**USAID Policy Paper**

**Domestic Water and Sanitation**

**Bureau for Program and Policy Coordination**

**U.S. Agency for International Development**

**Washington, D.C. 20523**

**May, 1982.**

**Water Supply and Sanitation Policy Paper**

**Table of Contents**

Page

Summary 1

I. Introduction 2

II\. Rationale for USAID Support of Water and

Sanitation Programs 3

III\. Current Situation in Developing Countries 5

and the Role of International Donors

A. The U.S. Commitment to Supporting Water and 6

Sanitation Programs in Developing Countries

B. USAID and Other International Donors 6

C. USAID\'s Role in Water Supply and Sanitation

in Developing Countries 6

D. The Linkages Between Domestic Water Supply

Sanitation, and Health 7

IV\. Guidance for the Development of the Drinking Water and Sanitation
Programs in Developing Countries: Major Issues 9

A. Technical Issues 10

B. Social and Cultural Issues 13

C. Issues of Implementation and Administration 14

V. Water in the Context of General Economic

Development 17

**Summary**

The combination of unsafe drinking water and inadequate sanitation
facilities constitutes one of the major causes of death and disability
among the poor in developing countries. Safe, conve­nient water supply
and adequate sanitation is a fundamental component of broad-based
economic growth strategies. Lowering mortality and morbidity from water
and sanitation-related diseases is a goal in itself; it can also lead to
increased productivity and decreased absenteeism among members of the
labor force and can reduce the time and energy burden on the house­hold,
leading to more time for crop cultivation, child care, and
income-generating activities, as well as more regular school attendance.

The availability of a minimum of 20-40 liters of relatively safe water
per person per day is essential to achieve sustained health improvements
in developing countries. Where this minimum is not readily available and
where inadequate domestic water and sanitation creates significant
health problems, USAID will consider funding projects for-improvements
in water and sanitation. The following criteria will guide USAID\'s
investment in the area:

1\. **Evidence of need and effective demand:** *The need for improved*

*water and sanitation is clearly indicated by high prevalence of disease
caused by (a) insufficient water, (b) consumption of highly contaminated
water, and/or (c) inadequate or inappropriate sanitation systems; and
consumers are willing to (a) support recurrent costs through some
combination of fees, contributions, and local or national budget
allocations, and (b) cover some portion of the investment costs to
improve traditional systems or build new ones. Where consumer are unable
to make such a commitment, but the absence of basic water and sanitation
systems poses a public health hazard for the community at large, the
government must demonstrate a commitment to shoulder a substantial
portion of the investment costs, as well as those recurrent costs which
the community cannot cover in the short-run while local arrangements for
financing are being developed. A.I. D. will not fund projects where
there is inadequate assurance that the community can and will support
operation and mainte­nance costs of the system within a reasonable time
frame.*

2\. **Institutional responsibility and capacity.** *The local or
national institutions responsible for national domestic water supply and
sanitation policy must have the responsibility, personnel, and budgetary
resources to ensure the construction, expansion and continued operation
and maintenance of the improved water and sanitation systems. At a
minimum, there must be evidence that the institution can be strengthened
to the point where it can assume such responsibility with only
**modest** outside support.*

3\. **Infrastructure:** *Roads and other aspects of transportation and
communications must be sufficiently developed to permit routine contact
with local communities for the purposes of supervision, technical
assistance, maintenance, and the delivery of fuel and spare parts.
Alternatively, the technology adopted in the improved water and
sanitation systems must be such that the system can be maintained by the
community without outside assistance or supervision.*

Where these conditions are met, USAID will consider funding water and
sanitation programs to improve health in rural areas as well as market
towns, secondary cities, squatter settlements, and urban centers.
Development Assistance funding for these programs is available from
Section 104, the Health and Population Account and when part of rural
development activities, from Section 103, the Agriculture, Rural
Development and Nutrition Account; in addition, Economic Support Funds
and the Housing Guarantee Program can support domestic water and
sanitation projects, principally in urban areas.

As noted above, USAID will not support water supply and sanitation
programs whose operation and maintenance costs cannot be financed over
the long-term by some combination of consumers, the local community, and
the regional and central government. Where possible, consumers
themselves should bear primary responsibility for covering all costs,
since it is under these conditions that the systems are most likely to
remain in operation over the long-term. USAID will give particular
attention to identifying and promoting opportunities for private sector
involvement in the construction, operation, and maintenance of water and
sanitation systems and in the manufacture of related equipment.

Among the factors that will guide the design of USAID-supported domestic
water and sanitation projects designed to improve health are the
following:

\- a minimum of 20-40 liters of relatively safe water per capita per
day;

\- improvements in water quality (as opposed to quantity) where
improvements can be introduced at reasonable cost without compromising
the reliability of the system;

\- selection of a technology that can be maintained and operated easily
and is acceptable within the local culture;

\- measures to promote water conservation and reuse;

\- project design and implementation that responds to the needs of the
community and, wherever feasible, encourages or requires active
community involvement in all phases of the project;

\- sustained educational efforts to instruct users in proper water use
and hygiene;

\- a demonstrated means of financing and ensuring operations and
maintenance of the project over the long-term;

\- training of community level workers and of personnel at the regional
and national level in the maintenance, operation and repair of water
supply and sanitation systems;

\- technical assistance or training, as required, to improve the
administration of water supply and sanitation systems.

In addition, USAID encourages attention to other factors which may have
implications for domestic water supply and sanitation, including: the
strength of existing institutions that govern the allocation of water
resources; opportunities to incorporate water supply and sanitation
activities into primary health care, agriculture (irrigation) and other
programs; and the implications of rapid urbanization for existing water
supply.

**I.** **Introduction**

This paper is the first of a series designed to give more explicit
guidance on major health issues, and draws on A.M.\'s experience with
domestic water and sanitation programs.[^1] The paper provides suggested
guidelines on how and under what conditions scarce U.S. development
funds may be used cost effectively to improve health conditions through
selective investments in domestic water supply and sanitation programs.

Improvements in water supply and sanitation have important ramifications
in areas other than health, including education, employment, nutrition,
agriculture, industry, housing, and the environment. This paper,
however, concentrates primarily on the health rationale for investments
in domestic water supply and sanitation, and brings together A.M.\'s
practical experience, that of other International donors, and the
findings of numerous research studies.

This paper is concerned with both water supply for \"domestic use\"[^2]
and sanitation in developing countries. The discussion of sanitation
deals principally with the disposal of human excreta, domestic waste
water, and other household waste materials. This paper addresses water
supply and sanitation policy issues pertinent to urban and per urban
populations as well as to rural communities.[^3] This paper does not
address issues arising from large-scale irrigation projects or from the
use of water for primarily agricultural purposes. Nor does it deal with
recent conservation or watershed management efforts which USAID also
finances.

USAID\'s policy on domestic water supply and sanitation can be
summarized as follows:

The availability of a minimum of 20-40 liters of relatively safe water
per person per day is essential to achieve sustained health improvements
in developing countries. Where this minimum quantity is not readily
accessible and where there are significant health problems associated
with inadequate water and sanitation, water supply and sanitation
programs deserve attention.

However, domestic water supply and sanitation programs require
considerable initial investment and are difficult (financially and
logistically) to maintain. To ensure that domestic water and sanitation
systems will be maintained over the long run, USAID believes that
projects sponsored by the Agency must address certain critical issues,
among them:

\- coverage of recurrent costs through fees, taxes or other means;

\- proper education of users of the system; adequate operation and
maintenance;

\- encouragement of the involvement of private enterprise;

\- adequate national or regional governmental capability for policy
formulation and oversight.

When these and other policy issues are satisfactorily addressed,
domestic water supply and sanitation programs rank high within USAID\'s
health sector priorities.

