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BACKGROUND: Antibiotic resistance is a leading cause of death, with the highest burden occurring in low-resource settings. There is little evidence on the potential for water, sanitation, and hygiene (WASH) access to reduce antibiotic resistance in humans. We aimed to determine the relationship between the burden of antibiotic resistance in humans and community access to drinking water and sanitation. METHODS: In this ecological study, we linked publicly available, geospatially tagged human faecal metagenomes (from the US National Center for Biotechnology Information Sequence Read Archive) with georeferenced household survey datasets that reported access to drinking water sources and sanitation facility types. We used generalised linear models with robust SEs to estimate the relationship between the abundance of antibiotic resistance genes (ARGs) in human faecal metagenomes and community-level coverage of improved drinking water and sanitation within a defined radii of faecal metagenome coordinates. FINDINGS: We identified 1589 metagenomes from 26 countries. The mean abundance of ARGs, in units of log(10) ARG fragments per kilobase per million mapped reads classified as bacteria, was highest in Africa compared with Europe (p=0·014), North America (p=0·0032), and the Western Pacific (p=0·011), and second highest in South-East Asia compared with Europe (p=0·047) and North America (p=0·014). Increased access to improved water and sanitation was associated with lower ARG abundance (effect estimate -0·22, [95% CI -0·39 to -0·05]) and the association was stronger in urban (-0·32 [-0·63 to 0·00]) than in rural (-0·16 [-0·38 to 0·07]) areas. INTERPRETATION: Although additional studies to investigate causal effects are needed, increasing access to water and sanitation could be an effective strategy to curb the proliferation of antibiotic resistance in low-income and middle-income countries.

O acesso equitativo ao saneamento básico ainda é um desafiono mundo e no Brasil. É nesse sentido que o conceito de justiçaambiental foi utilizado no presente trabalho como base paraestabelecer um Modelo de Avaliação Territorial Integrada da JustiçaAmbiental Aplicada ao Saneamento. Pretende-se apoiar os estados noaprimoramento de políticas públicas de promoção à universalizaçãodos serviços de saneamento, conforme estabelecido pelos Objetivosdo Desenvolvimento Sustentável (ODS). Para o desenvolvimento dotrabalho, foi elaborada metodologia quali-quantitativa em duasetapas, com base nos seguintes dados secundários selecionados:vulnerabilidade hídrica (VH); os seguintes índices: abastecimento deágua (AA), coleta de esgoto sem tratamento (CE), coleta de esgotocom tratamento (TE), investimento em abastecimento de água(IAA), investimento em esgotamento sanitário (IES), renda per capitamunicipal (RPM); e desenvolvimento humano municipal (IDHM).O modelo proposto foi aplicado no estado de Minas Gerais. Os dadosforam apresentados em mapas com sobreposição da divisão regionaloficial do estado, e a discussão foi realizada com base nas divergênciase semelhanças regionais. Notou-se a repetição de um padrão, emque índices desfavoráveis concentraram-se nas regiões Norte eJequitinhonha-Mucuri para vulnerabilidade hídrica, atendimento comcoleta e sem tratamento de esgoto, investimento total, investimentomédio, renda per capita e IDHM. Ambas também apresentam valoresbaixos de índice de atendimento com coleta e com tratamento deesgoto, e abastecimento de água quando comparadas às demais.Por outro lado, as regiões Zona da Mata e Triângulo apresentam índicesfavoráveis para vulnerabilidade hídrica, atendimento com coleta e sem tratamento de esgoto e abastecimento de água. A região doTriângulo Mineiro apresentou ainda índices favoráveis de investimentototal, investimento médio, renda per capita e IDHM. Dessa forma, adesigualdade entre as regiões mineiras no tema estudado é claramenteinfluenciada por condições naturais, assim como pelo contexto social. Equitable access to water and sanitation is still a challengeworldwide and in Brazil. In this sense, the concept of environmentaljustice was used in this paper as a basis for establishing anIntegrated Territorial Assessment Model for Environmental JusticeApplied to Sanitation. This research aims to give scientific supportfor the State Government to improve public policies and promotethe universalization of water and sanitation services as establishedby the Sustainable Development Goals (SDGs). This study wasbased on a quali-quantitative methodology. Secondary data wereselected as key information to analyze environmental justicein sanitation, including the following: hydric vulnerability (IV),water supply (WS); untreated sewage collection (SC); sewagecollection with treatment (ST); water supply investments (WSI);sewage system investments (SSI); municipal per capita income(MPI); and municipal human development index (MHDI). The datawere presented in maps by overlapping the State official regionaldivision and the discussion was carried out based on regionaldifferences and similarities. The repetition of a pattern was noted,in which unfavorable rates were concentrated in the North andJequitinhonha-Mucuri regions: water vulnerability, sewage systemwith collection and without treatment, total investment, averageinvestment, per capita income and municipal human developmentindex. Both also have low rates of the sewage system and watersupply when compared to others. On the other hand, Zona da Mataand Triângulo regions have favorable rates for hydric vulnerability,sewage system with collection and without treatment and watersupply. The Triângulo Mineiro region also presented favorable rates of total investment, average investment, per capita income,and municipal human development index. It is concluded thatthe inequality between the regions is, initially, of natural origin,and reinforced by the social context and inequality in sanitationinvestments in the different regions.

