The 2005 Act made access to safe water and sanitation a U.S. foreign policy objective. Specifically, the act aimed to promote the provision of access to safe water and sanitation to countries, locales, and people with greatest need, including the very poor, women, and other vulnerable populations. Congress passed the 2014 Act to strengthen the 2005 Act by improving the capacity of the U.S. government to implement, monitor, and evaluate programs that increase access to safe water, sanitation, and hygiene. The 2014 Act requires, among other things, that USAID ensure that WASH projects are designed to promote maximum impact and long-term sustainability. The 2014 Act also calls for rigorous monitoring and evaluation to assess improvements in WASH. State’s Office of Conservation and Water within the Bureau of Oceans and International Environmental and Scientific Affairs is responsible for the development and implementation of U.S. foreign policy on international water and sanitation assistance. USAID’s Office of Water within the Bureau for Economic Growth, Education and Environment is responsible for coordinating, managing, and overseeing USAID’s response to water policy initiatives, including the 2014 Act. Annual appropriations acts funding foreign operations have established a spending requirement for WASH. These spending requirements have ranged from $315 million to $365 million since 2012. USAID and State have provided annual guidance to USAID missions regarding activities for which they may attribute funding to the annual spending requirement. The guidance notes that for attribution, proposed activities must be able to demonstrate an impact on water supply, sanitation, or hygiene through objectively verifiable indicators to measure progress. The 2005 Act required State to submit an annual report to Congress detailing the status of WASH efforts; these reports included information from USAID about funds allocated to WASH activities to meet the spending requirements for WASH. This reporting requirement was repealed by the 2014 Act. Improving health outcomes through the provision of sustainable WASH is the first strategic objective of USAID’s Water and Development Strategy, 2013-2018 (Water Strategy). To achieve this objective, the Water Strategy includes three key WASH-related goals: Increase first-time and improved access to sustainable water supply. First-time access refers to access to an improved water source that is gained by previously unserved populations. Improved access refers to enhancing existing access to, and the quality of, an already improved water supply. Increase first-time and improved access to sustainable sanitation. First-time access to improved sanitation generally refers to access to a pit latrine with a slab, septic system, or similar type of improved sanitary facility. Improved access to sanitation generally refers to improvement of an existing sanitation facility. Increase adoption of key hygiene behaviors. The Water Strategy recommends the promotion of three hygiene practices with the greatest demonstrated impact on health: (1) hand washing with soap at critical times; (2) safe disposal and management of excreta; and (3) improving household water storage, handling, and treatment. Figure 1 shows USAID’s definitions for improved and unimproved drinking water and sanitation. In March 2014, USAID issued the Water Strategy Implementation Field Guide (Field Guide) as a tool to help missions understand and implement the Water Strategy. The Field Guide requires that USAID missions track progress toward the three WASH-related goals using standard indicators and some custom indicators, as shown in table 1. State’s annual reports to Congress detailing the status of WASH projects have included country-level results for two of the standard WASH indicators: (1) number of people gaining access to an improved drinking water source and (2) number of people gaining access to an improved sanitation facility. This information has also been reported in USAID’s annual report on international water-related assistance, Safeguarding the World’s Water. The Water Strategy projected that during the next 5 years, at least 10 million persons would receive sustainable access to improved water supply and 6 million persons would receive sustainable access to improved sanitation. These projections included persons receiving first- time and improved access to water supply and sanitation. According to the Water Strategy and the Field Guide, to achieve the greatest impact, WASH projects should include the following elements: expanded access to “hardware” (e.g., water and sanitation infrastructure and hygiene commodities); required “software” activities to promote behavior changes for sustained improvements in water and sanitation access/service and hygiene practices; and an improved enabling policy and institutional environment, including strengthened financial frameworks and public-private partnerships for WASH. The Field Guide states that the level of effort in each area may vary depending on local context and other factors. In addition, the Water Strategy and the Field Guide highlight gender issues in the water sector as a key focus. They note that the burden of inadequate access to water and sanitation often falls heavily on women and girls and that WASH activities should promote gender equality and female empowerment to address the needs and opportunities of both men and women. The Water Strategy emphasizes the importance of sustainable WASH services. USAID policy