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WASH (orWatSan,WaSH; stemming from the first letters of "water, sanitation and hygiene") is a sector indevelopment cooperation, or withinlocal governments, that provideswater,sanitation, andhygiene services to communities. The main purposes of providing access to WASH services are to achievepublic health gains, implement thehuman right to water and sanitation, reduce the burden of collecting drinking water for women, and improve education and health outcomes at schools and healthcare facilities. Access to WASH services is an important component ofwater security.[1] Universal, affordable, and sustainable access to WASH is a key issue withininternational development, and is the focus of the first two targets ofSustainable Development Goal 6 (SDG 6).[2] Targets 6.1 and 6.2 aim for equitable and accessible water and sanitation for all. In 2017, it was estimated that 2.3 billion people live without basic sanitation facilities, and 844 million people live without access to safe and clean drinking water.[3] Theacronym WASH is used widely bynon-governmental organizations andaid agencies indeveloping countries.
The WASH-attributableburden of disease and injuries has been studied in depth. Typical diseases and conditions associated with a lack of WASH includediarrhea,malnutrition, andstunting, in addition toneglected tropical diseases.[4] There are additional health risks for women, for example, duringpregnancy and birth, or in connection withmenstrual hygiene management.[5]Chronic diarrhea can have long-term negative effects on children in terms of both physical and cognitive development.[6] Still, collecting precise scientific evidence regarding health outcomes that result from improved access to WASH is difficult due to a range of complicating factors. Scholars suggest a need for longer-term studies of technological efficiency, greater analysis of sanitation interventions, and studies of the combined effects of multiple interventions to better analyze WASH health outcomes.[7]
Access to WASH is required not only at the household level but also in non-household settings like schools,healthcare facilities, workplaces, prisons, temporary use settings and for dislocated populations.[8] In schools, group handwashing facilities can improve hygiene. Lack of WASH facilities at schools often causes female students to not attend school, thus reducing their educational achievements.[9]
It is difficult to provide safely managed WASH services in urbanslums.WASH systems can also fail quite soon after installation (e.g., leakingwater distribution systems). Further challenges includepolluted water sources and theimpacts of climate change on water security. Planning approaches for more reliable and equitable access to WASH include, for example, national WASH plans and monitoring,women's empowerment,[10] and improving theclimate resilience of WASH services.Adaptive capacity in water management systems can help to absorb some of the impacts of climate-related events and increase climate resilience.[1]: 25 Stakeholders at various scales, for example, from small urban utilities to national governments, need to have access to reliable information about the regional climate and any expected changes due toclimate change.
The WASH concept groups together the various aspects ofwater supply, including access todrinking water services,sanitation, andhygiene because the impact of deficiencies in each area overlap strongly.
WHO andUNICEF state that a safe drinking water service is one that is located in an accessible location, available when needed, and uncontaminated.[11] Additionally,WHO andUNICEF use the termsimproved water source and unimproved water source as a water quality monitoring tool. The term "improved water source" refers to piped water on premises. Examples include a piped household water connection located inside the user's dwelling plot or yard, and other improved drinking water sources such as public taps orstandpipes,tube wells orboreholes, protected dugwells, protectedsprings, andrainwater collection.[12]
Access to drinking water is included in Target 6.1 ofSustainable Development Goal 6 (SDG 6), which states: "By 2030, achieve universal and equitable access to safe and affordabledrinking water for all."[13] This target's single indicator, Indicator 6.1.1, which states "Proportion of population using safely managed drinking water services."[14] In 2017, 844 million people still lacked even a basic drinking water service.[3]: 3 In 2019, it was reported that 435 million people used unimproved sources for their drinking water, and 144 million still usedsurface water, such as lakes and streams.[15]
Drinking water can be sourced from the following water sources: surface water,groundwater, or rainwater, in each case after collection, treatment, and distribution.Desalinatedseawater is another potential source for drinking water.
People without access to safe, reliable, domestic water supplies face lowerwater security at specific times throughout the year due to cyclical changes in water quantity or quality.[16][17] For example, where access to water on-premises is not available, drinkingwater quality at thepoint of use (PoU) can be much worse compared to the quality at the point of collection (PoC). Correct household practices around hygiene, storage, and treatment are therefore important. There are interactions between weather, water source, and management, and these in turn impact drinking water safety.[18]
Groundwater provides criticalfreshwater supply, particularly in dry regions where surface water availability is limited.[19] Globally, more than one-third of the water used originates from underground. In the mid-latitudearid and semi-arid regions lacking sufficient surface water supply from rivers and reservoirs, groundwater is critical for sustaining global ecology and meeting societal needs of drinking water and food production. The demand for groundwater is rapidly increasing with population growth, while climate change is imposing additional stress on water resources and raising the probability of severe drought occurrence.[19]
Theanthropogenic effects on groundwater resources are mainly due togroundwater pumping and the indirect effects ofirrigation and land use changes.[19]
Groundwater plays a central role in sustaining water supplies and livelihoods insub-Saharan Africa.[20] In some cases, groundwater is anadditional water source that was not used previously.[17]
Reliance on groundwater is increasing in sub-Saharan Africa as development programs work towards improving water access and strengthening resilience to climate change.[21] Lower-income areas typically install groundwater supplies without water quality treatment infrastructure or services. The assumption that untreated groundwater is typically suitable for drinking due to its relative microbiological safety compared to surface water underpins this practice, largely disregarding chemistry risks.[21] Chemical contaminants occur widely in groundwater sources that are used for drinking but are not regularly monitored. Example priority parameters arefluoride,arsenic,nitrate, orsalinity.[21]
Sanitation systems are grouped into several types. The ladder of sanitation services includes (from lowest to highest):open defecation,unimproved, limited, basic, safely managed.[22]: 8 A distinction is made between sanitation facilities that are shared between two or more households (a "limited service") and those that are not shared (a "basic service"). The definition of improved sanitation facilities is facilities designed to hygienically separate excreta from human contact.[22]: 8
