Water, sanitation conditions and implications for child survival in Kenya: a review of statistical evidence from the 1999 census of population

Kenya has been conducting decennial population censuses since 1969. In the 1979, 1989, and 1999 censuses, women aged 12 and above were asked how many live births they had had, and of these, how many children had since died (see Appendix I, part C). From the responses, the Central Bureau of Statistics (CBS) computed the proportions of dead children, data that can be used as a Child Mortality Index (Republic of Kenya 2002a). In the 1999 census results monograph on mortality, CBS displayed these mortality rates in correlation with water (Appendix II) and sanitation (Appendix III) parameters (Republic of Kenya 2002b).

The intention is to reflect on the worldwide concept that water and sanitation are significant determinants of child mortality in developing countries. Obviously this may not be the best way to generate causality data but, as Schmidt (2014) noted, usually there are many difficulties in getting perfect evidence linking water and sanitation improvement to reductions in morbidity and mortality of water-related diseases. More often than not researchers make do with the best information available.

The purpose of this review is to put the Kenyan case into the perspective of the global debate on water and sanitation as child mortality causal factors. The review uses frequency distributions and proportions, displayed in tables and bar graphs, to give a clear demonstration and interpretation of the Kenyan situation.

Globally, four out of ten (about 2.6 billion) people have no access even to simple pit latrines, while about half that number (1.1 billion) have no safe drinking water source (von Schirnding 2002; Bartram et al. 2005). Consequently inadequate water and sanitation are responsible for the deaths of 3,900 children every day (Bartram et al. 2005).

Studies linking water and sanitation with child health have been conducted widely in the developing world, including Sudan (Musa et al. 1999; Merchant et al. 2003), Peru (Checkley et al. 2004), Bangladesh (Hussain et al. 1999), Kenya, Uganda and Tanzania (White et al. 1972; Thompson et al. 2002; Tumwine et al. 2002; Tumwine et al. 2003), Eritrea (Woldemicael 2000), Mali (Plate et al. 2004) and Kenya (Dreibelbis et al. 2014). All of them bring out the causal relationship between water and sanitation, and child mortality.

In the last quarter century, water, sanitation and child mortality have been the top concern of scholars globally, owing to their inclusion as Millennium Development Goals (MDGs) (e.g., Fotso et al. 2007; Günther & Fink 2010, 2011; Hunter et al. 2010; Fink et al. 2011; Granados & Sanchez 2014). Target 7c on water and sanitation and Goal 4 on infant and child health were pertinent (Cheng et al. 2012). The MDGs ended in 2015 but water and sanitation remain pertinent, as declared in the MDGs successor, the Sustainable Development Goals (SDGs). SDG 6 aims to ensure the availability and sustainable management of water and sanitation for all: 6.1, achieve universal and equitable access to safe and affordable drinking water for all; and 6.2, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations, by 2030.

This review is unique in various respects. It is longitudinal – i.e. based on time progression: 1979, 1989 and 1999 – and, unlike all the others, which are based on limited sample surveys, it is based on national censuses. The most recent decennial census was taken in 2009 and reported in 2009 Kenya Population and Housing Census (Republic of Kenya 2010). However, the data were difficult to integrate into this review because of inconsistencies in the reporting of some statistics. For instance, where sources of drinking water are concerned, the 2009 report lumped together the frequencies of some sources e.g. pond/dam, spring/well/borehole, jabia/rain harvested (Republic of Kenya 2010, p 330), while the report for 1999 rightly treated each source separately.

Secondly the publication and distribution of analytical reports on relevant aspects, such as mortality or housing amenities, that could have updated the 1999 results have been curtailed by a court case challenging the data's authenticity. This leaves the 1999 data best suited for delivering the mission of this review.

Water is essential for life. Its availability or otherwise in the human environment entails several risks of disease transmission, including (UN-HABITAT 2003; Cairncross & Valdmanis 2006):

• Ingestion of contaminated water – water borne diseases

• Inadequate water for personal hygiene – washwater diseases

• Contact with pathogen-infested water – diseases caused by schistosoma and helminths

• Vector borne transmission – diseases like malaria and lymphatic filariasis.

