Sanitation, drinking-water and health: Achievements and challenges ahead by Alexander Pascual

Sanitation, drinking-water and health: Achievements and challenges ahead

© World Health Organization 2017 ISBN 978 92 9061 791 4 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules). Suggested citation. Sanitation, drinking-water and health: achievements and challenges ahead. Manila, Philippines. World Health Organization Regional Office for the Western Pacific; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. 1. Conservation of natural resources. 2. Drinking water. 3. Hygiene. 4. Sanitation. I. World Health Organization Regional Office for the Western Pacific. (NLM Classification: WC765). Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: wpropuballstaff@who.int Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. For inquiries and request for WHO Western Pacific Regional Publications, please contact the Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: wpropuballstaff@who.int

Contents Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.3 What is being measured? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2. The TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1 Overview of TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 Overall status of sanitation and drinking-water in TWG WSH countries. . . . . . 6 3. Sanitation coverage in TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1 Current status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.2 Sanitation inequities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2.1 Urban and rural disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2.2 Economic and social inequities in sanitation coverage. . . . . . . . . . . . . 13 4. Drinking-water coverage in TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.1 Current status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.2 Drinking-water inequities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.2.1 Urban and rural disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.2.2 Economic and social inequities in drinking-water coverage. . . . . . . . 19 5. The MDG drinking-water and sanitation target. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5.1 Achieving the MDG sanitation target. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5.2 Achieving the MDG drinking-water target. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 6. Sustainable Development Goals and targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 7. Health and economic development in drinking-water and sanitation. . . . . 31 7.1 Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 7.2 Drinking-water and sanitation in health-care facilities. . . . . . . . . . . . . . . . . . . . 33 7.3 The challenge of urbanization in TWG WSH countries. . . . . . . . . . . . . . . . . . . . 34 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Annexes Annex 1. Definitions of the post-2015 terms proposed by the JMP (WHO and UNICEF, 2017). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Annex 2. Country and regional estimates of improved sanitation coverage in TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Annex 3. Country and regional estimates of improved drinking-water coverage in TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

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Figures Figure 1. Proportion of urban, rural and total populations in TWG WSH region using improved sanitation, 1990 and 2015. . . . . . . . . . . . 6 Figure 2. Proportion of urban, rural and total populations in TWG WSH region using improved drinking-water sources, 1990 and 2015. . . . . . . . . . . . . . . . . . . 7 Figure 3. Proportion of population in TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 2015 . . . 7 Figure 4. Proportion of population in TWG WSH region using different types of drinking-water facilities, 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Figure 5. Proportion of population in TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 1990 and 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Figure 6. Number of people in TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 1990–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Figure 7. Proportion of populations in TWG WSH countries using improved, shared, or unimproved sanitation facilities, or practising open defecation, 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Figure 8. Distribution of population in TWG WSH region not using improved sanitation facilities, by country, 2015. . . . . . . . . . . . . . . . . . . . . . . . . . 11 Figure 9. Proportion of urban and rural populations in TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 1990 and 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Figure 10. Proportion of urban and rural populations in TWG WSH countries using improved sanitation, 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Figure 11. Urban and rural populations in TWG WSH region not using improved sanitation, 1990–2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Figure 12. Percentage of population using improved, shared, or unimproved sanitation facilities, or using open defecation by wealth quintile, Lao People’s Democratic Republic, 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Figure 13. Percentage of population using improved, shared, or unimproved sanitation facilities or using open defecation by education level, Lao People’s Democratic Republic, 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Figure 14. Proportion of population in TWG WSH region using different types of drinking-water sources, 1990 and 2015 . . . . . . . . . . . . . . . . . . . . . . . . . 15 Figure 15. Number of people in TWG WSH region using different types of drinking-water sources, 1990–2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Figure 16. Proportion of populations in TWG WSH countries using different types of drinking-water sources, 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Figure 17. Distribution of population in TWG WSH region not using improved drinking-water sources, by country, 2015. . . . . . . . . . . . . . . . . . . . . . 17 Figure 18. Proportion of urban and rural populations in TWG WSH region using different drinking-water sources, 1990 and 2015. . . . . . . . . . . . . . . . . . . 18

Figure 19. Proportion of urban and rural populations in TWG WSH countries using improved drinking-water sources, 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 20. Urban and rural populations in TWG WSH region not using improved drinking-water sources, 1990–2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Figure 21. Percentage of population using different types of drinking-water sources by wealth quintile, Lao People’s Democratic Republic, 2012. . . . . . 19 Figure 22. Percentage of population using different types of drinking-water sources by education level, Lao People’s Democratic Republic, 2012. . . . . . 20 Figure 23. Change in the use of improved sanitation from 1990 to 2015 and MDG targets in TWG WSH region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Figure 24. Difference between sanitation coverage in 2015 and the MDG sanitation target in TWG WSH countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Figure 25. Change in the use of improved drinking-water sources from 1990 and 2015 and MDG targets in TWG WSH region. . . . . . . . . . . . . . . . . . . . . . . . . . 23 Figure 26. Difference between drinking-water coverage in 2015 and the MDG drinking-water target in TWG WSH countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Figure 27. Distribution of causes of death among children under 5 years old in TWG WSH countries, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Figure 28. Deaths of children under 5 years old attributable to drinking-water, sanitation and hygiene in TWG WSH countries, 2012 (per 100 000 population). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Figure 29. Under-5 mortality rate (per 1000 live births), 1990 and 2013. . . . . . . . . . . . 32 Figure 30. Use of improved drinking-water and sanitation compared with under-5 mortality rate in TWG WSH countries, 2013. . . . . . . . . . . . . . . . . 33 Figure 31. Urban and rural populations in TWG WSH region, 1990 and 2015. . . . . . . 34

Tables Table 1. Drinking-water and sanitation categories of technologies according to the JMP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Table 2. Proposed indicators for monitoring sanitation services. . . . . . . . . . . . . . . . . . . 26 Table 3. Proposed indicators for monitoring drinking-water services. . . . . . . . . . . . . . 27 Table 4. Proposed indicators for monitoring hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Table 5. Contribution of JMP to SDG target 6.3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Abbreviations DHS GLAAS IBNET ISIC JMP LSB MDG MICS MoH SDG TWG WSH UN UNICEF WASH WHO WHS

Demographic and Health Survey UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water International Benchmarking Network for Water and Sanitation Utilities International Standard Industrial Classification of All Economic Activities WHO and UNICEF Joint Monitoring Programme for Water Supply and Sanitation Lao Statistics Bureau Millennium Development Goal Multiple Indicator Cluster Survey Ministry of Health Sustainable Development Goal Thematic Working Group on Water, Sanitation and Hygiene United Nations United Nations Childrenâ&#x20AC;&#x2122;s Fund water, sanitation and hygiene World Health Organization World Health Survey

Acknowledgements This document was prepared by the World Health Organization (WHO) for the Thematic Working Group on Water, Sanitation and Hygiene (TWG WSH). Many thanks are extended to Dr Rokho Kim, Dr Mohd Nasir Hassan and Ms Seoyeon Jeong of the WHO Regional Office for the Western Pacific for their support with the preparation of this document. Special mention is made to Mr Alexander von Hildebrand of the WHO Regional Office for the Western Pacific for his overall management of the project. Without his leadership, managerial guidance and quality assurance, preparing this document would not have been possible. Mr Jose Hueb was the author of the document.

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Summary This report deals primarily with the analysis of the drinking-water and sanitation situation in the member countries of the Thematic Working Group on Water, Sanitation and Hygiene (TWG WSH), based on statistics published by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation (JMP) updated in 2015. This document also provides key information on selected health and development issues for TWG WSH member countries. The member countries covered in this report are: Brunei Darussalam, Cambodia, China, Indonesia, Japan, the Lao People’s Democratic Republic, Malaysia, Mongolia, Myanmar, the Philippines, the Republic of Korea, Singapore, Thailand and Viet Nam. Previous documents prepared by WHO for the TWG WSH include extensive analyses of the drinking-water, sanitation and hygiene sector as a whole, based on country-level information. A key finding of this report is that the TWG WSH region has succeeded in meeting the Millennium Development Goal (MDG) target for drinking-water and sanitation, which is to “halve, by 2015, the proportion of the population without sustainable access to safe drinking-water and basic sanitation” (UN, 2017). Individually, nine TWG WSH countries achieved the MDG sanitation target, but four countries (i.e. Cambodia, Indonesia, Mongolia and the Philippines) did not. All TWG WSH countries met the MDG drinkingwater target except Mongolia, which fell short of the target by 13 percentage points. Overall, 77% of people in the TWG WSH region are using improved sanitation facilities, whereas 94% are using improved drinking-water sources (UNICEF and WHO, 2015). Despite an impressive effort made to provide drinking-water and sanitation infrastructure to the residents in this region, about one quarter of the population still lacks access to improved sanitation and 7% lacks access to improved drinking-water. Water-related diseases, including diarrhoeal diseases, are significant causes of death among children under 5 years old in the region. Almost 30 000 people in the TWG WSH region, especially children under 5, die each year due to water, sanitation and hygienerelated diseases (WHO, 2014). This document includes the following main sections: Section 1: Introduction

This section provides the rationale for preparing this document as well as its objectives and the overall characterization of the indicators under presentation according to the WHO and UNICEF JMP.

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Section 2: The TWG WSH countries

This section presents an overall analysis of the status of drinking-water and sanitation in TWG WSH countries, showing how drinking-water and sanitation coverage evolved in the TWG WSH region from 1990 to 2015. Section 3: Sanitation coverage in the TWG WSH countries

This section provides a more detailed analysis of the status of access to improved sanitation in TWG WSH countries, including key graphs showing how the status of these countries evolved over time. It includes statistics exposing different aspects of equity in sanitation service provision. Section 4: Drinking-water coverage in TWG WSH countries

This section provides a detailed analysis of access to improved drinking-water in TWG WSH countries and presents statistics on different aspects of equity in drinking-water use. Section 5: The MDG drinking-water and sanitation target

This section provides an analysis of the progress in achieving the MDG drinking-water and sanitation target for the region and analyses the individual progress of TWG WSH countries. Section 6: Sustainable Development Goals and targets

This section provides an overview of the 2030 Sustainable Development Goals (SDGs) drinking-water and sanitation targets and insight into the implications to the region of coping with such targets. Section 7: Health and economic development in drinking-water and sanitation

This section summarizes improved drinking-water and sanitation coverage in the region and includes a brief analysis of the health and social situation of the region. An attempt is made to demonstrate the link between drinking-water and sanitation and the health status of the population in the region. Annex 1: Definitions of the post-2015 terms proposed by the JMP

This list presents the proposed definitions associated with the SDG drinking-water and sanitation targets, taking into account the definitions adopted during the MDG era. Annex 2: Country and regional estimates of improved sanitation coverage in TWG WSH countries

This table summarizes the status of sanitation coverage in the TWG WSH region and in each country. It includes statistics from 1990, 2000, 2010 and 2015. Annex 3: Country and regional estimates of improved drinking-water coverage in TWG WSH countries

This table summarizes the status of drinking-water coverage in the TWG WSH region and in each country. It includes statistics from 1990, 2000, 2010 and 2015.

