Pathways for Sustainable Sanitation: Achieving the Millennium Development Goals

Pathways for Sustainable Sanitation: Achieving the Millennium Development Goals
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The goals cover the three dimensions of sustainable development: economic growth, social inclusion and environmental protection. Building on the success and momentum of the MDGs, the new global goals cover more ground, with ambitions to address inequalities, economic growth, decent jobs, cities and human settlements, industrialization, oceans, ecosystems, energy, climate change, sustainable consumption and production, peace and justice.

The new Goals are universal and apply to all countries, whereas the MDGs were intended for action in developing countries only. A core feature of the SDGs is their strong focus on means of implementation: the mobilization of financial resources; capacity-building and technology; as well as data and institutions. The new Goals recognize that tackling climate change is essential for sustainable development and poverty eradication.

SDG 13 aims to promote urgent action to combat climate change and its impacts. How this aspiration is reconciled with maintaining ecosystems and tackling climate change will be a challenge in itself. There is a wealth of published material on sustainable development in general and on the SDGs in particular from the UN, from international non-governmental organizations, and from many other concerned and committed organizations and individuals more locally. It is easy to get lost in all of this so we have been selective in the sources we have used. Most importantly, there is a widely held view that much more innovative ways to both collecting data and using data, from crowd sourcing to the use of big data, need to be used if the mechanisms for implementing and delivering the SDGs are to take full advantage of the data revolution.

Both sites have much supporting material on the SDGs and also on the challenge of integrating the three dimensions of sustainable development economic, social and environmental. And some countries notably Sweden, Germany, Colombia, the Philippines and Czechia already have national institutional arrangements. There is general agreement on the breadth and depth of the goals. There are clear obligations and responsibilities for all member states for which they will be held to account and a recognition that cross systems approaches to implementation will be needed.

This is a significant change from the MDG process and requires explicit contributions from every country, particularly in developing and aligning the complex analytical tools to assess progress and assist decision making. Getting accountability structures fit for purpose is already a key challenge. To help, different models have been developed, 9 including both scenario analysis and quantitative modelling. Some of these can be used as top-down macro-framework level tools and some as sectoral models for option level impact analysis.

This independent review 7 of 16 countries who volunteered for national review by the High Level Political Forum noted a range of different approaches to deal with the complexity of the implementation process. Some countries with existing national sustainable development strategies have built on these and tried to align existing objectives with the new goals.

Some have linked the SDGs to financial planning for sustainable development or sought to integrate SDGs either in sectoral planning nutrition, education etc. Other areas of agreement include the need to integrate the three dimensions of sustainable development economic, social and environmental , 10 , 11 the importance of raising awareness and creating ownership and the need for stakeholder engagement. No strategy, not even one agreed by all member states of the United Nations, can immediately address historical cultures; yet, it remains one of the most fundamental challenges and opportunities for us all to address.

The reality is that addressing all three dimensions collaboratively will yield the greatest benefits, whilst the alternative—addressing them separately and in competitive isolation—will deliver much less and with greater risks. This has been illustrated by recent worked examples and case studies. One worked example 8 concludes that action on the route to zero hunger in sub-Saharan Africa interacts positively with Goal 1 poverty , Goal 3 health and well-being , and Goal 4 quality education.

However, it also notes that food production has a more complex interaction with Goal 13 climate change mitigation. Additionally, food production Goal 2 can compete with renewable energy production Goal 7 and eco-system protection Goals 14 and Conversely, climate stability Goal 13 and preventing ocean acidification Goal 14 will support sustainable food production and fisheries Goal 2. Similarly, the UN paper on mainstreaming the three dimensions 11 highlights water as a nexus of integration and describes how water and sanitation Goal 6 underpin other areas such as health Goal 3 , food Goal 2 , energy Goal 7 , elimination of poverty Goal 1 , economic productivity Goal 8 , equity Goal 10 and access to education Goal 4.

Perhaps the biggest single controversy, particularly because simplicity and logic favour collaborative and system wide implementation, is the high number of goals, targets and supporting actions that have been agreed. Deciding which goals to prioritize and then assessing the positive or negative impacts on other goals, is a crucial step. There is scope for concern if governments, corporations or agencies were to prioritize energy production to meet Goal 7 , agricultural output to meet Goal 2 or development of business and infrastructure to meet Goals 8 and 9 , without considering impacts on climate Goal 13 , water Goal 14 or land Goal The root cause of this problem is the failure to imagine better ways of addressing energy, agricultural output and what defines success of a business in the 21st century.

It is rarely more of what has gone before. The SDGs are the formal stimulus for us to innovate collectively at scale and pace; and to think and act better not bigger. For instance, we need to be more open to the increasing evidence of the many potential positive interactions between different Goals. More equitable and sustainable food systems would help to meet Goal 2, produce ecological benefits Goals 13—15 and help tackle problems such as obesity and non-communicable disease Goal 3.

Interestingly, although the SDGs and supporting targets make little mention of tackling world population growth, there are several studies illustrating how coordinated, whole system approaches to the SDGs are already stabilizing the global population. One paper 13 looks at how the SDG targets on mortality, reproductive health and education for girls will directly and indirectly influence future demographic trends.

