Everyone, everywhere. A vision for water, sanitation … everywhere A vision for water, sanitation...

Everyone, everywhereA vision for water, sanitation and hygiene post-2015

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A WaterAid publication, written by Emma Back, Agulhas Applied Knowledge

Also available online in the publications section of www.wateraid.org This report should be cited as WaterAid (2013) Everyone, everywhere: A vision for water,sanitation and hygiene post-2015. WaterAid, London, UK

March 2013

For further information, contact:

Hannah EllisInternational Campaigns Manager Tel: +44 20 7793 4508Email: [email protected]

Regional and national contacts:

AustraliaJames WickenHead of Policy and Campaigns Tel: +61 3 9001 8245Email: [email protected]

East AfricaBethlehem Mengistu Regional Advocacy Manager – East Africa Tel: +251 911 408813 / +251 930 034 172 / +251 114 168 920Email: [email protected]

Pan-AfricaNelson GomondaPan-Africa Programme ManagerTel: +265 888 868 043 (Malawi); +27 792 819 525 (South Africa)Email: [email protected]

South AsiaMustafa TalpurRegional Advocacy Manager – South Asia Tel: +92 51 221 1361 / 62 / 63 (ext 116)Email: [email protected]

Southern AfricaKhumbuzile ZumaRegional Advocacy Manager – Southern Africa Tel: +27 12 756 1931 / 2015 (ext 206)Email: [email protected]

SwedenJenny FredbyHead of Policy and AdvocacyTel: +46 8 677 30 18 / +46 736 61 22 96 (SMS)Email: [email protected]

UKRhian LewisUK Campaigns ManagerTel: +44 20 7793 4985Email: [email protected]

USALisa SchechtmanHead of Policy and Advocacy Tel: + 1 202 729 6797Email: [email protected]

West AfricaAbdul NashiruRegional Advocacy Manager – West Africa Tel: +221 233 244 591 472Email: [email protected]

WaterAid works to transform lives in the following 27 countries in Africa, Asia, the Pacific region and CentralAmerica: Angola, Bangladesh, Burkina Faso, Ethiopia, Ghana, India, Kenya, Laos, Lesotho, Liberia, Madagascar,Malawi, Mali, Mozambique, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Papua New Guinea, Rwanda, Sierra Leone,Swaziland, Tanzania, Timor-Leste, Uganda and Zambia.

Foreword by Her Excellency President Ellen Johnson Sirleaf, President of the Republic of Liberia. . . . . . 3

Executive summary . . . . . . . . . . . . . . . . . . . . 4

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Improving access to water, sanitation and hygiene . . . . . . . . . . . . . . . . 7

The challenge ahead. . . . . . . . . . . . . . . . . . 14

Why water, sanitation and hygiene matter . . . . . . . . . . . . . . . . . . 18

Water, sanitation and hygiene in the post-2015 framework for development. . . . . . . . . . . . . . . . . . . . . . 32

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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Contents

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WaterAid/Dieter Telemans

A child washes their hands, St Joseph’s School, Chinnavilai village, Kanyakumari district, Tamil Nadu, India

In 2000, the international community set out avision for development through to 2015 – theMillennium Development Goals (MDGs). Thisvision included halving the proportion of peoplewithout sustainable access to safe drinking waterand sanitation. Globally, the target for water hasbeen met, but the sanitation target has not, andseveral regions of the world are seriously off-trackfor both. The best estimates available show thatat least 783 million people still lack clean water,while the true number may be far higher. Takingpopulation growth into account, there are almostas many people without access to sanitationworldwide as there were 20 years ago. Thepoorest and most marginalised people have seen least progress and continue to suffer thegreatest burden in terms of child deaths anddiseases associated with inadequate water,sanitation and hygiene (WASH).

History shows that the health, welfare andproductivity of developing country populationsare closely linked with improvements in water,sanitation and hygiene. Furthermore, there isstrong evidence to suggest that slow progress in Sub-Saharan Africa and Asia, which remain off-track for meeting the MDG water andsanitation targets, is acting as a brake onprogress towards related human developmentgoals, particularly nutrition and child health. Few interventions would have a greater impact on the lives of the world’s poorest and mostmarginalised people, particularly women andgirls, than reducing the time spent collectingwater and addressing the health problems causedby poor sanitation and hygiene. We thereforeurgently need to get back on-track and identifyways of accelerating future rates of progress.

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Executive summary

Girl washing dishes at the shore of polluted Lake Gulshan, Korail slum, Dhaka, Bangladesh

Charlie Bibby/Financial Times

It is important to recognise that the context fordevelopment has changed since 2000. Issuessuch as climate change and urbanisation presentgrowing risks and challenges. Natural resourcesare under growing pressure. Access to drinkingwater is now recognised as a basic human right,but water is also increasingly perceived as both a scarce and valuable economic commodity and a major source of risk. Safe management of humanwaste is a rapidly growing problem that posesserious risks to both human and environmentalhealth. Meanwhile, the global distribution ofpower and wealth is shifting, and newopportunities are emerging to draw on a broaderrange of knowledge and expertise, creativity andinnovation, and finance – public, private and civilsociety, from a much wider range of countries.

Against this backdrop, the international communityis in the process of developing a new frameworkto guide development efforts beyond 2015.WaterAid believes that poverty eradication andhuman development should be the overarchingaim of any future goal framework, and that priorityshould be given to human development outcomesthat are universally recognised as being important– including universal access to water, sanitationand hygiene. It should seek to improve on theMDGs by better reflecting the integrated nature offactors affecting development and creatingincentives for coordinated action across sectors.It should also have a more explicit focus onreducing inequalities by targeting poor andmarginalised groups and neglected or laggingareas of development, such as sanitation.

WaterAid was established over 30 years ago witha simple vision of a world where everyone hasaccess to safe drinking water, sanitation andhygiene. As the MDG era draws to a close and we look ahead to post-2015, there is a growingconsensus among sector professionals that, forthe first time in history, this longstanding goal of universal access is now within reach. It will notbe easy, but with sufficient political commitment,innovative partnerships and integratedapproaches, underpinned by sound financialinvestment, it could be achieved by 2030.

International leaders must be bold and set an ambitious timeline for achieving universal

access to water, sanitation and hygiene. Wecannot eradicate poverty without doing so, as improvements in these areas are of centralimportance to development outcomes in health,education, gender equality, growth andemployment, and environmental sustainability.

The political and technical processes throughwhich the framework is developed are key tobuilding consensus around a common vision, and should include strong representation fromdeveloping country governments and civil societyorganisations. It is vital that special efforts aremade to take account of the voices of poor andmarginalised groups around the world.

Whatever shape the emerging framework takes,the integrated nature of factors affecting humanand economic development must be recognised.Specifically, the contribution of safe drinkingwater, sanitation and hygiene to other areas ofpoverty reduction, including health, education,gender equality, growth and employment, andenvironmental sustainability should be reflected.The new framework should also seek to minimisewater-related risks, and build the resilience ofsocieties and economies by protecting them fromshocks and the added pressures of climatechange. Finally, concrete mechanisms need to beestablished to mobilise the resources required todeliver goals, create incentives for coordinatedaction across sectors, and strengthenaccountability for results.

In summary, WaterAid recommends that the post-2015 framework should:

• Include a goal on universal access to basicwater and sanitation services as a fundamentalhuman right.

• Specify a target date of 2030 for achievinguniversal access to safe water, sanitation andhygiene globally.

• Ensure that water, sanitation and hygienetargets and indicators focus explicitly onreducing inequalities, by targeting poor anddisadvantaged people as a priority, and onimproving the sustainability of services tosecure lasting benefits.

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In 2000, the United Nations (UN) General Assemblyadopted the Millennium Declaration, which setout its vision for development. This declarationevolved into eight goals – the MillenniumDevelopment Goals (MDGs)1. The MDGs, and thetargets and indicators used to measure progresstowards them, focus on development outcomesthat are achievable by 2015 and contribute to the eradication of extreme poverty.

