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This study aims to address the economic, social, and environmental wellbeing issues simultaneously by measuring the carbon intensity of wellbeing (CIWB) of Asian economies employing Prais-Winsten and pooled OLS estimator. The measure of CIWB is made taking into account a ratio of the two indicators—CO2 emissions per capita and life expectancy at birth. There is a paucity of studies that concentrate on human and social wellbeing indicators (i.e., water, sanitation, life expectancy) together applying the Environmental Kuznets Curve (EKC) hypothesis. Therefore, we have also investigated the EKC hypothesis as this theory hypothesizes the link involving human and environmental wellbeing and development. The findings utilizing the two econometric techniques indicate that in both the estimation models urban population access to an improved water source and total population access to improved water source has consistently negative and significant effects on CIWB. The fertility rate and prevalence of HIV pose no threat to CIWB. These findings demonstrate that social and human wellbeing indicators of the Asian economies are sustainable to this moment as they are lowering CIWB which is desirable. Contrary, GDP per capita, exports as a percent of GDP, and urban population have a significant and positive impact on CIWB which poses a challenge for the sustainability issue. We also have found the existence of the EKC hypothesis indicating environmental quality will increase past a turning point. The findings of the paper are well matched with the view of the “Economic and ecological modernization” theory and “human ecology” theory.

As national and global water, sanitation, and hygiene targets have been set and programs have been implemented, the study aimed to assess the attainment of these targets at the local level in selected areas in Davao region, the Philippines. Randomly selected households were assessed for water, sanitation, and hygiene indicators using a modified tool that combined national guidelines and global recommendations. Validated access to improved water source for drinking was below the targets in most barangays, while validated sanitary toilet coverages in all barangays did not meet the targets. Significant difference was observed between validated and reported access to improved water and sanitation services in some barangays. Approximately 87.5% of households had a handwashing facility, but only 51.2% of which had both water and soap available. Achieving the targets is challenged by the gap in monitoring due to a decentralized health system in the Philippines. There is a need to standardize indicators and optimize the tool to allow a comprehensive assessment of water, sanitation, and hygiene practices. This will help generate local data that are in line with national guidelines and global recommendations to enhance policy and to determine priority areas for improved water, sanitation, and hygiene service delivery.

According to the Kenya National School-Based Deworming program launched in 2012 and implemented for the first 5 years (2012–2017), the prevalence of soil-transmitted helminths (STH) and schistosomiasis substantially reduced over the mentioned period among the surveyed schools. However, this reduction is heterogeneous. In this study, we aimed to determine the factors associated with the 5-year school-level infection prevalence and relative reduction (RR) in prevalence in Kenya following the implementation of the program. Multiple variables related to treatment, water, sanitation, and hygiene (WASH) and environmental factors were assembled and included in mixed-effects linear regression models to identify key determinants of the school location STH and schistosomiasis prevalence and RR. Reduced prevalence of Ascaris lumbricoides was associated with low (< 1%) baseline prevalence, seven rounds of treatment, high (50–75%) self-reported coverage of household handwashing facility equipped with water and soap, high (20–25°C) land surface temperature, and community population density of 5–10 people per 100 m2. Reduced hookworm prevalence was associated with low (< 1%) baseline prevalence and the presence of a school feeding program. Reduced Trichuris trichiura prevalence was associated with low (< 1%) baseline prevalence. Reduced Schistosoma mansoni prevalence was associated with low (< 1%) baseline prevalence, three treatment rounds, and high (> 75%) reported coverage of a household improved water source. Reduced Schistosoma haematobium was associated with high aridity index. Analysis indicated that a combination of factors, including the number of treatment rounds, multiple related program interventions, community- and school-level WASH, and several environmental factors had a major influence on the school-level infection transmission and reduction.

The COVID-19 pandemic has emerged as a threat to global health security. This paper uses geospatial analyses to create a COVID Vulnerability Mapping Dashboard that examines and displays social vulnerability indices at the national and subnational levels in Indonesia. The dashboard answers three main questions: 1. Where are the vulnerable populations 2. What is the capacity of local health systems and 3. What is the local trend in COVID cases The dashboard prototype presented herein was developed and used to direct attention to geographic areas where risks are expected to be greatest.

The Sustainable DevelopmentGoals by the United Nations include a global target for Improved Water Source to reach 100% of population by 2030. There are still millions of people lacking the improved access to drinking water. We use the convergence methodology for 203 countries to determine whether the water shortage gap between water-rich versus water-poor countries has narrowed during 2000 to 2015. Results of our analysis show the narrowing of water shortage gaps. However, significant variations are found among income and regional subgroups. Implications of our findings indicate the reduction of water shortage gap within appropriate subgroups is needed. In particular, a set of policy recommendations are presented for sub Saharan Africa region where improvement of water supply is urgently needed.

Slum populations are commonly characterized to have poorly developed water and sanitation systems and speculated to access services through informal channels. However, there are limited representative profiles of water and sanitation services in slums, making it difficult to prioritize interventions that will make services safer for residents. This cross-sectional study examines quality and provision of access to water and sanitation services in government slums across Dhaka, Bangladesh. Access is overall high but is subject to quality issues related to safety, reliability, and liability. Services are often operated by informal middlemen at various stages of provision.

Safely managed drinking water services (SMDWS) is the service ladder used for the Sustainable Development Goal (SDG) monitoring of drinking water and expands on the Millennium Development Goal metric (“improved water source”) with three additional criteria, namely: availability when needed, accessibility on premises, and safety (free from faecal and priority chemical contamination). Multiple Indicator Cluster Surveys (MICS) have been used for progress monitoring accounting for a significant fraction of the water, sanitation, and hygiene (WASH) indicator data. In its most recent iteration MICS now includes additional SMDWS indicators. The objective of this study was to report on recent SDG target 6.1 baseline data on SMDWS from the Democratic People’s Republic of Korea gathered from a MICS conducted in 2017. Survey results indicated that 93.7% of the population used an improved drinking water source, but when this was combined with the SDG criteria of water availability, accessibility, and safety, coverage was reduced to 92.3, 78.2, and 74.4%, respectively. This resulted in estimates that 60.9% of the population used a SMDWS. The survey results illustrate how the improved SDG indicators can highlight the required gaps to be overcome with regard to universal and equitable access to SMDWS. Further analysis and discussion regarding water quality deterioration between source and household as well as population residence, wealth group index, geographical distribution, and other characteristics relative to SMDWS indicators are also further analysed and discussed.

