Home hygiene and environmental sanitation: a country situation analysis for India

Problems of the environment and of domestic hygiene are always related to poverty of population and the sanitation of settlements. Most cities and towns in developing countries, like India, are characterised by over-crowding, congestion, inadequate water supply and inadequate facilities of disposal of human excreta, waste water and solid wastes. Inadequacy of housing for most urban poor invariably leads to poor home hygiene. Personal and domestic hygiene practices cannot be improved without improving basic amenities, such as water supply, waste water disposal, solid waste management and the problems of human settlements. But even under the prevailing conditions, there is significant scope of improving hygiene practices at home to prevent infection and cross-infection. Unfortunately, in developing countries, public health concerns are usually raised on the institutional setting, such as municipal services, hospitals, environmental sanitation, etc. There is a reluctance to acknowledge the home as a setting of equal importance along with the public institutions in the chain of disease transmission in the community. Managers of home hygiene and community hygiene must act in unison to optimise return from efforts to promote public health. Current practices and perceptions of domestic and personal hygiene in Indian communities, the existing levels of environmental and peri-domestic sanitation and the 'health risk' these pose will be outlined, as well as the need for an integrated action for improving hygiene behaviour and access to safe water and sanitation.     

Estimating the costs and health benefits of water and sanitation improvements at global level

The aim of this study was to estimate the costs and the health benefits of the following interventions: increasing access to improved water supply and sanitation facilities, increasing access to in house piped water and sewerage connection, and providing household water treatment, in ten WHO sub-regions. The cost-effectiveness of each intervention was assessed in terms of US dollars per disability adjusted life year (DALY) averted. This analysis found that almost all interventions were cost-effective, especially in developing countries with high mortality rates. The estimated cost-effectiveness ratio (CER) varied between US$20 per DALY averted for disinfection at point of use to US$13,000 per DALY averted for improved water and sanitation facilities. While increasing access to piped water supply and sewage connections on plot was the intervention that had the largest health impact across all sub-regions, household water treatment was found to be the most cost-effective intervention. A policy shift to include better household water quality management to complement the continuing expansion of coverage and upgrading of services would appear to be a cost-effective health intervention in many developing countries.     

Estimating the costs and health benefits of water and sanitation improvements at global level

The aim of this study was to estimate the costs and the health benefits of the following interventions: increasing access to improved water supply and sanitation facilities, increasing access to in house piped water and sewerage connection, and providing household water treatment, in ten WHO sub-regions. The cost-effectiveness of each intervention was assessed in terms of US dollars per disability adjusted life year (DALY) averted. This analysis found that almost all interventions were cost-effective, especially in developing countries with high mortality rates. The estimated cost-effectiveness ratio (CER) varied between US$20 per DALY averted for disinfection at point of use to US$13,000 per DALY averted for improved water and sanitation facilities. While increasing access to piped water supply and sewage connections on plot was the intervention that had the largest health impact across all sub-regions, household water treatment was found to be the most cost-effective intervention. A policy shift to include better household water quality management to complement the continuing expansion of coverage and upgrading of services would appear to be a cost-effective health intervention in many developing countries.     

Water,sanitation and hygiene: a situation analysis paper for Lao PDR

The Lao People's Democratic Republic (Lao PDR) is located in the Greater Mekong sub-region in East Asia, neighbouring with China, Cambodia, Myanmar, Thailand and Vietnam, with a land area of 236,800 square kilometres, and an average population density of 22 persons per square kilometre. The population of Lao PDR is 5.5 million with 49 ethnic groups. Most of the population is located in rural areas, with a significant number of the neediest villages in remote localities. In the past decade, there have been many positive developments in the rural water supply and sanitation (RWSS) sector. Despite improved coverage in latrine and water supply services, health remains a serious problem. The improved services were often not sustained or poorly maintained, while hygiene received inadequate attention. In Lao PDR, as in many other countries, the provision of a safe and reliable water supply and appropriate sanitation services, based on sustainable approaches, therefore, remains a challenge. This paper will provide an overview of the Lao PDR's RWSS Sector. Special emphasis is placed on actual field level application of informed choices for water supply, sanitation and hygiene awareness.     

Providing clean water,keeping water clean: an integrated approach

Millions of people, most of whom are children in developing countries, die of basic hygiene-related diseases every year. Interventions in hygiene, sanitation and water supply have been shown to control disease burden. Universal access to improved water sources and basic sanitation remains elusive but is an important long-term goal. Studies have shown that improving the microbiological quality of household water by on-site or point-of-use treatment and safe storage in improved vessels reduces diarrhoeal and other waterborne diseases in communities and households of developing and developed countries. The extent to which improving drinking water quality at the household level reduces diarrhoeal disease probably depends on a variety of technology-related and site-specific environmental and demographic factors that require further investigation, characterisation and analyses.     

