EHJ March 2005, pages 8-11

To mark the imminent launch of EHN International, Rob Couch looks at the millennium goals and asks what progress has been made towards providing over a billon people worldwide with basic sanitation by 2015

The statistics are overwhelming. Diarrhoea alone kills 1.8 million people every year, 90 per cent are children under five. In 2000, 2.4 billion people lacked access to basic sanitation and 1.1 billion had no access to safe water. These statistics cannot hope to reveal the hopelessness and human loss caused by preventable diseases, or the determination and optimism for change. But, they do serve to show the enormous task before the international community in 2005, which has been heralded "crunch time" for alleviating poverty in the developing world.

The tsunami placed development squarely on the news agenda from the start. Chancellor of the exchequer, Gordon Brown, and the newly formed Commission for Africa have chosen 2005 to champion the development cause, while the UK's year-long presidency of the G8 group of industrialised states and, from July, the EU, are seen as opportunities to place development at the heart of international policy. But the most significant meeting this year, for the development community, will be held in September when the United Nations gathers to review what progress has been made in achieving the Millennium Development Goals (MDGs).

MILLENNIUM GOALS

In September 2000, at the United Nations Millennium Summit, 189 countries took a giant step towards reducing world poverty. They all signed the millennium declaration which gave birth to the MDGs, a set of eight targets aimed at uniting governments, aid agencies and civil society organisations behind tackling the key causes of preventable death and poverty. Mark Malloch Brown, former head of the United Nations Development Programme, describes the goals "as a development manifesto for ordinary citizens around the world" as well as holding "governments and the wider international community accountable for their achievement".

At first glance the goals appear quite distinct with targets such as promoting gender equality, eradicating extreme hunger, improving maternal health and reducing child mortality (see table 1). Deadlines for these goals vary between 2015 or 2020, with 1990 as the baseline. But within the eight goals there are 18 targets and 48 indicators turning them into a much more coherent and interrelated vision. Goal seven, for example, aims to ensure environmental sustainability by meeting three targets. One of these is target 10, to halve by 2015 the number of people without sustainable access to safe water and basic sanitation. By achieving this target, significant contributions to other millennium goals such as improving maternal health, child mortality, gender equality and reducing exposure to disease could also be realised. Critical to the goals' success is their development into nationally owned and driven strategies, the final goal in DG8, developing a global partnership, was designed to support this aim by building in a commitment from developed countries to support developing countries.

Five years on, progress towards the goals appears mixed. Professor Jeffrey Sachs, leader of the millennium project, a group set up to help developing countries meet the targets, claims that "many countries are achieving many or most of the MDGs, and large parts of the world are achieving significant progress in poverty reduction."

But for some, the picture is not quite so rosy. Gordon Brown has pointed out that based on progress to date, universal primary education in sub Saharan Africa will not be achieved until 2130, 115 years late. The World Health Organization, on the other hand, is optimistic about water supply targets, but believes that given current performance the millennium goal sanitation targets in some regions look hopelessly unrealistic.

South-central Asia and east Asia pose the greatest challenge. The WHO estimates that by 2015 an extra 355 million people will need access to sanitation in sub-Saharan Africa alone. Given current progress, rather than halving, those without sanitation in this region will double by 2015. Sanitation for the rural poor is currently worse than for those in cities. But as people migrate off the land into cities looking for a better life, the challenge of extending sanitation to dense urban slum areas is an increasing priority.

Set up in 2002, the millennium project established a water and sanitation taskforce to explore what obstacles will need to be overcome to halve the number of people without access to safe water and sanitation by 2015.

BARRIERS TO GOOD SANITATION

One of the greatest challenges for each country is defining "sanitation". For some it involves the management of human excreta, solid and hazardous wastes, waste water, storm water and other waste products. The United Nations defines "basic" sanitation as "access to, and use of, excreta and waste water facilities and services that provide privacy and dignity while at the same time ensuring a clean and healthy living environment both at home and in the immediate neighbourhood of users." Countries with poor basic sanitation will see the management of excreta at the household level as a priority. However, in dense urban environments sewers may be the only way to provide safe sanitation, along with solid waste and storm water programmes.

