The house- proach, as follows. hold commonly chooses the sanitation facilities, such as specific toilet hardware. However, it is not the household’s 6.1.2 IMPLEMENTATION APPROACH choice whether it is connected to the sewerage system or In rural areas, there are two main motivators for improve- not. In urban areas, the household covers the water bills and ments in sanitation. One is household self-motivation, maintenance fee. The government will fund the wastewater where (usually) the pit latrine is voluntarily constructed treatment systems and other management costs. It could by the household. In this sense it is autonomous and de- be said that this approach is partially demand-led from the mand-led. The technology is simple, and the human ex- household, as they demand more hygienic and comfortable creta is commonly reused in the fields. The other motivator sanitation facilities, including water flushing systems. for improved sanitation is supply-driven (project-driven). Under this implementation approach, the funds are com- Figure 44 shows the proportion of households with choice monly available, either from government subsidies or from to participate. In general, the rate of households who feel donor projects’ budgets. If the funds are from the govern- that they had a choice to participate in the projects is not ment, the implementation approach is usually “top-down,” very high. The highest voluntary participation rate is from in that limited consideration is taken of the local needs and Dali peri-urban areas, with a 30% voluntary participation conditions. The toilet type is chosen for households, but rate; the lowest is from Qiubei City areas, with less than a the households accept the project because it is almost free 10% voluntary participation rate. This may be related to for them. If they are not active in the project, other projects the top-down planning approach of government projects. may not be extended to their communities. Therefore, the Only a small part of the projects used participatory meth- actual use of the sanitation option may not be high, and ods to understand customers’ needs and opinions. In addi- hence the efficiency is affected. For example, there exist in- tion, shown in Annex Table H1, in most projects there are stances where the biogas toilet is constructed in households no other complementary activities. Only a small number of that do not raise any animals or where the climate is not projects conducted supporting activities, such as carrying very suitable for year-round biogas generation. Project-driv- out health awareness education or provision of water. This en sanitation requires better project design and post-project may be related to the narrow scope of project design and management. limited project funding. FIGURE 44: HOUSEHOLDS WHO STATED THEY HAD A CHOICE WHETHER TO PARTICIPATE OR NOT R1 R2 R3 U1 U2 U3 PU1 PU2 0 5 10 15 20 25 30 35 proportion of households able to choose to participate (%) Source: Annex Table H1 www.wsp.org 71 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up FIGURE 45: MORE THAN ONE SANITATION OPTION WAS GIVEN TO HOUSEHOLDS R1 R2 R3 U1 U2 U3 PU1 PU2 0 5 10 15 20 25 30 proportion of households able to choose sanitation option received (%) FIGURE 46: APPROPRIATE TECHNOLOGY – HOUSEHOLDS WITH INSUFFICIENT WATER FOR FLUSHING TOILETS R1 R2 R3 U1 U2 U3 PU1 PU2 0 1 2 3 4 5 6 7 8 proportion of households with insufficient water for flushing (%) Sometimes Often Source: Annex Table H3 Figure 45 shows that some projects provide options for are passively involved in the project, and the result is that users, but generally speaking, the percentage with differ- the utilization rate of some sanitation options is not high. ent options on offer is not high. The highest proportion For example, the utilization rate of UDDTs in Kunming of households with choice of option is in the Qiubei rural peri-city area is relatively low, and some users use them for area, with less than 25%, and the lowest is in Kunming city storage. area, with less than 5%. This may be related to the project design. In fact, at the project design phase, the project con- To assess the appropriateness of technology, an indicator tent and the type of toilets have been agreed and the users was selected from the household survey which asked house- are not involved in later project planning. Otherwise, users holds with flush toilets whether they had enough water cannot get any support and it may be considered that they for flushing their toilets. Figure 46 shows that only a small lack enthusiasm in the project, which may lead to no fu- number of users sometimes or often have insufficient water ture projects in the village or local area. Thus, most farmers to flush toilets, while most users state they have adequate 72 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up water to flush toilets. However, many cities like Kunming plants are relatively high and therefore funded by a govern- face water shortages, so water-saving and environment- ment agency. Flushing toilets in urban areas are uniformly friendly sanitation options should be alternatives, especially constructed by property developers when constructing the in water-scarce urban areas. A second indicator, the flood- residential housing. The basic construction cost including ing of pit latrines, also indicated very few problems: less the sewer, toilet and septic tank is included in the cost of than 5% of households have pit flooding or pit overflow. the houses, to be eventually paid by the house owners. During the rainy season, there is a higher proportion, but still less than 10 % of pit latrines overflow. Annex Table H3 International funds or national funds are provided by do- presents more details. nors, foundations and non-government organizations, which are mainly by means of projects implemented in the 6.1.3 FINANCING APPROACH communities or villages. The UDDT and biogas toilets are The investment for sanitation can come from many sources. mainly project driven. The funds mainly come from ex- A clear trend of sanitation programs is that a large part of ternal (foreign) donors. The UDDT project in the Qiubei funds come from projects or government subsidies, while urban site is funded by the Swiss Reinsurance Company the others need households to provide matching funds. and German Embassy, Beijing. The household contributes Information on financing sources was already presented in labor. Chapter 5.3. The main findings are presented briefly below. Figure 47 shows that the project financial support is differ- Government funds: from central, provincial and local fiscal ent in different projects and regions, and the investments allocation of funds. The funds of biogas toilets are provided from projects vary greatly. The project investment in Dali by the forestry department, poverty alleviation office, envi- rural areas and Qiubei City is the highest with more than ronmental protection bureaus or from women’s federations, 8,000 RMB per household. Qiubei rural areas receive sig- which are allocated from the central government for en- nificantly less, at under 700 RMB, and Kunming rural areas ergy saving, poverty reduction, environmental protection, have the least investment from the project. The investment and standard of living improvement. The toilets flushing to from households also varies among different regions and sewerage or septic tanks are different, as the construction sanitation options. The investments from households are in and operational cost of sewerage and wastewater treatment the form of cash, labor and materials. FIGURE 47: FINANCIAL INPUTS FROM HOUSEHOLD VERSUS PROJECT SOURCES (US$, 2009) R1 R2 R3 U1 U2 U3 PU1 PU2 0 200 400 600 800 1000 1200 project input household input US$ www.wsp.org 73 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up 6.1.4 PARTNERSHIP APPROACH In some cases, several parties make a concerted effort in with coordination by the Yunnan Provincial Environment order to achieve a common goal. This includes financing Protection Department and Qiubei Environment Protec- partnerships, implementation partnerships, coordination tion Bureau. and management partnerships. In term of financing part- nerships, the project may be co-funded by two or more 6.1.5 EFFECTIVENESS INDICATORS OF organizations or groups. As an example, in urban Qiubei, PROGRAMS IN FIELD SITES the UDDT project is co-funded by the Swiss Reinsurance Table 34 shows selected indicators from the program sites Company and German Embassy, Beijing, and implement- to illustrate the variation in the performance of different ed by the local construction department and households, sanitation programs (refer to Annex Table H4). TABLE 34: INDICATORS OF OVERALL PROGRAM EFFECTIVENESS IN FIELD SITES Rural sites Urban sites Peri-urban sites Variable R1 R2 R3 U1 U2 U3 PU1 PU2 Years of program 4 5 4 3 2 3 4 5 Approximate total investment 2648 8782 1935 3249 5511 11115 1900 5702 cost per household (RMB yuan) Main sanitation options UDDT, Septic/ Biogas/ Sewerage Sewerage Septic Septic Septic adopted biogas UDDT UDDT % HH contribution to cost 53.6% 38.3% 49.7% 28.3% 70.5% 47.2% 55.3% 28.3% % IMPROVED SANITATION HOUSEHOLDS, WITH MEMBERS SOMETIMES OR OFTEN, RESPONDING TO INTERVIEWER: Using bushes for defecation 3.3% 4.6% 10% 0 0 1.4% 0 5% Using bushes for urination 5.3% 6.1% 17% 0 1.6% 1.4% 0.7% 5% Children using latrine 24.5% 13.5% 18.1% 10% 24.6% 22.2% 29.1% 6.7% Children seen defecating in 27.2% 16.5% 24% 20% 34.4% 51.4% 30.5% 61.7% yard Washed hands with soap 94% 94.7% 85.4% 95.8% 100% 86.1% 97.2% 93.3% yesterday Washing hands after defecation 88.1% 69.9% 55% 75% 78.7% 77.8% 90.1% 71.7% % IMPROVED SANITATION HOUSEHOLDS, OBSERVED BY INTERVIEWER: Using well which is not covered 8.6% 0 29.8% - 13.1% 6.9% 13.5% - Using bucket to withdraw 17.2% 6% 11.7% - 18% 9.7% 22.7% - water from well Pit latrine/septic tank within 0 40% - - - - 0 0 10m of well Pit latrine/septic tank within 0 60% - - - - 0 50 20m of well Signs of feces/waste at toilet 23.8% 15.8% 12.3% 4.2% 29.5% 4.2% 34.8% 0 Signs of insects in toilet 62.9% 43.6% 14.6% 75.8% 67.2% 27.8% 75.2% 11.7% Running water in or near toilet 25.2% 51.9% 13.5% 70.8% 14.8% 65.3% 15.6% 80% Soap available for 32.8% 54.9% 13.5% 88.3% 25% 72.2% 22.7% 95% handwashing Data source: ESI household survey 74 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up To estimate actual economic performance, it is necessary Kunming peri-urban and Dali city are less satisfied due to to use selected key indicators of sanitation program perfor- lack of improved private toilets constrained by limited land mance to adjust the different benefits – health, water, access space. time and reuse – from the ideal efficiency level under highly performing options to get actual efficiency level under ob- Figure 49 shows that satisfaction of the households relating served performance. Table 35 shows the selected key indica- to the external environment does not vary a lot. Users in the tors, and presents the data. The extent of use of sanitation Kunming City area feel very satisfied with the external envi- facilities, the hygienic state of sanitation facilities, the access ronment, and users in the Qiubei Rural area feel the worst. time for sanitation, the extent of actual reuse of human ex- The external environment in rural areas is still moderately creta, the degree of satisfaction with key aspects of toilet poor quality, and the external environment in urban areas facilities and the degree of satisfaction with the external en- has been much improved. vironment: these variables can all show the effectiveness of the different types of sanitation. Figure 50 shows that people in rural areas use for urina- tion and defecation more frequently than people from city Figure 48 shows that most of the users are satisfied with the and peri-city areas. There are a few people using open areas sanitation facilities. In general, the households interviewed shrubs for urination and defecation after improvement of are satisfied with the sanitation options. The households in sanitation and hygiene. TABLE 35: SELECTED KEY INDICATORS FOR PROGRAM EFFECTIVENESS AVERAGELY CALCULATED FOR ALL THE SITES Impact Indicator area FOR QUANTITATIVE CBA TO ESTIMATE ACTUAL EFFICIENCY Health (sanitation) 78% household members using improved toilet instead of previous unimproved option Health (hygiene) 75% households answered “yes” to washing hands after defecation 16% improved latrines in which there were signs of feces around toilet Water treatment 14% households treating water use non-boiling water treatment methods Access time 75% household members using own toilet instead of off-plot options Reuse 71% households with UDDT or biogas use the bi-products (fertilizer or biogas) FOR QUALITATIVE ANALYSIS Intangibles Average score of 3.6 (out of maximum score of 5) for all relevant satisfaction questions External environment Average score of 3.0 (out of maximum score of 5) for 2 external environment questions relating to sewage (visibility and smell) FIGURE 48: SATISFACTION LEVEL TO SANITATION OPTIONS (5 = VERY SATISFIED; 0 = DISSATISFIED) Kunming Rural Dali Rural Qiubei Rural Kunming City Dali city Qiubei City Kunming Peri Dali Peri 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 www.wsp.org 75 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up FIGURE 49: THE SATISFACTION LEVEL TOWARDS THE EXTERNAL ENVIRONMENT (5 = VERY SATISFIED; 0 = DISSATISFIED) Kunming Rural Dali Rural Qiubei Rural Kunming City Dali city Qiubei City Kunming Peri Dali Peri 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 FIGURE 50: PROPORTION OF HOUSEHOLDS WITH MEMBERS WHO SOMETIMES OR REGULARLY URINATE OR DEFECATE IN OPEN AREAS, PER SITE (%) Kunming Rural Dali Rural Qiubei Rural Kunming City Dali City Qiubei City Kunming Peri Dali Peri 0 2 4 6 8 10 12 14 16 18 Use bush for defecation (%) Use bush for urination Figure 51 shows that the phenomenon of insects or animals and city areas. It may be related to the fact that the house- in toilets is relatively common, and signs of feces relatively holds in rural areas make use of human excreta as fertil- less common. In addition, the feelings of urban people to- izer in their own fields or as the materials for raw biogas. wards the insects in their toilets are stronger than that in With the increasing scaling-up of urbanization, and the rural areas. There is another trend that the more developed change of land-use, many farms in city and peri-city areas the economy, the more people concerned about the sanita- become industrial factory buildings or commercial residen- tion status of the toilets. tial buildings. Some of the users do not cultivate their farms anymore, and use flushing toilets, so the rate of waste reuse Figure 52 and Annex Table H3 show that there are a small is much lower. number of toilets (less than 10%) that often overflow dur- ing the rainy season. This shows that choosing appropriate 6.2 PROGRAM APPROACH ANALYSIS FROM A sanitation options in the areas with a rainy season is very BROADER ANALYSIS important to keep the environment free of pollution from Table 36 shows the basic features of sanitation programs human excreta. and the basic interventions. The UDDT project in Puzhe- hei (Qiubei Urban) and the Biogas projects in Qiubei Ru- Figure 53 shows that the utilization ratio of human excreta ral are included in this section for further analysis (project from rural areas is much higher than that of peri-city areas numbers 1 and 4 in the table). 76 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up FIGURE 51: THE SANITATION STATUS INSIDE AND AROUND THE TOILET BUILDING/ROOM Kunming Rural Dali Rural Qiubei Rural Kunming City Dali City Qiubei City Kunming Peri Dali Peri see waste/feces around the toilet 0 10 20 30 40 50 60 70 80 see insects around the toilet proportion of households FIGURE 52: PROPORTION OF HOUSEHOLDS WITH PIT OFTEN OVERFLOWING DURING RAINY SEASON (%) Kunming Rural Dali Rural Qiubei Rural Kunming City Dali city Qiubei City Kunming Peri Dali Peri 0 1 2 3 4 5 6 7 8 9 10 proportion of households FIGURE 53: PROPORTION OF HOUSEHOLDS REUSING HUMAN EXCRETA (%) Kunming Rural Dali Rural Qiubei Rural Kunming City Dali City Qiubei City Kunming Peri Dali Peri 0 10 20 30 40 50 60 70 80 90 proportion of households www.wsp.org 77 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up The program information shows that participation, co- the Yanshan Forestry Bureau are invited to be respon- ordination, financing, etc. are related to sustainability. sible for technical guidance. Yunnan Green Environment Here, the biogas project in Yanshan County of Wenshan Foundation was responsible for coordination and proj- Prefecture by Yunnan Green Environment Foundation ect management. The users’ participation was mobi- serves as an example. For financing, Hongkong Changchun lized to contribute labor in the construction. Project Society has funded the investment, program, and recur- monitoring was executed by the donor systematically. rent costs for the first two years. For technical assistance, Hongkong Changchun Society was responsible for project the Energy Office, the Yunnan Forestry Department and monitoring. TABLE 36: KEY INFORMATION ON SANITATION PROGRAMS House- Change in Site lo- Provinces holds Utiliza- Inter- coverage Project cation, covered/ covered Unit Funding Start End tion No ven- Implementer Funder over proj- name urban/ population/ (receiving cost mechanism year year per- tions ect period rural households interven- centage (%) tions) 1 Puzhe- Puzhe- The Yi UDDT 185 house- Yunnan Swiss Re- 1,080 The project 2004 2008 From 0 to 95% hei Up- hei Lake minority holds Environment insurance covered 57% stream water- residents Development Company; 80% of the Eco- shed, in lake Institute German construction sani- Qiubei adjacent to Embassy, costs; the tation County, villages of Beijing voluntarily Project Wen- Puzhehei participating Phase I shan watershed households & II Prefec- (population covered the ture, 40,000). remaining Yunnan 20%. Prov- ince, China 2 Luoguo Luoguo 372 house- Biogas 300 house- Yunnan Hongkong 3,000 100% 2008 2009 From 0 to 100% village village holds in holds Green En- Changchun covered by 96.4% Ameng Ameng Luoguo vil- vironmental Society project Town- Town- lage Ameng Development ship ship