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Institute of Medicine (US) Roundtable on Environmental Health Sciences, Research, and Medicine. Global Environmental Health: Research Gaps and Barriers for Providing Sustainable Water, Sanitation, and Hygiene Services: Workshop Summary. Washington (DC): National Academies Press (US); 2009.

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Global Environmental Health: Research Gaps and Barriers for Providing Sustainable Water, Sanitation, and Hygiene Services: Workshop Summary.

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5Achieving Water and Sanitation Services for Health in Developing Countries

Water-related efforts in the developing world are often balkanized and not sufficiently integrated to ensure sustainable water services. There can be different strategies to ensure access to safe water depending on the country and its social needs. The different strategies may have impacts on reaching the Millennium Development Goal of reducing by half the proportion of the population that lacks access to improved water and sanitation by 2015. This chapter focuses on presentations addressing the challenges in developing countries.


Christine Moe, Ph.D., Director

Center for Global Safe Water

Eugene J. Gangarosa Professor of Safe Water and Sanitation

Emory University

Water and sanitation concerns are of great magnitude: 1.1 billion individuals, approximately 17 percent of the world’s population, are without improved water and more do not have access to safe drinking water, and 2.6 billion, approximately 41 percent, are without improved sanitation. Even worse, many of the world’s school children attend a school without water or toilets. Not surprisingly, 40 percent of the world’s school-age children have worm infections, predisposing them to cognitive and developmental problems. It is further estimated that 5,000 children die every day from diseases because of lack of safe drinking water, inadequate sanitation, and poor hygiene (WSSCC, 2004).

In many regions of the world, collecting water is primarily the responsibility of women. Women’s lives are further impacted by lack of water and sanitation because they are responsible for the care of children, who are affected by diarrheal disease. Women do not always have the financial resources to pay for water purchases, treatment, or new investments. However, it is not just access to water that is a problem. The lack of sanitation means that, in some places, women and girls must wait until nightfall to defecate, while in some nations more than 50 percent of girls drop out of school due to the lack of toilets. These disparities have additional implications for health, education, and human rights.

Thus women and children place a higher value on water and sanitation. A study showed that microcredit loans provided to women in Bangladesh increased the presence of latrines in their household from 9 to 26 percent over three years; the control group showed a slight decrease in latrine presence during the same time period (Husain, 1998). A group of schoolgirls in Kenya demonstrated that children are thinking about sanitation. When asked about the type of preferred sanitation, they provided a detailed drawing depicting the location and construction of a latrine for their school (Dickman, 2008). Much work must be done in order to reach a global goal of increasing access to improved sanitation in many parts of the world.

The Past and Future of Sanitation and Water Improvement Goals

The first collaborative international effort to create significant impacts on the global water and sanitation situation came from the First International Drinking Water Supply and Sanitation Decade (1981–1990) which ultimately met with limited success. However, new innovations exist that may lead to greater success in the second decade International Decade for Action: Water for Life (2005–2015), such as increases in public-private partnerships, investments by large corporations, and more community-based organizations and nongovernmental organizations that work on improving access to water and sanitation. A greater focus on microfinancing and local initiatives, along with new discussion of ecological sanitation and culturally appropriate initiatives, is led by empowered community members. Other trends include the consideration of global water scarcity in sustainable planning and a move from simple water quality monitoring to the development of a more holistic water safety plan approach by the World Health Organization (WHO) as well as greater use of various household water treatment approaches.

With regard to standards for improved water and sanitation, it is important to recognize that improved water is not necessarily safe drinking water. Improved water access includes household connections, public standpipes, rainwater collection, boreholes, and protected wells, but not water vendors, unprotected wells, unprotected springs, rivers or ponds, or tanker truck water. Improved sanitation includes connections to public sewers, septic systems, pour-flush and improved pit latrines, but not shared, traditional, or open pit latrines. Results have been mixed—between 1990 and 2002, the number of people with improved water gradually increased (Figure 5-1).

FIGURE 5-1. Trends in service levels for drinking water.


Trends in service levels for drinking water. Between 1990 and 2002, there has been a gradual increase in the number of people with access to improved water sources. However, the data does not show that the gains are partially offset by individuals who (more...)