**II.** **Rationale for USAID Support of Water and Sanitation Programs**

An important goal of U.S. development assistance-indeed, perhaps the
most important goal- is to help developing countries bring about the
conditions under which their citizens can look forward to full lives,
sharing in the benefits of a sturdy and growing economy. As President
Reagan noted recently, \"In its ultimate form, development is human
fulfillment-an ability of all men and women to realize freely their full
potential. \"The challenge for development assistance agencies and LDC
governments alike is to identify the most critical obstacles to
guaranteeing individual freedom and initiative, and to design and
implement programs that overcome these obstacles with as few negative
side effects for the individuals and communities involved as possible.

Very clearly, in countries where a life of chronic, energy-sapping
illness and death at an early age is likely for most people, learning
potential and the options for exercising individual initiative are
extremely circumscribed. USAID\'s health policy paper, approved in 1980,
highlighted the problems which continued poor health in LDCs poses for
the achievement of important personal and national aspirations. This
paper investigates and provides guidance on one of the most important
vehicles for improving health and living conditions in LDCs: safe water
and adequate sanitation.

The combination of unsafe drinking water and inadequate sanitation
facilities constitutes one of the major causes of death and disability
among the poor in developing countries. The World Health Organization
estimates that more than 25,000 people (most of them children) die each
day from water and hygiene-related diseases.[^4] Less than one-half of
the people in developing countries have reasonable access to reliable
sources of safe drinking water and a satisfactory means of,excreta
disposal. Most of those who lack reasonable access to these sources live
in rural areas.

USAID\'s efforts to increase access[^5] to safe water supply, adequate
waste disposal and sanitation in developing countries reflect U.S.
interest in furthering economic growth by helping countries meet the
basic needs of their populations.

Safe,[^6] convenient water supply and adequate sanitation is a
fundamental component of a broad based economic growth strategy.[^7]
Water-borne and sanitation-related diseases, particularly diarrheal
disease and parasitic infections, are principal causes of morbidity and
mortality among infants and young children in Less Developed Countries
(LDCs). Lowering mortality and morbidity from water and sanitation
related diseases is, of course, a goal in itself. It can also lead to
increased productivity and decreased absenteeism among members of the
labor force, and is therefore an important factor in promoting economic
growth.[^8]

To satisfy basic needs, water must be not only safe, but also available
in quantities sufficient for personal hygiene and a healthful
environment.[^9] Sufficient safe water is particularly necessary for the
control of certain diarrheal diseases and skin and eye infections.
Trachoma, for example-the leading cause of preventable blindness in the
developing world-is in large measure a result of poor hygiene, as is
epidemic typhus, spread by human body lice.[^10]

There has been considerable debate over the trade-off between water
quantity and quality in improving health conditions. The issue appears
to turn on the prevalence and mode of transmission of diarrheal and
other diseases. Where these are almost entirely water-borne, or
water-based, improving water quality is likely to be the most effective
way to reduce disease incidence. Where diarrheal diseases are primarily
\"water-washed\", as opposed to \"water-borne\", priority should be
given to promoting the availability and use of water in greater
quantity, and to improved domestic hygiene.[^11]

Improved access to convenient, reliable sources of safe water also has
an impact on health through reducing the time and energy burden on the
household. This benefit is of particular significance to women and
children, who bear .the principal responsibility for seeking, drawing,
and carrying water in the developing world.. These responsibilities are
particularly burdensome for pregnant and lactating women, who are
already somewhat more vulnerable to disease and poor health.

Time saved as a result of more convenient sources of water has been used
in subsistence agriculture, in child care, in leisure, and in
income-generating activities-all of which can contribute both to
improved health and to increased income.[^12] Numerous studies have
documented the importance which beneficiaries of water projects attach
to these improvements in living conditions.[^13]

Indirect benefits of improved domestic water supply and sanitation may
be even more impor­tant than the direct benefits listed above. For
in­stance, some have suggested that the rate at which girls drop out of
school is directly linked to the burden of domestic responsibilities
they bear[^14]; carrying water competes directly with school attendance
since it can take anywhere from one-half hour daily in urban areas to
4-6 hours in difficult terrain, during dry seasons, or when numerous
trips and substantial waiting time are required. Getting girls into
school and making sure they stay in school is important not only for
them but also for their families. There is mounting evidence that
mother\'s education is directly related to family size (educated mothers
have fewer children) and to child health: mortality among children whose
mothers completed more than three years of primary school tends to be
significantly lower than for children born to women with less schooling,
*regardless of income*.[^15]

**III.** **Current Situation in Developing Countries and the Role of
International Donors**

In recent years there has been relatively little im­provement in the
proportion of people in LDCs who have access to adequate supplies of
safe water and basic sanitation, in large part because continued rapid
population growth has outpaced the expansion of basic health-related
services. Even a vigorous and well coordinated effort by LDCs and
developed countries is unlikely to result in safe water and adequate
sanitation for all the world\'s population by 1990, the goal of the
International Drinking Water Supply and Sanitation Decade. The U.N.
estimates that the cost of achieving universal access to adequate

water and sanitation will be \$300 billion over the decade. This
estimate probably falls short of ac­tual requirements, because the total
cost of pro­viding water to all rural areas, where the bulk of LDC
populations live, is very high. But the estimated \$300 billion far
exceeds the resources that are likely to be available over the decade
for drinking water and sanitation programs.

A. **The U.S. Commitment to Supporting Water and Sanitation Programs in
Developing Coun­tries**

The United States has voiced strong support for water supply and
sanitation programs in developing countries in numerous international
fora in recent years. The U.S. has supported resolutions endorsing the
provision of safe water supplies and hygienic means of waste disposal at
the U.N. Conference on Human Settlements (Habitat) in 1976; at the U.N.
Water Conference in 1977, which proposed that the U.N. establish the
1981-1990 International Drinking Water and Sanitation Decade; at the
International Con­ference on Primary Health Care (Alma Ata) in 1978; at
the U.N. World Health Assembly; and, most recently, at the convocation
of the U.N. General Assembly inaugurating the International Drinking
Water and Sanitation Decade.

B. **USAID and Other International Donors**

USAID is one of the leading international donors providing financial
support and technical assistance for water supply and sanitation
pro­grams in developing countries. (See Table 1). Compared with the
aggregate contribution of other donors, however, the level of USAID
financing for such activities is small. The World Bank (including IDA),
by far the largest donor in developing countries, lent nearly \$900
million for water supply and sanitation programs in 1979, primarily in
urban areas. UNICEF devotes one ­quarter of its budget (\$53 million in
1979) to water supply and sanitation activities. Other bilateral,
multilateral, and private voluntary donors in this area include the
Inter-American Development Bank, UNDP (\$698 million in 1979), the Asian
Development Bank, the various Arab development banks, and the bilateral
agen­cies of the OECD countries. While there is an im­pressive number of
organizations involved in development assistance in this sector, it
should be noted that at least 75 percent of the roughly \$10 billion
expended annually on improving domestic water supply and sanitation,
comes from the LDCs (both governments and con­sumers) themselves.

**TABLE I**

**USAID FUNDING, WATER SUPPLY AND SANITATION (1978-82)**

**(\$000)**

FY 1978 FY 1979 FY 1980 FY 1981 FY 1982\*

DA^1^ ESF^2^ DA ESF DA ESF DA ESF DA ESF

Asia 3,684 3,500 16,104 9,400 3,033

LAC 330 8,425 18,961 220 150

NE 3,844 166,500 8,469 192,100 2,910 139,500 5,000 237,000 1,450 163,000

Africa 6,557 3,060 8,330 11,980 7,597

S&T/H 545 66 2,652 2,650 2,450

HG 45,000 55,000 70,500 42,000 46,000

TOTALS

DA/ESF 59,960 166,500 78,529 192,100 118,737 139,500 71,250 237,900
60,680 163,000

Annual

Totals 226,460 270,620 258,237 309,150 217,180

^1^ Development Assistance Funds.

^2^ Economic Support Funds.

