Clean Air, Safe Water and Sanitation: A Plan, and Its Test in 2026

Introduction

Polluted air, unsafe water and the lack of a safe toilet together kill more people each year than any war now being fought. The Health Effects Institute’s State of Global Air 2025 report attributes 7.9 million deaths in 2023, about one death in eight worldwide, to air pollution. Of these, 4.9 million came from outdoor fine particulate matter (PM2.5), 2.8 million from smoke from cooking and heating with solid fuels at home, and 470,000 from ozone (State of Global Air 2025 report). The World Health Organization estimates that safe drinking water, sanitation and hygiene could have prevented at least 1.4 million deaths in 2019, and it treats that figure as a floor because it counts only four health outcomes (WHO).

These problems belong among the species-level problems because billions of people are exposed every day and the remedies are known, affordable and fast. Treating household drinking water cut the odds of child death by about a quarter in randomized trials, India reduced the number of people defecating in the open by 676 million between 2000 and 2024, and average PM2.5 in 74 Chinese cities fell 42 percent in the five years after a national action plan was adopted in 2013. The burden falls hardest on poor households, on women and girls, who do most of the cooking and water collection, and on small children. Air pollution shares its sources with climate change, cholera follows war and displacement, and the price of cooking gas ties millions of kitchens to the oil market.

This essay sets out a plan in eight elements and tests each against the world as of September 2026, a year shaped by deep cuts in foreign aid, a closure of the Strait of Hormuz that disrupted the world’s supply of liquefied petroleum gas (LPG), and an attempt by the United States government to loosen its own air and drinking-water standards.

Where things stand

Measure	Figure	Source
Deaths attributed to air pollution, 2023	7.9 million, of which 4.9 million from outdoor PM2.5	State of Global Air 2025
Deaths from household air pollution, 2021	2.9 million, including over 309,000 children under five	WHO
People without clean cooking	about 2 billion	Tracking SDG7 2026
People without safely managed drinking water, 2024	2.1 billion (1 in 4), of whom 106 million drink untreated surface water	JMP 2025
People without safely managed sanitation, 2024	3.4 billion, of whom 354 million defecate in the open	JMP 2025
People without basic hygiene services at home, 2024	1.7 billion	JMP 2025
Deaths preventable by safe water, sanitation and hygiene, 2019	1.4 million, including 395,000 children under five	WHO
Reported cholera cases and deaths, 2025	614,828 cases and 7,598 deaths in 33 countries	WHO

State of Global Air finds that 36 percent of the world’s population, 2.8 billion people, lives where annual PM2.5 exceeds even the least demanding WHO interim target of 35 micrograms per cubic metre, and that fewer than 1 percent live where the WHO guideline of 5 micrograms is met. The age-standardized death rate from air pollution fell 21 percent between 2013 and 2023, mainly because of less household smoke, while death rates from outdoor PM2.5 and ozone rose (State of Global Air 2025 report). Heart disease, stroke, lung disease and other noncommunicable diseases accounted for 86 percent of air pollution deaths, including about 625,000 from dementia (State of Global Air). The WHO’s own outdoor estimate, 4.2 million deaths in 2019, is older and lower (WHO). Only 14 percent of the 9,446 cities in IQAir’s 2025 monitoring data met the WHO annual PM2.5 guideline, down from 17 percent a year earlier (IQAir).

Water and sanitation are improving, though too slowly to meet the 2030 targets. Between 2015 and 2024, 961 million people gained safely managed drinking water, lifting coverage from 68 to 74 percent, and 1.2 billion gained safely managed sanitation, lifting coverage from 48 to 58 percent. The number of people defecating in the open fell by 429 million over the same period. The JMP calculates that progress on safely managed sanitation would have to run six times faster to reach the 2030 target, and that no region is on track for it (JMP 2025). In fragile countries, coverage of safely managed drinking water is 38 percentage points lower than elsewhere, and in sub-Saharan Africa and Central and Southern Asia many women and girls spend more than 30 minutes a day collecting water (WHO); the effect on girls’ schooling is covered in the plan for women and girls.