As we approach 2015, the internationalcommunity is assessing the progress madetowards each of the MDGs, and the overallobjective of poverty eradication. This includesmeasuring the progress made towards halving the number of people without sustainable accessto safe drinking water and basic sanitation, andlooking at why there has been relatively littleprogress on sanitation.

Decision-makers around the world are reviewingthe strengths and weaknesses of the MDGframework. For water, sanitation and hygiene(WASH), this includes considering the adequacyof the existing goals, targets and indicators, with

particular focus on hygiene, access to servicesbeyond the household, and issues of equity andsustainability. They are also assessing how failureto deliver water and sanitation has had an impacton progress towards the other MDG targets.

Against this backdrop, it is helpful to re-examinewhy improving access to water, sanitation andhygiene matters – both as a fundamental humanright, and because of the relationship with a broad range of human, economic andenvironmental development outcomes.

This report explores the ways in which access to water, sanitation and hygiene affectsdevelopment outcomes, including health,education, gender equality, growth andemployment, and environmental sustainability. It highlights the need for any post-2015framework for development to reflect this inter-relationship and encourage collaboration acrosssectors, and to set ambitious targets for theachievement of universal access to water,sanitation and hygiene as a human right.

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Introduction

Banna Bouri, 35, vice-president of the local water, sanitation and hygiene committee for the Lakatoorah tea garden,collecting clean water from the new tubewell, Sylhet, Bangladesh

WaterAid/GMB Akash/Panos

Global progress to dateThe MDG framework, under the environmentalsustainability goal, included a target ‘to halve theproportion of people without sustainable accessto safe drinking water and sanitation’ between1990 and 2015. Current estimates indicate thatthe target for access to safe drinking water hasalready been met globally, with more than twobillion people having gained access to improveddrinking water sources since 19902.

This milestone demonstrates the power of settingdevelopment goals and targets that are ambitiousbut also achievable. However, one in ten of theworld’s population – 783 million people – still donot use an ‘improved’ drinking water source3. Weknow that many of those who have gained access,particularly women and girls, still spend manyhours each day collecting water. The indicatorscurrently used do not measure distance, waterquality or the sustainability of drinking waterservices. Estimates of the extent of theseparameters are imprecise, but it’s likely that the true figure for those who do not have accessto a safe, sustainable water supply service is wellover one billion4.

The sanitation target is the most off-track of all theMDG targets5, with over 2.5 billion people withoutaccess to basic sanitation6. Taking populationgrowth into account, this means there are almostas many people without basic sanitation today asthere were in 19907. If present trends continue,the MDG target to halve the proportion of peopleliving without basic sanitation services will not bemet until 20498. According to the World HealthOrganisation, the world will need to have spent$32.2 billion each year between 2010 and 2015to meet the MDG targets on water and sanitationby 20159.

Data on global trends masks significant disparitiesbetween regions. For example, as Figures 1 and 2 show, Sub-Saharan Africa lags behind otherregions on both water and sanitation, with only19 countries on-track to meet the MDG watertarget10. In part, this is due to low investment by national governments and donors, as well asby the private sector, with the funding to meet the target nowhere near what is required11.Performance in the sector is also affected by the low capacity of national and local agencies,many of which suffer from weak leadership andplanning capability, staffing and skills gaps, andpoorly allocated budgets12.

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Improving access to water, sanitation and hygiene

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Fig 2 – Regional access to sanitation in 2010

Fig 1 – Progress towards the MDG drinking water target, 2010

Progress but insufficient: Coverage ratein 2010 was between 5% and 10% of the 2010rate required to meet the target

Insufficient data or not applicable:Data were unavailable or insufficient to estimatetrends or a progress assessment wasnot applicable

On-track: Coverage rate in 2010 was >95% or was within 5% of the 2010 rate required tomeet the target

Not on-track: Coverage rate in 2010 was thesame or lower than the rate in 1990 or below 10% of the 2010 rate required to meet the target

Caucasus and Central Asia

Developed countries

Eastern Asia

Latin America and the Caribbean

Northern Africa

Oceania

Southern Asia

South-Eastern Asia

Sub-Saharan Africa

Western Asia

O 20 40 60 80 100

96

95

66

80

90

55

41

69

30

85

Caucasus and Central Asia

Developed countries

Eastern Asia

Latin America and the Caribbean

Northern Africa

Oceania

Southern Asia

South-Eastern Asia

Sub-Saharan Africa

Western Asia

2010 Access to sanitation

Source (Figs 1 and 2): JMP 2012

% of population

Regi

on

The MDG framework did not include a target orindicators relating to hygiene, despite hygienepromotion being recognised by the World Bank as the most cost effective health intervention13.As a result, opportunities have been missed to improve individual and household hygienebehaviour, such as handwashing with soap andmenstrual hygiene management. Furthermore, the MDG water and sanitation targets focusedonly on households, neglecting access in othercritically important settings, such as workplaces,schools and hospitals. This represents a missedopportunity to improve public health and reducepressure on healthcare services, enhanceeducational outcomes (especially for girls) andincrease workforce productivity.

Inequities persist It is critical that the benefits of investment in water,sanitation and hygiene are experienced by all,particularly the poorest and most vulnerablepeople. Unfortunately, this has not been the realityto date. There is significant disparity betweenlevels of access to improved water sources andimproved sanitation facilities between rich andpoor, and between urban and rural communities.

This is demonstrated in Figure 3 (right), whichshows the extent to which access to drinkingwater varies by wealth quintiles, and betweenurban and rural areas, in Sierra Leone14.Nationally, 55% of people have access to animproved source of drinking water, just below the Sub-Saharan Africa average of 61%. However,while access for the wealthiest 20% of urbanresidents is almost universal, only one in ten ofthe poorest people living in rural areas has access.The rate of progress over the past two decadeshas also lagged for the poorest people. In SouthAsia, for example, the poorest 20% saw barelyany improvement in their access to sanitationbetween 1995 and 200815. Meanwhile, therichest 20% moved even closer to universalaccess, with the most dramatic gains seen by the second wealthiest 20%.

Furthermore, there is evidence that minoritygroups and those suffering discrimination (for example, on the basis of their caste, class,

religion or ethnicity) are frequently denied access to improved water and sanitation facilities. WaterAid’s research in India revealedthat scheduled caste children weren’t allowed to drink from shared water sources at school16.

Slums: A huge challengeThe MDG on environmental sustainabilityincluded a target to significantly improve the livesof at least 100 million slum-dwellers by 2020.While progress has been made, rapid urbanisationmeans that interventions to improve basicservices are being outpaced by the growth indemand, and gains for the world’s current slum-dwellers may be rapidly undone.

People living in informal settlements and slumsare particularly vulnerable to diseases caused bypoor quality water and inadequate sanitation andhygiene. This is due to many factors, includingpoverty, crowding and political marginalisation17.Yet their obvious need is often neglected, asunrecognised tenure may discourage investment

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Fig 3 – Regional and country averages maskhuge disparities

Source: JMP 2012 and Sierra Leone Demographic and Health Survey 2008

WorldWater coverage

Sub-Saharan Africa

Sierra Leone

RuralUrban

Poorest PoorestRichest Richest

35%

10%97% 59%56%

87%

89%

61%

55%

by the tenant or landlord, or the desire to keeprent affordable may lead to resistance toimproving services from tenants themselves.These issues are both causes and consequences of the difficulty slum dwellers experience inexercising political power. Meanwhile, nationaland municipal governments often fail to prioritiseurban water and sanitation services, and do notrecognise their obligation to improve servicedelivery to their communities, despite in mostcases recognising water and sanitation as human rights18.