With regard totoilets, improved sanitation includes the following types of toilets:flush toilet, connections to a pipedsewer system,septic systems, pour-flush pit latrines,pit latrines with slabs,ventilated improved pit latrines, andcomposting toilets.[23]
Access to sanitation services is included in Target 6.2 of Sustainable Development Goal 6, which is: "By 2030, achieve access to adequate and equitablesanitation andhygiene for all and endopen defecation, paying special attention to the needs of women and girls and those in vulnerable situations."[24] This target has one indicator: Indicator 6.2.1 which states "proportion of population using (a) safely managed sanitation services and (b) a hand-washing facility with soap and water".[24]
In 2017, 4.5 billion people did not have toilets at home that could safely manage waste, despite improvements in access to sanitation over the past decades.[25] Approximately 600 million people share a toilet or latrine with other households, and 892 million people practiceopen defecation.[25]
There are many barriers that make it difficult to achieve sanitation for all. These include social, institutional, technical and environmental challenges.[26] Therefore, the problem of providing access to sanitation services cannot be solved by focusing on technology alone. Instead, it requires an integrated perspective that includes planning, using economic opportunities (e.g. fromreuse of excreta), andbehavior change interventions.[27][28]
Sanitation services would not be complete without safefecal sludge management (FSM), which is the storage, collection, transport, treatment, and safe end use or disposal of fecal sludge.[29]: 3 Fecal sludge is defined very broadly as what accumulates inonsite sanitation systems (e.g.pit latrines,septic tanks andcontainer-based solutions) and specifically is not transported through asewer.[29]: 5 Sanitation workers are the people needed for cleaning, maintaining, operating, or emptying asanitation technology at any step of thesanitation chain.[30]: 2
Hygiene is a broad concept. "Hygiene refers to conditions and practices that help to maintain health and prevent the spread ofdiseases."[31] Hygiene can comprise many behaviors, includinghand washing,menstrual hygiene andfood hygiene.[22]: 18 In the context of WASH, hand washing with soap and water is regarded as a top priority in all settings and has been chosen as an indicator for national and global monitoring of hygiene access. "Basic hygiene facilities" are those where people have a hand washing facility with soap and water available on their premises.[22]: 18 Hand washing facilities can consist of a sink withtap water, buckets with taps,tippy-taps, and portable basins.[22]: 18
In the context of SDG 6, hygiene is included in the indicator for Target 6.2: "Proportion of population using [...] (b) a hand-washing facility with soap and water"[13]
In 2017, the global situation was reported as follows: Only 1 in 4 people in low-income countries had hand washing facilities with soap and water at home; only 14% of people in Sub-Saharan Africa have hand washing facilities.[3] Worldwide, at least 500 million women and girls lack adequate, safe, and private facilities formanaging menstrual hygiene.[32]
Approximately 40% of the world's population live without basic hand washing facilities with soap and water at home.[33]
The purposes of providing access to WASH services include achievingpublic health gains, improvinghuman dignity in the case ofsanitation, implementing thehuman right to water and sanitation, reducing the burden of collecting drinking water for women, reducing risks ofviolence against women, improving education and health outcomes at schools and health facilities, and reducingwater pollution. Access to WASH services is also an important component of achieving water security.[1]
Improving access to WASH services can improve health, life expectancy, student learning,gender equality, and other important issues ofinternational development.[34] It can also assist withpoverty reduction and socioeconomic development.[6]
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Health impacts resulting from a lack of safe sanitation systems fall into three categories:[36]: 2
TheWHO has investigated which proportion of death and disease worldwide can be attributed to insufficient WASH services. In their analysis they focus on the following four health outcomes:diarrhea,acute respiratory infections,malnutrition, and soil-transmittedHelminthiasis (STHs).[37]: vi These health outcomes are also included as an indicator for achievingSustainable Development Goal 3 ("Good Health and Well-being"): Indicator 3.9.2 reports on the "mortality rate attributed to unsafe water, sanitation, and lack of hygiene".
In 2023,WHO summarized the available data with the following key findings: "In 2019, use of safe WASH services could have prevented the loss of at least 1.4 million lives and 74 milliondisability-adjusted life years (DALYs) from four health outcomes. This represents 2.5% of all deaths and 2.9% of all DALYs globally."[37]: vi Of the four health outcomes studied, it wasdiarrheal disease that had the most striking correlation, namely the highest number of "attributableburden of disease": over 1 million deaths and 55 million DALYs from diarrheal diseases were linked with lack of WASH. Of these deaths, 564,000 deaths were linked to unsafe sanitation in particular.
Acuterespiratory infections were the second largest cause of WASH-attributable burden of disease in 2019, followed bymalnutrition andsoil-transmitted helminthiasis. The latter does not lead to such high death numbers (in comparison) but is fully connected to unsafe WASH; its "population-attributable fraction" is estimated to be 100%.[37]: vi
The connection between lack of WASH and burden of disease is primarily one of poverty and poor access in developing countries: "the WASH-attributable mortality rates were 42, 30, 4.4 and 3.7 deaths per 100 000 population in low-income, lower-middle income, upper-middle income and high-income countries, respectively."[37]: vi The regions most affected are in the WHO Africa andSouth-East Asia regions. Here, between 66% and 76% of the diarrheal disease burden could be prevented if access to safe WASH services was provided.[37]: vi
Most of the diseases resulting from lack of sanitation have a direct relation to poverty. For example,open defecation – which is the most extreme form of "lack of sanitation" – is a major factor in causing various diseases, most notably diarrhea andintestinal worm infections.[38][39]
An earlier report byWorld Health Organization which analyzed data up to 2016 had found higher values: "The WASH-attributable disease burden amounts to 3.3% of global deaths and 4.6% of global DALYs. Among children under 5 years, WASH-attributable deaths represent 13% of deaths and 12% of DALYs. Worldwide, 1.9 million deaths and 123 millionDALYs could have been prevented in 2016 with adequate WASH."[40] An even earlier study from 2002 had estimated even higher values, namely that up to 5 million people die each year from preventablewaterborne diseases.[41] These changes in the estimates of death and disease can partly be explained by the progress that has been achieved in some countries in improving access to WASH. For example, several large Asian countries (China,India,Indonesia) have managed to increase the "safely managed sanitation services" in their country from the year 2015 to 2020 by more than 10% points.[37]: 26
There are at least the following twelve diseases which are more likely to occur when WASH services are inadequate:[40]
There are also other diseases where adverse health outcomes are likely to be linked to inadequate WASH but which are not yet quantified. These include for example:[40]
