State of the World’s

An urgent call to transform sanitation for better health, environments, economies and societies Summary report Published by UNICEF and WHO Programme Division/WASH 3 Plaza New York, NY 10017 USA www..org/wash

© United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), 2020

Suggested citation: State of the World’s Sanitation: An urgent call to transform sanitation for better health, environments, economies and societies. New York: United Nations Children’s Fund (UNICEF) and the World Health Organization, 2020.

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Edited by Jeff Sinden. Publication design by Blossom and all graphs designed by Cecilia Silva Venturini. 4 STATE OF THE WORLD'S SANITATION 5

Sanitation is vital to health, child world’s population, 4.2 billion people, development and social and economic use sanitation services that leave human progress. Without it, we cannot fulfil waste untreated, threatening human child rights, and good physical, mental and . Of those, 673 and social -being is unattainable. million people have no at all and Sanitation was recognized as a distinct practise open . An estimated right by the United Nations General 367 million school-age children attend Assembly in 2015. In that same year, schools without toilets. More than 10 Member States committed to the 2030 per cent of facilities have Agenda for Sustainable Development, no sanitation service whatsoever. Only including target 6.2 of the Sustainable 32 per cent of forcibly displaced people Development Goals (SDGs): “By have basic sanitation. 2030, achieve access to adequate and equitable sanitation and for all With only 10 years left until 2030, and end , paying special the rate at which sanitation attention to the needs of women and coverage is increasing will need to girls and those in vulnerable situations”. quadruple if the world is to achieve the SDG sanitation targets. The world is alarmingly off-track At the current rate of progress, sanitation to deliver sanitation for all by for all will not be a reality until the 2030. Despite progress, over half the twenty-second century.

Despite progress, 2 billion people still lack even a basic level of sanitation service

GLOBAL SANITATION COVERAGE, 2000-2017

28% 28% 5% 17% 21% 1.7 billion 1.7 billion 335 million 1 billion 1.3 billion © UNICEF/UN0353556/Ijazah 2000 6.2 billion Summary report 2017 7.6 billion

45% 29% 8% 9% 9% 3.4 billion 2.2 billion 627 million 701 million 673 million

Safely managed Basic Limited Unimproved Open defecation Note: Each square represents 10 million people.

What is safe sanitation?

TOILET CONTAINMENT - CONVEYANCE TREATMENT END USE/DISPOSAL → STORAGE/ → → → S TREATMENT 6 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 7

What does the future look like with and without progress on sanitation?

CLIMATE CHANGE ACCELERATION Resilient sanitation services protect investments in essential sanitation services CHILD SURVIVAL INTESTINAL WORMS SAFETY and ensure sanitation systems are better (AMR) prepared to cope with future shocks More children survive and grow up to be Elimination of cholera in 20 countries Achievement of global targets for control Safe use of wastewater and in healthy adults. with recurrent outbreaks and no more of neglect tropical stand a greater Less antimicrobial use for preventable , horticulture and aquaculture can DECENT WORK uncontrolled outbreaks in fragile settings. chance of being met. Infections are less infections extending the useful of support and the circular economy likely to rebound if drug administration is last line of defense antimicrobials. Fewer and also reduce use of chemical fertilizers HEALTH SERVICES scaled back. untreatable sanitation related infections and recover some of the cost of sanitation Millions of new formalized jobs created that such as drug resistant typhoid. services. will sustain sanitation services, contribute to the green economy and protect Less stress on health systems. Polio could become the second Higher utilization of health services, in history to be eradicated freeing particularly among women, due to better humanity from a debilitating virus. SAFETY AND ENVIRONMENTAL JUSTICE RECREATION facilities. Fewer healthcare acquired Children can realize the full benefits of investment in better nutrition, are less stunted infections. Communities – particularly those with lower Millions of new formalized jobs created that and learn and achieve more at school. , safety, less stress contributing to incomes – have a cleaner environment and will sustain sanitation services, contribute to more equal world healthier neighborhoods. the green economy and protect public health

