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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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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