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Diarrhea is primarily transmitted throughfecal–oral routes. In 2011, infectious diarrhea resulted in about 0.7 million deaths in children under five years old and 250 million lost school days.[38][42] This equates to about 2000 child deaths per day.[43] Children suffering from diarrhea are more vulnerable to becomeunderweight (due tostunted growth).[44][45] This makes them more vulnerable to other diseases such asacute respiratory infections andmalaria. Chronic diarrhea can have a negative effect on child development (both physical andcognitive).[6]
Numerous studies have shown that improvements in drinking water and sanitation (WASH) lead to decreased risks of diarrhea.[46] Such improvements might include for example, the use ofwater filters, provision of high-qualitypiped water andsewer connections.[46] Diarrhea can be prevented - and the lives of 525,000 children annually be saved (estimate for 2017) - byimproved sanitation, cleandrinking water, andhand washing with soap.[47] In 2008 the same figure was estimated as 1.5 million children.[48]
The combination of direct and indirect deaths frommalnutrition caused by unsafe water, sanitation and hygiene (WASH) practices was estimated by the World Health Organization in 2008 to lead to 860,000 deaths per year in children under five years of age.[49] The multiple inter-dependencies betweenmalnutrition and infectious diseases make it very difficult to quantify the portion of malnutrition that is caused by infectious diseases which are in turn caused by unsafe WASH practices. Based on expert opinions and a literature survey, researchers atWHO arrived at the conclusion that approximately half of all cases of malnutrition (which often leads to stunting) in children under five is associated with repeated diarrhea or intestinal worm infections as a result of unsafe water, inadequate sanitation or insufficient hygiene.[49]
Water, sanitation and hygiene interventions help to prevent manyneglected tropical diseases (NTDs), for examplesoil-transmitted helminthiasis.[50] Approximately two billion people are infected withsoil-transmitted helminths worldwide.[51] This type of intestinal worm infection is transmitted via worm eggs in feces which in turn contaminate soil in areas where sanitation is poor.[52] An integrated approach to NTDs and WASH benefits both sectors and the communities they are aiming to serve.[53] This is especially true in areas that are endemic with more than one NTD.[50]
Since 2015, theWorld Health Organization (WHO) has a global strategy and action plan to integrate WASH with otherpublic health interventions in order to accelerate elimination of NTDs.[54] The plan aimed to intensify control or eliminate certain NTDs in specific regions by 2020.[55] It refers to the NTD roadmap milestones that included, for example, eradication ofdracunculiasis by 2015 and ofyaws by 2020, elimination oftrachoma andlymphatic filariasis as public health problems by 2020, intensified control ofdengue,schistosomiasis and soil-transmitted helminthiases.[56] The plan consists of four strategic objectives: improving awareness of benefits of joint WASH and NTD actions; monitoring WASH and NTD actions to track progress; strengthening evidence of how to deliver effective WASH interventions; and planning, delivering and evaluating WASH and NTD programs with involvement of allstakeholders.[57]
Women tend to face a higher risk of diseases and illness due to limited WASH access.[58][59] In their thirdtrimester, pregnant women face severe hardship walking to and from a water collection site. The consumption of unclean water leading to infection in thefetus accounts for 15% of deaths for women during pregnancy globally.[58] Illnesses and diseases that can come from poormenstrual hygiene management become more likely when clean water and toilets are unavailable.[60] InBangladesh and India, women rely on old cloths to absorb menstrual blood and use water to clean and reuse them. Without access to clean water and hygiene, these women my experience unnecessary health problems in connection with their periods.[60]
Occupational safety and health issues for sanitation workers include: diseases related to contact with the excreta; injuries related to the physical effort of extracting and transporting the waste, includingfalls from height; injuries related to cuts from non-fecal waste (e.g. glass or needles) disposed of down the toilet.[61][62] There are also the general dangers of working inconfined spaces, including lack of oxygen.[63]
Many sanitation workers in developing countries work without any form ofpersonal protective equipment (PPE) and no or minimal formal training.[64]: 9 Physical and medical conditions directly associated with sanitation work that is carried out unsafely can include: "headaches, dizziness, fever, fatigue, asthma,gastroenteritis,cholera,typhoid, hepatitis, polio, cryptosporidiosis, schistosomiasis, eye and skin burn and other skin irritation, musculoskeletal disorders (including back pain), puncture wounds and cuts, blunt force".[64]: 8Global climate change can increase the health risks for some of the infectious diseases mentioned above. See below in the section onnegative impacts of climate change.[37]
There is debate in the academic literature about the effectiveness on health outcomes when implementing WASH programs in low- and middle-income countries. Many studies provide poor quality evidence on the causal impact of WASH programs on health outcomes of interest. The nature of WASH interventions is such that high quality trials, such asrandomized controlled trials (RCTs), are expensive, difficult and in many cases not ethical. Causal impact from such studies are thus prone to being biased due toresidual confounding.[65] Blind studies of WASH interventions also pose ethical challenges and difficulties associated with implementing new technologies or behavioral changes without the knowledge of the involved participants.[66] Moreover, scholars suggest a need for longer-term studies of technology efficacy, greater analysis of sanitation interventions, and studies of combined effects from multiple interventions in order to more sufficiently gauge WASH health outcomes.[7]
Many scholars have attempted to summarize the evidence of WASH interventions from the limited number of high quality studies. Hygiene interventions, in particular those focusing on the promotion of handwashing, appear to be especially effective in reducingmorbidity. Ameta-analysis of the literature found that handwashing interventions reduced the relative risk of diarrhea by approximately 40%.[67][66] Similarly, handwashing promotion has been found to be associated with a 47% decrease in morbidity. However, a challenge with WASH behavioral intervention studies is an inability to ensure compliance with such interventions, especially when studies rely onself-reporting of disease rates. This prevents researchers from concluding a causal relationship between decreased morbidity and the intervention. For example, researchers may conclude that educating communities about handwashing is effective at reducing disease, but cannot conclude that handwashing reduces disease.[66]Point-of-use water supply and point-of-use water quality interventions also show similar effectiveness to handwashing, with those that include provision of safe storage containers demonstrating increased disease reduction in infants.[7]
