Thank you for inviting me to discuss Water Supply, Sanitation, and Hygiene programming (WASH) underway at the US Agency for International Development (USAID).

I Challenges:

USAID seeks to save and improve the lives of those threatened by unsafe water and sanitation related diseases. The motivations for our efforts are very compelling:

• Diarrheal diseases kill approximately 2 million children under five each year, either directly (1.3 million deaths) or from other causes as a consequence of diarrhea-related malnutrition (an additional 600,000 to 700,000 deaths).
• The numbers of people suffering from hunger and poverty worldwide exceeds one billion.
• Climate change, food shortages and inadequate water supply, water quality, and sanitation will significantly contribute to political, social and economic instability in the developing world.
• By 2025, the global population is projected to rise to 8 billion people, one third of which - 2.4 billion people, spread over 40 countries - will face absolute water scarcity.
• Between now and 2015, an estimated 700 million people will be without access to an improved water supply and approximately 1.6 billion will lack access to improved sanitation, with waterborne diarrheal diseases being a leading cause of morbidity and mortality in the developing world.
• In Africa, at least twice as much food must be produced by 2050 to avoid widespread starvation amongst an expected population of 1.8 billion. But, food production per capita has been declining, and cereal yields have remained stagnant since the 1960s. By the middle of the 21st century, annual average river runoff and water availability are projected to increase as a result of climate change at high latitudes and in some wet tropical areas, and decrease over some dry regions at mid-latitudes and in the dry tropics. Many semi-arid and arid areas such as southern Africa are particularly exposed to the impacts of climate change and are projected to suffer a decrease of water resources. Higher water temperatures and changes in extremes, including floods and droughts, are projected to affect water quality and exacerbate many forms of water pollution.
• The global search for energy and food supplies, as noted in the World Bank's 2011 World Development Report, is amplifying pressure on arable land in developing countries. This search for energy and food supplies impacts the availability and use of water.

Our WASH efforts are critical towards addressing these challenges. In today's discussion, I want to share with you today some of the key polices, knowledge and experience that help form our WASH program-and provide some examples of how policy, programs and experience all come together in this effort.

Policy Drivers

First, let me turn to the policy drivers which significantly influence our water programs:

1. The Water for Poor Act makes access to safe water and sanitation for developing countries a specific policy objective of the United States foreign assistance programs. The purposes of assistance authorized by this section are to,"… promote good health, economic development, poverty reduction, women's empowerment, conflict prevention, and environmental sustainability by providing assistance to expand access to safe water and sanitation, promoting integrated water resource management, and improving hygiene for people around the world."
2. The Presidential Policy Directive on Global Development supports three major initiatives to implement core elements of President Obama's new development policy:
   • Feed the Future (FTF) is the U.S. component of a global initiative launched by President Obama at the London Summit of the G20. FTF is aimed at promoting a comprehensive approach to food security by accelerating economic growth and increasing incomes through greater agricultural productivity, market access for the rural poor, and enhancing nutrition.
   • Global Health Initiative (GHI) expands our global health effort and impact by improving disease treatment, integrating our interventions and expanding our investments to strengthen health systems, improve maternal child health, address neglected tropical diseases, and foster increased research and development.
   • Global Climate Change Initiative (GCCI) integrates climate change considerations into the U.S. foreign assistance strategy by fostering a low-carbon future and promoting sustainable and resilient societies for the coming decades.

   WASH and the Presidential Initiatives 
   All three of these initiatives bear on WASH

   • A central focus of the GHI is inadequate access to water for household needs, both in quantity and quality. Beyond cholera and infectious disease risk mitigation, improved WASH has enormous benefits for the care and support of people living with HIV/AIDS.
   • Feed the Future (FTF) has multiple water links, particularly through water productivity. The major connection for WASH, however, is through improved nutrition and food utilization, one of the major objectives of FTF. The role of WASH in improved nutritional status is well documented, especially for young children, whose repeated bouts of diarrhea can cause stunted growth and brain development, as well as lowering resistance to other diseases. If a child does not die from acute diarrhea, she or he may well die from pneumonia as a consequence of chronic malnutrition.
   • Global climate change, associated with increased floods and droughts, threatens to negatively impact existing water and sanitation services and reduce future gains in access and service quality. Resilience to future variability depends upon improved drinking water and sanitation services for the highest risk regions.
3. Quadrennial Diplomacy and Development Review (QDDR). USAID focuses on six core areas: sustainable economic growth, food security, global health, climate change, democracy and governance, and humanitarian assistance. The QDDR proposes investments in innovation to spark more advances in those areas.
4. USAID FORWARD is a USAID initiative, an early outcome of the QDDR. The initiative changes the way the Agency does business: through the development of new partnerships, through new emphasis on innovation and technology, with a relentless focus on results, through improved monitoring and evaluation processes, and by giving proper attention to talent management.

