Water, Sanitation and Hygiene
At a glance

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Water, sanitation and hygiene and the Millennium Development Goals
How do water, sanitation and hygiene affect health?
Access to Water and Sanitation
Effectiveness of water supply, sanitation and hygiene interventions
What can the public health sector do?
School Health Programs
Do's and Don'ts in promoting hand washing and hygienic behaviors
For More Information
PDF Version (English, Russian)

Water, sanitation and hygiene and the Millennium Development Goals

Better hygiene and access to drinking water and sanitation will accelerate progress toward two MDGs:

"Reduce underfive child mortality rate by 2/3 between 1990 and 2015" and

"By 2015 halve the proportion of people without sustainable access to safe drinking water and basic sanitation".

Meeting the latter goal will require infrastructure investments of about US$23 billion per year, to improve water services for 1.5 billion more people (292,000 people per day) and access to safe sanitation for 2.2 billion additional people (397,000 per day). Fewer than one in five countries are on track for meeting this target.

How do water, sanitation and hygiene affect health?

Water supply, sanitation and health are closely related. Poor hygiene, inadequate quantities and quality of drinking water, and lack of sanitation facilities cause millions of the world's poorest people to die from preventable diseases each year. Women and children are the main victims.

Water, sanitation and health are linked in many ways:

• contaminated water that is consumed may result in water-borne diseases including viral hepatitis, typhoid, cholera, dysentery and other diseases that cause diarrhea
• without adequate quantities of water for personal hygiene, skin and eye infections (trachoma) spread easily
• water-based diseases and water-related vector-borne diseases can result from water supply projects (including dams and irrigation structures) that inadvertently provide habitats for mosquitoes and snails that are intermediate hosts of parasites that cause malaria, schistomsomisis, lymphatic filariasis, onchocerciasis and Japanese encephalitis
• drinking water supplies that contain high amounts of certain chemicals (like arsenic and nitrates) can cause serious disease.
  

Inadequate water, sanitation and hygiene account for a large part of the burden of illness and death in developing countries:

• Approximately 4 billion cases of diarrhea per year cause 1.35 million deaths, most-1.2 million-children under the age of five, about 15% of all under 5 deaths in developing countries.
• Diarrheal diseases account for 4.3% of the total global disease burden (62.5 million DALYs). An estimated 88% of this burden is attributable to unsafe drinking water supply, inadequate sanitation, and poor hygiene. These risk factors are second, after malnutrition, in contributing to the global burden of disease.
• intestinal worms infect about 10% of the population of the developing world, and can lead to malnutrition, anemia and retarded growth.
• 6 million people are blind from trachoma and the population at risk is about 500 million
• 300 million people suffer from malaria
• 200 million people are infected with schistosomiasis, 20 million of whom suffer severe consequences.

Water supply, sanitation and hygiene are about more than health.

Saved time, particularly for women and children, is a major benefit. Beneficiaries of water and santiation projects in India reported these benefits: less tension/conflict in homes and communities; community unity, self-esteem, women's empowerment (less harassment) and improved school attendance (WaterAid 2001).

Effectiveness of water supply, sanitation and hygiene interventions

Improved hygiene (hand washing) and sanitation (latrines) have more impact than drinking water quality on health outcomes, specifically reductions in diarrhea, parasitic infections, morbidity and mortality, and increases in child growth (Esrey et al 1991; Hutley et al 1997). Most endemic diarrhea is not water-borne, but transmitted from person to person by poor hygiene practices, so an increase in the quantity of water has a greater health impact than improved water quality because it makes it possible (or at least more feasible) for people to adopt safe hygiene behaviors (Esrey et al 1996).