ÂŠ WHO/Yoshi Shimizu

Access to water for laundry and bathing

Introduction

1.1 Justification The Regional Forum on Environment and Health in Southeast and East Asian Countries is a platform that brings together the ministries of environment and ministries of health of member countries at regular intervals to fulfil the vision and objectives of its membership. The ministers of environment and ministers of health nominate highlevel officials to represent their respective ministries. The high-level officials also serve as national communication focal points for the Regional Forum on Environment and Health and liaise with the Secretariat of the Regional Forum (United Nations Environment Programme and the World Health Organization). The membership of the Regional Forum comprises ten Southeast Asian countries (Brunei Darussalam, Cambodia, Indonesia, Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic, Malaysia, Myanmar, Philippines, Singapore, Thailand and Viet Nam) and four East Asian countries (China, Japan, Mongolia and the Republic of Korea). The objective of the Regional Forum on Environment and Health is to strengthen the cooperation of the ministries responsible for environment and health within their respective countries by providing a mechanism for sharing knowledge and experiences, improving policy and regulatory frameworks at the national and regional levels, and promoting the implementation of integrated environmental health strategies and regulations. The Thematic Working Group on Water, Sanitation and Hygiene (TWG WSH) is one of the seven intercountry thematic working groups established by the First Regional Forum on Environment and Health in Southeast and East Asian Countries on 9 August 2007 in Bangkok, Thailand. Currently, 13 of the 14 Regional Forum countries are collaborating members of the TWG WSH. This document provides an overview of the status of drinking-water and sanitation in member countries of the Thematic Working Group on Water, Sanitation and Hygiene (TWG WSH) based on the coverage estimates published by the World Health Organization (WHO) and United Nations Childrenâ&#x20AC;&#x2122;s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation (JMP) in 2015. The document also provides key statistics on health and development in the region. The drinking-water and sanitation estimates presented in this document are calculated from national censuses and nationally representative sample household surveys, including Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and many other surveys conducted by national statistics offices.

The countries included in this analysis are current members of the TWG WSH, namely: Brunei Darussalam, Cambodia, China, Indonesia, Japan, the Lao People’s Democratic Republic, Malaysia, Mongolia, Myanmar, the Philippines, the Republic of Korea, Singapore, Thailand and Viet Nam. (Note that Brunei Darussalam does not appear in most graphs as the JMP does not have statistics on drinking-water and sanitation coverage for this country.)

1.2 Objectives The objectives of this document are: zz to provide an overview of the status of sanitation, drinking-water and hygiene in TWG WSH countries; zz to look into the implications for TWG WSH countries of the 2030 Sustainable Development Goals (SDGs) targets on water and sanitation; zz to look into key health and development indicators to help characterize the drinking-water and sanitation status of TWG WSH countries; and zz to provide the basis for discussion on how to accelerate investment to improve drinking-water, sanitation and hygiene in the TWG WSH region.

The United Nations Millennium Project Task Force on Water and Sanitation defines basic sanitation as “the lowest-cost option for securing sustainable access to safe, hygienic, and convenient facilities and services for excreta and sullage disposal that provide privacy and dignity while ensuring a clean and healthful living environment both at home and in the neighbourhood of users” (Lenton et al., 2005, p. iv). WHO refers to sanitation as the provision of facilities and services for the safe, hygienic disposal of human urine and faeces. Safe drinking-water is defined by the Girl next to a water storage tank United Nations Millennium Project Task Force on Water and Sanitation as “water that is safe to drink and available in sufﬁcient quantities for hygienic purposes” (Lenton et al., 2005, p. iv). Safe drinking-water includes water used for drinking (direct ingestion), cooking and personal hygiene that is free from contamination by pathogens, hazardous chemicals or radiological hazards (WHO, 2008). The JMP is unable to report on coverage according to the traditional definitions of safe drinking-water and basic sanitation because data available through household surveys are limited. Hence, the JMP reports on the use of improved technologies that would

1.3 What is being measured?

likely fulfil the requirements of safe drinking-water and adequate sanitation. Such technologies are called “improved drinking-water” and “improved sanitation” and are shown in Table 1. Table 1.

Drinking-water and sanitation categories of technologies according to the JMP

JMP categories Improved sanitation facilities*

Description

Technologies

JMP categories

Description

Technologies

Sanitation facilities are likely to ensure hygienic separation of human excreta from human contact.

Flush or pour-flush to:

Piped drinkingwater on premises

Piped household water connection located inside the user’s dwelling, plot or yard.

Piped household water connection

piped sewer system septic tank pit latrine Ventilated improved pit (VIP) latrine Pit latrine with slab Composting toilet

Shared sanitation facilities

Sanitation facilities of an otherwise acceptable type shared between two or more households. Only facilities that are not shared or not public are considered improved.

Same as above but shared by two or more households

Other improved drinking-water sources

Sources likely to provide safe drinkingwater outside households.

Public taps, standpipes, tube wells, boreholes, protected dug wells, protected springs, rainwater collection

Unimproved sanitation facilities

Sanitation facilities that do not ensure hygienic separation of human excreta from human contact.

Flush or pour-flush to elsewhere**

Unimproved drinking-water sources

Sources are unlikely to provide safe drinkingwater.

Unprotected dug well, unprotected spring, cart with small tank/drum, bottled water***

Human faeces are disposed of in open spaces, or open water bodies, or disposed of with solid waste.

Absence of sanitation facilities

Open defecation

Pit latrine without a slab, or open pit Bucket latrine Hanging latrine

Surface water

River, dam, lake, pond, stream, canal, irrigation channels

* Only facilities that are not shared or public are considered improved. ** Excreta are flushed to the street, yard or plot, open sewer, ditch or drainage way. *** Bottled water is considered to be unimproved when there is no other source of improved drinking-water for cooking and hygiene purposes. Source: based on WHO and UNICEF (2017).

The fragile ecological balance and water-resources vulnerability in most TWG WSH countries require rethinking of what is safe and adequate. Some “improved” sanitation technologies may be hazardous to sources of drinking-water and the environment. Poorly maintained waterborne sanitation systems such as septic tanks can deteriorate groundwater quality. Public sewerage systems discharging untreated sewage into water bodies can cause serious harm to ecosystems. The discharge of raw sewage into rivers and coastal areas may also affect the food chain through fish and shellfish.

ÂŠ WHO/Yoshi Shimizu

Children playing near a stream

The TWG WSH countries

2.1 Overview of TWG WSH countries

Mongolia

Republic of Korea China

Lao People's Democratic Republic Cambodia

Japan

Hong Kong SAR Macao SAR Viet Nam

Guam

Brunei Darussalam

Marshall Islands

Federated States of Micronesia

Palau

Malaysia Singapore

Northern Mariana Islands

Philippines

Nauru Papua New Guinea Solomon Islands

Australia

Kiribati

Tuvalu Tokelau Samoa Wallis & Futuna American Samoa Niue Vanuatu Fiji Cook Islands Tonga New Caledonia

French Polynesia

Pitcairn Islands

New Zealand

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ÂŠ WHO Regional Office for the Western Pacific 2009. All rights reserved.

The population of the TWG WSH countries (2213 million) represents 30% of the global population (7301 million) (UN, 2014). The proportion of the TWG WSH population using improved sanitation facilities is currently 77%, whereas the proportion using improved drinking-water facilities is 94% (UNICEF and WHO, 2015). Most TWG WSH countries are vulnerable to the impacts of climate variability and change and are subject to a relatively high frequency of hazards such as cyclones, earthquakes, floods and drought, with serious consequences to water resources and drinking-water and sanitation facilities (IPCC, 2014).

2.2 Overall status of sanitation and drinking-water in TWG WSH countries Inadequate disposal of human excreta, lack of safe drinking-water and poor hygiene are associated with a range of water-related diseases, including diarrhoeal diseases. Improved sanitation and drinking-water and sound hygiene behaviours can significantly reduce the prevalence of diarrhoeal diseases, and significantly lessen the adverse health impacts of other disorders responsible for death and disease among millions of children in the TWG WSH region. Significant progress was made between 1990 and 2015 in terms of access to improved sanitation facilities (Figure 1). Sanitation coverage increased by 24 percentage points during this time period. Despite such progress, one in four people overall does not use improved sanitation facilities, while in rural areas, one third of the population does not use improved sanitation facilities. Rapid population growth and urbanization, as well as the need to improve the quality of services, will continue to demand huge investments in sanitation over the next decades. Figure 1. Proportion of urban, rural and total populations in the TWG WSH region using improved sanitation, 1990 and 2015 100 87

90 80

Coverage (%)

40 30 20 10 0

Urban coverage

Rural coverage 1990

Total coverage 2015

ÂŠ WHO/Terrence Thompson

Source: country coverage data from UNICEF and WHO (2015).

A pour-flush latrine

Universal access to improved drinking-water sources has been nearly achieved for residents of urban areas in the TWG WSH region (Figure 2). There was an impressive increase of 23% in drinking-water coverage from 1990 to 2015 in the TWG WSH region. However, these impressive statistics hide the fact that many improved drinking-water facilities might not deliver safe drinking-water. The JMP statistics currently do not take into account water quality, affordability, water quantity per capita, etc. They only report on the use of improved technologies as defined in section 1.3 of this report. Figure 2. Proportion of urban, rural and total populations in the TWG WSH region using improved drinking-water sources, 1990 and 2015 100

90 80

Coverage (%)

70 59

60 50 40 30 20 10 0

Urban coverage

Rural coverage 1990

Total coverage 2015

Source: country coverage data from UNICEF and WHO (2015).

About three quarters of the population in the TWG WSH region use improved sanitation facilities (Figure 3). The regionâ&#x20AC;&#x2122;s sanitation coverage of 77% is 9 percentage points higher than the global coverage of 68%. Despite such high coverage, 13% of the population still uses unsanitary, unimproved facilities and 4% defecates in the open. Figure 3. Proportion of population in the TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 2015

Shared 6% Unimproved 13% Open defecation 4% Improved 77%

Source: country coverage data from UNICEF and WHO (2015).

