Rural:urban inequalities in post 2015 targets and indicators for drinking-water

Bain RESa, Wright JAb, Christenson Ea and Bartram JK a,*

a The Water Institute at UNC, University of North Carolina at Chapel Hill, North Carolina, USA

b Geography and Environment, University of Southampton, Southampton, UK

*Corresponding author: Jamie Bartram (jbartram@unc.edu), 001 919-966-3934, jbartram@unc.edu, The Water Institute at UNC, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Rosenau Hall, 135 Dauer Drive, Chapel Hill, NC 27599-7431.

Keywords: drinking water; water safety; urban rural disparities; post-2015 Abstract:

Disparities in access to drinking water between rural and urban areas are pronounced. Although use of improved sources has increased more rapidly in rural areas, rising from 62% in 1990 to 81% in 2011, the proportion of the population using an improved water source remains substantially lower than in urban areas. Inequalities in coverage are compounded by disparities in other aspects of water service including safety. For example, evidence from a systematic review demonstrates that water in rural areas is more likely to contain detectable fecal indicator bacteria. We argue that an “urban bias” may have resulted in the post-2015 targets due to apparent stagnation in urban coverage and the inequity observed between urban and peri-urban areas. Proposed targets for drinking water post-2015 include both a provision to erode inequalities through universal access and progressive reduction in inequalities, but also a provision that will exacerbate already extreme rural disadvantage by setting a higher minimum standard in urban areas. Health, economic and human rights perspectives suggest that water access in urban areas should not be prioritized above rural areas.

Access to safe, reliable drinking water in sufficient quantities is

fundamental for good health and wellbeing (Hunter et al., 2010). Global monitoring of drinking-water and sanitation is provided by the Joint Monitoring Programme (JMP) of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). The JMP reports on the status and trends in drinking water and sanitation coverage at global, regional and country levels. It uses an internationally-comparable method (Bartram, 2014), and draws on censuses and the increasing number of nationally-representative household surveys that have become available since 1990. The outcome is considered one of the better-monitored of the targets associated with the Millennium Development Goals (MDGs) (Waage et al., 2010).

The MDGs include target 7c, to “halve, by 2015, the proportion of the population without sustainable access to safe drinking water” (UNGA, 2001). This target is measured via an indicator that assesses access to an ‘improved’ source, which identifies source types with some degree of protection from contamination (e.g. piped water, boreholes, protected springs). (WHO/UNICEF, 2011). An underlying rationale for targeting of drinking-water access in development policy, and the sole rationale for targeting of drinking-water safety, is health concern. Since the signing of the Millennium Declaration, the Human Right to water and sanitation has been recognized (de Albuquerque, 2012; UNCESCR, 2002; UNGA, 2010) drawing attention to the unacceptability of the MDG target which can be achieved with 768 million still lacking safe water. There is increasing consensus that future targets must strive for universal access (WHO/UNICEF 2013). Both public health and human rights perspectives bring to the fore the importance of increasing equality. While the public health evidence to underpin programmes to reduce inequality is contested (Lynch et al., 2000), associated arguments include the imperative to focus resources on the most vulnerable and the idea that reducing inequalities will benefit all sectors of society, not just the poorest (Woodward and Kawachi, 2000).

Unlike most MDG targets, the associated indicator was specified to be disaggregated for rural and urban populations from the outset (UNGA, 2002). However, separate rural and urban targets were not established, nor was progress against such targets monitored. The omission are noteworthy for two reasons. Firstly, rural versus urban status has been consistently reported on a country level and documents substantive and near-universal inequalities. Secondly, country-by-country progress towards the MDG target is reported even though the targets were originally meant to be global and no country-level indicator was specified in the Millennium Declaration (UNGA, 2002; Vandemoortele, 2009).

