State of the World’s SANITATION

An urgent call to transform sanitation for better health, environments, economies and societies 2 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 3 Acknowledgements

Published by UNICEF and WHO Programme Division/WASH 3 United Nations Plaza New York, NY 10017 USA www.unicef.org/wash This report is the result of collaboration between a large number of contributors, reviewers and editors. The development of the report was led by Brooke Yamakoshi (WASH Specialist, UNICEF) and Kate © United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), 2020 Medlicott (Sanitation and Wastewater Team Leader, World Health Organization), under the overall direction and guidance of Kelly Ann Naylor (Associate Director for WASH, UNICEF) and Bruce Gordon Suggested citation: State of the World’s Sanitation: An urgent call to transform sanitation for better health, (WASH Coordinator, World Health Organization). The report was compiled and edited by Clarissa environments, economies and societies. New York: United Nations Children’s Fund (UNICEF) and the Brocklehurst and Simon Mead. World Health Organization, 2020. This document could not have been produced without the valuable contributions of authors who UNICEF ISBN: 978-92-806-5187-4 provided text and graphics, including: WHO ISBN: 978-92-4-001447-3 • UNICEF Headquarters: Bisi Agberemi, Lizette Burgers, Guy Hutton and Leah Selim. Permission is required to reproduce any part of this publication. For more information on usage rights, please contact [email protected] • UNICEF Togo Country Office: Tagha Assih and Fataou Salami.

The designations employed and the presentation of the material in this publication do not imply the • United Nations High Commissioner for Refugees: Eva Barrenberg and Ryan Schweitzer. expression of any opinion whatsoever on the part of UNICEF or WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or • WHO: Sophie Boisson, Betsy Engebretson, Fiona Gore, Mark Hoeke, Sofia Murad and Marina boundaries. Dotted or dashed lines on maps represent approximate border lines for which there may not Takane. yet be full agreement. • WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene: Rob Bain, The mention of specific companies or of certain manufacturers’ products does not imply that they are Rick Johnston, Francesco Mitis and Tom Slaymaker. endorsed or recommended by UNICEF or WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial Thanks are due to Canisius Kanangire, Executive Secretary of the African Ministers’ Council on Water, capital letters. who facilitated learning from the preparation of the African Sanitation Policy Guidelines, and to Amaka Godfrey who led the team in the development of the guidelines, which was underway in parallel All reasonable precautions have been taken by UNICEF and WHO to verify the information contained in with the drafting of this document. Particular acknowledgement is due to two of the authors of the this publication. However, the published material is being distributed without warranty of any kind, either guidelines, Goufrane Mansour and Peter Hawkins, who contributed text for the financing solutions and expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In capacity building sections, respectively, and provided review of the document. Thanks are also due to no event shall UNICEF or WHO be liable for damages arising from its use. Ann Thomas and Mitsunori Odagiri (UNICEF Indonesia), Siddhi Shrestha (UNICEF Nepal), Jolly Ann Maulit (UNICEF Regional Office for West and Central Africa), Gloria Lihemo (UNICEF Regional Office The statements in this publication are the views of the author(s) and do not necessarily reflect the policies for South Asia), and Oliver Schmoll and Shinee Enkhtseteg (WHO Regional Office for Europe), who or the views of UNICEF or WHO. reviewed case studies included in the report. We acknowledge with thanks the detailed review provided by Jan Willem Rosenboom (Bill & Melinda Gates Foundation) and Andrés Hueso (WaterAid) and inputs Edited by Jeff Sinden. Publication design by Blossom and all graphs designed by Cecilia Silva Venturini. from Leanne Burney and Cheng Li (UN-Water). 4 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 5 Contents

WHY IS1 THIS REPORT 14 WHAT2 ARE THE 20 WHAT3 PROGRESS HAS 30 WHAT4 IS THE 52 IMAGINING5 A BETTER 62 GOVERNMENTS6 66 NECESSARY? CONSEQUENCES OF BEEN MADE TOWARDS STATUS OF POLICY FUTURE: A DRAMATIC CAN ACCELERATE POOR SANITATION? UNIVERSAL ACCESS AND FINANCE FOR ACCELERATION SANITATION 1.1 15 TO SANITATION? SANITATION? IN PROGRESS IS PROGRESS WITH Defining the challenge 2.1 21 POSSIBLE PROVEN, EFFECTIVE Health impacts 3.1 31 APPROACHES 1.2 17 Sanitation in 4.1 53 Things you need to 2.2 26 households Status of sanitation know before reading Economic costs policy 6.1 68 this report 3.2 42 Good governance 2.3 28 Sanitation in schools 4.2 56 begins with leadership, Social impacts The cost of achieving effective coordination 3.3 46 universal sanitation and regulation Sanitation in health care facilities 4.3 59 6.2 72 How much is being Smart public finance 3.4 49 invested, and where is unlocks effective Sanitation for forcibly it coming from? household and private displaced persons investment

6.3 75 Capacity at all levels drives progress and sustains services Acknowledgements 3 6.4 79 Foreword 8 Reliable data support better decision- Acronyms 10 making and stronger and abbreviations accountability

Executive summary 11 6.5 82 Innovation leads to Endnotes 90 better approaches and meets emerging challenges 6 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 7 Tables, figures FIGURE 18: Number of countries reporting formally approved policies supported by resourced plans, 54 2019 FIGURE 19: Number of countries with urban policies and plans that address faecal sludge 54 management, 2019 and boxes FIGURE 20: Percentage of respondent countries with formal national standards for wastewater, on-site 55 sanitation, faecal sludge and safe use, 2019 FIGURE 21: Annualized costs of achieving universal sanitation globally, 2017-2030 56 FIGURE 22: Annualized costs of achieving universal safely managed sanitation by SDG region, 2017-2030 57 FIGURE 23: Annual rural/urban funding gap to reach national sanitation targets, 2018 60 FIGURE 24: Percentage of countries indicating that more than 80 per cent of O&M costs are covered 60 by tariffs, 2013-2018 TABLES TABLE 1: Disease burden linked directly or indirectly to inadequate sanitation, 2016 21 TEXT BOXES BOX 1: SDG targets related to sanitation 17 FIGURES BOX 2: Sanitation terms and concepts 18 FIGURE 1: Health risk can come from all steps of the sanitation service chain 24 BOX 3: WHO/UNICEF JMP and the UN-Water Global Analysis and Assessment of Sanitation and 19 FIGURE 2: Economic losses associated with inadequate sanitation by region, as a 26 Drinking-Water (GLAAS) percentage of GDP, 2019 BOX 4: Reaping the economic benefits of improved sanitation in India 27 FIGURE 3: JMP service ladder for global monitoring of sanitation in households 33 BOX 5: Recognizing the human right to safe sanitation 29 FIGURE 4: Global sanitation coverage, 2000-2017 33 FIGURE 5: Progress towards eliminating open defecation, 2000-2017 34 BOX 6: Eliminating open defecation in Nepal 35 FIGURE 6: Percentage of population practising open defecation and living in communities 36 BOX 7: Improving sanitation in schools in Togo 45 where at least one household practises open defecation, 2015-2018 BOX 8: Estimating access to sanitation service amongst forcibly displaced persons in Afghanistan 51 FIGURE 7: Trends in coverage of basic sanitation among the richest and poorest wealth 37 quintiles, 2000-2017 BOX 9: Setting goals for health-protective sanitation based on global research and practice 64 FIGURE 8: Percentage of population using sewer connections, septic tanks, latrines and 39 BOX 10: Strengthening government leadership for sanitation in Ethiopia 65 other improved on-site systems in 2017, and percentage point change, 2000-2017 FIGURE 9: Percentage of population using safely managed sanitation services, 2017 40 BOX 11: Support to all levels of government in Indonesia 68 FIGURE 10: Percentage of population with sanitation services in 2000 and 2017, and rate of 41 BOX 12: Transformative leadership for sanitation successes in East Asia 69 change required to meet SDG targets by 2030 BOX 13: Supporting policy development through the African Sanitation Policy Guidelines 70 FIGURE 11: Sanitation services ladder for schools 42 BOX 14: Strengthened sanitation policy and planning for rapid progress in Nepal 71 FIGURE 12: Regional and global sanitation coverage in schools, 2015 and 2019 43 BOX 15: Harnessing public private partnerships for sanitation: Safe wastewater use in Durban, 74 FIGURE 13: Percentage of schools in rural sub-Saharan Africa where all sanitation facilities 44 South Africa meet additional criteria, 2017 BOX 16: Protecting sanitation worker health and safety in Bolivia 78 FIGURE 14: Sanitation services ladder for health care facilities 47 BOX 17: Monitoring safely managed sanitation in Ecuador 80 FIGURE 15: Percentage of health care facilities with elements of basic sanitation across 47 BOX 18: Monitoring of policy identifies gaps in Botswana and Namibia 81 three countries, 2019 BOX 19: Taking a new approach to improving sanitation coverage in Eastern Europe 83 FIGURE 16: Percentage of health care facilities with no sanitation service, 2019 48 BOX 20: Developing integrated sanitation solutions for all though citywide inclusive sanitation 84 FIGURE 17: Sanitation services available in refugee and non-refugee populations in 51 BOX 21: Growing government commitment to solving rural sanitation in Kenya and Tanzania 85 Afghanistan BOX 22: Making every drop count through safe use of wastewater in Jordan 87 8 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 9

of local governments, the private sector, civil society and households. Sometimes action begins with small incremental steps, but taking those first steps is key.

The COVID-19 pandemic has reminded us once again of the central role that water, sanitation and hygiene (WASH) play in protecting us from disease. The Foreword unprecedented levels of public investment in health and economic recovery from the pandemic create a once-in-a-lifetime opportunity to not only prevent future pandemics, but to imagine a more equitable future.

Progress is possible – we have seen many examples of countries dramatically improving sanitation through government leadership, political prioritization, partnerships and strategic public investment.

Learning from these successes, we can improve sanitation globally. But we must act now, work together and accelerate rapidly. We have no time to lose.

We are calling on Member States to rise to the challenge – to take action on sanitation and claim the many benefits to the health of their citizens, their economies and the environment. Our organizations are committed to supporting Member States as they meet this important challenge, and provide the strong, effective and lasting Safe sanitation is one of the foundations of a healthy, comfortable and dignified sanitation systems that communities deserve. life. Yet, the reality for billions of people is one of polluted environments, in which one or many of the links in the chain that makes up safe sanitation – toilets, waste treatment, disposal and safe re-use – is missing or out-of-reach.

Recognizing this, the global community is committed to achieving universal access to sanitation and hygiene by 2030, paying special attention to the needs of women, girls and those in vulnerable situations, and improving water quality and safe wastewater re-use.

But progress against the sanitation targets in Sustainable Development (SDG) 6 has been too slow. We need massive acceleration. And this challenge comes amid the trials of a global pandemic, an economic recession, and the on-going climate crisis.

As the world celebrates the tenth anniversary of the United Nations adoption of the human right to water and sanitation, and five years since sanitation was recognized as a distinct human right, we must ask: What will it take to close the inequality gap for sanitation in the next decade?

It is time to bend the arc of history and achieve sanitation for all within a generation.

All of us – individuals, communities and governments – must rise to the challenge. Sanitation benefits entire societies and must be treated as a common good, with every aspect of the sanitation chain addressed together. This calls for not only individual responsibility, but strong, coordinated national leadership. The collective benefit of sanitation cannot be fully achieved without government action in terms of robust policy, clear regulation and strategic, targeted investment that triggers and optimizes contributions from households and the private sector.

Although the challenge of meeting SDG 6 for sanitation is formidable, history shows us that countries can make tremendous gains in access to sanitation within just one generation. Governments that take action on sanitation will unlock further progress HENRIETTA H. FORE DR. TEDROS ADHANOM GHEBREYESUS in health, education, food security, nutrition, employment and tourism. Success Executive Director Director-General comes from demonstrated political will, adaptive planning and the engagement UNICEF World Health Organization 10 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 11 Acronyms Executive and Summary abbreviations

AMCOW African Ministers’ Council on Water The world is alarmingly off-track to deliver sanitation for all by 2030. Despite progress, over half of the world’s population, 4.2 billion people, use sanitation CWIS citywide inclusive sanitation services that leave human waste untreated, threatening human and environmental health. An estimated 673 million people have no toilets at all and practise open DALY disability-adjusted life year defecation, while nearly 698 million school-age children lacked basic sanitation services at their school. The consequences of poor sanitation are devastating to GDP gross domestic product public health and social and economic development.

GRP gross regional product With only 10 years left until 2030, the rate at which sanitation coverage is increasing will need GVA gross value added to quadruple if the world is to achieve the SDG GLAAS UN-Water Global Analysis of Sanitation and Drinking-Water sanitation targets.

IDP internally displaced person At the current rate of progress, it will be the twenty-second century before sanitation for all is a reality. Clearly this is too slow. JMP WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene While the challenge is significant, history shows that rapid progress is possible. To accelerate progress, sanitation must be defined as an essential public good – one O&M operations and maintenance that is foundational for a healthy population and prosperous society. Many countries have made rapid progress in sanitation coverage within a generation, transforming PPP public-private partnership lives, the environment and the economy. Every country that has made rapid progress has had strong political leadership, with government playing an important role in SBM Swachh Bharat Mission policy, planning, mobilizing investment and regulating services.

SDG Sustainable Development Goal Sanitation is a human right. Everyone is entitled to sanitation services that provide privacy, ensure dignity and safety, and that are physically accessible and affordable. UHC universal health coverage Sanitation is also a public good, providing benefits across society in improved health as well as economic and social development. The lack of safe sanitation leads UNHCR United Nations High Commissioner for Refugees to illness and disease that disproportionately affect children, including diarrhoea, worm infections and stunting. But poor sanitation affects everyone, and a polluted WASH water, sanitation and hygiene environment impacts the entire community, whether or not an individual household has a sanitation facility. In addition to hard-to-quantify effects on dignity, safety and WHO World Health Organization gender equality, there are significant financial costs related to lack of sanitation, 12 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 13

including increased health care costs, lost income, forgone educational opportunities 3. CAPACITY AT ALL LEVELS DRIVES PROGRESS AND SUSTAINS and costs resulting from pollution. Poor sanitation disproportionately affects SERVICES the most vulnerable and disadvantaged, particularly women and people Developing a strong sanitation sector will require a bigger workforce with better living with disabilities. Sanitation workers, often stigmatized and marginalized, face skills. Capacity development is more than training. It encompasses human resource unacceptable health risks and indignities in an unhealthy and unregulated environment. development, organizational development, resourcing and research and innovation. National governments need the skills to develop and administer effective Achieving universal access to safe sanitation will be expensive, but inaction brings regulations, policies, strategies and costed plans. The adoption of new approaches greater costs. Investments in sanitation – particularly safely managed sanitation to sanitation will require local government and utilities to have the necessary services – generate positive externalities across society. The economic benefits of capacity to oversee and deliver more service oriented sanitation and to implement sanitation have been estimated at about five times the cost – a cost-benefit ratio effective cost recovery mechanisms. Growing the private sector to capitalize on the greater than that of water supply1. Strong government leadership is key to accelerating ‘sanitation economy’ requires building the skills of service providers and their ability coverage of sanitation services and to ensuring that all of society reaps the benefits. to respond to environmental conditions and climate change.