Children in developing countries are prone to all these risks but the first two are the most critical for their survival. They stem from the provision of inadequate water and sanitation at household level, which are responsible for 88% of diarrheal disease (Bartram et al. 2005). Diarrhea is noted as the second greatest cause, after respiratory illness, of childhood deaths up to five years (Bartram et al. 2005).

Apart from its direct morbidity and mortality effects, diarrhea also causes malnutrition in children (Merchant et al. 2003; Checkley et al. 2004), by inhibiting normal adsorption of nutrients thereby leading to impaired physical growth and cognitive development, as well as reduced resistance to infection (Clasen & Cairncross 2004).

Two paradigms, can be adopted for solving water and sanitation health problems. The first involves supplying water of adequate drinking quality – Drinking Water Paradigm – and the second, improving sanitation and hygiene standards – Sanitation-Hygiene Paradigm.

This paradigm emphasizes the provision of safe drinking water, in terms of quality, for disease prevention. The ingestion of contaminated water by children is a worldwide problem, but the contamination parameters differ between developed and developing countries. In the developed world, for example, the concern is with the chemical contamination (copper, lead, iron, fluoride, nitrate, etc) of domestic water sources (Pettersson & Rasmussen 1999; Knobeloch et al. 2000; Hilbig et al. 2002). In the developing world the concern is with pathogen contamination leading to water-related diseases.

Where water quality was the issue in relation to the drinking water paradigm, its quantity is more important with respect to the sanitation hygiene paradigm. Clasen & Cairncross (2004 p. 187) observed that: ‘interventions for the prevention of diarrheal disease not only include enhanced water quality but also steps to (i) improve the proper disposal of human feces (sanitation), (ii) increase water quantity and improve access to it (water supply), and (iii) promote hand-washing and other hygiene practices within domestic and community settings (hygiene)’. However, statistics have always shown sanitation improvements to offer more benefits in reducing diarrhea than improvements in water supply (Esrey et al. 1985; Esrey 1996; Curtis et al. 2000; Bartram et al. 2005). Thus, Bartram et al. (2005) indicated that diarrhea morbidity could be reduced by about 21% through improved water supply and 37% through improved sanitation. In this context, Clasen & Cairncross (2004 p 188) stated that: ‘to achieve broad health impact, greater attention should be given to safe excreta disposal and proper use of water for personal and domestic hygiene rather than to drinking-water quality. The corollary has become equally well established: that interventions aimed solely at improving drinking water quality would have relatively little impact in reducing diarrheal disease’.

Domestic water supply refers to adequate access to safe drinking water in a dwelling or within a convenient distance of the user's dwelling (Tumwine et al. 2002). Rosen & Vincent (1999) took the latter to be 200 m. The methods of accessing water for domestic use in developing countries include drawing it at source, public standpipes, yard taps, and house connections (Kitawaki 2002). Drawing water at source is common in rural areas and involves the use of untreated water from open surfaces. Such water is highly prone to microbial contamination.

Sanitation comprises a wide range of factors influencing the human environment and hygiene (Kitawaki 2002), including sanitary treatment, and the disposal of human excreta and wastewater. Inadequate treatment of human excreta exposes drinking water and food to pathogens that cause and spread diseases (Kitawaki 2002), like those (bacterial and non-bacterial) that cause diarrhea. Kitawaki (2002) identified excreta disposal and treatment sanitation facilities found in developing countries, including: dry on-site – e.g. pit latrines, dry off-site (bucket latrines), wet on-site (pour-flush latrines), and wet off-site (including flush toilets with sewerage connections). WHO has defined access to sanitation as adequate excreta disposal facilities that can effectively prevent human, animal and insect contact with excreta (Tumwine et al. 2002).

The water supply and sanitation situation in Kenya is unappealing. According to the 1999 census report, 30.52% of households had access to piped water (see Table 1). This situation is not significantly different from the more recent 2009 census where 29.96% had access to piped water (K'Akumu 2013). The rest drew water from sources susceptible to contamination. All the open surface sources including ponds, dams, lakes and streams/rivers combined, account for 35.31% of households in Kenya. The quality of the water from piped sources is also questionable, however – the networks are liable to contamination due to poor management structures.

Piped water is mainly distributed in urban rather than rural areas. This disparity is not limited to the urban rural divide. Even within urban centers themselves, great disparities exist between low- and high- income households, vis-à-vis potable water. In all urban areas in Kenya the majority of households live in slums and informal settlements, where water is not provided per household. At best these people depend on community standpipes, but most rely on water vendors for access to water piped or not.

