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Water Supply, Sanitation, and Hygiene

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DOI: 10.1596/978-1-4648-0522-6_ch9

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 Chapter
9
Water Supply, Sanitation, and Hygiene
Guy Hutton and Claire Chase

INTRODUCTION systematic reviews and meta-analyses, evidence papers,

and literature reviews. When those sources were not
Safe drinking water, sanitation, and hygiene (WASH) are available, evidence was compiled from the next best
fundamental to improving standards of living for sources of published research, thus using accepted crite-
people. The improved standards made possible by ria of the hierarchy of evidence for studies on health
WASH include, among others, better physical health, effectiveness. Unpublished and grey literature was used
protection of the environment, better educational out- where no peer-reviewed published evidence exists.
comes, convenience time savings, assurance of lives lived This chapter is structured as follows:
with dignity, and equal treatment for both men and
women. Poor and vulnerable populations have lower • Progress in improving drinking water, sanitation, and
access to improved WASH services and have poorer hygiene coverage
associated behaviors. Improved WASH is therefore cen- • Impacts of poor WASH, thereby summarizing the
tral to reducing poverty, promoting equality, and sup- evidence on the continued decline in mortality from
porting socioeconomic development. Drinking water diarrheal disease and the emerging evidence on the
and sanitation were targets in the Millennium long-term developmental and cognitive effects of
Development Goals (MDGs) for 2015; under the inadequate WASH on children
Sustainable Development Goals (SDGs) for the post- • Effectiveness of interventions, thereby examining
2015 period, Member States of the United Nations (UN) the health effects of specific WASH interventions,
aspire to achieve universal access to WASH by 2030. The the approaches to service delivery, and the key role
Human Right to Safe Drinking Water and Sanitation of broader institutional policy in accelerating and
(HRTWS) was adopted in 2010 under a UN resolution sustaining progress
calling for safe, affordable, acceptable, available, and • Intervention costs, efficiency, and sustainability, thereby
accessible drinking water and sanitation services for all.1 assessing the socioeconomic returns of improved
The scope of WASH services included in this chapter WASH and considering the requirements for popula-
is shown in table 9.1. The focus is on services at the tions to have continued access to WASH services
household and institutional level and on services for • Challenges, opportunities, and recommendations.
personal rather than productive uses.
This chapter summarizes global evidence on current This chapter uses the World Health Organization
WASH coverage and effects of intervention options, and (WHO) classification of superregions as follows: Africa,
it recommends areas for research and policy. Evidence the Americas, South-East Asia, Europe, Eastern
comes from published synthesized evidence, such as Mediterranean, and Western Pacific.

Corresponding author: Guy Hutton, WASH Section, UNICEF. [email protected], formerly at the Water and Sanitation Program, World Bank.

171
 Table 9.1 Scope of Water, Sanitation, and Hygiene Services Included in This Chapter
Service Included Excluded
Water supply Water for drinking Water for productive uses
Other water uses in the home (cooking, hygiene, sanitation,
cleaning, laundry)
Treatment, safe handling, and storage of water
Sanitation Toilets and onsite excreta management Separate greywater management
Management of septage (fecal sludge) Industrial wastewater management
Sewerage or combined sewer-drainage systems Storm water drainage
Solid waste management
Hygiene Handwashing and other personal hygiene practices Food hygiene
Menstrual hygiene management Environmental hygiene and cleanliness measures

STATUS OF DRINKING WATER, SANITATION, All populations meet water and sanitation needs in some
AND HYGIENE way, but those ways are often not sufficient, reliable, safe,
convenient, affordable, or dignified. To monitor the
Targets MDG water and sanitation target, the UN distinguished
The MDG targets called for halving the proportion of between improved and unimproved water and sanitation
the population without sustainable access to safe drink- facilities at home. For the SDG targets, one indicator is
ing water and basic sanitation between 1990 and 2015. proposed per target: (1) for target 6.1, the percentage of
The targets were ambitious. In 1990, 76 percent of the population using safely managed drinking water services
global population used an improved drinking water and (2) for target 6.2, the percentage of population using
source, and 54 percent had access to safe sanitation. The safely managed sanitation services, including a hand-
MDG’s drinking water target was met in 2010; yet in washing facility with soap and water. Complementing
2015, the world remained 9 percentage points short of these proposals is a broader set of indicators distinguish-
achieving the sanitation target. The SDGs for 2015– ing basic and safely managed service levels (table 9.2)
2030 have broadened from the MDG period to include (WHO and UNICEF 2015a).
(1) water-use efficiency across all sectors, sustainable The indicators for global monitoring need to be kept
withdrawals, and supply of freshwater to people suffer- simple for feasibility and cost. However, countries, orga-
ing from water scarcity; (2) integrated water resource nizations, and programs often monitor different aspects
management, and (3) water-related ecosystems. The SDG of service performance, such as quantity, quality, prox-
also set ambitious WASH-related targets of universal imity, reliability, price, and affordability (Roaf, Khalfan,
access to safe water (target 6.1), adequate sanitation and Langford 2005). Some countries adopt more lenient
and hygiene, and the elimination of open defecation definitions, and some adopt stricter definitions.
(target 6.2) as well as reduced untreated wastewater The definitions in existing monitoring systems have
(target 6.3). In the overall aim of access for all, the SDG several limitations. Some limitations are partially
language and spirit emphasizes progressive reduction addressed by the new indicators for higher-level services.
of inequalities and leaving no one behind, as well as The new indicators were informed by the five normative
providing inclusive, quality, and sustainable services— criteria, as stated in the HRTWS and shown in table 9.2:
thereby ensuring access for women and for poor and accessibility, acceptability, availability, affordability, and
vulnerable populations. quality.2

• The Joint Monitoring Programme’s (JMP) definition

Definitions of improved facilities focuses on the technology type
To understand the status of drinking water, sanitation, and is an imprecise proxy for the quality of services
and hygiene, one must make a distinction between dif- (Moriarty and others 2010; Onda, LoBuglio, and
ferent levels of service access and population practices. Bartram 2012; Potter and others 2010).

172 Injury Prevention and Environmental Health

Table 9.2 Proposed Service Level Definitions for Monitoring SDG 6 WASH Targets
Service Basic services Safely managed services
Water Percentage of population using an improved Percentage of population using safely managed drinking water services.
drinking water source with a total collection “Safely managed” refers to an improveda drinking water source that is
time of 30 minutes or less for a round trip, located on premises, available when needed, and free from fecal (E. coli)
including queuing (termed “basic” water).a and priority chemical (arsenic and flouride) contamination.
Sanitation and Percentage of population not practicing open Percentage of population using safely managed sanitation services,
hygiene defecation. including a handwashing facility with soap and water. ”Safely managed”
Percentage of population using an improved refers to an improved sanitation facility that is not shared with other
sanitation facility that is not shared with households and where excreta are either safely disposed in situ or treated
other households (basic sanitation).b offsite.

Percentage of population with a handwashing

facility with soap and water at home.
Sources: Definitions of improved, WHO and UNICEF 2006; definitions of indicators, WHO and UNICEF 2015a.
Note: The higher service level indicators are proposed for SDG monitoring. SDG = Sustainable Development Goal; WASH = drinking water, sanitation, and hygiene; WatSan = water
and sanitation.
a. Same as improved water monitored as part of the MDG target 7c: piped water into dwelling, plot, or yard; public tap and standpipe; tubewell and borehole; protected dug well;
protected spring; rainwater collection.
b. Same as improved sanitation monitored as part of the MDG target 7c: flush or pour-flush to piped sewer system, septic tank, pit latrine or ventilated improved pit latrine; pit
latrine with slab and composting toilet.

• Self-reported responses of access by household mem- Water Supply

bers may be biased (Stanton and Clemens 1987). Globally, the use of improved drinking water sources
• Statistics on household access provide no indication increased from 76 percent in 1990 to 91 percent in 2015
of variations in access and practices among different (WHO and UNICEF 2015b). Regional breakdowns for
household members. For example, even in communi- progress between 1990 and 2015 are shown in figure 9.1.
ties with high coverage rates for sanitation, children In its 2012 report presenting 2010 estimates, the UN
still commonly defecate in the open.3 showed that its MDG target of halving the proportion of
• Indicators do not adequately reflect accountability the population without access to safe drinking water had
and sustainability, which are key elements that cut been met (WHO and UNICEF 2012b); however, such
across all the service levels. global estimates mask regional disparities and inequities
in access between urban and rural populations. As of
The existing approach to measuring access does not 2015, 663 million people still used unimproved water
provide a good indication of sustainability. The surveys sources, compared to 1.3 billion in 1990; 2.6 billion
use representative sampling and do not follow individual people have gained access to improved water since 1990.
households over time. Effective monitoring of higher Rural dwellers remain unserved compared with urban
service levels requires regulatory data, but coverage is dwellers (16 percent and 4 percent, respectively). In Sub-
poor in low- and middle-income countries (LMICs), Saharan Africa, 44 percent of rural dwellers continue to
especially in rural areas. use an unimproved water supply. Water hauling costs
Sub-Saharan Africans, especially women, billions of
hours each year. In 2008, more than 25 percent of the
Coverage of Water Supply, Sanitation, and Hygiene population in several Sub-Saharan African countries
This section presents the coverage data at global spent more than 30 minutes to make one round trip to
and regional levels for drinking water and sanitation collect water; 72 percent of the burden for collecting
according to the JMP definitions used for monitoring water fell on women (64 percent) and girls (8 percent),
MDG target 7c, thereby using the most recent update compared with men (24 percent) and boys (4 percent)
and MDG assessment report (WHO and UNICEF (WHO and UNICEF 2010).
2015b). Breakdowns are provided by rural and urban Urban areas enjoy a higher level of water service, as
areas.4 indicated by the use of piped water supply; in 2015,

Water Supply, Sanitation, and Hygiene 173

 Figure 9.1 Drinking Water Coverage Trends, by Regions and World, Using the JMP Improved Water Definition, 1990–2015

2 4 1 7 1 5 6 2 1 3 1 7 1 3 2 1 7 2
10 9 6 3 6 4 4 8 8 6 3
8 8 5 11 12 19 8 7
26 6 8 6
23 7 17
19 31 31 25
12 22
22 28 16 23
22 28
33 30 33
26 40 32
57 63 19 13
38
39
Percent

96
55 54 89 89 92
52 86
23 31 57
74 73
69
33 61 59 44 58
54
49
44
33 30 31
30 27 25
15 16 17 19
12
7
90

19 5
90

19 5
90

19 5
90

15
90

19 5
90

1915
90

19 5
90

19 5
90

19 5
90

19 5

19 5
90

19 5
90

15
90
1

1
19

20

20

20

20
19

20

20

20

20

20

20

20

20

20
Af aran

ia

As rn

nia

As rn

lA d

Af hern

As rn

ea d

tri d

gio g

gio d

ld
ra an

ibb n

un pe

re opin

re lope
As

or
he

ste

te

ar ca a
ea
ica

ia

ia

sia

ia

es

ns

ns
co elo

W
es
nt us
h

ut

rt
ric
st

Ea
Oc

ve
Sa

No

ve
r

W
So

Ce cas

e C ri

ev
Ea

De
th Ame
b-

De
t-d
h-

u
Su

Ca
ut

as
tin
So

Le
La

Piped on premises Other improved Unimproved Surface water

Source: WHO and UNICEF 2015b.