Township Foundation 2. Energy Yanshan Yanshan Office, County County Yunnan (Rural) (Rural) Forestry Department 3. Yanshan Forestry Bureau 3 Lanping City Jinding Flush 26,000 Urban and Govern- 49 The funds of 2009 On-going NA County Township, toilet people Rural Con- ment mil- waste water City Lanping and struction Bu- lion treatment Waste- County waste reau Lanping plant: 70% water (population water County of capital Treat- of 26,000) treat- from trea- ment ment sury bonds, program plant 20% from loans,10% matching funds by local govern- ment. 4 Qiubei Rural 23,898 bio- Biogas 23,898 Qiubei Coun- Yunnan 1,500 Project fund- 2000 2009 From County gas toilets households ty Forestry Forestry ing 66.7%, 0 to Biogas across 90 Bureau Department 33.3% 29.95% program villages in matching 14 town- funds by ships households 78 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up TABLE 37: APPROACH OF SELECTED PROJECT Project Participation Coordination Financing Sustainability Luoguo village Ameng User participation in Training and management Full financing Needs assessment for Township Yanshan contribution of labor strengthened, Maintenance by donor appropriate technology/ County Biogas program team for follow-up service monitoring, High adoption rate Based on a full investigation to understand the needs of to sewerage with flushing toilet. In these cases the sanitation the villagers, the local actual situation, as well as the fea- is designed and constructed by a property developer, and sibility of biogas toilets, they implemented the projects of commonly the buyer can choose the toilet type, but not the constructing the biogas toilet, pig sty, and kitchen-improv- sanitation option itself. ing in a comprehensive manner. The project attached great importance to the software components, such as training Project design and implementation modality play an impor- and management capacity of local users, focusing on the tant role in the overall effectiveness and impact on house- sustainability of projects. The project is also very popular holds and hence efficiency. The project design is crucial for as the utilization rate is 100%. The costs are all covered by site selection considering whether there is scarcity of land, the project. The total investment of the project is 1.24 mil- whether the option of the sanitation types can fit the local lion yuan (not including the farmers’ own labor converting residents’ habits, as well as local natural environmental con- 345,000 yuan), of which 1.12 million was earmarked for ditions. In addition, the project should consider the users’ the materials and design fees; 90,000 yuan to cover the labor ability to pay. As most of the projects need some matching costs, 30,000 yuan for establishing the service team of the funds from households and the poorer households do not project. The team consisted of two people, who were chosen have sufficient available cash, they may give up participat- by the villagers and trained. The team provides free techni- ing in the projects. cal guidance and maintenance services for the management, and comprehensive utilization two years after construction. 6.3.2 THE FACTORS DETERMINING SANITATION Two years from now, if the biogas pool has any problems, INTERVENTION CHOICES users need to pay maintenance costs to the team. There are many factors affecting users’ choice of sanita- tion options, including users’ economic levels, education 6.3 ANALYSIS OF PROGRAM APPROACHES levels, local natural conditions, hygiene habits, ethnicity and cultural factors, duration of life of sanitation options, 6.3.1 THE IMPACT OF PROJECT DESIGN/ accessibility to external support, and technical guidance METHODOLOGY ON THE PROJECT and community services. As for the natural conditions, the EFFECTIVENESS 3-in-1 biogas toilets require a relatively mild climate for the The program approaches affect the effectiveness of the amount of methane production to reach the required mini- programs. In the rural areas of China, the promotion of mum. The cost of sanitation facilities and family economic improved sanitation facilities is carried out mainly by the conditions also impacts on the options of sanitation types. government. The approach of government programs tends Compared with pit latrines and dry toilets, the construction to be top-down implementation and supplier-driven, not cost of 3-in-1 biogas toilets is much higher. Without the always considering local needs and conditions. As a result, full amount of subsidies from the government or donors, users sometimes do not use or do not properly use the op- poor households could not invest in biogas toilets and thus tions, leading to reduced efficiency. In rural areas, some san- would have to relinquish the chance to participate in the itation investment is “demand-led,” with voluntary invest- program. The users’ social and cultural acceptability also ment and construction by households. The technology is affects the project performance. For example, the urine di- simple, and the human excreta is often reused in the fields. verting dry toilets are eco-friendly toilets, but it requires the Due to the low cost and high utilization rate, the economic users to accept the facility and also spend time and effort efficiency of pit latrines is high. In urban areas, a technology managing it. It is challenged by the cultural acceptance. The planning approach is common, with households connected utilization rate of UDDT in the suburb of Kunming is very www.wsp.org 79 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up low. Although UDDT has a high “ideal” benefit-cost ratio, pecially in environmental protection areas such as reservoir the challenge to traditional habits in using and maintaining catchments. The three-grid septic tank is not suitable for it and other factors make the acceptance very low and hence the areas with high water levels. Centralized wastewater the “actual” benefit-cost ratio is low. treatment technology is not appropriate to extend to the sparsely populated mountainous areas, whose construction User preference of sanitation options is related mainly to and operation costs require a minimum population density the convenience and cleanliness of the sanitation options. to make the investment worthwhile. Rural users also consider reuse of human excreta. House- holds with toilets hope to improve health, reduce pollution Biogas toilets and UDDTs have some advantages over other and use energy more efficiently. By analyzing the satisfac- on-site sanitation options which are worth further consid- tion level with the sanitation options, the results show the eration. First, 3-in-1 biogas toilets provide highly efficient users are more concerned with convenience (especially for organic fertilizer. The nutrients of the sludge from biogas the elderly, and using toilets at night and on rainy days), toilets are comprehensive, after treatment, which can be disease prevention, hygiene (no smell and no insects), envi- reused as manure for aquaculture, fruit tree planting, and ronmentally non-polluting, and the possibility of generat- soil conditioning. It can be used to soak seeds, which can ing energy for home use. enhance the germination percentage and reduce the pests and disease. Human excreta can be treated safely through 6.3.3 THE REPLICABILITY OF THE SANITATION fermentation and drying, and if done properly, can reduce PROGRAMS infectious diseases. The gas produced by the biogas toilet is Different sanitation options have their advantages and limi- used for cooking and lighting as an alternative, clean en- tations for wide-scale adoption, as summarized in Table 38. ergy. The use of biogas relieves women from exposure to For example, the 3-in-1 biogas toilet requires a relatively indoor smoke and from collecting firewood, contributing mild climate (the most favorable temperature is 12 to 25 to improved health. Biogas as an alternative energy source, degrees Centigrade) and sufficient animal excreta available beside firewood, helps reduce the consumption of wood, to add to the human excreta. The UDDT is more suitable and therefore protects forests and conserves water and soil. for areas with a dry climate and low temperature, and es- It is estimated that every cubic meter of gas can release TABLE G: ADVANTAGES AND DISADVANTAGES OF DIFFERENT SANITATION OPTIONS Sanitation types Advantages Disadvantages • Hygiene status of the toilet is often poor • Low construction cost • Often pollutes the environment, especially in the • Simple technology Pit latrine rainy season • Human excreta commonly extracted from the pit • Human excreta is not safely treated, causing a and reused as fertilizer higher health risk Biogas • Saves energy for lighting and cooking • High construction cost • Provides highly efficient and safe organic • Occupies space in homestead fertilizers • Limited by availability of animal manure • Saves money • Not suitable for cold climates • Reduces pollution to the environment • Needs good post-phase management, including • Convenient, safe and healthy maintenance UDDT • Provides highly efficient and safe organic • Not seen as convenient by users fertilizers • Smells if not properly maintained • Reduces pollution to the environment • Needs time input of household and resources (such as rice husk/sawdust) • Higher investment and recurrent cost than simple pit latrine Water flushing toilet (with • Clean • High construction cost and operational cost septic tank or sewerage) • Hygienic • Needs a large amount of water • Convenient • Needs off-site wastewater treatment systems, and if not, black water released to the environment pollutes water bodies 80 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up 5,500,000 ~ 6,500,000 cal of heat. A 6-8 cubic meter bio- water for flushing toilets can account for between one third gas unit can save more than 2,000 kg of firewood a year and one half of domestic water use. The flushing water will (Chen Li, 2003). mix with other less contaminating wastewater in the family, which increases the effluent volume. If it is further mixed The UDDTs also have several potential advantages, includ- with industrial wastewater and rain water, it is more costly ing pollution prevention, recycling what is often considered to treat. “waste” into usable and economically valuable nutrients, re- ducing the need for chemical fertilizers and thus contribut- The project design should include sensitization and capac- ing to ecological balance. The UDDTs can save water, and ity-building of the users, and also a plan for management reduce the cost of fertilizer. Every person can excrete 25-50 after the project has been completed and has withdrawn, kg of manure every year, containing 0.55 kg of nitrogen, in order to ensure the sustainability of the sanitation op- 0.18 kg of phosphorous and 0.37 kg of calcium. Also, every tions delivered. In the process of promoting the sanitation adult produces 400-500 liters of urine annually, contain- project, it is important to select the technical sanitation ing 4 kg of nitrogen, 0.4 kg of phosphorous and 0.9 kg of options that reflect the local situation, such as the natu- calcium. It respectively exists in the form of urea, phosphate ral conditions, local residents’ economic status, hygiene and potassium ions, which are more conducive to being ab- and living habits, and the willingness of residents to adopt sorbed by plants. It is helpful for promoting ecological agri- the technology. In addition, it is crucial to follow up with culture (Chen Li, 2003). hygiene education, awareness promotion, and monitoring since these can significantly increase the effectiveness and The pit latrine toilet is mainly constructed by the house- economic efficiency of the program. holds themselves, which is demand-led. As the construc- tion cost is low and the technology is simple, it is very In conclusion, having the appropriate project design is popular in the rural sites. In addition, human excreta very important as it determines the efficiency of the sani- in the pit can be easily used for fertilizer on farmland. tation interventions. First, it should take into account However, unless the excreta is appropriately hygienized the local needs and willingness to pay. The household and dried before application in the fields, there are owners should have a variety of sanitation types and options health risks which due to health costs may lead to net nega- to choose from. Second, project design should consider tive impacts. the hidden cost of projects, taking into account the fact that some sanitation options require higher spending on The construction costs of water-flushing toilets and convey- maintenance and operation costs, such as personnel, ance systems are relatively high, usually with a long dura- water and energy. Third, the subsidy element from tion of life. It is convenient, and if waste is well isolated and government is important and should focus on software treated then disease rates can be reduced. Therefore, water- components, including strengthening the capacity based off-site sanitation systems have good potential for ap- and skills of local technical personnel and supporting plication in cities and towns. But the toilet requires more the establishment of local maintenance teams, which water to function. A water-flushing toilet consumes 2,000 improve overall project efficiency, impact and sustain- liters of water per person per year (Chen Li et al, 2004). The ability. www.wsp.org 81 VII. Efficiency of Improved Sanitation and Hygiene This Chapter synthesizes the information presented in 7.1 EFFICIENCY OF SANITATION AND Chapters 4 to 6 to present sanitation option efficiency un- HYGIENE IMPROVEMENTS COMPARED der both ideal and actual program conditions. Alongside TO NO FACILITY the quantitative cost-benefit and cost-effectiveness ratios, Economic analysis combines evidence on the cost and ben- non-quantified impacts are also presented. The chapter efits of sanitation improvements already presented in earlier consists of four sections: chapters, giving a number of alternative measurements of • Efficiency of sanitation interventions, compared efficiency. Efficiency measures are presented in Table 39 for with no sanitation option (Section 7.1) rural areas, Table 40 for urban areas, and Table 41 for peri- • Efficiency of moving from improved sanitation op- urban areas, under an analytical time horizon of 20 years. tions to other options “higher” up the sanitation lad- der (Section 7.2) 7.1.1 RURAL SITES • Contextualization of the results in a provincial con- Table 39 shows that all the sanitation options in rural areas text (Section 7.3) have a high level of efficiency. The main sanitation options • Overall cost benefit assessment (Section 7.4) in rural areas include shared, pit latrine, UDDT, biogas di- TABLE 39: RURAL AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” (COST DATA IN US$, YEAR 2009) Efficiency measure Scenario Shared Pit latrine UDDT Biogas Septic tank Field sites including per option1 R2, R3 R1,R2, R3 R2 R2 R1,R2, R3 No. of observations (households) 14 118 14 43 214 COST-BENEFIT MEASURES Ideal 10.2 12.9 14.9 11.4 7.6 Benefits per 1 US$ input ($) Actual 6.0 8.5 9.4 6.9 4.7 Ideal > 100% > 100% > 100% > 100% > 100% Internal rate of return (%) Actual > 100% > 100% > 100% > 100% > 100% Ideal <1 year <1 year <1 year <1 year <1 year Payback period (years) Actual <1 year <1 year <1 year <1 year 1.4 Ideal 484.9 758.6 1,079.5 1,110.1 916.6 Net present value ($) Actual 262.4 473.2 652.5 637.2 520.5 COST-EFFECTIVENESS MEASURES Ideal 160.6 207.7 155.8 190.1 296.2 Cost per DALY averted ($) Actual 284.9 413.9 271.6 348.6 478.8 Ideal 1.4 1.8 1.4 1.7 2.6 Cost per case averted ($) Actual 2.5 3.1 2.4 3.2 4.3 Ideal 2,903 3,750 2,818 3,430 5,335 Cost per death averted ($) Actual 5,151 6,277 4,909 6,287 8,623 1 See Annex Tables for site-specific information. Figures reflect unweighted average of three rural sites. 82 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Efficiency of Improved Sanitation and Hygiene gesters, and private septic tanks. In comparison with “no the highest efficiency performance under ideal conditions. toilet,” UDDT has the best ideal efficiency of BCR at 14.9 Improved pit latrines are mostly preferred in rural areas, and actual BCR of 9.4, while private septic tanks in rural followed by biogas as the second choice. areas have the lowest BCR with significant value in an ideal program situation of 7.6 and under actual program effec- Most of the farmers interviewed in the FGDs thought that tiveness of 4.7. BCR of private pit latrines also reached 12.9 the improved private pit-latrine is more suitable, it can be in terms of ideal efficiency and actual efficiency of 8.5. For used for storing excreta/compost, and it is convenient to all technologies except septic tanks, the payback period is less than one year. The actual net present value (NPV) of FIGURE 55: BENEFIT-COST RATIO OF PIT LATRINES IN THREE RURAL SITES UDDT is the highest, reaching US$652.5, a little higher than that of 3-in-1 biogas units, and more than two times higher than that of shared toilets. 16 14 There are noteworthy differences in economic performance for pit latrines among the three rural sites, shown in Figure 12 55. The actual BCR of pit latrines ranges from 9.4 in Dali Benefit-Cost Ratio to 8.8 in Qiubei to 6.6 in Luquan (near Kunming). 10 8 For the health efficiency measures, the top-ranked interven- tions are UDDT, shared toilet and biogas. There is little dif- 6 ference among the options in term of health cost-effective- ness. UDDTs have a cost per DALY averted of US$155.8, 4 cost per case averted of US$2.4, and cost per death averted 2 of US$4,908.7. 