For sanitation, large gains occurred in some areas and losses in others (Figure 5-2, UNICEF, 2004). Disparities exist between the rich and poor and are much greater in sanitation than water. The poor are half as likely to have water access and one-fourth as likely to have sanitation access. More than half of the 41 percent of worldwide population without improved sanitations live in India and China. Unmet needs are highest in sub-Saharan Africa (in Ethiopia, 94 percent of the country is without access to sanitation; in Chad, 92 percent; in Congo, 91 percent; in Eritrea, 91 percent; in Burkina Faso, 88 percent; in Guinea, 87 percent; in the Comoros, 77 percent) and Southeast Asia (in Cambodia, 84 percent) (UNICEF, 2004). In terms of access to improve water, coverage is lowest in Africa and Oceania (UNICEF, 2004).

FIGURE 5-2. Coverage with improved sanitation by region in 2002.


Coverage with improved sanitation by region in 2002. Fifty-eight percent of the world has access to improved sanitation; however, sub-Saharan African and regions in Oceania have the lowest rates of coverage. SOURCE: UNICEF (United Nations Children’s (more...)

What can be done about these large gaps in access to water and sanitation? The Millennium Development Goal Number Seven, outlined by the United Nations, includes reducing the proportion of those without improved water and sanitation by one-half worldwide by 2015 (DESA, 2008). Meeting this goal requires that 50 people receive services for water and 65 receive sanitation per minute (Stockholm Environment Institute, 2005). Reaching these goals would cost an estimated $11.3 billion per year, according to a WHO study (Hutton and Haller, 2004). These goals may be reached by addressing four major challenges to achieve greater gains in the current Water and Sanitation Decade.

Major Challenges to Improved Access: Need for Evaluation, Accountability, Sustainability, and Capacity

First, we must understand, respond to, and promote consumer demand for water and sanitation services. Without identifying why and how users would like improved services and subsidizing improvements without user input, many projects risk being abandoned or misused. The new goal is to spur consumer demand and provide market-based approaches, such as microcredits or loans instead of grants, in those areas where individuals and communities desire improvements. Investment will then be more sustainable than a generic installation by an outside organization.

Second, there must be a move away from implementation without evaluation. Water and sanitation projects must include monitoring and evaluation components from inception through implementation and follow-up, and the metrics should reflect the need, design, implementation, use, impact, efficiency, and sustainability of the project/program. Agencies often measure success by the number of wells or latrines installed, rather than the quantity used or the number still operational five years later. The metrics of successful water and sanitation projects need to reflect actual use as well as promote accountability for keeping the services operational. Furthermore, the results of the monitoring and evaluation and lessons learned need to get back to the decision makers so that the findings can inform policy.

Third, there needs to be an emphasis on sustainability. There is a need for additional longitudinal research to identify approaches that are sustainable technically, financially, and environmentally. Technical sustainability has been an ongoing problem in water and sanitation projects in developing countries. Too often, a pump or other piece of equipment breaks and cannot be repaired. This problem can occur all along the scale of services from a pump at a borehole to a pump in a modern water or wastewater treatment plant.

Financial sustainability depends on local capacity to recover the true costs of water and sanitation system operation and maintenance without reliance on long-term financial aid from external donors. This includes consideration of community management models, transparency, and good governance practices. However, there can be tension between the need to recover the costs of water supply and sanitation development, operation, and maintenance and the principle that safe water and sanitation are basic human rights that should be provided to all. It is essential that these services be adequately valued since they are also linked to the protection of scarce natural resources. Environmental sustainability includes consideration of the available water resources that can be developed for drinking water as well as for industry and agriculture needs and also weighing the long-term feasibility of waterborne sewerage and wastewater treatment. In developing countries, most cities and towns that have a sewerage system do not have sewage treatment, and the consequences of continued discharge of raw sewage into the environment are serious, irreversible damage to the aquatic environment as well as health risks from exposure to pathogens entering the environment.

Finally, there needs to be investment in building human capacity in-country in order to be able to construct, operate, manage and maintain water and sanitation services.

Sustainable Infrastructure: Structure for the Future

In the United States, 20–30 percent of production water is lost, and older systems, with many pipes nearing the end of their planned lifetimes, may lose as much as 50 percent of their water (NRC, 2006). However, upgrading water distribution systems is costly and difficult to implement. Therefore, there may be increased exposures to pathogens from distribution system contamination. This contamination can occur through illegal tapping into the pipes, breaks in pipes, and leaks and loss of pressure due to power outages and other factors. This is a problem not just in the United States. Recent studies found that 30 percent of homes with indoor plumbing in Uzbekistan had no residual chlorine levels. The addition of home chlorination subsequently led to a 62 percent reduction in diarrheal disease (Semenza et al., 1998). This finding challenges the idea that piped water is generally safe and indicates that in some settings home treatment may be necessary in addition to improved water sources.

