Infrastructure Construction In Morocco: Market Databook To 2014
Christal Rasband
Safe drinking water, sanitation, and hygiene (WASH) are fundamental to improving standards of living for people. The improved standards made possible by WASH include, among others, better physical health, protection of the environment, better educational outcomes, convenience time savings, assurance of lives lived with dignity, and equal treatment for both men and women. Poor and vulnerable populations have lower access to improved WASH services and have poorer associated behaviors. Improved WASH is therefore central to reducing poverty, promoting equality, and supporting socioeconomic development. Drinking water and sanitation were targets in the Millennium Development Goals (MDGs) for 2015; under the Sustainable Development Goals (SDGs) for the post-2015 period, Member States of the United Nations (UN) aspire to achieve universal access to WASH by 2030. The Human Right to Safe Drinking Water and Sanitation (HRTWS) was adopted in 2010 under a UN resolution calling for safe, affordable, acceptable, available, and accessible drinking water and sanitation services for all.1
This chapter summarizes global evidence on current WASH coverage and effects of intervention options, and it recommends areas for research and policy. Evidence comes from published synthesized evidence, such as systematic reviews and meta-analyses, evidence papers, and literature reviews. When those sources were not available, evidence was compiled from the next best sources of published research, thus using accepted criteria of the hierarchy of evidence for studies on health effectiveness. Unpublished and grey literature was used where no peer-reviewed published evidence exists.
To understand the status of drinking water, sanitation, and hygiene, one must make a distinction between different levels of service access and population practices. All populations meet water and sanitation needs in some way, but those ways are often not sufficient, reliable, safe, convenient, affordable, or dignified. To monitor the MDG water and sanitation target, the UN distinguished between improved and unimproved water and sanitation facilities at home. For the SDG targets, one indicator is proposed per target: (1) for target 6.1, the percentage of population using safely managed drinking water services and (2) for target 6.2, the percentage of population using safely managed sanitation services, including a handwashing facility with soap and water. Complementing these proposals is a broader set of indicators distinguishing basic and safely managed service levels (table 9.2) (WHO and UNICEF 2015a).
The indicators for global monitoring need to be kept simple for feasibility and cost. However, countries, organizations, and programs often monitor different aspects of service performance, such as quantity, quality, proximity, reliability, price, and affordability (Roaf, Khalfan, and Langford 2005). Some countries adopt more lenient definitions, and some adopt stricter definitions.
The definitions in existing monitoring systems have several limitations. Some limitations are partially addressed by the new indicators for higher-level services. The new indicators were informed by the five normative criteria, as stated in the HRTWS and shown in table 9.2: accessibility, acceptability, availability, affordability, and quality.2
The existing approach to measuring access does not provide a good indication of sustainability. The surveys use representative sampling and do not follow individual households over time. Effective monitoring of higher service levels requires regulatory data, but coverage is poor in low- and middle-income countries (LMICs), especially in rural areas.
This section presents the coverage data at global and regional levels for drinking water and sanitation according to the JMP definitions used for monitoring MDG target 7c, thereby using the most recent update and MDG assessment report (WHO and UNICEF 2015b). Breakdowns are provided by rural and urban areas.4
Globally, the use of improved drinking water sources increased from 76 percent in 1990 to 91 percent in 2015 (WHO and UNICEF 2015b). Regional breakdowns for progress between 1990 and 2015 are shown in figure 9.1. In its 2012 report presenting 2010 estimates, the UN showed that its MDG target of halving the proportion of the population without access to safe drinking water had been met (WHO and UNICEF 2012b); however, such global estimates mask regional disparities and inequities in access between urban and rural populations. As of 2015, 663 million people still used unimproved water sources, compared to 1.3 billion in 1990; 2.6 billion people have gained access to improved water since 1990. Rural dwellers remain unserved compared with urban dwellers (16 percent and 4 percent, respectively). In Sub-Saharan Africa, 44 percent of rural dwellers continue to use an unimproved water supply. Water hauling costs Sub-Saharan Africans, especially women, billions of hours each year. In 2008, more than 25 percent of the population in several Sub-Saharan African countries spent more than 30 minutes to make one round trip to collect water; 72 percent of the burden for collecting water fell on women (64 percent) and girls (8 percent), compared with men (24 percent) and boys (4 percent) (WHO and UNICEF 2010).