Note: JMP = Joint Monitoring Programme.

four of five people living in urban areas used piped have access to their own improved sanitation facility, a
water, compared to two of three in rural areas. Water fact that, due to population growth, reflects no change
sources classified as improved—even piped water—do in the unserved population of 1990. However, these
not guarantee the safety or continuity of the water numbers mask the fact that since 1990, 2.1 billion peo-
supply. Water quality surveys conducted in five coun- ple have gained access to improved sanitation. Regional
tries showed that microbiological compliance with the breakdowns in progress between 1990 and 2015 are
WHO guidelines varied between water sources and shown in figure 9.2. Globally, the proportion of popula-
countries (Onda, LoBuglio, and Bartram 2012). On tion practicing open defecation declined from 24 percent
average, compliance was close to 90 percent for piped in 1990 to 13 percent in 2015. In South Asia, 34 percent
water sources, and from 40 percent to 70 percent for still defecate in the open, compared to 23 percent in
other improved sources. Extrapolating to global esti- Sub-Saharan Africa. Globally, 638 million people
mates, the authors estimate that in 2010, 1.8 billion (9 percent) share their sanitation facility with another
people (28 percent) used unsafe water, more than family or families. Comparing rural and urban areas,
twice the population of 783 million (11 percent) that 51 percent of rural dwellers have access to improved
used an unimproved water supply. sanitation, compared with 82 percent of urban dwellers.
Rates of improved sanitation do not reflect the amount
Sanitation of fecal waste that is not isolated, transported, or treated
The use of improved sanitation increased from safely; a study of 12 cities in LMICs found that whereas
54 percent in 1990 to 68 percent in 2015, but those gains 98 percent of households used toilets, only 29 percent of
fell short of meeting the global MDG target (WHO and fecal waste was safely managed (Blackett, Hawkins, and
UNICEF 2015b). In 2015, 2.4 billion people still did not Heymans 2014).

174 Injury Prevention and Environmental Health

Figure 9.2 Sanitation Coverage Trends, by Regions and World, Using the JMP Improved Sanitation Definition, 1990–2015

7 1 3 2 8 2 1 3 2
8 3 3 2
13 12 11 17 16 2 4
7 2 16 13
17 7 10 20 24
23 31 31
36 34 7 7 2
7 11 45
40 10
6
5 12
65 10 5 17 9
15
48 48 20
25 10
27 5
7 6 3
Percent

26
12 94 96 6 94 96
90 25
89
83 17
77 80
20 4 5 7 72 71 68
14 67
6 10 62
54
48 50
47 43
35 35 38
30
24 22
20
90

19 5
90

19 5
90

19 5
90

15
90

19 5
90

1915
90

19 5
90

19 5
90

19 5
90

19 5

19 5
90

19 5
90

15
90
1

1
19

20

20

20

20
19

20

20

20

20

20

20

20

20

20
Af aran

nia

As rn

As ast

As rn

ea d

Af hern

As rn

lA d

tri d

gio g

gio d

ld
ibb n

ra an

un pe

re opin

re lope

or
he

ste

te
ar ca a
ea

E
a

ia

ia

ia

ia

sia

es

ns

ns
co elo

W
es
h-

nt us
h

ut

rt
ric

ric
Ea
Oc

ve
Sa

No

ve
W
ut
So

e C ri

Ce cas

ev

De
th Ame
b-

So

De
t-d
u
Su

Ca

as
tin

Le
La

Improved Shared Unimproved Open defecation

Source: WHO and UNICEF 2015b.

Note: JMP = Joint Monitoring Programme.

Hygiene population into five equal wealth quintiles using an

Although the MDG target 7c does not provide a global asset index. In 35 Sub-Saharan African countries, house-
indicator for hygiene, the data on the presence of a hand- holds in the poorest wealth quintile are 6 times less likely
washing facility with soap and water are increasingly to have water access compared with the richest quintile;
collected as part of nationally representative surveys and the difference for sanitation is at least 2.5 times less likely
will form the basis for efforts to monitor target 6.2 of the (WHO and UNICEF 2013). Figure 9.3 illustrates the
SDGs. Two main sources include nationally representa- levels of disparity—between regions, between countries
tive household surveys and a global review of published in a region, and at the country level—in the differences
studies (Freeman and others 2014). Research studies between rural and urban areas and between wealth
suggest that the global prevalence of handwashing with quintiles. Limited datasets are available on the dispari-
soap after contact with excreta is 19 percent; rates are ties between population subgroups—for example, slum
lower in Sub-Saharan Africa (14 percent) and South- populations, ethnic groups, women, the elderly, and
East Asia (17 percent), where the most studies have been persons who have physical impairments—as the sample
conducted (Freeman and others 2014). Proxy indicators size and sampling methodology in nationally represen-
for handwashing practice from nationally representative tative surveys generally do not enable sufficiently robust
surveys are not reliable and tend to over report hygiene comparisons.
practices (Biran and others 2008). Global reporting of institutional WASH has not yet
been standardized as it has for household-level WASH;
Distribution of Services efforts are under way to build a global reporting system of
The JMP has reported the distribution of water supply WASH in schools and health facilities for SDG monitor-
and sanitation services by wealth status, breaking the ing. The Demographic and Health Survey (DHS) Service

Water Supply, Sanitation, and Hygiene 175

 Figure 9.3 Mozambique Example: How Average Values Mask Massive Disparities in Household Coverage

100
96 Poorest 20%
Rural

80
77 South
Sudan 75 Zambezia

65 Chad
Open defecation prevalence (%)

60 60 Tete
57 Burkina
Faso

51 Rural
50 Sofala
50 Poorest 20%
46 Sudan Urban
43 Nampula
40 38 Southern 40 Mozambique
Asia 37 Manica

28 Sierra 28 Cabo
Leone Delgado
25 Sub-Saharan
Africa 23 Nigeria
20 20 Gaza
14 World
Richest 20%
13 South-East 13 Kenya 13 Inhambane 13
15 Urban Rural
Asia

7 Maputo
3 Northern
Africa 2 Niassa
0 0 Mauritius 0 Maputo cidade 0 Richest 20%
Urban

Source: WHO and UNICEF 2014.

Provision Assessment (SPA) monitors WASH in health understanding of the challenges facing the world to
facilities. WASH coverage in both primary schools and meet the goal of universal access to institutional
front-line health facilities is monitored and reported WASH within 15 years and to sustain that access
under the Service Delivery Indicators, currently for Sub- beyond 2030. Unsustainable water extraction, along
Saharan Africa. United Nations agencies collect data on with competing demands, population growth and
WASH in schools (Education Management Information migration (including urbanization), and climate
System operated by UNICEF), health facilities (Health change and variability, puts significant pressure on
Management Information System operated by the WHO), water supply systems. In addition, new settlements
and refugee camps (UN High Commissioner for Refugees). require systematic, coordinated planning, and existing
In addition to enhanced monitoring efforts by settlements require retrofitting to bring sustainable
UN agencies, UN member countries need greater WASH services to citizens.

176 Injury Prevention and Environmental Health

IMPACTS OF INADEQUATE WASH The availability of water for drinking and household
uses affects the quantity of water consumed and the time
Understanding the nature and extent of the demonstrated available to care for children in the household. Reducing
negative effects of inadequate WASH on individuals, the the distance required to fetch water is associated with
environment, and societies is important for those design- lower prevalence of diarrhea, improved nutrition, and
ing interventions and assessing benefits and efficiency. lower mortality in children under age five years
Many benefits of WASH interventions are nonhealth in (Pickering and Davis 2012); these effects may be due to
nature; including only health effects in impact evaluations better hygiene practices (Curtis and Cairncross 2003;
can severely underestimate the intervention benefits Esrey 1996; Esrey and others 1991), as well as to addi-
(Loevensohn and others 2015). tional time available for child care or income-generating
activities (Ilahi and Grimard 2000), thereby resulting in
healthier children.
Health Consequences Inadequate quantities or consumption of water can
Contaminated water and lack of sanitation lead to the also lead to dehydration, which has a number of adverse
transmission of pathogens through feces and, to a lesser effects on physical and cognitive performance and bodily
extent, urine. The F-diagram explained here but not functions (Popkin, D’Anci, and Rosenberg 2010). Because
shown provides a basic understanding of these pathways there are no adequate biomarkers for measuring a popu-
by which pathogens from feces are ingested through lation’s hydration status, such an effect remains largely
transmission by fingers, flies, fluids, fields (soil), and food: undocumented (Popkin, D’Anci, and Rosenberg 2010).
Safe drinking water provides the basis for oral rehydra-
• Diseases transmitted by the fecal pathway include tion salts that save lives (Atia and Buchman 2009).
diarrheal disease, enteric infection, hepatitis A and E, Exposure to harmful levels of arsenic in groundwater
poliomyelitis, helminths, trachoma, and adenoviruses is estimated to affect 226 million people in more than
(conjunctivitis) (Strickland 2000). Most of these dis- 100 countries (Murcott 2012). Arsenic exposure causes
eases are transmitted through the fecal-oral pathway, skin lesions and long-term illnesses such as cancer,
but some are transmitted through the fecal-skin path- neurological disorders, cardiovascular diseases, diabetes,
way (for example, schistosomiasis) and the fecal-eye and cognitive deficits among children (Naujokas and
pathway (for example, trachoma). These transmis- others 2013).
sions occur between humans, as well as between Excess levels of water from heavy rainfall and inade-
animals and humans. quate drainage lead to flooding, thus causing injuries
• Pathogens carried through urine (for example, and death, as well as heightened risk of fecal-oral and
leptospirosis) mainly result from animal-to-human skin diseases (Ahern and others 2005). Earthquakes,
transmission. volcanic eruptions, tsunamis, and other natural disasters
• Poor personal hygiene causes fungal skin infections, leave affected populations vulnerable to infection with
such as ringworm (tinea) and scabies. waterborne diseases such as diarrhea, hepatitis A and E,
• Lack of handwashing is associated with respira- and leptospirosis (Jafari and others 2011).
tory infections (Rabie and Curtis 2006); inadequate
hand hygiene during childbirth is linked to infec- Diarrheal Disease
tion (Semmelweis 1983) and neonatal mortality The most recent study estimated 842,000 global deaths
(Blencowe and others 2011; Rhee and others 2008). from diarrheal disease for 2012 (Prüss-Ustün and others
2014); 43 percent of these were children under age five
A systematic review and meta-analysis documented years. An estimated 502,000 deaths were caused by
large and significant associations between poor water, inadequate drinking water, 280,000 by inadequate sani-
sanitation, and maternal mortality (Benova, Cumming, tation, and 297,000 by inadequate hand hygiene
and Campbell 2014). The precise mechanism has not (table 9.3). The regional breakdowns indicate that the
been well established, but it is thought to be largely major share of global burden is in South-East Asia and
attributable to puerperal sepsis. Sub-Saharan Africa. Precise estimates remain elusive
Children under age five years are especially vulnera- because of poor quality data on the cause of death; insuf-
ble to infection. Regular exposure to environments with ficient data on hygiene practices; and poor quality evi-
high fecal loads causes enteropathy5; compromises nutri- dence on the effectiveness of some water and sanitation
tional status; and leads to long-term consequences, such interventions, especially onsite sanitation. This paucity
as stunting and retarded cognitive development of reliable data has led to conflicting estimates of the
(Humphrey 2009; Petri and others 2008). burden of disease. The Institute for Health Metrics and