0 In rural areas, the findings of the FGDs strengthen the con- clusion of low acceptance of UDDT even though it has Ideal Actual FIGURE 54: IDEAL AND ACTUAL BENEFIT-COST RATIOS OF RURAL SANITATION OPTIONS Shared toilet Pit Latrine Sanitation UDDT Option Biogas Septic Tank 0 2 4 6 8 10 12 14 16 ideal actual benefit-cost ratio Figures reflect unweighted average of three rural sites. www.wsp.org 83 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Efficiency of Improved Sanitation and Hygiene FIGURE 56: COST PER DALY AVERTED FOR RURAL SANITATION OPTIONS (US$, YEAR 2009) Shared toilet Pit Latrine UDDT Biogas Septic Tank 0 500 1,000 1,500 2,000 2,500 3,000 3,500 ideal actual cost per DALY averted (US$) clean. As a second choice they preferred to use the 3-in-1 of 36% and actual PBP of 4.4 years. In comparison, flush biogas unit. UDDT (Urine Diversion Dehydration toilet) toilets connected to septic tanks have a higher actual IRR was listed as their last choice; most of the families did not of 77% and lower actual PBP of 2.6 years. The net pres- like it due to the poor quality and radical change of habits ent value under actual conditions ranges from US$157 for in using and maintaining the toilet. Families without a toi- shared to US$402 for UDDT. let expected to have a public toilet or shared toilet within the community first, and then they expected to have an im- For NPV, the four sanitation options are ranked from pub- proved private pit latrine. lic flush toilet, with the highest value, followed by private pit latrine, private flush toilet with septic tank and private 7.1.2 URBAN SITES flush toilet with sewerage (the shared and UDDT are not In urban areas, sanitation options are mainly flush toilet calculated due to the small sample). In terms of cost-ef- connected to septic tank and sewerage as well as public toi- fectiveness, the four sanitation options in urban areas are lets. Some cities at county level like Qiubei have not yet in the same order as actual NPV. Cost-effectiveness mea- built a sewerage system, and therefore the main options are sures range from US$304.93 per DALY averted for pub- septic tanks together with shared and pit latrines. A city at lic toilet to US$886.4 per DALY averted for septic tank provincial level like Kunming has mostly sewerage, septic to US$1,385.3 per DALY averted for sewerage. Other less tanks, and public toilets connected to sewerage. common options found in urban areas – shared toilet and UDDT - also have potentially favorable efficiency, with a Table 40 shows that for urban areas, the BCR of private BCR ranging from 3.9 to 5.7, respectively. latrines is the highest with an ideal BCR at 7.9 and actual BCR at 5.4. Toilets with septic tanks have ideal and actual 7.1.3 PERI-URBAN SITES BCR of 4.2 and 2.8, respectively. In comparison, flush pri- According to the survey results in peri-urban areas in Ta- vate toilets with sewerage have less favorable BCR at 2.7 ble 41, the main sanitation options are shared pit latrines, (ideal) and 1.9 (actual). The lower ratios are mainly due private pit latrines, UDDT and private septic tanks. The to the high construction cost, leading to higher annual- sanitation options in peri-urban areas have very different ized costs per household than other sanitation options. economic performances than rural areas. UDDT and pri- Flush toilets with sewerage connection have an actual IRR vate latrines have the most favorable efficiency indicators. 84 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Efficiency of Improved Sanitation and Hygiene TABLE 40: URBAN AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” (COST DATA IN US$, YEAR 2009) Septic Sewer- Efficiency measure Scenario Shared Public toilet Pit latrine UDDT tank age Field sites including per option U3 U2 U2, U3 U3 U1, U2, U3 U1, U2 No. of observations (households) 2.0 16.0 26.0 3.0 156.0 44.0 COST-BENEFIT MEASURES Ideal 6.5 6.7 7.9 9.5 4.2 2.7 Benefits per 1 US$ input ($) Actual 3.9 4.5 5.4 5.7 2.8 1.9 Ideal >100% >100% >100% >100% 3.4 0.8 Internal rate of return (%) Actual >100% >100% >100% >100% 0.8 0.4 Ideal <1 year <1 year <1 year <1 year 1.6 2.4 Payback period (years) Actual 1.2 <1 year <1 year <1 year 2.6 4.4 Ideal 298.8 495.4 448.6 725.8 469.6 355.6 Net present value ($) Actual 157.3 305.0 285.4 401.7 262.0 180.6 COST-EFFECTIVENESS MEASURES Ideal 193.6 334.9 317.1 193.3 531.8 866.3 Cost per DALY averted ($) Actual 322.7 558.1 528.5 322.2 886.4 1,385.2 Ideal 1.9 3.0 2.9 1.9 5.1 8.2 Cost per case averted ($) Actual 3.2 5.0 4.8 3.2 8.4 13.0 Ideal 3,499 6,152 5,798 3,497 9,579 12,251 Cost per death averted ($) Actual 5,831 10,253 9,664 5,829 15,964 24,964 Figures reflect unweighted average of three urban sites. FIGURE 57: BENEFIT-COST RATIO OF SANITATION OPTIONS IN URBAN AREAS. Shared Public Toilet Pit Latrine UDDT Septic Tank Sewerage 0 2 4 6 8 10 ideal actual benefit-cost ratio For specific sites, the BCR of sewerage and septic tanks in the urban areas of Kunming, Dali, and Qiubei has little difference (see tables in annex). Figures reflect unweighted average of three urban sites. www.wsp.org 85 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Efficiency of Improved Sanitation and Hygiene FIGURE 58: COST PER DALY AVERTED FOR URBAN SANITATION OPTIONS (US$, YEAR 2009) Shared toilet Public Toilet Pit Latrine UDDT Septic Tank Sewerage 0 2,000 4,000 6,000 8,000 10,000 ideal actual cost per DALY averted (US$) Figures reflect unweighted average of three urban sites. UDDT and private latrines have an efficiency ratio of 5.3 or wet pit. In the peri-urban areas, families using public and 5.0 respectively. The actual BCR of septic tanks is at 2.7 toilets preferred the flush toilets–they anticipated installing as the minimum among the four sanitation options next a flush toilet if there was a septic tank or sewerage system. In to the shared option of 3.9. There is also a big difference peri-urban areas, public facilities for septage management between ideal and actual benefit cost ratios. for septic tanks, and sewerage, were not included in urban planning, and sanitation options used in peri-urban areas For IRR and PBP, the four sanitation options are ranked as are very similar to those in rural areas. UDDT, pit latrines, septic tanks and shared. Septic tanks have relatively low BCR and IRR compared to shared toi- 7.2 EFFICIENCY OF ALTERNATIVES FOR lets, but its actual NPV is higher than that of the toilets, MOVING UP THE SANITATION AND reaching US$245.9. HYGIENE LADDER It is important and practical to analyze the efficiency of al- For cost-effectiveness measures, UDDT is ranked first ternatives for moving up the sanitation ladder in Yunnan among the four sanitation options, followed by shared, pit Province, a context where sanitation coverage in still low latrine and septic tank. The cost-effectiveness measures for in rural areas and in future years many households may be the same sanitation option are higher than those in rural faced with improving their current toilet option. The long- areas, ranging from US$461 per DALY averted for UDDT term inputs from the government and other donors have to US$860 per DALY averted for septic tanks. helped the rural population to have better sanitation and hygiene. Many rural families have stopped practicing open Urban families using private wet pit or flush toilets were defecation. On the other hand, many sanitation options generally satisfied with the comfort of current sanitation currently used are not fully improved from both health options. However, for those families who used public toi- and environmental perspectives, thus requiring upgrad- lets, most of them thought that using a private toilet can ing. Hence, an examination of the efficiency of alternative provide more comfort; they expected to get a flush toilet options for moving up the sanitation and hygiene ladder 86 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Efficiency of Improved Sanitation and Hygiene TABLE 41: PERI-URBAN AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” (COST DATA IN US$, YEAR 2009) Efficiency measure Scenario Shared Pit latrine UDDT Septic tank Field sites including per option PU1, PU2 PU1, PU2 PU1, PU2 PU1, PU2 No. of observations (households) 71.0 29.0 24.0 75.0 COST-BENEFIT MEASURES Ideal 6.1 7.6 8.7 4.2 Benefits per 1 US$ input ($) Actual 3.9 5.0 5.3 2.7 Ideal >100% >100% >100% >100% Internal rate of return (%) Actual >100% >100% >100% >100% Ideal <1 year <1 year <1 year 1.6 Payback period (years) Actual 1.4 1.1 <1 year 2.8 Ideal 285.9 447.6 640.4 469.6 Net present value ($) Actual 159.9 271.8 354.0 246.0 COST-EFFECTIVENESS MEASURES Ideal 309.8 317.2 505.3 516.6 Cost per DALY averted ($) Actual 516.3 528.6 461.0 860.9 Ideal 2.8 2.9 2.5 4.7 Cost per case averted ($) Actual 4.7 4.8 4.2 7.9 Ideal 5,675 5,822 5,063 9,448 Cost per death averted ($) Actual 9,459 9,704 8,438 15,747 Figures reflect unweighted average of two peri-urban sites. FIGURE 59: BENEFIT-COST RATIOS OF PERI-URBAN FIGURE 60: COST PER DALY AVERTED OF PERI-URBAN SANITATION OPTIONS SANITATION OPTIONS (US$, YEAR 2009) 6,000 9 8 5,000 7 Cost per DALY averted (US$) Benefit-Cost Ratio 6 4,000 5 3,000 4 3 2,000 2 1,000 1 0 0 Ideal Actual Ideal Actual Figures reflect unweighted average of peri-urban sites. www.wsp.org 87 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up is important to provide evidence to policy makers and de- public toilets in the city, the analysis on the efficiency of velopment agencies as well as for households’ own autono- alternatives for moving up the sanitation ladder focuses on mous investment decisions. Below, representative sites for the private flush toilets due to insufficient sample of public rural and urban areas are selected to illustrate the issues. toilets in Kunming city. 7.2.1 RURAL SITE (QIUBEI) Table 43 shows that in urban areas, the economic perfor- In the Qiubei rural area, shared toilet and pit latrines are mance of moving from septic tanks (without septage man- widely used, so they are the starting points for an efficiency agement) to sewerage is not reasonable and feasible, but the analysis of alternatives for moving up the sanitation and health impacts of sewerage are potentially significant. The ladder. Table 42 shows that in rural areas, the efficiency of cost effectiveness ratio for moving from septic tanks to sew- improved sanitation moving from shared to private pit la- erage is US$6,177 per DALY averted. trine, UDDT and biogas are 2.89, 0.72 and 1.67 respec- tively. The efficiency of the UDDT alternative to shared is 7.3 SCALING UP RESULTS FOR PROVINCIAL less than 1, and the NPV is negative, but the health cost- POLICY MAKING effectiveness of the UDDT alternative to shared is favorable The ultimate use of this study is not only the improvement with a cost per DALY averted of US$632. The incremen- of sanitation decision making in the field sites of the study, tal efficiency of improved pit latrines is significant in com- but also in Yunnan province more generally. Also, given parison with the “shared.” Other sanitation options are not this is the first study of its kind throughout China, it is much different from pit latrines, so the incremental BCR of relevant to assess national policies in light of the study re- moving from pit latrine is not significant with a benefit cost sults. Therefore, how well do the field sites reflect different ratio of less than one; but cost effectiveness measures range decision making contexts in Yunnan Province and China in from US$448 per DALY averted for moving from shared to a broader sense? biogas, to US$1,084 per DALY averted for moving from pit latrines to septic tanks. First, the field sites were selected to be representative of different geo-physical, climatic, demographic and 7.2.2 URBAN SITE (KUNMING) socio-economic contexts in the province. Three different Kunming, as the provincial capital of Yunnan Province, has zones were represented: Northern, Central and South- a developed sanitation system with private flush toilets con- ern. In each zone, rural and urban sites were represented, nected to septic tanks and sewerage. There are some flush and in two zones (Central and Northern) also peri-urban toilets connected to septic tanks only. Although there are sites. TABLE 42: RURAL AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER (QIUBEI RURAL SITE) Moving from shared to Moving from pit latrine to Efficiency measure EcoSan EcoSan Pit latrine Biogas Biogas Septic + STF UDDT UDDT COST-BENEFIT MEASURES Benefits per US$ input ($) 3.8 4.5 7.3 4.5 5.0 2.1 Internal rate of return (%) >100% >100% >100% >100% >100% 40% Payback period (years) 1.2 <1.0 <1.0 <1.0 1.6 3.9 Net present value ($) 164 270 339 270 315 142 COST-EFFECTIVENESS MEASURES Cost per DALY averted ($) na 325 230 325 335 557 Cost per case averted ($) na 3.1 2.2 3.1 3.2 5.3 Cost per death averted ($) na 5,840 4,139 5,840 6,026 10,010 Note: na: not calculated due to improved pit latrine assumed to have the same health impact as improved shared latrine. 88 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up TABLE 43: URBAN AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER Efficiency measure Scenario Moving from septic tank to sewerage COST-BENEFIT MEASURES Ideal (1,453.6) Net present value ($) Actual (1,358.1) COST-EFFECTIVENESS MEASURES Ideal 6,176.8 Cost per DALY averted ($) Actual 9,617.9 Ideal 59.1 Cost per case averted ($) Actual 92.0 Ideal 110,636 Cost per death averted ($) Actual 172,273 Table 44 shows the characteristics of the eight field sites household stewardship. They can be extended to the rural based on climatic, social group, population size, economic areas with safe reuse of human excreta in small farming. and sanitation features. Biogas digesters can be scaled up in rural areas with a mod- The sites are diverse in terms of the climatic, geographic, erate temperature all year round and sufficient animal ex- cultural and economic characteristics. Field sites included creta for enough digestion to produce gas, since a family populations living in valleys or by lakesides to mountain- of four members does not have sufficient human excreta ous, hard to reach locations. The climate varied from a to digest. Private septic tanks currently under extension in low-altitude climate, monsoon climate to a mountainous lakeside rural areas are a feasible option, but not financially climate with a mean annual temperature ranging from 5 viable due to their high capital and financial investment. A degrees Celsius in the north to 24 degrees Celsius in the joint neighborhood septic tank is more economic, but the south. Economically, the income per capita differs by more maintenance is problematic due to a lack of institutional than ten-fold, ranging from US$219 to US$2,410 per year. teams in rural areas to manage them. Urban centers range from small towns of 50,000 to the pro- vincial capital of 3.2 million inhabitants, and rural areas Scaling up sanitation programs in rural villages with differ- range from villages of 200 to villages near towns of 10,000 ent ethnicities has to consider the physical conditions and inhabitants. This diversity has imposed challenges for gov- cultural preference for sanitation options in rural areas. The ernment stewardship capacity in sanitation and hygiene Yi ethnic group living upland and the Zhuang ethnic group scaling up, as it requires different program approaches as living by lakes or rivers will have markedly different sanita- well as technical options for different locations. tion options. In rural lakeside and plain areas, it’s difficult to maintain The peri-urban areas are under transformation from rural UDDT if maintenance is not properly carried out due to to urban, and some peri-urban areas have been included in flooding in the rainy season. The environmental protection urban planning to be demolished for total reconstruction. sector intends to extend UDDT near lakes to prevent the Governmental sanitation programs have to consider this discharge of human excreta into water bodies. factor to avoid wastage of funds. The choices of sanitation option of peri-urban residents are very different from rural Improved private pit latrines have a basic health function residents. Flush toilets with septic tank are mostly preferred and are well maintained due to a simple design, low cost and by peri-urban residents. Since peri-urban areas are between www.wsp.org 89 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up TABLE 44: CHARACTERISTICS OF FIELD SITES SELECTED IN THE ESI STUDY Average Population of Economy (average Sanitation Sites Climate Social group family size site income per capita) coverage (2008) Typical locations 1. Provincial capital 3 family Low altitude Han 3.2 million urban 16,495 yuan 87% of urban (Kunming, U1) members uplands dominated residents, 6.08 area (60% monsoon climate million including including rural with water rural residents area) scarcity 2. Prefectural capital 4 Mountainous Bai 610,000 urban 14,100 RMB yuan 67% (Dali, U2) monsoon climate residents per capita 3. County capital 4 Mountainous Yi, Miao Less than < 3,500 yuan per 50% (Qiubei, U3) monsoon climate 100,000 capita with flooding in rainy season 4. Small town (Pu1, 3 Lakeside, Han Less than 50,000 9,000 yuan per 67% Jinning, PU1) monsoon climate residents capita 5. Urbanizing rural 4 Lakeside Bai Around 10,000 5,135 yuan per 45% (Dali Zhoucheng, residents capita PU2) 6. Northern lakeside 4 Bai Around 10,000 3,480 yuan per 45% plain rural (Dali residents capita Shangguan, R2) 7. Mountainous 5 Cool Yi 200-500 villagers 1,632 yuan per 30% rural, watershed mountainous per village capita protected area (Kunming, Luquan, R1) 8. Southern lakeside 4 Flooding Zhuang 200-500 villagers < 1,500 yuan per 46% and mountainous per village capita rural (Qiubei, R3) city and rural, some are to be urbanized and other small extended to county-level cities with an increase in financial towns have more rural characteristics. It is important to investment from the central government. have a suitable sanitation program for specific sites. 7.4 OVERALL COST-BENEFIT ASSESSMENT Urban areas have been under strategic planning of the cit- This study has shown that the economic performances of ies, and household flush toilets are widely used. Public flush sanitation options and hygiene in all the sites of Yunnan are toilets should be well planned and constructed in com- favorable in comparison with “no toilet.” All the sanitation munities and crowded areas. While improving centralized options in rural areas have very high efficiency. In compari- wastewater treatment plants and the sewerage system, de- son with “no toilet,” the benefit-cost ratios of all sanitation centralized community-based wastewater treatment plants options are above 4, meaning the economic benefits of im- should be further promoted and enforced to reuse water proving sanitation and hygiene are at least four times the resources to mitigate the water scarcity problem. The coun- cost. Under ideal conditions they range from almost eight ty-level cities like Qiubei city have been targeted to con- for septic tanks to over 14 for UDDT. The most efficient struct sewerage systems and wastewater treatment plants by option is UDDT, followed by pit latrine and biogas. Cost- governmental programs. It is urgent to scale up sanitation effective measures range from US$271.6 per DALY averted and hygiene programs in the county-level cities with rapid for UDDT to US$478.8 per DALY averted for septic tank. urbanization and population expansion. Flush-toilets with However, as documented, there is a significant loss of ef- sewerage and wastewater treatment plants are a model to be ficiency from ideal to actual ratios. 