WHO WASH Strategy

• 16 Jan 2019

Introduction

• WHO’s 13^th General Programme of Work 2019–2023 describes how the Organization’s work will contribute to the health of three billion through multisectoral actions like better emergency preparedness and response; and one billion with universal health coverage (UHC).
• A limited number of high profile framework impact indicators, centred around these platforms, have been developed.
• Two of these indicators would accelerate the Organization’s work to increase access to safely managed drinking-water, sanitation and hygiene in households, and additional targets associated with UHC are linked to improving water, sanitation and hygiene (WASH) in health care facilities (HCF).
• Seven other indicators, largely linked to essential health services, child and maternal mortality, and antimicrobial resistance (AMR), will require improving water, sanitation and energy, especially in HCF.
• The WHO WASH Strategy has been developed in response to Member State Resolution WHA64.4 and the 2030 Agenda for Sustainable Development and its Sustainable Development Goals (SDGs).
• WHO WASH Strategy also takes on board the need for progressive realization of the human rights to safe drinking-water and sanitation, adopted by the UN General Assembly in July 2010.
• The 2025 end date of the WASH Strategy is proposed to allow both a reasonably manageable forward-looking time period as well as time to adopt a new WHO strategy in 2025 to enable course corrections in the final five-year period of the SDGs.

The WHO vision for WASH

• To substantially improve health through the safe management of the water, sanitation and hygiene services in all settings.

The WHO WASH Strategy Principles

• Prioritize actions with the highest public health benefit in areas where WHO has or can build comparative advantages.
• Strengthen health sector capacities in promoting safe WASH and taking up its public health oversight role in WASH, including effective outbreak response systems.
• Align with the SDGs, specifically targets relating to WASH, health, climate change and nutrition, as well as human rights principles.
• Employ the highest quality science including through collection, review and use of evidence about WASH impacts on health and a full range of practical experiences when developing norms and good practice procedures.
• Promote a contextual, incremental improvement approach when supporting countries to set national WASH standards and ambitious but achievable national targets.
• Capitalize on existing regional policy frameworks that promote WASH and stipulate national target setting.
• Stimulate sustainable change by strengthening government institutions and systems charged with implementation, oversight and regulation of WASH service delivery.
• Engage with partners and positively influence partnerships to ensure health issues are considered and addressed by the WASH sector and to also ensure that WASH issues, notably in health care facilities.

Key WHO Partners and Stakeholders for WASH

• Member States: National and local government agencies with responsibilities for policies and programmes in public health, drinking-water supply, sanitation and wastewater management, water resources development and management, environmental.
• Practitioners: Water suppliers, sanitation service providers, wastewater management entities.
• Institutions for research and development: Scientists organized in expert advisory panels, academia, research groups and WHO Collaborating Centres.
• WASH sector partners: For example, the United Nations Children’s Fund (UNICEF) and other UN agencies participating in UN-Water etc.
• Health sector partners: For example, global level partners such as the Global Task Force on Cholera Control (GTFCC), AMR Global Action Plan, neglected tropical diseases (NTDs) networks, infection prevention and control (IPC) practitioners including the Infection Control Africa Network (ICAN).
• External support agencies (ESAs): For example, The World Bank, Japan International Cooperation Agency (JICA), the Bill & Melinda Gates Foundation etc

WASH and HEALTH

• Safe WASH is not only a prerequisite to health, but contributes to livelihoods, school attendance and dignity and helps to create resilient communities living in healthy environments.
• Drinking unsafe water impairs health through illnesses such as diarrhoea; untreated excreta contaminate groundwaters and surface waters used for drinking and household purposes. This creates a heavy burden on communities.
• Chemical contamination of water continues to pose a health burden, whether natural in origin such as arsenic and fluoride, or anthropogenic such as nitrate.
• Safe and sufficient WASH plays a key role in preventing numerous Neglected Tropical Diseases.
• Diarrhoeal deaths as a result of inadequate WASH were reduced by half during the Millennium Development Goal (MDG) period, with the significant progress on water and sanitation provision playing a key role.
• Emerging challenge of AMR is looming large over the health sector medical interventions are gradually undermined by this phenomenon.
• Improvement of drinking-water supply, sanitation and wastewater management infrastructure and services will prevent infections and help save antibiotics and other drugs for future needs.
• WASH is an essential element of quality UHC, is recognized by the UN as a fundamental human right, and is cost-effective.