Water Supply, Sanitation, and Hygiene 177

 Table 9.3 Diarrheal Disease Mortality Attributed to Poor Water Supply, Sanitation, and Hygiene in Low-and
Middle-Income Countries, Regional and Risk Factor Breakdown
Region Water supply Sanitation Hygiene WASH
Africa 229,316 126,294 122,955 367,605
The Americas 6,441 2,370 5,026 11,519
Eastern Mediterranean 50,409 24,441 28,699 81,064
Europe 1,676 352 1,972 3,564
South-East Asia 207,773 123,279 131,519 363,904
Western Pacific 6,448 3,709 6,690 14,160
World 502,061 280,443 296,860 841,818
Source: Prüss-Ustün and others 2014.
Note: WASH = safe drinking water, sanitation, and hygiene. Totals may not be sum of rows because of rounding. Columns 2–4 do not sum to column 5 because of overlap in
risk pathways.

Evaluation’s Global Burden of Disease (GBD) study con- (Hales and others 2014). These estimates may be conser-
ducted a new meta-regression analysis of available vative because they do not account for diarrheal deaths
experimental and quasi-experimental interventions. caused by other risk factors such as declining water
It found that poor water and sanitation account for availability and undernutrition.
0.9 percent of global disability-adjusted life years (DALY) Cholera is an endemic diarrheal disease, but it is
or 300,000 deaths per year (Lim and others 2012). The strongly associated with natural disasters and civil con-
resulting difference between this study and the Prüss- flict. An estimated 2.9 million cases of cholera cause
Ustün and others (2014) study is 542,000 deaths, possibly 95,000 deaths each year in 69 endemic countries (Ali and
because the studies included in the GBD study do not others 2015). Cholera is transmitted through fecal con-
differentiate between different levels of quality of water tamination of water or food. Therefore, clean water and
supply and sanitation and between poor quality imple- proper sanitation are critical to preventing its spread.
mentation and lack of effect. However, good evidence is lacking as to which mix of
Not all diarrheal diseases are caused by pathogens interventions (including oral cholera vaccine, case man-
transmitted through inadequate WASH. Over time, dif- agement, and surveillance) is most cost-effective during
ferent estimates have been made for the burden of diar- outbreaks because few high-quality evaluation studies
rheal disease that can be attributed to fecal-oral have been conducted (Taylor and others 2015).
transmission. Earlier estimates attribute 94 percent of Institutional settings—such as schools, health
diarrheal disease to poor WASH (Prüss-Ustün and facilities, prisons, and other public settings such as
Corvalan 2007); the more recent study attributes refugee camps and public markets—can pose high risks
58 percent (Prüss-Ustün and others 2014). This latter if water and sanitation are not well managed. Studies
estimate is closely supported by a separate review of have documented higher rates of diarrheal disease and
more than 200 studies that examined the causes of diar- gastrointestinal infection in schools that lack access to
rhea in inpatients and found no pathogen present in improved drinking water and sanitation facilities (Jasper,
34 percent of cases (Lanata and others 2013). Importantly, Le, and Bartram 2012). Improved hand hygiene is partic-
deaths not easily preventable through WASH interven- ularly important in institutional settings, given the ease
tions (for example, rotavirus spread among young chil- with which infections spread in such environments.
dren and difficult to control) were excluded from the
global burden of disease estimates for diarrheal disease Helminth Infections
shown in table 9.3. Thus, the data in table 9.3 provide a Helminth infections are transmitted in water by fecal
more realistic picture on how many deaths are consid- matter (schistosomiasis) and in soil by soil-transmitted
ered preventable by WASH interventions. helminths (STH). Although routine monitoring of
Rising temperatures caused by climate change are infection rates is limited, the large number of prevalence
expected to exacerbate the burden of diarrheal disease. surveys permits global estimates to be made.
The WHO estimates that an additional 48,000 deaths One study of helminth prevalence data for 6,091
in children under age 15 years will be caused by cli- locations in 118 countries estimated that in 2010,
mate change by 2030 and 33,000 deaths by 2050 438.9 million people were infected with hookworm

178 Injury Prevention and Environmental Health

(Ancylostoma duodenale), 819.0 million with roundworm that a subclinical condition of the small intestine caused
(A. lumbricoides), and 464.6 million with whipworm by chronic ingestion of pathogenic microorganisms
(T. trichiura) (Pullan and others 2014). Of the 4.98 million results in nutrient malabsorption. This subclinical con-
years lived with disability (YLDs) attributable to STH, dition may be the primary causal pathway between poor
65 percent of those were attributable to hookworm, WASH and child growth (Humphrey 2009).
22 percent to A. lumbricoides, and 13 percent to T. trichi- The evidence on the etiology of diarrheal disease
ura. Most STH infections (67 percent) and YLDs finds an association between levels of intestinal inflam-
(68 percent) occurred in Asia (Central, East, South, and mation detected through fecal samples and subsequent
South-East). A separate study estimated 89.9 million STH growth deficits in infants. This evidence lends support to
infections in school-age children in Sub-Saharan Africa the environmental enteropathy hypothesis that stunting
(Brooker, Clements, and Bundy 2006). Annual global may be an outcome of frequent enteric infection and
deaths are estimated at 2,700 for A. lumbricoides and intestinal inflammation (Kotloff and others 2013).
11,700 for schistosomiasis (Lozano and others 2010). Because of the asymptomatic nature of environmental
Helminth infections cause several adverse health enteropathy, the extent and seriousness of the condition
outcomes, including anemia, malnutrition, growth stunt- is not known; however, it appears to be nearly universal
ing, and impaired physical and cognitive development; among those living in impoverished conditions (Salazar-
those outcomes result in low school attendance and Lindo and others 2004) and may be the cause of up to
educational deficits, thus leading to loss of future eco- 43 percent of stunting (Guerrant and others 2013).
nomic productivity (Victora and others 2008). The risk of The risks of low birth weight and stunting are height-
STH infection is greatest for those in specific occupations ened in undernourished mothers (Özaltin, Hill, and
and circumstances, such as people who work in agricul- Subramanian 2010), resulting in intergenerational con-
ture, who live in slums, who are poor, who have poor san- sequences of undernutrition and related conditions.
itation, and who lack clean water (Hotez and others 2006).

Undernutrition and Environmental Enteric Social Welfare Consequences

Dysfunction Improved water supply and sanitation provide individu-
Undernutrition causes an estimated 45 percent of all als with increased comfort, safety, dignity, status, and
child deaths (Black and others 2013) and is responsible convenience, and also have broader effects on the living
for 11 percent of global disease burden (Black and others environment (Hutton and others 2014). The social wel-
2008). Inadequate dietary intake and disease are directly fare effects are difficult to quantify, given their subjective
responsible for undernutrition; however, multiple indi- nature. Nevertheless, those benefits are consistently cited
rect determinants exacerbate these direct causes, includ- as among the most important for beneficiaries of water
ing food insecurity, inadequate child care practices, low supply and sanitation (Cairncross 2004; Jenkins and
maternal education, poor access to health services, lack Curtis 2005) and may be particularly relevant for women
of access to clean water and sanitation, and poor hygiene (Fisher 2006).
practices (UNICEF 1990). Political, cultural, social, and
economic factors play a role as well. Stunting (height- In or Near Homes
for-age below minus two standard deviations from Water supply in or adjacent to homes provides greater
median height-for-age of reference population) and comfort to household members, notably women and
underweight (weight-for-age below minus two standard girls tasked with fetching water; water sources closer
deviations from median weight-for-age of reference to home, especially piped water, are associated with
population) are forms of undernutrition associated with increased use (Howard and Bartram 2003; Olajuyigbe
weakened immune systems and severe long-term conse- 2010).
quences that include poor cognitive development, a Data from 18 countries indicate that women are five
lower rate of school attendance, a lower level of job times more likely than men to have the responsibility for
attainment, and a potentially higher risk of chronic dis- collecting household water (WHO and UNICEF 2012b).
ease in adulthood (Victora and others 2008). As the distance to the water source increases, the time
The links between diarrhea and child undernutrition that women could spend on income-generating activities,
(Fishman and others 2004; Prüss-Ustün and Corvalan household chores, and child care decreases (Ilahi and
2006) and other enteric infections (Brown, Cairncross, Grimard 2000). A regular piped water supply can intro-
and Ensink 2013; Checkley and others 2008; Guerrant duce the possibility of purchasing time- and labor-saving
and others 2008; Lin and others 2013) are well devices, such as washing machines and dishwashers.
documented. An emerging body of evidence suggests Although access to water infrastructure does not always

