Background: Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners. Main body: Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health. Conclusion: These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle thatin any contexta comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.
This policy brief sets out key concepts, principles and practical implications for the citywide inclusive sanitation (CWIS) approach. Rapid urbanization, aging infrastructure, and climate change are exacerbating a sanitation crisis. The focus of most urban sanitation interventions remains incremental expansion of centralized sewer infrastructure; little attention is paid to reaching the poor, long-term service provision, financial viability, or the public system functions required to achieve those outcomes. Meeting SDG targets requires a radical rethink of the urban sanitation sub-sector. CWIS offers this. This paper presents a public services framework, set out by the Gates Foundation, for pursuing equitable, safe and sustained service outcomes, at city scale. It reviews the genesis and evolution of the CWIS framework and shares key principles and policy implications.
Infections
with enteric pathogens impose a heavy disease burden,
especially among young children in low-income countries. Recent findings
from randomized controlled trials of water, sanitation, and hygiene
interventions have raised questions about current methods for assessing
environmental exposure to enteric pathogens. Approaches for estimating
sources and doses of exposure suffer from a number of shortcomings,
including reliance on imperfect indicators of fecal contamination
instead of actual pathogens and estimating exposure indirectly from
imprecise measurements of pathogens in the environment and human interaction
therewith. These shortcomings limit the potential for effective surveillance
of exposures, identification of important sources and modes of transmission,
and evaluation of the effectiveness of interventions. In this review,
we summarize current and emerging approaches used to characterize
enteric pathogen hazards in different environmental media as well
as human interaction with those media (external measures of exposure),
and review methods that measure human infection with enteric pathogens
as a proxy for past exposure (internal measures of exposure). We draw
from lessons learned in other areas of environmental health to highlight
how external and internal measures of exposure can be used to more
comprehensively assess exposure. We conclude by recommending strategies
for advancing enteric pathogen exposure assessments.
The urban population will rise to 6.7 billion by 2050. The United Nations has committed to provide everyone with safely managed sanitation, but there is limited understanding of the scale of the challenge. This paper describes a methodology for rapid assessment of sanitation in cities including a graphical representation (a shit-flow diagram or SFD) and reports on findings from implementation in 39 cities. The SFD provides high level information for planning purposes covering the entire sanitation system in a city. More than half of the human excreta produced in these cities is not safely managed. The most significant portions of the unsafely managed excreta are: (i) contents of pits and tanks which are not emptied and are overflowing, leaking, or discharging to the surrounding environment (14%); (ii) contents of pits and tanks which are emptied but not delivered to treatment (18%); (iii) fecal sludge and supernatant delivered to treatment but not treated (3%); (iv) wastewater in sewers not delivered to treatment (14%); and (v) wastewater delivered to treatment but not treated (6%). Many cities currently relying on onsite sanitation for safe storage, particularly in Africa, will need new strategies as populations grow. Containment systems that discharge to open drains are common in some Asian cities; these pose a public health risk. Dumping of excreta is widespread and there is a lack of realistic performance data on which estimates of the extent and effectiveness of treatment can be made. The SFD production process can be challenging due to a lack of data and low technical capacity in cities. There is often uncertainty over terminology and over the status of infrastructure. Formalizing definitions for the SFD preparation process was found to be useful in overcoming capacity constraints in cities. The SFD produces a credible snapshot of the sanitation situation in a city. The paper provides evidence of the urgent need for improved management and monitoring of urban sanitation in cities around the world and highlights the role of the SFD as a planning tool.
Deliberative decision-making processes are becoming increasingly important around the world to make important decisions about public and private goods allocation, but there is very little empirical evidence about how they actually work. In this paper the authors use data from India extracted from 131 transcripts of village meetings matched with data from household surveys conducted in the same villages prior to the meetings, to study whose preferences are reflected in the meetings. The meetings are constitutionally empowered to make decisions about public and private goods. The findings show that the more land a person owns, the This paper-a product of the Poverty Team, Development Research Group-is part of a larger effort in the department to understand local government and citizen-based engagement in developing countries. Policy Research Working Papers are also posted on the Web at http://econ.worldbank.org. The author may be contacted at vrao@worldbank.org.higher the likelihood her preference is mentioned in the meeting, the longer the amount of time spent discussing this preference, and the higher the likelihood that a decision to provide or repair this public or private good is taken. At the same time, the voices of disadvantaged castes, while not dominating the meeting, are also heard. By contrast, the preferences of Muslims are given less time. High village literacy and the presence of higher level officials during village meetings mitigate the power of the landed, but political reservations for low castes for the post of village president increase the power of the landed.
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