Specific types of water quality improvement projects can have a protective effect on morbidity andmortality. A randomized control trial in India concluded that the provision ofchlorine tablets for improving water quality led to a 75% decreased incidence ofcholera among the study population.[68] A quasi-randomized study on historical data from the United States also found that the introduction of clean water technologies in major cities was responsible for close to half the reduction in totalmortality and over three-quarters of the reduction in infant mortality.[69] Distributing chlorine products, or other water disinfectants, for use in the home may reduce instances of diarrhea.[70] However, most studies on water quality improvement interventions suffer from residual confounding or poor adherence to the mechanism being studied. For instance, a study conducted inNepal found that adherence to the use of chlorine tablets or chlorine solution to purify water was as low as 18.5% among program households.[68] A study on awater well chlorination program inGuinea-Bissau in 2008 reported that families stopped treating water within their households because of the program which consequently increased their risk ofcholera. It was concluded that well chlorination without proper promotion and education led to a false sense of security.[68]
Studies on the effect of sanitation interventions alone on health are rare.[67] When studies do evaluate sanitation measures, they are mostly included as part of a package of different interventions.[66] A pooled analysis of the limited number of studies on sanitation interventions suggest that improving sanitation has a protective effect on health.[71][67] AUNICEF funded sanitation intervention (packaged into a broader WASH intervention) was also found to have a protective effect on under-five diarrhea incidence but not on household diarrhea incidence.[72]
Women and girls are particularly burdened from lack of proper WASH services.[10][73] Inadequate access to water and sanitation affect women and girls in several ways because of social norms in some cultures that position them as principal household water collectors and managers, the inability tourinate easily outside of an unclean stall or where no toilets are nearby, and due to the effects ofmenstruation beginning duringpuberty. These effects include low participation in thelabor market and community activities, adversebiomedical outcomes,psychosocial stress, and poor educational outcomes.[73] Women and girls often bear higher health and social costs associated with water and sanitation insecurity than men and boys, such as higher exposure to water-related disease,discriminatorytaboos, and unrealized economic productivity.[10]
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The lack of accessible, sufficient, clean and affordablewater supply has adverse impacts specifically related to women indeveloping nations.[58] It is estimated that 263 million people worldwide spent over 30 minutes per round trip to collect water from an improved source.[3]: 3 Insub-Saharan Africa, women and girls carry water containers for an average of three miles each day, spending 40 billion hours per year on water collection (walking to the water source, waiting in line, walking back).[74]: 14 The time to collect water can come at the expense of education, income generating activities, cultural and political involvement, and rest and recreation.[75]: 2 For example, in low-income areas ofNairobi, women carry 44 pound containers of water back to their homes, taking anywhere between an hour and several hours to wait and collect the water.[76]: 733
In many places of the world, getting and providing water is considered "women's work," sogender and water access are intricately linked.[77]: 256 Water gathering and supply to family units remains primarily a woman's task inless developed countries where water gathering is considered a main chore.[77]: 256 This water work is also largely unpaid household work based onpatriarchal gender norms and often related to domestic work, such aslaundry, cooking and childcare.[78]: 5 Areas that rely on women to primarily collect water include countries inAfrica,South Asia and in theMiddle East.[78]: 4
Women and girls usually bear the responsibility for collecting water, which is often very time-consuming andarduous, and can also be dangerous for them.[79] Women and girls who collect water may also facephysical assault andsexual assault along the way (violence against women).[80] This includesvulnerability torape when collecting water from distant areas,domestic violence over the amount of water collected, and fights over scarce water supply.[81] A study inIndia, for example, found that women felt intense fear ofsexual violence when accessing water and sanitation services.[82] A similar study inUganda also found that women reported to feel a danger for their security whilst journeying to toilets, particularly at night.[82]
Gender norms can negatively affect how men and women access water through such behavior expectations along gender lines—for example, when water collection is a woman's chore, men who collect water may facediscrimination for performing perceived women's work.[83] Women are likely to be deterred from enteringwater utilities in developing countries because "social norms prescribe that it is an area of work that is not suitable for them or that they are incapable of performing well".[84]: 13 Nevertheless, a study byWorld Bank in 2019 has found that the proportion of female water professionals has grown in the past few years.[84]: x
In many societies, the task of cleaning toilets falls to women or children, which can increase their exposure to disease.[83]: 19
Non-household settings for WASH include the following six types: schools, health care facilities, workplaces (including prisons), temporary use settings, mass gatherings, and dislocated populations.[8]
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More than half of all primary schools in thedeveloping countries with available data do not have adequate water facilities and nearly two thirds lack adequate sanitation.[85] Even where facilities exist, they are often in poor condition. Children are able to more fully participate in school when there is improved access to water.[78]: 24
Lack of WASH facilities can prevent students from attending school, particularly female students.[9] Strong cultural taboos aroundmenstruation, which are present in many societies, coupled with a lack ofMenstrual Hygiene Management services in schools, results in girls staying away from school during menstruation.[86]
Reasons for missing or poorly maintained water and sanitation facilities at schools in developing countries include lacking intersectoral collaboration; lacking cooperation between schools, communities and different levels of government; as well as a lack inleadership andaccountability.[87]
WASH in schools, sometimes called SWASH or WinS, significantly reduces hygiene-related disease, increases student attendance and contributes to dignity andgender equality.[85] WASH in schools contributes to healthy, safe and secure school environments. It can also lead to children becoming agents of change for improving water, sanitation and hygiene practices in their families and communities.[85]
For example, data from over 10,000 schools inZambia was analyzed in 2017 and confirmed that improved sanitation provision in schools was correlated with high female-to-male enrollment ratios, and reduced repetition and drop-out ratios, especially for girls.[88]
Methods to improve the situation of WASH infrastructure at schools include, on a policy level: broadening the focus of the education sector, establishing a systematic quality assurance system, distributing and using funds wisely.[87] Other practical recommendations include: have a clear and systematic mobilization strategy, support the education sector to strengthen intersectoral partnerships, establish a constant monitoring system which is located within the education sector, educate the educators and partner with the school management.[87]
