Drinking Water and Sanitation
Michelle V Fanucchi, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
Ó 2017 Elsevier Inc. All rights reserved.
This article is an updated version of the previous edition article by Meghan Checkley, William Checkley, volume 2, pp. 234–244, Ó 2008, Elsevier Inc.
Introduction
Few topics carry as great importance to public health as do
water and sanitation. At the World Day for Water on 22 March
2005, then United Nations Secretary General Kofi Annan
stated, “We shall not finally defeat AIDS, tuberculosis, malaria,
or any of the other infectious diseases that plague the devel-
oping world until we have also won the battle for safe drinking
water, sanitation and basic health care.” Although great strides
have been made in improving the world’s access to safe
drinking water (2.6 billion people have gained access to an
improved drinking water source since 1990, World Health
Organization, 2015), there is still much to be done. Currently,
it is estimated that 1.8 billion people still drink water contam-
inated with fecal material and 2.4 billion people lack adequate
sanitation worldwide (World Health Organization, 2015).
Disparities in coverage are far greater in developing countries
than in developed countries, particularly in some regions of
Asia and in Africa. Human health is greatly affected by the
lack of adequate water and sanitation. Indeed, contaminated
water and poor hygiene practices are the main sources of trans-
mission for waterborne diseases and large-scale epidemics. The
most important water- and sanitation-related illness is acute
infectious diarrhea, which is responsible for 1.5 million deaths
per year (World Health Organization, 2016), with 1.25 million
deaths per year in children adolescents worldwide (Global
Burden of Disease Pediatrics Collaboration, 2016). This
statistic equates to 3425 child/adolescent deaths each day or
approximately 12 child/adolescent deaths every 5 min. The
adverse effects of water and sanitation extend to other aspects
of human health that include poor growth and development
and that consequently translate into impaired physical and
cognitive capacities later in life. The goal of this article is to
summarize current knowledge of the effects of water and sani-
tation on human health and to provide a summary of current
international initiatives to improve water and sanitation and
common barriers to their progress. The first section provides
a brief historical perspective. The second section discusses the
diseases associated with inadequate water and sanitation, and
the third section summarizes potential health benefits. The
fourth section reviews recent international initiatives for the
improvement of water and sanitation. The last section summa-
rizes barriers and health policy challenges to the achievement
of these initiatives.
Historical Perspectives
There is good archeological evidence that early civilizations
recognized the importance of water and sanitation, especially
in large metropolises (Gray, 1940). One of the earliest excava-
tions to reveal an advanced sanitation system was found in
Iraq, 50 miles northeast of present Baghdad. At the ruins of
Eshnunna (2500 BC), a Sumerian city that was later conquered
350 International Encyclopedia of Public Health, 2nd edition, Volume 2
by Babylon, archeologists have identified exposed sewer lines
made of brick with household water-flush latrines directly con-
nected to these sewer lines. Other cultures of the same era, such
as the Indus Valley Civilization, also appeared to have devel-
oped complex water and sanitation systems in their cities. At
the ruins of Mohenjo-daro (2600–1700 BC), a city located in
southern Pakistan on the banks of the Indus River, archeolo-
gists have identified bathrooms and latrines that were directly
connected to street drains or drained into the sewer system
via terra-cotta pipes with closely fitting spigot joints. Archeolo-
gists also identified what appeared to be independent lines for
kitchen water and bath water. Another example is the Minoan
civilization (2700–1450 BC), on the island of Crete, which was
found to have well-developed stone sewer drains and the
ability to carry water in pipes under pressure. Archeologists
have also found pictorial evidence that the Egyptians
(1450 BC) may have been one of the first civilizations to
discover the importance of filtration and flocculation of water
(Figure 1).
More recent civilizations, including medieval Europe, were
less successful at implementing adequate water and sanitation
systems in large cities or had different priorities for water such
as its use for agricultural irrigation. The modern concept of
urban waste removal did not develop until the late eighteenth
and early nineteenth centuries. Most cities removed excrement
and other wastes through street gutters or dumped ‘night soil’
on vacant land and into nearby watercourses. Individual
homes at best had cesspools. As populations in the cities
grew dramatically during the nineteenth century, the crisis of
uncovered waste attracted increasing attention. Aesthetically,
city side-streets and waterways declined rapidly to nearly
Figure 1 Egyptian hieroglyph illustrating water clarification tech-
niques. Tomb of Amenophis II at Thebes (1450 BC). Adapted from
Wilkinson, 1879. Manners and Customs of the Ancient Egyptians.
William Clowes and Sons, London.
http://dx.doi.org/10.1016/B978-0-12-803678-5.00118-1
 Drinking Water and Sanitation 351

