WASH

The WASH concept groups together the various aspects of water supply, including access to drinking water services, sanitation, and hygiene because the impact of deficiencies in each area overlap strongly. Drinking water services to fill their containers with water (Labuje IDP camp, Kitgum, Kitgum District, Northern Region of Uganda)WHO and UNICEF state that a safe drinking water service is one that is located in an accessible location, available when needed, and uncontaminated. Additionally, WHO and UNICEF use the terms improved water source and unimproved water source as a water quality monitoring tool. The term "improved water source" refers to piped water on premises. Examples include a piped household water connection located inside the user's dwelling plot or yard, and other improved drinking water sources such as public taps or standpipes, tube wells or boreholes, protected dug wells, protected springs, and rainwater collection. Access to drinking water is included in Target 6.1 of Sustainable Development Goal 6 (SDG 6), which states: "By 2030, achieve universal and equitable access to safe and affordable drinking water for all." This target's single indicator, Indicator 6.1.1, which states "Proportion of population using safely managed drinking water services." In 2017, 844 million people still lacked even a basic drinking water service. Drinking water can be sourced from the following water sources: surface water, groundwater, or rainwater, in each case after collection, treatment, and distribution. Desalinated seawater is another potential source for drinking water. People without access to safe, reliable, domestic water supplies face lower water security at specific times throughout the year due to cyclical changes in water quantity or quality. For example, where access to water on-premises is not available, drinking water quality at the point of use (PoU) can be much worse compared to the quality at the point of collection (PoC). Correct household practices around hygiene, storage, and treatment are therefore important. There are interactions between weather, water source, and management, and these in turn impact drinking water safety. Groundwater Groundwater provides critical freshwater supply, particularly in dry regions where surface water availability is limited. Globally, more than one-third of the water used originates from underground. In the mid-latitude arid and semi-arid regions lacking sufficient surface water supply from rivers and reservoirs, groundwater is critical for sustaining global ecology and meeting societal needs of drinking water and food production. The demand for groundwater is rapidly increasing with population growth, while climate change is imposing additional stress on water resources and raising the probability of severe drought occurrence. In some cases, groundwater is an additional water source that was not used previously. Lower-income areas typically install groundwater supplies without water quality treatment infrastructure or services. The assumption that untreated groundwater is typically suitable for drinking due to its relative microbiological safety compared to surface water underpins this practice, largely disregarding chemistry risks. A distinction is made between sanitation facilities that are shared between two or more households (a "limited service") and those that are not shared (a "basic service"). The definition of improved sanitation facilities is facilities designed to hygienically separate excreta from human contact. Access to sanitation services is included in Target 6.2 of Sustainable Development Goal 6, 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." This target has one indicator: Indicator 6.2.1 which states "proportion of population using (a) safely managed sanitation services and (b) a hand-washing facility with soap and water". Approximately 600 million people share a toilet or latrine with other households, and 892 million people practice open defecation. Fecal sludge management and sanitation workers Sanitation services would not be complete without safe fecal sludge management (FSM), which is the storage, collection, transport, treatment, and safe end use or disposal of fecal sludge. Fecal sludge is defined very broadly as what accumulates in onsite sanitation systems (e.g. pit latrines, septic tanks and container-based solutions) and specifically is not transported through a sewer. Hygiene in Ghana for washing her hands. Hygiene is a broad concept. "Hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases." Hygiene can comprise many behaviors, including hand washing, menstrual hygiene and food hygiene. Approximately 40% of the world's population live without basic hand washing facilities with soap and water at home. == Purposes ==

The purposes of providing access to WASH services include achieving public health gains, improving human dignity in the case of sanitation, implementing the human right to water and sanitation, reducing the burden of collecting drinking water for women, reducing risks of violence against women, improving education and health outcomes at schools and health facilities, and reducing water pollution. Access to WASH services is also an important component of achieving water security. It can also assist with poverty reduction and socioeconomic development. == Health aspects of lack of WASH services ==