In Bangladesh, for example, around 31 millionpeople live in urban areas. 35% of these peoplelive in slums where there is no legal framework to ensure access to water and sanitation services.People who lack an official address or the legalright to own property or sign contracts have nolegal right to a water connection, so only 5-10%of slum-dwellers in Dhaka have access to a legalwater supply. Others must go to traders sellingwater from illegal connections at inflated prices,or use polluted water from lakes and streams towash themselves and their dishes, and even fordrinking and cooking19.

Aid does not respond to needA central objective of the emerging ‘globalpartnership for development’ envisaged in 2000 as MDG8 was an increase in the level offinancing committed to development by richercountries through their aid budgets. Aid levelshave risen since 2000, but have levelled off inrecent years. Only a few donor countries have metor are close to reaching the UN target of 0.7% ofgross national income (GNI) spent on aid20.

The water, sanitation and hygiene sector hasfared less well than others – such as health,education and governance – in securingincreased financing, with sanitation and hygieneparticularly neglected. Aid to water, sanitationand hygiene has not yet been targeted mosteffectively at the poorest and most vulnerablecommunities, and the sector is dominated by a small number of large bilateral and multilateralagencies (see Figures 4 and 5 – below)21.

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Fig 4 – Largest donors to water supply, 2010 Fig 5 – Largest donors to sanitation, 2010

7.7%2.2%

2.4%

5.6%

22.5%59.5% 60.7%

3.2%1.6%

2.2%

6.2%

26.1%

Japan International Development Association

Arab Fund for Economic and Social Development

Islamic Development Bank Spain Others

Japan International Development Association EU Institutions

Spain Netherlands Others

Source: Development Initiatives/WaterAid (2012)

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We have to do betterThe human right to water and sanitation is nowwidely recognised by UN Member States andimplies increased attention to reducinginequalities in access to water, sanitation andhygiene22. Yet, many people have been excludedfrom recent improvements in access to water and

sanitation because they are poor – and thisongoing lack of access keeps them poor.Improving access in marginalised communities is therefore key to addressing both poverty and inequality, and to breaking the cycle ofdeprivation. This must be a central focus of future development efforts.

“With 2015 clearly on the horizon, the international community needs to start offering answers to some essential questionsabout its development priorities: Who has been excluded fromaccess to water and sanitation? Why has this happened? Andhow can progress be more effectively measured in the comingdecades in order to stop ignoring the most marginalised?”

Catarina de Albuquerque, UN Special Rapporteur on the human right to safe drinking water and sanitation, UN GeneralAssembly, October 2012


An unsanitary hanging latrine over an open sewer that runs through Mollar slum, Dhaka, Bangladesh

Fig 6 – Much of the world remains off-track to meet the water and sanitation 2015 targets

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Source (both): JMP 2012

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A woman walking home with water she’s collected from an unsafe source, Kewachora tea garden, Sylhet, Bangladesh

The international community must continue tofocus on making progress towards the MDGs, withparticular attention to areas that are lagging, suchas sanitation. However, discussions to identifystrategic priorities and define a new frameworkand set of goals to guide poverty reduction effortsbeyond 2015 are already underway.

We therefore need to develop a sharedunderstanding of the challenges ahead fordevelopment and for water, sanitation andhygiene. We must ascertain where and how the international community can best supportnational and local governments and communities to overcome these challenges, while simultaneously advancing progress in other areas.

A rapidly changing worldThe world is still experiencing rapid populationgrowth, particularly in regions where childmortality has been declining, many of whichremain with limited access to water, sanitationand hygiene. By 2050, the world population isexpected to reach more than nine billion people,

compared to just over seven billion today.Virtually all of this growth will be in developingcountries, with Africa’s population expected to atleast double, from 1.1 billion today to around 2.3billion in 205023. This will change the context inwhich stress on resources such as water, food and energy is addressed. It will also affect efforts to achieve universal goals relating to health,education and nutrition, all of which aredependent on access to safe drinking water,sanitation and hygiene.

The scale of urbanisation is equally significant. By2050, the number of people living in urban areasis expected to reach 6.3 billion, meaning that theworld’s population will be 67% urban. Most of thegrowth will be in developing regions, with Asiaabsorbing 1.4 billion more people living in urbanareas by 2050, and Africa 0.9 billion24. Thispresents a significant challenge to those workingto ensure access to basic services and legalprotections – including supplying safe drinkingwater and managing, transporting and treatingsewage and wastewater – particularly as much of this growth will be concentrated in informalsettlements and slums.

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The challenge ahead

“Public policies for water and sanitation provision are being outpaced by rapid urbanisation.”

UN Water (2011) World Water Day 2011: Water and urbanisation

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WaterAid/Des Willie

A water drainage site, Kifumbira area, Kampala, Uganda

Climate change poses an additional challenge.Extreme weather-related events are likely tobecome more frequent and more intense, andchanges in rainfall will affect the timing andavailability of rainwater. The 783 million poor and marginalised people that rely on unsafe andvulnerable water sources25 will be particularlyaffected as these sources are more exposed to

the effects of climate change26. Improved watersources help protect poor people from theimpacts of a variable climate by giving them more reliable access to water27. However,increased effort is needed to ensure that existingservice delivery arrangements are both resilientand sustainable.

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A boy walks home with water through a landscape made barren by salination after Cyclone Aila struck in 2009, Koyra, Bangladesh

Water resources under pressureA number of countries already experienceconsiderable water stress, as a result ofinsufficient and unreliable rainfall, changingrainfall patterns or flooding.

Demographic changes, changes in consumptionpatterns, and gross domestic product (GDP)growth add to existing stress by driving demandfor water; from 1960-2000, global waterwithdrawals doubled in volume. The added challenge of climate change willfurther increase pressure on water supply byaltering existing patterns of availability28.

These physical stresses are overlaid witheconomic and political scarcity. Around 1% ofglobal water is freshwater, but a less-recognisedstatistic is that less than 10% is actually used,partly due to poor water resource management29.Comparing water availability to water use showsthat while there are some highly stressedcountries, a significant proportion of countries use very little (less than 5%) of the water that isavailable to them30.

Globally, 783 million people still lack safe water –not because the water isn’t there, but becausethey cannot access it. A lack of investment resultsin an absence of supply infrastructure, such ashandpumps. Where such infrastructure is in place,sustainability is often not addressed. For example,in 2007, an estimated 36% of handpumps in Sub-Saharan Africa were classed as ‘non-functional’due to falling into disrepair31.

Capacity to respond and adaptProgress on water, sanitation and hygiene is held back by acute pressure on public finances,particularly in the continuing aftermath of the2008 economic crisis. This affects the level offinancial support available from donors andmultilateral agencies, and has a potential impacton financial resources, both public and private,within developing countries.

More positively, many developing countries areseeing their economies grow (in some cases very rapidly), demonstrating greater capacity and scope for innovation and investment. Newdonor countries are emerging, such as India,China and Brazil. Several countries consideredlow-income until recently are now classified asmiddle-income by the World Bank – Ghana,Zambia and Laos, for example32.

Several low-income countries, such as Uganda,Kenya and Bangladesh, are developing strongknowledge sectors, which are home to active andsocially engaged entrepreneurs and technologicalinnovators. There is good potential for localsolutions to be found to both local and globalchallenges, including those related to water,sanitation and hygiene.

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“‘Scarcity’ is as much a distributional issue of ‘fairness’ andaccess as it is of availability.”

Evans A (2011) Resource scarcity, fair shares and development

Safe water, adequate sanitation and goodhygiene are basic needs and human rights.Progress in these areas underpins all sustainabledevelopment efforts. Communities that lackaccess to water consistently highlight it as a development priority33. Any future developmentframework must reflect this reality and createincentives and accountability for progressiverealisation of the human right to water and sanitation.

The lack of progress in improving access tosanitation in particular is acting as a brake onprogress in economic and human development,particularly in areas such as health, nutrition andeducation. This was highlighted during theInternational Year of Sanitation in 2008, then at the MDG Review Summit in 2010, and again in The Millennium Development Goals Report201234. Meanwhile, the people within thesesectors are often failing to take the necessarysteps within their areas of responsibility to ensureuniversal access to water, sanitation and hygiene.

