Water and Sanitation Projects Should Involve the Health Sector Early

Since 1854, improvements in water and sanitation have been linked to improved health.  But to this day unsafe water and a lack of basic sanitation kills at least 1.6 million children under the age of five every year. 

International organizations have been working with Governments of developing countries for years to address these challenges.  But are water and sanitation projects really leading to improved health?  The answer was sought during a September, 2008 meeting held by the Human Development Network of the World Bank and attended by the Water and Sanitation Program (WSP) and the Water Anchor of the World Bank. 

Although health benefits have long been used as an argument for water and sanitation improvements, they are not regularly the primary motivators for local government investments in water and sanitation systems, or for individual improvements in their household sanitation facilities, suggested the panel.  

The primary motivators for both sets of investments include convenience (especially time savings and ease of use), improved environment (such as reduced odor and flies) and greater privacy.  While health concerns are frequently mentioned, they usually rank low on priority lists.  Major gastrointestinal disease epidemics occasionally push health concerns to the top of these lists temporarily, as the surge in cholera deaths due to the Broad-Street Pump contamination did in London in 1854.  Though even then, the environmental and political concerns surrounding “The Great Stink” of London in 1855 were arguably more important in the eventual development of the London Sewer System. 

Consistent with this anecdote, large scale water and sanitation projects typically do not effectively plan for or measure the optimal health benefits of their projects.  Part of the reason is that water and sanitation projects that respond to local demands typically fall under infastructure, rather than health ministries.  And since infrastructure investments are not generally conducive to randomized-control evaluations, the costly burden of establishing scientifically valid measures of health impacts are of little interest to those making the investments. 

By contrast, numerous small-scale, point-of-use water treatment and handwashing projects have been piloted in recent years, with the explicit objective of improving health outcomes and demonstrating scientifically valid health impact measures.  And most have demonstrated relatively large ones. 

The panel agreed that it was not advisable to compare these pilot project health impacts with the dearth of evidence from infrastructure projects.  The small-scale projects need to be implemented at scales similar to infrastructure projects to be compared.  There also needs to be a clear health focus to the infrastructure investments:  To identify what share of the costs are motivated by health concerns; to establish the health outcomes that are intended; and to monitor and evaluate these benefits.  The participants concluded that improved design and measurement of the health benefits of WSS infrastructure investments require involvement of the health sector early in their planning stages, and throughout the projects.  

To find out more, please see the presentations given at the event:


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Christopher Walsh
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