USING MONITORING DATA TO IDENTIFY WATER AND SANITATION SERVICE DELIVERY IMPROVEMENT OPPORTUNITIES IN LOW- AND MIDDLE-INCOME COUNTRIES Ryan D. Cronk A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Environmental Sciences and Engineering in the Gillings School of Global Public Health. Chapel Hill 2017 Approved by: Jamie Bartram Clarissa Brocklehurst Richard Johnston Peter Kolsky Mark Sobsey © 2017 Ryan D. Cronk ALL RIGHTS RESERVED ii ABSTRACT Ryan D. Cronk: Using monitoring data to identify water and sanitation service delivery improvement opportunities in low- and middle-income countries (Under the direction of Jamie Bartram) Universal access to basic sanitation and water services and their progressive improvement are important for human development, health, and human rights; and are recognized in program, national, and international policies such as the Sustainable Development Goals (SDGs). Monitoring data are important for measuring progress toward universal access and improvements in service levels. In the SDG era, substantially more data will become available with new and expanded monitoring. These data can be analyzed beyond their immediate purpose to answer policy-relevant questions. However, these data are underused for service delivery research and there are opportunities to improve the reliability and quality of monitoring. To address these challenges, I analyzed monitoring data to identify opportunities to improve monitoring and water and sanitation service delivery. Using water supply infrastructure data from sub-Saharan Africa and Central America, Bayesian networks predicted water system functionality and continuity increased by as many as 20 percentage points when best-observed conditions were in place. I systematically compiled health care facility (HCF) datasets to produce the first coverage estimates for 21 indicators of environmental conditions in HCFs in low- and middle-income countries, where 52% of HCFs lack piped water and 30% lack improved sanitation. Statistically significant inequalities in coverage exist between HCFs by urban-rural setting, managing authority, facility type, and iii administrative unit. Using frontier analysis, I transformed household monitoring data into indicators of water and sanitation performance. Water and sanitation performance analysis provides policymakers with a new accountability instrument for assessing country progress on meeting full realization of human rights obligations. There are many simple data collection improvement opportunities that do not add substantial cost or burden which would make monitoring data more valuable for service delivery research. Improvement opportunities include the use of: relevant and appropriate survey questions, clear definitions, and quality assurance/quality control measures. Together, these studies demonstrate substantial, unrealized value that can be derived from monitoring. Monitoring improvements and analysis of these data are major opportunities to make better use of limited resources, inform evidence-based decision-making for better management, policy, programming, and practice, and improve water and sanitation service delivery. iv ACKNOWLEDGEMENTS I would like to thank Jamie Bartram for his advising support, inspiration, and creative energy throughout my masters and PhD work. My committee members, Clarissa Brocklehurst, Richard Johnston, Pete Kolsky, and Mark Sobsey deserve additional thanks for their critical insight and feedback on drafts of this work. Many thanks are due to my colleagues in the Department of Environmental Sciences and Engineering and the Water Institute at UNC – especially Kaida Liang, Mike Fisher, Kate Shields, and Jeanne Luh. I am grateful to my friends and family who have supported me throughout this process and I am particularly grateful for the support, patience, and encouragement from my wife Christina. This work was supported by grants from the Conrad N. Hilton Foundation, the World Health Organization, the Wallace Genetic Foundation, and by a training grant from the National Institute of Environmental Health Sciences (Grant Number: T32ES007018). v TABLE OF CONTENTS LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES ...................................................................................................................... xii LIST OF ABBREVIATIONS ...................................................................................................... xiv CHAPTER 1: INTRODUCTION ................................................................................................... 1 Dissertation research questions ................................................................................................... 4 CHAPTER 2: LITERATURE REVIEW ........................................................................................ 7 Methods ....................................................................................................................................... 7 Results and Discussion ................................................................................................................ 9 Implications for policy and practice .......................................................................................... 39 CHAPTER 3: FACTORS INFLUENCING WATER SYSTEM FUNCTIONALITY IN NIGERIA AND TANZANIA: A REGRESSION AND BAYESIAN NETWORK ANALYSIS ............................................................................... 43 Introduction ............................................................................................................................... 43 Methods ..................................................................................................................................... 45 Results ....................................................................................................................................... 50 Discussion ................................................................................................................................. 60 CHAPTER 4: IDENTIFYING OPPORTUNITIES TO IMPROVE PIPED WATER CONTINUITY IN HONDURAS, NICARAGUA, AND PANAMA USING BAYESIAN NETWORKS AND REGRESSION............................... 67 Introduction ............................................................................................................................... 67 Methods ..................................................................................................................................... 71 vi Results ....................................................................................................................................... 76 Discussion ................................................................................................................................. 83 Conclusions ............................................................................................................................... 90 CHAPTER 5: ENVIRONMENTAL CONDITIONS IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES: COVERAGE AND INEQUALITIES........................................................................................... 91 Introduction ............................................................................................................................... 91 Methods ..................................................................................................................................... 94 Results ..................................................................................................................................... 101 Discussion ............................................................................................................................... 113 Conclusion ............................................................................................................................... 123 CHAPTER 6: USING MONITORING DATA TO COMPARE COUNTRY PERFORMANCE IN REALIZING UNIVERSAL ACCESS TO DRINKING WATER AND SANITATION ........................................................ 125 Introduction ............................................................................................................................. 125 Methods ................................................................................................................................... 127 Results and Discussion ............................................................................................................ 133 Implications for policy and practice ........................................................................................ 150 CHAPTER 7: JOINT DISCUSSION ......................................................................................... 153 Deriving additional value from monitoring ............................................................................ 153 Opportunities to improve monitoring ...................................................................................... 156 Parting thoughts....................................................................................................................... 159 APPENDIX 1 FOR CHAPTER 3 ............................................................................................... 160 APPENDIX 2 FOR CHAPTER 4 ..............................................................................................