Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, ...and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners.
Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health.
These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
This policy brief sets out key concepts, principles and practical implications for the Citywide Inclusive Sanitation (CWIS) approach. Rapid urbanization, aging infrastructure, and climate change are ...exacerbating a sanitation crisis. The focus of most urban sanitation interventions remains incremental expansion of centralized sewer infrastructure; little attention is paid to reaching the poor, long-term service provision, financial viability, or the public system functions required to achieve those outcomes. Meeting SDG targets requires a radical rethink of the urban sanitation sub-sector. Citywide Inclusive Sanitation offers this. This paper presents a public services framework, set out by the Gates Foundation, for pursuing equitable, safe and sustained service outcomes, at city scale. It reviews the genesis and evolution of the CWIS Framework and shares key principles and policy implications.
A growing body of evidence shows that there is a strong causal link between exposure to poor sanitation and detrimental health, human capital, and economic outcomes. At the same time a number of ...recent impact evaluations of specific sanitation interventions show mixed results. This heterogeneity in findings raises the questions of whether and how the demonstrated benefits of improved sanitation can be consistently achieved through regular project implementation. This paper attempts to show that the benefits of improved sanitation can be consistently achieved through investing in interventions that address the drivers of latrine use and by divesting from interventions that do not address the drivers of latrine use.
The urban population will rise to 6.7 billion by 2050. The United Nations has committed to provide everyone with safely managed sanitation, but there is limited understanding of the scale of the ...challenge. This paper describes a methodology for rapid assessment of sanitation in cities including a graphical representation (a shit-flow diagram or SFD) and reports on findings from implementation in 39 cities. The SFD provides high level information for planning purposes covering the entire sanitation system in a city. More than half of the human excreta produced in these cities is not safely managed. The most significant portions of the unsafely managed excreta are: (i) contents of pits and tanks which are not emptied and are overflowing, leaking, or discharging to the surrounding environment (14 per cent); (ii) contents of pits and tanks which are emptied but not delivered to treatment (18 per cent); (iii) faecal sludge and supernatant delivered to treatment but not treated (3 per cent); (iv) wastewater in sewers not delivered to treatment (14 per cent); and (v) wastewater delivered to treatment but not treated (6 per cent). Many cities currently relying on onsite sanitation for safe storage, particularly in Africa, will need new strategies as populations grow. Containment systems that discharge to open drains are common in some Asian cities; these pose a public health risk. Dumping of excreta is widespread and there is a lack of realistic performance data on which estimates of the extent and effectiveness of treatment can be made. The SFD production process can be challenging due to a lack of data and low technical capacity in cities. There is often uncertainty over terminology and over the status of infrastructure. Formalizing definitions for the SFD preparation process was found to be useful in overcoming capacity constraints in cities. The SFD produces a credible snapshot of the sanitation situation in a city. The paper provides evidence of the urgent need for improved management and monitoring of urban sanitation in cities around the world and highlights the role of the SFD as a planning tool.
The role of deliberation among citizens to determine and forge agreement on policy is often seen as a crucial feature of democratic government. This paper provides the first large-N empirical ...evidence on the credibility of voice in a deliberative democracy in an non-laboratory setting, using a unique dataset collected from transcripts of deliberation that occurred between January and September 2003 in 127 functioning village parliaments (gram sabhas) in Southern India. We exploit a natural experiment in the arrangement of India's state borders across ethnolinguistic lines that led exogenously to increased caste fragmentation and a reduced degree of consensus on public goods priorities. We then examine the patterns of deliberation. We reject the presence of pure cheap talk in both heterogeneous and homogeneous villages. Instead, we show that in caste‐fragmented South Indian villages, where there is less village-wide agreement on the relative importance of different public goods, the probability of an individual's highest priority being discussed increases as the household becomes more credible: its preferences approach the pivotal agent in a pure representative democracy, the median household. These effects are lower in ethnically homogeneous villages where there is greater consensus on the prioritization of public goods. Taken together, our results suggest that India's village parliaments, rather than being mere talking shops or being entirely captured by elites, seem instead to be both democratically representative and to be assigning roles to credible agents in their deliberative processes.
Socio-economic and demographic determinants of child growth at ages 0-5 years in developing countries are well documented. However, Precision Public Health interventions and population targeting ...require more finely grained knowledge about the existence and character of temporal changes in child growth associations.
We evaluated the temporal stability of associations between height-for-age z-score (HAZ) of children aged 0-59 months and child, parental, household, and community and infrastructure factors by following 25 countries over time (1991-2014) in repeated cross-sections of 91 Demographic and Health Surveys using random effect models and Wald tests.
We found that child growth displayed relatively more time stable associations with child, parental, and household factors than with community and infrastructure factors. Among the unstable associations, there was no uniform geographical pattern in terms of where they consistently increased or decreased over time. There were differences between countries in the extent of temporal instability but there was no apparent regional grouping or geographic pattern. The instability was positively and significantly correlated with annual changes in HAZ.
These findings inform about the generalizability of results stemming from cross-sectional studies that do not consider time variation - results regarding effects of child, parental, and household factors on HAZ do not necessarily need to be re-evaluated over time whereas results regarding the effects of infrastructure and community variables need to be monitored more frequently as they are expected to change. In addition, the study may improve the Precision Public Health population targeting of interventions in different regions and times - whereas the temporal dimension seems to be important for precision targeting of community and infrastructure factors, it is not the case for child, parental, and household factors. In general, the existence of temporal instability and the direction of change varies across countries with no apparent regional pattern.
Do self-help groups (SHGs), village-based associations designed to encourage savings, household production and social cohesion among the poor, meet their goals? We examine economic outcomes and the ...pro-social behavior of 540 households in a randomized control trial (RCT) of a SHG program (randomized at the commune level) in rural Siem Reap, Cambodia using survey data and a rich set of economic and social capital indicators. We measured social capital—defined as social norms and the social networks that support them—with household and network surveys and lab activities that gauge altruism, trust, trustworthiness and the willingness to contribute to public goods. We find that the program successfully increased participation in SHGs and strengthened SHG-related networks. As intended the program significantly increased the number of households with non-zero savings as well as savings levels and it led to a noticeable shift in household production towards livestock. We cannot document increases in household incomes, assets or expenditure. There were also no sizeable wider effects on social capital and networks other than those related to SHGs directly, although we cannot statistically rule out small positive effects in the case of some social capital indicators. In addition to these empirical findings the study provides an example of innovative program evaluation techniques that employed a field experiment, lab-in-the-field behavioral measures, network measures as well as traditional survey measures.
...interventions often demand a large investment of time and financial resources from those least able to bear the costs, and underestimate or overlook the structural challenges faced by people ...living in poverty. ...the true costs of these so-called low-cost approaches are often born by women as the de-facto water managers or caregivers who are tasked with additional responsibilities, reinforcing gender inequalities.14 International attention focuses almost exclusively on low-income and middle-income countries (LMICs), suggesting WASH is no longer a truly global concern. ...the cost of achieving universal access to at least safely managed WASH services will be immense but so too are the potential benefits. ...the Commission will make concrete recommendations for reform focused on the establishment of national systems that are capable of both professionalised delivery of WASH services for all and responding to key challenges such as climate change and rapid urbanisation.
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