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Editor's Note: This post discusses the work of Water & Sanitation for the Urban Poor (WSUP) in Zambia to improve sanitation in low-income communities by trialing a pit-emptying service operated by a community-based organization. This post originally appeared on WSUP's blog, to view the original post please click here.

Providing sanitation services to unsewered parts of a city is complex. The challenge goes way beyond simply building toilets – its about finding financially viable ways to collect, treat, and dispose of waste.

WSUP’s new film tells the story of our work in Lusaka, Zambia, to improve sanitation in low-income communities by working closely with the utility, micro-enterprises, residents, and community-based organisations.

Because sewers haven’t been built where they live, low-income residents have to dig a pit for the waste from the toilet. When the pit fills up, residents have to dig another pit or empty the waste out by hand, sometimes dumping it illegally. This is clearly an unsustainable practice, made worse by the fact that in the rainy season, many of the pits flood – spreading faecal waste across the residential area.


So to tackle this, in Lusaka we’ve been trialing a pit-emptying service for low-income customers, operated by a community-based organisation, the Kanyama Water Trust in partnership with the Lusaka Water & Sewerage Company. The service enables customers to have the sludge from their pits safely transported to a treatment facility, where it is processed and safely disposed of or resold as a soil conditioner and fertiliser.

So far, the scheme has benefited 25,000 people, such as Shawa Margarete, who lives in Kanyama, one of the pilot communities. Shawa (pictured below) says in the film that she is positive about the benefits that the service brings: “The service is worth the money that we pay for it”, she says. Mbewe Brown agrees: “This has really made our lives easier, because we had a really big problem and now, with the pit emptiers we have a service which is easily available,” he says.


But the model still needs work. The service is generating income, but is not yet covering costs of collection, treatment and disposal. This is vital to achieve if the service is to be expanded to other urban communities in the country.

“Our priority at WSUP now is to see how this current model can be improved so that it can become more financially viable – because when it does so, we will be able to recommend it for scale up to other low-income communities,” says Reuben Sipuma, WSUP Zambia country programme manager.


This film was produced in partnership with Sandec, the Department of Sanitation, Water and Solid Waste for Development at Eawag. It will feature in Eawag’s new online course on Planning and design of sanitation systems and technologies. To sign up for the course, click here.

Editor's Note: In this post, Guang Z. Chen, Senior Director of Water Global Practice at World Bank Group, discusses the role of World Bank and its partners in meeting the water-related challenges facing our world. This post originally appeared on The Water Blog of the World Bank Group, to view the original post please click here


To many people, it is a surprise to learn that in an age of such advanced technology, at least 663 million people still lack access to basic needs, like safe drinking water, or that 2.5 billion people lack access to sanitation, such as a toilet or latrine. And while much progress has been made, receiving safe drinking water 24 hours a day, seven days a week simply by turning a tap is still a dream for many in the developing world.
Even fewer realize this is not just a problem for families, but also for those on which families rely and that also need water: the farmers who grow the families’ food, the environment that protects and sustains their homes and communities, the businesses that employ them, the cities that house them, the schools that educate their children, the clinics and hospitals that treat them, and even the power plants that generate their electricity.
Why does this challenge persist? How can this challenge be met? And an increasingly urgent question: is there enough water to go around?