Another paper, 14 looking from the opposite perspective, describes how reductions in fertility in Africa could reduce dependency ratios the proportion of population not economically active and thus help tackle poverty Goal 1 , increase productivity Goal 8 , and improve education and gender equality Goals 4 and 5. It should be clear that each country will pursue these Global Goals differently, and that a key benefit of the SDG approach is a degree of local flexibility. This is of increasing importance with the recent expressions of electoral judgements in some western countries. The danger is that electorates are seduced into abandoning collective responsibility for the three dimensions of sustainable development in the hope that this will produce short-term benefits for individual countries while ignoring the wider longer term environmental, social and economic costs, knowingly leaving these to be borne by future generations.

This approach risks increasing health inequity alongside continued restraints on social assistance and environmental protection, with negative impacts on many of the SDGs. Alternatively, a country, region or state could seek to build an economy which is directed at realizing the combined economic, social and environmental benefits associated with implementing the SDGs, with a focus on renewable energy, sustainable food and agriculture and environmentally sustainable technology recycling, energy conservation and the like.

This may also provide a model of sustaining prosperity given the demographic changes and likely labour shortages if countries, such as the UK, shift away from an economic model which depends on a migrant labour force for continued growth. Given that it took 21 years of annual conferences of parties to the United Nations Framework Convention on Climate Change before a substantial agreement for action the Paris Agreement was achieved in December , there could well be international controversy if reneging on key global commitments weakens the collective resolve.

If we accept the fact that human health, and its future survival and prosperity, depend on a liveable earth, we would argue therefore that a refocus of population health to ecological 16 and planetary health 15 is the golden thread which binds the SDGs together as a systems approach. To what extent can we seek to implement the SDGs by improvements in current systems and at what point do we need a paradigm shift in our outlook and aspirations? This subject has been explored in relation to health and food systems 17 and in relation to regional trade agreements and health related SDGs.

It is not enough to simply wait until action is obviously needed. At the policy level, budgets and resource allocations are fragmented among subsectors, levels of government, and sector partners or financiers. Considerable differences exist between budget allocations and disbursements. At the program or service delivery level, implementers do not easily share information on their costs, and budgets may not be structured to provide simple break down between software and hardware costs.

For WASH technologies, the cost studies are more abundant, and at local level the market or subsidized price is available. However, the price is rarely exactly the same as the cost, as the price commonly contains either a profit or a subsidy, and as both are transfer payments they should ideally be excluded from economic analysis. However, to ease the research burden it is common practice for economic analysis to use prices as a proxy for cost, adjusting for any known subsidy or profit.

Published cost evidence is available in both aggregated and unit form. Aggregated cost includes the expenditure required to meet specified targets.

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These costs are equivalent to 0. These needs compare with 0. However, substantial further spending is needed to meet the higher standard of safely managed services. The costs as a proportion of gross regional product are shown by MDG region in Figure 5. Regions most challenged to reach universal access are sub-Saharan Africa and Southern Asia. Many countries also produce investment plans for meeting national targets, focusing on the financing to be provided by government.

The tool has been applied in at least 12 countries [ ]. Costs of basic and safely managed services as percentage of gross regional product GRP by MDG region, with uncertainty range. Reproduced with permission from the World Bank [ ]. Gross regional product is based on the aggregated GDP of countries in each region. An economic growth rate of 5 percent is assumed all regions.

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A key input to these aggregated studies is the unit costs of WASH provision at the household or community level. Due to climatic, topographical and socio-economic differences, costs of service provision are highly variable between studies, contexts and levels of service. The cost per m 3 of water and wastewater services, as well as average monthly household bills, are available for utility services via national regulators, as well as regional associations and global initiatives [ 87 ].

Studies commonly compare the cost of different sources of water supply, finding piped water to be significantly cheaper on a per unit basis compared with vendor supplied water, while monthly expenditure is more similar due to higher consumption of piped water than other water sources [ ].

On the other hand, cost per household served is usually significantly less for community water interventions e. Comparison of alternative sanitation transportation and treatment technologies also provides important policy direction—in general fecal sludge management is considerably cheaper than sewerage such as in Dakar, Senegal, where it was found to be five times cheaper [ ].

Ideally, the costs of water supply and sanitation services should consider the externalities and the long-run cost of supply. Reproduced with permission from [ ].

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From a policy perspective, the affordability and willingness to pay for these costs is a critical issue. WASH services have a large array of welfare and development benefits. Table 6 classifies these benefits under health, convenience, social, educational, reuse, water access, and other benefits. Source: adapted from [ 63 , 84 ]. These benefits have been evaluated extensively, but few studies evaluate benefits comprehensively. The most robust scientific studies, such as randomized or matched prospective cohort studies, have been conducted on health impacts, but there are only few of these, and economic variables are rarely captured.

The majority of economic studies build models filled with input data from a mixture of sources. Global studies assessing the economic benefits of improved water supply and sanitation include health economic and convenience time savings [ 84 , ]. Country studies have also evaluated the value of health and time savings [ ]. Regional studies from Southeast Asia assess the water access, reuse, and tourism benefits of improved sanitation [ 63 , ] as a proportion of avoided damage costs Figure 4.

Willingness to pay studies have estimated economic value of water quality improvements [ , ], while others have assessed willingness to pay to avoid health impacts [ , ] and to receive piped water [ ]. A systematic review has shown that willingness to pay for water quality improvement is less than the cost of producing and distributing it [ ].

