2. How do Water and Sanitation Look from a Child Health Perspective? John Borrazzo U.S. Agency for International Development World Water Forum V Istanbul, Turkey March 20, 2009

5. The child health problem - targeting Relevant programmatic strategies – focusing Outcomes and impact - measuring

6. 90% preventable Undernutrition implicated in 50% of child deaths, and is also associated with diarrhea 9.2 million child (<5 yrs) deaths annually Source: State of the World’s Children, UNICEF 2008

7. Source: “Safer Water, Better Health”, WHO 2008

8. Diarrhea – Real Progress in Reducing Mortality 1990 World Summit for Children Goal met by 2000 (reduce under-five diarrheal deaths by half) Almost 3 million child deaths/year averted by 2005 But - Estimated 1.5 billion child diarrhea episodes/year (in developing countries) Still over 1.5 million child deaths/year

9. Where do child deaths from diarrhea occur?

10. 11 countries account for over 70% of the annual deaths globally from diarrhea

11. Deaths from Diarrhea have declined in all regions Source: WHO, 2002; ECA=Europe and Central Asia, LAC=Latin America and the Caribbean, MENA=Middle East and North Africa, SA=South Asia, EAP=East Asia and the Pacific, SSA=sub-Saharan Africa

12. Under-five mortality rate from diarrhea (deaths per thousand live births) Source: The Lancet Child Survival Series, 2003

13. Median Age-specific Incidences for Diarrheal Episodes per Child per Year from Three Reviews of Prospective Studies in Developing Areas, 1955-2000 Source: Disease Control Priorities in Developing Countries, Second Edition; 2006

14. Breastfeeding (13%) ITM & IPT for malaria (7%) Zinc (5%) Complementary feeding (6%) Water/sanitation/hygiene (3%) Prevention Full coverage with proven interventions could reduce under-five mortality by 66%, equivalent to 6 million child deaths/year. ORT (15%) Antibiotics for pneumonia/sepsis (6%) Newborn care (4%) Antimalarials (5%) Antibiotics for dysentery (3%) Zinc (4%) Treatment Lancet Child Survival Series…

16. Access to Hardware Community Water Systems Sanitation Facilities Household-level Technologies and Materials Hygiene Promotion Behavioral/Social Change Methods: Community Mobilization Social Marketing School Programs Community Participation in Problem Identification and Solutions Hygiene Improvement Policy Improvement Community Organization Financing and Cost Recovery Public-Private Partnerships Institutional Strengthening Enabling Environments

17. Focus on the evidence-based interventions with greatest potential for reducing morbidity and mortality POU water treatment & safe storage – approximately 30- 50% reduction in DD prevalence (Cochrane Review, Clasen et al., 2006) Optimal handwashing (meta-analysis showed 43% reduction in diarrhea prevalence, April 2003, Lancet) Sanitation – basic, low-cost systems can reduce DD by 30% or more Increasing quantities of water used – impact on general hygiene and specifically facilitates handwashing

18. Costs vs. impact of various WSH program strategies (WHO 2007)

20. Use of Appropriate Technologies: Tippy Tap

22. Impact of Key Interventions on Diarrhea

23. Take-home messages TARGET - Countries with high DD burden (severity, magnitude), children ages 6-24 months, newborns (caregiver handwashing) FOCUS - On key behavioral outcomes – water use, water quality (at POU), feces disposal, and handwashing MEASURE - Behaviors, not diarrhea