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In 1977, the United Nations Water Conference declared that all people, regardless of their stage of development or social and economic conditions, have the right of access to drinking water in quantities and quality equal to their basic needs (23). Two decades later, however, an estimated 1.4 billion people still do not have access to safe drinking water, and 2.9 billion do not have access to adequate sanitation (24).
Improved water supply and sanitation services for those who lack them would do much to reduce the global burden of water-related diseases and to improve quality of life. Studies have consistently shown that improvements in water and sanitation coverage – including the implementation of low-cost, simple technology systems – can reduce the incidence of diarrhea, ascariasis, guinea worm, schistosomiasis, and other water-related diseases (25) (26) (27) (28) (29). Furthermore, providing water and sanitation confers multiple benefits beyond reducing water-related diseases, including alleviating the time and economic burden of having to collect water. As one researcher put it, “Most investments by government and aid donors in water and sanitation are fully justified irrespective of their health benefits; because they save drudgery and expense, contribute to human dignity and the emancipation of women, and offer many other benefits” (30).
Expanding access to water and sanitation, however, will not be easy. Much has been written about how to improve water and sanitation coverage; indeed, a whole decade was devoted to the effort (31)(32). The inability of the efforts undertaken during the International Drinking Water Supply and Sanitation Decade to do more than keep up with population growth provides sobering proof of the difficulty of finding effective solutions when the objective is clear but situations vary greatly and are extremely complex (33). A critical component of success, therefore, is to tailor solutions to individual circumstances rather than to search for simple, universal fixes.
Because one of the largest obstacles to providing water and sanitation coverage results from the huge cost of the initial installation of the system (and not necessarily the price of the water), assisting poor communities in financing simple connections may provide good near-term results. In Rufisque, Senegal, for example, nine low-income communities worked in partnership with an international NGO (ENDA-Tiers Monde) and the local authorities to set up a revolving community fund that helps pay for initial sanitation and sewage pipe connections. Grants from international agencies provided the initial jumpstart for the fund and covered initial management expenses; now community members contribute small amounts of money each month and provide the bulk of the US$50,000 fund. In addition, using the narrow pipes (as opposed to thicker sewer pipes needed to withstand freezing in colder climes) has reduced the cost of sewage installation to 5 percent of conventional systems, increasing the number of families that can afford connection. Since the project’s inception in 1990, community members have noticed a decrease in illnesses related to local environmental conditions (34).
Although community involvement in providing water and sanitation can help expand coverage at low cost, it should not be considered a panacea. Well-organized community groups do not simply emerge from the complex terrain of local politics because planners say they should; often outside support is necessary (35). NGOs can help mobilize residents or strengthen existing leadership functions and roles in the community. Local governments can also help foster organization by explicitly recognizing the rights of communities to organize and by encouraging women’s education.
Equally important, governments have a major role to play in providing safe water and sanitation because these essentials confer benefits to not just the individual but to the broader public as well. If fecal material from one home is swept or washed into a street-side gutter because of lack of sanitation facilities, it is not only one household that is affected (36). For this reason, water and sanitation services have traditionally been highly subsidized by governments. However, these subsidies rarely reach the urban poor. as a result, in many cities,the poor often pay proportionately more for less water than do the rich. For example, in Onitsha, Nigeria, poor households spend an estimated 18 percent of their income on water during the dry season, compared with upper-income households, who pay a mere 2 to 3 percent (37). Conversely, the rich tend to waste water because they are not charged the full price of the water they receive. Utilities therefore cannot generate sufficient revenue to expand coverage to new peri-urban settlements or to perform routine maintenance (38).
Because of this situation, government efforts to adjust subsidies or to otherwise alter water pricing can be an effective tool in improving water services, if measures are taken to ensure equity. Recovering a greater percentage of the costs of water services would provide funds to expand coverage into new areas or to maintain and improve existing facilities. To address equity concerns, fees could be structured so that all consumers receive a basic amount of water at low cost and pay a proportionately greater amount for any additional water.
Involving the private sector, by either shifting management of water services to the private sector or by creating public-private partnerships, can also improve water delivery. Privatization schemes are being tried in Latin America (Argentina, Colombia, and Mexico); Asia (Bangladesh, Indonesia, Nepal, Pakistan, the Philippines, and Sri Lanka); and Africa (Cote d’Ivoire, Madagascar, Morocco, Niger, Senegal, and Tunisia) (39). For instance, in Abidjan, Cote d’Ivoire, the privately run SODECI has been providing water to the city for more than 30 years. By regularly collecting fees from its customers and using profits to extend coverage, the company has been able to provide water to 7 out of 10 urban dwellers. It has made a conscious and consistent effort to serve poor neighborhoods, even waiving – for three out of four such households – its usual charges for hooking up consumers to its pipelines (40).
Neither water pricing nor public-private partnerships will be effective without strong governments and sufficient political will. Many of the same circumstances that prevent the public sector from providing services to low-income settlements (including governance problems, low public-sector wages, public utility financing shortfalls, illegal land settlement, and politically powerless residents) also threaten the viability of public-private partnerships (41). There is no guarantee, for instance, that a financially motivated utility will invest the additional funds in low-income neighborhoods rather than high-income suburbs (42).
However, placing water and sanitation programs – in addition to oral rehydration therapy (ORT) and health education – firmly on the political agenda can achieve dramatic improvements in health. Mexico in the early 1990s provides an apt example. In 1984, Mexico had begun to tackle childhood diarrheal deaths through the widespread promotion of ORT, with some success. In 1991, however, prompted by the fear of cholera that was sweeping over Latin America, the government deliberately went about improving basic sanitation, initiating widespread chlorination of water for human consumption, and prohibiting the irrigation of fruit and vegetables with sewage water–in addition to continuing measles immunization efforts and ORT use. The results of the more comprehensive package were marked: between 1991 and 1993, the annual mean number of episodes of diarrhea among children younger than 5 years of age decreased from 4.5 to 2.2, while the corresponding mortality rate fell from 101.6 to 62.9 per 100,000 (43).