Social benefits have been assessed, but few have expressed in money values, except willingness to pay studies, which tend to capture all benefits and make difficult to differentiate social from other benefits. Economic value is associated with river clean up that includes improved management of municipal wastewater as well as improved management of industrial discharge, agricultural runoff, and solid waste [ ]. The financial viability of WASH services is expressed in terms of financial returns.

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Washington, D. The SDG agenda sets out five key opportunities for development that is i inclusive, ii universal, iii integrated, iv locally-focused, and v technology-driven. The other proposal Kassebaum et al. These conditions and factors are responsible for pervasive and persistent health inequalities and inequities throughout the Americas. According to these authors, the inequalities in the two countries illustrate the close connection between use of the health services and the design of each health system 6.

The most comprehensive source of data is from projects of multilateral development banks that routinely conduct a financial assessment of WASH services prior to project approval, and in some cases, provide a project implementation completion report. The discussion of efficiency should distinguish between cost-benefit analysis, which uses a common money metric for all costs and benefits, and cost-effectiveness analysis, which compare interventions for one type of outcome.

Reviewed cost-benefit studies are provided in Table S2. Efficiency studies can be conducted in two ways [ ]. Generate estimates of cost and benefit in specific sites or field studies, for the purposes of either evaluating intervention performance or selecting a site for a future project [ 63 ]. Model costs and benefits for specific sites or larger jurisdictions, such as country or global level, using best-available evidence from multiple sources [ , ].

Introduction

Pathways for Sustainable Sanitation Achieving the Millennium Development Goals. Article (PDF Available) · November with Reads. It reviews the global progress being made towards achieving the Millennium Development Goal (MDG) target on sanitation. A literature review is presented on .

Given the high costs and challenges associated with collecting all the cost and benefit data required for the first approach, it is common practice to combine site-specific values with data extrapolated from other sources [ 63 ]. Table 7 shows the latest available global studies that have modeled selected water supply and sanitation interventions.

One important finding from these studies is that lower technology interventions have higher returns than more expensive networked options. Source: [ , ]. All studies include the value associated with health and convenience time savings. Global studies indicate the projected overall costs and benefits from intervention alternatives, but they are not particularly useful in guiding decisions on which technology and service level to choose in specific settings.

In a review of willingness-to-pay WTP studies for improved water supply in low- and middle-income countries, 40 studies provided estimates of WTP [ ]. The authors compared average WTP with costs of service provision in three regions; they found that WTP exceeds costs for improved water coverage, while costs exceeded WTP for piped water coverage. A study from South Africa estimates a benefit-cost ratio of 3.

A study from Indonesia compared three wastewater treatment interventions and finds limited economic rationale for the interventions [ ]. On the other hand, a broader cost-benefit study at the river basin level estimated the benefits of cleaning up the Upper Citarum River in Indonesia exceeded costs by 2.

Targeting the poor could be justified by the fact that children from poorer households are at increased health risk as they live in communities with lower access to improved water and sanitation facilities.

source site A study in Bangladesh, India, and Pakistan estimating cost-per-episode for income quintiles shows that costs of an illness represent a higher proportion of income for lower quintiles [ ]. The cost-efficiency of technologies is context specific and depends on the local geological setting, population density, and number of households to be served. For example, large water distribution and sewerage systems may only be cost-efficient if serving large, dense populations; smaller-scale water service provision via either communal or in-compound wells or boreholes and onsite household sanitation may be a more appropriate and cost-efficient service level for sparsely populated areas [ ].

The main outcomes used in cost-effectiveness studies are health and environment related.

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To compare programs within a sector, cost-effectiveness can be measured in terms of programmatic outcomes such as number of latrines constructed, water connections installed, or percentage of beneficiaries changing behavior. For water supply interventions, a number of health cost-effectiveness studies have been conducted see Table S3. Studies focus on improved water supply as per JMP definition and point-of-use treatment by households or schools.

A global study compares water supply interventions at the regional level [ 90 ]. It should be noted that cost-effectiveness analysis CEA focuses on measurable health outcomes but exclude user preferences are a major determining factor in technology choice. Figure 6 shows the cost per healthy life year gained for four interventions in two regions, showing that the selected interventions vary by a factor of approximately 2. However, all interventions have a cost per healthy life-year HLY that is below the GDP of countries in these regions, indicating a cost-effective use of health resources.

Source: [ 89 ]. Health cost-effectiveness analyses of sanitation and hygiene interventions have been conducted in fewer studies. Two global studies by the WHO and World Bank examine cost-effectiveness of water supply and sanitation combined [ , ]. Environmental cost-effectiveness studies compare the costs of achieving pollution or nutrient emission reductions through different approaches to wastewater or fecal sludge management [ , ].

The majority of studies have been conducted in developed countries. WASH intervention sustainability can be examined from several angles—whether interventions are functionally sustained i. The challenge of any service is that after the initial investment, the proportion of population using the service declines over time due to a variety of reasons that include both supply e. Increasingly, evidence has become available on the extent to which services are not sustained [ ]. However, there are few rigorous studies which capture a meaningful time frame to measure sustainability of outcomes.