Water is becoming increasingly scarce, including in places where it was once considered plentiful. Meanwhile, extreme water events, such as floods and droughts, are increasing in frequency and intensity because of climate change. Further, cities are growing faster than ever, which means more demand coming up against a decreasing supply.
This is an urgent challenge. Business as usual will see some areas lose up to an additional 6 percent off of their GDP growth by 2050. Something has to change.
I recently assumed the role as head of the World Bank Group’s Water Global Practice (GP)to help countries do just that. With a portfolio of roughly $35 billion in 170 water related projects globally, the World Bank Group is the largest external financier of water related development projects. In response to demand from countries for support in implementing these changes — in the form of Sustainable Development Goals (SDGs) related to water — we will leverage this portfolio and draw on a team of over 300 experts from 78 nationalities based in nearly 60 countries around the world to help our clients identify options for economically, environmentally and socially sustainable solutions tailored to their context. Success will require a focus on institutions, information, and infrastructure.
We will do this working with the United Nations, civil society organizations, the High Level Panel on Water, and other sectors like agriculture, environment, energy, urban development, and the climate policy community to help countries bring about that change in a way that acknowledges the right to water and sanitation for all, the value of water and water-related services, in behavioral, cultural, and economic terms, and the role of water in climate change adaptation and mitigation.
Today, many people have the false perception that freshwater resources are infinitely available and therefore of lesser value. This leads to behaviors like overconsumption and poor services. Given this, it is important to recognize the call to action by the High Level Panel on Water (HLPW), which met for the second time a few weeks ago at the UN General Assembly in New York. At that meeting led by World Bank President Jim Yong Kim and UN Secretary-General Ban Ki-moon, the HLPW launched an action plan to mobilize the global community around SDG 6 and related targets. I echo their call for a fundamental shift in the way the world thinks about and values water, with the vision of a future where individuals and societies automatically make better decisions with respect to water and how it is used and allocated.
However, I also believe donor support is one piece of a larger puzzle. Countries need support from their leaders, citizens, and neighbors to bring about this kind of change in mindset towards water stewardship.
At the World Bank Group, with an eye towards ending poverty by 2030 and promoting shared prosperity, we will do our part working with partners to drive towards the water related SDGs and continue building support for this change to encourage the political will and financial resources needed to help countries meet their targets with home grown, scalable, and sustainable solutions.
I am glad to see the Water GP has advanced in an area for which I have advocated for some time: connecting the water supply and sanitation subsector to broader water resources management. I also believe it is increasingly impossible to separate the Water agenda from the urban agenda, just as we cannot separate the climate and Water agendas. There is much we can do on Integrated Urban Water Management to help countries tackle these challenges.
Similarly, it is increasingly difficult for countries to separate water from agriculture, environment, energy, health, and others, which all rely on water. We’ll work closely with our colleagues in other GPs at the World Bank Group to help identify cross-sector solutions that could help our country clients leapfrog ahead.
We must also work hard to ensure focus on global trends does not take focus away from trends like slow progress in ending the practice of open defecation. Sanitation was the most off track of the MDGs, so we must continue the focus on the SDG targets for water supply and sanitation. In addition to our work on rural sanitation, we are intensifying our efforts on urban sanitation and fecal sludge management.
Thanks to support from bilateral donors, we will continue to supplement Bank operations with thoughtful analysis, cultivated partnerships, and advocating for high level support on issues like sanitation and climate change, which we hope will help us continue to be a reliable, effective partner for our clients.
Looking ahead, I do believe it is possible to achieve much together with our eyes set on the World Bank's twin goals of ending extreme poverty and boosting shared prosperity and the SDGs related to water. I look forward to hearing feedback from you during this journey together. 

Editor's Note: In this post, Eve Mackinnon, a researcher working on innovative responses and evidence-based solutions to the sanitation crisis, discusses how WASH programs in nurseries or child care centers could protect child health. Eve is a water, sanitation and hygiene practitioner with over five years of hands–on emergency humanitarian response experience across Asia and Africa. Her current research focuses on more effective, sustainable and safer sanitation management, across the entire sanitation service chain to deliver positive changes to the way that human waste is managed. 


Although global death rates of children under five resulting from diarrheal disease has fallen from a global high of 1.2 million in 2000 to 500,000 in 2015, it still represents the second leading cause of morbidity for this age group. These deaths are mainly preventable; 88% of them are attributed to a lack of access to water, sanitation and hygiene (WASH). The significant decrease in the last 15 years is a major achievement largely due to improvements in access to better quality drinking water, toilets, and better hygiene and care practices. These changes prevent young children being infected with harmful microbes that come from drinking dirty water and living in dirty environments, and contracting severe diarrheal diseases, which without sufficient treatment or in vulnerable children ultimately leads to death. 

Of course diarrhea is not the only threat to infant and young children. Ongoing research indicates that the same WASH factors that lead to diarrhea, also lead to stunting and malnutrition in young children. This is because low level of exposure to harmful microbes damages the intestinal tract and prevents proper absorption of nutrients in children. Infants and children under five are more vulnerable to being infected by microbes and get ill far quicker. From a health perspective, the targeting of effective WASH infrastructure is crucial to reach the most vulnerable groups.

Provision of WASH programs for vulnerable children whilst at nurseries or child care centers could be the most efficient way to protect their health. In Naivasha whilst researching risks of diarrheal disease for my PhD case study, I was shown Vision Nursery. The nursery cares for on average around 40 children in one small room. There is no drinking water provision, only water stored in containers from a tap stand. The nursery has access to a child adapted toilet (a container based toilet, provided by Sanivation), a positive step in WASH provision, however, without handwashing or regular cleaning the use of the toilet carries its own risks. Moreover, the nursery is also host to resident chickens, which are major carriers of harmful bacteria and co-habitation with people is linked to malnutrition and stunting in children according to recent research. The mud and rough concrete floor means cleaning and hygiene is difficult to maintain. There is inadequate space and utensils to safely prepare the childrens’ meals, and food cannot be re-heated or stored in secure containers.

Despite all of these shortcomings, the nursery provides an essential service. The female entrepreneur who started Vision Nursery has been running it for almost seven years and rents the small space. She is constrained by small margins, high rents, and lack of borrowing power. Her operation is linked to the Kenyan flower industry- a global success story of export growth. Naivasha is an epicenter of this booming export center for flowers, and it is driven overwhelmingly by a female workforce.  The associated employment opportunities allow women to gain a regular income with positive consequences of independence, empowerment, and rising equality for women in Kenyan society. An unintended consequence of female empowerment is the growth in a secondary industry of local nurseries and childcare. There are little to no regulations for nurseries in Kenya, and if they do exist,  they are not enforced. This allows for poor standards to exist, particularly in regard to WASH provision.

