Water and sanitation comprise an increasingly important focus for global health and development philanthropy, but the approach has often been piecemeal, resulting in broken pipes and pumps, disillusioned donors, and suffering beneficiaries.

Most funders prioritize the number of people served, and support short-term, infrastructure-oriented interventions around water, sanitation and hygiene (WASH). It’s well-intentioned. But too often, there’s no plan to keep things running once the funders move on—leaving communities, schools and healthcare facilities without safe water and sanitation systems. Gender equality, nutrition and food security, economic development, and of course, health, all suffer.

Perhaps there is no better case in point for the limits of current WASH approaches than the fact that across low- and middle- income countries, a shocking 50 percent of healthcare facilities lack piped water, 33 percent lack basic toilets, and 39 percent lack soap. [See landmark reports in 2018 and 2019.] Doctors, nurses and midwives do not have handwashing available at points of care in 43 percent of hospitals and clinics, putting 2 billion people, and especially newborns, at risk of contamination from human and medical waste.

Key philanthropy leaders are now calling for a better, more systemic approach to improving access to water and sanitation. They’re aiming to bring people, institutions and resources out of their silos to build integrated and resilient WASH systems that include training, monitoring and ongoing maintenance, financing and incentives to keep things running.

Among those funders looking beyond the broken pumps and rusty pipes are Peter Laugharn, president and CEO of the Conrad N. Hilton Foundation, a leading investor in WASH, and Louis Boorstin, managing director of the Osprey Foundation, which co-founded the WASH Agenda for Change to gather and share knowledge to support systems approaches to global WASH. Louis previously launched and led the WASH program at the Bill & Melinda Gates Foundation.

Laugharn and Boorstin recently sat down for interviews at the All Systems Go Symposium in The Hague, Netherlands. Organized by IRC WASH, this symposium brings together funders, practitioners, theoreticians and governments focused on building and strengthening WASH systems to deliver services that will alleviate suffering and increase opportunity for years to come. This post combines their respective interviews.

Q. What brought you to WASH systems funding?

Boorstin: There is a long history in this sector of very well-intentioned funding ending up in not-so-good outcomes. If you don’t focus on sustainability from the start, you’re likely to end up with something that works for a few months or years, then stops working. If you support a one-off project—put in a borehole or give away a bunch of toilets—then the likelihood that it’s going to keep running forever is very low. If you want people to get sustainable services, the only way to do that is to make sure that the systems where they live—the operations, maintenance, funding, regulations and governance—are all functioning effectively. I don’t know any other way to get it done.

Laugharn: Yesterday, we heard the Minister of Water and Sanitation Resources for Ghana [Hon. Cecilia Dapaah] saying that it is medieval to think of girls carrying water on their heads for kilometres, or even a 30-minute round trip. And I think she is right, we have to up our game, we have to be more ambitious, and really, what we are looking at now is what is necessary to support the ultimate goal of piped water on premises, and that is a more complex system than just putting a well into the earth.

Boorstin: It’s easier to pay just for hardware and then hope that it will last for a long time. But I’d rather support an approach that has a much higher likelihood of success in the long run, even if upfront that’s going to cost some more and is harder to organize.

Q: When was that “aha!” moment when you needed to switch toward supporting the underlying structures?

Boorstin: When I started the WASH program at the Bill & Melinda Gates Foundation in 2005, I spent a lot of time listening to a range of stakeholders in the sector—households, community leaders, local and international NGOs, government officials, development agencies, academics and others. It didn’t take me long to realize that delivering sustainable services was one of the keys to making a real impact in WASH. When I joined the Osprey Foundation a decade later, Osprey’s president and benefactor, Bill Clarke, already had sufficient experience on the ground to realize that sustainability is what matters and that strengthening systems is the only way to address that fundamental challenge.

Laugharn: The easiest form of intervention in water of course, is digging wells and putting in boreholes. I think our (early) idea in digging wells was that we were bringing something that was immediately valuable, that had a lifesaving and life-changing value for people, and you could see that right away. What we were not thinking about was that wells break down—boreholes, especially—and that the rate of maintenance of those wells was well below what we would have wanted. It was such a task putting in all those wells knowing that many of them would not be giving water in the way that they are supposed to, and not meeting the challenges of the new millennium. Over time, we came to see that it is very important to have a wider program.

We had that realization in the 2000s, the decade of the MDGs (U.N. Millennium Development Goals). I think it was around 2011 that we introduced the New Water strategy that is much more about systems, and I think we are still getting our heads wrapped around it. After all, our board was used to the comfort of knowing how many tens of thousands of wells we had put in, and we are still developing the vocabulary of making the systems feel as tangible as that. I think our board, our stakeholders, know it is important, but they also want to feel on top of the progress made.

