Despite sustained efforts over several decades, no region is projected to achieve universal sanitation access by 2030, according to international monitoring frameworks. Climate change is increasingly disrupting human and ecological systems, in turn deepening existing inequalities in access to essential services, including sanitation. Coupled with broader socio-economic and political dynamics, these pressures are expected to further widen the global sanitation service gap. Strengthening the resilience of sanitation systems to climate-related impacts represents a critical component of addressing this challenge. Building resilience requires an understanding of the attributes of sanitation systems and the adaptation actions across scales that contribute to their capacity to anticipate, withstand and recover from climate hazards. While existing scholarship has primarily examined the impacts of climate hazards on sanitation system performance, less attention has been given to resilience-building processes and practices. This systematic review is the first to synthesise the evidence on resilience in sanitation systems. It identifies twenty-seven (n=27) attributes and adaptation actions with potential to enhance resilience. However, with only seventeen (n=17) studies meeting the inclusion criteria and limited empirical evidence, substantial knowledge gaps remain. These findings underscore the urgent need for targeted research and the development of measurable indicators of climate resilience to inform international monitoring frameworks and guide effective adaptation strategies.

Half of the global population menstruate as part of their life cycle. This involves water, sanitation, and hygiene (WASH) needs that are often overlooked. Experience from the Millennium Development Goals shows that states focus on targets that are measured globally. Data and indicators on menstrual hygiene management (MHM) for women and girls can have a positive impact on raising awareness, national policy making, and in finding sustainable WASH sector solutions. With this paper, we explore the possible use of Joint Monitoring Programme for Water Supply and Sanitation estimates for representing women and girls' unique WASH experience, through a focus on MHM. We reviewed definitions of MHM alongside indicators monitored by the JMP and calculated estimates for 18 case-study low- and middle-income countries. Consultation with a broad range of experts identified open defecation and handwashing indicators as the best proxy indicators for inadequate MHM. Globally around half a billion women (13 per cent) defecate in the open and likely lack privacy for MHM. Data on handwashing suggest that a lack of cleansing materials is a particular challenge for MHM. In six of 10 study countries with data, over three-quarters of women lacked handwashing facilities with water and soap. Further research is needed to establish the validity of various aspects of these proxies and to gain greater understanding of the principal WASH-related challenges and barriers faced by women. Nevertheless, it seems clear that interventions among communities with highest open defecation rates and lowest handwashing levels are needed to address barriers to MHM.

Monitoring access to safely managed drinking water services requires information on water quality. An increasing number of countries have integrated water quality testing in household surveys however it is not anticipated that such tests will be included in all future surveys. Using water testing data from the 2016 Ethiopia Socio-Economic Survey (ESS) we developed predictive models to identify households using contaminated (≥1 E. coli per 100 mL) drinking water sources based on common machine learning classification algorithms. These models were then applied to the 2013–2014 and 2018–2019 waves of the ESS that did not include water testing. The highest performing model achieved good accuracy (88.5%; 95% CI 86.3%, 90.6%) and discrimination (AUC 0.91; 95% CI 0.89, 0.94). The use of demographic, socioeconomic, and geospatial variables provided comparable results to that of the full features model whereas a model based exclusively on water source type performed poorly. Drinking water quality at the point of collection can be predicted from demographic, socioeconomic, and geospatial variables that are often available in household surveys.