unlivable conditions: drainage ditches often overflowed, few solutions for sewer drainage should be implemented to
were built with any inclines, and even fewer connected to improve health (Mackenbach, 2007). Sir Chadwick began
each other in any organized system of sewerage. The social inquiries into public health as a means of reducing the costs
climate in the latter half of the nineteenth century for Europe of public relief. He was instrumental in establishing the first
was one of unrest. In the case of London, lime had to be British Public Health Act of 1848 and provided a framework
hung on the windows of the British Parliament, and the slogans for a comprehensive approach toward sanitation that included
such as “India is revolting and the Thames stinks” were the implementation of new technologies along with legal,
commonly voiced. Finally, health epidemics occurred, administrative, and governmental support.
touching the lives of rich and poor alike. For example, in During the same period, Dr John Snow made a seminal
1832, it is estimated that cholera claimed the lives of 5000 scientific discovery linking inadequate water and sanitation to
people in London and over 20 000 in Paris. In this environ- the spread of cholera. His observations in 1854 identified the
ment, the seeds of the urban hygiene movement flourished. Broad Street water pump in London as a likely source for the
Championing the hygiene campaign was Sir Edwin Chad- spread of cholera (Figure 2) and, despite general disbelief, he
wick, who believed that acute infectious diseases were caused convinced the Board of Guardians at Saint James Parish to
by air contaminated from poor drainage and argued that better remove the pump handle. The experiment of removing the

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Figure 2 Location of death from cholera in central London for September 1854. The Broad Street pump is located at the center of the map. Repro-
duced from Gilbert, E.W., 1958. Pioneer maps of health and disease in England. Geogr. J. 124, 172–183. With permission from Blackwell Publishing.
352 Drinking Water and Sanitation

pump handle was an effective measure to curb the cholera Oceania

outbreak in that neighborhood, which had claimed more than 51
500 lives. The contribution of John Snow’s work, however, 52
was underrecognized until the republication of his work by Dr Sub-Saharan Africa 1990
Wade Hampton Frost in the 1930s (Vandenbrouke et al., 1991). 49 2002
Outbreaks of cholera continue into modern times despite 58
our advanced epidemiological knowledge and increased aware-
Eastern Asia
ness. Two events deserve special mention. The first is the 1991
72
cholera epidemic in Peru that resulted in 1.3 million cases of
78
cholera and approximately 13 000 deaths in South and Central
America between 1991 and 1995. The spread of cholera in this Southeastern Asia
region was probably multifactorial, including the lack of 73
proper disposal of human waste especially in rapidly growing 79
periurban communities, limited and poorly maintained water Southern Asia
treatment and distribution systems, poor hygiene practices, 71
and disposal of cholera-contaminated sewage into coastal 84
waters. A second notable occasion occurred in July of 1994, Western Asia
when an estimated 500 000 to 800 000 refugees fled from 83
Rwanda to the Democratic Republic of Congo over a 4-day 88
period. This large migration of refugees overwhelmed Congo’s
Latin America and the Caribbean
capacity to respond, creating a major humanitarian crisis. Over
83
a 1-month period, approximately 50 000 Rwandans died
89
mostly from cholera until proper public health measures
were implemented at refugee camps. Northern Africa
88
90
Diseases Associated with Inadequate Water and CIS
Sanitation 92
93
Current statistics describing the lack of improved water and Developing regions
sanitation services worldwide are alarming. Despite progress 71
made to increase the coverage of populations with water and 79
sanitation, approximately one-quarter of the world’s popula-
tion still remain without access to safe water (Figure 3) and 0 20 40 60 80 100
approximately half of the population lack adequate sanitation
(Figure 4). The health of populations is significantly affected by Figure 3 Proportion of population using improved sources of
the lack of improved services. Children in the developing world drinking water, 1990 and 2002 (percentage). Reproduced from United
are the main victims of this coverage deficit. Approximately Nations, 2005. Millennium Development Goals Report 2005. UN, New
60% of child mortality in developing countries is linked to York, with permission.
infectious diseases, most of them related to water and sanita-
tion and to hygiene practices. age of 5 (World Health Organization, 2015). In 2001,
Diseases related to inadequate water and sanitation are diarrhea was responsible for 59 million disability-adjusted
transmitted via contaminated water, poor fecal disposal, poor life years lost, approximately 4.2% of the global burden of
hygiene practices, and inadequate water collection and storage. disease (Lopez et al., 2006). In comparison, malaria was
Bradley described four main epidemiological categories of responsible for 40 million disability-adjusted life years lost
water-related infections which relate to the engineering tech- in 2001, and tuberculosis was responsible for 36 million
nologies needed to cope with them: waterborne, water- lost in 2001 (Lopez et al., 2006). Approximately 90% of the
washed, water-based, and water-related insect vectors (Bradley, burden associated with diarrhea is potentially attributable
1977). This classification system questioned the classic notion to inadequate water and sanitation. Therefore, diarrhea
that water quality was the prime driver of the relationship control via water and sanitation interventions is one of the
between water and health. highest priorities for disease control worldwide.
Acute infectious diarrhea is the most important water- and Another group of diseases related to contaminated water is
sanitation-related illness. Although cholera and typhoid fever that of diseases caused by parasites. Although parasitic infec-
are important diseases because of disease severity and rapid tions are widespread worldwide, exact numbers of infected
spread, acute infectious diarrhea in children is the most people are unknown because the majority of these infections
important cause of morbidity and mortality worldwide. are asymptomatic. Indeed, relatively few infected individuals
Diarrheal diseases are responsible for 1.5 million deaths and manifest with severe symptoms, and even fewer die as a result
between 2 and 4 billion cases of disease episodes globally of infection. However, these infections are associated with
(World Health Organization, 2016). Diarrheal diseases a high burden of chronic malnutrition, poor longitudinal
account for 18% of all-cause mortality in children under the growth, and iron-deficient anemia. Asymptomatic infections,