About three out of five people in the TWG WSH region use drinking-water through household connections from piped systems. Around 94% of the population has

access to some source of improved drinking-water (e.g. piped system, protected wells, protected springs), which is above the global coverage of 91%. The use of surface water for domestic use is still practised by 1% of the population in the TWG WSH region (Figure 4). Figure 4. Proportion of population in the TWG WSH region using different types of drinking-water facilities, 2015

Surface water 1% Unimproved 5% Other improved 31% Piped onto premises 63%

ÂŠ WHO/Yoshi Shimizu

Source: country coverage data from UNICEF and WHO (2015).

Children fetching drinking-water

Sanitation coverage in TWG WSH countries

3.1 Current status Significant progress has been made in the TWG WSH region in terms of access to improved sanitation. About 77% of the TWG WSH region currently uses improved sanitation facilities, while 4% practises open defecation. It is important to highlight that sanitation facilities classified as “improved” do not necessarily hygienically separate human excreta from humans. The household surveys used by the JMP to derive sanitation coverage do not systematically collect information on the quality and effectiveness of improved sanitation facilities. The term “improved sanitation” refers to types of facilities that are more likely than others to be sanitary. The JMP uses a variety of household surveys to estimate coverage, including DHS, MICS, World Health Surveys (WHS), and numerous national surveys and censuses. These instruments do not include an assessment of cleanliness, affordability, sustainability, and whether the sanitation facility effectively protects human and environmental health. While the proportion of the population in the TWG WSH region using improved sanitation facilities increased by 24 percentage points from 1990 to 2015, the proportion of the population using unimproved sanitation was reduced by 18 percentage points over the same period of time (Figure 5). Figure 5. Proportion of population in the TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 1990 and 2015 100 90 77

Coverage (%)

70 60

50 40

30 20 10 0

12 4

6 1990 Improved

4 2015

Shared

Unimproved

Open defecation

Source: country coverage data from UNICEF and WHO (2015).

It is clear that a serious effort has been made in the region to reduce open defecation. The proportion of the population practising open defecation in 2015 has been cut to one third of the 1990 proportion. The population using improved sanitation in the TWG WSH region nearly doubled from 1990 to 2015, benefiting almost 800 million people gaining access to improved facilities in this time period (Figure 6). Such an impressive achievement outpaced the population growth in the region (population growth: 25% in 25 years). Despite a reduction to less than half of the population practising open defecation in 1990, more than 80 million people continued to practise open defecation in 2015 and more than 500 million people were still using unimproved or shared sanitation facilities or practising open defecation in the TWG WSH region. Figure 6. Number of people in the TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 1990â&#x20AC;&#x201C;2012 2500 93

Population (millions)

2000

159 209

1500 570 1000

374

135

120

496

Population practising open defecation Population using unimproved sanitation

90 1547

500

82 290

1706

Population sharing improved sanitation Population using improved sanitation

1233 935

0 1990

2000

Year

2010

2015

ÂŠ WHO/Yoshi Shimizu

Source: country coverage data from UNICEF and WHO (2015).

Women washing clothes in the river

Statistics on the use of improved sanitation by country are uneven in the TWG WSH region. Coverage ranges from 42% in Cambodia to 100% in Japan, the Republic of Korea and Singapore (Figure 7). Only three countries in the region have improved sanitation coverage below the world average of 68%. Open defecation is practised by at least 20% of the population in Indonesia, the Lao People’s Democratic Republic and Cambodia. Figure 7. Proportion of populations in TWG WSH countries using improved, shared, or unimproved sanitation facilities, or practising open defecation, 2015 100

4 4 12

7 1

3 3

70 Coverage (%)

9 23

60 50

100

3 8

93 80

71 61

60 42

20 10

Improved

Shared

Unimproved

Brunei Darussalam

Cambodia

Mongolia

Indonesia

Lao People’s Democratic Republic

Philippines

China

Viet Nam

Myanmar

Thailand

Malaysia

Singapore

Republic of Korea

Japan

NA 0

Open defecation

NA = not available Source: country coverage data from UNICEF and WHO (2015).

Most people without access to improved sanitation in the TWG WSH region are residents of China, mainly because the population of this country represents two thirds of the region’s population and because one quarter of its population does not use improved sanitation (Figure 8). About 20% of the region’s population without access to improved sanitation facilities lives in Indonesia. Figure 8. Distribution of population in the TWG WSH region not using improved sanitation facilities, by country, 2015 65

China Indonesia Philippines Viet Nam Cambodia Myanmar Lao People‘s Democratic Republic Thailand Japan Malaysia Mongolia Republic of Korea Singapore

20 5 4 2 2 1 1 0 0 0 0 0 0

40 Percentage (%)

Source: country coverage data from UNICEF and WHO (2015).

3.2 Sanitation inequities 3.2.1 Urban and rural disparities There is significant disparity between urban and rural sanitation coverage in the TWG WSH region (Figure 9). While about nine in every 10 urban residents enjoy access to improved sanitation, only six in every 10 rural residents enjoy this type of service. Open defecation is practised by 6% of the rural population. In urban areas, only 2% of the population still practises open defecation. Figure 9. Proportion of urban and rural populations in the TWG WSH region using improved, shared, or unimproved sanitation facilities, or practising open defecation, 1990 and 2015 100

Urban

Rural

90 80

70 Coverage (%)

Coverage (%)

100 87

60 50 40 30

60 50

30 16

20 10

20 7

4 1990

Year

2 Shared

2015 Improved

1990

Unimproved

2015

Year

Open defecation

Source: country coverage data from UNICEF and WHO (2015).

Improved sanitation coverage in Cambodia is nearly three times greater in urban areas than in rural areas (Figure 10). In six out of 14 TWG WSH countries, the disparity between urban and rural coverage exceeds 20 percentage points. For the region as a whole, the disparity is 22 percentage points. Figure 10. Proportion of urban and rural populations in TWG WSH countries using improved sanitation, 2015 100

100

84 77

70 Coverage (%)

96 78 71

56 47

50 40

30 20 10

Country Urban

*Singapore is totally urban Source: country coverage data from UNICEF and WHO (2015).

Rural

Region

Mongolia

Indonesia

Philippines

Myanmar

China

Cambodia

Thailand

Viet Nam

Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic

Malaysia

Singapore*

Republic of Korea

Japan

Considerable progress has been achieved in reducing the number of people not using improved sanitation over the last 25 years, especially in rural areas. The number of rural residents without access to improved sanitation has been halved since 1990 (Figure 11). Despite this impressive progress, 344 million rural residents and 162 million urban residents do not use improved sanitation and are thus exposed to severe risks of sanitation-related infectious diseases. Figure 11. Urban and rural populations in the TWG WSH region not using improved sanitation, 1990â&#x20AC;&#x201C; 2015 800 700699 Population (millions)

600

579

500 400

344

300 200 142

166

Rural population not using improved sanitation

172 162

100 0 1990

Urban population not using improved sanitation

415

2010

2000

2015

Year Source: country coverage data from UNICEF and WHO (2015).

3.2.2 Economic and social inequities in sanitation coverage It is well known that higher-income households and people with better education have access to better sanitation facilities. Such economic and social inequities reflect similar situations globally. The socioeconomic status of a household is obtained by dividing the population in five equal parts (quintiles) based on a wealth index. The wealth index is a composite index composed of key asset variables, including means of transportation, radio, television, refrigerator, roofing materials, flooring type and number of animals; it is used as a proxy indicator of household-level wealth. Although the available data do not allow for an analysis of economic and education inequities for the entire TWG WSH region, it was possible to obtain information to characterize one country as an example in the region. The graphs and text below reflect the situation of the Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic in this regard. The sanitation statistics presented in Figures 12 and 13 refer to one single household survey conducted in 2011â&#x20AC;&#x201C;2012, whereas the JMP statistics are based on all the surveys conducted in the country. Therefore, the statistics presented in these figures may differ from those presented by the JMP.

In 2012, the richest 20% of the population in the Lao People’s Democratic Republic was almost eight times more likely to use an improved sanitation facility than the poorest 20% (Figure 12). Open defecation was practically nonexistent (3%) among the richest quintile. On the other extreme, 82% of the poorest quintile was likely to practise open defecation. Figure 12. Percentage of population using improved, shared, or unimproved sanitation facilities, or using open defecation by wealth quintile, Lao People’s Democratic Republic, 2012

Wealth quintile

Richest

Fourth

Middle

57 33

Second Poorest

3 2

37 61

82 20

40 60 Proportion of people served by wealth quintile (%)

Improved sanitation

Shared facilities

Unimproved facilities

100

Open defecation

Source: MoH and LSB (2012).

While open defecation was almost nonexistent among people with higher education, 59% of the population without education practised open defecation in 2012 in the Lao People’s Democrative Republic (Figure 13). While 95% of the population with higher education used improved sanitation, only 38% of the population without any formal education used this type of facility. Figure 13. Percentage of population using improved, shared, or unimproved sanitation facilities or using open defecation by education level, Lao People’s Democratic Republic, 2012 Higher

Education level

Post secondary non tertiary

Upper secondary

Lower secondary

4 2

Primary

3 3

None

2 4

38 0

2 2

Source: MoH and LSB (2012).

Shared facilities

40 60 Proportion of people served by education level (%)

Improved sanitation

2 3

Unimproved facilities

80 Open defecation

100

Drinking-water coverage in TWG WSH countries

4.1 Current status Despite a high proportion of people using improved drinking-water sources (94%), about 63% of the population uses piped drinking-water on premises. As indicated in the introductory section of this report, people using drinking-water from improved sources are not necessarily using safe drinking-water. The household surveys used as a basis for the JMP analysis do not include an analysis of drinking-water quality. In addition, there is no information on whether the drinking-water used by households is affordable and provided in quantities according to basic requirements. The proportion of people using piped water on premises more than doubled from 1990 to 2015, whereas the proportion of people using other types of improved facilities in 2015 dropped to three quarters of the 1990 value (Figure 14). This is a clear indication that the region is evolving towards the construction of centralized piped drinkingwater systems with individual household connections. Figure 14. Proportion of population in the TWG WSH region using different types of drinking-water sources, 1990 and 2015 100 90 80 Coverage (%)

60 50 40 30

40 31

31 22

20 7

10 0

1990 Piped onto premises

5 Year Other improved

2015 Unimproved

Surface water

Source: country coverage data from UNICEF and WHO (2015).

