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BACKGROUND: Antibiotic resistance is a leading cause of death, with the highest burden occurring in low-resource settings. There is little evidence on the potential for water, sanitation, and hygiene (WASH) access to reduce antibiotic resistance in humans. We aimed to determine the relationship between the burden of antibiotic resistance in humans and community access to drinking water and sanitation. METHODS: In this ecological study, we linked publicly available, geospatially tagged human faecal metagenomes (from the US National Center for Biotechnology Information Sequence Read Archive) with georeferenced household survey datasets that reported access to drinking water sources and sanitation facility types. We used generalised linear models with robust SEs to estimate the relationship between the abundance of antibiotic resistance genes (ARGs) in human faecal metagenomes and community-level coverage of improved drinking water and sanitation within a defined radii of faecal metagenome coordinates. FINDINGS: We identified 1589 metagenomes from 26 countries. The mean abundance of ARGs, in units of log(10) ARG fragments per kilobase per million mapped reads classified as bacteria, was highest in Africa compared with Europe (p=0·014), North America (p=0·0032), and the Western Pacific (p=0·011), and second highest in South-East Asia compared with Europe (p=0·047) and North America (p=0·014). Increased access to improved water and sanitation was associated with lower ARG abundance (effect estimate -0·22, [95% CI -0·39 to -0·05]) and the association was stronger in urban (-0·32 [-0·63 to 0·00]) than in rural (-0·16 [-0·38 to 0·07]) areas. INTERPRETATION: Although additional studies to investigate causal effects are needed, increasing access to water and sanitation could be an effective strategy to curb the proliferation of antibiotic resistance in low-income and middle-income countries.

Argentina is a developing Latin American nation that has an aim of achieving the United Nations Millennium Development Goals for potable water supplies. Their current regulations however, limit the continued development of improved potable water quality and infrastructure from a microbiological viewpoint. This is since the current regulations are focused solely to pathogenic Eschericia coli (E. coli), Pseudomonas aeruginosa (P. aeruginosa) and fecal indicators. Regions of lower socioeconomic status such as peri-urban areas are particularly at risk due to lessened financial and political ability to influence their environmental quality and infrastructure needs. Therefore, a combined microbiological sampling, analysis and quantitative microbial risk assessment (QMRA) modeling effort were engaged for a peri-urban area of Salta Argentina. Drinking water samples from home taps were analyzed and a QMRA model was developed, results of which were compared against a general 1:10,000 risk level for lack of a current Argentinian standard. This QMRA model was able to demonstrate that the current regulations were being achieved for E. coli but were less than acceptable for P. aeruginosa in some instances. Appropriate health protections are far from acceptable for Giardia for almost all water sources. Untreated water sources were sampled and analyzed then QMRA modeled as well, since a significant number of the community (∼9%) still use them for potable water supplies. For untreated water E. coli risks were near 1:10,000, however, P. aeruginosa and Giardia risks failed to be acceptable in almost all instances. The QMRA model and microbiological analyses demonstrate the need for improved regulatory efforts for the peri-urban area along with improved investment in their water infrastructure. Fil: Rodriguez Alvarez, Maria Soledad. Ministerio de Ciencia. Tecnología e Innovación Productiva. Agencia Nacional de Promoción Cientifíca y Tecnológica; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Instituto de Investigaciones en Energia No Convencional. Universidad Nacional de Salta. Facultad de Ciencias Exactas. Departamento de Física. Instituto de Investigaciones en Energia No Convencional; Argentina Fil: Weir, Mark H.. Temple University; Estados Unidos. CAMRA Consultants ; Estados Unidos Fil: Pope, Joanna M.. CAMRA Consultants; Estados Unidos Fil: Seghezzo, Lucas. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Instituto de Investigaciones en Energia No Convencional. Universidad Nacional de Salta. Facultad de Ciencias Exactas. Departamento de Física. Instituto de Investigaciones en Energia No Convencional; Argentina Fil: Rajal, Verónica Beatriz. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Instituto de Investigaciones Para la Industria Química. Universidad Nacional de Salta. Facultad de Ingeniería. Instituto de Investigaciones Para la Industria Química; Argentina Fil: Salusso, Maria Monica. Ministerio de Ciencia. Tecnología e Innovación Productiva. Agencia Nacional de Promoción Cientifíca y Tecnológica; Argentina Fil: Moraña, Liliana Beatriz. Ministerio de Ciencia. Tecnología e Innovación Productiva. Agencia Nacional de Promoción Cientifíca y Tecnológica; Argentina