Background An alarming number of public health-care facilities in low-income and middle-income countries lack basic water, sanitation, hygiene (WASH), and waste management services. This study estimates the costs of achieving full coverage of basic WASH and waste services in existing public health facilities in the 46 UN designated least-developed countries (LDCs). Methods In this modelling study, in-need facilities were quantified by combining published counts of public facilities with estimated basic WASH and waste service coverage. Country-specific per-facility capital and recurrent costs to deliver basic services were collected via survey of country WASH experts and officials between Sept 24 and Dec 24, 2020. Baseline cost estimates were modelled and discounted by 5% per year. Key assumptions were adjusted to produce lower and upper estimates, including adjusting the discount rate to 8% and 3% per year, respectively. Findings An estimated US$6.5 billion to $9.6 billion from 2021 to 2030 is needed to achieve full coverage of basic WASH and waste services in public health facilities in LDCs. Capital costs are $2.9 billion to $4.8 billion and recurrent costs are $3.6 billion to $4.8 billion over this time period. A mean of $0.24-0.40 per capita in capital investment is needed each year, and annual operations and maintenance costs are expected to increase from $0.10 in 2021 to $0.39-0.60 in 2030. Waste management accounts for the greatest share of costs, requiring $3.7 billion (46.6% of the total) in the baseline estimates, followed by $1.8 billion (23.1%) for sanitation, $1.5 billion (19.5%) for water, and $845 million (10.7%) for hygiene. Needs are greatest for non-hospital facilities ($7.4 billion [94%] of $7.9 billion) and for facilities in rural areas ($5.3 billion [68%]). Interpretation Investment will need to increase to reach full coverage of basic WASH and waste services in public health facilities. Financial needs are modest compared with current overall health and WASH spending, and better service coverage will yield substantial health benefits. To sustain services and prevent degradation and early replacement, countries will need to routinely budget for operations and maintenance of WASH and waste management assets. Copyright (C) 2022 World Health Organization; licensee Elsevier.

Sustainable Development Goal target 6.2 calls for universal access to adequate and equitable sanitation, setting a more ambitious standard for ‘safely managed sanitation services’. On-site sanitation systems (e.g., septic tanks) are widely used in low- and middle-income countries (LMICs). However, the lack of indicators for assessing fecal exposure risks presents a barrier to monitoring safely managed services. Furthermore, geographic diversity and frequency of disasters require a more nuanced approach to risk-informed decision-making. Taking Indonesia as an example, the purpose of this paper is to provide insights into current status and practices for on-site sanitation services in the contexts of LMICs. Using a dataset from a national socio-economic survey (n = 295,155) coupled with village census (n = 83,931), we assessed (1) household sanitation practices across Indonesia stratified by city-level population density and meteorological factors, (2) factors associated with septic tank emptying practice, and (3) inequalities in potential fecal exposure as measured by population density and WASH access by wealth quintile. We found a high reliance on on-site sanitation facilities (80.0%), almost half of which are assumed to be ‘uncontained’ septic tanks and one in ten facilities discharging untreated waste directly into the environment. The most densely populated areas had the highest rates of septic tank emptying, though emptying rates were just 17.0%, while in the lowest population density group, emptying was rarely reported. Multivariate regression analysis demonstrated an association between flooding and drought occurrence and septic tank emptying practice. Higher groundwater usage for drinking among poorer households suggests unsafe sanitation may disproportionally affect the poor. Our study underscores the urgent need to strengthen the monitoring of on-site sanitation in LMICs by developing contextualized standards. Furthermore, the inequalities in potential fecal exposure require greater attention and tailored support mechanisms to ensure the poorest gain access to safely managed sanitation services.

Background: An alarming number of health care facilities in low- and middle-income countries lack basic water, sanitation, hygiene, and waste management (WASH services). This study estimates the costs of achieving universal coverage of basic WASH services in health facilities in the 46 least developed countries (LDCs).Methods: In-need facilities were quantified by combining published facility counts with estimated WASH service coverage. Country-specific per-facility capital and recurrent costs to deliver basic service standards were collected via survey. Baseline estimates were modelled alongside lower and upper estimates for which key assumptions were adjusted.Findings: An estimated US$6·5–9·6 billion over 10 years is needed to achieve universal coverage of basic WASH services in LDCs' health facilities. Capital and recurrent costs are 44–50% and 50–56% of the total, respectively. On average, US$0·24–40 per capita in capital investment is needed each year, while annual maintenance and operation costs are expected to increase from US$0·10 in 2021 to US$0·39–0·60 in 2030. Waste management accounts for the greatest share of costs (43–49%), followed by sanitation (21–28%), water (20%), and hygiene (10–11%). Needs are greatest for non-hospital facilities (94%) and in rural areas (68%).Interpretation: Investment will need to be scaled up to reach universal coverage of basic WASH services in health facilities. Financial needs are modest compared to overall health and WASH spending and will yield numerous health benefits. To sustain services, countries will need to routinely budget for operations and maintenance.Funding Information: World Health Organization (including underlying grants from the governments of Japan, Netherlands, and UK), World Bank, and UNICEF.Declaration of Interests: MC reports personal fees from the World Health Organization during the conduct of the study and from Results for Development, ThinkWell, and the World Bank outside the submitted work. SM reports personal fees from the World Health Organization during the conduct of the study and from Vysnova Partners outside the submitted work. RJ reports grants from Agence française de développement, Bill and Melinda Gates Foundation, Government of the Netherlands Ministry of Foreign Affairs, UN-Water Inter-Agency Trust Fund, United Kingdom Foreign, Commonwealth & Development Office, and Swiss Agency for Development and Cooperation, both during the conduct of the study and outside the submitted work. IA, JA-ST, SG, OH, TS, CC, GH, and MM have nothing to disclose.