For sustainability of rural water supply, research in Liberia, Sierra Leone, Uganda shows that while quality of construction plays a role, poor management and lack of operations and maintenance are the primary drivers [ ]. The bulk of the evidence suggests that handwashing with soap behaviors are not sustained long after the intervention [ ]. Funding and partner agencies have increased their focus on service sustainability leading to the development of new sustainability indicators [ ].

The energy-water nexus is now coming to the fore, raising the issue not only of the energy requirements of water supply and wastewater systems including transport, treatment and disposal , but also the resulting over extraction of groundwater resulting from energy subsidies and polluted surface water. Municipal water supply is also being sourced from further away in several mega-cities e. Wastewater transportation and treatment require considerable amounts of energy. Furthermore, the systems vary in terms of their greenhouse gas emission [ ].

Emissions can be cost-effectively reduced by capturing methane emission and using it as a source of energy for the rest of the treatment process [ ]. These sources not only need to expand coverage to meet global and national targets, but also need to maintain existing coverage, including maintenance, rehabilitation and where necessary, replacement. While the estimates of global investment needs for water supply and sanitation are available e. First, it is largely unknown how much households are spending. Second, few developing country governments routinely provide breakdown between different line items to enable separation of water and sanitation in budgets and expenditure at both central and decentralized levels [ ].

Some donors are increasingly reporting annual disaggregated disbursement on water and sanitation projects, but many transfers are excluded such as from non-governmental organizations. A decade ago, a landmark report from the Report of the World Panel on Financing Water Infrastructure chaired by Michael Camdessus ventured that current financing needs to double to meet the MDG targets for water supply and sanitation [ ]. Given how far short the world fell in meeting the sanitation MDG target, financing clearly did not keep up with needs. A more recent paper from the World Bank proposes four main ways of making up the financing deficit: more efficient operations of service providers, increase tariffs towards full cost recovery, more public resources allocated, and government and donors leveraging investments from municipal bonds and the private sector [ ].

Furthermore, spending should be directed towards poor people and rural areas of the poorest countries with the greatest WASH challenges. A long-term vision with a solid strategy based on solid data is considered as key for moving forward [ ]. The ability to mobilize financing will be critical in achieving universal access of safely managed WASH services by the year [ ]. However, given the variable performance of utilities [ 87 ] and poor budget absorption [ ] in many low- and middle-income countries, the ability to translate financing into effective services will be even more critical.

Furthermore, given the insufficiency of public funds to meet the targets, these will need to be targeted at households less able to afford WASH services [ ]. However, current public spending in a sample of 15 African countries is 0. Since reliable global data sets have been available and comparable over time during the MDG era, important progress has been made towards global water and sanitation targets. At current rates of progress and using current indicators, achieving universal access targets will take at least 20 years for water supply and 60 years for sanitation [ 18 ]. Covering the poor and marginalized populations will continue to be a challenge for some time, as the remaining unserved populations are likely to be harder to reach as universal access is approached.

This raises a new set of challenges, on the global monitoring of new definitions and indicators and on the set of policy, regulatory and spending requirements to achieve a higher WASH standards. The new standards will raise questions about priorities, and countries will face a trade-off between dedicating policy space and public subsidies on moving already-served populations higher up the water and sanitation ladders versus reaching the unserved with basic WASH services.

The global WASH sector is not static, neither are populations or the economic context. Populations are growing and moving, economies are developing and becoming richer, and the climate is changing. Each one has its challenges and opportunities. Population migration to greenfield sites offers a chance of implementing new and appropriate technologies, ensuring these not only meet the expectations of populations but are also cost-effectively and affordably implemented.

Economic growth also leads to greater tax revenues of local governments and enhances their ability to upgrade infrastructure and expand urban renewal. Climate change challenges the delivery of WASH services by affecting rainfall patterns, freshwater availability, and frequency of heat events. At least 2. However, this new threat, when taken seriously, can be an opportunity to overhaul outdated policies and technologies. Furthermore, as nutrient sources for chemical fertilizer become scarcer, price increases will force suppliers to seek alternatives; the price of composted sludge is expected to increase, attracting investments.

While climatic factors are harder to control, water scarcity can be mitigated by changing water usage patterns and reducing pollution of surface waters. New research, data and technologies are becoming available at an increasing rate, thus opening new possibilities for dealing with seemingly entrenched problems in the WASH sector. On the health front, while global deaths from diarrhea have declined significantly over the past 20 years, poor water supply, sanitation and hygiene are still responsible for a significant disease burden.

An estimated , global deaths were due to diarrhea caused by poor WASH in , and there remain other less well quantified but important long-term health impacts of poor WASH, such as helminthes and enteric dysfunction. WASH-related epidemics—whether regular ones such as cholera or ones that mobilize global responses such as Ebola—affect the poorest most of all, and can devastate communities.

To adequately address equity considerations in the post-MDG era, there is a need to understand where the poor live and what their levels of access are. Disaggregated data on the underserved—including slum populations, ethnic groups, women, elderly, and persons with disabilities can also support prioritization. Greater focus is needed on how to increase access in the lagging regions of South Asia and Africa where a large proportion of the unserved live. At the country level, policy and financial incentives need to be aligned and the economic arguments made for allocating resources to WASH services, especially to sanitation.