Water Supply, Sanitation, and Hygiene 179

 translate into wage employment for women (Lokshin (Sebastian, Hoffmann, and Adelman 2013). Lack of
and Yemtsov 2005), one study finds that it can provide adequate MHM is frequently described as a hindrance to
time savings in water collection, thus improving gender girls’ education, but high-quality evidence is lacking
equality (Koolwal and Van de Walle 2013). (Sumpter and Torondel 2013). A randomized controlled
Individuals with access to on-plot sanitation benefit trial in Nepal suggests that menses, and poor menstrual
from greater privacy, comfort, and convenience. hygiene technology in particular, has no effect on absen-
Accompanying a child to the toilet is more convenient teeism of girls; girls miss less than one school day a year
if it is nearby and safe, and mothers can comfortably on average because of menstruation (Oster and Thornton
step away from household duties to practice hygiene. 2011). However, girls may avoid going to school while
In Ghana, more than 50 percent of households consid- they are menstruating, not because they lack manage-
ering adopting a toilet included convenience in their ment methods but because they lack proper facilities for
top three reasons for investing in sanitation (Jenkins managing menses (Jasper, Le, and Bartram 2012).
and Scott 2007). In six countries of South-East Asia,
the rural households that owned their own latrine
saved from 4 to 20 minutes of travel time per trip Environmental Consequences
(Hutton and others 2014). Privacy, comfort, and con- Two major environmental consequences of poor WASH
venience benefits are magnified for vulnerable groups, practices are (1) the excessive extraction of water to meet
such as the elderly or persons living with disabilities or population needs and (2) the pollution caused by poorly
debilitating chronic illness. managed human excreta.
On-plot sanitation reduces the risk of theft or assault The water supply for domestic use represents a small
(including rape and sexual harassment), especially at proportion of overall extraction, but the concept of
night or in isolated locations. Improved pit latrines are virtual water trade6 has led to a greater understand-
safer, less likely to collapse, and easier for small children ing of the implications of population consumption
to use. On-plot water supply and sanitation help to patterns for water use. Globally, the combined effects of
avoid conflicts with neighbors, landowners, or others socioeconomic growth and climate change indicate that,
over the use of shared water resources and sanitation by 2050, the population at risk of exposure to at least
facilities and the use of fields or rivers for open a moderate level of water stress could reach 5 billion
defecation. people (Schlosser and others 2014). A population of up
to an estimated 3 billion in 2050 is nearly double the
Schools and Workplaces current estimate of 1.7 billion people who live in areas
Access to improved WASH services in schools and work- with a high degree of water stress. The projections are
places contributes to school attendance, school perfor- made on the basis of a risk metric of frequency of water
mance, and choice of where to work, especially for girls shortage in reservoirs (Sadoff and others 2015). This
and women. Recent evidence from India shows that a metric combines hydrological variability and water
national government program to build toilets in schools usage trends, which may be mitigated by storage infra-
led to an 8 percent increase in enrollment among structure. This class of water insecurity is most severe in
pubescent-age boys and girls and a 12 percent increase South Asia and Northern China, although the risk of
among younger children of both genders (Adukia 2014). water shortage exists on all continents.
The comparably large effect of school sanitation on pri- Overextraction of groundwater and pollution of local
mary school children and the robust effects for boys and surface water bodies have led many large urban popula-
girls at all ages suggest that at least some of the effect of tion centers to source municipal water supplies from
school sanitation is related to health (Jasper, Le, and reservoirs or rivers that are tens or hundreds of kilome-
Bartram 2012). Research has seldom analyzed academic ters from the site of treatment or consumption.
performance as an outcome; however, given the role that Such schemes cost tens of millions of dollars each in
improved water and sanitation have on child health and reservoir construction, pipeline, and pumping costs.
school attendance rates, the current evidence lacks Groundwater resources are under increasing stress from
research into their role in academic performance. unsustainable agricultural practices resulting from crop
choice and energy subsidies to enable farmers to pump
Menstrual Hygiene groundwater. In India and Mexico, for example, subsi-
Menstrual hygiene management (MHM) is a poorly dized electricity and kerosene for farmers have led to
understood and underresearched area of WASH services. serious groundwater overdraft (Scott and Shah 2004).
This neglect has left women in many LMICs without Poorly managed human excreta have major
access to appropriate products, facilities, and services environmental consequences; excreta pollute human

180 Injury Prevention and Environmental Health

settlements, groundwater, and surface water such as INTERVENTION OPTIONS AND
lakes, rivers, and oceans. The degree of pollution EFFECTIVENESS
depends on wastewater, sludge, and sewage manage-
ment practices; climatic factors; and the population Three main categories of interventions to improve
size and density in relation to the volume of water. In WASH are as follows:
highly populated river basins, municipal sewage and
wastewater contribute a high proportion to overall bio- • Technology options and WASH practices cover
logical oxygen demand (Corcoran and others 2011; the type of hardware, equipment, and associated
Rabalais and Turner 2013). behaviors of WASH services. Not all water or san-
Heavily polluted surface water has serious effects on itation technologies perform the same function,
ecosystems, food webs, and biodiversity (Turner and so they can be classified by the service level they
Rabalais 1991). Coastal areas that are near the discharge provide.
of large, polluted rivers have reported compromised • Service delivery models cover the components of
fish catch, such as in Argentina (Dutto and others WASH service implementation. Those compo-
2012). In the coastal areas of the Philippines, water nents include (1) approaches to demand generation
pollution was estimated to cost US$26 million per year and WASH behavior change, (2) approaches to
in lost fish catch and degraded coral reefs (World Bank strengthen supply of water and sanitation goods and
2009). Water pollution of recreational areas affects the services, and (3) approaches to improve the effective-
tourism industry, thus lowering visit rates or causing ness of WASH service delivery.
gastrointestinal illness or both. • Strengthening the enabling environment for WASH
service delivery includes (1) measures to strengthen
capacity, (2) legal framework, (3) policy and plan-
Financial and Economic Consequences ning, (4) resource allocation, (5) monitoring and
Financial and economic studies convert the health, evaluation, and (6) other interventions to provide
social, and environmental effects of poor WASH to a a stronger foundation for implementing the tech-
common money metric, thereby enabling aggregation nology and service delivery models. The evidence is
as well as comparison across locations and over time. provided in annex 9B.
However, these estimates are often incomplete, using
crude estimates of economic value or relying on the
imprecise physical effects underlying the economic Effectiveness of Technologies and Practices
values. Water technologies are designed to source, treat, distrib-
Damage cost studies account for the broader welfare ute, and monitor the supply of water. Epidemiological
and productivity consequences of poor WASH beyond studies evaluate the effectiveness of water interventions
the health effects. A review of economic impacts of poor in terms of the quantity and (microbial) quality of water
water and sanitation found estimates from more than 30 supplied (Waddington and others 2009). Increasing evi-
countries (see annex 9A), as well as global studies. dence enables the comparison of the incremental health
Studies with economic impacts expressed as a percentage benefits of different water interventions, such as
of gross domestic product (GDP) are shown in figure 9.4, improved community source, piped water, higher-quality
disaggregated between health and nonhealth damages. piped water, and point-of-use treatment (chlorine, solar,
Although all the studies presented in figure 9.4 and filter). Utility regulators, as well as regional and
present effects in monetary units, the results are not global initiatives, monitor water quality according to
directly comparable. They have different base years and service standards, such as continuity, consumption, and
different effects included; some include only sanitation, number of complaints (IBNET 2014). In 2010, The
and others include water and sanitation. In East Asian International Benchmarking Network for Water and
and Pacific and Sub-Saharan African economies, the Sanitation Utilities (IBNET) of the World Bank reported
cost of poor sanitation exceeded 2 percent of total that only 16 percent of utilities in low-income countries
GDP; in South Asia, it exceeded 4 percent of GDP. A supply water continuously 24 hours per day, compared
global study, including the health and time losses, val- to 86 percent of utilities in middle-income countries
ued the costs in LMICs at 1.5 percent of global domes- (Van den Berg and Danilenko 2010). Even a few days of
tic product (Hutton 2012). These significant economic interrupted water supply can result in significant adverse
effects raise awareness of the extent of the problem, but health consequences if beneficiaries revert to using
they do not indicate how to address the problem in a unimproved sources of water (Hunter, Zmirou-Navier,
cost-effective manner. and Hartemann 2009).

Water Supply, Sanitation, and Hygiene 181

 Figure 9.4 Economic Costs of Poor Water and Sanitation in Selected Countries, as a Percentage of GDP

7
Cost as percentage of GDP

0
-Sa Indo n (20 )
Ban India 008)

Lao sh (20 )
Pak R (20 )

11)
Nic frica 009)
Phi gua 08)
ine 10)

Iran Mo m (2 )
)
Alg p. (20 )
Mo ria (19 2)
co 99)
Egy Leb an (2 0)
ian Ara non ( 2)
epu (19 )
blic 99)
isia 01)
pt, Gha 1999)

Pak ep. (2 4)
Gu istan 03)
ma 2003)
eria 06)
Ban Nepa 004)
h (2 5)
El S Peru 002)
Ho dor (2 3)
Phi duras 05)

Tun s (20 )
Sen ia (19 )
ega 99)

Pak na (2 5)
)
)
)
)
Per 003)
)
de 2011
11
09

08
008
0

ine 07
07

ista 005
Ind (2005
Ind 1995
Chi 2009

990
ic R (201
0

Jor (200
00
Ara b R 199

b R (200

a 200

Gh l (200
ara (20
lipp (20
Vie s (20

Tun (20

Nig la (20

gla l (20

0
lipp (20
2

(2

(2
u (1
ia (

an ia (

ia (
ia (
lam lia

b R ep.

Ara na

na
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des
PD
bod

har nes

tna

is
roc
, Is ngo

a
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alv
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ate
Cam

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Syr pt,

Egy
Sub

Country (year of cost)

ESI studies Cost of environmental Country environmental analyses (World Bank/ Other studies
degradation studies environment department)
(World Bank/METAP)
Nonhealth Health
Source: See annex 9A for fuller datasets and references.
Note: GDP = gross domestic product. Economics of Sanitation Initiative (ESI) studies have been implemented by the World Bank’s Water and Sanitation Program in 34 countries of Latin
America and the Caribbean, East Asia and Pacific, South Asia, and Sub-Saharan Africa. These studies estimated the costs of poor sanitation, including health and nonhealth impacts (access
time, costs of accessing safe water, tourism). The Mediterranean Environmental Technical Assistance Program (METAP) of the World Bank conducted studies on the costs of environmental
degradation in eight Mediterranean countries from 1999 to 2002. Country environmental analyses conducted by the World Bank in more than 20 countries since 2003 have estimated the health
costs of poor water and sanitation.

