Unsafe drinking water and poor sanitation are among the major causes of child deaths, illnesses and malnutrition. Studies have shown that improvements in safe
GOAL
Water: universal access to safe
drinking water
Sanitation: universal access
to sanitary means of excreta disposal
Guinea worm disease:
elimination
GAINS
• 900 million additional people obtained access to improved water supplies over the decade.
• 987 million additional people gained access to decent sanitation facilities.
• The number of reported cases has declined by 88 per cent. The disease is now eliminated in all regions except one country in North Africa and 13 countries in sub-Saharan Africa.
UNFINISHED BUSINESS
• Some 1.1 billion people still lack access. Global coverage increased by 5 percentage points, to 82 per cent. • Water-quality problems have
grown more severe in a number of countries.
• Access in low-income areas remains poor, especially in informal settlements.
• 2.4 billion people, including half of all Asians, lack access. Global access increased by 10 percentage points.
• 80 per cent of those lacking sanitation live in rural areas.
• Momentum towards the elimination of guinea worm disease needs to be maintained.
water supply, and particularly in sanitation and hygiene, can reduce the incidence of diarrhoea by 22 per cent and resulting deaths from it by 65 per cent. A similar impact is likely on cholera, hepatitis, parasitic worm infections and trachoma.
The World Summit for Children, recognizing the unfinished work of the International Drinking Water Supply and Sanitation Decade of the 1980s, re-endorsed the goal of achieving universal access to safe drinking water and sanitary means of excreta
disposal. Revised estimates from the 2000 WHO/UNICEF Global Water Supply
and Sanitation Assessment suggest that, taking population growth into account, the number of people lacking access to these basic services has remained essentially unchanged. Although large numbers of people gained access to improved water supply services for the first time during the 1990s, universal access is still a long way off. The percentage of people with some form of improved supply rose from 77 per cent in 1990 to 82 per cent in 2000. This leaves more than 1 billion people without access to safe water.
Between 1990 and 2000, the proportion of the world’s population with access to sanitation facilities increased from 51 per cent to 61 per cent. An estimated 2.4 billion people still lack access to improved sanitation.
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Sub-Saharan Africa has the lowest safe drinking water access, at 54 per cent. Its overall sanitation coverage has been static and is also estimated at 54 per cent. South Asia’s safe water supply access is relatively good at 87 per cent, but it has by far the lowest sanitation coverage, at 37 per cent. Asia, with 61 per cent of the world’s population, accounts for the vast majority of people without access to improved services.
Chemical contamination of water supplies emerged as a grave concern during the 1990s. One of the most serious problems was the contamination of drinking- water sources by naturally occurring inorganic arsenic in Bangladesh and other parts of South Asia. Arsenic does great damage to human health. The response to it has included: identifying wells that draw on contaminated aquifers and working with families to ensure that such sources are not used for drinking or cooking; pro- viding alternative sources; and involving affected communities in the search for and management of alternative sources. Another naturally occurring chemical contami- nant – fluoride – poses threats to people in a number of countries, including China and India, though in this case household filters can help protect people.
Sanitation has historically been viewed as a lower priority than having a safe water supply and so has attracted less investment. Population growth and urbaniza- tion have also made it more difficult to provide adequate sanitation for all. Between 1990 and 2000, the global total of people living in urban areas increased by 25 per cent, while the number living in rural areas increased by less than 10 per cent. The Global Environmental Sanitation Initiative, launched in 1998, has sought to raise the profile of sanitation and hygiene practices among governments, development planners and other professionals.
Several international organizations, including UNICEF, WHO, the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Bank and Education International, have encouraged increased attention to the health of children in schools and have launched the FRESH initiative – Focusing Resources on Effective School Health. FRESH is part of the effort to create a school environment in which children can learn and flourish. School health – including clean water, separate toilet facilities for girls and boys and hygiene education – is a key component of a child-friendly learning environment.
Improved water coverage, change over period 1990-2000 48 70 80 81 83 83 54 75 87 84 88 100 Sub-Saharan Africa East Asia and Pacific
South Asia Latin America and Caribbean CEE/CIS and Baltic States Middle East and North Africa Industrialized countries 0 20 40 60 80 100 91 Coverage (%) Source: UNICEF/WHO, 2000. 100 1990 2000
43 25 38 55 67 76 98 37 49 54 76 81 100 89 Coverage (%) 0 20 40 60 80 100
South Asia East Asia and Pacific Sub-Saharan Africa Latin America and Caribbean Middle East and North Africa CEE/CIS and Baltic States* Industrialized countries Source: UNICEF/WHO, 2000.