WHO and WASH

• WHO has performed the function of global WASH monitoring since its inception, and WHO provides an increasingly reliable and comprehensive evidence base to inform country policy decisions.
• WHO does not directly implement WASH infrastructure projects.
• WHO also plays a role responding to public concern regarding WASH issues that may have health implications, such as emerging pollutants.

How WHO Makes a Difference

• WHO’s ability to improve intersectoral planning for WASH and health stems from its ability to convene ministries of health, water and environment, regulators, water and sanitation service providers, rural authorities and external support agencies.
• WHO has used its leverage, either through coordination with other UN agencies or through ministries of health, to influence standards and norms.

The Need for Transformation

• Rapid and recent changes in the global environment, including the impacts of climate change and unprecedented growth of urban populations, have led to new WASH-related issues and challenges.
• Moreover, WASH-related diseases still prevail despite years of collective efforts. Significant inequities persist between urban and rural, poor and rich, and general and vulnerable population groups.
• Widespread use of antibiotics has allowed for control of infections arising from deplorable sanitary and hygiene conditions, yet conversely, has also allowed for neglect of WASH. Now with AMR looming, new and innovative responses and approaches are required.
• WASH is a complex, multi-faceted area typically spread across many government ministries and institutions, implicating the health sector’s disease prevention and control programmes and quality care initiatives, and an array of non-health sectors.
• To increase the effectiveness of WHO’s WASH efforts, we need to more effectively communicate growing evidence of the cost-effectiveness and positive economic and health impacts of WASH in combination with other interventions.
• Linking WASH to other programmes such as AMR, cholera, climate change, emergencies, IPC, MNCH, nutrition and NTDs enables access to resources and demonstrates the central role of WASH in increasing sustainable impacts of these programmes and strengthening their resilience.
• Incorporating longer-term climate change considerations into risk assessment for drinking-water quality and supply and particularly for sanitation is often overlooked, but will become increasingly necessary.

The SDGs, WHO and WASH

• Beyond the WASH-focused Goal 6, the SDGs highlight the importance of WASH to the inter-sectoral collaboration and synergetic efforts required to achieve ambitious SDG goals across health, education, climate change, nutrition, energy and ending poverty.
• Achievement of numerous SDGs, including Goal 3 on health and Goal 13 on climate change, cannot be met without meaningful progress on Goal 6.
• The emphasis of the 2030 Agenda on integrated and multi-sectoral responses implies an increased need for WHO’s established WASH coordination and leadership within and beyond WHO, including education, urban planning, financing and beyond.
• WHO is centrally involved in monitoring WASH-related SDG targets through its role as custodian or co-custodian of SDG 6 targets through Global Expanded Monitoring Initiative (GEMI), Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) and Global Analysis and Assessment of Sanitation and Drinking-water (GLAAS).

Strengthening Inter-sectoral and Cross Programme Collaboration

• Increasing WASH integration and collaboration across sectors and programmes and at all levels.
• While the health sector will remain a primary partner of WHO, a growing focus on whole-of-government approaches means that WHO work on WASH must significantly expand engagement beyond the health sector.
• Partners at country level such as UNICEF adds value to their service delivery efforts with provision of WHO standards or training specifications.

WHO Strategic Plan for WASH: 2018-2025

Strategic approaches 2018–2025

WHO is uniquely positioned to achieve impact through the following five strategic approaches, building on its existing work and established credibility and expertise.

• Develop, update and disseminate health-based guidance documents and best practice guides, norms and standards that support standard-setting and regulations at national level.
• Empower countries through multi-sectoral technical cooperation, advice and capacity building to governments, practitioners and partners.
• Monitor research and report reliable and credible WASH data to inform policies and programmes.
• Coordinate with multi-sectoral partners, lead or engage with global and regional platforms, and advocate for WASH.
• Promote integration of WASH with other health programmes for example disease programmes for cholera and NTDs.
• Respond to emerging issues such as climate change and WASH, including the impact of water scarcity on public health, and AMR.

