Monitoring water and sanitation beyond taps and toilets (3/4)

This third blog is part of a four-part blog series on monitoring the Global Goal on water and sanitation & the challenge of data aggregation. This week’s blog is authored by Kate Medlicott, Sanitation Team Lead, and Betsy Engebretson (WHO Water, Sanitation, Hygiene and Health Unit).  It offers some insights on the importance to successfully monitor all components of Global Goal 6, including wastewater and faecal sludge. 

The Millennium Development Goal covering WASH (Goal 7) focused on access to improved water sources and sanitation. While the number of first time users for improved water and sanitation did greatly increase, the fact is that the entire story wasn’t being considered. Was the water at improved sources safe to drink? Were we considering access in all settings, including WASH in healthcare facilities, in schools or in the workplace where we spend most of our time? What was happening to wastewater and faecal sludge? Were they being safely managed and treated or ending up back in the environment and making people sick? Were water and sanitation systems being managed and sustained?

These unanswered questions sparked the Global Goals to take a broader view of water and sanitation. Instead of focusing solely on access and the enabling environment needed to provide access to improved water and sanitation, discussions included topics such as water quality, water reuse, water resource management, and faecal sludge management. These topics are all covered under Global Goal 6, which is focused on water and sanitation, but moves beyond access to taps and toilets and focuses on the entire water cycle.

At the global level, we do not have the data to fully monitor this ambitious agenda. For example, sanitation data on disposal or treatment of excreta are not available for most countries.  However, existing data from the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) shows that most household in the developing world use onsite facilities that are not connected to sewers even in urban areas.  Where sewers and treatment plants exist many are overloaded or dysfunctional.  Therefore, it is critical to analyze flows and treatment for all sanitation types to represent everyone and help decide where to make improvements towards the Global Goal target for sanitation.  A faecal flow framework for all facilities can be used to estimate safe management and treatment.

This broader focus will give the world a better understanding of what is (or isn’t) happening with wastewater and faecal sludge, both of which can cause serious illness and negative environmental impacts. By including these topics in targets for Global Goal 6, governments will need to take stock of these issues, and the less glamorous, but extremely important, side to water and sanitation will be in the spotlight.

The international community has created an  expanded monitoring initiative for Global Goal 6 to assist countries in getting an accurate picture of what is currently happening with the water cycle and track progress  during the Global Goal period.  The initiative brings together expertise from UNEP, UN-Habitat, UNICEF, FAO, UNESCO, WHO and WMO under the umbrella of UN-Water and links with ongoing monitoring by the WHO/UNICEF JMP that tracked MDG progress to ensure that all components of these complex issues are successfully monitored.

With the Global Goals, we have moved beyond access to taps and toilets and are working to achieve sustainable, safely managed water and sanitation systems.

By Kate Medlicott and Betsy Engebretson, WHO Water, Sanitation, Hygiene and Health Unit.

-> Read the previous blogs in the series “The challenges of monitoring WASH in Health Care Facilities” (2/4) and  “WASH Monitoring and the Global Goals” (1/4)

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The challenges of monitoring WASH in Health Care Facilities (2/4)

This second blog is part of a four-part blog series on monitoring the Global Goal on water and sanitation & the challenge of data aggregation. This week’s blog is authored by Dr. Margaret Montgomery and Betsy Engebretson (WHO Water, Sanitation, Hygiene and Health Unit) with inputs from Ryan Cronk (University of North Carolina at Chapel Hill).  It offers some suggestions on how to overcome the challenges related to monitoring WASH in Health Care Facilities in low- and middle-income countries.  

Many health care facilities around the world lack access to water, sanitation and hygiene (WASH). Earlier this year, WHO and UNICEF published the first landscape review of WASH in low- and middle-income countries, which found that 38% of health care facilities surveyed lack a water source, 35% lack soap or alcohol-based hand rubs for handwashing and 20% lack improved sanitation. Inadequate WASH leads to increased risk of infection for patients and hinders efforts to improve quality of care. Adequate WASH at health care facilities has a number of benefits beyond improved health outcomes, including improved disaster resilience, increased uptake of services and more efficient services.

While the statistics are shocking, solutions exist and the time to act is now.  Tools, standards and methods are available to ensure WASH access in every facility, in every location. To meet the fundamental need for WASH in health care facilities, the WHO and UNICEF led the development of a global action plan. This includes four task teams: advocacy and leadership; monitoring; evidence and operational research; and policies, standards and facility improvements. Change requires health sector leadership, WASH sector support and engagement from the bottom up and top down.

