Learning Lessons Independent

Evaluation
April 2011

Attaining Health Outcomes through

Synergies of Rural Water Supply,
Sanitation, and Hygiene
Background
Water and sanitation crisis claims lives through diseases and supply, but also at the quality of water? How do we ensure
associated illnesses. About 3.6 million people die each year the synergy of results of the interventions on water supply,
from water-related diseases. The 2010 report of the World sanitation, hygiene, and wastewater management? This
Health Organization of the United Nations and the United synthesis draws key lessons from evaluations and completion
Nations Children’s Fund concerning the progress on sanitation reports of ADB-financed rural WSS projects, particularly
and drinking water insights into ways for improving project contributions to the
revealed that 884 million attainment of health outcomes.
people in the world “ 884 million people in
do not use improved the world do not use
source of drinking water; improved source of Highlights of Lessons
almost all of them are Delivering meaningful health outcomes requires synergy
from developing regions.
drinking water; almost
between development and management of WSS,
About 2.6 billion people all of them are from wastewater, and solid waste, together with the promotion
do not use improved developing regions. of hygiene. Addressing sanitation concerns and improving the
sanitation, and most of About 2.6 billion people management, including disposal and treatment, of solid waste
them live in South Asia
and East Asia. The vast
do not use improved and wastewater can minimize hazards that often threaten the
delivery of clean water to communities (i.e., from the water
majority of population sanitation, and most of
source to distribution points). For example, experiences in
without access to water them live in South Asia Pakistan and the Philippines have shown that sanitation and
and sanitation lives in and East Asia.”
rural areas. Seven out of
10 people without basic
sanitation, and more than eight out of 10 people without
access to improved drinking water sources, are rural dwellers.
While the water policy of the Asian Development
Bank (ADB) became effective in 2001, ADB’s operations have
included water supply and sanitation (WSS) projects since
1992. Recognizing the need to provide people with access to
adequate clean water, most of the ADB loan approvals for the
water sector in 1992–2009 went to WSS projects for both rural
ADB Photo Library

and urban populations.

Common to most rural WSS projects is the goal of
improving health and living conditions of rural communities,
in part, by reducing the incidence of water-related and
waterborne diseases. Clean water supply is a determinant of
A woman fetches water in a river in Papua New Guinea. Contamination of water
public health. How then do we ensure that projects are not sources by solid waste, animal droppings, and wastewater from washing and
only looking at sourcing, distribution, and expansion of water laundry often poses health and sanitation hazards to the community.
wastewater hazards have threatened the quality of water,
causing situations that have rendered the supply of
nonpotable water in some project areas. Contamination of
water sources has been attributed to wastewater leakage
from septic tanks and poor drainage systems (i.e., runoff
water near wells and standpipes is susceptible to solid wastes,
animal droppings, and
wastewater from washing Appreciation of the
and laundry). Development
critical links between
synergy between water
supply, sanitation, and water, sanitation,
waste management can hygiene, and health
be strengthened through is important in
strong commitment and achieving health
focus, supported by sizable
investment in sanitation outcomes that last.
aimed at improving
drainage and street pavements, minimizing sanitation hazards
in and around water supply systems, and managing solid
waste and wastewater at both the household and community
levels effectively. Appreciation of the critical links between
water, sanitation, hygiene, and health is important in achieving
health outcomes that last. For example, in Monaragala District
in Sri Lanka, hygiene education and water conservation
campaigns have effectively reinforced health benefits derived
from the rural WSS pilot project.
Conceptual frameworks demonstrating clear logical
links between planned development interventions, expected
outcomes, and impacts (i.e., social, environmental, economic
and institutional) tend to provide better results. For example,
lessons from rural WSS development interventions in Pakistan
indicated that the interventions did not result in significant
reduction of waterborne diseases. Time savings in collection
and delivery of water did not result in increased incomes
as opportunities for income generation were limited. The
poor achievements of desired outcomes indicate the lack
of conceptual and logical links between inputs, outputs,
outcomes, and impacts in the project design. It is important
cluttered project design (i.e., having multiple expected
outcomes with a range of diverse components) could create
implementation difficulties and result in the non-attainment
of results.
Gender roles in the management of household health
should be acknowledged at the onset. In many situations,
women have critical and recognized roles to play in taking care
of their families’ health and general well-being. Participation
and involvement of women in the design and management of
sanitation facilities, as well as in promoting public awareness
and education in personal hygiene, is important. For example,
a WSS project in Sri Lanka recognized women as the principal
water collectors and users. Their participation was considered
a top priority in all aspects
of the project development, Imbalanced and poorly
implementation, and
operations. Consequently,
recognized gender roles
the beneficiaries were can seriously threaten
highly motivated and the development
willing to make substantial effectiveness of
financial contributions for
projects.
the construction of water
supply facilities and latrines.
In contrast, poor social mobilization and lack of women’s
participation in the WSS projects in Pakistan and Indonesia
did not contribute to the sustainability of project benefits.
Therefore, imbalanced and poorly recognized gender roles can
seriously threaten the development effectiveness of projects.

