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Community-Based Management (CBM) is an important part of Indonesia's goal of universal access to water. However, approaches to CBM tend to neglect the impact of power relationships between community-based organisations (CBOs) and their external donor partners on CBO management capacity. This paper explores the power dynamics between a CBO and their donor partner, the international NGO Engineers Without Borders Australia (EWB), in a rural water supply project in Tenganan, Indonesia. A diffracted power frame was used to analyse the response of CBO power to EWB's participatory approach. The approach was sensitised to power, gave primacy to the CBO's vision, used local assets, and had a flexible timeline. The CBO's power was evident in the strength of its vision, its resistance to government involvement, the occasional rejection of technical advice from EWB, and its increased confidence in its capacity to manage Tenganan's water supply. The findings reinforce the political nature of participation, with implications for approaches to establishing CBM in Indonesia and elsewhere. Strengthened outcomes in rural water supply are likely to result from greater self-reflection by external partners regarding their own positionality, coupled with a focus on strategies for maintaining and enhancing the power of CBOs. [ABSTRACT FROM AUTHOR]

While citywide sanitation planning is perceived to be an enabler of coordinated improvements in sanitation services for developing countries, intended outcomes have often been elusive. In order to illustrate how political economy, chosen planning approaches, and ideas about change and development have acted as determinants of outcomes, this paper draws on three case study countries that took qualitatively different approaches to sanitation planning - Indonesia, the Philippines and Malaysia. The analysis found that the assumptions informing the planning methods were often not valid, which then undermined the potential for successful implementation. Based on the analysis, the paper argues that urban sanitation planning and implementation in developing countries needs to be transformed to reduce the emphasis on comprehensiveness and instead emphasise flexibility, a learning orientation and strategically chosen incentives. This approach demands tighter cycles of planning and action, direct testing of assumptions, and an in-depth understanding of the local- and national-level political economy and the links between them. It requires innovation to be enabled, with funding mechanisms that focus on outcome rather than input. In this way it would be possible to shift away from the typical emphasis on prescriptive procedural planning steps and towards delivery of the much-needed improved sanitation outcomes. [ABSTRACT FROM AUTHOR]

Enterprises are playing increasing roles in facilitating access to sanitation products and services in Indonesia and other developing economies. This study investigated the factors affecting the sustainability of sanitation enterprises in rural Indonesia. Interviews with 33 organisations representing sanitation enterprises, associations of sanitation enterprises, national and international civil society organisations (CSOs), donor organisations and national and local government agencies were conducted to explore different stakeholder perceptions about enterprise roles. The research revealed factors specific to the sanitation entrepreneurs themselves, such as their skills, entrepreneurial traits, pro-social motivations and intrinsic motivations, as well as factors within their enabling environment. Insufficient customer demand, inadequate capacity building opportunities, lack of financing options for entrepreneurs and their customers, and limited government support were observed to undermine sanitation enterprise success. Industry associations were found to be a useful intermediary support mechanism, particularly in the absence of significant government support for enterprises. However, such associations could also stifle innovation, and their role needs to be carefully developed, including financially sustainable models for such associations. This study has implications for how governments and CSOs in Indonesia and elsewhere might best support the role of enterprises and entrepreneurship towards improved sanitation outcomes. [ABSTRACT FROM AUTHOR]

Climate change is likely to affect the pattern of disasters in the Pacific and, by extension, the organizations and systems involved in disaster response. This research focused on how immediate humanitarian health-related needs following disasters are met using the concept of adaptive capacity to investigate the resilience of organizations and the robustness of the broader system of disaster response. Four case study countries (Cook Islands, Fiji, Samoa, and Vanuatu) were chosen for deeper investigation of the range of issues present in the Pacific. Key findings were that adaptive capacity was enhanced by strong informal communication and relationships as well as formal relationships, appropriate participation of traditional leaders and churches, and recognition and support for the critical role national disaster management offices play in disaster coordination. Adaptive capacity was found to be constrained by lack of clear policies for requesting international assistance, lack of coordinated disaster assessments, and limited human resources for health in disaster response. Limitations in psychosocial support and Australian medical services to meet specific needs were observed. Finally, the research revealed that both Pacific and Australian disaster-response agencies would benefit from a strengthened ‘future’ focus to better plan for uncertainty and changing risks. [ABSTRACT FROM PUBLISHER]