Globally, many millions of people still lack access to safe drinking water and sanitation facilities. Here, we examined whether household availability of improved drinking water and sanitation, respectively, is associated with utilization of maternal and child health (MCH) services in South Asia. Demographic and Health Survey population-based data from Bangladesh, Nepal, India, and Pakistan were used, restricted to women with a child aged 0–36 months (n = 145,262). Types of households’ water source and sanitation facilities were categorized based on the World Health Organization and UNICEF’s definitions of “improved” and “unimproved”. We applied logistic regressions to estimate odds ratios (OR) and 95% confidence intervals (CI) for improved water and sanitation, respectively, in relation to reported antenatal care visits, having a skilled attendant at birth, and infant vaccination coverage, stratified by maternal education. Among lower educated women, access to improved water was associated with greater ORs for presence of a skilled attendant at delivery and their children having up-to-date immunizations (OR: 1.29, 95% CI: 1.17, 1.42). Among lower and higher educated women, improved sanitation (vs. unimproved) was associated with greater ORs for having had adequate antenatal care visits (OR: 1.74, 95% CI: 1.62, 1.88, OR: 1.71, 95% CI: 1.62, 1.80), and similarly for having had a skilled attendant at birth, and children with up-to-date immunizations. MCH services and water/sanitation should be addressed across sectors aiming at improvement of MCH.

BackgroundThe COVID-19 pandemic has highlighted important needs in water, sanitation and hygiene (WASH) services and standard practices for infection prevention and control in sub-Saharan Africa. We assessed the availability of WASH and standard precautions for infection prevention in health facilities across 18 countries in sub-Saharan Africa, as well as inequalities by location (rural/urban) and managing authority (public/private). Data from health facility surveys conducted between 2013 and 2018 in 18 sub-Saharan African countries were used to estimate the access to an improved water source within 500 m, an improved toilet, soap and running water or alcohol-based hand rub, and standard precautions for infection prevention at health facilities. Rural-urban differences and public-private differences in access to services were calculated. We also compared population level access to health facility access to services.ResultOverall, 16,456 health facilities from 18 countries were included. Across countries, an estimated 88 % had an improved water source, 94 % had an improved toilet, 74 % had soap and running water or alcohol-based hand rub, and 17 % had standard precautions for infection prevention available. There was wide variability in access to water, sanitation and hygiene services between rural and urban health facilities and between public and private facilities, with consistently lower access in both rural and public facilities. In both rural and urban areas, access to water, sanitation and hygiene services was ubiquitously better at health facilities than households.ConclusionsAvailability of WASH services in health facilities in sub-Saharan Africa has improved but remains below the global target of 80 % in many countries. Ensuring adequate access to WASH services and enforcing adherence to safety and hygiene practices in health facilities will be essential to minimize the risk of COVID-19 transmission.

The informal sector in developing economies is a significant source of livelihood for a sizable portion of the population. This study uncovers the effect of poor water infrastructure on the productivity of informal firms. This is achieved using firm-level data for 12 developing economies between 2009 and 2014. The findings indicate that an increase of one standard deviation of the total duration of water shortages in a month can lead to annual average losses of about 14.5 percent of the monthly sales per worker for the average informal firm in the sample that uses water for business activities.

Background Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers' practice of exclusive breastfeeding. Methods We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries. Results The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78). Conclusion Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

Background South Africa has unique and diverse social and economic factors that have an impact on the provision of basic water, sanitation, hygiene and waste management infrastructure and practices at health care facilities in ensuring patient safety and prevent the spread of diseases. Methods The aim of this study was to evaluate water, sanitation and hygiene access and standards at 50 government owned public health care clinics in the rural region of the Vhembe district of South Africa during 2016/2017, using self-observation, an observation checklist, record reviews and interviews with clinic managers. Water quality from all available water sources on the clinic compound was analysed for Total coliform and E. coli counts using the Colilert Quanti-tray/2000 system. The prevalence of pathogenic diarrhea causing E. coli strains was established using multiplex-Polymerase Chain Reaction. Results The health care clinics in the Vhembe District generally complied with the basic WASH services guidelines according to the World Health Organisation. Although 80% of the clinics used borehole water which is classified as an improved water source, microbiological assessment showed that 38% inside taps and 64% outside taps from the clinic compounds had TC counts higher than guideline limits for safe drinking. Similarly, EC counts above the guideline limit for safe drinking water were detected in 17% inside taps and 32% outside taps from the clinic compounds. Pathogenic EAEC, EPEC, ETEC and EHEC strains were isolated in the collected water samples. Although improved sanitation infrastructures were present in most of the clinics, the sanitary conditions of these toilets were not up to standard. Waste systems were not adequately managed. A total of 90% of the clinics had hand washing basins, while only 61% of the clinics had soap present and only 64% of the clinics had adequate signs and posters reminding the staff, care givers and patients to wash their hands. Conclusions Various WASH aspects within the primary health care system in South Africa needs to be improved and corrected. A more rigorous system that is inclusive of all role players in the WASH sectors, with regular monitoring and training sessions, should be used.

The fallout of nitrogen pollution is considered one of the largest global externalities facing the world, impacting air, water, soil, and human health. This paper combines data from the Demographic and Health Survey data set across India, Vietnam, and 33 African countries to analyze the causal links between pollution exposure experienced during the very earliest stages of life and later-life health. The results show that pollution exposure experienced in the critical years of development—from birth until age three—is associated with decreased height as an adult, a well-known indicator of overall health and productivity, and is robust to several statistical checks. Because adult height is related to education, labor productivity, and income, this also implies a loss of earning potential. The analysis begins within an assessment in India, where the data are more available, and is then extended to geographic settings including Vietnam and 33 countries in Africa. The results are consistent and show that early-life exposure to nitrogen pollution in water can lower height-for-age scores during childhood in Vietnam and during infancy in Africa. These findings add to the evidence on the enduring consequences of water pollution and identify a critical area for policy intervention.