Technically, providing sanitation to communities may appear straightforward, but often it is anything but. Sanitation must be seen as part of an integrated water resources management system, which often makes providing environmentally acceptable sanitation difficult, particularly in urban areas. By providing more sanitation where water is in short supply, you may end up disposing of more and more pollutants into less and less water.

There are also debates on what constitutes appropriate sanitation in low-income settings, particularly between waterborne and dry sanitation options. The right technology in the right area could help to achieve other millennium goals. A composting latrine in a rural agricultural area might help meet nutritional goals. However, people may be reluctant to handle their compost. There is also a risk of parasite survival.

Institutional factors at all levels present another challenge. Some countries may suffer a policy vacuum with no institutional home responsible for sanitation and inadequate institutions at a community level. The United Nations has found that those responsible for sanitation often lack resources, incentives and accountability. Laws and legal frameworks, often in the form of bylaws, may be in place, but they are sometimes poorly enforced.

There can also be problems at the community level. New skills have to be learnt, community groups set up. Insecure land ownership in urban slums often results in service providers being reluctant to do any works. Creating a demand for good sanitation also poses a problem. In rural Benin, status, comfort, cleanliness and convenience drove people to want improved sanitation, but not improved health. Research is showing that local governments may have a role in supporting and promoting improved sanitation to their communities to overcome barriers such as high cost and technical problems.

There also has to be political will. The WHO has found that the poorest African countries are not providing for sanitation in their national budgets. Some finance ministers may see sanitation as providing lower returns compared to areas like roads or energy.

MAKING THE SANTIATION TARGET A REALITY

According to the sanitation taskforce donor agencies and governments will have to commit to low-income countries and the unserved poor if targets are to be met. Support and ownership of water supply and sanitation projects will also have to be achieved at community levels.

The taskforce also wants to see the "plain truth" of open defecation placed at the top of the political agenda. "That 42 per cent of the world's people lack what virtually all readers of this report take for granted - a toilet - is a travesty with devastating impacts on people's daily lives, health, and self respect," stated the taskforce earlier this year.

In 10 action points the taskforce is also calling for the empowerment of local authorities and communities to provide safe water and sanitation and for governments and their partners to support technically, socially, environmentally and financially appropriate water and sanitation solutions. The needs, roles and priorities of the men and women requiring help must also be met while the United Nations and its international partners must provide strong support to help meet sanitation and water targets.

The Millennium Development Goals present humanity with the greatest of challenges and choices. Significant progress has already been made, particularly in India and China, but progress in the very poorest countries remains slow. At last year's World Federation of Public Health Associations Congress, Prof. Ilona Kickbusch, architect of the Ottawa Charter, called for nothing less than a third public health revolution, a global revolution that positions health as the defining characteristic of the global society of the 21st century. For public health professionals faced with such challenges, she called for what the poet Adrienne Rich describes as "wild patience", combining ingenuity, evidence, common sense, passion, a sense of urgency and above all a sense of justice.

According to Prof. Sachs, achieving the MDGs will require a global partnership suitable for an interconnected world, where we all share a common fate. We have at our disposal the proven technologies, policies, financial resources and most importantly, the human courage and compassion to make it happen.

However, Dr. Jamie Bartram, of the WHO, reminds us that even if the sanitation target is achieved, 1.7 billion people - almost a quarter of humanity - would still be left without access to even a simple improved latrine by 2015. This year may prove whether we are truly friends of the human race

For further information on the Millennium Development Goals please visit: http://www.unmillenniumproject.org

EHN International is a new quarterly magazine with news on CIEH and Rehis twinning arrangements along with the latest news from the world of development. It will aim to raise the profile of environmental health in the world of development.

Rob Couch is a lecturer at Middlesex University and is researching the work of public sector environmental health practitioners in urban sanitation in Africa.