National financing strategies that engage a fuller range of stakeholders, including the private sector and non-traditional financing sources, will expand the resources drawn into the provision of WASH services; these strategies also need to be translated to lower administrative levels. More evidence is needed to support our emerging understanding of the wider health effects of water, sanitation and hygiene.

The social welfare consequences of poor WASH are not well documented, but are potentially very large. In particular, a greater understanding of the gender impacts of inadequate WASH and how improved WASH services contribute to gender equality is needed. The role of multi-sectoral approaches will become more important as the complementarities between WASH, health and nutrition are better understood.

Further rigorously designed, controlled studies are needed to quantify these benefits, including measurement of cost-effectiveness to guide policy and program design. A large part of the remaining challenge of improving access to sanitation and hygiene is behavioral rather than technical but there is little evidence that behavior change using conventional methods is effective at scale, or that behavior change interventions that are successful in a particular context are effective elsewhere.

A better understanding of habit formation and what leads to sustainable behavior change is needed. Given the continuing rate of rural-urban migration, a better understanding is needed on which WASH interventions work in slum areas and low-income neighborhoods, and under what conditions they work. Innovative delivery platforms that leverage national poverty reduction programs, such as conditional cash transfers CCT and community driven development CDD programs have potential to achieve wide coverage at little marginal cost.

These approaches can also provide the methodology and data sources to support poverty targeting of WASH services. There is also a need to understand how output-based approaches can be used to improve WASH service delivery and lead to greater sustainability of services. Innovations in subsidies and consumer financing have been shown to help the poor gain access to improved sanitation.

This review has shown there exists significant evidence on many aspects of WASH which can be utilized in designing and implementing improved policies and programmes. However, to optimize available resources, further evidence is still needed. This relates in part to the expanded scope of global targets—higher service levels, the inclusion of hygiene and the recognized need for better institutional WASH.

It also relates to the need to achieve better targeting of programmes to poor and marginalized households and communities including children and women , improved mechanisms for achieving demand creation and behavior change, and some of the challenges we face on continued urbanization, population growth and climate change. While global overviews of evidence are useful as a first step, to be truly useful for WASH decision makers—evidence needs to be compiled and reviewed that relates to specific contexts, such as rural or urban areas, or at country or regional level.

The research was conducted as preparation for the Disease Control Priorities project, edition 3 www. The following are available online at www. Table S2. Cost-benefit studies on water, sanitation and hygiene. Table S3. Cost-effectiveness studies on water, sanitation and hygiene. National Center for Biotechnology Information , U. Published online May Paul B.

Tchounwou, Academic Editor. Author information Article notes Copyright and License information Disclaimer. Received Feb 29; Accepted May This article has been cited by other articles in PMC. Associated Data Supplementary Materials ijerphs Abstract Safe drinking water, sanitation, and hygiene WASH are fundamental to an improved standard of living. Keywords: water, sanitation, hygiene, health, nutrition, cost-effectiveness, cost-benefit, economic analysis, environment, water security.

Introduction Safe drinking water, sanitation, and hygiene WASH are fundamental to an improved standard of living, including the protection of health and the environment, improved educational outcomes, greater convenience, dignity and gender equality. Materials and Methods The aim of this paper is to summarize global evidence on WASH and to recommend future focus areas for research and policy. Table 1 Scope of water, sanitation, and hygiene services included. Service Included Excluded Water supply Water for drinking; Other water uses in the home cooking, hygiene, sanitation, cleaning, laundry ; Treatment, safe handling and storage of water Water for productive uses Sanitation Toilets and onsite excreta management; Management of fecal sludge; Sewerage or combined sewer-drainage systems Separate gray water management; Industrial wastewater management; Storm water drainage; Solid waste management Hygiene Hand washing; Menstrual hygiene management Food hygiene; Environmental hygiene and cleanliness measures; Other personal hygiene practices, including face and body cleansing.

Open in a separate window. Source: Authors. Results 3. Status of Drinking-Water, Sanitation, and Hygiene 3. Targets The MDG 7c targets called for halving the proportion of the population without sustainable access to safe drinking water and basic sanitation between and Definitions To understand the status of drinking water, sanitation, and hygiene, a distinction is necessary between different levels of service access and population practices. Sanitation and hygiene Percentage of population not practicing open defecation. When off-site, fecal waste is safely extracted and conveyed to treatment and disposal sites.

Percentage of population with handwashing facilities with soap and water at home. Figure 1. Figure 2. Coverage of Hygiene Although the MDG Target 7C does not provide a global indicator for hygiene, the data on the presence of a handwashing facility with soap and water present are increasingly collected as part of nationally representative surveys, and will form the basis for efforts to monitor Target 6. Distribution of Services The JMP has reported the distribution of water supply and sanitation services by wealth status, breaking the population into five equal wealth quintiles using an asset index.

Figure 3. Impacts of Inadequate WASH Understanding the nature and extent of the negative impacts of inadequate WASH on individuals, the environment, and societies is important for those designing interventions and assessing benefits and efficiency. Health Consequences Contaminated water and lack of sanitation lead to the transmission of pathogens through feces, and to a lesser extent, urine.