On cooking, the Tracking SDG7 report published on 8 July 2026 counts around 2 billion people still without clean cooking. The WHO counts 2.1 billion people cooking over open fires or on inefficient stoves burning biomass, kerosene or coal (WHO). Africa’s gap has grown 26 percent since 2010, while India cut its gap by about 260 million people between 2018 and 2024, raising access from 61 to 81 percent (SEforALL).

Part I: The plan

1. Make the water people already drink safe

The cheapest and fastest step is to treat water where people collect or store it. Health ministries, utilities and nonprofits can run chlorine dispensers at wells and springs, inline chlorinators on small piped systems and free chlorine distribution through clinics. A meta-analysis of 18 randomized trials by Michael Kremer, Stephen Luby and colleagues found that water treatment reduced the odds of death from any cause among children under five by 24 to 27 percent, at a cost of $28 to $72 per disability-adjusted life year averted, which places it among the most cost-effective health measures known (NBER). Evidence Action’s Safe Water Now programme shows the approach at scale, with 53,000 chlorine dispensers in active use in rural Kenya, Malawi and Uganda, inline chlorinators in the Indian state of Andhra Pradesh, and nearly 10 million people served for less than $1.70 per person per year; the organization estimates that the programme averted more than 15,000 deaths of children under five between 2013 and 2024 (Evidence Action). Health ministries should fund chlorination as a standing service in every district where water is not reliably safe, starting with the 106 million people who drink directly from rivers, lakes and ponds.

2. Build water and sanitation systems that are paid for and maintained

Lasting safety requires piped water and managed sanitation, run by utilities with enough revenue to maintain what they build. The World Bank estimated in 2016 that reaching the water and sanitation targets of the Sustainable Development Goals in 140 countries would cost about $114 billion a year including operations and major maintenance, or about 0.39 percent of those countries’ combined GDP (World Bank; World Bank blog). The UN-Water GLAAS 2025 update found that most countries have water and sanitation plans but fewer than 13 percent report the money and staff to carry them out. Fewer than a third say user tariffs cover at least 80 percent of operation and maintenance costs, and 56 countries reported that their three largest water suppliers fail to bill for an average of 39 percent of the water they produce (WHO/UN-Water GLAAS). National governments should adopt costed plans, cut water losses, set tariffs that cover running costs with targeted subsidies for poor households, and regulate service quality. Development banks and bilateral donors should lend against those plans, and grant money should go first to rural areas and fragile states that cannot yet borrow.

3. End open defecation and manage faecal waste safely

Toilets reduce disease only when the waste they collect is contained and treated. Local governments should pair latrine construction with pit-emptying services, faecal sludge treatment and hygiene promotion, including handwashing stations with soap in homes, schools and clinics. Diarrhoeal disease accounts for over a million of the 1.4 million deaths that the WHO attributes to unsafe water, sanitation and hygiene (WHO). India’s Swachh Bharat Mission, launched in 2014, built over 100 million household toilets by 2019 (Swachh Bharat Mission). A study of 640 districts by Suman Chakrabarti and colleagues in Scientific Reports associated each 10-point rise in district toilet access with 0.9 fewer infant deaths per 1,000 live births and estimated that the mission may have averted 60,000 to 70,000 infant deaths a year, though the authors note doubts about actual toilet use and over-reported open-defecation-free status (India Water Portal). The JMP credits India with 676 million of the 943 million fewer people defecating in the open worldwide between 2000 and 2024. Cambodia cut open defecation from 42 percent of its population in 2015 to 7 percent in 2024 (JMP 2025). Sub-Saharan Africa is the counterexample: the share practising open defecation halved, but population growth left the number almost unchanged, at 192 million. Schools should be an early target, because adolescent girls need water, toilets and privacy there to manage menstruation.