^\*^82 = Estimated

**C.** **USAID\'s Role in Water Supply and Sanitation in Developing
Countries**

Many of the water supply and sanitation pro­grams supported by major
donors other than USAID have traditionally been urban-oriented and have
generally employed relatively sophis­ticated levels of technology.
However, the ma­jority of LDC populations lives in rural areas and in
villages and market towns, and it is in these areas that access to safe
water and sanitation is most limited.[^16] Another residential grouping
that has largely been bypassed by traditional water and sanitation
systems is the recent immi­grants living in the slums, squatter
settlements and fringe areas of burgeoning LDC cities. Their poverty,
their illegal or squatter status, and their lack of familiarity with
urban life all tend to deny them the basic services more likely to be
avail­able to other urban residents. The neediest groups in developing
countries include not only rural households but also those in cities
and, in particular, in high density urban slums, and it is USAID\'s
policy to assist in providing water sup­ply and sanitation to both.

The cost-effectiveness of alternative technologies in various settings
therefore becomes of para­mount concern in USAID\'s investment decisions.
For instance, providing domestic water and sanitation to people who live
in extremely isolated regions or in widely dispersed households is
likely to be more costly on a per capita basis than providing the same
technology and services to settlements that are somewhat more densely
populated and more readily accessible. But less costly technology and
related design factors can narrow considerably if not close this gap. In
certain regions the minimum community size for provision of improved
water supply and sanitation at a reasonable cost will be 2,000-10,000,
whereas in others, as a result of less costly technologies and other
factors, it may be as low as 500.[^17] Providing improved sanitation in
rural areas does not necessarily involve a large capital investment in
construction; sanitation in urban areas, on the other hand, tends to be
more costly on a per capita basis, because relatively sophisticated
technology is frequently required.[^18]

In the selection of technologies for water supply and sanitation
programs, planners should also pay attention to \"software\" components.
These might include training, technical assistance, the development of
host country institutions, hygiene education, the promotion of community
participation, the support of complementary nutrition and health
activities, and the develop­ment of national and regional water and
sanita­tion policies and plans. USAID does not and should not support
water supply and sanitation programs where these essential software
elements have not been adequately considered in the design of the
project.

In general, USAID\'s increasingly scarce and limited levels of funding
in many countries are not likely to be sufficient to support the capital
investment costs of major urban water supply and sanitation
programs.[^19] The Agency will finance \"software\" components of
programs in urban and urban fringe areas. This policy is based on
several considerations, not the least of which is expense. More
substantial resources for major capital investment in water supply and
sanitation tend to be available from other donors and lending
institutions such as the World Bank; these funds are less often
available for the technical assistance elements of such projects.
Furthermore, in fine with growing U.S. concern for assuring the
long-term viability of LDC in­stitutions, USAID is placing strong and
increasing emphasis on the \"software\" and technical assistance
components mentioned above.

**D.** **The Linkages Between Domestic Water Supply, Sanitation, and
Health**

What priority should water supply and sanita­tion programs have in
USAID\'s overall health ob­jectives? There is a strong temptation to
compare health improvements that result from water and sanitation
programs with those from other health activities, especially
interventions such as im­munizations or oral rehydration that appear to
achieve comparable health objectives at lower per capita cost.

Although improvements in water supply and sanitation are generally
linked to improvements in life expectancy and decreases in mortality and
morbidity,[^20] water and sanitation programs tend to be relatively
costly per capita compared with other health interventions.[^21] While
per capita costs of establishing and operating water and sanitation
systems are important considerations, and in many cases will be the most
important factor determining investment strategies in health, other
factors should also be considered. For instance, water and sanitation
systems, depending on the type of system, water source, storage and
treatment (if any), may not require heavy involvement of highly skilled
manpower. In settings where the absence of such skilled per­sonnel is a
major constraint, water and sanita­tion projects can be competitive
alternatives to other health programs designed to combat diarrheal and
other water-related diseases.[^22]

In addition, in any assessment of water and sanitation benefits, effects
other than health must be taken into account.[^23] Thus while an
analysis of the relative cost-effectiveness of water pro.­grams in
improving health might discourage in­vestments in domestic water supply
and sanita­tion programs in favor of simpler or \"more direct\" health
interventions (immunizations, etc.), a cost-benefit analysis (of all
benefits, not only health) might argue strongly in favor of in­vestments
in water projects.

The Agency\'s past experience has resulted in a fairly thorough
appreciation of what is needed to keep water supply and sanitation
systems func­tioning in the developing countries in which USAID typically
works. Unfortunately, there is much less certainty about the precise
character­istics of water and sanitation systems that have the greatest
impact on improving health. Will more convenient, reliable, and safe
water sup­plies necessarily improve health in all com­munities, or must an
area have achieved a certain level of socioeconomic development (whether
measured in terms of educational level, level of agricultural or
industrial production, or family income) before health improvements
result?[^24] What types of health improvements can be ex­pected in given
settings and what is the best means of bringing about the behavioral
changes necessary to translate improved water and sanitation into
improved health?

While USAID continues to support economic and social research on these
important questions, it has developed some general guidelines, listed
below, for its support of improved domestic water supply and sanitation
programs. More specifically, USAID will consider funding pro­jects for
improvements in domestic water supply and sanitation where:

1\. A clear need exists, as indicated by high prevalence of disease
caused by (a) insufficient water, (b) consumption of highly contami­nated
water, and/or (c) inadequate or inappropriate sanitation systems; and
demand for services is indicated by a willingness on the part of users
to W support recurrent costs through some combination of fees, taxes or
labor contributions, and (b) cover some portion of the investment costs
to improve traditional systems or build new ones; or

2\. The absence of basic water and sanitation services poses a public
health hazard for the community at large and the national government
demonstrates a commitment to shoulder a substantial portion of
investment costs where demand is insufficient to generate the revenue
necessary to cover these costs[^25]; and

3\. The local or national institution responsible for water and
sanitation programs has the personnel and budgetary resources to assist
in the construction, operation, and maintenance of the improved systems,
or, with modest out­side support, can be strengthened to the point where
it has that capacity; and

4\. Infrastructure (both roads and other means of communication) is
developed enough to permit routine contacts for supervision, technical
assistance, maintenance, and the delivery of fuel or spare parts; or
where the technology adopted is such that the system can be sustained by
the community itself.

There are numerous complementary programs, in the areas of education,
nutrition, primary health care, housing, irrigation, cottage indus­tries,
and rural development with which domestic water supply and sanitation
programs can be combined to improve the impact of the program; such
integrated approaches should be adopted wherever technically and
financially feasible. For instance, where improved water supply and
sanitation systems have been intro­duced in a community to improve health
condi­tions, especially among young children, high priority should be
given to constructing latrines and providing adequate water supplies in
the local schools, and to including hygiene in the curriculum. In some
settings, the school environ­ments are so unhealthy that parents are
reluctant to allow their children to attend. Furthermore, having
appropriate sanitation facilities in the schools is a powerful way of
reinforcing the hygiene lessons being taught in the classroom. Where
provision of more convenient water in greater quantity is designed to
lessen diarrheal disease, simultaneous introduction of oral rehydration
(teaching women to mix solutions hygienically) can enhance the health
impact of the new water supply, thus further diminishing mortality.

Among the benefits generally thought to flow from investments in water
are: (1) improved health, (2) more cash income, (3) increased food
production or diversification of crops, (4) more employment, and (5)
more leisure.[^26] The extent to which any one of these benefits is
realized or sustained varies considerably from setting to set­ting.[^27]
In subsequent sections of this paper, the factors that tend to lead to
sustained health im­provements and ancillary benefits are discussed in
greater detail. Except in unusual circumstan­ces,

USAID programs will be expected to adhere to the guidance contained
below.

**IV.** **Guidance for the Development of the Drinking Water and
Sanitation Programs in Developing Countries: Major Issues**

The issues in water supply and sanitation pro­grams in developing
countries can be divided into three categories: technical issues; social
and cultural issues; and issues concerning the imple­mentation and
administration of programs.