Water Scarcity: Increasing Need, Decreasing Supply

A new focus for WHO is the development of water safety plans, that include analysis of water needs and usage and evaluation of water safety and system factors that lead to problems. The plans also include remediation of deficient factors, from operator training to repairs. However, goals need to be taken into account. Given increasing water scarcity problems and limited resources, should the goal be to create potable drinking water in large quantities, or would it be more viable to provide a small supply of high quality drinking water and greater quantity of less pristine household water for other uses? Many parts of the world suffer from physical or economic water scarcity; that may indicate a need to change how we use and value water.

The number of countries that are classified as water-scarce or water-stressed is projected to increase from 31 in 1995 to 48 in 2025 and to reach 54 countries in 2050. At the same time, the number of people living under water-scarce or water-stressed conditions will increase from 460 million in 1995 to 4 billion in 2050 (Hinrichsen et al., 1997). The implications of this scarcity are serious for global stability, food security, and health. In addition, global use of water has rapidly increased in this century for agricultural, industrial, and municipal purposes (Figure 5-3).

FIGURE 5-3. Global annual water withdrawal by sector, 1900–2000.


Global annual water withdrawal by sector, 1900–2000. Global water use has been rapidly increasing during the past century for all purposes—agricultural, industrial, and municipal. Agriculture use has had the largest increase. SOURCE: Worldwatch (more...)

An important question is how to incorporate water efficiency into water programming to address scarcity. One method is to look at behavior and lifestyle change, such as decreasing meat consumption and water waste. Another is to implement infrastructure improvements that repair leaks in water pipes—both to prevent loss as well as protect water quality, as discussed earlier. Finally, agriculture is the greatest water consumer; how can efficiency be improved in irrigation and land use?

Global trade of water-intensive products leads to virtual water flows (Figure 5-4). This is because different foods and diets have different water requirements. For example, a kilogram of beef requires 15 cubic meters of water, a kilogram of poultry requires 6.0 cubic meters of water, and a kilogram of cereal requires 1.5 cubic meters of water. The water footprints of industry and manufacturing also need to be considered. With regard to wastewater, toilet flushing alone can consume 50 liters of water per person per day (assuming 12 liters per flush for a conventional toilet [4–6 liters per flush for a low-flush toilet] and 4 flushes per day). Perhaps it is time to stop using water for the purpose of sanitation, particularly in areas where water is limited.

FIGURE 5-4. Virtual water balances of the 13 world regions, 1995–1999.


Virtual water balances of the 13 world regions, 1995–1999. The biggest net flows (> 20 Gm3/yr) as a result of the trade of water-intensive products are indicated with arrows SOURCE: Hoekstra, A.Y., and P.Q. Hung. 2002. Virtual water trade. (more...)

Sanitation Improvements: Investing the Community in Their Health

There are vast unmet needs in sanitation, and the question remains as to why water is considered a human right, but sanitation is seen as a commodity. A survey of attitudes on sanitation in Benin and the Philippines revealed that most of the reasons that sanitation was considered desirable were based on comfort, privacy, and prestige, with health falling lower in terms of priorities (Cairncross, 2004). Leaders need to speak out about the sanitation crisis and be willing to publicly address the deficiencies and push funding toward parity. From 1990 to 2000, the total annual investment in sanitation in Africa, Asia, Latin America, and the Caribbean was $3.1 billion in comparison to a $12.5 billion annual investment in water during the same period (WHO-UNICEF-WSSCC, 2000).

Dry sanitation is an attractive option for many parts of the world because of the water scarcity costs described above and the complex infrastructure needs and costs associated with waterborne sewerage and wastewater treatment. Ecological toilets are toilets that do not use water for function, contain human excreta to prevent environmental contamination and disease transmission, promote the inactivation of microbial pathogens in excreta through high pH, desiccation, heat, and time, and recycle nutrients from human excreta (urine and feces) for agriculture to promote better crop production, home gardens and ultimately, improved nutrition. Most ecological toilets store excreta in an alternating, two-chamber system and separate the urine from the feces, thus allowing fecal waste to decompose to biosolids and collecting urine separately for use as fertilizer. Urine separation reduces odor and promotes more rapid desiccation of the feces. Desiccation can also be facilitated by adding absorptive material to the storage chamber or using a solar structure to dry and decompose the feces more quickly. One research project found a greatly increased yield of corn associated with increasing amounts of urine fertilizer, as urine has a chemical composition virtually identical to agricultural needs (Morgan, 2005).