Lessons from development programming inrecent years indicate the need for a stronger focuson cross-sectoral integration and for different

stakeholders to work in partnership at communitylevel. Effective, integrated programmes reflect the reality of people’s lives and the significant inter-relationships between differentdevelopment outcomes.

HealthGlobally, between 1990 and 2012, the number of children dying before the age of five fell frommore than 12 million to 6.9 million. However,despite progress on child mortality, infectiousdiseases such as pneumonia, and diarrhoearemain the top killers of children under five35.

Increasing access to water, sanitation and hygienecan contribute significantly to improving healthoutcomes, and is particularly important to effortsaimed at reducing the burden of disease andmalnutrition, as well as relieving pressure on thehealthcare system as a whole. The UN estimatedin 2006 that half of all hospital beds indeveloping countries were filled by people withillnesses caused by inadequate water, sanitationand hygiene36.

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Why water,sanitation andhygiene matter

Safe, effective healthcare for allImproving access to safe water, sanitation andhygiene is particularly important in healthcaresettings, and for those with chronic conditions. For example, access to clean water helps thosetaking regular medication, and those with weakimmunity, who are more susceptible to infection.It is estimated that people living with HIV and AIDSneed around five times more clean water thanthose who are not immuno-compromised37. A study in Southern Africa found that providinghome-based care for someone living withadvanced AIDS can require up to 24 buckets ofclean water a day38. Safe drinking water is also

critical for maintaining the nutritional requirementsfor greatest efficacy of anti-retroviral therapy forpeople living with HIV and AIDS.

Access to water, sanitation and hygiene has adirect impact on the health of women and girlsthroughout their lives. The absence of adequatesanitation and menstrual hygiene facilities atschool often lead to absenteeism or dropping-out.These basic facilities also reduce vulnerability tothe risks involved with pregnancy and childbirth,through unhygienic home birth environments,unhygienic health facilities, and intestinalhelminth infections and the associated anaemiathat contribute to maternal mortality39.

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“Providing sustainable access to improved drinking water sourcesis one of the most important things we can do to reduce disease.”

Dr Margaret Chan, WHO Director-General

Most cost-effective health interventionPromoting sanitation and hygiene is highly cost-effective, and can have even more impact whencombined with other health interventions. A 2006

report showed that hygiene promotion could savean estimated 333 disability-adjusted life years(DALYs) for every $1,000 spent, as Figure 7 shows.

Fig 7: The cost-effectiveness of child survival interventions

Diarrhoeal disease: oral rehydration therapy

HIV/AIDS: antiretroviral therapy

Haemophilus influenzae type B, hepatitis B, diphtheria, pertussis, and tetanus: pentavalent vaccine

Malaria: Intermittent preventive treatment inpregnancy with sulfadoxine-pyrimethamine

Malaria: insecticide-treated bed nets (two treatmentsof permethrin per year – WHO recommended)

Immunodeficiency: vitamin A programme

Diarrhoeal disease: sanitation promotion

Diarrhoeal disease: hygiene promotion

DALYs avoided per $1,000 spent

0 50 100 150 200 250 300 350

53

24

1

1

59

91

91

333

Source: Adapted from World Bank (2006) Disease control priorities in developing countries (second edition)

Healthy childrenDiarrhoeal disease is the second biggest singlekiller of children under five. It accounts for 11% of all deaths in under-fives worldwide40 – an estimated 760,000 deaths in 201141. Water-related diseases – such as typhoid,cholera, leishmaniasis and schistosomiasis(bilharzia) – constitute a high proportion of theburden of disease in endemic regions in thedeveloping world. Tackling diarrhoea requires the implementation of a package of life-savinginterventions that includes vaccines, treatment,clean water, sanitation and hygiene, and nutrition.

These interventions are most effective whenimplemented in an integrated way, rather than in isolation. For example, the delivery of thevaccine against rotavirus, a major cause of severe diarrhoea, offers excellent opportunitiesfor delivering behaviour change interventions,such as the promotion of handwashing with soap. Further opportunities are offered throughprogrammes to control neglected tropicaldiseases, such as onchocerciasis, lymphaticfilariasis and trachoma. Pneumonia, which isspread largely due to poor hygiene, accounts for14% of all under-five mortality worldwide and isthe biggest killer of children under-five globally.

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“The water is dirty, brown, and we can see worms in it. This is whymy son is sick… After it rains the water washes the faeces and thisruns through the houses and even into the well, into the water wedrink. My wish and aspiration for my family and the community isto have clean water.”

Yaya Dembelè, Niala Bagadaji, Mali

Yaya Dembelè and his son Ousmane who has been diagnosed with cholera, Niala Bagadaji, Mali

WaterAid/Layton Thompson

Better nutritionApproximately a third of all child deaths areattributable to nutrition-related factors, such aslow birth weight, stunting (low height for age),and severe wasting, all of which are closely linkedto a lack of access to water, and particularlysanitation and hygiene42. Although the proportionof children under age five that are underweightdropped from 29% in 1990 to 18% in 2010, theworld remains off-track to meet the MDG target of halving hunger43. Many children in developingregions suffer stunting, which reflects chronicnutritional deficiencies, repeated ingestion ofanimal and human faeces due to poor wastemanagement, and lack of sanitation44. Accordingto the World Bank, open defecation accounts formost or all excess child stunting in India45.

Children who suffer repeated or persistent boutsof diarrhoea or intestinal worms lose vital nutrientsand can easily become malnourished. The converseis also true – children who are malnourished aremore susceptible to infection through poor qualitydrinking water or inadequate sanitation andhygiene. The World Health Organisation estimatesthat 50% of malnutrition is associated withrepeated diarrhoea or intestinal nematodeinfections, as a result of unsafe water, inadequatesanitation or insufficient hygiene. Improvementsin water and sanitation services and hygiene

behaviours are essential to break this vicious cycle. With improved sanitation and a secure, safe watersupply, communities are not only better able toavoid illness; they can also invest the time thatwould have been spent fetching water in growingnutritious food, such as fruit, vegetables andpulses, particularly when supported by integratedwater resource management to ensure the bestuse of water and a conservation approach. This improves household food security and canprovide additional income if produce is taken to market.

Healthier places to liveEnhancing sanitation, waste management andenvironmental health more broadly can alsoreduce the number of sites where disease vectorscan breed. Where sanitation is poor, humanfaeces attract flies – such as those that transmittrachoma – which find faeces a perfect place tolay their eggs. Stagnant water also provides the ideal breeding site for mosquitoes, which transmitmalaria, dengue, yellow fever and West Nile virus.As climate change has an impact on traditionalsites of standing water, these disease vectors arepredicted to be able to survive in new places,requiring new and innovative approaches tomanage water and prevent the spread of disease.

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“We have to do a better job of building nutrition outcomes intoprogrammes across all relevant sectors. So water, sanitation,hygiene programmes, health programmes and agricultureprogrammes… should all be cross-linked.”

Dr Rajiv Shah, Administrator, US Agency for International Development, 29 June 2010, at Statesmen’s Forum, Centre for Strategic and International Studies, Washington, DC

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Education Significant progress has been made worldwide in improving primary school enrolment andcompletion, and secondary school enrolment isalso on an upward trend. This is true even forcountries facing school-age population growthand other challenges, such as those in Sub-Saharan Africa, which saw an increase in primaryschool enrolment from 58% to 76% between1999 and 201046. The focus is now shifting toimproving the quality of teaching and the overalllearning environment, to help children stay inschool and achieve good educational outcomes,and to the transition to secondary school for allchildren. Improvements in water, sanitation and hygiene within schools are a vital part of this effort.

Better school facilitiesRecent data from least-developed and low-income countries shows that, in 2011, only 51%of schools had an adequate water source andonly 45% had adequate sanitation facilities47.

