Access to clean water is essential for human development, the environment, and the economy. More than two billion people, however, lack access to safe drinking water, sanitation, and hygiene (World Health Organization & United Nations Children’s Fund, 2017, pp. 4–6). Poor water quality and inadequate sanitation affect all aspects of life. Inadequate access to clean water and sanitation sources hinders sustainable development efforts worldwide (World Health Organization & United Nations Children’s Fund, 2015). The chapter Water and Sanitation uses two indicators to measure the health risks associated with unsafe sanitation and drinking water sources.
- Sanitation. We measure sanitation as the proportion of a country’s population exposed to health risks from their access to sanitation, defined by the primary toilet type used by households.
- Drinking water. We measure drinking water as the proportion of a country’s population exposed to health risks from their access to drinking water, defined by the primary water source used by households and the household water treatment, or the treatment that happens at the point of water collection.
Both sanitation and drinking water are measured using the number of age-standardized disability-adjusted life years (DALYs) lost per 100,000 persons. Minimizing the health risks posed from unsafe sanitation and drinking water is a vital step in evaluating a country’s ability to maintain clean water systems and minimize contact with dangerous bacteria and viruses.
|Water and Sanitation Indicators|
|Drinking water||DALY rate|
Reliable sources of clean water and sanitation facilities are necessary for sustainable development, but more than two billion people worldwide lack access to safe drinking water, sanitation, and hygiene (World Health Organization & United Nations Children’s Fund, 2017, pp. 4–6). Polluted water and sanitation are associated with the spread of illnesses including diarrhea, typhoid fever, and cholera. Inadequate access to clean water and sanitation facilities hinders efforts to eradicate preventable diseases worldwide (World Health Organization & United Nations Children’s Fund, 2015).
Environmental: Adequate water quality is also vital for ecosystem health. Adverse environmental consequences from water pollution, such as increased toxicity, eutrophication, and salinization, pose great danger to our natural ecosystems. Humans introduce a number of harmful substances into the water cycle, such as pharmaceuticals and personal care products, which can disrupt aquatic environments (United Nations Water, 2014). Large amounts of nutrients entering the water stream can cause eutrophication, or intense growth at the bottom of aquatic food chains. Eutrophication leads to oxygen depletion, die-offs of organisms, and reduced ecosystem services (United Nations Water, 2016a, p. 14). Major sources of nutrient pollution include agricultural runoff, domestic sewage, and industrial effluents (United Nations Water, 2016a, p. 12). Increased levels of salinity further causes declines in biodiversity and reductions in crop yields (Tilman, Cassman, Matson, Naylor, & Polasky, 2002, p. 672).
Social: Large access gaps in safe drinking water exist between developing and developed regions. As seen in Figures 6–1 and 6–2, developed regions have made substantial progress gaining access to safe drinking water and improving sanitation sources, but coverage remains variable among developing countries. Further inequalities, such as rural-urban access gaps, exist on a more granular level. Data from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) show that while 96% of the global urban population has access to improved drinking water sources, only 84% of the rural population has the same access (World Health Organization & United Nations Children’s Fund, 2015, p. 4). Unsafe water and poor sanitation are leading causes of childhood mortality globally. More than 525,000 children under five years of age die every year from diarrheal diseases (World Health Organization, 2017c), and 50% of child malnutrition is associated with these health risks (Prüss-Üstün, Bos, Gore, & Bartram, 2008, p. 7). Eliminating the risks from unsafe water and poor sanitation help children both through better health and greater school attendance (Prüss-Üstün et al., 2008, p. 17).
Economic: Inadequate water quality and poor sanitation also limit economic development (Cooley et al., 2013, p. 5). Illnesses associated with unsafe water, for example, increase the costs of healthcare (Prüss-Üstün et al., 2008, p. 21). Achieving levels of safe water quality globally, however, is not without its costs. The World Bank estimates that achieving universal basic water and sanitation will incur US$28.4 billion per year in global capital costs (Hutton & Varughese, 2016, p. 7). Over the past three years, countries have collectively increased their budgets for water, sanitation, and hygiene measures by nearly 5% per year, but 80% of countries find their budgets for water and sanitation services are still inadequate to meet national targets (United Nations, 2017a, p. 5).