Background: The newly identified Coronavirus disease (COVID-19) has currently expanded and shifted from an epidemic to global pandemic. To date there is no proven vaccine for this contagion, prevention measures are the only option for the world to stay safe. According to the World Health Organization, frequent handwashing with soap for 20 seconds is the most effective prevention measures to reduce the incidence of this global pandemic. Method: Our present study was based on the national presentative publicly available two datasets. One is the latest Multiple Indicator Cluster Survey (MICS 2019) to explore hand washing situation in Bangladesh, another one is the confirmed cases of COVID-19 throughout Bangladesh from Institute of Epidemiology, Disease Control and Research (IEDCR), Bangladesh as of June 20, 2020. Both data were cross-sectional in nature. Findings: Prevalence of household handwashing was found 56.3%, and the prevalence was significantly varied across the socio-economic status of the households (HH). We observed a higher number of COVID-19 cases (as of June 20, 2020) where there is a relatively lower prevalence of handwashing. Northern part of Bangladesh had the highest handwashing practice whereas it had less effected by COVID-19 cases. However, central Bangladesh had the hardest hit by COVID-19 cases, and it had around 50% handwashing practice coverage. Poorer HHs, low education of the HH heads, HH with no improved water source facility had a strong correlation with not practicing HH handwashing. Interpretation: Around half of Bangladesh does not practice HH level handwashing. Areas where higher the HH handwashing practice, lower the COVID-19 cases were observed. Funding Statement: Authors did not receive any funding for this study. Declaration of Interests: The authors have no conflict of interest to declare.

Inadequate drinking water provision in many regions of the world has given rise to a vibrant packaged-water industry that sells water in single-serving sized bottles and plastic bags.1 In lieu of a piped water connection, low-cost bagged or “sachet” water has been shown around the world to often exhibit the lowest levels of contamination among available drinking water options2 and has become a particularly important drinking water source in West Africa.3 The reclassification of high-quality packaged water as an improved water source would improve progress toward global drinking water targets,1 and the World Health Organization (WHO) is slowly incorporating packaged water into its revised drinking water ladder where appropriate.4 Some of the highest rates of sachet water consumption are in Ghana, where in 2014, 29% of all households nationally (43% of urban households and 12% of rural households) relied on it as the primary drinking water source.5 In Ghana, households must diversify their water sources to meet their consumption needs, a practice long observed throughout sub-Saharan Africa.6,7 Diversifying the households’ water supply makes sense in areas with unreliable infrastructure, as it provides households a hedge against uncertain availability. A recent study of five regions in Ghana found that more than half of households are collecting water from improved sources,8 although they rely on many sources to meet their household water needs. During the rainy season, 76% of households collect rainwater, 24% use public taps, 43% collect from boreholes, and 6% buy sachet water. Because all non-rainwater sources are vended, 46% of households were observed to pay for water in some way.8 Although sachet water has been ubiquitous in urban Ghana for more than a decade, it is increasingly becoming a popular drinking water source in rural areas.9 The formalization of the packaged-water industry has led to increased competition in urban centers, and this has been associated with the increase in product quality as large corporate producers replace smaller cottage-industry players in these large markets. Rural Ghanaian communities are often secondary markets with higher distribution costs, thus cottage-industry producers often continue to operate with less competition, and unfortunately, less regulation, and quality control.3 One nationally representative study in Ghana observed that sachet water had a strong protective effect from Escherichia coli contamination of drinking water relative to other water sources.9 Although the study observed that rural localities were associated with higher contamination rates at the point of consumption in bivariate analysis, urban versus rural disparities were not assessed in multivariable analysis because of multicollinearity between the urban–rural classification and other demographic covariates. The study of packaged water quality remains dynamic but remains focused primarily in dense urban centers with the largest consumer markets. Recent Ghanaian studies from urban areas have identified traditional indicator bacteria10,11 and antibiotic resistance,12 explored differences between brands,13 and evaluated vendor practices.14 Despite significant growth in the number of sachet water quality studies this decade, just a handful have assessed sachet quality in rural contexts where it is a relatively newer product.3 Packaged water is theorized to confer a public health benefit if consumed in lieu of water stored in the household because of limited opportunity for cross-contamination.15,16 The quality of stored water is well known to deteriorate due to improper storage or treatment at home,17 and recent evidence confirms that sachet water tends to be of better quality at the point of consumption.9 But there has been no systematic assessment of how sachet water compares with water from other sources at the point of collection (POC). This approach was piloted in a previous Accra study, where POC and point-of-use (POU) water samples from 15 households were tested along with sachet water samples; a decline in quality was observed from sachet to POC to POU samples.15 This study compares the microbiological quality of sachet water and other drinking water sources tested across a sample of 42 Ghanaian communities in rural and peri-urban areas and small towns. We specifically compare the quality of sachet water sold in communities with water from other POC in those communities and with water stored in households. We hypothesized that in smaller communities located beyond large urban centers such as Accra, Kumasi, Sekondi-Takoradi, Sunyani, and Tamale, where sachet water producers and distributors can more easily evade regulatory scrutiny,3 sachet water will exhibit lower rates of microbiological contamination than POC water samples, which in turn will exhibit lower rates of contamination than POU water samples. Our findings present a rare opportunity to assess Ghana’s evolving sachet water landscape outside of Ghana’s major urban centers.

Stunting is recognised as a major public health problem in Rwanda. We therefore aimed to study the demographic, socio-economic and environmental factors determining the spatial pattern of stunting. A cross-sectional study using the data from the 2014- 2015 Rwanda Demographic and Health Survey and environmental data from external geospatial datasets were conducted. The study population was children less than two years old with their mothers. A multivariate linear regression model was used to estimate the effects of demographic, socio-economic and biophysical factors and a proxy measure of aflatoxins exposure on height-for-age. Also, a spatial prediction map of height-for-age to examine the stunting pattern was produced. It was found that age of child, height of mother, secondary education and higher, a child being male and birth weight were associated with height-for-age. After adjusting for demographic and socioeconomic factors, elevation and being served by a rural market were also significantly associated with low height-for-age in children. The spatial prediction map revealed the variability of height-for-age at the cluster-level that was lost when the levels are aggregated at the district level. No associations with height-for-age were found for exclusive breastfeeding, use of deworming tablets, improved water source and improved sanitation in the study population. In addition to the child and mother factors known to determine height-for-age, our study confirms the influence of environmental factors in determining the height-of-age of children in Rwanda. A consideration of the environmental drivers of anthropometric status is crucial to have a holistic approach to reduce stunting.