Priority intervention areas 2018–2025

WHO will organize WASH activities in the following priority areas where it has existing activities and partnerships or an emerging critical role:

• Drinking-water quality and safety to provide authoritative and objective information on human health risks associated with water quality contaminants in national contexts
• Improving safety of sanitation and wastewater management, maximising health benefits of sanitation interventions.
• WASH in health care facilities (including health care waste management) to support development of country standards and policies and monitoring.
• GLAAS to provide policy and decision-makers with a comprehensive global analysis of investments and the enabling environment for WASH.
• JMP to support national, regional and global monitoring and reporting of progress towards universal access to safely managed drinking-water, sanitation and hygiene.
• Integration of WASH with health and other programmes such as AMR, cholera, climate change, emergencies, IPC, NTDs, nutrition, UHC, water security to increase synergies and impacts.
• Emerging issues on WASH to address critical new areas including AMR, climate change and emerging contaminants of concern.

Delivering WASH Through This Strategy

Resourcing the work

• Political will, financial resources and human resources with WASH expertise and experience and collaboration and outreach skills will be required at global, regional, national and sub-national levels to deliver the expected results described above.

Investment case

• The WHO Investment Case highlights that investments in WASH – both within and beyond the health sector – will provide returns of three times the investment, and directly save nearly 1 million lives between 2019 and 2023.
• In addition, the integration of WASH in other health programmes such as AMR and climate resilience is an important contribution to the significant health and economic gains of these programmes.

Value for money

WHO will ensure that operationalization of the strategy offers good value for money by:

• WHO’s work on tracking national financing to the WASH sector (TrackFin) supports more effective use of WASH funds to achieve national WASH targets.
• WHO’s multi-sectoral convening power enables greater efficiency across the many government and non-government actors in WASH.

Who WASH Priority Intervention Areas

Drinking-water and recreational water quality and safety

• Change objectives:
  • To support continuous and sustainable improvements in water safety and the achievement of the SDG 6 indicator, Public health criteria incorporated in national and regional recreational water quality regulations.
  • Coordinated and inter-sectoral planning and implementation of the above activities.
  • Reduction of inequalities in access by targeting endemic areas and vulnerable groups.
• Problem Statement/Opportunity:
  • With 2.1 billion people lacking a safe drinking-water supply, the SDG ambition for safely managed drinking-water for every household underscores the significant potential health impact of achievement of SDG.
  • Experience has demonstrated that increased attention is needed to support countries in implementing the Guidelines. 

Sanitation and Wastewater

• Change objectives:
  • Health risk assessment and management built into national policies and local level service delivery, including through a sanitation safety planning approach.
  • Reduction of inequalities in access by targeting endemic areas and vulnerable groups and by tailoring interventions to better interrupt disease transmission.
  • A substantial increase of safe reuse of wastewater and climate resilient planning of sanitation systems implemented as climate change adaptation measures.
  • Emerging risks and priorities characterized through evidence-based reviews and disseminated.

Wash in Health Care Facilities (HCF)

• WASH and health care waste management in HCF is included in global and national health policies and programmes.
• This includes priority areas such as AMR, IPC, and quality UHC. Development and implementation of such plans require that key decision-makers, health facility staff and users champion WASH in HCF.
• Global and national health and WASH monitoring includes harmonized core and expanded indicators to track WASH in HCF.