Over the last 30 years, numerous international efforts have sought to address unsafe water, poor sanitation, and the many issues that stem from them. The Millennium Development Goals (MDGs) aimed to halve the proportion of people without sustainable access to safe drinking water and basic sanitation between 1990 and 2015 (World Health Organization & United Nations Children’s Fund, 2015). The international community reached its global MDG drinking water target in 2010. As of 2015, almost 90% of the population – about 6.5 billion people worldwide – use an improved drinking water source, which the WHO defines by the type of water treatment that happens at the point of water collection (World Health Organization & United Nations Children’s Fund, 2017, p. 3). Improved access to clean drinking water is recognized as one of the most successful accomplishments of the MDGs. However, global sanitation outcomes were not as widespread. In 2015, the MDG sanitation target fell short of halving the proportion of the population without access to improved sanitation by about 700 million people (World Health Organization & United Nations Children’s Fund, 2017, p. 4).
While much of the world has gained access to improved sanitation and drinking water sources, worldwide accomplishments conceal regional inequalities – see Figure 6–1 (Prüss-Üstün et al., 2008). The WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation (JMP) estimates that 884 million people lack access to improved drinking water sources, most of them located in sub-Saharan Africa and Oceania (World Health Organization & United Nations Children’s Fund, 2017, p. 3,4).
Billions of people also lack access to basic sanitation services (World Health Organization & United Nations Children’s Fund, 2017). As with water quality, regional disparities are often masked by the global trends. As seen in Figure 6–2, individuals in least developed countries still lack access to basic sanitary facilities (World Health Organization & United Nations Children’s Fund, 2017, p. 4).
Recent studies in access further emphasize the scale of the water and sanitation access gap (World Health Organization, 2017a, p. 24). Fifty-eight percent of the 159 million people who collected drinking water directly from surface water in 2015 lived in sub-Saharan Africa (World Health Organization & United Nations Children’s Fund, 2017, p. 3). As seen in Figures 6–1 and 6–2, significant improvements in access to water and sanitation services still need to be made for several million people. A 2017 UN press release noted that countries must “radically” increase investments in water and sanitation services in order to protect their populations from water-related illnesses (World Health Organization, 2017b).
Water and Sanitation is covered under several Sustainable Development Goals (SDGs) and Targets.
Goal 6: Ensure availability and sustainable management of water and sanitation for all
Goal 3, Target 3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases
Goal 3, Target 9: By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.
Goal 11, Target 5: By 2030, significantly reduce the number of deaths and the number of affected people and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations
Goal 12, Target 4: By 2020, achieve the environmentally sound management of chemicals and all wastes throughout their life cycle, in accordance with agreed international frameworks, and significantly reduce their release to air, water and soil in order to minimize their adverse impacts on human health and the environment
Goal 15, Target 1: By 2020, ensure the conservation, restoration and sustainable use of terrestrial and inland freshwater ecosystems and their services, in particular forests, wetlands, mountains and drylands, in line with obligations under international agreements
Goal 15, Target 8: By 2020, introduce measures to prevent the introduction and significantly reduce the impact of invasive alien species on land and water ecosystems and control or eradicate the priority species
In addition to the specific SDGs for Water and Sanitation, access to safe water and sanitation reinforces other SDGs. Clean water and sanitation are essential for many SDGs such as those related to health, gender equality, economic growth, and climate action (United Nations Childrens Fund, 2016, p. 4).
United Nations Water (UN-Water): UN-Water coördinates efforts of numerous groups working on issues relating to water and sanitation. http://www.unwater.org/.