Less than 50%
50%–75%
76%–90%
91%–100%
Insufficient data
Figure 4 Half the developing world lacks improved sanitation. Proportion of population using improved sanitation, 2002 (percentage). Reproduced
from United Nations, 2005. Millennium Development Goals Report 2005. UN, New York, with permission.
given their higher prevalence rates than symptomatic infec-
tions, may have adverse health consequences such as subop-
timal growth (Checkley et al., 1997). Of the parasites, the
10% of individuals are infected with helminthic infections
such as Ascaris lumbricoides and other nematodes. Protozoan
infections are also highly prevalent in contaminated water.
Protozoan infections that are associated with diarrhea, such
as Cryptosporidium parvum, are particularly important because
they are resistant to interventions such as chlorination. This
resistance means that Cryptosporidium is of concern to high-
income countries, such as the United States, as well as to
low-income countries. In 1993, a waterborne outbreak of
Cryptosporidium occurred in Milwaukee, Wisconsin. This
outbreak affected approximately 403 000 residents (out of
a population of 1.61 million) at a total estimated cost of
$96.2 million (Corso et al., 2003). The following year
(1994), another outbreak of Cryptosporidium occurred in Las
Vegas, Nevada, this time affecting immunocompromised
HIV-infected patients (Roefer et al., 1996). The Milwaukee
outbreak was traced back to a large rain event and runoff
from a cattle farm. The Las Vegas incident occurred even
though no breaches in water treatment were found, and the
outbreak ended abruptly without changes in water
treatment. Helicobacter pylori is a chronic bacterial infection
that may be transmitted through contaminated water.
Helicobacter pylori is the major cause of chronic gastric disease
worldwide. In developing countries, approximately 75–90%
of individuals become infected with H. pylori during their
lifetime, compared to 25–50% in developed countries.
Recent epidemiological and microbiological evidence
suggests that H. pylori may be transmitted through drinking
water. In Lima, Peru, one study found that children from
low-income families were more likely to become infected
with H. pylori than children from higher-income families. In
Drinking Water and Sanitation 353
addition, children from high-income families whose homes
were supplied with municipal water were 12 times more
likely to be infected with H. pylori than children from high-
income families whose homes were supplied from
community wells (Klein et al., 1991). More recently, several
investigators have identified H. pylori in drinking water
samples by using polymerase chain reaction–based methods.
Water- and sanitation-related illnesses extend beyond the
gastrointestinal tract. For example, trachoma is a preventable
eye disease that is perpetuated by the presence of inadequate
sanitation and poor hygiene practices. Trachoma is caused by
infection with Chlamydia trachomatis. Transmission occurs
through direct contact or is transmitted by flies from person
to person. The flies that transmit this bacterium breed in
human feces. Trachoma is endemic in 55 countries, and it
predominantly affects children. Currently, it is estimated that
over 150 million people have active disease and that
10 million are at immediate risk of blindness. Interventions
for the prevention of trachoma include facial cleanliness and
hygiene, as well as environmental improvements, particularly
in sanitation. A number of studies have found that families
with latrines have less trachoma and that households that
used more water for washing children also had less trachoma
(Cairncross, 1999).
Schistosomiasis is a water-based disease that is transmitted
through the contamination of water sources with urine and
fecal material. It is estimated that schistosomiasis affects
approximately 200 million people in 74 countries around the
world and that 20 million suffer severe consequences from
the infection. Interventions to reduce this disease include pre-
venting disposal of urine and feces in surface water. Dracuncu-
liasis is a debilitating disease that causes painful ulcers on the
lower limbs. It is transmitted exclusively through drinking
water. Successful campaigns that focus on safe water through
354 Drinking Water and Sanitation
filtration have reduced the burden of cases from 3.5 million in
1980 to approximately10 000 in 2005. The transmission of
vectorborne diseases such as malaria may be increased when
water sources are poorly protected and provide habitats for
mosquito breeding.
Hepatitis A virus is a liver pathogen that occurs worldwide
but more commonly in countries with poor hygienic and sani-
tary standards. It is estimated that 1.5 million clinical cases of
hepatitis A occur worldwide, but seroprevalence data suggest
that the population affected is 10 times that of acute clinical
cases. In young children, the majority of cases are asymptom-
atic, but in older children and adults, hepatitis A can lead to
jaundice, fever, and life-threatening fulminant hepatitis.
Although a vaccine is currently available, it is not used in
many developing countries given high rates of endemicity of
hepatitis A. Therefore, improved water sources and better sani-
tation would likely decrease the prevalence of this disease
worldwide.
Finally, chemical pollutants such as arsenic and nitrates also
present major threats to public health. Arsenic is a common
natural element and may be found in water that has flowed
through arsenic-rich rocks. Chronic exposure to arsenic via
drinking water leads to skin cancer, lung cancer, bladder cancer,
kidney cancer, and other skin lesions. The technology for
arsenic removal from piped water supply, however, is moder-
ately costly and requires technical expertise. Control of arsenic
is more complex where drinking water is obtained from many
individual sources, and it may be difficult to achieve in periur-
ban communities of developing countries and in most rural
areas worldwide.
Of increasing concern is the contamination of lead in
drinking water. Lead was the material of choice in the United
States for municipal water service lines before 1930, with
a decrease in its use after that date. A national survey of
community water systems in the United States has found that
approximately 6.1 million partial or full lead service lines pres-
ently in use in the United States serving a population of
293 million people (Cornwell et al., 2016). The danger of
continuing to utilize lead service pipes has become apparent
following the community-wide lead exposure through munic-
ipal drinking water in Flint, MI. In 2013, the city of Flint, Mich-
igan, decided to change water sources, from the Detroit Water
and Sewerage Department (distributing water from Lake
Huron) to the newly established Karegnondi Water Authority
(KWA – also to distribute water from Lake Huron). However,
KWA would not be ready to distribute water until 2016, leaving
Flint to find an alternative water source until KWA is ready. A
political ‘water war’ followed, with the Detroit Water and
Sewerage Department terminating Flint’s water contract in
April 2014. The city of Flint began to use water from the Flint
River in April 2014; however, corrosion control was not used
nor required by state officials, even though Flint had aging
water infrastructure and the Flint River water was more corro-
sive than Lake Huron water. Residents complain about the
water quality soon after the switch. By December 2014, the
automobile company General Motors switches to another
water source due to rust spots appearing on newly machined
engine parts. During this time period, there were boil water
advisories due to bacteria in the system prompting increases
of chlorine for disinfection. This leads to an increase in
trihalomethanes (TTHMs – chlorine-disinfectant by-products)
that exceed federal drinking water limits by January 2015.
The University of Michigan–Flint tests its water and finds
lead in drinking fountains. Because of their struggles with
drinking water quality, Flint is offered water services again
from the Detroit Water and Sewerage Department, but the
city rejects the offer. It is not until 25 September 2015 that
a lead advisory is issued to the citizens of Flint (the advisory
instructed residents to only use cold tap water for drinking
cooking and making baby formula) due to concerns of the local
medical community. On 1 October 2015, the Genesee County
Health Department declared a public health emergency due to
increased blood levels and concentrations of lead in the water,
and residents are told not to drink the water. On 16 October
2015, Flint is reconnected to the Detroit Water and Sewerage
Department 18 months after the crisis begins, but it is too
late. A State of Emergency is declared for Flint, and residents
must use bottled water for all drinking, cooking, and bathing
(Dixon, 2016). The most recent studies available indicate that
the percentage of children under the age of 5 years with
elevated blood lead levels increased from 2.4% in 2013 (before
the water source switch) to 4.9% in 2015 (after the water source
switch) with socioeconomically disadvantaged neighborhoods
affected the most (Hanna-Attisha et al., 2016).
When several infectious diseases related to inadequate
water, sanitation, and hygiene were combined into one anal-
ysis, it was estimated that they were responsible for more
than 82 million disability-adjusted life years lost in 2000
(Prüss et al., 2002). Indeed, unsafe water and sanitation
accounted for 3.7–5.7% of the global burden of disease,
making it the leading environmental risk factor worldwide
(Prüss et al., 2002; Ezzati et al., 2003).
Potential Health Benefits of Water and Sanitation
Interventions
The effects of inadequate water and sanitation on human
health in developing countries are difficult to measure
because poverty is linked to poor nutrition, higher rates of
disease, and to the lack of improved water and sanitation
services. Nonetheless, there is a considerable body of litera-
ture that documents potential health benefits of water and
sanitation interventions. A comprehensive review based on
67 studies investigated the relationship between diarrheal
disease and water quality, water availability, and fecal
disposal (Esrey et al., 1985). The results of this study sug-
gested that median reductions in diarrheal disease from water
availability (25%) were higher than those recorded for water
quality improvements (16%) and those recorded for improve-
ments in fecal disposal (22%). Many concluded that although
hygiene and water quality are important interventions,
adequate supply of water needs to be achieved before
improvements in quality can yield health benefits. A subse-
quent review of 144 water and sanitation interventions (Esrey
et al., 1991) found that improved water supply and sanitation
facilities resulted in substantial reductions in morbidity of
diarrhea (26%), ascariasis (29%), guinea worm infection
(78%), schistosomiasis (77%), and trachoma (27%).
 Drinking Water and Sanitation 355