90 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Sanitation Program Design and Scaling Up The sanitation options in peri-urban areas have very differ- septic tanks, to US$1,385 per DALY averted for sewerage. ent economic performances from rural areas. UDDT and private latrines have a higher efficiency of 5.3 and 5.0 re- In rural areas, the efficiency of improved sanitation moving spectively. Septic tanks have an actual BCR of 2.7, which to higher cost options from shared to private pit latrines to is the minimum among the four sanitation options after UDDT to biogas are 2.9, 0.7 and 1.7 respectively. The ef- shared toilets of 3.9. Very few biogas units were extended ficiency of the UDDT alternative to shared is less than 1.0 in peri-urban areas because few peri-urban households have and the NPV is negative. The health cost-effectiveness of domestic animal husbandry for providing the raw materials. the UDDT alternative to shared is significant with a cost Cost-effectiveness measures for the same sanitation option per DALY averted of US$632. The incremental efficiency are higher than those in rural areas, ranging from US$461 of improved pit latrines is significant in comparison with per DALY averted for UDDT to US$861 per DALY avert- shared toilets. Other sanitation options are not very differ- ed for septic tanks. ent from pit latrines, so the incremental BCR of moving from pit latrines is not favorable, with a benefit-cost ratio The economic performance of sanitation options in urban of less than one. But cost effectiveness measures range from areas in comparison with “no toilet” is lower than those of US$448 per DALY averted for moving from shared to bio- rural areas due to higher annual investment costs in com- gas, to US$1,084 per DALY averted for moving from pit parison with the benefits obtained. Benefit-cost ratios range latrine to septic tank. from 2.5 for sewerage to 4 for septic tanks to between 6 and 7 for shared and public toilets, to 8 or over for pit la- In urban areas, the economic performance of moving from trines and UDDT. As in rural areas, there is a significant septic tank to sewerage is not favorable, but the health im- loss of efficiency from ideal to actual ratios in urban areas. pact of sewerage is significant. Cost-effectiveness measures Cost-effectiveness measures range from US$305 per DALY for moving from septic tank to sewerage is US$1,408 per averted for public toilets to US$ 886 per DALY averted for DALY averted. www.wsp.org 91 VIII. Discussion 8.1 STUDY MESSAGES AND INTERPRETATION The incremental efficiency of improved pit latrines and bio- gas in rural areas is significant in comparison with shared 8.1.1 MAIN MESSAGES toilets, due to additional time savings and value of excreta This study has shown that the economic performance of reuse. Moving higher up the ladder from pit latrines – for sanitation options and hygiene in all sites of Yunnan is example – to UDDT, biogas and septic tanks brings only highly favorable in comparison with not having basic sani- limited additional economic gain. Therefore, the incremen- tation. In rural areas, all the sanitation options are highly tal BCR of upgrading from a pit latrine to these options is efficient, with UDDT, private pit latrines, 3-in-1 biogas not worthwhile from the perspective of quantified benefits. units, shared toilets and private septic tanks having a bene- However, if the pit latrine has come to the end of its use- fit-cost ratio ranging from 4.7 to 9.4 under actual program ful life and needs to be replaced or significantly renovated, conditions. If all program beneficiaries had used their new then from an economic perspective it is more worthwhile to latrines appropriately, economic returns would have varied consider moving higher up the ladder or to more costly op- between 7.6 and 14.9. The sanitation options in peri-urban tions. In urban areas, the economic performance of moving areas have slightly lower economic performances than ru- from septic tanks to sewerage is not economically justified. ral areas, but still highly favorable. In urban sites, the most However, households may wish to improve their sanitation common sanitation options of public toilets, septic tanks option for several reasons not quantified in the cost-benefit and sewerage have benefit-cost ratios of 1.9 to 4.5 under analysis such as intangible factors and the external environ- actual program conditions. The benefits analyzed include ment. benefits from health, water, access time, intangibles, the ex- ternal environment and waste reuse. The economic value of The study provides strong arguments to support that im- health benefits is the largest contributor to overall quanti- proved sanitation and hygiene have a significant health fied benefits. economic impact. It informs decision makers that health benefits contribute the most, especially in rural populations However, there are benefits that are important but not mon- and for children, who have relatively more to gain from etized or included in the calculation. For instance, the FGD improved sanitation. In general, it is estimated that it costs revealed that about 40% of women and men considered an average household around 1,000 RMB for disease treat- privacy and convenience to be the main reason/advantage ment per year. In severe cases, it can cost several thousand, to have a private toilet. These and other benefits are hard- up to 10,000 RMB yuan for inpatient treatment with ad- to-quantify “intangible” benefits related to the toilet itself ditional 500 RMB income losses from time off productive (e.g. comfort, prestige, privacy status and safety) as well as activities. The 0-4 year old age group – those most vulner- the “external” environment benefit (e.g. cleaner surround- able to the negative health impacts of poor sanitation – has ings and less exposure to insects and rodents). Economic the highest health care cost, productivity cost (from carer savings from improved water resource access and reduced time), and premature mortality cost. household water treatment attributed to water pollution were not fully quantified in this study, but can be significant The program approach analysis analyzed the effectiveness of to downstream water resources in particular. existing sanitation options from two important aspects: the 92 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Discussion project implementation approach (associated with the con- US$200 for the former and US$770 for the latter. All the struction phase) and the post-construction management other sanitation options of moving up to the targeted op- (use and maintenance). It is somewhat concerning that less tions need full cost because of the investment in the full than 30% of the households stated that they had a choice hardware costs. Septic tanks and sewerage at the top of the whether to participate in the project or not, and less than sanitation option cost ladder have a total economic cost of 25% of households were provided with a choice of options US$1,400 and US$2,170 per household, respectively. Mov- when constructing their facilities, thus indicating that gov- ing up the sanitation ladder is to be expected in the longer ernment programs are heavily “top-down”. The feedback run as populations’ disposable income grows, but shifting on satisfaction levels of households towards sanitation op- from one option to another option at the same level should tions and the external environment was around 3.0 – 3.5 be avoided. It is important to consider the cost and technol- on average (1 = not satisfied and 5 = very satisfied), and ogy suitability from a long-term perspective when making waste reuse rate was 71%, suggesting some economic value investment decisions. is not being captured by households or communities, and having significant room for improvement. It also indicates Sanitation infrastructures in China are largely subsidized by that even for households already equipped with improved the government: 54-68% of capital investment and about sanitation facilities, many of them are not capturing the full 30% of overall sanitation costs when recurrent cost is in- health and environmental benefits. Sanitation and hygiene cluded for sites of the ESI study. The FGD hinted that at all awareness, operation and maintenance training are required sites, when reasons were asked for why households did not to reach full effectiveness of these facilities. have a private latrine, both men and women responded that “no external support” was the main reason. This reason was People perceive comfort (83%) proximity (82%), privacy given more often than the response that the cost of a latrine (77%) and cleanliness (70%) to be the most important rea- is too high. It explains the reluctance of potential users in sons for having a private toilet. Rural households without contributing their own funds, indicating a heavy depen- their own toilets expect to have private improved pit latrines dence on government investment. To fill the gap between or use public toilets in the community. Most villagers think available financial resources and the actual budget required having an improved private pit latrine is more applicable as for achieving full access and increase users’ ownership to- it can collect manure and is easy to clean, with a 3-in-1 bio- wards sanitation facilities, sanitation beneficiaries’ demand gas unit taking second place. UDDT is not accepted widely needs to be stimulated, for which innovative approaches are by most households and is ranked in third place because of required. the poor quality of sanitation facilities provided and this technology requires a change of habits in using and main- 8.1.2 GENERALIZABILITY OF RESULTS taining it. Urban households with flush toilets have a high Yunnan is the eighth largest province in terms of area in level of satisfaction, and those without flush toilets wish to China and its geographical, cultural, ecological, climatic, have their own flush toilet in the future. Peri-urban house- social and economical development differ very much from holds using public toilets prefer flush toilets connected to place to place, which implies that sanitation in Yunnan will septic tanks or sewerage. be very location-specific. Therefore the ESI study attempted to select field sites which reflected different contexts within Moving up the ladder can involve a cost saving when hard- the province, hence enabling broader lessons to be drawn ware is reused, and thus it is more relevant to measure incre- from the site-specific studies. Given the available research mental rather than full cost of the higher ladder sanitation resources, eight sites covering three regions were identified. options. When full cost is applied, the hardware is replaced. The sites were based on various considerations such as eco- Moving up the ladder from pit latrines to biogas units and nomic development, rural/urban/peri-urban, population from septic tanks to sewerage involves a partial cost saving: size, sanitation options, ethnicity of local residents, alti- www.wsp.org 93 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Discussion tude, and proximity to important water resources. Extreme sanitation practitioners and promoting organizations, have geographical locations, such as alpine, tropical and border different financial and economic implications. The features areas, were not selected. of each sanitation option, not only technical, but also social acceptance, financial and economical costs, are important The three urban sites – Kunming, Dali and Qiubei – repre- and determine the success of an installation. The study re- sent provincial, prefectural and county level cities, respec- sults help understand the household perceptions, and on tively. It is likely that other cities of the same level will have the other hand, the right messages about the technical and similar costs and benefits from improved or unimproved financial strengths and weaknesses of sanitation technolo- sanitation and incremental cost for climbing up the lad- gies can be passed on to households as well. Improved com- der. Kunming is large in population and area size. Under munication between suppliers and beneficiaries ensures Kunming’s administration, Anning city, considering its size that the most appropriate technology is adopted and fully and development, is comparable to Dali city (urban, peri- accepted by the users. Particularly when a budget is limited, urban and rural), Songming (peri-urban), Qiubei (rural) it is helpful to compare the BCRs, NPVs, and incremental and Luquan (rural). Its counties, except for Songming, are costs of different options, to prioritize investment and de- more or less identical to Songming (peri-urban), Qiubei cide the level of sanitation technology. (urban/small size city and rural), Luquan (rural) and Dali (peri-urban and rural). Program design and implementation: The Chinese gov- ernment’s annual investments on sanitation are significant, Areas with low improved sanitation coverage, with typical and requests for rapid scale-up often mean a large number characteristics such as open defecation practices and unpro- of sanitation infrastructures are to be built within a short tected ground water sources, will have similar health status period. Either insufficient attention or inadequate financial and water variables. Likewise, areas with similar demo- and human resources prevent thorough planning, aware- graphic situations such as population density, age composi- ness raising, training, beneficiary consultation, supervision tion of family members and average wage, will have similar and post-evaluation that are essential for effective sanita- benefits once their sanitation facilities are improved. tion improvement initiatives. The messages coming across from PAA also emphasize the importance of shifting from a 8.2 POTENTIAL USES OF RESULTS supply-driven approach to a demand-driven approach. There are several opportunities that the study results can be used for: Sanitation investment: cost-benefit analysis results provide indicative figures for each technical option, costs for mov- Advocacy for sanitation improvement: costs and benefits ing up the sanitation ladder and periods over which there of improved sanitation can be convincing points for request- are returns on the investment. This is helpful for calculating ing stronger support from the governmental budget, donors the overall cost for achieving certain sanitation access rates and other organizations. They can be used by program staff and comparing the general effectiveness of technologies at to convince households actively participating in sanitation a similar level. improvement programs to contribute to the hardware con- struction. The general media, health sector, environmental Research study: The ESI study methodology and approach sector and public societies can use these messages in their itself can serve as a starting point for carrying out further advocacy campaigns for raising public awareness towards sanitation-related research, for instance, on how to quan- the importance of improved sanitation. tify environmental impacts of unimproved sanitation, how to monetize the intangible benefits of improved sanitation, Selection of sanitation options: different sanitation op- and the comparative costs of scaling up different types of tions, which are perceived differently by households and sanitation options. 