Bounded by the Himalaya Mountains, Nepal is a country rich in freshwater resources. These resources, however, are unevenly distributed and remain undeveloped. In rural Nepal, vast numbers of people lack access to safe drinking water and rudimentary sanitation services. Currently, only 34% of the population has access to safe water and only 3% to sanitary facilities. The implications for the people of Nepal are severe. Incidence rates of infectious disease are high, and as a result of poor health care infrastructure, illness often results in death. Lack of access to water also creates a tremendous burden on women's time and energy, as they must spend many hours each day collecting sufficient water for drinking and cooking. This burden places additional stresses on the population which can ultimately result in negative impacts on health status. Thus, the problem of drinking water is one of both quality and quantity. Improving public health through water and sanitation requires attention in four main areas: water quality, water quantity and accessibility, hygiene education, and sanitation facilities.

The international community responded to the global drinking water crisis by initiating the International Drinking Water Supply and Sanitation Decade (IDWSSD) from 1980- 1990. This served as a tremendous impetus for action in Nepal. Though the goal of universal coverage was not attained during the IDWSSD, current efforts continue to reflect the aims of the decade. To meet these aims, Nepal has shifted to a decentralized, participatory approach.

A unique non-government organization (NGO), Nepal Water for Health (NEWAH), is presently working in the water and sanitation sector in Nepal. This group has embraced a community-based approach which focuses on the integration of water, sanitation and health education. A case study of two villages in Western Nepal reveals the importance of working with a community rather than in a community. The differing perceptions, gender roles, ethnicity and religion of each village demand thoughtful consideration, as these features influence the outcome of any project.

As Nepal synthesizes the lessons of the past and articulates goals for the future, it is clear that improving public health is a top priority. The successful realization of this goal requires careful monitoring of health-related outcomes in addition to traditional coverage indicators. It is no longer sufficient to base success simply on the number of people for whom safe water is provided. Nepal must expand the definition and evaluation of success to consider improvements in health and productivity.

Achieving success requires increased attention and action in a number of areas. Geographic feasibility surveys must be instituted with all projects to avoid unsustainable projects. In areas where current technology is not applicable, alternative technologies, such as horizontal wells, rainwater catchment, and deep boreholes must be explored. Water quality testing is necessary to ensure that newly delivered water supplies are 'safe'. Responsibility for project implementation should shift to non-government and community based organizations, following a set of standardized criteria. These criteria must include the use of a participatory approach including three key components: water, sanitation, and health education.