4. Move two billion people to clean cooking

Households should be able to cook with LPG, electricity, biogas or ethanol at a price close to what they pay for wood or charcoal. Governments can subsidize the stove and first cylinder and then the refills. India’s Pradhan Mantri Ujjwala Yojana, launched in 2016, has enrolled 105 million beneficiaries (Down To Earth), directs the subsidy to women, and tripled the share of rural households using LPG as their main fuel; modelling cited by State of Global Air estimates that exclusive LPG use by all its households would avert more than 150,000 deaths a year. Ecuador has subsidized about 90 percent of the cost of an LPG refill since the 1970s, more than 95 percent of its people cook with gas, and the switch has been associated with a steep fall in child deaths from lower respiratory infection (State of Global Air 2025 report). Governments can also cut taxes and import duties on clean fuels, fund rural cylinder depots, and support pay-as-you-go electric cooking wherever grid or mini-grid power reaches. The International Energy Agency (IEA) estimates that closing Africa’s gap would take about $4 billion a year for the rest of this decade (Climate Home News). Families that cannot afford refills go back to wood and end up using both fuels, so refill subsidies need as much attention as stoves.

5. Set outdoor air standards and enforce them

Every country should adopt legally binding ambient air standards on a path toward the WHO guidelines, with deadlines, monitoring and penalties; in 2023 only a quarter of countries met their own PM2.5 standard (State of Global Air 2025 report). The US Environmental Protection Agency’s review of the 1990 Clean Air Act Amendments estimated that they would prevent more than 230,000 early deaths in 2020, with central-estimate benefits exceeding costs by more than 30 to 1 (US EPA). China adopted its Air Pollution Prevention and Control Action Plan in September 2013. According to the Ministry of Ecology and Environment, average PM2.5 in 74 cities fell 42 percent between 2013 and 2018 and sulphur dioxide 68 percent, while the number of civilian vehicles rose 83 percent and energy consumption 11 percent (China News Service).

6. Cut pollution at its main sources

Standards need matching action on the sources of particulate matter: emission controls on power plants and factories, fuel and tailpipe standards for vehicles, support for farmers to manage crop residue without burning it, and regional airshed agreements, since pollution crosses city and national borders. Household fuel belongs on this list because smoke from home cooking and heating supplies nearly 20 percent of outdoor PM2.5 worldwide and nearly 30 percent in India. China’s rural Clean Heating Program, begun in 2015, banned household coal in participating villages and subsidized electric or gas heating; by 2021 about 36 million households were enrolled, outdoor PM2.5 fell by 2.4 to 7 micrograms more than in nearby areas without the programme, and heart attacks fell 6.6 percent in Beijing townships with high coverage (State of Global Air 2025 report). The climate plan covers the coal transition.

7. Measure what people breathe and drink

Governments should run reference-grade air monitoring networks and publish the readings in real time, and water regulators should test drinking water regularly for bacteria and for chemical contaminants such as arsenic, fluoride, lead and PFAS. Data on sanitation have improved quickly: the number of countries with estimates of safely managed sanitation rose from 83 to 145, and the share of the world’s population covered from 48 to 86 percent (JMP 2025).

8. Protect water and sanitation in war and displacement

Cholera and other diarrhoeal outbreaks follow conflict and mass displacement. The WHO reports that conflict, displacement, disasters and climate change have intensified cholera outbreaks, especially in rural and flood-affected areas (WHO). Humanitarian budgets should pay for water trucking, chlorination, latrines and oral cholera vaccination in camps and host communities in the first weeks of a crisis. Parties to conflicts, and the governments that back them, should be held to the rules of war that protect water systems from attack, as set out in the plans on ending war and displacement.

Sequencing

In the first two years, the plan should fund what saves lives fastest: chlorination, cholera response, refill subsidies that keep poor households on clean fuel, and enforcement of air standards already in law. From years two to ten it should build utilities, sanitation services that carry waste from pit to treatment plant, supply networks for LPG and electric cooking, and monitoring systems. Replacing coal in power and industry and extending piped water and sewerage to every town will take one to two decades and runs alongside the climate transition.

What makes it stick politically

Programmes last when their costs are shared fairly, when utilities are run well enough that people will pay their bills, and when fuel subsidies are targeted, so that finance ministries do not cut them in the first budget crisis. India’s rural sanitation campaign was tied to a public national deadline, the 150th anniversary of Gandhi’s birth in 2019 (Swachh Bharat Mission), and Ecuador’s LPG subsidy has run since the 1970s. Standards survive best when they are set in statute, rest on a published scientific review, and produce health gains that courts and voters can see.

