53659 Water, sanitation & hygiene at a glance Inadequate water, sanitation and hygiene account for a Water and Health -- two precious resources linked to large part of the burden of illness and death in developing one another. countries: Water for Health, World Water Day, 2001 Approximately 4 billion cases of diarrhea per year cause 2.2 million deaths, most--1.7 million--children under Water, sanitation and hygiene and the the age of five, about 15% of all under 5 deaths in developing countries. Millennium Development Goals (MDGs) Diarrheal diseases account for 4.3% of the total global Better hygiene and access to drinking water and sanitation disease burden (62.5 million DALYs). An estimated 88% will accelerate progress toward two MDGs: "Reduce under- of this burden is attributable to unsafe drinking water five child mortality rate by 2/3 between 1990 and 2015" supply, inadequate sanitation, and poor hygiene. These and "By 2015 halve the proportion of people without risk factors are second, after malnutrition, in contributing sustainable access to safe drinking water and basic to the global burden of disease. sanitation". Meeting the latter goal will require infrastructure investments of about US$23 billion per year, to improve Intestinal worms infect about 10% of the population of water services for 1.5 billion more people (292,000 the developing world, and can lead to malnutrition, people per day) and access to safe sanitation for 2.2 anemia and retarded growth. billion additional people (397,000 per day). Fewer than 6 million people are blind from trachoma and the one in five countries are on track for meeting this target. population at risk is about 500 million. 300 million people suffer from malaria. How do water, sanitation and hygiene 200 million people are infected with schistosomiasis, 20 affect health? million of whom suffer severe consequences. Water supply, sanitation, and hygiene and health are Water supply, sanitation and hygiene are about more than closely related. Inadequate quantities and quality of health. Saved time, particularly for women and children, is drinking water, lack of sanitation facilities, and poor a major benefit. Beneficiaries of water and sanitation hygiene cause millions of the world's poorest people to die projects in India reported these benefits: less from preventable (primarily diarrheal) diseases each year. tension/conflict in homes and communities; community Women and children are the main victims. unity, self-esteem, women's empowerment (less harassment) Water, sanitation and health are linked in many ways: and improved school attendance (WaterAid 2001). contaminated water that is consumed may result in water- borne diseases including viral hepatitis, typhoid, cholera, Effectiveness of water supply, sanitation dysentery and other diseases that cause diarrhea and hygiene interventions without adequate quantities of water for personal Improved hygiene (hand washing) and sanitation (latrines) hygiene, skin and eye infections (trachoma) spread easily have more impact than drinking water quality on health water-based diseases and water-related vector-borne outcomes, specifically reductions in diarrhea, parasitic diseases can result from water supply projects (including infections, morbidity and mortality, and increases in child dams and irrigation structures) that inadvertently provide growth (Esrey et al 1991; Hutley et al 1997). Most habitats for mosquitoes and snails that are intermediate endemic diarrhea is not water-borne, but transmitted from hosts of parasites that cause malaria, schistomsomisis, person to person by poor hygiene practices, so an increase lymphatic filariasis, onchocerciasis and Japanese in the quantity of water has a greater health impact than encephalitis improved water quality because it makes it possible (or at least more feasible) for people to adopt safe hygiene drinking water supplies that contain high amounts of behaviors (Esrey et al 1996). certain chemicals (like arsenic and nitrates) can cause serious disease. Experience shows that constructing water supply and November 2003 Access to Water and Sanitation More people have access to safe drinking water and sanita- tion than ten years ago but population growth has eclipsed these accomplishments. One sixth (1.1 billion) of the world population lacks access to improved water supply, two-fifth (2.4 billion) have no improved sanitation. Most of these people live in Asia and Africa. Rural services lag far behind urban services. Water supply Sanitation Distribution of Distribution of unserved population unserved population 2% 7% 2% 5% 28% 13% 9 countries achieved a median reduction in diarrhea incidence of 35% (Hill, Kirkwood and Edmond, 2001). Many of the most successful interventions provided soap to 83% 80% mothers, explained the oral-fecal route for disease transmission, and asked mothers to wash their hands before Total unserved: 1.1 billion Total unserved: 2.4 billion preparing food, and after defecation. There are fewer studies of results of interventions to improve feces disposal, Europe Latin America/Caribbean Africa Asia but Hill et al. found a median reduction of diarrheal disease of 26% (9 studies, range 0­68%), a median Source:WHO/UNICEF 2000 reductions in all-cause child mortality of 55% (6 studies, range 20­80%) and a median reduction in mortality from sanitation facilities is not enough to improve health; diarrhea of 65% (3 studies, range 43­70%). sanitation and hygiene promotion must accompany the infrastructure investments to realize their full potential as a public health intervention. Changing hygiene behavior is What can the public health sector do? complex. Hygiene promotion is most successful when it The public health sector can do several things, in targets a few behaviors with