Here we argue that an “urban bias” may have resulted in the post-2015

targets from the increasing population of urban areas and the inequity observed between urban areas and peri-urban areas or slums; and that the differences between rural and urban settings have been obscured by this with adverse impacts on both. Although we show that use of improved sources has increased more rapidly in rural than urban areas, the proportion of the

population using an improved water source remains substantially lower in rural than urban areas. Additionally, the improved-unimproved classification does not incorporate water quality, affordability, and sustainability dimensions (Clasen, 2012; Shaheed et al., 2014); we have previously presented evidence (Bain et al. 2014) that rural water quality is often worse than urban water quality and that economic classes are difficult to compare between urban and rural areas. Neither health, economic nor human rights perspectives suggest that water access in urban areas should be prioritized above rural areas. Status of rural:urban inequalities in drinking water

The JMP has consistently reported substantive inequality between rural and urban use of improved sources of drinking-water. Most recently, the JMP reported that only 4% of the global urban population uses unimproved sources of drinking-water but that 19% of the rural population does so. This trend in inequality is consistent globally, for all MDG regions and for the overwhelming majority of countries (WHO/UNICEF, 2013a; Table 1).

“Access” alone does not fully reflect inequalities between rural and

urban areas since water may be unsafe or not available in sufficient quantities. Differences in access can be compounded by disparities in the other aspects of water service: accessibility, quantity, accessibility, affordability, continuity of supply, and quality issues (WHO, 2011). For example, rural dwellers spend longer collecting water. An analysis of survey data from sub-Saharan Africa found that almost one in five rural dwellers had to walk at least 30 minutes to collect their water whereas only 7% of urban dwellers did so (WHO/UNICEF, 2011). Such differences may partly reflect more widespread purchasing of drinking water from vendors in urban areas, and point to great difference in water services between the two settings. Time taken to collect water has also linked to the quantity of water used by households (Cairncross and Cliff, 1987) suggesting that there may be a disparity in the amount of water used by urban and rural dwellers. Water sources in urban and rural areas can both be unreliable, providing intermittent water access. However, data collected on urban piped supplies, for example those available through the International Benchmarking Network for Water and Sanitation Utilities, cannot readily be compared with the frequency of non-functioning community sources such as handpumps in sub-Saharan Africa (Foster, 2013).

Disparities in health outcomes are also evident. According to an extensive analysis of household survey data, children in rural areas are more likely to have diarrhea in the weeks prior to the survey and their chances of survival are lower than those living in urban areas (Gunther and Fink, 2010).

Similar disparities exist for sanitation (Rheingans et al., 2014;

WHO/UNICEF, 2013a) and lack of adequate sanitation facilities, including safe storage and treatment of feces, has a strong influence on the availability of safe water. For example, it is well established that the use of pit latrines, which are more common in rural areas, can negatively influence ground water quality (Graham and Polizzotto, 2013).

Inequalities are also reflected in developed nations, where the burden of disease outbreaks (Craun et al., 2010) and exposure to non-compliant drinking-water (Richardson et al., 2009) disproportionately affect rural populations supplied by small systems. Such small systems are a major focus of efforts to improve water quality in higher income countries, for example as part of the Protocol on Water and Health (Rickert and Schmoll, 2014). Table 1: Proportion of rural and urban households using improved drinking-water and piped water in the home in 2011. Source: Data downloaded from wssinfo.org (WHO/UNICEF, 2013a). Use of improved

sources1 of drinking-water (%)

Use of piped drinking water in the

home (%)

Population in 2011 (in millions)

Rural Urban Rural Urban Rural Urban

Caucasus and Central Asia

78 96 29 84 44 34

Developed countries

97 100 79 97 277 972

Eastern Asia 85 98 45 95 685 746

Latin America and the

Caribbean 82 97 64 94 124 472

Northern Africa 89 95 73 91 75 93

Oceania 45 95 11 74 8 2

Southern Asia 88 95 15 54 1166 563

South-eastern Asia

84 94 13 51 332 268

sub-Saharan Africa

51 84 5 34 557 321

Western Asia 78 96 66 88 68 144

Global 81 96 29 80 3335 3615 1Improved water sources include piped water on premises and collection from protected

shared community sources including standpipes, protected wells, boreholes, and rainwater harvesting.