Background: The 2030 Sustainable Development Goals (SDGs) set an ambitious new benchmark for safely managed drinking water services (SMDWs), but many countries lack national data on the availability and quality of drinking water. Objectives: We quantified the availability and microbiological quality of drinking water, monitored SMDWs, and examined risk factors for Escherichia coli (E. coli) contamination in 27 low-and middle-income countries (LMICs). Methods: A new water quality module for household surveys was implemented in 27 Multiple Indicator Cluster Surveys. Teams used portable equipment to measure E. coli at the point of collection (PoC, n=61,170) and at the point of use (PoU, n=64,900) and asked respondents about the availability and accessibility of drinking water. Households were classified as having SMDW services if they used an improved water source that was free of E. coli contamination at PoC, accessible on premises, and available when needed. Compliance with individual SMDW criteria was also assessed. Modified Poisson regression was used to explore household and community risk factors for E. coli contamination. Results: E. coli was commonly detected at the PoC (range 16–90%) and was more likely at the PoU (range 19–99%). On average, 84% of households used an improved drinking water source, and 31% met all of the SMDW criteria. E. coli contamination was the primary reason SMDW criteria were not met (15 of 27 countries). The prevalence of E. coli in PoC samples was lower among households using improved water sources [risk ratio (RR)=0.74; 95% confidence interval (CI): 0.64, 0.85] but not for households with water accessible on premises (RR=0.99; 95% CI: 0.94, 1.05) or available when needed (RR=0.95; 95% CI: 0.88, 1.02). E. coli contamination of PoU samples was less common for households in the richest vs. poorest wealth quintile (RR=0.70; 95% CI: 0.55, 0.88) and in communities with high (>75%) improved sanitation coverage (RR=0.94; 95% CI: 0.90, 0.97). Livestock ownership (RR=1.08; 95% CI: 1.04, 1.13), rural vs. urban residence (RR=1.10; 95% CI: 1.04, 1.16), and wet vs. dry season sampling (RR=1.07; 95% CI: 1.01, 1.15) were positively associated with contamination at the PoU. Discussion: Cross-sectional water quality data can be collected in household surveys and can be used to assess inequalities in service levels, to track the SDG indicator of SMDWs, and to examine risk factors for contamination. There is an urgent need for better risk management to reduce widespread exposure to fecal contamination through drinking water services in LMICs. https://doi.org/10.1289/EHP8459

