Water, sanitation, and hygiene access in southern Syria: analysis of survey data and recommendations for response

Emergencies, including natural disasters, disease outbreaks, and complex emergencies, are occurring at increasing rates, and affecting an increasing number of people [1‐4]. As classified by the United Nations, complex emergencies are defined as ‘situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance, and large-scale movements of people, in which any emergency response has to be conducted in a difficult political security environment [5]. Today, more than 1.5 billion people are threatened by conflict and violence [6]; and there are more than 65 million displaced persons worldwide, the highest number ever recorded [7].

Water, sanitation, and hygiene (WASH) are immediate priorities for human survival and dignity in emergencies [8]. WASH interventions commonly implemented in emergency response in households and facilities include: 1) water supply, including construction or repair of water infrastructure, and support for operation and maintenance of systems; 2) water treatment, including operationalizing simple water safety plans at central and household levels; 3) excreta disposal, supporting sewage systems or constructing emergency facilities; and, 4) promotion of hygiene practices and provision of hygiene items [8]. WASH interventions in middle income or urban settings generally focus on supporting existing large-scale infrastructure, while interventions for displaced populations generally focus on facility construction. Adequate WASH coverage in emergencies may prevent displacement, reduce risk of outbreaks, reduce risk of malnutrition, and play a fundamental role in dignity, protection, school attendance, and livelihoods [9]. WASH interventions reduce both the risk of disease and the risk of transmission of disease [10], although program design, implementation characteristics, and community aspects were found critical to program success in a recent systematic review.

In March 2011, armed conflict began in Syria. Today, 13.5 million Syrians are estimated in need of humanitarian assistance [11], 6.1 million are internally displaced within Syria [12], and an estimated 12 million need WASH services [13]. Before the conflict, Syria provided > 90% of its population with access to improved drinking water, according to the definitions and indicators then used to track the Millennium Development Goals [14]. Because of conflict, infrastructure functionality progressively deteriorated, mainly due to lack of power supply [15]. Unavailability of spare parts and consumables due to international sanctions and insecurity, displacement of trained professionals, lack of investment in preventive maintenance, and lack of financial resources also contributed to decreased utility functionality. Additionally, water has been used as weapon of war, by all parties in the conflict. In some cases, portions of the civil population have been deprived of centralized supply for protracted periods of time.

Since August 2015, Security Council resolution 2165 authorized the United Nations to carry out humanitarian operation inside Syria, in areas under the control of different actors, with cross border operations. A coordination mechanism termed the Whole of Syria (WoS) was established, with the goals of coordinating interventions from different hubs and maximizing humanitarian action efficiency. The WoS 2017 Humanitarian Response Plan focuses on three objectives: saving lives, ensuring protection, and increasing resilience and access to services [16]. The WASH Cluster is responsible for coordinating WASH responses to meet these objectives, and has collected data on WASH access within Syria to inform response efforts. As Syria is an example of an emerging type of complex emergency (a protracted conflict in a middle-income context with pre-existing infrastructure and vibrant local market), data collection is particularly relevant as traditional intervention strategies are less than optimal. Currently, the WASH sector in Syria is: 1) providing support to urban infrastructure and promoting Water Safety Plans (WSPs) as a risk-based community management strategy; and, 2) promoting traditional WASH activities of small-scale emergency infrastructure, hygiene kit provision, and community mobilization.

Water Safety Plans (WSP) are a systematic approach that consistently ensures the safety of drinking-water supply through the use of a comprehensive risk assessment and risk management approach encompassing all steps in the water supply from catchment to consumer [17]. Depending on the situation, WSPs vary in complexity. In case of southern Syria, WSP implementation involved conducing a risk assessment at three levels (household, trucked water system, and piped network system) followed by implementation appropriate risk management measures. The implemented risk management measures included chlorination training, distribution of chlorine and chlorine testing equipment, installation of chlorination stations at the water collection wells, household- and community- based water safety awareness campaigns, and fixing water lines and pumps of the supply network.

Our goal was to analyze WoS WASH sector data collected in opposition controlled southern Syria to identify the most effective WASH interventions.