Water, sanitation, and hygiene interventions are increasingly recognized as essential for improving nutritional outcomes in children. Emerging literature describes the negative effects of poor sanitation on child growth. However, limited evidence has shown a link between water quality and nutritional outcomes. Similar to poor sanitation, it is plausible that water contaminated with E. coli could affect the nutritional status of children through various possible biological pathways, such as repeated episodes of diarrhea, environmental enteropathy, parasites, or other mechanisms that inhibit nutrient uptake and absorption. This study explores the relationship between contaminated water and stunting prevalence among children younger than age five years, using unique cross-sectional data from the 2012–13 Bangladesh Multiple Indicator Cluster Survey, which was one of the first nationally representative surveys to include water quality testing for E. coli. E. coli contamination in drinking water is measured at household and source points. Stunting is measured using height-for-age z-scores for children under five, where a child is considered stunted when he or she is two or more standard deviations below the median of the World Health Organization reference population. The results of multiple probit regression models indicate a 6 percent increase in the prevalence of stunting in children who are exposed to highly contaminated drinking water at household point compared with those exposed to low-to-medium contamination. When contamination is measured at the source level, the association is greater, with a 9 percent increase in the likelihood of stunting when exposed to a high level of contamination.

Despite Bangladesh's notable progress toward the eradication of open defecation, the country still faces severe deficits in the availability of improved sanitation. This paper analyzes the impact of exposure to unimproved sanitation early in childhood on primary school enrollment status, using pseudo-panel data for children ages six to nine years in Bangladesh. The results indicate that unimproved sanitation has a negative and significant impact on primary school enrollment. A child's early exposure to unimproved sanitation decreases the likelihood of being enrolled in primary school by eight to ten percentage points on average compared with a child with access to improved sanitation. The effect is particularly strong -- a difference of 8 to 10 percentage points -- for children ages six to seven. It is also strong in rural areas. The results are statistically robust to errors due to potential omitted variable bias.

Background: Makwanpur district was declared Open Defecation Free in 2013 as the movement started in Nepal since 2003 to address the high burden of diarrhoeal disease among under five children. As the water supply, sanitation and hygiene situation of the district is not known after the declaration, the need for this study was visualized.Methods: It was a cross sectional study among randomly sampled 178 households using interview and observation. Water, sanitation and hygiene situation was assessed in terms of related facilities, knowledge and practices of mothers. Results were compared with the standard open defecation free criteria of Nepal. Five years trend of diarrhoeal disease was analysed from the health facility records to assess the impact of declaration.Results: Of the total households 92% had toilets and 90% had access to improved water source. About 79% mothers had high knowledge on safe water, sanitation and hygiene and 43% practiced hand washing with soap at critical times. Proper disposal of solid and liquid waste was found among 32% and 46% of households respectively. About 68% of households had good water, sanitation and hygiene situation and was found to be significantly associated with related knowledge among mothers irrespective of their economic status. Diarrhoeal disease among under five children was found declining after open defecation free declaration.Conclusions: Water, sanitation and hygiene status in the study area is found lower than the criteria for open defecation free declaration. However, diarrhoeal disease among children under five is declining after the declaration.

Background: Makwanpur district was declared Open Defecation Free in 2013 as the movement started in Nepal since 2003 to address the high burden of diarrhoeal disease among under five children. As the water supply, sanitation and hygiene situation of the district is not known after the declaration, the need for this study was visualized.Methods: It was a cross sectional study among randomly sampled 178 households using interview and observation. Water, sanitation and hygiene situation was assessed in terms of related facilities, knowledge and practices of mothers. Results were compared with the standard open defecation free criteria of Nepal. Five years trend of diarrhoeal disease was analysed from the health facility records to assess the impact of declaration.Results: Of the total households 92% had toilets and 90% had access to improved water source. About 79% mothers had high knowledge on safe water, sanitation and hygiene and 43% practiced hand washing with soap at critical times. Proper disposal of solid and liquid waste was found among 32% and 46% of households respectively. About 68% of households had good water, sanitation and hygiene situation and was found to be significantly associated with related knowledge among mothers irrespective of their economic status. Diarrhoeal disease among under five children was found declining after open defecation free declaration.Conclusions: Water, sanitation and hygiene status in the study area is found lower than the criteria for open defecation free declaration. However, diarrhoeal disease among children under five is declining after the declaration.Keywords: Diarrhoeal disease; Makwanpur; ODF; WASH.

In rural sub-Saharan Africa, one in three handpumps are non-functional at any time. While there is some evidence describing factors associated with non-functional water systems, there is little evidence describing the categories of water system breakdowns that commonly occur. Insufficient water availability from broken down systems can force people to use unimproved water sources, which undermines the health benefits of an improved water source. We categorized common water system breakdowns using quantitative and qualitative monitoring data from Liberia, Nigeria, Tanzania, and Uganda (each N>3600 water systems) and examined how breakdown category varies by water system type and management characteristics. Specific broken parts were mentioned more frequently than all other reasons for breakdown; hardware parts frequently found at fault for breakdown were aprons (Liberia), pipes (Tanzania and Uganda), taps/spouts (Tanzania and Uganda), and lift mechanisms (Nigeria). Statistically significant differences in breakdown category were identified based on system type, age, management type, and fee collection type. Categorization can help to identify common reasons for water system breakdown. The analysis of these data can be used to develop improved monitoring instruments to inform actors of different breakdown types and provide reasons for system non-functionality. Improved monitoring instruments would enable actors to target appropriate resources to address specific breakdowns likely to arise based on system type and management characteristics in order to inform improved implementation of and post-construction support for water systems in sub-Saharan Africa.