94 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Discussion 8.3 INTEGRATING ECONOMIC CONSIDERATIONS INTO A DECISION MAKING PROCESS Currently in Yunnan or even China, sanitation planning largely relies on qualitative arguments. Limited economic aspects are considered, except for large sanitation infra- structure (sewage system and treatment plants, centralized human waste disposal sites) and in the context of develop- ment loans from external agencies and banks. Economic evidence from this study can now be used to strengthen the feasibility and planning phases of future sanitation projects. However, it might require more solid and robust studies to be carried out in the specific context of the projects to justify the decisions made. Similar studies need to be con- ducted in other provinces of China. www.wsp.org 95 IX. Recommendations The aim of this study is to provide the evidence and the and hence reducing health care costs, productivity losses arguments for national and provincial decision makers to and welfare losses due to premature mortality. Investment make more efficient investments in sanitation. This study in sanitation and hygiene is an important method of disease has quantified the economic efficiency of selected sanitation control, which reduces household, government and private options. It supports several agendas, leading to both im- sector expenses associated with disease. Sanitation and hy- proved sanitation at the household level as well as improved giene interventions should be planned and implemented environmental protection contributing to watershed pro- jointly in order to promote the health of the people. Sanita- tection, thus resulting in benefits to public health, the natu- tion should include toilets and the facilities for solid waste ral environment, economic development, and poverty al- treatment, wastewater treatment and hand washing. Com- leviation. The following policy recommendations are based prehensive sanitation programs should be promoted in or- on the major findings of the study. der to avoid piece-meal projects with little connection to one another. Integrating hygiene awareness and improving Recommendation 1. Populations without access to basic hygiene practices in sanitation programs are crucial to cap- sanitation should be prioritized by sanitation and hy- turing the important health benefits. Awareness campaigns giene programs and be the first to receive subsidies. on hand washing should be strengthened since hand wash- ing is a low cost method of reducing transmission of infec- The findings of the research show that the investment on tious diseases. improving access to basic sanitation targeted to those with- out basic sanitation generates the highest efficiency. Ef- Recommendation 3. Go beyond basic sanitation provi- ficiency is significantly lower for those who already have sions. basic sanitation but are moved up the sanitation ladder by sanitation programs. Therefore, those without basic sanita- In many municipalities and counties of Yunnan Province, tion or improved sanitation in remote mountainous areas funds are adequate to deliver more sustained and quality and peri-urban areas should be targeted by governmental services, which better capture the full environmental and projects. The central and local governments should increase health benefits of better sanitation, and respond to the pop- the investment in sanitation and hygiene development for ulation’s wish for a clean, livable environment. those without sanitation in the western region of China. Preferential policies should be given to low-income popula- Recommendation 4. Innovative funding strategies are tions without improved sanitation in Yunnan. These poli- required to encourage multiple sources of contribution. cies need to be included in the socio-economic develop- ment plan and sectoral plans of the province. Governmental funds for sanitation and hygiene are far from adequate for achieving full basic sanitation. For Yunnan, Recommendation 2. The importance of hygiene and a province with nearly 6.4% of its population under the health aspects should be better reflected in sanitation nationally-defined poverty line (less than US$0.5 per day), programs. this is even more challenging. To respond to the investment deficit, flexible and diversified co-financing mechanisms Improved sanitation with waste management and hygiene need to be applied, particularly mechanisms to attract pri- has a high degree of impact in averting the disease burden vate sector investment and approaches to raise beneficiary 96 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Recommendations demand. In this respect, international experiences can be Department is responsible for urban areas and the Health drawn upon and adapted to conditions in China, such as Department is in charge of rural areas. Community-led Total Sanitation (CLTS), which has had widespread success in South and Southeast Asia as well as Recommendation 6. People-centered implementation Eastern Africa. Program costs on education, training, wa- approaches are advised to improve participation and ter supply, and evaluation components of sanitation-related consultation of beneficiaries. programs, as well as liquids and solids management and hand washing, have to be secured to maximize the benefits As the program approach analysis indicated, the supply-led of sanitation infrastructure. approach has some advantages but also several weaknesses such as low willingness to participate, lack of ownership, Recommendation 5. Closer and stronger inter-sectoral low acceptance of the technology or infrastructure, among coordination and cooperation are required for effective other problems. The traditional supply-driven program and sustainable sanitation improvement. approach adopted by the majority of projects should shift away from business-as-usual to a more demand-oriented Although cross sectoral coordination and cooperation are approach. In order to understand the demand of the tar- taking place in Yunnan, government programs are still geted users, implementing agencies should adopt novel ap- largely vertical. The many agencies involved in sanitation proaches to interact with local people by building dialog provision suggest that efficiency gains could be made from and communication. It is necessary to involve the users, improved cross-sectoral coordination and cooperation, especially women, in the full project life cycle, from plan- which will lead to improved planning and choice of tech- ning, decision making, design, construction, maintenance, nologies, strengthened mutual learning and resource saving. and monitoring and evaluation of the sanitation facilities. With continued rapid urbanization and rural development in Yunnan Province, the line between rural and urban solu- Recommendation 7. Women should be motivated and tions will become less clear; therefore, stronger cooperation empowered in decision making, implementation as well between the existing separate coordination systems for ur- as monitoring; the demonstrative and educational func- ban and rural areas is needed–or even an overall coordinat- tion of schools should be exploited. ing mechanism covering both rural and urban areas. The study findings demonstrate that women’s needs are Successful sectoral coordination and cooperation implies somewhat different from men’s needs when it comes to improved planning, optimizing investment effectiveness, sanitation. Women demand safer, more private, cleaner strengthened mutual learning and communication and sanitary latrines. In fact, women are responsible for most resource saving. For this purpose the study suggests to es- household tasks, including house and toilet cleaning and tablish an inter-departmental cooperation mechanism for hygiene, family members’ health, especially young children. both urban and rural sanitation. As inter-departmental Therefore women’s central role in family sanitation should cooperation requires a strong governmental body to lead be more fully appreciated and taken into account in deci- all activities, this report recommends that the Provincial sion making at the community level. It is crucial for chil- Government or the Provincial Development and Reform dren to develop hygiene and sanitation awareness from the Commission act as an overall coordinating body to inte- very beginning, and children’s influence in the family can grate sectoral resources and invest in sanitation. The tech- also be prominent and is worth promoting. For the above nical guidance and coordination role should remain as it reasons, hygiene and sanitation knowledge should be pro- currently is: the Housing and Urban-Rural Development vided to women and students in various ways. www.wsp.org 97 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Recommendations Recommendation 8. Setting up comprehensive databas- Recommendation 9. Conduct further sanitation-related es is crucial for information sharing. research. As indicated in Chapter 1, the sanitation system in China Based on the results presented in this study, more specific is highly complex, due to the multiple and multi-sector studies would help in verifying, supporting or extending stakeholders involved, different program orientations, va- the messages, especially the economic valuation of the ben- riety of funding sources and mechanisms, and the very dis- efits of improved sanitation. The following topics are sug- tinct sanitation situations by region and localities. During gested for follow-up in the near future: 1) valuation of envi- the program approach analysis, the team identified several ronmental impacts of unimproved sanitation; 2) valuation weaknesses in the current data system caused by the sys- of intangible benefits of improved sanitation; 3) program tem’s complexity. First, different data sources present very costs of governmental and non-governmental sanitation different figures for the coverage of sanitary latrines in rural programs; and 4) market-based private sector involvement areas. Second, in the past, systematic surveys of sanitary la- and demand oriented approaches. trine coverage focused on rural areas, resulting in a lack of data on sanitation coverage in urban areas. This, in turn, Recommendation 10. Promote evidence-based sanita- translates into a lack of combined urban and rural statistical tion decision making. data. Third, program cost is often missing in governmental budget plans as governmental programs mainly focus on Variations in economic performance of options suggest a physical infrastructure. Therefore the actual cost is under- careful consideration of site conditions is needed to select estimated and the budgeting requirement for software cost the most appropriate sanitation option and delivery ap- in programs is not appreciated by either decision makers or proach. Decisions should take into account not only the implementers. measurable economic costs and benefits, but also other key factors for a decision, including intangible impacts and As the primary goal of all hygiene and sanitation projects socio-cultural issues that influence demand and behavior is to improve public health and social well-being, all sec- change, availability of suppliers and private financing, and tor projects should share an overall set of health, environ- actual household willingness and ability to pay for services. mental, socio-economic and technical indicators, in addi- tion to project-specific indicators. These indicators should capture the multiple benefits of environmental health and sanitation facilities, including health gains, renewable en- ergy development, avoided water pollution, quality of life improvement (especially for women), and the opportunity cost of time (productive uses). Future efforts should build on the databases and experiences from the ESI study. This report recommends that the Patriotic Health Cam- paign Committee (PHCC) coordinate with other depart- ments and come to an agreement on a revised database to address the abovementioned problems. Regular exchanges and information sharing among relevant sectoral depart- ments should be institutionalized for better coordination. PHCC should make data and information available to the public as well, for instance, via information bulletins up- loaded to their website. 98 Economic Assessment of Sanitation Interventions ANNEX A: STUDY METHODS TABLE A1: SELECTION OF FIELD SITES FOR ECONOMIC STUDY Program name Location(s) covered Implementing agents Funding mechanism SELECTED PROGRAMS REASON FOR INCLUSION Biogas program by Daleshao Village, Energy Station, 66.7% covered by The data can be Qiubei County Forestry Qiubei County Forestry Bureau government, 33.3% obtained, and can Bureau Qiubei County covered by the be compared with household the same type of sanitation. Puzhehei Upstream Eco- Puzhehei Lake Yunnan Environment The project sanitation Project Phase watershed, Qiubei Development Institute covered 80% of I & II County, Wenshan the construction Prefecture, Yunnan costs, voluntarily Province, China participating households covered the remaining 20%. Luoguo village Ameng Luoguo village Ameng Yunnan Green Project covered all the Township Yanshan Township Yanshan Environment expenses County Biogas program County Development Foundation Lanping County City Jinding Township Urban and Rural 70% of capital from Wastewater Treatment Lanping County Construction Bureau treasury bonds, program Lanping County 20% from loan,10% matching funds by local government NON-SELECTED REASON FOR PROGRAMS EXCLUSION Jinning UDDT program Zhonghe Village, Kunming City The data is not by Kunming City Jinning Kunming Environment sufficient for analysis, Environment Protection Protection Bureau and the wastewater Bureau treatment plant of Yunlong has not been The WWT program in Yunlong Reservoir Kunming Dianchi in operation. Luquan Area Investment Company, Kunming Municipal Land Resource Committee www.wsp.org 99 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A2: ASSESSMENT OF ADVANTAGES AND LIMITATIONS OF DIFFERENT DESIGN OPTIONS No Design Advantages Limitations DESIGNS INVOLVING FIELD DATA COLLECTION 1 Economic study designed entirely for • Addresses the specific questions of • Expensive and lengthy period research purposes, including matching the research • May not capture health impact and randomization of comparison groups • Highly scientific design • Limited generalisability 2 Economic research attached to other • Captures health impact with degree of • Expensive and lengthy period research studies (e.g. randomized clinical precision • Few ongoing clinic trials trials) • Can conduct additional research on • Requires collaboration from start other impacts • Trials may not reflect real conditions • Add-on research cost is small • Limited comparison options • Statistical analysis possible 3 Economic research attached to pilot • Add-on research cost is small • Few pilot programs available study, with or without randomization • Options are policy relevant • Pilots often not designed with scientific • Matched case-control possible evaluation in mind (e.g. before vs. after • Can start research in mid-pilot surveys) • Pilot conditions not real life • Limited comparison options 4 Economic research attached to routine • Reflects real life conditions (e.g. • No research infrastructure government or NGO/donor programs, uptake and practices) • No scientific design without randomization • Research addresses key policy • Limited comparison options questions • Matched case-control possible DESIGNS INVOLVING SECONDARY DATA COLLECTION 5 Collection of data from a variety of local • Relatively low cost • Results imprecise and uncertain sources to conduct a modeling study • Short time frame feasible • Actual real-life implementation issues • Can compare several options and not addressed settings in research model • Can mix locally available and non-local data 6 Extraction of results from previous • Low cost • Limited relevance and results not economic studies • Results available rapidly trusted by policy makers • Gives overview from various • Published results themselves may not interventions and settings be precise 100 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A3. METHODOLOGY FOR BENEFIT ESTIMATION (CALCULATIONS, DATA SOURCES, EXPLANATIONS) Impacts included Variable Data sources Specific value/comment 1. HEALTH (All calculations are made using disaggregated data inputs on disease and age grouping: 0-4 years, 5-14 years, 15+ years) Diarrheal disease incidence (0-4 years) Diarrheal disease incidence (over WHO statistics 5 years) Helminthes prevalence Global review Hepatitis A and E incidence National health statistics Indirect diseases incidence WHO statistics 1.1 Health care savings (malaria, ALRI) Calculation: Malnutrition prevalence UNICEF/WHO statistics [Prevalence or incidence X Attribution to poor sanitation X Scabies and trachoma Incidence National health statistics ((% seeking outpatient care X visits per case X unit cost per Attribution of fecal-oral diseases WHO (Prüss et al. 2002) Value = 88% visit (medical and patient)) + to poor sanitation (Inpatient admission rate X days Attribution of helminthes to poor Global review Value = 100% per case X unit cost per day sanitation (medical and patient))] X Proportion of disease cases % disease cases seeking health ESI household survey, health averted care statistics Outpatient visits per patient Inpatient admission rate Health facility statistics, ESI Inpatient days per admission household survey Health service unit costs Other patient costs (transport, ESI household survey food) % disease cases averted International literature review See Annex B for review 1.2 Health morbidity-related Days off productive activities ESI household survey productivity gains Basis of time value: GDP per National economic data Average product per capita Calculation: capita (at sub-national level, where [Prevalence X Attribution to available) – 30% for adults, poor sanitation X Days off 15% for children productive activities X Value of time] X Proportion of disease cases averted Mortality rate (all diseases) WHO statistics (cross-checked with local stats) Basis of time value: GDP per National economic data Annual value of lost production capita of working adults(human 1.3 Premature mortality savings capital approach) , from the time of death until the end of Calculation: (what would have been) their [Mortality rate X Attribution to productive life poor sanitation X Value of life] X Proportion of disease cases Discount rate for future earnings National government Cost of capital estimate (8%) averted Long-term economic growth Assumption Value-of-statistical-life Developed country studies Adjusted to local purchasing power by multiplying by GDP per capita differential www.wsp.org 101 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A3. METHODOLOGY FOR BENEFIT ESTIMATION (CALCULATIONS, DATA SOURCES, EXPLANATIONS) (CONTINUED) Impacts included Variable Data sources Specific value/comment 1.4 Disability-adjusted life- Duration of disability ESI household survey based on average length of years (DALY) averted each disease Disability weighting WHO burden of disease project Calculation: DALY = YLD+YLL Healthy life expectancy WHO statistics YLD: discounted disability based on weight and years Discount rate for future disease National governments Cost of capital estimate (8%) equivalent time burdens YLL: discounted future years Morbidity and mortality rates Various: see 1.1 and 1.3 (above) of healthy life lost 2. WATER (for household use) (weighted average costs were estimated for each water source and for each household water treatment method) Drinking water sources (%) in ESI household survey wet and dry seasons 2.1 Household water access Annual financial cost per ESI household survey; ESI savings household, per water source market survey Calculation: Annual non-financial cost per ESI household survey Annual costs X % costs household, per water source reduced, per water source Proportion of access cost ESI household survey; reduction under scenario of assumption 100% improved sanitation, per water source Proportion of households ESI household survey Validated by other national 2.2 Household water treating their water, by method statistics (DHS, SES) treatment savings Full annual cost per water ESI household survey; ESI treatment method market survey Calculation: (% households