Underreporting of high-risk water and sanitation practices undermines progress on global targets

Abstract

Water and sanitation indicators under the Millennium Development Goals failed to capture high-risk practices undertaken on a regular basis. In conjunction with local partners, fourteen rounds of household surveys using mobile phones with a customized open-source application were conducted across nine study geographies in Asia and Africa. In addition to the main water and sanitation facilities, interviewees (n = 245,054) identified all water and sanitation options regularly used for at least one season of the year. Unimproved water consumption and open defecation were targeted as high-risk practices. We defined underreporting as the difference between the regular and main use of high-risk practices. Our estimates of high-risk practices as the main option matched the widely accepted Demographic and Health Surveys (DHS) estimates within the 95% confidence interval. However, estimates of these practices as a regular option was far higher than the DHS estimates. Across the nine geographies, median underreporting of unimproved water use was 5.5%, with a range of 0.5% to 13.9%. Median underreporting of open defecation was much higher at 9.9%, with a range of 2.7% to 11.5%. This resulted in an underreported population of 25 million regularly consuming unimproved water and 50 million regularly practicing open defecation. Further examination of data from Ethiopia suggested that location and socio-economic factors were significant drivers of underreporting. Current global monitoring relies on a framework that considers the availability and use of a single option to meet drinking water and sanitation needs. Our analysis demonstrates the use of multiple options and widespread underreporting of high-risk practices. Policies based on current monitoring data, therefore, fail to consider the range of challenges and solutions to meeting water and sanitation needs, and result in an inflated sense of progress. Mobile surveys offer a cost-effective and innovative platform to rapidly and repeatedly monitor critical development metrics.

Multiple Household Water Sources and Their Use in Remote Communities With Evidence From Pacific Island Countries

“…The use of multiple water sources to meet daily household needs is practiced in diverse developing country settings that vary in precipitation patterns, water resources, piped water availability, etc. For example, it has been observed in Southeast Asia (Brown et al, ; Evans et al, ; Özdemir et al, ; Shaheed et al, ), Sub‐Saharan Africa (Adekalu et al, ; Almedom & Odhiambo, ; Dos Santos et al, ; Evans et al, ; Foster & Hope, ; Howard et al, ; Thompson et al, ; Tucker et al, ; Vedachalam et al, ), North Africa (Devoto et al, ), Western Asia (Coulibaly et al, ), East Asia (Wang et al, ), South Asia (Ahmed & Hossain, ; Madanat & Humplick, ), and central America (Smith et al, ). This study is the first on multiple sources in SIDS or PICs, the first contrasting practices between countries, one of three to report cross‐seasonal differences, and one of the few to provide detailed description or quantification of the practices.…”

“…There is a small body of economics literature on modeling household demand for multiple water sources in developing countries (e.g., Coulibaly et al, ; Devoto et al, ; Madanat & Humplick, ; Mu et al, ; Nauges & Whittington, ; Pattanayak et al, ). However, we could identify only a few journal articles (Adekalu et al, ; Almedom & Odhiambo, ; Howard et al, ; Özdemir et al, ; Tucker et al, ; Vedachalam et al, ) and one conference proceedings paper (Smith et al, ) that describe in detail and/or quantify multiple household water sources. Nearly all of these articles concern Sub‐Saharan Africa.…”

Addressing how multiple household water sources and uses build water resilience and support sustainable development

“…These challenges have been largely overcome through the development of computer-assisted personal interviewing (CAPI) approaches, as discussed by MacDonald et al 11 Prior to 2010, only a few articles reporting in detail or quantifying the use of multiple water sources had been published [12][13][14] but in recent years there has been a marked increase in research interest. 1,3,[15][16][17][18][19] The routine use of multiple household water sources is practiced across settings that vary in precipitation patterns, water resources, piped water availability, etc. For example, it has been reported in many countries across Southeast Asia, 17,[20][21][22] Sub-Saharan Africa, 2,3,12-16,22-24 North Africa, 25 Western Asia, 26 East Asia, 27 South Asia, 8,28 Oceania 1,11,19 , and Latin America.…”

“…Seasonality heavily influences the choice of water source, as rainfall affects the relative availability, price and aesthetic attributes of different water sources. 1,2,15,16,38 This highlights another potential weakness of conventional monitoring efforts: the prospect of a systematic seasonal bias impacting the way national and global statistics are derived, through household surveys that mostly take place in the dry season (Table 1). 39 MWSU presents both an opportunity and a risk for advancing the health and welfare of low-income households.…”

“…For example, switching between drinking sources may constitute a 'high-risk' practice that heightens the chance of exposure to water-borne pathogens. 16 There are also reports of vector-borne diseases increasing when open or standing water sources are introduced close to villages 40 and this must be considered when implementing sources that are dependent on storage (e.g., rainwater collection). While there is still a paucity of evidence on this in a multiple water source context, analogous studies indicate even momentary lapses in water quality could have major health ramifications; [41][42][43] therefore, provision of low quality, high volume sources must be considered in the context of possible consumption.…”