The first Sustainable Development Goal targets ending poverty in all its forms everywhere by 2030. And one of the most remarkable achievements during the MDG era was the significant decline in the share of the extremely poor in the global population, leading to the global attainment of cutting the extreme poverty rate to half its 1990 level by 2015. However, Sub-Saharan Africa remained the only developing region where the MDG 1 target was not achieved. Based on the updated poverty line of $1.90 a day, poverty reduction in Sub-Saharan Africa significantly lags other developing regions. Understanding the key drivers and ways of tackling poverty in Sub-Saharan Africa becomes one of the pressing development challenges of our time. Our empirical estimates for the period, 1980 to 2013, show that the key factors significantly feeding poverty incidence and poverty depth in the region include high income inequality, oil-dependence, institutionalized democracy, high prevalence of HIV among the female youth, and increased civil war episodes. On the other hand, the key drivers significantly reducing poverty in the region are higher levels of economic development (income per capita), higher general government final consumption expenditure, higher official development assistance and aid received, urbanization, and access to improved water source. The policy implications are discussed.

Residents in the Eastern Region, Ghana with access to improved water sources (e.g., boreholes and covered wells) often choose to collect water from unimproved sources (e.g., rivers and uncovered wells). To assess why, we conducted two field studies to coincide with Ghana&rsquo, s rainy and dry seasons. During the rainy season, we conducted semi-structured in-depth interviews among a convenience sample of 26 women in four rural communities (including one woman in the dry season). We asked each participant about their attitudes and perceptions of water sources. During the dry season, we observed four women for &le, 4 days each to provide context for water collection and water source choice. We used a grounded theory approach considering the multiple household water sources and uses approach to identify three themes informing water source choice: collection of and access to water, water quality perception, and the dynamic interaction of these. Women selected water sources based on multiple factors, including season, accessibility, religious/spiritual messaging, community messaging (e.g., health risks), and ease-of-use (e.g., physical burden). Gender and power dynamics created structural barriers that affected the use of unimproved water sources. A larger role for women in water management and supply decision-making could advance population health goals.

This document summarizes evidence and guidance on project design and results framework indicators for nutrition-sensitive irrigation and water management investments for which improving nutrition in vulnerable populations is a specific objective of the project. Drawing on the current body of evidence on the links between irrigation, water management, and nutrition through the pathways of production, income, women’s empowerment, and water and hygiene, the report describes eight nutrition-sensitive approaches for achieving greater impacts on early child nutrition. Results framework indicators are proposed to support monitoring and evaluation of nutrition-sensitive investments in water management and irrigation.

Since 2016 the World Bank has explored a wide range of country experiences in delivering better water supply and sanitation services. The analyses led to publication of three new global frameworks for designing water reforms: Policy, Institutional, and Regulatory Incentives, which looks at the broader sector enabling environment; Water Utility Turnaround Framework, which looks at utility-level reforms; and Maximizing Finance for Development, which looks at shifting the financing paradigm to reach the Sustainable Development Goals. The three frameworks—individually and as a compendium—set forth the key principles of a more holistic approach to reform that diverges from the traditional focus on infrastructure economics to a deeper understanding of the behavior of and between sector institutions and of the people within those institutions. Each country-specific reform path will gradually bring the sector to higher degrees of maturity with a strong focus on improving financial sustainability. This summary note integrates the three lines of work—utility reform, sector reform, and sector finance—for readers to understand the critical links between the three spheres. New contributions of this note are a Maturity Matrix for assessing where a country is in its reform process and where it wants to go and a Maturity Ladder that identifies typical actions to move from one stage of maturity to the next. Tools and references are also provided to help governments start on their reform path.

BackgroundThe associations between anemia and household water source and sanitation remain unclear.ObjectivesWe aimed to assess the associations between anemia and household water source or sanitation in preschool children (PSC; age 6-59 mo) using population-based surveys from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.MethodsWe analyzed national and subnational data from 21 surveys, representing 19 countries (n = 35,963). Observations with hemoglobin (Hb) and ≥1 variable reflecting household water source or sanitation were included. Anemia was defined as an altitude-adjusted Hb concentration

Background Since 2010, the humanitarian aid organization World Vision has implemented a community-based water, sanitation, and hygiene (WASH) program in 76 area development programs (ADPs) for a total target population of 2,831,535 in three Southern Africa countries: Malawi, Mozambique, and Zambia. # Methods This study was conducted using the Lives Saved Tool (LiST) to analyze the isolated impact of World Vision WASH interventions on child morbidity and mortality during the four-year implementation period from 2010 to 2014. The combined effects of WASH interventions -- improved water source, home water connection, improved sanitation, handwashing with soap, hygienic disposal of children's stools -- were analyzed through LiST. # Results It showed that 917 to 929 children under five years of age were saved from death caused by diarrhea, pneumonia, meningitis, or measles between 2010 and 2014. WASH interventions led to a 131% mean increase in the percentage of under-five lives saved, alongside a 4.47% mean decrease in under-five mortality rates across the three countries. In addition, 809,552 cases of diarrhea among 541,935 children under the age of five were prevented. # Conclusions LiST acted as an effective tool for conducting the quantitative modeling assessment of the program retrospectively at a subnational level. World Vision WASH interventions in Malawi, Mozambique, and Zambia successfully saved children's lives, and various approaches to WASH for the future program are necessary to reach the goal of preventing all three cases of diarrhea per child each year by 2020.