, fingers, flies, fields, fluids, food), showing pathways of fecal–oral disease transmission. The vertical blue lines show barriers: toilets, safe water, hygiene and hand washing. Categories of health impacts Health impacts resulting from a lack of safe sanitation systems fall into three categories: • Direct impact (infections): The direct impacts include fecal–oral infections (through the fecal–oral route), helminth infections and insect vector diseases (see also waterborne diseases, which can contaminate drinking water). For example, lack of clean water and proper sanitation can result in feces-contaminated drinking water and cause life-threatening diarrhea for infants. • Sequela (conditions caused by preceding infection): These impacts include stunting or growth faltering, consequences of stunting (obstructed labour, low birth weight), impaired cognitive function, pneumonia (related to repeated diarrhea in undernourished children), and anemia (related to hookworm infections). • Broader well-being: Including anxiety, sexual assault (and related consequences), adverse birth outcomes as well as long-term problems such as school absence, poverty, decreased economic productivity, and antimicrobial resistance. An earlier report by World Health Organization which analyzed data up to 2016 had found higher values: "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. Worldwide, 1.9 million deaths and 123 million DALYs could have been prevented in 2016 with adequate WASH." These changes in the estimates of death and disease can partly be explained by the progress that has been achieved in some countries in improving access to WASH. For example, several large Asian countries (China, India, Indonesia) have managed to increase the "safely managed sanitation services" in their country from the year 2015 to 2020 by more than 10% points. • Diarrheal diseases • Respiratory infections • Soil-transmitted helminth infections • Malaria • Trachoma • Schistosomiasis • Lymphatic filariasis • Onchocerciasis • Dengue • Japanese encephalitis • Protein–energy malnutrition • Drowning There are also other diseases where adverse health outcomes are likely to be linked to inadequate WASH but which are not yet quantified. These include for example: 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). Such improvements might include for example, the use of water filters, provision of high-quality piped water and sewer connections. 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 inter-dependencies 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. Approximately two billion people are infected with soil-transmitted helminths worldwide. This type of intestinal worm infection is transmitted via worm eggs in feces which in turn contaminate soil in areas where sanitation is poor. 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. The plan aimed 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 programs with involvement of all stakeholders. Additional health risks for women Women tend to face a higher risk of diseases and illness due to limited WASH access. In their third trimester, pregnant women face severe hardship walking to and from a water collection site. The consumption of unclean water leading to infection in the fetus accounts for 15% of deaths for women during pregnancy globally. In Bangladesh and India, women rely on old cloths to absorb menstrual blood and use water to clean and reuse them. Without access to clean water and hygiene, these women my experience unnecessary health problems in connection with their periods. Blind studies of WASH interventions also pose ethical challenges and difficulties associated with implementing new technologies or behavioral changes without the knowledge of the involved participants. 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. 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. == Gender aspects of lack of WASH services ==

Women and girls are particularly burdened from lack of proper WASH services. Inadequate access to water and sanitation affect women and girls in several ways because of social norms in some cultures that position them as principal household water collectors and managers, the inability to urinate easily outside of an unclean stall or where no toilets are nearby, and due to the effects of menstruation beginning during puberty. These effects include low participation in the labor market and community activities, adverse biomedical outcomes, psychosocial stress, and poor educational outcomes. 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. 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. 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. == In non-household settings ==