UN-water Global Analysis and Assessment of Sanitation and Drinking-water (GLAAS)

• WHO has extensive experience in monitoring and is an objective, credible source to collect, analyse and present data. WHO, through GLAAS, has been monitoring the enabling environment for WASH, since 2008.
• GLAAS is now an established process with a wide reach – over 100 countries have participated in GLAAS. GLAAS’s focus on finance and the enabling environment complement and provide input to national target-setting processes.
• GLAAS data contribute to strengthening transparency and accountability; allow the identification of issues and challenges common to many developing countries.
• Activities and outputs:
  • Work with countries and partners to collect and validate data on the WASH enabling environment through the GLAAS country survey.
  • Strengthen national capacity and national monitoring systems and processes through the GLAAS and TrackFin data collection processes.
  • Compile and analyse data on the WASH enabling environment and disseminate results through GLAAS reports, regional and country highlights, SDG reporting, and online databases.
  • Track and classify national WASH targets. 5607011

WASH and Emergencies

• Change objectives:
  • WASH included as a core element of health emergency preparedness, response and recovery and reflected in key trainings, guidance and national budgets.
  • Operational evidence base strengthened on key value-added WASH practices in emergencies (i.e. effective disinfection practices in emergencies at both household and central levels, and broader issues related to safe disposal of human waste in emergencies).
  • Intersectoral planning and collaboration facilitated between WASH and health clusters and between ministries at country level.
• Problem Statement/Opportunity: 
  • Emergencies are increasingly becoming more complex and affecting more populations than ever before. Climate change, natural disasters, growing inequities and urbanization all contribute to the record 65 million people who have been forced from their homes.
  • WHO is coordinating a global response to events in 27 countries.
• Unique role and added value of WHO:
  • WHO is working with countries to respond to crises and emergencies by ensuring effective and timely action to address public health priorities.
  • In emergencies, WHO has the mandate to work with ministries of health to ensure water quality, minimize water-related health risks, and support provision of WASH in health care facilities.
  • WHO’s expertise in developing international standards and normative information that build on experience responding to WASH-related emergencies, authoritative technical guidance makes it ideally placed to provide technical support in emergencies.
  • WHO’s WASH programme will work closely with WHO’s new Health Emergencies (WHE) programme, global and national WASH and health clusters, and other sector partners.

WASH and Neglected Tropical Diseases (NTDs)

• WASH is critical in the prevention and management of NTDs scheduled for intensified control or elimination by 2020.
• Provision of safe water, sanitation and hygiene is one of the five key interventions within the global NTD roadmap. Yet to date, the WASH component of the strategy has received little attention and the potential to link efforts on WASH and NTDs has been largely untapped.
• Focused efforts on WASH are urgently needed if the global NTD roadmap targets are to be met.
• Support joint cross-NTD and WASH coordination processes at regional and country levels.

WASH and Emerging Issues

WASH and climate change

• Change objectives:
  • Strengthened evidence based on linkages between the impacts posed by climate change to health via WASH and effective coordination mechanisms, and guidance developed.
  • Intersectoral planning and collaboration facilitated at all levels.
  • Climate variability and change considerations included in relevant WASH risk assessment and management approaches.
  • Climate change considerations included in relevant WASH monitoring systems at all levels.
• Problem Statement/Opportunity:
  • An increasing number of water and sanitation systems will become vulnerable to climate change.
• Unique role and added value of WHO:
  • The implementation of the WHO WASH Strategy will strengthen integration of climate change considerations into WASH risk assessment and programming.
  • The Strategy informs action by WHO at all levels as well as by ministries of health and ministries responsible for the delivery of WASH programmes, meteorological services, and climate change and WASH programme managers at all levels.
  • It also informs the actions of development agencies addressing WASH and climate change, including donors, NGOs and other UN agencies.

Water resources and health

• Problem Statement/Opportunity:
  • Water-associated vector-borne diseases continue to be a major public health problem in many countries including malaria and many of the NTDs.
  • Significant progress has been made in the prevention and control of some of these diseases through strengthening of case detection and treatment, a combination of drug treatment, vector control and the development and delivery of vaccines.
  • The broadened scope on water in the SDG framework creates an opportunity for WHO’s WASH programme to revitalize efforts to deal with water-associated vector-borne diseases in a sustainable manner.
  • The diversity in the ecology and biology of disease vectors requires evidence-based assessments of local situations where water resources development is taking place. This is important under conditions of rapid change in hydrology and aquatic ecosystems.