Global trends

Here we analyse the implications of separately applying the MDG target formulation of halving the proportion of the unserved to rural and urban populations (Figure 1).

Figure 1: Access to improved sources and piped water on premises during the Millennium Development Goal in terms of (A) the proportion

of the population with access and (B) absolute numbers of people, assessed separately for urban and rural areas.

If separate global targets had been applied, the rural target would have

been met in 2011. Between 1990 and 2011, the proportion (Figure 1A) of the rural population without access to an improved source reduced from 38% to 19% (WHO/UNICEF 2013a). In contrast, little progress was made in reducing the proportion of the urban population without improved sources (5% in 1990 and 4% in 2011)(WHO/UNICEF, 2013a). The slow progress in urban areas is driven in part by rapid urbanization: from 1990 to 2011 the proportion of urban residents grew from 43% to 52%, with global urban population growing from 2.27 billion to 3.62 billion people (59.5% growth), whereas the rural population only grew by 10.6% from 3.02 billion to 3.34 billion (WHO/UNICEF, 2013a). Easterly (Easterly, 2009) has argued that targets can be framed as percentage versus absolute changes, in terms of change versus levels, or positively (focusing on those with safe water) versus negatively (focusing on those without safe water). Whilst the study examines the impact of such target

formulation decisions on apparent MDG progress across Africa, the same target formulation choices affect rural versus urban comparisons. In absolute terms (Figure 1B) progress in urban areas was greater with 1.3 billion people gaining access to an improved source between 1990 and 2011 compared with 0.8 billion in rural areas (WHO/UNICEF, 2013a).

Yet, a substantial disparity remains; at current rates of progress it would take around fifteen years from 2011 for rural areas to reach coverage levels enjoyed by urban dwellers since 1990. This estimate is based on a linear extrapolation of proportion of population coverage over time (see Figure 1) and may understate the disparity, since progress is thought to in fact be nonlinear, with the rate of progress decreasing as universal coverage is approached (Anderson and Langford, 2013). In 2011, 633 million rural dwellers did not have an improved source, compared with only 145 million urban dwellers (WHO/UNICEF 2013a). Moreover, progress in rural areas has primarily been driven by the construction of boreholes and protected dug wells in most regions whereas urban areas have maintained high levels of piped water on premises coverage (~80%) throughout the MDG period; thus the headline progress figures mark a greater inequality in service level or quality as well as in access/use.

Although rural areas have clearly been worse off throughout the period,

the MDG target would only have been met in rural areas. Conversely, urban areas have enjoyed relatively high levels of coverage and on the whole better types of supply (e.g. piped on premises as opposed to community wells) but have made virtually no progress against the MDG target. Several other authors have highlighted the conundrums that arise from the formulation of the MDG target as halving the proportion of people without access (Anderson and Langford, 2013; Luh et al., 2013); and the adoption of a dichotomous classification which has masked substantive disparities in quality of service (Lloyd and Bartram, 1991).

JMP monitoring has been criticized on several grounds (Sch fer et al , 2007), firstly for overestimating coverage in both rural and urban areas through the exclusion of water quality, affordability, and sustainability dimensions from the improved/unimproved typology (Clasen, 2012; Shaheed et al., 2014). Secondly, it is argued that systematic misclassification of peri-urban areas or slums as ‘rural’ has occurred and results in an over-estimation of urban progress towards targets. Some argue further that the use of a single, common set of indicators for both rural and urban areas is misguided ( ch fer et al , 7).

