Module 9: Water and Sanitation

Quantity and quality of water are two aspects that are often taken for granted in the developed world. First, consider quantity. Whereas the average Malian draws 4 cubic metres a year for domestic use, the average American draws 215 cubic meters.(1) Limitations of water can have obvious implications for malnutrition, but can also affect hydration therapies for diseases such as cholera. The quality of water can also be limited in the developing world. 98 % of water-related deaths occur in the developing world, and the combination of unsafe water and a general lack of basic sanitation is thought to account for 80 % of diseases.(2) Indeed, the World Health Organization estimates that 10 % of the global disease burden could be alleviated by achievable improvements in water supply, sanitation, hygiene, and management of water resources.(3) Highlighting the importance of this objective, one of the Millennium Development Goals is to reduce by half the number of people without access to safe drinking water.

The humbling consequence of unavailable and unsafe water is a death toll of 42,000 every week, including 90 % to children under age 5.(4) Furthermore, there are economic reasons to support increased water attention. Direct economic benefits of cleaner and more accessible water, including fewer deaths and increased work productivity, are estimated to total 84 billion dollars annually. This achievement would require an investment of 11.3 billion dollars annually.(5) The economic benefits do not take into account the indirect effects on increasing agricultural production.

A Case Study: charity: water

Unsafe water costs Africa 28 billion dollars annually, accounting for 5 % of GDP annually. Water, when purchased, can cost families up to 11 % of their income, which even then does not guarantee a safe water supply. It has been said that waterbourne disease could be decreased 21% by having fresh water, 37% from having general sanitation, and 45% from hand washing.(5) Charity: water is an organization that empowers African men and women to build wells, while also developing sanitation facilities such as hand-washing stations.

According to the Nobel Prize-winning economist Amartya Sen, true poverty is a not function of income, but of freedom and choice. (6) Supplying fresh water through providing wells does more than prevent water-bourne disease. Africans spend 40 billion years every year walking for water, most of which is done by women and children, who risk assault and chronic back pain. Furthermore, having a fresh well can grant access to extra water for irrigation, allowing families to be self-sufficient and less affected by famine, conflict, or the presence of government services. All of this is achieved at minimal economic cost. According to charity: water, 20 USD is sufficient to supply water to an individual for 20 years.(7) Today, charity: water has served over one million individuals in over 2,500 projects.(8)

Long-Term Water Solutions: All’s Well That Ends Well

The construction of wells in the developing world is an important first step in ensuring a safe water supply; however, in order for wells to provide a reliable, long-term water source for villagers, they must be maintained. Strikingly, regular maintenance of facilities can be rare. According to the World Bank, more than a third of rural water infrastructure in South Asia does not work properly, and a quarter of India’s water infrastructure is in disrepair.(9),(10)

These problems have been reflected in a recent Disease Control Priorities Report, which stated that:

 “Providing a public water point appears to have little effect on health, even where the water provided is of good quality and replaces a traditional source that was heavily contaminated with fecal material.”(11)

For effective change to occur, the new water supply needs to lead to an improvement in hygiene behaviors. Teaching local communities about the links between poor sanitation and common diseases should be done in the months leading up to the construction of the well, allowing fresh water to be coupled with good sanitation practices.(12)

To ensure long-term sustainability of the wells, the first step should be to establish need. One of the ways in which this can be done is to build wells on a demand-driven process; that is, to only consider constructing wells once local communities have contacted an organization with a request.(13) Other coniderations include a discussion about who is responsible for well maintenance, how the well will be free of waterbourne diseases, and who the well will serve. By discussing these topics, those intending to build a well can gauge need and enforce responsibility, ensuring that the building of the well will translate to a sustainable supply of clean water., an organization that helps establish wells, has a regular practice of sending teams to evaluate the efficacy and maintenance of wells for several months. The organization tracks the wells for five years to ensure that they are being used properly by the local communities.(14)

Historically, organizations have implemented maintenance strategies based on community-based ownership. Community-based maintenance is a strategy based on collective ownership, designed to help foster community unity. However, in western Kenya, nearly 50 % of borehole wells dug in the 1980s and maintained using a community-based maintenance model fell into disrepair by 2000.(15) Analysts have suggested that when wells are community-owned, no single individual will feel enough ownership to take control of the well, which eventually leads to its deterioration. A compromise might be to have community members elect selected representatives with specific roles in maintaining the well. This strategy would synthesize collective ownership with accountability.