United Nations Children’s Fund (UNICEF): UNICEF’s water, sanitation, and hygiene team works all over the world on improving water and sanitation services to children and their families. https://www.unicef.org/wash/.
World Bank: The World Bank is one of the largest investors in water quality globally, providing technical assistance and working with governments to improve access to water and sanitation services. http://www.worldbank.org/en/topic/water.
World Health Organization (WHO): WHO’s work on water, sanitation, and hygiene aims to address the burden of disease stemming from poor water quality and inadequate sanitation. http://www.who.int/water_sanitation_health/about/en/.
WaterAid: WaterAid is an international non-profit that was set-up the after International Drinking Water & Sanitation Decade in 1981. https://www.wateraid.org/us/.
22nd Conference of the Parties: The UN climate change conference in Marrakech, Morocco devoted a special day to highlight water as part of the climate change solution and as a way to help implement the Paris Climate Agreement (United Nations, 2016). http://www.un.org/sustainabledevelopment/blog/2016/11/cop22-spotlights-water-as-part-of-the-climate-change-solution/.
Call to Action on Sanitation: On World Water Day 2013, the WHO launched the Call to Action on Sanitation aiming to eliminate open defecation by 2025 (World Health Organization & United Nations Children’s Fund, 2015). http://sanitationdrive2015.org/call-to-action/.
General Comment No. 15. The Right to Water: In November 2002, the Committee on Economic, Social and Cultural Rights adopted General Comment No. 15 which states that, "[t]he human right to water is indispensable for leading a life in human dignity. It is a prerequisite for the realization of other human rights." It also defined the right to water as the right of, “everyone to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic uses,” (Office of the High Commissioner for Human Rights, 2003, p. 1). http://www.refworld.org/pdfid/4538838d11.pdf.
High-Level Panel on Water (HLPW): The HLPW, formed in 2016 by the UN and the World Bank Group, works to provide leadership on ways to improve access to clean drinking water and sanitation facilities (United Nations, 2017b). https://sustainabledevelopment.un.org/HLPWater.
Human Rights Council Resolution: In September 2011, the UN adopted a resolution which calls on Member States to ensure enough financing for sustainable delivery of water and sanitation services, further highlighting access to safe water and sanitation as a human right (United Nations General Assembly, 2011). http://www.un.org/es/comun/docs/?symbol=A/HRC/RES/18/1&lang=E.
International Conference on Water & the Environment and the Earth Summit: In 1992, both conferences had a focus on water, which helped people in developing countries gain access to safe drinking water sources (United Nations, n.d.). http://www.un.org/en/sections/issues-depth/water/.
The human right to water and sanitation 64/292: In 2010, the UN declared for the first time that access to clean water and sanitation is a fundamental human right (United Nations General Assembly, 2010). http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/64/292.
The World Health Organization and the United Nations Children’s Fund’s Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD): The GAPPD’s goal is to achieve universal access to drinking water by 2025 (World Health Organization, 2016, p. 7). http://www.who.int/maternal_child_adolescent/documents/global_action_plan_pneumonia_diarrhoea/en/.
WASH4Work: The WASH4Work initiative was launched on World Water Day 2016 to mobilize businesses to improve workplace access to water, sanitation, and hygiene (United Nations Foundation, 2016). https://wateractionhub.org/wash4work/.
World Health Assembly Resolution: In May 2011, the WHO adopted this resolution asking Member States "to ensure that national health strategies contribute to the realization of water- and sanitation-related Millennium Development Goals while coming in support to the progressive realization of the human right to water and sanitation” (World Health Organization, 2011). http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_R24-en.pdf.
World Toilet Day: On November 19 every year, World Toilet Day seeks to raise global awareness of access to sanitation facilities. Coördinated by UN-Water, World Toilet Day is part of a campaign to ensure global access to toilets by 2030 (United Nations Water, 2016b). http://www.worldtoiletday.info/.
