Fighting arsenic poisoning in Bangladesh through partnerships, research and education the World Bank

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• Fighting arsenic poisoning in Bangladesh through
  partnerships, research and education the World
  Bank perspective
• Carter Brandon
• Lead Economist, World Bank
• Prepared for presentation at Arsenic in Drinking
  Water An International Conference at Columbia
  University,
• New York, November 27, 2001

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History of World Bank Involvement in Arsenic in
Bangladesh

• No World Bank involvement in rural water supply
  until the late 1990s.
• Bangladesh Arsenic Mitigation Water Supply
  Project (BAMWSP), approved in 1998 and
  co-financed with the Swiss Development
  Corporation.
• Project design uncertainties included
• Prevalence and distribution of Arsenic
• Field testing methods
• Methods for providing safe water

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BAMWSP Components

• Testing and Mitigation
• Screening of tubewells
• Provision of safe water sources.
• Improving Understanding
• Assessment of technologies
• Hydrogeological investigation
• Patient identification and management.
• Strengthening Capacity
• Awareness raising in affected communities
• Local Government Arsenic Committees
• Training of health personnel.

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BAMWSP Status - Testing

• 249 subdistricts (thanas or upazilas) known
  affected
• 3 phases under BAMWSP
• 1 - 6 upazilas (1999-2000)
• 2 - 35 upazilas (1999-2001)
• 3 - 147 upazilas (2001-2002)
• (Total of 188, or 75 of total)
• Project will cover a total of 188 subdistricts,
  or 75 of those affected
• 3rd phase complete in 2002
• Remaining upazilas covered by other programs

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BAMWSP Status - Mitigation

• Offered where gt 40 tubewells affected
• Community chooses
• Deep tubewell (in coastal areas)
• Dug well
• Pond sand filter
• Rainwater harvesting
• Removal technologies on experimental basis (to be
  expanded after verification)
• Mitigation already underway in phase 1
  subdistricts
• All subdistricts completed mid 2002

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BAMWSP Status Improving Understanding

• Assessment of test kits and household arsenic
  removal technologies
• Rapid Assessment completed
• Technology Verification Program at the Bangladesh
  Centre of Scientific and Industrial Research, by
  mid-2002
• Hydrogeological investigation Groundwater Task
  Force developing strategy for implementation in
  2002
• Arsenic patient identification and management
  international conference in January, 2002

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BAMWSP Status Strengthening Capacity

• Awareness raising during screening and through
  electronic media
• Building capacity of local government arsenic
  committees
• Training of health personnel
• Support for technology verification program

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BAMWSP Status Institutional Arrangements

• National level
• Inter-ministerial Task Force and Secretaries
  Committee guides multi-sector response
• Arsenic Policy Support Unit in Local Government
  Division coordinates programmatic approach
• Arsenic Donor Coordination Unit coordinates
  development partners response
• Local level
• NGOs acting as training and support organizations
  to build local capacity
• Local Government Arsenic Committees coordinating
  local response
• Community-Based Organizations being assisted to
  develop action plans responsive to local
  requirements

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BAMWSP Issues and Lessons

• A common problem in many projects in Bangladesh
  is slow or poor implementation.
• BAMWSP is no exception. It has disbursed less
  than 25, while its more than 75 into the
  project period. Why?
• Many unknowns little consensus on what to do.
• Lack of test kits of an appropriate design.
• NGOs and local government institutions were not
  sufficiently involved from the outset.
• The independent project management Unit (PMU) did
  not get broad support.
• Some corruption-related delays.
• Inter-agency turf problems, reducing bureaucratic
  motivation and effectiveness.
• Constrained role of private sector in addressing
  mitigation.

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BAMWSP Mid-Course Corrections

• In response, the government of Bangladesh has
• restructured project management, including
  appointment of a new authority to assess quickly
  arsenic removal technologies.
• strengthened inter-agency and donor coordination.
• broadened its partnerships with local government,
  community organizations, and NGOs particularly
  larger NGOs who were less involved early on in
  BAMWSP.
• improved communication with the general public.
• Initiated a new Bank-financed project on the
  health aspects of arsenic.

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World Bank Arsenic Public Health Project
(proposed)

• Duration 2002 2006
• Components
• Public education
• Provider education
• Epidemiological research
• Case management

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Arsenic Public Health Project Public Education
Component

• National in scope
• Use all media sources
• Parallel to BAMWSP program
• Educate about
• Testing and color coding
• Health effects
• Treatments
• Water alternatives
• NOT contagious
• NOT treatable with folk remedies
• Coordinate with water testing

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Arsenic Public Health Project Provider
Education Component

• National in scope
• Education to providers at all levels
• Add to medical school curriculum
• Patient counseling

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Arsenic Public Health Project Research Component

• Expert steering committee
• Foster rapid research and dissemination without
  excessive overlap
• Topics of interest
• Incidence, prevalence,
• latency, dose-response
• Predictive value of skin lesions
• Risk factors
• Treatment, reversibility

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Arsenic Public Health Project Case Management
Component

• Scope undetermined
• Must be consonant with the ongoing Health and
  Population Sector Program (multi-donor)
• Arsenic objectives will be kept in perspective
  with all other health threats and public health
  programs. (For example, annual health
  expenditure 3.47 per capita per year. Arsenic
  programs will be scaled commensurate with
  incidence and risk.
• Arsenic programs to be integrated with other
  MoHFW programs by end of project.

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Policies and institutions must work despite lack
of crucial information
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Conclusions and Lessons Learned (1)

• Priority-setting. Adaptive management is
  essential in the face of uncertainties and the
  need to use research, learning and dissemination
  to constantly shape priorities.
• The centrality of education. Prevention is key
  which requires education of both the general
  population and service providers.
• Coordination matters. Proper sequence of
  awareness and availability of alternatives to
  limit panic/frustration under control.
• The media. The media has played an important and
  constructive role in keeping arsenic in the
  forefront of public concern.

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Conclusions and Lessons Learned (2)

• Financial flows look at cost recovery,
  demand-responsive approaches, and the mandate of
  government vs. NGO vs. private sector agencies
  involved in testing and mitigation.
• Balance community-driven development with local
  skills
• The arsenic problem will serve as a major
  driving force for the administrative
  decentralization program of the government.
• But this has also slowed down the arsenic
  response mechanism. The right balance between
  expediency and optimality may differ by region,
  depending on local circumstances.
• Technology gaining the socio-economic
  acceptance of new technologies is harder than
  developing the technology itself.

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Conclusions and Lessons Learned (3)

• NGOs and Community Based Organizations
  involvement of local CBOs is essential, and must
  be built up over time through partnerships with
  national NGOs and others. Government should not
  try to build up local organizations by itself.
• Sustainability Local institutions must pick up
  when outside financing dries up. Ultimately, it
  is up to the communities themselves.

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Final note the role of the World Bank

• Provider of financing necessary but not
  sufficient.
• Can help broaden the scope of arsenic programs
  involving not just Water Supply and Health
  agencies, but Ministries of Finance, Planning,
  Education and Information.
• Facilitator of process to develop a national
  arsenic strategy.
• Can offer expertise in economics,
  capacity-building, and international experience.
• Can help leverage NGO, donor, or international
  partnerships.
• Bottom line for the World Bank Fighting
  arsenic poisoning through partnerships, research
  and education and not simply Fighting arsenic
  poisoning through more financing.