Introduction Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. Methods Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021–2030, and estimated total cost probabilistically using Monte Carlo simulation. Results An estimated US$12.2–US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for ‘top-up’ promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%). Conclusion The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Background The Sustainable Development Goals set an ambitious new benchmark for safely managed drinking water services (SMDW), but many countries lack data on the availability and quality of drinking water. Objectives To quantify the availability and microbiological quality of drinking water, monitor SMDW and examine risk factors for E. coli contamination in 20 low-and middle-income countries. Methods A new water quality module for household surveys was implemented in Multiple Indicator Cluster Surveys. Teams used portable equipment to measure E. coli at the point of collection (PoC, n=48,323) and at the point of use (PoU, n=51,345) and asked respondents about the availability and location of drinking water services. E. coli levels were classified into risk categories and SMDW was calculated at the household- and domain-levels. Modified Poisson regression was used to explore risk factors for contamination. Results E. coli was commonly detected at PoC (range 16-90%) and was more likely at PoU (range 20-97%). Coverage of SMDW was 56% points lower than improved drinking water with water quality the limiting factor for SMDW in 14 countries. Detection of E. coli at PoC was associated with use of improved water sources (RR=0.64 [0.52-0.78]) located on premises (RR=0.78 [0.67-0.91]) but not with availability (RR=0.94 [0.82-1.06]). Households in the richest quintile (RR=0.67 [0.50-0.90]) and in communities with high (>75%) improved sanitation coverage (RR=0.95 [0.91-0.98]) were less likely to use contaminated water at PoU whereas animal ownership (RR=1.08 [1.03-1.14]) and rural residence (RR=1.11 [1.03-1.19]) increased risk of contamination. Discussion Water quality data can be reliably collected in household surveys and can be used to assess inequalities in service levels, to track the SDG indicator of SMDW, and to examine risk factors for contamination. There is an urgent need to implement scalable and sustainable interventions to reduce exposure to faecal contamination through drinking water. ### Competing Interest Statement RB TS RJ work for the WHO/UNICEF Joint Monitoring Programme. AH and SK work for the UNICEF Multiple Indicator Cluster Survey Programme. Authors' opinions do not reflect position of WHO or UNICEF. ### Funding Statement Funding for the integration of water testing in household surveys was provided by the Netherlands Directorate-General of International Cooperation (DGIS), the UK Department for International Development (DFID) and the United States Agency for International Development (USAID). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Office of Research Compliance & Outreach, Baruch College determined that this study was exempt from IRB/HRPP review. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data are available from the UNICEF Multiple Indicator Cluster Survey website. <http://mics.unicef.org/surveys>

Safely managed drinking water services (SMDWS) is the service ladder used for the Sustainable Development Goal (SDG) monitoring of drinking water and expands on the Millennium Development Goal metric ("improved water source") with three additional criteria, namely: availability when needed, accessibility on premises, and safety (free from faecal and priority chemical contamination). Multiple Indicator Cluster Surveys (MICS) have been used for progress monitoring accounting for a significant fraction of the water, sanitation, and hygiene (WASH) indicator data. In its most recent iteration MICS now includes additional SMDWS indicators. The objective of this study was to report on recent SDG target 6.1 baseline data on SMDWS from the Democratic People's Republic of Korea gathered from a MICS conducted in 2017. Survey results indicated that 93.7% of the population used an improved drinking water source, but when this was combined with the SDG criteria of water availability, accessibility, and safety, coverage was reduced to 92.3, 78.2, and 74.4%, respectively. This resulted in estimates that 60.9% of the population used a SMDWS. The survey results illustrate how the improved SDG indicators can highlight the required gaps to be overcome with regard to universal and equitable access to SMDWS. Further analysis and discussion regarding water quality deterioration between source and household as well as population residence, wealth group index, geographical distribution, and other characteristics relative to SMDWS indicators are also further analysed and discussed.

Background Limited data have been available on the global practice of handwashing with soap (HWWS). To better appreciate global HWWS frequency, which plays a role in disease transmission, our objectives were to: (i) quantify the presence of designated handwashing facilities; (ii) assess the association between handwashing facility presence and observed HWWS; and (iii) derive country, regional and global HWWS estimates after potential faecal contact. Methods First, using data from national surveys, we applied multilevel linear modelling to estimate national handwashing facility presence. Second, using multilevel Poisson modelling on datasets including both handwashing facility presence and observed HWWS after potential faecal contact, we estimated HWWS prevalence conditional on handwashing facility presence by region. For high-income countries, we used meta-analysis to pool handwashing prevalence of studies identified through a systematic review. Third, from the modelled handwashing facility presence and estimated HWWS prevalence conditional on the presence of a handwashing facility, we estimated handwashing practice at country, regional and global levels. Results First, approximately one in four persons did not have a designated handwashing facility in 2015, based on 115 data points for 77 countries. Second the prevalence ratio between HWWS when a designated facility was present compared with when it was absent was 1.99 (1.66, 2.39) P <0.001 for low- and middle-income countries, based on nine datasets. Third, we estimate that in 2015, 26.2% (23.1%, 29.6%) of potential faecal contacts were followed by HWWS. Conclusions Many people lack a designated handwashing facility, but even among those with access, HWWS is poorly practised. People with access to designated handwashing facilities are about twice as likely to wash their hands with soap after potential faecal contact as people who lack a facility. Estimates are based on limited data.