World Water Day: On March 22 every year, World Water Day focuses on actions that can be taken to work toward achieving universal access to safe drinking water. The new theme for this decade for action has been dedicated towards (United Nations Water, n.d.): “Water and Sustainable Development”, 2018 – 2028 (United Nations General Assembly, 2016). http://www.worldwaterday.org/.
Measuring water quality on a worldwide scale is critical for human health and well-being. Srebotnjak et al. (2012) provide the most comprehensive description of a global data system monitoring access to clean water and sanitation. They specify several components of such a system, including indicators that measure the distribution of access, quantity, continuity, and reliability of safe drinking water and sanitation facilities. They find an ideal water quality metric would be capable of being defined at both the local and national levels over multiple time periods in order for decisionmakers to allocate resources most effectively (Srebotnjak, Carr, de Sherbinin, & Rickwood, 2012).
There is currently no standard global data collection approach for obtaining a comparable metric of country-specific water quality. Poor data quality and international coverage hinder global water quality measurement efforts. Water quality measurement, for example, is influenced by the level of background pollution at the monitoring location, the flow of the water, and the likely end use of the water (Srebotnjak et al., 2012).
There are two primary methods of collecting data: administrative reports and censuses and surveys. The JMP used the administrative reports to monitor the MDGs and often experienced problems with data collection, standardization, and reporting methods (World Health Organization & United Nations Children’s Fund, 2015, p. 28). The JMP and Institute for Health Metrics and Evaluation (IHME) now use census and survey data to track water quality. This process has produced more comprehensive datasets. The JMP’s Access to Water dataset, however, lacks information on whether water is priced affordably and whether the water is actually safe for consumption (Cooley et al., 2013). Further work is needed to improve current methods to attain to the ideals laid out by Srebotnjak et al. (2012).
The 2018 EPI uses two indicators to measure the health risks from unsafe sanitation and drinking water globally: drinking water and sanitation. Data come from the IHME’s Global Health Data Exchange database (Institute for Health Metrics and Evaluation, 2017)and measure the number of age-standardized disability-adjusted life years (DALYs) lost per 100,000 persons – otherwise known as the DALY rate – from unsafe drinking water and sanitation.
We measure unsafe sanitation as the proportion of a country’s population exposed to health risks from their access to sanitation, defined by the primary toilet type used by households (Institute for Health Metrics and Evaluation, 2016). Adequate sanitation facilities help to reduce and prevent fecal pollution from entering the environment, thereby reducing the transmission of diseases. Unsafe sanitation exposure is classified by the primary toilet type used by households (Institute for Health Metrics and Evaluation, 2016). Improved sanitation sources must meet specific requirements. An “improved” sanitation facility is one that hygienically separates human excreta from human contact (World Health Organization & United Nations Children’s Fund, 2017, p. 50). “Improved” and “Unimproved” sources are classified by the JMP and described in Table 6–1.
|Source: World Health Organization & United Nations Children’s Fund, 2017, p. 50.|
|“Improved” Sanitation||“Unimproved” Sanitation||No facilities|
• Flush and pour flush toilets connected to sewers On-site sanitation
• Flush and pour flush toilets or latrines connected to septic tanks or pits
• Ventilated improved pit latrines
• Pit latrines with slabs
• Composting toilets, including twin pit latrines and container-based systems
• Pit latrines without slabs
• Hanging latrines
• Bucket latrines
The IHME data recognize access to improved sanitation does not guarantee of elimination of health risks. The Global Burden of Disease (GBD) project from IHME estimates the actual health outcomes from exposure to risks, and our indicator includes the health risks from all types of sanitation.