Pit latrines stand out as the main means of human waste disposal (used by 72.1% of households) and are common in rural areas. Some 16.4% of households, however, mainly in rural areas, have no means of human waste disposal and have to defecate in the bush.

Figure 3 shows that child mortality rates are relatively low for the children of mothers in households that have access to main sewers or septic tanks for sewage disposal, compared to the others. The children of those in the bush are those with the highest proportional likelihood of childhood death that may be due to sanitation related diseases. This has significant policy implications for public health.

Child mortality, like infant mortality, is strongly associated with poor health conditions, particularly those relating to general hygiene, sanitation and malnourishment (Republic of Kenya 2002b). Child mortality can be a sensitive indicator of the health of any nation. Bartram et al. (2005) note that for every person who dies of water- and sanitation- related diseases many more become ill. They say that improvement in water sanitation and hygiene would contribute to improved health, generate savings for domestic and national budgets, and contribute to poor households' economies through reduced treatment costs and time loss. Investment in water and sanitation is therefore a priority. A recent cost-benefit analysis on investment in water and sanitation (Evans et al. 2004) has shown that every investment made would yield a return exceeding 300% and, sometimes, more than ten times that.

In developing countries simple diseases like diarrhea kill children, while in developed countries it is diseases associated with old age that are mainly responsible for mortality (Kitawaki 2002). This, in essence, has led to disparities in life expectancy, with developing countries recording much lower life expectancy than developed ones. Bartram et al. (2005) note that the trauma of child death from a preventable disease like diarrhea can have lasting psychological and emotional impacts on surviving parents and siblings.

Analysis of child deaths by main source of water has shown low child mortality rates for treated water sources and high rates for untreated sources. Piped water to every household is still a remote dream for Kenya, so far only 30% or so of households have access to the service. However, to deal with child mortality, there is a need to encourage point of use water treatment as public policy.

Analysis of the proportion of children dying as a result of sewage disposal also indicates low mortality rates for homes with main sewer connections or septic tanks. ‘Bush’ disposal of human waste shows the highest child mortality rate. Where open means of disposal like pit or bucket latrines, or disposal in the bush are used, mortality rates are high, as shown in Figure 3. Implementing stronger public health policy, to save children's lives, could easily eliminate the use of bush disposal in rural areas. A study carried out in Kenya, Tanzania and Uganda found that households in Kenya were more likely to have poorly maintained sanitation facilities than those in Tanzania, where hygiene laws are enforced strictly (Tumwine et al. 2003). A three-decade decline in the prevalence of diarrhea has also been shown in Tanzania, compared to Uganda and Kenya (Tumwine et al. 2002).

Dreibelbis et al. (2014) observed that Water, Sanitation and Hygiene (WASH) interventions in schools can influence diarrheal outcomes among children less than 5 years old, through the diffusion of awareness of the value of good hygienic practices in domestic environments and the broader community, and by interrupting pathogen transmission in the public sphere, reducing transmission to and exposures in domestic environments. In 2007–2009 a study was undertaken in Kenya to test the effectiveness of school wash programs. This confirmed that school WASH interventions reduced diarrhea and gastrointestinal-related clinic visits among children less than 5 years old. School-based WASH programs should therefore be made mandatory in Kenya.

It has also been shown that rural areas are not favored in the distribution of water and sanitation facilities. Indeed, rural areas tend to have higher child mortality rates than urban areas. For the sake of social equity, there is a need to balance the distribution of water and sanitation facilities, which should help to reduce the high incidence of rural child mortality.

In Kenya, as in many countries, water and sanitation have significant impacts on child health and survival. Evidence from the 1999 population census, in particular, and previous censuses in general, indicates differential mortality rates according to the quality of water sources and sanitation types. Piped water and main sewers, for example, each record the lowest proportional child mortality rates, while lake waters and bush disposal record the highest rates for single sources/types of facility.

The recommendations made in this review will go a long way towards reducing child mortality and the burden of disease arising from inadequate water and sanitation conditions (Hutton et al. 2007; Jeuland et al. 2013; Clasen et al. 2014) and thereby contribute to the achievement of MDGs and SDGs in Kenya.