Report of a Consultation

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1 Report of a WHO/UNICEF JMP Technical Consultation on the Measurability of Global WASH Indicators for Post-2015 Monitoring Contents Report of a Consultation Introduction and background... 0 Objectives and expected outcomes... 3 summary outcomes... 3 Proceedings... 6 Review of targets and indicators... 8 Annex A. Approved Agenda Annex B. list of Participants Annex C. Consolidated drinking water, sanitation and hygiene targets, indicators and definitions... 40

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3 INTRODUCTION AND BACKGROUND The United Nations Children s Fund (UNICEF) and the World Health Organization (WHO) have initiated a consultative process to formulate a technical proposal for evidence-based targets and indicators to support the monitoring of progress towards a global water, sanitation and hygiene (WASH) goal on the post-2015 development agenda. This initiative uses the WHO/UNICEF Joint Monitoring Programmeme for Water Supply and Sanitation (JMP) as its platform, in line with the JMP mandate set out in its strategy. 1 A first Consultation on Post-2015 Monitoring of Water and Sanitation was hosted by the German Government in Berlin, Germany, in May It agreed on guiding principles for the process and on a roadmap. As a result, four working groups were established. Three working groups addressed drinking-water, sanitation and hygiene, respectively. The fourth working group, on equity and non-discrimination (END), considered targets and indicators for measuring (in)equality and provided guidance and criteria to ensure the targets and indicators developed by the other three working groups effectively reflected elements of equity and non-discrimination. The guiding principles articulated by the Berlin Consultation referred to the need for A simple, inspirational goal, articulated around universal use of water, sanitation and hygiene. Targets that focus primarily on outcomes. A clear reflection of issues related to the human rights to water and sanitation in the targets, including the concept of progressive realization of the rights. An increase in the number of people using water, sanitation and hygiene as well as improvements in their level of service. A global perspective with relevance to all countries. Monitoring that goes beyond the household to include schools and health care facilities. A focus on the poor, disadvantaged and excluded, and on the elimination of inequalities and inequities. Over the course of 2012, each working group developed a proposal for targets and indicators within its specific remit. The working groups were composed of WASH practitioners, representatives of international NGOs and academia, human rights professionals and national and international monitoring specialists, and largely focused on the normative aspects of targets and indicators. Their deliberations took place in the context of a scenario of desirable, plausible goals, selecting those aspects that were considered most important to reflect under a global WASH vision in the post-2015 UN development agenda, with the fourth working group identifying opportunities for incorporating human rights obligations. To this end, it developed a checklist as well as a list of elements that need to be integrated in targets and indicators to reflect various elements of equality. This integration was considered crucial since global monitoring that has been 1 One of the four strategic outcomes reads new indicators and data collection mechanisms related to sustainable access to safe drinking water and basic sanitation developed and validated, focusing on the needs of post-2015 monitoring 1

4 calibrated to elucidate these elements can be expected to shed light on dynamics that otherwise remain hidden, to spur action for change and to have a direct impact on people s lives. The working groups were specifically asked to keep the political bankability of the proposed targets and indicators in mind, focusing on critical as well as politically actionable elements. The indicators developed through the consultative process would, if adopted at the end of the post intergovernmental process, expand on the current MDG indicators for drinking-water and sanitation. It was agreed that the validity of the proposed indicators would be greatly enhanced if they were independently appraised for the feasibility, reliability and cost-effectiveness of their periodic measurement, as required for the tracking of progress towards a possible post-2015 global water goal and corresponding WASH targets. Such an appraisal must not only focus on measurability, but also take into account existing and new monitoring mechanisms through which information underlying the newly proposed indicators could be collected or compiled. Recommendations are needed regarding those proposed indicators that require new methods of measurement, for either an alternative formulation that might render them measurable or for further research to ensure the indicators can be brought on-line eventually. It is, however, crucial to ensure that such recommendations do not undermine the content, substance and rationale behind the proposed targets and indicators, as developed by the working groups. On the above premise, UNICEF and WHO organized a Technical Consultation on the Measurability of Global WASH Indicators for Post-2015 Monitoring in New York, USA, on 5 and 6 November The Technical Consultation brought together a group of independent experts who reviewed the proposed post-2015 global WASH indicators to determine what is or can become technically feasible, how they can best be measured, and what the evidence base and knowledge gaps are for their reliable and cost-effective measurement at national and global levels. It is recognized that household surveys provide an invaluable foundation for global WASH monitoring and are likely to continue to do so for some time. However, the meeting was strongly encouraged to review and consider other data sources as well to complement the information obtained through household surveys. There is a strong belief among the working group members that the ambitions for post-2015 monitoring should not be limited by current data collection instruments and that the recommendations of the meeting should allow for exploring and developing new monitoring instruments to capture aspects not measurable at the household level. The recommendations of this Consultation served as an important input into the second Consultation on Post-2015 Monitoring of Drinking-water and Sanitation, hosted by the Government of the Netherlands in The Hague, the Netherlands, on 3, 4 and 5 December It was not the purpose of the Consultation to accept or reject the working groups recommendations, which are the result of in-depth, iterative considerations and consultations. Rather, the Consultation was to advise on how those recommendations might best be advanced given technical possibilities and limits. 2