**A.** **Technical Issues**

**1.** **Convenience, Reliability, Quantity, and Quality**

These four characteristics are key to the success of water supply
programs; the first two apply to sanitation programs as well. Safe water
supplies and sanitary means of excreta disposal must be both convenient
(as perceived by the consumer) and reliable (in good working order
throughout the year). Water should be available in at least some minimum
quantity, which will vary among regions and even within countries, but
should fall within the range of 20-40 liters per capita per day for the
domestic uses defined above if health improvements are to be
sustained.[^28] This range may be too high for certain and zones, where
limited availability of water may dictate more modest objectives.

The importance of water quality must be weighed not only against the
diseases prevalent in the region but also- against other factors such as
cost, quantity, and reliability (e.g., the ability of a system to
operate continuously, during reasonable periods every day, throughout
the year).[^29]

**Water quantity:** Domestic water should be available in adequate
quantity to satisfy minimal requirements for drinking, cooking, and food
preparation as the highest priority. Ten liters per capita per day is
the minimum estimated for these requirements. Second in priority is
suffi­cient water for bathing, personal hygiene, and washing utensils,
for which 10-15 liters per capita per day is the minimum. Third, if
feasible, domestic water should be available for washing clothes, and
for watering small garden plots and/or small numbers of livestock or
poultry. [^30]

**Water quality:** Water treatment should be in­troduced where needed to
improve water qual­ity, especially for drinking, cooking, and food
preparation. Water treatment to improve the quality of water for
bathing, personal hygiene, clothes washing, or garden plots should only
be introduced where treatment does not prejudice the reliability of the
water supply and where water quality can be improved at a reasonable
cost. Simple household treatment may be suffi­cient to assure adequate
quality for domestic use. Education (particularly for mothers and
school­age children) can help ensure maintenance of the water\'s quality
during its storage and transporta­tion from point of collection to point
of use (see pp. 11-13 below).

Where these minimum standards of quantity and quality cannot be assured,
investments in water supply are not likely to achieve completely their
desired health impact.

**2.** **Site Selection and Source Development**

In selecting the site and the appropriate method of developing and
providing the water for domestic uses, attention should be given to
potential future demands on the system, which should be designed with a
view of possible future expansion if population growth or other
condi­tions require it. These considerations lead to several guidelines:

\- **Water and sanitation surveys** should be con­ducted to aid project
designers and the commun­ity in selecting the most appropriate water
sources among available alternatives and to iden­tify feasible, efficient
and appropriate methods of waste disposal.

\- **Social and cultural factors** should be taken into account in site
selection and source develop­ment (e.g., location of communal washing
areas,­identification of cultural norms pertaining to the tasks of
fetching water, cleaning, etc.; and con­sideration of water laws and
current patterns of ownership, allocation and access to water). Where
feasible the beneficiaries themselves should be actively consulted and
involved in the development of the project activity.

\- In most cases, *groundwater should be the first possible source of
water considered*, since it is often the least costly and most reliable
source that is relatively free of bacteria and does not normally require
treatment. However, where surface water can be easily treated, and where
sufficient quantities are available year round, surface water may be the
least-costly and most reliable source for systems that require large
quantities of water. Gravity-fed systems that re­quire no pumping are
less costly and less suscep­tible to mechanical failure than alternative
methods.

\- When surface water is used, its variable qual­ity requires monitoring
throughout the year. It should be treated when necessary to meet minimum
standards of safety for purposes of drinking, cooking, and food
preparation.

**3.** **Selection of a Suitable Technology**

Experience in many developing countries has shown that the selection and
adaptation of technologies suitable to the local setting is crucial in
finding a balance among desirable charac­teristics of water and
sanitation systems: conve­nience, reliability, costs and, in water
systems, quantity and quality. There is some evidence that utilizing LDC
private sector enterprise for the manufacture and installation of water
and sanitation systems is not only cost-effective, but also stimulates
the private sector and promotes employment.

There are now a large number of alternatives to Western style water and
sanitation systems, in­cluding pit latrines and water-sealed latrines
(pour-flush commodes).[^31] Selection of a suitable technology should
take into consideration local preferences as well as social and cultural
factors, the repair and maintenance support systems, availability of
labor and management, ap­propriate institutional structures, the level of
investment and recurrent cost implied, and the willingness and ability
of beneficiaries to cover the expected costs. Although the selection
pro­cess is not an easy one, the factors discussed in this section should
serve as a guide.

The local manufacture of parts and equipment can significantly ease the
operation and repair of the system, and often with substantial cost
sav­ings. A simple well screen that would cost \$10-30 per foot to
manufacture in the United States may cost only \$2-3 per foot in many
developing coun­tries, because of lower production costs. A hand pump
costing \$300 to produce in the United States may be manufactured for
\$40-\$60 in a country like Indonesia. In estimating potential cost
savings through local manufacture of parts and equipment, however, it is
necessary to assure that locally manufactured equipment is of sufficient
reliability and durability, and is as easy to install properly and
maintain as the more expensive foreign equipment, or else the cost
differential may involve no savings at all.

USAID has been active in the development and testing of technologies
suitable for local manufacture (e.g., improved handpumps and well
screens) and has also sponsored comparative reviews of other locally
producible equipment and machinery (eg., non-sewered excreta disposal
devices, desalinization devices, small diameter pipe, and well-drilling
equipment). The Agency\'s guidelines for the promotion of ap­propriate
technologies for water and sanitation projects include the following:

\- USAID supported water supply and sanita­tion programs should encourage
LDCs to use ef­ficient technologies that can be maintained and operated
easily and are acceptable within the local culture.[^32]

\- USAID should investigate the potential of private firms in LDCs to
develop and operate ef­ficient water and sanitation systems.

\- USAID should stimulate local manufacture and field testing of simple
equipment. In specific instances (where local capacity is not adequate
or where a small market is involved), manufacture on a regional level
may be preferable.

\- Instead of introducing a new system, USAID should support the
improvement of traditional systems, where local preferences or cost
con­siderations indicate system upgrading is the most desirable approach.

\- USAID recognizes that success of water and sanitation programs
depends in large measure on the ability and commitment of people to use,
operate, and maintain the system properly. Thus, USAID should also
support programs to train maintenance and other personnel and to educate
current and potential users of the ser­vices.

\- USAID should promote standardization of water and sanitation
equipment and parts, even while seeking technologies in which hardware
can be produced efficiently on a small scale. USAID\'s efforts to
eliminate wastage and maintenance failure currently caused by a
pro­liferation of mechanical designs and specifica­tions will necessitate
closer coordination among donors and local private investors, and may on
occasion require a procurement waiver.

**4.** **Water Conservation and Reuse**

In most LDCs, potable water is neither cheap nor abundant, and with
continued rapid population growth, water shortages may affect
significant proportions of LDC populations. Certain areas of the world
(e.g. The Sahel) have already experienced grave water crises. Water
conservation is playing an increasingly important role development
planing, not only because water recognized as a scarce resource but also
because wastage of water contributes to health problems: pools of water
that collect around taps present health hazards, and saturation of the
soil with waste water (such as has been observed in rural Egypt) can
contaminate the aquifer.[^33] Water metering in urban areas, safe
restricted flow measures, increasing block rates,[^34] reduction of
leakage by proper installation and regular repair and maintenance, and
reuse of waste water for agricultural and industrial purposes are among
the means that can contribute to water conservation.

**B.** **Social and Cultural Issues**

Water and sanitation programs are most likely to succeed when the
respond to the needs of the community. Those needs - and how they are
perceived by the community - will differ greatly depending on the
country, whether the setting rural or urban, the current availability
and ade­quacy of water and sanitation, and other factors. A thorough
understanding of social, cultural and institutional factors and
relationships is therefore a basis for developing and implementing
effecti­ve water and sanitation programs.

