The problem of sanitation - WSSCC Working Group on Promotion of Sanitation
The burden of poor sanitation
Every year, 2.5 million (1) children die of diarrhoea that could
have been prevented by good sanitation: millions more suffer the nutritional,
educational, and economic loss through diarrhoeal disease that improvements in
sanitation, especially human excreta management, can prevent. Human excreta are
responsible for the transmission of diarrhoea, schistosomiasis, cholera,
typhoid, and other infectious diseases affecting thousands of millions. Overall,
WHO estimates that nearly 3.3 million people die annually from diarrhoeal
diseases, and that a staggering 1.5 thousand million suffer, at any one time,
from parasitic worm infections stemming from human excreta and solid wastes in
the environment (2). Heavy investments have been made in water supply since
1980, but the resulting health benefits have been severely limited by poor
progress in other areas, especially the management of human excreta. In
additional to this toll of sickness and disease, the lack of good excreta
management is a major environmental threat to the world's water resources, and a
fundamental stumbling block in the advancement of human dignity.
Characteristics of the problem
Like all complex problems, poor sanitation can be analysed on
many interrelated levels. The Collaborative Council Working Group on Promotion
of Sanitation has identified problems, barriers, and themes that appear to
operate on three levels.
Level 1 - The basic problem: sanitation isn't happening
Despite years of rhetoric, good intentions, and hard work, we
are, in fact, making little or no progress in improving sanitary conditions for
much of the world's population. Without major changes, the number of people
without access to sanitary excreta management will not change in the next 40
years, remaining above 3000 million people (3). This is astonishing, given the
human capacity to solve problems, the fundamental nature of this basic need, and
the enormous suffering caused by our failure to meet it. Yet those of us working
in sanitation agree that, with some notable exceptions, we are either losing
ground or barely holding the line in our ability to dispose of our wastes in a
healthy and ecologically sound, and safe, manner.
Level 2 - Barriers to progress: why improvements in
sanitation aren't happening
Given the magnitude and importance of the problem, why is there
so little progress? The barriers to progress found by the Working Group were
varied and complex, but could generally be grouped into the following linked and
Lack of political will. There is little political
incentive for governments to deal with this difficult subject. Politicians
rarely lose their jobs because of poor sanitation programmes, particularly as
the people most in need have the least political power. Political commitment is
needed to create an environment in which demand for sanitation can grow, and
which, in turn, can strengthen political will. The issue of political will is
thus both a cause and an effect of the other problems, and a key to successful
Low prestige and recognition. Promoting low-cost
sanitation facilities and hygiene education has never been prestigious;
politicians and movie stars do not demonstrate latrines. Among professionals,
many of the best and the brightest avoid working on approaches to excreta
management that are readily affordable because of the low-status and low-pay of
such work. Others, recognizing the frustration of dealing with extremely limited
resources, public apathy, and lack of political will, often seek the more
professionally rewarding route of higher, more exciting, and better-funded
technologies. Even among potential consumers, low-cost solutions to excreta
management have little prestige compared to the conventional sewer systems used
by the world's more affluent populations.
Poor policy at all levels. Agencies responsible for
creating a supportive environment for sanitation, in general, have had
ineffective and counterproductive policies at all levels. These include too much
attention to water supply at the expense of excreta management and hygiene
education, a focus on short-run outputs (hardware) rather than long-term
behaviour change, and subsidies that favour middle- and high-income communities.
More fundamentally, a philosophical approach to the problem, upon which sound
policy can be based, is often lacking.
Poor institutional framework. Many players are affected
by sanitation, and many more could be involved in its promotion. However, the
institutional frameworks in place often fragment responsibilities in a
multiplicity of government agencies and departments, neglect the needs of the
most vulnerable segments of the population, and ignore the powerful role that
NGOs and the private sector can play. It is clear that governments by themselves
have failed to promote sanitation, and that existing institutional frameworks
need to change.
Inadequate and poorly used resources. Excreta management
and hygiene education attract only a fraction of the resources needed to do the
job. Sanitation is at least as important for health as water supply, and is a
far more demanding problem; yet sanitation receives far fewer resources.
Increasing resources are required just to maintain the status quo, since
urbanization and population growth are making the hazards of poor sanitation
more acute. Where resources are available, far too much goes into hardware, and
not enough into community mobilization and hygiene promotion.