Improving water, sanitation and hygiene in schoolsplays an important role in reducing absence dueto illness and keeping children in educationthroughout their primary and secondary schoolyears. This can provide trans-generational

benefits, since educated mothers generally havemore control over their fertility and are more likelyto send their own children to school.

Improved facilities also provide a better workingenvironment for teachers and other staff, aidingjob satisfaction, retention and productivity. Adequate school sanitation facilities areparticularly important for older girls and femalestaff, who need to manage their menstrualhygiene, and can be a factor in preventingsecondary school pupils from being absent. Key factors are whether toilets are safe and clean,and have good levels of privacy, separate areasfor boys and girls, and reliable handwashingfacilities.

These factors are critical not only for theacceptability of toilets, but also for safeguardingagainst bullying, sexual harassment and violence,which can all occur at toilets that are not sex-segregated or do not provide appropriate levels of privacy and security.

There is evidence to suggest that the provisionof safe drinking water and adequate sanitationand hygiene facilities in schools helps to limitabsenteeism, and reduces levels of illness among schoolchildren48.

“I often come late to school because I have to fetch water… When I miss class I really worry about my exam. Due to absence I may fail… Especially in the summer I get sick. I can’t come toschool. I don’t know the sole reason but my health book says thatwe get dysentery and diarrhoea from dirty water, open defecationand garbage. I have learned this from school.”

Ganga, 14, Sindhuli district, Nepal

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WaterAid/Tom Van Cakenberghe

Ganga, 14, in class at Shree Heera Thumlee Secondary School, Tosramkhola VDC, Sindhuli district, Nepal

Good hygiene behaviourSchools can play a vital role in educating children,families and communities about water, sanitationand hygiene. Habits developed by children atschool can have lifelong benefits for them asindividuals and for their families.

In the Philippines, an initiative to reducechildhood diarrhoea and other illness introducedsupervised tooth-brushing and handwashing withsoap in schools, alongside deworming49. Within a year, participants in the programme saw schoolabsenteeism drop by 30%. The numbers of

underweight children and those with oralinfections were also significantly lower than in non-participating schools50. The educationministry and local NGO, Fit For School, are nowrolling out the initiative nationwide, with supportfrom international partners51.

Children can also be agents of change within theirschools, families and communities. In Uzbekistan,for example, children are leading a hygienepromotion initiative that complements efforts toimprove access to safe water supplies in remoteand disadvantaged communities52.

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“We wash our hands to remove cholera.”

Mishek, 7, Chiobola School, Nyimba ward, Zambia

WaterAid/Anna Kari

Boys washing their hands at Chiobola School, Nyimba ward, Zambia

Gender equality Gender inequality persists worldwide, and womencontinue to face discrimination in access tohealthcare, education, work, and assets such as land. Women and girls often struggle toparticipate in decision-making, at communitylevel and nationally. Violence against women andgirls continues to undermine efforts to reach alldevelopment goals. Gender inequalities aremanifested in unequal levels of access to waterand sanitation, and the disproportionate impactof poor access on women and girls.

Increased productivity for womenWomen continue to bear the greatest burden ofwater collection. Even those with access may have a water source many hours’ walk away. 25 Sub-Saharan African countries indicated thataround 71% of the water collected is done so bywomen and girls. In these countries alone, it isestimated that women spend a combined total ofat least 16 million hours every day collecting water.Only 25% of people in these countries had accessto water at or near their home in 201053. Securingaccess to water for the other 75% of householdswould dramatically improve the lives of affectedwomen – as well as children and men – byenhancing their productivity, health and wellbeing.

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WaterAid/Anna Kari

WaterAid/Tom Van Cakenberghe

Ukhamaya Sarki collecting water with her ten month old baby, Mangali, Sindhuli district, Nepal

“It’s a 30 minute journey to get water; in the dry season we have to go further and it takes 40 minutes. It takes longer goingback as it’s uphill… Don’t even talk to me about queuing. I have to queue for two or three hours in the morning sometimes,because every household needs water.”

Ukhamaya Sarki, Mangali, Sindhuli district, Nepal

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“The lack of sanitation facilities in Kibera affects women morethan men… Women tell us regularly how they are at risk of beingraped or assaulted after dark or at night if they were to attempt towalk even 100 metres to a latrine near their houses.”

Amnesty International official, Kibera, Nairobi, Kenya54

“It has become more dangerous to be a woman fetching water orcollecting firewood than a fighter on the frontline.”

Margot Wallström, UN Special Representative on Sexual Violence in Conflict

In many communities, women manage kitchengardens and other forms of homesteadagriculture. Improving the security and proximityof their water supply, and combining this withadvice and support on issues such as effectiveirrigation and crop management, can thereforeyield real benefits for women’s productivity, statusand empowerment. In Senegal, for example, it hasbeen estimated that half of women’s incomesderive from productive water use, throughactivities such as gardening and raisinglivestock55.

Reduced vulnerabilityWomen’s vulnerability can also be reduced bybringing improved water sources and sanitationfacilities closer to communities, and ensuringtheir sustainability and reliability. Where access is poor, women and children can also faceviolence and other threats while fetching water,washing, or finding somewhere to urinate ordefecate. At greatest risk are the 526 millionwomen worldwide who have no choice but to go to the toilet in the open56, although public or shared latrines can also present safety issues for women, particularly after dark.

Improved status and dignityImproved sanitation brings further benefits towomen and girls, improving their status, as wellas their health and wellbeing. In addition to beingsafer and more secure, well-designed toilets withhandwashing facilities assist with menstrualhygiene management. This can help women andgirls maintain good reproductive health, and togradually free themselves from the taboos,restrictive rituals and customs regarding whatthey can and can’t do while menstruating.

In Afghanistan, as in many countries, women and girls who are menstruating are considered‘unclean’. Many face restrictions related to diet,washing, or cutting their hair or nails. The Afghan Government, supported by UNICEF, hasdeveloped information booklets that addresspopular myths and try to improve understandingof menstruation and related sanitation andhygiene issues57.

Environmentalsustainability Freshwater ecosystems provide water for manydifferent uses – from essential daily needs tocultural, spiritual, recreational and aestheticpurposes. These different values shape the waythat we talk about water and frame the policyissues. Water also plays an essential role in otherecosystems necessary for sustaining life. Efforts toimprove water, food and energy security, andenvironmental sustainability, are increasinglyrecognised as being interdependent.

Resilient communities People living in marginal environments oftendepend on rainfall for their lives – whether it is fordrinking water, washing or sustaining livestock.This leaves them vulnerable to extreme weatherevents like floods or droughts. Providing secureand reliable sources of water for drinking andother basic needs can significantly enhance theability of vulnerable groups to cope with andadapt to livelihood shocks.

For those displaced by conflict or naturaldisasters, access to basic services such as safe

drinking water and sanitation can be among thefirst things lost. Ensuring these are available canhelp to provide security, especially in campsettings, where research shows that sexualviolence most often occurs when women mustleave secure camp boundaries in search offirewood or water58.

Sustainable cities Reaching people in cities with improved access to safe water, sanitation and hygiene will continueto pose a significant challenge, as more peoplemove into urban and peri-urban areas indeveloping countries, and with slums andinformal settlements likely to expand.

Creativity and innovation will be needed, as wellas sharing and replicating good practice withinand between cities and countries, as the C40cities network has done in relation to climatechange59. Another example is the African Waterand Sanitation Local Authorities Network’s plan toprovide a platform for local governments to shareknowledge and experience about how best toensure sustainable, resilient and equitable urbanwater and sanitation in African cities60.

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“I have lost my livestock. I am empty. Everything is finished.I lost 30 goats and sheep. I had ten cattle. But I lost all of them.”

