The first global overview of basic water and sanitation indicators in refugee camps is presented (using data from [2003][2004][2005][2006]) and compared with selected health and nutrition indicators. This demonstrates that average levels of water and sanitation provision are acceptable at camp level but many refugee operations are suffering from gaps that cross-cut these sectors; e.g. typically poor sanitation provision is corresponding with low per capita availability of water. These findings were confirmed at household level with two household surveys undertaken in African refugee camps; households reporting a case of diarrhoea within the previous 24 hours collect on average 26% less water than those not reporting any cases. In addition, typically higher levels of morbidity of one infectious agent are also reflected across other infectious agents; this is reinforced by comparing the relationship between morbidity and nutrition status from selected camps. The importance that hygiene, environmental conditions and local settings have on health (both of refugees and also local communities) is underlined.Interventions to improve indicators across the water, sanitation, health and nutrition sectors rely not only on increased and sustained resources but must entail an integrated approach to simultaneously tackle short-comings across all these vital sectors.

A WHO methodology is used for the first time to estimate the burden of disease directly associated with incomplete water and sanitation provision in refugee camps in sub-Saharan African countries. In refugee camps of seven countries, containing just fewer than 1 million people in 2005, there were 132,000 cases of diarrhoea and over 280,000 reported cases of malaria attributable to incomplete water and sanitation provision. In the period from 2005 to 2007 1,400 deaths were estimated to be directly attributable to incomplete water and sanitation alone in refugee camps in Ethiopia, Kenya and Tanzania. A comparison with national morbidity estimates from WHO shows that although diarrhoea estimates in the camps are often higher, mortality estimates are generally much lower, which may reflect on more ready access to medical aid within refugee camps. Despite the many limitations, these estimates highlight the burden of disease connected to incomplete water and sanitation provision in refugee settings and can assist resource managers to identify camps requiring specific interventions. Additionally the results reinforce the importance of increasing dialogue between the water, sanitation and health sectors and underline the fact that efforts to reduce refugee morbidity would be greatly enhanced by strengthening water and sanitation provision.

Refugees are often the most vulnerable members of society. This means that not only do they need adequate clean water, but they also need to feel safe when they fetch it. The UNHCR works to ensure that water supplies do not compromise refugees' health or safety. Figure 1 Map of Kakuma camp, Kenya, showing how the area with the lowest household mean water consumption was the hardest hit by the cholera outbreak. The use of average camp-wide water consumption figures (16 litres in this case) often hides such inequalities in distribution.

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