Oh crap, challenges to universal sanitation by 2030

By Bonnie Leko-Shapiro, Consultant, Global Health Council 

World Toilet Day is tomorrow November 19. In the intersection of water, sanitation, and hygiene (WASH) and global health, this is a significant opportunity to highlight the critical need for better sanitation around the world. A new report, Overflowing Cities, The State of the World’s Toilets 2016, from WaterAid America, delves deeply into this complex issue.

Access to basic sanitation was incorporated into the Millennium Development Goals (MDGs), but was not achieved before the sunset of the MDGs. It is one of the stark failures of the MDG agenda. With the adoption of the Sustainable Development Goals, one goal (Goal 6) specifically calls for the need to “ensure the availability and sustainable management of water and sanitation for all.” There is now recognition that sanitation is an integral part of human development and target 6.2 specifies achieving “adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations” by 2030.

The challenges in failing to meet the sanitation target in the MDG era will continue to pose challenges for universal sanitation moving forward in the SDGs. First, people are moving from rural areas to urban areas very rapidly. In fact, in many places, city populations are growing much faster than sanitation improvements. This results in increasingly densely populated areas, and often in informal settlements, which leads to the second major challenge: infrastructure.

Improving sanitation is an inherently costly proposition; and to do it properly, financial and political commitments must be complemented with community buy-in. The rush to urban areas creates or exacerbates open sewage systems, if any sewage system exists at all. Pit latrines may be progress in rural areas where no other safe sewage option exists, but they are insufficient and dangerous in crowded areas.

Exposed feces, including those flowing through settlements in open trenches or rivers, cause illnesses and diarrhea, which kill hundreds of thousands of people annually. The health threat of open defecation and stagnant sewage is widely understood, however there are also cultural challenges to improving sanitation:

1. Sanitation is not glamourous. It is not exciting for officials or the average person to talk about. Understanding the requirements of a well-built, effective, and properly maintained sewage system is highly technical and many people find the subject matter unpleasant.
2. Context matters. Sanitation projects require support from governments on all levels –national down to the municipal levels. There are also many locations where land rights are legal obstacles to developing and implementing sanitation projects. Navigating these murky waters is costly in both time and money.
3. Not priority infrastructure (unlike roads or telecoms). As one of 169 targets specified in the SDG agenda, sanitation is clearly completing against dozens of other priorities. Civil society, the private sector, and government must all work together to plan, fund, and maintain sanitation systems.
4. Social taboos. Discussing menstruation, defecation, and urination ranges from distasteful to prohibited in several cultures. As target 6.2 specifically mentions, women and girls require consideration, something that is not automatically assumed in some places.

Ultimately, improvements can only be made by addressing systemic challenges in political, cultural, and financial approaches to development. There is no silver bullet to fix the complex barriers to universal access to quality sanitation. However, there are a couple of case studies of successful sanitation development projects. Nongovernmental organizations (NGOs) can serve a key function in bringing disparate groups to the table and facilitate connections among the communities to be served; between the communities and their governments; and between the communities, governments, and private sector. Public-private partnerships have great potential to invigorate this area.

An attitudinal shift that adequate housing, a commonly agreed on metric of development, must include good sanitation is also necessary. The focus of World Toilet Day 2017 is Toilets & Jobs. Building sufficient sewer and treatment infrastructure is not enough. To be sustainable, people must be trained to maintain the infrastructure and products, creating opportunities for micro and small businesses to develop. Loans and subsidies from government and the private sector have been moderately successful in some places to help jump-start a sanitation market.

Creative solutions are required to get investment in sanitation as returns do not tend to be obvious or immediate. Rather, they are usually secondary through improved school attendance, better community health, increased productivity by workers, etc.

WASH and global health are intricately linked. There are only 14 years to achieve the SDGs, so we need to all give a crap about urban sanitation improvements.