5 OBJECTIVES AND EXPECTED OUTCOMES The objectives of the Technical Consultation were: - to consider and advise on: o the practical and cost considerations of collecting the required information periodically at global level, and o the options for approaches and mechanisms through which the proposed indicators could best be measured; o the specificity of both the numerators and denominators of the proposed indicators, and o the identification of alternative formulations for those indicators that it finds cannot be unambiguously, accurately and/or cost effectively measured at global level. - to recommend steps to validate the measurability of those indicators that are currently not yet systematically collected at international level; - to establish a first research agenda to address gaps in our knowledge that impair global monitoring of critical indicators; - to review the outcome of the working group on equity and non-discrimination and utilize its recommendations in assessing the proposed goal, targets, and indicators. SUMMARY OUTCOMES Following a number of stage-setting presentations, the group systematically reviewed all targets and indicators formulated by the working groups. The criteria for measurability were applied, including technical and operational feasibility, evidence base, cost and cost-effectiveness and reliability. Effective incorporation of human rights criteria was assessed. Clarifications were sought on definitions, and suggestions made for their strengthening. The content and outcome of the detailed discussions is reflected in the Proceedings section below. In the course of the discussions, items requiring further follow-up emerged and research questions were formulated. These are presented in the lists below and form the basis for the development of a programmeme of activities aimed at further strengthening the evidence base for the proposed indicators. LIST OF ITEMS RECOMMENDED FOR FOLLOW-UP F-1 Develop a final recommendation on the exact metric to be used for monitoring progressive realization and identify the groups to be monitored. F-2 Consult with UN-Women to integrate with Thematic Consultation on Women and Equality. It will be especially important to discuss approaches to intra-household inequalities with UN-Women as this is an issue the agency and UNIFEM have identified as a barrier for some years. F-3 Consider a more aspirational water target for For example, by what date could the intermediate level of service be achieved in schools and health care facilities for all sectors? 3

6 F-4 Clarify the definition of shared sanitation facilities to specify whether the intention is to measure the number of households and persons using a particular facility or to apply a ratio at the village or regional scale. F-5 Identify and track targets and indicators that are more aspirational in nature, but could not be included due to limitations of current data collection methodologies. F-6 Assess the feasibility of achieving the proposed targets within the timeframes specified and revise where necessary. What acceleration in rates is needed and which countries need priority? F-7 Assess the internal consistency between Target 1 (open defecation free by 2025) and Targets 2 and 3 (provide adequate sanitation facilities). Is this the most logical sequencing, considering that the objective is to eliminate open defecation by providing adequate sanitation facilities? F-8 Consider whether Target 1-b (hygienic disposal of the stools of children under 5) could be modified to accommodate safe disposal in a sanitary landfill. F-9 Ensure that non-fixed handwashing alternatives (e.g. pitchers) are adequately incorporated into the definitions used in the consolidated targets and current DHS and MICS survey questions. F-10 Define health care centers in order to agree on the denominator. F-11 Harmonize the use of the words adequate and basic. Basic is used frequently in conjunction with water services, whereas adequate is used with sanitation and hygiene for similar levels of service. Both appear to be an updated term for improved. Basic is the suggested term because it connotes room for improvement, whereas adequate may give the impression of sufficiency. F-12 Provide a definition for the term discontinuity of service in the consolidated document. F-13 Safe management of excreta should be addressed but was not yet sufficiently developed into a specific proposal ready for consideration by the Consultation. Further definition is needed, including interfaces with Wastewater and Environment thematic groups. F-14 Develop a definition of regulated water and sanitation service providers. F-15 Consider adding the following question to household survey instruments: Was there any day within past two weeks when you could not meet your basic drinking water needs? If yes, then was the reason because you could not afford water, could not access water, or the water source was not functioning? F-16 Pass the Target 4, Raw water quality meeting national standards indicator on to the Wastewater Management post-2015 working group. F-17 Hygiene should be adequately incorporated into indicators for Target 4. 4