Convenient access to safe water is central to human health and development. Water-borne disease remains a major cause of mortality and morbidity in the world, much of which could be eliminated by a combination of better water, sanitation and hygiene (WaSH). The WHO estimates that around 502 000 deaths a year in low and middle income countries from diarrheal disease are attributable to unsafe water, and that over 1 000 children under 5 die each day from diarrheal disease caused by inadequate WASH. UNWomen estimates that in Sub-Saharan Africa alone, women and girls spend 40 billion hours a year collecting water, the time valued at around $20 billion a year. Sustainable development goal no. 6 ‘ensure availability and sustainable management of water and sanitation for all’ creates a framework for tackling the challenge of mobilizing the large investments required and making WaSH available at affordable prices. The purpose of the study on which this report is based is to analyze, capture and synthesize lessons learned from closed GPOBA water projects in order to evaluate the impact of the subsidy schemes and inform the scale-up and replication of OBA approaches. These lessons offer insight to successes and failures of project design and implementation as well as solutions to more complex projects and/or less tested environments.

Provision of safe drinking water is a basic necessity and has been a major topic for key political discourses in the country over the last decade. The Government of India has been focusing on safe drinking water since 1972-73 when it introduced the Accelerated Rural Water Supply Program (ARWSP) to assist States and Union Territories to accelerate the coverage of drinking water in the country. Despite increased outlays since then, access to safe drinking water in India remains a challenge. Apart from access, water quality and sustainability of resources (water points and infrastructure developed) are issues of major concern. The National Rural Drinking Water Program (NRDWP), which is supplementing the efforts of the State Governments by providing technical and financial assistance, is looking at rural drinking water from a holistic viewpoint. The Ministry has shifted its focus from hand pumps to piped water supply systems with the aim of providing monitored clean water and is focusing on those States which have low levels of piped water supply. The Water and Sanitation Program has compiled an excellent collection of success stories and best practices from the States of Kerala, Karnataka, Maharashtra, Gujarat, Jharkhand, Punjab and Uttarakhand which address these key constraints. Some of these success stories, such as the Asoga village intervention in Karnataka which showcases a unique demand driven approach to facilitate participatory decision making leading to community ownership, the Bidholi piped water supply scheme in Uttarakhand which manages and recovers 100 per cent operation and maintenance costs from the community, the Shikayat Nivaran Kendra experiment in Punjab which uses information technology for online web enabled centralised complaint redressal and the Water and Sanitation Management Organisation experiment in Gujarat where the registered body acts as a facilitator in developing water and sanitation facilities owned and managed by communities, are all outstanding examples of how to address various challenges and shortcomings the program is facing.

Reliable evidence on the quality of current WSS service conditions is scarce and consumer experience and views and voices are not systematically collected and used for policy development. International experience suggests that poor drinking water and sanitation services can cause households to incur high costs for dealing with this situation. However, in Uzbekistan and other Central Asian countries, there is a lack of data on service quality and on such coping costs. Together with limited feedback from consumers to those that design WSS policies and programs this makes it difficult to design effective reform measures and assess their ex-ante impact on households, in particular for those at the bottom of the income distribution. This study assesses consumer experiences with current WSS services across a range of selected sites in Uzbekistan and determines consumer readiness for reform. First of all, the study analyses how surveyed consumers currently meet their drinking water and sanitation needs and what proportion of their household budget is spent on meeting their WSS needs. Second it assesses the interaction between consumers and service providers. Third it examines stakeholder views and positions on service modernization needs and assesses consumer willingness to pay for quality networked WSS services. Comparisons are made across consumers in a selection of cities, small towns and rural areas, between consumers that are connected to a networked service and those that are not, and between households in the bottom 40 percent and top 60 percent of the income distribution (as estimated through a wealth index).