The support provided bydevelopment agencies to the government at national, state and district levels is helpful to gradually create what is commonly referred to as anenabling environment for WASH in schools.[89][90]
Success also hinges on local-level leadership and a genuine collective commitment of schoolstakeholders towards school development. This applies to students and their representative clubs, headmaster, teachers and parents. Furthermore, other stakeholders have to be engaged in their direct sphere of influence, such as: community members,community-based organizations, educations official,local authorities.[91][92]
Supervised daily grouphandwashing in schools is an effective strategy for building goodhygiene habits, with the potential to lead to positive health and education outcomes for children.[93] This has for example been implemented in the "Essential Health Care Program" by theDepartment of Education in the Philippines.[94]Mass deworming twice a year, supplemented by washing hands daily with soap and brushing teeth daily withfluoride, is at the core of this national program. It has also been successfully implemented inIndonesia.[95][96]
The provision of adequate water, sanitation and hygiene is an essential part of providing basic health services inhealthcare facilities. WASH in healthcare facilities aids in preventing the spread of infectious diseases as well as protects staff and patients. WASH services in health facilities indeveloping countries are currently often lacking.[97]
According to theWorld Health Organization, data from 54 countries in low and middle income settings representing 66,101 health facilities show that 38% of health care facilities lackimproved water sources, 19% lackimproved sanitation while 35% lack access to water and soap for handwashing. The absence of basic WASH amenities compromises the ability to provide routine services and hinders the ability to prevent and control infections. The provision of water in health facilities was the lowest in Africa, where 42% of healthcare facilities lack an improved source of water on-site or nearby. The provision of sanitation is lowest in the Americas with 43% of health care facilities lacking adequate services.[97]
In 2019, WHO estimated that: "One in four health care facilities lack basic water services, and one in five have no sanitation service – impacting 2.0 and 1.5 billion people, respectively." Furthermore, it is estimated that "health care facilities in low-income countries are at least three times as likely to have no water service as facilities in higher resource settings". This is thought to contribute to the fact thatmaternal sepsis is twice as great in developing countries as it is inhigh income countries.[98]: vii
Barriers to providing WASH in health care facilities include: Incomplete standards, inadequate monitoring, disease-specific budgeting,disempoweredworkforce, poor WASH infrastructure.[98]: 14
The improvement of WASH standards within health facilities needs to be guided by national policies and standards as well as an allocated budget to improve and maintain services.[97] A number of solutions exist that can considerably improve the health and safety of both patients and service providers at health facilities:[99][100]
Improving access to hand washing and sanitation facilities in healthcare settings will significantly reduce infection and mortality rates, particularly inmaternal andchild health.[33]
In developing countries,prison buildings are very often overcrowded and dilapidated.[101]: 12 A report byICRC states that "Measures depriving persons of their freedom must in no way, whatever the circumstances, be made more severe by treatment or material conditions of detention which undermine the dignity and the rights of the individual."[101]: 12 The water supply systems and sanitary facilities in prisons are often insufficient to meet the needs of the prison population in cases where the number ofdetainees exceeds a prison's capacity.[101] Overuse of the facilities results in rapid deterioration.
The budget allocated by the State for prisons is often insufficient to cover the detainees' needs in terms of food and medical care, let alone upkeep of water and sanitation facilities.[101]: 12 Nevertheless, even with limited funds, it is possible to maintain or renovate decaying infrastructure with the right planning approaches and suitable low-cost water supply and sanitation options.
There are inequalities in access to water, sanitation and hygiene services.[15]: 11 Such inequalities are for example related to income level and gender. In 2019 in 24 countries where disaggregated data was available, basic water coverage among the richest wealthquintile was at least twice as high as coverage among the poorest quintile.[15] For example, inBangladesh,minority ethnic groups have lower levels of access to WASH than the rest of the Bengali population.[102] This is due to "structural racial discrimination" in Bangladesh.[102]
Access to WASH services also varies internally within nations depending onsocioeconomic status, political power, and level ofurbanization. In 2004 it was found that urban households are 30% and 135% more likely to have access to improved water sources and sanitation respectively, as compared to rural areas.[103]
Thehuman rights to water and sanitation prohibit discrimination on the grounds of "race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, disability or other status". These are all dimensions of inequality in WASH services.[15]: 13
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There are three main barriers to improvement of urban services in slum areas: Firstly, insufficient supply, especially of networked services. Secondly, there are usually demand constraints that limit people's access to these services (for example due to low willingness to pay).[104] Thirdly, there are institutional constraints that prevent the poor from accessing adequate urban services.[105]
Water supply sources includesurface water andgroundwater. These important water resources are often at risk of being polluted or overused.
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The failures ofwater supply system (such aswater points,wells andboreholes) and sanitation systems have been well documented.[110][26] This has been attributed to financial costs, inadequate technical training for operations and maintenance, poor use of new facilities and taught behaviors, and a lack of community participation and ownership.[111] The poorest populations often cannot afford fees required for operation and maintenance of WASH infrastructure, preventing them from benefitting even when systems do exist.[103]
Contamination of water indistribution systems is a challenge and can contribute to the spread ofwaterborne diseases.[103]
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Asanitation worker (or sanitary worker) is a person responsible for cleaning, maintaining, operating, or emptying the equipment or technology at any step of thesanitation chain.[64]: 2 This is the definition used in the narrower sense within the WASH sector. More broadly speaking, sanitation workers may also be involved in cleaningstreets,parks,public spaces,sewers,stormwater drains, andpublic toilets.[112] Another definition is: "The moment an individual's waste is outsourced to another, it becomes sanitation work."[113]: 4 Some organizations use the term specifically formunicipal solid waste collectors, whereas others exclude the workers involved in management ofsolid waste (rubbish, trash) sector from its definition.