The prominence of health in donor policy for water supply and sanitation: a review

Improved water supply, sanitation and hygiene used in combination are effective at achieving better health for poor people in developing countries. However, donor policy has been dominated by interventions in water supply, at the expense of achieving the potential health benefits of improved sanitation and hygiene. Commitments recently made by the international community require greater emphasis on improved sanitation and hygiene and their impacts on health. This review assesses whether such a shift in emphasis is apparent in donor policy. It examines the prominence given to achieving better health in water supply and sanitation policies of three donors: the World Bank, the European Union and the Department for International Development of the British Government. It finds that health benefits are explicit and integral in recently updated policy documentation concerning water supply and sanitation. This has taken place in an environment focused on poverty reduction and demand-led, financially sustainable interventions. Mechanisms that have enabled donors to prioritise the health impacts in this environment are discussed, including adoption of an asset-based conceptualisation of poverty and a cross-sectoral approach.     

Water,sanitation, and hygiene in schools: Status and implications of low coverage in Ethiopia,Kenya, Mozambique,Rwanda, Uganda,and Zambia

Adequate access to water, sanitation, and hygiene (WaSH) in schools impacts health, educational outcomes, and gender disparities. Little multi-country research has been published on WaSH in rural schools in Sub-Saharan Africa. In this multi-national cross-sectional WaSH study, we document WaSH access, continuity, quality, quantity, and reliability in 2270 schools that were randomly sampled in rural regions of six Sub-Saharan African countries: Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Data collection included: school WaSH surveys containing internationally established WaSH indicators, direct observation, and field- and laboratory-based microbiological water quality testing. We found 1% of rural schools in Ethiopia and Mozambique to 23% of rural schools in Rwanda had improved water sources on premises, improved sanitation, and water and soap for handwashing. Fewer than 23% of rural schools in the six countries studied met the World Health Organization’s recommended student-to-latrine ratios for boys and for girls. Fewer than 20% were observed to have at least four of five recommended menstrual hygiene services (separate-sex latrines with doors and locks, water for use, waste bin). The low access to safe and adequate WaSH services in rural schools suggest opportunities for WaSH interventions that could have substantive impact on health, education, and gender disparities.     

Waterborne health risks and the WHO perspective

The benefits of improved water and sanitation include both health and non-health effects. The direct health benefits are related to two contrasting roles of water: that of disease vector when it carries pathogens; and that of health mediator through its use in personal and domestic hygiene. Indirect effects related to health include for example improved quality of life and decreased expenditure on medical expenses. Non-health effects include time savings for productive activity or education. The fact that the health impact of inadequate water supply services, especially in the developing world, has never been established is recognised (Troare, 1992) and recent work highlights unrecognised health burdens elsewhere--both from apparently good quality supplies (Payment et al., 1991; Payment et al., 1997); and from outbreaks of disease (Ford and Colwell, 1996). This paper looks at the WHO perspective on waterborne health risks and is divided into three main sections: our knowledge of the existing situation; recognised and emerging priorities arising from the changing context; and the availability of approaches and tools to meet the recognised and emerging priorities.     

The status of water and sanitation among Pacific Rim nations

Analysis of relationships among national wealth, access to improved water supply and sanitation facilities, and population health indices suggests that the adequacy of water resources at the national level is a poor predictor of economic development--namely, that low water stress is neither necessary nor sufficient for economic development at the present state of water stress among Pacific Rim nations. Although nations differ dramatically in terms of priority provided to improved water and sanitation, there is some level of wealth (per capita GNP) at which all nations promote the development of essential environmental services. Among the Pacific Rim countries for which there are data, no nation with a per capita GNP > US$18,000 per year has failed to provide near universal access to improved water supply and sanitation. Below US$18,000/person-year, however, there are decided differences in the provision of sanitary services (improved water supply and sanitation) among nations with similar economic success. There is a fairly strong relationship between child mortality/life expectancy and access to improved sanitation, as expected from the experiences of developed nations. Here no attempt is made to produce causal relationships among these data. Failure to meet Millennium Development Goals for the extension of improved sanitation is frequently evident in nations with large rural populations. Under those circumstances, capital intensive water and sanitation facilities are infeasible, and process selection for water/wastewater treatment requires an adaptation to local conditions, the use of appropriate materials, etc., constraints that are mostly absent in the developed world. Exceptions to these general ideas exist in water-stressed parts of developed countries, where water supplies are frequently augmented by water harvesting, water reclamation/reuse, and the desalination of brackish water resources. Each of these processes involves public acceptance of water resources that are at least initially of inferior quality. Despite predictions of looming increases in water stress throughout the world, adaptation and resourcefulness generally allow us to meet water demand while pursuing rational economic development, even in the most water-stressed areas of the Pacific Rim.     