Inappropriate approaches. Even where the promotion of
sanitation is attempted, the approach taken is often wrong. Frequently, attempts
are made to find universal solutions. These fail to acknowledge the diversity of
needs and the cultural, economic, and social contexts in which they occur. For
example, although the expectations of urban populations often differ from those
living in rural settings, the technological options offered are often the same.
Critical issues of behaviour are frequently ignored or handled badly. Short-term
fixes have been generally favoured over long-term solutions, and we
fail to learn from collective experience. This situation is further aggravated
by a lack of awareness among engineers and government decision-makers on the
performance characteristics of on-site excreta management systems. This lack of
awareness is, in large part, due to the focus of traditional engineering
education on conventional sewerage systems. Rejection of an on-site excreta
management approach is also often based on the belief that the available
hardware for on-site management is technically inferior, less
sophisticated, and a managerial and administrative burden on households and
government agencies alike.
Sanitation also fails by being defined and applied too broadly
or too narrowly within a specific environment. In some cases, for example, the
scope of environmental protection and pollution control becomes so broad that
the focus on basic household excreta management is lost. In others, a narrow
focus on a single technology, such as pit latrines, may ignore other community
needs (such as drainage) that may exacerbate disease transmission during floods.
Failure to admit disadvantages of conventional excreta
management systems. The collection and transport of human excreta by water
carriage has been usefully employed in many parts of the world, and has resulted
in the development of extensive social, political, and technical
infrastructures. Nevertheless, the disadvantages of this system should be
considered as well. These include: costs, the volume of water required for
carriage, and the energy needed for treating the collected wastewater. Other
disadvantages include the health, economic, and environmental effects of
inadequately treated wastes and the loss of potentially valuable nutrients for
Neglect of consumer preferences. Too often we try to
promote what people do not want or cannot afford or both. Low-cost technologies
are often seen by consumers as low-status technologies. Others, found
appropriate by their promoters, are far beyond the financial reach of those in
most need. Promoters try to sell excreta management systems based on health
benefits, when most people are really more interested in the privacy, comfort,
and the status that such technologies can offer. Further, much hygiene promotion
is based on messages that ignore existing knowledge, belief, and experience. Put
simply, most of us promoting sanitation simply do not hear what the people we
serve say they want or believe.
Ineffective promotion and low public awareness. Although
people have opinions about excreta management, they are reluctant to talk about
the management of their excreta. Thus, selling the idea of improvements in
sanitation is difficult. Engineers and health care professionals who are
responsible for promoting sanitation are often unaware of effective promotional
techniques and continue with top-down approaches that alienate the target
populations by denying their voice, desires, and involvement in the
process. Those who are charged with promoting sanitation are seldom prepared to
do so in their education of others or in their professional practice. Adoption
of social marketing and participatory approaches to sanitation is promising, but
is still in its infancy; we have much to learn.
Women and children last. Women are potential agents of
change in hygiene education and children are the most vulnerable victims of poor
sanitation. Yet it is men who usually make the decisions about whether to tackle
the problem and how. Many sanitation programmes ignore the need for safe
management of children's faeces, even though they are a major source of
pathogens. Women, more than men, often want privacy and security in their
excreta management systems but are unable to express needs effectively in many
societies. Hence, those with the most at stake have the weakest voice.
Level 3 - Cross-cutting themes: demand and taboo
Little effective demand. If more people expressed a
desire for improvements in sanitation loudly enough, many of the problems would
resolve themselves. This seeming lack of demand is often considered a
constraint. People may want sanitation very badly, yet be powerless to express
that desire in financial or political terms. Some may want safe excreta
management facilities, but not at the available price. Others may not want the
available improvements at any price. We need to examine critically
the factors that limit demand, especially those with economic or political
roots. Where sanitation is poor, we need to understand why the effective demand
is low and to determine whether it is most amenable to political, financial,
technical or information change.
Cultural taboo and beliefs. In most cultures, the
handling of excreta is considered as taboo, and viewed as a disgusting or a
dangerous nuisance not to be discussed openly or seriously or both. No one wants
to be associated with excreta; even those who reduce its offensive
characteristics for others are stigmatized by association. Problems cannot be
solved if people do not want to talk about them and do not want to be associated
with their solution. In many contexts, taboos, including modern technological
ones, block the safe recovery of valuable agricultural resources from human
wastes. The excreta taboo lies behind many of the barriers to progress in this
area. To counter this, sanitation promotion and hygiene education should link
the value of excreta (faeces and urine) with ecology. They should promote an
understanding of the essential roles it plays in the life cycle of plants and
animals, as well as the damaging effect that it can have on health and
environment when improperly handled, discharged or reused.