ADB Photo Library

for a project to have a logic model to explain the best ways to
achieve the expected outcomes and impacts.
Project designs should be realistic. Only directly relevant
components should be included in a project design. Although
reducing poverty, improving health conditions, and ensuring
Nepali women fetch water for their families. Participation and involvement of
positive environmental women in the design and implementation of sanitation facilities, as well as in
impacts are legitimate Project designs promoting public awareness and education in personal hygiene, is important.
objectives of development should be realistic.
initiatives, they may be less Health benefits of WSS projects should be inclusive and
relevant in a given project Only directly relevant accessible to the poor. Alternative water sources and supply
context. WSS projects components should be schemes, as well as sanitation technology options, should be
directly aimed at achieving included in a project made available to the poorest and vulnerable segments of the
health outcomes should design. population who are too cash constrained to participate in rural
not be loaded and be infrastructure development. Affordability is a key consideration
mistaken with components for inclusiveness among the intended beneficiaries, although
that are aimed at reducing income poverty, especially if these the poor have often demonstrated their willingness to pay
components are not provided with adequate institutional for water. For instance, the cost of household water supply
support or resource provision. An overly complex and connection has limited the participation of poor households in
 Punjab, Pakistan. Provision of community standpipes at
selected but convenient locations may have been more
appropriate to reach out to this segment of beneficiaries.
Health outcomes should be realistically established.
Baseline data (i.e., at the individual, household, and
community levels) should be utilized as benchmarks to set
realistic improvement
targets. Good baseline
data and realistic targets Good baseline data
can help steer project and realistic targets
implementation toward can help steer project
achieving expected results.
implementation
Without such benchmarks,
the monitoring of project toward achieving
expected results.
implementation may
face difficulties, and the
measurement of outcomes
and impacts that can be attributed to a project can be elusive.
For example, the cited rural water supply projects in the
Philippines and Bangladesh had failed to provide appropriate
baseline indicators for measuring improved public health.
This has resulted in difficulties in measuring the impact of the
projects on public health.
The supply of safe water should be appropriately
maintained to sustain health benefits. Water shortages
can undermine the sustainability of health benefits of WSS
projects. Ideally, a water system should be able to meet the
needs of a community for at least 10 years before requiring
a large-scale expansion. In this regard, WSS project designs
should include demand forecasts that take into account
population growth projections to minimize risks of water
shortages. Conducting groundwater investigations, over a
period of time to determine variations in yield and recharge
rates, could also prevent water shortages. An effective water
demand management, coupled with public awareness
campaigns, can also serve as a cost-effective alternative to
water supply expansion, particularly in water-scarce areas.
Much can be learned from the Philippine experience in the
ADB Photo Library
Many residents in the southern Philippine island of Mindanao do not have
easy access to potable water in their homes. The Mindanao Agrarian Reform
Communities Project—funded by ADB—is helping change that.
late 1990s. Due to water abstraction beyond the
replenishment rate, communities suffered from water
shortages during the dry season. In some cases, water supply
facilities were abandoned as a result of over-abstraction
of water.
ADB Photo Library
A woman collects water sample for checking and testing in one of the water
distribution points in the People’s Republic of China.
Improving the delivery of safe water entails capacity
building of stakeholders and beneficiaries, and requires
partnership with appropriate organizations. Effective
solutions to problems can often be delivered through
acquisition of knowledge and practical skills. For example,
cases of high-level bacteriological contamination, both at the
water source and distribution
points, can be prevented with Effective solutions
proper training on simple to problems can
chlorination and other basic
often be delivered
water treatment methods.
Further, increasing demand through acquisition
for sanitation—by establishing of knowledge and
a functional partnership practical skills.
with community-based
organizations, nongovernment
organizations, and private sector entities—
can help reduce or eliminate sanitary hazards at water
sources. Implementation of appropriate operation and
maintenance systems has been proven to contribute to
the delivery of safe water. This entails enhancement of
commitment and ownership among the beneficiaries
through, among others, effective social mobilization,
formation of community-level water users’ associations,
cash and labor contributions, designation of operation
and maintenance responsibility, and provision of appropriate
training thereto. For example, the lack of recognition by
public officials of the importance of community involvement