Bolivia has the lowest sanitation coverage in Latin America and high rates of diarrheal disease (Franco, 2007). Recent surveys in communities with sanitation interventions by several nongovernmental organizations (NGOs) indicate that households with access to bathrooms (most of them with ecological sanitation) were more willing to pay for improved sanitation service than those without, and half of those without toilets were willing to pay for sanitation (Moe et al., unpublished) Regardless, most households surveyed reported that they would not have a bathroom if they had not received technical assistance (usually construction materials). Microcredit in this setting may be an ideal solution to meet such a need. A new project, funded by The World Bank Development Marketplace, has four strategies for improving access to sanitation in poor communities in Bolivia: (1) development of low-cost sanitation models, (2) examining and stimulating consumer demand, (3) creating small sanitation businesses to meet this demand, and (4) establishing microcredit systems to help finance sanitation purchases. This project addresses previously identified barriers to sanitation access and examines market-based approaches to improve access and sustainability.

Meeting Water and Sanitation Needs: Research and Evaluation

In summary, a number of challenges remain, including important research needs for sanitation. In the past, many water and sanitation intervention programs took their own designs and implemented them in areas with need. This led to some unsustainable, culturally inappropriate, or irrelevant installations that were not always effective. New concepts focus on smaller, community-based projects that are chosen by the household and implemented through microcredit. The major research areas mirror these approaches, leading to more social marketing research, health behavior research, technical and microbiological investigation, and health outcomes and impacts research. The future of sanitation improvement lies in trying new approaches—creative approaches to technology and delivery, greater dissemination of information on what works and what does not, providing greater training and building capacity in human resources, and greater political and financial commitment.


Andrei Jouravlev, Economic Affairs officer

United Nations Economic Commission for Latin America and the Caribbean (ECLAC)1

Latin American and Caribbean countries have made great efforts to improve their population’s access to drinking water supply and sanitation services. Although the situation varies considerably among countries, levels of coverage can generally be considered reasonable, with the possible exception of wastewater treatment.

Approximately 91 percent of the region’s population has access to drinking water supply services, either through household connections or through easy access to a public source. With regard to sanitation services, only 51 percent of the regional population is connected to conventional sewerage systems, and another 26 percent use in situ sanitation systems. As a result, some 50 million people in the region lack access to drinking water supply services and approximately 130 million lack access to sanitation. The majority of those without access to services are poor and live in rural areas.

In many countries in the region, drinking water supply services are intermittent, even in extensive areas of the main cities. Owing to inadequate maintenance and poor commercial management, there are high levels of water losses in the drinking water supply systems of almost all the countries in the region. The proportion of the population covered by adequate systems of monitoring and control of drinking water quality is low in urban areas and insignificant in rural areas. However, the monitoring of drinking water quality and its disinfection has increased in most countries.

Wastewater from about 370 million people is discharged into recipient water bodies without any treatment, causing significant water pollution problems. The insufficient coverage and poor quality of services not only have negative impacts on the health of the population but also affect the environment, the economy, foreign trade, and the availability of water for various uses.

All these problems, together with the reappearance of cholera in the region at the beginning of the 1990s, have led the governments of Latin American and Caribbean countries to give high priority to the drinking water supply and sanitation sector. As a result, over the past two decades, this sector has been subject to extensive reforms in the majority of the region’s countries. Despite the inevitable differences in a region that includes very different countries, there are many common trends in the reforms carried out, or under way, in the countries of the region:

  • Modification of the institutional structure of the drinking water supply and sanitation sector. The reforms invariably include institutional separation of the functions of sectoral public policy making, economic regulation, and systems administration.
  • Modifications to the industrial structure of the sector, with an emphasis on decentralization of service provision, in many cases to the municipal level.
  • In many countries, policies have been adopted to ensure nonpolitical management of services by autonomous public agencies or local governments, in accordance with technical and commercial criteria. There is also a general interest in promoting private-sector participation.
  • A desire to formulate new regulatory frameworks for the sector both to facilitate private participation and to bring about a significant improvement in the efficiency of public provision of services.
  • The changes in the institutional and industrial structure of the sector have gone hand in hand with a requirement for services to be self-financing. Interest has also been shown in establishing sophisticated subsidy systems for low-income social groups.