This note explores the Bangladesh experience in implementing the widespread use of a private operator model for building and operating rural piped water schemes. Since the early 1990s, the World Bank has, through a series of development projects, designed, piloted, and attempted to scale up use of the model as a mechanisms to address the very real issues of arsenic contamination and delivery at scale. The latest of these projects is still in implementation. The experience with these projects to date has been disappointing, and while a limited number of schemes are still in operation, the model has not been replicated in a large number of communities as intended and has not proved to be particularly sustainable. Over this same period, the government and other development partners also have been using alternative methods to deliver the same kinds of services in rural areas. Some of these efforts seem to have been modestly successful. However, much of the evidence about the performance of these other models is anecdotal and there has been little rigorous analysis to compare the performance of these different models with the private sponsor approach. This paper attempts to do this on the basis of a desk review of existing World Bank literature, including project documents and research reports, coupled with interviews with key stakeholders and World Bank staff. The first section of the paper provides an overview of the rationale and key issues associated with efforts to scale up a private operator model in Bangladesh. The second section reviews government efforts and those of its other development partners, to use a more traditional mode of service provision, involving community management. The third, fourth, and fifth sections review efforts by the government and the World Bank to design, test, and scale up a private operator model for service provision. A sixth section reviews some of the international research that provides insights into the use of such models in other countries and sectors. The paper ends with tentative conclusions about the experience in Bangladesh, lessons learned, and several options for further analysis.

This paper is organized into three main sections. Section one presents the background, objectives, scope, and limitations of the study. It also provides a general definition of OM and presents prototypical OM arrangements for rural CDD and community-based subprojects. Section two presents the detailed case studies for the seven selected projects. Section three summarizes the conclusions from the review and recommends steps for moving ahead. Five annexes provide extra background information, including the complete list of projects from which the seven main case studies were selected, as well as: examples of maintenance requirements for rural infrastructure; considerations for task teams planning for OM design and implementation; sample OM measures and timelines; and links to OM materials.

The purpose of this economic and sector work (ESW) is to support the Republic Forum for potable water and sanitation (FOCARD-APS) member countries in improving the resilience of water supply and sanitation (WSS) services. This report summarizes the findings from seven country-specific assessments carried out in 2013 and 2014 that characterize the national disaster risk management (DRM) and climate change adaptation (CCA) frameworks and efforts designed to reduce the vulnerability of WSS services to disasters and climate change. This activity also supports the World Bank strategy for enhancing DRM in Central America. This analytical effort is the result of a comprehensive participatory process that contributed to building the analytical capacities of the institutions that conform the FOCARD-APS’s regional thematic group (RTG) for DRM. It involved thorough document reviews and two rounds of country visits for data collection, as well as consultation with national and regional experts. The findings of all assessments were validated through national and regional workshops by the RTG-DRM. Regional learning exchanges and study visits were organized as part of this activity to provide policy makers with concrete examples of approaches and potential measures for addressing disaster risk challenges from a WSS service provision perspective and through a broader political and sectoral scope covering policy development, financing, capacity building, and institutional reform.