From 1990 to 2015, about 828 million additional people in the TWG WSH region gained access to improved drinking-water facilities, whereas 851 million additional people gained access to piped drinking-water on premises. This means that there has been a huge effort towards increasing coverage through centralized water systems and piped distribution systems (Figure 15). The population still using surface water as its source of

drinking-water is currently a small fraction of the 1990 value (12%). The population not using improved drinking-water has been reduced by 391 million over the last 25 years. The use of surface water such as rivers, lakes and ponds as the primary source of drinking-water poses a huge threat to people with this type of access, especially children (Prüss-Üstün et al., 2008). Only a small quantity of water can be hauled daily, and serious microbial, parasites and chemical hazards are typical of this type of source. Figure 15. Number of people in the TWG WSH region using different types of drinking-water sources, 1990–2015 2500

Population (millions)

2000

84 279

126 1500

24 102

30 165

391

Use of surface water

684

697

Unimproved facilities

724 1000

Other types of improved facilities

707

500

1403

1242

891

Piped water onto the household

552 0

1990

2000

2010

Year

2015

Source: country statistics from UNICEF and WHO (2015).

Improved drinking-water coverage was above 60% in all TWG WSH countries (Figure 16). Higher regional statistics hide a low performance of many countries in terms of quality of service. For example, in seven out of 12 countries for which information is available, less than 50% of the population uses drinking-water piped on premises. Figure 16. Proportion of populations in TWG WSH countries using different types of drinking-water sources, 2015 100

2 1

49 100

12 12

2 11

55 73

Republic of Korea

Brunei Darussalam

Myanmar

Cambodia

24 Mongolia

27 Viet Nam

Philippines

Thailand

China

Malaysia

Japan

Singapore

Lao People’s Democratic Republic

Indonesia

20 0

5 14

60 50

4 32

70 Coverage (%)

3 5

Country Piped onto the household NA = not available Source: country coverage data from UNICEF and WHO (2015).

Other improved

Unimproved

Surface water

More than half of the people who are not using improved drinking-water facilities in the TWG WSH region live in China. This is followed by Indonesia, which is home to about one quarter of the population not using improved drinking-water (Figure 17). Figure 17. Distribution of population in the TWG WSH region not using improved drinking-water sources, by country, 2015 51

China Indonesia Myanmar Philippines Cambodia Lao Peopleâ&#x20AC;&#x2DC;s Democratic Republic Malaysia Mongolia Thailand Brunei Darussalam Japan Republic of Korea Singapore

26 9 7 3 1 1 1 1 0 0 0 0 0

30 Percentage (%)

Source: country statistics from UNICEF and WHO (2015).

4.2 Drinking-water inequities 4.2.1 Urban and rural disparities People living in urban areas of TWG WSH countries are, on average, almost twice more likely to have water piped to their dwelling than their rural counterparts. While 80% of urban residents enjoy piped water, only 43% of rural citizens use this type of source (Figure 18). In urban areas, the proportion of people with access to drinking-water piped on premises increased by 7 percentage points from 1990 to 2015; those with access to other types of improved facilities decreased by a similar amount (6 percentage points).

In urban areas, the use of surface water as a source of drinking-water has been practically eradicated in TWG WSH countries; however, about 7% of the rural population still uses drinking-water directly from rivers, lakes, streams and canals. Woman fetching water

ÂŠ WHO/Yoshi Shimizu

In rural areas, the proportion of people using piped drinking-water on premises nearly quadrupled over the last 25 years.

Figure 18. Proportion of urban and rural populations in the TWG WSH region using different drinkingwater sources, 1990 and 2015 100

100

Urban

90 80

70 Coverage (%)

Rural

60 50 40 30

20 3

1990

20 3

Year Piped on premises

2015 Other improved

1990

Year Surface water

Unimproved

2015

Source: country coverage data from UNICEF and WHO (2015).

Cambodia has the highest disparity in the region between urban and rural improved drinking-water coverage (31 percentage points). Urbanâ&#x20AC;&#x201C;rural disparity is less than 10 percentage points in nine out of 14 TWG WSH countries. Urban drinking-water coverage in the TWG WSH region is about 6 percentage points higher than rural coverage (Figure 19). Figure 19. Proportion of urban and rural populations in TWG WSH countries using improved drinking100

100

99 97

98 98

Philippines

Indonesia

China

Thailand

Viet Nam

Republic of Korea

Singapore*

Malaysia

86 74

Urban

Region

Mongolia

100

Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic

100

Myanmar

100

Japan

100 90 80 70 60 50 40 30 20 10 0

Cambodia

Coverage (%)

water sources, 2015

Rural

*Singapore is totally urban Source: country coverage data from UNICEF and WHO (2015).

Most people not using improved drinking-water sources in the TWG WSH region live in rural areas (Figure 20). The urban population not using improved drinking-water sources increased by 42% over the last 25 years, while the rural population not using improved drinking-water sources was reduced to less than one fifth of the 1990 value. The rural unserved population decreased by about 400 million people, while the urban unserved population increased by 10 million from 1990 to 2015.

These statistics indicate that investments in both urban and rural areas have been huge and overstepped population growth. Figure 20. Urban and rural populations in the TWG WSH region not using improved drinking-water sources, 1990–2015 600

Population (millions)

500 493 400

334

Urban population not using improved drinking-water

300

Rural population not using improved drinking-water

200

163 92

100 24 0 1990

30 2000

2010

2015

Year Source: country statistics from UNICEF and WHO (2015).

4.2.2 Economic and social inequities in drinking-water coverage

Household surveys conducted in TWG WSH countries lacked sufficient information to provide a regional perspective of improved drinking-water coverage according to education levels and wealth quintiles. Despite a lack of sufficient information to characterize the entire TWG WSH region in this regard, it was possible to obtain information to characterize one country as an example in the region. The Lao People’s Democratic Republic was selected to illustrate how economic aspects and education influence drinking-water coverage. The drinking-water statistics presented in this section refer to one single household survey conducted in 2011–2012, whereas the JMP statistics are based on all the surveys conducted in the country. Therefore, the statistics presented in these figures may differ from those presented by the JMP.

Water storage and station

In 2012, the richest 20% of the population in the Lao People’s Democratic Republic was nearly 20 times as likely to use piped drinking-water on premises as the poorest 20%. The poorest 20% of the population was four times more likely not to use an improved source of drinking-water than the richest 20% (Figure 21). Figure 21. Percentage of population using different types of drinking-water sources by wealth quintile, Lao People’s Democratic Republic, 2012

Richest

Wealth quintile

Fourth

Middle

Second

Poorest

40 60 Proportion of people served by wealth quintile (%)

Piped onto dwelling, plot or yard

Other improved

100

Unimproved drinking-water

Source: MoH and LSB (2012).

About 69% of the population with higher education uses drinking-water piped onto their property, whereas only 11% of the population without any formal education counts on this type of service (Figure 22). People with no formal education are twice as likely to use an unimproved source of drinking-water than those with higher education. Figure 22. Percentage of population using different types of drinking-water sources by education level, Lao People’s Democratic Republic, 2012

Higher

Education level

Post-secondary non-tertiary

Upper secondary

Lower secondary

51 20

40 60 Proportion of people served by education level (%)

Piped onto dwelling, plot or yard Source: MoH and LSB (2012).

11 0

None

Primary

Other improved

Unimproved drinking-water

100

The MDG drinking-water and sanitation target

In September 2000, building on a decade of major United Nations conferences and summits, world leaders adopted the United Nations Millennium Declaration, committing their nations to a global partnership to reduce extreme poverty and setting out time-bound goals and targets to be achieved by 2015. These became known as the Millennium Development Goals (MDGs). MDG target 7.C is to “halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation” (UN, 2017). As information is not available to measure access to “safe drinking-water” and “basic sanitation”, the international community adopted the proxies “improved drinking-water” and “improved sanitation” to measure progress in coverage since 1990 (see section 1.3).

5.1 Achieving the MDG sanitation target The MDG sanitation target, to halve the proportion of the population without sustainable access to adequate sanitation by 2015, has been met in the TWG WSH region. Between 1990 and 2015, the region experienced an increase in improved sanitation coverage of 26 percentage points, with millions of people gaining access to improved sanitation facilities. The TWG WSH region exceeded the MDG sanitation target by 1 percentage points. Despite this major achievement, about one quarter of the population still lacks access to improved sanitation facilities (Figure 23). Figure 23. Change in the use of improved sanitation from 1990* to 2015 and MDG target** in the TWG WSH region 100 93

Country Sanitation coverage in 1990

Sanitation coverage in 2015

61 35

77 60

Sanitation MDG target (2015):

42 3

Achieved

Region

74 57

Bruunei Darussalam

Cambodia

1990 data not available

Mongolia

Indonesia

1990 data not available

Myanmar

Thailand

99 100

Malaysia

100 100

Singapore

100

Republic of Korea

100

Lao People’s 1990 data not available Democratic Republic

Philippines

China

100

Viet Nam

100

Japan

Coverage (%)

100 90 80 70 60 50 40 30 20 10 0

Not achieved

* The JMP has not provided 1990 improved sanitation coverage statistics for the Lao People’s Democratic Republic, Mongolia and Myanmar. The MDG target was estimated for these countries based on 1995 data. ** The MDG target is achieved if the percentage point difference between sanitation coverage in 2015 and the MDG target is equal to or greater than –1%. Source: country coverage data from UNICEF and WHO (2015).

Four countries (the Philippines, Indonesia, Cambodia and Mongolia) failed to meet the MDG sanitation target. Two countries (Viet Nam and China) made every effort to expand coverage and achieve the MDG sanitation target even considering the difficulty posed by their very low coverage in 1990. A country-by-country analysis of performance against the MDG sanitation targets shows that Cambodia and Mongolia have the biggest gaps, having missed the targets by 9 and 13 percentage points, respectively (Figure 24). The same analysis reveals the Lao People’s Democratic Republic and Viet Nam as the best performers, having exceeded the MDG sanitation target by 11 and 10 percentage points, respectively. Figure 24. Difference between sanitation coverage in 2015 and the MDG sanitation target in TWG WSH countries Brunei Darussalam

NA 11

La o People's Dem. Republic 10

Vi et Na m 3

Ma l a ysia

Mya nma r 2

Chi na Ja pa n

Republic of Korea

Si ngapore

Tha iland

–5

Phi l ippines

–7

Indonesia

–9

Ca mbodia

–13

Mongolia Regi on

–15

–10

–5

0 Percentage points (%) Percentage points gap to achieve the MDG sanitation target

Percentage points higher than MDG sanitation target

Source: country statistics from UNICEF and WHO (2015).