Regarding USAID FORWARD emphasis on evaluation:

• USAID Administrator Rajiv Shah approved the new evaluation policy in January 2011, which will set a new standard in our field. By aggressively measuring and learning from our results, we will extend the impact of our ideas and of knowledge we helped generate.
• We will provide performance evaluations for every major project, conducted by independent third parties, not by the implementing party themselves. And we will release the results of all of our evaluations within three months of their completion.
• When programs are successful, we will look to scale them up. But when we learn that a program has not produced results warranting taxpayer money, we will scale it back or shut it down, and learn from our experience. And in the spirit of extreme transparency, we will release in either case--success or failure--the results of our evaluations publicly, within three months of their completion so that you, your colleagues and the American public can see the results of their investments, whether they tell a story of success or failure. We will integrate this project evaluation data into our foreignassistance.gov dashboard. Regarding the USAID Forward emphasis on innovation:
• To support promising new approaches in the Water, Sanitation, and Hygiene (WASH) sector, the U.S. Agency for International Development (USAID), with co-funding from the Bill & Melinda Gates Foundation, is announcing WASH for Life. Over the next four years, the $17 million partnership will use USAID's Development Innovation Ventures (DIV) program to identify, test, and help scale evidence-based approaches for cost-effective and sustained services in developing countries. WASH for Life is particularly interested in interventions that operate in Bangladesh, Ethiopia, Ghana, Haiti, India, Kenya, and Nigeria; address issues in the sanitation and hygiene sectors in particular; and target beneficiaries earning under $2 a day (PPP adjusted).

Bringing policy, knowledge and experience together

Now, let me turn to the knowledge and experience that are influencing our decisions. In so doing, I will share with you examples of USAID's work in the field which implement both the overarching polices discussed previously and the knowledge and experience we have gained.

While the debate continues about the relative impact and cost-effectiveness of the different WASH interventions, and more research is needed in many key areas, we believe have drawn several conclusions from the current state of the art related to scale and sustainability which we reflect in our WASH programming.

We anticipate that over time we will be increasingly emphasizing these areas: Behavior Change; Sanitation and Market Development; Bringing Sustainable services to un-served populations; and the Integration of WASH and Humanitarian Assistance. We also see opportunities to significantly enhance our knowledge and impact, such as in the overall area of women and water. Let me elaborate:

1. Behavior change:

The evidence suggests that behavioral and enabling environment interventions are by almost any measure cost-effective in averting the burden of disease from diarrhea, in terms of averting "Disability-Adjusted Life Years" lost, a measure that combines morbidity and mortality impacts. Hygiene promotion is amongst the most cost-effective health interventions, not just for diarrhea but across the board. And this has resulted in renewed interest in sanitation and hygiene within the health sector, particularly as it has been clear that state-of-the-art approaches, largely centering on behavior rather than infrastructure, are amongst the most cost-effective tools for the prevention of mortality and morbidity from diarrhea, still the second leading cause of death for children under five. These approaches rely on improvements and investments by households themselves, using approaches such as Community-Led Total Sanitation to ignite change.

The end of open defecation reflects a change in cultural norms and is an enormous change from the previous status quo.

• An example of such approaches by USAID is its support of the West Africa Water Initiative (WAWI) where WAWI partners decided to test Community-Led Total Sanitation (CLTS) programs in Mali, Ghana, and Niger that relies on highly trained facilitators to help communities analyze their current sanitation practices through a series of participatory exercises that help community members confront the reality of negative impacts of mass open defecation, including demonstrating how people are exposed to each other's feces in unsanitary environments.
• An example of experience coming together with behavior change occurred during the Haiti earthquake response. One of our Haiti response leaders had read a behavioral economics study that found people were more likely to purify emergency supplies of water if they received chlorine tablets at the point of distribution, rather than afterwards as had traditionally been done. So when we hired firms to provide water to earthquake survivors, we wrote into their contracts a requirement to distribute chlorine tablets as well. As a result, water was cleaner in Port-au-Prince and there were fewer cases of diarrheal disease than before the earthquake struck. While this intervention didn't prevent an outbreak of cholera from reaching the capital, it had a significant role in limiting its spread.
• In Ethiopia, nearly 3.6 million people in the Amhara region have stopped the practice of open defecation and now use a basic pit latrine as a result of hygiene promotion activities conducted through the existing regional health extension network and Health Bureau with technical support from USAID (through the Hygiene Improvement Project) in partnership with the Water and Sanitation Program of the World Bank. The practice of open defecation in the region dropped from 64 to 40 percent from 2007 to 2010. USAID and its partners provided training and tools to a cadre of frontline workers including health extension workers, farmers, and others who used modified Community-led Total Sanitation approaches to motivate communities and increase demand for improved sanitation facilities to end the practice of open defecation.