CHILD SURVIVAL CHOLERA INTESTINAL WORMS ANTIMICROBIAL RESISTANCE (AMR) Every year 830,000 people will die from Outbreaks will continue in hotspots with Regular drug administration will keep Increasing scarcity and Sanitation system will become more preventable diseases. poor sanitation. Precious funds will be infections at bay, but people will continue to Hundreds of millions of doses of will increase demand from peri-urban farms vulnerable to flooding from storms and sea spent on WASH for be re-infected where open defecation and antimicrobials will be used each year for for water and nutrients. Unsafe use of level rise or have less water for flushing and that could be more sustainably spent on use of untreated wastewater for is infections that could have been prevented wastewater and sludge will cause outbreaks conveying . Even small losses will HEALTH SERVICES sanitation to fix the underlying cause. practiced. with better sanitation. Wastewater laden and a increase in chronic foodborne affect the health of whole communities. diseases. with resistant will continue to spread AMR. Health services in communities with poor POLIO NUTRITION ENVIRONMENTAL JUSTICE DECENT WORK sanitation will be burdened with treating preventable infections. Where health centres lack sanitation, women will choose not The goal of global eradication may remain Repeated diarrhoea, caused by poor SAFETY AND Poor and marginalized groups, particularly Sanitation workers, especially in the informal just out of reach due to re-emergence in sanitation, resulting in poor gut function will in low lying areas, will continue to be sector, will continue to suffer indignity to give birth there and there will be more MENTAL HEALTH infections among patients. areas with poor sanitation. prevent people, especially children, from disproportionately affected by other people’s and disease and even death though poor absorbing the nutrients in food needed to unmanaged faecal sludge and sewage. working conditions. grow and thrive. Without sanitation at home, schools and workplaces people, especially women and girls will continue to suffer of anxiety, RECREATION BUSINESS AS USUAL and fear while trying to find a safe place urinate, defecate and manage menstrual Beaches polluted with wastewater will continue to deter or sicken swimmers and damage hygiene. economies in places that rely on clean water bodies for tourism and sports events. 8 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 9

Achieving universal access by 2030 will require dramatic community can have a negative impact and generate positive externalities acceleration in current rates of progress on everyone, through open defecation across society. or discharge of untreated wastewater. In PERCENTAGE OF POPULATION WITH SANITATION SERVICES IN 2000 AND 2017, AND RATE addition to the hard-to-quantify effects The economic benefits of sanitation have OF CHANGE REQUIRED TO MEET SDG TARGETS BY 2030 on dignity, safety and gender equality, been estimated at about five times the there are significant financial costs cost. Estimates indicate that between 100 100 1x No open defecation related to lack of sanitation, including 2017 and 2030, the annual cost to Basic sanitation 91 2x Safely managed preventable health care costs, lost income, achieve universal sanitation would be sanitation forgone educational opportunities, US$105 billion (including capital costs 80 79 74 4x Acceleration decreased productivity and costs resulting and operations and maintenance, with required from environmental . basic sanitation costing US$36 billion 60 per year and safely managed sanitation 56 Achieving universal access to safe US$69 billion per year). The total global 45 sanitation will be expensive, but average capital cost per beneficiary to 40 inaction brings even greater costs. gain access to safely managed sanitation

28 Lack of sanitation results in greater is US$24. recurrent and preventable healthcare 20 Proportion of the population (%) costs, lost income and educational Strong government leadership at opportunities, loss of productivity, and the highest level is key to accelerate 0 environmental pollution. Investments in investment in sanitation services and 2000 2005 2010 2015 2020 2025 2030 sanitation – particularly safely-managed to ensure that all of society reaps the sanitation services – avert these costs benefits.