Non-household settings for WASH include the following six types: schools, health care facilities, workplaces (including prisons), temporary use settings, mass gatherings, and dislocated populations. In schools , Bangladesh) , Dhaka, Bangladesh) stands at a school in Mysore district, Karnataka, India 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. Children are able to more fully participate in school when there is improved access to water. Lack of WASH facilities can prevent students from attending school, particularly female students. Reasons for missing or poorly maintained water and sanitation facilities at schools in developing countries include lacking intersectoral collaboration; lacking cooperation between schools, communities and different levels of government; as well as a lack in leadership and accountability. Outcomes from improved WASH at schools WASH in schools, sometimes called SWASH or WinS, significantly reduces hygiene-related disease, increases student attendance and contributes to dignity and gender equality. Methods to improve WASH in schools 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. Success also hinges on local-level leadership and a genuine collective commitment of school stakeholders towards school development. This applies to students and their representative clubs, headmaster, teachers and parents. 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 with sinks for people of different heights. During the COVID-19 pandemic in Rwanda handwashing was part of a system of public health measures encouraged to reduce transmission. Supervised daily group handwashing in schools is 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. Mass 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. In healthcare facilities with unsafe drinking water at the Boromata well in Central African Republic. The provision of adequate water, sanitation and hygiene is an essential part of providing basic health services in healthcare facilities. WASH in healthcare facilities aids in preventing the spread of infectious diseases as well as protects staff and patients. WASH services in health facilities in developing countries are currently often lacking. 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. Barriers to providing WASH in health care facilities include: Incomplete standards, inadequate monitoring, disease-specific budgeting, disempowered workforce, poor WASH infrastructure. • Availability of safe water for drinking but also for use in surgery and childbirth deliveries, food preparation, bathing and showering: There is a need for improved water pump systems within health facilities. • Improved handwashing practices among healthcare staff must be implemented. This requires functional hand washing stations at strategic points of care within the health facilities, i.e. at points of care and at toilets. • Waste system management: Proper health care waste management and the safe disposal of excreta and waste water is crucial to preventing the spread of disease. • Hygiene promotion for patients, visitors and staff. • Accessible and clean toilets, separated by gender, in sufficient numbers for staff, patients and visitors. Improving access to hand washing and sanitation facilities in healthcare settings will significantly reduce infection and mortality rates, particularly in maternal and child health. A report by ICRC states that "Measures depriving persons of their freedom must in no way, whatever the circumstances, be made more severe by treatment or material conditions of detention which undermine the dignity and the rights of the individual."The water supply systems and sanitary facilities in prisons are often insufficient to meet the needs of the prison population in cases where the number of detainees exceeds a prison's capacity. Overuse of the facilities results in rapid deterioration. The budget allocated by the State for prisons is often insufficient to cover the detainees' needs in terms of food and medical care, let alone upkeep of water and sanitation facilities. Nevertheless, even with limited funds, it is possible to maintain or renovate decaying infrastructure with the right planning approaches and suitable low-cost water supply and sanitation options. == Challenges in WASH implementation ==

Equitable access to drinking water supply There are inequalities in access to water, sanitation and hygiene services. This is due to "structural racial discrimination" in Bangladesh. Thirdly, there are institutional constraints that prevent the poor from accessing adequate urban services. Polluted water sources , Bangladesh: The woman on the right is putting a sari filter onto a water-collecting pot (or kalash) to filter water for drinking.|alt= Water supply sources include surface water and groundwater. These important water resources are often at risk of being polluted or overused. Failures of WASH systems over time at a school in Nyanza Province, Kenya The failures of water supply system (such as water points, wells and boreholes) and sanitation systems have been well documented. 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. The poorest populations often cannot afford fees required for operation and maintenance of WASH infrastructure, preventing them from benefitting even when systems do exist. Contamination of water in distribution systems is a challenge and can contribute to the spread of waterborne diseases. Working conditions of sanitation workers == Climate change aspects ==