In June/July 2016 and February 2017, under the umbrella of the Whole of Syria WASH cluster, the working group in the Amman hub (comprising of UNICEF as sector lead and other program implementation partners), conducted a household survey to assess WASH services in 17 sub-districts of Dar’a (13 sub-district comprised of 50 communities) and Quneitra (4 sub-districts comprised of 14 communities) governorates where Amman hub operates humanitarian assistance (Fig. 1). The sampling frame was households in opposition-controlled areas, where safe access was possible. The data were collected at the same time by all implementing partners.

A list of sub-districts and their population was prepared using the Humanitarian Needs Overview (HNO) 2015 data [13]. Sample size was calculated using the Krejcie and Morgan model [18]; set for 95% confidence with 10% margin of error and one degree of freedom, to allow for generalizable results by sub-district. The calculated sample size was 87–96 households per sub-district; this was increased to 106 to account for response rate. The number of households sampled in communities within sub-districts was proportionate to population. The individual household randomization process within a community varied, but followed a systematic method (e.g. if maps were available the sample was divided equally by neighborhood or random routes were used). Permanent residents and internally displaced persons (IDPs) of urban and rural areas were surveyed. Enumerators were trained on ethical survey administration; local community councils were informed, and household consent was obtained before conducting the survey. If armed conflict prevented access to a community, data collection was deferred until the area became accessible. Secondary analysis of de-identified data was approved by the Institutional Review Board of Tufts University (IRB Study #1706006).

In opposition controlled Southern Syria, surveys conducted in 2016 and 2017 found that: 1) pipped water supply as main water source in the last 30 days declined from > 90% before the conflict to 22.0% in 2016 and 15.3% in 2017, with privately operated water trucking networks filling the gap; 2) water security was a moderate concern, as households accessed 50–60 lpcd, but some households reported days without water, not having enough water, and modifying hygiene practices due to lack of water; 3) water safety improved from 2016 to 2017, as households with > 0.1 mg/L FCR increased from 4.1% to 27.9%, with households in communities targeted with WSP programming 24.16 times more likely to have FCR > 0.1 mg/L; additionally households reporting trucked water as the main source were more likely to have FCR > 0.1 mg/L (as trucked water can be chlorinated at collection); 4) the majority of households had access to a clean and functional toilet, a handwashing station with soap and/or water, and a garbage disposal method; 5) the proportion of households where respondents self-reported childhood diarrhea over a period of two weeks declined from a high (but commonly seen in emergency situations) of 32.8% to a more moderate level of 20.4% from 2016 to 2017; and, 6) sanitation (functional toilet) and hygiene (hygiene access and reported handwashing) indicators were protective against diarrheal disease in children in 2016 and 2017, respectively; some water supply indicators were identified as risk factors; these results should be interpreted with caution as further research on household water practices is needed to contextualize these results.

While this data highlights promising trendlines between 2016 and 2017, this water access comes at high cost, as respondents consistently reported paying ~ 20% of their income on water. While markets remain functional, and hygiene items were available, respondents also reported they could not afford consumable hygiene items such as washing powder, shampoo, dish and household cleaners, menstrual hygiene products, and diapers. Overall, the results indicate the private sector has effectively replaced decaying piped water infrastructure, with services that would be considered “basic” under the new Sustainable Development Goals [19]. However, these services absorb a high percentage of household disposable income, and as household purchasing power is low, water safety remains an issue. Despite all this, WSP programming successfully reduced the risk of disease transmission by increasing FCR concentrations.

The ideal WASH solution in Syria would be to maintain and restore pre-existing infrastructure services to a level considered “safely managed” under the Sustainable Development Goals. However, infrastructure requires support systems; all of these have been strained by protracted conflict. The estimated operations and maintenance costs for this infrastructure greatly exceeds humanitarian funding levels available for WASH response in Syria. The data herein thus raises questions on: 1) How should responders support affected populations in accessing safe, sufficient, and reliable drinking water supplies at reasonable cost? 2) Should hygiene kits be distributed in kind in contexts where hygiene products are widely available in markets? 3) How can community-level WASH interventions, such as WSPs, be scaled up? and, 4) What are the appropriate criteria to use to prioritize beneficiaries when there are insufficient resources and capacities, respecting the humanitarian principles of equity and universality?

