Water, Sanitation,

Hygiene and Health

in the framework of new
WHO priorities
Robert Bos
Water, Sanitation, Hygiene and Health

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Water, Sanitation and Hygiene in the WHO | October 2009

Overview
The links between water sanitation, hygiene and health

The rationale for water and sanitation interventions

WHOs comparative advantage in water and sanitation

Current WHO activities in water and sanitation

Strengthening WHOs role

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Water, Sanitation and Hygiene in the WHO | October 2009

Sanitation: the #1 medical milestone

Dec 2006: BMJ readership votes sanitation as the greatest
medical milestone since 1840
Sanitation beat the discovery of antibiotics, the creation of the anticonception pill, the development of vaccines and the discovery of the
structure of DNA.

Water and sanitation are iconic interventions in public health

history
Figures like Snow and Chadwick led the way
Water and sanitation were a key engine in the success of the industrial
revolution

The margin by which sanitation was voted on top was

substantial
Of 11,000 votes cast with a choice of 150 topics, some 1700 voted for
sanitation; some 30% of those who voted were MDs.
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Water, Sanitation and Hygiene in the WHO | October 2009

Sanitation: the #1 medical milestone

Prof Johan Mackenbach (Erasmus University, Rotterdam)
said on the occasion:
I'm delighted that sanitation is recognized by so many people as
such an important milestone. The general lesson which still holds is
that passive protection against health hazards is often the best way
to improve population health.
Did he mean to say passive protection or should he really have said

primary prevention?

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Water, Sanitation and Hygiene in the WHO | October 2009

Why Water, Sanitation and Health?

Burden of disease: the headlines
1.9 million attributable annual deaths from diarrhoea
1.2 million malaria deaths each year

Burden of disease: the details

1.4 million preventable child deaths from diarrhoea
860 000 preventable child deaths from malnutrition
One third of the world population (2 billion infections)
affected by intestinal parasitic worms
25 million people seriously incapacitated by lymphatic
filariasis
200 million people with preventable schistosomiasis
infections
5 million people visually impaired by trachoma
280 000 prevetable deaths from drowning
Half a million malaria deaths that could have been prevented
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Water, Sanitation and Hygiene in the WHO | October 2009

Why Water, Sanitation and Health?

In a more generic way, the old Bradley and
Feachem definitions (1983) lead us to key
interventions:
Water-borne diseases
(microbial contamination of drinking water)
Water-washed diseases
(sufficient water quantities )
Water-based diseases
(infection through contact with water)
Water-associated vector-borne
diseases
(ecosystems conducive to vector breeding)
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Water, Sanitation and Hygiene in the WHO | October 2009

Diseases with largest environmental

contributions (I)
Diarrhoea
Lower resp. infections
Other unintentional inj.
Malaria
Road traffic injuries
COPD
Perinatal conditions
Ischaemic heart dis.
Childhood cluster
Lead-caused MMR
Drownings
HIV/AIDS

Environmental fraction

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1%

2%

3%

Non-environmental

Water, Sanitation and Hygiene in the WHO | October 2009

4%

5%
6%
% of global disease burden in DALYs

Diseases with largest environmental

contributions (II)
Malnutrition
Cerebrovascular dis.
Asthma
Tuberculosis
Suicide
Depression
Poisonings
Falls
Hearing loss
Violence
Lymphatic filariasis
Lung cancer
0

Environmental fraction

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1%

2%

3%

Non-environmental

Water, Sanitation and Hygiene in the WHO | October 2009

4%

5%
6%
% of global disease burden in DALYs

Water, sanitation, hygiene interventions

Providing sustainable access to safe drinking-water
Infrastructure improvements, service improvements, strengthened policy and
regulatory frameworks, household water treatment

Providing access to adequate sanitation

Infrastructure improvements, community engagement, management of
medical waste, promoting wastewater as a resource for small-scale
agriculture

Promoting hygiene
Providing access to sufficient quantities of water, handwashing campaigns,
sanitation in schools, sanitation in health care settings, safe storage of water

Best practice in water management

Environmental management: modification of infrastructure, management to
maintain low vector receptivity, incentives and sanctions for water use in
agriculture and energy, improved housing, health impact assessment

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Water, Sanitation and Hygiene in the WHO | October 2009

Water, sanitation, hygiene interventions

The rationale for primary prevention
The public health imperative
The economic argument
Sustainability and resilience
Development objectives

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Water, Sanitation and Hygiene in the WHO | October 2009

The rationale for primary prevention

The public health imperative
The WHO definition of health
Principles of public health focus on community health, on
tackling the root causes of ill-health and on evidence-based risk
reduction
Managing environmental determinants of health is not only
about risk reduction, but also about maximizing health
opportunities
For some water-associated infections there are no other
interventions than water interventions

