Water, Sanitation, Hygiene and Health in the …...5| Water, Sanitation and Hygiene in the WHO | October 2009 Why Water, Sanitation and Health? Burden of disease: the headlines –1.9

Water, Sanitation and Hygiene in the WHO | October 20091 |

Water, Sanitation,

Hygiene and Health

in the framework of new

WHO priorities

Robert Bos

Water, Sanitation, Hygiene and Health


Overview

The links between water sanitation, hygiene and health

The rationale for water and sanitation interventions

WHO’s comparative advantage in water and sanitation

Current WHO activities in water and sanitation

Strengthening WHO’s role


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 anti-conception 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.


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?


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


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)


0 1% 2% 3% 4% 5% 6%

Environmental fraction Non-environmental

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

Diseases with largest environmental

contributions (I)

% of global disease burden in DALYs


Environmental fraction Non-environmental

Diseases with largest environmental

contributions (II)

% of global disease burden in DALYs

Malnutrition

Cerebrovascular dis.

Asthma

Tuberculosis

Suicide

Depression

Poisonings

Falls

Hearing loss

Violence

Lymphatic filariasis

Lung cancer

0 1% 2% 3% 4% 5% 6%


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


Water, sanitation, hygiene interventions

The rationale for primary prevention

– The public health imperative

– The economic argument

– Sustainability and resilience

– Development objectives



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



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.



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



The development objectives

– 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 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;



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



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 Organization’s

goal

– As non-contentious issues in public health, involvement in water and

sanitation enhances WHO’s 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 women’s health is immediately served by

water and sanitation activities


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:– Cholera and epidemic diarrhoeal disease

– Health impact assessment

– Integrated Water Resources Management

– WSH in emergencies

– WSH / health care waste management in health care facilities


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 world’s 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


Normative role in water quality issues

Promoting health-based

water quality regulations • Regulators Network

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

Maintaining up-to-date Global

Drinking-water Quality Guidelines

Priority settings• WASH standards in

hospitals and schools

Household level /

vulnerable groups • Household Water

Treatment and Safe

Storage Network

Maintaining up-to-date Guidelines

for the safe use of wastewater in

agriculture

Developing, testing and promoting

water safety plans (WSPs) as the

instrument for guidelines

implementation

Maintaining up-to-date Guidelines

for recreational waters

Rolling revisions • 4th edition Guidelines

for Drinking-water

Quality (GDWQ) - 50+

items on rolling revision

Training in WSPs • with AusAID, IWA and

PAHO

Research on non-

treatment options of

wastewater use • with IDRC and IWMI



Focus on Africa



Focus on Africa

The Libreville DeclarationEstablishes 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



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 peri-

urban areas

– Improve water management and drainage in urban areas for

urban malaria control.



Focus on Africa

Key interventions for Africa tomorrow– Comprehensively build capacity in health impact assessment of

water resources development (only 10% of Africa’s 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


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.


New challenges

Water scarcity

Climate change

The green

economy


Climate change and

water supply/sanitation



in the framework of new WHO priorities

Water, sanitation, hygiene and health is a dynamic and responsive programme that addresses key public health issues in line with WHO’s mandate and relevant to the Organization’s 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 WHO’s priorities for the 21st century

Conclusions



in the framework of new WHO priorities

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

Conclusions


More information on water,sanitation and

hygiene in WHO

Thank you for your attention

www.who.int/water_sanitation_health

Documents

Water, Sanitation, Hygiene and Health in the …...5| Water, Sanitation and Hygiene in the WHO | October 2009 Why Water, Sanitation and Health? Burden of disease: the headlines –1.9