Sanitation workers are essential in maintaining safe sanitation services in homes, schools, hospitals, and other settings and protecting public health but face many health risks in doing so, including from exposure to a wide range of biological and chemical agents. Additionally, they may be at risk of injury from heavy labor, poor and prolonged postures and positions andconfined spaces, as well aspsychosocial stress. These risks are exacerbated under conditions of poverty, illness, poor nutrition, poor housing,child labor, migration, drug and alcohol abuse, discrimination,social stigma and societal neglect. In manydeveloping countries, sanitation workers are "more vulnerable due to unregulated or unenforced environmental and labor protections, and lack ofoccupational health and safety".[114]Water and sanitation services contribute togreenhouse gas emissions. These emissions are grouped into three scopes in the international greenhouse gas protocol: direct emissions, as well as two types of indirect emissions (see below).[115][116]: 9
Scope 1 includes "direct emissions resulting directly from the activity". In the WASH sector, this ismethane andnitrous oxide emissions duringwastewater andsewage sludge treatment. Sanitation services produce about 2–6% of global human-causedmethane emissions.[117]Septic tanks,pit latrines,anaerobic lagoons,anaerobic digesters are all anaerobic treatment processes that emit methane which may or may not be captured (in the case of septic tanks it is usually not captured).
It has been estimated, using data from 2012 and 2013, that "wastewater treatment in centralized facilities contributes alone some 3% of global nitrous oxide emissions and 7% of anthropogenic methane emissions".[116]: 11 Data from 2023 from centralized sewage treatment plants in the United States indicate that methane emissions are about twice the estimates provided by IPCC in 2019, i.e. 10.9 ± 7.0 compared to 4.3-6.1 MMT (million metric tons) CO2-eq/yr.[118][119]
Current methods for estimating sanitation emissions underestimate the significance of methane emissions fromnon-sewered sanitation systems (NSSS).[120] This is despite the fact that such sanitation systems are prevalent in many countries.[120] NSSS play a vital role in the safe management of fecal sludge and account for approximately half of all existing sanitation provisions. The global methane emissions from NSSS in 2020 was estimated to be 377 Mt CO2e/year or 4.7% of global anthropogenic methane emissions. This is comparable to the greenhouse gas emissions from conventionalwastewater treatment plants.[120] Therefore, the GHG emissions from the non-sewered sanitation systems are a non-negligible source. India and China contribute extensively to methane emissions of NSSS because of their large populations and NSSS utilization.[120]
Scope 2 includes "indirect emissions associated with the energy required by the activity". Companies that deal with water and wastewater services need energy for various processes. They use theenergy mix that is available in the country. The higher the proportion offossil fuels in the energy mix is, the higher the GHG emissions under Scope 2 will be high too.[116]: 12 The processes that need energy include:water abstraction (e.g. groundwater pumping), drinking water storage, water conveyance,water treatment,water distribution,treatment of wastewater, water end use (e.g.water heating),desalination andwastewater reuse.[116]: 20–24 For example, electrical energy is needed for pumping of sewage and for mechanical aeration inactivated sludge treatment plants.
When looking at the emissions from the sanitation and wastewater sector most people focus on treatment systems, particularly treatment plants. This is because treatment plants require considerable energy input and are estimated to account for 3% of global electricity consumption.[121] This makes sense for high-income countries, where wastewater treatment is the biggest energy consumer compared to other activities of the water sector.[116]: 23 The aeration processes that are used in manysecondary treatment processes are particularly energy intensive (using about 50% of the total energy required for treatment).[116]: 24 The amount of energy needed to treat wastewater depends on several factors: wastewater quantity and quality (i.e. how much and how polluted is it), treatment level required which in turn influences the type of treatment process that gets selected.[116]: 23 The energy efficiency of the treatment process is another factor.[116]: 23
| Parameter | Value | Additional comments | Source | Year of estimate |
|---|---|---|---|---|
| Total energy used by water sector worldwide | 1400 TWh | [116]: 20 | 2014 | |
| Proportion of total energy used as electricity | 60% | Mostly for pumping up groundwater for irrigation. | [116]: 20 | 2014 |
| Proportion of total energy used as thermal energy | 40% | [116]: 20 | 2014 | |
| Percentage of global electricity consumption used by the water sector | 4% | The energy for the use of water by end users (e.g. heating up water) is not included. | [116]: 20 | 2014 |
| Usage breakdown for electricity consumed for water supply | Water extraction: 40% Wastewater treatment: 25% Water distribution: 20%Seawater desalination: 5% | [116]: 20 | 2014 | |
| Percentage of global electricity consumption used for wastewater treatment plants | 3% | [121] | 2020 |
Scope 3 includes "indirect emissions related to the activity but caused by other organizations". The indirect emissions under Scope 3 are difficult to assess in a standardized way. They include for example emissions from constructing infrastructure, from the manufacture of chemicals that are needed in the treatment process and from the management of the by-product sewage sludge.[116]: 12
Solutions exist to reduce the greenhouse gas emissions of water and sanitation services.[122] These solutions into three categories which partly overlap: Firstly "reducing water and energy consumption through lean and efficient approaches"; secondly "embracingcircular economy to produce energy and valuable products"; and thirdly by "planning to reduce GHG emissions through strategic decisions".[116]: 28 The mentionedlean and efficient approaches include for example finding ways to reduce water loss from water networks and to reduce infiltration of rainwater or groundwater into sewers.[116]: 29 Also, incentives can to encourage households and industries toreduce their water consumption and their energy requirements forwater heating.[116]: 31 There is another method to reduce the energy requirements for the treatment of raw water to make drinking water out of it: protecting the quality of the source water better.[116]: 32
Methods that fall into the category ofcircular economy include:Reusing water, nutrients and materials; Low-carbon energy production (e.g.solar power on roofs of utility buildings,recovery of waste heat from wastewater, producinghydro-electricity by installingmicro-turbines, producing energy frombiosolids andsewage sludge.[116]: 33–37 Strategic decisions around reducing GHG emissions include: awareness raising and education, governance that supports changing practices, providing economic incentive to conserve water and reduce consumption, and finally choosing low-carbon energy and supplies.[116]: 38–39
Theeffects of climate change can have negative impacts on existing sanitation services in several ways, for example by damage and loss of services fromfloods and reduced carrying capacity of waters receiving wastewater.[122][123][37]: 23 The weather and climate-related aspects (variability, seasonality andextreme weather events) have always had an impact on the delivery of sanitation services.[124]: 3 But now, extreme weather events, such as floods anddroughts, are generally increasing in frequency and intensity due to climate change in many regions.[125]: 1157 They affect the operation ofwater supply,storm drainage andsewerage infrastructure, andwastewater treatment plants.[126]