Menstrual hygiene management (MHM) is a critical issue, yet it remains a taboo subject in many cultures, often causing embarrassment. Inadequate MHM can affect one’s health and education and is a particularly severe problems in developing regions (World Health Organization, 2017a). It is estimated that poor menstrual hygiene causes approximately 70% of reproductive diseases in India (Venema, 2014). MHM may also jeopardize a girl’s chance at an education. Girls in India miss on average 5 days of school per month, and 23% drop out of school once they start menstruating due to the lack of clean sanitary facilities (Sinhal, 2011). Clean water and sanitation facilities are thus essential to manage menstruation hygienically.
In 2015, the Government of India recognized the public health and sanitation problem associated with inadequate MHM and released the first National Guidelines on Menstrual Hygiene Management (Government of India, 2015). India’s national guidelines are a first step to explicitly recognize that girls and women require access to a separate toilet with a private space for washing facilities and infrastructure for disposal of used menstrual products. India has 113 million adolescent girls, but a survey in 2015 found that only 53% of government schools have separate sanitation facilities for them (Government of India, 2015, p. 1). These measures are necessary to both improve self-worth among women and allow them to remain in school (Government of India, 2015).
Our drinking water indicator measures the proportion of a country’s population exposed to health risks from their access to drinking water, defined by the primary water source used by households and the household water treatment, or the treatment that happens at the point of water collection. Due to an absence of national data on the safety of drinking water for many countries, drinking water is the best currently available proxy for monitoring improved access to safe drinking water. It also uses the JMP definitions of water sources, shown in Table 6–2. The JMP defines an “improved” drinking water source as a facility or delivery point that protects water from external contamination (World Health Organization & United Nations Children’s Fund, 2017).
|Source: World Health Organization & United Nations Children’s Fund, 2017, p. 50.|
|“Improved” sources of drinking water||“Unimproved” sources of drinking water||No facilities|
• Tap water in the dwelling, yard or plot
• Public standposts
• Protected wells and springs
• Packaged water, including bottled water and sachet water
• Delivered water, including tanker trucks and small carts
• Unprotected wells and springs
Data for the sanitation and drinking water indicators come from IHME’s Global Burden of Disease (GBD) project. Data are available for years 2005–2016 for 195 countries (Institute for Health Metrics and Evaluation, 2016, p. 52). Exposure by country was estimated from the Global Health Data Exchange databases of household surveys and census reports. The modeling shows both the prevalence of households with improved sanitation or improved drinking water sources and the proportion of households with a sewer connection or piped water.
The GBD evaluates three adverse health outcomes from exposure to sanitation and drinking water: diarrheal diseases, typhoid fever, and paratyphoid fever. In conducting the GBD, IHME relies on the scientific literature to provide key assumptions and data about health risks (Institute for Health Metrics and Evaluation, 2016, p. 52). The epidemiological studies on diarrheal disease are much stronger than the studies on typhoid and paratyphoid. The gaps in the literature are an important source of uncertainty in GBD estimates.
Water quality assessments also rest on the assumption that “improved” water supplies are safe, but a significant amount of water supplies that meet the definition of an “improved” source still do not meet WHO guidelines (Clasen et al., 2014, p. 889). Water supplied through pipes may be contaminated, and groundwater may also be contaminated by faulty latrines, or the treatment of the water is inadequate (Clasen et al., 2014; Institute for Health Metrics and Evaluation, 2016).
There is an urgent need to ramp up sanitation efforts in India. About half of India’s population of 1.3 billion people still defecate and urinate in open areas (World Health Organization & United Nations Children’s Fund, 2015). Efforts to eliminate open defecation in Nadia, India’s first open defecation free district, present and interesting case for how similar districts might address the issue.