**1.** **Community Participation**

Recent project impact evaluations and other project reviews of USAID\'s
experience have documented the importance of community par­ticipation to
effective water supply and sanita­tion programs in developing
countries.[^35] Local residents must have a strong interest in keeping
the system functioning. They must use the system, and be able to support
the bulk of the costs of operating and maintaining the system,[^36]
whether in the form of cash, labor, or in-kind contributions. It is
their contribution that can help ensure commitment to maintaining the
system over the long-term.[^37]

Participation of the community is for these reasons often crucial in
rural areas, small com­munities and low-income urban areas served by
communal facilities such as standpipes. USAID­-funded programs intended
for such areas should adhere to the following guidelines. These
guidelines may need to be modified or relaxed in the case of higher
income urban residential or commercial areas served by
building-to-building connections where a high degree of community
participation is not practical. However, even in such situations some
indication of community interest is desirable.

\- USAID should require a request by community leaders or by a
representative community group, or some other formal evidence of
community support, and the community should be involved in the program
from the outset. Communities where support is lacking will be bypassed
unless a compelling public health need exists.

\- Wherever possible, the community must be fully aware of the costs and
benefits of alter­native systems, and should help select the site, level
of service, and technology employed. Com­munities must understand and
agree to water rates and other fees at the outset. They must be
consistent with the beneficiaries\' ability to pay. The project should
where feasible include a plan to train community workers in the
construc­tion, operation, and maintenance of systems. Women as well as
men should be trained. (See p. 13.)

\- Wherever possible, the project will use the ex­isting indigenous
organizations to assure com­munity participation and to institutionalize
maintenance, management and administration of the system.

Social analysis, especially at the initial stage of project design, is
essential to determine whether or not these conditions have been or can
be met.

**2.** **User Education**

The provision of basic sanitation and a reliable supply of safe,
convenient water is not sufficient to guarantee improved health. A
variety of social and cultural attitudes affect the pattern of usage of
water and sanitation facilities: people must use facilities and use them
property to discourage en­vironmental contamination (particularly with
fecal material) and disease transmission. In some areas, for instance,
children are not encouraged to use the latrines, which are dark and
distant from the home, because children\'s feces are considered
harmless. In other areas, men and women prefer not to share the same
latrines, which tends to limit use of household latrines to female
members of the family. As a recent study noted: \"Decisions about
drinking water are often based on sensory perception - color, taste or
smell - rather than technical purity.\"[^38]

Water supply and sanitation interventions can be most effective in
improving health when they are coordinated with other primary health
care ac­tivities, especially health and hygiene education, and maternal
and child health services. Examples of user education which seem obvious
but which are often overlooked include: advice on the pro­tection of
stored household water from microbial contamination and mosquito
breeding; promo­tion of handwashing (particularly by food handlers);
promotion of hygienic food prepara­tion, including the proper use of
water for clean­ing utensils; promotion of breastfeeding, especially
during the first six months of life; pro­motion of safe excreta disposal
by all family members; and instruction on preparing water for use in
oral rehydration therapy, infant formula, where used, and weaning foods.

Consumers must be encouraged to transport water in clean containers, and
store it under sanitary conditions. They must know how to wash their
hands and bathe properly to break the fecal-oral cycle of many diarrheal
diseases.

Hygiene education can be provided in a variety of ways: by
community-based, primary health care workers or other health personnel;
by \"promoters\" working with a water agency through primary schools; or
by extension workers in other sectors. Evidence from evalua­tions of
development projects suggests that sporadic information and education
campaigns do not result in real behavioral changes. Therefore hygiene
education associated with water and sanitation programs must be
in­corporated in continuous education program ef­forts.

\- Effective hygiene education is almost always a necessary complement
to the provision of safe water supplies and adequate sanitation in
USAID-sponsored programs.

\- Whenever possible, proper hygiene should be taught in primary
schools, and water and latrines should be provided in schools and their
use en­couraged so that children may begin to practice the normative
hygiene behavior they are taught.

\- Mothers should be a main target of hygiene education programs, since
they are primarily responsible for the health and training of their
children; and women will be included among those employed to carry out
the promotional and hygiene education activities associated with
USAID-supported programs.

**C.** **Issues of Implementation and Administration**

1\. **Costs and Financing of Water Supply and Sanitation Systems**

The long-term financing of water supply and sanitation systems is a
matter of critical concern for developing countries and donor agencies.
Per capita cost of water systems vary according to the country,
characteristics and distance of the water source, and kind of technology
used (e.g., communal standpipes or household connec­tions).[^39] Most
estimates of long-term operation and maintenance costs ignore indirect
costs, in­cluding such factors as the cost of running regional and
national offices and training middle management personnel, and therefore
seriously underestimate the costs of water systems.

Initial investment costs for water systems have been estimated to range
from approximately \$25 per capita for household connections in both
ur­ban and rural areas. The annual cost of installing and maintaining an
adequate sanitation system also varies enormously, from about \$20 per
household per year (capital and recurrent costs) for single pour-flush
toilets, to \$400 per house­hold per year for sewerage systems.[^40]

Where water and sanitation systems are provided through household
connections, con­sumers must be charged fees which at least cover
operating expenses, and preferably the full cost, possibly through loan
arrangements. Where ser­vices are provided as public goods and no
con­sumer can be excluded, as in the case of water standpipes or public
sanitation services, their costs must be recovered through some other
mechanisms such as increasing the price of water for house connections
and raising the per unit cost of water as the volume used rises
(increasing block rates). Other means of financing include the use of
community funds or assessment of consumers based on ability or
willingness to pay criteria.[^41]

Whether in urban or rural settings, water and sanitation tariffs must be
structured so that users can afford them. Charges for initial hook-ups
and policies that compel all new users to pur­chase a tank or other
equipment at a uniform price may effectively exclude poor households
from the system. Such devices as a loan fund, long-term credit
arrangements, or charges peg­ged to income can help ensure more
broad-based participation in the system. Where charges do not cover the
costs of at least maintaining the system, and where the difference
cannot be guaranteed through general tax revenues, USAID will not, in
general, support a major investment in domestic water supply.

While most people in developing countries may be prepared to pay a
significant portion of their income for improved water supply, in many
areas they are less persuaded or even unaware of the need for improved
sanitation facilities, especially when they do not understand or believe
the importance of these improvements for health. Thus an education
program to highlight the benefits of improved sanitation may have to be
coupled with initial subsidization of sewerage systems or, in urban
areas at any rate, sewerage charges may have to be subsidized by water
users who have water piped to their household.

\- The economic analysis of all water supply and sanitation projects
will explicitly demonstrate a feasible means of financing the program
over the long-term.

\- USAID will not support water supply and sanitation programs whose
operation and maintenance costs cannot be paid by the users through
fees, taxes and/or contributed labor.

Where possible, each user household should bear primary responsibility
for covering all costs, and certainly recurrent costs, except in areas
with extremely poor households where some level and combination of cross
subsidy and/or allocation of general tax revenues may be required. USAID
encourages adoption of methods, such as cross subsidies, which do not
exclude the poorest members of the community.

**2.** **Operation and Maintenance**

Too frequently the success of a water and sanita­tion project has been
measured in terms of the total number of wells, handpumps, or latrines
constructed, with little attention to actual opera­tion, maintenance, or
usage. Long-term success of these systems depends on the availability of
supplies, parts, equipment, and the trained peo­ple needed to monitor,
maintain, and repair the systems.

\- In general, USAID will give preference to water supply and sanitation
systems that are ap­propriate to the setting, inexpensive, and simple to
install, operate, and maintain.

\- In rural and village water and sanitation systems, revenues for
operation and main­tenance should be generated and controlled by the
local community, which has a vested interest in maintaining the system,
so that they are read­ily available when breakdowns occur.