The World Health Organization (WHO) and United Nations Children's Fund (UNICEF), through the Joint Monitoring Programme (JMP), are responsible for global monitoring of the Sustainable Development Goal (SDG) targets for drinking water, sanitation and hygiene (WASH). The SDGs represent a fundamental shift in household WASH monitoring with a new focus on service levels and the incorporation of hygiene. This article reflects on the process of establishing SDG baselines and the methods used to generate national, regional and global estimates for the new household WASH indicators. The JMP 2017 update drew on over 3000 national data sources, primarily household surveys (n = 1443), censuses (n = 309) and administrative data (n = 1494). Whereas most countries could generate estimates for basic drinking water and basic sanitation, fewer countries could report on basic handwashing facilities, water quality and the disposal of waste from onsite sanitation. Based on data for 96 and 84 countries, respectively, the JMP estimates that globally 2.1 billion (29%) people lacked safely managed drinking water services and 4.5 billion (61%) lacked safely managed sanitation services in 2015. The expanded JMP inequalities database also finds substantial disparities by wealth and sub-national regions. The SDG baselines for household WASH reveal the scale of the challenge associated with achieving universal safely managed services and the substantial acceleration needed in many countries to achieve even basic services for everyone by 2030. Many countries have begun to localise the global SDG targets and are investing in data collection to address the SDG data gaps, whether through the integration of new elements in household surveys or strengthening collection and reporting of information through administrative and regulatory systems.

Reviews the current indicators proposed by the World Health Organization/United Nations Children's Fund (WHO/UNICEF) Joint Monitoring Programme (JMP) for Water and Sanitation, offering a summary of limitations during the Millennium Development Goal (MDG) period, which can inform improved Sustainable Development Goal (SDG) monitoring and address MDG limitations while balancing the likely availability of robust data sources. During the MDG period, international monitoring of water, sanitation and hygiene (WASH) services in developing countries relied on household surveys identifying access to "improved" and "unimproved" services. However, these indicators fell short of the health-based conditions the MDG water and sanitation targets sought to encourage. Overly simplistic metrics used to monitor progress on important health and development goals and inadequate assessments of environmental health interventions can prove misleading and undermine the proper allocation of resources for advancing intended goals. The SDG period offers an opportunity to learn from these limitations to better align indicators and measures with intended outcomes.

The Sustainable Development Goals (SDGs) include ambitious targets for universal access to drinking water, sanitation and hygiene by 2030. These targets apply to all countries and not only aim to end open defecation and extend access to basic services for all, but also to progressively improve service levels over time. This reflects a growing concern within the WASH sector with the equity, safety and sustainability of services provided. This chapter outlines the evidence base and recommendations from international consultations on post-2015 monitoring and discusses the conceptual and practical challenges associated with monitoring inequalities in service levels based on the normative criteria of the Human Rights to Water and Sanitation. It describes WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) proposals for enhanced WASH monitoring using water, sanitation and hygiene 'ladders' which build on MDG indicators and establish new international benchmarks for the SDG period. A key principle guiding emerging proposal for SDG WASH monitoring has been the concept of progressive achievement of universal access while reducing and eliminating inequalities in service levels.