2. Sanitation and Market Development: There is growing evidence that development of the market is the only sustainable and scalable approach to meeting the need for sanitation in the developing world. Sanitation Marketing aims to invest in activities that will facilitate the purchase of sanitation products by the poor. Access to sanitation has been largely achieved through the private sector supplying individual households. It is now widely understood that interventions must respond to what people want, rather than what "officials" think they should have. Market research can reveal what people are used to and comfortable with, as well as what they're willing to pay.

• In Madagascar, the USAID Hygiene Improvement Project (HIP) developed a sanitation marketing approach, including consumer surveys to identify which products were most feasible, desirable and affordable and support for local entrepreneurs to make is easier for consumers to find and buy the necessary sanitation hardware. This hardware component complemented demand creation activities that began with a national WASH campaign, followed by regional and community behavior change promotion activities, including CLTS. The USAID-grantee, Water and Sanitation for the Urban Poor is also implementing a sanitation marketing strategy in the capital among peri-urban communities.
• In Uganda, USAID worked with the National Sanitation Working Group to create broader support for sanitation marketing approaches. Through the Hygiene Improvement Project, USAID developed guidance and tools to support district level sanitation marketing programs and trained masons in latrine construction to complement behavior change and demand creation activities underway through USAID funded partners.

3. Sustainability: Ensuring the sustainability of water supply and sanitation improvements is a critical problem in both the rural and urban communities where USAID is supporting expanded access to these basic services. Sustaining water supply service improvements is especially difficult in rural areas because of weak government monitoring systems and human resource back-up support, and the often poor availability of spare parts and repair services. Sustaining investments in urban water supply and sanitation can be just as problematic, if not more. Because of the complex nature and high cost of operating and maintaining urban water and sanitation infrastructure, these systems all too often fail because the operators responsible for maintaining the infrastructure are poorly skilled, poorly motivated, and/or lack sustainable sources of revenue to cover costs.

Throughout rural sub-Saharan Africa, thousands of water systems are developed every year, such as boreholes equipped with motorized or hand/foot pumps. These systems often fall into disrepair shortly after installation. It's estimated that 50,000 water supply systems are not functioning across Africa - representing a lost investment of nearly $300 million. There have been new models developed for improving rural water services that aim to better incorporate enabling environment factors and increase sustainability and scale. These models address:

• Investing on the basis of need for the entire district, as well as investing in support services and frameworks.
• Allowing flexibility for water systems so that different management and technical approaches can be used.
• Working to achieve full coverage within established geographic/administrative boundaries.
• Seeking to coordinate all actors to work collectively under an overarching strategy, including commonly agreed model(s) depending on the service provided.

We believe that sustainable sanitation and water supply should be subjected to the same checks on sustainability. Looking at numbers served or population-based measures of access to services do not of course totally convey true impact. Since there are multiple dimensions to sustainability, the challenge is to measure the long term impacts on sustainability which addresses the impact of WASH programs not just of water, supply, and sanitation and hygiene but on other critically related development objectives such as nutrition, gender, and climate and conflict mitigation. Ultimately sustainability of a result is probably the most important measure of success. The only way to know you have been successful is by documenting sustained change which may not be evident over a short time period. Proxies for sustained change might be sustained behavioral or physical change, a set period after project completion; or independent replication/adoption of intervention by communities/individuals not included in original grant scope. This might entail having a single data base in countries for monitoring sources of water and sanitation facilities.

