Water and sanitation infrastructure for health: The impact of foreign aid

Background: The accessibility to improved water and sanitation has been understood as a crucial mechanism to save infants and children from the adverse health outcomes associated with diarrheal disease. This knowledge stimulated the worldwide donor community to develop a specific category of aid aimed at the water and sanitation sector. The actual impact of this assistance on increasing population access to improved water and sanitation and reducing child mortality has not been examined. Methods: We performed a country-level analysis of the relationship between water and sanitation designated official development assistance (WSS-ODA) per capita, water and sanitation coverage, and infant and child mortality in low-income countries as defined by the World Bank. We focused our inquiry to aid effectiveness since the establishment of the Millennium Development Goals (MDGs). Results: Access to improved water has consistently improved since 2002. Countries receiving the most WSS-ODA ranged from odds ratios of 4 to 18 times more likely than countries in the lowest tertile of assistance to achieve greater gains in population access to improved water supply. However, while there were modestly increased odds of sanitation access, these were largely non-significant. The countries with greatest gains in sanitation were 8-9 times more likely to have greater reductions in infant and child mortality. Conclusions: Official development assistance is importantly impacting access to safe water, yet access to improved sanitation remains poor. This highlights the need for decision-makers to be more intentional with allocating WSS-ODA towards sanitation projects.