This paper presents the design a set of three simple and replicable behavioral interventions, which use stickers that can be added to water bills at low cost, and test their impact on water consumption in Belen, Costa Rica, using a randomized control trial. Two of the three interventions were found to decrease water consumption significantly in the months following the intervention. A descriptive social norm intervention using neighborhood comparisons reduces consumption by between 3.7 and 5.6 percent relative to a control group, while a plan-making intervention reduces consumption by between 3.4 and 5.5 percent. While the two interventions have similar results, they are effective on different subpopulations, with the plan-making intervention being most effective for low-consumption households, while the neighborhood comparison intervention is most effective for high-consumption households. The results demonstrate that behavioral interventions, which have hitherto utilized sophisticated software to deliver customized messages, can be effectively implemented by local governments in developing countries, where technology and resource constraints render the sorts of customized messaging that has typically been used to deliver them in developed countries unfeasible. The results further confirm that raising awareness about how much water an individual consumes, and comparing this consumption level with peers, can go a long way in helping change individuals’ behavior regarding the use of a finite resource such as water.

This toolkit for the preparation of a drinking water security plan provides a model for taking a Gram Panchayat and Support Organization through an action planning process. The toolkit includes a basic action planning format. It is a step-by-step process, covering practical guidelines and a water security plan template. The practical guidelines are designed to standardize and streamline water security planning for all the pilot blocks. The toolkit focusses on the planning and community mobilization as well as the institutional and financial aspects of implementing a drinking water security program in pilot blocks.

The history of fluoridation in the United States provides a convenient case study of the intersection of scientific authority and its social and political counterparts. Between 1952 and 1970, proposals to fluoridate community water supplies were a magnet to social scientists, whose attraction to conflict analysis meant a focus on investigating the issues involving referenda. Waves of investigations attempted to link demographic findings to behavioral and social theories. In doing so, US researchers largely ignored the negative aspects of the history of fluoride, the phenomenon of fluoride acceptance and post-World War 11 North American concerns about chemicals in food. However, social scientists provided aggregate data on the social characteristics of those who voted for and against fluoridation and enunciated a critical influence on decision-outcome: centralized authority. Refereed/Peer-reviewed

This document aims to share lessons learned from the implementation of the World Bank financed component of the rural water supply and sanitation project (EPAR) in the Sud region after its final evaluation. Leading the reform of the drinking water and sanitation sector in Haiti, the EPAR of the National Directorate of Drinking Water and Sanitation (DINEPA) involved the construction or rehabilitation of drinking water schemes in small towns with fewer than 10,000 inhabitants in the Sud region. As a result of the project, there will be a real and sustainable increase in the water supply to Haiti’s populations of benefitting communities of the Sud region, thus providing improved access for most households. A long-term solution must be implemented in order to make the meters more affordable to the operators and thus enable them to continue expanding their customer base.

This report presents insights from the FY11 review of the World Bank s water portfolio. The report includes a methodological section followed by reviews of four broad areas: the water related commitments managed by the World Bank Group (WBG) for FY011; the water-related commitments of the International Bank for Reconstruction and Development (IBRD) and of the International Development Association (IDA) for FY11; water-related projects approved in FY11; and analytic and advisory activities (AAA), in particular economic and sector work (ESW) and technical assistance (TA), delivered in FY11. The focus of the report is on the new IBRD and IDA commitments in FY11, which are analyzed not only based on data provided in the World Bank s project database but also with data generated by reviewing the Project Appraisal Documents (PADs) using a newly developed questionnaire. Some of the key findings of the FY11 review are the following: Water-related IBRD and IDA commitments comprised about 95% of the overall WBG managed commitments for water. From FY02 to FY11 they grew more than five-fold, from US$1.3 billion to US$7.4 billion largely driven by increased commitments for water supply and sanitation. In FY11 a total of 105 water-related IBRD and IDA projects were approved. Commitments by region were largest for the East Asia and Pacific Region (EAP) and the South Asia Region (SAR) with 30% and 29%, respectively. With regard to the number of projects, Africa was by far the leading Region with 33 projects. Of the 105 water-related projects, only 22% were mapped to the Water Sector Board (WAT) and most of these were water supply and sanitation projects.