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Water, Sanitation and Hygiene in the WHO | October 2009

The rationale for primary prevention

The economic argument
WHO and World Bank global estimates of returns on
investments in water and sanitation: upto USD34 per USD
invested
A return to primary health care (as opposed to selective PHC)
conceives a cross-sectoral approach to health, placing
alternative interventions in a wider economic perspective
In the context of development, cost-effective opportunities for
preventive action at the planning stage will be substituted by
much less cost-effective curative after the fact repair at the
operational stage.
WHO Commission on Macro-economics and Health water and
sanitation are highly cost-effective interventions.
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Water, Sanitation and Hygiene in the WHO | October 2009

The rationale for primary prevention

Sustainability and resilience
Growing pressures on medical interventions: drug resistance,
insecticide resistance
The drug dilemma: mass treatment for ever or expensive case
detection and treatment reduction of the environmental risk
factors provides the answer.
Resilience of technology and systems in the face of change, for
example climate change
Resilience of infrastructure at times of civil unrest and
breakdown of services

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Water, Sanitation and Hygiene in the WHO | October 2009

The rationale for primary prevention

The development objectives

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The MDGs MDG 7 with its water and sanitation targets

The water and sanitation ladders to climb out of poverty
Water and sanitation as engines for development
The intricate relationship between poverty and ill-health

Water, Sanitation and Hygiene in the WHO | October 2009

Water and Sanitation

why at WHO?
The simple answer:
it is mandated by the Constitution
CHAPTER II FUNCTIONS
Article 2 In order to achieve its objective, the functions of the
Organization shall be:
(a) to act as the directing and co-ordinating authority on international
health work;

(i) to promote, in co-operation with other specialized agencies where

necessary, the improvement of nutrition, housing, sanitation, recreation,
economic or working conditions and other aspects of environmental
hygiene;

(u) to develop, establish and promote international standards with

respect to food, biological, pharmaceutical and similar products;

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Water, Sanitation and Hygiene in the WHO | October 2009

Water and Sanitation

why at WHO?
The comparative advantages of WHO
Authoritative source of health statistics, incl water-associated diseases
A long tradition in normative functions related to drinking-water and
sanitation
Its constitutional link to MoHs in Member States: the possibility to influence
public health legislation in relation to water and sanitation
The elderly statesman position of WHO in the UN system (good
governance, legal authority, solid reputation)
An effective institutional infrastructure (water advisors at the regional level,
environmental health officers in country offices)
A broad network of international and national partners in the area of water
and sanitation: collaborating centres, international and national NGOs
Acclaimed neutrality in interpreting research data

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Water, Sanitation and Hygiene in the WHO | October 2009

Water and Sanitation

why at WHO?
What is in it for WHO ?
Work in water and sanitation helps WHO being perceived as fulfilling its
constitutional obligations
Evidence-based water and sanitation efforts help meet the Organizations
goal
As non-contentious issues in public health, involvement in water and
sanitation enhances WHOs corporate image
As traditional pillars of Primary Health Care, water and sanitation strengthen
the main WHO strategy of health for all
Water and sanitation provide an entry point for interagency and intersectoral
collaboration
The current focus on Africa and womens health is immediately served by
water and sanitation activities

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Water, Sanitation and Hygiene in the WHO | October 2009

Water, Sanitation and Health (WSH) at WHO

Two flagship activities
Global Monitoring of Access to Water and Sanitation (JMP)
Normative water quality issues, including rolling revision of
the Guidelines for Drinking Water Quality

Mainstream issues:

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Cholera and epidemic diarrhoeal disease

Health impact assessment
Integrated Water Resources Management
WSH in emergencies
WSH / health care waste management in health care facilities

Water, Sanitation and Hygiene in the WHO | October 2009

Global Monitoring:
Headlines from latest Report
The world is likely to meet the MDG drinking-water target
by 2015
the number of people using unimproved sources of drinking
water has fallen below 1 billion
More than half of the worlds households now have piped water
connections in or near their homes
Progress is slowest in sub-Saharan Africa, home to a third of the
global population using unimproved drinking water sources

Trends
Drinking water quality issues not captured
Disagregation: how far, at what expense?
Devolving responsibilities
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Water, Sanitation and Hygiene in the WHO | October 2009

Normative role in water quality issues

Maintaining up-to-date Global
Drinking-water Quality Guidelines
Developing, testing and promoting
water safety plans (WSPs) as the
instrument for guidelines
implementation

Rolling revisions
4th edition Guidelines
for Drinking-water
Quality (GDWQ) - 50+
items on rolling revision