Investment in five key ‘accelerators’ – governance, financing, capacity 4. RELIABLE DATA SUPPORT BETTER DECISION-MAKING development, data and information, and innovation – identified under the AND STRONGER ACCOUNTABILITY UN-Water SDG 6 Global Acceleration Framework – can be a pathway towards Accelerating progress on sanitation will require more comprehensive data achieving universal and safe sanitation for all. on each aspect of the sanitation chain from toilet type to arrangements for storage, conveyance, treatment and reuse of human waste. Reliable, consistent 1. GOOD GOVERNANCE BEGINS WITH LEADERSHIP, EFFECTIVE and, wherever possible, disaggregated data are essential to stimulate political COORDINATION AND REGULATION commitment, inform policy-making and decision-making, and enable well- Governments must establish institutions to coordinate and regulate the activities targeted investments that maximize health, environmental and economic gains. of government, service providers and service users, and generate public benefits. Robust sanitation monitoring mechanisms to track policy and regulation are Sanitation must be included in national policies, strategies and plans, and needs needed at the lowest administrative level, using existing structures and linked to be backed by human and financial resources. Many countries have significant with reporting and accountability structures at the local and national level. policy gaps. For instance, in countries where open defecation is still practised, about one quarter lack specific policies and plans to address it. Similarly, the 5. INNOVATION LEADS TO BETTER APPROACHES critical issue of faecal sludge management is not addressed in one quarter of AND MEETS EMERGING CHALLENGES urban sanitation policies and plans. Even where policies are in place, few countries Achieving universal access to safe sanitation requires innovative solutions. New have adequate human and financial resources to support them. While most approaches and systems can ‘future-proof’ the sector against disease outbreaks, countries are responding to the SDG imperative to ‘leave no one behind’ – over urbanization, climate change and increasing pressure on natural resources, two thirds of countries reported policy measures to reach poor populations with with solutions that are practical, cost-effective and scalable. Adopting such sanitation – only one quarter have identified the means of funding these policies2. innovations can also support equity and universality of services, helping extend sanitation to the hardest-to-reach areas and groups. Governments must think Safe sanitation can be delivered effectively through a mix of approaches and beyond conventional sewage systems, which are costly and time-consuming systems tailored to the local context. Coverage must include entire communities to install. Governments can enable innovation through sound regulation, and extend beyond the household to schools, health care facilities, workplaces performance criteria and standards that reduce risk but do not stifle new ideas and public places. Well-balanced regulation is key to ensuring effective risk and entrepreneurship. management, while also developing effective and innovative responses. This report presents the state of sanitation in the world today to increase awareness 2. SMART PUBLIC FINANCE UNLOCKS EFFECTIVE HOUSEHOLD of the progress made towards achieving the SDG targets for sanitation, and the AND PRIVATE INVESTMENT challenges that remain. It calls on Member States, the United Nations system Most countries report insufficient resources to meet their national sanitation and partners to rise to these challenges within the context of the SDG 6 Global targets. Identifying and mobilizing appropriate funding sources and financing Acceleration Framework. instruments is critical if countries are to meet their aspirations in the most cost- effective and efficient manner. Public funding is important to lay the foundation By presenting best practices, case studies, successes and challenges, this report for safe sanitation services that reach the poorest. There are multiple sources seeks to inspire Member States and all stakeholders to learn from each other and of funding for sanitation that governments can access and combine, including work together towards achieving universal access to safe sanitation by 2030. taxes, transfers from external donors, and tariffs and user fees. Government investments must be used strategically to attract and optimize other investments, recognizing that most funding for sanitation comes from households themselves. Various forms of repayable finance can be mobilized, such as loans, bonds and other financing instruments. Governments can enter into public-private partnerships (PPPs) to access financing and expertise from the private sector. 14 STATE OF THE WORLD'S SANITATION 15

1.1 © WHO Defining the challenge

© UNICEF/India/Qadri Sanitation is vital to health, child before 2030, the rate at which development, and social and economic sanitation coverage is increasing progress. Safe sanitation is also a human will need to quadruple to achieve right – essential for the fulfilment of child SDG target 6.2. At the current rate of rights and the achievement of good progress, it will be the twenty-second Why is this report physical, mental and social well-being century before sanitation for all is a – recognized as a distinct right by the reality. This is too slow. necessary? General Assembly of the United Nations in 2015. In the same year, Member Sanitation suffers from chronic under- States committed to the 2030 Agenda prioritization, lack of leadership, under- 1.1 Defining the challenge for Sustainable Development, including investment and a lack of capacity. While target 6.2 of the SDGs: “By 2030, achieve the majority of countries have national 1.2 Things you need to know before reading this report access to adequate and equitable policies and plans to support sanitation, sanitation and hygiene for all and end few have allocated adequate human open defecation, paying special attention and financial resources to actually to the needs of women and girls and implement them.3 Donors tend to those in vulnerable situations”. prioritize water over sanitation. In fact, aid disbursements for sanitation were Progress towards universal half that for drinking-water between 2010 sanitation is alarmingly off track, and 2018. Within the larger water and and uneven in its coverage, sanitation sector (including, for example, resulting in inequalities and the water resources management and river further marginalization of the most basin development), aid disbursements 1 vulnerable. With only 10 years left for sanitation systems in the last nine 16 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 17

years have never exceeded 15 per cent sanitation coverage. More recently, of the total.4 The total investment in India has created a mass movement sanitation from governments and donors which has dramatically reduced and is not enough to provide the sustainable, almost eliminated the undignified and 1.2 resilient, safely managed services that will dangerous practice of open defecation, bring about substantive benefits to health, which disproportionately affects the rural Things you need to know the economy and the environment. poor. Since 2000, Cambodia and Ethiopia reduced open defecation by more than Achieving universal access to 50 percentage points, and Cambodia, before reading this report sanitation by 2030 will require Indonesia, the Lao People’s Democratic dramatic acceleration in current Republic and Nepal increased the use of rates of progress. Global rates of at least basic sanitation services by more This report uses a variety of terms that Box 1 summarizes the SDG targets most progress need to double to achieve basic than 40 percentage points. Governments the reader may not be familiar with. directly related to sanitation, which are sanitation for all, and universal access in many other countries are helping They are summarized in Box 2 to aid the focus of this report. However, linkages to safely managed sanitation requires individuals and communities move up the understanding of the report. have been identified between sanitation them to quadruple. However, these sanitation ladder towards universal access and 130 of the SDG 169 targets.6 global averages mask the fact that some to safely managed sanitation services – by countries, and some communities within mobilizing communities, strengthening SDG targets related to sanitation countries, are starting from a much markets and service providers, deploying lower baseline. In these places, the rate a range of funding and financing BOX 1 of change must be even greater if the mechanisms to build resilient sanitation pledge to ‘leave no one behind’, made by services that make better use of scarce SDG GLOBAL TARGETS SDG GLOBAL TARGETS Member States when they adopted the resources, recycling waste for economic 2030 Agenda, is to be honoured. and environmental benefits, and building 6.2: By 2030, achieve access 6.2.1: Proportion of population the circular economy. to adequate and equitable using (a) safely managed Governments have a critical role sanitation and hygiene for all sanitation services and (b) a to play. Sanitation is a public good The COVID-19 pandemic has exacerbated and end open defecation, paying handwashing facility with soap in need of public funding that will many sanitation challenges. People special attention to the needs of and water allow everyone to benefit from have been isolated at home, where they women and girls and those in vulnerable situations improved health as well as social have unsafe sanitation facilities or are Additional indicator for SDG and economic development. Poor forced by their lack of sanitation facilities 6.3: By 2030, improve water quality 6.2: Proportion of population sanitation creates serious negative into unsafe, communal areas, such as by reducing pollution, eliminating practising open defecation externalities, creating public health poorly managed public latrines or open dumping and minimizing release hazards and jeopardizing economic defecation areas. Sanitation workers, of hazardous chemicals and 6.3.1: Proportion of wastewater development for all. Conversely, good obliged to keep working as they perform materials, halving the proportion safely treated sanitation generates economic benefits an essential service, add one more of untreated wastewater and substantially increasing recycling and unlocks human productivity. health hazard to what is often a long list. and safe reuse globally Regulation throughout the The pandemic has reinforced what the sanitation chain is crucial to ensure evidence makes clear: poor sanitation 1.4: By 2030, ensure all men and 1.4.1: Proportion of population living that the benefits are realized by everyone. puts everyone at risk. women, in particular the poor and in households with access to basic vulnerable, have equal rights to services (including access to basic History shows it can be done. There This report presents the state of economic resources as well as drinking-water, basic sanitation are many countries that have been sanitation in the world today to increase access to basic services… and basic handwashing facilities) successful in making rapid progress awareness of the progress towards 3.8: Achieve universal health [Proportion of health care facilities in sanitation coverage, transforming achieving the SDG target for sanitation, coverage (UHC), including financial with basic water, sanitation lives, the environment and the economy and the challenges that remain. Within risk protection, access to quality and hygiene (WASH) services, within a generation. With strong political the context of the recently-developed essential health care services, and including basic sanitation] leadership, sufficient resources and a SDG 6 Global Acceleration Framework5, access to safe, effective, quality ‘whole-of-government’, multi-stakeholder it presents best practices, successes and and affordable essential medicines and vaccines for all approach, governments can quickly challenges. It calls on Member States, transform sanitation and find ways the United Nations system and other 4.a: Build and upgrade education 4.a.1: Proportion of schools with to put the last first. In the 1960s and stakeholders to rise to the challenge, facilities that are child, disability and access to…. (e) basic drinking- 1970s, Malaysia, the Republic of Korea, learn from one another and work gender sensitive and provide safe, water, (f) single-sex basic Singapore and Thailand produced rapid together to achieve universal access to non-violent, inclusive and effective sanitation facilities, and (g) basic and remarkable results to achieve total safe sanitation by 2030. learning environments for all handwashing facilities 18 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 19

Sanitation terms and concepts BOX 2

SANITATION The management of human excreta, defined here as faeces, urine and menstrual blood.

SANITATION The sanitation service chain includes the stages in a safe SERVICE CHAIN sanitation system: capture, containment, emptying, transport, treatment and safe disposal.

SANITATION LADDER The World Health Organization (WHO)/UNICEF Joint Monitoring Programme (JMP) for Water Supply, Sanitation and Hygiene defines five levels of service: open defecation; unimproved; limited; basic; and safely managed (see Chapter 3).

SAFELY MANAGED The indicator used to measure progress on SDG target 6.2 SANITATION is the percentage of the population using “safely managed sanitation services”. To be safely managed, sanitation facilities should not be shared with other households, and the excreta produced should either be: treated and disposed in situ; stored temporarily and then emptied and transported to treatment off- site; or transported through a sewer with wastewater and then treated off-site.

SEWERED A sanitation system in which waterborne excreta (referred to as SANITATION wastewater or sewage) is collected and transported to treatment Quarmyne © WaterAid/Nyani before disposal or use. This type of system relies on sewers and flush water for transport. It is often referred to as ‘off-site’ sanitation as waste is transported away from the location where WHO/UNICEF JMP and the UN-Water Global Analysis and it is generated for treatment. Assessment of Sanitation and Drinking-Water (GLAAS) NON-SEWERED A sanitation technology or system in which excreta (referred to SANITATION as faecal sludge) is collected and stored at the location where it BOX 3 is generated (for this reason it is sometimes referred to as ‘on- site’ sanitation). It is then either treated and disposed of on-site, Two monitoring platforms have been mandated data compiled by the JMP not only reveal or emptied and transported to another location for treatment to monitor progress towards the achievement of progress, but highlight persistent inequalities and disposal. Examples include pit toilets, septic tanks and the sanitation-related targets of SDG 6: in the sanitation sector. container-based systems.

DISABILITY-ADJUSTED A measure of overall disease burden, expressed as the number of • The JMP produces internationally comparable • The GLAAS is implemented by WHO on LIFE YEAR (DALY) years lost due to ill-health, disability or early death, and calculated estimates of progress on drinking-water, behalf of UN-Water. It monitors components by adding the number of years of life lost to the number of years sanitation and hygiene and is responsible of WASH systems, including governance, lived with disability for a certain disease or disorder. for monitoring the SDG targets related to monitoring, finance and human resources, WASH. Since the establishment of the SDGs, necessary to sustain and extend WASH CIRCULAR ECONOMY An economy in which waste and pollution do not exist by the JMP has published global baseline services to all, and especially to the most design, products and materials are kept in use, and natural reports on WASH in households, schools vulnerable. WHO, through GLAAS, also systems are regenerated. This is considered a key component and health care facilities, which are updated monitors the means of implementation of several SDGs. with progress reports every two years. The targets for SDG 6. 20 STATE OF THE WORLD'S SANITATION 21 2.1 Health impacts

The lack of safe sanitation systems leads • Antimicrobial resistance, by to a range of adverse health impacts, increasing the risk of preventable including:7 infections that are treated with • Diarrhoea, a major public health antibiotics and by spreading concern and a leading cause of excreted resistant organisms in disease and death among children the environment though untreated under five years of age in low- wastewater and sludge.8 and middle-income countries. • Anaemia and spontaneous This includes cholera, an acute abortion and pre-term birth diarrhoeal disease that can kill within associated with soil-transmitted hours if left untreated. helminth infections (worms).9 • Neglected tropical diseases such as soil-transmitted helminth Globally, it is estimated that 1.9 million infections, schistosomiasis and deaths and the loss of over 120 million trachoma, which account for a disability-adjusted life years (DALYs) significant burden of disease globally. could have been prevented with adequate • Vector-borne diseases such as WASH in 2016. Inadequate sanitation West Nile virus or lymphatic filariasis contributes directly or indirectly - via (through poor sanitation facilitating contaminated drinking-water and hands the proliferation of Culex mosquitos). - to approximately 830,000 deaths and • Stunting, which affects almost over 49 million DALYs due to diarrhoeal one quarter of children under five diseases and many more from other years of age globally through several diseases and conditions including © UNICEF/UN0202171/Sokhin mechanisms, including repeated soil-transmitted helminth infections, diarrhoea, helminth infections and malnutrition, trachoma, schistosomiasis, environmental enteric dysfunction lymphatic filariasis and those linked to related to unsanitary conditions, inadequate wastewater management and leads to poor physical and practices (see Table 1). What are the cognitive development.

TABLE 1. Disease burden1 linked directly or indirectly to inadequate consequences of sanitation, 201610

poor sanitation? DISEASE DEATHS DALYS POPULATION- (1,000S) ATTRIBUTABLE FRACTION 2.1 Health impacts Diarrhoeal diseases 828,651 49,774 0.60 Other diseases and conditions 2.2 Economic costs Soil-transmitted helminth 6,248 3,431 1 2.3 Social and equality impacts infections Malnutrition2 28,194 2,995 0.16 Trachoma <10 244 1 Schistosomiasis 10,405 1,096 0.43 Lymphatic filariasis <10 782 0.67 Total other diseases 44,848 8,548 NA Includes disease burden of protein–energy malnutrition and malnutrition of protein–energy burden disease Includes Disease burden estimates and population-attributable fraction are are fraction and population-attributable estimates burden Disease presented for WASH combined. Disease burden estimates are for for are estimates combined. burden Disease WASH for presented countries. in high-income LMICs; burden include disease diarrhoea consequences < 5 years only. in children 2 1 2 22 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 23

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

CLIMATE CHANGE ACCELERATION Resilient sanitation services protect investments in essential sanitation services CHILD SURVIVAL CHOLERA INTESTINAL WORMS ANTIMICROBIAL RESISTANCE FOOD 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 of Safe use of wastewater and sludge in healthy adults. with recurrent outbreaks and no more neglected tropical diseases stand a greater Less antimicrobial use for preventable agriculture, horticulture and aquaculture can DECENT WORK uncontrolled outbreaks in fragile settings. chance of being met. Infections are less infections extending the useful life of support nutrition 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 POLIO 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 public health. Less stress on health systems. Polio could become the second human NUTRITION Higher utilization of health services, disease 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 MENTAL HEALTH investment in better nutrition, are less stunted infections. Communities – particularly those with lower Communities have clean environments and and learn and achieve more at school. Dignity, safety and less stress, contributing incomes – have a cleaner environment and beaches for recreational activities, promoting to a more equal world. healthier neighborhoods. public health, exercise and tourism.