OBJECTIVES: We aimed to assess the associations between water source and sanitation with anemia in preschool children (age: 6–59 months) in 16 population-based surveys. METHODS: We analyzed data from the BRINDA project. Sixteen surveys, representing 15 countries (n = 25,214), that had measures of hemoglobin, household water source and sanitation, type of residence, and socioeconomic (SES) status were included in this analysis. Anemia was defined as altitude-adjusted hemoglobin concentration

Adequate environmental conditions, comprising sufficient environmental hygiene items (e.g. gloves, soap, and disinfectant), adequate infrastructure (e.g. sanitation facilities, water supply), a clean environment, and hygienic behaviors in healthcare facilities (HCFs) are necessary for safe care in maternity wards. Few data are available describing environmental conditions in maternity wards in rural areas of low- and middle-income countries (LMICs). We collected data on these conditions from 1547 HCFs with maternity wards in 14 countries (Ethiopia, Ghana, Honduras, India, Kenya, Malawi, Mali, Mozambique, Niger, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe). We described patterns and availability of essential environmental conditions, and a regression model was developed to explore predictive factors. 73% of HCFs offering maternal and neonatal health (MNH) services did not meet the guidelines for the World Health Organization ‘six cleans’ (clean perineum, clean bed surface, clean hands, clean blade, clean cord tie, and clean towels to wrap the baby and mother). The items with the lowest availability were clean towels (40%). In a multivariable logistic regression model, HCFs that provided maternity services were more likely to have all ‘six cleans’ available if they: had at least an improved water source; had an infection prevention and control (IPC) protocol; had a budget considered sufficient that included funding for water, sanitation, hygiene, and IPC; and emphasized the importance of IPC within the nearby community. Our results demonstrate substantial differences between countries in the availability of environmental hygiene items, facility cleanliness, and quality of environmental health infrastructure in HCF maternity wards. There are several low-cost, high-impact, context-relevant opportunities to enhance essential environmental conditions that would improve the quality of neonatal and maternal care in maternity wards in HCFs in LMICs.

Despite high distribution of Primary Health Care Centres (PHC) and low cost of care provision, patronage is low in Nigeria. Findings for the determinants of health care demand are one sided with focus on patient related factors. Less attention is given to facility determinants. This study examined facility determinants of the demand for PHC service in Nigeria using basic infrastructures, equipment and staff type. The 2013-2014 SDI data covering 11,690 primary health care facilities was used. The Negative Binomial regression model was fitted to determine the effects of facility factors on number of visits. The results show more community workers and paraprofessionals and few medical Doctors and Nurses in PHC’s. Facilities are equipped with weighing scales, sphygmomanometer and stethoscope with few thermometer. High staff absence rate, lack of improved water source and non-regular power supply are also observed. Findings associate presence of Nurses with increased number of visits than other staff type. Child weighing scale, regular power supply and improved water are also key positive determinants. Better use of PHC’s in Nigeria is possible with medical personnel especially nurses in employment. Improved water, regular power and instruments like child weighing scale are also vital.

Poultry production in low income countries provides households with nutrient‐rich meat and egg products, as well as cash income. However, traditional production systems present potential health and nutrition risks because poultry scavenging around household compounds may increase children's exposure to livestock‐related pathogens. Data from a cross‐sectional survey were analysed to examine associations between poultry, water, sanitation, and hygiene practices, and anthropometric indicators in children (6–59 months; n = 3,230) in Burkina Faso. Multilevel regression was used to account for the hierarchical nature of the data. The prevalence of stunting and wasting in children 6–24 months was 19% and 17%, respectively, compared with a prevalence of 26% and 6%, respectively, in children 25–60 months. Over 90% of households owned poultry, and chicken faeces were visible in 70% of compounds. Caregivers reported that 3% of children consumed eggs during a 24‐hr recall. The presence of poultry faeces was associated with poultry flock size, poultry‐husbandry and household hygiene practices. Having an improved water source and a child visibly clean was associated with higher height‐for‐age z scores (HAZ). The presence of chicken faeces was associated with lower weight‐for‐height z scores, and no associations were found with HAZ. Low levels of poultry flock size and poultry consumption in Burkina Faso suggest there is scope to expand production and improve diets in children, including increasing chicken and egg consumption. However, to minimize potential child health risks associated with expanding informal poultry production, research is required to understand the mechanisms through which cohabitation with poultry adversely affects child health and design interventions to minimize these risks.

This study provides a basic diagnostic of access to safe water and sanitation in Uganda and their relationship with poverty. While the analysis is not meant to lead directly to policy recommendations, some of the findings are relevant for policy. The analysis relies on a series of nationally representative household surveys for the period 2002–2013, as well as on qualitative data collection. The study first analyzes trends in access to safe water and some of the constraints faced by households in this area using mostly household survey data (chapter 2). The issue of the cost of water for households without a connection to the water network is discussed with a focus on public stand pipes (chapter 3). Qualitative data are then presented on the obstacles faced by households in accessing safe water (chapter 4). The last two chapters are devoted to sanitation. As for safe water, the focus is first on household survey data about sanitation, including with respect to toilets, bathrooms, waste disposal, and hand washing (chapter 5), and next on an analysis of qualitative data from focus groups and key informants (chapter 6). Finally, the study reviews policies and programs that have been implemented in order to provide access to water and sanitation for the poor, as well as options going forward (chapter 7).

Background United Nations Children’s Fund (UNICEF) designed EQUitable Impact Sensitive Tool (EQUIST) to enable global health community address the issue of equity in maternal, newborn and child health (MNCH) and minimize health disparities between the most marginalized population and the better-off. The purpose of this study was to use EQUIST to provide reliable evidence, based on demographic health surveys (DHS) on cost–effectiveness and equitable impact of interventions that can be implemented to improve MNCH outcomes in Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal. Methods Using the latest available DHS data sets, we conducted EQUIST Situation Analysis of maternal and child health outcomes in the six countries by sub-national categorization, wealth and by residence. We then identified the poorest population class within each country with the highest maternal and child mortality and performed EQUIST Scenario Analysis of this population to identify intervention package, bottlenecks and strategies to address them, cost of the intervention and strategies as well as the number of deaths avertible. Results Under-five mortality was highest in Atlantique (Benin), Sahel (Burkina Faso), Northern (Ghana), Sikasso (Mali), North-West (Nigeria), and Diourbel (Senegal). The number of under-five deaths was considerably higher among the poorest and rural population. Neonatal causes, malaria, pneumonia and diarrhoea were responsible for most of the under-five deaths. Ante-partum, intra-partum, and post-partum haemorrhages, and hypertensive disorder, were responsible for highest maternal deaths. The national average for improved water source was highest in Ghana (82%). Insecticide treated nets ownership percentage national average was highest in Benin (73%). Delivery by skilled professional is capable of averting the highest number of under-five and maternal deaths in the six countries. Redeployment/relocation of existing staff was the strategy with highest costs in Burkina Faso, Nigeria and Senegal. Ghana recorded the least cost per capita ($0.39) while the highest cost per capita was recorded in Benin ($4.0). Conclusion EQUIST highlights the most vulnerable and deprived children and women needing urgent health interventions as a matter of priority. It will continue to serve as a tool for maximizing the number of lives saved; decreasing health disparities and improving overall cost effectiveness. Electronic supplementary material The online version of this article (10.1186/s12992-018-0422-1) contains supplementary material, which is available to authorized users.

