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Attaining Health Outcomes through Synergies of Rural Water Supply, Sanitation, and Hygiene

Attaining Health Outcomes through Synergies of Rural Water Supply, Sanitation, and Hygiene

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This synthesis draws key lessons from evaluations and completion reports of ADB-financed rural water supply and sanitation projects, particularly insights into ways for improving project contributions to the attainment of health outcomes.
This synthesis draws key lessons from evaluations and completion reports of ADB-financed rural water supply and sanitation projects, particularly insights into ways for improving project contributions to the attainment of health outcomes.

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Water and sanitation crisis claims lives through diseases andassociated illnesses. About 3.6 million people die each yearrom water-related diseases. The 2010 report o the WorldHealth Organization o the United Nations and the UnitedNations Children’s Fund concerning the progress on sanitationand drinking waterrevealed that 884 millionpeople in the worlddo not use improvedsource o drinking water;almost all o them arerom developing regions.About 2.6 billion peopledo not use improvedsanitation, and most o them live in South Asiaand East Asia. The vastmajority o populationwithout access to waterand sanitation lives inrural areas. Seven out o 10 people without basicsanitation, and more than eight out o 10 people withoutaccess to improved drinking water sources, are rural dwellers.
While the water policy o the Asian DevelopmentBank (ADB) became eective in 2001, ADB’s operations haveincluded water supply and sanitation (WSS) projects since1992. Recognizing the need to provide people with access toadequate clean water, most o the ADB loan approvals or thewater sector in 1992–2009 went to WSS projects or both ruraland urban populations.Common to most rural WSS projects is the goal o improving health and living conditions o rural communities,in part, by reducing the incidence o water-related andwaterborne diseases. Clean water supply is a determinant o public health. How then do we ensure that projects are notonly looking at sourcing, distribution, and expansion o water
Attaining Health Outcomes throughSynergies of Rural Water Supply,Sanitation, and Hygiene
supply, but also at the quality o water? How do we ensurethe synergy o results o the interventions on water supply,sanitation, hygiene, and wastewater management? Thissynthesis draws key lessons rom evaluations and completionreports o ADB-nanced rural WSS projects, particularlyinsights into ways or improving project contributions to theattainment o health outcomes.
Highlights of Lessons
Delivering meaningul health outcomes requires synergybetween development and management o WSS,wastewater, and solid waste, together with the promotiono hygiene.
Addressing sanitation concerns and improving themanagement, including disposal and treatment, o solid wasteand wastewater can minimize hazards that oten threaten thedelivery o clean water to communities (i.e., rom the watersource to distribution points). For example, experiences inPakistan and the Philippines have shown that sanitation and
“ 884 million people inthe world do not useimproved source o drinking water; almost all o them are romdeveloping regions. About 2.6 billion peopledo not use improved sanitation, and most o them live in South Asiaand East Asia.”  
A woman etches water in a river in Papua New Guinea. Contamination o watersources by solid waste, animal droppings, and wastewater rom washing andlaundry oten poses health and sanitation hazards to the community.
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April 2011
wastewater hazards have threatened the quality o water,causing situations that have rendered the supply o nonpotable water in some project areas. Contamination o water sources has been attributed to wastewater leakagerom septic tanks and poor drainage systems (i.e., runo water near wells and standpipes is susceptible to solid wastes,animal droppings, andwastewater rom washingand laundry). Developmentsynergy between watersupply, sanitation, andwaste management canbe strengthened throughstrong commitment andocus, supported by sizableinvestment in sanitationaimed at improvingdrainage and street pavements, minimizing sanitation hazardsin and around water supply systems, and managing solidwaste and wastewater at both the household and communitylevels eectively. Appreciation o the critical links betweenwater, sanitation, hygiene, and health is important in achievinghealth outcomes that last. For example, in Monaragala Districtin Sri Lanka, hygiene education and water conservationcampaigns have eectively reinorced health benets derivedrom the rural WSS pilot project.Conceptual rameworks demonstrating clear logicallinks between planned development interventions, expectedoutcomes, and impacts (i.e., social, environmental, economicand institutional) tend to provide better results. For example,lessons rom rural WSS development interventions in Pakistanindicated that the interventions did not result in signicantreduction o waterborne diseases. Time savings in collectionand delivery o water did not result in increased incomesas opportunities or income generation were limited. Thepoor achievements o desired outcomes indicate the lack o conceptual and logical links between inputs, outputs,outcomes, and impacts in the project design. It is importantor a project to have a logic model to explain the best ways toachieve the expected outcomes and impacts.Project designs should be realistic. Only directly relevantcomponents should be included in a project design. Althoughreducing poverty, improving health conditions, and ensuringpositive environmentalimpacts are legitimateobjectives o developmentinitiatives, they may be lessrelevant in a given projectcontext. WSS projectsdirectly aimed at achievinghealth outcomes shouldnot be loaded and bemistaken with componentsthat are aimed at reducing income poverty, especially i thesecomponents are not provided with adequate institutionalsupport or resource provision. An overly complex andcluttered project design (i.e., having multiple expectedoutcomes with a range o diverse components) could createimplementation difculties and result in the non-attainmento results.