Where reasonable people disagree

How much clean cooking improves health. In the Household Air Pollution Intervention Network (HAPIN) trial, 3,200 pregnant women in Guatemala, India, Peru and Rwanda were randomly assigned either a free LPG stove and fuel or their usual biomass stove. Uptake was nearly complete and median personal exposure to PM2.5 was 23.9 micrograms per cubic metre in the LPG group against 70.7 in the control group, yet mean birth weight differed by only 19.6 grams, which was not statistically significant (NEJM, Clasen et al. 2022). Some researchers conclude that exposure must fall much further, including from outdoor and neighbours’ smoke, before health gains appear; others rest the case for clean cooking on time saved, forests spared and adult disease avoided.
LPG or electricity. LPG works now and at scale, but it is a fossil fuel that most poor countries import. Electric cooking suits a decarbonizing grid but needs reliable power that many households lack.
Cost recovery or subsidy. One school holds that utilities must charge full costs to stay solvent; another treats basic water as a public good to be paid for from taxes. Most countries already cover part of their utilities’ operating deficits from public budgets, so the practical question is how to target those subsidies.
Stricter standards or faster growth. Industry groups argue that tighter air standards block factories and jobs; health researchers reply that pollution costs economies more in illness and lost work.

This plan holds that the health returns justify public spending, with subsidies targeted to poor households and standards phased in on deadlines that can be met.

Part II: The plan in the world of September 2026

New data: steady progress, off track (all elements)

The Tracking SDG7 report calculates that about 400 million people a year would need to gain clean cooking to reach universal access by 2030, and that 20 countries account for three-quarters of the global gap (SEforALL). The IEA’s Clean Cooking in Africa 2026 report, launched in July, found that about 15 million people in sub-Saharan Africa gained access in 2025, 35 percent more than the average of the previous five years, which population growth still outran; more than a billion people on the continent still lack access (Mongabay). The IEA figures in this essay come from press coverage of the report.

What this means for the plan. The elements hold, but the pace needed for 2030 is several times anything achieved so far. Money should go first to the 20 countries that hold most of the clean cooking gap and to fragile states, where water coverage lags most.

Elements 1, 2 and 8: aid cuts hit water and sanitation

As the United States dismantled the US Agency for International Development in 2025, its water-sector programmes fell from 254 to 99 between March and August and obligated funding from $3.45 billion to $1.23 billion, according to David Michel of the Center for Strategic and International Studies. The cuts stranded irrigation canals in Kenya, water towers for schools and clinics in Mali and water systems in Nepal, and Michel links them to higher cholera death rates in several African countries where contracts were ended (CSIS).

Using OECD Creditor Reporting System data, the GLAAS 2025 update reports that aid disbursements for water supply and sanitation were $6.9 billion in 2023, and that commitments fell 9 percent between 2022 and 2023 to $8.5 billion, a far steeper fall than the 1.1 percent drop in total aid. The World Bank’s International Development Association, Japan, Germany and the EU institutions provided 60 percent of water-sector aid disbursements in 2023, and bilateral donors that have since announced cuts supplied 28 percent, or $2.4 billion. Japan’s JICA, the largest bilateral donor to the sector, foresees no change, and the African and Asian development banks expect to lend more (WHO/UN-Water GLAAS). Preliminary OECD data released in April 2026 show total aid from donor countries falling 23.1 percent in real terms in 2025 to $174.3 billion, the steepest drop on record, with US aid down 57 percent (Focus 2030). The wider collapse in aid is covered in the plan on ending poverty.

In 2025 the WHO recorded 614,828 cases and 7,598 deaths across 33 countries. The Democratic Republic of the Congo reported 2,071 deaths, Sudan 1,830 and South Sudan 1,286, all three countries affected by armed conflict (WHO). The European Centre for Disease Prevention and Control counted fewer so far in 2026: 212,857 cases and 1,943 deaths worldwide between 1 January and 26 August 2026, against 338,340 cases and 4,324 deaths in the same period of 2025. Afghanistan had reported 80,968 cases by 20 July, and Nigeria reported 41,296 new cases between 12 July and 9 August (ECDC). The WHO cautions that under-reporting and delays affect cholera data.