5.2 Achieving the MDG drinking-water target The MDG drinking-water target, to halve the proportion of the population without sustainable access to safe drinking-water by 2015, has been met in the TWG WSH region. Between 1990 and 2015, the region as a whole saw an increase in improved drinking-water coverage of 23 percentage points. The TWG WSH region exceeded the MDG drinking-water target by 9 percentage points (Figure 25). All TWG WSH countries achieved and exceeded the MDG drinking-water target except Mongolia, which fell short of the target by 13 percentage points. Despite very low coverage in 1990, Cambodia made a tremendous effort over the last 25 years, not only achieving the target, but also meaningfully exceeding it.

Figure 25. Change in the use of improved drinking-water sources from 1990* and 2015 and MDG target** in the TWG WSH region

53 64

Drinking-water MDG target (2015):

Mongolia

Region

Cambodia

Lao People’s 1990 data not available Democratic 76 Republic

84 92

Country Drinking-water coverage in 2015

Drinking-water coverage in 1990

87 98

Viet Nam

Malaysia

Thailand

Republic 1990 data not available of Korea 98

100 100 Singapore

100 100 Japan

Bruunei Darussalam NA

Myanmar

92 83

Indonesia

Philippines

100

China

100

Coverage (%)

100 90 80 70 60 50 40 30 20 10 0

Achieved

Not achieved

* The JMP has not provided 1990 improved drinking-water coverage statistics for the Lao People’s Democratic Republic and the Republic of Korea. The MDG target was estimated for these countries based on 1995 data. Similarly, the JMP has not provided 2015 improved drinking-water coverage statistics for the Republic of Korea. Data from 2010 were used. ** The MDG target is achieved if the percentage point difference between drinking-water coverage in 2015 and the MDG target is greater than –1%. Source: country statistics from UNICEF and WHO (2015).

Viet Nam and Cambodia show the best performance in the region, having exceeded the MDG drinking-water target by 17 and 14 percentage points, respectively (Figure 26). The region as a whole exceeded the MDG drinking-water target by 9 percentage points. Mongolia was the only country in the TWG WSH region that did not succeed in achieving the MDG drinking-water target. Figure 26. Difference between drinking-water coverage in 2015 and the MDG drinking-water target in TWG WSH countries 17

Viet Nam 14

Cambodia 12

China 6

Lao People’s Democratic Republic 4

Thailand 3

Malaysia Indonesia

Myanmar

Republic of Korea

Japan

Philippines

Singapore

–13

Mongolia

Regi on –15

–10

–5

9 0 5 Percentage points (%)

Percentage points exceding the drinking-water MDG target

Percentage points gap to achieve the drinking-water MDG target

Source: country statistics from UNICEF and WHO (2015).

View of a river

Â© WHO/Yoshi Shimizu

TEMP IMAGE

Sustainable Development Goals and targets

On 25 September 2015, the United Nations General Assembly adopted a resolution titled “Transforming our world: The 2030 Agenda for Sustainable Development” (A/RES/70/1). The resolution proposed 17 Sustainable Development Goals (SDGs) with 169 associated targets addressing different aspects of sustainable development. The targets associated with SDG 6 – “ensure availability and sustainable management of water and sanitation for all” (UN, 2015, p. 20) – are as follows: 6.1 By 2030, achieve universal and equitable access to safe and affordable drinking-water for all 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations 6.3 By 2030, improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally 6.4 By 2030, substantially increase water-use efficiency across all sectors and ensure sustainable withdrawals and supply of freshwater to address water scarcity and substantially reduce the number of people suffering from water scarcity 6.5 By 2030, implement integrated water resources management at all levels, including through transboundary cooperation as appropriate 6.6

By 2020, protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers and lakes

6.a By 2030, expand international cooperation and capacity-building support to developing countries in water- and sanitation-related activities and programmes, including water harvesting, desalination, water efficiency, wastewater treatment, recycling and reuse technologies 6.b Support and strengthen the participation of local communities in improving water and sanitation management

Targets 6.1, 6.2 and 6.3 are of greatest interest to this report. Different formulations of indicators to determine progress in achieving such targets have been proposed over the past few years by different groups, individuals and institutions. The SDG drinkingwater, sanitation and hygiene indicators are presented in Tables 2, 3 and 4 (WHO and UNICEF, 2015). The baseline year for measuring progress is 2015. The contribution of the JMP to target 6.3 is indicated in Table 5. Table 2. Proposed indicators for monitoring sanitation services Sanitation service ladder

Proposed indicator

Definition

Data sources and measurability

Safely managed sanitation

Percentage of population using safely managed sanitation services

Percentage of population using a basic sanitation facility that is not shared with other households and where excreta is safely disposed in situ or treated off-site. This multipurpose indicator also covers the domestic part of wastewater treatment of target 6.3.

Household surveys can provide information on types of sanitation facilities and disposal in situ. Administrative, population and environmental data can be used to estimate safe disposal/treatment of excreta.

Basic sanitationa

Percentage of population using a basic sanitation service

Percentage of population using a basic sanitation facility not shared with other households.

Household surveys

Shared sanitation

Percentage of population using a shared sanitation service

Percentage of population using a basic sanitation facility shared with other households.

Household surveys

Unimproved sanitationb

Percentage of population using an unimproved sanitation facility

Percentage of population using unimproved sanitation facilities, with or without sharing with other households.

Household surveys

Open defecation

Percentage of population practising open defecation

Percentage of population defecating in bushes, fields, open water bodies or other open spaces.

Household surveys

Basic sanitation in schoolsc

Percentage of pupils enrolled in schools that provide basic sanitation services

Percentage of pupils enrolled in primary and secondary schools with basic sanitation facilities that are functional and separated for males and females on or near premises.

Institution surveys, administrative data, education management information systems

Basic sanitation in health-care facilitiesd

Percentage of patients using health-care facilities providing basic sanitation services

Percentage of beneficiaries using health-care facilities with basic sanitation facilities that are functional and separated for males and females on or near premises.

Institution surveys, administrative data, health management information systems

Basic sanitation facilities (MDG “improved sanitation” indicator) include the following: flush/pour-flush toilets to sewer systems, septic tanks or pit latrines, ventilated improved pit latrines, pit latrines with a slab, and composting toilets. b Unimproved sanitation facilities (MDG “unimproved sanitation” indicator) include the following: flush/pour-flush latrines not connected to sewer/septic/pit, pit latrines without a slab, and hanging and bucket latrines. c Basic sanitation in schools means at least one toilet/latrine for every 25 girls, at least one toilet/latrine for female school staff, at least one toilet/latrine and one urinal for every 50 boys, and at least one toilet/latrine for male school staff. d Basic sanitation in health-care facilities means at least one toilet for every 20 users at inpatient centres, and at least four toilets – one each for staff, female, male and child patients – in outpatient centres. a

Source: based on WHO and UNICEF (2015).

Table 3. Proposed indicators for monitoring drinking-water services Drinking-water service ladder

Data sources and measurability

Proposed indicator

Definition

Safely managed water

Percentage of population using safely managed drinking-water services

Percentage of population using a basic drinking-water source that is located on premises and available when needed; free of faecal (and priority chemical) contamination.

Household surveys can provide data on basic water on premises, availability when needed and if free from contamination via direct water quality testing. Official drinking-water regulators can provide data on compliance with national standards.

Basic watera

Percentage of population using basic drinking-water services

Percentage of population using a basic drinking-water source with a total collection time of no more than 30 minutes for a round trip including queuing.

Household surveys

Unimproved waterb

Percentage of population using inadequate sources of drinking-water

Percentage of population using unimproved drinking-water sources or basic drinking-water sources with a total collection time of more than 30 minutes.

Household surveys

Surface waterc

Percentage of population using water directly from surface water sources

Percentage of population using surface water sources.

Household surveys

Basic water in schools

Percentage of pupils enrolled in schools providing basic water services

Percentage of pupils enrolled in primary and secondary schools with a functional basic drinking-water source on or near premises and water points accessible to all users during school hours.

Institution surveys, administrative data, education management information systems

Basic water in healthcare facilities

Percentage of beneficiaries using health-care facilities providing basic water services

Percentage of beneficiaries using health-care facilities with a functional basic water source on premises and water points accessible to all users at all times.

Institution surveys, administrative data, health management information systems

Basic drinking-water sources (MDG “improved drinking-water” indicator) include the following: piped water into dwelling, yard or plot (on premises); public taps or standpipes; boreholes or tubewells; protected dug wells; protected springs and rainwater. Packaged drinking-water is considered to be a basic source if households use a basic water source for other domestic purposes. b Unimproved drinking-water sources (MDG “unimproved” indicator) include the following: unprotected dug well, unprotected spring, cart with small tank/drum, and bottled water. c Surface water includes rivers, dams, lakes, ponds, streams, canals and irrigation channels. a

Source: based on WHO and UNICEF (2015).

Table 4. Proposed indicators for monitoring hygiene Hygiene indicators

Proposed indicator

Definition

Data sources and measurability

Handwashing at home

Percentage of population with handwashing facilities with soap and water at home

Percentage of population with handwashing facilities with soap and water in the household.

Household surveys

Handwashing in schools

Percentage of pupils enrolled in schools with basic handwashing facilities

Percentage of pupils enrolled in primary and secondary schools with functional handwashing facilities with soap (or ash) and water available to girls and boys.

Institution surveys, administrative data, education management information systems

Menstrual hygiene management in schools

Percentage of pupils enrolled in schools with basic menstrual management facilities

Percentage of pupils enrolled in primary and secondary schools with adequate and appropriate sanitation facilities for washing, change management and disposal of menstrual waste. These facilities must offer privacy, safety and dignity to menstruating students and teachers.

Institution surveys, administrative data, education management information systems

Handwashing in health-care facilities

Percentage of beneficiaries using health-care facilities with basic handwashing facilities

Percentage of beneficiaries using health-care facilities with adequate hand hygiene supplies (running water, liquid soap, singleuse towels/alcohol-based hand rinse) available at key locations.

Institution surveys, administrative data, health management information systems

Basic menstrual hygiene management in health-care facilities

Percentage of beneficiaries using health-care facilities with basic menstrual management facilities

Percentage of beneficiaries using health-care facilities with improved separated sanitation facilities for females that provide privacy; soap, water and space for washing hands, private parts and clothes; and places for changing and disposing of materials used for managing menstruation.