CHILD SURVIVAL CHOLERA INTESTINAL WORMS ANTIMICROBIAL RESISTANCE FOOD SAFETY CLIMATE CHANGE (AMR) Every year 830,000 people will die from Outbreaks will continue in hotspots with Regular drug administration will keep Increasing water scarcity and urbanization 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 outbreak response 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 irrigation is infections that could have been prevented wastewater and sludge will cause outbreaks conveying sewage. 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 bacteria 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 from anxiety, RECREATION BUSINESS AS USUAL shame and fear while trying to find a safe place to urinate, defecate and manage Beaches polluted with wastewater will continue to deter or sicken swimmers and damage menstrual hygiene. economies in places that rely on clean water bodies for tourism and sports events. 24 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 25

Adverse health outcomes stem not only Achieving the ambitious goals around Access to safe sanitation systems of care and infection prevention and from a lack of toilets but from failures safely managed sanitation systems – in homes, schools, workplaces, control strategies, especially to prevent and hazards all along the sanitation (SDG target 6.2) and the treatment health facilities, public spaces and exposure of health service users and chain (see Figure 1). These failures and use of wastewater (SDG target other institutional settings (such staff to infections, and particularly to are not included in the estimates of 6.3) is therefore critical to reducing the as prisons and camps for forcibly protect pregnant women and newborns the disease burden shown in Table 1, unacceptably high burden of sanitation- displaced persons) – is essential. Safe from infections that may lead to adverse making the actual burden of disease related disease.11 sanitation in health facilities is an pregnancy outcomes, sepsis and likely to be significantly higher. indispensable component of quality mortality.

Sanitation systems can pose risks to health FIGURE 1 at all steps of the sanitation service chain

CONTAINMENT - TOILET STORAGE/ CONVEYANCE TREATMENT END USE/ → TREATMENT → → → DISPOSAL

Without quality toilets that Without proper on-site Workers without adequate Communities are put at risk Drinking or coming into If wastewater and sludge everyone uses, families and containment or treatment, protections face life-threatening when untreated wastewater contact with untreated are used safely, valuable communities are at increased water used for drinking, risks when emptying pits and and sludge pollute beaches, water perpetuates the cycle water, nutrients and risk of disease, anxiety and recreation and agriculture septic tanks and cleaning drinking water, and water of infection – especially energy can be returned violence. can be contaminated. sewers. Waste spilled or sources used for irrigation of of intestinal worms and to the circular economy. dumped before treatment puts food crops. diarrhoea. whole communities and food supplies at risk. 26 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 27

Many country-level studies have The economic losses presented here, been published on the economic and the rate of return of investing consequences of poor sanitation. A in sanitation interventions, provide 2.2 review of studies found the cost of poor compelling evidence for policymakers to sanitation exceeded 2 per cent of GDP take action. Indeed, such a scale of loss Economic costs in East Asia and the Pacific and sub- must receive urgent attention from the Saharan Africa, while in South Asia, it highest levels of government. exceeded 4 per cent of GDP.13 Significant financial costs can result increased food production and increased from sickness and death related to poor educational opportunities. sanitation: out-of-pocket payments and Reaping the economic benefits of improved travel costs for households seeking health A 2012 WHO study estimated the sanitation in India care; government subsidies implicit in economic costs of not investing in public health care provision; income water and sanitation in 135 low- and BOX 4 losses associated with sickness; lost middle-income countries.12 It found that productivity due to time spent seeking economic losses from poor sanitation The Swachh Bharat Mission (SBM), also known in a significant reduction in economic costs a place for open defecation; and coping and inadequate water supply would as Swachh Bharat Abhiyan or ‘Clean India nationwide. In the fiscal year 2018/2019, the costs resulting from environmental be equivalent to 0.5 per cent to 3.2 per Mission’, was an India-wide campaign run from economic cost of poor sanitation was estimated and water resource pollution such as cent of gross domestic product (GDP) 2014 to 2019 to eliminate open defecation and to be 3.87 per cent of gross value added (GVA), water treatment or switching to a more between regions, or 1.3 per cent globally improve solid waste management. SBM is compared to 9.77 per cent of GVA if sanitation expensive but cleaner water source. (see Figure 2). The highest impact was in considered to have been the world’s largest coverage had remained at 2013/2014 levels – a Conversely, these can be quantified as sub-Saharan Africa. The study also found sanitation programme, which had high-level reduction in economic costs of 5.90 per cent the loss of the benefits and savings that that investing in sanitation had a greater political support and catalysed a mass movement of GVA over the five year period.15 The SBM would be accrued with a safely managed benefit-cost ratio (over five) than investing that engaged government, households and is estimated to have led to annual economic sanitation system, including time, income, in water supply (around two). the private sector, and used community-led savings of 7.35 per cent of GVA by 2019-2020, methodologies focussing on behaviour change to assuming India achieves 100 per cent improved The economic costs of poor sanitation are end open defecation. sanitation usage in 2019-2020. The economic FIGURE 2 significant in all regions, particularly sub-Saharan savings are estimated to increase to 8.55 per Africa and South Asia A recent economic assessment of SBM drew on cent of GVA by 2023-2024, provided sustained an economic survey implemented in over 10,000 investments in the sanitation sector to achieve ECONOMIC LOSSES ASSOCIATED WITH INADEQUATE SANITATION BY REGION, AS A households across the country.14 The study found 100 per cent safe faecal sludge management PERCENTAGE OF GDP, 2012 annual cost savings per household of US$727, are maintained. The study showed additional 3.5 with medical cost savings, averted premature economic benefits, as the sanitation input death, and the benefits of reduced travel time to market (toilets, haulage and treatment facilities) places for open defecation all accounting for a and the sanitation output market (solid and 3.0 3.2 significant share of the benefits. liquid waste recycling) were each worth over 0.34 per cent of GDP at the height of the 2.5 A follow-up study estimated that India programme in 2017/2018, and employed 2.2 2.6 becoming open defecation free would result million full-time workers.

2.0

1.5

1.3 1.0 1.2 1.3 1.0

0.5 0.7 0.7 0.6 Percentage of Gross Regional Product 0.5

0 a a a a a a i i i i i c s s s i n r a Asia A A A f A s outh

e Africa A S World estern astern c Central orthern E O W N outh-East S ub-Saharan S WaterAid/CS Sharada Prasad/Safai Karmachari Kavalu Samiti Kavalu Karmachari Prasad/Safai Sharada © WaterAid/CS the Caribbean Source: WHO, 2012.Source: WHO, atin America and L 28 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 29

the poor, they often end up benefiting women. For instance, women who wealthier households already suffer from worm infections and connected to networked services.17 other diseases may become anaemic • Disability: People with disabilities and undernourished, increasing the and people who experience risk of maternal death. Women who incontinence suffer additional lack sanitation may resort to harmful affronts to their dignity from a lack of coping mechanisms, such as delayed appropriate sanitation services.18 The urination or reduced water intake, poorest households are at higher risk resulting in urinary tract infections, of being affected by disability, and for which can in turn lead to increased example in Malawi were found to be risk of pre-eclampsia, miscarriage more than three times more likely to and anaemia. Workplaces that do not lack adequate sanitation compared have adequate sanitation facilities with the wealthiest households can dissuade women from seeking in the same country.19 This leaves employment, further reinforcing lower people living with disabilities more labour participation by women and susceptible to disease, and forces their reduced access to resources. them to resort to harmful coping Similarly, lack of public toilets reduces mechanisms. Inaccessible toilets can women’s mobility and participation in force people with disabilities to wait public life and the economy. until dark to defecate, increasing their • Education: Poor sanitation has risk of abuse. Many have no choice been shown to act as a barrier to but to crawl on the floor or ground school attendance and enrolment in to use a toilet20 and many, due to many countries. This affects girls in delaying, or waiting for assistance, soil particular, especially after puberty, themselves.21 when their need for menstrual hygiene

© UNICEF/Jordan/Saman • Safety: Poor access to sanitation management may not be addressed. services can expose vulnerable groups – particularly women and girls – to Inequalities extend beyond homes 2.3 sexual, psychological and physical and schools and into workplaces. violence. The perceived threat of Sanitation workers are critical for service Social impacts violence or harassment can cause provision, yet too often they are subject psychosocial stress and prevent to conditions that expose them to the women and children from venturing worst consequences of poor sanitation In addition to the economic costs, lack mobility.16 A girl or woman without outside the home to use toilets. in their daily work, including debilitating of sanitation has negative impacts that access to water, soap and a toilet, • Gender: Poor sanitation increases infections, injuries, social stigma and cannot easily be quantified. Impacts whether at home, school, or work, will health risks that are specific to even death. on dignity, poverty, disability, safety, face great difficulties in managing her gender and education represent menstrual hygiene with dignity. unrealized human potential and are • Poverty: The poor are less likely Recognizing the human right to safe sanitation disproportionately borne by the most to benefit from public investments vulnerable and disadvantaged. in sanitation, and their health is BOX 5 • Dignity: The ability to manage disproportionately impacted by lack of bodily functions, including urination, sanitation. Sanitation rates are lower in The United Nations General Assembly The human right to sanitation entitles everyone defecation and menstruation, is at rural areas, and only a small minority recognized the human right to water and to sanitation services that provide privacy and the core of dignity. A complete lack of countries are on track to eliminate sanitation in 2010, and sanitation as a distinct ensure dignity, and that are physically accessible of service, forcing people to resort to open defecation among the poorest human right in 2015. This right is assured for all and affordable, safe, hygienic, secure, and socially open defecation, presents the greatest rural dwellers. Poor and marginalized – regardless of income, gender, disability status, and culturally acceptable. All dimensions of the indignity. Similarly, crowded or poorly- groups tend to live ‘downstream’, age or ethnicity. The human right to sanitation human right to sanitation are equally important. managed shared sanitation facilities making them disproportionately implies that people not only have the right to a Human rights criteria are reflected in global may increase exposure to health risks affected by other people’s unmanaged hygienic toilet but also have the right not to be sanitation guidelines and SDG 6 monitoring and may lead to reduced dignity, faecal waste. While subsidies are negatively affected by unmanaged faecal waste. frameworks. privacy and safety, especially for intended to ensure that water and women, girls and those with limited sanitation services are affordable for 30 STATE OF THE WORLD'S SANITATION 31

This chapter highlights the current state and respecting national policies and of sanitation in households, schools priorities. and health care facilities, and, where possible, provides information on rates of Data availability for monitoring progress progress. Global data show that current towards the SDG targets on sanitation rates of progress will not be sufficient to remains limited in many countries. While reach the SDGs, particularly for those in almost all countries have comparable vulnerable situations. While global data data on rates of open defecation and are not available for other settings, such access to basic sanitation services, fewer as public places, workplaces, prisons than half have estimates for coverage and markets, progress in these settings of safely managed sanitation services. is also needed to ensure people can use Estimates for open defecation and access a toilet when needed in all aspects of to basic services can be disaggregated daily life. by rural and urban settings, sub-national region and wealth quintile, but very The WHO/UNICEF Joint Monitoring few countries have the disaggregated Programme for Water Supply, Sanitation data needed to identify and address and Hygiene (JMP) uses national data inequalities in safely managed services. to produce internationally comparable Furthermore, the limited availability of estimates of progress on drinking time-series data makes it difficult to water, sanitation and hygiene which are determine rates of progress. used to monitor progress towards the SDG targets related to WASH. All data While JMP estimates allow international presented here come from recent data comparison, they are not a substitute updates prepared by the JMP.22 for national monitoring and reporting. Governments are expected to Governments need to establish their own localize the global SDG targets systems to routinely monitor progress related to WASH and set their own on sanitation, with suitable levels of national targets for progressively disaggregation that allow progress to reducing inequalities in services, be tracked within sub-sectors of the taking into account national contexts, population (urban, rural, poor, minority © UNICEF/UN0267918/Latif capacities and levels of development, groups, etc.). What progress has been made towards universal access to sanitation?

3.1 Sanitation in households

3.2 Sanitation in schools

3.3 Sanitation in health care facilities

3.4 Sanitation for forcibly displaced persons 3 © UNICEF/UN0139474/Prinsloo 32 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 33

JMP service ladder for global monitoring of sanitation FIGURE 3 in households

SERVICE LEVEL DEFINITION

Safely managed Use of improved facilities that are not shared with other households and where excreta are safely disposed of in situ or transported and treated off-site. Basic Use of improved facilities that are not shared with other households. Limited Use of improved facilities that are shared with other households. Unimproved Use of pit latrines without a slab or platform, hanging latrines or bucket latrines. Open defecation Disposal of human faeces in fields, forests, bushes, open bodies of water, beaches or other open spaces, or with solid waste.

Note: Improved facilities include flush/pour to piped sewer systems, septic tanks or pit latrines, ventilated improved pit latrines, composting toilets or pit latrines with slabs.

Despite progress, 2 billion people cent) (see Figure 4). Over the same still lack even a basic level of period, the population with either basic sanitation service. From 2000 to 2017, or safely managed sanitation increased the global population increased by 1.4 from 3.4 to 5.5 billion, which means that billion people. During this period, the the number of people lacking even a basic population using safely managed sanitation service decreased from 2.7 to sanitation services doubled, from 2.0 billion. The population practicing open 1.7 billion (28 per cent of the global defecation was cut in half, from 1.3 billion population) to 3.4 billion (45 per to 673 million. © UNICEF/India/Singh Despite progress, 2 billion people still lack even a basic 3.1 FIGURE 4 level of sanitation service Sanitation in households GLOBAL SANITATION COVERAGE, 2000-2017

28% 28% 5% 17% 21% The SDGs challenge Member States to not a realistic target, but milestones 1.7 billion 1.7 billion 335 million 1 billion 1.3 billion achieve three progressively ambitious and interim targets can still be set. targets with respect to household Even for high- and middle-income sanitation: countries, it is a challenge to reach 2000 • Eliminating open defecation: this entire populations with sanitation 6.2 billion is explicitly mentioned in the target text, services that ensure proper and is particularly relevant to a small management of excreta along the number of high-burden countries. entire sanitation chain. • Achieving universal access to basic sanitation services: most The JMP uses a sanitation service 2017 countries aim to provide at least a ladder to benchmark and compare 7.6 billion basic level of sanitation services to progress across countries on sanitation their entire populations within the in households (see Figure 3). The service 45% 29% 8% 9% 9% SDG period. ladder tracks how populations progress 3.4 billion 2.2 billion 627 million 701 million 673 million • Achieving universal access from practising open defecation and to safely managed sanitation using unimproved technologies to services: for many countries using an improved sanitation facility Safely managed Basic Limited Unimproved Open defecation reaching universal coverage with that hygienically separates excreta from safely managed sanitation by 2030 is human contact. Note: Each square represents 10 million people. 34 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 35