Potential baby WASH strategies to combat infection at the nursery level focus on robust barriers to specific exposure pathways that are specific for infant behaviours. For example, ingestion of pathogens occurs indirectly when children place contaminated objects in their mouths. Termed ‘mouthing’ it is responsible for almost 90% of a child’s exposure in one study.

Other direct exposure pathways include placing of hands directly into mouths and touching dirty floors. It’s important to regularly disinfect toys and maintain hygienic floor surfaces—possibly through use of mats or plastic, washable floor covers. Informed WASH strategies should be developed which can identify a broad range of baby-specific exposure routes. Indeed these indirect routes may be far more of consequence for children than direct routes of drinking contaminated water and food, which are traditionally the focus of WASH household campaigns.

The safe disposal of faeces remains the primary barrier to prevent dispersal of pathogenic bacteria in the environment and subsequent exposure routes. Despite a recent systematic review of health impact from sanitation intervention that concludes there is a lack of robust evidence, provision of safe sanitation is ultimately necessary to reduce contaminated environments that occurs as a result of open defecation.

In addition to focusing on specific prevention strategies at the nursery level, it is also crucial to increase integration between WASH, early childhood development (ECD), nutrition, and maternal newborn and child health (MNCH) programming. In addition, it’s important that outcome and impact monitoring is not uniquely focused on reduction in diarrheal disease. Impact monitoring and value for money evaluations should also explore targets that are linked with nutrition, undernutrition, and height and weight. It is notoriously difficult to link specific WASH interventions with impacts, without radnomised controlled trials, due to the huge variety of exposure pathways and variables that exist.

The WASH and sanitation sector might consider moving its focus from mostly household WASH and school sanitation to specialist WASH needs during infant care. If children survive the first year they are less vulnerable to further infection or severe outcomes. Therefore, intentionally focusing on activities at this juncture, as well as better integrating our efforts with other sectors—as the new does—could have an enormous impact on child health.

Editor’s Note: In this post, Amy Pickering (Stanford University) and Clair Null (Mathematica Policy Research), co-principal investigators of the Povu Poa Project in Kenya, describe how with funding from the USAID Global Development Lab’s Development Innovation Ventures program, they teamed up with Innovations for Poverty Action, and using a human-centered design process developed a new handwashing station for settings that lack piped water. In this article, the authors describe its methods and preliminary findings. This article was cross-posted with permission, to view the original article please click here.

A member of a focus group in Kisumu, Kenya, provides user preference input for a handwashing station customized for areas without access to piped water. Photo Credit: Noel Wilson

A member of a focus group in Kisumu, Kenya, provides user preference input for a handwashing station customized for areas without access to piped water. Photo Credit: Noel Wilson

The theme of this year’s Global Handwashing Day on October 15, 2016, was “Make Handwashing a Habit!” In places without access to piped water, new products and technologies are needed to make handwashing with soap convenient enough to become a habit. Handwashing with soap is a powerful weapon against diarrhea and respiratory illness, the leading causes of death among children under 5. It is estimated that handwashing with soap could save 1 million lives annually. Unfortunately, only 19 percent of the global population wash their hands with soap after contact with feces.

raditional handwashing with a basin. Photo Credit: Amy Pickering

raditional handwashing with a basin. Photo Credit: Amy Pickering

Without access to water on tap in the home, handwashing is inconvenient — using one hand to pour water over the other is awkward and requires more water than washing two hands together. Moreover, if everyone followed the standard recommendations about how often to wash their hands (after defecation, before cooking, before eating), women and children would likely have to spend more time fetching water from sources outside the home. Soap is another challenge — if left at locations where handwashing would ideally occur (near latrines, cooking areas, and eating areas), it is vulnerable to being wasted by children or stolen.

We set out to design a water- and soap-conserving handwashing system that could address the barriers faced by millions of people who don’t have access to piped water in their homes. We wanted it to be adaptable for a variety of contexts, ranging from space-constrained urban dwellings to schools with hundreds of students. For plastics manufacturers to produce it, the system needed to be a desirable product that consumers would want to buy. Our goal was to seed the market with a good idea and then let the private sector take over.

From Boring Bar Soap to “Cool Foam”

With funding from the USAID Global Development Lab’s Development Innovation Ventures program, our team of researchers from Innovations for Poverty Action partnered with engineers from Catapult Design to invent an innovative, appealing, and practical new handwashing station in Kenya. Using a human-centered design process, we started by holding focus groups and tinkering around with available handwashing products — buckets, pitchers, and tanks with taps — trying to locate features that would create value for a handwashing product. We watched people wash their hands using different types of handwashing stations and soap, interviewed them about their experiences, and engaged them in games and activities to reveal preferences that they might not have thought to explain.