Following publication of the manuscript, the authors were contacted by Mr Shaun Kies-Ryan, a hydrogeologist working in the Solomon Islands urban water sector. Section 3.1, second paragraph: replace the sentence "Countries where piped water in urban areas was found to be wholly or substantially drawn from groundwater included Kiribati, Timor-Leste and Vanuatu with 67%, 65% and 68% of urban households respectively using piped water drawn from groundwater sources." with the corrected text "Case study countries where piped water in urban areas was found to be wholly or substantially drawn from groundwater included Solomon Islands, Vanuatu, Kiribati and Timor-Leste with 94%, 68%, 67% and 65% respectively of urban households using piped water drawn from groundwater sources". Section 3.1, third paragraph: replace the first clause of the sentence "For most case study countries, rates of reliance on groundwater for drinking were reasonably comparable across urban and rural areas, with two notable exceptions: Vanuatu, where urban rates of groundwater reliance were found to be almost four times higher than rural, and Cambodia" with the corrected text "For most case study countries, rates of reliance on groundwater for drinking were reasonably comparable across urban and rural areas, with three notable exceptions: Vanuatu and the Solomon Islands, with much higher rates of urban groundwater reliance, and Cambodia...". [Extracted from the article]

Implementing a circular economy approach to sanitation requires knowledge of the costs to construct, operate and maintain resource-oriented systems. Yet the dearth of data on costs of urban sanitation in general, and resource-oriented systems in particular, limit opportunities to progress sustainable sanitation in low- and middle-income countries. This paper contributes empirical data on the life-cycle costs of a resource-oriented sanitation system in urban Sri Lanka, addressing a gap in evidence about how much it costs, and who pays, for a system that integrates fecal sludge management with nutrient capture and reuse. Costs across the system life-cycle were analyzed according to: (i) cost type; (ii) phases of the sanitation chain; and (iii) distribution between actors. Over a 25-year lifespan, the system had an annualized cost of USD 2.8/person or USD 11/m3 of septage treated. Revenue from co-compost sales covered reuse-related costs plus 8% of present value costs for other phases of the sanitation chain. Findings affirm both the potential for resource-oriented sanitation to generate revenue, and the need for substantial complementary investment in the overall system. The system was found to be reliant on household investment, yet financially viable from the service provider perspective with revenue from desludging services (89%) and co-compost sales (11%) that exceeded costs over the system lifespan and in most years. The analysis of total costs, financial perspectives, and reuse specifics contributes critical evidence to inform policy and planning that supports a purposeful and equitable transition towards circular economy approaches to sanitation. • A circular economy approach to sanitation is a normative goal, requiring cost data. • Life-cycle costing of an established system revealed cost drivers and distribution. • Reuse-related revenue covered reuse plus 8% of other sanitation chain costs. • The system was financially viable from the service provider perspective. • Successful resource-oriented sanitation needs investment across the service chain. [ABSTRACT FROM AUTHOR]

The emergence of gender-transformative approaches in the international development sector has ushered in a new paradigm for gender and development, refocusing on core feminist principles. This rise has paralleled the growth of transformative research and a strengthened emphasis on social transformations in the field of international development practice. Gender-transformative approaches aim to reshape gender dynamics by redistributing resources, expectations and responsibilities between women, men, and non-binary gender identities, often focusing on norms, power, and collective action. In this paper, we trace the history of gender-transformative approaches (1990 to March 2022); explore the breadth of applications in development described in both grey and academic literature; and identify five principles to guide future gender-transformative approaches with a focus on interventions. We hope that these clarifying principles will make the rich conceptual contribution of gender-transformative thinking relevant to a broad audience of researchers and practitioners and provide a basis for further academic debate and refinement. [ABSTRACT FROM AUTHOR]

Multiple established connections link access to safely managed water, sanitation and hygiene (WASH) and gender equality. As development actors seek to attain the fifth and sixth Sustainable Development Goals, the need to measure WASH programs' contributions to gender equality outcomes is increasingly pressing. Yet the measurement of such outcomes remains challenging. This article describes and justifies the theory, concepts and decisions that underlie a recently developed quantitative measure of gender equality in WASH — the water, sanitation and hygiene gender equality measure (WASH-GEM) — and outlines key tensions navigated in its development. We developed the WASH-GEM through a collaborative, iterative process informed by a feminist perspective, critical review of relevant literature, pilot implementation and partner engagement. We report on five design considerations critical for the robust design of quantitative measures of social change: conceptual framing; measurement focus; measurement context; sectoral scope; and evaluative scope. We also define the WASH-GEM's five domains of measurement: Resources; Agency; Critical consciousness; Wellbeing; and Structures, and discuss how we balanced theoretical integrity with practical application and relevance to WASH. In reflecting on the WASH-GEM design, this article contributes to a critical discourse on methodological challenges and imperatives in the measurement of complex social change. • A feminist perspective strengthened design of a quantitative gender equality measure. • The measure explores gender equality associated with water, sanitation and hygiene. • A collaborative, iterative process informed five critical design considerations. • Domains are Resources, Agency, Critical consciousness, Wellbeing and Structures. • The measure offers a theoretically robust approach to measuring gendered change. [ABSTRACT FROM AUTHOR]