Resumo O artigo visa compreender como ocorre o acesso à água e ao esgotamento sanitário na Ocupação Vitória e a percepção dos moradores acerca da associação entre esse acesso e as condições de saúde: aparecimento de doenças, qualidade de vida e as relações de gênero na comunidade. Trata-se de estudo qualitativo, fundamentado na imersão no trabalho de campo, empregando observação participante na Ocupação e em entrevistas com seus moradores. Observou-se a precariedade do acesso à água pela população, que ocorre por meio de ligações irregulares às redes formais, e a predominância de fossas rudimentares. A população relaciona a falta de saneamento com o surgimento de doenças infecciosas e parasitárias e impactos sobre a desigualdade de gênero. O acesso inadequado à água e esgoto impacta a qualidade de vida da comunidade ao comprometer a produção de alimentos agroecológicos e as práticas culturais e identitárias. A informalidade do assentamento se traduz em maior vulnerabilidade social e maior exposição da população a efeitos sobre sua saúde, principalmente de mulheres e crianças. Abstract The article aims to understand how access to water and sanitation occurs in the Vitória Occupation and the residents' perception of the association between this access and health conditions: the emergence of diseases, quality of life and gender relations in the community. This is a qualitative study, based on immersion in fieldwork, employing participant observation in the Occupation and in interviews with residents of the Occupation. It was observed the precariousness of access to water by the population, which occurs through irregular connections to formal networks, and the predominance of rudimentary septic tanks. The population relates the lack of sanitation with the emergence of infectious and parasitic diseases and impacts on gender inequality. Inadequate access to water and sewage impacts the community's quality of life by compromising the production of agroecological food and cultural and identity practices. The informality of the settlement translates into greater social vulnerability and greater exposure of the population to effects on their health, especially on women and children.

Background: As of the year 2014, about 2.5 billion people globally lacked access to improved sanitation. The situation is even worse in the sub-Saharan African countries including Kenya. The practice of open defecation (OD) peaks beyond 72% of the population in Turkana County, Kenya, despite various interventions to end it. Methods: This article reports on both qualitative and quantitative aspects of a cross-sectional study. A partially mixed sequential dominant (quantitative) status was used to understand various socioeconomic factors associated with OD practice in Lodwar’s human settlements, Turkana County. Simple random sampling technique was chosen to select participants for this study with the sample drawn from various administrative units of Lodwar. Standardized questionnaires, focus group discussions, and key informant interviews were used to collect data. Results: The quantitative findings revealed that culture was the leading factor as to why people practiced OD with a frequency of 44%. The findings further revealed that poverty was the major influencing factor for latrine ownership among the households (frequency 27%). Pearson χ2 tests revealed that there was a significant association between latrine presence and education level of the household head (χ2 = 107.317; P 2 = 403; P 2 = 74.51; P Conclusions: In addition to cultural aspects, high poverty levels influence latrine adoption and consequently OD practices. Future sanitation interventions addressing OD should assess and factor in these cultural aspects in such communities to come up with appropriate eradication measures which have otherwise been difficult to solve through poverty eradication and sanitation campaigns that have been in existence.