Q. How important is it to get a common language and spread it to other actors in the sector?

Laugharn: If we want to attract other funding, it’s got to be something that people can understand—that money invested here will have a multiple benefit on the other end. I think it is important to be able to connect a systems-strengthening agenda with people actually benefiting. Our mission is about improving lives of the disadvantaged and reducing human suffering, it not about strengthening systems, so we need a clear language that says if we do this, then many people will have their lives improved. We are not satisfied simply that there is a stronger system; it has to benefit those especially in the bottom quintile.

Boorstin: One of the important things is to develop a vocabulary around this because the elevator pitch or tweet about getting someone a toilet or a tap is much easier than the elevator pitch or tweet about sustainable services and about systems. At the most basic level, I use the analogy of teaching someone to fish instead of giving them a fish, but we need to get better about communicating what we mean by systems change.

Q. Why is the sector hung up so much on taps and toilet-type funding rather than supporting systems—on doing the short term at the expense of the long term?

Laugharn: Endorphins! It is thrilling to be able to change the life opportunity of a girl or boy or a community; that is why we got into this work, that is our incentive as private voluntary organizations. If you are raising money from the public, that is what they want to see. And not 20 years down the line—but my 20 dollars, 100 dollars, 50 thousand dollars has really bought something that is of value to someone now. I think that is part of it. And frankly, often it is easier to work with communities than it is to work with ministries—less complex, less contentious, easier to solve for immediate progress.

Boorstin: If you are lucky enough to live in a place with a flush toilet, that’s all you see of the system. What you’re not seeing is everything else needed to keep that toilet running—from the financial to the organizational to the regulatory structures. Typically, when funders get into the WASH sector, they want to pay for hardware. But after a while if you go visit some communities and see all the things that have stopped working, you’ll realize that’s not enough to get the job done.

Q. Why do you feel it important to put resources into the longer term compared to others who focus on the short term, towards strengthening WASH systems?

Boorstin: In most cases, the further away you get from the households in need of better WASH services, the harder it is to raise funding. This explains why, at least for now, Osprey is the largest direct funder of the WASH Agenda for Change, a collaboration among leading WASH sector implementers, advisors and funders dedicated to supporting systems change.

We decided to fund the Agenda for Change secretariat directly because the evidence from other sectors shows that you need a ‘backbone’ organization to support and coordinate this type of collective action approach.

From one perspective, you can look at this as being far from the households getting better services. From another angle, you can see this as very high-leverage funding, because everything that we put into the secretariat is being multiplied many times by the budgets of the member organizations, as well as household payments and government contributions. In that sense, Osprey sees it as a very good investment.

Laugharn: It seems to be the logical way to approach the Sustainable Development Goals (SDGs). Counting backward from 2030, if we are seriously posing these as goals and lofty aspirations, how can the modest resources that we and all the development actors have, how can they launch a process to get there? Typically, development actors do not do that. They think in annual tranches.

Starting with the end in mind, we know that just for (SDG) Target 6.1 about safe drinking water, we have hundreds of millions of people that need access to that water—if you say that it has to be water of quality, then a much higher number. We have got thousands of authorities and service providers that need to be strengthened and supported. We have got dozens of countries that have good to very good policies that need to be executed and implemented in clear and dynamic and well-financed ways. That is a big challenge! No one organization is going to make it happen, so we want our money used in a way that has the highest leverage, that is bringing everyone together, and helping the symphony and not just individuals playing their own instruments.

Q. How can philanthropic organizations work smarter to crowd in new resources?

Boorstin: Osprey takes an unusual approach for a small foundation. Typically, small foundations will focus on getting people taps and toilets. But we want to support systems change, and organizations taking that type of approach, like IRC or Water for People or WaterAid or Splash, often get funding for service delivery from the big players—government, official aid agencies, larger foundations. What those implementers rarely have are flexible funding sources that allow them to try new things and learn. So Osprey doesn’t provide nearly the amount that the larger funders provide, but we do provide the flexible funding for innovation and reflection that helps our grantees get better at what they do.

I would like to see the WASH sector reach the point in the next few years where implementers find it hard to get funding if they are not taking a systems-strengthening approach. I would like to see that expectation spread from a relatively small number of funders now to everyone providing resources, including the large bilateral and multilateral agencies. It can be difficult for these agencies to support a systems approach because of political pressures to focus on outcomes, which typically means the number of people being served. But it’s not just the numbers being served, it’s whether those people are being sustainably served, and we’re starting to see the big funders figure out metrics to capture that.

Laugharn: Classically, we are first-stage investors who can put money on the line that others won’t be willing to put. For philanthropy, we lose money on every grant, and we do it with joy. What we need to do is to make sure we don’t squander that place in the ecosystem—that we really are making our grants with an idea toward a value chain of investors that is more rigorous but more sustainable. I think notably in the WASH sector, since it is so infrastructural, that we need to bring in the very largest investors very quickly. There, I would point to multilateral development banks and some bi-laterals as key colleagues.