In general terms, it may be said that the reforms relating to modification of the institutional and industrial structure of the sector, the formulation of new legal and regulatory frameworks, the setting up of the designated institutions and, in some cases, the transfer of services to the private sector, have made relatively rapid progress.

There are still significant lags, however, in reforms associated with tariff readjustments to levels that guarantee the self-financing of services, the creation of effective subsidy systems for the poor, implementation of the regulatory frameworks, and modification of the behavior of public service providers. As a result of these gaps, and also the macroeconomic instability and structural deficit of public finances, the reforms have not achieved the expected degree of success.

To understand the situation in Latin America and the Caribbean, one must also look at regional trends. Some countries have been much more successful than others. So the question remains as to what factors or drivers could help explain the different levels of progress. The variance among nations could not be explained by economic development alone, since only 0.35 of the coverage variation can be attributed to per capita gross domestic product (Figure 5-5). Extending the analysis to institutional quality, a much better predictor is found in terms of service coverage, 0.56, which increases even further when corruption is controlled. Thus such government priorities as budget allocations, good institutions, efficient public policies, and corruption control are important predictors of success.

FIGURE 5-5. Coverage of sanitation and access to drinking water can not be explained by economic development alone as there is a low correlation (.35) between percent covered and per capita GDP.


Coverage of sanitation and access to drinking water can not be explained by economic development alone as there is a low correlation (.35) between percent covered and per capita GDP. SOURCES: Derived from ECLAC (Economic Commission for Latin America and (more...)

The experience of the past two decades suggests some of the main priorities of the countries in the region in reforming the drinking water supply and sanitation sector:

  • Improving regulatory frameworks. The regulatory frameworks adopted in the region are relatively weak, especially compared with the regulatory practices in countries with a long tradition of public utility services being provided by the private sector. The main priorities for improvement are (1) strengthening the professional, technical, and financial capacity of the regulatory entities and ensuring their independence and stability; (2) developing procedures for accessing the internal information of regulated companies, especially regulatory accounting and monitoring of purchasing and contracts with associated companies; (3) promoting the participation of consumers and civil society in general in the regulatory process; (4) improving arbitration mechanisms and dispute resolution procedures; (5) strengthening regulatory frameworks, for both public and private service providers, based on the notions of fair and reasonable rate of return, good faith, due diligence, and duty of efficiency; and (6) conducting a critical analysis of available options for service provision and structuring them in such a way that they do not become a burden on the economy or the citizens, or ultimately a regressive factor that hinders socioeconomic development. Other important tasks include adapting regulatory practices to the specific characteristics of public service providers and deepening the analysis of the effects of international investment protection agreements on the national capacity for regulating public utility services. With regard to international arbitration tribunals, the reasons for concern include the secret nature of their procedures, the lack of obligatory precedent, the absence of principles of public interest, and the fact that these tribunals are ad hoc bodies comprised of members paid by the parties involved.
  • Creating subsidy systems for low-income groups. The financing of drinking water supply and sanitation services has been and remains a critical unresolved problem in most of the region’s countries. Given that the rate adjustments needed to achieve self-financing are limited by the low payment capacity of large groups of the population, the creation of effective subsidy systems, which should be based as far as practicable on direct and focused compensation mechanisms and should avoid cross-subsidies, is a prerequisite to reverse the chronic lack of finances in the sector. In many countries, the state needs to recover its traditional role of financing investment, particularly for the purposes of extending coverage to low-income groups and rural areas.
  • Consolidating horizontal industrial structure. Many of the decentralizing reforms have left the sector with a highly fragmented and inefficient industrial structure. It is made up of numerous service providers, without real possibilities for achieving economies of scale or economic viability, and is the responsibility of local bodies that lack the necessary resources to deal effectively with the complexity of the processes involved in providing drinking water supply and sanitation services. Most countries clearly need to consolidate the sector’s industrial structure by achieving a happy medium between the excessive centralization of the 1960s and 1970s and the extreme fragmentation of the 1980s and 1990s. Regulatory frameworks should therefore offer incentives for such consolidation and provide the means of achieving it.

The experience of the past decade has also demonstrated the need to harmonize macroeconomic and sectoral policies in order to strengthen trends toward sustainability in service provision, as well as to ensure a rigorous sequencing over time of economic, social, and environmental goals.



The views expressed in this presentation are those of the author and do not necessarily reflect the views of the organization.

Copyright © 2009, National Academy of Sciences.
Bookshelf ID: NBK50770


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