There is potential to make rapid progress by improving monitoring. While some data on WASH in health care facilities are available, quality data are lacking. For example, health care facility surveys typically measure presence of a water source at or near the facility. However, the continuity, safety and provision of water in the actual rooms where it is needed most, such as maternity wards, is critical. Further, not all surveys and indicators are harmonized, making it difficult to compare across countries and over time. Monitoring should be harmonized and reflect global and national norms, such as water available at the point of care and gender-separated, functional toilets.

Steps are in place to improve indicators and increase their use in national health assessments and monitoring systems. The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) will monitor WASH in schools and health care facilities as part of Sustainable Development Goal six on WASH. This improves on the Millennium Development Goals where water and sanitation were only tracked at the household level.

With support from the monitoring task team, the JMP is developing core and expanded indicators for WASH in health care facilities. Draft indicators include:

  • Basic drinking water services in health care facilities, which means the percentage of facilities:
    • with an improved source providing sufficient water,
    • on premises,
    • accessible to all users,
    • at all times.
  • Basic sanitation in health care facilities are those that effectively separate excreta from human contact and ensure that excreta do not re-enter the immediate environment. An adequate sanitation facility at a health care facility:
    • is located in close proximity to the health care facility;
    • is accessible to all users, including adults and children, the elderly, and those with physical disabilities;
    • provides separate facilities for males and females, and for adults and children;
    • is equipped with handwashing stations that include soap and water and are inside or immediately outside the sanitation facility;
    • provides basic menstrual management facilities in sanitation facilities that are used by women and girls of menstruating age;
    • at in-patient health centres, includes at least one toilet per 20 users;
    • at out-patient health centres, includes at least four toilets – one each for staff, female patients, male patients, and child patients.

Data analysis exploring service levels of WASH in health care facilities, trends over time, equity in access, and determinants of low levels of service will enable governments and external support agencies to target investments where services are needed most. The sector will be able to assess the gains in improving access and most importantly ensure that all individuals benefit from quality, people-centred care. To learn more about this effort and to get involved visit: www.washinhcf.org. You can also read our editorial and the report, as well as the latest WaSH Policy Digest. The data for each country are also available on the WASHwatch platform.

By Dr. Margaret Montgomery and Betsy Engebretson (WHO Water, Sanitation, Hygiene and Health Unit) with inputs from Ryan Cronk (University of North Carolina at Chapel Hill).

-> Read last week’s blog in the series “WASH Monitoring and the Global Goals” (1/4)

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Monitoring the Global Goal on water and sanitation: the challenge of data aggregation (1/4)

Over the MDG era, the “WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation” and the “UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water”,  most commonly called JMP and GLAAS, have emerged as the two main monitoring tools in the Water, Sanitation and Hygiene (WASH) sector.  Therefore, WASHwatch naturally thought to invite these two teams to introduce this month’s blog series on data aggregation.  This first blog will give WASHwatch users more insights on how the lessons learned from the MDGs have helped set the foundation for better monitoring and serve both national and global objectives in the next 15 years.

WASH Monitoring and the Global Goals (1/4)

A major shift in the newly adopted Global Goal 6 on water and sanitation[i] is that the role of Member States in setting targets and monitoring progress will be much more prominent. While the Global Goal targets are defined as global and aspirational, each country is expected to set its own national targets, taking into account national circumstances. In the MDG period, global monitoring focused on aggregating a small set of consistent indicators, derived from national data, to regional and global levels for tracking progress towards Target 7C. We can anticipate that in the Global Goal period the targets set by countries, and the indicators used to track them, will be highly diverse. The role of regional and global monitoring will change to focus more on experience sharing and periodic thematic reports, while the accountability for targets will be based primarily on national monitoring.

Over the past 25 years the JMP has become the leading source of data on access to drinking-water and sanitation globally, and has assessed progress towards the MDG target for water and sanitation at country, regional, and global levels. Since 2006, GLAAS has emerged as a complementary monitoring tool focusing on inputs (financial and human resources) and the enabling environment (governance and monitoring practices).