Testing prototype handwashing stations in Kisumu, Kenya. Photo Credit: Noel Wilson

Testing prototype handwashing stations in Kisumu, Kenya. Photo Credit: Noel Wilson

We then brainstormed a large number of new concepts for handwashing products. We focused on water-frugal devices and soapy foam dispensers rather than regular soap or soapy water. We invited households to test out our models, lining up multiple options of water and soap dispensers side by side so we could see how users interacted with them and hear their opinions.

After several months of this exploratory and iterative design phase, we honed in on several key user design preferences: soap security, affordability, and adaptability. Ultimately we developed what is now branded as the Povu Poa, or “cool foam” in Swahili. The product comes in a pipe model, which can be hung from a tree or nail in a wall and is very portable. There is also a bucket model, which captures the runoff and has a larger capacity but is more cumbersome to move around. Both models incorporate a water-frugal swing tap that allows only a small amount of water to flow and a foaming soap dispenser. The dispenser transforms 5 grams of powdered soap and 250 milliliters of water into 100 handwashes, and both systems can be locked into place to reduce theft.

Povu Poa handwashing stations, as bucket (left) and pipe (right) models. Image Credit: Noel Wilson

Povu Poa handwashing stations, as bucket (left) and pipe (right) models. Image Credit: Noel Wilson

Importantly, the Povu Poa reduces the everyday cost of handwashing by more than half compared to conventional systems because of its exceptional soap and water efficiency. In Kenya, the cost of soap and water is only $0.10 per 100 handwashes using widely available powdered laundry detergent to make the foam. The Povu Poa is also adaptable to institutional settings; for example, the pipe model can be connected to large tanks for higher water storage capacity.

Prospects for Scale-Up

To understand the price that Kenyan households are willing and able to pay for the Povu Poa, we marketed and offered the products for sale to 200 households at varying price points. We also contracted a local Kenyan firm to create a logo and messaging for marketing the Povu Poa. We found that 78 percent of households bought the product at a price of $4, while approximately one-third (35 percent) bought it at $8. When offered side-by-side, the bucket model was more popular than the pipe, perhaps because it has a more familiar appearance or because it has a larger capacity.

Interestingly, among consumers who were only offered the pipe model, sales were almost identical to the bucket model and there is evidence that suggests some consumers would purchase the soap foamer alone. Even though the current estimated price point of a mass-produced Povu Poa is slightly higher at $12, we were very encouraged to see this real demand for a convenient and efficient handwashing system in Kenya. Notably, the Povu Poa could pay for itself with soap and water savings in 2.5 years for a family of five.

Currently, the Povu Poa is being field tested in 30 schools and health clinics in peri-urban Kenya to see if the product can increase handwashing rates among students, teachers, doctors, and nurses. We will use these longer-term evaluations to refine the product design and continue mass production discussions with plastic manufacturers in Africa.

“Foam is exciting,” said one head teacher, capturing a typical user reaction to the Povu Poa system. “It won’t be wasted.”

Editor's Note: In this post, Georges Mikhael, Head of Sanitation at Water & Sanitation for the Urban Poor (WSUP), explores the importance of government buy-in for improving sanitation.


I think I may have recently witnessed a real toilet revolution! As Water & Sanitation for the Urban Poor’s (WSUP’s) Head of Sanitation, a general poop enthusiast, and having been born on World Toilet Day, I hope you can understand how exciting this is for me.

I recently visited Visakhapatnam (‘Vizag’ for short) for the second time to support the WSUP Advisory India team in their implementation of a USAID project supporting the Greater Visakhapatnam Municipal Corporation (GVMC). Vizag is the largest city in Andhra Pradesh state, found on India’s eastern coast.

The project aims to improve sanitation across the whole city – eliminating open defecation and making sure that all residents have access to a toilet.

Since my first visit, I found an unmistakable urgency and energy in the way sanitation is being tackled in India by different institutions as a result of Prime Minister Modi’s commitment to Swachh Bharat Abhiyan, a national campaign to clean up India in time for Mahatma Gandhi’s 150th birthday on  October 2, 2019.

I had heard reports from my Indian colleagues about the speed at which authorities are making decisions on sanitation issues, and I had seen maps showing the rapid progress being made on the ground - a lot of toilet building!

But this urgency only really hit me once I got out to the Bnr Nagar community in Vizag. Everywhere I looked, literally every few steps I took, there was a toilet at a different stage of construction. I wasn’t taken to this community because it represented a standout example of progress on construction of toilets – there are plenty of other communities just like it around the city.

Of course, constructing toilets is just one part of improving sanitation, but GVMC, supported by WSUP, is already looking at the next steps, including how to deal with the challenge of emptying toilets on the hillsides around Vizag.

At WSUP, we always talk about this so called ‘enabling environment’, and how important it is to making progress in sanitation. It is core to our theory of change; it’s in all of our national business plans. But it can be hard to grasp what it actually is, and how to make it more effective.