In a recent systematic review (Bain et al., 2014), we found that water quality is generally worse in rural areas. This is also supported by our spatial analysis of data from a large study in Nigeria which indicates that fecal contamination of drinking-water is greater in rural areas (Christenson et al., 2014). A household survey in Peru showed that rural supplies of the same type are more likely to suffer from fecal contamination than those in urban areas (Miranda 2010). While these studies concern faecal contamination of drinking-water; and the diarrhoeal disease associated with such

contamination dominates the water borne burden of disease, it is likely that other water borne diseases are also disproportionately borne by rural populations. This includes fluoride and arsenic which WHO indicate to be the principal chemical contaminants of global concern. For example, following the methods used by Christenson et al. (2014), we find that protected dug wells are less likely to exceed the WHO guideline for fluoride (1.5 mg/L) in urban areas compared with rural areas of Nigeria in seven out of eight definitions of “urban” (data not presented). Future perspectives

In 2011 and 2012 WHO and UNICEF organized a series of expert groups and consultations to explore potential future drinking water and sanitation goals and targets. Proposals for post-2015 targets and goals call for universal access (UN, 2013) and for the erosion of inequalities (WHO/UNICEF, 2013b). The proposals also include monitoring safety through measurement of E. coli (WHO/UNICEF, 2013b) which will respond to concerns regarding the safety of improved sources (Bain et al., 2012) as well as highlighting disparities (Yang et al., 2012). Striving for universal access will require addressing both stagnation in urban progress and low coverage in rural areas of many countries. One recommendation was to cease recognizing protected springs and protected dug wells as ‘improved sources’ in urban areas (WHO/UNICEF, 2013a; WHO/UNICEF, 2013b). This was founded on the belief that the safety of drinking-water from these source types is more imperiled in urban areas. In fact our analysis in Nigeria (Christenson et al. 2014) and systematic review (Bain et al 2014) show that there is little difference in microbial water quality for protected dug wells or boreholes between rural and urban settings.

If post-2015 targets do not have renewed focus on rural areas they are likely to continue to lag behind their urban counterparts in both improved water access, piped water access and water safety. This may also have knock on effects on the prospects of achieving other post-2015 targets in rural areas such as those focusing on health and education. A renewed focus and tougher targets for urban areas, as argued by some ( ch fer et al , 7), may detract from efforts to address the greatest and most persistent disparities in use of improved sources, access to piped water at home and overall water safety. In fact the apparent stagnation in urban progress is in large part explained by relative population growth and belies the number of people with increased access. Similarly a partial explanation of rural progress relates to far lesser levels of rural population growth.

Proportional reduction targets, as embodied in the MDGs and future sustainable development proposals can only be pro-equity if applied to different sub-groups, thereby driving actions that erode inequalities. In the case of drinking-water we find that on this basis rural:urban inequality has reduced and urban progress has stagnated. Given relative costs and also relative benefits of piped water on premises versus other ‘improved sources, it is noteworthy that urban coverage with drinking-water is substantially greater for piped water and that progress in piped water is largely urban. More than two thirds of the 1.5 billion people who gained access to piped supplies at

home live in urban areas and only 29% of rural dwellers have a piped supply at home (WHO/UNICEF 2013a).

It has been argued that a simple comparison of rural and urban populations is an over-simplification ( ch fer et al , 7) and that urban areas should be disaggregated into ‘nuclear urban’ and peri-urban areas or “slums” We agree that urban areas represent a complex continuum (Christenson et al. 2014) and suggest that further disaggregation within either urban or rural areas would be beneficial in highlighting inequalities. Whilst there is some consensus regarding definitions of rural and urban areas, definitions and methods for further disaggregation are contested and insufficient data are available (Bradley and Bartram, 2013). For the purposes of the MDGs, “slums” have primarily been defined by inadequate infrastructure, especially use of unimproved water and sanitation (UN-Habitat, 2003).

Although an urban-rural dichotomy is widely used and can shed

valuable insights on differing vulnerabilities and disparities, a more nuanced continuum using meaningful indicators would better measure inequitable access to safe water. These urban indicators should be multi-dimensional, incorporating population density, the built environment, service access, and socioeconomic characteristics which describe different components of urban:rural continuum (Champion and Hugo, 2004; Dahly and Adair, 2007). Disaggregating the urban:rural dichotomy allows graduated distinctions to be made between the urban core, slums, other peri-urban areas, rural towns, and remote areas based on indicators measured. Identifying population subgroups in the urban and rural environments would better characterize inequitable access to safe water, although sub-classification of urban and rural environments has not been well defined. Studies that have examined intra-urban disparities have found differences in the types and safety of water sources between socio-economic groups in urban areas (Elala et al., 2011; Yongsi, 2010) suggesting that such sub-classifications would be valuable in highlighting and addressing inequalities.