treating water Proportion of households ESI household survey; As well as stopping to treat per method X annual cost) currently treating who stop assumption water, households may switch X % households who stop treating under scenario of 100% to an alternative – cheaper – treating improved sanitation treatment method if the cleaner water sources enable different water purification methods 3. ACCESS TIME SAVINGS (weighted average costs estimated for each age category and gender – young children, children and male and female adults) Household composition ESI household survey (demographics) Sanitation practice, by age ESI household survey group Calculation: Average round trip time to ESI household survey For households moving from % household members using access site of open defecation shared to private toilet, access OD X Time saved per trip due time to shared toilets is used to private toilet X average trips instead of OD per day X value of time Average number of round trips ESI household survey to defecation site per day Basis of time value: GDP per National economic data Average product per capita capita (at sub-national level, where available) – 30% for adults, 15% for children 102 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A3. METHODOLOGY FOR BENEFIT ESTIMATION (CALCULATIONS, DATA SOURCES, EXPLANATIONS) (CONTINUED) Impacts included Variable Data sources Specific value/comment 4. EXCRETA REUSE GAINS (reuse of excreta as fertilizer from either UDDT or double-vault pit latrine; and reuse of energy value from biogas digester) % households using reuse ESI household survey methods Calculation: % households using product (% households using product ESI household survey themselves themselves X value in own use) + (% households selling % households selling product ESI household survey product X selling price) to others Selling price ESI household & market survey Value in own use ESI market survey; assumption www.wsp.org 103 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A4: DISEASES LINKED TO POOR SANITATION AND HYGIENE, AND PRIMARY TRANSMISSION ROUTES AND VEHICLES Primary transmission Disease Pathogen Vehicle route DIARRHEAL DISEASES (GASTROINTESTINAL TRACT INFECTIONS) Rotavirus diarrhea Virus Fecal-oral Water, person-to-person Typhoid/paratyphoid Bacterium Fecal-oral and urine-oral Food, water + person-person Vibrio cholera Bacterium Fecal-oral Water, food Escherichia Coli Bacterium Fecal-oral Food, water + person-person Amebiasis (amebic dysentery) Protozoa 1 Fecal-oral Person-person, food, water, animal feces Giardiasis Protozoa 1 Fecal-oral Person-person, water (animals) Salmonellosis Bacterium Fecal-oral Food Shigellosis Bacterium Fecal-oral Person-person + food, water Campylobacter Enteritis Bacterium Fecal-oral Food, animal feces Helicobacter pylori Bacterium Fecal-oral Person-person + food, water Protozoa Other viruses 2 Virus Fecal-oral Person-person, food, water Malnutrition Caused by diarrheal disease and helminthes HELMINTHES (WORMS) Intestinal nematodes 3 Roundworm Fecal-oral Person-person + soil, raw fish Digenetic trematodes (e.g. Flukes (parasite) Fecal/urine-oral; fecal-skin Water and soil (snails) Schistosomiasis Japonicum) Cestodes Tapeworm Fecal-oral Person-person + raw fish Eye diseases Trachoma Bacterium Fecal-eye Person-person, via flies, fomites, coughing Adenoviruses (conjunctivitis) Protozoa 1 Fecal-eye Person-person Skin diseases Ringworm (Tinea) Fungus (Ectoparasite) Touch Person-person Scabies Fungus (Ectoparasite) Touch Person-person, sharing bed and clothing OTHER DISEASES Person-person, food (especially shellfish), Hepatitis A Virus Fecal-oral water Hepatitis E Virus Fecal-oral Water Poliomyelitis Virus Fecal-oral, oral-oral Person-person Leptospirosis Bacterium Animal urine-oral Water and soil - swamps, rice fields, mud Sources: WHO http://www.who.int/water_sanitation_health/en/ and [75, 76] 1 There are several other protozoa-based causes 2 Other viruses include: 3 Intestinal nematodes include: of GIT, including • Adenovirus – respiratory and • Ascariasis (roundworm - soil) • Balantidium coli – dysentery, intestinal gastrointestinal infections • Trichuriasis trichiura (whipworm) ulcers • Astrovirus – gastrointestinal infections • Ancylostoma duodenale/Necator americanus • Cryptosporidium parvum - gastrointestinal • Calicivirus – gastrointestinal infections (hookworm) infections • Norwalk viruses – gastrointestinal infections • Cyclospora cayetanensis - gastrointestinal • Reovirus – respiratory and gastrointestinal infections infections • Dientamoeba fragilis – mild diarrhea • Isospora belli/hominus – intestinal parasites, gastrointestinal infections 104 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A5: WATER QUALITY MEASUREMENT PARAMETERS PER LOCATION, AND TEST METHOD Test conducted for Parameter Test Location Surface water Well water Piped tap water E.coli (cfu/100 ml) Multitube fermentation Laboratory Yes Yes Yes Biological Oxygen Demand (BOD5) (mg/L) 5 day incubation Laboratory Yes Chemical Oxygen Demand (COD) (mg/L) 5 day incubation Laboratory Yes Dissolved Oxygen (DO) (mg/L) Iodometric Method Field Yes Ammonia (NH3-N) Spectrophotometer Laboratory Yes Yes Yes Nitrate (NO3-) (mg/L) DX-120 HPIC Laboratory Yes Nitrite (NO2-) (mg/L) DX-120 HPIC Laboratory Yes Total Phosphorous (TP) (mg/L) Spectrophotometer Laboratory Yes Total Nitrogen (TN) (mg/L) Ultraviolet Laboratory Yes spectrophotometer Conductivity (µS/cm) DDS — 11A Field Yes Yes Yes Conductivity meter Turbidity (NTU) Turbidity meter Field Yes Yes Yes pH pH Probe Field Yes Water temperature (oC) Thermometer Field Yes Residual chlorine (Cl) (in places provided Field Kit Field Yes with centralized chlorinated water supply) (mg/L) www.wsp.org 105 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A6: HOUSEHOLDS SAMPLED VERSUS TOTAL HOUSEHOLDS PER VILLAGE/COMMUNITY Sampling Sewerage/STF Septic Pit Shared Biogas Public Site of With Without UDDT OD Total tank latrine toilet toilet toilet households treatment treatment Sample 33 85 2 120 Site 1 Kunming Total 120 120 120 120 Urban % sampled 28 71 2 100 Sample 11 21 13 16 61 Site 2 Dali Total 61 61 61 61 61 Urban % sampled % 18 34 21 26 100 Sample 50 13 3 2 4 72 Site 3 Qiubei Total 72 72 72 72 72 72 Urban % sampled 69 18 4 3 6 100 Sample 58 12 15 55 1 141 Site 4 Kunming Total 141 141 141 141 141 141 Peri-urban % sampled 41 9 11 39 1 100 Sample 17 17 9 16 1 60 Site 5 Dali Total 60 60 60 60 60 60 peri-urban % sampled 28 28 15 27 2 100 Sample 117 33 1 151 Site 6 Kunming Total 151 151 151 151 rural % sampled 77 22 1 100 Sample 52 49 9 7 13 3 133 Site 7 Dali Total 133 133 133 133 133 133 133 rural % sampled 39 37 7 5 10 2 100 Sample 45 36 5 7 30 48 171 Site 8 Qiubei Total 171 171 171 171 171 171 171 rural % sampled 26 21 3 4 18 28 100 Sample 33 11 445 173 41 87 43 16 60 909 Total Total 909 909 909 909 909 909 909 909 909 909 4 1 49 19 5 10 5 2 7 100 106 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE A7: SAMPLE SIZES OF OTHER SURVEYS IN STUDY SITES Focus Group Discussion Physical location Health facilities Site Group Women Men Other groups surveys Hospital Clinic Unimproved Site 1 Improved 10 10 1 1 2 Sub-total 10 10 Unimproved 5 5 Site 2 Improved 5 5 1 1 2 Sub-total 10 10 Unimproved 5 5 Site 3 Improved 5 5 1 1 1 Sub-total 10 10 Unimproved 5 5 Site 4 Improved 5 5 2 1 2 Sub-total 10 10 Unimproved 5 5 Site 5 Improved 5 5 1 1 2 Sub-total 10 10 Unimproved 5 5 Site 6 Improved 10 10 3 1 2 Sub-total 15 15 Unimproved 5 5 Site 7 Improved 10 10 2 1 2 Sub-total 15 15 Unimproved 5 5 Site 8 Improved 10 10 3 1 2 Sub-total 15 15 Unimproved 35 35 Total Improved 60 60 14 8 16 95 95 www.wsp.org 107 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX B: HEALTH IMPACT TABLE B1: RATES PER POPULATION FOR CASES OF DISEASE Average Site 7 Site 8 Average Average Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 peri- Kunming Dali rural urban Kunming Dali Qiubei Kunming Dali Qiubei urban peri- peri- sites sites urban urban urban rural rural rural sites urban urban DIRECT DISEASES Mild diarrhea 1.03 0.767 0.8 0.60 0.80 0.90 0.90 1.00 1.20 0.70 0.90 Severe 0.2 0.13 0.15 0.10 0.10 0.20 0.10 0.10 0.40 0.10 0.20 diarrhea Helminthes 0.387 0.373 0.36 0.36 0.36 0.40 0.40 0.36 0.40 0.36 0.36 Hepatitis A, E 0.001 0.001 0.001 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Scabies 0.1 0.1 0.1 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 Trachoma 0.001 0.001 0.001 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 INDIRECT DISEASES Malnutrition 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 Malaria 0.1 0.002 0.0005 0.00 0.01 0.00 0.10 0.10 0.10 0.00 0.00 ALRI 0.1 0.04 0.05 0.02 0.05 0.05 0.10 0.10 0.10 0.05 0.05 Total 1.932 1.4273 1.4725 1.1925 1.427 1.6625 1.712 1.772 2.312 1.3225 1.6225 TABLE B2: RATES PER 1,000 POPULATION FOR DEATHS Average Site 7 Site 8 Average Average Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 peri- Kunming Dali rural urban Kunming Dali Qiubei Kunming Dali Qiubei urban peri- peri- sites sites urban urban urban rural rural rural sites urban urban DIRECT DISEASES Mild diarrhea 6.348E-06 6.348E-06 6.348E-06 0.00001 6.348E-06 0.00001 6.348E-06 6.348E-06 6.348E-06 6.348E-06 6.348E-06 Severe 0.0002 0.0001333 0.00015 0.00010 0.0001 0.00020 0.0001 0.0001 0.0004 0.0001 0.0002 diarrhea Helminthes 0.0003867 0.0003733 0.00036 0.00036 0.00036 0.00040 0.0004 0.00036 0.0004 0.00036 0.00036 Hepatitis A, E 0.000001 0.000001 0.000001 0.00000 0.000001 0.00000 0.000001 0.000001 0.000001 0.000001 0.000001 Scabies 0.0001 0.0001 0.0001 0.00010 0.0001 0.00010 0.0001 0.0001 0.0001 0.0001 0.0001 Trachoma 0.000001 0.000001 0.000001 0.00000 0.000001 0.00000 0.000001 0.000001 0.000001 0.000001 0.000001 INDIRECT DISEASES Malnutrition 0.00001 0.00001 0.00001 0.00001 0.00001 0.00001 0.00001 0.00001 0.00001 0.00001 0.00001 Malaria 0.0001 0.000002 0.0000005 0.00000 0.000005 0.00000 0.0001 0.0001 0.0001 0.0000005 0.0000005 ALRI 0.0001 3.333E-05 0.00005 0.00002 0.00005 0.00003 0.0001 0.0001 0.0001 0.00005 0.00005 Measles 0.000005 0.000005 0.000005 0.00001 0.000005 0.00001 0.000005 0.000005 0.000005 0.000005 0.000005 Other indirect 0.000005 0.000005 0.000005 0.00001 0.000005 0.00001 0.000005 0.000005 0.000005 0.000005 0.000005 Total 0.000915 0.0006703 0.0006888 0.0006088 0.0006433 0.0007588 0.0008283 0.0007883 0.0011283 0.0006388 0.0007388 108 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE B3: RATES PER 1,000 POPULATION FOR DALYS Average Site 7 Site 8 Average Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 Average peri- Kunming Dali urban Kunming Dali Qiubei Kunming Dali Qiubei rural sites urban peri- peri- sites urban urban urban rural rural rural sites urban urban DIRECT DISEASES Mild 0.001490299 0.001105705 0.00115378 0.00087 0.0011538 0.001298 0.001298 0.0014422 0.001731 0.00101 0.001298 diarrhea Severe 0.003251833 0.002167889 0.00243887 0.00163 0.0016259 0.0032518 0.0016259 0.0016259 0.006504 0.001626 0.003252 diarrhea Helminthes 0.006376066 0.006556106 0.00593634 0.00594 0.0059363 0.0077956 0.0065959 0.0059363 0.006596 0.005936 0.005936 Hepatitis 1.25515E-05 1.25515E-05 1.2552E-05 0.00001 1.255E-05 1.255E-05 1.255E-05 1.255E-05 1.26E-05 1.26E-05 1.26E-05 A, E Scabies 0.001126047 0.001126047 0.00112605 0.00113 0.001126 0.001126 0.001126 0.001126 0.001126 0.001126 0.001126 Trachoma 0.000578196 0.000578196 0.0005782 0.00058 0.0005782 0.0005782 0.0005782 0.0005782 0.000578 0.000578 0.000578 INDIRECT DISEASES Malnutrition 0.000114912 0.000114912 0.00011491 0.00011 0.0001149 0.0001149 0.0001149 0.0001149 0.000115 0.000115 0.00001 Malaria 0.001311462 2.62292E-05 6.5573E-06 0.00001 6.557E-05 6.557E-06 0.0013115 0.0013115 0.001311 6.56E-06 0.0000005 ALRI 0.001426817 0.001444999 0.00071341 0.00029 0.0007134 0.0033362 0.0014268 0.0014268 0.001427 0.000713 0.00005 Measles 5.24563E-05 5.24563E-05 5.2456E-05 0.00005 5.246E-05 5.246E-05 5.246E-05 5.246E-05 5.25E-05 5.25E-05 0.000005 Other 5.24563E-05 5.24563E-05 5.2456E-05 0.00005 5.246E-05 5.246E-05 5.246E-05 5.246E-05 5.25E-05 5.25E-05 0.000005 indirect Total 0.000915 0.0006703 0.0006888 0.0006088 0.0006433 0.0007588 0.0008283 0.0007883 0.0011283 0.0006388 0.0007388 TABLE B4: EVIDENCE ON TREATMENT SEEKING BEHAVIOR FOR OTHER DISEASES % seeking treatment from No Data source Observations Public Private Informal Self- Total Pharmacy treatment provider formal clinic care treatment RURAL AREAS ESI sites (diarrheal disease 215 20 30 20 20 9 1 100 only)1 Yunnan Province - 41 30 10 10 9 1 100 (all diseases)2 URBAN AREAS ESI sites (diarrheal disease 185 40 10 20 10 20 0 100 only)1 Yunnan Province - 49 17 16 1 15 2 100 (all diseases)2 PERI-URBAN AREAS ESI sites (diarrheal disease 150 38 12 20 10 20 0 100 only)1 1 Incidentals: non-health patient costs such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay. 2 ALOS: average length of stay. 3 Inpatient health care costs are presented per stay. Data source: “2009 China Health Statistics Yearbook”, and supplemented by interviews with doctors and patients. www.wsp.org 109 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE B5: UNIT COSTS ASSOCIATED WITH TREATMENT OF SEVERE DIARRHEA (US$, 2009) Outpatient cost (US$) Inpatient cost (US$) Health Provider Health care Incidental s1 ALOS 2 Health caree3 Incidentals1 PUBLIC/NGO Rural 15.62 0.29 0.44 34.11 5.86 Peri-urban 15.62 0.73 0.44 39.23 4.68 Urban 15.62 0.73 0.44 39.23 2.93 PRIVATE FORMAL Rural 7.76 0.29 0.44 23.42 4.39 Peri-urban 11.71 0.73 0.44 26.35 2.93 Urban 13.61 0.73 0.44 26.35 2.20 INFORMAL Rural 4.39 0.73 - - - Peri-urban 4.39 0.59 - - - Urban 4.39 0.29 - - - 1 Incidentals: non-health patient costs such as transport, food, and incidental expenses, per outpatient visit and per inpatient stay. 2 ALOS: average length of stay. 3 Inpatient health care costs are presented per stay. 110 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX C: WATER QUALITY IMPACT TABLE C1: FULL WATER QUALITY MEASUREMENT RESULTS Distance Con- Sampling Tur- Uses from Temp. pH DO COD NH3-N TP E. coli BOD5 duc- TN NO3-N NO2-N location bidity toilet tivity US1 I 500 15 7.9 7.54 17.12 0.015 0.06 ≥24000 2L 31 0.18 0.87 0.15 0.03L US2 I 10 15 7.7 5.36 21.02 0.015 0.14 ≥24000 2L 34 0.21 2.18 0.33 0.03L US3 I 10 17 7.6 —— 264.66 66.46 2.56 ≥240000 140.7 123 2.4 61.22 —— —— US4 I >1000 16 7.6 5.75 16.54 0.002 0.05 ≥24000 2L 39 0.27 1.35 0.43 0.03L US5 I >1000 16 7.4 —— 124.54 13.474 2.44 ≥240000 59 76 1.41 59.92 —— —— US6 I >1000 16 7.7 5.65 21.22 0.015 0.1 ≥24000 2.38 40 0.28 1.89 0.32 0.03L US7 I 10 17 7.5 4.36 11.68 0.002 0.04 ≥24000 2L 38 0.25 1.04 0.44 0.03L RS8 L 5 21 7.2 3.67 35.81 0.005 0.11 16000 5.11 53 0.46 2.4 0.29 0.03L RS9 L 5 20 7 0.6 61.1 16.01 0.24 ≥240000 20 75 0.76 14.65 —— —— RS10 IL 5 20 7 1.59 35.03 0.002 0.13 ≥24000 7.3 32 0.21 0.97 0.16 0.03L RS11 IL 50 22 7.2 2.38 19.46 0.005 0.03 9200 5 28 0.21 0.68 0.17 0.03L RS12 IL 50 24 7.2 3.08 23.35 0.005 0.03 ≥24000 4 28 0.18 0.77 0.24 0.03L RS13 IL >1000 23 8 7.04 12.65 0.015 0.03 ≥24000 2L 41 0.54 1.6 0.2 0.03L RS14 IL >1000 22 8 7.39 11.68 0.018 0.04 ≥24000 2L 37 0.77 1.64 0.57 0.03L Dingjia IL 20 25 8.18 6.42 6.15 1.96 0.04 1700 2.4 21 / 1.61 0.96 0.036 Shiqiao* Puzhehei IL >1000 27 7.54 3.88 5.33 0.28 0.03 16000 2L 24 / 1.52 1.36 0.03L Qiaotou* Outlet of I >1000 27 8.01 7.77 5.74 0.44 0.01 1100 2L 25 / 1.29 1.08 0.03L Puzhehei Lake* Note: 1. Unit for temperature is oC; no unit for pH, unit for E.coli is unit/L, unit for conductivity is mS/m, and unit for other items is mg/L; unit for distance between sampling points and nearest toilet is m. 2. “Detection limit + L” means that the result is lower than the detection limit. 3. Data marked with * are taken from routine monitoring by the same vendor from the monitoring report coded as HWJZ 2009-118. The parameters quoted here were measured with the same methods given in table 3. 4. I: irrigation; L: landscape www.wsp.org 111 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE C2: WATER QUALITY MEASUREMENT RESULTS OF GROUND WATER Sampling Distance from Uses Temp. pH NH3-N Conductivity Turbidity E.coli location toilet UG1 CBD 5-10 20 6.8 0.002 92 0.12 9200 UG2 CBD 5-10 21 7.1 0.002 62 0.09 2200 UG3 CBD 5-10 22 6.6 0.002 63 0.12 ≥24000 UG4 CBD 5-10 19 6.4 0.002 73 2.58 20 UG5 CBD 5-10 20 6.4 0.002 61 0.09 ≥24000 UG6 CBD 5-10 20 4.1 0.002 25 0.09 1800 UG7 CBD 5-10 21 9 0.002 8 0.12 110 UG8 CBD 5-10 19 6.9 0.002 7 0.14 90 RG9 CBD 5-10 19 5.4 0.005 43 0.15 70 RG10 CBD 5-10 21 6.3 0.005 42 0.09 9200 RG11 CBD 5-10 20 5 0.004 101 0.12 170 RG12 CBD 5-10 20 6.8 0.002 150 0.09 2400 RG13 CBD 5-10 20 6.1 0.005 135 0.11 ≥24000 RG14 CBD 5-10 23 7 0.002 118 0.11 5400 RG15 CBD 5-10 20 6.6 0.002 140 0.09 ≥24000 RT1 CBD 5 20 7 0.005 64 0.09 3500 RT2 CBD 5 22 7 0.008 64 0.09 1600 RSP1 CBD 500 19 6.8 0.002 64 0.09 ≥24000 RSP2 CBD >1000 20 7.1 0.005 60 0.12 2200 Note: 1. Unit for temperature is oC; no unit for pH, unit for E.coli is unit/L, unit for conductivity is mS/m, and unit for other items is mg/L; unit for distance between sampling points and nearest toilet is m. 2. “Detection limit + L” means that the result is lower than the detection limit. 