It was obvious to me during this trip that an important part of the enabling environment is without a doubt government spending: the Government of India’s 2016 budget for the Swachh Bharat was US$ 1.3 billion. That’s about $1 per person across the country in just one year. As WaterAid’s recent study of East Asian countries has shown, it is obvious that commitment by political leadership is a major factor for improving access to safe sanitation.  

What could be done in Maputo if $1 per resident per year were spent on sanitation by the municipal authority? Lusaka? Freetown? Without a doubt, we could make much more rapid progress on Sustainable Development Goal 6 if this level of government buy-in were replicated around the world.

So if you’re curious what a real toilet revolution looks like, if you want some inspiration, consider a trip to Vizag. Maybe bring an aspiring politician with you.

Editor's Note: In this post, David Kreamer, Professor of Geoscience, a Graduate Faculty member in Civil and Environmental Engineering, and past Director of the interdisciplinary Water Resources Management Graduate Program at the University of Nevada, Las Vegas, offers suggestions for the hydrophilanthropist wanting to make a positive impact on communities and ecosystems.

Northern Ghana. Photo Credit: David K. Kreamer

The Challenge

Say you wanted to put in a well in a small community that needed water, in an economically depressed part of the world. You did your homework on how a well could be built for sustainable, good quality water. You gathered the resources, knew the well would not dry up nearby springs because you understood the local hydrogeology, and had a pump design that could be supported by the community and repaired if broken in the future. You set up a system for the community to periodically test the water quality, ensuring it would remain safe.  Sounds perfect, right?

But what if that well was placed in the backyard of someone in the community that everyone disliked? You may have just started a local water war that could last generations. 

There are a multitude of ways that a well-meaning hydrophilanthropic person or group, with clear objectives and an eagerness to improve the human condition, can make things worse. Rather than alleviate suffering, imprudent actions can reduce the quality of community life, and individual health and safety. Plunging unawares in one of countless pitfalls is surprisingly easy, particularly for those lacking a holistic view and having little background in water projects.

Perspectives and Strategies for Getting It Right – Some Suggestions

Water can help both communities and ecosystems by propelling agriculture and economic growth, ensuring improvements in health, reducing work absenteeism,  increasing opportunities for childhood education (which is sometimes gender-biased against girls who gather water), and  combating the effects of drought and climate change. 

As many readers know, statistics suggest that the water and sanitation crisis will expand.  Estimates related to water scarcity indicate that approximately 3.4 million people, over half of which are children, die from lack of clean drinking water each year, and 748 million people do not have access to clean water. In addition to direct mortality from thirst and waterborne disease, mortality could be even greater because of cascading effects, such as death from malnutrition caused by water shortages to agriculture and herd animals. Sanitation statistics are even worse with the World Bank (2014) estimating 2.5 billion people don’t have access to improved sanitation and 1 billion practicing open defecation.

Here are a few suggestions for the hydrophilanthropist wanting to make a positive impact on communities and ecosystems:

  • Take a long term view. Studies support the idea that fewer, sustainable water and sanitation developments are more beneficial than numerous, short-lived developments which can be neglected and fall into disrepair.  
  • Ensure follow up and sustainability. Make sure there are local resources, expertise, and educational programs for continued project viability. Consider regular sustainability audits.
  • Plan a post-project monitoring program, with community-based stewardship. Try to anticipate multiple outcomes for your project, and think about future, mid-course corrections (create Plan B, and maybe C and D).
  • Ensure that those who use water or sanitation facilities will be physically safe and secure. This may involve carefully planning the location of and access to facilities.
  • Also when considering location, make sure the science and engineering are right. Get experts and/or facilitators involved.  Wells that are too close to pit privies can cause disease. Wells that are hydrologically connected to springs or other wells could dry them up. A borehole in the wrong geologic media could have an adverse water quality that could poison people, domestic animals, and wildlife.
  • Seek engineering designs for wells and other facilities that are the appropriate technology for the community.  Sometimes low-tech is the right tech.
  • Include community education for two reasons. First, so outside people wishing to help a village can be educated by the community to understand local needs, cultural wealth and values, existing local resources, economic goals, religious appreciations, and identify gaps in human and physical resources. Second, outside people can work with locals to bring in additional educational resources, help establish  household education and action plans, and  explore possible connections and collaborations with nearby schools and universities.
  • Work with the local community to understand the social and moral norms. Research culture and traditions prior to your arrival, and ensure language translation accurately communicates ideas. It is not advantageous to impose pre-conceived values on a community. Pre-planning and pre-construction site visits can be key to establishing trust, understanding, and rapport.
  • Be aware of the political landscape. Be cognizant of the impacts of any local policies and laws, note any corruption and unrest, appreciate positive community resources, and determine how hydrophilanthropic work might best fit in. 
  • Know the impacted population’s goals for economic development and specifically how a water or sanitation development can strategically help boost economic growth. Think about how your project fits into a livelihoods-based approach to community development.
  • Seek experienced project leadership for hydrophilanthropic efforts. Water and sanitation efforts with strong leadership, mentoring, technical expertise, and continuing communication among practitioners and stakeholders typically have built-in resilience, underlying confidence, and the perspective provided by that experience.