What this means for the plan. Elements 1 and 8 should have first claim on scarce money. Chlorination and cholera response are cheap and fast, and they protect the people most exposed while larger projects stall. The donors that have held steady, Japan, Germany and the development banks, should concentrate on finishing stranded projects and keeping utilities solvent, which is the work of element 2.

Element 4: the Hormuz shock reaches the kitchen

About 30 percent of the world’s seaborne LPG exports, some 44.2 million tonnes a year, normally pass through the Strait of Hormuz. Within three weeks of the first strikes the Argus Far East propane index had risen 53 percent, and Saudi Aramco’s contract price for propane rose from about $542 a tonne in February to $750 in May (Payne Institute). Brent crude reached $109.20 a barrel on 10 September after new attacks on Gulf shipping (Al Jazeera), and traded between about $104 and $108 in the last week of September (Al Jazeera; Trading Economics).

India, which imports about 60 percent of its LPG, was hit hard. Oil ministry data reported by the Press Trust of India show LPG consumption of 2.2 million tonnes in April 2026, 16 percent below April 2025, as the government cut supplies to hotels and industry and lengthened the interval between household refills (Outlook Business/PTI); Down To Earth, using a year-earlier figure of 2.5 million tonnes, puts the fall at 13.1 percent. The government held retail price rises to 6 to 7 percent while world prices rose 40 to 50 percent, absorbing a loss of Rs 300 to 400 on each 14.2-kilogram refill, and rural households under financial strain went back to firewood and dung cakes (Down To Earth). India also cut the annual quota of subsidized refills for its poorest beneficiaries from nine cylinders to four (Payne Institute).

The Associated Press reported in April that families in Nairobi’s Kibera settlement who had switched to LPG were cooking on charcoal again, and that waste-picking families in New Delhi earning under $3 a day had gone back to firewood (AP via WTOP). In July the IEA’s executive director, Fatih Birol, said that 3.4 billion people, most of them in Africa, had been negatively affected by the LPG crisis and that many countries held less than 15 days of fuel storage. The IEA said it was developing a clean cooking security programme to expand LPG storage, strengthen supply chains and improve cooperation between producing and consuming countries (Climate Home News).

Finance for clean cooking held up better than fuel supply. Of the $2.2 billion pledged at the 2024 Summit on Clean Cooking in Africa in Paris, Mongabay reports that $740 million had been disbursed across 30 countries by June 2026, with Kenya receiving 19 percent. About 49 percent of that money went to LPG and 8 percent each to electric cooking and biogas (Mongabay). Climate Home News gives $750 million across 22 countries and reports $900 million of new commitments announced by the IEA in July (Climate Home News).

What this means for the plan. Element 4 treated clean cooking as a question of access and affordability, and 2026 added supply security, since a household with a gas connection but no affordable refill goes back to wood. The plan should add strategic LPG storage in importing countries, refill subsidies that switch on automatically when world prices spike, and a larger share of new finance for electric cooking and biogas, which received only 16 percent of disbursed summit money and do not depend on a shipping lane.

Elements 5 and 6: the energy crisis and coal

Gas shortages pushed Bangladesh, Pakistan, the Philippines, Thailand, Japan, South Korea, Germany and Italy to announce more coal generation. The think tank Ember, in an analysis reported by Carbon Brief, found that the worst case was a rise in global coal power of 175 terawatt-hours, or 1.8 percent, in 2026, and that solar, wind and batteries were covering much of the lost gas generation (Carbon Brief).

What this means for the plan. The air-quality risk from the energy crisis is concentrated in South Asia, where Pakistan and Bangladesh already had the highest average PM2.5 of any country in IQAir’s 2025 ranking (IQAir). Under element 6, any coal plant returned to service should be required to run its emission controls, and clean energy should be presented as protection against both fuel shocks and smog.