Despite growing concerns about the possible security implications of extreme precipitation shortfalls in vulnerable and politically fragile regions, the particular conditions that make armed violence more or less likely in times of drought remain poorly understood. Using a spatially disaggregated research design and focusing on sub-Saharan Africa, the present analysis assesses how far violent and nonviolent outcomes in the wake of drought can be accounted for by regional differences in the provision of key infrastructures that help coping with drought and preventing violence. The results indicate that civil conflict events in connection with drought are more likely in administrative areas with poorly developed road infrastructures. Drought-related communal violence, on the other hand, is more likely in regions where an important part of the population lacks access to an improved water source. Thus, while the provision of key infrastructures seems to moderate local conflict risks in connection with drought, there are nevertheless important distinctions with regard to different types of infrastructures and forms of armed violence. However, the importance of precipitation shortfalls as a conflict-facilitating factor in sub-Saharan Africa should not be overstated, as the overall contribution of drought measures to predicting violent events is modest in all calculated models.

Water, sanitation, and hygiene (WaSH) technologies and behaviors can prevent infection by soil-transmitted helminth species independently, but may also interact in complex ways. However, these interactions are poorly understood. The purpose of this study was to characterize how school and home WaSH exposures were associated with Ascaris lumbricoides infection and to identify relevant interactions between separate WaSH technologies and behaviors. A study was conducted among 4,404 children attending 51 primary schools in western Kenya. We used multivariable mixed effects logistic regression to characterize how various WaSH exposures were associated with A. lumbricoides infection after annual school-based deworming. Few WaSH behaviors and technologies were independently associated with A. lumbricoides infection. However, by considering relevant interdependencies between variables, important associations were elucidated. The association between handwashing and A. lumbricoides depended largely upon the pupils' access to an improved water source. Among pupils who had access to improved water sources, A. lumbricoides prevalence was lower for those who handwashed both at school and home compared with neither place (odds ratio: 0.38, 95% confidence interval: 0.18–0.83; P = 0.01). This study contributes to a further understanding of the impact of WaSH on A. lumbricoides infection and shows the importance of accounting for interactions between WaSH technologies and behaviors.

Background : Safe drinking water and basic sanitation is of crucial importance to the prevention of human heath1. Water can become a vehicle for transmission of feco oral group of infections, because the fecal contamination of water is common and its avoidance and subsequent purification is vigilant2. One of the goal of MDG states - Halve, by 2015, the proportion of people without sustainable access 3 to an improved water source and sanitation3. Materials and methodology : A descriptive study was undertaken among 300 samples, in adopted villages of MCON Manipal, Udupi District using structured questionnaire. SPSS 16.0 software was used for data analysis. Results : Findings of the study showed that 42% had average knowledge and majority (75 %) of the subjects followed unsafe practices on water, sanitation and hygiene. Majority (88 %) of the subjects performed unskilled hand washing. Conclusion: Water pollution is a growing hazard in many developing countries due to human activity. Water is an essential factor in the economic, social and cultural development of community. It can eliminate diseases, and improve quality of life

Achieving the proposed water, sanitation, and hygiene (WASH) post-MDG goals will require targeted measures if the human right to water and sanitation is ever to be realized. Particularly in rural areas, among urban poor populations and marginalized communities where access remains low, the human right to water and sanitation is an important vehicle to raise attention to inequalities in access. In this paper, we explore the journey of Usoma, a small community in Western Kenya, as they move toward the realization of a human right to water and sanitation. In the face of international pressure for increasingly privatized water and sanitation services that emphasize efficiency and financial sustainability, we conclude that translating the human right to water and sanitation requires adequate commitment to ‘pro-poor’ policies, innovative financing models, monitoring of water service providers, and stakeholder engagement at all levels of government. Only in this way will access to water and sanitation be realize...

Access to improved water source for drinking and other domestic uses is a major developmental challenge in many developing countries like Ethiopia due to its different geological formations and climatic conditions water distribution is uneven spatial and temporal across Ethiopia country. Even though accessible water supply is a critical issue to ensure the quality of life there no study conduct on Water accessibility in Jigjiga town before, therefore this study was aimed to assess the accessibility of water supply and associated factors among residents of town on May 2016. Community based cross sectional study design was used and 408 households and 14 key informant was randomly and purposive selected for quantitative and qualitative approaches respectively. All independent variables with p- value of < 0.3 at bivariate analysis were included in multivariate model to determine the predictors of the outcome variable, and to control the confounding factors. Overall 56.7% of households reported using an improved water source as the main source of drinking water supply within recommended distance and only 35.2% of households consume 20 liters per person per day and less than half households (44.8%) affordable to water supply access (pay less than five percent of their income). Combining these three indicators results only a fifth of households (19%) of households accessible to water supply that meet standard. Head of household with higher level of education [(AOR=4.2, 95% CI (1.0, 18.06)] and those having private pipe water supply [(AOR=19.1, 95% CI: (5.1, 71.39)] were identified as positively significant associated factors with water accessibility compared to those who cannot read and write and those that share water from neighbor pipe respectively. Access to water supply in the study area was very low. Therefore, those local authorities must pay special emphasis to improve accessibility and reliability of water supply and closely supervise and monitor private water vendors. Further in-depth studies should also be encouraged to look for improved interventions.