Middle-aged man speaking about the impact of drought, Meeto, Ethiopia61

WaterAid/Kate Holt

Delia tends the garden in Bokola village, Malawi

Local artisans for the Self-Supply project in Itemba ward, at a finished well, Mambwe village, Itemba ward, Luapula province,Zambia

WaterAid/Anna Kari

Growth and employment Water is an essential resource underpinningactivity in all economic sectors, ranging fromagriculture and industry, through to energy,tourism and transportation. Effective waterresource management is therefore fundamental to stimulating economic growth and productivity,and to providing ongoing employmentopportunities.

If the MDG targets on water and sanitation weremet, the total economic benefit would be $60billion annually – of which, $54 billion can beattributed to improved sanitation62. Attaininguniversal access to sanitation would significantlyenhance the benefits, yielding $220 billion a yearif starting from the existing level of coverage63. For some African and Latin American countries,achieving universal access to both water andsanitation could yield gains equivalent to morethan 15% of GDP64.

Improved productivityImproving access to water, sanitation and hygienealso benefits the economy by helping people stayhealthy and resilient enough to work productively,whether they are working in their households andcommunities, studying, or in paid employment.

The costs as well as potential benefits aregreatest for reaching the poorest people. It hasbeen estimated that meeting the MDG targets onwater and sanitation would save 3.2 billion adultworking days annually, and 443 million schooldays, which would ultimately increase productivityand earning potential by improving education65.

WHO estimates, as a bare minimum, that for every$1 invested in improving water and sanitation, anaverage of more than $4 is returned economically,much of which relates to the productive timesaved by increasing the proximity of water andsanitation services to the people who use them66.

Reduced economic riskThe total global economic losses due toinadequate water supply and sanitation serviceshave been estimated at $260 billion a year.Effective water resource and waste managementreduces the risks faced by critical economicsectors – including industry, agriculture andtourism – and offers reassurance to businesses asthey make investment decisions. It can also havea positive impact on other economic indicators,such as property prices67. Improvements in accessto water, sanitation and hygiene contribute togrowth and prosperity in the domestic privatesector, and also help attract direct investmentfrom external sources, which in turn boosts GDPand can reduce poverty.

Investment in water, sanitation and hygiene canreduce the costs to health services, businessesand society arising from disease outbreaks. Forexample, the 1991 outbreak of cholera in Peruwas estimated to cost the country as much as $1 billion in lost tourism and food tradeembargoes alone68. A recent modelling of choleraepidemics in Bangladesh and Mozambiquecalculated the total economic cost of an outbreakto be 2% of GDP69.

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The central importance of water, sanitationThe table below summarises the impact that investing in water, sanitation and

Health

•Reducing childhoodillness and death dueto diarrhoeal andother water-relateddiseases

•Reducing the burdenof water, sanitationand hygiene-relatedillness on healthcaresystems

•Improving foodsecurity and nutrition

•Reducing malnutritionand hunger, mitigatingstunting and chronicwasting

•Reducing exposure todisease

•Maintaining thewellbeing of thosewith chronic illness

Education

•Improving educationaloutcomes

•Keeping girls inschool, especiallypost-puberty

•Reducing schoolabsenteeism due toillness

•Enabling increasededucational accessand attainment,increasing lifelongearning potential

•Improving workingconditions forteachers

Gender equality

•Saving women andgirls time by reducinghours spent fetchingwater, improvingproductivity

•Expanding livelihoodoptions for women

•Reducing women andgirls’ vulnerability,including to physicaland sexual violence

•Improving menstrualhygiene, with benefits to women and girls’reproductive health,dignity, status and self-esteem

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n and hygiene to developmentd hygiene can have on other development outcomes:

Environmentalsustainability

•Improvingenvironmental healthin slums and informalsettlements

•Helping make citiesmore sustainable

•Reducingcontamination offreshwater sources

•Protecting freshwaterand marineecosystems

•Strengthening waterresource management

•Helping communitiesto become moreresilient, particularlyto climate change

Growth andemployment

•Improving productivityat individual,household,community andnational workforcelevels

•Reducing risks andcosts to key economicsectors, helping toattract investment

•Underpinning activityin sectors that dependdirectly on water, egenergy, transportation

•Helping people stay healthy enough to work

•Bringing services closer to people, saving them time

“W

“We cannot stop here. Our next step must be to target the most difficult to reach, the poorest and the most disadvantagedpeople across the world. The United Nations General Assemblyhas recognised drinking water and sanitation as human rights. That means we must ensure that every person has access.”

Ban Ki-Moon, UN Secretary General

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Water, sanitationand hygiene in thepost-2015framework fordevelopment

A key strength of the MDG framework has beenthe provision of a coherent, measurable, time-bound and comprehensive agenda that hasestablished norms and standards for internationaldevelopment cooperation.

The post-2015 framework must continue the bestaspects of the MDG framework, while applyinglessons learned from its weaknesses andimplementation challenges. Communities,

governments, companies, civil society,international NGOs and other stakeholders need a shared, ambitious and achievable vision forpoverty reduction and sustainable developmentonce the MDG project comes to an end. Thisshould reflect the importance of water, sanitationand hygiene to the attainment of povertyeradication, increased equality, and sustainablehuman and economic development.

A strengthenedframework for achievingpoverty eradicationA recognised weakness of the MDG framework is that the separation of targets by the variousthematic goals discouraged effective collaborationacross sectors, limiting progress significantly.

The post-2015 development framework needs tobetter reflect the complex nature of people’s livedexperiences, recognising the central importance ofwater, sanitation and hygiene to health, education,gender equality, economic growth andenvironmental sustainability – to strengthen theefficiency of interventions and to deliver sustainablehuman development outcomes. Broad outcomes-based goals must be established, and their targetsand associated indicators must reflect the full rangeof interventions and human rights required to meeteach outcome, so that integrated and holisticapproaches are institutionalised.

The post-2015 framework should not only setgoals, targets and indicators, but also set out howthese will be measured and monitored. Animplementation strategy should be agreed,reflecting the collective lessons learned fromefforts to meet the MDG targets, and providingenough flexibility to be adapted by each countryfor its own needs, contexts and priorities. Thisshould include estimates of the resourcesrequired to reach the post-2015 developmentgoals from domestic and international sources.

The post-2015 framework must prioritisereaching people who have been marginalisedfrom progress to date. For example, it may bemost effective to take an integrated, cross-sectoral approach towards addressing the needsof specific groups of people – such as the ruralpoor, slum-dwellers or people with disabilities. A monitoring framework must require that allUnited Nations Member States are accountablefor a focus on equity, so that no one is left behind.

School children wash their hands with clean water in the new hand basins, Soavina, Betafo district, Madagascar

WaterAid/Rindra Ramasomanana

Few interventions would have a greater impact onthe lives of the world’s poorest and mostmarginalised people, particularly women andgirls, than reducing the time spent collectingwater and addressing the health problems causedby poor sanitation and hygiene. There is agrowing consensus among sector professionalsthat universal access to water, sanitation andhygiene should have a central place within thepost-2015 framework. This was reflected in thevision and summary targets presented by theWHO and UNICEF Joint Monitoring Programme(JMP)70 expert working groups in The Hague inDecember 2012:

Vision: Safe and sustainable sanitation, hygieneand drinking water used by all.

Summary targets1 Everyone has water, sanitation and hygiene

at home.2 All schools and health centres have water,

sanitation and hygiene.3 Water, sanitation and hygiene are equitable

and sustainable.

WaterAid supports the JMP process and hasengaged closely with it. The emerging vision andsummary targets are comprehensive andbalanced; however, the work to develop detailedtargets and indicators is ongoing, and it is vitalthat these are bold and ambitious.

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Manu Nayek outside his adapted latrine, Burjan tea garden, Sylhet, Bangladesh

A common vision of universal access to water,sanitation and hygiene by 2030WaterAid’s vision is of a world where everyone has access towater, sanitation and hygiene. For the first time, this longstandinggoal of universal access is now within reach.