Diarrheal Disease The most recent study estimated a total of , global deaths from diarrheal disease for [ 36 ]—43 percent of these in children under five years of age. Helminth Infections Helminth infections are transmitted via fecal matter in water schistosomiasis and in soil soil-transmitted helminths, STH. Impacts on Well-Being Improved water supply and sanitation provide individuals with increased comfort, safety, dignity, status and convenience; along with broader impacts on the environment [ 63 ].

Environmental Consequences Two major environmental consequences of poor WASH practices are the excessive extraction of water to meet population needs and the pollution caused by poorly managed human excreta. Financial and Economic Consequences Financial and economic studies convert the health, social and environmental impacts of poor water supply, sanitation and hygiene to a common money metric, enabling aggregation as well as comparison across locations and over time.

Figure 4. Effectiveness of Technologies and Practices Water technologies are designed to source, treat, distribute, and monitor the supply of water. Baseline Intervention Baseline water Improved community source Piped water, non-continuous Piped water, high quality Filter and safe storage in the household Unimproved source 0. Effectiveness of Service Delivery Models Effectiveness of service delivery models is measured in terms of intervention uptake, change in risky behaviors, sustainability, and to a lesser extent, health outcomes.

Intervention Costs, Benefits, Efficiency, and Sustainability As societies do not have limitless resources, any intervention in the WASH sector requires an economic rationale, thus satisfying conditions of efficiency, affordability and relevance i. Costs The cost of interventions is one key piece of evidence for decision making, because it is relatively easy to obtain and is an often-cited constraint for an investment decision, whether governments, the private sector, or households and individuals.

Figure 5. Benefits WASH services have a large array of welfare and development benefits. Table 6 Benefits of improved drinking water supply and sanitation. Intervention Efficiency: Cost-Benefit Analysis The discussion of efficiency should distinguish between cost-benefit analysis, which uses a common money metric for all costs and benefits, and cost-effectiveness analysis, which compare interventions for one type of outcome. Intervention Efficiency: Cost-Effectiveness Analysis The main outcomes used in cost-effectiveness studies are health and environment related. Figure 6.

Sustainability WASH intervention sustainability can be examined from several angles—whether interventions are functionally sustained i. Discussion Since reliable global data sets have been available and comparable over time during the MDG era, important progress has been made towards global water and sanitation targets.

Conclusions This review has shown there exists significant evidence on many aspects of WASH which can be utilized in designing and implementing improved policies and programmes. Acknowledgments The research was conducted as preparation for the Disease Control Priorities project, edition 3 www. Supplementary Materials The following are available online at www.

Click here for additional data file. Conflicts of Interest The authors declare no conflict of interest. References 1. Post Wash Targets and Indicators. World Health Organization. A Handbook for Implementation. The Urban and Rural Challenge of the Decade. Roaf V. Moriarty P.

Potter A. Assessing Sanitation Service Levels. Onda K. Global access to safe water: Accounting for water quality and the resulting impact on MDG progress.

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Public Health. Stanton B. Twenty-four hour recall, knowledge-attitude-practice questionnaires, and direct observations of sanitary practices: A comparative study. World Health Organ. Progress on Drinking Water and Sanitation. Blackett I.

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Water and Sanitation Program Research Brief. Freeman M. Hygiene and health: Systematic review of handwashing practices worldwide and update of health effects. Biran A. Comparing the performance of indicators of hand-washing practices in rural Indian households. Loevensohn M. The cost of a knowledge silo: A systematic re-review of water, sanitation and hygiene interventions.

Health Policy Plan. Strickland G. Burton M. The global burden of trachoma: A review. PLoS Negl. Rabie T. Handwashing and risk of respiratory infections: A quantitative systematic review. Semmelweis I. Blencowe H. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: A systematic review and delphi estimation of mortality effect. BMC Public Health. Rhee V. Maternal and birth attendant hand washing and neonatal mortality in southern Nepal.

Benova L. Systematic review and meta-analysis: Association between water and sanitation environment and maternal mortality. Pickering A. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: A cluster-randomised controlled trial. Lancet Glob. Curtis V. Effect of washing hands with soap on diarrhoea risk in the community: A systematic review.

Lancet Infect. Ilahi N. Public infrastructure and private costs: Water supply and time allocation of women in rural Pakistan. Popkin B. Water, hydration and health. Atia A. Oral rehydration solutions in non-cholera diarrhea: A review. Murcott S. Naujokas M. The broad scope of health effects from chronic arsenic exposure: Update on a worldwide public health problem. Health Perspect. Ahern M. Global health impacts of floods: Epidemiologic evidence. Points out that a new set of indicators other than GDP is necessary in order to achieve prosperity and development and overcome new social and environmental challenges, and should therefore include indicators such as the human development index, the poverty headcount ratio, the poverty gap index, and the Income Gini coefficient;.

Points out that clear and measurable indicators, including outputs and outcomes, are crucial for monitoring and reporting on progress achieved in respect of areas such as poverty eradication and economic and social development, and should include gender equality, employment, social protection e. Calls on the EU to develop relevant baselines, indicators and targets for measuring the impact of PCD;.

Private sector. Stresses the need to implement the UN Guiding Principles on Business and Human Rights; against this background, calls on all countries to establish a genuine business regulatory framework, promotion of full and productive employment and decent work, respect for human rights, including ILO standards, transparency and social and environmental standards;. Considers that the principal aim of support to the private sector should be to lift people in developing countries out of poverty and help strengthen the private sector in developing countries, given that failure to do so would result in unbalanced development and growth;.