Institution surveys, administrative data, health management information systems

ÂŠ WHO/Yoshi Shimizu

Source: based on WHO and UNICEF (2015).

A girl washes her hands before lunch at a kindergarten

Table 5. Contribution of JMP to Target 6.3 Wastewater ladder Safe treatment of wastewater

Proposed indicator Percentage of wastewater safely treated

Definition Proportion of wastewater generated through domestic (sewage and faecal sludge) and industrial sources safely treated compared to total wastewater generated through domestic and industrial sources.

Data sources and measurability To build on the monitoring framework of the JMP, data sources could include AQUASTAT, GLAAS, IBNET, population density, and land-use/land-cover data from earth observations. The calculation of the indicator value as derived from the framework is the amount treated (off-site and on-site) divided by the total amount of waste produced. Data on treatment of domestic wastewater will come from the above data sources. Data on volumes of industrial wastewater can be estimated from inventories of industries, which will be available in the majority of Member States disaggregated by ISIC classifications. The breakdown of treated wastewater can be calculated based on compliance records, related to national standards. Unless verified otherwise, through audited compliance records, the waste generated will be considered untreated.

GLAAS, Global Analysis and Assessment of Sanitation and Drinking-Water; AQUASTAT, Global Information System on Water and Agriculture; IBNET, International Benchmarking Network for Water and Sanitation Utilities; ISIC, International Standard Industrial Classification of All Economic Activities; JMP, WHO and UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Source: based on WHO and UNICEF (2015).

ÂŠ WHO/Yoshi Shimizu

The proposed targets are ambitious, especially given the lack of baseline data and national reporting systems for many of the criteria. For TWG WSH countries, the implications would be significant as the time frame might be too short to provide drinking-water, sanitation and hygiene services to billions of people over the next 15 years.

Women washing clothes

Â© WHO/Yoshi Shimizu

Woman fetching water

Health and economic development in drinking-water and sanitation

The most effective way to prevent deaths and illnesses from diarrhoea and other waterand sanitation-related diseases is to provide adequate sanitation and drinking-water services. Such diseases hinder the learning capacity of millions of school-aged children in the TWG WSH region. This section provides an overview of the status of water and sanitation, as well as social and health-related issues in the region.

7.1 Health Diarrhoeal disease, which is largely attributable to unsafe drinking-water, unimproved sanitation facilities and inadequate hygiene, is still a major cause of under-five mortality in selected TWG WSH countries, including Viet Nam and the Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic (Figure 27). In half of the TWG WSH countries, diarrhoeal disease is responsible for over 6% of all deaths of children under 5 years old. Despite the appalling number of deaths due to diarrhoeal disease among children under 5 years old, the situation has improved considerably because of overall improvements in drinking-water sources and sanitation facilities, and because of more effective policies and practices in case management. Figure 27. Distribution of causes of death among children under 5 years old in TWG WSH countries, 2013

11 12

Viet Nam

1 11

21 8

Injuries Other diseases

32 7

22 24

6 11

13 2

5 8

26 39

3 9

2 4 9 6 2

17 16 17 7

2 5 1 6

14 4

8 11 3

7 12

2 6

1 7

8 1

27 2 8 25 41

Singapore

7 6

Republic of Korea

Brunei Darussalam

Cambodia

30 20

Malaysia

Japan

6 7

Thailand

Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic

Percentage of deaths (%)

China

Indonesia

Philippines

Myanmar

Mongolia

100

Country Congenital anomalies Neonatal sepsis

Birth asphyxia Prematurity

Pneumonia Malaria

Measles HIV/AIDS

Diarrhoea

Source: WHO (2015).

As indicated above, case management has improved in many TWG WSH countries, but high mortality rates due to diarrhoeal disease remain in low-income countries (Figure 28). Almost 30 000 people in the TWG WSH region – especially children under 5 years old – die each year due to water, sanitation and hygiene-related diseases. Figure 28. Deaths of children under 5 years old attributable to drinking-water, sanitation and hygiene in TWG WSH countries, 2012 (per 100 000 population) 140

Deaths per 100 000

120 100 80 60 40

Singapore

Republic of Korea

Japan

Brunei Darussalam

Malaysia

China

Viet Nam

Mongolia

Thailand

Indonesia

Philippines

Cambodia

Lao People’s Democratic Republic

Myanmar

Source: WHO (2014).

In most TWG WSH countries, the under-5 mortality rate in 2013 was less than half the value in 1990. However, comparing extremes between countries, such as Japan and the Lao People’s Democratic Republic, it is clear there is room for huge improvement (Figure 29). The reduction of the under-5 mortality rate in China is remarkable: the rate in 2013 was less than one quarter of the 1990 value. Figure 29. Under-5 mortality rate* (per 1000 live births), 1990 and 2013 Under-5 mortality rate (per 1000 live births)

180 160 140 120 100 80 60 40 20

1990

2013

* Defined as the probability of a child born in a specified year dying before reaching the age of 5 years. Source: WHO (2013).

Singapore

Japan

Republic of Korea

Malaysia

Brunei Darussalam

Country

China

Thailand

Viet Nam

Indonesia

Philippines

Mongolia

Cambodia

Myanmar

Lao People’s Democratic Republic

Drinking-water and sanitation coverage and under-5 mortality are clearly linked. Although other risk factors exist, drinking-water, sanitation and hygiene fundamentally influence this indicator (Figure 30). Figure 30. Use of improved drinking-water and sanitation compared with under-5 mortality rate in TWG WSH countries, 2013 100 90

Coverage with improved drinking-water and sanitation (%)

80 70 60 50 40 30 20 10 0 0

20 40 60 Under-five mortality rate (deaths per 1000 live births)

Cambodia (water) China (water) Indonesia (water) Japan (water) Lao People's Democratic Republic (water) Malaysia (water) Mongolia (water) Myanmar (water) Philippines (water) Republic of Korea (water) Singapore (water) Thailand (water) Viet Nam (water) Cambodia (sanitation) China (sanitation) Indonesia (sanitation) Japan (sanitation) Lao People's Democratic Republic (sanitation) Malaysia (sanitation) Mongolia (sanitation) Myanmar (sanitation) Philippines (sanitation) Republic of Korea (sanitation) Singapore (sanitation) Thailand (sanitation) Viet Nam (sanitation)

Sources: WHO (2013); UNICEF and WHO (2015).

7.2 Drinking-water and sanitation in health-care facilities In many health-care facilities in the TWG WSH countries, handwashing facilities are not available and toilets are in disrepair. Water, sanitation and hygiene (WASH) in healthcare facilities are fundamental for reducing health careâ&#x20AC;&#x201C;related infections, increase trust and uptake of services, increase efficiency and decrease cost of service delivery. In low- and middle-income countries, WASH facilities in many health-care facilities are absent. Data from 54 countries, representing 66â&#x20AC;Ż101 facilities worldwide, show that 38% of health-care facilities do not have an improved water source, 19% do not have improved sanitation and 35% do not have water and soap for handwashing. This lack of adequate facilities compromises the ability to provide safe and quality care and places both those providing and those seeking care at considerable and preventable risk (WHO and UNICEF, 2017a). In Cambodia, although 91% of the health-care facilities had improved drinking-water systems, only 39% had sanitation facilities and only 15% basic hygiene facilities (WHO, 2017).

The WHO/UNICEF global action plan that was launched in 2015 aims at ensuring that all health-care facilities in all settings have adequate and safely managed WASH services by 2030. To realize this aim, global task teams composed of WASH and health professionals have been established to drive progress in four main areas: advocacy and policy, monitoring, evidence and research, and standards and facilities. Within all four streams of work there is a focus on national action and solutions, documenting lessons learned, and working jointly with health sector colleagues to drive change in key areas such as quality universal health coverage; maternal, newborn and child health; infection prevention and control; and antimicrobial resistance (WHO and UNICEF, 2017b). Achieving the target of universal coverage of health-care facilities with safely managed WASH services requires a huge effort. Such effort cannot even be determined quantitatively by the Western Pacific Regional Office as there is a lack of information for generating baseline statistics on this issue. Because there is little reliable information on the status of drinking-water and sanitation facilities in health-care facilities in the TWG WSH countries, it is desirable that future national surveys include questions and response categories on this subject.

7.3 The challenge of urbanization in TWG WSH countries The TWG WSH region has gone through rapid urbanization over the last 25 years. While the urban population more than doubled from 1990 to 2015, the rural population had a reduction of nearly 20% over the same period of time (Figure 31). The TWG WSH region, which was predominantly rural in 1990 (about 68% of the population was made up of rural residents), is now predominantly urban (about 56% of the population is composed of urban residents). Unfortunately, the JMP statistics do not capture information on the use of drinking-water and sanitation in peri-urban areas. Moreover, because of the urban-rural dichotomy, it is not clear whether the peri-urban areas are counted as urban or rural in national or global statistics. This issue will need to be resolved if a better characterization of risk groups and challenges is to be achieved. Figure 31. Urban and rural populations in the TWG WSH region, 1990 and 2015 2500

Population (millions)

2000 971 1500

Rural 1200

Urban

1000 1242

500 576 0

Source: UN (2014).

1990

Year

2015

References Hutton G (2012). Global costs and benefits of drinking-water supply and sanitation interventions to reach the MDG target and universal coverage. Geneva: World Health Organization (http://www.who.int/water_sanitation_health/publications/2012/global_ costs/en/, accessed 16 August 2017). IPCC (2014). Summary for policymakers. In: Climate change 2014: Impacts, Adaptation, and Vulnerability. Part A: global and sectoral aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. New York, NY: Cambridge University Press; 1–32 (http://www.ipcc.ch/pdf/assessment-report/ar5/wg2/ ar5_wgII_spm_en.pdf; accessed 16 August 2017). Lenton R, Wright A, Lewis K (2005). Health, dignity and development: What will it take? New York, NY: UN Millennium Project Task Force on Water and Sanitation. MoH and LSB (2012). Lao PDR Social Indicator Survey 2011-12 (Multiple Indicator Cluster Survey/Demographic and Health Survey). Vientiane: Ministry of Health and Lao Statistics Bureau (http://dhsprogram.com/pubs/pdf/FR268/FR268.pdf, accessed 16 August 2017). Prüss-Üstün A, Bos R, Gore F, Bartram J (2008). Safer water, better health: Costs, benefits and sustainability of interventions to protect and promote health. Geneva: World Health Organization (http://apps.who.int/iris/bitstream/10665/43840/1/9789241596435_eng.pdf; accessed 16 August 2017). UN (2014). World urbanization prospects: The 2014 revision [CD-ROM]. New York, NY: United Nations. UN (2015). Transforming our world: The 2030 Agenda for Sustainable Development. New York, NY: United Nations (https://sustainabledevelopment.un.org/post2015/ transformingourworld/publication, accessed 16 August 2017). UN (2017). Millennium Summit [website]. New York, NY: United Nations (http://www.un.org/ millenniumgoals/bkgd.shtml, accessed 16 August 2017). UN and WHO (2014). UN-Water Global Analysis and Assessment of Sanitation and Drinkingwater (GLAAS) 2014 – report: Investing in water and sanitation: increasing access, reducing inequalities. Geneva: World Health Organization (http://www.who.int/water_sanitation_ health/publications/glaas_report_2014/en/, accessed 16 August 2017). UNICEF (2012). Water, sanitation and hygiene (WASH) in schools. New York: United Nations Children’s Fund (http://www.unicef.org/publications/files/CFS_WASH_E_web.pdf, accessed 16 August 2017). UNICEF and WHO (2015). Progress on sanitation and drinking water – 2015 update and MDG assessment. Geneva: United Nations Children’s Fund and World Health Organization (http:// apps.who.int/iris/bitstream/10665/177752/1/9789241509145_eng.pdf?ua=1, accessed 16 August 2017).