1 Identify targets for universal access to water, sanitation and hygieneby 2030

The post-2015 framework must set an ambitious target date for achievinguniversal access to water and sanitation services. Goal or outcomeindicators should be added for both safe drinking water and sanitation,calling for universal access to each by 2030. Clear targets for hygienepractices should be added to the new framework. These targets shouldreflect the need for people to access drinking water, sanitation and hygieneat the household level, and also in schools, health facilities andworkplaces. Alongside specific targets for water, sanitation and hygiene,these interventions should be recognised as critical to the achievement ofhealth, equity and education outcomes, and should be embedded inrelevant targets in those areas.

2 Address inequalities in water, sanitation and hygiene accessWater, sanitation and hygiene targets and indicators within the post-2015framework should focus explicitly on reducing inequalities by targetingpoor and disadvantaged groups as a first priority. These targets andindicators should also explicitly reflect the major barriers to access andforms of discrimination faced by poor people, women and girls, olderpeople and disabled people. There is a particularly urgent need torecognise and address the significant time spent, usually by women andgirls, collecting water and finding somewhere safe to defecate.

3 Embed human rights in water, sanitation and hygiene provisionUniversal access to basic water and sanitation services are fundamentalhuman rights that should be acknowledged within the post-2015framework. Water, sanitation and hygiene outcome targets and theirassociated indicators should reflect the key principles and obligationsderived from existing treaties relating to human rights.

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WaterAid believes that the post-2015 framework for developmentshould:

4 Ensure sustainability of water, sanitation and hygiene servicesSustainability should be fully embedded within new water, sanitation andhygiene targets and indicators, in order to ensure lasting benefits overtime. Targets and indicators should also reflect the need to measure qualityalongside access. For example, the current MDG drinking water target refersto sustainable access to safe drinking water, but the MDG indicator – ‘useof an improved drinking water source’ – does not include a measurement ofeither drinking water safety or sustainable access. This means that accurateestimates of the proportion of the global population with sustainableaccess to safe drinking water are likely to be significantly lower thanestimates of those reportedly using improved water sources71. The post-2015 framework must address this.

5 Take a holistic approach to poverty eradication and sustainabledevelopment that recognises the central importance of water,sanitation and hygiene

The critical linkages between health, education, gender equality, economicand environmental interventions and outcomes should be reflected in thepost-2015 framework. Water, sanitation and hygiene targets must bereflected wherever they are required for a given goal or objective to besuccessful. This will strengthen the efficiency of development interventionsand help build sustainable outcomes. The new framework should also seekto minimise water-related risks and build the resilience of societies andeconomies by protecting them from shocks (principally floods anddroughts) and the added pressures of climate change. This includesprotecting ecosystem services and using water within resource thresholds.

6 Promote accountability for progress on water, sanitation and hygieneThe integrated nature of sustainable development requires a more holisticapproach to monitoring performance and ensuring accountability. Theframework should reflect the fact that many of the poorest people live in middle-income countries and should therefore ensure relevant andmeaningful targets for all countries, not only the least developed. Newarchitecture is required to measure and track global progress effectively,and to identify blockages so that they can be addressed.

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WaterAid recommends that specific sections of the post-2015development framework relating to water, sanitation and hygiene should:

• Include a goal on universal access to basic water and sanitation servicesas a fundamental human right.

• Specify a target date of 2030 for achieving universal access to safe water, sanitation and hygiene globally in households, schools and health facilities.

• Ensure that water, sanitation and hygiene targets and indicators focusexplicitly on reducing inequalities, by targeting poor and disadvantagedpeople as a priority, and on improving the sustainability of services tosecure lasting benefits.

11 The Millennium Development Goals include: MDG 1:Eradicate extreme poverty and hunger; MDG 2: Achieveuniversal primary education; MDG 3: Promote genderequality and empower women; MDG 4: Reduce childmortality; MDG 5: Improve maternal health; MDG 6:Combat HIV/AIDS, malaria and other diseases; MDG 7:Ensure environmental sustainability; MDG 8: Develop aglobal partnership for development.

12 World Health Organisation/UNICEF Joint MonitoringProgramme for Water Supply and Sanitation (2012)Progress on drinking water and sanitation: 2012 update

13 Improved water is defined as piped water into a dwellingor yard/plot, a public tap or standpipe, a tubewell orborehole, a protected dug well, a protected spring, orharvested rainwater. More information is available at:www.wssinfo.org/definitions-methods/watsan-categories

14 Onda K, LoBuglio J and Bartram J (2012) Global accessto safe water: Accounting for water quality and theresulting impact on MDG progress, The InternationalJournal of Environmental Research and Public Health, vol9, pp 880-894. Available at: www.mdpi.com/journal/ijerph

15 United Nations Office of the High Commissioner forHuman Rights (2012) ‘Of all places… a toilet’. Pressrelease, World Toilet Day, 19 November 2012


17 1990 is the baseline year for measuring the MDGs.There were 2.4 billion people without sanitation in1990, compared with the latest figure of 2.5 billion in2010. World Health Organisation/UNICEF JointMonitoring Programme for Water Supply and Sanitation(2012) Progress on drinking water and sanitation: 2012update, p15

18 UK Department for International Development (2012)Water, sanitation and hygiene portfolio review, p6

19 Hutton G (2012) Global costs and benefits of drinking-water supply and sanitation interventions to reach theMDG target and universal coverage, pp5-6. World HealthOrganisation, Geneva, Switzerland. Available at:www.who.int/water_sanitation_health/publications/2012/global_costs/en/index.html

10 World Health Organisation/UNICEF Joint MonitoringProgramme for Water Supply and Sanitation (2012)Progress on drinking water and sanitation: 2012update, p6

11 WaterAid (2011) Off-track, off-target: Why investment inwater, sanitation and hygiene is not reaching those whoneed it most, p5. WaterAid, London, UK. Available at:www.wateraid.org/documents/off-track-off-target.pdf

12 WaterAid (2011) Off-track, off-target: Why investment inwater, sanitation and hygiene is not reaching those whoneed it most, p35. WaterAid, London, UK. Available at:www.wateraid.org/documents/off-track-off-target.pdf

13 World Bank (2006) Disease control priorities indeveloping countries, 2nd edition



16 WaterAid (2011) Off-track, off-target: Why investment inwater, sanitation and hygiene is not reaching those whoneed it most, p13. WaterAid, London UK

17 UN-Habitat (2007) The urban penalty: The poor dieyoung. Background note to The state of the world’s cities,2006/7. Available at:www.unhabitat.org/downloads/docs/5636_27492_SOWCR%2022.pdf

18 Mitlin D and Satterthwaite D (2013) Urban poverty inthe global south: Scale and nature, pp 258-261. London

19 Observations by WaterAid Bangladesh20 OECD-DAC CRS database. Available at:

http://stats.oecd.org/index.aspx?DataSetCode=CRS121 Development Initiatives/WaterAid (2012) Addressing

the shortfall: The urgent need for increased and bettertargeted aid to the water and sanitation sector

22 See, for example, Catarina de Albuquerque, UN SpecialRapporteur on the human right to safe drinking waterand sanitation, Report to the UN General Assembly,October 2012. Available at:www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=12853&LangID=E

23 Population Reference Bureau (2012) Fact sheet: Worldpopulation trends 2012

24 United Nations (2012) World urbanisation prospects:The 2011 revision – highlights. Department ofEconomic and Social Affairs, March 2012

25 World Health Organisation/UNICEF Joint MonitoringProgramme for Water Supply and Sanitation (2011)

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Endnotes

26 World Health Organisation (2010) Vision 2030: Theresilience of water supply and sanitation in the face ofclimate change – shows that ‘improved’ water sourcesare more resilient to climate change.