Greenhouse gas emissions Water and sanitation services contribute to greenhouse gas emissions. These emissions are grouped into three scopes in the international greenhouse gas protocol: direct emissions, as well as two types of indirect emissions (see below). Septic tanks, pit latrines, anaerobic lagoons, anaerobic digesters are all anaerobic treatment processes that emit methane which may or may not be captured (in the case of septic tanks it is usually not captured). It has been estimated, using data from 2012 and 2013, that "wastewater treatment in centralized facilities contributes alone some 3% of global nitrous oxide emissions and 7% of anthropogenic methane emissions". Current methods for estimating sanitation emissions underestimate the significance of methane emissions from non-sewered sanitation systems (NSSS). NSSS play a vital role in the safe management of fecal sludge and account for approximately half of all existing sanitation provisions. The global methane emissions from NSSS in 2020 was estimated to be 377 Mt CO2e/year or 4.7% of global anthropogenic methane emissions. This is comparable to the greenhouse gas emissions from conventional wastewater treatment plants. This makes sense for high-income countries, where wastewater treatment is the biggest energy consumer compared to other activities of the water sector. The mentioned lean and efficient approaches include for example finding ways to reduce water loss from water networks and to reduce infiltration of rainwater or groundwater into sewers. The weather and climate-related aspects (variability, seasonality and extreme weather events) have always had an impact on the delivery of sanitation services. But now, extreme weather events, such as floods and droughts, are generally increasing in frequency and intensity due to climate change in many regions. They affect the operation of water supply, storm drainage and sewerage infrastructure, and wastewater treatment plants. Changes in the frequency and intensity of climate extremes could compound current challenges as water availability becomes more uncertain, and health risks increase due to contaminated water sources. The effects of climate change can result in a decrease of water availability, an increase of water necessity, damage to WASH facilities, and increased water contamination from pollutants. In that region, it is the poorly managed WASH systems, for example in informal settlements, which make people more vulnerable to the effects of climate change than people elsewhere. In terms of the water cycle, climate change can affect the amounts of soil infiltration, deeper percolation, and hence groundwater recharge. The required adaptation measures need to consider measures for droughts and those for floods. Engineers and planners need to adapt design standards for water and sanitation systems to account for the changing climate conditions. Otherwise these infrastructure systems will be more and more vulnerable in future. The same applies for other key infrastructure systems such as transport, energy and communications. Improving climate resilience Climate-resilient water services (or climate-resilient WASH) are services that provide access to high quality drinking water during all seasons and even during extreme weather events. Climate resilient development has become the new paradigm for sustainable development. This concept thus influences theory and practice across all sectors globally. Climate resilient policies can be useful for allocating water, especially when regional water availability may change in future. This requires a good understanding of the current and future hydroclimatic situation. For example, a more accurate prediction of future changes in climate variability leads to a better response to their possible impacts. Such preventive actions can include for example elevating the infrastructure to be above expected flood levels. Secondly, managers assess the scope for reducing greenhouse gas emissions and put in place suitable options, e.g. using more renewable energy sources. Thirdly, the water utilities ensure that water sources and sanitation services are reliable at all times during the year, also during times of droughts and floods. Finally, the management and service delivery models are strengthened so that they can withstand a crisis. To put climate resilience into practice and to engage better with politicians, the following guide questions are useful: "resilience of what, to what, for whom, over what time frame, by whom and at what scale?". For example, "resilience of what?" means thinking beyond infrastructure but to also include resilience of water resources, local institutions and water users. Another example is that "resilience for whom?" speaks about reducing vulnerability and preventing negative developments: Some top-down interventions that work around power and politics may undermine indigenous knowledge and compromise community resilience. Adaptive capacity for climate resilience Adaptive capacity in water management systems can help to absorb some of the impacts of climate-related events and increase climate resilience. Stakeholders at various scales, i.e. from small urban utilities to national governments, need to have access to reliable information which details regional climate and climate change. For example, context-specific climate tools can help national policy makers and sub-national practitioners to make informed decisions to improve climate resilience. A global research program called REACH (led by the University of Oxford and funded by the UK Government's Foreign, Commonwealth & Development Office) is developing and using such climate tools for Kenya, Ethiopia and Bangladesh during 2015 to 2024. == Approaches for planning and implementation ==

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." 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. Still, most national policies on WASH services do not set out how to address climate risks and how to increase the resilience of infrastructure and management. The Empowerment in WASH Index (EWI) was developed in 2019 to guide WASH practitioners in measuring and monitoring gender outcomes, empowerment, and inclusivity in WASH-related interventions. National indices and tools also exist to capture changes in gender disparities at the national level: Gender Empowerment Measure (GEM), Gender Inequality Index (GII), and Gender Development Index (GDI). In 1996, the World Bank Group published a Toolkit on Gender in Water and Sanitation. Gender-sensitive approaches to water and sanitation have proven to be cost effective. == History ==

The history of water supply and sanitation is the topic of a separate article. 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. == Society and culture ==

Global goals (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 in 2015 by the Sustainable Development Goal 6 (SDG 6), which is to "ensure availability and sustainable management of water and sanitation for all" by 2030. WaterAid International is a non-governmental organization (NGO) that works on improving the availability of safe drinking water in some the world's poorest countries. Sanitation and Water for All is a partnership that brings together national governments, donors, UN agencies, NGOs and other development partners. They work to improve sustainable access to sanitation and water supply. In 2014, 77 countries had already met the MDG sanitation target, 29 were on track and, 79 were not on-track. UNICEF includes WASH initiatives in their work with schools in over 30 countries. • UN-Water - an interagency mechanism which "coordinates the efforts of UN entities and international organizations working on water and sanitation issues". celebrations in Indonesia Awareness raising through observance days 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. Awareness raising for the importance of WASH takes place through several United Nations international observance days, namely World Water Day, Menstrual Hygiene Day, World Toilet Day and Global Handwashing Day. ==By country and region==