\- USAID-supported programs for water and sanitation systems should
include training for regional and national level personnel in the
operation, maintenance and repair of water sup­ply and sanitation
systems, and for community members when community participation is a
ma­jor feature of a program. Special emphasis will be placed on training
women, since they are the major users of the systems. Emphasis will be
placed on short-term, in-service training of village-level personnel.

3\. **Management and Logistics: The Administra­tion of Water Supply and
Sanitation Programs**

Effective institutional support for water supply and sanitation programs
is essential. However, in many LDCs, the administration of water sup­ply
and sanitation programs is divided among numerous ministries and
coordination among them is often deficient. In some LDC settings, there
may be no clearly demonstrated capacity anywhere in the public sector to
initiate and sup­port water and sanitation programs.

The participation of the private sector in both the construction and
operation of water and sanita­tion systems can increase the efficiency of
such efforts, especially where water and sanitation services are
provided directly to households will­ing to pay for services. However,
where the ser­vices are.not provided directly to households but are
\"public goods\" in the form of standpipes or other communal facilities,
special private sector incentives or public sector involvement may be
necessary to ensure broad access to water.[^42]

Given the fact that utilities such as water supply tend to be natural
monopolies, some public sec­tor oversight is required to set service
standards and tariff structures, to endorse operation and maintenance
procedures and schedules, and bill­ing and collection activities, and,
most impor­tant, to plan for efficient and equitable water use.
Relatively small, individual communities can generally take direct
responsibility for man­agement of water systems, but larger jurisdic­tions
normally require a local or national water agency (either public or
private), and where private firms are involved, public oversight is
necessary.

\- A thorough analysis of existing and potential institutions, including
private sector entities, should be part of any project analysis for
water supply and sanitation projects.

\- USAID-supported water supply and sanita­tion programs should include
technical assistance and/or training to improve the efficiency and
ef­fectiveness of program administration by government institutions and
private firms.

\- An established, national or regional level unit responsible for
domestic water supply and sanitation programs is a prerequisite for
substan­tial USAID assistance for domestic water supply programs. The
public water authority can be governmental or parastatal, but must be
respon­sible for assessing long term water and sanitation needs, planning
for effective utilization of na­tional local water resources, assessing
and monitoring environmental hazards, rate setting, the establishment of
standards, and, where ap­plicable, oversight of private sector activities
in water and sanitation. In terms of implementation of the other aspects
of water supply and sanita­tion systems, the governmental agency and/or
private firms must have responsibility for at least the following:

\- administering national/local water and sanitation systems;

\- establishing technical requirements for water supply and sanitation;

\- ensuring operation and maintenance of the system, including
procurement and distribution of equipment and supplies;

\- assessing manpower needs, and providing ap­propriate training for
operations and maintenance.

**4.** **Role of the Private Sector**

USAID endorses the role of private enterprise in water supply and
sanitation activities, particu­larly with respect to operations and
manage­ment. Where private entrepreneurs are in­terested, franchises can
be auctioned by the public sector for building and/or operating ur­ban
water systems. The public water and sanita­tion authority would then set
rates based on ac­ceptable rate of return criteria and ensure that where
necessary public goods stands and, where relevant, sanitation systems
are financed through some combination of innovative com­munity financing,
common central government revenues, or cross-subsidies. Opportunities
for private businesses to operate and maintain water supply systems and
waste disposal (including cartage) exist, and USAID should fully explore
the feasibility of expanding and improving these activities. However
USAID recognizes that, given the high cost and modest returns as well as
the uncertainty and risk associated with such in­vestments in LDCs, the
private sector is generally reluctant to finance establishment of water
and sanitation systems.

5\. **Program Evaluation and Applied Research**

Careful evaluation of water supply and sanita­tion programs is needed to
ascertain which types of water supply and sanitation systems work best
under particular field conditions. To date, USAID -supported applied
research has stressed the development of technical and engineering
aspects of water supply and sanitation programs. In the future, USAID
will give much more atten­tion to social, economic, and administrative
con­siderations, and will evaluate regularly the water and sanitation
programs it supports. Programs that involve major innovations - either a
new technology or a new combination of interven­tions - will have a
built-in evaluation compo­nent. USAID will -also continue to support
applied research studies.

V. **Water in the Context of General Economic Development**

Development programs do not operate in a vacuum, and there are, of
course, a variety of other factors and considerations that have a
bearing on the nature and extent of USAID sup­port for water and
sanitation programs. More specifically, the need and demand for improved
water supply and sanitation services can both af­fect and be affected by
changes in other develop­ment sectors. Four such intersectoral linkages
are highlighted below to illustrate the contextual issues that surround
water and sanitation pro­grams in developing countries.

A. **Water, Sanitation and Natural Resources**

The exploitation of natural resources may unintentionally diminish the
availability and quality of water for domestic use. For instance, dam
and irrigation projects may divert water supplies that would otherwise
be available for domestic use.[^43]

Domestic water supplies may be contaminated by municipal sewage,
agricultural chemicals, or industrial wastes. The availability and
quality of water can also be compromised by such develop­ment activities
as irrigation, pesticide spraying, and vector-borne disease control
programs.

The reverse is also true: water supply and sanita­tion practices can have
a detrimental effect on the natural environment. The increased use of
water that generally follows the provision of more convenient water
sources can lead to the discharge of large volumes of potentially
con­taminated, untreated waste water which may create health and
environmental problems. En­vironmentally sound and cost-effective
waste­water and excreta disposal procedures must be a part of USAID
-supported water supply pro­grams.

B. **Water, Sanitation, and Primary Health Care**

Sound primary health care programs must in­corporate a mix of activities,
since neither im­proved water supply nor any other single health
­promoting activity can by itself fully meet the health objectives of
LDCs in any reasonable time frame. Although for many poorer countries
water and sanitation programs may not be in­cluded in the initial primary
health care services provided (because of cost, logistics, and other
factors), improvements over time in water sup­ply and sanitation are a
necessary part of a com­prehensive primary health care program.[^44]

Some aspects of water supply and sanitation can be incorporated readily
into primary health care programs. Village health workers can be taught
to recognize diseases that are caused by inadequate or poor water and
sanitation and can learn to provide hygiene education as part of their
preventive health activities. Community-level personnel can be trained
to carry out simplified sanitary surveys and to provide encouragement
and advice to communities for the construction of water supply and
simple excreta disposal systems.

C. **Water Supply, Sanitation, and Agriculture**

Rural development activities can have both beneficial and detrimental
effects on water sup­ply and sanitation in developing countries. Pro­grams
to increase agricultural production and increase farm family income can
enable rural families to pay for improved water and sanita­tion systems,
and irrigation activities themselves may make greater quantities of
water available for domestic use.

Irrigation programs can also have a directly detrimental effect on the
quality of water available for domestic use: in many countries,
large-scale irrigation programs have resulted in chemical contamination
of domestic water sup­plies and in the spread of communicable disease.
Careful local and regional planning which gives particular attention to
possible environmental degradation is therefore essential.

D. **Water Supply, Sanitation, and Urban Development**

Rapid urbanization, a result of natural popula­tion increase and of
rural- to urban-migration, has strained the already limited capacity of
ex­isting water supply and sanitation and other public service systems.
In addition to the health sector programs cited earlier, USAID funds
water supply and sanitation programs in urban areas through its shelter
sector program.[^45] Sites and services programs provide utilities,
including domestic water and sanitation; the construction of core
housing generally includes water and sanitation facilities; slum
upgrading projects often include improved water supplies, excreta
disposal, and sewage treatment; and home im­provement loans offered to
property owners are frequently used to finance better domestic water
supply and sanitation systems. Through its shelter program, USAID can
help developing countries devise innovative and effective re­sponses to
the massive water supply and sanita­tion needs of third world cities.