Exposure to enteric pathogens in the environment poses a serious risk for infection and disease. The accurate detection and quantification of enteric pathogens in environmental samples is critical for understanding pathogen transport and fate and developing risk assessment models. In this study, we successfully applied TaqMan real-time PCR assays to quantitatively detect five human-specific pathogens (Shigella/EIEC , Salmonella Typhi , Vibrio cholera , Norovirus, and Giardia) in samples from open drains, canals, floodwater, septic tanks, and anaerobic baffled reactors (ABR) collected in Mirpur, Dhaka, Bangladesh from April to October 2019. Overall, the grab and sediment samples showed low inhibition but the ultrafiltration samples collected from open drain had significantly higher (P = 0.0049) degree of PCR inhibition (median Ct = 31.06) compared to the extraction controls (Ct = 28.54). We developed a two-step method to adjust underestimation of pathogen quantities due to PCR inhibition and non-optimum PCR efficiency. Compared to other sample types, ultrafiltration samples demonstrated a wide range of concentration increase (1.0%–182.5%) by pathogens after adjusting for PCR inhibition and non-optimum efficiencies. These quantitative qPCR assays are successful in quantifying multiple enteric pathogens in environmental samples, and the adjustment method would be useful for correcting underestimates of pathogen quantities due to partial PCR inhibition and non-optimum efficiency. • 154 environmental samples from open drains, canals, floodwater, septic tanks, and anaerobic baffled reactors (ABR) were collected. • Five quantitative TaqMan real-time PCR assays were used to detect Shigella/EIEC , Salmonella Typhi , Vibrio cholera , Norovirus , and Giardia. • Spiking the samples with MS2 and PhHV indicated that ultrafiltration samples had significantly higher degree of PCR inhibition. • A method was developed to adjust the underestimation of pathogen quantification due to PCR inhibition and non-optimum PCR efficiency. • The correction method resulted in an approximately two-fold increased Giardia concentration and a significant increase of other pathogens. [ABSTRACT FROM AUTHOR]

Faecal-oral infections are a major component of the disease burden in low-income contexts, with inadequate sanitation seen as a contributing factor. However, demonstrating health effects of sanitation interventions - particularly in urban areas - has proved challenging and there is limited empirical evidence to support sanitation decisions that maximise health gains. This study aimed to develop, apply and validate a systems modelling approach to inform sanitation infrastructure and service decision-making in urban environments by examining enteric pathogen inputs, transport and reduction by various sanitation systems, and estimating corresponding exposure and public health impacts. The health effects of eight sanitation options were assessed in a low-income area in Dhaka, Bangladesh, with a focus on five target pathogens (Shigella, Vibrio cholerae, Salmonella Typhi, norovirus GII and Giardia). Relative to the sanitation base case in the study site (24% septic tanks, 5% holding tanks and 71% toilets discharging directly to open drains), comprehensive coverage of septic tanks was estimated to reduce the disease burden in disability-adjusted life years (DALYs) by 48-72%, while complete coverage of communal scale anaerobic baffled reactors was estimated to reduce DALYs by 67-81%. Despite these improvements, a concerning health risk persists with these systems as a result of effluent discharge to open drains, particularly when the systems are poorly managed. Other sanitation options, including use of constructed wetlands and small bore sewerage, demonstrated further reductions in local health risk, though several still exported pathogens into neighbouring areas, simply transferring risk to downstream communities. The study revealed sensitivity to and a requirement for further evidence on log reduction values for different sanitation systems under varying performance conditions, pathogen flows under flooding conditions as well as pathogen shedding and human exposure in typical low-income urban settings. Notwithstanding variability and uncertainties in input parameters, systems modelling can be a feasible and customisable approach to consider the relative health impact of different sanitation options across various contexts, and stands as a valuable tool to guide urban sanitation decision-making. [ABSTRACT FROM AUTHOR]