Experience shows that constructing water supply and sanitation facilities is not enough to improve health; sanitation and hygiene promotion must accompany the infrastructure investments to realize their full potential as a public health intervention. Changing hygiene behavior is complex. Hygiene promotion is most successful when it targets a few behaviors with the most potential for impact. Based on extensive research, WHO and UNICEF have identified hand washing with soap (or ash or other aid) after stool disposal and before preparing food; safe disposal of feces and use of latrines; and safe weaning food preparation, water handling and storage as the key hygiene behaviors. A recent review (Curtis) of all the available evidence suggests that handwashing with soap could reduce diarrhea incidence by 47% and save at least one million lives per year. This is consistent with other studies which found that 12 hand washing interventions in 9 countries achieved a median reduction in diarrhea incidence of 35% (Hill, Kirkwood and Edmond, 2001). Many of the most successful interventions provided soap to mothers, explained the oral-fecal route for disease transmission, and asked mothers to wash their hands before preparing food, and after defecation. There are fewer studies of results of interventions to improve feces disposal, but Hill et al. found a median reduction of diarrheal disease of 26% (9 studies, range 0-68%), a median reductions in all-cause child mortality of 55% (6 studies, range 20-80%) and a median reduction in mortality from diarrhea of 65% (3 studies, range 43-70%).

What can the public health sector do?

The public health sector can do several things, in collaboration with other sectors, to help ensure that investments in water supply and sanitation result in greater health impact. Public health promotion and education strategies are needed to change behaviors so as to realize the health benefits of improved waster supplies. Programs to improve hand washing behavior appear to be feasible and sustainable especially when they incorporate traditional hygiene practices and beliefs. There is less experience with interventions that focus on changing feces disposal behavior and the results are mixed (Hill et al 2001). New, better approaches to behavior change are being developed, including a recent project that has shown excellent results through persuading the private sector (soap manufacturers and the media) to transmit health information by advertising soap and its appropriate use to prevent diarrhea (see The Story of a Successful Public-Private Partnership in Central America: Handwashing for Diarrheal Disease Prevention, 2001).
School health programs School health programs offer a good entry point for improved water supply and sanitation facilities and for community hygiene promotion. It is a realistic goal in most countries to ensure that all schools have clean water and sanitation. This enables schools to reinforce health and hygiene messages, ensure they translate into action, and set an example to students and the community. This can lead to community demands for similar facilities.

The inter-agency partnership for Focusing Resources on Effective School Health (FRESH) aims to increase access to, and improve the quality, of schools and child-friendly learning environments around the world. Guidelines and tools are being developed to help design, implement, monitor and evaluate school sanitation and hygiene components of school, health, and water and sanitation projects.

Additional things the public health sector can do:

• work with other agencies that plan, develop and manage water resources and basic water and sanitation services to advocate and promote these investments, and ensure that activities to promote hand washing, safe disposal of feces and continuous use and cleanliness of sanitation facilities are included;
• work with the agency responsible for monitoring water quality and sanitation to help ensure that this monitoring is carried out;
• provide other sectors with reliable data on water associated diseases and effectiveness of interventions to facilitate better decisions with respect to water and sanitation projects;
• provide leadership for action in hygiene education, including building coalitions with private sector agencies to achieve better results;
• design, implement, and monitor hygiene education and promotion components of water supply and sanitation projects;
• advocate for including water, sanitation and hygiene interventions in poverty reduction strategies and plans.

Do's and Don'ts in promoting hand washing and hygienic behaviors

DO assess sanitation and hygiene beliefs and practices as the basis for planning, and involve community members/beneficiaries in planning and implementing interventions. Maximize the impact of hygiene promotion and education by using participatory techniques, targeting women and children, and using women as facilitators.

DO identify practices to be changed, targeting the four most critical: hand washing with soap (or ash or other aid) before food preparation and after dealing with feces; latrine use and safe disposal of childrenfs feces; safe weaning food preparation; and safe water handling and storage.

DO offer a range of technology options (e.g., different kinds of latrines) and explain associated costs, maintenance requirements, advantages and disadvantages. Public funds are better spent on promotional campaigns and training/establishing latrine artisan businesses than on subsidies for constructing latrines.

DO incorporate programs to change hygiene practices in water supply, sanitation and health projects. In order for water supply projects to achieve positive health benefits, they need to include sanitation and hygiene components. Health sector involvement can contribute to the success of water and sanitation projects. Don't provide hardware (water pipes and latrines) without the software (hygiene promotion) and community training and organization to sustain/maintain services.