Regional disparities in the burden of disease attributable to unsafe water and poor sanitation in China

Objective

To estimate the disease burden attributable to unsafe water and poor sanitation and hygiene in China, to identify high-burden groups and to inform improvement measures.

Methods

The disease burden attributable to unsafe water and poor sanitation and hygiene in China was estimated for diseases resulting from exposure to biologically contaminated soil and water (diarrhoeal disease, helminthiases and schistosomiasis) and vector transmission resulting from inadequate management of water resources (malaria, dengue and Japanese encephalitis). The data were obtained from China’s national infectious disease reporting system, national helminthiasis surveys and national water and sanitation surveys. The fraction of each health condition attributable to unsafe water and poor sanitation and hygiene in China was estimated from data in the Chinese and international literature.

Findings

In 2008, 327 million people in China lacked access to piped drinking water and 535 million lacked access to improved sanitation. The same year, unsafe water and poor sanitation and hygiene accounted for 2.81 million disability-adjusted life years (DALYs) and 62 800 deaths in the country, and 83% of the attributable burden was found in children less than 5 years old. Per capita DALYs increased along an east–west gradient, with the highest burden in inland provinces having the lowest income per capita.

Conclusion

Despite remarkable progress, China still needs to conduct infrastructural improvement projects targeting provinces that have experienced slower economic development. Improved monitoring, increased regulatory oversight and more government transparency are needed to better estimate the effects of microbiologically and chemically contaminated water and poor sanitation and hygiene on human health.     

Global cost-benefit analysis of water supply and sanitation interventions

The aim of this study was to estimate the economic benefits and costs of a range of interventions to improve access to water supply and sanitation facilities in the developing world. Results are presented for eleven developing country WHO sub-regions as well as at the global level, in United States Dollars (US$) for the year 2000. Five different types of water supply and sanitation improvement were modelled: achieving the water millennium development goal of reducing by half in 2015 those without improved water supply in the year 1990; achieving the combined water supply and sanitation MDG; universal basic access to water supply and sanitation; universal basic access plus water purification at the point-of-use; and regulated piped water supply and sewer connection. Predicted reductions in the incidence of diarrhoeal disease were calculated based on the expected population receiving these interventions. The costs of the interventions included estimations of the full investment and annual running costs. The benefits of the interventions included time savings due to easier access, gain in productive time and reduced health care costs saved due to less illness, and prevented deaths. The results show that all water and sanitation improvements are cost-beneficial in all developing world sub-regions. In developing regions, the return on a US$1 investment was in the range US$5 to US$46, depending on the intervention. For the least developed regions, investing every US$1 to meet the combined water supply and sanitation MDG lead to a return of at least US$5 (AFR-D, AFR-E, SEAR-D) or US$12 (AMR-B; EMR-B; WPR-B). The main contributor to economic benefits was time savings associated with better access to water and sanitation services, contributing at least 80% to overall economic benefits. One-way sensitivity analysis showed that even under pessimistic data assumptions the potential economic benefits outweighed the costs in all developing world regions. Further country case-studies are recommended as a follow up to this global analysis.     

Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities

Safe environmental conditions and the availability of standard precaution items are important to prevent and treat infection in health care facilities (HCFs) and to achieve Sustainable Development Goal (SDG) targets for health and water, sanitation, and hygiene. Baseline coverage estimates for HCFs have yet to be formed for the SDGs; and there is little evidence describing inequalities in coverage. To address this, we produced the first coverage estimates of environmental conditions and standard precaution items in HCFs in low- and middle-income countries (LMICs); and explored factors associated with low coverage. Data from monitoring reports and peer-reviewed literature were systematically compiled; and information on conditions, service levels, and inequalities tabulated. We used logistic regression to identify factors associated with low coverage. Data for 21 indicators of environmental conditions and standard precaution items were compiled from 78 LMICs which were representative of 129,557 HCFs. 50% of HCFs lack piped water, 33% lack improved sanitation, 39% lack handwashing soap, 39% lack adequate infectious waste disposal, 73% lack sterilization equipment, and 59% lack reliable energy services. Using nationally representative data from six countries, 2% of HCFs provide all four of water, sanitation, hygiene, and waste management services. Statistically significant inequalities in coverage exist between HCFs by: urban-rural setting, managing authority, facility type, and sub-national administrative unit. We identified important, previously undocumented inequalities and environmental health challenges faced by HCFs in LMICs. The information and analyses provide evidence for those engaged in improving HCF conditions to develop evidence-based policies and efficient programs, enhance service delivery systems, and make better use of available resources.     