Promoting health-based
water quality regulations
Regulators Network

Maintaining up-to-date Guidelines

for the safe use of wastewater in
agriculture

Training in WSPs

Maintaining up-to-date Guidelines

for recreational waters

Research on nontreatment options of

wastewater use

with AusAID, IWA and

PAHO

with IDRC and IWMI

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Water, Sanitation and Hygiene in the WHO | October 2009

Rural areas
Small Community Water
Supply Network
Volume 3 of the GDWQ
Water Safety Plans

Urban areas
O&M network
Establishment of regional
networks with IWA
Water Safety Plans

/ Household level
vulnerable groups
Household Water
Treatment and Safe
Storage Network

Priority settings
WASH standards in
hospitals and schools

Water and Sanitation

Focus on Africa

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Water, Sanitation and Hygiene in the WHO | October 2009

Water and Sanitation

Focus on Africa
The Libreville Declaration
Establishes a strategic alliance between the health and environment
sectors, which will come to expression
through integration and harmonization of policies, regulations, national
strategies and institutions, and
through mechanisms for joint monitoring and evaluation of critical indicators,
and information exchange, and
Through the promotion of multi-disciplinary research, health impact assessment
and management of development, and fostering of intersectoral negotiation
skills.

In all three categories, Water and Sanitation activities are on-going,

can contribute to the furtherance of the goals set by the Declaration
and can gain benefits from the proposed integration of health and
environment

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Water, Sanitation and Hygiene in the WHO | October 2009

Water and Sanitation

Focus on Africa
Key interventions for Africa now
Favour investment and efforts for sanitation improvement and
hygiene over extension of access to safe drinking-water
Promote a basic package at the household level: household
water treatment, safe storage, hygiene in particular
handwashing
Strengthen capacities in the safe use of wastewater in periurban areas
Improve water management and drainage in urban areas for
urban malaria control.

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Water, Sanitation and Hygiene in the WHO | October 2009

Water and Sanitation

Focus on Africa
Key interventions for Africa tomorrow
Comprehensively build capacity in health impact assessment of
water resources development (only 10% of Africas water
resources have been developed).
Strengthen policies and institutions so Africans can take the
development of drinking-water infrastructure into their own hand
Assess resilience of drinking-water and other hydraulic
infrastructure in the light of climate change

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Water, Sanitation and Hygiene in the WHO | October 2009

Working with other agencies

WHO is a founding member of UN-Water and chaired UN-Water for its first
two years
WHO has strong bilateral links with sister UN agencies: FAO on water
quality, irrigation water management and wastewater use; UNEP on water
quality and impact assessment
WHO liaises with major international NGOs: the International Water
Association, the IUCN and WWF, the National Sanitation Foundation in the
USA
WHO maintains strong links with a number of key bilateral donors on issues
of water and sanitation: USAID, AusAID, DFID, AFD, BMZ
WHO maintains strong links with a number of health ministries on issues of
water and sanitation: Health Canada, MoHLW of Japan; and with USEPA in
the USA
WHO has a strong network of collaborating centres in the field of water,
sanitation and hygiene.
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Water, Sanitation and Hygiene in the WHO | October 2009

New challenges

Water scarcity
Climate change
The green
economy

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Water, Sanitation and Hygiene in the WHO | October 2009

Climate change and

water supply/sanitation

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Water, Sanitation and Hygiene in the WHO | October 2009

Water, Sanitation, Hygiene and Health

in the framework of new WHO priorities

Conclusions
Water, sanitation, hygiene and health is a dynamic and
responsive programme that addresses key public health
issues in line with WHOs mandate and relevant to the
Organizations goals.
Global trends towards a green economy and concerns
over poverty levels that remain too high (especially in
Africa) and over the impact on health of climate change
create new challenges and opportunities for WSH in the
context of WHOs priorities for the 21st century

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Water, Sanitation and Hygiene in the WHO | October 2009

Water, Sanitation, Hygiene and Health

in the framework of new WHO priorities
Conclusions

WSH has a proven track record of responding to new needs of

Member States, and its present focus on water quality and
global monitoring is the result. Efforts will be needed to broaden
and diversify its financial resource base and strengthen its
human resource base.
The Libreville Declaration has created a new context to push
for rapid advance in water and sanitation in the African context,
where it is most needed.
WHO takes a central position in the UN system on water
activities, with an authoritative voice on health claims and
interventions

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Water, Sanitation and Hygiene in the WHO | October 2009

More information on water,sanitation and

hygiene in WHO

www.who.int/water_sanitation_health

Thank you for your attention

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Water, Sanitation and Hygiene in the WHO | October 2009