There is an urgent need to provide practical guidelines for Chinese decision makers and officials to better understand the key issues and constraints related to rural wastewater management and to identify feasible solutions and tools to improve the performance and sustainability of these projects. To address these needs, the World Bank has developed this guide for wastewater management in rural villages in China. The Guide is intended to be a useful resource for Chinese policy makers and practitioners. It includes a review of historical and current policies and practices related to wastewater management in rural China. The Guide outlines a framework and strategies for establishing municipal and village level wastewater management programs. The overall objective of the guide is to identify key issues and to present effective strategies and approaches to implement sustainable wastewater management programs at the local jurisdictions in order to improve rural sanitation in China. A key objective of the guide is to present institutional, programmatic and technical guidelines that can be adopted by local jurisdictions, forming the basis for consistent, affordable, practical, and effective sanitation project planning, design, implementation, and operations.

In this issue: trends: 10 years of private-sector participation in water; interview: Mozambiques industry behind the tap; and feature: irrigating Brazils semi-arid northeast.

This paper provides an overview of major groundwater issues for Sub-Saharan Africa, with an assessment of their policy implications in terms of potential development and appropriate management. In terms of construction time, capital outlay and drought resilience, groundwater is the preferred source to meet most water-supply demands, despite hydro geological complexity, natural constraints on water well yields and quality, and institutional weaknesses. The 'new developmental agenda' relates to improving urban water-supply security and expanding irrigated agriculture to meet these challenges many countries need to undertake strategic assessment of their groundwater and prioritize investment on institutional strengthening so as to facilitate appropriately-managed groundwater development. Without effective use of available groundwater resources, improved livelihoods and climate-change adaptation will prove much more difficult to achieve.

The study is conducted in two states with different geographic, public health, and socioeconomic characteristics, together spanning a range of conditions in rural India: Maharashtra and Orissa. The secondary objectives of the study were to develop proxy indicators for routine monitoring of the health impact of water and sanitation projects. A proxy is an easy-to-measure indicator for a hard to- measure impact. Here the goal is to identify the intermediate outcomes (for example coverage of toilets and taps) that are causally linked to the policy or intervention and to the outcome. The success of the analysis in establishing such links will determine the salience of the proxy indicators. Finally, World Bank also evaluate the broader impacts of water, sanitation, and hygiene interventions on rural livelihoods, such as savings in time, materials, and money invested in coping activities; improvements in convenience and privacy; and indirect benefits to caregivers (for example gains in work efficiency, and time and work reallocation within the household).

The involvement of the rural private sector in water supply in Cambodia is unique to the country. The presence of this private sector allows other entities to respond to new demands from people living in the larger villages for household water supply, which the State is not yet able to address. These entrepreneurs operate on a merchant basis, lacking an institutional structure which is still being created. Their business is most often based on pushcart delivering water barrels at the house of villagers or more recently on small piped networks usually distributing raw surface water. Service is rough; the water quality is uncertain, but the users are satisfied with this service, because for them, it constitutes another alternative to the already considerable choice of water supplies available-ponds, wells, boreholes, and rivers. Their demands focus more on a practical objective (a supply in the household) than on a sanitary one, even if surveys show that villagers have a good understanding of health risks associated with water. Through the implementation of 14 small scale water supply systems, the goal was to enhance a qualitative improvement of the water service in some Cambodian small towns through the transformation of rough and informal merchant services to a basic water service supplying drinking water to an extended population under a formal institutional arrangement. The MIREP (Mini Reseaux d'Eau Potable - Small Scale Piped Water Supply System) program, launched in 2001 to transform these very basic initiatives into basic services, began as a pilot project supporting one entrepreneur in the implementation of a small piped water system. In order to move forward, the MIREP program made a choice, in particular linked to its proximity to the Ministry of rural development, to assist the nascent involvement of communes in decentralization, to strengthen provincial power through the process of decentralization, and to respect the cultural heritage of those who devised and financed the project.