Improvements in water supply alone, however, are unlikely
to accomplish full health benefits. One recent longitudinal
study underscored the additional need to improve both sanita-
tion and water storage practices to attain better health
outcomes (Checkley et al., 2004). Using data from the Cebu
Longitudinal Health and Nutrition Survey, another study
found that improvements in water quality had large health
benefits where community sanitation was good, whereas
improvements in water quality had small health benefits where
community sanitation was very poor (VanDerslice and Briscoe,
1995).
A follow-up analysis that used nationally representative
data from eight countries identified that an incremental
improvement in sanitation was associated with less diarrhea
and better anthropometric indicators (Esrey, 1996). The health
benefits of improved water were less pronounced than those of
improved sanitation, and health benefits from improved water
occurred only when sanitation was improved. More recently,
the implementation of a citywide sanitation program to
improve sewage coverage from 26% of households to 80% in
Salvador, Brazil, was accompanied by a reduction of 22% in
the longitudinal prevalence of diarrhea in the population of
the city as a whole, and 43% in the areas where the baseline
prevalence of diarrhea was highest (Barreto et al., 2007).
A systematic review of 2120 publications and meta-
analysis of 46 studies (Fewtrell et al., 2005) suggested that
water supply, sanitation, and hygiene interventions, as well
as their combination, were effective at reducing diarrheal
illness (Figure 5). Hygiene interventions, and particularly
handwashing (relative risk 0.56; 95% confidence interval
0.33 to 0.93), were as effective as water supply and sanitation
improvements. In this review, water quality interventions
were more effective than previously acknowledged. The
authors, however, raised concern about the possibility of
publication bias among included studies of water quality. A
recent meta-analysis of 33 reports from 21 countries docu-
menting 42 comparisons found that water quality interven-
tions were generally effective at reducing diarrheal disease
even in the absence of improved water supply and sanitation
(Clasen et al., 2007). The heterogeneity in findings across
studies, however, reflects the difficulty in making policy deci-
sions on the health effects of a single intervention and high-
lights the interplay among water, sanitation, and hygiene at
the community level. It therefore follows that, at the popula-
tion level, there is not a necessary sequence to improvements
in water and sanitation.
Intervention studies of the health impacts achieved by
coverage gains have presented inconsistent results. A review
of these studies reported a wide range of results measured
across settings. This range and the history of conflicting conclu-
sions from field studies have led many decision-makers to
believe that large-scale investments required to improve water