To increase safety, drinking water can be treated either To reduce the transmission of pathogens, sanitation
at the source or at the point of use through a process of technologies isolate, transport, and treat fecal waste, and
filtration or disinfection or both. The greatest health they also provide users with a dignified and comfortable
effects for improved water treatment technologies con- experience when going to the toilet. Different rungs on
cern the piped water supply, with greater health benefits the “sanitation ladder” confer different health impacts
associated with higher-quality piped water (water that is and user experiences; hence, utilization of different
safe and continuously available) (Wolf and others 2014). kinds of sanitation services or facilities can vary. For
Among household-level studies, filter interventions that example, communal facilities may be poorly main-
also provided safe storage (for example, ceramic filters) tained, in which case they are less likely to be used by
were associated with a large reduction in diarrheal dis- women, children, and individuals who are disabled or
ease (Wolf and others 2014). Neither chlorine treatment infirm. Distance also decreases usage of communal
nor solar disinfection shows significant impact on diar- toilets (Biran and others 2011).
rhea after meta-analysis adjusted for non-blinding of the Hygiene technologies enable users to perform basic
intervention (Wolf and others 2014), although an earlier personal hygiene functions. Epidemiological studies have
systematic review and meta-analysis of water quality typically used the presence of a place for handwashing
interventions found household-level treatment to be with soap and water as a proxy for handwashing practice;
more effective than source treatment (Clasen and others however, this has been shown to be only loosely cor-
2005). Blinding participants to the intervention and lon- related with observed handwashing behavior (Ram 2013).
ger follow-up periods are recommended to better under- One synthetic review and meta-analysis of health
stand the impact of point-of-use water treatment impact assessments of water and sanitation interven-
interventions on diarrhea (Clasen and others 2005). tions includes 61 individual studies for water,

182 Injury Prevention and Environmental Health

12 observations comparing unimproved and improved (95% CI: 0.44–0.61) for the three soil-transmitted hel-
sanitation conditions, and only 2 observations com- minths combined, 0.54 (95% CI: 0.43–0.69) for A.
paring unimproved sanitation and sewer connections lumbricoides, 0.58 (95% CI: 0.45–0.75) for T. trichiura,
(Wolf and others 2014). and 0.60 (95% CI: 0.48–0.75) for hookworm
Table 9.4 shows relative risk reductions for different (Ziegelbauer and others 2012).
movements up the water supply and sanitation ladders. Access to sanitation has been associated with lower
The summary risk ratio for all observations on diarrhea trachoma, as measured by the presence of trachomatous
morbidity is 0.66 (95% confidence interval [CI]: inflammation–follicular or trachomatous inflammation–
0.60–0.71) for water interventions and 0.72 (95% CI: intense with odds ratio 0.85 (95% CI: 0.75–0.95) and
0.59–0.88) for sanitation interventions (Wolf and others C. trachomatis infection with odds ratio 0.67 (95% CI:
2014). An earlier review of 25 studies investigating the 0.55–0.78) (Stocks and others 2014).
association between sewerage and diarrhea or other A systematic review examined the impact of
related outcomes estimated an average risk ratio of 0.70 improved WASH on child nutritional status. Specifically,
(95% CI: 0.61−0.79), which increased to as much as 0.40 a meta-analysis of five randomized controlled trials
when starting sanitation conditions were very poor found a mean difference of 0.08 in height-for-age
(Norman, Pedley, and Takkouche 2010). z-scores of children under age five years (95% CI:
A meta-analysis of hygiene interventions found an 0.00–0.16) for solar disinfection of water, provision of
average risk ratio for diarrhea of 0.60 for promotion soap, and improvements in water quality (Dangour and
of handwashing with soap (95% CI: 0.53–0.68) and others 2013). However, the authors raised concerns
0.76 for general hygiene education alone (95% CI: about the low methodological quality of the included
0.67–0.86) (Freeman and others 2014). These results studies and the short follow-up periods; there was
are summarized in table 9.4. An earlier systematic insufficient experimental evidence on water supply
review found a relative risk compared to no handwash- improvement and sanitation to include in the meta-
ing of 0.84 (95% CI: 0.79–0.89) for respiratory infection analysis. Since publication of the Dangour and others
(Rabie and Curtis 2006). (2013) review, several additional randomized controlled
A meta-analysis that combined sanitation availabil- trials of household sanitation interventions have been
ity and use examined the impact of improved sanita- completed (Briceno, Coville, and Martinez 2014;
tion on soil-transmitted helminths. The meta-analysis Cameron, Shah, and Olivia 2013; Clasen and others
reported the following overall odds ratios:7 0.51 2014; Hammer and Spears 2013; Patil and others 2014),

Table 9.4 Meta-Regression Results for Water and Sanitation Interventions: Relative Risks Compared with No
Improved Water, Sanitation, or Hygiene Practice
Baseline Outcomea
Baseline water Outcome water
Improved community Piped water, Piped water, high Filter and safe storage
source noncontinuous quality in the household
Unimproved source 0.89 [0.78, 1.01] 0.77 [0.64, 0.92] 0.21 [0.08, 0.55] 0.55 [0.38, 0.81]
Improved community source 0.86 [0.72, 1.03] 0.23 [0.09, 0.62] 0.62 [0.42, 0.93]
Basic piped water 0.27 [0.10, 0.71] 0.72 [0.47, 1.11]
Baseline sanitation Outcome sanitation
Improved sanitation, no sewer Sewer connection
Unimproved sanitation 0.84 [0.77, 0.91] 0.31 [0.27, 0.36]
Improved sanitation, no sewer 0.37 [0.31, 0.44]
Baseline hygiene Outcome hygiene
General hygiene education Handwashing with soap
No hygiene education or handwashing 0.76 [0.67, 0.86] 0.60 [0.53, 0.68]
Sources: Water and sanitation: Wolf and others 2014; hygiene: Freeman and others 2014.
a. Brackets represent 95 percent confidence intervals.

Water Supply, Sanitation, and Hygiene 183

 most of them failing to find a significant relationship chemicals, solar and ultraviolet lamps, and flocculation)
between the interventions and child health or growth and safe storage technologies with communication- and
outcomes. One exception is a study in rural Mali of behavior-change techniques (Peal, Evans, and van der
Community-Led Total Sanitation (CLTS), which led Voorden 2010). Despite substantial evidence pointing to
to taller children on average (+0.18 height-for-age health benefits of HWTS, skepticism remains that the
z-score, CI on z-score: 0.03–0.32). These children were results may largely be the result of bias; concerns remain
6 percentage points less likely to be stunted after the about the extent of uptake, use, and scalability of com-
intervention (Pickering and others 2015). Econometric mercially marketed HWTS, particularly among poor
studies drawing on time series data establish links populations most at risk of diarrheal disease (Schmidt
between open defecation and stunting (Spears 2013), and Cairncross 2009).
between open defecation and childhood diarrhea in Handwashing promotion has been tested in forma-
India (Andres and others 2014), and between open def- tive research and has applied social cognitive models to
ecation and cognitive development in India (Spears and determine what motivates and changes behavior. The
Lamba 2013). A source of regularly updated evidence promotion has used a variety of communication
reviews on WASH interventions with strict inclusion channels—such as television, radio, theater groups,
criteria is the Cochrane Library.8 community meetings, and face-to-face visits—to reach
target groups who typically are mothers of young chil-
dren or school-age children. A pre- and post-evaluation
Effectiveness of Service Delivery Models of the approach in Burkina Faso, which targeted the
Effectiveness of service delivery models is measured by behavior of safe disposal of child feces and handwashing
intervention uptake, change in risky behaviors, sustain- after contact, documented increases in handwashing
ability, and, to a lesser extent, health outcomes. Large- (Curtis and others 2001). A similar approach to improve
scale approaches that include demand raising and handwashing behavior was piloted on a large scale under
behavior change are needed to achieve universal access, the Water and Sanitation Program’s Global Scaling Up
but experience has shown these approaches result in Handwashing Projects in Peru, Senegal,10 Tanzania, and
lower average effectiveness. Vietnam. Experimental evidence from Peru (Galiani and
others 2015), Tanzania (Briceno, Coville, and Martinez
Approaches to Demand Generation and WASH 2014), and Vietnam (Chase and Do 2012) suggests the
Behavior Change campaigns were only marginally successful. The Peru
Demand-based approaches start from the premise that study did find large changes in behavior in a subset of
lasting change is brought about when individual and communities with children who participated in a school-
community behaviors are affected. CLTS and its school- based handwashing promotion intervention. Effects on
based counterpart, School-Led Total Sanitation (SLTS), health were not observed in any of the countries, and the
promote broader changes in sanitation and hygiene sustainability of handwashing was not measured. A key
behaviors at the community level. Since its founding in obstacle identified in both Tanzania and Vietnam was
1999, the CLTS approach has rapidly expanded to more the difficult trade-off between scale and intensity of
than 50 developing countries, where many thousand activities.
successful applications of the approach have been made; The Global Public-Private Partnership for
at least 16 national governments have adopted CLTS as Handwashing (PPPHW) combines the marketing
national policy.9 Rigorous evaluation of the CLTS expertise of the soap industry with government support
approach has been limited, and the reliance on the and the enabling environment to trigger behavior
emergence of natural leaders presents difficulties in change and reduce diarrhea. Whereas the PPPHW has
testing the effectiveness of CLTS using conventional expanded globally, the coalition has not yet been subject
experimental methods. One exception comes from a to rigorous effectiveness trials (Peal, Evans, and van der
recent example in rural Mali, in which CLTS was well Voorden 2010). Evaluations of PPPHWs have been
implemented in a random set of villages and shown to commissioned by private soap companies and involved
almost double coverage of a private latrine (Pickering providing free soap to households (Nicholson and
and others 2015). others 2013), thus limiting their external validity.
Specific behaviors, such as household water treat-
ment and storage (HWTS) and handwashing with soap, Approaches to Strengthening Supply of Water and
have been the subject of behavior change campaigns. Sanitation Goods and Services
HWTS combines marketing of low-cost water treatment Supply-side approaches to water and sanitation service
(for example, boiling, filtration, disinfection using delivery cover the full value chain from production and