Background:Poor latrine conditions, structure, and design may deter latrine use and provoke reversion to open defecation (OD). Statistics show that only 18% of the households in Turkana County, Kenya, have access to a latrine facility with most of these facilities in poor structural designs and poor hygienic conditions, which encourages rampant OD practices.Aim:This article reports on quantitative aspects of a larger cross-sectional survey to assess latrine structure, design, and conditions, and the practice of OD in Lodwar.Methods:An observational study was carried out to examine latrine conditions, structure, and design in Lodwar, Kenya. A standardized questionnaire was also used to collect quantitative data. Stratified random sampling technique was employed to select respondents for this study with the sample drawn from 4 administrative units of Lodwar town covering the low-, medium-, and high-income households. Data were managed using Statistical Packages for Social Science (SPSS) software.Results:Nineteen percent of the sampled households did not possess a latrine facility at their homesteads with 73% of the latrines constructed using poor materials (mud, mats, polythene bags, and grass). Twenty percent of the respondents were scared of using a latrine with the main reason being loose soils that do not support strong constructions. Eighty-seven percent of the respondents agreed that the presence of feces on the latrine floor encouraged the practice of OD and 321 (80%) respondents stated that the latrine construction materials influenced latrine ownership and its subsequent use.Conclusions:Respondents attributed rampant OD practices to poor latrine structure, design, and conditions. In addition, rampant cases of latrine sharing result in latrine filthiness, which eventually encourages OD practice. Inequality in sanitation, among counties, should be addressed in Kenya. The government should take charge of provision of good-quality communal latrines to the less-privileged societies like Turkana. Community empowerment and introduction of a small fee for cleaning and maintenance of these facilities will also improve their conditions. Ending the practice of OD will lead to increased positive public health and environmental outcomes in the study area

Urban sanitation remains a significant challenge for most low- and middle-income countries. While sanitation coverage has been increasing across both the 48 least developed countries (LDCs) and developing regions as a whole, progress has been relatively slow. In many cities, even where improved on-site facilities are used to contain excreta, the level of quality and access to services for the emptying, conveyance, treatment, and disposal of the resulting fecal sludge is usually limited. These services are collectively called fecal sludge management (FSM) services. FSM services are the focus of this study, within the broader context of urban sanitation and integrated urban water management (IUWM). This document provides a summary of the diagnostic tools developed for assessing FSM services and is based on field work carried out in the five cities of Balikpapan in Indonesia, Dhaka in Bangladesh, Hawassa in Ethiopia, Lima in Peru, and Santa Cruz in Bolivia. It summarizes the tools themselves, lessons learnt about their use, and general policy recommendations.

Urbanization is occurring rapidly in Melanesia at 3-4 percent per annum. Due to unaffordable land and housing in formal urban areas, new migrants settle on marginal land without formal legal titles (‘informal settlements’). These settlements are growing and new settlements are emerging within and on the outskirts of towns and cities across Melanesia, at a rate that outpaces efforts to serve them. Settlements in the Melanesian capitals of Suva, Port Vila, Honiara, and Port Moresby comprise 20 percent-45 percent of the city population and at current urbanization rates will be between 30 percent and 65 percent by 2023. Information about informal settlements is scarce. This report provides a rapid review of water and sanitation services in the informal settlements in and around the capital cities of Solomon Islands, Fiji, Vanuatu, and Papua New Guinea.

From 2012 to 2014 water and sanitation service delivery assessments (SDA) have been carried out in seven selected countries in the East Asia and Pacific region under the guidance of the World Bank’s water and sanitation program and with valuable contributions of other development partners, such as United Nations Childrens Fund (UNICEF), WaterAid, and Asian Development Bank (ADB). Countries where SDA were carried out are Cambodia, Indonesia, Lao Peoples Democratic Republic (PDR), Papua New Guinea, Philippines, Timor-Leste, and Vietnam, while in Myanmar, a broad joint sector assessment took place by World Bank, UNICEF, ADB, and Japan International Cooperation Agency (JICA). SDA were implemented as a country-owned process led by key government agencies, and drew on the experience and methodology of similar assessments conducted in more than 40 countries (and states) in Africa, Latin America, and South Asia. It has three main components: a review of past water and sanitation access trends, a costing model to assess the adequacy of anticipated future investments, and a scorecard that allows diagnosis of bottlenecks along the service delivery pathways.

This synthesis report details the process, outputs and intermediate outcomes of the World Bank’s Water and Sanitation Program (WSP) Technical Assistance (TA) to Support Government of India for implementation of the National Urban Sanitation Policy (P131963). The objective of this TA was to (i) strengthen urban sanitation services and target the urban poor by development of strategies for regulation, funds allocation, improved accountability mechanisms and implementation of inclusive sanitation policies at national level and in at least five states, with two of these low-income states (LIS). This was to be supplemented with (ii) enabling design and use of improved performance monitoring systems by Government of India, 3 states and 300 urban local bodies by 2015, and (iii) strengthen capacity of local urban government institutions to provide improved – inclusive and sustainable – sanitation services for all. This TA provides the building blocks for sustainable sanitation improvements which are being adopted and implemented as part of another TA (P131967) in Madhya Pradesh and Tripura to pilot and operationalize City Sanitation Plans (CSPs) towards outcome oriented sector improvements. The areas addressed in this TA include the following specific goals of the NUSP: open defecation free cities, and integrated city-wide sanitation. The TA provided assistance to central government and the states in putting in place various elements identified as necessary for sector improvement, including planning, provisioning and monitoring processes. The TA also identified the need for the cities to see opportunities for financial recovery of investments through reuse and recycle strategies, to strengthen the incentive for investment in sanitation improvements.