3. C: cooking; B: bathing; D: drinking TABLE C3: POLLUTION FROM POOR SANITATION AND WASTEWATER MANAGEMENT (% OF HOUSEHOLDS) Human excreta management (%) Household wastewater (%) Not isolated Partial isolation Full isolation Drain to Drain to Field sites ground water OD Flush to Dry pit Wet pit sources water U1 1.74% 0 31.30% 1.74% 65.22% 37.50% 0 R1 0.68% 0 14.38% 2.05% 82.88% 23.84% 0 PRU1 1.47% 0 8.82% 0.00% 89.71% 17.02% 0 U2 0.00% 0 27.66% 4.26% 68.09% 40.98% 0 R2 3.23% 0 37.90% 0.81% 58.06% 57.89% 0 PRU2 2.38% 0 40.48% 0.00% 57.14% 70.00% 0 U3 4.55% 0 13.64% 0.00% 81.82% 23.61% 0 R3 27.95% 0 22.98% 0.00% 49.07% 74.85% 0 Average rural 7.44% 0 15.63% 0.60% 40.48% 52.97% 0 Average peri-urban 1.14% 0 13.07% 0.00% 48.30% 32.84% 0 Average urban 1.59% 0 18.41% 1.27% 51.11% 34.39% 0 Total 1.59% 0 18.41% 1.27% 51.11% 34.39% 0 Source: ESI Field Surveys 112 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE C4: WATER ACCESS AND COSTS (US$, 2009) Non-piped protected source Piped water (treated) Non-piped unprotected source Field (including untreated piped) Location site % access Average % access Average % access Average monthly cost monthly cost monthly cost U1 Urban - Kunming 98.29% 39.91 0.85% 15 0.85% 30 R1 Rural - 85.26% 14.95 10.26% 27 4.49% 25 Luquan - Kunming PRU1 Peri-urban - 80.88% 23.82 15.44% 53.25 3.68% 23.33 Jinning, Kunming U2 Urban - Dali 86.54% 68.1 11.54% 12 1.92% 19.09 R2 Rural - Dali 83.22% 20.98 13.99% 15 2.80% 20 PRU2 Peri-urban - 98.33% 10.85 / / 1.67% / Zhoucheng, Dali U3 Urban - Qiubei 88.41% 1.06 4.35% 0 7.25% 0 R3 Rural - Qiubei 29.05% 14.91 37.16% 18.04 33.78% 13.64 Average rural 66.00% 16.46 20.36% 19.06 13.65% 6.3 Average peri-urban 86.22% 16.26 10.71% 53.25 3.06% 23.33 Average urban 92.86% 29.83 4.20% 9 2.94% 18.46 Total 77.75% 23.63 13.85% 18.26 8.40% 10.25 TABLE C5: HOUSEHOLDS CITING POOR WATER QUALITY FROM THEIR PRINCIPAL DRINKING WATER SOURCE Non-piped protected source Piped water (treated) Non-piped unprotected source (including untreated piped) Field site Bad Bad Bad Contain Bad Bad Bad Contain Bad Bad Bad Contain appear- smell (%) taste solids appear- smell (%) taste solids appear- smell (%) taste solids ance (%) (%) (%) ance (%) (%) (%) ance (%) (%) (%) U1 5.83% 1.67% 6.67% 3.33% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% R1 1.99% 0.00% 1.32% 3.97% 0.00% 0.66% 0.00% 0.66% 0.00% 0.66% 0.00% 0.66% PRU1 1.42% 0.71% 2.13% 0.71% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% U2 1.64% 1.64% 8.20% 4.92% 0.00% 1.64% 0.00% 1.64% 0.00% 1.64% 0.00% 1.64% R2 6.02% 3.01% 1.50% 3.01% 0.75% 0.00% 1.50% 2.26% 0.75% 2.26% 1.50% 2.26% PRU2 5.00% 0.00% 11.67% 8.33% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% U3 8.33% 0.00% 0.00% 9.72% 0.00% 0.00% 0.00% 1.39% 0.00% 1.39% 0.00% 1.39% R3 4.09% 0.00% 0.00% 2.34% 4.68% 0.00% 3.51% 15.20% 7.60% 14.62% 3.51% 14.62% Average rural 3.96% 0.88% 0.88% 3.08% 1.98% 0.22% 1.76% 6.59% 3.08% 0.44% 1.76% 6.37% Average peri- 2.49% 0.50% 4.98% 2.99% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% urban Average urban 5.53% 1.19% 5.14% 5.53% 0.00% 0.40% 0.00% 0.79% 0.00% 0.40% 0.00% 0.79% Total 4.07% 0.88% 2.97% 3.74% 0.99% 0.22% 0.88% 3.52% 1.54% 0.33% 0.88% 3.41% 1 Bad appearance covers bad color, or containing solids, sediments or particles www.wsp.org 113 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE C6: HOUSEHOLD RESPONSES TO POLLUTED WATER – REASONS FOR USING WATER SOURCES Non-piped protected source Piped water (treated) Non-piped unprotected source Field site (including untreated piped) Quality Quantity Cost Quality Quantity Cost Quality Quantity Cost U1 42.86% 32.38% 24.76% 0.00% 100.00% 0.00% - - - R1 53.02% 31.63% 15.35% 47.62% 38.10% 14.29% 90.00% 0.00% 10.00% PRU1 45.93% 39.26% 14.81% 51.61% 32.26% 16.13% 84.62% 0.00% 15.38% U2 57.38% 34.43% 8.20% 50.00% 25.00% 25.00% 66.67% 16.67% 16.67% R2 58.18% 28.18% 13.64% 72.97% 21.62% 5.41% 83.33% 16.67% 0.00% PRU2 39.18% 32.99% 27.84% - - - 0.00% 100.00% 0.00% U3 51.46% 33.98% 14.56% 50.00% 33.33% 16.67% 71.43% 28.57% 0.00% R3 48.39% 45.16% 6.45% 63.16% 28.95% 7.89% 58.82% 32.94% 8.24% Average 35.18% 41.30% 23.52% 97.96% 1.31% 0.73% 99.88% 0.07% 0.05% rural Average 47.47% 37.35% 15.18% 91.24% 6.57% 2.19% 99.01% 0.77% 0.22% peri urban Average 43.10% 36.64% 20.26% 97.74% 1.50% 0.75% 99.91% 0.03% 0.06% urban Total 41.95% 38.75% 19.30% 95.87% 2.95% 1.18% 99.62% 0.28% 0.10% TABLE C7: TREATMENT PRACTICES Field site Boiling Filtration Deposition Nothing U1 88.33% 0.83% 0.00% 10.83% R1 83.44% 0.66% 0.66% 15.23% PRU1 87.23% 0.71% 1.42% 10.64% U2 68.85% 1.64% 1.64% 27.87% R2 90.23% 0.00% 0.00% 9.77% PRU2 91.67% 0.00% 0.00% 8.33% U3 56.94% 1.39% 1.39% 40.28% R3 59.06% 0.00% 0.00% 40.94% Average Rural 76.26% 0.22% 0.22% 23.30% Average Peri-urban 88.56% 0.50% 1.00% 9.95% Average Urban 74.70% 1.19% 0.79% 23.32% Total 78.55% 0.55% 0.55% 20.35% 114 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE C8: TREATMENT COSTS (US$, 2009) Field site Boiling Filtration Decomposition U1 9.20 - 8.75 R1 8.77 3.00 8.00 PRU1 16.97 32.00 14.00 U2 8.75 - 12.50 R2 8.50 - 9.85 PRU2 15.00 - - U3 10.00 - 10.00 R3 6.00 - 4.50 Average rural 8.54 - 9.00 Average peri-urban 16.85 32.00 14.00 Average urban 8.94 3.00 9.55 Total 10.40 17.50 10.85 TABLE C9: WATER ACCESS AND HOUSEHOLD TREATMENT COSTS INCURRED AND AVERTED (US$, 2009) Annual average costs saved per household Annual average costs per household Variable following 100% sanitation coverage Water source access Water treatment Water source access Water treatment U1 305.00 472.55 29.70 51.10 R1 516.72 193.01 6.40 48.80 PRU1 825.00 316.80 7.20 47.60 U2 577.97 594.00 0.70 47.70 R2 522.60 244.56 23.60 47.80 PRU2 212.63 130.19 16.60 48.20 U3 820.26 12.24 12.20 49.70 R3 671.51 188.45 7.30 40.20 Average rural 567.74 341.07 12.43 45.60 Average peri-urban 570.28 185.11 14.20 49.50 Average urban 518.82 215.88 11.90 47.90 Total 556.46 247.35 12.84 47.67 www.wsp.org 115 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX D: ACCESS TIME TABLE D1: PLACE OF DEFECATION OF HOUSEHOLDS WITH NO “OWN” TOILET Women Men Children Own Outside Own Outside Own Outside N Neighbor N Neighbor N Neighbor plot plot plot plot plot plot Site 1 Rural 21 0 19 2 20 0 19 1 1 1 0 0 (Luquan), Kunming Site 2 Rural in Dali 12 5 7 0 12 5 7 0 0 0 0 0 Site 3 Rural in 53 0 12 41 55 0 12 43 40 3 7 30 Qiubei Site 4 Urban in 10 9 0 1 11 9 0 2 0 0 0 0 Kunming Site 5 Urban in Dali 0 0 0 0 0 0 0 0 0 0 0 0 Site 6 Urban in 3 0 0 3 3 0 0 3 3 0 0 3 Qiubei Site 7 PRU (Jinglin) 12 0 11 1 12 0 11 1 1 1 0 0 in Kunming Site 8 PRU in Dali 8 7 0 1 8 7 0 1 0 0 0 0 Average rural 28.7 1.7 13 14 29 1.7 12.7 14.7 13.7 1.3 2.3 10 Average urban 4.3 3 0 1.3 4.7 3 0 1.7 1 0 0 1 Average PRU 10 3.5 5.5 1 10 3.5 5.5 1 0.5 0.5 0 0 TABLE D2: DAILY TIME SPENT (MINUTES) ACCESSING TOILET FOR THOSE WITH NO TOILET Women Men Children Time per trip No. of times Time per trip No. of times Time per trip No. of times and waiting per day and waiting per day and waiting per day Site 1 Rural (Luquan) in 7 3 7 3 7.7 4 Kunming Site 2 Rural in Dali 4 6.5 4 6.5 10 6 Site 3 Rural in Qiubei 8 3 8 3 7.6 4 Site 4 Urban in Kunming 0 5 0 5 0 5 Site 5 Urban in Dali 8 3 8 3 12.5 4 Site 6 Urban in Qiubei 4 4 4 4 5 5 Site 7 PRU (Jinglin) in 8 3 8 3 8.1 4 Kunming Site 8 PRU in Dali 0 5 0 5 11.3 6 Average rural 6.3 4.2 6.3 4.2 8.4 6 Average urban 3 4 3 4 5.8 4.7 Average PRU 4 4 4 4 9.6 5 116 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE D3: PRACTICES RELATED TO YOUNG CHILDREN Parents accompanying young Of which: children % outside plot No. of times per day R1 75 41.1 4 R2 285 21.1 6 R3 228 13.3 4 U1 380 0 5 U2 150 33.3 4 U3 66 37.9 5 PRU1 61 53.1 4 PRU2 143 47.4 6 Av. Rural 196 25.7 6 Av. Urban 199 13.7 5 Av. PRU 102 47.1 5 TABLE D4: PREFERENCES RELATED TO TOILET CONVENIENCE, FROM HOUSEHOLD QUESTIONNAIRE Perceived benefits of sanitation (B6.1): Those without toilet: reasons to get a toilet proximity cited as satisfied or very satisfied Site Saves time Proximity is an important Those with toilet Those without toilet (B7.16) characteristic (B7.17) Site 1 Rural (Luquan) in 3.4 3.0 5.0 5.0 Kunming Site 2 Rural in Dali 3.9 4.4 4.6 Site 3 Rural in Qiubei 3.3 2.2 3.6 3.9 Site 4 Urban in Kunming 4.4 2.0 4.0 4.8 Site 5 Urban in Dali 3.1 Site 6 Urban in Qiubei 4.1 1.0 4.5 4.5 Site 7 PRU (Jinglin) in 2.9 3.0 5.0 5.0 Kunming Site 8 PRU in Dali 4.4 1.0 3.0 5.0 Average rural 3.5 2.7 4.3 4.4 Average urban 3.9 1.5 4.3 4.7 Average PRU 3.7 2.0 4.0 5.0 www.wsp.org 117 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE D5: OPPORTUNITY COST OF TIME – WHAT RESPONDENTS WOULD SPEND AN EXTRA 30 MINS A DAY DOING (%) Ranking Respondents with toilet (%) Respondents with no toilet (%) FINDINGS FROM THE RURAL SITES Ranking 1 Leisure 34.5% Work/help to generate income/output/economic practice 5.7% Ranking 2 Work/help to generate income/output/economic practice Leisure 2.0% 31.0% Ranking 3 Cleaning room, washing clothes, cleaning yard etc. 21.5% Sleeping 1.5% FINDINGS FROM THE URBAN SITES Ranking 1 Leisure 41.5% Leisure 1.2% Ranking 2 Cleaning room, washing clothes, cleaning yard etc. 19.4% Work/help to generate income/output/economic practice 0.8% Ranking 3 Sleeping 17.0% Cleaning room, washing clothes, cleaning yard etc 0.8% TABLE D6: AVERAGE TIME SAVINGS PER YEAR, BY HOUSEHOLD MEMBER (US$, 2009) Adult time with Per average Site Women Men Children young children household Site 1 Rural (Luquan) in Kunming 5.3 5.3 7.8 7.8 26.2 Site 2 Rural in Dali 6.6 6.6 15.2 15.2 43.6 Site 3 Rural in Qiubei 6.1 6.1 7.7 7.7 27.6 Site 4 Urban in Kunming 0 0 0 0 0 Site 5 Urban in Dali 6.1 6.1 12.7 12.7 37.6 Site 6 Urban in Qiubei 4.1 4.1 6.3 6.3 20.8 Site 7 PRU (Jinglin) in Kunming 6.1 6.1 8.2 8.2 28.6 Site 8 PRU in Dali 0 0 17. 2 17.2 34.4 Average rural 6 6 12.8 12.8 37.6 Average urban 5.1 5.1 6.9 6.9 24 Average PRU 6.1 6.1 12.2 12.2 36.6 TABLE D7: AVERAGE ANNUAL VALUE OF TIME SAVINGS (US$, 2009) Adult time with Per average Site Women Men Children young children household Site 1 Rural (Luquan) in Kunming 134 134 99 99 466 Site 2 Rural in Dali 169 169 195 195 728 Site 3 Rural in Qiubei 132 132 83 83 430 Site 4 Urban in Kunming 0 0 0 0 0 Site 5 Urban in Dali 156 156 163 163 638 Site 6 Urban in Qiubei 88 88 68 68 312 Site 7 PRU (Jinglin) in Kunming 143 143 96 96 478 Site 8 PRU in Dali 0 0 220 220 440 Average rural 145 145 126 126 542 Average urban 122 122 116 116 476 Average PRU 143 143 158 158 602 118 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX E: INTANGIBLE USER PREFERENCES FOR SANITATION TABLE E1: RESPONDENTS’ UNDERSTANDING OF SANITATION - TOP RANKED RESPONSES PER SITE Focus Group Discussions Household interview With sanitation Without sanitation Men Women Men Women Average 1. flush toilet 1. improved pit-latrine 1. improved pit-latrine 1. shared toilet 4.3% 1. shared toilet 5.7% rural connected to 18.3% 19.7% 2. improved pit latrine 2. improved pit latrine sewerage 17% 2. 3-in-1 biogas unit 2. 3-in-1 biogas unit 3% 3.3% 2. private toilet 7% 11.3% 18.6% 3. flush toilet with 3. UDDT 0.7% 3. toilet built in yard or 3. UDDT 10% 3. UDDT 10.3% septic tank or near the residence sewerage 1.3% 4% Average 1. flush toilet 1. flush toilet 1. flush toilet 1. flush toilet 1. flush toilet urban connected to (connected to connected to septic connected to septic connected to septic sewerage 6% septic tank and tank and sewerage tank and sewerage tank and sewerage 2. improved public sewerage) 20.3% 26.7% 22.7% 27.6% toilet 2.3% 2. public toilet 7.3% 2. public toilet 8.7% 2. public toilet 9.7% 2. public toilet 10% 3. toilet building near 3. improved pit-latrine 3. improved pit latrine 3. improved pit-latrine 3. flush toilet 10.3% the yard or house 1.7% 6.3% 7.3% 1.7% Average 1. improved flush 1. flush toilet 1. flush toilet 1. flush toilet 1. flush toilet peri-urban toilet 9% connected to septic connected to septic connected to septic connected to septic 2. improved public tank and swerage tank and sewerage tank and sewerage tank 22% toilet 6.5% 20% 19% 19% 2. public flush toilet 3. toilet installed in the 2. public flush toilet 2. public flush toilet 2. public flush toilet 11.5% house 5% 10% 12% 10% 3. UDD 10% 3. UDDT 4% 3. UDDT 5.5% 3. UDDT 4% 4. 3-in-1 biogas unit 5.5% www.wsp.org 119 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE E2: REASONS FOR CURRENT SANITATION COVERAGE – TOP 3 RANKED RESPONSES PER SITE Focus Group Discussions Why families without toilet do not have a Why families with toilet have a toilet toilet Household interview Men (accounting Women Men (accounting Women for heads) (accounting for for heads) (accounting for heads) heads) Average 1. Privacy of toilet 1. clean19% 1. clean 22% 1. high cost 1% 1. high cost 5.7% rural 44% 2. convenient and 2. convenient and 2. no space 0.7% 2. no space 2.7% 2. Proximity to the safe19% safe 15.3% 3. incapable 0.7% 3. incapable 1.3% house 34% 3. protect the 3. protect the 4. never considered 4. never considered 3. use toilet on rainy headwater 18.3% headwater 21.7% this 0.7% this 3.3% days 17% 4. alone and not 4. health 13.3% 5. no one provided 5. no one provided 4. Comfortable being disturbed 6% 5. save energy 8.3% facility 3.3% facility 2.6% location 10% 5. health 3% 5. avoid snakes and pests 8% Average 1. Privacy of toilet 1. convenience, 1. safety 10.7% 1. limited by location 1. limited by location urban 27% sanitary 8.3% 2. convenience, 8% 12% 2. Avoid snakes and 2. environment sanitary 10% 2. limited by money 2. limited by money pests 26% protection 8.3% 3. environment 8% 12% 3. convenient for 3. safety 5.7% protection 7.3% 3. limited by city 3. limited by city using on rainy days 4. health 3% 4. health 7.3% planning 8% planning 12% 23% 5. civilized 2% 5. civilized 3% 4. Proximity to house 18% 5. comfortable location 11% Average 1. privacy of toilet 1. convenience 8.5 1. convenience 10% 1. no space 10% 1. no space 11% peri-urban 33% 2. sanitary 8.5 2. sanitary 10% 2. incapable 10% 2. incapable 11% 2. avoid snakes and 3. environment 3. environment 3. use public toilet 3. use public toilet pests 19% protection 8.5 protection 10% 10% 11% 3. showering in the 4. safety 8 4. safety 10% 4. live in rented room 4. live in rented room toilet 19% 5. comfort 7 5. comfort 6% 10% 11% 4. comfortable 5. not necessary 10% 5. not necessary 10% location 7% 5. proximity to the house 6% 120 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE E3: LEVEL OF SATISFACTION WITH CURRENT TOILET OPTION, BY OPTION TYPE (1 = NOT SATISFIED; 5 = VERY SATISFIED) Those with improved sanitation Those with unimproved sanitation Characteristic Sewer/ Wet pit Dry pit Compost Unimproved Shared No septic Average Average latrine latrine toilet pit or bucket toilet toilet tank Toilet position 3.3 3.6 4.0 3.7 3.7 1.5 3.2 1.9 2.2 Cleanliness 3.2 3.4 3.8 3.4 3.5 1.5 3.1 2.1 2.2 Status 3.3 3.4 3.7 3.5 3.5 1.0 2.9 1.8 1.9 Visitors 3.4 3.3 3.6 3.0 3.3 1.0 2.9 1.8 1.9 Maintaining 3.4 3.5 3.8 3.5 3.6 1.0 3.2 2.2 2.1 Health 3.2 3.4 4.1 3.3 3.5 1.0 3.1 1.8 2.0 Conflict avoidance 3.3 3.4 4.1 3.8 3.7 1.5 3.0 2.2 2.2 Convenience for children 3.4 3.2 4.2 3.5 3.6 1.0 3.0 1.7 1.9 Convenience for elderly 3.3 3.4 4.2 3.4 3.6 1.0 3.0 2.0 2 Night use of toilet 3.1 3.4 4.0 3.4 3.5 1.0 2.9 1.8 1.9 Avoid rain 3.0 3.3 4.1 3.4 3.5 1.0 2.8 1.7 1.8 Showering 3.8 3.8 4.2 3.5 3.8 1.0 2.7 1.8 1.8 Dangerous animals 3.3 3.4 3.8 3.2 3.4 1.0 3.1 2.0 2.0 Source : Household interviews TABLE E4: IMPORTANT CHARACTERISTICS OF A TOILET FOR THOSE CURRENTLY WITHOUT (1=NOT IMPORTANT; 5= VERY IMPORTANT) Characteristic No. responses Average score Comfortable toilet position 77 4.2 Cleanliness and freedom from unpleasant odors and insects 79 4.0 Having a toilet not needing to share with other households 77 3.6 Having privacy when at the toilet 77 4.2 Proximity of toilet to house 71 4.2 Pour-flush compared to dry pit latrine 64 3.2 Having a toilet disposal system that does not require emptying (piped sewer vs septic tank) 70 3.4 Having a toilet disposal system that does not pollute your, neighbors’, or your community’s 67 3.6 environment Preferred type of toilet households would like to get 72 5.6% dry pit 38.9% wet pit www.wsp.org 121 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX F: EXTERNAL ENVIRONMENT TABLE F1: SCORING OF DIFFERENT TYPES OF LIVING AREA (1 = CLEAN; 2 = MINOR SOILING; 3 = MODERATE SOILING; 4 = MAJOR SOILING; 5 = EXTREME SOILING) Private plots Community living areas (market, roadside) Site Human excreta Animal excreta Human excreta & Animal excreta & Solid waste U1 (Urban: Kunming) 2.83 3.47 3.30 R1 (Rural-Luquan: Kunming) 2.28 4.02 2.68 PRU1 (Peri-urban-Jinning: Kunming) 2.34 3.60 2.69 U2 (Urban: Dali) 2.39 3.44 2.88 R2 (Rural: Dali) 2.59 3.92 3.07 PRU2 (Peri-urban-Zhoucheng: Dali) 3.47 3.64 3.03 U3 (Urban: Qiubei) 3.30 3.67 2.57 R3 (Rural: Qiubei) 2.79 4.45 3.52 Average rural 2.53 4.13 3.09 Average urban 2.84 3.52 2.91 Average peri-urban 2.9 3.6 2.86 TOTAL 2.76 3.75 2.95 Source of data: for private plots - ESI household observation instrument; for community areas - physical location survey. TABLE F2: PROPORTION OF HOUSEHOLDS WITH AND WITHOUT TOILET WITH UNIMPROVED SANITATION PRACTICE Households with toilet Households with no toilet Site Open Seen others or Disposal of own child’s Seen others or own defecation own children stool in environment last children defecating in and urination defecating in yard2 time they defecated1 yard2 U1(Urban- Kunming) 4.00% 29.4% Data could not be identified 64.29% R1(Rural-Luquan, Kunming) 14.71% 41.3% Data could not be identified 40.00% PRU1 (Peri-urban-Jinning,Kunming) 33.33% 42.5% Data could not be identified 66.67% U2 (Urban—Dali) 25.00% 38.9% Data could not be identified 66.67% R2 (Rural-Dali) 2.38% 16.7% 33.3% 41.7% PRU2 (Peri-urban-Zhoucheng, Dali) 0.00% 66.7% 0.0% 91.7% U3 (Urban-Qiubei) 1.04% 87.9% 14.29% 44.4% R3 (Rural-Qiubei) 3.53% 85.7% Data could not be identified 50.0% Average rural 3.44% 43.0% Data could not be identified 68.82% Average urban 4.04% 51.0% Data could not be identified 35.76% TOTAL 3.60% 48.0% Data could not be identified 48.36% 1 Answering “put in drain or ditch,” “thrown out garbage,” “buried in ground” and “left out in open”) 2 Answering “sometimes” or “often” 122 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE F3: IMPLICATION OF CURRENT TOILET OPTION FOR EXTERNAL ENVIRONMENT (1 = NOT SATISFIED; 5 = VERY SATISFIED) Improved sanitation Unimproved sanitation Pour- Three- 3- in-1 Characteristic Private flush com- biogas Private Private Shared sewer- private partment septic Average OD Average wet pit ecosan toilet age septic septic tank tank tank latrine U1 3.93 4.50 3.91 4.10 2.50 3.33 4.26 N/A 2.00 2.00 U2 3.40 3.31 3.36 2.22 4.00 3.00 3.10 3.00 N/A 3.00 U3 4.17 4.00 3.00 3.00 N/A 4.50 4.06 4.00 2.00 3.33 R1 3.06 4.00 3.53 3.69 N/A 3.00 3.45 N/A 3.00 3.00 R2 N/A 4.00 3.64 3.50 3.74 3.33 3.47 3.17 N/A 2.11 R3 5.00 3.25 2.70 N/A 3.75 3.91 3.47 3.25 2.63 2.75 PRU1 2.47 2.98 2.00 2.00 4.00 N/A 2.75 2.98 3.00 2.98 PRU2 N/A 4.18 4.06 4.25 3.50 3.00 4.33 4.18 1.00 4.00 Average rural 4.03 3.75 3.29 3.60 3.75 3.41 3.46 3.21 2.82 2.62 Average urban 3.83 3.94 3.42 3.11 3.25 3.61 3.81 3.50 2.00 2.78 Peri-urban 2.47 3.58 3.03 3.13 3.75 3.00 3.54 3.58 2.00 3.49 TOTAL 3.67 3.78 3.28 3.25 3.58 3.44 3.61 3.43 2.27 2.90 Sample size 83 229 137 140 65 14 120 54 Source : Household interviews TABLE F4: PERCEPTIONS OF ENVIRONMENTAL SANITATION STATE, BY OPTION TYPE (1 = VERY BAD; 5 = VERY GOOD) Perception of environmental sanitation state Site Standing Dirt Dirt Rubbish Sewage Smoke Smell Rodents Insects water outside inside U1 (Urban- Kunming) 2.70 2.57 2.79 2.97 2.71 2.76 3.03 2.92 2.87 R1 (Rural-Luquan, 3.32 3.13 3.17 3.59 3.29 3.19 3.34 3.47 3.27 Kunming) PRU1 (Peri-urban- 3.31 