defines sustainable services as public services in which host country partners and beneficiaries take ownership of development processes and maintain project results beyond the life of a USAID project. The strategy notes that the pillars of sustainability for water projects include integrated water resource management, sound governance, and appropriate environmental design, among other factors. In particular, regarding projects to provide first-time and improved access to quality water supply services, the strategy states that methods for ensuring the sustainability of water quality in the long term should be incorporated into project design and that this may include developing monitoring systems to ensure that water quality and supply are sustained at acceptable levels. Further, regarding sanitation services, the strategy notes that it supports the development and testing of improved, low-cost sanitation and waste management technologies, as well as innovative management and financing approaches, to ensure sustainability and to facilitate more rapid expansion of basic sanitation solutions. In fiscal year 2014, USAID designated 22 countries as tier 1 or tier 2 priorities for WASH assistance on the basis of their need and the opportunity to achieve significant impact. The 6 tier 1 countries are those where USAID found an opportunity to have a transformative impact on national-level policies and to leverage host country resources for the development and implementation of assistance. The 16 tier 2 countries are those where USAID determined that relatively small investment levels were likely to generate a significant impact in at least one dimension of WASH. USAID reported attributing about $463.1 million to the annual spending requirements for WASH in fiscal years 2012 through 2014 for these priority countries. Figure 2 shows the locations of the tier 1 and 2 priority countries. In the nine countries we selected for our review, USAID missions reported $214.5 million in WASH funding for 74 activities, with 6 key focus areas. Each mission’s total funding for WASH activities in these nine countries ranged from about $53.4 million, in Indonesia, to about $4.4 million, in Haiti. Missions reported implementing from as many as 19 WASH activities, in Kenya, to as few as 3 activities, in both Tanzania and Zambia. The most frequent key focus areas for these activities were capacity building and behavior-change communication, followed by infrastructure construction, technical assistance, policy and governance, and financing. Figure 3 provides additional detail about the activities implemented by each selected mission in fiscal years 2012 through 2014. Table 2 describes the 74 activities’ key focus areas and provides examples of the types of WASH activities in each focus area for the nine selected countries. Missions noted that some of the 74 reported activities included WASH as one of several other components, such as maternal-child health, nutrition, or natural resources management. For example, the Senegal mission’s Yaajeende Agriculture activity is an agricultural activity that aims to increase nutritional status by diversifying foods produced and eaten. The activity includes a WASH component to expand access to clean drinking water and improved sanitation and also includes water resources management efforts to promote effective small irrigation technologies. In another example, the DRC mission’s Integrated Health Project aims to improve the enabling environment and increase the availability of services, products, and practices for family planning; maternal, newborn, and child health; nutrition, malaria, and tuberculosis; and WASH in targeted health zones. Additionally, the nine missions reported implementing WASH activities targeting three types of geographic areas: rural, peri-urban (e.g., small towns), and urban. For example, the Tanzania mission’s Integrated Water, Sanitation, and Hygiene activity targeted rural and peri-urban areas (e.g., small towns) to provide support including community piped water schemes, rehabilitated wells, training for community groups to operate and maintain water systems, and school latrines, among other efforts. In contrast, the Indonesia mission’s Indonesia Urban Water, Sanitation, and Hygiene activity aimed to increase access to clean water and improve sanitation facilities for people in urban settings, where about half of Indonesia’s population lives. According to the Indonesia mission, the activity focused on fostering demand for WASH, building capacity, and strengthening the policy and financing environment for WASH through its work with central and local governments, including entities responsible for delivering water and sanitation services. Table 3 includes information about the geographic focus of the 74 activities in the nine selected countries. In the nine countries we selected for our review, we found that USAID missions are taking steps to develop and implement WASH plans and are incorporating the Water Strategy’s principles and approach into recent and planned WASH activities. The missions are considering sustainability as part of WASH project planning, and USAID’s Office of Water is developing guidance for missions specific to WASH sustainability. We found that the missions in the nine selected countries have made varying degrees of progress in developing WASH plans. In addition, we found that these missions have generally taken steps to implement WASH plans and enhance the strategic approach in recent WASH projects.