Keeping some of these principles in mind can direct hydrophilanthropy in a positive way and increase the efficacy of water and sanitation projects. 

More information can be found at:

Editor's Note: In this post, Anita Zaidi, Director of the Enteric and Diarrheal Diseases (EDD) program at the Bill and Melinda Gates Foundation, discusses how we can use data-driven approaches to defeat diarrheal diseases. This post originally appeared on Huffington Post, to view the original article please click here

When I was a young girl in Pakistan, my mother would remind me daily to only drink boiled water. We almost lost my sister to severe diarrhea and my mother was determined to make sure this didn’t happen to our family again.

Back then, I didn’t fully understand her. It wasn’t until years later, when I became a pediatrician and a child health researcher, that I realized how deadly watery stools can be.

Unlike for adults, the rapid loss of liquids caused by severe diarrhea can bring children and babies to the brink of death in a matter of hours. Last year alone, over half a million children under five died from diarrheal diseases - that’s more than one every minute. And for those that survive, the resulting rapid dehydration and metabolic disturbances can lead to long-term damage to the gut and increased risk of malnutrition.

The sad truth is that the ripple effects of something as seemingly simple as a case of childhood diarrhea often extend far beyond health: children miss out on school, treatment costs can drive their families into poverty and in many countries, nursing a sick kid back to health can use up resources that are needed for other essentials like food or education.

Shockingly, although the illness touches almost every family on the planet at one time or another, the primary bugs that cause diarrhea remained obscure until recent years.

In the early 1900s, many members of the scientific community accredited causes as varied as changes in seasons, feelings of panic, teething or capillary restriction. And while we’ve known for decades that water, sanitation, hygiene, bacteria, viruses and parasites play a role in diarrhea, it wasn’t until 2013 - when the Global Enteric Multicenter Study (GEMS) released - that we were able to identify the top four culprits.

The study, which looked at 22,000 kids across seven countries in sub-Saharan Africa and South Asia, was game-changing. Not only did it identify the pathogens that cause half of all cases of diarrhea in developing countries, it also singled out the biggest offender: rotavirus.

Based on the study, the global health community rallied behind prioritizing the need to get children life-saving rotavirus vaccines. But even so, we still had an imprecise understanding of these bugs.

That changed a few days ago.

The Lancet just published a reanalysis of samples from GEMS. The updated study looked at the same samples as before, but used more sensitive and advanced diagnostic methods that were able to identify the cause of diarrhea for approximately 90% of all the cases. For the first time in human history, we can identify almost all of the bugs that cause diarrhea - and what you can identify, you can prevent.

While the updated study confirmed that rotavirus remains one of the top causes of diarrheal diseases, we also learned that a bacteria unrecognizable by most, Shigella, is responsible for more illness than we previously thought.

In a world where cholera, typhoid and dysentery are well known as common diseases, it turns out that the greatest killers of children have almost no name recognition amongst parents or policymakers.

So what can we do?

For starters, most children can be saved with the solutions we have today and raising awareness of these is key. My mom was right, boiling drinking water is essential in many parts of the world. But we can also prevent diarrheal disease by improving immunization rates, community sanitation practices and encouraging moms to exclusively breastfeed throughout early infancy to build babies’ immune systems.

Furthermore, increasing access to prevention and treatment tools is critical to give all children the chance they deserve. It is essential to make sure that life-saving oral rehydration solutions and zinc therapy are quickly available.

Vaccines for Shigella don’t yet exist but are being studied and developed by scientists, and we need to support and speed up that research. However, vaccines for rotavirus are available now, and we need to make sure every child in the world gets them. Since 2013, the number of countries that have introduced rotavirus vaccines into their national immunization programs has increased from 17 to 81. Despite this, only 15% of the children in the world’s poorest countries have access to it.

There is much to do, and scientists, while mighty, cannot do it alone. Governments have a pivotal role to play to ensure children everywhere have access to these lifesaving tools. This will require increased political will including increased financial commitments and policies that prioritize child health.

Every child should have the opportunity to live a long, healthy and productive life - and it’s up to us to make sure they have that chance.

Editor's Note: In this post, Vincent Masterson, an International Education & Training Advisor at CAWST, discusses the importance of training people how to be effective WASH promoters in order to achieve real behavior change in communities. This post originally appeared on CAWST's blog, to view the original post please click here


When designing training, program managers often include only technical knowledge. Subject matter knowledge is essential, but developing skills to present and communicate information, relate to target audiences, and disseminate complex information for the purpose of learning are equally important.