Examples of our sustainability driven programs include:

• To achieve sustainability on a country by country basis, USAID's largest per capita investments in WASH basic access improvement are currently ongoing in Liberia. USAID's flagship program in that country is the Improved Water Supply and Sanitation (IWASH) program. IWASH is aiming to achieve measurable county-level improvements in water supply, sanitation, hygiene in the three largest counties in Liberia and selected communities of greater Monrovia. In addition to a central focus on sustaining service improvements through building up the capacity of government sector capacity at the county and national level, IWASH aims to develop critical WASH product supply chains among the private sector to facilitate continued expansion of service into the future.
• An another example of USAID's commitment to sustainability is its support of the PEPAM project in Senegal which:
  • Increases the demand for sustainable water sanitation and hygiene services and products by promoting appropriate low-cost systems that ensure a hygienic environment, and improving the sanitary and hygiene behaviors identified as critical by the community;
  • Strengthens the capacity of small-scale service providers and water users associations (WUAs) to respond to the demand for improved water and sanitation services;
  • Encourages private sector involvement in the installation and rehabilitation of water and sanitation infrastructure.
• In urban water and sanitation, a flagship USAID program that is working to build sustainable improved services for the urban poor is the Sustainable Water and Sanitation in Africa (SUWASA). The program is fostering the transformation of water and sanitation delivery services in Africa to achieve long-term financial sustainability through the application of market-based principles. SUWASA is designed to spread effective models of reform at the water utility and sector levels, and to facilitate innovative financing approaches for African water providers. SUWASA and other similar programs in Egypt, Afghanistan and Indonesia aims at building partnerships with utilities and small service providers, governments, donors, communities and businesses to demonstrate and promote best practices both for water service reform and governance, as well as innovative financing strategies. SUWASA puts special consideration on improving and expanding the delivery of water and sanitation services in urban and peri-urban settings, with a focus on meeting the needs of the poor. Working through local partners and networks, the program supports countries committed to reform initiatives with technical assistance and capacity building, supplemented with limited financial support for infrastructure as required.

4. Integration of WASH and Humanitarian Assistance

Our WASH programs play a key role in our international disaster assistance efforts. For example:

• Since 2009 in Madagascar USAID has been constrained by the political situation, and can only work through non-governmental channels as part of humanitarian assistance. However, the current WASH programming builds off of years of USAID's development investments.
• Catholic Relief Services leads a consortium in implementing a flagship three year, $7.5million WASH project in two Malagasy regions severely affected by disease and illnesses resulting from lack of access to adequate drinking water and sanitation. Further supporting integration, CRS also leads a multi-year assistance program funded by USAID's Office of Food for Peace with a significant emphasis on WASH.

Expanding our Knowledge: Women and Water

While we have considerable knowledge and evidence related to the above areas, we need to learn far more about how to support long-lasting solutions to persistent vulnerabilities for women and girls, the linkages between violence connected to water access and the wider conflict context in which the challenge is embedded. But, we have learned that:

• Women must be empowered to lead and participate in community projects that identify and implement WASH solutions that are responsive to community needs and priorities.
• Women benefit in multiple ways from improved WASH, including reduction of time gathering water and reduced risk from sexual violence while gathering water or defecating in the "privacy" of the night.
• Schools with proper sanitation facilities can attract and retain more teachers and students, especially young girls who are reaching puberty.
• An example of USDAID supported work addressing women and water is found in Mara Kenya, one of the driest areas in Kenya. On average, a household requires about 40 liters of water a day. But because women must walk up to six hours to get water, they must live on 15-20 liters a day. The journey is not only arduous; it is also very dangerous, as the source of water is shared with lions and elephants. Women have been killed by wildlife at watering holes. USAID is partnering with World Concern to better empower women and protect them. The project builds wells near the community, in this case some 20 minutes away, and at the same time engages women in a wide range of community development activities including latrine construction, hygiene and sanitation practices, and community involvement through community development committees, water management committees, and training for health promoters and women's groups.
• Another example of USAID's work is with Women Farmer's Advancement Network (WOFAN) in Nigeria. WOFAN provides a wide range of services, including education about health issues, literacy training, and economic empowerment, micro-credit for farmers, childcare development, leadership skills, and HIV/AIDS awareness. One of its primary goals is teaching women about soil, water, and agro-forestry conservation. WOFAN achieves its goals by organizing gender-specific groups of 10-20 people each and training the group members, who must be together at least six months to benefit from WOFAN's programs, on a variety of topics, including encouraging good gender relationships and discouraging social exclusion. Women's groups account for 75% of the total, while 25% consist of young men or children.

IV Conclusion: Bringing Knowledge, Experience and Policy Together

All in all, the integration of knowledge, experience and policy form the foundation for the actions-such as those which I described in my presentation -- which USAID, working closely with its public and private sector partners, take to sustain human life.

Knowledge, experience and policy are not immutable. We all continue to learn and adjust our actions based upon what we have learned and done. Clearly the way in which we - USAID and our partners--share knowledge and cooperate together is critical to improving our impact. Today's dialogue here at CSIS is an important aspect of the continuing effort to both learn from one another and apply what we learn for the betterment of so many in need.

Thank you.