This is a joint post with Claire Chase, an Evaluation Specialist with the Water and Sanitation Program of the World Bank.
The recently released report by UNICEF and WHO on Progress on Drinking Water and Sanitation brought both good and bad news. The good news is that the world has ostensibly ‘reached’ part of the United Nations Millennium Development Goal (MDG) on drinking water: 88 percent of the world's population now has access to an improved drinking water source. The bad news is that the world is still off track to meet the MDG target for sanitation. About 2.5 billion people still lack access to an ‘improved toilet’ and 1.1 billion of these practice open defecation. Sanitation matters greatly to the health of children and is an influential factor contributing to childhood diarrhea, the second leading cause of under-5 child mortality after pneumonia. Diarrhea claims more child deaths than HIV, malaria, and measles combined.
For many years, improved toilets have been neglected in comparison to water. UNICEF and other donors have recently begun calling for greater attention to the sanitation agenda and in some circles this has led to a re-branding of the phrase ‘Water and Sanitation’ to ‘Sanitation and Water’. The Gates Foundation, too, has joined the push for sanitation by calling to reinvent the toilet and producing a fun video; even celebrity Matt Damon talked Sh*t for Global Sanitation on World Toilet Day in November last year.
But how will increased donor attention translate to changes in countries? We see two key challenges that need to be addressed explicitly by donors and governments. First, we ask whether an increased focus on ‘sanitation’ will ironically lead to further neglect of ‘hygiene’, and second, which sector should hold responsibility for scaling up access to sanitation?
While the renewed attention on sanitation is critical, we fear it may lead to further neglect of hygiene. Simply building toilets will not be sufficient to reach sanitation targets. Sanitation promotion that incorporates improvements in hygiene behavior will be essential to ensuring that building more toilets will lead to increased use and reductions in diarrhea. For instance, even if a household has an improved toilet, that toilet must be kept clean and free of feces in order to avoid contamination and to encourage use. One key form of hygiene is handwashing after fecal contact, an extremely effective way to prevent diarrhea and possibly as effective as sanitation and water interventions (there is still much debate on this). Yet there are no global targets for handwashing and no consistent measurement of global handwashing behavior. Indeed, handwashing is not reported in the WHO Statistics database and the WHO, in its important Global Health Risks report of 2009, does not even once mention handwashing. In fact we know very little about handwashing and other hygiene behaviors internationally. In contrast there are global MDG targets for condom use and the Demographic and Health Surveys (DHS) measures all sorts of self-reported behaviors related to sexual and reproductive health especially fertility, family planning, and contraception. As far as we know, only a handful of DHS surveys (over 1999–2005) have measured the availability of handwashing materials, child stool disposal, and household water treatment.
In addition to handwashing and other forms of personal hygiene, there are a whole range of hygienic behaviors that are important for ensuring the effectiveness of water and sanitation coverage. These include home hygiene (safe treatment and storage of household water, safe food storage, solid waste disposal, safe disposal of child feces, separation of domestic animals) and medical hygiene (sterilization of medical instruments, safe disposal of medical waste). Re-introducing the importance of hygiene in the water agenda could be a way for the water community to explicitly engage the health community to meet the sanitation targets.
Which leads us to our next question: Which sector should be responsible for scaling up access to sanitation? From an MDG “view of the world”, the target for sanitation is categorized under MDG7 which also includes targets to slow deforestation, prevent biodiversity loss, and improve slums. But on the other hand, safe sanitation is key to preventing certain infectious diseases such as diarrhea that cause infant and child mortality (MDG4). One might think that this dual-sector interest would lead to greater attention, but it seems to be opposite: Do the environmentalists and infrastructure people assume that the health people are taking the lead, and vice versa? This tension – between a sector with a responsibility to provide uninterrupted access to water and safe disposal of sewage and a sector with primarily responsibility for health – plays out saliently within countries. Responsibility for sanitation falls under different ministries in different countries, making coordinated action within countries and even at the international donor level difficult. Where sanitation falls under Ministries of Water, it may not benefit from the health promotion and behavior change approaches of the public health sector. In contrast under Ministries of Health, sanitation may get pushed aside by immunization and nutrition programs.
As we write, the 6th World Water Forum is taking place in Marseilles and in a few months World Water Week will be held in Stockholm with a focus on Water and Food Security. While sanitation will likely play an important, if not subdued role in these meetings, will hygiene get the attention it deserves? Similarly will sanitation and hygiene feature at all in the major health forums such as the Beijing Symposium on Health Systems Research?