Under the Millennium Development Goals (MDGs), significant progress was made with 2.6 billion people gaining access to an improved drinking water source and 2.1 billion gaining access to improved sanitation facilities between 1990 and 2015. However, improvements in monitoring over the same period have highlighted disparities in rates of progress between regions and countries, and among population groups. This chapter describes the progress made in tracking inequalities in both access and service levels. It characterises the main types of inequality identified during the MDG era and the challenges associated with the collection and analysis of related data. The chapter includes data and analysis drawn from the WHO/UNICEF Joint Monitoring Programme and other relevant sources. It shows that while our understanding of water, sanitation and hygiene (WASH) inequalities has greatly improved, much remains to be done to track their progressive elimination under the Sustainable Development Goals (SDGs). Future efforts to enhance national and subnational capacity for monitoring and reporting on inequalities in WASH will need to focus on further harmonising indicators and measurement techniques, especially for the new SDG indicators, to better integrate data on WASH and other dimensions of inequality, and to present data in a format that is easier for policy makers and practitioners to understand and use.

The inclusion of water, sanitation and hygiene (WASH) in non-household settings in the Sustainable Development Goals (SDGs) elicits the need for data to track progress over time. This review focuses on schools and health care facilities, and seeks to: (1) assess the availability of SDG baseline data for ten case study countries; (2) evaluate the extent to which existing national data allow monitoring against the SDG criteria; and (3) identify opportunities to improve the availability and quality of data for SDG monitoring. While none of the ten countries could provide all of the data needed to establish comprehensive SDG baselines, every country had information on at least some of the indicators. Education Management Information Systems (EMIS) currently provide the majority of national data on WASH in schools and, in many cases, could be aligned with the SDG criteria with only minor changes. Far fewer data are available for health care facilities. Health Management Information Systems (HMIS) provide a potential entry point for national monitoring. However, where HMIS are administered monthly, annual data collection instruments, such as facility inventory surveys, may be more appropriate. These findings have implications for monitoring WASH in other settings, such as workplaces and prisons.

Target 6.2 of the Sustainable Development Goals calls for universal access to sanitation by 2030. The associated indicator is the population using ‘safely managed’ sanitation services. Shared sanitation is classified as a ‘limited’ sanitation service and some donors and governments are reluctant to invest in it, as it will not count towards achieving Target 6.2. This could result in poor citizens in dense slums being left out of any sanitation improvements, while efforts are diverted towards better-off areas where achieving ‘safely managed’ sanitation is easier. There are sound reasons for labelling shared sanitation as ‘limited’ service, the most important being that it is extremely difficult – for global monitoring purposes – to differentiate between shared toilets that are hygienic, accessible and safe, and the more common ones which are poorly designed and managed. There is no reason to stop investing in shared sanitation. ‘Safely managed’ represents a standard countries should aspire to. However, the 2030 Agenda and the human rights recognise the need for intermediate steps and for reducing inequalities. This calls for prioritising investments in high-quality shared toilets in dense informal settlements where it is the only viable option (short of rehousing) for improving sanitation services.

Background The Sustainable Development Goals (SDGs) require household survey programmes such as the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) to enhance data collection to cover new indicators. This study aims to evaluated methods for assessing water quality, water availability, emptying of sanitation facilities, menstrual hygiene management and the acceptability of water quality testing in households which are key to monitoring SDG targets 6.1 and 6.2 on drinking Water, Sanitation and Hygiene (WASH) and emerging issues. Methods As part of a MICS field test, we interviewed 429 households and 267 women age 15-49 in Stann Creek, Belize in a split-sample experiment. In a concurrent qualitative component, we conducted focus groups with interviewers and cognitive interviews with respondents during and immediately following questionnaire administration in the field to explore their question comprehension and response processes. Findings About 88% of respondents agreed to water quality testing but also desired test results, given the potential implications for their own health. Escherichia coli was present in 36% of drinking water collected at the source, and in 47% of samples consumed in the household. Both questions on water availability necessitated probing by interviewers. About one quarter of households reported emptying of pit latrines and septic tanks, though one-quarter could not provide an answer to the question. Asking questions on menstrual hygiene was acceptable to respondents, but required some clarification and probing. Conclusions In the context of Belize, this study confirmed the feasibility of collecting information on the availability and quality of drinking water, emptying of sanitation facilities and menstrual hygiene in a multi-purpose household survey, indicating specific areas to improve question formulation and field protocols. Improvements have been incorporated into the latest round of MICS surveys which will be a major source of national data for monitoring of SDG targets for drinking water, sanitation and hygiene and emerging issues for WASH sector programming.