3.1.1 Figure 5 shows that while 30 countries Eliminating open defecation in Nepal are on track to achieve open defecation Ending open defecation free status, progress is too slow in BOX 6 30 other countries, and in 10, open Though the global average reduction defecation is actually increasing as the In 2019, Nepal announced that it had achieved subsidies for sanitation, a no-subsidy approach in open defecation appears to be on population grows. This means that open open defecation free status after 10 years of was adopted, with support mechanisms for the track to eliminate the practice, much of defecation remains a persistent inequality, concerted and coordinated government support to most vulnerable groups. Government support for the progress in eliminating open with nine out of ten open defecators living the sanitation sector. The initial impetus for action improved planning processes informed resource defecation is being driven by gains in rural areas, and poorer people much was a 2009 deadly cholera outbreak in Karnali allocations and a dedicated budget line, and in a few high population countries. more likely to practise open defecation. Province. The regional government achieved pooled funds for sanitation were created. Local consensus among civil society and stakeholders WASH coordination committee leadership allowed across the health, education and WASH sectors, a stronger focus on local contexts and needs and Few countries are on track to eliminate open and signed a joint commitment to move forward better utilization of local government resources FIGURE 5 defecation by 2030 in sanitation, mobilizing ‘multiple levels, multiple and partner support to reach the most vulnerable. sectors’. Political leaders and administrators in all Local leadership fostered learning and adaptive PROGRESS TOWARDS ELIMINATING OPEN DEFECATION, 2000-2017 districts organized sanitation conferences, where management, with lessons shared through commitments were made to eliminate open regional and national platforms. defecation in their area. 8 The combined efforts of government and a broad WASH coordination committees were established range stakeholders to build a strong foundation 7 at all administrative levels, involving representatives for sanitation in Nepal have sustained progress from civil society, nearly every sector and across the through numerous setbacks, such as the 2015 30 COUNTRIES political spectrum. Karnali Province demonstrated earthquake, floods in 2017 and 2019, crippling ARE ON TRACK 6 that results at scale could be achieved through this political strikes and country-wide restructuring approach, showing a 7 per cent increase in access to a federal system of government. Since to sanitation within a year. declaring open defecation status in 2019, Nepal 5 has continued its journey on sustaining and The success in Karnali Province was reflected in addressing a wider scope of behaviors under the Government of Nepal’s 2011 Sanitation and its total sanitation manifesto. The government is 4 Ethiopia Hygiene Master Plan. Sanitation conferences focussed on moving households to higher levels were initiated across the country and helped build of service, with recent household surveys showing PROGRESS IS TOO Cambodia

Delivering Rural Sanitation Programs at Scale, at Delivering Programs Sanitation UNICEF, Rural WaterAid, WSSCC, SNV, Bank, International, Plan World momentum for a government-led social movement that the proportion of the population using basic 3 SLOW IN Nepal India at the village, district, region and national levels. sanitation services has increased from 60 per cent 30 COUNTRIES Lao PDR Source: with Equity and Sustainability: A Call Action to , 2019. Instead of the previous heavy investment in in 2014 to 79 per cent in 2019. 2

Percentage points per year 1

Annual rate of reduction, 2000-2017 The concept of ‘open defecation free’ However, the protective effects of communities is an important one. In community-wide coverage are not 0 these communities every member of being realized by many households, every household uses hygienic sanitation even though they have invested in facilities all the time, thus maintaining their own toilet. Data from household -1 OPEN DEFECATION an uncontaminated environment for surveys reveal that even though the IS INCREASING all. Research has shown that this is percentage of individual households IN 10 COUNTRIES -2 important to realize the health benefits of in which open defecation is practised sanitation, since even a small number of has been reduced in many countries, households practising open defecation the percentage of households living -3 can compromise the health of the whole in communities where at least one 0 20 40 60 80 100 community. Safe disposal of faeces by one other household still practises open household prevents disease transmission defecation remains high (see Figure 6). to all households nearby23 and can also protect soil, water and food.24 36 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 37

Many people live in communities that are not FIGURE 6 open defecation free PERCENTAGE OF POPULATION PRACTISING OPEN DEFECATION AND LIVING IN COMMUNITIES WHERE AT LEAST ONE HOUSEHOLD PRACTISES OPEN DEFECATION, 2015-2018

Mexico 1 8

Malawi 5 63

Colombia 5 15

Indonesia 9 48

Pakistan 12 50

Nigeria 23 51

Timor-Leste 24 74

Haiti 25 76

Ethiopia 33 90 © UNICEF/India/Qadri Chad 69 91 Source: surveys household Selected national

0 20 40 60 80 100 Progress in sanitation has sometimes been made at the FIGURE 7 expense of increasing inequalities Household open defecation Community open defecation TRENDS IN COVERAGE OF BASIC SANITATION AMONG THE RICHEST AND POOREST WEALTH QUINTILES, 2000-2017 3.1.2 defecation have found it challenging to achieve basic sanitation. For instance, Achieving universal BASIC SANITATION Ethiopia reduced open defecation from coverage of basic 79 per cent to 22 per cent between Lao People's Cambodia Mongolia Thailand services 2000 and 2017. However, in the same Democratic Republic time period basic sanitation coverage 98 100 95 95 94 94 increased from 3 per cent to just over 7 92 92 Many countries have made progress per cent. Similarly, Burkina Faso reduced in ensuring that people have at least a open defecation by 25 percentage points 77 minimum level of sanitation that ensures over the same time period, while basic excreta is hygienically separated from sanitation coverage increased by only 8 human contact. This basic level of service percentage points. represents significant progress, as it 41 means households have a toilet, such as a Another challenge has been to 37 pit latrine, or a pour flush toilet emptying achieve progress in basic sanitation 29 to a septic tank or pit, which is not shared while also eliminating inequalities. As with other households. To maintain this Figure 7 shows, some countries have 15 level of sanitation, facilities must be reduced the coverage gap between 5 4 durable enough to last multiple seasons. the wealthiest and poorest households, 0 while in other countries overall 2000 2017 2000 2017 2000 2017 2000 2017 Some countries that have made progress has been made, but the gap significant progress on eliminating open has widened. Richest Poorest Gap between richest and poorest quintiles 38 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 39

Sewer connections are driving progress in some FIGURE 8 regions, while on-site systems are predominant in others

PERCENTAGE OF POPULATION USING SEWER CONNECTIONS, SEPTIC TANKS, LATRINES AND OTHER IMPROVED ON-SITE SYSTEMS IN 2017, AND PERCENTAGE POINT CHANGE, 2000-2017

30

20 22 22 17 17 14 10 10 9 7 3 7 6 1 3 5 5 1 1 5 0 -1 0 -1 -1 -1 0 -1 -7 -2 -3 -3 -2 -10 CHANGE IN USE OF IMPROVED SANITATION FACILITIES, BY TYPE,  % PT­

Central and Eastern and Northern Latin America Europe and Least Sub-Saharan Australia and Oceania Southern South-Eastern Africa and and the Northern Developed World Africa New Zealand Asia Asia Western Asia Caribbean America Countries

USE OF IMPROVED SANITATION FACILITIES BY TYPE,  %­ 100

88 80 84 © UNICEF/UN0352551/Ose 66 60 59 3.1.3 48 such as pit latrines and septic tanks, 40 41 Accelerating progress may be compromised due to a number 34 31 33 towards safely managed of factors, including poor design, 28 inadequate operation and maintenance, 20 23 23 20 21 damage or flooding, high population 19 17 sanitation services 14 12 13 12 12 density in urban areas and lack of 10 8 10 9 9 8 6 1 A range of technologies can be used appropriate regulation. 0 4 to achieve safely managed sanitation, including sewerage systems, which On-site systems are widely used Sewer Septic Latrine and other transport waterborne waste through and their use is growing in some pipes to off-site treatment, and on- regions. In 2017, 41 per cent of the Data on the performance of on-site with an advisory notice, and one in four site systems. On-site, also called world’s population reported using sanitation is hard to obtain, but is were found to present a risk to human non-sewered, systems either provide improved sanitation facilities with on- available from some household surveys health or the environment.25 treatment in-situ (such as simple pit site storage, such as flush or pour-flush and reports compiled by governments latrines) or contain waste that can be toilets connected to a septic tank, and from periodic inspections. For example, Relatively few countries have transported to off-site treatment (such as dry or wet pit latrines (including facilities the Environmental Protection Agency of sufficient data to report on safely septic tanks or emptiable latrines). shared with other households). Use of Ireland is a rare example of an agency managed sanitation. In 2017, there on-site sanitation was more common in that publishes the results from periodic were 94 countries with national data, On-site facilities are effective and low- rural areas (51 per cent) than in urban inspections of decentralized wastewater mostly countries with relatively small cost, and can provide safe sanitation for settings (32 per cent). Use of sewers and treatment systems, including septic populations using on-site sanitation users when designed, built and used on-site systems varies widely between tanks and small-scale secondary or (see Figure 9). Despite the lack of data, well, and when part of a functional regions, but on-site systems are clearly tertiary treatment plants. Of the 6,000 it is clear that in many countries a low sanitation service chain. However, on- driving progress in least-developed systems inspected between 2013 and proportion of the population is using site storage and treatment systems, countries (see Figure 8). 2018 in Ireland, nearly half were issued safely managed sanitation. 40 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 41 © UNICEF/UN0139454/Prinsloo

3.1.4 Achieving universal access to safely Current rates of managed sanitation by 2030 would require quadrupling the current global progress rate of progress. But these are global averages; the required rate of change Achieving universal access to in least-developed countries is even sanitation by 2030 will require higher. To achieve basic sanitation in dramatic acceleration in current these countries, the rate of change rates of progress. To achieve universal would have to increase from an access to at least basic sanitation estimated 0.7 percentage points per by 2030, global rates of progress year to 5 percentage points per year, a would need to double (see Figure 10). seven-fold increase. © UNICEF/UN0352570/Ose

Achieving universal access by 2030 will In many low-income countries, less than 50 per FIGURE 10 require dramatic acceleration in current rates FIGURE 9 cent of the population uses safely managed of progress sanitation PERCENTAGE OF POPULATION WITH SANITATION SERVICES IN 2000 AND 2017, AND RATE PERCENTAGE OF POPULATION USING SAFELY MANAGED SANITATION SERVICES, 2017 OF CHANGE REQUIRED TO MEET SDG TARGETS BY 2030

100 100 1x No open defecation Basic sanitation 91 2x Safely managed sanitation 80 79 74 4x Acceleration required

60 56

45 40

28

20 Proportion of the population (%)

0 2000 2005 2010 2015 2020 2025 2030 42 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 43

Nineteen per cent of schools worldwide 2019, Bhutan and Nigeria increased were estimated to have no service in the proportion of schools with basic 2019.26 Children and teachers at these sanitation by 3 percentage points schools either rely on unimproved per year. South Sudan reduced the facilities, such as pit latrines without a slab proportion of schools with no sanitation or platform, hanging latrines or bucket service by 4 percentage points per year latrines, or had no sanitation facility at all. over the same period.

An estimated 367 million children attend However, achieving universal access to a school in which there is no sanitation basic sanitation services in schools by facility at all. Over half of these children 2030 will require a five-fold increase in the live in two SDG regions: sub-Saharan current rate of progress. Figure 12 shows Africa (213 million children) and Central the trends in reaching sanitation coverage and Southern Asia (200 million children). in schools globally, in the eight SDG regions and in least-developed countries. Some countries have made progress in school sanitation. Between 2015 and

Globally, less than two thirds of schools have FIGURE 12 basic sanitation REGIONAL AND GLOBAL SANITATION COVERAGE IN SCHOOLS, 2015 AND 2019 © UNICEF/UN033691/Arcos

0 0 100 1 1 10 6 11 10 3.2 16 23 19 24 27 3 25 22 30 11 19 10 33 32 80 40 40 Sanitation in schools 20 18 20 17 28 27 60 27 27 13 13 100 100 SDG 4 calls for the global community to to “Build and upgrade education 98 99 78 87 “Ensure inclusive and quality education facilities that are child, disability and 40 75 79 for all and promote lifelong learning”. gender sensitive and provide safe, 64 60 63 47 56 51 The goal includes a range of targets non-violent, inclusive and effective 43 47 47 48 related to educational outcomes from learning environments for all”. One of 20 early years through to adulthood, and the indicators used to track progress additional targets addressing the means towards this target is the “Proportion of 0 of achieving them. Target 4.a focusses schools with access to single-sex basic 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 on school infrastructure and the need sanitation facilities”. Asia Least Africa World and the Oceania America Northern Northern Countries Africa and Caribbean Developed Europe and Central and Eastern and Sub-Saharan Australia and New Zealand Western Asia Latin America Southern Asia FIGURE 11 Sanitation services ladder for schools South-Eastern

SERVICE LEVEL DEFINITION No service Limited Basic Insuƒicient data

Basic service Improved sanitation facilities at the school that are single-sex and usable (available, functional and private) at the time of the survey. Analysis of data from rural schools in 12 had a bin with a lid inside the cubicle for sub-Saharan African countries revealed garbage disposal. Both of these features Limited service Improved sanitation facilities at the school that are either not that many school toilets did not meet are important to female students and single-sex or not usable at the time of the survey. criteria for accessibility, quality staff who need a safe place to practise No service Unimproved sanitation facilities or no sanitation facilities at the or acceptability (see Figure 13). In menstrual hygiene management. school. particular, almost half did not have doors Two thirds of school toilets were not that locked from inside, and hardly any accessible to children with disabilities. 44 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 45

In rural sub-Saharan Africa, many school FIGURE 13 toilets do not meet criteria for accessibility, quality or acceptability

PERCENTAGE OF SCHOOLS IN RURAL SUB-SAHARAN AFRICA WHERE ALL SANITATION FACILITIES MEET ADDITIONAL CRITERIA, 2017

Accessibility

Located on premises 99

Accessible by smallest children* 91

No barriers blocking entry or use 86

Always unlocked or key available 71

Accessible by children with limited mobility* 31

Quality

No pit that is full 97

No pit that is caving or flooded 91

Slab stable and not cracked or broken 81

Functional lighting 13 © UNICEF/UNI284675/Prinsloo

Water available 12

Lid covering hole/slab 5 Improving sanitation in schools in Togo

Soap available 4 BOX 7

Bin with lid within cubicle 1 In Togo, the proportion of the country’s nearly strategy. School-led total sanitation has resulted 9,000 schools with basic sanitation facilities in significant progress in sanitation and hygiene increased from 44 per cent in 2016 to 65 per practices in over 2,000 schools. Acceptability cent in 2019. Strong government leadership in

No major holes in superstructure 78 policy and planning for WASH in schools laid Supported by the World Bank, between 2010 the foundation for this considerable increase. and 2019 the government implemented a school Doors that can be locked from inside 56 The Education Sector Plan (2014-2025) and the infrastructure construction programme that National Action Plan for the Water and Sanitation included the construction of at least 1,000 toilets No faeces present on floor, slab or walls 55 (2016-2030) both identify WASH in schools as a in schools. WASH programmes funded by others, priority area and provide dedicated support and such as UNICEF, the French Development No flies present 28 capacity building. The Ministry of Education has Agency and the Islamic Development Bank, also led the development of norms and standards supported the construction of gender-separated No bad smell 27 to improve the quality of WASH infrastructure toilets that enable adolescent girls to manage and hygiene promotion programmes and has their menstruation. The Government of Togo plans Private space for washing 3 incorporated WASH indicators into its Integrated to consolidate its achievements by focussing Education Information System. The 2017 Roadmap on sustainability, strengthening national-level 0 20 40 60 80 100 for an Open Defecation Free Togo by 2025 also coordination of WASH in schools under the

Source: Survey of sanitation facilities in rural schools in Ethiopia, Ghana, Kenya, Malawi, Mali, Mozambique, Niger, Rwanda, Rwanda, Mozambique, Niger, Mali, Malawi, Source: Kenya, Survey Ghana, schools in Ethiopia, of facilities sanitation in rural 2017. Vision, Zambia and Zimbabwe, World Republic of Tanzania, United Uganda, Proportion of schools where all sanitation facilities meet criteria contributed to strengthening sanitation in schools leadership of the education sector, and mobilizing by including school-led total sanitation as a key resources for capital and recurrent costs. * At least one facility accessible to the smallest children and children with limited mobility. 46 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 47

Sanitation services ladder for health care FIGURE 14 facilities

SERVICE LEVEL DEFINITION

Basic service Improved sanitation facilities are usable, with at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for people with limited mobility. Limited service At least one improved sanitation facility is available, but not all requirements for basic service are met. No service Toilet facilities are unimproved (e.g. pit latrines without a slab or platform, hanging latrines, bucket latrines) or there are no toilets.