One of my favorite questions is, what resources exist in the system that the system doesn’t realize? What are communities able to do? What are they not called upon to do now? What are local government officials capable of? What is the system not asking them to do now? I think that’s the way that we are going to make progress.

Q. What’s the future of foundation funding in this space?

Laugharn: You would think that this would satisfy a number of donor criteria: the tangibility of it, the fact that you can make both grants and loans because it’s an infrastructure area, and all the law that goes along with water, and symbolic attachments to it. But in practice, there are only half a dozen philanthropic funders putting in significant amounts, and not the largest funders, or the ones that are involved in the SDGs, with the exception of the Gates work on sanitation.

Our mission as a foundation is to alleviate human suffering and improve the lives of the vulnerable and the disadvantaged. There are few things that are going to incapacitate or block a person more than access to drinking water. It is something in industrialized countries that we take for granted. But something in a lot of countries that is expensive or unsafe or very inconvenient to find. For Hilton, it is a basic need.

Boorstin: Well, in the long run we want to be out of this business—that’s the whole point of sustainable services!—meaning that eventually, a combination of household payments, and where necessary, government subsidies are covering the full systems costs of safe, sustainable WASH services for everyone.

For the foreseeable future, however, we’d like to see more foundations and other funders taking the long view and considering all elements of the system, not just the hardware. We are part of an informal consortium of five or six WASH funders [including Hilton] that has met once or twice a year for the last four years to discuss how we can get better at this, and which approaches merit our support. There’s now interest from other funders in joining that group, which is a very good sign.

Laugharn: I look at it certainly as part of my role to invite others in. We have been in the area of WASH and particularly drinking water for over 30 years now. Right now, every five years or so, we are spending 50 million dollars, and in the future, that money may increase. It is a drop in the bucket for what is necessary, but we are trying to use it in a way that brings in other funding.

Q. There are still funders staying close to the end user. What is your call to action to the philanthropic community?

Boorstin: Broadly speaking, funders should take a step back and consider what’s needed to deliver sustainable services for everyone, and whether the organizations they are supporting are contributing to that goal. There isn’t just one path to get there; Osprey supports systems builders as well as innovators developing new ways to deliver WASH services. We fund organizations that work closely with government and those taking a market-based approach. But all of them understand the system they’re working in and how they’re contributing to make it better.

For funders supporting service delivery, one particular challenge is what I call the ‘attribution versus contribution’ problem. Funders have traditionally sought to attribute specific outcomes (e.g., number of people served) to their own actions. However, an effective system has multiple elements that work together to deliver sustainable services. So funders have to accept that they will contribute to the outcome instead of being able to attribute an outcome solely to their investment. If funders get better at that, then we will be more of the solution and less of the problem.

Another change I’d like to see among funders is to improve our metrics. Instead of counting the number of households with first-time access to water or a latrine, let’s actually measure how many people have sustained water and sanitation services over the long run, say 15 years. By aligning our indicators of success with what it takes to deliver sustained services, funders—both small and large, both private and official—will catalyze changes in the decision-making of implementers and governments, changes that will reduce the chance we keep coming across old boreholes and latrines that are no longer functioning.

Laugharn: You can work at a systems level in a system that is still evolving—that is not rigid in the way that health and education may be—that you can help form and you can help it actually do a moonshot! The idea of piped water in premises in Africa is thrilling, and within our grasp.

This is a tremendous sector to invest in. You can see progress immediately, but you can also have a very impressive accomplishment arc in front of you over a 10-year span. The more funders we have, the more likely we are to have momentum, and I think for funders who are interested in leverage, I think there are tremendous possibilities.

Interviews conducted by Andy Narracott of Finding Impact. Introduction and editing by Susan K. Barnett, Global Water 2020. Special acknowledgement to Marc Jaffrey, Vera van der Grift and Petra Brussee at IRCWASH for their support in making these interviews happen.

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Special Authors’ Note: On June 19, 2019, a pledge of $100 million will be just one of more than 60 commitments in funding, technical assistance, research and advocacy that will be announced at a historic convening with one shared purpose: to ensure that no person, wherever they live, receives treatment at a hospital or health clinic without water, soap and toilets. The lack of WASH services in healthcare facilities worldwide is a serious and solvable global health crisis. Among the philanthropies, non-governmental organizations (secular + faith-based), financial institutions, corporations, associations and universities revealing commitments will be an NGO with a new $100 million initiative spanning 35 countries with funding from multiple foundations, family philanthropies and corporate funding. More information and invitation at: Historic Commitments to Global Healthcare.