WHO (2008). Guidelines for drinking-water quality. Third edition: Incorporating the first and second addenda. Volume 1: Recommendations. Geneva: World Health Organization (http:// www.who.int/water_sanitation_health/dwq/fulltext.pdf, accessed 16 August 2017). WHO (2013). World health statistics 2013. Geneva: World Health Organization (http://www. who.int/gho/publications/world_health_statistics/2013/en/; accessed 16 August 2017). WHO (2014). Preventing diarrhoea through better water, sanitation and hygiene: exposures and impacts in low- and middle-income countries. Geneva: World Health Organization (http://apps.who.int/iris/bitstream/10665/150112/1/9789241564823_eng.pdf; accessed 16 August 2017). WHO (2017). Achieving quality universal health coverage through better water, sanitation and hygiene services in health care facilities: a brief focus on Cambodia and Ethiopia. Geneva: World Health Organization (http://www.who.int/water_sanitation_ health/publications/uhc-thru-better-wash.pdf, accessed 16 January 2018). WHOandUNICEF(2013).Progressonsanitationanddrinking-water:2013update.Geneva:World Health Organization (http://apps.who.int/iris/bitstream/10665/81245/1/9789241505390_ eng.pdf, accessed 16 August 2017). WHO and UNICEF (2015). WASH POST-2015: proposed indicators for drinking water, sanitation and hygiene. Geneva: World Health Organization and United Nations Children’s Fund (http://www.who.int/water_sanitation_health/monitoring/coverage/wash-post2015-rev.pdf?ua=1/; accessed 16 August 2017). WHO and UNICEF (2017). WASH in the 2030 agenda: New global indicators for water, sanitation and hygiene. Geneva: World Health Organization and United Nations Children’s Fund (https://washdata.org/reports, accessed 17 August 2017). WHO and UNICEF (2017a). Progress on drinking water, sanitation and hygiene: 2017 update and SDG baselines. Geneva: World Health Organization and United Nations Children’s Fund (https://washdata.org/report/jmp-2017-report-final-en, accessed 16 January 2018). WHO and UNICEF (2017b). WASH in health care facilities: global action to provide universal access by 2030 [website]. Geneva: World Health Organization (https://www. washinhcf.org/home/, accessed 16 January 2018). World Bank (2017). GDP per capita (current US$) [website]. Washington, DC: World Bank (http://data.worldbank.org/indicator/NY.GDP.PCAP.CD, accessed 16 August 2017).

Annex Annex 1. Definitions of the post-2015 terms proposed by the JMP (WHO and UNICEF, 2017) Open defecation: defecation in which excreta of adults or children are deposited (directly or after being covered by a layer of earth) in the bush, a field, a beach or other open area; are discharged into a drainage channel, river, sea or other water body; or are wrapped in temporary material and discarded. Basic drinking-water service at home: households are considered to have a basic drinking-water service when they use water from an improved source (pre-2015 JMP definitions in rural areas; piped water into dwelling, yard or plot, or a standpipe/public tap or a tubewell/borehole in urban areas) with a total collection time of 30 minutes or less for a round trip, including queuing. Basic handwashing facilities at home: handwashing facilities, with soap and water, available near sanitation facilities and where food is prepared or consumed. Adequate sanitation facilities in schools and health centres: facilities that effectively separate excreta from human contact, and ensure that excreta do not re-enter the immediate environment. An adequate school or health centre sanitation facility: zz is located in close proximity to the school or health centre; zz is accessible to all users, including adults and children, the elderly, and those with physical disabilities; zz provides separate facilities for males and females (boys and girls at school), and for adults and children; zz is equipped with handwashing stations that include soap and water and are inside or immediately outside the sanitation facility; zz provides adequate menstrual management facilities in sanitation facilities that are used by women and girls of menstruating age; zz at schools, provides at least one toilet per 25 girls and at least one toilet for female school staff, as well as a minimum of one toilet plus one urinal (or 50 centimetres of urinal wall) per 50 boys, and at least one toilet for male school staff; zz at inpatient health centres, includes at least one toilet per 20 users; and zz at outpatient health centres, includes at least four toilets â&#x20AC;&#x201C; one each for staff, female patients, male patients and child patients. Basic drinking-water service in schools: water from an improved source on premises (in rural, pre-2015 JMP definitions; in urban, piped water into school, yard or plot or a stand pipe/public tap or a tubewell/borehole) capable of delivering sufficient water at all times for drinking, personal hygiene and, where appropriate, food preparation, cleaning and laundry. Basic drinking-water service in health centres: water from an improved source on premises (in rural, pre-2015 JMP definitions; in urban, piped water into health centre 37

yard or plot or a stand pipe/public tap or a tubewell/borehole) capable of delivering the minimum quantity of water that is required for different situations in the healthcare setting as defined by WHO (2008). Drinking-water points are accessible to all users, including those with disabilities, throughout the school day. Adequate menstrual hygiene management facilities in schools and health centres: facilities that provide privacy for changing materials and for washing hands, private parts and clothes with soap and water; include access to water and soap within a place that provides an adequate level of privacy for washing stains from clothes and drying reusable menstrual materials; include disposal facilities for used menstrual materials (from collection point to final disposal). Adequate handwashing facilities in schools and health centres: handwashing facilities, with soap and water, available inside or immediately outside sanitation facilities, where food is prepared or consumed, and in patient-care areas. Intermediate drinking-water services at home: households are considered to have intermediate drinking-water service when they use water from an improved source (pre-2015 JMP definitions in rural areas; piped water into dwelling, yard or plot, or a tubewell/borehole in urban areas) located on their premises, which delivers an acceptable quantity of water with only moderate levels of discontinuity (non-functional for no more than two days in the last two weeks), water quality at source meets a threshold of less than 10 colony-forming units (cfu) Escherichia coli (E. coliâ&#x20AC;&#x160;) per 100 millilitres year-round, and the water point is accessible to all household members at the times they need it. Adequate sanitation at home: each of the following sanitation facility types is considered as adequate sanitation for monitoring progress towards the household sanitation targets, if the facility is shared among no more than five families or 30 people, whichever is fewer: zz a pit latrine with a superstructure, and a platform or squatting slab constructed of durable material (a variety of latrine types can fall under this category, including composting latrines, pour-flush latrines, and ventilated improved pit latrines); zz a toilet connected to a septic tank; or zz a toilet connected to a sewer (small bore or conventional). Safe management of household excreta: the containment, extraction and transport of excreta to a designated disposal or treatment site, or the safe reuse of excreta at the household or community level, as appropriate to the local context. The share of households with safely managed excreta is defined as the fraction of households whose excreta: zz

are carried through a sewer network to a designated location (e.g. treatment facility); are hygienically collected from septic tanks or latrine pits by a suction truck (or similar equipment that limits human contact) and transported to a designated location (e.g. treatment facility or solid waste collection site); or are stored on site (e.g. in a sealed latrine pit) until they are safe to handle and reuse (e.g. as an agricultural input).

Mongolia

Malaysia

Lao People's Democratic Republic

Japan

Indonesia

China

Cambodia

Brunei Darussalam

Country

Urban population (thousands)

169 236 302 331 1408 2272 2846 3254 308 167 459 383 669 386 779 479 54 633 87 758 120 155 137 400 94 546 98 873 115 282 118 572 655 1184 2118 2712 9068 14 515 20 051 22 898 1246 1370 1833 2106

Year

1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015

88 96 98 98 7649 9951 11 519 12 423 857 262 821 045 690 435 622 108 124 000 121 180 120 521 118 309 27 703 26 842 12 070 8246 3589 4204 4277 4308 9143 8905 8225 7753 938 1028 880 817

Rural population (thousands)

0 3 7 8 3 4 4 5 7 8 10 11 0 0 0 0 1 2 3 4 4 4 4 26 30 31

3 16 34 42 48 59 71 76 35 47 57 61 100 100 100 100 28 59 71 86 91 95 96 48 57 60

10 2 0

9 5 3 6 3 0 0

8 6 2 3 42 33 24 18 18 14 10 8 0 0 0 0

Unimproved

Urban sanitation coverage (%)

16 11 9

62 34 23 4 2 1 0

89 75 57 47 7 4 1 1 40 31 23 20 0 0 0 0 66 86 94 90 93 96 96 65 65 66 66

19 43 74 88 68 75 83 87 61 66 70 72 100 100 100 100 3 4 4 4 4 4 4 31 32 32 32

3 6 10 12 5 5 6 6 8 9 9 10 0 0 0 0 8 3 1 5 3 0 0 3 2 1 1

13 8 1 0 24 19 11 7 12 9 7 5 0 0 0 0

Unimproved

Rural sanitation coverage (%)

23 7 1 1 0 0 0 1 1 1 1

65 43 15 0 3 1 0 0 19 16 14 13 0 0 0 0

26 37 43

17 45 56 83 88 94 96

0 10 24 30 40 50 59 64 24 34 44 47 100 100 100 100

18 26 30

1 1 2 4 4 4 4

0 2 6 7 2 3 3 3 6 8 11 12 0 0 0 0

21 5 -1

9 6 5 5 4 0 0

6 6 3 3 49 42 36 31 21 17 13 12 0 0 0 0

Unimproved

35 32 28

73 48 37 8 4 2 0

94 82 67 60 9 5 2 2 49 41 32 29 0 0 0 0

Change in proportion of population using improved Sharing Other unOpen sanitation from 1990 to Sharing Other unOpen Sharing Other unOpen Improved improved improved defecation Improved improved improved defecation Improved improved improved defecation 2012 (percentage points)

