Access to Safe Drinking Water: Challenges and Opportunities for Improving Global Health

In developing countries, women and girls spend an estimated 40 billion hours a year collecting water.

-by Jo Geere, originally posted on March 12, 2016


Since humans established permanent settlements and systems of agriculture, efforts to develop water supplies and waste management for the successful maintenance and growth of societies have been apparent. Archaeologists have found evidence of ancient wells, water pipes and both public and private bathing and toilet facilities in the Bronze Age. In ancient Greece and Rome, the importance of water for public health was recognized, and inequalities of access according to wealth and status must have been present.

In Europe, in more recent times, links between better water and waste management systems and improved public health were recognized in 1854, from the work of the physician John Snow in London’s Soho district during the cholera outbreak of the time. Snow’s communication with residents and careful observations traced the source of the cholera outbreak to a public water pump. The pump drew water from a well found to have loose bricks, allowing sewage from a nearby cesspool to easily contaminate it. This led to changes in water and waste systems of London and other cities, which were implemented to attempt to keep sewerage separate from water supplies. Since then, the public health, social and economic benefits of safe water and sanitation have been well-supported by research evidence.

Globally, people of many nations—or high income regions within nations—now enjoy the health benefits of vast, reliably maintained infrastructure and water management systems that pipe safe, clean water into people’s homes for drinking, cooking, washing and flushing their waste into sewerage systems. In these regions, people no longer have the responsibility of maintaining their own supply of safe water, or collecting water from a shared source outside of their own house or yard. Instead, people are billed, with variable levels of efficiency and cost recovery, for water services provided by government or private utility companies.


Despite the overwhelmingly clear evidence that providing safer, accessible and more reliable supplies of fresh water leads to healthier populations and economies, millions of people still struggle to access safe drinking water, and more than 840,000 people die each year from poor water, sanitation and hygiene.

The most commonly used definition of “access” is defined as having a source of safe water within 1 kilometer of the dwelling. It is estimated that in 2015, 663 million people still lacked access to “improved” drinking water sources. Improved sources are those deemed to be relatively protected from contamination and, therefore, likely to provide water safe for human consumption and household use, such as piped water supplies into the house, yard, boreholes or protected wells or springs.

Most unimproved sources—for example, surface water or unprotected wells or springs—and many improved water sources are located away from the home and publicly shared. Transportation of water from the supply point to the house is, therefore, required, and globally this is most often achieved through unpaid, informal work performed by women. In developing countries, women and girls spend an estimated 40 billion hours a year collecting water.

Significant inequalities exist at regional, national and even local levels. For example, within communities, particular households and individuals who must physically collect and carry their own water can face barriers to accessing sufficient safe water due to poverty, disability, ethnicity or age.

Jessica Budds and researchers at the University of East Anglia Water Security Research Centre, United Kingdom, highlight that only about 0.5% of water on Earth is usable freshwater, as most of the 1.4 billion cubic kilometers of water on the planet (70% of the planet) is seawater. Water scarcity affects 40% of the world’s population, and water use is predicted to increase by 50% in developing countries and 18% in developed countries by 2025. It is thought that water scarcity will be exacerbated by population growth, expanding agriculture and climate change. However, physical availability of water is not a good indicator of access, with 70% of global freshwater used by agriculture, and only 10% used for domestic purposes.


Water is not an easy substance to transport: It is heavy, unstable and energy-intensive to move. The infrastructure that supports piping water into houses is expensive to install and maintain. Many cities currently reap the benefits of past investments in infrastructure and face huge costs of repairing and replacing old materials. Piped water services are simply unaffordable in many communities of low-income regions or countries, particularly in remote rural areas.

The health and social impact of the work of water carriage on people who must regularly collect water from out of home sources has received little attention to date. It is likely that for healthy, fit, working-age adults, the physical health impact of collecting water may not be problematic. The regular physical exercise of walking to a water point may be beneficial and counteract lifestyle changes leading to reduced physical activity in many developing regions.

