Water and health interlinkages of the sustainable development goals in remote Indigenous Australia

The paper examines how health (SDG 3) and clean water and sanitation (SDG 6) are interlinked within the broader UN 2030 Agenda and why integrated implementation is necessary to ensure no one is left behind in Australia. Despite national reporting indicating near-universal access to safely managed water and sanitation, remote Indigenous communities experience poorer water, sanitation, hygiene (WASH) conditions and a higher burden of waterborne and hygiene-related diseases. The research aims to clarify intersections between SDG 3 and SDG 6 in remote Indigenous Australian contexts to inform integrated policy and practice. It situates health within social and environmental determinants, highlights the need for vertical integration across government levels to achieve the SDGs, and underscores that progress assessments must account for sub-populations whose experiences are obscured by aggregate national data.

The study draws on international and national literature describing SDG interlinkages, the importance of integrated planning (UN, UN ESCAP, ICSU), and evidence that WASH is a major risk factor for infectious diseases. Prior analyses suggest SDG 3 outcomes are influenced by poverty (SDG 1), education (SDG 4), gender (SDG 5), water and sanitation (SDG 6), settlements (SDG 11), and ecosystems (SDG 15). Australian policy commitments (Foreign Policy White Paper; participation in the UN High Level Panel on Water) and global reports (World Water Development Report 2019) call for closing service gaps for vulnerable populations. Extensive Australian literature documents environmental health challenges in remote Indigenous communities, including contamination events, crowding, and hygiene infrastructure deficits, and persistent neglected tropical diseases (e.g., scabies, trachoma) linked to inadequate WASH.

The study employed a case study design focused on remote Indigenous Australian communities. The research team included two Aboriginal Australian co-authors to ensure culturally appropriate portrayal and communication. Methods comprised: (1) a literature and information review to map issues where health interacts with water and sanitation; (2) selection of relevant SDG targets and indicators from SDG 3 (health) and SDG 6 (WASH) based on documented relationships; and (3) an analytical deliberation connecting evidence from the review to the chosen SDG targets and indicators through author dialogue and synthesis. All data were drawn from public sources.

- Disparities in child health: Under-5 mortality rate was 3.8 per 1,000 live births nationally (2016) versus 6.2 per 1,000 for Indigenous Australians (2016), improving from 13.5 per 1,000 in 1998 for Indigenous children. - Infectious disease burden: While specific national SDG 3.3.5 data are lacking, overall infectious disease burden was 11.3 per 1,000 for Indigenous versus 2.9 per 1,000 for non-Indigenous Australians (2011). - WASH-related mortality: Mortality attributed to unsafe water, sanitation and hygiene is low nationally (0.1 per 100,000; 2015) and not among the top five causes of death for Indigenous Australians, yet WASH-related diseases remain disproportionately prevalent in remote Indigenous communities. - Neglected tropical diseases and WASH-linked conditions: High prevalence of scabies with sequelae including ARF, PSGN, CKD, and rheumatic heart disease; endemic Strongyloides in parts of QLD, NT, WA, and NSW; trachoma persists in some remote communities, uniquely among developed countries, associated with inadequate hygiene and crowded housing. - Drinking water: 99% of urban Australians use ‘improved’ water, but rural/remote national coverage data are lacking. In 274 WA remote Indigenous communities, drinking water failed to meet Australian standards about 30% of the time, with monthly detections of E. coli and/or Naegleria over two years. Elevated nitrates and uranium above standards were identified in some groundwater-reliant communities in NT, QLD, and WA. Enteric pathogens detected include Cryptosporidium (disproportionately high in remote Indigenous communities), Salmonella, Shigella, Campylobacter, E. coli, and Rotavirus. - Sanitation and hygiene: Nationally, 74% use safely managed sanitation (2017 baseline). In remote Indigenous areas (2014–15), 38% of Indigenous adults lived in crowded housing versus 13% in non-remote areas; 28% lived in dwellings where key health hardware (washing facilities, waste removal, food storage/cooking) was unavailable or non-functional. Soap availability was low in some Central Australian remote households, undermining hand/face washing critical for trachoma control. - Wastewater: Many remote communities historically relied on septic systems; upgrades under COAG strategies have increased centralized treatment. Nonetheless, maintenance gaps persist; WA audits reported communities not meeting standards and sewage-derived contamination (E. coli/Naegleria) in at least 68 communities over two years; 19 WA remote communities reported 37 wastewater overflows (2012–2014). - Ambient water quality: Assessments range from very poor to good; overall ecosystems often rated poor. There is no single national repository nor regular national/state-scale surface water quality assessments, limiting evaluation of SDG 6.3.2. - Social determinants amplify risks: Overcrowding, poverty, geographic isolation, and service delivery/maintenance shortfalls impede sustained WASH functionality and elevate infectious disease risks, linking SDG 3 and SDG 6 outcomes with SDGs 1, 8, 10, and 11.

The findings demonstrate that Australia’s aggregate progress toward SDGs 3 and 6 obscures substantial inequities for remote Indigenous communities. Elevated burdens of WASH-related infections, persistent NTDs (scabies, trachoma, Strongyloides), and documented drinking water and wastewater non-compliance show that health outcomes (SDG 3) are tightly coupled to water, sanitation, and hygiene services (SDG 6). These relationships are mediated by social determinants such as crowding, poverty, and remoteness, reinforcing the need for integrated, cross-sectoral actions. The evidence underscores that improving WASH infrastructure functionality, maintenance, and affordability, alongside behavior support (e.g., consistent access to soap and reliable ‘health hardware’), can reduce infectious disease burden and downstream chronic disease sequelae. The analysis also highlights systemic data gaps—absence of disaggregated rural/remote water and sanitation coverage, lack of national ambient water quality repositories, and reliance on community-level audits—hindering precise SDG monitoring. Addressing vertical integration across national, state/territory, and local service providers and aligning investments across related SDGs (1, 8, 10, 11, 15) are essential to close the gap for remote Indigenous populations and uphold the “leave no one behind” imperative.

Remote Indigenous Australian communities face ongoing risks from microbial and chemical contamination of drinking water, sanitation system shortcomings, and inadequate hygiene conditions exacerbated by household crowding and non-functional health hardware. While sanitation infrastructure has improved in some areas, maintenance and monitoring gaps persist. The greatest immediate need is strengthening hygiene enabling conditions (reliable water, soap access, functional facilities) to prevent infections such as trachoma and skin conditions that contribute to long-term morbidity. The case study shows that coordinated progress on SDG 3 and SDG 6—considering broader social determinants and related SDGs—can deliver more effective, sustainable outcomes. To ensure high-income country standards and the SDG commitment to universality, governments should: improve granular, disaggregated data collection and reporting; integrate policy and service delivery across levels and sectors; and prioritize long-term, culturally appropriate solutions for remotely located and marginalized populations.

- Data gaps and aggregation: National SDG datasets often lack disaggregation for rural/remote and Indigenous populations, masking inequities; several SDG indicators have no comparable data for remote Indigenous communities. - Monitoring limitations: No single national repository for ambient surface water quality and limited regular national/state-scale assessments impede evaluation of SDG 6.3.2. - Comparability issues: Available community-level water quality and wastewater audit data are not directly comparable to population-level indicators, limiting generalizability. - Case study scope: The synthesis relies on publicly available literature and audits; it is descriptive and may not capture all regional variability or recent changes in infrastructure/service performance.