the most potential for impact. collaboration with other sectors, to help ensure that Based on extensive research, WHO and UNICEF have investments in water supply and sanitation result in greater identified hand washing with soap (or ash or other aid) health impact. Public health promotion and education after stool disposal and before preparing food; safe strategies are needed to change behaviors so as to realize disposal of feces and use of latrines; and safe weaning food the health benefits of improved water supplies. Programs to preparation, water handling and storage as the key improve hand washing behavior appear to be feasible and hygiene behaviors. A recent review (Curtis) of all the sustainable especially when they incorporate traditional available evidence suggests that handwashing with soap hygiene practices and beliefs. New, better approaches to could reduce diarrhea incidence by 47% and save at least behavior change are being developed, including a recent one million lives per year. This is consistent with other project that has shown excellent results through persuading studies which found that 12 hand washing interventions in the private sector (soap manufacturers and the media) to transmit health information by advertising soap and its appropriate use to prevent diarrhea (see The Story of a Handwashing is one of the most effective Successful Public-Private Partnership in Central America: interventions for reducing diarrhea Handwashing for Diarrheal Disease Prevention, 2001). Based on research findings and lessons learned from the successful public-private partnership "Handwashing for Diarrheal Disease Prevention Project" in Central America, the School health programs World Bank, the Water and Sanitation Program, the London School health programs offer a good entry point for School of Hygiene and Tropical Medicine, the Academy for Educational Development and the private sector, in improved water supply and sanitation facilities and for collaboration with USAID, UNICEF, and the Bank-Netherlands community hygiene promotion. It is a realistic goal in most Water Partnership developed a global initiative in 2001 to countries to ensure that all schools have clean water and promote handwashing with soap in developing countries. The sanitation. This enables schools to reinforce health and first pilot project locations are Ghana, Kerala, India, Senegal, hygiene messages, ensure they translate into action, and set Peru, China and Nepal. Results are being monitored and an example to students and the community. This can lead to lessons documented and disseminated. Global advocacy community demands for similar facilities. events promote handwashing. The inter-agency partnership for Focusing Resources on advocate for including water, sanitation and hygiene Effective School Health (FRESH) aims to increase access to, interventions in poverty reduction strategies and plans. and improve the quality, of schools and child-friendly learning environments around the world. Guidelines and tools are being developed to help design, implement, monitor and Do's and Don'ts in promoting hand evaluate school sanitation and hygiene components of school, washing and hygienic behaviors health, and water and sanitation projects. DO assess sanitation and hygiene beliefs and practices as Additional things the public health sector can do: the basis for planning, and involve community members/ beneficiaries in planning and implementing interventions. work with other agencies that plan, develop and manage Maximize the impact of hygiene promotion and education water resources and basic water and sanitation services by using participatory techniques, targeting women and to advocate and promote these investments, and ensure children, and using women as facilitators. that activities to promote hand washing, safe disposal of feces and continuous use and cleanliness of sanitation DO identify practices to be changed, targeting the four most facilities are included; critical: hand washing with soap (or ash or other aid) before food preparation and after dealing with feces; latrine use work with the agency responsible for monitoring water and safe disposal of children's feces; safe weaning food quality and sanitation to help ensure that this monitoring preparation; and safe water handling and storage. is carried out; provide other sectors with reliable data on water- DO offer a range of technology options (e.g., different kinds associated diseases and effectiveness of interventions to of latrines) and explain associated costs, maintenance facilitate better decisions with respect to water and requirements, advantages and disadvantages. Public funds sanitation projects; are better spent on promotional campaigns and training/establishing latrine artisan businesses than on provide leadership for action in hygiene education, subsidies for constructing latrines. including building coalitions with private sector agencies to achieve better results; DO incorporate programs to change hygiene practices in water supply, sanitation and health projects. In order for design, implement, and monitor hygiene education and water supply projects to achieve positive health benefits, promotion components of water supply and sanitation they need to include sanitation and hygiene components. projects; Millennium Intermediate Development Goal mechanism Target group Indicator Reduce infant and child Reduce diarrhea morbidity Children under 5 % children under 5 with diarrhea in mortality by 2/3 by the and mortality the past 2 weeks (diarrhea is defined year 2015 as more than 3 loose stools in 24 hours) Key behaviors Interventions Target group Indicator Hand washing with soap Demonstrate good hand washing People caring for % child caregivers and food preparers Educate on when to wash