Elements 5 and 7: the United States reverses course, and the courts push back

The US Environmental Protection Agency tightened the annual PM2.5 standard from 12 to 9 micrograms per cubic metre in 2024, estimating that the change could prevent up to 4,500 premature deaths a year. On 24 November 2025 the agency asked the federal appeals court in Washington to strike down its own rule and proposed a return to the 2020 level of 12 (Eos). In June 2026 the D.C. Circuit unanimously upheld the 9-microgram standard and refused the administration’s request to vacate it without a new rulemaking (Harvard EELP). On 28 August the National Association of Manufacturers and other business groups asked the Supreme Court to hear the case, arguing that the standard threatens at least 474 manufacturing projects announced since January 2025 (NAM).

Drinking-water rules moved in the same direction. On 18 May 2026 the EPA proposed to rescind its 2024 limits for PFHxS, PFNA, GenX and a mixture of these with PFBS, citing procedural errors in how they were adopted (US EPA). A companion proposal keeps the limits of 4.0 parts per trillion for PFOA and PFOS but would let water systems delay compliance from April 2029 to April 2031, provided they notify customers and take short-term steps where levels reach 12 parts per trillion (US EPA).

The State Department stopped publishing data from its air monitors at embassies and consulates on 4 March 2025. The Centre for Research on Energy and Clean Air found that six countries lost all public air quality monitoring, 28 lost access to regulatory-grade data and 16 more needed urgent review, and that in 13 countries the embassy monitor had been the only regulatory-grade source (CREA). A study in PNAS led by Zoey Yiyuan Zhou of Columbia University found that satellite measures of pollution in 46 cities rose 24 to 33 percent after the data stopped, roughly a 4 percent rise in ground-level PM2.5; the State Department says it is restoring public reporting but has given no date (NPR via KPBS).

What this means for the plan. The PM2.5 rule has survived so far because a court required the EPA to follow the statute’s procedures before changing it, which supports element 5’s emphasis on standards set in law. Under element 7, other governments, cities, universities and philanthropies should take over the embassy monitoring sites, starting with the 13 countries where the US monitor was the only regulatory-grade source.

Upcoming decision points

The UN 2026 Water Conference, co-hosted by the United Arab Emirates and Senegal, meets in Abu Dhabi from 8 to 10 December to accelerate progress on the water and sanitation goal (UN DESA). It is the year’s main opportunity for new water funding. The Supreme Court’s decision on the PM2.5 petition is the other near-term test.

Part III: Revised priorities for the next 6 to 12 months

Protect chlorination and cholera response in conflict zones. Fund point-of-use water treatment, emergency sanitation and cholera vaccination in the Democratic Republic of the Congo, Sudan, South Sudan, Nigeria and Afghanistan before the next rainy seasons.
Keep clean-cooking households from going back to wood. Importing countries should fund temporary, targeted refill subsidies while LPG prices stay high, and donors should back the IEA’s clean cooking security programme on LPG storage and supply cooperation.
Diversify cooking energy. Direct a larger share of new clean cooking finance, including the $900 million announced in July, toward electric cooking and biogas where power supply allows, to reduce dependence on a single shipping route.
Use the Abu Dhabi water conference to fill the aid gap. Japan, Germany, the Gulf states and the development banks should commit to finishing stranded water projects and financing utilities in the countries hit hardest by the US withdrawal.
Defend air standards and data. Keep the US PM2.5 standard in force while the Supreme Court decides whether to take the case, require emission controls on coal plants restarted during the energy crisis, and replace the lost embassy monitoring network.

Conclusion

The events of 2026 leave the plan’s core intact, since the tools that prevent deaths from polluted air and unsafe water remain cheap and well tested, but the conditions for using them worsened. Donor money for water and sanitation has shrunk, the cooking-gas supply for hundreds of millions of households runs through a strait that has been closed for much of the year, and the United States government has tried to weaken standards that its own courts have so far upheld.

India held down cylinder prices at great fiscal cost, and the Paris summit donors kept disbursing clean cooking finance. The question for 2027 is whether governments will protect clean air and safe water in a crisis as they already protect electricity and food supplies.

The situation in the Strait of Hormuz, the Supreme Court’s handling of the PM2.5 case, the final PFAS rules and the Abu Dhabi conference could each change this assessment within weeks.