Water carriage may be a valued role that facilitates family and community cohesion and creates opportunities for reciprocity in providing care and support to extended family. It can be a source of income for adults or school-age children and an activity that supports engagement with and conservation of the local environment.

However, this assumes the absence of population tensions, violence, corruption and health problems, which can individually or in combination create a very challenging or unsafe environment for water collection, such that individuals or households struggle to obtain sufficient water to meet their needs. Distance to water source, frequency of trips, terrain and climate in which water fetching is performed will also influence the level of difficulty that households face in accessing water. Injury, disability, age or long-term health conditions may further compromise an individual’s capacity to physically collect enough water.

There is growing evidence that regularly carrying heavy loads on the head, typical of water carriage in Sub-Saharan Africa, is associated with musculoskeletal pain and disability. The aftermath of infectious disease epidemics, conflict or natural disaster may mean that children or the elderly in poor families bear the burden of collecting water for household use, and it is clear that the very young and the elderly have reduced capacity for such physical work.

The 2014 Ebola outbreak in West Africa tragically demonstrated this. The charity Street Child, in its 2015 Ebola Orphan Report, states that 12,023 children lost their primary caregiver and 3,241 lost both parents to Ebola in 2014-15, highlighting examples of teenagers who must provide for their siblings and take on household responsibilities since being orphaned.

As water is a basic requirement for life, and most of this work is unpaid, informal and time-consuming, it has been described as an example of “occupational injustice.” Occupational justice theory proposes that unequal access to opportunities and resources restrict people’s ability to participate in meaningful occupations, and that this restriction can be harmful to their health, wellbeing and prosperity. Research evidence confirms that time spent collecting water restricts opportunities for other occupations, such as education and paid or other subsistence work. Globally, as women and young girls perform the bulk of water fetching work, it affects them disproportionately.


Water is also not so easy to keep clean, particularly if it must be transported from a shared source to the point of use. It has been shown that “improved sources” are not always safe, and can be contaminated by chemical pollutants or human or animal excrement. Infectious diarrhea is the most common disease related to unsafe water, sanitation and hygiene, mainly affecting children under 5. Globally it causes the deaths of over 1,000 children every day.

Other common water borne- or water access-related diseases include malnutrition and its consequences (which is associated with repeated bouts of diarrhea and also mainly affects children under 5), intestinal nematode infections, trachoma (a preventable cause of blindness), schistosomiasis and lymphatic filariasis.

Stauber and Casanova report that globally, naturally occurring arsenic contamination is the chemical pollutant of most concern. In Bangladesh, contamination of drinking water wells has resulted in exposure to potentially disease-causing concentrations of arsenic, estimated to affect 20-50 million people. Long-term exposure has been associated with skin, bladder and lung cancers and kidney disease.

Several studies have shown that even if the water quality is high at a public source point, contamination frequently occurs during transport, handling and storage in the home. A variety of household water treatment technologies have been reported by the World Health Organization (WHO) to be effective methods of improving drinking water quality at the household level.


Gary Haugen and Victor Boutros, in their book The Locus Effect, have collated extensive evidence of the daily violence that undermines development and safety of people living in poor communities. In the absence of effective law enforcement, women and children collecting water from an out of home source, or forced to defecate in the open, are not safe in many communities. Consider the horrific example of two teenage girls raped and murdered in India in 2014 while looking for a toilet after dark.

Poverty and local power inequalities can exacerbate inequalities of access to water. For example, in rural South Africa, the value of scrap metal can lead to theft of communal taps and water pipes. Whilst utilities and water vendors play a huge role in distributing water to homes in low-income regions, wealth and power inequalities can lead to behaviors that are not in the public interest and extract excessive payments for water from poor households.

In areas where informal providers are the only source of water delivery to poor households, and monopolies of access to water sources or vehicles to transport water exist without regulation to ensure fair pricing, extortion and bribery can inflate the cost of this essential service, such that the poorest households can in fact be paying the most for their water.