Background: Despite wide usage of on-site sanitation, there is limited field-based evidence on the removal or release of pathogens from septic tanks and other primary treatment systems, such as anaerobic baffled reactors (ABR). In two low-income areas in Dhaka, we conducted a cross-sectional study to explore pathogen loads discharged from commonly used on-site sanitation-systems and their transport in nearby drains and waterways.Methods: We collected samples of drain water, drain sediment, canal water, and floodwater from April-October 2019. Sludge, supernatant, and effluent samples were also collected from septic tanks and ABRs. We investigated the presence and concentration of selected enteric pathogens (Shigella, Vibrio cholerae (V. cholerae), Salmonella Typhi (S. Typhi), Norovirus Genogroup-II (NoV-GII), and Giardia) and presence of Cryptosporidium in these samples using quantitative polymerase chain reaction (qPCR).The equivalent genome copies (EGC) of individual pathogens were estimated in each sample by interpolation of the mean Ct value to the corresponding standard curve and the dilution factor for each sample type. Absolute quantification was expressed as log10 EGC per 100 mL for the water samples and log10 EGC per gram for the sediment samples.Results: Among all samples tested (N = 151), 89% were contaminated with Shigella, 68% with V. cholerae and NoV-GII, 32% with Giardia, 17% with S. Typhi and 6% with Cryptosporidium. A wide range of concentration of pathogens [range: mean log10 concentration of Giardia = 0.74 EGC/100 mL in drain ultrafiltration samples to mean log10 concentration of NoV-GII and Giardia = 7.11 EGC/100 mL in ABR sludge] was found in all environmental samples. The highest pathogen concentrations were detected in open drains [range: mean log10 concentration = 2.50-4.94 EGC/100 mL], septic tank effluent [range: mean log10 concentration = 3.32-4.65 EGC/100 mL], and ABR effluent [range: mean log10 concentration = 2.72-5.13 EGC/100 mL].Conclusions: High concentrations of pathogens (particularly NoV-GII, V.cholerae and Shigella) were frequently detected in environmental samples from two low-income urban neighbourhoods of Dhaka city. The numerous environmental exposure pathways for children and adults make these findings of public health concern. These results should prompt rethinking of how to achieve safe sanitation solutions that protect public health in dense low-income areas. In particular, improved management and maintenance regimes, further treatment of liquid effluent from primary treatment processes, and appropriate application of onsite, decentralised and offsite sanitation systems given the local context. [ABSTRACT FROM AUTHOR]

Background: Lack of access to functional and hygienic toilets in healthcare facilities (HCFs) is a significant public health issue in low- and middle-income countries (LMICs), leading to the transmission of infectious diseases. Globally, there is a lack of studies characterising toilet conditions and estimating user-to-toilet ratios in large urban hospitals in LMICs. We conducted a cross-sectional study in 10-government and two-private hospitals to explore the availability, functionality, cleanliness, and user-to-toilet ratio in Dhaka, Bangladesh., Methods: From Aug-Dec 2022, we undertook infrastructure assessments of toilets in selected hospitals. We observed all toilets and recorded attributes of intended users, including sex, disability status, patient status (in-patient/out-patient/caregiver) and/or staff (doctor/nurse/cleaner/mixed-gender/shared). Toilet functionality was defined according to criteria used by the WHO/UNICEF Joint-Monitoring Programme in HCFs. Toilet cleanliness was assessed, considering visible feces on any surface, strong fecal odor, presence of flies, sputum, insects, and rodents, and solid waste., Results: Amongst 2875 toilets, 2459 (86%) were observed. Sixty-eight-percent of government hospital toilets and 92% of private hospital toilets were functional. Only 33% of toilets in government hospitals and 56% in private hospitals were clean. A high user-to-toilet ratio was observed in government hospitals' outpatients service (214:1) compared to inpatients service (17:1). User-to-toilet ratio was also high in private hospitals' outpatients service (94:1) compared to inpatients wards (19:1). Only 3% of toilets had bins for menstrual-pad disposal and <1% of toilets had facilities for disabled people., Conclusion: A high percentage of unclean toilets coupled with high user-to-toilet ratio hinders the achievement of SDG by 2030 and risks poor infection-control. Increasing the number of usable, clean toilets in proportion to users is crucial. The findings suggest an urgent call for attention to ensure basic sanitation facilities in Dhaka's HCFs. The policy makers should allocate resources for adequate toilets, maintenance staff, cleanliness, along with strong leadership of the hospital administrators., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Amin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Climate change is exacerbating events such as floods and droughts, and trends including sea-level rise, leading to failures in sanitation technologies, increased public health risks and environmental pollution. To reduce these risks, it is crucial to incorporate climate resilience into sanitation technology designs. In this study, we reviewed academic and selected grey literature and identified 25 design features that can contribute to the technology's resilience to an increasingly volatile and extreme climate. Design features that were conceptually similar were collated into seven categories. These categories included: (i) avoid exposure to hazards, (ii) withstand exposure to hazards, (iii) enable flexibility, (iv) contain failures, (v) limit consequences of complete failure, (vi) facilitate fast recovery and (vii) features that provide resilience benefits beyond technological resilience. In this paper we define the categories and design features, and provide examples of each feature in practice. We also outline how the resilience design features can support sanitation designers and implementers to critique the climate resilience of sanitation technology, and prompt more resilient designs of sanitation technology., Supplementary Information: The online version contains supplementary material available at 10.1007/s11027-024-10177-7., Competing Interests: Competing InterestsThe authors declare no competing interests., (© The Author(s) 2024.)