led to the poor achievement of outcomes in the first rural
WSS project in Indonesia. After almost 4 years after project
completion, most of the water supply and sanitation facilities
were abandoned or not functioning as originally intended.
These problems were primarily due to poor maintenance
and the inability of communities to pay for the operation
and maintenance of the facilities.
In summary, while significant progress has been achieved in
the implementation of rural WSS projects, in terms of coverage
and achievements of health outcomes, experiences have led
us to the following lessons, which can help in ensuring good
project designs and sustaining project benefits. These include
n Ensuring synergies among WSS, wastewater, and solid
waste management, together with hygiene and health
promotion programs, to attain desired health outcomes
and impact;
n Acknowledging, catalyzing, and enabling gender roles in
health management;
n Ensuring inclusiveness in the design of a project, with
appropriate schemes that would ensure that the poor
are not excluded from the health benefits of
WSS projects;
n Establishing baseline data and realistic targets for
health outcomes;
n Addressing water resource capacity, demand forecast, and
supply management, and taking population growth rates
into account to prevent or minimize water shortages; and
n Building capacity of beneficiaries, and building partnership
with appropriate organizations, to ensure sustained supply
of safe water for lasting development effectiveness.
References
ADB. 1995a. Performance Audit Report: District Towns Water
Supply Project in Bangladesh. Manila (Loan No. 571-BAN,
para. 50). Available at www.adb.org/Documents/PPARs/
BAN/ppar_ban_15006.pdf
___. 1995b. Performance Audit Report: Island Provinces Rural
Water Supply Sector Project. Manila (Loan No. 812-PHI,
paras. 50 and 63). Available at www.adb.org/Documents/
PERs/PE441.pdf
___. 2000a. Performance Audit Report: Second Island
Provinces Rural Water Supply Sector Project in the
Philippines. Manila (Loan No. 1052-PHI, paras. 53, 59, 65–66,
and 68). Available at www.adb.org/Documents/PERs/
pe-536.pdf
Disclaimer
The views and assessments contained herein do not necessarily reflect the
views of the Asian Development Bank (ADB) or its Board of Directors or the
governments they represent. ADB does not guarantee the accuracy of the data
and accepts no responsibility for any consequence of their use.
About the Asian Development Bank
ADB’s vision is an Asia and Pacific region free of poverty. Its mission is to help its
developing member countries reduce poverty and improve the quality of life of
their people. Despite the region’s many successes, it remains home to two-thirds
of the world’s poor: 1.8 billion people who live on less than $2 a day, with 903
million struggling on less than $1.25 a day. ADB is committed to reducing poverty
through inclusive economic growth, environmentally sustainable growth, and
regional integration.
Based in Manila, ADB is owned by 67 members, including 48 from
the region. Its main instruments for helping its developing member countries
are policy dialogue, loans, equity investments, guarantees, grants, and
technical assistance.
___. 2000b. Project Completion Report: Second Water Supply
and Sanitation Project in Sri Lanka. Manila (Loan No.
1235-SRI, paras. 48 and 51). Available at www.adb.org/
Documents/PCRs/SRI/pcr_sri23209.pdf
___. 2002. Impact Evaluation Study: Water Supply and
Sanitation Projects in Selected Developing Member
Countries. Manila (Appendixes 3 and 6, paras. 41 and
74). Available at www.adb.org/Documents/IES/Water/
ies_reg_2002_17.pdf
___. 2003. Project Completion Report: Punjab Rural Water
Supply and Sanitation (Sector) Project in the Islamic
Republic of Pakistan. Manila (Loan No. 1349-PAK, paras. 47
and 52–53). Available at www.adb.org/Documents/PCRs/
PAK/pcr_pak_23221.pdf
___. 2005. Performance Audit Report: Rural Water Supply and
Sanitation Sector Project in Indonesia. Manila (Loan No.
1352-INO, paras. 45–46, 52, and 55). Available at
www.adb.org/Documents/PPARs/INO/ppa-ino-26314.pdf
___. 2009a. Impact Evaluation Study: Impact of Rural Water
Supply and Sanitation in Punjab, Pakistan. Manila (paras.
44–45, 57, 64–65, 75, 81, 84–87, 89, 90–92, and 96).
Available at www.adb.org/Documents/IES/PAK/
IES-PAK-2009-26.asp
___. 2009b. Project Completion Report: Rural Infrastructure
Support Project in Indonesia. Manila (Loan No. 2221-INO,
para. 54). Available at www.adb.org/Documents/PCRs/
INO/39597-INO-PCR.pdf
___. 2009c. Project Completion Report: Third Water Supply
and Sanitation Sector Project in Sri Lanka. Manila (Loan
No. 1575-SRI, para. 52.ii and iv). Available at www.adb.org/
Documents/PCRs/SRI/28153-SRI-PCR.pdf
Water Facts. Available at www.water.org/learn-about-the-
water-crisis/facts/
World Health Organization Media Centre. 2010. Access to
Safe Drinking Water Improving; Sanitation Needs Greater
Efforts. Available at www.who.int/mediacentre/news/
releases/2010/water_20100315/en/index.html
Water for All. Available at www.adb.org/water/policy
/default.asp
Learning Lessons are a synthesis of key lessons drawn from evaluation and
completion reports of ADB-supported projects and programs. Lessons presented
in this brief are not prescriptive, and users are advised to carefully review these
lessons in the context of country, sector, and thematic conditions. Lessons are
extracted from the Evaluation Information System (EVIS).
Contact Us
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