Background. The Philippines adopted the Conditional Cash Transfer (CCT) program as the Pantawid Pamilyang Pilipino Program (4Ps) that serves as the government’s flagship social assistance program for the poor. This provides short-term income support to poor families while investing on health and education to overcome future poverty. Objective. This study aimed to characterize the beneficiary and non-beneficiary households and evaluate the impact of 4Ps program on housing facilities and diet diversity. Methods. Quasi-experimental design was used to evaluate survey outcomes between 91 randomly sampled beneficiaries and 91 completely enumerated non-beneficiaries (incoming grantees). FANTA Household Dietary Diversity Score (HDDS) was used as an indicator for dietary diversity while structured questionnaire on housing profile was based on BIDANI and CEM-UPLB tools. Results. The 4Ps beneficiaries had significantly higher maternal education, household size (ρ=0.038), and improved water source (ρ=0.004) than non-beneficiaries. Cash transfer among 4Ps households provided 11% increase in the average monthly income of P7,324 pre-transfer. Diet diversity using FANTA scoring (0-12) showed that nonbeneficiaries were significantly lower by 0.4 than 4Ps score of 7.9 (ρ=0.003). Maternal education was found to have significant positive correlation with diet diversity. Both groups had high cereals and fats intake (>90%) while low in complex carbohydrates and legumes (

Variability of water sources and water consumption patterns throughout the year is an under-explored characteristic of household water insecurity globally. In this paper, I examine how expected uncertainties in access and quality, as well as and cultural dimensions shape experiences of household water insecurity in a remote Alaska Native community detrimentally affected by climate change. I use ethnographic and quantitative data from Niugtaq (Newtok), Alaska, as a case study to explore how household water security is affected by sudden changes in water access and quality, water sources, and cultural dynamics. Under normal conditions, the community uses an average of 7.2 l per capita per day (lpcd, 1.9 Gal/c/d) of water from the central facility. However, individual households reported great variation in their water use patterns, from 1.1 to 16.2 l/c/d (0.3 to 4.23 Gal/c/d). The primary factors affecting per capita treated water consumption are those that affect reliable access to an improved water source throughout the year. Household consumption of natural sources is a strategy to increase water access, and reflects how concerns about quality and safety of treated water that are part of the water insecurity experience. At the same time, consumption of natural sources reflects their cultural importance. This case study suggests that providing reliable access at least one improved water source, and incorporating trusted (traditional) water sources into improved water source development may be an effective approach to improving household water security in Indigenous communities affected by climate change.

We conducted a nationally representative cross-sectional study of 875 health-care facilities (HCFs) to determine water, sanitation, and health-care waste disposal service levels in Bangladesh for doctors, staff, and patients/caregivers in 2013. We calculated proportions and prevalence ratios to compare urban versus rural and government versus other HCFs. We report World Health Organization (WHO)-defined basic HCF service levels. The most common HCF was nongovernmental private (80%, 698/875), with an average of 25 beds and 12 admissions per day. There was an improved water source inside the HCF for doctors (79%, 95% confidence intervals [CI]: 75, 82), staff (59%, 95% CI: 55, 64), and patients/caregivers (59%, 95% CI: 55, 63). Improved toilets for doctors (81%, 95% CI: 78, 85) and other staff (73%, 95% CI: 70, 77) were more common than for patients/caregivers (54%, 95% CI: 50, 58). Forty-three percentage (434/875) of HCFs had no disposal method for health-care waste. More urban than rural and more government than other HCFs had an improved water source on the premises and improved toilets for staff. WHO-defined basic service levels were detected in > 90% of HCFs for drinking water, among 46-77% for sanitation, and 68% for handwashing at point of care but 26% near toilets. Forty-seven percentage of HCFs attained basic health-care waste management service levels. Patient/caregiver access to water, sanitation, and hygiene facilities is inadequate in many HCFs across Bangladesh. Improving facilities for this group should be an integral part of accreditation.

Despite the reported achievement of the Millennium Development Goals (MDGs) with respect to drinking water, lack of access to water remains widespread worldwide. The indicator used there to measure access to water in the MDGs refers to the use of an improved water source. However, the amount of time spent in collecting water is high in countries where access to drinking water supplies located on premises is not common. 26.3% of the world's population did not have such access in 2015. Thus the need to travel to a water point, possibly queue, fill water containers, and carry them home is prevalent. The amount of time and effort used in water collection can be considerable, and household surveys increasingly provide data on collection time. This study aims to demonstrate the effect of adding a 30-minute collection time component to monitor access to drinking water. This study draws on household surveys from 17 countries to highlight the widespread burden of fetching water and its significant impact on estimates of coverage. The proportion of the population with access decreased by 13% on average for these 17 countries when collection time was added as a consideration.

Many healthcare facilities (HCFs) in rural areas of low- and middle-income countries (LMICs) lack safe, sufficient water supplies. We sought to understand which factors affect water quality in rural HCF in LMICs. In Ethiopia, Ghana, Honduras, India, Kenya, Malawi, Mali, Mozambique, Niger, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe, doctors and nurses were interviewed at over 2000 outpatient HCFs about their water source, staff training, and management practices. Water samples were also tested for contamination with E. coli. We generated descriptive analyses and logistic regressions. Overall, 52% of surveyed HCFs used at least a basic water service, 23% used a limited water service, and 25% had no water service as defined by the WHO/UNICEF Joint Monitoring Programme. Use of an improved water source type (OR ≈ 1.4–1.7), treatment of water (OR = 1.26), management by a person with medical training (OR ≈ 3.4–8.9), and presence of a protocol for operations and management (OR = 1.29) were associated with safer water. These results suggest that in addition to addressing water source, storage, and treatment, stakeholders should also target organizational factors in order to improve water quality in HCFs.

The main objective of the discussion note is to inform dialogues among Government policy makers and other stakeholders on how to move forward with the critical water supply and sanitation (WSS) sector reforms in the Philippines, focusing on how private sector participation might be harnessed to help achieve the universal access to safe and sustainable water supply and sanitation services. The note aims to provide an initial analysis on: (i) current trends of private participation in the water sector, (ii) the liquidity of the commercial finance markets to support these activities, (iii) any current challenges or bottlenecks in financing the private sector (including issues relating to the enabling environment), and (iv) possible solutions to encourage effective investment into the sector. During the roundtable discussion, both the public and private sector providers confirmed that they would be willing to enter into less commercially viable service areas, provided there was substantial support from the government in the form of capital grants that would make the projects viable, and might even be able to leverage commercial finance. Hence, the discussion note proposed to: a) set up Project Preparation Facility, b) strengthen the government joint venture guidelines and PPP Act, and c) promote Blended Finance.