Take the case of Community WASH Promoters. They certainly need to know how to treat water, how to collect rainwater safely, how to build a basic latrine, and to understand the importance of handwashing. To be effective in their role’s objective of achieving behaviour change in their communities, however, it is also crucial for them to have interpersonal and observational skills. They need to identify WASH issues in a household, effectively deliver key messages using education materials, actively listen, ask questions, and fill out forms.

We have spent 15 years listening to our clients who work with Community WASH Promoters and collected learnings from program managers about what has worked and what has failed in the implementation of their programs. Across continents and cultures, one of the top challenges they have shared is getting people to change their behaviours. Although WASH organizations clearly see the link between improved WASH and improved health, this is not always the case for community members.

We have listened to our clients’ challenges and designed a new Community WASH Promotion workshop. In addition to WASH technical knowledge, it teaches participants how to be effective WASH promoters, and provides them the forum to practice that role in a safe simulation setting.

Only one-third of our Community WASH Promotion workshop covers technical knowledge of WASH. The rest of the time is allocated to preparing participants to perform their role effectively. The entire first day of the training is used to prepare Community WASH Promoters to think critically about the reasons why community members may have difficulty, or may not want, to change their behaviour and adopt healthy WASH practices. They learn how to actively listen to understand the needs of community members, and then practice on-the-spot modifying their key messages to meet those reasons.

Two important traits of being an effective trainer are: 1) Delivering the information in such a way that it is relevant to the experience of the learner; and 2) Creating the opportunity for the learner to use the newly acquired knowledge and skills in real life. We use the Kirkpatrick framework in our instructional design process, which gives us the ability to focus on the behavioural outcomes of how the learner will use the information in real life. Community WASH Promoters will be much more effective in their role if they are given the opportunity to practice and receive feedback on their performance in that role.

The implications of this instructional design approach are profound. As program managers, we need to assess not the knowledge of the Community WASH Promoter, but their ability to create positive behaviour change and impact in their communities; and the way this workshop was designed, does exactly that. This workshop focuses on the result of their work, rather than their knowledge.

CAWST’s new Community WASH Promotion workshop will be piloted in Kenya in October.

Editor's Note: In this post, Edson Monteiro, a WASH Project Officer at UNICEF Angola, highlights UNICEF's partnership with Andrex to bring a Community Led Total Sanitation (CLTS) programme to rural villages in Angola. This post originally appeared on UNICEF's site, to view the original post please click here.


© Karin Schermbrucker. Eugenia, 11, washes her hands after learning about sanitation and hygiene during a ‘triggering’ meeting in Calipanguela Village, Angola.

I recently returned from a trip to visit rural villages in Angola to look at the impact that UNICEF’s sanitation partnership with Andrex is having on children and families there. It’s incredible to think that seven out of ten people living in rural Angola do not have a clean, safe toilet to use. This has a huge impact on the health of Angola’s children and is one of the reasons the country has the highest rate of child mortality in the world.

As I began my journey into the heart of Angola, I visited villages that were in different stages of learning about sanitation. Due to a number of reasons, such as the poor economic climate in Angola and the poverty that the country suffers, many people do not have access to basic sanitation. Without a toilet, the reality is that many people still have to go to the toilet out in the open, often in the bush or a lake and near their homes. This risks faeces contaminating their food and drink, causing sickness to children and families.

The first village I visited was called Calipanguela, located over an hour away from the nearest city, Nharea. The village is incredibly rural, with mud huts, dirt tracks and livestock. The process of educating the community about the importance of using a toilet, washing their hands and sanitation in general had not reached this village yet, but would start with a ‘Triggering’ meeting.

The meeting involves gathering all of the villagers together and sharing food and water between them. Then something shocking happens. To exemplify the danger of open defecation, the facilitators place fresh human faeces, found that day in the village, near the food and water they’d been sharing. The flies become instantly attracted and begin moving between the faeces, food and water. 

The method is deliberately provocative. People immediately understand the danger of going to the toilet outside and realize they may have been eating food contaminated by their faeces. The village then designs an action plan to tackle the reasons why so many people go to the toilet outside, and to improve the health of the community.

I went on to the village of Luwawa, which was triggered a year ago. After being monitored on a monthly basis to ensure the community were using and maintaining their toilets, it was about to be awarded a certificate. Villagers no longer went to the toilet out in the open, and Luwawa had been declared ‘open defecation-free’. This is a huge honour in Angola, and to mark the occasion, there was singing, dancing, and a party.


© Karin Schermbrucker. Sabina and two of her four children in their home in Waleka, Angola, where newly built toilets have made everyone healthier.

Finally, to complete my journey, I visited a village that had been declared ‘open defecation-free’ for a year. Here I met a wonderful family, with a mother named Sabina, who wanted to share her story. Sabina is 39, is married, has four children, and lives in a village called Waleka.