In the global baseline report published in on the adequacy of facilities, including 2019, only 18 countries had sufficient data whether or not there are private toilets to estimate coverage of basic sanitation for men and women, accessible facilities services in health care facilities in 2017.27 for people with limited mobility and When WHO and UNICEF updated the menstrual hygiene facilities. Lack of global database in 2020, the number data mean that the actual situation is increased by 50 per cent. However, the 27 likely much worse than the available countries with sufficient data still represent figures suggest. Figure 15 shows three only 12 per cent of the global population.28 contrasting countries, in which the proportion of health care facilities with To fully assess progress towards basic elements of basic sanitation varies sanitation coverage, data are required considerably.

Sanitation in health care facilities varies FIGURE 15 considerably between countries

© UNICEF/UN0306431/Abdul PERCENTAGE OF HEALTH CARE FACILITIES WITH ELEMENTS OF BASIC SANITATION ACROSS 3.3 THREE COUNTRIES, 2019 KUWAIT BRAZIL NIGER Sanitation in health Facility 100 100 - care facilities Improved 100 100 74 & usable 100 84 29 & dedicated for staff 100 82 30 The availability of sanitation in health associated with unclean births, while & dedicated for women 100 - 31 care facilities, especially in maternity infections account for 26 per cent of and primary-care settings, supports neonatal deaths and 11 per cent of & menstrual hygiene management 100 - 0 health care quality and equity, helping maternal mortality. An estimated 15 per & limited mobility 100 45 27 ensure dignity for all people. Basic cent of patients in low- and middle- sanitation services in health care income countries develop one or more Basic 100 45 0 facilities are fundamental to providing infections during a hospital stay. Many quality care. of these patients are women who come While many countries lacked some of the In 28 countries, more than 10 per to health facilities to deliver. Inadequate data needed to report on basic sanitation cent of health care facilities had no Evidence shows that lack of access WASH in health care facilities has been services, they did have some information sanitation service, and in the sub- to WASH in health care facilities may linked to the spread of antimicrobial- about how many health care facilities Saharan African countries with data, significantly compromise safe childbirth resistant infections, placing patients lacked any kind of improved sanitation 29 per cent of health care facilities and access to primary health care. More and staff at risk of serious infections that facilities, and are classified as having no had no sanitation service. than one million deaths each year are are hard to treat. sanitation service (see Figure 16). 48 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 49

In 28 countries, more than ten per cent of FIGURE 16 health care facilities had no sanitation service PERCENTAGE OF HEALTH CARE FACILITIES WITH NO SANITATION SERVICE, 2019

United Republic of Tanzania 52 Nigeria 51 Comoros 49 Democratic Republicof the Congo 36 Niger 26 Uganda 25 Liberia 24 Ethiopia 24 Senegal 19 Somalia 16 Sub-Saharan Kenya 16 Africa Chad 14 Guinea 12 Mauritania 11 Sierra Leone 11 Namibia 9 Benin 9 Malawi 7 Zambia 7 Burkina Faso 7 Djibouti 5 Mali 5 Rwanda 1 Zimbabwe 1

Sudan 37 Armenia 19 Northern Africa Lebanon 18 and Western Asia 5 Libya © UNICEF/UN013597/Georgiev Iraq 4 Vanuatu 36 3.4 Papua New Guinea 32 Oceania Cook Islands 20 Tonga 14 Sanitation for forcibly

Russian Federation 18 Europe and Romania displaced persons 3 Northern America Serbia 2

Indonesia Achievement of SDG target 6.2 ‘for all’ hygiene services may be limited. In these Eastern and 13 Timor-Leste 3 implies the inclusion of refugees, asylum situations, sanitation implementation South-Eastern Asia China 3 seekers, stateless people and IDPs. The approaches must take into consideration world is currently witnessing the highest the weak institutional context and unique Nicaragua 12 levels of human displacement on record. deprivations and vulnerabilities of the Paraguay 12 Latin America Haiti 11 At the end of 2019, there were 79.5 population to fulfil every individual’s right and the Peru 10 million people globally who were forcibly to sanitation. Carribean Guatemala 10 displaced as a result of persecution, Honduras 4 conflict, violence, human rights violations The United Nations High Commissioner or other events.29 Approximately 26 for Refugees (UNHCR) and its Nepal 8 million of these are refugees and another partners manage over 220 camps and Central and Sri Lanka 7 45 million are internally displaced settlements globally and collect data on Southern Asia Bangladesh 6 Bhutan 1 persons (IDPs). The vast majority, 85 WASH services in them. According to per cent, of displaced people live in data from 175 of these sites in September 0 20 40 60 80 100 developing countries where access to 2020, only 32 per cent of households at 30 Note: Not showing 21 countries reporting less than 1 per cent of health care facilities with no sanitation service. safely managed water, sanitation and the sites used basic sanitation services. 50 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 51

Estimating access to sanitation service amongst forcibly There are considerable practical Instead, the focus should be on displaced persons in Afghanistan challenges to reaching the SDG targets minimizing the number of individuals for sanitation in camps and settlements. sharing a facility, and safe excreta BOX 8 One challenge is the lack of sufficient management (transport and treatment space for installing household facilities. off-site), while ensuring that the At the end of 2018, there were over 2.7 million The survey found a significant disparity in service A recent review found that globally 43 planning, design, location and forcibly displaced persons in Afghanistan.33 between female- and male-headed households. per cent of sites exceeded UNHCR management of facilities is done with full There is only one managed camp in Among the forcibly displaced, a significantly population density standards.31 For participation of the affected population. Afghanistan, which hosts less than 1 per cent higher proportion of female-headed households example, in the Kutapalong camp in of the forcibly displaced living in the country. (30 per cent) reported not having access to an Bangladesh, the average population An estimated 60 to 70 per cent In 2018, a survey was carried out to look at the improved latrine compared to male-headed density is almost 44,000 people per of forcibly displaced persons live needs of the 99 per cent of forcibly displaced households (21 per cent). square kilometre, making it one of outside of camps and settlements. who are dispersed throughout the country. the highest population densities on Unfortunately very few countries have The results show a dramatic disparity between These disparities demonstrate the importance earth.32 In these situations, designing disaggregated sanitation data for refugees and the rest of the population, of ensuring that monitoring programmes and installing improved sanitation displaced populations which makes it as shown in Figure 17. Only 28 per cent of systematically include vulnerable groups to systems, which are not shared between difficult to track whether they are being refugees had access to basic sanitation, and generate the evidence needed to design and households, may not be feasible. left behind the rest of the population. as many as 55 per cent of refugee households deliver programmes to reach them. In the practiced open defecation.34 These figures are absence systematic monitoring, there is a in stark contrast to JMP figures for Afghanistan, considerable risk that the most vulnerable will be which estimate that 43 per cent of the overall left behind. population had access to basic sanitation in 2017. 35 Even in rural areas, only 17 per cent of households practiced open defecation.

Sanitation services available in FIGURE 17 refugee and non-refugee populations in Afghanistan

100 0 13 17 16

80

21 55 34 40 60

10

40 6 Population (%) 16 62 1 43 20 37 27

0 1 National* Rural* Urban* Refugees

Safely managed Basic Limited Unimproved Open defecation Source: UNHCR © UNICEF/UNI238976/Chak 52 STATE OF THE WORLD'S SANITATION 53 © UNICEF/Indonesia/Fauzan

© UNICEF/UNI189329/Gilbertson VII Photo 4.1 Status of sanitation policy

What is the status Sustainable and effective WASH The majority of countries have service delivery is determined not only national policies and plans for of policy and finance by the state of infrastructure, but also sanitation, but few have adequate by complex institutional, governance human and financial resources to and financial management systems. implement them. Of the 115 countries for sanitation? Governance and financing systems need participating in the GLAAS 2018/2019 to be articulated in policy, and must be cycle, only three had policies and coordinated and aligned, ensuring the plans for rural sanitation with sufficient 4.1 Status of sanitation policy sustainability of resources and institutions resources to implement them, and only to support sanitation service delivery. six had sufficient resources to implement 4.2 The cost of achieving universal sanitation urban sanitation plans. Three quarters of Recent insights into the status of policy respondent countries cited the existence 4.3 How much is being invested, and where is it coming from? and finance for sanitation are highlighted of a financing plan for sanitation. in the 2019 GLAAS report, which However, only about one quarter said features data from 115 countries.36 they have financing plans that have been 4 defined, agreed and consistently used. 54 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 55

Few countries have formally approved, adequately In countries where open defecation with sanitation, only one quarter FIGURE 18 resourced sanitation policies is still practised, approximately have ways of financing them. three quarters have specific NUMBER OF COUNTRIES REPORTING FORMALLY APPROVED POLICIES SUPPORTED BY measures in policies and plans to Governments are also challenged RESOURCED PLANS, 2019 address open defecation.37 Two by regulation and standard setting. thirds of these countries have Over two thirds of countries have

Countries with formally approved policy established national targets to formal national standards for and approved and costed plan eliminate open defecation. For wastewater treatment, but far 3 with suicient financial 5 and human resources example, the National Open Defecation fewer have national standards for

Countries with formally Free Kenya 2020 Campaign Framework safe use of wastewater or faecal 44 approved policy and 46 aims to “eradicate open defecation and to sludge. While 77 per cent of countries approved and costed plan declare 100 per cent of villages and Kenya have a formal national standard for Countries with formally open defecation free by 2020”. Zambia wastewater treatment, only 36 per cent 48 approved policy 51 and approved plan recently launched the Open Defecation of countries have a standard for safe use Free Zambia Strategy (2018–2030), which of wastewater and sludge for agriculture Countries with formally aims to end open defecation, especially and other productive purposes. 63 67 approved policy among populations living in vulnerable situations. The institutions tasked with Countries with policies formally 101 approved OR under revision 104 oversight of sanitation standards OR under development Countries are responding to the SDG are stretched, lacking sufficient 100 80 60 40 20 0 0 20 40 60 80 100 120 imperative to ‘leave no one behind’ funds and sufficient human

Number of countries Number of countries by establishing policy measures to resources to undertake the Rural sanitation Urban sanitation reach populations living in vulnerable necessary surveillance and situations. For example, in Senegal, the enforcement. Only 32 per cent of Action Plan for the Implementation of the countries reported having sanitation/ Households that are most in need of Governments need to recognize the National Policy for Rural Sanitation by wastewater regulatory authorities that faecal sludge management services important role of adequate faecal sludge 2025 proposes measures to ensure that fully take corrective action in urban; and (emptying, transport, treatment and management in achieving national the poorest can access sanitation, with only 23 per cent in rural areas. Two thirds end use or disposal) are often located sanitation targets and the SDGs by payment based on their financial capacity. of countries reported that they have less in dense urban settings. However, addressing the issue in sanitation However, while over two thirds of than 50 per cent of the human resources faecal sludge management is not policies and plans, and supporting countries report they have policy they need for wastewater surveillance in addressed in a quarter of urban them with sufficient resources for measures to reach poor populations urban areas. sanitation policies or plans. implementation.

Not all urban sanitation policies and plans address Few countries have national standards for safe use of FIGURE 19 faecal sludge management FIGURE 20 wastewater or faecal sludge

NUMBER OF COUNTRIES WITH URBAN POLICIES AND PLANS THAT ADDRESS FAECAL PERCENTAGE OF RESPONDENT COUNTRIES WITH FORMAL NATIONAL STANDARDS FOR SLUDGE MANAGEMENT, 2019 WASTEWATER, ON-SITE SANITATION, FAECAL SLUDGE AND SAFE USE, 2019

77 Faecal sludge treatment Wastewater (n=112) 77 49

74 On-site sanitation (n=111) Faecal sludge emptying 68 and transport 50 Faecal sludge (n=111) 56 59 Use of municipal wastewater and faecal sludge 38 Safe re-use (n=110) 36

0 10 20 30 40 50 60 70 80 90 100 Number of countries 0 10 20 30 40 50 60 70 80 90 100

Urban policy or plan Rural policy or plan 56 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 57 4.2 The cost of achieving universal sanitation

There are multiple ways in which A study of 140 low- and middle-income sanitation can be funded, drawing on the countries, published by the World Bank resources of households, governments in 2016,38 and updated for this report,39 and international aid agencies. estimates that, from 2017 to 2030, Government support has a catalytic role the annual costs to achieve universal

to play, triggering effective investments sanitation would be US$105 billion (see © UNICEF/Jordan/Saman from households and the private sector. Figure 21). This does not mean, however, that the Eliminating open defecation alone will The region with by far the highest cost public purse has to bear all the costs. This require a capital outlay of US$1.5 billion is sub-Saharan Africa, which would is further discussed in Chapter 6. annually, with significantly greater need an average of US$25.7 billion in operations and maintenance (O&M) annual capital spending, supported by costs of US$3.9 billion annually due to the an additional US$13.2 billion in annual The annual costs to achieve universal sanitation by regular replacement of latrines. O&M costs. The high cost of effective FIGURE 21 2030 are estimated to be US$105 billion O&M is often not well anticipated and The cost of achieving safely managed hence not sufficiently budgeted, leading ANNUALIZED COSTS OF ACHIEVING UNIVERSAL SANITATION GLOBALLY, 2017-2030 sanitation varies considerably between to breakdowns and backsliding. regions, as shown in Figure 22.