27 DARA (2010) Climate vulnerability monitor, pp120-12128 Intergovernmental Panel on Climate Change (2012)

Managing the risks of extreme events and disasters toadvance climate change adaptation. Available at:www.ipcc.ch/pdf/special-reports/srex/SREX_Full_Report.pdf

29 Shiklomanov I (2003) World water resources at thebeginning of the twenty-first century. CambridgeUniversity Press, Cambridge, UK

30 Muller M (2012) Africa’s path to water security: Rocks,hard places, road blocks. Presentation at Water Security,Risk and Society conference, Oxford

31 Rural Water Supply Network (2007) Handpump data forselected countries in Sub-Saharan Africa

32 World Bank Country Lending Groups. Available at:data.worldbank.org/about/country-classifications/country-and-lending-groups

33 Gaehl B (unpublished draft) Is clean water one of themost important priorities of people living in thedeveloping world? WaterAid, London, UK

34 United Nations (2012) The Millennium DevelopmentGoals report 2012


36 United Nations Development Programme (2006)Human development report 2006, p45. Available at:hdr.undp.org/en/media/HDR06-complete.pdf

37 WaterAid (2011) Off-track, off-target: Why investment inwater, sanitation and hygiene is not reaching those whoneed it most. WaterAid, London, UK

38 UNAIDS, UNFPA and UNIFEM (2004) Women and AIDS:Confronting the crisis. Available at:www.unfpa.org/hiv/women/docs/women_aids.pdf

39 The World Health Organisation (2005) The world healthreport 2005: Make every mother and child count.Geneva, Switzerland. Available at:www.who.int/whr/2005/whr2005_en.pdf

40 Liu L, Johnson H L, Cousens S, Perin J, Scott S, Lawn J E,Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, BlackR E (2010) Global, regional, and national causes of childmortality: An updated systematic analysis for 2010 withtime trends since 2000. Child Health EpidemiologyReference Group of WHO and UNICEF

41 Calculated from: Liu L, Johnson H L, Cousens S, Perin J,Scott S, Lawn J E, Rudan I, Campbell H, Cibulskis R, Li M,Mathers C, Black R E (2010) Global, regional, andnational causes of child mortality: An updatedsystematic analysis for 2010 with time trends since2000. Child Health Epidemiology Reference Group ofWHO and UNICEF; and UNICEF (2012) Levels and trendsin child mortality: Report 2012. Available at:www.unicef.org.uk/Latest/Publications/Child-Mortality-Child-Survival

42 UNICEF (2012) Committing to child survival: A promiserenewed. Available at:www.unicef.org/videoaudio/PDFs/APR_Progress_Report_2012_final.pdf

43 UNICEF (2012) Committing to child survival: A promiserenewed. Available at:www.unicef.org/videoaudio/PDFs/APR_Progress_Report_2012_final.pdf

44 Humphrey J (2009) Child undernutrition, tropicalenteropathy, toilets, and handwashing, The Lancet, vol.374, pp 1,032-1,035

45 Spears D (2013) How much international variation inchild height can sanitation explain? World Bank policyresearch working paper. Available at:http://econ.worldbank.org/external/default/main?pagePK=64165259&piPK=64165421&theSitePK=469372&menuPK=64166093&entityID=000158349_20130205082533


47 UNICEF (2012) Raising even more clean hands:Advancing health, learning and equity through WASH inschools. Available at:www.unicef.org/wash/schools/files/Raising_Even_More_Clean_Hands_Web_17_October_2012(1).pdf

48 Jasper C, Le T and Bartram J (2012) Water and sanitationin schools: A systematic review of the health andeducational outcomes, International Journal ofEnvironmental Research and Public Health, no 8, vol 9,pp 2,772-2,787. Available at: www.mdpi.com/1660-4601/9/8/2772

49 Monse B, Naliponguit E, Belizario V, Benzian H and vanPalenstein Helderman W (2010) Essential health carepackage for children – the ‘Fit for School’ programme inthe Philippines. Available at:www.fitforschool.ph/data/publication-ffs-munich.pdf

50 WaterAid and partners (2011) Join up, scale up: Howintegration can defeat disease and poverty, p14

51 www.fitforschool.ph/about/about-ehcp.html 52 UNICEF (2012) News Uzbekistan, vol 4, January-February

2012. Available at:www.unicef.org/wash/schools/files/UZNewsletter-1-12.pdf


54 Van Houweling E, Hall R P, Sakho Diop A, Davis J andSeiss M (2012) The role of productive water use inwomen’s livelihoods: Evidence from rural Senegal. WaterAlternatives, vol 3, no 5, pp 658-677


56 Amnesty International (2010) Insecurity and indignity:Women’s experiences in the slums of Nairobi, Kenya,p21

57 House S, Mahon T and Cavill S (2012) Menstrualhygiene matters: A resource for improving menstrualhygiene around the world. WaterAid, London, UK.Available at: www.wateraid.org/documents/MHM/Compiled_MHbook_LR.pdf

58 Taken from WaterAid (unpublished) Voices from thesource, p14

59 See, for example, Médecins Sans Frontières (2005) Thecrushing burden of rape: Sexual violence in Darfur.Médecins Sans Frontières, The Netherlands. Available at:www.doctorswithoutborders.org/publications/reports/2005/sudan03.pdf

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60 C40 is a network of the world’s megacities taking actionto reduce greenhouse gas emissions. www.c40cities.org

61 www.awasla.org 62 Hutton G (2012) Global costs and benefits of drinking-

water supply and sanitation interventions to reach theMDG target and universal coverage, p5. World HealthOrganisation, Geneva, Switzerland. Available at:www.who.int/water_sanitation_health/publications/2012/global_costs/en/index.html

63 Hutton G (2012) Global costs and benefits of drinking-water supply and sanitation interventions to reach theMDG target and universal coverage, p5. World HealthOrganisation, Geneva, Switzerland. Available at:www.who.int/water_sanitation_health/publications/2012/global_costs/en/index.html

64 Hutton G (2012) Global costs and benefits of drinking-water supply and sanitation interventions to reach theMDG target and universal coverage, pp57-64. WorldHealth Organisation, Geneva, Switzerland. Available at:www.who.int/water_sanitation_health/publications/2012/global_costs/en/index.html

65 United Nations Development Programme (2006)Human development report 2006, p45. Available at:hdr.undp.org/en/media/HDR06-complete.pdf



68 Appleton B and van Wijk C (2003) Hygiene promotion:Thematic overview paper. IRC International Water andSanitation Centre. Available at:www.dwaf.gov.za/dir_ws/tkc/vdFileLoad/file.asp?ID=77

69 Oxford Economics (2010) Economic impact of a choleraepidemic on Mozambique and Bangladesh. Report forthe International Vaccine Institute, June 2010. Availableat: www.oxfordeconomics.com/publication/open/222590

70 World Health Organisation/UNICEF Joint MonitoringProgramme for Water Supply and Sanitation (2012)Proposal for consolidated drinking water, sanitation andhygiene targets, indicators and definitions. Available at:www.wssinfo.org/fileadmin/user_upload/resources/A-proposal-for-consolidated-WASH-goal-targets-definitions-and-indicators_version7_Nov22_final.pdf

71 UNICEF and World Health Organisation (2011) Drinkingwater equity, safety and sustainability: Thematic reporton drinking water 2011. Available at:www.wssinfo.org/fileadmin/user_upload/resources/report_wash_low.pdf

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WaterAid/Zute Lightfoot

Nadia at the rehabilitated borehole, Nyamigende village, Juru sector, Bugesera district, Rwanda

Registered charity numbers:

Australia: ABN 99 700 687 141Sweden: Org.nr: 802426-1268, PG: 90 01 62-9, BG: 900-1629UK: Registered charity numbers 288701 (England and Wales) and SC039479 (Scotland)US: WaterAid America is a 501(c)(3) non-profit organization

www.wateraid.org

March 2013

WaterAid’s mission is to transform lives byimproving access to safe water, hygiene andsanitation in the world’s poorest communities.We work with partners and influence decision-makers to maximise our impact.

Everyone, everywhere presents a strong and compelling case why safe water, sanitation andhygiene are key to tackling poverty and promoting sustainabledevelopment post-2015.

Everyone, everywhere. A vision for water, sanitation … everywhere A vision for water, sanitation...

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