The urban poor and rural poor have different vulnerabilities to water access. For the urban population there is a greater reliance on cash income for water and sanitation services and, for the rural population, a greater travel time and reduced access to services (Ruel et al., 2009). Nevertheless, richer rural dwellers may be less likely to have access to an improved water source than the urban poor. For example, in Sub-Saharan Africa the second richest rural quintile is less likely to have access to an improved source of drinking-water than the poorest urban quintile (respectively 54% vs 65%)(WHO/UNICEF, 2011). These findings suggest that intra-urban inequalities in access to improved sources of drinking water are less pronounced than those between urban and rural areas.

A further reason to prioritise urban populations might derive from cost effectiveness or affordability. This would apply if it were the case that the per capita cost of establishing and sustaining urban water supply were significantly less than that for rural populations, such that arguments

concerning the best use of finite resources and doing the maximum good with available funds might be put forth. However, this does not appear to be the case; recently reported cost estimates indicate that water supplies are less expensive to build and maintain in rural areas (Hutton, 2012). And such an argument would also run foul of human rights based pro-equity reasoning which would not accept the exacerbation of inequalities in the name of cost-effectiveness, but rather argue that the pursuit of equality is of itself a valid argument to act to the contrary (Woodward and Kawachi, 2000).

Little is known about the relative financing for rural and urban areas

due to the lack of disaggregated data, but the available estimates suggest that expenditure has been substantially higher in urban areas (Bain et al., 2013). Furthermore, many urban utilities are reliant on heavy government subsidies (WSP, 2011) undermining arguments that urban areas can better afford water services.

Acknowledging the need for progressive improvements in both rural and urban areas, there have been calls for global monitoring to be based on more than counting haves and have-nots (Bartram, 2008). In contrast to setting different targets for urban and rural areas, proposals for basic and intermediate service levels (WHO/UNICEF, 2013b) would ensure that the focus is kept on achieving universal access to safe water (primarily in rural areas) whilst monitoring progress towards higher service levels, including greater water safety (both in rural and urban areas). Conclusion

The proposed sustainable development targets for drinking-water post-2015 include both a provision to erode inequalities through universal access and progressive reduction in inequalities, but also a provision that will exacerbate already extreme rural disadvantage by setting a higher minimum standard in urban areas. Globally, rural improved water service coverage is substantially lower than urban coverage and there is evidence that water quality is also worse in rural areas. To focus on urban water access does not reflect health nor economic nor human rights rationales. Indeed these three perspectives would, at face value, all suggest that greater priority be placed on improving the situation of rural populations. References Anderson E, Langford M. A Distorted Metric: The MDGs and State Capacity,

2013. [Accessed: Feb 2014. Available: www.jus.uio.no/smr/english/about/programmes/serp/docs/mdgs-post-2015.pdf]

Bain RES, Cronk R, Wright JA, Yang H, Slaymaker T, Bartram JK. Fecal Contamination of Drinking-Water in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. PLoS Medicine 2014; 11: e1001644.

Bain RES, Gundry SW, Wright JA, Yang H, Pedley S, Bartram JK. Accounting for water quality in monitoring access to safe drinking-water as part of the

Millennium Development Goals: lessons from five countries. Bulletin of the World Health Organization 2012; 90: 228-235.

Bain RES, Luyendijk R, Bartram JK. WIDER Working Paper No. 2013/88. 2013. [Accessed: Feb 2014. Available: www.wider.unu.edu/publications/working-papers/2013/en_GB/wp2013-088/]

Bartram, JK; Brocklehurst, C; Luyendijk, R; Hossain, R; Fisher, MB; Wardlaw, T; and Gordon, B. Global monitoring of water supply and sanitation: A critical review of history, methods, and future challenges. (In submission).