Number Relative risk

of studies (95% Cl)
Hygiene 11 0.63 (0.52–0.77)
Excluding poor quality studies 8 0.55 (0.40–0.75)
Hand washing 5 0.56 (0.33–0.93)
Education 6 0.72 (0.63–0.83)

Sanitation 2 0.68 (0.53–0.87)

Water supply 6 0.75 (0.62–0.91)

Diarrhea only 4 1.03 (0.73–1.46)
Household connection 2 0.90 (0.43–1.93)
Standpipe or community connection 3 0.94 (0.65–1.35)

Water quality 15 0.69 (0.53–0.89)

Source treatment only
Household treatment only
Household treatment
• Excluding poor quality studies
• Rural location
• Urban/periurban locations
• Urban/periurban excluding sathe
3 0.89 (0.42–1.90)
12 0.65 (0.48–0.88)
8 0.61 (0.46–0.81)
6 0.61 (0.39–0.94)
5 0.86 (0.57–1.28)
4 0.74 (0.65–0.85)

Multiple 5 0.67 (0.59–0.76)

0.4 0.6 0.8 1.0

Pooled effect

Figure 5 Summary of a meta-analysis of water and sanitation interview. Reproduced from Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W.,
Haller, L., Colford Jr., J.M., 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review
and meta-analysis. Lancet Infect. Dis. 5, 42–52. Elsevier, London, with permission.
356 Drinking Water and Sanitation
and sanitation in the community are not cost-effective in terms
of health benefits alone. As a result, ministries of health with
limited resources have assigned a low priority to water and
sanitation. This issue has subsequently initiated much dialogue
among international agencies and developing country govern-
ment officials. Time and again, measurement of the success of
a capital investment in piped water supply or sewerage by the
interruption in fecal–oral disease transmission alone has
proven to be fraught with sanitation is undervalued by
measuring short-term impacts alone and by failing to consider
nonhealth benefits (Briscoe, 1987). In fact, the long-term bene-
fits on childhood survival are likely to be substantial. Better
information is needed to support available evidence that
improvements in water supply and sanitation are necessary if
not sufficient keystones to public health progress, particularly
among the urban poor.
In particular, improvements in water, sanitation, and
hygiene are likely to play an important role in breaking the
vicious cycle between diarrhea and malnutrition in children
of poor communities. Education about better practices of water
storage, improved water pressure, and more reliable water sour-
ces is likely to discourage storage of contaminated water,
improve hygiene practices, and decrease the frequency of diar-
rhea. Additional improvements in sanitation facilities, namely
access to flush toilets, are likely to result in better health
outcomes in developing countries.
International Initiatives
In 1977 at the United Nations Conference on Water in Mar de
Plata, Argentina, water was defined as a common good and
a human right. Three years later, the United Nations General
Assembly urged governments of developing countries to ‘adopt
national targets for drinking water supply and sanitation
services, commensurate with resource availability, absorptive
capacity and ability’ and proclaimed 1981–90 as the Interna-
tional Drinking Water Supply and Sanitation Decade. Although
the quantitative goals were not reached, the Decade was a success
in many ways. From a policy perspective, the Decade saw
increasing coordination of activities at the national and local
level and recognition of water as a finite resource. Governments
and international agencies invested more than $US134 billion.
Water supplies reached an estimated additional 1.2 billion
people, and sanitation services reached an additional
770 million (World Health Organization, 1992). In 1990, the
United Nations reemphasized the importance of the goals iden-
tified in the International Drinking Water Supply and Sanitation
Decade and extended the deadline to the end of the century.
Despite this momentum, international interest again began
to wane during the 1990s particularly in donor nations whose
focus moved toward agricultural use of water, chemical
contamination, and global climate change. Meanwhile, events
such as the Cryptosporidium outbreak in Milwaukee in 1993 and
Las Vegas in 1994 rekindled interest in water quality and the
need to monitor the safety of municipal water systems.
However, it also highlighted the difference between options
available in industrialized nations, where sophisticated water
treatment processes could be considered, versus the continued
struggle in transition economies to provide basic piped water
for more than a few hours a day. Certain international initia-
tives were notable in this period, including:
l United Nations Development Programme event in 1990 in
New Delhi, India, which drew attention to inequities in
coverage: “Some for all rather than more for some.”
l 1992 Dublin International Conference on Water and the
Environment, which emphasized the need to manage water
in an integrated fashion and treat it as an economic good,
the role of women in the management and security of water
systems, and the need to be participatory in development
plans.
l First World Water Forum in 1997, which not only
continued to prioritize gender equality and shared water
management, but also recognized the danger inherent in
water being viewed as an economic good alone.
During the 1990s, data collected from household surveys
demonstrated that although the gross number of people with
access to improved water increased – a total of 5.3 billion
people in 2004 compared with 4.1 billion in 1990 – so did
the world’s population. Uneven investment in sanitation
remained a trend in all regions of the world. Rural regions
were even less likely to have access to basic water supply and
sanitation than they were just 10 years before. Hence gains in
coverage were modest at best.
In 2002, the consensus reached at the World Summit for
Sustainable Development, in Johannesburg, South Africa, was
that very little gain in coverage of water and sanitation has
been achieved in the last decade. Nonetheless, poor popula-
tions in developing countries continue to grow, further
widening the gap of those in need of water and sanitation.
One of the clear successes of the Summit was to affirm a goal
for water and to add a new goal for sanitation since the Water
and Sanitation Decade.
At the turn of the twenty-first century, the United Nations
dedicated several Millennium Development Goals (MDGs) to
target poverty reduction and ensure sustainable development,
including Goal 7: “Halve, by 2015, the proportion of people
without sustainable access to safe water and basic sanitation.”
The MDG target for drinking water was met in 2010, with
58% of the world’s population enjoying improved drinking
water quality. In addition, 2.1 billion people (or 68% of the
world’s population) also gained access to improved sanitation
since 1990, but this number did not meet the MDG of 77%.
Progress is still needed: 663 million people still lack access to
improved drinking water sources, and 2.4 billion people do
not have access to improved sanitation facilities. The majority
of people without access to improved drinking water live in
sub-Saharan Africa (319 million) and southern Asia
(134 million). Of those without improved sanitation facilities,
953 million live in southern Asia, 695 million in sub-Saharan
Africa, and 337 million in eastern Asia.
The magnitude of the crisis is much greater than what is
implied by coverage shortcomings alone, however. Beyond
achieving basic access, communities at all levels of develop-
ment are faced with the need to sustain the systems that they
already have in place. For instance, the majority of cities in
Eastern Europe and Central Asia already have infrastructure
but are facing extensive repairs and serious financial invest-
ments in order to arrest system deterioration.