This synthesis report details the process, outputs and intermediate outcomes of the World Bank’s Water and Sanitation Program (WSP) Technical Assistance (TA) to pilot and operationalize city sanitation plans (CSPs) towards outcome oriented sector investments (P131967). This TA addresses issues of ad hoc planning though CSPs that are holistic, intended for city-wide implementation and address the full cycle of sanitation. However, prior to preparation and operationalization of CSPs, it was recognized that this needed to be anchored in a statewide sanitation program. The statewide sanitation program needed to: estimate and provide for the capital requirements to address the gaps in sanitation infrastructure across the sanitation service delivery chain (collection, treatment and disposal), estimate the operation and maintenance (OM) requirements, and set out the framework for prioritization of cities, and attendant institutional frameworks. This TA aimed at piloting and operationalization of CSPs towards outcome oriented sector investments, by supporting (i) select state and local governments with technical assistance to operationalize city sanitation plans by targeting outcome oriented investments, and (ii) improving the institutional and regulatory framework and strengthening state and local government capacity for efficient and sustainable delivery of Government of India or World Bank or other development partner funded programs.

Title: The Impact Study of Community Based Total Sanitation to Sanitation Access in District of Wonogiri. Background: Enhancement number of achievement sanitation access in District of Wonogiri decline every years in last three years. Enhancement sanitation access in 2012 is 4,1%, 2013 is 3,1% and 2014 is 1,6%. While improved sanitation facility growth in 2013 and 2014 only 1,3%. Methode: This research aimed to description various enabling factors CBTS to sanitation access enhancement in District of Wonogiri. This research was an analytic with cross sectional approach. The samples were 7 peoples member of AMPL organization, 25 peoples sub-district government agency and 73 village government agency. The data was analyzed by Mann-Whitney test, Kruskall Wallis test and Correlation Pearson. Results: Based on researh, AMPL manage organization performance is good. Sub-district which as CBTS manage organization reach 68% while village only 25%. Sanitation access poliy realitation in sub-district is 24% and village 25%. Sub-district government rating that Public Health Care Headman with big contribute in sanitation access enhancement is 48% and village government is 29%. BOK funding allocation enhancement average is 44%. Only one sub-district has organized capacity building. Conclusion: Analysis results refer to CBTS manage organization performance, Policy, Capacity Building in sub-district and village, Public Health Care Headman policy, not different contribute for sanitation access in District of Wonogiri. While BOK funding allocation enhancement not influence sub-district sanitation access enhancement in District of Wonogiri.