Urges EU-based companies with production facilities in developing countries to comply with their obligations to respect human rights and freedoms, social and environmental standards, gender equality, core labour standards, international agreements and payment of taxes in a transparent manner;. Points out the importance of protecting private property in order to enhance an investment environment and the rule of law;. Stresses that, although the private sector plays a crucial role in the economy, it is the main responsibility of the state to provide basic quality services to its citizens, and therefore contribute to fighting poverty;.

Stresses that those in the public and private sectors must find new ways to combine their interests, capacities and efforts in order to contribute to the attainment of the post agenda;. Underlines that economic growth and development should be sustainable, inclusive and contribute to strengthening production capacities, decent job creation and social inclusion for all in order to enable developing countries to transform their economies; calls for the establishment of nationally-defined social protection floors in developing countries and for an end to all forms of child labour;.

Points out that Fair Trade is a trading partnership based on dialogue, transparency and respect that seeks greater equity in international trade 7 ; takes the view that Fair Trade is an example of a successful partnership, involving many stakeholders around the world and at different stages along a supply chain, that ensures market access for disadvantaged producers, guarantees sustainable livelihoods, respects labour standards, phases out child labour and encourages environmentally sustainable farming and production practices;.

Calls on the EU, whilst ensuring that PCD is firmly incorporated into the post framework, to continue to pay particular attention to the following priority areas: trade and finance, health and education, climate change, natural resources, agriculture, fisheries, health care, nutrition and food security, migration, energy, peace and security policies, and human rights;. Takes the view that, while the MDGs have certainly been a success in shining a brighter spotlight on development aid, a mere focus on aid is too narrow; considers that a new approach is needed that embraces global governance, with a strong focus on policy coherence for development and the provision of global public goods;.

Believes that a post agenda for development needs to identify essential global public goods, set how they are financed and specify which global institutions can be held accountable for their provision;. Points out that PCD can only achieve real and effective results by means of a collective effort and the active involvement of developed and developing countries, emerging economies and international organisations;. Urges the EU to act as a driving force, ensuring complementarity and division of labour within the development process in an inclusive and transparent manner, including through an increased use of joint programming;.

Comprehensive guidance to wards a post development framework. Stresses that the following principles should be taken into consideration in defining a coherent EU position with a view to the negotiation of a new development framework:.

GLOBAL 3000 - The Millennium Goals

PCD will be absolutely crucial for the success of a future framework, taking into account the shifting nature of poverty and the impact of domestic policies in the global context;. Instructs its President to forward this resolution to the Council, the Commission, the governments and parliaments of the Member States and the Secretary-General of the United Nations.

In September , the UN adopted a Millennium Declaration, followed by the setting of concrete, time-bound targets to be reached by Considerable progress has been made in the achievement of the MDGs: the target of reducing extreme poverty by half has been reached, as has the target of halving the proportion of people who lack dependable access to improved sources of drinking water, and the conditions of over million people living in slums have been ameliorated. We have seen accelerating progress in reducing child and maternal mortality.

Progress has also been made towards the goal of improving access to primary education. All in all, the MDGs have been a success at political level, providing a basis for mobilizing political activity and public opinion around development issues. Nevertheless, two years away from the deadline, there is still a lot to be done.

People around the world continue to suffer from poverty, hunger, inequality, and insecurity. It is estimated that 1. Why do we need this document? This year the UN will carry out a review of progress of the current MDGs and will start to look towards a development framework for post It intends to highlight some substantive elements and principles that should be taken into account in the design of a future overarching framework.

Lessons learned and a renovated approach in a demanding global landscape. We need to take into account the lessons learned from the current MDGs and, at the same time, consider that the global landscape has dramatically changed over the last decade: poverty is taking on new dimensions, differences between developing countries have increased, several countries have become donors, while others, facing high levels of inequality, continue to be highly vulnerable to crisis shocks climate change, food crises, demographic changes, refugees, etc.

These challenges are interrelated and need to be addressed together by all countries. A rapidly changing global environment requires a comprehensive and effective approach in the EU development policy. Priority areas for action: poverty eradication and sustainable development.

There is a crucial link between poverty eradication and environmental sustainability. It is not possible to eliminate the first without addressing, among others, climate change, degradation of freshwater sources and biodiversity loss, all of which have a negative impact on the poorest populations.

Thus, the eradication of poverty and the achievement of sustainable development should be the priority areas of the new framework, in order to ensure a decent life for all. Moreover, as poverty eradication is multidirectional, its definition should be broadened and not be reduced to the single matter of monetary threshold.

Health and education. Accessibility to a better standard of secondary education should lead to an increase in employment opportunities. To further eradicate hunger while improving food security we must first reach the goal of providing key standards in education, nutrition and clean water. Special attention should also be paid to tackling non-communicable diseases such as cancer. Good Governance. Therefore, a clear commitment to democratic governance should be reflected in the new framework. Addressing this objective means that parliaments should play a role in building ownership of sustainable development policies, holding policy debates and translating international development commitments and sustainable development policies into national legislation.