Bartram J. Improving on haves and have-nots. Nature 2008; 452: 283-284. Bradley DJ, Bartram JK. Domestic water and sanitation as water security:

monitoring, concepts and strategy. Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences 2013; 371.

Cairncross S, Cliff JL. Water use and health in Mueda, Mozambique. Trans R Soc Trop Med Hyg 1987; 81: 51-4.

Champion AG, Hugo G. New forms of urbanization: beyond the urban-rural dichotomy: Ashgate Publishing, Ltd. Farnham: United Kingdom, 2004.

Christenson E, Bain RES, Wright JA, Rifat H, Bartram JK. Safety of drinking water in rural and urban Nigeria: water quality and sanitary risk. (In submission).

Clasen TF. Millennium Development Goals water target claim exaggerates achievement. Tropical Medicine & International Health 2012; 17: 1178-1180.

Craun GF, Brunkard JM, Yoder JS, Roberts VA, Carpenter J, Wade T, et al. Causes of outbreaks associated with drinking water in the United States from 1971 to 2006. Clin Microbiol Rev 2010; 23: 507-28.

Dahly DL, Adair LS. Quantifying the urban environment: a scale measure of urbanicity outperforms the urban-rural dichotomy. Soc Sci Med 2007; 64: 1407-19.

de Albuquerque C. On the right track: Good practices in realising the rights to water and sanitation, 2012. [Accessed: Feb 2014. Available: www.ohchr.org/Documents/Issues/Water/BookonGoodPractices_en.pdf]

Easterly W. How the Millennium Development Goals are Unfair to Africa. World Development 2009; 37: 26-35.

Elala D, Labhasetwar P, Tyrrel SF. Deterioration in water quality from supply chain to household and appropriate storage in the context of intermittent water supplies. Water Science and Technology: Water Supply 2011; 11: 400-408.

Foster T. Predictors of Sustainability for Community-Managed Handpumps in Sub-Saharan Africa: Evidence from Liberia, Sierra Leone, and Uganda. Environmental Science & Technology 2013; 47: 12037-12046.

Graham JP, Polizzotto ML. Pit latrines and their impacts on groundwater quality: a systematic review. Environ Health Perspect 2013; 121: 521-30.

Gunther I, Fink G. Water, Sanitation and Children's Health: Evidence from 172 DHS Surveys: World Bank, 2010. [Accessed: Feb 2014. Available: elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-5275]

Hunter PR, MacDonald AM, Carter RC. Water supply and health. PLoS Med 2010; 7: e1000361.

Hutton G. Global costs and benefits of drinking-water supply and sanitation interventions to reach the MDG target and universal coverage. WHO,

Geneva, Switzerland, 2012. [Accessed: Feb 2014. Available: www.who.int/water_sanitation_health/publications/2012/globalcosts.pdf]

Lloyd BJ, Bartram JK. Surveillance solutions to microbiological problems in water-quality control in developing-countries. Water Science and Technology 1991; 24: 61-75.

Luh J, Baum R, Bartram J. Equity in water and sanitation: developing an index to measure progressive realization of the human right. Int J Hyg Environ Health 2013; 216: 662-71.

Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000; 320: 1200-1204.

Rheingans R, Anderson JD, Luyendijk R, Cumming O. Measuring disparities in sanitation access: does the measure matter? Tropical Medicine & International Health 2014; 19: 2-13.

Richardson HY, Nichols G, Lane C, Lake IR, Hunter PR. Microbiological surveillance of private water supplies in England: the impact of environmental and climate factors on water quality. Water Res 2009; 43: 2159-68.