The momentum due to the successes and improvements
gained by the MDGs is being transferred to the new 2030
Agenda for Sustainable Development adopted by world
leaders in 2015. The 2030 Agenda outlines 17 goals, and
Sustainable Development Goal (SDG) 6 is specifically written
to ensure access to water and sanitation for all by the year
2030. The goals set forth by the Agenda for Sustainable Devel-
opment much more far-reaching and lofty than the MDGs
because clean and accessible water is essential for life. In addi-
tion, it is estimated that by 2050, one in four people is likely to
live in a country affected by chronic or recurring shortages of
fresh water. To this end, the targets for SDG 6 include
achieving universal and equitable access to safe and affordable
drinking water and sanitation and hygiene for all; halving the
portion of untreated wastewater and increasing recycling
and safe reuse globally; implementing water resource manage-
ment and protecting/restoring water-related ecosystems; and
improving local participation and building capacity for water
and sanitation management. Any successful strategy must
rely not only on scaling-up available funds and using effective
and appropriate technologies but also on the capacity of the
unserved population to respond to international efforts. In
Zimbabwe, for example, creating demand for sanitation and
hygiene at the community level was not only shown to be
cost-effective but also resulted in significant gains in sanitation
coverage over a short period of time (Waterkeyn and Cairn-
cross, 2005).
Health Policy Challenges
Multiple health policy challenges lie ahead, both at the
national level and multinational level. Recognizing that
enumerating service coverage alone is not enough to achieve
health and economic development goals, the focus of current
public health campaigns needs to be more expansive. Access
to water and sanitation is considered basic human rights
and is essential for economic development and human
dignity. Nonetheless, although water is a human right, it
does not mean that it should be provided for free by
governments.
The following section highlights a few of the challenges
facing local and national governments as they face the coming
decades of urbanization, water scarcity, and population
growth.
Innovative Financing
The argument is often made that water is a basic human
right and therefore should be free. ‘Free’ water and sanita-
tion services, however, are not sustainable. They in fact
advance coverage minimally and often fail to change the
service levels of the poor at all. Retrospective evaluation of
failed schemes has taught us that the sustainability of a water
and sanitation project depends in part on the recovery of
capital and operational costs (Brikké and Rojas, 2001).
This emphasis is relatively new, particularly in developing
countries whose water and sanitation schemes were histori-
cally financed through donor agencies and loans. In
Drinking Water and Sanitation 357
a 1988 survey of water charges in 122 developing countries,
researchers revealed that no-cost recovery occurred in 28%
of the projects, and partial return on operation and mainte-
nance costs were recovered in only 30% (Briscoe and de
Ferranti, 1988). Full-cost recovery was achieved in only 6%
of the countries.
The shift toward cost recovery is necessary but difficult to
achieve even for large-scale, urban projects. It requires multiple
advancements, including raised consumer awareness, encour-
agement of community participation, and confidence in those
delivering the services. Government officials are often
unwilling to raise the price of a public good, such as water or
sanitation. Much of the water delivered to public water taps
is still delivered at less than full cost, and collection rates for
household connections are notoriously low, particularly in
poor regions. Low revenues develop into limited system main-
tenance, in turn leading to leakage and further decline in
system efficiency. The challenge to finance water supply and
sanitation systems thus requires innovations in local financing
as well as less tangible social and legal reforms to create an
enabling environment for potential investors.
In response to the poor performance of public providers,
many governments have considered various management
reforms. The 1990s saw the introduction of public–private
partnerships into the operations of water supply and sanitation
systems. From South America to Southeast Asia, traditionally
state-owned providers contracted out to private companies
(Mwanza, 2005). Various relationships developed from
concessions for water supply in Jakarta, Indonesia, to service
contracts for leakage repairs and revenue collection in Manila.
Reviews of the performance of these private ventures are mixed,
however. Experience thus far has shown that healthy public–
private partnerships require solid institutional arrangements
and well-defined regulatory frameworks, which often do not
exist prior to the privatization efforts. For this reason, only
some privately managed water agencies offer success stories.
Several other governments under pressure to perform have
kept management of the water supply and sanitation public,
but have adopted reform strategies and management principles
associated with the private sector. This second type of reform
comes in many colors but collectively is referred to as the
New Public Management (NPM) (Lane, 2000). Key principles
of NPM include the decentralization of authority, separation
of regulatory tasks from service provision, achievement of
cost recovery, stimulation of competition in the water sector,
and development of customer-oriented, accountable services.
Some examples of such efforts include Uganda’s performance
contracts, Zambia’s water watch groups, tariff increases to cover
operations and management costs in Mexico, and Vietnam’s
benchmarking and local management offices (Schwartz,
2007). No one solution works alone. In their attention to the
local level and performance indicators, these practices may
foster more progress toward the MDGs than previously failed
attempts.
Reaching the Poor
Service inequities exist universally in cities, where the poorest
live with the worst levels of coverage. Traditionally,
358 Drinking Water and Sanitation