While the challenge is significant, Sanitation is also a public good, history shows that rapid progress providing benefits across society in is possible. Many countries have made improved health and economic and social rapid progress in sanitation coverage development. To accelerate progress, within a generation, transforming , sanitation must be defined as an essential the environment and the economy. In the public service, foundational for a healthy 1960s and 1970s, , the Republic of population and prosperous society. Korea, Singapore and produced Progress also requires responsibility and rapid and remarkable results to achieve across multiple sectors total sanitation coverage. More recently, and levels of government for ensuring countries such as Ethiopia, India and sanitation for all – along all steps of the Nepal have dramatically reduced open sanitation service chain, from the , to defecation and made progress towards treatment and disposal, to end use. universal access to basic sanitation. In each case, the common factor has Lack of safe sanitation leads to been strong political leadership, with multiple negative outcomes. It can government playing an important role cause illness and disease, particularly in setting policies and plans, mobilizing among children, such as diarrhoea, worm investment, regulating services, infections and stunting. The impacts of galvanizing widespread participation and poor sanitation disproportionately continuously learning and adapting. affect the most vulnerable and disadvantaged, particularly women Sanitation is a human right. and people living with disabilities. Everyone is entitled to sanitation Sanitation workers, who are services that ensure privacy, dignity essential to sustain services, often and safety, and that are accessible and face higher health risks, stigma and affordable. To safeguard health and the marginalization in an unhealthy and environment, everyone needs sanitation unregulated environment. services that prevent exposure to unmanaged wastewater and harmful, Even if some have sanitation

unmanaged waste. facilities, poor sanitation elsewhere in the © UNICEF/UN0348903/Modola 10 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 11

Sustainable and effective water, sanitation the practice. Similarly, the critical and hygiene (WASH) service delivery is issue of faecal sludge management is Imagining a better future: determined not only by but not addressed in a quarter of urban also by complex institutional, governance sanitation policies or plans. Further, A dramatic acceleration in and financial management systems. regulatory institutions often lacking Currently, sanitation suffers from chronic sufficient funds and human to progress is possible under-prioritization, lack of leadership, undertake surveillance and enforcement under-investment and a lack of capacity. of regulations. Often, operations and maintenance are not well planned, with Investment in five key ‘accelerators’ recognized as a multi-sectoral issue Most countries have national costs not covered through existing tariffs – governance, financing, that has impacts across health, social policies and plans for sanitation, and user fees. Countries are responding capacity development, data and development, education, the economy yet few have adequate human and to the SDG imperative to ‘leave no information, and innovation – and the environment. Sanitation financial resources to support one behind’, with over two-thirds of identified under the UN-Water SDG must be included in national policies, them. Many countries’ sanitation countries reporting that they have policy 6 Global Acceleration Framework – strategies and plans, and needs policies have significant gaps. For measures to reach poor populations with can be a pathway towards countries’ to be backed by adequate human instance, about one-quarter of countries sanitation. However, only one quarter achievement of safe sanitation for all, and financial resources. Sanitation where open defecation is practiced lack have identified the means of funding with coordinated support from the service provision, including through specific policies and plans to address these policies. multilateral system and partners. the private sector and informal A World Health Organization (WHO) provision, should be supported analysis categorized countries into five through a legislative framework and Few countries have formally approved, adequately resourced groups according to historical rates of policies, accompanied by standards sanitation policies sanitation progress and asked: "how for service quality throughout the many more people could be reached if sanitation chain (sewered and non- NUMBER OF COUNTRIES REPORTING FORMALLY APPROVED POLICIES SUPPORTED BY every country accelerated to match the sewered) and a simple, transparent, RESOURCED PLANS, 2019 highest achievers in their group?". With effective regulatory and enforcement just this shift, an additional 200 million environment, allowing innovation, cost Countries with formally approved policy people would gain access in the next recovery and provision for serving the and approved and costed plan 3 with suicient financial 5 five years, bringing the world much poor and vulnerable. Clearly defined and human resources closer to universal access by 2030. leads and institutional arrangements Countries with formally that avoid gaps and overlaps in 44 approved policy and 46 approved and costed plan Governments must ensure that coverage mandates across the sanitation extends to entire communities, deploying service chain, have enabled success Countries with formally a mix of approaches and services. in many countries. Safe sanitation 48 approved policy 51 and approved plan Sanitation programmes must ensure can be delivered effectively through universal access and use of toilets that a mix of approaches and systems Countries with formally safely contain excreta. Sanitation coverage tailored to the local context. Well- 63 approved policy 67 must extend beyond the so balanced regulation is key to ensuring