Nadia is a rural district in West Bengal with approximately 5.4 million people. In 2013, almost 40% of the Nadia’s population practiced open defecation (United States Agency for International Development Water Team, n.d.). To address this, the government of Nadia developed a campaign to end open defecation in their district. The Sabar Shouchagar (Toilets for All) initiative was launched in October 2013. In addition to subsidizing toilet construction, the initiative also addressed social norms and emphasized behavioral changes (World Bank, 2015). Program implementation included mass awareness campaigns, partnerships with local organizations, and a 10% user fee to cover the cost of toilet construction (Ghosh, 2015). The localized ownership of the Sabar Shouchagar initiative within local government allowed for collaboration across almost all departments in the region (World Bank, 2015). Similar regions or countries struggling to end open defecation at a large-scale may benefit from studying the good practices and successes of the Sabar Shouchagar initiative.
|Note: Metrics are in units of age-standardized Disability Adjusted-Life Years lost due to each risk. Current refers to data from 2016, and Baseline refers to historic data from 2005.|
Over the past decade, millions of people have obtained access to adequate drinking water and sanitation sources, and we find DALY’s have decreased for both indicators. Global trends show an improvement in the proportion of a country’s population exposed to health risks from their access to drinking water and sanitation. As a result, global drinking water and sanitation scores to increase by 7.76 and 8.15 points, respectively.
As the world population increases, the threat of deteriorating water quality remains an issue of global concern (United Nations Water, 2014). Substantial improvements in access safe drinking water and sanitation services still need to be made in many regions and, as seen in Maps 6–1 and 6–2, geographic inequalities in access are evident. Developed regions have made significant progress gaining access to safe drinking water and improving sanitation sources, while coverage is variable among developing countries. Most regions saw a decrease in the total amount of people practicing open defecation. WHO and UNICEF report that sub-Saharan Africa and Oceania, however, saw an increase in open defecation rates from 204 to 220 million, and from one to 1.3 million, respectively (World Health Organization & United Nations Children’s Fund, 2017).
Leaders & Laggards
Results for Water and Sanitation indicate that European countries have remained committed to providing sustainable access to drinking water and sanitation for the past decade. Greece, Iceland, Italy, Malta, and Spain all received scores of 100 in 2016 and in 2005. Other leaders in Water Quality – Finland, Ireland, the United Kingdom, Switzerland, and Norway – also received scores of over 95 this year and in previous iterations of the EPI. The European Union (EU) has implemented multiple policies spanning numerous decades that target water supply and sanitation. The Drinking Water Directive, adopted in 1998, aims "to protect human health from adverse effects of any contamination of water intended for human consumption by ensuring that it is wholesome and clean” (The Council of the European Union, 1998). The policies implemented in the EU, as well as policies in other countries at the top of the leaderboard, reflect sustained investment to clean drinking water and safe sanitation services (World Health Organization & United Nations Children’s Fund, 2015).
|180||Central African Republic||0|
All of the top ten laggards are located in sub-Saharan Africa, and the region is substantially behind the rest of the world in obtaining access to safe drinking water and adequate sanitation. Sub-Saharan Africa did not meet the MDG targets for both drinking water and sanitation. Over 300 million people still lack access to safe drinking water (World Health Organization & United Nations Children’s Fund, 2015). In fact, the number of people without access to sanitation has actually increased to almost 700 million people since 1990 (World Health Organization & United Nations Children’s Fund, 2015). The UN estimates that 115 people die every hour in Africa from diseases associated with contaminated drinking water and inadequate access to sanitation sources (United Nations, 2014). These numbers are of grave concern because of the health burden associated with a lack of access to drinking water and sanitation sources.
Population growth and poverty are the most important causal factors behind sub-Saharan Africa’s water status (United Nations, 2014). Rising populations in sub-Saharan Africa are driving demand for water. The number of people living in slums, often without water or sanitation infrastructure, is expected to double to approximately 400 million people by 2020, putting even more pressure on water provisions. The UN further estimates that about half of the population in sub-Saharan Africa is living on less than a dollar a day, making it the world’s poorest and least developed region (United Nations, 2014). Extensive poverty, along with rapid population growth, hinders efforts to provide safe and adequate drinking water and sanitation services in sub-Saharan Africa. Considerable action is still needed to ensure that safe drinking water and sanitation services are available worldwide.
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