* Insufficient data for 2000. 1990 2000 Improved sanitation coverage, change over period 1990-2000
Impoverished families are most likely to lack access to clean drinking water and adequate sanitation. The price paid by such families is extraordinarily high in terms of ill health and of time and energy spent collecting water from distant sources – burdens that usually fall on women and girls. The participation of women in solving local water supply and sanitation problems is increasingly seen as crucial to developing successful programmes. Governments are partnering with community organizations to raise matching resources to improve local water supplies.
GUINEA WORM DISEASE
Over the past decade, the world has witnessed a 88 per cent decline in the number of reported cases of the highly debilitating guinea worm disease (dracunculiasis). In a highly successful effort, the disease has been eliminated in all regions of the world except for one country in North Africa and 13 in sub-Saharan Africa. Sudan accounts for nearly three quarters of the remaining reported cases.
Because the foremost requirement is the provision of clean drinking water, there are no substantial technical barriers to guinea worm eradication. However, clean water provision needs to be combined with effective health education. Improvements in existing rural water supplies, water filters and community health education also need to be implemented in countries with new cases.
Case-containment measures are particularly useful in areas where the levels of guinea worm are already low. Where the disease is still widespread, surveillance needs to be strengthened with village-level participation.
Guinea worm eradication efforts have contributed to the wider services available to communities and their successful methods can be used by community-based health programmes to reach marginalized populations. In addition, the reporting of cases has been a cost-effective form of village-level monitoring and the use of maps for guinea worm surveillance has benefited planning in other programmes.
The great strides that have been made towards the goal of guinea worm eradication are the result of a broad and effective coalition involving United Nations and bilateral assistance agencies, Global 2000 of the Carter Center, the private sector, NGOs, nation- al ministries and political leaders – all of whom have supported people in endemic areas to rid themselves of this parasite. This momentum – and the high level of political and financial support – needs to continue until full eradication is reached.
LESSONS LEARNED IN WATER AND SANITATION
Overall progress towards the water and sanitation goals has been mixed. But it is unquestionably those countries and regions affected by conflicts, large debt burdens, lack of investment resources and weak institutional capacity that have faced the great- est difficulties. These problems are most severe in sub-Saharan Africa, where people still suffer from guinea worm disease, the final eradication of which has been delayed by conflict and lack of safe water supplies in some of the most endemic areas.
Water quality needs to be more effectively monitored to ensure that health hazards are avoided. This can be done by introducing basic testing for bacteriological contamination. Selective chemical testing on the basis of local problems can be very effective and costs little if appropriate technology is used.
Sector-wide approaches (SWAPs) to water supply and sanitation may bring major improvements in investment and efficiency levels, but must work in concert with strate- gies in health, nutrition and education. Schools can help kick-start community action, for instance. Teachers can serve as leaders and role models, not only for the children, but also for the wider community. Schoolchildren can influence family members and whole communities to improve sanitary conditions and hygiene practices.
Community management and hygiene are critical to ensure that water and sanitation services result in sustained improvements in children’s lives. Longer-term benefits will not be realized unless water and sanitation infrastructure is effectively used and maintained. Clean water may be available in the household but if hand- washing and other hygienic practices are not routine, health benefits will not materialize. Not least because of their direct implications for child survival and development, household water security, environmental sanitation and adequate hygiene practices need to be priorities for the next decade.
HIV/AIDS
The scale of the HIV/AIDS pandemic now exceeds the worst-case projections made in 1990. Worldwide, the number of people living with HIV or AIDS is 50 per cent higher than the figure pro- jected in 1991. Sub-Saharan Africa has the highest sero- prevalence, with 70 per cent of all new infections in the world. The rapid spread of the virus in the Caribbean, Eastern Europe and Asia is of urgent concern, but every region is experiencing rising numbers of infections.
HIV/AIDS has emerged as the greatest immediate threat to children and women in sub-Saharan Africa. The HIV/AIDS crisis both exacerbates and deepens many of the interlocking problems that affect much of the region, including poverty, dis- crimination, malnutrition, poor access to basic social services, armed conflict and the sexual exploitation of girls and women. The epidemic has strained capacities at all levels, for example, by the deaths of parents and of trained personnel. Life expectancy