An empowered CSO is a crucial component of any democratic system. CSOs have a crucial role in: the definition and implementation of policies; the promotion of equitable and sustainable development; conflict resolution; and transparency and accountability. In negotiations for a post framework, the EU should give strong support to the achievement of an enabling environment for CSOs. Human rights principles should be at the core of the post framework owing to their universality. They should be recognised at national and international levels and need to be respected not only by the public, but also by the private sector.

Peace, security and development. Armed conflict and post-conflict situations are some of the major obstacles to development. One and a half billion people live in fragile or conflict-affected states which have not met a single MDG 1. Those countries thus require specific attention. Progress in achieving MDGs was halted in countries characterised by high insecurity and vulnerability. The rapporteur considers that the capacity of post-conflict countries to achieve any goals must be prioritised in a future development framework, bearing in mind the Peace Building and State Building goals agreed on in Busan.

Environmental sustainability. There seems to be a widespread consensus that climate change affects the achievement of current and future development goals. To correctly address this major threat, the rapporteur considers that negotiations on climate change under the UN Framework Convention on Climate Change can provide useful insights, namely on the principles of common but differentiated responsibilities 2. The rapporteur considers that UN member states should accurately address the question of resources allocation on climate change mitigation and adaptation, in order to ensure continual progress on poverty eradication.

The EU should support the use of concise SDG and the definition of concrete targets, such as for energy, water, sustainable land use, resources efficiency, marine protection and biodiversity. As we know, water is at the core of development sustainability and is directly linked to a significant part of key global challenges.

Sustainable energy services contribute to poverty eradication, improve health, save lives and give a key input to production. Energy security requires an implementation of strategies based on the diversification of sources and routes, protection of ecosystems and natural resources, reduction of disaster risks, integrated water resources management, improvement of markets and infrastructures. Taking into consideration the fact that a new framework will primarily be built on political compromises, inclusive policy discussions on the means to finance sustainable development objectives after are indispensable between the Commission and all relevant stakeholders.

The rapporteur recalls that during the UN Development Cooperation Forum, the need for greater coordination between different aid mechanisms and donors was clearly highlighted. ODA, foreign direct investment FDI , trade, debt, climate change, technology transfer, business environment and aid agency procurement policies should all be aligned to promote better development. The Rapporteur believes that mobilising all financial sources, including from the private sector, is crucial for the attainment of post development goals. In this respect, further developing blending loans and grants can boost financial resources for development.

Another aspect, which needs special attention in this context, is aid dependency. It is of utmost importance that developing countries introduce adjusted fiscal policies with effective taxation mechanisms in order to sustain development in a long-term perspective. Strengthening domestic revenue t h rough effective taxation and the fight against corruption.

Currently, the revenue collection levels in developing countries are significantly low when compared to the global average. In large part this is due to inefficient national tax systems and administration. In addition, the issue of illicit financial flows of roughly eight times the size of ODA are escaping from these countries each year through tax evasion and fraud. Estimates show that about USD billion would be mobilised in domestic revenues annually if these illicit financial flows were taxed. It is particularly relevant that the EU continues to support developing countries in their revenue collection and in the strengthening of national tax systems.

Addressing the question of corruption and its impact on development policy requires the EU and its member states to develop legislation that would require oil, gas and mining companies to publish payments they make to governments. Clear and transparent indicators are crucial, either to monitor progress, promote accountability, raise awareness or highlight country best practises.

The EU, UN agencies and international organisations need to move to an appropriate mix of quantitative and qualitative measurement criteria and indicators. A multidimensional mechanism should be able to assess and take into consideration relevant topics, such as sustainable development, poverty, inequality, gender equality and aid effectiveness.

The rapporteur is of the opinion that the private sector should be engaged as a development partner. A healthy and competitive private sector is crucial to the attainment of poverty reduction, as it creates productive and decent job opportunities and leverages additional funding for sustainable and inclusive growth. However, an enabling environment for the private sector to develop is crucial, including establishing a clear and effective business regulatory framework with a code of conduct that ensures respect for human rights, health and environment protection.

Policy coherence for Development PCD and coordination among donors. Lack of coordination between donors and coherence between policies, generates unnecessary costs resulting in negative effects and is harmful to otherwise significant policies. Therefore, it is absolutely crucial that the EU takes account of the objectives of development cooperation in all policies that it implements, which are likely to affect developing countries, according to the legal basis contained in the Lisbon Treaty and the European Consensus on Development.

A coordinated and coherent EU position on the post development framework is absolutely vital, taking into consideration the preparatory process of the next UN General Assembly Special Event, otherwise there might be a serious risk of faltering momentum. The current economic crises besetting much of the developed world must not be allowed to decelerate the progress that has been made. We should build on the successes which have been achieved so far. The rapporteur supports an accountable, comprehensive post framework, which will be based on principles of human rights, equality, non-discrimination, sustainability, good governance and policy coherence for development, with the objective of creating a just and sustainable world in which every human being can achieve their rights and live free from poverty.

Rapporteur: Anne Delvaux. Considers it regrettable that the current MDG framework has not been able to address effectively the underlying structural causes of gender inequality and the multiple and intersecting forms of discrimination experienced by women and girls around the world; recognises that women should be central players in the development of the post framework, but also central actors in its implementation, monitoring and evaluation; calls on the Commission and the Member States to emphasise the need to identify equality between women and men as a stand-alone goal and a precondition to achieving other development goals;.