Halfway through the Sustainable Development Goal (SDG) period, there has been little research on the criteria for monitoring safely managed sanitation under SDG target 6.2. For reporting against SDGs, global indicators are necessarily limited and exclude many safety aspects from a public health perspective. Primary survey data from 31,784 households in seven countries in Asia and Africa were analysed, comparing estimates of safely managed on-site sanitation based on global indicators with five complementary indicators of safety: animal access to excreta, groundwater contamination, overdue emptying, entering containments to empty and inadequate protection during emptying. Application of additional criteria reduced the population with safely managed sanitation by 0.4-35% for specific indicators, with the largest impact due to the risk of groundwater contamination, animal access, and containments overdue for emptying. Combining these indicators across the service chain, excluding transport and treatment, found almost three-quarters of on-site systems currently assessed as safely managed with global indicators were considered unsafe based on complementary indicators. A more comprehensive assessment of safety of on-site sanitation can be achieved through these indicators, which could be integrated into national monitoring systems and used to inform sanitation investments that address local health-related risks., Competing Interests: Competing interestsF.M., R.M., A.K., T.F., B.E., G.H. and A.N. declare no financial or non-financial competing interests. J.W. serves as a guest editor of this journal and had no role in the peer-review or decision to publish this manuscript., (© The Author(s) 2024.)

In this Perspective, Juliet Willetts and colleagues discuss opportunities to stimulate progress in gender-related aspects of water, sanitation and hygiene., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Willetts et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Self-supply is a ubiquitous response by households to the public water supply inadequacies found worldwide. Self-supply is invested in and managed by an individual household, accessible on-premises and unregulated. Vulnerability to faecal contamination is a concern due to reliance on low-cost technologies and shallow groundwater. This review aims to evaluate the evidence base on the safety of groundwater self-supply in low- and middle income countries in relation to faecal contamination. Differences in microbial water quality between source types, settings, countries and ownership were investigated. A search of peer-reviewed studies in low- and middle income countries was conducted in online databases, including PubMed, Web of Science, ProQuest and Environmental Complete. Studies were included if they had sufficient detail about the water samples to be related to groundwater self-supply, contained extractable data on faecal indicator bacteria (FIB) including thermotolerant coliform or Escherichia coli and were published in English between 1990 and April 2020. A total of 30 studies were included, resulting in 100 datasets and 26,981 water samples across the studies. FIB were present in 36% self-supply samples. The odds of FIB being detected was significantly higher for unimproved sources (OR=8.19, 95% CI [4.04-16.59], p<0.001) and for sources in low income countries (OR=3.85, 95% CI [1.85-7.69], p<0.001). Self-supply was significantly more likely to be contaminated than piped supply (OR=3.45, 95% CI [1.52-7.82], p=0.003). However, water quality was highly heterogeneous (I 2 =90.9%). Egger's test found no evidence of small study publication bias for self-supply compared to public supply. No evidence of bias due to lack of randomization or season was found, but study design and quality could potentially bias the results. To achieve Sustainable Development Goal 6.1 on safe drinking water for all, more attention is needed from governments to engage with self-supply and formulate balanced policy responses., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.

The National Rural Faculty of the Royal Australian College of General Practitioners received commonwealth funding between 2000-2002 to develop a rural medical family support project. There were three elements to this project: a counselling and communication skills or mentoring workshop for rural GP spouses in each state. The development of a resource kit of existing rural medical family support strategies, and the piloting of a range of strategies designed to address family support needs in collaboration with rural GPs, registrars and their families. This article focusses on the last of these three elements.