7 F-18 Define the geographic level of monitoring desired (global, national, regional) for all indicators. F-19 Should water and sanitation indicators be combined? What would the impacts be? LIST OF RECOMMENDED RESEARCH QUESTIONS R-1 Assess the available evidence on the prevalence, scale, and types of intrahousehold inequality in access to WASH services. What are the available methods for assessesing intra-household inequality during surveys? Does the scale of these inequalities justify the additional burden of monitoring? R-2 Evaluate whether evidence from longitudinal studies of inequality could be helpful in setting the inequality metric. R-3 What level of piped service is possible within each country based on hydrological and other constraints, and within what timeframe? R-4 Examine the available evidence on use of shared sanitation facilities to determine whether the target definitions of maximum 5 households and/or 30 persons per facility are supported and at what scale this ratio should be applied (e.g. household, village, region). Also determine if a maximum acceptable distance to a facility should be included. R-5 Should a minimum distance to a shared sanitation facility in schools be included in the definitions? R-6 Further research into methods to measure hygiene behaviours at the global level is needed. Access to a facility is only a precondition for adequate hygiene, but what needs to be measured is the use of facilities. R-7 Are there reliable survey methods to assess open defecation practices among all members of a household? Is self-reported open defecation and use of sanitation facilities too susceptible to bias? R-8 Review methods currently available for monitoring schools and health facilities to determine what is required to scale up to global monitoring of the proposed WASH indicators. R-9 Review the two possible approaches for water quality monitoring (direct measurement during surveys versus correction factors derived from models), addressing issues such as potential for scale-up, costs, and policy implications. R-10 Review the two possible approaches for water quality monitoring (direct measurement during surveys versus correction factors derived from models), addressing issues such as potential for scale-up, costs, and policy implications. R-11 Investigate what an acceptable benchmark value for household expenditure on water, sanitation, and hygiene services might be. Determine if a different metric is 5

8 required for rural areas. Also address the reliability of household surveys to assess expenditures on such services. R-12 Investigate how other sectors are dealing with their interfaces to WASH issues and develop a coherent approach between sectors on sustainability indicators. R-13 Investigate approaches for determining the total renewable water resources to better define the denominator for Target 4-e. PROCEEDINGS Presentation: Progress in the post-2015 working group activities (Robert Bos, WHO) Robert Bos introduced the JMP process of formulating post 2015 targets and indicators, referred to the objectives and expected outputs of the Consultation and presented a calendar of events in relation to the UN Post-2015 development agenda. Presentation: Current JMP indicators and their measurement, development of new indicators and the incremental expansion of the JMP scope over the past decade (Rolf Luyendijk and Attila Hancioglu, UNICEF) The discrepancy between the formulation of the MDG target and the indicators by which progress towards the target is measured has been a recurrent topic of discussion over the past decade. Current methods and procedures for the collection of information on the use of improved drinking water and sanitation facilities have limited the options for the formulation of new or improved indicators. JMP largely relies on health- and demography-related household surveys. Indicators to assess the many aspects of sustainable access to safe drinking water and basic sanitation would require a new set of questions many more than can be added to the non-wash-specific surveys on which the JMP relies for its data. A wealth of information is already collected through household surveys that is not used in global analyses yet. New indicators could draw on some of these data. A summary of the JMP discussions of the past decade on the measurability of additional aspects of access to drinking water, sanitation and hygiene was presented as a set of challenges many of which remain unresolved and are still relevant today. Challenges for global monitoring of access to drinking water, sanitation and hygiene: Drinking water: Collecting representative water quality and quantity data, taking into account the impact of seasonality on possible use of different sources in different seasons Defining and measuring reliability of services and establishing a broadly applicable cut-off value. Defining sustainable access in broadly measurable terms. Determining a metric for affordability of drinking water consumption 6

9 Sanitation: Measuring cleanliness of facilities Classifying facility types in a reliable and unambiguous manner Monitoring the final and safe disposal of wastewater and fecal sludge Classifying the use of well-managed, improved sanitation facilities that are shared or public Hygiene: Measuring of actual hand washing behaviour is hugely challenging. Current proxies that determine the presence of a specific place for handwashing with water and soap are deemed too limited yet there is broad agreement among scientists and practitioners that this is the best indicator to date that handwashing regularly takes place. Definitions of the disposal of child faeces do not accommodate disposal in sanitary landfills as a suitable and safe disposal method Measuring the conditions which allow for adequate menstrual hygiene management poses challenges MICS and DHS types of household survey were introduced to fill data gaps left by inadequate vital registration and information management systems. It is expected that for many countries it may well take decades before reliable systems are in place that would eliminate the need for periodic household surveys. However, economic development will likely bring about greater coverage rates and more effective utility monitoring systems in many countries, so over time global monitoring could increasingly draw on such systems as well, as it now already does largely in the high-income countries. The session closed with brief comments from Sanjay Wijesekera, who emphasized the high level of visibility of the meeting with UNICEF senior management and the importance of integrating the process with UN Water and the impending Thematic Consultation on Water. Proposed menu of options of post-2015 WASH targets and indicators (Tom Slaymaker, Water Aid) The process to consolidate the targets and indicators from the Water, Sanitation, Hygiene and Equity and Non-Discrimination working groups began just over a month before the Consultation. This process aimed to reduce working group outputs to a small number of targets that are focused on outcomes, which had been a key strength of the MDG era. A tentative timeframe for the targets ( ) had been provided to the working groups; this is, however, likely to change as a function of the on-going post-2015 development dialogue. A major criticism of the MDG drinking water and sanitation targets remained their lack of focus on sustainability and insufficient attention to inequalities. There was a broad consensus among the working groups to expand the focus of post-2015 targets so they incorporate extra-household settings such as schools and health care centers, as well. Recognizing that the process to formulate an overarching WASH goal will be left to politicians, the working groups thought it important to anchor their proposed targets under one succinct WASH goal: Safe and sustainable sanitation, hygiene and drinking water for all. 7