children and with appropriate hand washing Hygiene education preparing food behavior* Provide soap Sanitation Build toilets and pit latrines Population % population who use toilet or pit Promote use of toilets and latrines latrine** Promote defecation in designated areas Promote burial of feces Clear feces from homes and yards *"appropriate" hand washing behavior includes time of washing -- after handling feces and before food preparation; and the technique used -- using soap, ash or other aid, for long enough, using clean water **Toilets or pit latrines must be hygienic; that is, no feces on the floor or seat Data for these indicators are collected in the standardized Demographic and Health Surveys (DHS) conducted in over 100 countries around the world. (DHS website url: http://www.measuredhs.com/ ) A second source of these data are the Multiple Indicator Cluster Surveys (MICS) and modules supported by UNICEF, and used in 100 countries since 1998 (full information and MICS data available at www.unicef.org, search for MICS). Indicators for other water and sanitation interventions are described in "Water and Sanitation Indicators Measurement Guide", Billig et al 1999. Health sector involvement can contribute to the success of DO monitor and evaluate interventions, and collect baseline water and sanitation projects. Don't provide hardware data. Don't claim health benefits without measuring and (water pipes and latrines) without the software (hygiene documenting the impact of water and sanitation activities. promotion) and community training and organization to sustain/maintain services. DO carry out pilot projects to test new technologies or mechanisms such as cost-recovery. DO include education and information to increase community demand for improved sanitation facilities. DO ensure that adequate water and sanitation are provided in schools and health facilities. DO establish partnerships to stretch resources, e.g. public/private partnerships with private soap manufacturers to achieve complementary goals. For more information and Hygiene at the Global Level, Environmental Health Perspectives, 110(5):537-542 People (World Bank contacts) Tumwine JK, J Thompson, M Katua-Katua, M Mujwajuzi Jennifer Sara and Rita Klees (Water and Sanitation), and I Johnstone Porras 2002, Diarrhea and Effects of Joana Godinho (Public Health) Different Water Sources, Sanitation and Hygiene Behavior in East Africa, Trop Med Int Health, 7(9):750-756 Key Documents and References Varley R, J Tarvid, D Chao 1996, A Reassessment of the Boot M, S Cairncross (ed.) 1993, Actions Speak: The Cost-Effectiveness of Water and Sanitation Interventions Study of Hygiene Behaviors in Water and Sanitation in Programs for Controlling Childhood Diarrhea, WHO Projects, The Hague, IRC Bulletin 76 (6): 617­31 Curtis V, S Cairncross 2003, Effect of washing hands WaterAid 2001, Looking Back, Participatory Assessment with soap on diarrhea risk in the community, a of Older Projects, London systematic review, Lancet Infectious Disease 3:275-281 WHO 2002 World Health Report: Reducing Risks, Cairncross, S, D O'Neill, A McCoy, D Sethi, 2003, Promoting Health Life. Geneva Health, Environment and the Burden of Disease: A Guidance Note, Dept for Intl Development, DFID, WHO 2000 Global Water Supply and Sanitation Assess- London ment Year 2000 Report, Geneva, WHO with UNICEF Esrey S, J Potash, L Roberts, C Shiff 1991, Effects of Web sites Improved Water Supply and Sanitation on Ascariasis, Global Applied Research Network in Water Supply and Diarrhea, Dracunculiasis, Hookworm Infection, Sanitation (GARNET): http://info.lut.ac.uk/ Schistosomiasis, and Trachoma, WHO Bulletin departments/cv/wedc/garnet/grnttnc.html 69(5):609­621 IRC International Water and Sanitation Center: Esrey S 1996, Water, Waste and Well-being: A Multi- http://www.irc.nl Country Study, American Journal of Epidemiology 143(6):608­623 IRC Community Water Supply Management: http://www.irc.nl/manage/index.html Hill Z, B Kirkwood and K Edmond 2001, Family and Community Practices that Promote Child Survival, IRC internet journal: Women, Water and Sanitation: Growth, and Development: A review of the Evidence", http://www.irc.nl/products/publications/ajw/index.htm Public Health Intervention Research Unit, Department of Rural Water Supply and Sanitation Toolkit for Multisector- Epidemiology & Population Health, London School of al Projects ­ a rich set of resources including guidelines Hygiene for all project stages, numerous best practice examples Hutley S, S Morris, V Pisana 1997, Prevention of http://www.worldbank.org/watsan/rwsstoolkit/index.htm Diarrhea in Young Children in Developing Countries, Sanitation Connection: An Environmental Sanitation WHO Bulletin 75 (2): 163­174 Network: http://www.sanicon.net Huttly S 2002, The Impact of Inadequate Sanitary UNICEF water, environment and sanitation (WES): Conditions on Health in Developing Countries, Maternal http://www.unicef.org/programme/wes and Child Epidemiology Unit, London School of WaterAid: http://www.wateraid.org.uk Hygiene and Tropical Medicine, London. Water Supply and Sanitation Collaborative Council: Klees R, J Godinho, M Dawson-Loe 2000, Sanitation, http://www.wsscc.org Health and Hygiene in World Bank Rural Water Supply WELL Project, Water and Environmental Health at London and Sanitation Projects, Washington DC, World Bank and Loughborough: http://www.lboro.ac.uk/well (includes key design principles for community water WHO Water, Sanitation and Health: supply and sanitation projects) http://www.who.int/water_sanitation_health/index.htm Pruss A, D Kay, L Fewtrell and J Bartram 2002, World Bank Water and Sanitation Program: Estimating the Burden of Disease from Water, Sanitation, http://www.wsp.org Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp