WASH
WASH (or Watsan, WaSH) is an acronym that stands for "water, sanitation and hygiene". Universal, affordable and sustainable access to WASH is a key public health issue within international development and is the focus of the first two targets of Sustainable Development Goal 6 (SDG 6). Targets 6.1 and 6.2 aim at equitable and accessible water and sanitation for all. "Access to WASH" includes safe water, adequate sanitation and hygiene education. Improving access to WASH services can improve health, life expectancy, student learning, gender equality, and other important issues of international development. This can reduce illness and death, and  also affect poverty reduction and socio-economic development. Challenges include providing services to urban slums, improper management of water distribution systems, failures of WASH systems over time, providing equitable access to drinking water supply and gender issues. WASH services have to be provided to household locations but also to schools, healthcare facilities, work places, markets, prisons, train stations, public locations etc. In 2015 the World Health Organization (WHO) estimated that "1 in 3 people, or 2.4 billion, are still without sanitation facilities" while 663 million people still lack access to safe and clean drinking water. In 2017, this estimate changed  to 2.3 billion people without sanitation facilities and 844 million people without access to safe and clean drinking water. Lack of sanitation contributes to about 700,000 child deaths every year due to diarrhea, mainly in developing countries. Chronic diarrhea can have long-term negative effects on children, in terms of both physical and cognitive development. In addition, lack of WASH facilities at schools can prevent students (especially girls) from attending school, and reduce their educational achievements and later work productivity. Definition and purpose. The concept of WASH groups together water supply, sanitation, and hygiene because the impact of deficiencies in  each area overlap strongly (WASH is an acronym that uses the first letters of "water, sanitation and hygiene"). Addressing these deficiencies together can achieve a strong positive impact on public health. Health aspects. Overview. Effective sanitation separates human excreta from contact with people, and this can prevent many diseases such as (but not only) waterborne diseases. The World Health Organization (WHO) collated information on sanitation and health in their "Guidelines on Sanitation and Health". Health impacts of the lack of safe sanitation systems can be grouped into three categories: Direct impact (infections), sequelae (conditions caused by preceding infection) and broader  well-being. These categories include the following: Adequate sanitation in conjunction with good hygiene and safe water are essential to good health. Lack of proper sanitation causes diseases. Most of the diseases resulting from sanitation have a direct relation to poverty. The lack of clean water and poor sanitation causes many diseases and the spread of diseases. It was estimated in 2002 that inadequate sanitation was responsible for 4.0 percent of deaths and 5.7 percent of disease burden worldwide. Open defecation – or lack of sanitation – is a major factor in causing various diseases, most notably diarrhea and intestinal worm infections . WASH-attributable burden of diseases and injuries. A report by World Health Organization in 2019 found that "Worldwide, 1.9 million deaths and 123 million DALYs could have been prevented in 2016 with adequate WASH. The WASH-attributable disease burden amounts to 3.3% of global deaths and 4.6% of global DALYs. Among children under 5 years, WASH-attributable deaths represent 13% of deaths and 12% of DALYs." An earlier study from 2002 had estimated that up to 5 million people die each year from preventable waterborne diseases. Twelve diseases associated with inadequate WASH where "population attributable fractions" can be quantified: Diseases  where adverse health outcomes or injuries linked to inadequate WASH are described but not yet quantified: Diarrhea, malnutrition and stunting. Diarrhea is primarily transmitted through fecal-oral routes. In 2011, infectious diarrhea resulted in about 0.7 million deaths in children under five years old and 250 million lost school days. This equates to about 2000 child deaths per day. Children suffering from diarrhea are more vulnerable to become underweight (due to stunted growth). This makes them more vulnerable to other diseases such as acute respiratory infections and malaria. Chronic diarrhea can have a negative effect on child development (both physical  and cognitive). Numerous studies have shown that improvements in drinking water and sanitation WASH lead to decreased risks of diarrhea. Such improvements might include for example use of water filters, provision of high-quality piped water and sewer connections. Diarrhea can be prevented - and the lives of 525,000 children annually be saved (estimate for 2017) - by improved sanitation, clean drinking water, and hand washing with soap. In 2008 the same figure was estimated as 1.5 million children. The combination of direct and indirect deaths from malnutrition caused by unsafe water, sanitation and hygiene (WASH) practices was estimated by the World  Health Organization in 2008 to lead to 860,000 deaths per year in children under five years of age. The multiple interdependencies between malnutrition and infectious diseases make it very difficult to quantify the portion of malnutrition that is caused by infectious diseases which are in turn caused by unsafe WASH practices. Based on expert opinions and a literature survey, researchers at WHO arrived at the conclusion that approximately half of all cases of malnutrition (which often leads to stunting) in children under five is associated with repeated diarrhea or intestinal worm infections as a result of unsafe water, inadequate sanitation  or insufficient hygiene. Neglected tropical diseases. Water, sanitation and hygiene interventions help to prevent many neglected tropical diseases (NTDs), for example soil-transmitted helminthiasis. An integrated approach to NTDs and WASH benefits both sectors and the communities they are aiming to serve. This is especially true in areas that are endemic with more than one NTD. In August 2015, the World Health Organization (WHO) unveiled a global strategy and action plan to integrate WASH with other public health interventions in order to accelerate elimination of NTDs. The plan aims to intensify control or eliminate certain NTDs in specific regions by  2020. It refers to the NTD roadmap milestones that included for example eradication of dracunculiasis by 2015 and of yaws by 2020, elimination of trachoma and lymphatic filariasis as public health problems by 2020, intensified control of dengue, schistosomiasis and soil-transmitted helminthiases. The plan consists of four strategic objectives: improving awareness of benefits of joint WASH and NTD actions; monitoring WASH and NTD actions to track progress; strengthening evidence of how to deliver effective WASH interventions; and planning, delivering and evaluating WASH and NTD programmes with involvement of all stakeholders. The aim is to use synergies between WASH and  NTD programmes. Evidence regarding health outcomes. There is debate in the academic literature about the effectiveness on health outcomes when implementing WASH programs in low- and middle-income countries. Many studies provide poor quality evidence on the causal impact of WASH programs on health outcomes of interest. The nature of WASH interventions is such that high quality trials, such as randomized controlled trials (RCTs), are expensive, difficult and in many cases not ethical. Causal impact from such studies are thus prone to being biased due to residual confounding. Blind studies of WASH interventions also pose ethical challenges and difficulties associated  with implementing new technologies or behavioral changes without participant's knowledge. Moreover, scholars suggest a need for longer-term studies of technology efficacy, greater analysis of sanitation interventions, and studies of combined effects from multiple interventions in order to more sufficiently gauge WASH health outcomes. Many scholars have attempted to summarize the evidence of WASH interventions from the limited number of high quality studies. Hygiene interventions, in particular those focusing on the promotion of handwashing, appear to be especially effective in reducing morbidity. A meta-analysis of the literature found that handwashing interventions reduced the relative risk of diarrhea by  approximately 40%. Similarly, handwashing promotion has been found to be associated with a 47% decrease in morbidity. However, a challenge with WASH behavioral intervention studies is an inability to ensure compliance with such interventions, especially when studies rely on self-reporting of disease rates. This prevents researchers from concluding a causal relationship between decreased morbidity and the intervention. For example, researchers may conclude that educating communities about handwashing is effective at reducing disease, but cannot conclude that handwashing reduces disease. Point-of-use water supply and point-of-use water quality interventions also show similar effectiveness to handwashing, with  those that include provision of safe storage containers demonstrating increased disease reduction in infants. Specific types of water quality improvement projects can have a protective effect on morbidity and mortality. A randomized control trial in India concluded that the provision of chlorine tablets for improving water quality led to a 75% decrease in incidences of cholera among the study population. A quasi-randomized study on historical data from the United States also found that the introduction of clean water technologies in major cities was responsible for close to half the reduction in total mortality and over three-quarters of the  reduction in infant mortality. Distributing chlorine products, or other water disinfectants, for use in the home may reduce instances of diarrhea. However, most studies on water quality improvement interventions suffer from residual confounding or poor adherence to the mechanism being studied. For instance, a study conducted in Nepal found that adherence to the use of chlorine tablets or chlorine solution to purify water was as low as 18.5% among program households. A study on a water well chlorination program in Guinea-Bissau in 2008 reported that families stopped treating water within their households because of the program which consequently increased  their risk of cholera. It was concluded that well chlorination without proper promotion and education led to a false sense of security. Studies on the effect of sanitation interventions alone on health are rare. When studies do evaluate sanitation measures, they are mostly included as part of a package of different interventions. A pooled analysis of the limited number of studies on sanitation interventions suggest that improving sanitation has a protective effect on health. A UNICEF funded sanitation intervention (packaged into a broader WASH intervention) was also found to have a protective effect on under-five diarrhea incidence but not  on household diarrhea incidence. Non-household locations. Schools. WASH in schools, sometimes called SWASH or WinS, significantly reduces hygiene-related disease, increases student attendance and contributes to dignity and gender equality. WASH in schools contributes to healthy, safe and secure school environments that can protect children from health hazards, abuse and exclusion. It also enables children to become agents of change for improving water, sanitation and hygiene practices in their families and communities. Lack of WASH facilities can prevent students from attending school, impose a burden on women, and diminish productivity. Data from over 10,000 schools in Zambia was analysed  in 2017 and confirmed that improved sanitation provision in schools was correlated with high female-to-male enrolment ratios, and reduced repetition and drop-out ratios, especially for girls. The study thus confirmed the linkages between adequate toilets in schools and educational progression of girls. More than half of all primary schools in the developing countries with available data do not have adequate water facilities and nearly two thirds lack adequate sanitation. Even where facilities exist, they are often in poor condition. Boys and girls are able to more fully participate in school when there is improved access to water . Reasons for missing or poorly maintained water and sanitation facilities at schools in developing countries include lacking inter-sectoral collaboration; lacking cooperation between schools, communities and different levels of government; as well as a lack in leadership and accountability. Strong cultural taboos around menstruation, which are present in many societies, coupled with a lack of Menstrual Hygiene Management services in schools, results in girls staying away from school during menstruation. Approaches. Methods to improve the situation of WASH infrastructure at schools include on a policy level: broadening the focus of the education sector, establishing a systematic quality assurance system, distributing  and using funds wisely. Other practical recommendations include: have a clear and systematic mobilization strategy, support the education sector to strengthen intersectoral partnerships, establish a constant monitoring system which is located within the education sector, educate the educators and partner with the school management. The support provided by development agencies to the government at national, state and district levels is helpful to gradually create what is commonly referred to as an enabling environment for WASH in schools. This includes sound policies, an appropriate and well-resourced strategy, and effective planning. Such efforts need to be sustained over longer time periods  as ministries and departments of education are very large organizations, which generally show much inertia and are slow to reform. Success also hinges on local-level leadership and a genuine collective commitment of school stakeholders towards school development. Developing human and social capital amongst core school stakeholders is important. This applies to students and their representative clubs, headmaster and teachers, parents and SMC members. Furthermore, other stakeholders have to be engaged in their direct sphere of influence, such as: community members, community-based organizations, educations official, local authorities. Group handwashing. Supervised daily group handwashing in schools can be an effective  strategy for building good hygiene habits, with the potential to lead to positive health and education outcomes for children. This has for example been implemented in the "Essential Health Care Program" by the Department of Education in the Philippines. Deworming twice a year, supplemented by washing hands daily with soap and brushing teeth daily with fluoride, is at the core of this national program. It has also been successfully implemented in Indonesia. Approximately 40% of the world's population live without basic hand washing facilities with soap and water at home. According to the World Health Organization, over half of  the people who live in rural areas in less developed parts of the world do not practice hand washing methods due to a severe lack of water and soap. Improving access to hand washing and sanitation facilities in healthcare settings will significantly reduce infection and mortality rates, particularly in maternal and child health. Health facilities. The provision of adequate water, sanitation and hygiene is an essential part of providing basic health services in healthcare facilities. WASH in Health facilities aids in preventing the spread of infectious diseases as well as protects staff and patients. Urgent action is needed to improve  WASH services in health facilities in developing countries. According to the World Health Organization, data from 54 countries in low and middle income settings representing 66,101 health facilities show that 38% of health care facilities lack improved water sources, 19% lack improved sanitation while 35% lack access to water and soap for handwashing. The absence of basic WASH amenities compromises the ability to provide routine services and hinders the ability to prevent and control infections. The provision of water in health facilities was the lowest in Africa, where 42% of healthcare facilities lack an improved source of water on-site  or nearby. The provision of sanitation is lowest in the Americas with 43% of health care facilities lacking adequate services. In 2019, WHO estimated that: "One in four health care facilities lack basic water services, and one in five have no sanitation service – impacting 2.0 and 1.5 billion people, respectively." Furthermore, it is estimated that "health care facilities in low-income countries are at least three times as likely to have no water service as facilities in higher resource settings". This is thought to contribute to the fact that maternal sepsis is twice as great in developing countries as it  is in high income countries. Barriers to providing WASH in health care facilities include: Incomplete standards, inadequate monitoring, disease-specific budgeting, disempowered workforce, poor WASH infrastructure. The improvement of WASH standards within health facilities needs to be guided by national policies and standards as well as an allocated budget to improve and maintain services. A number of solutions exist that can considerably improve the health and safety of both patients and service providers at health facilities. Challenges. Urban slums. Part of the reason for slow progress in sanitation may be due to the "urbanization of poverty", as poverty is increasingly  concentrated in urban areas. Migration to urban areas, resulting in denser clusters of poverty, poses a challenge for sanitation infrastructures that were not originally designed to serve so many households, if they existed at all. There are three main barriers to improvement of urban services in slum areas: Firstly, insufficient supply, especially of networked services. Secondly, there are usually demand constraints that limit people's access to these services (for example due to low willingness to pay). Thirdly, there are institutional constraints that prevent the poor from accessing adequate urban services. Water distribution systems. Improper management of water distribution systems  in developing nations can exacerbate the spread of water-borne diseases. The World Health Organization estimates that 25%-45% of water in distribution lines is lost through leaks in developing countries. These leaks can allow for contaminated water and pathogens to enter the distribution pipes, especially when power outages result in a loss of pressure in the water supply pipes. Cross-contamination of wastewater into potable water lines has resulted in major disease outbreaks, such as a Typhoid fever outbreak in Dushanbe, Tajikistan in 1997. Failures of WASH systems. National government mapping and monitoring efforts, as well as post-project monitoring  by NGOs or researchers, have identified the failure of water supply systems (including water points, wells and boreholes) and sanitation systems as major challenges. Many water and sanitation systems are unsustainable, failing to provide extended health benefits to communities in the long-term. This has been attributed to financial costs, inadequate technical training for operations and maintenance, poor use of new facilities and taught behaviors, and a lack of community participation and ownership. Access to WASH services also varies internally within nations depending on socio-economic status, political power, and level of urbanization. A 2004 estimate by UNICEF stated that  urban households are 30% and 135% more likely to have access to improved water sources and sanitation respectively, as compared to rural areas. Moreover, the poorest populations cannot afford fees required for operation and maintenance of WASH infrastructure, preventing them from benefitting even when systems do exist. Equitable access to drinking water supply. A global monitoring report by the Joint Monitoring Program for Water Supply and Sanitation of WHO and UNICEF published in 2019 stated that 435 million people used unimproved sources for their drinking water, and 144 million still used surface water. Reducing inequalities in basic water, sanitation  and hygiene services is a longstanding WASH sector objectives. Such inequalities are for example related to income level and gender. For example, in 24 countries where disaggregated data was available, basic water coverage among the richest wealth quintile was at least twice as high as coverage among the poorest quintile. The human rights to water and sanitation prohibit discrimination on the grounds of "race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, disability or other status". These are all dimensions of inequality in WASH services. Dealing with inequalities of water access falls under international  human rights law. In 2000, the Second World Water Forum in The Hague concluded that women are the primary users of domestic water, that women used water in their key food production roles, and that women and children were the most vulnerable to water-related disasters. At the International Conference on Water and the Environment, the Dublin Statement on Water and Sustainable Development included "Women Play a central part in the provision management and safeguarding of water" as one of four principles. Water supply schemes in developing nations have shown higher success when planned and run with full participation of  women in the affected communities. For example, a study including 88 communities in 14 countries showed that projects where men and women from intended user households were included in selection of site facilities, and where water projects were initiated by user households, rather than by external agencies or local leaders, achieved a final higher access to services than those that did not. Gender. The lack of accessible, sufficient, clean and affordable water supply has adverse impacts specifically related to women in developing nations. It is estimated that 263 million people worldwide spent over 30 minutes per round trip to collect  water from an improved source. In sub-Saharan Africa, women and girls carry water containers for an average of three miles each day, spending 40 billion hours per year on water collection (walking to the water source, waiting in line, walking back). The time to collect water can come at the expense of education, income generating activities, cultural and political involvement, and rest and recreation. For example, in low-income areas of Nairobi, women carry 44 pound containers of water back to their homes, taking anywhere between an hour and several hours to wait and collect the water. In many  places of the world, getting and providing water is considered "women's work," so gender and water access are intricately linked. Water gathering and supply to family units remains primarily a woman's task in less developed countries where water gathering is considered a main chore. This water work is also largely unpaid household work based on patriarchal gender norms and often related to domestic work, such as laundry, cooking and childcare. Areas that rely on women to primarily collect water include countries in Africa, South Asia and in the Middle East. Gender norms can negatively affect how men and  women access water through such behavior expectations along gender lines—for example, when water collection is a woman's chore, men who collect water may face discrimination for performing perceived women's work. For example, women are likely to be deterred from entering water utilities in developing countries because "social norms prescribe that it is an area of work that is not suitable for them or that they are incapable of performing well". Nevertheless, a study by World Bank in 2019 has found that the proportion of female water professionals has grown in the past few years. In many societies , the task of cleaning toilets falls to women or children, which can increase their exposure to disease. Gender-sensitive approaches to water and sanitation have proven to be cost effective. Many women's rights and water advocacy organizations have identified water privatization as an area of concern, sometimes alleging negative effects that specifically affect women. The World Bank Gender and Development Group has addressed gender issue at an institutional level, citing successful "Gender-Mainstreaming" efforts in many of its Water Supply and Sanitation projects. Already in 1996, Worldbank published a "Toolkit on Gender in Water and Sanitation". The United Nations  Interagency Network on Women and Gender Equality (IANWGE) established the Gender and Water Task Force in 2003. The Task Force became a UN-Water Task Force and took responsibility for the gender component of International Water for Life Decade (2005-1015). The Task Force's mandate ended in 2015 and the Task Forces later turned into Experts Groups (there is no Expert Group on gender). Country policy examples. A study in 2003 assessed the trends in gender mainstreaming at policy and institutional levels. It also touched on the parallel trend towards Integrated Water Resources Management (IWRM). The study concluded that : In Uganda, the National Water Policy has the full participation of women at all levels as one of its principles. Violence against women. Women and girls usually bear the responsibility for collecting water, which is often very time-consuming and arduous, and can also be dangerous for them. Women and girls who collect water may also face physical assault and sexual assault along the way (violence against women). This includes vulnerability to rape when collecting water from distant areas, domestic violence over the amount of water collected, and fights over scarce water supply. A study in India, for example, found  that women felt intense fear of sexual violence when accessing water and sanitation services. A similar study in Uganda also found that women reported to feel a danger for their security whilst journeying to toilets particularly at night. Climate change. Climate change poses increased risk to WASH systems, particular in Sub-Saharan Africa where access to safely managed basic sanitation is low. In Sub-Saharan Africa poorly managed WASH systems and widespread informal settlements with limited access to water and sanitation infrastructure are particularly vulnerable to climate extremes such as flooding. Changes in the frequency and intensity of climate extremes  could compound current challenges as water availability becomes uncertain, and health risks increase due to contaminated water sources. Climate change proposes many difficulties and challenges for WASH initiatives around the globe. Particularly, climate change can cause in a decrease of water availability, an increase of water necessity, damage to WASH facilities, increased water contamination from pollutants, etc. Global goals, planning and monitoring. Sustainable Development Goal Number 6. Since 1990, the Joint Monitoring Programme (JMP) for Water Supply, Sanitation and Hygiene by WHO and UNICEF has regularly produced estimates of global WASH progress. The JMP was responsible for monitoring the UN 's Millennium Development Goal (MDG) Target 7.C, which aimed to "halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation". This has been replaced by the 2030 Sustainable Development Goals (SDG), where Goal 6 aims to "ensure availability and sustainable management of water and sanitation for all". The JMP is responsible for tracking progress toward those SDG 6 Targets focused on improving the standard of WASH services, including Target 6.1 which is: "by 2030, achieve universal and equitable access to safe and affordable drinking water for all"; and Target 6.2 which is : "by 2030, achieve access to adequate and equitable sanitation and hygiene for all, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations". In addition, the JMP collaborates with other organizations and agencies responsible for monitoring other WASH-related SDGs, including SDG Target 1.4 on improving access to basic services, SDG Target 3.9 on reducing deaths and illnesses from unsafe water, and SDG Target 4.a on building and upgrading adequate WASH services in schools. To establish a reference point from which progress toward achieving the SDGs could be monitored, the JMP  produced "Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines". According to this report, 844 million people still lacked even a basic drinking water service in 2017. Of those, 159 million people worldwide drink water directly from surface water sources, such as lakes and streams. In addition, the JMP report found that, globally, 4.5 billion people do not have toilets at home that can safely manage waste despite improvements in access to sanitation over the past decades. Approximately 600 million people share a toilet or latrine with other households and 892 million people practice open defecation. Furthermore , only 1 in 4 people in low-income countries have handwashing facilities with soap and water at home; only 14% of people in Sub-Saharan Africa have handwashing facilities. Worldwide, at least 500 million women and girls lack adequate, safe, and private facilities for managing menstrual hygiene. Planning approaches. National WASH plans and monitoring. UN-Water carries out the "Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS)" initiative. This work examines the "extent to which countries develop and implement national policies and plans for WASH, conduct regular monitoring, regulate and take corrective action as needed, and coordinate these  parallel processes with sufficient financial resources and support from strong national institutions." In 2019 it was found that many countries' WASH plans are not supported by the necessary financial and human resources. This hinders their implementation and intended outcomes for WASH service delivery. Integrated water resources management (IWRM). In 1992, the United Nations proposed Integrated water resources management (IWRM) as a solution to WASH challenges and policy failures. An integrated approach to water management aims to minimize challenges associated with water-borne disease, water justice, poor compliance with safe hygiene behaviors, and sustainability by involving stakeholders at every level of  management and consumption. This approach also recognizes the political, economic, and social influence of WASH as well as the need to coordinate water and sanitation management. Critics of current implementation of IWRM argue it has been externally imposed on developing countries and can be culturally inappropriate to the needs of individual communities. Instead, a hybrid approach that includes greater community-level management and flexibility but with the same goals as IWRM has been suggested. History. The history of water supply and sanitation is the topic of a separate article. Abbreviation. The abbreviation WASH was used from the year 1988 onwards  as an acronym for the "Water and Sanitation for "Health"" Project of the United States Agency for International Development. At that time, the letter "H" stood for "health", not "hygiene". Similarly, in Zambia the term WASHE was used in a report in 1987 and stood for "Water Sanitation Health Education". An even older USAID "WASH project report" dates back to as early as 1981. From about 2001 onwards, international organizations active in the area of water supply and sanitation advocacy, such as the Water Supply and Sanitation Collaborative Council and the International Water and Sanitation Centre (IRC) in the Netherlands  began to use "WASH" as an umbrella term for water, sanitation and hygiene. "WASH" has since then been broadly adopted as a handy acronym for water, sanitation and hygiene in the international development context. The term "WatSan" was also used for a while, especially in the emergency response sector such as with IFRC and UNHCR, but has not proven as popular as WASH. Focus areas and trends. The United Nation's International Year of Sanitation in 2008 helped to increase attention for funding of sanitation in WASH programs of many donors. For example, the Bill and Melinda Gates Foundation has  increased their funding for sanitation projects since 2009, with a strong focus on reuse of excreta. Society and culture. Awards. Several prizes are awarded for individuals or organizations working on WASH, notably: Awareness raising. Awareness raising for the importance of WASH is regularly carried out by various organizations through their publications and activities on certain special days of the year (United Nations international observance days), namely: World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October). International networks and partnerships