10 Discussion ensued about whether questioning the technical definitions set forward by the working groups could be assessed during this meeting on measurability, and it was determined that this was permissible in as much as measurability is impacted by the definition, but the primary focus of the meeting should be on identifying issues rather than pursuing a revision of targets. Robert Bos raised the possibility of establishing, after 2015, a rolling revision process to allow the targets to be adapted as new realities and technologies emerge and Jamie Bartram pointed out that this was effectively what happened during the MDG process even though it had not been planned. Presentation: Potential of using big data for global monitoring followed by discussion (Robert Kirkpatrick, UN Global Pulse) Mr. Kirkpatrick presented work undertaken by data scientists and academic partners to harness the power of big data for global development. The definition of big data includes Online info: news, blogs, twitter, FB, job postings Private data exhaust: data generated during routine transactions or use of a communication network (mobile-to-tower communication, transactions, search strings) Physical sensors: satellite, video, traffic Crowd-sourced reports: information solicited actively from citizens We are just beginning to realize the potential of big data to track global issues such as communicable disease prevalence and incidence. For example, the 2012 Ebola outbreak in Uganda was detected through social media analysis two weeks before epidemiologists were able to detect it by conventional means. The potential benefits of harnessing this data include better early warning, more real-time awareness and the potential for real-time feedback to inform actions. UN Global Pulse works with donors, governments and business to develop projects to explore the uses of big data approaches. A laboratory is currently set up in Jakarta, Indonesia, and a second will be in operation soon in Kampala, Uganda. Mr. Kirkpatrick concluded by expressing his enthusiasm for potential collaboration with the WASH monitoring sector. In the ensuing discussion, Robert Kirkpatrick acknowledged that it is unlikely that big data anytime soon will be able to replace the rigour and robustness of household surveys for periodic, nationally representative monitoring of the type of global development outcomes listed under the MDGs. REVIEW OF TARGETS AND INDICATORS The review of targets and indicators began with a series of thematic overview presentations from each of the four working groups. These are summarized briefly in the following sections. Following the presentation summaries, each target and related indicators are presented using the original language from the consolidated document (presented in Annex C). The review process was conducted in a structured manner by first examining the target formulation, then moving on to the indicator formulation and related definitions, with special emphasis placed on clarifying the numerator and denominator for the indicator, and finally considering potential measurement mechanisms. 8

11 Although the participants felt it was important to determine measurability based on reasonable adaptations of current methodologies such as household surveys and demographic information systems, it was also recognized that in order to raise the bar beyond the MDG era achievements, new methods and technologies must be considered. In cases where modifications of current methods might be sufficient without requiring significant new research, follow-up items were identified and listed, whereas issues that appeared to require more in-depth research or literature review were identified and listed as research items. Follow-up items are identified by the letter F and research issues are identified by the letter R (e.g. F-7 or R-3). Complete lists of follow-up and research issues can be found starting on page 24. Presentation: Proposed menu of options of post-2015 WASH targets and indicators (Tom Slaymaker, WaterAid) The consolidated targets and indicators reflect the efforts of the working groups to arrive at a small number of targets that are focused on outcomes. The core principles were: Recognition of the human right to water and sanitation Progressive realization Cohesiveness of targets across working groups For the first time, the targets will incorporate extra-household settings, with schools and health care facilities serving as the initial focus. Equity and Non-Discrimination Equity, Equality and Non-Discrimination (END) are cross-cutting issues that are relevant to all WASH targets. For this reason, these principles were not designed to be relegated to a separate target. Instead of formulating proposed targets and indicators, the END Working Group produced a detailed report that included: (a) a checklist 2 to ensure that issues of equity, equality and nondiscrimination were addressed when developing WASH targets and indicators; (b) recommended elements for goals, targets and indicators; and (c) a series of recommendations concerning measurement and data sources. In order to keep these guidelines in mind throughout the meeting, the END recommendations were presented before the formal review of targets. Presentation: Recommendations of the Equity and Non-Discrimination Working Group Meg Satterthwaite (NYU) Inequalities were perceived to be one of the most significant blind spots in the MDG targets and little attention was paid to such disparities throughout the MDG era, in part due to a lack of data. This lack of data is due both to methodological challenges as well as a lack of political will in some settings. The Special Rapporteur s efforts toward reducing WASH inequalities has therefore 2 JMP Working Group on Equity and Non-Discrimination Final Report monitoring/working-groups/equity-and-non-discrimination/. 9