The use of improved sanitation increased from 54 percent in 1990 to 68 percent in 2015, but those gains fell short of meeting the global MDG target (WHO and UNICEF 2015b). In 2015, 2.4 billion people still did not have access to their own improved sanitation facility, a fact that, due to population growth, reflects no change in the unserved population of 1990. However, these numbers mask the fact that since 1990, 2.1 billion people have gained access to improved sanitation. Regional breakdowns in progress between 1990 and 2015 are shown in figure 9.2. Globally, the proportion of population practicing open defecation declined from 24 percent in 1990 to 13 percent in 2015. In South Asia, 34 percent still defecate in the open, compared to 23 percent in Sub-Saharan Africa. Globally, 638 million people (9 percent) share their sanitation facility with another family or families. Comparing rural and urban areas, 51 percent of rural dwellers have access to improved sanitation, compared with 82 percent of urban dwellers. Rates of improved sanitation do not reflect the amount of fecal waste that is not isolated, transported, or treated safely; a study of 12 cities in LMICs found that whereas 98 percent of households used toilets, only 29 percent of fecal waste was safely managed (Blackett, Hawkins, and Heymans 2014).
Although the MDG target 7c does not provide a global indicator for hygiene, the data on the presence of a handwashing facility with soap and water are increasingly collected as part of nationally representative surveys and will form the basis for efforts to monitor target 6.2 of the SDGs. Two main sources include nationally representative household surveys and a global review of published studies (Freeman and others 2014). Research studies suggest that the global prevalence of handwashing with soap after contact with excreta is 19 percent; rates are lower in Sub-Saharan Africa (14 percent) and South-East Asia (17 percent), where the most studies have been conducted (Freeman and others 2014). Proxy indicators for handwashing practice from nationally representative surveys are not reliable and tend to over report hygiene practices (Biran and others 2008).
Global reporting of institutional WASH has not yet been standardized as it has for household-level WASH; efforts are under way to build a global reporting system of WASH in schools and health facilities for SDG monitoring. The Demographic and Health Survey (DHS) Service Provision Assessment (SPA) monitors WASH in health facilities. WASH coverage in both primary schools and front-line health facilities is monitored and reported under the Service Delivery Indicators, currently for Sub-Saharan Africa. United Nations agencies collect data on WASH in schools (Education Management Information System operated by UNICEF), health facilities (Health Management Information System operated by the WHO), and refugee camps (UN High Commissioner for Refugees).
In addition to enhanced monitoring efforts by UN agencies, UN member countries need greater understanding of the challenges facing the world to meet the goal of universal access to institutional WASH within 15 years and to sustain that access beyond 2030. Unsustainable water extraction, along with competing demands, population growth and migration (including urbanization), and climate change and variability, puts significant pressure on water supply systems. In addition, new settlements require systematic, coordinated planning, and existing settlements require retrofitting to bring sustainable WASH services to citizens.
Understanding the nature and extent of the demonstrated negative effects of inadequate WASH on individuals, the environment, and societies is important for those designing interventions and assessing benefits and efficiency. Many benefits of WASH interventions are nonhealth in nature; including only health effects in impact evaluations can severely underestimate the intervention benefits (Loevensohn and others 2015).
Contaminated water and lack of sanitation lead to the transmission of pathogens through feces and, to a lesser extent, urine. The F-diagram explained here but not shown provides a basic understanding of these pathways by which pathogens from feces are ingested through transmission by fingers, flies, fluids, fields (soil), and food:
A systematic review and meta-analysis documented large and significant associations between poor water, sanitation, and maternal mortality (Benova, Cumming, and Campbell 2014). The precise mechanism has not been well established, but it is thought to be largely attributable to puerperal sepsis.
Children under age five years are especially vulnerable to infection. Regular exposure to environments with high fecal loads causes enteropathy5; compromises nutritional status; and leads to long-term consequences, such as stunting and retarded cognitive development (Humphrey 2009; Petri and others 2008).
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