government schemes assumed that coverage extension to the
poor would operate at a loss unless subsidized. Across
cultures, however, the poor pay more per unit for their water
than their wealthier counterparts (Adrianzen and Graham,
1974; Gilman et al., 1993). Household data also reveal that
people, even poor people, are willing to spend considerable
amounts for improved sanitation. Previous propoor measures
such as low tariffs and subsidies are now recognized as pro-
rich, benefiting those already connected to a system dispro-
portionately and failing to secure funds sufficient to achieve
cost recovery. Using this information creatively to expand
services to the poor is clearly one of the present-day policy
challenges.
Water Quality
Contaminants in water used at the household level play an
important adverse effect on health. Households may store
water for use in containers when availability is unreliable or
may obtain the water from a pipe far from the water treatment
site. Such water is subject to poor pipe conditions and illegal
siphoning, which in turn leads to a loss of water from the
system and permits unforeseen changes in pressure. Once these
dynamics occur, cross-contamination between wastewater and
drinking water can increase significantly. Less than a handful of
developing countries achieve the international benchmark of
20% water leakage. Even fewer operate with functional water-
quality monitoring systems. As highlighted from the experi-
ences of Mexico (Jiménez et al., 1999), analysis of water quality
cannot simply transfer standards developed in the United
States or Canada. Rather, standards should be based on criteria
that are affordable to measure and appropriate to the water use.
Government restructuring may also be necessary, as the respon-
sibility for water-quality monitoring usually resides within
a department whose enforcement powers lie far from the
parties responsible for maintaining water supply and sanitation
infrastructure. In summary, in most cases, achieving water
quality standards at the household level will require attention
to water continuity, delivery system leakage, wastewater treat-
ment, and monitoring enforcement.
Discussion of water quality from a policy perspective must
also address the downside of increased water access: the ever-
growing water pollution from industry, agriculture, and urban-
ization. No country can ignore the impacts of wastewater on
groundwater resources. Dr Perry McCarty, winner of the 2007
Stockholm Water Prize, summarized it well when he stated:
“Attempting to remediate groundwater is extremely expensive,
so we need to make a great effort in prevention before contam-
ination happens. This is very important especially for the devel-
oping world to understand, because once groundwater is
contaminated, it is contaminated for centuries” (Environment
News Service, 2007).
Sanitation
The MDG target called for halving the proportion of the pop-
ulation that did not have sustainable access to basic sanitation
between 1990 and 2105 (REF). The World Health
Organization estimates that access to improved sanitation
facilities increased from 54% to 68% globally, missing the
global target by about 700 million people. In 2015, there
are still 47 counties or territories in which less than half of
the population uses improved sanitation facilities. As there
are disparities among countries, there are also disparities
between urban and rural areas. While only 7% of urban
dwellers use unimproved sanitation or open defecation,
42% of rural dwellers do so (World Health Organization,
2015). This is a result, in part, of the lack of political commit-
ment, which has traditionally lagged behind water supply
development. Sanitation appropriated only 20% of the
US$16 billion invested between 1990 and 2000 by national
governments and external support agencies (World Health
Organization/UNICEF, 2000).
This gap in coverage promises to grow, as current sanitation
schemes are largely unsustainable. The operation of most off-site
sanitation systems requires significant financial commitment, as
well as stable political environments to ensure proper mainte-
nance of public components. Moreover, most urban sewerage
systems require an enormous quantity of water input in order
to transport waste away from the household and into a waste
treatment facility. According to sanitation engineers, wastewater
is produced at rates of nearly 50 m3 per person per year in devel-
oping cities. This translates into sufficient water being produced
from a city of 1 million people to irrigate 1500–3500 ha (World
Health Organization, 2006). It also translates into large quanti-
ties of wastewater polluting surface and groundwater sources.
Clearly, the challenge for the future will be to implement low-
cost, appropriate sanitation and to consider the selective reuse
of treated effluents.
Although future projects in sanitation may still be less
successful than their water counterparts, an emphasis on
community-driven demand, not top-heavy supply, will be
likely to produce more sustainable results. Projects in Pakistan
and Mexico demonstrate that reorganization of sewage and
waste removal into community clusters improves flexibility to
population growth, reduces water demand and unit price for
purchase as well as operations and maintenance, and enhances
accountability. This, in turn, helps identify the parties respon-
sible for repair and maintenance of system components
(United Nations Development Programme, 2006; Domínguez
et al., 2007).
Managing Water Resources
Water scarcity, related to either overextraction of groundwater
reserves or pollution of existing surface water resources, prom-
ises only to increase as a problem. Currently, agriculture
accounts for over 70% of water use. In most countries,
production-linked support policies still dominate. This frame-
work encourages overuse and inefficiency and fails to address
the environmental damage that results from polluted runoff.
As populations increase, competition between uses of water
and regulation of wastewater will develop into significant
policy concerns. Already, India and China have been faced on
numerous occasions with the decisions between providing
for water-heavy crops or population settlements. Judicial policy
to address multicountry ownership of surface and groundwater