120

Annual costs to achieve safely managed sanitation vary by region, and are highest in sub-Saharan Africa 100 36 FIGURE 22

ANNUALIZED COSTS OF ACHIEVING UNIVERSAL SAFELY MANAGED SANITATION BY SDG REGION, 2017-2030 80

45,000 n o

i 21

l 69 l

i 40,000

B 60 $

S 13,236

U 35,000

48 30,000 40 n o i l 15 l 25,000

M i 25,653 $ S

U 20,000 20 6,372 21 6,696 15,000 3.9 1.5 5,212 13,603 10,000 12,093 0 3,918 8,670 5,000 7,537 Elimination of Basic Safely managed Total 13 open defecation sanitation sanitation 7 0 Operations and maintenance costs Capital costs Latin America Sub-Saharan Nothern Africa Central and Eastern and Oceania and the Caribbean Africa and Western Asia Southern Asia South-Eastern Asia

Operations and maintenance costs Capital costs 58 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 59

Regional costs of achieving basic Globally, more than 70 per cent of and safely managed sanitation as a basic sanitation costs are in urban proportion of gross regional product areas, with the figure rising to more than (GRP) are estimated to be highest in 90 per cent in North Africa and Western sub-Saharan Africa (1.1 per cent for basic Asia and Eastern and Southern Asia, and 4.3 and 2.5 per cent for safe sanitation), approximately 60 per cent in sub-Saharan with capital costs at US$10 billion Africa and Caucasus and Southern Asia. How much is being per year and O&M costs of US$7.2 For safely managed sanitation, about billion per year. Challengingly, sub- 65 per cent of the globally costs are for invested, and where is it Saharan Africa also has fewer financial urban areas, while one region – Caucasus resources available than other regions. and Southern Asia – has over 60 per cent coming from? The proportions in other regions are accounted for by rural costs. significantly lower. In Eastern and South Eastern Asia, for example, it would cost The total global average capital cost An analysis of data from 18 countries non-governmental organizations and 0.04 per cent of GRP to achieve basic per beneficiary to gain access to safely participating in the 2018/2019 GLAAS foundations, amounted to only 1 per sanitation and 0.13 per cent to achieve managed sanitation is US$24, varying survey indicates that, on average, in cent of the total investment in sanitation. safely managed sanitation, with capital from US$13 per beneficiary in Caucasus those countries, households contribute However, they contribute, on average, 42 costs of US$3.6 billion per year and and Southern Asia, to US$28 in sub- the largest share of funding for per cent of non-household expenditures O&M costs of US$2.2 billion per year. Saharan Africa, and over US$41 in Latin sanitation through tariffs and self-supply in the 11 low-income countries that America and the Caribbean. expenditures on their own facilities. reported sanitation expenditure data. Across the 18 countries, households contributed an average 68 per cent of the The total disbursement of official current investment in sanitation, followed development assistance grants and by governments, at 19 per cent.40 loans that is allocated to sanitation is difficult to estimate as external support Sixty countries have provided agencies do not always disaggregate information to GLAAS in the 2018/2019 their data by sub-sector. It is estimated survey on government budgets for that support to sanitation has increased WASH. Overall, the reported average since 2010, and in 2018 was over US$1 WASH budget per capita was US$9, billion, which is approximately half ranging from US$1 to US$150. Thirty of the support reported for drinking- countries were able provide information water. Grants were mainly targeted to on their government budget for low-income countries, with wealthier sanitation. Reported annual budgets countries accessing repayable finance ranged from US$75 million in Panama from development banks. to less than US$1 million in some small countries. Overall, the average sanitation Eighty per cent of respondent budget per capita for these 30 countries countries reported insufficient was US$1.43, less than one quarter of the funding to meet their national overall WASH budget per capita.41 sanitation targets. Data from the 12 countries that were able to report Government budgets on overall WASH quantitative funding gaps by sub-sector are increasing at an average rate of revealed that the funding gap was 11.1 per cent per year. Detailed data on greatest in urban sanitation (74 per cent government sanitation budgets over of the total investment needed to achieve time is very limited. Only nine countries national targets), but also significant for reported comparable sanitation-specific rural sanitation (59 per cent). government budget data in the last two GLAAS surveys. Five of those nine Fewer than half of the countries reported decreased sanitation budgets reported that the costs of operating between surveys, with an average and maintaining sanitation systems decrease of 1.2 per cent per year.42 are covered through existing tariffs and user fees (see Figure 24). However, this

© UNICEF/UN0348917/Modola Investments from external sources, proportion has been increasing over time. such as donor grants and funds from 60 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 61

Eighty per cent of respondent countries reported FIGURE 23 insufficient funding to meet their national sanitation targets

ANNUAL RURAL/URBAN FUNDING GAP TO REACH NATIONAL SANITATION TARGETS, 2018

2500

2000

1500 Funding gap n o i

l (74%) l M i $

S 1000 U

500 Funding gap (59%)

0

Urban sanitation Rural sanitation (n=11) (n=11)

Annual additional funds Annual available funds needed to reach targets

Fewer than half of countries reported that the FIGURE 24 costs of operating and maintaining sanitation systems are covered through existing tariffs

PERCENTAGE OF COUNTRIES INDICATING THAT MORE THAN 80 PER CENT OF O&M COSTS ARE COVERED BY TARIFFS, 2013-2018

45

40

35 39 38 34 30 32 25

20 22 15 18

10

5

0 Rural sanitation Urban sanitation

2013 (n=91) 2016 (n=64) 2018 (n=96) © UNICEF/UNI165897/Noorani 62 STATE OF SANITATION REPORT 63

Despite considerable progress in global year, bringing the world much closer to sanitation coverage in recent years, the 2.0 percentage points per year needed achieving sanitation for all will require an to reach 100 per cent coverage by 2030. ambitious and well-coordinated scale-up. This analysis shows that rapid progress is So what might be feasible in the next possible. It is feasible to change the story five years? An analysis done for WHO’s around sanitation from one of continued 2019-2023 five-year strategy categorized ill-health, indignity and economic countries into five groups according losses to a public health success. But to historical rates of progress for basic acceleration requires governments to sanitation services and asked: How many leverage their role successfully, and that more people could be reached if every both public and private investments are country accelerated to match the highest well used and sustained. achievers in their group?43 If countries below the group average were to match Every country that has made rapid the group average, and countries already progress in sanitation has had above the group average were to match strong political leadership, with the highest achievers in their group, an government playing an important additional 200 million people would gain role in policy, planning, mobilizing access in the next five years, an increase investment and regulating services. in coverage of 1.6 percentage points per UNICEF/India/Qadri © Imagining a better future: a dramatic acceleration in progress is possible UNICEF/Jordan/Saman 5 © 64 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 65

Setting goals for health-protective sanitation based The SDG 6 Global Acceleration • Capacity development: Focus on global research and practice Framework44, coordinated by UN- on inclusive human and institutional Water, has identified five accelerators to capacities at all levels to deliver SDG 6. BOX 9 support the achievement of SDG 6: • Innovation: Leverage and scale • Governance: Make SDG 6 up innovative practices and In 2018, WHO published Guidelines on Many more sanitation workers are needed. everyone’s business through technologies, including technologies Sanitation and Health that collectively analysed Providing more formalized, safe, adequately paid cross-sector and transboundary that are accessible for rural areas over 1,000 studies to distil what needs to happen and dignified jobs in the sanitation sector is key to collaboration, clear roles, stakeholder and marginalized communities. in sanitation to make a difference in health and providing safely managed sanitation services. involvement and effective and well-being and lay a foundation for social and inclusive institutions. The accelerators provide a valuable economic development. The core learnings and Efficient and sustainable sanitation needs • Financing: Optimize financing for framework for achieving accelerated recommendations are: to have a higher profile in its own right, water and sanitation, particularly progress on sanitation. There are and be addressed in coordination with for countries and communities with promising examples of where investing Everyone, everywhere needs to have and other local services. One reason for slow limited access to financial resources. in these five accelerators has been use a decent toilet. Half measures that leave progress on sanitation is because it has lacked • Data and information: Build trust effective. For instance, the Government out people who are hard to reach and unable visibility, investment and specialized skills. It through data generation, validation, of Ethiopia has worked to take leadership to change behaviour is both a violation of those suffers from being integrated with water supply, standardization and information of the sanitation sector, coordinate individuals’ human rights and a social and public which is typically more appealing to the public exchange for decision-making and development partners, and streamline health risk that affects society at large. Sanitation and politicians. In recent years, sanitation has accountability. funding for the sector (see Box 10). interventions must be universal and achieve levels gained greater traction as a sub-sector in its own of service that will make a difference to the health right. However, the interface and coordination Strengthening government leadership for sanitation in Ethiopia and well-being of everyone. Poor quality facilities with other services – such as water supply and are not better than nothing – they can create more hygiene, safe disposal of child faeces, drainage BOX 10 risks for the user, bring excreta nearer to where and management of domestic animals – is key people live, and become a wasted investment for sustainability and health impact. Similarly, In 2013, the Government of Ethiopia adopted the human and financial resources to create when users revert to open defecation in disgust or sanitation services can be more efficiently planned One WASH National Programme, a sector wide demand for better WASH services; and because the toilets were easily damaged or filled and financed when tackled as part of a package approach aimed at streamlining Ethiopia’s WASH • Capacity development for improved delivery and cannot be emptied. Reaching everyone in a of locally-delivered services such as housing, programming to achieve universal access to of WASH services at all levels. community will sometimes necessitate shared water supply, solid waste management and WASH. The programme’s catchphrase ‘One Plan. and public toilet facilities, that also meet minimum transportation. One Budget. One Report.’ sums up its philosophy, The Government of Ethiopia financed 47 per cent service levels, as an incremental step when detailed further in the guiding principles: of phase 1 of the programme, with the remainder household facilities are not feasible. Providing Health actors have critical functions to • Integration of the water, health, education coming via a pooled fund of financing for WASH. hardware for toilets alone or working on behaviour ensure sanitation protects health and and finance sectors, with the aim of creating This pooled fund is managed by the government, change alone is not cost effective or sustainable. reduces the burden on the health system. synergy among the sectors through which contributes 10 per cent of all pooled finances. To reach everyone, both supply and demand These include: coordination and collaborative planning, The government also provides matching funding of approaches need to be delivered at the same time. • Integrating sanitation into all health policies implementation, monitoring and reporting. 20 to 30 per cent of donor contributions. and programmes where sanitation is needed • Alignment of partners’ activities with To properly protect heath, toilets must be for primary prevention; government systems, policies and priorities, Many stakeholders and development partners connected to safe systems and services all • Contributing to the development of sanitation ensuring that WASH is placed among the needed to completely reframe their ways of the way from defecation to safe disposal norms and standards, ensuring they are broader development programme. operating to respond to this dramatic shift in and use. Safely managed sanitation systems protective of health and the environment; • Harmonization aimed at moving away from the role of government. There have also been are needed to really make a difference for health. • Using health surveillance to target sanitation discrete project-oriented endeavours to challenges in implementation and coordination, Copying the dated sanitation service provision investment in high-disease-burden areas and programmatic approaches to ultimately but there has been significant progress. An systems of developed countries is too slow, to prevent outbreaks; achieve one plan, one budget and one report acceleration in sanitation coverage has been too costly, reaches too few, favours the most • Including community level sanitation in providing WASH services. achieved as a consequence of increased privileged, misses exciting opportunities for promotion and monitoring in local level health • Solidifying partnerships with development prioritization for the WASH sector, better sector resource recovery and climate resilience, and services; and agencies and expanding partnerships to coordination, avoiding duplication of efforts, delivers limited health benefits. Solutions for the • Ensuring sanitation in healthcare facilities for include more private sector actors and civil stimulating donor interests to finance the sector, future require a mix of technologies and services patients, staff and carers. society organizations. introducing key policies and strategies, and responding to the local context of physical, social improving capacities. According to JMP data, and institutional conditions. In doing so, countries Increased sectoral integration is achieved through between 2010 and 2017 the proportion of the can leapfrog with a resilient mix of systems and three programme pillars: population practising open defecation decreased services within the circular economy. • Creating an enabling environment and good from 44 per cent to 22 per cent, making Ethiopia governance; the country with the fastest reduction of open

One WASH National Program - A Multi-Sectoral SWAP, Review of Phase 1, 2018 Review 1, of Phase SWAP, - A Multi-Sectoral Source: Program One WASH National • Maximizing availability and efficient use of defecation globally. 66 STATE OF SANITATION REPORT 67

This chapter outlines how strategic among the (often fragmented) actions and investments in government ministries, departments governance, financing, data, and agencies responsible for sanitation capacity development and delivery as well as the private sector, civil innovation can help governments society and households. make rapid progress towards achieving universal access to safe sanitation. The choice of implementation approaches should be based on National and local government can drive research and lessons learned from the uptake of new approaches to both previous sanitation programmes, and rural and urban sanitation programmes, should be determined by context, which must be backed with adequate including the level of capacity and human and financial resources. They resources needed to support them. must be inclusive, mobilize participation Where communities are remote and from across society, and be scalable. markets are weak, the sanitation Governments can also nurture a learning implementation strategy is likely to be culture, where monitoring and reviews more community-based. Conversely, lead to adaptation and innovation to where markets are stronger, and reach those being left behind, respond sanitation access and expectations are more effectively to public health crises higher, the strategy may promote more and increase climate resilience. Scaling market-based solutions and embrace up successful sanitation models also systems with higher management requires strengthened coordination requirements. UNICEF/UNI90586/d'Elbee ©

Governments can accelerate sanitation progress with proven, effective approaches

6.1 Good governance begins with leadership, effective coordination and regulation

6.2 Smart public finance unlocks effective household and private investment

6.3 Capacity at all levels drives progress and sustains services

6.4 Reliable data support better decision-making and stronger accountability

6.5 Innovation leads to better approaches All for & Water Sanitation © 6 and meets emerging challenges 68 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 69

Transformative leadership for sanitation successes in East Asia 6.1 BOX 12 Good governance begins In the 1960s and 1970s, during their formative Second, leaders at all levels encouraged local stages as nation states, Malaysia, the Republic innovation and adaptation so that trial and of Korea, Singapore and Thailand produced error, or ‘adaptive management’ practices, led to with leadership, effective rapid and remarkable results in delivering total solutions to address local problems and contexts. sanitation coverage.45 Under strong government coordination and regulation leadership, publicly subsidized sanitation Lastly, leaders built coordination bodies at infrastructure was developed in parallel to all levels that were tasked with ‘breaking changes to public health and hygiene policies. bottlenecks’. These bodies met regularly to Good governance begins with must also have a clear vision, roadmap In each country, improvements in sanitation identify barriers to progress and to propose leadership that prioritizes and and targets endorsed, promoted and came as part of wider public health, housing and local solutions. If the obstacles required higher- champions sanitation. Experience followed up on by a prominent champion. hygiene programmes, rather than being pursued level action, they were passed up the decision- shows this can be from a head of state, Such a champion can be critical in as a stand-alone goal. making chain for leaders to resolve, based on minister or another senior political figure catalysing public participation towards recommendations and lessons learned from the ready to assume the challenge of driving collectively delivering a shared vision of Robust leadership played a vital role in delivering ground. At the outset of their national sanitation progress. Local leadership is equally improving sanitation. dramatic progress in sanitation. First, leaders sector planning stages in the 1960s, the per important. States, districts or villages built a clear and compelling case for sanitation capita income levels in the East Asian states and changed hygiene behaviours by drawing on studied were equivalent to that of many sub- nationally or culturally significant symbols and Saharan African countries. This is significant Support to all levels of government in Indonesia motivations. In Singapore, sanitation and hygienic because it suggests that the overall strategy and practices were tied to notions of modernity and vision came first, and the sector investments from BOX 11 integration with global markets. In Thailand, a variety of sources were sought subsequently. where a focus on sanitation was established Indonesia made significant improvements in • A consolidated district sanitation strategy to at the highest level of government through the The lesson from these East Asian ‘tigers’ is that sanitation, reducing open defecation from over enable multiple programmes to work toward King of Thailand, and was reflected at all levels, success is possible if leaders make it clear to 19 per cent in 2011 to less than 8 per cent in 2019 a common objective and leverage earmarked from the central government to village or district the public and to bureaucrats that sanitation and achieving gains in extending basic sanitation national funds for sanitation; officials, sanitation subsequently benefited from is central to national development efforts, and services. This was achieved through a concerted • Innovative funding mechanisms, such as 40 years of sustained public intervention. In are actively engaged with learning, problem effort by the Government of Indonesia to support the use of Islamic alms funding (zakat, infak, the Republic of Korea, sanitation was central resolution, ‘progress-chasing’ and building a the sanitation sector at all levels, with a focus on shadaqah and wakaf, referred to as ZISWAF), to the government’s public health planning culture of regular course correction. sub-national peer-to-peer learning. An alliance micro-credit to reach the poorest households, and promotion of the idea of communities and of former mayors and district heads provided output-based grants to support communal Source: WaterAid country ‘living well’. leadership, mobilizing their peers across the level investments, and provincial and country to share lessons on WASH. With support national-level funds to support larger scale from a range of development partners, this systemic investments in infrastructure; and initiative has been successful at inspiring local • Leveraging of non-traditional partners – such leaders and mobilizing communities. as faith-based organizations and the private Sanitation needs to be defined the sanitation chain (sewered and non- sector –to mainstream behaviours and as an essential service for which sewered) and a simple, transparent, Many lessons were learned on the most effective practises and ensure long-term sustainability. government is responsible and can effective regulatory and enforcement ways to address sanitation issues, including the be held accountable. Governments environment allowing innovation, cost need for: The government has integrated these lessons must establish institutions to coordinate recovery and provision for serving the • Continuous and more systematic advocacy into the new Medium-term National Development and regulate the activities of government, poor and vulnerable. The inclusion of and capacity building for local governments; Policy for 2020 to 2024 to support targets on open service providers and service users, sanitation in national policies, strategies • Stronger coordination between institutions in defecation and safely managed sanitation. and generate public benefits. Sanitation and plans can serve as a concrete

