An alarmingly high percentage of drinking water systems in the developing world do not provide design service, or may even fail. This has health implications for vulnerable populations forced to consume water from alternative, often unimproved sources. The Sustainability Assessment Tool developed in this research serves as a diagnostic to inform decision-making, characterize specific needs of rural communities in the management of their water systems, and identify weaknesses in training regimes or support mechanisms. Fifteen specific measures result in a score of sustainability likely (SL), possible, or unlikely for eight indicators. A weighting factor is applied to each indicator to provide an overall sustainability score. The framework was tested on 61 statistically representative geographically stratified sample communities with rural water systems in the Dominican Republic. Twenty-three percent of systems were assessed to be SL, 59% sustainability possible, and for 18% it is unlikely the community will be able to overcome a significant challenge(s). As post-construction support increased so did community participation (p = 0.005) and financial durability (p = 0.004). Increased accounting transparency was correlated to increased compliance with user tariffs (p < 0.001) and system age was inversely correlated to transparency (p = 0.003) and community activity level (p = 0.005).

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