12 mainly focused on improved data collection, increased attention to new methods for analyzing and collecting data, and stronger political commitments from national governments. Household surveys are currently the principal instrument for collecting data relevant to JMP and improvements are needed if they are to be adequate to the task of monitoring inequalities. Some improvements related to measurement and data sources recommended by the END Working Group include: Include questions that would reveal information related to intra-household inequality, in particular about use of facilities (as opposed to only access) disaggregated by gender, age, health status, and disability (see related Research Item R-1). Add a question concerning menstrual hygiene management that would focus on whether all menstruating women and girls in the household have access to the facilities and materials they need to manage menstruation hygienically, with dignity, and in safety. Improve categorization and sampling of informal settlements and slums. Expand data sources beyond the household, such as schools and health centers but also detention centers and prisons. Make use of emerging data sources and methods. Many inequalities can already be monitored using existing mechanisms, by examining differences between attainment of the targets and indicators along the following dimentions: Wealth Urban / rural Tenured / informal urban and periurban settlements END Definitions Equality the legally binding obligation to ensure that everyone enjoys equal enjoyment of their rights Equity the moral imperative to reduce unjust differences Non-discrimination a legal principle prohibiting the less favourable treatment of individuals or groups Disadvantaged groups. Membership of a disadvantaged group may result from a wide variety of individual- or group-related discriminatory processes; household surveys often include data related to a small subset of the relevant groups, including ethnicity, race, nationality, language, religion, or caste. While such forms of discrimination occur globally, the actual groups vary across countries. These groups will be identified through a participatory national process. The END Working Group stressed that individual-related inequalities that are relevant in every country of the globe, such as those based on sex/gender, age, disability and health conditions imposing access constraints are not adequately addressed in current household surveys. The Working Group therefore recommended that new approaches were needed to address these inequalities (see below). 10

13 Approaches to measuring inequality A major topic of discussion on both days concerned the exact metrics that might be used to track inequalities in achievement of the proposed targets. The core philosophy embedded within the END recommendations, discussed in the END Working Group Final Report, and reflected in the consolidated draft goals, targets and indicators was that of progressive reduction and elimination of inequalities. This principal was incorporated into each target in the consolidated proposal and it implies that all groups within a society achieve access to improved WASH services in a manner that increases overall access while also progressively reducing or eliminating inequalities between the groups. There were several technical proposals for measuring the progressive elimination of inequalities: 1. Targeted gap reduction. In this approach, a goal is formulated to reduce the gap between an advantaged and a disadvantaged group (e.g. reduce the gap in access to adequate sanitation between the highest and lowest wealth quintiles by half ). This type of target is simple to communicate but does not explicitly require progressive realization because it could be achieved without increasing access for all groups. 2. Rate of progress metric. A more technical approach is to target rates of increase in indicator attainment for each group that are higher for disadvantaged groups but ensure that all groups achieve higher service levels over time. A simple expression of this metric is to require that the rate of indicator attainment for each group be positive and that the rate for disadvantaged groups is higher to ensure that the gap is reduced without retrogression, or lowering of attainment for higher-achieving groups. 3. Minimum service level. This approach sets a minimum acceptable service level for disadvantaged groups, which implicitly defines what the acceptable gap could be since the maximum achievable level for the advantaged group is full attainment. 4. Inequality index. Statistical approaches are available for defining and comparing inequality across different societies. One approach explored by JMP in the past is the Gini Coefficient of wealth inequality 3 ; however, UNICEF found that this approach was not satisfactory because large disparities could still exist within the poorest wealth quintile even at high Gini coefficients. An alternative Index of Inequality Betterment was proposed by END Working Group member, Dr. Shea Rutstein, but a new indicator will require research to determine if it provides meaningful comparisons. Discussion at the meeting focused on a proposal explained by Meg Satterthwaite that the language progressive elimination of inequalities be understood to mean: (a) that the inequality between the relevant groups (top/bottom quintile; urban/rural; formal/informal settlements; general population/disadvantaged groups) was increasingly reduced/ eliminated; (b) that this reduction was not achieved through retrogression or leveling-down of the better-off group; and (c) that the progress was at a rate adequate for each group to achieve the target. 3 Frank A. Farris, The Gini Coefficient and Measures of Inequality, The Mathematical Society of America Monthly 851 (2010)