Source: SUSENAS of Indonesia Government the sanitation sector; service provision, including through the indicator of the political will and priority private sector and informal provision, given to sanitation. The higher the profile of should be supported through a legislative sanitation in national development plans, framework and policies, accompanied by the more likely the issue is to be prioritized standards for service quality throughout by decision makers and politicians. 70 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 71

Supporting policy development through the African Strengthened sanitation policy and planning Sanitation Policy Guidelines for rapid progress in Nepal BOX 13 BOX 14 The African Ministers’ Council on Water coverage and improving service quality. The Since the 1950s, Nepal has produced five-year of wastewater. The target is for 100 per cent (AMCOW) was formed in 2002 to promote guidelines encourage the development of national development plans that establish socio- of the population to have access to improved cooperation on water and sanitation. AMCOW stand-alone sanitation policy, and provide economic objectives. The Fifteenth Periodic Plan sanitation facilities, achieve and maintain the open has since become a specialized committee for background information, advice on the process, (2019/2020–2024/2025) outlines key strategies to defecation free status of the country, and to work water and sanitation within the African Union. In recommended contents of a policy, and guidance achieve middle-income country status for Nepal. progressively towards total sanitation, with at least response to demand from African governments, for developing an implementation strategy. The The plan includes WASH objectives, focussing on 20 per cent of wastewater treated and properly AMCOW is coordinating the development of guidelines are designed for use at national level, improving public health by ensuring accessibility discharged. Total sanitation in Nepal includes the the African Sanitation Policy Guidelines. These but are also applicable to local governments. The of reliable, affordable and safe drinking-water basic requirement of having access to a toilet, guidelines will enable governments to develop overarching theme is government leadership, and sanitation facilities for all in urban, peri-urban as well as additional considerations, such as policies specifically related to sanitation, with the responsibility and initiative. and rural areas. It also includes maintaining handwashing, safe drinking-water, safe food and objective of accelerating progress on sanitation a clean environment by proper management an overall clean environment in the community. Source: and Policy Sanitation WHO (2019). Nepal Discussion. for Study Case Framework Planning

Government decision makers should and local governments need to establish recognize that safe sanitation clear roles, responsibilities and mandates systems need to be delivered for all steps in the sanitation service through a mix of technologies, chain to address both overlaps and gaps implemented through service in organizational mandates. For instance, models tailored to the local some countries, including Bangladesh context and based on sound risk and Nepal, have developed institutional assessments. Strategies and plans and regulatory frameworks specifically should explicitly recognize the utility of for faecal sludge management to better both sewered and non-sewered sanitation define roles and responsibilities.47 (including decentralized systems) and Governments must also improve cross- appreciate the importance of building and sector collaboration, and increase supporting the entire sanitation chains of involvement of all stakeholders, including both. The role of informal sanitation service the private sector, users and civil society. providers should be acknowledged, recognizing that their experience is a Sanitation must be recognized

© UNICEF/UN0348911/Modola valuable resource that should be utilized as a multi-sectoral issue that has within the formal system. impacts across health, social development, education and the Service quality must be regulated economy. While lead institutions are at all steps in the sanitation important, governments must establish Sanitation policies can only be agriculture and urban planning. Effective service chain, based on public health clear mandates, backed with capacity successful when complemented plans must have time-bound targets risk assessment and management. for sanitation delivery, in all sectors, by implementation plans that and goals, adequate budget allocation Government policy must enable including local government, education, have been costed and backed by and monitoring frameworks, including and encourage more private sector housing, healthcare, labour and sufficient human and financial both outcomes and outputs (e.g. focus producers, suppliers and services to agriculture. It is particularly important to resources. Lead institutions need to on open defecation free communities increase competition, lower costs, ensure the lead sector in sanitation has develop multi-sectoral sanitation policies rather than just toilet coverage). increase innovation and allow the dedicated staffing and resourcing, and that use inter-sectoral coordination Development partners must align their availability of a diverse range of products is involved in all aspects of planning, mechanisms and planning processes. programmes to national strategies and in the marketplace. delivery, promotion and monitoring. Plans should be based on a review of priorities. Regular, coordinated, national existing policies to identify impediments or multi-sectoral reviews of sanitation Clearly defined leads and The sanitation workplace to improving sanitation along the whole policies, plans and progress have been institutional arrangements for requires increased regulation and service chain and in all settings, including effective in strengthening planning and sanitation across the sanitation formalization. Many more sanitation linkages with related sectors, such as governance.46 service chain have enabled workers are needed, yet sanitation success in many countries. National workers, who are often poorly paid and 72 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 73

stigmatized, are repeatedly exposed Through partnerships and platforms, sanitation chain, including infrastructure In addition to sanitation systems and to health risks. Their work may expose governments can learn from one another for conveyance, treatment and disposal. services, governments must also them to hazards such as pathogens in and support each other towards greater These require coordinated government- budget for the costs associated with faecal sludge and wastewater, injury from political prioritization of sanitation and led investment, including costed plans a conducive enabling environment, collapsing pits, asphyxiation from gases strengthening of governance systems. and dedicated budget lines. Clarifying sustained over the long term, particularly in sewers and drug and alcohol abuse to The Sanitation and Water for All multi- which funding sources and financing related to building and maintaining cope with the dehumanizing conditions stakeholder partnership of governments, instruments can be mobilized, as institutional and regulatory capacity. of the worst types of informal sanitation civil society, the private sector, UN well as the role of each entity in work. Working conditions need to be agencies, and research institutions funding sanitation investments, There are multiple sources of progressively formalized to safeguard encourages partners to increase political is critical if countries are to meet funds for sanitation, including the health and safety, and to ensure decent prioritization of WASH; ensure adequate their aspirations in the most cost- ‘3Ts’: taxes disbursed via government working conditions, as called for by SDG financing; and build better governance effective and efficient manner. budgets, transfers from external donors, 8.48 Workers’ rights must be protected, structures and institutions to achieve and tariffs and user fees. Where large and they need freedom and support to SDG 6. Sanitation is a public good that investments are required to develop organize as a labour force. delivers benefits for health as sanitation services, and revenues from well as social and economic taxes and tariffs are insufficient to meet development, and warrants the initial investment costs, additional strategic, well-targeted public funds can be mobilized by governments funding. The process by which and service providers via a range of developed countries achieved near- financing instruments. These are used universal access to water and sanitation to borrow from donors or commercial clearly demonstrates that domestic public banks, and the amounts borrowed are finance, including targeted subsidies, has repaid in the future, usually with taxes been and remains critically important, or tariffs. Repayable finance can be even in strongly market-led economies.49 coupled with specialist expertise through Policies need to make explicit what is to PPPs, in which a private company and be funded, when and how government a government entity work together to funds will be used, and how funding is to provide a public service. A common be coordinated. form of PPP in the sanitation sector is a concession contract for the operation and Investments in sanitation bring management of a faecal sludge treatment significant financial returns to plant. Repayable finance can also be households and society. A 2012 accessed, at small scale, by households WHO study estimated that the economic or service providers through microfinance. UNICEF/China

© benefits of sanitation are more than five Governments seeking to support private times greater than the costs. A follow-up sector investment in sanitation must 6.2 global study in 2018 showed an overall develop a robust regulatory environment, return on basic sanitation of just over enabling the private sector to generate five times in rural areas and a return of reliable and sufficient revenue streams to Smart public finance six times costs from eliminating open cover their investments and operations. defecation. In urban areas, ratios were Governments must also build capacity in unlocks effective lower, at almost three times costs, as a commercial and financial management, result of the higher unit costs of sanitation and contract oversight. interventions in urban areas.50 household and private Choosing the funding arrangements Studies showing the long-term benefits that work best requires understanding investment of sanitation can help galvanize political the costs of sanitation and the different will and investment. Studies such as that funding sources and instruments undertaken by the World Bank in India available. If the full costs of sanitation In most countries, the investment needed and investment in toilets and on-site in 2011, which showed that inadequate cannot be funded, then governments will to meet sanitation targets is considerable. containment and treatment technologies. sanitation was costing the country billions face a situation in which services cannot It is households, not governments, that However, a reliance on household funding of dollars,51 along with similar studies be extended to all, or cannot be sustained currently provide the largest proportion can exacerbate inequalities. Household in Bangladesh52 and Pakistan53, have over time, or both. of funding for sanitation through funding also does not address the need had a significant impact on government connection tariffs, emptying service fees for larger investments in the broader investment in the sector.54 74 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 75

Good practice is to set tariffs that Governments must make evidence- cover at least operating costs. based decisions on the allocation However, subsidies may be needed to of funds and hold service providers achieve universal coverage for vulnerable accountable. Government financial groups and to ensure that no one is tracking systems can be used to support left behind. Public funds can be used decision-making by monitoring sanitation to cover the affordability gap between financial flows and expenditures.55 minimum sanitation service standards Establishing separate budget lines for and users’ ability and willingness to pay. sanitation is key, as is making clear Subsidies can be effective if they are budget allocations to fund sanitation well-designed, transparent and targeted programmes. Better coordination in so that scarce public resources reach budgeting between agencies with those most in need. Poorly designed primary responsibility for different SDG subsidies, by contrast, can serve the rich targets (e.g. housing, urban development, rather than the poor, with the latter often health, education) can result in synergies paying more for services. and cost savings.

Harnessing public private partnerships for sanitation: Safe wastewater use in Durban, South Africa BOX 15

During the 1990s, Durban was facing a sewage contract (2001-2021). The total cost of the project treatment capacity constraint. Existing infrastructure (construction for the new tertiary plant, purchase could not cope with the growing population and the and upgrade of the municipal utility assets economic development of the city, and significant used for the project and the required piping investment was required. The municipality initiated system) was financed by the private partner. a PPP agreement to recycle wastewater for The municipal utility remained in charge of the

industrial use. The goal of the project was to treat preliminary and primary wastewater treatment 6.3 © UNICEF/UNI62693/Noorani around 48 million litres per day (approximately plant, but the consortium undertook the risk 10 per cent of the city’s wastewater) and achieve of meeting the water quality needs of the two an acceptable quality for safe use by two large industrial users. The high prevailing cost of Capacity at all levels industrial plants, a paper plant and an oil refinery, water and the guaranteed demand for treated which were interested in using treated wastewater wastewater from the two industrial users made drives progress and at half the cost of potable water. the project economically attractive and allowed the consortium to undertake the investment risk. sustains services Durban Water Recycling, a consortium led by Vivendi Water Systems (Veolia), was chosen The project was the first of its type in South through international bidding to finance, design, Africa and is an example of a win-win PPP that The low emphasis historically placed governance, financing, innovation and data construct and operate the tertiary wastewater considers wastewater as an asset rather than on sanitation has resulted in significant management needed to reach and sustain treatment plant at the city’s Southern Wastewater a liability, reduces environmental impact and capacity shortfalls across all dimensions sanitation targets. Capacity development is

Wastewater: From Waste to Resource, to The Case of Durban, South Waste Bank, From Source: Wastewater: World Africa, Bank, World , DC, 2018. Washington Treatment Works under a 20-year concession contributes to the circular economy. of the system. Investments made in far more than just training. It encompasses: institutions and infrastructure without • Human resources development: addressing capacity needs will result in Ensuring that the institutions employ failing services and a waste of scarce the right types and numbers of funds. Capacity development and adequately qualified, trained and institutional strengthening are essential motivated personnel. at all levels of government, communities • Organizational development: and the private sector, and across Ensuring that the institutions are sectors (WASH, health, education, adequately empowered and use finance) to plan, design, finance, build effective systems and procedures. and sustain improved sanitation. • Resourcing: Ensuring that the institutions have access to sufficient Capacity development is essential to financial, material and technical build strong foundations for the effective resources. © UNICEF/UNI82512/Majola 76 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 77

• Research and innovation: shared toilets, maintenance, repair determinant of health outcomes but The principal focus of capacity Undertaking applied research and cleaning, as well as the products there is often little involvement of various development must be at the local to develop better technical and derived from sanitation, such as water, levels of the health sector in planning level. This is the level at which services managerial solutions for sanitation. fuel, proteins and organic fertilizers. and financing sanitation promotion must be provided and problems solved in The sanitation economy is estimated and implementation. Capacity must a continuous, adaptive process. Sufficient numbers of adequately to represent a US$62 billion market be strengthened through a number of skilled and motivated government opportunity in India alone by 2021.56 strategic interventions, including: Capacity building for sanitation staff, at the highest levels, are Growth of the private sector and the • Creating senior posts with dedicated must be integrated into curricula. essential. National governments circular economy will require building responsibility for sanitation and Because of the scale of the effort, it need the capacity to develop and skills in these areas, as well as for ensuring they are well resourced, is imperative to include sanitation in administer the fundamentals of effective improved environmental management trained and have adequate autonomy the curricula of universities, vocational and sustainable sanitation systems, and climate change considerations, and to make change. training schools and other specialized including regulations for all steps of the the business opportunities that sanitation • Building capacity of environmental institutions, such as local government sanitation chain, policies, time-bound presents. The sanitation economy health staff to fulfil health sector training schools. strategies and costed plans, along with can only thrive with development of a functions in the sanitation sector, coordination mechanisms to ensure supportive regulatory environment that such as incorporating sanitation Peer-to-peer learning and cross-sectoral integration and private encourages initiative. into health programme delivery, mentoring are very effective in sector involvement. A well-balanced promoting sanitation behaviour sanitation. This must be explicitly gender, ethnic and cultural mix among Research and innovation must be change, and ensuring adequate recognized so that resources can sanitation personnel is important to scaled up to meet the challenges sanitation in healthcare facilities. be made available. For instance, enable a fully responsive relationship with and opportunities of universal • Establishing sanitation oversight, government exchanges can be users and provide equal opportunities for sanitation. There are a number of monitoring and enforcement facilitated within or between countries employment to all. areas where the knowledge, skills and mechanisms, including routine to disseminate good practices and techniques needed to address challenges monitoring of sanitation in schools promote peer competition around the Local government must have are lacking. Globally, conditions in large and healthcare facilities. achievement of programme targets. adequate capacity to oversee and urban areas are changing quickly, small deliver service-oriented sanitation. towns are growing rapidly, roads and Capacity development is a The private sector must be included The adoption of new approaches telecommunications are opening up permanent activity. Sanitation in the capacity development effort. to sanitation, and an increasingly even the most remote areas, and the requires a large number of personnel. While the private sector has some ability decentralized approach to delivery, changing climate is creating new barriers With such a large workforce, there is a to develop its own capacity (which it will requires adjusting the skills mix and to the provision and sustainability of continuous need for capacity building at eventually charge for indirectly), public level of resources for staff to effectively sanitation systems. These new challenges many levels. New staff posts are needed sector investment in this area will yield implement their mandate. A more and opportunities require research and to work in traditionally neglected areas, faster and better results. service-oriented approach to sanitation – capacity development in areas such as: such as non-sewered sanitation and with a much higher degree of interaction • Management of non-sewered hygiene promotion. with users, greatly increased activity with sanitation; respect to non-sewered sanitation, and • Pit emptying and faecal sludge openness to market-based solutions – processing technology (including a means that the organizational culture and focus on safe valorization and use); mix of educational backgrounds in local • Providing formal services to government sanitation departments and previously unserved communities; utilities may need to change. • Developing appropriate climate- resilient sanitation technologies; and Appropriate skills need to be built • Developing effective behaviour among artisans and entrepreneurs change methodologies. working in the sanitation chain. With the increased need for private sector Effective integration and involvement in parts of the sanitation coordination of sectors addressing chain, there is an opportunity to grow sanitation will require increased the ‘sanitation economy’, which is a capacity. In many countries, there marketplace of products and services, is a lack of coordination between renewable resource flows, data and sanitation and other sectors such as information. The sanitation economy health, education, environment and

includes construction of individual and water. For instance, sanitation is a major © UNICEF/UNI79278/Pietrasik 78 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 79

