MITIGATING LONG-TERM IMPACTS OF COVID-19 BY STRENGTHENING SOCIAL JUSTICE IN ACCESS TO WASH AND HEALTH SERVICES: INSIGHTS FROM NEPAL

Mitigating long-term impacts of COVID-19 by strengthening social justice in access to WASH and health services: Insights from Nepal

Using Demographic and Health Survey data, the authors show that ethnic identity mediates access to water, sanitation and health services in Nepal. As COVID-19 strains Nepal’s public health programs and government resources, ethnicity should be considered when deciding where to strengthen the supply of critical services. – Samuel Scott, series co-editor and Research Fellow, IFPRI

Ganesh Kumari Karki (60) drinks water from a public tap at Dhap village.Photo credit: Tom van Cakenberghe / IWMI 

COVID-19 has disproportionately affected African American, Latino, migrant, and other vulnerable socio-economic groups globally, due to their limited prior access to health care, nutrition, and social protection. With future epidemics and pandemics becoming likelier because of urbanization, globalization and climate change, long-term investments in water supply and sanitation, health care and nutrition will need to be made in a manner that reduces existing inequities in access. But progress can only be made if we broaden the criteria for targeting to include ethnic and racial identities.

The case of Nepal

Nepal is a case in point. The country has 126 ethnic groups, officially classified into seven groups on the basis of caste, religious and ancestral lines. The Government of Nepal uses these categories as part of its initiatives to improve proportional representation in elected offices and higher education. Nepal is also a low-income country, with 39% of the population earning less than US$3.20 per day. Despite improvements, 21% of rural households and 11% of urban households in 2016 did not have access to toilet facilities, while only 31% of rural and 57% of urban households had soap and water available for handwashing. Nepal is also heavily dependent on remittances from abroad, which accounted for 26% of the national GDP in 2018-2019. Unfortunately, these remittances are threatened by job losses, falling wages and return of workers from India and the Middle East.

Nepal’s access to WASH and health services

Using the 2016 Nepal Demographic and Health Survey (DHS), we assessed the interlinkages among ethnicity, migration, and access to Water, Sanitation and Hygiene (WASH) and health facilities. We find that differences in access to WASH and health facilities are mediated in large part by ethnic identity, independent of household wealth. In other words, the problem is that the supply of such services and facilities continues to be systematically lower for specific ethnicities, especially Muslims and Dalits, the lowest castes based on the prevalent hierarchical caste system, even though some of these groups fare better on economic indicators such as wealth and incomes, as compared to upper castes. For example, when we control for wealth and other household characteristics, we find that Terai Dalit households are 15-18% less likely to have access to piped drinking water, 22-29% more likely to not have toilet facilities, and 13-21% less likely to have soap and water for handwashing, as compared to upper caste households. Similarly, Muslim households are 28-29% less likely than upper caste households to have piped drinking water, 14-27% more likely to have no toilets, and 7-21% less likely to have soap and water for handwashing. Additionally, we also find that ethnic groups most likely to be affected by the collapse of remittances due to reverse-migration and job losses are also those who have the poorest access to WASH and health services. These results suggest that the COVID-19 crisis may deepen the pre-existing inequities in the supply of such services.

The under-supply of health and WASH services to ethnic minorities have been widely observed, including in countries like China and the United States. However, under-supply of services key to addressing health crises like COVID-19, coupled with reliance on and loss of access to remittances for these communities, becomes particularly formidable for developing countries like Nepal.

Expanding targeting approaches to ensure access to all communities

There is a consensus that long-term investments in handwashing facilities, sanitation and public health need to be accelerated in developing countries. However, the fall in domestic economic activity and loss of remittances due to lockdown measures to contain COVID-19 will lower government revenues and public investments. Identifying communities that have the lowest supply can help in setting priorities and effective targeting.

From a programming perspective, this will require expanding targeting approaches beyond the traditional income and wealth metrics and bringing ethnicity center-stage. An example of this type of approach is the seven-point scale of deprivation used by India to classify households in the 2011 census as Below Poverty Line (BPL). In India, one of the criteria for BPL status is being part of marginalized and constitutionally protected castes and tribes, with members of severely marginalized castes and tribes automatically categorized as BPL.

Decentralized approaches to reach out to vulnerable groups

As our assessment brings to light the need to take ethnicity and caste into account to increase inclusivity of targeting, decentralized approaches to delivering water-sanitation and public health services to economically and socially disadvantaged households may hold promise for countries like Nepal. Given Nepal’s newly established federal government structure, this is an opportune moment for local governments to deliver water-sanitation and public health services. Building local governments’ fiscal, technical and human capacity for planning and implementing water-sanitation programs that provide services to those who have been undersupplied can help build the resilience of vulnerable groups.

Nepal has had successful programs in the past, such as the Female Community Health Volunteer (FCHV) program that targeted pregnant women and children, and demonstrated noteworthy gains in improving maternal and infant health and nutritional outcomes through a dense network of volunteers drawn from within the community. While the FCHV program is not focused exclusively on WASH it could provide an effective model upon which a WASH program can be built to improve access to and resilience toward future health emergencies.

Our findings from Nepal on how to better target households and communities that lack access to WASH services and public health facilities, and are experiencing large remittance shocks and the return of jobless migrant family members, point toward strengthening social justice in the country. Ethnicity needs to be explicitly considered in targeting essential public investments and relief services for long-term, sustainable and equitable development in the country.

Soumya Balasubramanya is Economics Research Group Leader at the International Water Management Institute (IWMI). David Stifel is Charles A. Dana Professor of Economics at Lafayette College and Sabbatical Research Fellow at IWMI. Muzna Alvi (IFPRI) is Associate Research Fellow at IFPRI’s Environment, Production and Technology Division (EPTD). Claudia Ringler (IFPRI) is Deputy Division Director of IFPRI’s EPTD. The analysis and opinions expressed in this piece are solely those of the authors.

 This blog has been published as a part of the International Food Policy Research Institute (IFPRI), South Asia, blog series on analyzing the impacts of the COVID-19’s pandemic on the sub-national, national, and regional food and nutrition security, poverty, and development. To read the complete blog series click here