14 Measurement of intra-household inequalities Some forms of inequality are experienced at the individual level instead of the household level. These inequalities may produce, or be correlated with, differences in WASH access within households. These inequalities are not currently captured within household surveys. For example, a household may have an adequate sanitation facility according to JMP definitions but if a person with a disability, an older member of the household or a domestic servant, cannot access the facility, then the access to sanitation would be unequal. This illustrates the need to move beyond access to actual use of facilities by different individuals in the household. Participants involved in conducting household surveys agree that these inequalities are important but caution that a method for collecting data about intra-household differences in access would pose a substantial new measurement burden for survey organizations. More research is needed to determine the relative scale of these inequalities, into approaches for measuring them, and the impacts in terms of expense and complexity on current survey methods. There was no consensus among those members involved in conducting household surveys about whether the additional measurement burden was justifiable or even feasible; therefore, this issue was identified as a research item (R- 1). Longitudinal studies were mentioned as a possible resource for research methods in this field (R-2). Follow-up items and research questions regarding Equity and Non-discrimination Follow-up F-1 Develop a final recommendation on the exact metric to be used for monitoring progressive realization and integrate a definition into the consolidated document. F-2 Consult with UN-Women to integrate with Thematic Consultation on Women and Equality. It will be especially important to discuss approaches to intra-household inequalities with UN-Women as this is an issue the agency and UNIFEM have identified as a barrier for some years. Research R-1 Assess the available evidence on the prevalence, scale, and types of intra-household inequality and discrimination and their impact on access to WASH services and use of facilities. What are the available methods for assessesing intra-household inequality during surveys? Does the scale of these inequalities justify the need for more specific monitoring? R-2 Evaluate whether evidence from longitudinal studies of inequality could be helpful in setting the inequality metric. 12

15 Drinking Water Presentation: Introduction to drinking water targets and indicators (Tom Slaymaker, WaterAid) The Drinking Water Working Group formed a consensus around addressing issues of water quality (including acceptability), accessibility, affordability, and availability (considering both quantity and reliability). A water quality target of less than 10 colony-forming units (CFU) of the fecal indicator bacterium, E. coli, per 100 ml sample is proposed. This target is 10 times less stringent than the WHO guidelines, and represents a compromise that accommodates inexpensive measurement methods that do not require laboratory equipment and should be considered an intermediate step toward establishing more comprehensive national water quality standards and surveillance mechanisms In considering extra-household settings for the first time, the following categories were considered: High use areas: schools, workplaces, transit hubs, and markets High risk areas: hospitals, health centers, and prisons Special events: mass gatherings and pilgrimages Of these categories, schools and health centers were determined to be the most appropriate and feasible settings for national monitoring efforts. Discussion centered on the sequencing and the ambition of the proposed water targets, particularly in relation to the sanitation targets. The working groups developed a graphical representation (reproduced in the inset below) that mirrors the ladder approach to increasing service levels, which has been used in the past by the JMP 4 for global monitoring. Although the Consultation was not directly tasked with assessing the technical scope of the proposed targets, it was noted that when compared side-byside in this manner, the water theme lacks an aspirational high service level that would be comparable in ambition to Safe Water Intermediate (on premises, discontinuity <2 days in 2 weeks, E coli <10/100 ml) Basic (not on premises, improved source, <30 min collection time) Sanitation Safe management of excreta (containment, extraction, and transport to a designated disposal or treatment site, safe re-use at the household or community level) Adequate (pit latrine, sewer or septic tank, shared by no more than 5 families or 30 persons) No open defecation No one practices open defecation management of excreta (it should be noted that safe management was found in need of further definition during review of the Sanitation targets). In effect, the bar for water is not raised between 2030 and 2040 as it is for sanitation. 4 For more on the ladder approach, see The drinking-water and sanitation ladders, available at the JMP website 13

16 Considering that even the poorest residents of many industrialized countries enjoy piped water into the home, many participants believed that this highest level of service should not be left out of the formulation of targets that will span the next 25 years of international development. However, not enough data are available on the feasibility of obtaining this service level, particularly when local hydrological and economic conditions are taken into consideration. More research is needed to establish whether such a target would be feasible within the SDG timeframe (R-3). One proposal for a more aspirational yet achievable water target was to focus on the intermediate service level in all schools and health centers by It is suggested that the JMP assess the feasibility of this proposal (F-3). Follow-up items and research questions regarding Water Follow-up F-3 Consider a more aspirational water target for For example, by what date could the intermediate level of service be achieved in schools and healthcare facilities for all sectors? Research R-3 What level of piped service is possible within each country based on hydrological and other constraints, and within what timeframe? Sanitation Presentation: Introduction to sanitation target and indicators (Jenna Davis, Stanford University) The proposed post-2015 agenda for sanitation expands on the single MDG target in several areas, including open defecation, the recognition of shared sanitation facilities, and the addition of a target for safe management of excreta. Discussion ensued about the precise definition of acceptable shared sanitation facilities, including the maximum acceptable users of a shared facility, the distance from household to facility that is permissible, and whether managed toilet blocks or for-fee toilet schemes should be allowed. Dr Davis explained that the current evidence supports sharing of facilities to be sufficiently safe when they are shared among a small group of mostly extended family members. There was broad agreement that further research on this subject is needed (R-4) to validate the numbers currently included in the shared facility definition (less than 30 persons and less than 5 families per facility) and to consider whether a maximum distance limit should also be imposed. Another important issue concerning the measurement of shared sanitation facilities is whether the intention is to directly count the number of households and persons using a particular facility (i.e. a bums per seat approach ) or if the ratio should simply be assessed at the village or regional scale (F-3). It was noted that research currently being conducted by the SHARE Consortium 5 in collaboration with UNICEF and WHO will address issues of shared sanitation facilities