184 Injury Prevention and Environmental Health

assembly of inputs, importation, sales, distribution, models could be improved to enhance the quality of
installation, and maintenance of water infrastructure services as well as increase take-up of services, especially
and latrines. Services range from micro and small-scale among the poorest populations.
independent water resellers; network operators; well Results-based approaches11 to development that
and pit diggers; operators offering masonry, pit, and offer financial or nonmonetary rewards upon demon-
septic tank emptying; and public toilet operators to stration of measurable outputs or outcomes are used
medium-scale sanitation markets—or sanimarts— increasingly for achieving desirable outcomes. The spe-
offering a full range of sanitation goods and services. cific details differ, but such approaches share a common
Small-scale operators can effectively serve rural mar- aim of shifting the overall incentive structure from
kets, where the majority of people without access to financing infrastructure to delivering services. Until
piped water and sanitation live. However, the existing recently, the experience using results-based approaches
literature highlights several obstacles to growth and the in water and sanitation was limited. A review by the
ability of such providers to effectively serve these rural World Bank in 2010 indicated that less than 5 percent of
populations. its output-based aid (OBA) portfolio was in water and
Rural operators often face higher per capita costs sanitation (Mumssen, Johannes, and Kumar 2010). The
because they lack economies of scale enjoyed by larger use of OBA has increased under the Global Partnership
utilities and therefore have lower revenue potential (Baker on Output-Based Aid (GPOBA), which lists 22 projects
2009). Investment financing needed for growth can be in water supply and sanitation whose outputs include
difficult to secure, and the lack of formalization in the water, sewerage, or sanitation connections.12 Multilateral
sector can result in insecure operating environments and bilateral agencies such as the World Bank, Inter-
(Sy, Warner, and Jamieson 2014). The availability of alter- American Development Bank, and Department for
native sources of free or low-cost water makes rural areas International Development (DfID) have shifted funding
less attractive to independent operators. Low or uneven toward results-based approaches in water and sanita-
demand has limited growth opportunities for small-scale tion. As of early 2016, the World Bank’s Program-for-
onsite sanitation service providers. Despite these obstacles, Results Financing (PforR) has six active operations in
small-scale service providers are increasingly recognized water supply, sanitation, and hygiene.
as a central part of the solution to close the gap in water Microfinance or microcredit can help poor households
and sanitation access, particularly among the poor. facing liquidity constraints to invest in water supply and
Supply-side strengthening is predominant in the sanitation by (1) smoothing consumption over time, (2)
Community Approach to Total Sanitation (CATS) pro- encouraging households to be more willing to adopt
moted by the United Nations Children’s Fund and the improved services, and (3) giving those households an
Total Sanitation and Sanitation Marketing (TSSM) opportunity to purchase more durable, higher levels of
approach of the World Bank Water and Sanitation service. Consumer credit has been applied successfully to
Program. Recent randomized control trial impact evalu- increase the installation and use of household piped
ations of TSSM in Madhya Pradesh, India (which water connections (Devoto and others 2011), but exper-
included a hardware subsidy to households below the imental evidence of consumer lending for sanitation
poverty line); East Java, Indonesia; and 10 rural districts remains limited. However, emerging interest in the
of Tanzania found the approach varied widely in its potential of microfinance for household sanitation and
effectiveness across the countries, with no increase in the results of small-scale pilots are promising. A ran-
improved sanitation in Indonesia (Cameron, Shah, and domized study in Cambodia found a fourfold increase in
Olivia 2013) and increases of 19 and 15.7 percent in uptake when households were offered a 12-month
Madhya Pradesh (Patil and others 2014) and Tanzania low-interest loan to purchase a latrine (Shah 2013).
(Briceno, Coville, and Martinez 2014), respectively. Finally, interest is emerging for using large-scale
Despite better sanitation coverage in Madhya Pradesh, delivery platforms for social services and poverty reduc-
large numbers of adults continued to practice open tion. These platforms can help improve the targeting of
defecation. WASH services and will make use of the tools and mech-
anisms those programs have for improving livelihoods
Approaches to Improve the Effectiveness of WASH and outcomes for the poor. Examples include the
Service Delivery following:
Addressing the supply- and demand-side constraints of
WASH service delivery has led to large increases in • Sanitation subsidies and financing can be targeted to
access. But the persistence of regional and socioeco- conditional-cash transfer (CCT) participants, many
nomic disparities in access suggests that current delivery of whom lack adequate sanitation. A more ambitious

Water Supply, Sanitation, and Hygiene 185

 approach could make receipt of cash transfers condi- Despite its importance, cost information is not
tional on a household’s use of improved sanitation. commonly tabulated in an appropriate format to sup-
These programs also provide outreach and coun- port decision making. At the policy level, budgets and
seling to reach target households with sanitation resource allocations are fragmented among subsectors,
promotion messages that build awareness and help levels of government, and sector partners or financiers.
change behavior. Considerable differences exist between budget alloca-
• Community-driven development (CDD) programs tions and disbursements. WASH-BAT (bottleneck
can be used as a platform to deliver CLTS and to analysis tool), developed by UNICEF, helps consolidate
follow up with participatory planning and budgeting the budgetary needs so that sector bottlenecks can be
to ensure that communities become free of open removed (see annex 9B) (UNICEF 2014). At the pro-
defecation. gram or service delivery levels, implementers do not
• Safety-net programs that build skills and strengthen easily share information on their costs, and budgets
sources of livelihood can include sanitation busi- may not be structured for simple breakdowns between
nesses and services such as masonry, plumbing, and software and hardware costs. Cost studies for WASH
electrical skills among the list of profitable invest- technologies are more abundant, and at the local level,
ments for beneficiaries. the market or subsidized price is available. However,
• Many nutrition interventions already promote the price is rarely the same as the cost. The price com-
handwashing with soap, safe water, and sanitation. monly contains either a profit or a subsidy; because
Handwashing demonstrations are often included in both are transfer payments, they should be excluded
promotions for breastfeeding and interventions for from economic analysis. However, to ease the research
feeding infants and young children, which also stress burden, it is common practice in economic analysis to
the use of safe water in food preparation. use prices as a proxy for cost, adjusting for any known
subsidy or profit.
More innovative integration approaches may use Published cost evidence is available in aggregated
those same channels to discuss with the community and unit forms. Aggregated cost includes the expendi-
sanitation product options and services that are avail- ture required to meet specified targets. The World
able. Evidence is needed on the effectiveness and the cost Bank estimates that the global capital costs of achieving
of integrated approaches. Such information may high- universal access to WASH services by 2030 are
light the need for more operational research and impact US$28.4 billion per year confidence interval [CI]:
evaluations to inform policy and program design. US$13.8 billion to US$46.7 billion) from 2015 to 2030
for basic WASH and $114 billion per year (CI:
US$74 billion to US$166 billion) for safely managed
INTERVENTION COSTS, EFFICIENCY, AND WASH (Hutton and Varughese 2016).13 Those costs
SUSTAINABILITY are equivalent to 0.10 percent of global product for
basic WASH and 0.39 percent of global product for
Any intervention in the WASH sector requires an eco-
safely managed WASH, including 140 LMICs. Those
nomic rationale, thus satisfying conditions of efficiency,
needs compare with 0.12 percent of its gross product
affordability, and relevance. Cost-benefit analysis com-
spent on meeting the MDG water target and making
pares the intervention costs with the benefits, expressed
progress toward the sanitation target. Universal basic
in monetary units. Cost-effectiveness analysis compares
access by 2030 is feasible at current spending but
the intervention costs with the benefits, expressed in
requires reallocations to sanitation, to rural areas, and
some other common unit, such as lives gained or pollu-
to off-track regions. However, substantial further
tion load to the environment averted.
spending is needed to meet the higher standard of
safely managed services. The costs as a proportion of
Costs gross regional product are shown by MDG region in
The cost of interventions is one key piece of evidence for figure 9.5. Regions most challenged to reach universal
decision making, because it is relatively easy to obtain access are South Asia and Sub-Saharan Africa.
and is often cited as a constraint for an investment deci- Many countries also produce investment plans for
sion, whether by governments, private sectors, house- meeting national targets, thereby focusing on the financ-
holds, or individuals. Costs can be measured for the ing the government will provide. The Organisation for
WASH technology (the hardware), the service delivery Economic Co-Operation and Development (OECD) has
approach (the “software” or program management), and created FEASIBLE, a tool for developing national financ-
the enabling environment. ing strategies by comparing the costs of meeting national

186 Injury Prevention and Environmental Health

Figure 9.5 Costs of Basic and Safely Managed Services as a Percentage of GRP, by Region, with Uncertainty Range

3.0

2.5

2.0 2.01
Cost as a percentage of GRP

1.5

1.0

0.64 0.85

0.58
0.5 0.45
0.39 0.36
0.31 0.27
0.21 0.23
0.12 0.10 0.15 0.12
0.10 0.09 0.04 0.05 0.02
0.04 0.03
0
ca

ia

ld

ia

ia
A

ia

ed
nia

C
As

or

As

As
SS

fri
As

LA
CC

lop
W

ea
nA

st

rn

rn
rn

ve
Oc
Ea

te

ste
he

er

De
es
h-
rth
ut

Ea
W
ut
So

No

So

SDG targets 6.1 and 6.2 Basic WASH

Upper and lower estimates of the cost Upper and lower estimates of the cost
of meeting SDG targets 6.1 and 6.2 of achieving basic WASH

Source: Hutton and Varughese 2016.