Maintenance can be also be helped by implementing a user-fee, since one of the prime reasons for well failure is overuse of the pump.(16) Implementing a user-fee can help to pay for well repairs. Another way to create value for the well is to use cost-sharing for the construction of the well. has communities contribute at least 10 % of the total cost of the well, and the organization also provides small loans (microfinancing) if necessary, which generally ranges from 50 to 250 USD.(17) To train and teach local workers about how the well works, community members can be recruited to work on well construction. Building the well with communities also ensures that the technologies are appropriate and that the materials are local, which can also lower construction costs. Overall, ensuring that communities are engaged with the well personally and financially can promote better maintenance of the wells.(18)

A Case Study on Sanitation: Ecotact

In 2002, only 48 % of Kenya’s population had toilet access. Although there were public toilets, they were often unhygienic, badly maintained, or even unsafe, causing many to entirely avoid the use of toilets. In the capital of Nairobi, it had been 30 years since the government last invested in public sanitation facilities.(19) As a result, the large amount of human feces in the environment creates a breeding ground for disease, especially for the poor living in dense, crowded urban areas. The feces contaminate the water, promoting the cycle of diseases transmitted by the fecal-oral route. General sanitation and hygiene is a principal mode of transmission of trachoma, the leading cause of the world’s infectious blindness.(20) As Mohatma Gandhi once said, “Sanitation is more important than independence.”

To improve general sanitation, Ecotact created a pay-per-use public toilet and shower system called ikotoilet. Ecotact has an arrangement with municipalities to use public land in exchange for constructing the facilities and relinquishing control of them after a period of time. Ikotoilets are located in urban areas and have high standards of cleanliness and sanitation. Toilets are cleaned after each use. The ikotoilet facilities also sell small goods. Overall, the different aspects of the Ecotact system create a number of jobs for the local communities. The model has proven not only profitable, but also successful in promoting sanitation for the urban poor. Plans are now in place to expand the ikotoilet model to 200 facilities in Kenya over the next five years.(21)

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(1) The Economist. “Buisness Begins to Stir.” 20 May 2010. The Economist.Accessed on June 4, 2010.

(2) Prüss-Üstün, A., Bos, R., Gore, F. and Bartram, J. “Safer Water, Better Health: Costs, Benefits and Sustainability of Interventions to Protect and Promote Health.” The World Health Organization. 2008. Geneva, Switzerland.

(3) Ibid.

(4) Ibid.

(5) Hutton, G. and Haller, L. “Evaluation of the Costs and Benefits of Water and Sanitation Improvements at the Global Level.” World Health Organization. 2004. Geneva, Switzerland.

(6) Charity: water. “Main page.” Charity: water.

(7) Sen, A. “Poverty as Capability Deprivation.” Development as Freedom. p. 87-110. 1999. San Francisco, CA: Ignatius Press. 

(8) Charity: water. “Main page.” Charity: water.

(9) Ibid.

(10) Ray, I. “Water for All? Peri-Urban and Rural Water Delivery Options: The Case of India.” 2004. UC Berkeley Energy and Resources Group Fall Colloquium Series. Berkeley, CA, UC Berkeley.

(11) World Bank. “World Development Report 2004: Making Services Work for Poor People.” 2003. Washington, D.C.: World Bank.

(12) Cairncross, S. and Valdmanis, V. “Water Supply, Sanitation, and Hygiene Promotion.” Chapter 41. 2006. Disease Control Priorities in Developing Countries. p.777.

(13) “Digging is Easy.”

(14) Ibid.

(15) Ibid.

(16) Miguel, E. and Gugerty, M. K. “Ethnic Divisions, Social Sanctions, and Public Goods in Kenya.” Journal of
Public Economics. 89.11–12 (2005): 2325–68.


(18) Ibid.

(19) Ibid.

(20) Acumen Fund. “Ecotact: Quality Sanitation Facilities for the Urban Poor.” Acumen Fund. Accessed on June 17, 2010.

(21) Wright, H.R., Turner, A. and Taylor, H.R. “Trachoma.” Lancet. 371.9628 (2008): 1945-1954.

(22) Acumen Fund. “Ecotact: Quality Sanitation Facilities for the Urban Poor.” Acumen Fund. Accessed on June 17, 2010.