La OMS considera desigualdades en Salud, las diferencias, injustas y evitables, entre un grupo poblacional definido social, económica, demográfica o geográficamente, relacionadas con la salud. Son el resultado de las distintas oportunidades y recursos que tienen las personas en función de su clase social, sexo, territorio o etnia, y que se traducen en una peor salud entre los colectivos socialmente menos favorecidos. La bibliografía evidencia que la posición socioeconómica y el género son los dos factores de desigualdad más influyentes sobre la salud de la población y que puede generar inequidad ya desde la prevención. Este hecho se ha objetivado mediante diversos estudios que demuestran que en la mayoría de los ámbitos preventivos existen colectivos vulnerables que no acceden a la prevención tanto por razones socioeconómicas como de género. Las causas de la falta de acceso se han relacionado con factores culturales, idiomáticos, geográficos y económicos. Cuando estos factores influyen en que cierto grupo de personas no acuden a los programas preventivos, se habla de que existen barreras de acceso, y dichas barreras van a ser condicionantes de desigualdades en salud. De dichas desigualdades surge la pregunta que guía el presente trabajo: ¿Existen en el ámbito de la Prevención en Salud Sexual y Reproductiva barreras en el acceso, que ocasionarían grupos de mujeres más vulnerables ante la patología ginecológica? Para dar respuesta a esta cuestión se han planteado en el estudio dos objetivos, uno observacional y otro exploratorio. De esta manera el trabajo se ha dividido en dos ejes metodológicos uno cuantitativo y otro cualitativo: 1, En el primero se ha intentado “Conocer el grado de acceso y de utilización del Programa de Atención a la Salud Sexual y Reproductiva”, mediante un estudio descriptivo de corte transversal para estimar la frecuencia de la falta asistencia o el seguimiento inadecuado de las actividades preventivas. 2, El segundo eje metodológico del trabajo ha pretendido dar respuesta al objetivo “Explorar los factores que pueden favorecer o dificultar el acceso a las actividades preventivas del Programa de Atención a la Salud Sexual y Reproductiva, en el área de salud de Sabadell”, recurriendo a la metodología cualitativa, para entender mejor el porqué de la no participación de determinadas mujeres en los programas preventivos. Los resultados del estudio nos muestran la existencia de desigualdades en el acceso y utilización de los programas preventivos en Salud Sexual y Reproductiva en el área de Sabadell, en base al nivel socioeconómico. Mediante el análisis cualitativo, se identifican tanto barreras como facilitadores de la prevención en ginecología. La utilización de ambas metodologías permite obtener un análisis global del acceso y utilización de los programas preventivos, y explorar desde la perspectiva de las propias mujeres, las causas y mecanismos que influyen en la falta de acceso o en la utilización inadecuada de los programas. Estos resultados pueden utilizarse para generar nuevas hipótesis de investigación y obtener resultados que permitan diseñar actividades preventivas que mejoren el acceso de las poblaciones más vulnerables a dichos programas., OMS considers as health inequalities, the differences, unjust and avoidable, between population groups defined socially, economically, demographically or geographically. Bibliography brings out that socioeconomic status and gender are the two more influential factors of inequality over the health of the population, and can generate inequality even from prevention. From these inequalities arises the question that guides this dissertation: Are there, in the field of Prevention in Sexual and Reproductive Health, barriers to access which would cause most vulnerable groups of women to gynecologic pathology? To answer this issue, this study has set two objectives, one observational and another one exploratory. Therefore the dissertation has been divided into two methodological axes: a quantitative one and a qualitative one: 1 On the first one, we have tried to "Know the degree of access and use of the Care for Sexual and Reproductive Health Program ", by a descriptive and cross-sectional study to estimate the frequency of non-attendance or inadequate monitoring of the preventive activities 2 The second methodological focus of the work has sought to respond to the target "Exploring the factors that can favor or hinder the access to the preventive activities of the Care for Sexual and Reproductive Health Program, in the health area of Sabadell ", using a qualitative methodology for a better understanding of the reasons for non-participation of certain women in prevention programs . The results of this study show the existence of disparities in the access and utilization of preventive programs in Sexual and Reproductive Health in the area of Sabadell, based on socioeconomic status. Through the qualitative analysis, both barriers and facilitators of prevention in gynecology are identified. The use of both methods provides a global analysis of the access and use of preventive programs, and explores from the perspective of the women themselves, the causes and mechanisms that influence the lack of access or misuse of the programs. These results can be used to generate new research hypotheses and to obtain results that allow designing preventive activities to improve the access of vulnerable populations to such programs.

This report examines the social economic impact of inadequate sanitation in Nicaragua. The study on which it is based has been promoted by the Economics of Sanitation Initiative (ESI), led by the Water and Sanitation Program of the World Bank (WSP). The report includes basic information on Nicaragua, records of sanitation in the country and the results of the analysis of the economic impacts on health, water resources, tourism, and other impacts on welfare.

Sanitation services are beneficial for communities at large. They generate strong positive health and environmental benefits to society ('externalities'). Public financing is an important way to stimulate the provision of these services, but there are serious issues with the way public subsidies for sanitation have been delivered up to now. Recent estimates show that the sanitation millennium development goals (MDGs) will simply not be met in a number of countries if 'business-as-usual' continues. The study looks at how such Output-Based Aid (OBA) schemes might be designed by analyzing the sanitation value-chain, and what institutional, financing and risk mitigation measures would be required for each type of OBA scheme. Questions discussed include 'what' outputs should be subsidized and 'who' are the most likely candidates to provide output-based sanitation services.

This briefing note provides a rapid scan of partnership initiatives by the World Bank, the African Development Bank (AfDB) and the Water and Sanitation Program (WSP) to improve the state of water and sanitation services in Africa. The note aims to highlight the gains and challenges of the major collaborative initiatives, focusing on where progress has been made or activities are ongoing at a strategic, thematic, and regional or country level. The collaboration is now focusing on: a) intensifying operational cooperation and joint work in additional African countries, including fragile and post-conflict countries; b) continuing to share information and to participate in capacity-building activities, with an emphasis on training in operational contexts; c) intensifying joint work in water supply, and particularly sanitation and hygiene; and, d) developing a monitoring system focused on results rather than inputs.