Among the topics currently being addressed in USAID\'s research and
development program in urban development that bear on water supply and
sanitation are: improving the financial and managerial capacity of local
government to pro­vide essential services (including water supply and
sanitation) efficiently and equitably; demonstrating the feasibility and
economic viability of safe disposal, recycling, and produc­tion of useful
byproducts from the wastes generated in secondary cities; and field
testing a strategy to help cities increase efficiency in the consumption
of important scarce resources (e.g., land, water, and energy).

E. **Future Strategy Considerations**

A number of strategy questions emerge for priority consideration by
USAID For instance, the development of local financing systems for
domestic water and sanitation programs is clearly an extremely important
area for attention of economists and other development planners. Under
what conditions is a user\'s fee preferable to a local tax to assuring
continued operation of a common water system? Under what conditions
should the government be prepared to contribute to the ongoing costs of
water and sanitation pro­grams, and what sort of government support is
most effective? How reliable are government supported programs? Answers
to these questions are critical to the maintenance and expansion of
basic water systems in the developing world over the next several years.

Other topics on the Agency\'s strategy agenda include questions of
program integration (e.g., under what conditions should water and
sanita­tion activities accompany or precede other de­velopment
interventions); community partici­pation (e.g., what are the most
practical ways of assuring meaningful community involvement in water
programs); and suitable technology (e.g., what practical information is
available to guide program planners in the selection among and
adaptation of alternative small-scale tech­nologies in the water and
sanitation field). Work on these strategy questions will continue, as
will efforts to collect and disseminate information that will allow the
Agency to do a better job of targetting its water and sanitation
programs to the most appropriate groups. Underlying all this effort and
continuing attention is the recognition that water is not only a basic
requirement of life but also contributes to overall economic growth and
development. It is for both these reasons that USAID has supported and
will continue to sup­port the efforts of LDCs to assure basic water and
sanitation services for their populations.

[^1]:     ^?^U.S. Agency for International Development, \"Community
    Water Supply in Developing Countries, Lessons from Experience\"
    (Draft), 1982.

[^2]:     ^?^As used here, this term encompasses water used for
    drinking; for hygiene (handwashing, bathing, cleaning the home
    washing kitchenware and eating utensils, food preparation, and
    frequently for washing clothes as well); for watering poultry and
    livestock, in small numbers, near the dwelling and , in minor
    amounts, for irrigation in small household gardens.

[^3]:     ^?^U.S development assistance has long supported rural and
    village water supply programs. In recent years, through the Housing
    Garrantry Program, through urban development projects, and through
    Economic Support Fund programs, USAID has given increasing attention
    to water and sanitation programs that serve the poor in rapidly
    growing urban centers of the developing world as well. (See Table I
    for trends in USAID funding of water and sanitation programs). The
    project criteria developed in this paper are intended as guidance
    for ESF and HG programs as well as for DA projects.

[^4]:     ^?^WHO Rapid Assessment Report, 1980 (United Nations, Report
    of the Secretary General, International Drinking Water Supply and
    Sanitation Decade: Present Situation and Prospects, No. A/3567,
    July, 1980).

[^5]:     ^?^According to the World Health Organization (WHO)
    definitions, \"reasonable access\" in urban areas denotes a public
    fountain or tap not mere than 200 meters from a house; in rural
    areas \"reasonable access\" implies that members of a household do
    not have to spend a \"disproportionate part of the day\" obtaining
    water for the family (\"World Health Statistical Report, \"World
    Health Organization, Vol. 29, No. 10, 1976). Access is a somewhat
    subjective term, varying according to the perceptions of a given
    society and with topography (e.g., reasonable access may be defined
    in relation to available alternative water sources only, or the
    energy and time required to haul water over a distance considered
    when the terrain is flat).

[^6]:     ^?^In this context, \":safe\" is a term of art, often used
    interchangeable with \"potable,\" \"clean,\" etc. to mean water of
    sufficient quality that it can be used, untreated, without major
    risk of contracting serious disease. \"Safe\" does not imply
    quantifiable standard, see pp. 8-9.

[^7]:     ^?^\"Foreign Assistance Act of 1961, Amended.\" U.S. Agency
    for International Development, \"Basic Human Needs Discussion
    Paper,\" 1977.

[^8]:     ^?^Evidence of the indirect links between improved water
    supply and overall economic growth is found in Saunders, Robert J.
    and Jeremy J. Warford, Village Water Supply, Baltimore: John Hopkins
    University Press (for the World Bank), 1976; Feacham, Richard et.
    al., Water, Health, and Development, 1978; White, Gilbert F., et.
    al., Drawers of Water, University of chicago Press, 1972; and
    Feacham, Richard, et. al. (eds.), Water Wastes and Health in Hot
    Climates, Chichester: John Wilen & Sons, 1977.

[^9]:     ^?^It is generally agreed that 20-40 liters per capita per day
    is the minimum required to assure adequate supplies for consumption,
    sanitation, and hygiene.

[^10]:     ^?^Feacham, 1977 and 1978, op. cit.

[^11]:     ^?^Feacham, et. at., 1978, cit., p. 217, Thus both water
    quantity and water quality are important to health, and should be
    addressed in project design. The minimal quantity needed to promote
    health is at least 20-40 liters per capita per day. Additional
    quantities are desirable; however, as quantity exceed about 100
    liters per capita per day marginal health benefits decline. The most
    important quality parameter is microbiological purity. This is best
    assured by selection of nonpolluted, protected sources, and, if
    necessary water treatment (purification). Given the scarcity of
    resources in most developing countries, investments in additional
    improvements in quality and quantity should be weighed against
    providing these minimal services to a larger population.

[^12]:     ^?^For an excellent discussion of some of the difficulties
    involved in quantifying the health and economic benefits of
    improvements in water supply and sanitation, see White, Gilbert F.,
    et. al., 1972, op. cit.

[^13]:     ^?^Time saved in rural Thai village where water was provided
    in or near the home made possible economically productive
    activities - such as crafts and small vegetables gardens. Villagers
    cited increased craft activities and more gardening and farming as
    the most beneficial consequences of the piped water systems.
    (Dworkin, D. and B.L.K. Pillsbury, \"The Potable Water Project in
    Rural Thailand, \"USAID Project Evaluation Report No. 3, Washington,
    D.C. 1980). Findings such as these have been cited in numerous
    recent studies. See, for instance, White, et. al., 1972, op. cit.

[^14]:     ^?^Russell, Annemarie, \"Report on the Situation of Women in
    the Target Village of the UNICEF Domestic Water Supply Project in
    Bahr El Ghazal Province, Sudan,\" Khartoum: UNICEF, 1979.

[^15]:     ^?^Cochran, Susan, The Effects of Education on Health,
    Washington, D.C. IBRD Working Paper 405, 1980.

[^16]:     ^?^It may be extremely costly to provide these services for
    the poorest, most widely dispersed groups (who are the least able to
    pay for them) but USAID is committed to the search for low-cost
    technologies that lower the cost of serving the poorest population
    in LDCs (see pp. 21-24 below).

[^17]:     ^?^Saunders and Warford, op. cit. Total costs depends on the
    quality and quantity of the water available, the type of
    \"hardware\" selected, the related training, administrative, and
    other costs, and much more.

[^18]:     ^?^\"Water Supply and Waste Disposal,\" Poverty and Basic
    Needs Series, The World Bank, Washington, D.C., 1980.

[^19]:     ^?^Housing Guaranty and Economic Support Fund Programs which
    operate primarily in urban areas are exceptions.