Sabina told me about life before her village was triggered and her family built a toilet. “Before we had a toilet, we went outside to the bush to defecate, which made me feel uncomfortable. When we went to the toilet outside, I was worried about my family getting sick or being bitten by a snake.

“Defecating outside made my children sick; they were always ill. When they were ill, they didn’t manage to go to school.”

Sabina told me that it always smelt before the village was triggered and the toilets were built. Sometimes there would be faeces all around the village, and it didn’t feel clean. Now that they have all built toilets and been declared open defecation-free, she feels happy, and can see that there has been a reduction in illness for all of the villagers.

Sabina said: “Now there is a real change in the village. Now everything is OK.”

The Andrex partnership raises funds for UNICEF’s Community Led Total Sanitation (CLTS) programme, which empowers communities to build, maintain and take pride in their own hygiene and sanitation. The great work that the partnership has helped to fund was clear to see in all of the villages that we visited, no matter what stage of the journey they were in. 60,000 lives will be impacted this year thanks to the funds raised by Andrex for the UNICEF programme.

As I plan my next trip back to the villages, I feel confident that thanks to this partnership, villagers will continue to feel empowered to use their toilets and benefit from the programme.

Editor's Note: In Part Two of this series on wastewater treatment, Craig Fairbaugh, a Research Fellow at Engineering for Change, highlights technologies that meet the challenge as described in E4C’s Solutions LibraryPart One of this series can be found here.

Designers and engineers have long recognized the need for wastewater treatment in developing communities but often are met with the challenges of no piped sewer system, high capital investment, and limited technical skills necessary for operation and maintenance. Enter decentralized wastewater treatment; a solution that treats waste effectively on site and requires no existing piped infrastructure. Decentralized anaerobic treatment systems have existed since the 1800s as septic tanks, but in order to meet the Sustainable Development Goals with a rapidly growing population in the developing world, engineers are attempting to design solutions that are affordable, scalable, more effective, and easier to maintain.

The Engineering for Change Solutions Library features technology reviews of three solutions for decentralized wastewater treatment: Biopipe, the Biofil Digester, and DEWATS.

Biopipe is a decentralized pipe network that treats domestic wastewater for reuse in irrigation and secondary applications (but not for drinking). The system is comprised of a tank, pipe modules, circulation and water pumps, and a UV filter. Bacteria lining the inside of the pipe remove microbiological pathogens, similar to the treatment processes that occur naturally in river beds. 


Biopipe uses aerobic treatment, filtration, and UV sterilization to treat domestic wastewater.

Biopipe is making the transition out of the prototype phase with a recent exclusive distribution deal for Asia and Africa with Metito, a water management design and engineering firm in emerging markets.

Biofil Digester
The Biofil Digester mimics the natural world with a process similar to the natural decomposition that occurs in soil on a forest floor. Developed in Ghana, the typical digester is housed in a 2’ x 2’ x 6’ concrete structure. Liquid waste rapidly separates from solid as it filters through a layer of permeable pavement. Macro-organisms in the soil below break down pathogens. The digester can be connected to an existing toilet or septic system, is scalable to meet small or large demands, and produces no waste product. The Biofil Digester can be installed above or below ground in a concrete structure with a “microflush” option which conserves the amount of water needed for flushing. Since 2008, more than 4500 Biofil Digesters have been installed across Africa and South Asia.

The Biofil Digester uses aerobic treatment and macro-organisms in soil to break down and remove harmful pathogens in domestic wastewater.

While the Biopipe and Biofil Digester are manufactured treatment systems, BORDA’s Decentralized Wastewater Treatment System (DEWATS) is a technical design approach to treating wastewater at the household and community level. Founded by the Bremen Overseas Research and Development Association, DEWATS uses physical and biological treatment mechanisms such as sedimentation, floatation, aerobic, and anaerobic treatment to remove pathogens from household wastewater. These treatment stages are commonplace in centralized systems, but what separates the DEWATS design approach is employing a passive system (no power required), low maintenance requirements, and construction from affordable and locally available materials. Hundreds of DEWATS treatment systems have been implemented and are currently operational across Africa, South Asia, and Southeast Asia.


DEWATS design methodology employs a series of baffled chambers and planted horizontal gravel filters to promote removal of pathogens by anaerobic and aerobic processes.


A DEWATS treatment facility in South Africa serves as an educational treatment system for neighboring communities. A primary treatment vault (top) and horizontal gravel filter (bottom) are constructed and inspected by local officials and tradesmen.

In a recent expansion of our Solutions Library, E4C added these three technologies as examples of decentralized treatment, which has the potential to scale up and meet needs in cities and rural communities. Visitors to this web site know better than most that wastewater treatment is often overlooked in discussions about global development. With these new additions and more sanitation technology planned for the future, we hope to draw attention to the options available to those in need.

For more on wastewater treatment technologies, including the EkoLakay Toilet, the Easy Latrine, the Elephant Toilet and others, please visit E4C’s Solutions Library

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