A sanitation revolution
What is needed to turn this sector around is no less than a
revolution in thought and action. The sector simply cannot continue as in the
past. It is necessary to define principles, make priorities, create strategies
and search for new technological, financial and institutional solutions.
Advocacy and mobilization of new partners will be large parts of this
An approach to the sanitation challenge
An approach to the sanitation challenge is emerging that is not
only human-centred, but also ecologically sustainable. It is concerned with
equity, the protection of the environment, and the health of both the user and
the general public. Its goal is to create socially, economically, and
ecologically sustainable systems. To reach this goal, three key principles have
been identified as critical to designing successful sanitation systems for the
Equity, within the sanitation sector, means that all
segments of society have access to safe appropriate sanitation systems adapted
to their needs and means. Currently, inequities are found at many levels,
between rich and poor, men and women, and urban and rural. Equity implies that:
- access to safe sanitation systems is ensured for
- sanitation systems are being implemented that are safe and
adapted to the economic means of the users;
- genuine community involvement takes place in both planning and
management of systems;
- political will is mobilized to assure the rights of all in
sharing needed resources for improved sanitation; and
- the information required for decision-making is available to
all segments of user communities.
Health promotion and protection from disease, within the
sanitation sector, means that systems are capable of preventing people from
contracting excreta-related diseases as well as interrupting the cycle of
disease transmission. Health promotion and protection from disease implies that:
- the importance of social and behavioural
dimensions in achieving health benefits is given priority; and
- future sanitation technologies have the demonstrated capacity
to prevent the transmission of pathogens.
Protection of the environment, within the sanitation
sector, means that future sanitation systems must neither pollute ecosystems nor
deplete scarce resources. Environmental protection implies that sanitation
- do not lead to water or land degradation, and,
where possible, ameliorate existing problems caused by pollution; and
- are designed to recycle to the maximum extent the renewable
resources, such as water and nutrients present in human excreta, as well as
Programmes that fulfil all these principles simultaneously
should lead to long-term sustainability.
Operationalizing the approach to the sanitation challenge of
the 21st century
The unprecedented sanitation challenge requires that new
strategies and methods to improve sanitation be applied to ensure equitable
access for everyone, that human health be protected, and that environmental
resources be protected and conserved, while moving towards the goal of achieving
sustainability. This requires:
- to learning from personal experiences and those of
- to new and innovative approaches;
- to applying a mix of technologies and systems;
- to considering the impact of a sanitation system on equity and
- to consider the alternatives if a proposed sanitation system
cannot be implemented completely; and
- to be aware of changing situations/crises.
Change in attitudes
- towards conservation and protection of
- towards participatory approaches; and
- towards accepting
waste as a resource.
This means adopting two operational strategies:
- flexibility in developing and applying sanitation
systems, incorporating respect for community values, perceptions, and practices;
- considering sanitation on its own merits and not as a sub-set
of another sector.
The time has come to cease perceiving sanitation as an
afterthought of water systems. To handle the magnitude of existing and future
sanitation requirements, the sector should be restructured so that sanitation,
as an essential public service, can be given appropriate consideration.
Recommendations for sanitation programmes
For implementation of sanitation programmes the following
recommendations are made:
· Develop mechanisms
to ensure that sanitation systems help prevent environmental pollution and
· Provide impetus for innovative
research and development for a range of systems applicable to differing cultural
and environmental conditions.
· Treat sanitation as a major
field of endeavour in its own right, with sufficient levels of investment to
revitalize training programmes and professional standing.
· Create a demand for systems
that move increasingly towards reuse and recycling of human excreta.
· Encourage a review of
sanitation policies within government, nongovernment, private, and sector
· Involve people for whom the
systems are being built in the design process.
(1) WHO. Health and environment in sustainable development.
Five years after the Earth Summit. Geneva, World Health Organization, 1997
(unpublished document WHO/EHG/97.8).
(2) WHO: Community water supply and sanitation: needs,
challenges and health objectives. Report by the Director-General. Forty-eighth
World Health Assembly, Provisional agenda item 32.1. Geneva, World Health
Organization, 1995 (unpublished document A48/INF.DOC/2).
(3) WHO/UNICEF Water supply and sanitation sector monitoring
report: sector status as at 31 December 1994. Geneva, World Health