Global cost-benefit analysis of water supply and sanitation interventions

The aim of this study was to estimate the economic benefits and costs of a range of interventions to improve access to water supply and sanitation facilities in the developing world. Results are presented for eleven developing country WHO sub-regions as well as at the global level, in United States Dollars (US$) for the year 2000. Five different types of water supply and sanitation improvement were modelled: achieving the water millennium development goal of reducing by half in 2015 those without improved water supply in the year 1990; achieving the combined water supply and sanitation MDG; universal basic access to water supply and sanitation; universal basic access plus water purification at the point-of-use; and regulated piped water supply and sewer connection. Predicted reductions in the incidence of diarrhoeal disease were calculated based on the expected population receiving these interventions. The costs of the interventions included estimations of the full investment and annual running costs. The benefits of the interventions included time savings due to easier access, gain in productive time and reduced health care costs saved due to less illness, and prevented deaths. The results show that all water and sanitation improvements are cost-beneficial in all developing world sub-regions. In developing regions, the return on a US$1 investment was in the range US$5 to US$46, depending on the intervention. For the least developed regions, investing every US$1 to meet the combined water supply and sanitation MDG lead to a return of at least US$5 (AFR-D, AFR-E, SEAR-D) or US$12 (AMR-B; EMR-B; WPR-B). The main contributor to economic benefits was time savings associated with better access to water and sanitation services, contributing at least 80% to overall economic benefits. One-way sensitivity analysis showed that even under pessimistic data assumptions the potential economic benefits outweighed the costs in all developing world regions. Further country case-studies are recommended as a follow up to this global analysis.     

Diseases associated with poor water and sanitation: hazards,prevention, and solutions

This paper examines one of the most staggering challenges facing the mankind, the challenge to conquer diseases associated with poor water and sanitation. Although rapid strides have been made in the last decade of the last century to provide improved water supply and sanitation, the world is still rampant with diseases. More than 1.1 billion individuals lack access to improved water supply and 2.4 billion lack access to improved sanitation in a world that boasts of human rights and sustainable development. The paper details the various types of diseases associated with water and suggests preventions and solution and also examines international development targets and the number of likely deaths from diseases associated with water. Even if the set targets are met successfully, an estimated 40 to 58 million lives would still be lost by the target year of 2015, while the massive efforts of international agencies and governments would be able to salvage an estimated 15 to 22 million lives. The threat of diseases associated with poor water qualities and services makes a fitting case for world resources, finances, and expertise to be focused and diverted to the Water and Sanitation (WATSAN) sector on an unprecedented scale and at a much higher pace than that envisaged in the targets to avoid the large scale death and misery.     

Quantifying the burden of disease associated with inadequate provision of water and sanitation in selected sub-Saharan refugee camps

A WHO methodology is used for the first time to estimate the burden of disease directly associated with incomplete water and sanitation provision in refugee camps in sub-Saharan African countries. In refugee camps of seven countries, containing just fewer than 1 million people in 2005, there were 132,000 cases of diarrhoea and over 280,000 reported cases of malaria attributable to incomplete water and sanitation provision. In the period from 2005 to 2007 1,400 deaths were estimated to be directly attributable to incomplete water and sanitation alone in refugee camps in Ethiopia, Kenya and Tanzania. A comparison with national morbidity estimates from WHO shows that although diarrhoea estimates in the camps are often higher, mortality estimates are generally much lower, which may reflect on more ready access to medical aid within refugee camps. Despite the many limitations, these estimates highlight the burden of disease connected to incomplete water and sanitation provision in refugee settings and can assist resource managers to identify camps requiring specific interventions. Additionally the results reinforce the importance of increasing dialogue between the water, sanitation and health sectors and underline the fact that efforts to reduce refugee morbidity would be greatly enhanced by strengthening water and sanitation provision.     