As documented by the International Committee of the Red Cross 2015 report, protracted armed conflict, particularly in urban areas, can cause and maintain water and sanitation service disruption to large populations. For example, in densely populated areas, one broken pipe can deprive 100,000 people of water. Combined with disruption of health services, deteriorating public health, increased rates of physical trauma and disability from war, and living in unsafe physical environments, collecting water in these circumstances becomes a massive challenge.

Corruption in the water sector is one of the key reasons that so many people lack access to safe water and sanitation. It can mean that public contracting does not serve the public good, but leads to inflated prices and bribery for services, dumping of pollutants into water bodies and poorly constructed facilities. For example, the Water Integrity Network describes the situation of inequalities in water service delivery in Delhi. It reports that in 2014, the average household in the city paid around $20 as a bribe—from a minimum payment of $5 for a water tanker to a maximum payment of $75 to reduce a water bill, which are considered significant amounts for low-income families in India.

Poorly constructed and maintained facilities lead to regular breakdown of supply systems with prolonged repair times. Unreliable water supplies increase the work of water carriage—people may need to access more distant sources, revert to alternative sources such as surface water, or transport as much water as possible during periods of limited availability. It can mean that ability to plan, pace and organize the work of water carriage is compromised, adding to the distress associated with household water insecurity. Combined with short-term political focus, corruption can lead to community needs for water security losing out against competing demands of other more wealthy or powerful lobby groups.


The Joint Monitoring Programme (JMP) of UNICEF and the WHO reported that target 7 of the Millennium Development Goals (MDGs)—to halve by 2015 the proportion of the global population without sustainable access to safe drinking water—was met in 2010. This means that some 2.6 billion people gained access to improved drinking water sources since 1990, and 91% of the global population now have improved drinking water.

Whilst much of this progress was achieved in China, the JMP reported that in Sub-Saharan Africa, 427 million people have gained access, which equates to an average of 47,000 people per day every day for 25 years. Although some 2.1 billion people have gained access to improved sanitation since 1990, the world has missed the MDG target on sanitation for 2015 by nearly 700 million people, and it is estimated that globally, 946 million people practice open defecation.

Mobile devices and networks have revolutionized communication globally, including developing countries and Sub-Saharan Africa. The communication revolution creates opportunities to improve monitoring, evaluation and maintenance of water and sanitation services, and potentially to leverage improved access to water. Smartphones, devices and networks may provide ways to improve communication between water service providers and users, for better data collection, information sharing, strengthening partnerships, better cost recovery and reduced opportunities for corruption.

Better service provider-user relationships have been demonstrated to improve maintenance and reliability of water supply systems, which would reduce the work of water carriage in many regions, particularly those unlikely to be provided with piped water services. Better communication about service disruptions could enable households to plan and choose appropriate coping strategies. For example, people may start to use household water treatment during supply failures or increase use of alternative water sources commonly used for activities such as bathing, laundry or gardening. A more consistently reliable supply, even if not available 24 hours per day, can enable women to plan and pace their water collection trips, rather than rushing to obtain as much water as possible before it runs out.

Several global initiatives provide grounds for optimism about the future. The 2013 Resolution of the International Conference of Labour Statisticians to recognize water fetching and other unpaid or informal labor as work indicates increasing recognition of the huge burden of activity currently required by many to secure access to drinking water. Integrity Pacts developed by the Water Integrity Network and Transparency International provide a framework, tools and implementation guides for reducing corruption and improving governance in the water sector.

The United Nations Sustainable Development Goals (SDG) to ensure availability and sustainable management of water and sanitation for all by 2030 builds on the achievements of the MDGs, and will ensure ongoing dialogue and monitoring of global progress and regional inequalities.

In working to achieve the SDG target of universal access to safe drinking water and sanitation, the challenges discussed in this article must be addressed. The issues that complicate and perpetuate the realities of water collection faced by so many people in the world every day will not go away easily, but progress over the past 25 years and the building momentum, dialogue and political will toward transformation indicated by the SDGs provide evidence that real change for the better is possible.



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