DO include education and information to increase community demand for improved sanitation facilities.

DO establish partnerships to stretch resources, e.g. public/private partnerships with private soap manufacturers to achieve complementary goals.

DO monitor and evaluate interventions, and collect baseline data. Don't claim health benefits without measuring and documenting the impact of water and sanitation activities.

DO carry out pilot projects to test new technologies or mechanisms such as cost-recovery.

DO ensure that adequate water and sanitation are provided in schools and health facilities.

For more information

People (World Bank contacts)

• Jennifer Sara and Rita Klees (Water and Sanitation), Joana Godinho (Public Health)

Key Documents and References

• Boot M, S Cairncross (ed.) 1993, Actions Speak: The Study of Hygiene Behaviors in Water and Sanitation Projects, The Hague, IRC
• Curtis V, S Cairncross 2003, Effect of washing hands with soap on diarrhea risk in the community, a systematic review, Lancet Infectious Disease 3:275-281
• Cairncross, S, D O¡¯Neill, A McCoy, D Sethi, 2003, Health, Environment and the Burden of Disease: A Guidance Note, Dept for Intl Development, DFID, London
• Esrey S, J Potash, L Roberts, C Shiff 1991, Effects of Improved Water Supply and Sanitation on Ascariasis, Diarrhea, Dracunculiasis, Hookworm Infection, Schistosomiasis, and Trachoma, WHO Bulletin 69(5):609¨C621
• Esrey S 1996, Water, Waste and Well-being: A Multi-Country Study, American Journal of Epidemiology 143(6):608¨C623
• Hill Z, B Kirkwood and K Edmond 2001, Family and Community Practices that Promote Child Survival, Growth, and Development: A review of the Evidence", Public Health Intervention Research Unit, Department of Epidemiology & Population Health, London School of Hygiene
• Hutley S, S Morris, V Pisana 1997, Prevention of Diarrhea in Young Children in Developing Countries, WHO Bulletin 75 (2): 163¨C174
• Huttly S 2002, The Impact of Inadequate Sanitary Conditions on Health in Developing Countries, Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London.
• Klees R, J Godinho, M Dawson-Loe 2000, Sanitation, Health and Hygiene in World Bank Rural Water Supply and Sanitation Projects, Washington DC, World Bank (includes key design principles for community water supply and sanitation projects)
• Pruss A, D Kay, L Fewtrell and J Bartram 2002, Estimating the Burden of Disease from Water, Sanitation, and Hygiene at the Global Level, Environmental Health Perspectives, 110(5):537-542
• Tumwine JK, J Thompson, M Katua-Katua, M Mujwajuzi and I Johnstone Porras 2002, Diarrhea and Effects of Different Water Sources, Sanitation and Hygiene Behavior in East Africa, Trop Med Int Health, 7(9):750-756
• Varley R, J Tarvid, D Chao 1996, A Reassessment of the Cost-Effectiveness of Water and Sanitation Interventions in Programs for Controlling Childhood Diarrhea, WHO Bulletin 76 (6): 617¨C31
• WaterAid 2001, Looking Back, Participatory Assessment of Older Projects, London
• WHO 2002 World Health Report: Reducing Risks, Promoting Health Life. Geneva
• WHO 2000 Global Water Supply and Sanitation Assessment Year 2000 Report, Geneva, WHO with UNICEF

Web sites

• Global Applied Research Network in Water Supply and Sanitation (GARNET)
• IRC International Water and Sanitation Center
• IRC Community Water Supply Management
• IRC internet journal: Women, Water and Sanitation:
• Rural Water Supply and Sanitation Toolkit for Multisectoral Projects - a rich set of resources including guidelines for all project stages, numerous best practice examples
• Sanitation Connection: An Environmental Sanitation Network
• UNICEF water, environment and sanitation (WES)
• WaterAid:
• Water Supply and Sanitation Collaborative Council
• WELL Project, Water and Environmental Health at London and Loughborough
• WHO Water, Sanitation and Health
• World Bank Water and Sanitation Program

Updated December 2003

updated: 23 April, 2014