Changes in the frequency and intensity of climate extremes could compound current challenges as water availability becomes more uncertain, and health risks increase due to contaminated water sources.[127] The effects of climate change can result in a decrease of water availability, an increase of water necessity, damage to WASH facilities, and increased water contamination from pollutants.[123][37]: 23 Due to these impacts, climate change can "exacerbate many WASH-related risks and diseases".[37]: 23
Climate change poses increased risks to WASH systems, particular in Sub-Saharan Africa where access tosafely managed basic sanitation is low.[128] In that region, it is the poorly managed WASH systems, for example in informal settlements, which make people morevulnerable to the effects of climate change than people elsewhere.[129][130]
In terms of thewater cycle, climate change can affect the amounts of soil infiltration, deeperpercolation, and hencegroundwater recharge.[19] Also, rising temperature increasesevaporative demand over land, which limits the amount of water to replenish groundwater.[19]
Globalclimate change has increased the occurrence of someinfectious diseases.[131] Infectious diseases whose transmission is impacted by climate change include, for example,vector-borne diseases likedengue fever,malaria,tick-borne diseases,leishmaniasis,zika fever,chikungunya andEbola. One mechanism contributing to increased disease transmission is that climate change is altering the geographic range and seasonality of the insects (ordisease vectors) that can carry the diseases.[132] Scientists stated a clear observation in 2022: "The occurrence of climate-relatedfood-borne andwaterborne diseases has increased."[133]: 11
Infectious diseases that are sensitive to climate can be grouped into: vector-borne diseases (transmitted viamosquitos,ticks etc.),waterborne diseases (transmitted via viruses or bacteria through water), andfood-borne diseases (spread through pathogens via food).[134]: 1107 Climate change affects the distribution of these diseases due to the expanding geographic range and seasonality of these diseases and their vectors.[135]: 9 Like other ways climate change affectshuman health, climate change exacerbates existing inequalities and challenges in managing infectious disease.
Rising temperatures are increasing the areas where dengue fever, malaria and othermosquito-carried diseases are able to spread.[134]: 1062 [136] Mosquito-borne diseases that are sensitive to climate includemalaria,lymphatic filariasis,Rift Valley fever,yellow fever, dengue fever,Zika virus, andchikungunya.[137][138][139] Warmer temperatures are also advancing to higher elevations, allowing mosquitoes to survive in places that were previously in hospitable to them.[134]: 1045 This risks malaria returning to areas where it was previously eradicated.[140]Adaptation efforts in the WASH sector include for example protection of local water resources (as these resources become source water for drinking water supply) and investigating improvements to the water supply and storage strategy. It might also be necessary to adjust the utility's planning and operation.[116]: 41 Climate change adaptation policies need to consider the risks from extreme weather events.[141] The required adaptation measures need to consider measures for droughts and those for floods.[141]: 61 Adaptation measures for droughts include for example: reduce leakages in a pro-active manner, communicate restrictions on water use to consumers. Adaptation measures for floods include for example: Review the siting of the water and wastewater treatment plants in floodplains, minimize the impact of floodwater on operational equipment.[141]: 61
Nature-based solutions (NbS) can play an important role for climate change adaptation approaches of water and sanitation services.[116]: 45 This includesecological restoration (which can improve infiltration and thus reduce flooding),ecological engineering for wastewater treatment,green infrastructure for stormwater management, and measures for natural water retention.[116]: 45
Most National Adaptation Plans published by theUN Framework Convention for Climate Change include measures to improve sanitation and hygiene.[142]
Engineers and planners need to adapt design standards for water and sanitation systems to account for the changing climate conditions. Otherwise these infrastructure systems will be more and more vulnerable in future. The same applies for other key infrastructure systems such as transport, energy and communications.[143]: 13
Climate-resilient water services (orclimate-resilient WASH) are services that provide access to high quality drinking water during all seasons and even during extreme weather events.[18]Climate resilience in general is the ability to recover from, or to mitigate vulnerability to, climate-related shocks such as floods and droughts.[144]Climate resilient development has become the new paradigm forsustainable development. This concept thus influences theory and practice across all sectors globally.[144] This is particularly true in thewater sector, sincewater security is closely connected to climate change. On every continent, governments are now adopting policies for climate resilient economies. International frameworks such as theParis Agreement and theSustainable Development Goals are drivers for such initiatives.[144]
Several activities can improvewater security and increase resilience toclimate risks: Carrying out a detailed analysis of climate risk to makeclimate information relevant to specific users; developing metrics for monitoring climate resilience in water systems (this will help to track progress and guide investments for water security); and using new institutional models that improve water security.[145]
Climate resilient policies can be useful for allocating water, especially when regional water availability may change in future. This requires a good understanding of the current and future hydroclimatic situation. For example, a more accurate prediction of future changes in climate variability leads to a better response to their possible impacts.[17]
To build climate resilience into water systems, people need to have access to climate information that is appropriate for their local context.[145]: 59 Climate information products are useful if they cover a wide range of temporal and spatial scales, and provide information on regional water-related climate risks.[145]: 58 For example, government staff need easy access to climate information to achieve better water management.[17]
Four important activities to achieve climate resilient WASH services include: First, a risk analysis is performed to look at possible implications of extreme weather events as well as preventive actions.[146]: 4 Such preventive actions can include for example elevating the infrastructure to be above expected flood levels. Secondly, managers assess the scope for reducinggreenhouse gas emissions and put in place suitable options, e.g. using morerenewable energy sources. Thirdly, the water utilities ensure that water sources and sanitation services are reliable at all times during the year, also during times of droughts and floods. Finally, the management and service delivery models are strengthened so that they can withstand a crisis.[146]: 5
To put climate resilience into practice and to engage better with politicians, the following guide questions are useful: "resilience of what, to what, for whom, over what time frame, by whom and at what scale?".[144] For example, "resilience of what?" means thinking beyond infrastructure but to also include resilience of water resources, local institutions and water users. Another example is that "resilience for whom?" speaks about reducing vulnerability and preventing negative developments: Some top-down interventions that work around power and politics may undermineindigenous knowledge and compromise community resilience.[144]