Total sanitation coverage (%)

Annex 2. Country and regional estimates of improved sanitation coverage in TWG WSH countries

10 350 13 067 16 309 18 469 30 101 37 238 42 288 45 173 31 732 36 607 39 701 41 031 3016 3918 5079 5619 16 649 19 570 29 270 33 952 13 958 19 716 27 064 31 384 575 698 795 707 1 091 684 1 242 380

Year

1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015

NA = not available Source: based on WHO and UNICEF (2015)

Region

Viet Nam

Thailand

Singapore

Republic of Korea

Philippines

Myanmar

Country

Urban population (thousands)

31 773 35 386 35 622 35 695 31 848 40 414 51 156 56 630 11 240 9370 8753 8719 0 0 0 0 39 934 42 773 37 132 33 449 54 952 61 172 61 983 62 003 1 200 119 1 182 366 1 042 671 970 558

Rural population (thousands)

Urban sanitation coverage (%)

Rural sanitation coverage (%)

62 77 80 57 64 70 74 100 100 100 100 99 100 100 100 87 91 93 93 36 53 70 78 53 62 73 77

17 6 4 14 8 4 1 0 0 0 0 0 0 0 0 0 0 0 23 23 21 16 31 25 17 13

9 11 12 14 16 17 18 0 0 0 0 0 0 0 5 6 7 7 2 3 4 5 4 5 6 6

Unimproved

12 6 4 15 12 9 7 0 0 0 0 0 0 0 0 8 3 0 0 39 21 5 1 12 8 4 4

79 83 84 69 72 76 78 100 100 100 100 99 100 100 100 89 89 90 90 65 77 88 94 75 79 84 87 0 0 0 10 10 10 10 4 4 5 5 5 6 6 7

12 13 13 17 17 18 19 0 0 0 0 0 0 0 0 1 0 0 7 8 7 1 16 12 8 4

7 3 2 7 5 2 0 0 0 0 0

Unimproved

2 1 1 7 6 4 3 0 0 0 0 0 0 0 0 1 0 0 0 24 11 0 0 4 3 2 2 86 92 96 96 29 45 62 70 42 51 60 65

56 74 77 46 56 66 71 100 100 100 100

4 4 4 4 2 3 4 4 3 4 5 6

8 10 11 12 14 17 18 0 0 0 0

0 0 0 0 26 27 27 25 40 34 28 23

20 8 6 19 12 4 1 0 0 0 0

Unimproved

10 4 0 0 43 25 7 1 15 11 7 6

16 8 6 23 18 13 10 0 0 0 0

Change in proportion of population using improved Sharing Other unOpen Sharing Other unOpen Sharing Other unOpen sanitation from 1990 to Improved improved improved defecation Improved improved improved defecation Improved improved improved defecation 2012 (percentage points)

Total sanitation coverage (%)

Annex 2. Country and regional estimates of improved sanitation coverage in TWG WSH countries (Cont.)

Malaysia

Lao People's Democratic Republic

Japan

Indonesia

China

Cambodia

Brunei Darussalam

Country

Urban population (thousands)

169 236 302 331 1408 2272 2846 3254 308 167 459 383 669 386 779 479 54 633 87 758 120 155 137 400 94 546 98 873 115 282 118 572 655 1184 2118 2712 9068 14 515 20 051 22 898

Year

1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015

88 96 98 98 7649 9951 11 519 12 423 857 262 821 045 690 435 622 108 124 000 121 180 120 521 118 309 27 703 26 842 12 070 8246 3589 4204 4277 4308 9143 8905 8225 7753

Rural population (thousands)

23 42 64 76 67 80 91 95 69 78 84 87 100 100 100 100 40 45 67 76 90 94 97 98

42 31 19 12 26 16 8 4 25 18 14 11 0 0 0 0 28 23 20 9 5 2 1

2 7 16 21 28 47 66 73 9 15 20 22 94 97 98 98 11 22 28 76 86 94 96

27 10 4 1 1 1 1

35 27 17 12 7 4 1 1 6 4 2 2 0 0 0 0

Surface water

Unimproved

Total (%)

Piped Total onto the improved household

Improved

34 57 86 100 97 97 97 98 89 91 93 94 100 100 100 100 70 72 82 86 95 97 100 100 37 56 64 88 93 99 100

15 32 61 75 78 81 85 87 25 28 31 33 97 98 99 99 23 16 14 5 3 0 0

40 26 8 0 2 2 3 2 10 8 7 6 0 0 0 0 5 2 0 0 0 0 0

26 17 6 0 1 1 0 0 1 1 0 0 0 0 0 0

Surface water

Unimproved

Urban (%)

Piped Total onto the improved household

Improved

22 38 59 69 56 71 86 93 61 68 76 79 100 100 100 100 34 38 60 69 86 89 92 93

0 2 5 7 11 29 46 55 2 5 8 9 86 91 95 95 3 4 5 6 65 74 82 86 29 26 24 12 9 6 5

42 33 21 16 35 23 12 5 31 26 20 18 0 0 0 0

33 14 7 2 2 2 2

36 29 20 15 9 6 2 2 8 6 4 3 0 0 0 0

Surface water

Unimproved

Rural (%)

Piped Total onto the improved household

Improved

Proportion of Proportion of population that population that gained access to gained access to improved drink- piped water into ing-water from the household 1990 to 2015 from 1990 to (percentage 2015 (percentpoints) age points)

Annex 3. Country and regional estimates of improved drinking-water coverage in TWG WSH countries

1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010 2015 1990 2000 2010

Year

1246 938 1370 1028 1833 880 2106 817 10 350 31 773 13 067 35 386 16 309 35 622 18 469 35 695 30 101 31 848 37 238 40 414 42 288 51 156 45 173 56 630 31 732 11 240 36 607 9370 39 701 8753 41 031 8719 3016 0 3918 0 5079 0 5619 0 16 649 39 934 19 570 42 773 29 270 37 132 33 952 33 449 13 958 54 952 19 716 61 172 27 064 61 983 31 384 62 003 575 698 1 200 119 795 707 1 182 366 1 091 684 1 042 671 1 242 380 970 558

Rural population (thousands)

NA = not available Source: based on WHO and UNICEF (2015)

Region

Viet Nam

Thailand

Singapore

Republic of Korea

Philippines

Myanmar

Mongolia

Country

Urban population (thousands) 53 56 63 64 58 67 78 81 84 87 90 92 91 93 98 98 100 100 100 100 87 92 96 98 63 77 91 98 71 82 91 94 100 100 100 100 29 38 51 57 9 15 24 27 31 45 58 63

87 93

26 23 24 24 5 6 8 8 25 33 40 43

Piped Total onto the improved household

Improved

0 0 0 0 11 7 4 2 21 12 6 1 22 14 8 5

20 24 30 32 15 13 14 14 12 9 7 5

0 0 0 0 2 1 0 0 16 11 3 1 7 4 1 1

27 20 7 4 27 20 8 5 4 4 3 3

Surface water

Unimproved

Total (%)

77 74 69 66 80 85 91 93 91 92 93 94 97 98 100 100 100 100 100 100 96 97 97 98 90 94 97 99 96 96 97 97

44 39 34 33 17 17 18 19 43 49 56 59 96 97 99 99 100 100 100 100 74 75 76 76 43 51 59 61 73 75 78 80

Piped Total onto the improved household

Improved

18 23 31 34 8 6 7 7 7 7 6 6 3 2 0 0 0 0 0 0 4 3 3 2 4 3 3 1 3 3 3 3

5 3 0 0 12 9 2 0 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 6 3 0 0 1 1 0 0

Surface water

Unimproved

Urban (%)

84 90 96 98 56 72 89 97 59 72 84 91

22 32 50 59 51 60 72 74 77 83 88 90 67 75 88

10 21 32 37 0 4 9 10 11 25 37 43

46 64

2 2 2 2 1 2 3 3 9 17 26 30

Piped Total onto the improved household

Improved

14 9 4 2 26 15 7 2 31 21 13 7

23 26 30 25 18 16 17 18 16 11 7 6

2 1 0 0 18 13 4 1 10 7 3 2

55 42 20 16 31 24 11 8 7 6 5 4

Surface water

Unimproved

Rural (%)

-2

Annex 3. Country and regional estimates of improved drinking-water coverage in TWG WSH countries (Cont.)

A summary of the WASH status in the TWG WSH region Sanitation statistics in TWG WSH region

Drinking-water statistics in TWG WSH region

As of 2015, about 1.7 billion people (77% of the TWG WSH region population) have access to improved sanitation – an increase of 82% from 1990.

As of 2015, nearly 2.1 billion people (94% of the TWG WSH region population) have access to an improved drinking-water source – an increase of 66% from 1990.

About 500 million people (about one quarter of the region’s population) still do not have access to improved sanitation.

Nearly 1.4 billion people now use piped water on premises, an increase of 150% from 1990.

Seven out of 10 people without improved sanitation facilities live in rural areas. About 82 million people still practise open defecation in TWG WSH region – three quarters live in rural areas. The TWG WSH region exceeded the MDG sanitation target by 1%. Despite this major achievement, one quarter of the region’s population still lacks improved sanitation. While the target in 2015 was 76%, the projected coverage is 77%. While nine countries met the MDG target for sanitation, four countries remain off-track. The JMP has no statistical information on coverage for Brunei Darussalam. About 70% of people in TWG WSH region who are not using improved sanitation live in rural areas – 65% are in China. Nearly 30 000 children under 5 years old in TWG WSH region die each year due to infirmities attributable to unsafe drinking-water, unsanitary excreta disposal and poor hygiene.

About 830 million people gained access to improved drinking-water sources since 1990. However, over 120 million people still do not use improved drinking-water sources. The TWG WSH region exceeded the MDG drinking-water target by 9%. The target in 2015 was 85% and the current coverage is 94%. Excepting Mongolia, all TWG WSH countries met the MDG target for drinking-water coverage. More than 70% of the population without improved drinking-water sources live in rural areas. Half of the people in TWG WSH region without improved drinking-water sources live in China. Drinking-water and sanitation coverage and under-5 mortality rates are linked. This report demonstrates that under-5 mortality rates drop dramatically as water and sanitation coverage increases.