It draws on a set of indicators of both the technical and financial performance of water utilities. It discusses the specific challenges in rural areas, given that coverage rates tend to be much lower, with self-provision, rather than piped networks, being an important form of supply. It elaborates on the consequences of inadequate service quality on health and the environment. Overall, WSS performance has tended to continue to decline, although there are substantial differences from one country to the next and/or within some countries (especially between rural and urban areas and small cities versus large cities). In such cases, lack of maintenance means that further deterioration is likely, unless significant reforms and investments are carried out.