Countries with policies formally that everyone in schools, health care effective , while also 101 approved OR under revision 104 facilities, workplaces and public places developing effective and innovative OR under development has access. Incremental progress, responses. This extends to the 100 80 60 40 20 0 0 20 40 60 80 100 120 addressing the highest risks first, must sanitation workforce, which requires Number of countries Number of countries ensure safe management at all steps of increased regulation and formalization. Rural sanitation Urban sanitation the sanitation chain to be sustainable and to truly protect public health and the 2. Smart public finance unlocks environment as described in the WHO effective household and private Guidelines on Sanitation and Health. investment Most countries report insufficient 1. Good governance begins resources to meet their national with leadership, effective sanitation targets. Identifying and coordination and regulation mobilizing appropriate funding Sanitation needs to be defined sources and financing instruments is as an essential service for which critical if countries are to meet their government is responsible and can be aspirations in the most cost-effective held accountable. Sanitation must be and efficient manner. Public funding 12 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 13

is important to lay the foundation oriented sanitation and to implement for safe sanitation services that effective cost recovery mechanisms. reach the poorest, and to galvanize Supporting the private sector to other actors’ contributions in the capitalize on the ‘sanitation economy’ sector. Government investments – a marketplace of products and must be used strategically to attract services, renewable flows and optimize other investments, and data and information related to recognizing that most funding for sanitation – requires building the skills sanitation comes from households of service providers and their ability to themselves in the form of tariffs, respond to environmental conditions user fees and toilet purchases. There and climate change. are multiple sources of funding for sanitation that governments can 4. Reliable data support better access and combine, including decision-making and stronger taxes, transfers from external donors, accountability and tariffs and user fees. Various Reliable, consistent and, whenever forms of repayable finance can be possible, disaggregated data are mobilized, such as loans, bonds essential to stimulate political and other financing instruments. commitment, inform policymaking Governments must make evidence- and decision-making, and enable based decisions on the allocation well-targeted investments and course of funds and hold service providers corrections to maximize health, accountable. Governments can enter environmental and economic gains. into public-private partnerships The value of survey and census to access financing and expertise data can be increased by using from the private sector. In addition harmonized questions that allow to sanitation systems and services, comparison with other surveys and governments must also budget for enable tracking of national, regional the costs associated with a conducive and global indicators. Robust enabling environment, sustained over sanitation monitoring mechanisms are the long-term, particularly concerning needed at the lowest administrative building and maintaining institutional level, using existing structures and and regulatory capacity. linked with existing reporting and

accountability structures at the local © UNICEF/Jordan/Saman 3. Capacity at all levels drives and national level. progress and sustains services The lack of emphasis historically 5. Innovation leads to better meeting the needs of high-density This report presents the state of sanitation placed on sanitation has resulted approaches and helps meet populations living in poverty, often in in the world today and is intended to in significant capacity shortfalls emerging challenges informal settlements. In rural areas, increase awareness of the progress made throughout the system. Developing Achieving universal access to context-specific, community-based towards achieving the SDG targets for a strong sanitation sector will require safe sanitation requires innovative approaches help ensure , and to identify opportunities to a larger workforce with better skills. solutions. New approaches and services for all. Climate change meet the challenges that remain. It calls Capacity development is more than systems can ‘future-proof’ the and mounting resource pressure on Member States, the United Nations training. It encompasses human sector against disease outbreaks, necessitate innovative ways to system and partners to urgently rise to resource development, organizational urbanization, climate change and deliver services that will be resilient these challenges as part of the SDG 6 development and research and increasing pressure on natural and enable resource-recovery. Global Acceleration Framework. innovation. National governments resources, with solutions that are Governments must think beyond need the skills to develop and practical, cost-effective and scalable. conventional systems, By presenting best practices, case administer effective strategies, Adopting such innovations can also which are costly and time-consuming studies, successes and challenges, policies, costed plans and regulations. support equality and universality of to install. Governments can enable this report seeks to inspire Member To adopt new approaches, local services, helping extend sanitation innovation through sound regulation, States and all stakeholders to learn from government and utilities need to the hardest-to-reach areas and performance criteria and standards each other and work together towards to have the necessary capacity groups. Increased urbanization that reduce risk but do not stifle new achieving universal access to safe to oversee and deliver service- and migration call for new ways of ideas and entrepreneurship. sanitation by 2030. 14 STATESTATE OF SANITATION OF THE WORLD'S REPORT SANITATION References

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Programme Division/WASH 3 United Nations Plaza New York, NY 10017 USA www.unicef.org/wash