The COVID-19 pandemic has shone a light on handwashing as an inexpensive, widely applicable response measure. In consequence, most governments have taken action to promote access to water and sanitation services for all. This paper documents an overview of initiatives and interventions that countries have implemented during the first months of the COVID-19 response. Initiatives have been identified across 84 countries worldwide, and categorized into those that aimed at securing water, sanitation, and hygiene (WASH) for all, and those that sought to provide technical and financial support to service providers. The pandemic has not hit countries in the same way. Accordingly, results show disparities in the response between and within regions, with the level of activity found in the countries varying largely in terms of ambition and scope. Hygiene promotion and infection prevention and control (IPC) has been widely adopted – at least one response measure found in 94% of mapped countries -, although not always matched in ambition with the assured availability of soap, water, and handwashing facilities. Support to vulnerable households to promote basic access to WASH services at scale was weak (38% of countries) or implemented locally (25%), and requiring additional focus, particularly in rural areas and small towns. In addition, parallel support needs to be extended to service providers or to households themselves in the form of cash transfers, in order to ensure the financial viability and the continuity of services.

An alarming number of public health-care facilities in low-income and middle-income countries lack basic water, sanitation, hygiene (WASH), and waste management services. This study estimates the costs of achieving full coverage of basic WASH and waste services in existing public health facilities in the 46 UN designated least-developed countries (LDCs). In this modelling study, in-need facilities were quantified by combining published counts of public facilities with estimated basic WASH and waste service coverage. Country-specific per-facility capital and recurrent costs to deliver basic services were collected via survey of country WASH experts and officials between Sept 24 and Dec 24, 2020. Baseline cost estimates were modelled and discounted by 5% per year. Key assumptions were adjusted to produce lower and upper estimates, including adjusting the discount rate to 8% and 3% per year, respectively. An estimated US$6·5 billion to $9·6 billion from 2021 to 2030 is needed to achieve full coverage of basic WASH and waste services in public health facilities in LDCs. Capital costs are $2·9 billion to $4·8 billion and recurrent costs are $3·6 billion to $4·8 billion over this time period. A mean of $0·24–0·40 per capita in capital investment is needed each year, and annual operations and maintenance costs are expected to increase from $0·10 in 2021 to $0·39–0·60 in 2030. Waste management accounts for the greatest share of costs, requiring $3·7 billion (46·6% of the total) in the baseline estimates, followed by $1·8 billion (23·1%) for sanitation, $1·5 billion (19·5%) for water, and $845 million (10·7%) for hygiene. Needs are greatest for non-hospital facilities ($7·4 billion [94%] of $7·9 billion) and for facilities in rural areas ($5·3 billion [68%]). Investment will need to increase to reach full coverage of basic WASH and waste services in public health facilities. Financial needs are modest compared with current overall health and WASH spending, and better service coverage will yield substantial health benefits. To sustain services and prevent degradation and early replacement, countries will need to routinely budget for operations and maintenance of WASH and waste management assets. WHO (including underlying grants from the governments of Japan, the Netherlands, and the UK), World Bank (including an underlying grant from the Global Water Security and Sanitation Partnership), and UNICEF. For the Arabic, French and Portuguese translations of the abstract see Supplementary Materials section.

In most countries, local governments bear primary responsibility for ensuring everyone has access to water and sanitation services. For the human rights to water and sanitation to move from recognition to realisation, they need to become part of the everyday practice of local authorities. Yet the potential for the human rights to water and sanitation to practically inform local efforts towards inclusive, sustainable service delivery has received limited attention to date, with human rights discourse more typically focusing on national and international levels or on building the capacity of rights holders to claim their rights from government. There is considerable opportunity to consider how human rights can constructively inform local government efforts to expand and improve services. This Communication article presents a novel approach to making human rights relevant and actionable for local authorities. Developed by a consortium of WASH-focused organisations and informed by design thinking, the Making Rights Real approach combines user-centred materials showing how human rights can inform local action, with a process of constructive engagement between civil society and local government professionals. The Making Rights Real approach has been applied in 12 countries by 37 civil society organisations to date. In this paper, we describe the development and features of the Making Rights Real approach, share initial results from its implementation, and reflect on the potential for the approach to catalyse transformational change towards local realisation of the human rights to water and sanitation.

Background: An alarming number of health care facilities in low- and middle-income countries lack basic water, sanitation, hygiene, and waste management (WASH services). This study estimates the costs of achieving universal coverage of basic WASH services in health facilities in the 46 least developed countries (LDCs). Methods: In-need facilities were quantified by combining published facility counts with estimated WASH service coverage. Country-specific per-facility capital and recurrent costs to deliver basic service standards were collected via survey. Baseline estimates were modelled alongside lower and upper estimates for which key assumptions were adjusted. Findings: An estimated US$6·5–9·6 billion over 10 years is needed to achieve universal coverage of basic WASH services in LDCs’ health facilities. Capital and recurrent costs are 44–50% and 50–56% of the total, respectively. On average, US$0·24–40 per capita in capital investment is needed each year, while annual maintenance and operation costs are expected to increase from US$0·10 in 2021 to US$0·39–0·60 in 2030. Waste management accounts for the greatest share of costs (43–49%), followed by sanitation (21–28%), water (20%), and hygiene (10–11%). Needs are greatest for non-hospital facilities (94%) and in rural areas (68%). Interpretation: Investment will need to be scaled up to reach universal coverage of basic WASH services in health facilities. Financial needs are modest compared to overall health and WASH spending and will yield numerous health benefits. To sustain services, countries will need to routinely budget for operations and maintenance. Funding Information: World Health Organization (including underlying grants from the governments of Japan, Netherlands, and UK), World Bank, and UNICEF. Declaration of Interests: MC reports personal fees from the World Health Organization during the conduct of the study and from Results for Development, ThinkWell, and the World Bank outside the submitted work. SM reports personal fees from the World Health Organization during the conduct of the study and from Vysnova Partners outside the submitted work. RJ reports grants from Agence française de développement, Bill and Melinda Gates Foundation, Government of the Netherlands Ministry of Foreign Affairs, UN-Water Inter-Agency Trust Fund, United Kingdom Foreign, Commonwealth & Development Office, and Swiss Agency for Development and Cooperation, both during the conduct of the study and outside the submitted work. IA, JA-ST, SG, OH, TS, CC, GH, and MM have nothing to disclose.