resources needs to become a priority before water becomes like
oil as a commodity. Improved pricing structures, tradable
permits, enforceable government regulations, and more
sustainable agricultural water management are necessary to
address the crisis of water scarcity. Such initiatives also need
to take place on local as well as national levels.
Summary
Better water and sanitation are two of the most important
public health priorities worldwide. Although improvements
in water supply and sanitation are part of an international
agenda to reduce poverty, the necessary political commitment
at the national and local levels must still increase. Although
many strides have been made in the last decade, the gross
numbers of people who lack water and sanitation services
have remained high. A more effective strategy must identify
and combine programs and policies that are likely to have
the greatest sustained effect. Conventional approaches – such
as education about hygiene and sanitation, or installation of
sanitation facilities – have proven unsuccessful. It is clear that
people will not practice adequate hygiene or install and use
sanitation facilities unless they clearly see the need to do so.
It follows that any effective strategy must take into account
the need to create demand for services. A multidisciplinary
approach is particularly important as poverty, with its associ-
ated unsanitary living conditions and lack of access to water,
proper nutrition, health care, and education, is the over-
whelming determinant of infection and malnutrition. The
results of such efforts will better help us achieve the goals iden-
tified in the new SDGs: 17 Goals to Transform our World and
consequently serve the billions of people who currently live
without improved water or sanitation.
See also: Cholera and Other Vibrioses; Contaminants
Associated with Drinking Water; Intestinal Infections: Overview;
Parasitic Diseases, an Overview.
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