Adaptive capacity in water management systems can help to absorb some of the impacts of climate-related events and increase climate resilience.[1]: 25 Stakeholders at various scales, i.e. from small urban utilities to national governments, need to have access to reliable information which details regional climate and climate change. For example, context-specific climate tools can help national policy makers and sub-national practitioners to make informed decisions to improve climate resilience.[1] A global research program called REACH (led by theUniversity of Oxford and funded by theUK Government's Foreign, Commonwealth & Development Office) is developing and using such climate tools for Kenya, Ethiopia and Bangladesh during 2015 to 2024.[1]
UN-Water carries out theGlobal Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) initiative. This work examines the "extent to which countries develop and implement national policies and plans for WASH, conduct regular monitoring, regulate and take corrective action as needed, and coordinate these parallel processes with sufficient financial resources and support from strong national institutions."[147]
Many countries' WASH plans are not supported by the necessary financial and human resources. This hinders their implementation and intended outcomes for WASH service delivery.[147]
As of 2022, it is becoming more common for countries to include "climate change preparedness approaches" in their national WASH plans.Preparedness in this context means working onmitigation,adaptation and resilience of WASH systems.[148]: 11 Still, most national policies on WASH services do not set out how to address climate risks and how to increase the resilience of infrastructure and management.[148]: vii
There has been a growing understanding of the role of gender in development in recent decades (often calledgender mainstreaming).[10]Women's empowerment plays an important role in reducing gender disparities and related adverse outcomes across all sectors, including the WASH sector.[10] Women's empowerment is particularly crucial in WASH, as prevalent social norms assign the majority of water collection roles to women in many developing countries.[10] Empowerment is largely described in the literature as both a process by which WASH services could be improved as well as the result of improved WASH services.[149]
TheEmpowerment in WASH Index (EWI) was developed in 2019 to guide WASH practitioners in measuring and monitoring gender outcomes, empowerment, and inclusivity in WASH-related interventions.[10][150] National indices and tools also exist to capture changes ingender disparities at the national level:Gender Empowerment Measure (GEM),Gender Inequality Index (GII), andGender Development Index (GDI).[10]
A scoping review of the literature found five key interrelated dimensions of empowerment in the WASH sector:[149]
A qualitative study inAsutifi North District inGhana conceptualized empowerment in terms of four major themes: availability of resources, WASH information, social and cultural structures, andagency (the ability to define and act on individual or shared goals, and to put them into effect).[10]
TheDublin Statement on Water and Sustainable Development in 1992 included "Women Play a central part in the provision management and safeguarding of water" as one of four principles.[151] In 1996, theWorld Bank Group published aToolkit on Gender in Water and Sanitation.[152] Gender-sensitive approaches to water andsanitation have proven to be cost effective.[153]
Thehistory of water supply and sanitation is the topic of a separate article.
The abbreviationWASH was used from the year 1988 onwards as an acronym for theWater and Sanitation for Health Project of theUnited States Agency for International Development.[154] At that time, the letter "H" stood forhealth, nothygiene. Similarly, in Zambia the term WASHE was used in a report in 1987 and stood forWater Sanitation Health Education.[155] An even older USAIDWASH project report dates back to as early as 1981.[156]
From about 2001 onwards, international organizations active in the area of water supply and sanitation advocacy, such as theWater Supply and Sanitation Collaborative Council and the International Water and Sanitation Centre (IRC) in the Netherlands began to useWASH as an umbrella term for water, sanitation and hygiene.[157]WASH has since then been broadly adopted as a handy acronym for water, sanitation and hygiene in theinternational development context.[158] The termWatSan was also used for a while, especially in the emergency response sector such as withIFRC andUNHCR,[159] but has not proven as popular as WASH.
Since 1990, theJoint Monitoring Program for Water Supply and Sanitation (JMP) of WHO and UNICEF has regularly produced estimates of global WASH progress.[160][161] The JMP was already responsible for monitoring the UN'sMillennium Development Goal (MDG) Target 7.C, which aimed to "halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation".[162] This has been replaced in 2015 by theSustainable Development Goal 6 (SDG 6), which is to "ensureavailability and sustainable management of water and sanitation for all" by 2030.[2] To establish a reference point from which progress toward achieving the SDGs could be monitored, the JMP produced "Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines".[3]
Expanding WASH coverage and monitoring in non-household settings such as schools, healthcare facilities, and work places, is included inSustainable Development Goal 6.[163]
WaterAid International is anon-governmental organization (NGO) that works on improving the availability of safe drinking water in some the world's poorest countries.[164]
Sanitation and Water for All is a partnership that brings together national governments, donors, UN agencies, NGOs and other development partners. They work to improve sustainable access to sanitation and water supply.[165] In 2014, 77 countries had already met the MDG sanitation target, 29 were on track and, 79 were not on-track.[11]
Important awards for individuals or organizations working on WASH include theStockholm Water Prize since 1991 and theSarphati Sanitation Awards since 2013, for sanitation entrepreneurship.
The United Nation'sInternational Year of Sanitation in 2008 helped to increase attention for funding of sanitation in WASH programs of manydonors. For example, theBill and Melinda Gates Foundation has increased their funding for sanitation projects since 2009, with a strong focus onreuse of excreta.[169]
Awareness raising for the importance of WASH takes place through severalUnited Nations internationalobservance days, namelyWorld Water Day,Menstrual Hygiene Day,World Toilet Day andGlobal Handwashing Day.
Water supply and sanitation by country | ||
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| By region |  | |
| Africa | ||
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Text was copied from this source, which is available under aCreative Commons Attribution 4.0 International LicenseWork of the Statistical Commission pertaining to the 2030 Agenda for Sustainable Development
Text was copied from this source, which is available under aCreative Commons Attribution 4.0 International License Text was copied from this source, which is available under aCreative Commons Attribution 4.0 International LicenseLicence: CC BY-NC-SA 3.0 IGO
Work of the Statistical Commission pertaining to the 2030 Agenda for Sustainable Development
Text was copied from this source, which is available under aCreative Commons Attribution 4.0 International License. Text was copied from this source, which is available under aCreative Commons Attribution 4.0 International LicenseLicence: CC BY-NC-SA 3.0 IGO
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