17 Public sanitation facilities have been successful in many settings, but the Sanitation working group concluded that these approaches should not be included in global targets because of the greater distances involved, the risk of violence against women, and the uncertain financial sustainability of fee-based toilet schemes. One final instance of shared facilities is in schools and a research item was identified to investigate whether a minimum distance to facility in schools is needed (R-5). Follow-up items and research questions regarding Sanitation Follow-up F-4 Clarify the definition of shared sanitation facilities to specify whether the intention is to measure the number of households and persons using a particular facility or to apply a ratio at the village or regional scale. Research R-4 Examine the available evidence on use of shared sanitation facilities to determine whether the target definitions of maximum 5 households and/or 30 persons per facility are supported and at what scale this ratio should be applied (e.g. household, village, region). Also determine if a maximum acceptable distance to a facility should be included. R-5 Should a minimum distance to a shared sanitation facility in schools be included in the definitions? Hygiene Presentation: Introduction to hygiene targets and indicators (Orlando Hernandez, FHI 360) The Hygiene Working Group considered health, social impact and human dignity to be the primary issues in setting hygiene targets. The challenge in setting targets is that most of the benefits of improved hygiene are realized through changes in behaviour, which is difficult to measure in yearly sampling surveys. Although the group initially included indicators specifying percentages of critical times when adequate hygiene was used, these were dropped because the only methods currently available to monitor behaviour are structured observations, which would be impractical to implement in large-scale national surveys. As a result, the proposed hygiene targets focus on the provision of adequate facilities and enabling environments for hygiene. Menstrual hygiene management (MHM) is considered an important new area of global WASH concern, both from a human rights perspective and because of the economic and educational impacts that inadequate MHM has on women and girls. The original targets for MHM attempted to ensure that information and education was provided to women and girls; however, process indicators (i.e. institute a national programme) were dropped in favour of more quantitative outcome indicators. The JMP rationale for avoiding process indicators was that the quality of 15

18 national policies is difficult to assess, but some participants did not share this view since even targets with less concrete measurability can influence national policies. Participants felt that it was important not to lose sight of the original aspirational goals of the hygiene group for the sake of measurability. Since international monitoring of hygiene practices is a relatively new field, further research on methods to measure the actual use of facilities rather than merely their presence was considered critical (R-6). It is not recommended that questions about behaviours be added to household surveys, as self-reported information is frequently unreliable and subject to bias. On several occasions throughout the Consultation, discussions returned to this concern about limiting the targets aspirations because of the limitations of current methodological constraints. It is proposed that during the post-2015 process, the JMP make an effort to identify and track targets that are more aspirational but excluded due to these constraints (F-5). Formal recognition of these methodological challenges will help drive the future research agenda toward better solutions. Follow-up items and research questions regarding Hygiene Follow-up F-5 Identify and track targets and indicators that are more aspirational in nature, but could not be included due to limitations of current data collection methodologies. Research R-6 Further research into methods to measure hygiene behaviours at the global level is needed. Access to a facility is only a precondition for adequate hygiene, but what needs to be measured is the use of facilities. 16

