Despite economic growth and improvements in basic water access, waterborne diseases remain a leading cause of illness and hospitalization in the Philippines, particularly among the poor, according to a comprehensive new study from the Philippine Institute for Development Studies (PIDS).
The study, “The Last-Mile Challenge: Water, Sanitation, and Hygiene (WASH) in the Philippines” was authored by PIDS Senior Research Fellow Valerie Gilbert Ulep, Research Assistant Jann Trizia Talamayan, Research Specialist Lyle Daryll Casas, UNICEF Philippines WASH Specialists Jon Michael Villaseñor, and Elmira Bacatan.
The research paper, released in November 2024, reveals that while 97% of Filipino households have access to basic drinking water, only half of the population has safely managed water services – highlighting a critical “last mile” challenge in delivering essential Water, Sanitation and Hygiene (WASH) services to the most vulnerable communities.
The study also found that only about half of the population has access to safely managed WASH services and these deficiencies are most severe in the country’s poorest regions
“The longstanding issue of WASH in the Philippines underscores the difficulty in delivering essential services to the poorest population and areas to attain universal coverage,” said lead author Valerie Gilbert Ulep and colleagues in the PIDS discussion paper.
Regional and Economic Disparities
The study found stark disparities across regions and income groups. In the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM), one of the country’s poorest regions, about 20% of households still practice open defecation, presenting considerable public health risks due to environmental contamination and waterborne diseases.
Access to potable water shows a clear socio-economic gradient, with only 90% of households in the bottom wealth quintile able to access improved sources compared to almost 100% of the top 20% wealth quintile. About 8% of the poorest 20% lack access to clean drinking water entirely.
While the Ilocos Region exhibited high access rates to safe water sources, BARMM reported the lowest access rate, with a striking 20-percentage point gap between the two regions highlighting severe geographic inequities.
The research revealed that in some municipalities in BARMM and MIMAROPA (Mindoro, Marinduque, Romblon, and Palawan), 10-50% of the total population and children under five still drink surface water, despite its known health risks.
Health Impact and Disease Burden
The inadequate access to clean water and sanitation facilities has serious health consequences. According to the study, around 86% of all diarrhea-related deaths in 2019 could be linked to poor WASH access, with children under five accounting for 35% of these deaths.
Children from poor households were found to be three times more likely to experience diarrhea compared to their more affluent counterparts. The research also revealed that approximately 20% of individuals who experienced diarrhea did not receive proper treatment with zinc and oral rehydration salts.
The study found a positive correlation between province-level poverty incidence and diarrhea-related death rates. While the country has made progress in reducing overall death rates from diarrhea nationwide, certain provinces with higher poverty incidence continue to struggle with elevated death rates from this preventable disease.
Beyond diarrhea, other diseases persist due to poor sanitation. Soil-transmitted helminths affect 28.4% of school-aged children in the country—exceeding the global average of 24%. These infections are more prevalent in resource-constrained areas facing challenging environmental conditions and where open defecation is common.
The Philippines also recorded around 80,000 dengue cases in 2021, with a national case fatality rate of 0.4%. In 2019, dengue-related deaths in the Philippines were at 4-6 per 1,000 population of children under-five and 5-14 years old, the highest among ASEAN peers.
Infrastructure and Service Delivery Challenges
The study identified significant gaps in water infrastructure and delivery systems. While the country has various types of water service providers, the majority are supplying water through Level I service, which often involves unsafe sources. Only 45% come from safe sources, with 23% sourced from waterworks and 22% from shared communal faucets.
“The emergence of community water service providers, managed by cooperatives and associations, is a response to the failure or incapacity of the government—along with that of other central utilities—to connect off-grid and impoverished communities,” the researchers noted.
Analysis of water service providers revealed that approximately 34% function as community-based organizations, while 31% are private and unnamed providers serving at least 15 households. These unregistered providers often lack formal management structures or enforced systems, potentially compromising water quality and safety.
Sanitation Infrastructure
Sanitation coverage remains problematic. Only 83% of Filipino households have access to basic sanitation facilities, with significant regional variations. The study found that nearly all households from the richest quintile have access to basic sanitation facilities, while only 58% of households in the bottom wealth quintile have the same privilege.
The research highlighted particular concerns about child feces disposal practices. Many households still report unsafe disposal methods, with only less than 20% managing child excreta properly. About 70% of households dispose of children’s stools in garbage, which is considered neither appropriate nor safe given the country’s subpar waste management practices.
WASH in Educational Settings
The study also examined WASH facilities in schools and early childhood care centers. Approximately 20,000 early learning centers still lack essential facilities in 2023, with nearly 30% lacking access to clean water, functional toilets, handwashing facilities with soap, and deworming programs.
In schools, while access to drinking water has improved, other critical indicators fall short of targets. Regular group handwashing continues to be the most difficult criterion for schools to meet, with only about half of schools incorporating this parameter.
The research found particular challenges for adolescent girls, with inadequate access to clean water, functional and private toilet facilities, and hygiene and menstrual materials within schools. These obstacles often lead to school absenteeism and reduced classroom engagement.
Healthcare Facilities
While most healthcare facilities have high access to basic water service and environmental cleaning indicators, there are significant gaps in sanitation, hygiene, and waste management. The situation is particularly concerning in primary healthcare facilities, which are often the first point of care, especially for those living in rural areas.
Governance Challenges
The research identified fragmented institutional arrangements as a major challenge. Multiple agencies oversee different aspects of WASH services, leading to overlaps and inefficiencies in governance.
To address these challenges, Executive Order No. 22 was issued in 2023, establishing the Water Resources Management Office to provide overall direction in the water sector and integrate the fragmented responsibilities of various agencies.
Local Government Units (LGUs) face particular challenges in implementing WASH services. A World Bank simulation cited in the study found that despite increased funding through the Mandanas ruling, the investment needed to bridge gaps in access to safe water and sanitation services would still surpass 50% of LGUs’ estimated water supply and sanitation budget.
The study noted that LGUs’ public spending on health accounts for only 20% of total health expenditure, with a significant portion of public health funds remaining unallocated despite the devolution of health services being mandated and increased funding being available.
Climate Change Impact
The research also highlighted how climate change compounds WASH challenges. As a climate-vulnerable and disaster-prone nation, the Philippines experiences high temperatures and abundant rainfall that can contaminate water sources with sewage, pathogens, and pollutants, heightening infection risks.
Recommendations and Way Forward
The researchers recommended several key interventions to address these challenges:
- Targeted investments in infrastructure, focusing on regions and communities facing the most significant disparities
- Enhanced coordination between national and local governments for efficient resource utilization
- Improved healthcare services, especially for vulnerable populations
- Tailored initiatives considering regional and socio-economic variations
- Strengthened monitoring and evaluation systems
- Development of clear standards and criteria for water systems in LGUs
- Streamlined arrangements among regulatory agencies to avoid overlaps in oversight functions
- Integration of climate resilience in WASH infrastructure planning
The study emphasized the need for a robust and integrated monitoring and evaluation system to track progress against targets and identify gaps for intervention. It also called for addressing management issues in water supply and sanitation systems to enhance service efficiency and effectiveness.
“A comprehensive and integrated approach encompassing infrastructure development, behavioral change, targeted interventions, and streamlined governance is essential to address the diverse challenges in the delivery of WASH services,” the researchers concluded.
