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TOWARD UNIVERSAL ACCESS TO BASIC AND SAFELY MANAGED DRINKING WATER: REMAINING CHALLENGES AND NEW OPPORTUNITIES IN THE ERA OF SUSTAINABLE DEVELOPMENT GOALS

Mitsuaki Hirai1 and Jay Graham2

1 Milken Institute School of Public Health at the George Washington University, DC, USA

2 Public Health Institute, Oakland, CA, USA

1.1 BACKGROUND

Improvements in water supply, sanitation, and hygiene have greatly advanced the health of industrialized countries [1], where diarrhea, cholera, and typhoid were once the leading causes of childhood illness and death. Access to safe drinking water, adequate sanitation, and good hygiene provides a wide range of explicit and implicit benefits, including increased time, reduced morbidity, and mortality from various diseases, augmented agriculture and commerce, improved school attendance, reduced healthcare costs, and reduced physical burden. The time savings can allow women to engage in non‐illness‐related tasks, provide more time for childcare and time for socialization and education activities [2]. Further, when water supplies are brought closer to homes, women’s savings in energy expenditure can result in a reduction of energy intake. The energy savings may then be transferred to children’s intake of food at no extra cost [3]. The implicit benefits of an improved water supply include improved quality of life through an available supply of drinking water and increased potential for communities to engage in other improvements once they have achieved improved access to a safe water supply (Figure 1.1).

FIGURE 1.1 A woman fetching water in India.

Source: License information: McKay Savage from London, UK (https://commons.wikimedia.org/wiki/File:India_‐_Sights_&_Culture_‐_32_‐_woman_fetching_water_(2458024353).jpg), “India – Sights & Culture – 32 – woman fetching water (2458024353),” https://creativecommons.org/licenses/by/2.0/legalcode.

Globally, an estimated 2.1 billion people lack access to safely managed water services, defined as “an improved drinking water source that is located on premises, available when needed and free from faecal and priority chemical contamination” [4]. Under the Sustainable Development Goals (SDGs), the proportion of the population using safely managed drinking water services will be promoted and monitored.

The lack of basic access to drinking water results in significant health impacts because of water‐related diseases as well as lost productivity. Globally, under‐five child mortality from diarrhea – linked to the lack of access to water and sanitation infrastructure and poor hygiene – was estimated at 0.58 million (95% confidence interval, 0.45–0.75), representing an estimated 9.2% of total deaths in 2013 [5].

Improvements to water supply – in terms of quantity, reliability, and quality – are an essential part of a country’s overall development, but a number of obstacles may limit success.

Rapid population growth, degradation of the environment, increase of poverty, inequality in the distribution of resources, and misappropriation of funds are some of the factors that have prevented water supply interventions from producing optimal results [6]. Further, numerous studies have shown that resources and time are being spent in water supply interventions that do not take into account beneficiaries’ needs, preferences, customs, beliefs, ways of thinking, and socioeconomic and political structures (i.e., the enabling environment).

1.2 PAST EFFORTS TO IMPROVE ACCESS TO SAFE WATER

Development interventions began to flourish in the 1970s as disparities became evident in terms of quality of life and access to basic services between wealthy and poor countries. The original motivation for providing water and sanitation to the inhabitants of less developed countries was based upon the consideration of water and sanitation as a cornerstone to public health and as a basic human right [7]. As a human right, those services should be financed by the national government of each country. The governments of economically developing countries, however, did not have the resources needed to provide basic water and sanitation services to their entire population. Thus, developed countries and international organizations provided assistance in the provision of these services [8].

The approach utilized for the design and implementation of most early projects did not typically consider the preferences of beneficiaries as it was perceived that they did not have the knowledge and ability to contribute. Facilities constructed soon fell into disrepair due to the lack of operation and maintenance ensuing from a deficiency in organization, training, and sense of ownership by beneficiaries. Shortly after many water supply and sanitation interventions, communities often found themselves in the same conditions as before the project. The results were not promising and it became evident that community involvement was missing.

During the International Drinking Water Supply and Sanitation Decade (1981–1990), the international community established a common goal of providing safe water supplies and adequate sanitation services to all the communities around the world. This meant that by 1990 every person worldwide should have their basic water and sanitation needs met. In 1981, it was estimated that 2.4 billion people would need to gain access to improved water supplies – equal to connecting 660 000 people each day for 10 years [9]. Although the goal was far from accomplished, an estimated 370 000 people on average received access to improved water supplies each day (Table 1.1). Following the decade and after two world conferences (New Delhi in 1990 and Dublin in 1992), the international community determined that water and sanitation could no longer be regarded simply as a right. After the Dublin conference, there was a shift to consider water as an economic good because it had an environmental and a productive value. It was made clear that need was no longer a sufficient reason for the provision of water and sanitation to any community [7].

TABLE 1.1 Number of people who received improved water supplies (1981–2000).

Source: Mara and Feacham [9].

Water supply category

Avg. number of people who gained access per day (1981–1990)

Avg. number of people who gained access per day (1991–2000)

Urban

100 000

130 000

Rural

270 000

90 000

Total

370 000

220 000

After the World Conference on Water and Sanitation held at the Hague, Netherlands, in March 2000, the international community set a new common goal and published “Vision 21: Water for People.” Vision 21 proposed to achieve a world by 2025 where everybody knows the importance of hygiene and education and enjoys safe water and appropriate sanitation services. At the United Nation Summit in September 2000, 189 UN member States adopted the Millennium Declaration, from which the Millennium Development Goals (MDGs) emerged. Target 10 of MDG 7 was to “halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation” (over 1990 estimates) [10]. The MDGs were a significant force in garnering donor support and government commitment to increasing water supply and sanitation.

A very important aspect of Vision 21 and the MDGs, reflecting concerns of the international community, was the recognition of the need for a new approach. The new approach emphasized “buy‐in” before the implementation of a water project in any community and a stronger focus on ensuring that improvements made are sustained. Another particular aspect of Vision 21 was the ratification of water and sanitation as basic human rights. After the Water Decade, the international community indicated that water and sanitation could not be seen as basic rights anymore because the beneficiaries of the projects did not value the improvements made and facilities constructed when they were not required to contribute monetarily. In other words, people will not appreciate, continue to utilize, and preserve something that they have not contributed to. Based on previous experiences, the Conference concluded that the lack of a sense of ownership and commitment to project improvements on the part of the beneficiaries was due to the inadequate and often neglected inclusion of beneficiaries’ preferences into project design and implementation. Further, beneficiaries of water projects should be responsible for the costs of the operation and maintenance of the system but not for the costs of the water itself, based on the idea that all people on earth have the right to obtain and consume enough water to guarantee their survival.

1.3 TRANSITION FROM THE MILLENNIUM DEVELOPMENT GOALS TO THE SUSTAINABLE DEVELOPMENT GOALS

Under the MDGs, global access to improved water sources increased from 76% of the population in 1990 to 91% in 2015. By reducing the number of people who rely on unimproved water sources from 1.3 billion in 1990 to 663 million in 2015, the MDG target of halving the proportion of the population...