Recently, there has been international focus on market-based solutions in emergencies, including providing support and regulation to markets and providing direct cash transfers to affected populations [20, 21]. These solutions are particularly appropriate for emergencies in urban settings, where the private sector can become the main WASH service provider. When compared to current standard practice (distribution of pre-packaged hygiene kits that may not meet beneficiary needs), using markets has the positive aspect that affected populations can obtain what they need sustainably [10]. Provided the service is adequate, in unregulated environments there are two negative consequences for users: affordability and quality. Affordability can be addressed with well-targeted subsidies, including coupons or vouchers [20, 21]. However, quality of water delivered by unregulated vendors remains a concern.

Water Safety Plans (WSPs) are a comprehensive risk assessment and management approach to water delivery, with the goal of ensuring drinking water safety by preventing or minimizing contamination. [22] The five steps in developing a WSP are: preparation; system assessment; monitoring; management and communication; and, feedback and improvement. WSPs are generally implemented in large utilities in development contexts, and have not traditionally been considered an emergency response activity. In southern Syria, the WSP approach targeted the middle (public and private wells, piped network, chlorination stations) and end of the water chain (consumers), including vendors that transport water and users that store it. Key lessons for success were: 1) extensive mobilization and follow-up at the household level using a volunteer network; 2) focusing on the key, simple parameter of FCR with pooltesters for operational monitoring and verification; and, 3) flexibility in adapting the programmatic strategy with evidence. The Syrian experience shows the WSP approach can yield results in emergencies. Community-level WSP programming also reaches a scale that allows cost-effective use of limited resources to reach those most in need.

The limitations of this analysis include: 1) southern Syria is not representative of all Syria, especially for power supply, and therefore water network, availability; 2) no microbiological water quality data was collected, although FCR presence is an indicator of no/low bacterial contamination; 3) self-reported diarrhea is an indicator subject to response bias, and no standard definition of diarrhea was provided to respondents; 4) sample size calculation was not specifically completed for households with children < 5 and we removed a large number of households from the dataset; 5) data are from cross-sectional surveys, not experimental evaluations; thus, causation cannot be determined; and, 6) the survey was not designed to distinguish between hygiene item availability and affordability, which are different constructs, and further research is necessary to disaggregate the reasons for lack of hygiene items. Results should be understood within these limitations.

The results presented herein highlight the importance of collecting data locally in emergencies to develop appropriate, targeted response activities to ensure water and sanitation access and reduce the risk of disease transmission. The Syrian experience presents a new and unique challenge by combining protracted conflict with a middle-income context with pre-existing infrastructures, and questions the traditional WASH humanitarian response. Markets, the private sector, and water vendors should not be overlooked: in contexts with a market capable of satisfactory WASH service provision, markets-based programming can be leveraged to reach larger populations and to build and encourage resilience. Additionally, authorities should be seen not only as service providers, but regulators. The risk management approaches in WSPs should not be considered only a development intervention, but instead can be considered a primary emergency response intervention to ensure water safety. The lesson from the Syria WASH response is that allowing market forces to manage services and quantity, and targeting response activities on increasing affordability, quality, and regulation can be an effective, scalable, and cost-effective strategy to guarantee the human right to water and sanitation in protracted emergencies.

Syria is an example of an emerging complex emergency. Based on about 2000 surveys conducted in opposition controlled southern Syria, we found that piped water supply on the premises as the main water source in the last 30 days declined significantly both in 2016 and in 2017, with privately operated water trucking networks filling the gap. Additionally, water safety improved from 2016 to 2017, with communities targeted with WSP programming were more likely to have FCR in households stored water. Lastly, the data showed that sanitation and hygiene indicators were protective against diarrheal disease in children. The lesson from the Syria WASH response is that allowing market forces to manage services and quantity, and targeting response activities on increasing affordability, quality, and regulation can be an effective, scalable, and cost-effective strategy to guarantee the human right to water and sanitation in this new type of protracted complex emergency settings with prior infrastructure and vibrant markets.