[^20]:     ^?^Barnum, Howard, et. al., A Resource Allocation Model for
    Child Survival, Cambridge, Ma: Oelgeschlager

[^21]:     ^?^See, for instance, Grosse, Robert N., \"International
    Between Health and Population: Observations Derived from Field
    Experience,\" Social Science and Medicine, Vol. 14C No. 2, pp.
    99-120, 1980.;

[^22]:     ^?^Barnum, op. cit. p. 4

[^23]:     ^?^See, for instance, the studies cited in footnote 11. See
    also Hollister, Arthur C., Jr., et. al., \"Influence of Water
    Availability on Shigella Prevalence in Children of Farm Labor
    Families,\" American Journal of Public Health, 45 (3):354-362, 1995;
    Moore Helen, et. al. \"Diarrheal Disease Studies in Costa Rica. Iv.
    The Influence of Sanitation Upon the Prevalence of Intestinal
    Infection and Diarrheal Disease.\" American Journal of Epidemiology,
    82(2): 162-184, 1965: Schliessman, DE.J., et. al., \"Relation of
    Environmental Factors to be Occurrence of Enteric Diseases in Areas
    of Eastern Kentucky,\" Public Health Monograph No. 54 (Issued
    concurrently in Public Health Reports, 73 (11).), Washington, 1958.

    Section 611(b) of the Foreign Assistance Act requires\" \...a
    computation of benefits and costs made insofar as practical in
    accordance with the procedures set forth in the Principles and
    Standards for Planning Water and Related Land Resources, dated
    October 25, 1973, with respect to such computations.\"

[^24]:     ^?^Shuval, Hillel, et. al., \"The Effect of Water Supply and
    Sanitation Investments in Health Status: A Threshold-Saturation
    Theory,\" in press, 1981.

[^25]:     ^?^In situations where the public need is compelling, host
    government subsidization of recurrent costs may be necessary on an
    interim basis, with the expectation that consumers will eventually
    assume the costs.

[^26]:     ^?^Carruthers, I.D., \"Impact and Economics of Community
    Water Supply: A Study of Rural Water Investments in Kenya\" (Kent,
    England: Agrarian Development Studies Report No. 6), 1973, p. 30.

[^27]:     ^?^Warner, Dennis, \"Social and Economic Preconditions for
    Water and Sanitation Programs,\" Washington, D.C.: U.S.USAID, 1981.

[^28]:     ^?^White et. al., op. cit. (See also page 18).

[^29]:     ^?^The WHO\'s International Drinking Water Standards, are
    currently being reformulated. See also: Chamberlain, Charles E., et.
    al. *Wholesome and Palatable Drinking Water: A Background Paper on
    Water Quality Aspects of Water Supply*, Washington, D.C.. 1979;
    Woman, Abel, et. al., \"A Panel Report to U.S. Agency for
    International Development on Sanitary Services During 1980-1990,\"
    Washington, D.C.: U.S.USAID, 1979.

    The issue was thoroughly reviewed by USAID during 1979, by an
    external panel of experts. Guidelines on water quality are based on
    findings in their report, which is available from USAID\'s Office of
    Health. (Chamberlain, et. al., op. cit.)

[^30]:     ^?^Donaldson, David, \"Sanitation and Health: An Overview,\"
    in *The Impact of Interventions in Water Supply and Sanitation in
    Developing Countries*, U.S.USAID, April, 1981.

[^31]:     ^?^In many arid regions, traditional societies developed
    water supply and excreta disposal systems which were designed to fit
    within the constraints imposed by the environment. For example, in
    the Near East, huge cisterns were built to store rain water for the
    dry season. Dry toilets built within the homes provided an
    ecologically sound means of human waste disposal. Excreta deposited
    in an isolated chamber was readily available as a soil additive or
    fuel supplement. Planners should consider modifying time-tested
    traditional approached such as these, rather than automatically
    replacing them with modern methods that may waste resources already
    in short supply. New technologies, such as pumps and self-closing
    valves that curtail water waste, should also be considered. See
    Winblad, Uno and Wen Kilama, *Sanitation Without Water,* Stockholm:
    SIDA, 1980, Kalbermatten, John M, et. al., *Appropriate Technology
    for Water Supply and Sanitation, Technical and Economic Options*,
    Washington: World Bank, 1980.

[^32]:     ^?^The level of technology that is appropriate in a given
    situation should not be underestimated. The evaluation of USAID\'s
    potable water project in rural Thailand demonstrated that the best
    technology was not necessarily that which appeared to be the most
    capital saving technology. Villages perceived piped water systems
    with household connections as preferable to traditional sources of
    hand-pumps. They were therefore willing to finance and maintain the
    piped systems, while few of the handpumps have remained in
    operation. Dworkin, D. and B. L. K. Pillsbury, 1980, op. cit.

[^33]:     ^?^Varisco, Daniel and Max Kroeschel, \"Rural Sanitation in
    the Arab Republic of Egypt,\" Washington, D.C.: Metametrics (for
    U.S.USAID), 1981.

    Pools of waste water may promote mosquito breeding (especially of
    *Culex fatigans* and *Aedes egypti*, vectors of filariasis and
    yellow (fever) and may create soil conditions favorable to
    transmission of geohelminthic diseases, e.g., hookworm and
    ascariasis.

[^34]:     ^?^Increasing block rates refers to the pricing structure
    where the first units of water are provided at low prices, with cost
    per unit increasing with the volume of water consumed.

[^35]:     ^?^**Observations of Rural Water Supply and Sanitation
    Programs in eight Developing Countries**. IBRD, Report no. PUN 42,
    1978; Self, george, \"Social Analysis of rural Potable Water
    Programs,\" USAID, 1979. **UNICEF/WHO Joint Study on Water Supply
    and Sanitation Components of Primary Health Care**, JC
    22/UNICEF-WHO/79.3.

[^36]:     ^?^Larger and more complex systems will require full-time
    staff and supervisors. Even when systems can be operated and
    maintained by the users, access to the expertise of a central water
    authority will occasionally be necessary.

[^37]:     ^?^**Social and Behavioral Aspects of Project Work in Water
    Supply and Waste Disposal**, IBRD, Transportation, Water and
    Telecommunications Department Public Utilities Notes, 1980.

[^38]:     ^?^Elemdorf, M.L., and R. B. Iseley. \"The Role of Women as
    Participants and Beneficiaries in Water Supply and Sanitation
    Programs,\" Washington: Mimeographed draft, 1981, p. 4.

[^39]:     ^?^The World Bank has recommended that (1) \"minimum\" water
    service be available to all and (2) the charge not exceed 5-6
    percent of the income of the poorest household to be served.
    Unfortunately, the high cost of reaching isolated groups may make
    total coverage of populations in developing countries and
    \"impractical and perhaps unattainable objective. See The World Bank
    \"Water Supply and Waste Disposal.\" op. cit.

[^40]:     ^?^Kalbermatten, John M., et. al., op. cit. Precise figures
    for recurrent costs of alternative water systems are unavailable,
    and estimates vary widely. The World Bank, \"Water Supply and Waste
    Disposal,\" op. cit.

    In some unusual settings, such as Bangladesh (which has an alluvial
    delta, high water table, and high population density), the cost of
    shallow wells with handpumps may be as low as \$3 per capita (F.
    Eugene McJunkin, personal communication).

[^41]:     ^?^Building on established community financing mechanisms is
    a useful starting point for developing financial schemes. In some
    instances leasing standposts or similar public sources of water to
    private entrepreneurs can improve operation and maintenance and
    simultaneously ensure the system\'s financial viability. However,
    problems encountered in the use of private vendors have included
    price fixing, failure to maintain water quality, and the use of
    insufficient technologies.

[^42]:     ^?^For example, where the private sector is encourages to
    provide public goods (for example, sanitation), incentives such as
    higher water fees could be allowed by the water authority to cover
    costs of sanitation services.

[^43]:     ^?^The environmental assessment required by the Agency for
    all such projects under the provisions of 22 CFR 26, \"USAID
    Environmental Procedures\", should address this issue directly.

[^44]:     ^?^**Primary Health Care: Report of the International
    Conference on Primary Health Care, Alma Ata, USSR, 6-12 September,
    1978**, Geneva: World Health Organization, 1978.

[^45]:     ^?^\"Urbanization and the Urban Poor,\" U.S. Agency for
    International Development, Policy Determination 67, Supplement
    Handbook 1, 1976.