Hygiene and health in developing countries: defining priorities through cost - benefit assessments

Presented here are the four preliminary conclusions in the assessment of health and hygiene in developing countries: (a) child mortality, and disease burden associated with hygiene, water and sanitation in the developing and the developed regions of the world, has declined substantially in the past two decades, but substantial inter-regional and cross-country differences persist; (b) while child mortality and disease burdens decline with higher income levels, a substantial number of countries have been performing far better in reducing child mortality and disease burdens than their income levels would indicate, suggesting that active policy and investment interventions can yield significant health improvements without necessarily jeopardising economic growth; (c) despite the evidence of the role of water and sanitation services in reducing mortality and morbidity, service coverage at the country level has not increased as much as one may have expected in the past decade, in part because of the substantial resource requirements; (d) the paper will provide some new perspectives and evidence on the cost-effectiveness of interventions to reduce the disease burden of poor water and sanitation services and inadequate hygiene practices, in particular with regard to economic evaluation and in reference to hygiene programmes.     

Global costs of attaining the Millennium Development Goal for water supply and sanitation

OBJECTIVE: Target 10 of the Millennium Development Goals (MDGs) is to "halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation". Because of its impacts on a range of diseases, it is a health-related MDG target. This study presents cost estimates of attaining MDG target 10. METHODS: We estimate the population to be covered to attain the MDG target using data on household use of improved water and sanitation for 1990 and 2004, and taking into account population growth. We assume this estimate is achieved in equal annual increments from the base year, 2005, until 2014. Costs per capita for investment and recurrent costs are applied. Country data is aggregated to 11 WHO developing country subregions and globally. FINDINGS: Estimated spending required in developing countries on new coverage to meet the MDG target is US$ 42 billion for water and US$ 142 billion for sanitation, a combined annual equivalent of US$ 18 billion. The cost of maintaining existing services totals an additional US$ 322 billion for water supply and US $216 billion for sanitation, a combined annual equivalent of US$ 54 billion. Spending for new coverage is largely rural (64%), while for maintaining existing coverage it is largely urban (73%). Additional programme costs, incurred administratively outside the point of delivery of interventions, of between 10% and 30% are required for effective implementation. CONCLUSION: In assessing financing requirements, estimates of cost should include the operation, maintenance and replacement of existing coverage as well as new services and programme costs. Country-level costing studies are needed to guide sector financing.     

Quantitative bacterial examination of domestic water supplies in the Lesotho Highlands: water quality, sanitation, and village health

Reported are the results of an examination of domestic water supplies for microbial contamination in the Lesotho Highlands, the site of a 20-year-old hydroelectric project, as part of a regional epidemiological survey of baseline health, nutritional and environmental parameters. The population's hygiene and health behaviour were also studied. A total of 72 village water sources were classified as unimproved (n = 23), semi-improved (n = 37), or improved (n = 12). Based on the estimation of total coliforms, which is a nonspecific bacterial indicator of water quality, all unimproved and semi-improved water sources would be considered as not potable. Escherichia coli, a more precise indicator of faecal pollution, was absent (P < 0.001) in most of the improved water sources. Among 588 queried households, only 38% had access to an "improved" water supply. Sanitation was a serious problem, e.g. fewer than 5% of villagers used latrines and 18% of under-5-year-olds had suffered a recent diarrhoeal illness. The study demonstrates that protection of water sources can improve the hygienic quality of rural water supplies, where disinfection is not feasible. Our findings support the WHO recommendation that E. coli should be the principal microbial indicator for portability of untreated water. Strategies for developing safe water and sanitation systems must include public health education in hygiene and water source protection, practical methods and standards for water quality monitoring, and a resource centre for project information to facilitate programme evaluation and planning.     

四川省汶川、理县部分地区地震后卫生状况及居民卫生需求调查

目的了解汶川县、理县部分地区地震后卫生状况及居民灾后卫生与健康教育需求,为地震灾区卫生防疫与健康教育工作提供参考依据。方法地震发生后第14～36天,在四川省理县和汶川县部分城乡居民点进行卫生现状与需求调查,调查访谈受灾居民90人。结果城乡各安置点饮用水供应充足,食品供应基本充足。居民最急需的是帐篷（81．1％）。81．0％的居民认为厕所蹲坑数量能满足需要,66．7％的居民认为厕所比较脏或很脏。92．2％的居民地震后从不饮用生水。8．1％的居民能做到生熟刀板分开。24．6％的居民能将剩菜剩饭煮透后再吃。近一半农村居民没有获得过任何形式的健康教育。82．0％的居民希望获得传染病防治知识,地震后城乡卫生状况与居民卫生需求在多个方面存在统计学差异（P〈0．05）。结论地震后农村地区厕所卫生、垃圾处理等问题较突出,农村居民卫生防病知识和技能还很欠缺。卫生工作者与村干部在健康教育中发挥了作用。