Note: CCA = Caucasus and Central Asia; GRP = gross regional product; LAC = Latin America and the Caribbean; SDG = Sustainable Development Goal; SSA = Sub-Saharan Africa;
WASH = water, sanitation, and hygiene. See table 9.2 for details on upper and lower values on variables varied in sensitivity analysis. GRP is based on the aggregated gross domestic product
of countries in each region. An economic growth rate of 5 percent is assumed across all regions.

targets with the projected financing available.14 FEASIBLE However, those studies find monthly expenditure is
has been applied in at least 12 countries (OECD 2011). more similar between the two sources because of
A key input to these aggregated studies is the unit higher consumption of piped water than of other
costs of WASH provision at the household or water sources (Whittington and others 2009). The
community level. Because of climatic, topographical, IRC WASHCost project calculated benchmark capital
and socioeconomic differences, the costs of providing and recurrent costs for basic levels of water service in
service vary highly between studies, contexts, and lev- Andhra Pradesh, India; Burkina Faso; Ghana; and
els of service. The costs per cubic meter of water and Mozambique (Burr and Fonseca 2013). Benchmark
of wastewater services, as well as average monthly capital costs ranged from US$20 per person for bore-
household bills, are available for utility services holes and hand pumps to US$152 for larger water
through national regulators, regional associations, and schemes. Benchmark recurrent costs ranged from
global initiatives (IBNET 2014). Studies commonly US$3 to US$15 per person per year, but actual expen-
compare the cost of different sources of water supply, ditures were substantially lower. Construction cost for
and they find piped water to be significantly cheaper equivalent latrines varies widely between settings
per unit compared with vendor-supplied water. (Hutton and others 2014). Comparison of alternative

Water Supply, Sanitation, and Hygiene 187

 sanitation transportation and treatment technologies economic variables are rarely captured. The majority of
also provides important policy direction; in general, economic studies build models filled with data from a
fecal sludge management is considerably cheaper than mixture of sources. Global studies assessing the economic
sewerage, as in Dakar, Senegal, where it was found to benefits of improved water supply and sanitation include
be five times cheaper (Dodane and others 2012). health economic benefits and convenience time savings
Extrapolating available data from one context to (Hutton 2013; Whittington and others 2009). Country
another carries risks. Therefore, simple costing tools studies have also evaluated the value of health and time
and investment in evidence gathering are required so savings (Pattanayak and others 2010). Regional studies
that cost estimates of specific locations can be made.15 from Southeast Asia assess the water access, reuse, and
Ideally, those who determine the costs of water supply tourism benefits of improved sanitation as a proportion
and sanitation services would consider the externalities of avoided damage costs (Hutton and others 2008, 2014).
and the long-run cost of supply. One study provides an Willingness-to-pay (WTP) studies have estimated the
illustrative example of the full costs of water supply and economic value of water quality improvements, but only
sanitation (including opportunity costs and very few studies use experimental methods (Null and
environmental costs) with the low costs, varying from a others 2012). Other studies have assessed WTP to avoid
high of US$2.00 per cubic meter to a low of US$0.80 per health impacts (Guh and others 2008; Orgill and others
cubic meter (table 9.5) (Whittington and others 2009). 2013) and to receive piped water (Whittington and
From a policy perspective, the affordability and others 2002). A systematic review of those studies has
willingness to pay for those costs is a critical issue. shown that the economic value derived from the WTP
A global review found that water supply costs as a for improved water quality is less than the cost of pro-
proportion of household income are significantly higher ducing and distributing it (Null and others 2012). Social
for poorer populations (Smets 2014) and well above the benefits have been assessed, but few have been expressed
benchmark of between 3 percent and 5 percent used by in money values except WTP studies, which tend to cap-
some governments and international organizations. ture all benefits and make differentiating social from
other benefits difficult.
Economic value is associated with river cleanup
Benefits that includes improved management of municipal
WASH services have a large array of welfare and wastewater, as well as improved management of indus-
development benefits. Table 9.6 classifies those benefits trial discharge, agricultural runoff, and solid waste.
under health, convenience, social, educational, reuse, The financial viability of WASH services has been
water access, and other. expressed in terms of financial returns. The most com-
Those benefits have been evaluated extensively, but prehensive source of data is from projects of multilat-
few studies evaluate the benefits comprehensively. The eral development banks that routinely conduct a
most robust scientific studies, such as randomized or financial assessment of WASH services before project
matched prospective cohort studies, have been conducted approval and that, in some cases, report on the com-
on health effects. But only few of those studies exist, and pletion of project implementation.

Table 9.5 Cost Estimates of Improved Water and Sanitation Services

US$ per cubic meter
Cost component Full cost Minimal cost
Opportunity cost of raw water supply 0.05 0.00 (“steal it”)
Storage and transmission to treatment plant 0.10 0.07 (minimum storage)
Treatment to drinking water standards 0.10 0.04 (simple chlorination)
Distribution of water to households 0.60 0.24 (PVC pipe)
Collection of wastewater from home and conveyance to treatment plant 0.80 0.30 (condominial sewers)
Wastewater treatment 0.30 0.15 (simple lagoon)
Damages associated with discharge of treated wastewater 0.05 0.00 (“someone else’s problem”)
Total 2.00 0.80
Source: Whittington and others 2009.
Note: PVC = polyvinyl chloride. Discount rate used is 6 percent. Using a 3 percent discount rate, the total cost is US$1.80 per cubic meter at full cost and US$0.70 per cubic meter at minimal cost.

188 Injury Prevention and Environmental Health

Table 9.6 Benefits of Improved Drinking Water Supply and Sanitation
Benefit Water Sanitation
Health, burden of • Averted cases of diarrheal disease • Averted cases of diarrheal disease
disease • Reduced malnutrition, enteropathy, and • Averted cases of helminths, polio, and eye diseases
malnutrition-related conditions (stunting) • Reduced malnutrition, enteropathy, and malnutrition-related
• Less dehydration from lack of access to water conditions (stunting)
• Less disaster-related health impacts • Less dehydration from insufficient water intake because of poor
latrine access
• Less disaster-related health impacts
Health, economic • Costs related to diseases, such as health care, • Costs related to diseases, such as health care, productivity
savings productivity losses, and premature mortality losses, and premature mortality
Convenience • Saved travel and waiting time for water • Saved travel and waiting time from having nearby private toilet
time savings collection
Educational • Improved educational levels because of higher • Improved educational levels because of higher school enrollment
benefits school enrollment and attendance rates from and attendance rates from school sanitation
school water • Higher attendance and educational attainment because of
• Higher attendance and educational attainment improved health
because of improved health
Social benefits • Leisure and nonuse values of water resources • Safety, privacy, dignity, comfort, status, prestige, aesthetics, and
and reduced effort of averted water hauling and gender effects
gender impacts
Water access • Pretreated water at lower costs for averted • Less pollution of water supply and hence reduced water
benefits treatment costs for households treatment costs
Reuse • Soil conditioner and fertilizer
• Energy production
• Safe use of wastewater
Economic effects • Incomes from more tourism and business • Incomes from more tourism and business investment
investment • Employment opportunity in sanitation supply chain
• Employment opportunity in water provision • Rise in value of property
• Rise in value of property
Sources: Adapted from Hutton 2012; Hutton and others 2014.

Intervention Efficiency: Cost-Benefit Analysis and best-available evidence from multiple sources
The discussion of efficiency should distinguish between (Hutton 2013; Whittington and others 2009)
cost-benefit analysis, which uses a common money met-
ric for all costs and benefits, and cost-effectiveness Given the high costs and challenges associated with
analysis, which compares interventions for one type of collecting all the cost and benefit data required for the
outcome. Reviewed cost-benefit studies are provided in first approach, it is common practice to combine
annex 9C. site-specific values with data extrapolated from other
Efficiency studies can be conducted in two ways sources (Hutton and others 2014). Table 9.7 shows the
(Whittington and others 2009): most recently available global studies that have modeled
selected water supply and sanitation interventions. One
• By generating estimates of cost and benefit in specific important finding from these studies is that lower tech-
sites or field studies for the purposes of either evalu- nology interventions have higher returns than more
ating intervention performance or selecting a site for expensive networked options.
a future project (Kremer and others 2011) Global studies indicate the projected overall costs
• By using model costs and benefits for specific sites or and benefits from intervention alternatives, but they
larger jurisdictions, such as country or global level, are not particularly useful in guiding decisions on

Water Supply, Sanitation, and Hygiene 189

 Table 9.7 Benefit-Cost Ratios from Global Studies they serve large, dense populations. Providing water
service on a smaller scale through either communal or
Study and intervention Benefit-cost ratio in-compound wells or boreholes and onsite household
Whittington and others (2009): modeled approach a sanitation may be a more appropriate and cost-efficient
Networked water and sewerage services 0.65 service level for sparsely populated areas (Ferro, Lentini,
and Mercadier 2011).
Deep borehole with public hand pump 4.64
Total sanitation campaign (South Asia) 3.00
Household water treatment (biosand filters) 2.48 Intervention Efficiency: Cost-Effectiveness Analysis
The main outcomes used in cost-effectiveness studies
Hutton (2013): modeled approach b
are health and environmental outcomes. When used
Improved water supply (JMP definition) 2.00 to compare programs in a sector, cost-effectiveness
Improved sanitation (JMP definition) 5.50 can be measured by program outcomes, such as the
Sources: Hutton 2013; Whittington and others 2009. number of latrines constructed, the number of water
Note: All studies include the value associated with health and convenience time connections installed, or the percentage of beneficia-
savings.
a. Ranges on each parameter value are then used to conduct Monte Carlo simulation
ries changing behavior. For water supply interventions,
that enables exploration of intervention performance in a range of different settings. health cost-effectiveness studies have been conducted
Hence, even interventions with a benefit-cost ratio of 2.0 or more are expected to have (see annex 9C). Studies focus on improved water
a benefit-cost ratio of less than 1.0 under some runs of the model.
b. Estimates indicate global averages, and regional averages are available in the paper.
supply according to the JMP definition and
A separate working paper provides results for each country (Hutton 2012). point-of-use treatment by households or schools.
A global study compares water supply interventions at
the regional level (Clasen and others 2007).
Figure 9.6 shows the cost per healthy life-year
which technology and service level to choose in spe- (HLY) gained for four interventions in two regions. It
cific settings. One randomized implementation study shows that the selected interventions vary by a factor
in India finds similar health costs between study arms. of approximately 2.5 between the most cost-effective
However, it finds statistically significant savings in (chlorination) and the least cost-effective (ceramic
time in the intervention group of US$7 per household filter). However, all interventions have a cost per HLY
(US$5 for water and US$2 for sanitation) during the that is below the GDP of countries in these regions,
dry season, or roughly 5 percent of monthly cash thereby indicating a cost-effective use of health
expenditures (Pattanayak and others 2010). A study resources. Another global study found the incremental
from South Africa estimates a benefit-cost ratio of costs averted of adding point-of-use water disinfection
3.1 for small-scale water schemes (Cameron and others on top of improved water supply costs resulted in a
2011). A study from Indonesia compared three waste- cost per DALY averted of less than US$25 in
water treatment interventions and finds limited eco- Sub-Saharan Africa, of US$63 in India and Bangladesh,
nomic rationale for the interventions (Prihandrijanti, and of less than US$210 in South-East Asia and
Malisie, and Otterpohl 2008). However, a broader the Western Pacific (Haller, Hutton, and Bartram
cost-benefit study at the river basin level estimated the 2007).
benefits of cleaning up the Upper Citarum river in Fewer studies have conducted health cost-effectiveness
Indonesia exceeded costs by 2.3 times (Hutton and analyses of sanitation and hygiene interventions. Two
others 2013). global studies by the WHO and World Bank examine
Targeting the poor could be justified; children from the cost-effectiveness of water supply and sanitation
poorer households are at increased health risk because combined (Günther and Fink 2011; Haller, Hutton, and
they live in communities with lower access to improved Bartram 2007). Using regions defined by epidemiologi-
water and sanitation facilities. A study in Bangladesh, cal strata, WHO estimates that the cost in countries
India, and Pakistan estimating the cost per episode for with high child and high adult mortality is less than
income quintiles shows that costs of an illness represent US$530 per DALY averted in the Eastern Mediterranean
a higher proportion of income for lower quintiles and Middle East, US$650 in Sub-Saharan Africa,
(Rheingans and others 2012). US$1,400 in South and South-East Asia, and US$2,800
The cost efficiency of technologies depends on the in Latin America and the Caribbean. A World Bank
local geological setting, population density, and num- study on child mortality reduction estimates the average
ber of households to be served. Large water distribu- cost per life year saved in Sub-Saharan African countries
tion and sewerage systems may only be cost efficient if is US$1,104 for basic improved water and sanitation

