The sanitation arc: an alternative examination of WASH behavior change

A primary goal of the WASH sector is to facilitate transitions from open defecation to improved sanitation. Many residents of low-income countries desire improved sanitation but lack the resources to obtain or maintain access to toilets. For such persons, describing the goal as ‘behavior change’ implies a deficiency in mindset, failing to capture contextual factors affecting sanitation access. Furthermore, household circumstances affect movement both up and down the sanitation ladder, a phenomenon that the sector tends to overlook. This study, based on interviews with 308 former subscribers to Haitian container-based-sanitation service EkoLakay, tracks household sanitation access at four points in time: prior to subscribing, during the subscription period, immediately upon unsubscribing, and at the time of interview. We describe this movement through time as the ‘sanitation arc’. Prior to subscribing, households were more likely to practice open defecation or rely on non-household sanitation, and less likely to have private improved sanitation than the average urban Haitian. This distribution is reversed among former subscribers. Nearly half of former subscribers, however, could not afford continuous access to EkoLakay; 80% of involuntary terminations resulted in loss of access to private improved sanitation, and over one-third of these households reverted to open defecation.

Sanitation Ladder and Undernutrition Among Under-Five Children in Pakistan

While the state of sanitation in Pakistan has improved in the last decade, a significant proportion of its population is still using inadequate sanitation or no toilet facility at all. Open defecation has decreased over the years; however, it has been replaced by poor quality sanitation in rural areas that might still cause diarrhoea and undernutrition. The research regarding inadequate sanitation in Pakistan, especially in terms of the sanitation ladder, remains limited. The present research thus fills this research gap by assessing the impact of different types of sanitation on the prevalence of stunting and underweight (moderate as well as severe) among under-five children in Pakistan using the nationally representative micro survey, Pakistan Demographic and Health Survey (2017-18). The sanitation ladder comprises of Piped to Sewer (highest level, base) followed by Flush to Septic Tank, Flush to Pit Latrine, Other Improved, Unimproved Sanitation, and Open Defecation. In order to estimate the adjusted and unadjusted odds ratios of the determinants, this research uses logistic regressions are used to estimate adjusted and unadjusted odds ratios of the determinants. We show that toilets connected to piped sewerage network are rare in the rural areas of Pakistan and a large segment of the rural population is still practicing open defecation. The logistic regressions show that piped sewerage network and flush to septic tanks are associated with lowest odds (both adjusted and unadjusted) of stunting and underweight among under-five children. In multivariate regressions, pit latrines are associated with even higher adjusted odds of severe and moderate and severe stunting as well as underweight among under-five children, showing that poor quality pit latrines may bring the source of faecal contamination to the doorstep of the households. Therefore, interventions targeting reduction in open defecation should promote good quality toilets for sustainable long-term improvements in child health.

Moving up the sanitation ladder with the help of microfinance in urban Malawi

We carried out a stated preference survey in Malawi to examine whether access to microfinance for sanitation would significantly increase the proportion of households upgrading to improved pit latrines or alternative improved sanitation technologies (urine diverting dry toilet, fossa alterna, pour flush). We presented a range of sanitation options at local market prices, initially without and then with a real microfinance option, to 1,300 households sampled across 27 low-income urban settlements in the two largest cities, Lilongwe and Blantyre. When we gave respondents a microfinance option, the proportion of households stating an intention to install improved and unimproved pit latrines decreased significantly, while the proportion stating an intention to upgrade to alternative improved sanitation technologies increased significantly. However, households in the lowest wealth quintile were more likely to state a preference for unimproved pit latrines, suggesting that the benefits of microfinance for sanitation may not accrue equally across wealth strata. Organisations seeking to improve access to safely managed sanitation by promoting alternative sanitation technologies would succeed if households have access to affordable alternative sanitation technologies and microfinance for sanitation. However, poorer households would need more affordable improved sanitation technologies, flexible microfinance options and possibly targeted subsidies to gain access to safely managed sanitation.

Getting a foot on the sanitation ladder: user satisfaction and willingness to pay for improved public toilets in Accra, Ghana

Rapid urban growth in developing countries has led to an increase in unplanned, high-density settlements dependent on public toilets for sanitation, yet we know relatively little about users' perceptions and concerns about such facilities. This paper seeks to explore user satisfaction and willingness to pay for improved sanitation services in Accra. Utilising a questionnaire, data were gathered from 245 users of public toilets in two low-income communities of Accra. 80.8% of users expressed overall dissatisfaction with the public toilets, the main areas of concern being: long queues and waiting times, unpleasant smells, dirtiness, concerns about security and lack of running water and soap. The majority of the respondents said that they would be willing to pay higher fees for improved services. Operators should take note of this and explore the potential market for building and maintaining high-quality public toilet facilities as a means to ending open defecation and getting on the first step on the sanitation ladder.

Mobility up the sanitation ladder following community-led total sanitation in rural Zambia

Scaling the sanitation ladder decreases exposure to various illnesses including diarrheal disease, soil-transmitted helminths and trachoma. In rural Zambia, community-led total sanitation (CLTS) has been deployed to help Zambians scale the sanitation ladder. Analysis of monthly routine surveillance data of village-level sanitation coverage of 13,688 villages shows that villages moved up the sanitation ladder following CLTS intervention with more than one third of villages achieving 100% coverage of adequate sanitation. Villages also moved down the sanitation ladder – approximately half of those achieving 100% coverage of adequate sanitation also dropped from that coverage at some point during monitoring. Larger villages were less likely to achieve 100% coverage, and more likely to drop if they did achieve 100% coverage. Drops were more likely to occur during the wet season. Of those villages dropping from 100% coverage, more than half rebounded to 100% coverage. The adequate latrine components most likely to drop off from 100% coverage were handwashing stations and lids to cover holes, both key components in preventing disease transmission. These results have implications for water, sanitation and hygiene (WASH) programming – sustained support may be required to ensure villages move up the sanitation ladder and stay there.

Monitoring sanitation performance: unpacking the figures on sanitation coverage

An understanding of the sanitation situation is crucial for planning and evaluating effectiveness of sanitation interventions. Such knowledge is gained through monitoring sanitation performance. At the international level, sanitation monitoring is done by the Joint Monitoring Programme (JMP) of the World Health Organization (WHO) and United Nations Children's Fund (UNICEF). The JMP tracks progress made towards the Millennium Development Goal (MDG) sanitation target using information collected from household surveys. This article critically describes and reviews the JMP sanitation monitoring approach based on information from literature. The paper argues that while JMP methods have been useful in reporting sanitation progress, it has a number of weaknesses which have led to questions being raised on the sanitation coverage figures. Specifically, the JMP has been criticized for its usage of the term ‘improved’ sanitation and the technology-based sanitation ladder. It is argued that this approach does not monitor other components of sanitation systems such as storage, transport, treatment and disposal and/or re-use of human excreta. In addition, the sustainability of the sanitation systems is also overlooked. All these factors have led to an overestimation of sanitation coverage. A monitoring approach which considers the function of sanitation and sustainability of sanitation systems is therefore recommended.