Gender roles in the management of household healthshould be acknowledged at the onset.
In many situations,women have critical and recognized roles to play in taking careo their amilies’ health and general well-being. Participationand involvement o women in the design and management o sanitation acilities, as well as in promoting public awarenessand education in personal hygiene, is important. For example,a WSS project in Sri Lanka recognized women as the principalwater collectors and users. Their participation was considereda top priority in all aspectso the project development,implementation, andoperations. Consequently,the benefciaries werehighly motivated andwilling to make substantialfnancial contributions orthe construction o watersupply acilities and latrines.In contrast, poor social mobilization and lack o women’sparticipation in the WSS projects in Pakistan and Indonesiadid not contribute to the sustainability o project benefts. Thereore, imbalanced and poorly recognized gender roles canseriously threaten the development eectiveness o projects.
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Appreciation o thecritical links betweenwater, sanitation,hygiene, and healthis important inachieving healthoutcomes that last.Project designsshould be realistic.Only directly relevant components should beincluded in a project design.Imbalanced and poorly recognized gender rolescan seriously threatenthe development efectiveness o  projects.
Health benefts o WSS projects should be inclusive andaccessible to the poor.
Alternative water sources and supplyschemes, as well as sanitation technology options, should bemade available to the poorest and vulnerable segments o thepopulation who are too cash constrained to participate in ruralinrastructure development. Aordability is a key considerationor inclusiveness among the intended beneciaries, althoughthe poor have oten demonstrated their willingness to payor water. For instance, the cost o household water supplyconnection has limited the participation o poor households in
Nepali women etch water or their amilies. Participation and involvement o women in the design and implementation o sanitation acilities, as well as inpromoting public awareness and education in personal hygiene, is important.
Learning Lessons
Punjab, Pakistan. Provision o community standpipes atselected but convenient locations may have been moreappropriate to reach out to this segment o beneciaries.
Health outcomes should be realistically established.
 Baseline data (i.e., at the individual, household, andcommunity levels) should be utilized as benchmarks to setrealistic improvementtargets. Good baselinedata and realistic targetscan help steer projectimplementation towardachieving expected results.Without such benchmarks,the monitoring o projectimplementation mayace difculties, and themeasurement o outcomesand impacts that can be attributed to a project can be elusive.For example, the cited rural water supply projects in thePhilippines and Bangladesh had ailed to provide appropriatebaseline indicators or measuring improved public health. This has resulted in difculties in measuring the impact o theprojects on public health.
The supply o sae water should be appropriatelymaintained to sustain health benefts.
Water shortagescan undermine the sustainability o health benets o WSSprojects. Ideally, a water system should be able to meet theneeds o a community or at least 10 years beore requiringa large-scale expansion. In this regard, WSS project designsshould include demand orecasts that take into accountpopulation growth projections to minimize risks o watershortages. Conducting groundwater investigations, over aperiod o time to determine variations in yield and rechargerates, could also prevent water shortages. An eective waterdemand management, coupled with public awarenesscampaigns, can also serve as a cost-eective alternative towater supply expansion, particularly in water-scarce areas.Much can be learned rom the Philippine experience in the
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A woman collects water sample or checking and testing in one o the waterdistribution points in the People’s Republic o China.
late 1990s. Due to water abstraction beyond thereplenishment rate, communities suered rom watershortages during the dry season. In some cases, water supplyacilities were abandoned as a result o over-abstractiono water.
Improving the delivery o sae water entails capacitybuilding o stakeholders and benefciaries, and requirespartnership with appropriate organizations.
Eectivesolutions to problems can oten be delivered throughacquisition o knowledge and practical skills. For example,cases o high-level bacteriological contamination, both at thewater source and distributionpoints, can be prevented withproper training on simplechlorination and other basicwater treatment methods.Further, increasing demandor sanitation—by establishinga unctional partnershipwith community-basedorganizations, nongovernmentorganizations, and private sector entities—can help reduce or eliminate sanitary hazards at watersources. Implementation o appropriate operation andmaintenance systems has been proven to contribute tothe delivery o sae water. This entails enhancement o commitment and ownership among the beneciariesthrough, among others, eective social mobilization,ormation o community-level water users’ associations,cash and labor contributions, designation o operationand maintenance responsibility, and provision o appropriatetraining thereto. For example, the lack o recognition bypublic ofcials o the importance o community involvementled to the poor achievement o outcomes in the rst ruralWSS project in Indonesia. Ater almost 4 years ater projectcompletion, most o the water supply and sanitation acilitieswere abandoned or not unctioning as originally intended. These problems were primarily due to poor maintenanceand the inability o communities to pay or the operationand maintenance o the acilities.
Good baseline dataand realistic targetscan help steer project implementationtoward achievingexpected results.Efective solutionsto problems canoten be delivered through acquisitiono knowledge and  practical skills.
Many residents in the southern Philippine island o Mindanao do not haveeasy access to potable water in their homes. The Mindanao Agrarian ReormCommunities Project—unded by ADB—is helping change that.
Learning Lessons

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