190 Injury Prevention and Environmental Health

Figure 9.6 Cost Per HLY Gained from Four Water Supply and Water Quality Interventions in Two World Subregions, US$, 2005

a. Africa epidemiological stratum D (AFR-D) b. South Asia and South-East Asia

epidemiological stratum D (SEAR-D)
350 350

300 300
Cost per HLY gained, US$

Cost per HLY gained, US$

250 250

200 200

150 150

100 100

50 50

0 0
Chlorination Solar Ceramic water Source-based Chlorination Solar Ceramic water Source-based
disinfection filter interventions disinfection filter interventions

Source: Clasen and others 2007.

Note: AFR-D = African Region–high child, high adult mortality countries; HLY = healthy life-year; SEAR-D = South-East Asian Region–high child, high adult mortality countries. AFR-D and
SEAR-D are part of the World Health Organization’s epidemiological subregions.

and is US$995 for privately piped water and flush toilets and mental development. Overall, the health impacts of
(Günther and Fink 2011). poor WASH lead to economic consequences of sev-
In country studies in South-East Asia, the cost per eral percent of GDP and continue to significantly affect
DALY averted of basic sanitation is less than US$1,100 in quality of life and the environment. Furthermore, water
selected rural areas of Cambodia, China, Indonesia, the stress is a growing phenomenon that will affect at least
Lao People’s Democratic Republic, and Vietnam; the 2.8 billion people in 48 countries by 2025. Climatic fac-
exception is in the Philippines, where it is US$2,500 tors are harder to control, but water scarcity can be mit-
(Hutton and others 2014). Few recent country-specific igated by changing water use patterns and reducing
studies are available on hygiene interventions; one study pollution of surface waters.
from Burkina Faso estimates a cost of US$51 per death Important progress has been made in achieving the
averted for health education to mothers (Borghi and MDG global water and sanitation targets. In September
others 2002). 2015, new global targets for universal access to safe
Sustainability of water supply, sanitation, and hygiene WASH were adopted. At the current rates of progress
is covered in annex 9D; financing is covered in annex 9E. and using current indicators, achieving those targets will
take at least 20 years for water supply and 60 years for
sanitation (WHO and UNICEF 2014). Covering the
CONCLUSIONS poor and marginalized populations will continue to be a
Although global deaths from diarrhea have declined challenge; the remaining unserved populations are likely
significantly over the past 20 years, poor water supply, to be harder to reach as universal access is approached.
sanitation, and hygiene are still responsible for a signifi- The service level benchmark of targeting safely managed
cant disease burden. An estimated 842,000 global deaths services will require better policy and regulatory frame-
in 2012 were due to diarrhea caused by poor WASH. works and more resources. Indeed, as environmental
Other less well-quantified but important long-term consequences intensify and populations demand a
health consequences of poor WASH, such as helminths higher quality of service, a higher target for service level
and enteric dysfunction, remain. Those diseases affect will be increasingly required. This demand will raise
children’s nutritional status, thereby inhibiting growth questions about priorities; countries will face a trade-off

Water Supply, Sanitation, and Hygiene 191

 between (1) dedicating policy space and spending public including the measurement of cost-effectiveness to
subsidies to move populations that are already served guide policy and program design.
higher up the water and sanitation ladder and (2) reach- • The social welfare consequences of poor WASH are
ing populations that are not served with basic WASH not well documented but are potentially very large.
services. Each country will have its unique set of chal- In particular, a greater understanding is needed
lenges. The human right to drinking water and sanita- of the gender effects of inadequate WASH and of
tion can serve as a reminder that priority should be given how improved WASH services contribute to gender
to ensuring at least a minimum level of affordable equality.
WASH service for all citizens. • A large part of the remaining challenge of improving
Populations are growing and moving, economies are access to sanitation and hygiene is behavioral rather
developing and becoming richer, and the climate is than technical. However, little evidence exists on the
changing. Each one has its challenges and opportunities. effectiveness of behavior change using conventional
Population migration to greenfield sites offers a chance methods at scale or on the transferability of behavior
of implementing new and appropriate technologies, and change interventions that are successful in a particu-
selection of cost-effective and affordable technologies in lar context. A better understanding of habit forma-
urban planning is essential. Economic growth leads to tion and what leads to sustainable behavior change
greater tax revenues for local governments and increased is needed.
ability to upgrade infrastructure and expand urban • Innovative delivery platforms that leverage national
renewal. Climate change challenges the delivery of poverty reduction programs, such as CCT and CDD
WASH services by affecting rainfall patterns, freshwater programs, have the potential to achieve wide cover-
availability, and frequency of heat events, and it exacer- age at little marginal cost. Such approaches can also
bates health risks. However, this new threat, when taken provide the methodology and data sources to support
seriously, can be an opportunity to overhaul outdated targeting areas of poverty in WASH services.
policies and technologies. Furthermore, as nutrient • A better understanding is needed on which WASH
sources for chemical fertilizer become scarcer, price interventions work in slum areas and low-income
increases will force suppliers to seek alternatives; the neighborhoods and under what conditions the inter-
price of composted sludge is expected to increase, ventions work.
thereby attracting investments. New research, data, and • A greater understanding is needed of how output-
technologies are increasingly available to present new based incentives can be used to improve WASH
possibilities for addressing entrenched problems in the service delivery and to lead to greater sustainability
WASH sector. of services.
The following research priorities are recommended • Innovations in subsidies and microfinance are needed
for immediate attention: to ensure that the poor gain access to improved
sanitation. Despite greater availability and lower
• To adequately address equity considerations in the cost of sanitation goods and services, some people
SDG era, there is a need to understand where remain too poor to afford adequate water supply and
poor people live and what their levels of access sanitation. Such populations should be identified to
are. Disaggregated data on the underserved— receive hardware and financial subsidies.
including slum populations, ethnic groups, women,
elderly, and persons with disabilities—can support
prioritization. Greater focus is needed on how to ANNEXES
increase access in the lagging regions of South Asia
and Africa, where a large proportion of the unserved The annexes to this chapter are as follows. They are avail-
live. At the country level, policy and financial incen- able at http://www.dcp-3.org/environment.
tives need to be aligned and the economic arguments
made for allocating resources to WASH services. • Annex 9A. Overview of Studies Presenting Damage
• More evidence is needed to support the emerging Costs of Poor Water, Sanitation, and Hygiene at the
understanding of the wider health effects of water, National Level
sanitation, and hygiene. Multisectoral approaches • Annex 9B. Effectiveness of Enabling Environments
will become more important as the complementa- • Annex 9C. Cost-Effectiveness and Cost-Benefit Studies
rities among WASH, health, and nutrition are better on Water, Sanitation, and Hygiene
understood. Further, rigorously designed and con- • Annex 9D. Intervention Sustainability
trolled studies are needed to quantify these benefits, • Annex 9E. Intervention Financing

192 Injury Prevention and Environmental Health

NOTES (same as JMP improved definition). Basic hygiene: per-
centage of population with handwashing facilities with
World Bank Income Classifications as of July 2014 are as soap and water at home. Safely managed water: percent-
follows, based on estimates of gross national income (GNI) age of population using safely managed drinking water
per capita for 2013: services. Corresponds to population using an improved
drinking water source located on the premises, available
• Low-income countries (LICs) = US$1,045 or less when needed, and free of fecal and priority chemical
• Middle-income countries (MICs) are subdivided: contamination. Safely managed sanitation: percentage
a) lower-middle-income = US$1,046 to US$4,125 of population using safely managed sanitation services.
b) upper-middle-income (UMICs) = US$4,126 to US$12,745 Includes safe onsite isolation, extraction, conveyance,
• High-income countries (HICs) = US$12,746 or more. treatment and disposal, or reuse.
14. For information about the OECD’s methodology and
1. United Nations Human Rights Council, Resolution FEASIBLE computer model, see http://www.oecd.org/env
18/1, “The Human Right to Safe Drinking Water and /outreach/methodologyandfeasiblecomputermodel.htm
Sanitation,” adopted September 28, 2011, http://www (accessed November 11, 2015).
.worldwatercouncil.org/fileadmin/wwc/Right_to_Water 15. For example, the IRC International Water and Sanitation
/Human_Rights_Council_Resolution_cotobre_2011.pdf. Center has developed the WASHCost Calculator (www
2. United Nations Human Rights Council, Resolution 18/1. .ircwash.org/washcost), whereas the World Bank’s
3. Whereas no academic literature is available with such Economics of Sanitation Initiative has developed an
examples, national surveys (such as the Demographic economic assessment toolkit under the Economics of
and Health Survey or the Multiple Indicator Cluster Sanitation Initiative (http://www.wsp.org/esi).
Survey) show that a higher proportion of households
practice unsafe management of children’s feces as com-
pared with overall household unimproved sanitation
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