3.15 3.20 3.63 3.29 3.13 3.32 3.53 3.28 Jinning, Kunming) U2 (Urban - Dali) 3.12 2.72 2.93 3.22 2.95 2.98 3.25 3.03 3.00 R2 (Rural-Dali) 2.93 2.80 2.84 3.02 2.87 2.82 2.99 2.79 2.67 PRU2 (Peri-urban- 2.97 2.93 3.07 3.12 3.07 3.17 3.25 3.28 3.22 Zhoucheng, Dali) U3 (Urban-Qiubei) 3.43 3.42 3.42 3.51 3.42 3.48 3.54 3.48 3.52 R3 (Rural-Qiubei) 2.48 2.54 2.78 2.84 2.49 2.71 2.71 2.51 2.53 Av. Rural 2.89 2.81 2.92 3.14 2.86 2.90 3.00 2.91 2.82 Av. Urban 3.09 2.95 3.07 3.31 3.08 3.07 3.25 3.26 3.16 TOTAL 2.99 2.88 3.00 3.22 2.97 2.99 3.12 3.08 2.99 www.wsp.org 123 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE F5: RANKING THE IMPORTANCE OF ENVIRONMENTAL SANITATION, BY OPTION TYPE (1 = NOT IMPORTANT; 5 = VERY IMPORTANT) Perceived importance of environmental sanitation management Site Dirt Dirt Rubbish Sewage Water Smoke Smell Rodents Insects outside inside U1 (Urban- Kunming) 4.41 4.32 4.23 4.18 4.39 4.19 4.10 4.24 4.32 R1 (Rural-Luquan, 4.49 4.22 4.07 4.23 4.42 4.29 4.14 4.54 4.53 Kunming) PRU1 (Peri-urban- 4.53 4.25 4.10 4.21 4.39 4.31 4.17 4.42 4.39 Jinning, Kunming) U2 (Urban - Dali) 4.30 4.03 3.82 3.86 4.19 4.10 3.72 4.41 4.34 R2 (Rural-Dali) 3.89 3.97 3.92 3.84 4.03 3.87 3.77 4.09 4.18 PRU2 (Peri-urban- 4.78 4.53 4.52 4.55 4.67 4.48 4.38 4.45 4.55 Zhoucheng, Dali) U3 (Urban-Qiubei) 4.13 4.15 4.01 4.12 4.09 4.00 4.01 4.19 4.21 R3 (Rural-Qiubei) 4.11 3.95 3.78 3.75 4.18 3.86 3.81 4.42 4.50 Av. Rural 4.17 4.05 3.92 3.93 4.21 4.00 3.91 4.36 4.42 Av. Urban 4.44 4.26 4.14 4.19 4.35 4.23 4.09 4.34 4.36 TOTAL 4.30 4.15 4.03 4.06 4.28 4.11 4.00 4.35 4.39 124 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX G: COST TABLES TABLE G1: AVERAGE RURAL COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, YEAR 2009) Cost Item Hygiene Shared Pit UDDT Biogas Septic INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 33.4 134.7 159.1 165.7 336.0 484.0 2. Program 2.9 0.0 0.0 19.0 25.5 23.3 Sub-total 36.3 134.7 159.1 184.7 361.4 507.4 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 5.4 4.4 5.3 5.7 10.4 15.4 4. Maintenance 6.6 11.4 14.1 14.6 16.8 21.2 5. Program 2.9 0.0 0.0 4.4 4.4 6.0 Sub-total 15.1 15.8 19.3 24.7 31.6 42.6 AVERAGE ANNUAL COST CALCULATIONS Duration 5.0 10.0 10.0 10.0 10.0 20.0 Cost/household 22.3 29.2 35.3 43.2 67.8 68.0 Cost/capita 6.4 8.3 10.1 12.3 19.4 19.4 OF WHICH: % capital 0.3 0.5 0.5 0.4 0.5 0.4 % program 0.0 0.0 0.0 0.0 0.0 0.0 % recurrent 0.7 0.5 0.5 0.6 0.5 0.6 Observations 403.0 14.0 118.0 14.0 43.0 214.0 www.wsp.org 125 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE G2: AVERAGE URBAN COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, YEAR 2009) Sewer- Sewer- Public Septage Septage Cost Item Hygiene Shared Pit UDDT Septic age age toilet optimal actual optimal actual INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 37.9 133.2 187.4 164.0 168.3 497.9 537.2 571.7 629.9 653.3 2. Program 2.9 4.4 13.9 0.0 20.5 24.2 27.8 30.7 29.4 31.3 Sub-total 40.8 137.6 201.3 164.0 188.8 522.2 565.1 602.4 659.3 684.8 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 6.6 5.9 14.6 5.9 7.3 18.4 24.2 24.6 27.8 28.4 4. Maintenance 9.1 8.1 8.8 13.8 17.6 23.3 31.5 32.2 40.1 41.1 5. Program 2.9 2.2 5.1 0.0 4.4 4.4 4.4 4.8 4.4 4.7 Sub-total 18.4 16.1 28.5 19.6 29.3 46.0 60.0 61.6 72.3 74.2 AVERAGE ANNUAL COST CALCULATIONS Duration 5.0 10.0 10.0 10.0 10.0 20.0 20.0 20.0 20.0 20.0 Cost/household 26.6 29.9 48.7 35.9 48.2 72.1 88.3 91.7 105.2 108.5 Cost/capita 7.6 8.5 13.9 10.3 13.8 20.6 25.2 26.2 30.1 31.0 OF WHICH: % capital 0.3 0.4 0.4 0.5 0.3 0.3 0.3 0.3 0.3 0.3 % program 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 % recurrent 0.7 0.5 0.6 0.5 0.6 0.6 0.7 0.7 0.7 0.7 Observations 257.0 2.0 16.0 26.0 3.0 156.0 10.0 10.0 44.0 44.0 126 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE G3: AVERAGE PERI-URBAN COST PER HOUSEHOLD FOR DIFFERENT SANITATION AND HYGIENE OPTIONS, USING FULL (ECONOMIC) COST (US$, YEAR 2009) Cost Item Hygiene Shared Pit UDDT Septic INVESTMENT COSTS: INITIAL ONE-OFF SPENDING 1. Capital 37.6 135.3 166.7 169.2 498.3 2. Program 2.9 0.0 0.0 17.0 24.6 Sub-total 40.5 135.3 166.7 186.4 522.9 RECURRENT COSTS: AVERAGE ANNUAL SPENDING 3. Operation 6.9 5.9 5.9 7.9 18.3 4. Maintenance 8.3 11.4 14.8 15.8 22.7 5. Program 2.9 0.0 0.0 4.4 4.4 Sub-total 18.2 17.3 20.6 28.3 45.4 AVERAGE ANNUAL COST CALCULATIONS Duration 5.0 10.0 10.0 10.0 20.0 Cost/household 26.3 30.8 37.3 46.8 71.5 Cost/capita 7.5 8.8 10.7 13.4 20.4 OF WHICH: % capital 0.3 0.4 0.4 0.4 0.3 % program 0.0 0.0 0.0 0.0 0.0 % recurrent 69.1 56.0 55.4 60.2 63.5 Observations 199 71 29 24 75 www.wsp.org 127 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE G4: PROPORTION OF TOTAL (ECONOMIC) COSTS WHICH ARE FINANCIAL (US$, YEAR 2009) Sewer- Sewer- Public Pit Septic Septage Septage Sanitation Options Hygiene Shared UDDT Biogas age age toilet latrine tank optimal actual optimal actual Financial 20.5 89.3 143.5 110.8 123.6 282.5 421.2 453.8 481.6 534.3 553.2 Capital Total 35.7 135.1 187.4 161.2 168.1 336.0 491.3 537.2 571.7 629.9 653.3 (total) Proportion 0.6 0.7 0.8 0.7 0.7 0.8 0.9 0.8 0.8 0.8 0.8 Program Financial 1.5 0.0 10.2 0.0 14.3 21.1 18.6 20.5 22.7 21.7 23.0 (total) Total 2.9 0.1 13.9 0.0 18.0 25.5 23.9 27.8 30.7 29.4 31.3 Proportion 0.5 0.7 0.8 0.8 0.8 0.7 0.7 0.7 0.7 Recurrent Financial 11.0 7.6 17.6 8.8 12.9 15.7 19.6 29.3 30.3 34.8 35.9 (annual) Total 16.8 17.0 28.5 19.6 27.1 31.6 44.2 60.0 61.6 72.3 74.2 Proportion 0.7 0.5 0.6 0.4 0.5 0.5 0.4 0.5 0.5 0.5 0.5 Average Financial 15.4 16.6 32.9 19.9 26.6 46.0 41.6 53.0 55.5 62.6 64.6 (annual) Total 24.5 30.5 48.7 35.7 45.7 67.8 70.0 88.3 91.7 105.2 108.5 Proportion 0.6 0.5 0.7 0.6 0.6 0.7 0.6 0.6 0.6 0.6 0.6 Duration (years) 5.0 10.0 10.0 10.0 10.0 10.0 20.0 20.0 20.0 20.0 20.0 TABLE G5: INCREMENTAL COSTS OF MOVING UP THE SANITATION LADDER (US$, 2009) Public Sewerage Hygiene Shared Pit latrine UDDT Biogas Septic tank toilet with actual sewerage Duration 5.0 10.0 10.0 10.0 10.0 20.0 20.0 20.0 Sub-total 40.8 136.3 161.2 185.9 361.4 515.1 201.3 684.8 investment Sub-total 17.7 17.4 19.6 27.1 31.6 44.2 28.5 74.2 annual recurrent Total economic 129.6 310.2 357.0 456.7 677.6 1,400.5 772.2 2,169.9 costs Shared Pit latrine UDDT Biogas Septic tank Public Sewerage toilet with actual sewerage Shared - 357.0 456.7 677.6 1,400.5 772.2 2,169.9 Pit latrine - - 456.7 200.4 1,400.5 772.2 2,169.9 UDDT - - - 677.6 1,400.5 772.2 2,169.9 Biogas - - - - 1,400.5 772.2 2,169.9 Septic tank - - - - - 772.2 769.3 Public - - - - - - 2,169.9 toilet with sewerage 128 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX H: PROGRAM APPROACH ANALYSIS TABLE H1: HOUSEHOLD CHOICES AND OTHER INTERVENTIONS Was household Was household given a Hygiene awareness Water intervention given a choice to choice of options (%) (%) offered (%) Number of participate? (%) Rural/ Site households Yes, No, urban Yes, No, not interviewed choice choice volun- volun- Yes No Yes No avail- not tary tary able available 1. Kunming Rural 151 (54) 9.9% 25.8% 4.6% 31.1% 10.6% 24.5% 28.5% 7.3% 2. Dali Rural 133 (59) 15% 29.3% 14.3% 30.1% 24.8% 19.5% 9% 35.3% 3. Qiubei Rural 171 (75) 21.6% 14.6% 24% 18.1% 32.2% 9.4% 15.2% 26.9% 4. Kunming City 120 (59) 18.3% 29.2% 11.7% 35.8% 11.7% 35.8% 3.3% 44.2% 5. Dali City 61 (25) 23% 19.7% 16.4% 22.2% 19.7% 23% 29.5% 11.5% 6. Qiubei City 72 (19) 9.7% 9.7% 11.1% 13.9% 12.5% 12.5% 12.5% 13.9% 7. Kunming Peri 141 (53) 12.1% 26.2% 7.8% 30.5% 11.3% 26.2% 83% 17% (Jinning) 8. Dali Peri 60 (34) 30% 28.3% 16.7% 41.7% 11.7% 46.7% - 58.3% TABLE H2: FINANCING FROM HOUSEHOLD AND PROJECT SOURCES Number of Household Rural/ Value of household inputs Project value Site households contribution urban input (USD) interviewed Yes No Cash (USD) Labor (days) Materials (USD) 1. Kunming Rural 151 (54) 0.54 0.34 131.46 2.00 141.85 99.69 2. Dali Rural 133 (59) 0.38 0.38 66.31 1.50 27.23 1,181.07 3. Qiubei Rural 171 (75) 0.50 0.18 141.56 2.00 32.21 94.86 4. Kunming City 120 (59) 0.28 0.43 160.88 2.00 19.32 280.77 5. Dali City 61 (25) 0.71 0.28 202.60 1.50 463.03 130.14 6. Qiubei City 72 (19) 0.47 0.35 262.48 2.00 167.62 1,182.39 7. Kunming Peri 141 (53) 0.55 0.32 62.65 1.00 84.47 123.70 (Jinning) 8. Dali Peri 60 (34) 0.28 0.53 519.39 1.00 150.63 157.37 www.wsp.org 129 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE H3: APPROPRIATE TECHNOLOGY Number % households with % households with pit % households with pit Rural/ of house- insufficient water for flushing flooding overflow Site urban holds in- Often (rainy Often (rainy terviewed Sometimes Often Sometimes Sometimes season) season) 1. Kunming Rural 151 1.3% 1.3% 0.7% 0.7% 2% 0.7% 2. Dali Rural 133 1.5% 5.2% 0 1.5% 0.8% 1.5% 3. Qiubei Rural 171 1.6％ 4.5％ 4.7% 2.3% 4.7% 9.1% 4. Kunming City 120 0.8% 3.3% - - 0.8% 0.8% 5. Dali City 61 3.3% 3.3% - - - - 6. Qiubei City 72 4.2% 1.4% - 1.4% 1.4% 1.4% 7. Kunming Peri 141 1.4% 1.4% 0.7% 0.7% 1.4% 0.7% (Jinning) 8. Dali Peri 60 3.3% 3.3% - - - - TABLE H4: ACTUAL PROGRAM PERFORMANCE IN RELATION TO KEY SELECTED INDICATORS FOR PROGRAM EFFECTIVENESS Kunming Dali Qiubei Kunming Dali Qiubei Kunming Dali Impact Indicator (Rural) (Rural) (Rural) (City) (City) (City) (Peri) (Peri) Health % household members 65.9% 44.7% 51.4% 82.9% 70.4% 77.8% 62.9% 81.5% (sanitation using improved toilet intervention) regularly Health 88.1% 69.9% 55% 75% 78.7% 77.8% 90.1% 71.7% % households washing (hygiene hands after defecation intervention) % latrines with signs of 23.8% 15.8% 12.3% 4.3% 29.5% 4.2% 34.8% 0 feces around toilet Water % households using non- 4.6% 4.6% 32.7% 6.7% 3.3% 25% 4.3% 5% treatment boiling household water treatment methods Access time % household members 88.6% 85.1% 75.7% 82.9% 81.5% 77.8% 68.6% 81.5% using own toilet instead of off-plot options Men Women Children 5-14 Children 0-4 Reuse Own use: % households 63.6% 85.1% 75.7% 26.8% 37% 14.8% 25.7% 33.3% applying human excreta in own land or using human excreta for biogas Intangibles Average score (as % of 3.18 3.78 3.24 4.18 2.80 4.02 2.75 4.28 maximum score of 5) of satisfaction questions External Average score (as % of 3.23 2.86 2.57 4.34 2.93 3.42 3.24 3.01 environment maximum score of 5) of external environment questions relating to sewage 130 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables ANNEX I: CBA AND CEA RESULTS TABLE I1: SITE 6 - RURAL LUQUAN EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Pit latrine Septic tank No. observations (households) 33 117 COST-BENEFIT MEASURES Ideal 11.1 7.1 Benefits per 1 US$ input ($) Actual 6.6 4.3 Ideal na na Internal rate of return (%) Actual na 2.2 Ideal na na Payback period (years) Actual na 1.5 Ideal 725.9 884.6 Net present value ($) Actual 401.8 481.1 COST-EFFECTIVENESS MEASURES Ideal 254.5 328.6 Cost per DALY averted ($) Actual 386.2 498.6 Ideal 2.3 2.9 Cost per case averted ($) Actual 3.4 4.5 Ideal 4,577.8 5,904.5 Cost per death averted ($) Actual 6,946.6 8,959.7 www.wsp.org 131 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE I2: SITE 7 - RURAL DALI EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Shared Pit latrine UDDT Biogas Septic tank No. observations (households) 7 49 9 13 52 COST-BENEFIT MEASURES Ideal 8.3 13.1 14.5 10.6 7.9 Benefits per 1 US$ input ($) Actual 5.1 9.4 9.4 6.6 5.5 Ideal na na na na na Internal rate of return (%) Actual na na na na 7.1 Ideal na na na na na Payback period (years) Actual na na na na 1.2 Ideal 407.1 766.8 1,065.2 1,078.4 935.6 Net present value ($) Actual 229.2 533.8 663.0 629.0 606.2 COST-EFFECTIVENESS MEASURES Ideal 196.8 224.5 176.6 252.8 303.9 Cost per DALY averted ($) Actual 328.1 533.8 294.3 421.4 506.5 Ideal 1.7 1.9 1.5 2.2 2.6 Cost per case averted ($) Actual 2.8 3.2 2.6 3.7 4.4 Ideal 3,569.9 4,070.6 3,198.4 4,580.1 5,504.9 Cost per death averted ($) Actual 5,949.9 6,784.3 5,330.7 7,633.5 9,174.9 TABLE I3: SITE 8 – RURAL QIUBEI EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Shared Pit latrine UDDT Biogas Septic tank No. observations (households) 7 36 5 30 45 COST-BENEFIT MEASURES Ideal 12.1 14.4 15.5 11.7 8.5 Benefits per 1 US$ input ($) Actual 6.8 8.8 9.3 7.1 5.0 Ideal na na na na na Internal rate of return (%) Actual na na na na 3.8 Ideal na na na na na Payback period (years) Actual na na na na 1.3 Ideal 562.8 777.4 1,105.3 1,123.8 977.8 Net present value ($) Actual 295.6 456.3 633.7 640.7 523.9 COST-EFFECTIVENESS MEASURES Ideal 124.3 142.0 118.6 163.0 203.2 Cost per DALY averted ($) Actual 241.8 276.2 230.7 317.1 395.4 Ideal 1.2 1.3 1.1 1.5 1.9 Cost per case averted ($) Actual 2.2 2.6 2.2 3.0 3.7 Ideal 2,236.7 2,555.3 2,132.7 2,931.4 3,655.4 Cost per death averted ($) Actual 4,351.5 4,971.4 4,149.2 5,703.1 7,111.7 132 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE I4: SITE 1 – URBAN KUNMING EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Septic tank Sewerage No. observations (households) 85 33 COST-BENEFIT MEASURES Ideal 3.5 2.6 Benefits per 1 US$ input ($) Actual 2.4 1.8 Ideal 1.3 0.7 Internal rate of return (%) Actual 0.5 0.3 Ideal 1.8 2.6 Payback period (years) Actual 3.1 4.6 Ideal 390.9 332.1 Net present value ($) Actual 212.7 168.0 COST-EFFECTIVENESS MEASURES Ideal 654.7 904.2 Cost per DALY averted ($) Actual 1,091.1 1,408.0 Ideal 6.3 8.6 Cost per case averted ($) Actual 10.4 13.5 Ideal 11,725.9 11,725.9 Cost per death averted ($) Actual 19,543.1 25,218.9 TABLE I5: SITE 2 – URBAN DALI EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Public toilet Pit latrine Septic tank Sewerage No. observations (households) 16 13 21 11 COST-BENEFIT MEASURES Ideal 6.7 7.2 4.2 3.2 Benefits per 1 US$ input ($) Actual 4.5 5.1 2.9 2.1 Ideal na na 2.2 1.1 Internal rate of return (%) Actual na na 0.8 0.4 Ideal na na 1.5 2.0 Payback period (years) Actual na na 2.4 3.6 Ideal 495.4 418.3 475.9 426.2 Net present value ($) Actual 305.0 275.4 278.2 218.6 COST-EFFECTIVENESS MEASURES Ideal 334.9 407.9 562.0 752.5 Cost per DALY averted ($) Actual 558.1 679.9 936.7 1,317.1 Ideal 3.0 3.6 5.0 6.7 Cost per case averted ($) Actual 5.0 6.0 8.3 11.7 Ideal 6,152.0 7,507.5 10,325.4 13,824.8 Cost per death averted ($) Actual 10,253.4 12,512.5 17,209.1 24,197.1 www.wsp.org 133 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE I6: SITE 3 – URBAN QIUBEI EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Shared Pit latrine UDDT Private septic tank No. observations (households) 2 13 3 50 COST-BENEFIT MEASURES Ideal 6.5 8.5 9.5 5.4 Benefits per 1 US$ input ($) Actual 3.9 5.6 5.7 3.5 Ideal na na na 7.4 Internal rate of return (%) Actual 7.0 na na 1.2 Ideal na na na 1.2 Payback period (years) Actual 1.2 na na 1.9 Ideal 298.8 479.0 725.8 600.9 Net present value ($) Actual 157.3 295.5 401.7 339.0 COST-EFFECTIVENESS MEASURES Ideal 193.6 226.3 193.3 310.4 Cost per DALY averted ($) Actual 322.7 377.1 322.2 517.3 Ideal 1.9 2.2 1.9 3.0 Cost per case averted ($) Actual 3.2 3.7 3.2 5.1 Ideal 3,498.7 4,089.2 3,497.1 5,614.4 Cost per death averted ($) Actual 5,831.2 6,815.4 5,828.5 9,357.4 TABLE I7: SITE 4 – PERI-URBAN KUNMING EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Shared Pit latrine UDDT Septic tank No. observations (households) 55 12 15 58 COST-BENEFIT MEASURES Ideal 5.2 6.3 7.4 3.8 Benefits per 1 US$ input ($) Actual 3.3 4.1 4.3 2.4 Ideal na na na 1.5 Internal rate of return (%) Actual 2.9 12.9 na 0.5 Ideal na na na 1.7 Payback period (years) Actual 1.4 1.1 na 3.1 Ideal 236.5 368.4 550.6 416.9 Net present value ($) Actual 125.7 211.9 289.4 209.8 COST-EFFECTIVENESS MEASURES Ideal 341.7 425.5 334.4 569.7 Cost per DALY averted ($) Actual 569.4 709.2 557.4 949.4 Ideal 3.1 3.9 3.1 5.2 Cost per case averted ($) Actual 5.2 6.5 5.1 8.7 Ideal 6,252.9 7,787.2 6,110.5 10,408.1 Cost per death averted ($) Actual 10,421.4 12,978.6 10,184.2 17,346.8 134 Economic Assessment of Sanitation Interventions Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE I8: SITE 5 – PERI-URBAN DALI EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARED TO “NO TOILET” Efficiency measure Scenario Shared Pit latrine UDDT Septic tank No. observations (households) 16 17 9 17 COST-BENEFIT MEASURES Ideal 9.2 8.6 11.0 5.4 Benefits per 1 US$ input ($) Actual 6.0 5.7 6.9 3.5 Ideal na na na 8.7 Internal rate of return (%) Actual na na na 1.2 Ideal na na na 1.1 Payback period (years) Actual na na na 1.9 Ideal 455.9 503.4 790.1 649.4 Net present value ($) Actual 277.4 314.0 461.7 369.5 COST-EFFECTIVENESS MEASURES Ideal 200.2 240.7 790.1 335.4 Cost per DALY averted ($) Actual 333.7 401.1 300.4 559.1 Ideal 1.8 2.2 1.6 3.0 Cost per case averted ($) Actual 3.0 3.6 2.7 5.0 Ideal 3,689.4 4,435.6 3,317.2 6,173.5 Cost per death averted ($) Actual 6,149.0 7,392.7 5,528.6 10,289.2 TABLE I9: SITE 8 – RURAL QUIBEI AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER (US$, YEAR 2009) Moving from shared to Moving from Pit latrine to (US$) Efficiency measure Scenario Pit latrine UDDT Biogas UDDT Biogas Septic tank COST-BENEFIT MEASURES Ideal 3.8 4.5 7.3 4.5 5.0 2.1 Benefits per 1 US$ input ($) Actual 2.9 0.7 1.67 0.7 0.9 na Ideal 5.1 na na na 1.8 0.4 Internal rate of return (%) Actual 1.5 na 0.3 na 0.0 na Ideal 1.2 na na na 1.6 3.9 Payback period (years) Actual 1.7 na 4.9 na na na Ideal 163.6 269.7 339.2 269.7 314.5 142.3 Net present value ($) Actual 109.7 (21.4) 36.6 (21.4) (14.3) (131.2) COST-EFFECTIVENESS MEASURES Ideal na 325.1 230.4 325.1 335.4 557.2 Cost per DALY averted ($) Actual na 632.5 448.2 632.5 869.3 1,084.0 Ideal na 3.1 2.2 3.1 3.2 5.3 Cost per case averted ($) Actual na 6.0 4.2 6.0 8.2 10.2 Ideal na 5,840.3 4,139.2 5,840.3 6,025.9 10,010.4 Cost per death averted ($) Actual na 11,362.4 8,052.9 11,362.4 15,617.9 19,475.4 www.wsp.org 135 Economic Assessment of Sanitation Interventions in Yunnan Province, People’s Republic of China | Annex Tables TABLE I10: SITE 1 – URBAN KUNMING AREA EFFICIENCY MEASURES FOR MAIN GROUPINGS OF SANITATION INTERVENTIONS, COMPARING DIFFERENT POINTS ON THE SANITATION LADDER (US$, YEAR 2009) Moving from septic tank to Efficiency measure Scenario sewerage (US$) COST-BENEFIT MEASURES Ideal na Benefits per 1 US$ input ($) Actual na Ideal na Internal rate of return (%) Actual na Ideal na Payback period (years) Actual na Ideal (1,453.6) Net present value ($) Actual (1,358.1) COST-EFFECTIVENESS MEASURES Ideal 6,176.8 Cost per DALY averted ($) Actual 9,617.9 Ideal 59.1 Cost per case averted ($) Actual 92.0 Ideal 110,636.0 Cost per death averted ($) Actual 172,272.9 136 Economic Assessment of Sanitation Interventions