Dirty water and poor sanitation sicken and kill tens of thousands of people each year in Sub-Saharan Africa, and imposes a heavy economic cost on countries equal to 1.4 percent of GDP in some countries. No one should accept this situation as destiny. We can change it.

Since access to potable water and sanitation was first recognized as a Millennium Development Goal in 2000, budgets for water and sanitation has grown in much of Africa. But bigger budgets and more spending have not appreciably expanded access to services in most countries. This is because the continent s population continues to grow strongly, the extra public financing is not being effectively spent, too little is being done to maintain existing water facilities and infrastructure, and water systems in countries embroiled in conflict have been destroyed or damaged.

Later this week, the World Bank and UNICEF will co-host a high-level Ministerial Dialogue on Sanitation and Water, to take stock of the water and sanitation situation around the world. This will be a vital opportunity for governments, donors, civil society, the private sector, and other key partners to confront the stark truth that safe water and sanitation in Africa remains out of reach of many, especially poor people.

In a recent World Bank study of water and sanitation services in 15 countries of Sub-Saharan Africa, we found that public spending still falls considerably short of government commitments and of international and national policy goals. On average, governments spent $1.71 per person on water supply and sanitation. This corresponds to less than half a percent of gross domestic product (GDP) and is five times lower than what is estimated to be needed each year to meet Sub-Saharan MDG targets.

We also found that actual patterns of spending stand in stark contrast to the economic and social rationales behind such spending. Too small a share of available funds is spent to expand poor people s access to essential services and to address the health and environmental problems created by unsafe water. Too little is spent on maintaining the water supply infrastructure. Too little is spent on sanitation, which is saves lives, especially those of young children. Too great a share of public funding goes to subsidize water for richer citizens who can afford to pay unsubsidized prices. Too great a share is wasted by inefficient utility practices such as over-staffing and underbilling, just to name several problems.

Targeting public spending to the poor will call for well-off citizens to pay for the water they use. Water and sanitation cannot develop sustainably until the wealthy begin paying for their services so that public financing can be directed to where it is needed most, to improve the lives of poor people.

Low utility tariffs are a major issue. However, before making changes to the tariffs, utilities should improve their efficiency by addressing their low billing and collection ratios. Promoting better maintenance of existing assets can cut spending on costly rehabilitation and thus increase the budget available for expanding access. While many African governments have updated their water policies, they have been less effective at putting them into practice, with national and local governments unsure about what their respective duties should be. Tanzania, a notable exception, has embraced a decentralized approach to water and sanitation where national government transfers to Tanzanian local governments reached nearly 40 percent of the water budget in 2008, up from zero in 2005.

Only two thirds of water and sanitation budgets are actually spent. To improve budget execution, government capacities in project management, especially at the local level, will need to be strengthened to make well-intentioned plans succeed. More detailed planning and speedier procurement will decrease the number of abandoned works and reduce delays.

Fortunately, we found some positive examples. For example, Benin has combined reforms of public expenditure management, while developing new investment programs. Donors helped the government to improve its management and implementation capacity so that the allocated budget was actually spent within a budget cycle. Between 2001 and 2008, the number of new water points built annually surged more than fourfold. Meanwhile, better budgeting and greater transparency in public financing persuaded several donors to increase their funding to Benin.

Finally, we found that donor funds were often badly targeted and unpredictable, resulting in execution rates that are lower than those of internal resources. Donors need to work together more closely and organize themselves behind a country s water and development plans. Donor funding is critical, as internal spending is not enough to fund improved water and sanitation. But donor funds are often fragmented.

One water utility in Mozambique, for example, had 19 separate donors in 2008. Donor funding commitments for the coming years are a good start. But greater harmonization and pooling of their aid money are vital to avoid overwhelming a country s ability to plan, budget, implement, and report back to the donors on how their aid is being used effectively. As a first step, development partners should consider forming a donor group for the sector to jumpstart the necessary pooling, harmonization, and joint evaluation.

Our review revealed a lack of efficient public spending and showed how better-off citizens end up capturing the benefits of public spending on water and sanitation at the expense of poorer people. The emotional argument for more on clean water and better sanitation will be greatly strengthened by improving the targeting and the execution of public spending so that clean drinking water and healthy sanitation services become a reality for all Africans.

The writer, Jamal Saghir, is Director for Sustainable Development in the World Bank s Africa Region.