The challenge for the Global goals will be to support countries in strengthening monitoring systems so that the data are first and foremost fit for tracking progress towards national targets, but that a subset of these data can be aggregated to regional and global levels. JMP and GLAAS have extensive experience working with national authorities in harmonizing definitions used at national and global levels. One of the critical achievements of the JMP during the MDG period was the establishment of core questions for use in surveys with agreed definitions of improved and unimproved water and sanitation facilities. In the Global Goals era, agreement on terms and definitions of indicators will be even more important. The JMP has proposed normative interpretations of key terms in the text of the targets such as universal, equitable, access, adequate and for all. Additionally, based on recommendations from an extensive consultation of sector experts, the JMP has expanded its drinking-water and sanitation ladders as well as created ladders for handwashing and WASH in institutions, such as schools and health care facilities, which provide clear definitions of service levels. GLAAS is also harmonizing definitions and language in its indicators in order to successfully aggregate means of implementation data at the global level based on national data and information.

JMP and GLAAS are well-positioned to contribute to global monitoring of Goal 6. In particular, the first two targets within the goal focus on universal access to drinking-water, sanitation and hygiene (WASH), and represent extensions of the JMP’s work. The last two targets within the goal, on “means of implementation”, relate to the work of GLAAS on financing and the enabling environment. The remaining four targets address broader aspects of water and sanitation (water resource quality, water-use efficiency, water resource management, and ecosystem health) which were largely absent from the MDG targets. A new coalition of monitoring systems coordinated by UN-Water (GEMI – integrated monitoring of water and sanitation related Global Goal targets) is emerging to develop or adapt global monitoring systems for these targets. For all targets, there will be a greater emphasis on reducing inequalities, with the philosophy of “no target met unless met for all”.

JMP GLAAS

While global monitoring of the Global Goals will pose new challenges, the experience of GLAAS and the JMP  working with countries will help further establish clear definitions, and compiling and analyzing data generated at the country level. This will give a solid foundation on which to build an improved system for global monitoring of the WASH targets of Goal 6.

[i]Ensure availability and sustainable management of water and sanitation for all.

This blog was co-written by the GLAAS and JMP Teams

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Why has the number of children dying from diarrhoeal disease due to poor WASH significantly dropped?

Last year, we estimated that over 500,000 children were dying every year from diarrhoea caused by unsafe water and poor sanitation. This year, we are estimating that in 2013, 314,824 under 5 died under these circumstances. If significant progresses have been made in one year, the drop in number is mainly due to a change in methodology. This blog explains in details the methodology that was used to reach this more robust number.

Approximately 5.9 million children under age five will have died in 2015.
This figures is from the 2015 Progress Report “A Promise Renewed” published yearly by the UNICEF, and in conjunction with the child mortality estimates of the United Nations Inter-agency Expert Group, on child survival to track progress, promote accountability for global commitments made to children, and help sustain political commitment. These new estimates are for mid-2014 to mid-2015.

Diarrhoeal disease alone amounts to an estimated 9.2% of the Global distribution of deaths among children under age 5 in 2013.
This estimates comes from the Global Health Observatory Data Repository using model developed by experts for UNICEF and WHO. This estimate is for 2013.

58% of Diarrhoeal death are caused by unsafe water and poor sanitation
This data is from the recent study “Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries“. Until this year, Wateraid was using the estimation given by the latest global burden of disease (GBD) study, dating from 2000, according to which 88% of diarrhoeal mortality was attributable to inadequate WASH globally. However, this estimates used a very low baseline of “no disease transmission through water and sanitation” a situation that is a lower level of risk than is commonly encountered even in high-income countries. The Prüss-Ustün study from 2014 offers a revision of methods and estimates of the burden of diarrhoeal disease associated with inadequate WASH. The study estimates that, globally, 842 000 diarrhoea deaths are estimated to be caused by inadequate WASH, which amounts to 58% of diarrhoeal diseases.

→ 9.2% of 5.9 million = 542,800 ; 58% of 542,800 = 314,824

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Aid money for water and sanitation received per missing water and sanitation service

The amount of aid money for water and sanitation received per missing water and sanitation service is calculated as follows:

1: Adding the absolute number of people without access to an improved source of water to the absolute number of people without access to adequate sanitation in a country (1).
2. Dividing the net water and sanitation ODA (aid) received by this country (2) by this number

All of the 10 countries with the lowest access in water and sanitation received less than 5 USD of WASH AID per missing service each year, thinking of the lifetime of a service, that’s less than 100 dollars over 20 years to build and maintain the service.

To compare this with the need, the WASHCost calculation of a  minimum benchmark cost for sustainable basic WASH services in developing countries revealed that the combined costs for the provision of most basic sanitation and water services would be between US$ 137 – 287 per person over 20 years (3).

These estimations do not include investments for the provision of Hygiene services.


(1) WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation
(2) OECD-DAC Creditor Reporting System
(3) IRC, Providing a basic level of water and sanitation services that last: cost benchmarks, 2012
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