19 Target 1 Review Target 1 is specific to sanitation and reads as follows: Target 1 Indicator 1-a Indicator 1-b Indicator 1-c By 2025 no one practices open defecation and inequalities in the practice of open defecation have been progressively reduced. 6 Percentage of households practicing open defecation Percentage of households with children under five reporting hygienic disposal of the stools of children under five Percentage of households in which open defecation is practiced by any members of household (men, women, children under five) Target 1 discussion Target 1 was viewed as an aggressive but appropriately aspirational objective. It was noted that current rates of progress in reducing open defecation must be greatly accelerated if Target 1 is to be achieved by After further discussion, it was concluded that assessing the feasibility of achieving the various targets is important but outside the scope of the meeting; therefore, a followup item was recorded to rigourously assess feasibility across all WASH targets (F-6). A concern was raised regarding the sequencing of Target 1 and the future sanitation targets, which call for adequate sanitation facilities and safe management of excreta. It is possible that in order to reach Target 1, a country could pursue a programme of providing inferior facilities that reduce open defecation but do not meet the definitions of adequate sanitation in the later targets. Since the intention is clearly to achieve open defecation free status by providing adequate sanitation facilities, the sequencing of the targets might need to be reconsidered (F-7). The statement included in Target 1, and inequalities in the practice of open defecation have been progressively reduced, might be considered unnecessary since the target wording already requires full attainment. Furthermore, since a relatively short timeline is specified (10 years) and most data are obtained at 3-5 year intervals, it may be difficult to assess inequality in attainment of this target. The Equality and Non-Discrimination Group recognizes these difficulties, but strongly supports this language or the related formulation of progressive elimination of inequalities as a means to maintain an international emphasis on the most marginalized groups during the timeframe. Recent work by JMP to report disaggregated data by wealth quintiles provides evidence that such inequalities are measurable. 6 The italicized text did not appear in the consolidated targets definition but was added after further consultation between the working group leads prior to the Consultation. 17

20 The consideration of Target 1 indicators followed. In order to achieve continuity between historical data from the MDG era and Post-2015 monitoring, it is suggested that the previous sanitation indicator be included (suggested revisions to the target are shown in the table at the end of each section). Some participants questioned whether an ODF indicator was necessary or practical in households that have access to adequate sanitation, but the Sanitation Working Group pointed to significant evidence indicating that not all members of a household use the sanitation facilities. It is not clear whether a reliable method to assess open defecation practices during household surveys currently exists. Surveys of self-reported behaviours are subject to bias, particular when the use of sanitation facilities or avoiding open defecation is perceived to be associated with higher socio-economic status. Further research is suggested to determine reliable measurement methods for Indicators 1-a and 1-c (R-7). Likewise, Indicator 1-b (hygienic disposal of the stools of children under five) is a behaviour and would also rely heavily on self-reporting. Furthermore, concern was expressed that under the current definition of open defecation (italicized text in definition), disposal of a child s stool in a hygienic landfill would be excluded. This is a practice that is generally regarded as safe and widely used even in countries with high levels of sanitation services. The JMP Harmonization Task Force in 2004 considered this issue and concluded that adequate municipal solid waste disposal systems are rare in many countries and that solid waste disposal is difficult to assess during surveys; therefore, the present formulation was left intact. After lengthy consideration of this issue, the participants agreed that the indicator should be retained but follow-up action is suggested to specifically address the issue of sanitary landfill disposal (F-8). Suggested revisions to Target 1 Definition of open defecation defecation in bush, field or ditch; excreta deposited on the ground and covered with a layer of earth; excreta wrapped and thrown away; and defecation into surface water (drainage channel, beach, river, stream or sea) Target 1 Indicator 1-a Indicator 1-b Challenging: Indicator 1-c By 2025 no one practices open defecation and inequalities in the practice of open defecation have been progressively reduced. Percentage of households practicing open defecation Percentage of households with children under five reporting hygienic disposal of the stools of children under five Percentage of households in which open defecation is practiced by any members of household (men, women, children under five) 18

21 Follow-up items and research questions for Target 1 Follow-up F-6 Assess the feasibility of achieving the proposed targets within the timeframes specified and revise where necessary. What acceleration in rates is needed and which countries need priority? F-7 Assess the internal consistency between Target 1 (open defecation-free by 2025) and Targets 2 and 3 (provide adequate sanitation facilities). Is this the most logical sequencing, considering that the objective is to eliminate open defecation by providing adequate sanitation facilities? F-8 Consider whether Target 1-b (hygienic disposal of the stools of children under five) could be modified to accommodate safe disposal in a sanitary landfill. Research R-7 Are there reliable survey methods to assess open defecation practices among all members of a household? Is self-reported open defecation and use of sanitation facilities too susceptible to bias? Target 2 Review Target 2 is complex, involving water, sanitation and hygiene for households and extra-household settings such as schools and health centers. It was not clear to the participants if the different elements within the target are interdependent, meaning that all conditions have to be met at the same time or if the different elements can be considered stand-alone targets. This issue requires further clarification and is captured later as a follow-up item (F-19). The original Target 2 reads as follows: Target 2 By 2030 everyone uses basic water supply and handwashing facilities at home, all schools and health care centers provide all users with basic water supply and adequate sanitation, handwashing facilities and menstrual hygiene facilities, and inequalities in access to all these services have been progressively reduced The target statements and related indicators are separated into sections based on their thematic scope and reviewed separately below. At the end of each thematic section, the proposed revisions to the targets and indicators are presented. 19