Rickert B, Schmoll O. Small-scale water supplies in the pan-European region. UNECE/WHO, 2014. [Accessed: Feb 2014. Available: www.unece.org/fileadmin/DAM/env/water/publications/documents/Small_scale_supplies_e.pdf]

Ruel MT, Garrett JL, Hawkes C, Cohen MJ. The Food, Fuel, and Financial Crises Affect the Urban and Rural Poor Disproportionately: A Review of the Evidence. The Journal of Nutrition 2010; 140:170S-6S.

ch fer , erchota , lle monitoring for urban water supply and sanitation Catching up with reality in ub- aharan frica eutsche esellschaft f r Technische usammenarbeit (GTZ), Eschborn, 2007. [Accessed: Feb 2014. Available: www.susana.org/lang-en/library?view=ccbktypeitem&type=2&id=1489]

Shaheed A, Orgill J, Montgomery MA, Jeuland , Brown J hy “improved” water sources are not always safe. Bulletin of the World Health Organization 2014; 92:283–289.

UN. A new global partnership: eradicate poverty and transform economies through sustainable development. The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, 2013. [Accessed: Feb 2014. Available: www.post2015hlp.org/wp-content/uploads/2013/05/UN-Report.pdf]

UN-Habitat. Global Report on Human Settlements 2003, London, UK, 2003. [Accessed: Feb 2014. Available: www.unhabitat.org.jo/pdf/GRHS.2003.pdf]

UNCESCR. Substantive issues arising in the implementation of the international covenant on economic, social and cultural rights. General comment no. 15 (2002). United Nations: Geneva, 2003; Vol. E/C.12/2002/11.

UNGA. Road map towards the implementation of the United Nations Millennium Declaration, 2001. [Accessed: Feb 2014. Available: www.un.org/millenniumgoals/sgreport2001.pdf]

UNGA. Implementation of the United Nations Millennium Declaration, 2002. [Accessed: Feb 2014. Available: www.un.org/millenniumgoals/sgreport2002.pdf]

UNGA. Human Rights and Access to Safe Drinking Water and Sanitation, 2010. [Accessed: Feb 2014. Available: ap.ohchr.org/documents/E/HRC/resolutions/A_HRC_RES_7_22.pdf]

Vandemoortele J. The MDG Conundrum: Meeting the Targets Without Missing the Point. Development Policy Review 2009; 27: 355-371.

Waage J, Banerji R, Campbell O, Chirwa E, Collender G, Dieltiens V, et al. The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 Lancet and London International Development Centre Commission. Lancet 2010; 376: 991-1023.

WHO. Guidelines for Drinking-Water Quality. Vol 1. Geneva: WHO, 2011. WHO/UNICEF. Drinking water: Equity, safety and sustainability.

WHO/UNICEF, 2011. [Accessed: Feb 2014. Available: www.wssinfo.org/fileadmin/user_upload/resources/report_wash_low.pdf]

WHO/UNICEF. Progress on Sanitation and Drinking-Water: 2013 Update WHO/UNICEF, 2013a. [Accessed: Feb 2014. Available: www.wssinfo.org/fileadmin/user_upload/resources/JMPreport2013.pdf]

WHO/UNICEF. Proposal for consolidated drinking water, sanitation and hygiene targets, indicators and definitions, 2013b. [Accessed: Feb 2014. Available: www.wssinfo.org/fileadmin/user_upload/resources/A-proposal-for-consolidated-WASH-goal-targets-definitions-and-indicators_version7_Nov22_final.pdf]

Woodward A, Kawachi I. Why reduce health inequalities? Journal of Epidemiology and Community Health 2000; 54: 923-929.

WSP. Country Status Overviews Regional Synthesis Report: Pathways to Progress, 2011. [Accessed: Feb 2014. Available: www.wsp.org/sites/wsp.org/files/publications/CSO-Synthesis-Report.pdf]

Yang H, Bain R, Bartram J, Gundry S, Pedley S, Wright J. Water Safety and Inequality in Access to Drinking-water between Rich and Poor Households. Environmental Science & Technology 2012; 47: 1222-1230.

Yongsi HBN. Suffering for Water, Suffering from Water: Access to Drinking-water and Associated Health Risks in Cameroon. Journal of Health Population and Nutrition 2010; 28: 424-435.