Protecting sanitation worker health and safety in Bolivia BOX 16 6.4 In Bolivia, on-site sanitation solutions are Solutions that are being implemented in Santa meeting the need in response to low access, Cruz include: Reliable data support rapid population growth and high investment • The use of a toilet technology that limits costs for conventional sewers and wastewater workers’ exposure to faecal matter; treatment plants. Consequently, small- and • The application of national occupational better decision-making and medium-sized private vacuum truck companies health and safety standards for sanitation have emerged to meet the demand to empty workers; stronger accountability pits and septic tanks. In cities such as Santa • The standardization of procedures for Cruz, emptying companies have been operating collection, transport, and discharge of for more than 30 years without any official household faecal sludge, focussed on High quality data allow governments management, for example, is vital to inform control or regulation. industrial safety and environmental to target investment, monitor progress and tailor sanitation investment based on protection; and and make timely course corrections. health and sanitation coverage. Likewise,

Source: World Bank, ILO, WaterAid and WHO, Health, and WHO, WaterAid Bank,Source: ILO, World Safety and Dignity of Workers: Sanitation An Initial Assessment, DC, 2019. Bank, Washington, World Despite the lack of regulation, there has been • Training modules developed in partnership Governments need to fully harness the accurate and regular data collection will progress in protecting sanitation workers. with universities. potential of data and evidence, and be essential to efforts to effectively target support the institutionalization of data climate resilience responses. collection and monitoring within national systems and at all levels(community, Reliable, consistent and utilities, sub-national and national). disaggregated data are essential Robust sanitation monitoring to stimulate political commitment, mechanisms at the lowest administrative inform policy-making and decision- level, using existing structures, need to making, and enable well-targeted be established and linked with existing investments that maximize health, reporting and accountability structures. environment and economic gains. Consistent methodology, including Quality data can be used to inform standardized terms and questions in more effective policies, targets, budget data collection and monitoring, need to allocations and pro-poor strategies. be used. Sanitation must be included Quality data is also important in within health surveillance systems to measuring progress towards SDG targets help target of high-burden settings, and and other goals, critical in all aspects to support outbreak prevention efforts. of sector governance, and essential to It is vital to build trust through data ongoing efforts to improve accountability, generation, validation, standardization transparency and participation. and information exchange for decision- making and accountability. The value of survey and census data can be increased by using Data can be paramount in harmonized questions that allow developing political will and comparison with other surveys commitment. However, many countries and enable tracking of national, lack the financial, institutional and human regional and global indicators. Since resources to acquire and analyse the data 2006, the JMP has worked with statistical required for effective decision-making offices, international survey programmes and governance.57 The establishment of and WASH experts to develop sets of simple, robust data collection systems, harmonized core questions for monitoring linked to accountability mechanisms, is WASH in households, schools and important to inform political commitments healthcare facilities. The quality and and well-targeted investments. comparability of datasets has improved steadily.58, 59, 60 Accurate and appropriate data allows for informed decision-making. Official public data sources, including UNICEF/Jordan/Saman

© Health sector surveillance and data national accounts, censuses, surveys 80 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 81

of households and businesses, able to provide data on government Monitoring of policy identifies gaps in Botswana administrative records and regulatory WASH expenditure. Many countries have and Namibia data, are increasingly being expressed interest in obtaining better complemented by new types of data from quality and more detailed information BOX 18 private sources, including mobile phones, on WASH financial flows. The Trackfin electronic transactions and satellites. initiative was developed to address this In Botswana, a policy gap analysis carried highlighted through GLAAS 2018/2019 Developing country governments need through a methodology for producing out through GLAAS highlighted that access data have resulted in a stronger and more to make use of both types of data. They WASH accounts. to sanitation has lagged behind water supply. inclusive process for developing Namibia’s should continue to invest in public The response from the Ministry of Land new sanitation strategy, which will now sources, which provide reliable data While many countries have data on the Management, Water and Sanitation Services, reference the WHO Guidelines on Sanitation covering the entire population that can treatment of wastewater from sewers, with support from the United States Agency for and Health, and include sanitation safety be disaggregated for populations of relatively few have data on the collection, International Development’s Resilient Waters planning, financing mechanisms, faecal sludge interest, and also seek to harness data treatment and disposal of faecal sludge Program, has been to develop a sanitation management and the entire sanitation service from other sources if these offer greater from on-site sanitation facilities such as roadmap. In Namibia, gaps in sanitation chain, all of which were previously omitted. frequency, timeliness or granularity. In septic tanks and latrines. There is also fact, new sources of data are essential, as a lack of independent regulatory data information on safely managed sanitation – aggregated to national level – for all cannot be collected from household steps of the sanitation chain, especially surveys alone, and must be collected for non-sewered services. Further work from service providers, such as utilities is required to integrate new questions on and private sanitation businesses, that management of on-site sanitation into maintain and empty septic tanks. household surveys, to increase coverage of public health surveillance systems, Surveys at country level reveal a including sanitary inspections, and to consistent data gap in WASH financial strengthen regulatory data systems on data. In the 2018/2019 GLAAS survey the collection, transport and treatment of cycle, less than half of countries were waste from on-site facilities.

Monitoring safely managed sanitation in Ecuador BOX 17

Levels of basic sanitation services are facilities (septic tanks and latrines), asking generally high in Ecuador, but national data on where effluent from septic tanks is discharged the quality of these services have been scarce. and whether latrines and septic tanks have The National Statistical Office collaborated been emptied. The results allowed Ecuador to with the World Bank Global Water Practice and report on the current status of safely managed the JMP to pilot a new module in a national sanitation services nationally by combining household survey in 2016. Households were information from the survey with data from asked questions about sanitation that focussed municipalities on wastewater treatment and to on the management of on-site sanitation drive action at the local level.61 © UNICEF/UNI137336/LeMoyne 82 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 83

Taking a new approach to improving sanitation coverage in Eastern Europe BOX 19

In Eastern Europe, sanitation systems built in the addressed. More than half of the countries in Soviet era were largely centralized sewers serving the region have no standards and inadequate urban centers. In the 30 years that followed the monitoring for faecal sludge management. The dissolution of the Soviet Union, sewered sanitation situation is exacerbated by a lack of human remained the dominant paradigm. The newly resources for monitoring, design, construction formed states struggled to maintain existing and O&M of systems. Many Eastern European infrastructure, let alone extend services. Without countries have major financing gaps that need leadership for on-site sanitation, services changed to be filled to meet national targets. Many little for people not served by sewers. countries do not have a sanitation financing plan or schemes to make household investments in Recent estimates show gradual increases in sanitation affordable. All of these challenges are sanitation access in both urban and rural areas in most pronounced in rural areas.63 most post-Soviet countries compared to the period between 1992-2000. Countries such as Azerbaijan, In the past decade, a step-change has come Belarus, Lithuania, Latvia, the Russian Federation through the WHO/UNECE Protocol on Water and Ukraine have made significant improvements and Health. This gives greater recognition to the in providing new sewer connections. The Republic role of small-scale sanitation systems and the of Moldova has increased coverage by building government mandate and leadership to improve septic tanks in rural areas.62 safe management of non-sewered systems, and has accelerated progress through setting and Despite recent progress, critical issues around implementing dedicated targets.64 governance and management need to be 6.5 © UNICEF/UN0353564/Ijazah

Urbanization and migration call for The challenge of urbanization has already Innovation leads to better new ways of meeting the needs of driven the development of successful and high-density populations living in innovative programming approaches and approaches and meets poverty, often in informal settlements. To sanitation systems. These approaches date, most urban sanitation interventions combine new ways of providing facilities emerging challenges have relied on the expansion of and services with community mobilization centralized sewer infrastructure that and action to strengthen demand and rarely reach low-income communities collective action, along with building Business-as-usual is no longer Governments can encourage innovation and are ill-suited to dense urban slums government and service provider capacity. an option if we are to achieve the and experimentation through supportive and unplanned settlements, where the Meeting the urban sanitation challenge transformative progress needed to government policy and regulation, majority of urbanization is happening. has also sparked new approaches, such meet SDG 6. ‘Future-proofing’ the sector accompanied by rigorous monitoring Recognizing the urban sanitation crisis, as citywide inclusive sanitation (CWIS), necessitates innovative approaches, and evaluation of systems and proposed its disproportionate burden on the described in Box 21. It has also led to partnerships, systems and technologies solutions. Innovative practices and urban poor, and the limited progress of innovations in facilities and inclusive that will meet the challenges of tomorrow, technologies can be leveraged, including prevailing approaches, there is a need service models, such as container-based including disease outbreaks, migration, those that support accelerating sanitation for a radical shift in approach. sanitation, that can meet needs where urbanization, a changing climate and services for rural areas and marginalized space, tenure, tenancy and geology make increasing pressure on natural resources. communities. Governments can also conventional approaches untenable. Reducing rather than exacerbating support the sharing and dissemination inequalities will require governments of research and innovation. Partnerships and service providers to respond with between service providers and academic solutions that are practical, cost-effective institutions have proven valuable and and scalable. mutually beneficial. 84 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 85

Developing integrated sanitation solutions for all In rural areas, context-specific, show that risk-based, cost-effective, though citywide inclusive sanitation community-based approaches scalable innovations can drive major help ensure sustainable services gains in the use of sanitation services. BOX 20 for all. The past decades have seen a To meet the challenge of the SDGs, shift from construction-driven sanitation however, programmes for rural areas CWIS is an approach to planning and • Comprehensive long-term planning fosters approaches towards demand-focussed, must also seek new ways to ensure implementing urban sanitation services along demand for innovation and is informed by community-based social mobilization sustainable services in the most hard- the entire sanitation value chain. CWIS integrates analyses of needs and resources. and behaviour change approaches to-reach areas, reaching the poorest and financial, institutional, regulatory and social • Political will and accountability systems that are aimed at the creation of new most vulnerable populations, building aspects of sanitation service delivery, requiring incentivize service improvements in social norms that support consistent strong supply chains and markets, authorities to demonstrate political will, technical planning, capacity and leadership. and community-wide toilet use. These sustaining new behaviours and ensuring capacity and management leadership, as well innovative programming approaches climate-resilience. as harmonizing solutions with related urban CWIS prioritizes everyone’s right to sanitation, services, such as water supply, drainage and solid with inclusive strategies and mechanisms to waste management. reach the most marginalized population in Growing government commitment to solving urban areas. The focus is on service outcomes, rural sanitation in Kenya and Tanzania The CWIS approach is guided by the following rather than technologies, and it embraces principles: innovation, diversity of technical solutions and BOX 21 • Everyone in an urban area, including the incremental approaches. CWIS recognizes urban poor, benefits from equitable and safe sanitation’s contribution to a thriving urban In 2010, the new constitution of Kenya (I am ready), has been launched in pursuit sanitation services. economy by integrating sanitation into urban recognized water, sanitation and a clean of universal sanitation and hygiene by 2025. • Gender and social equity are designed into planning, reforming regulatory policies, and environment as a basic human right. It assigned The campaign engages a broad group of planning, management and monitoring. embracing resource recovery and re-use. the responsibility for water supply and sanitation government and non-government stakeholders, • Human waste is safely managed along On-site and sewage solutions are promoted, provision to 47 county governments. However, builds political commitment at the local level, the sanitation service chain, starting with combined in either centralized or decentralized sanitation was an entirely new mandate for leverages resources, and develops the capacity containment. systems to better respond to the sanitation the counties, and the target to achieve an of local authorities to implement and monitor • Authorities operate with a clear, inclusive needs of expanding cities in low- and middle- open defecation free rural Kenya by 2013 district-wide sanitation plans. Progress is mandate, along with performance targets, income countries. Stakeholders commit to could not be met. In 2014, a national sanitation reported through the national management resources and accountability. work in partnership across sectors to make conference was convened to instil a new sense information system. In 14 districts, an area- • Authorities deploy a range of funding, progress through clear institutional mandates of urgency. Counties were encouraged to meet wide approach has been piloted, through business and hardware approaches (sewered with accountability, embedding sanitation within commitments set out in ‘open defecation free which stakeholder forums are established

Source: Citywide Sanitation Inclusive and non-sewered) to achieve the goals. urban governance systems. roadmaps’. In 2016, the national government to foster engagement, sector alignment and renewed efforts to support counties to meet collaboration. Sanitation networks, known as their obligations. It aligned national policies and Jirani (neighbour) groups, are formed at the strategies with the new constitution, through community level, with leaders for every 10- a nationwide Kenya Environmental Sanitation 15 households, to mobilize the communities and Hygiene Policy, Strategy and Open to achieve and sustain open defecation free Defecation Free Campaign Roadmap. National status. Informed by evidence from door-to-door coordination, leveraging the critical contribution surveys, the Jirani groups have played a pivotal of a range of development partners, has allowed role in understanding which households have for effective support. Although reaching the or have not adopted safe sanitation practices. national open defecation free target is still Based on the lessons learned, innovative far off, three counties have been certified as and targeted measures are being piloted to open defecation free, and open defecation has reach ‘last mile’ households, including socially decreased from 18 per cent in 2010 to 12 per marginalized and poor households, as well as cent in 2017. households that have the economic resources to build latrines, but choose not to do so. Open In Tanzania, under the leadership of the defecation has been reduced to less than 10 per President’s Office, ministries are working cent in the 14 districts, and the learning is being together to implement a five-year National used to adapt and scale up similar approaches Sanitation Campaign. A national behaviour in other districts.

Source: World Bank, Plan International, Water Supply and Sanitation Collaborative Council, SNV, WaterAid and UNICEF, Delivering and UNICEF, WaterAid Council, SNV, Collaborative Supply and Sanitation Water Bank, International, Source: Plan World Scale, at Programs Sanitation with DC, Equity 2019. Rural and Sustainability: Bank, A Call Action, to Washington, World change communications campaign, Nipo Tayari © UNICEF/UN0348903/Modola 86 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 87

The challenges of climate change Governments should consider using a Making every drop count through and mounting resource pressure mix of sanitation services based on an safe use of wastewater in Jordan call for innovative ways of delivering assessment of local housing and sanitary services that will be resilient and conditions, prioritizing institutionally BOX 22 enable resource-recovery. Climate and financially feasible interventions variability and change will increase that address the greatest identified Due to water scarcity, Jordan is a pioneer in farmers to cultivating fodder crops and trees, the strain on sanitation systems, and public health risks in the shortest time. practicing planned use of wastewater and although regulations also allow irrigation of therefore must be considered to ensure A combination of technologies for sludge in agriculture. Since 1977, the Jordanian vegetables eaten cooked, cereals and industrial sanitation technologies and services are containment, conveyance, treatment government has officially promoted agricultural crops. The additional restriction exists primarily designed, operated and managed in a and safe disposal or end use, that are use of wastewater and coordinated policy, due to perceptions of health risks and limited way that minimizes risks to human and linked and properly managed, can form implementation and monitoring between monitoring capacities. environmental health. Well-designed a safe sanitation chain. Such systems stakeholders in the sanitation and agricultural sanitation services in turn increase can be safer, more resilient, more cost- sectors to ensure safety. In 2014, the Jordanian authorities issued national community resilience to climate change effective, environmentally-friendly and guidelines and an implementation framework, through continuity of services that provide beneficial inputs for other Approximately 93 per cent of treated wastewater adopting flexible health-based targets and contain waste after extreme events. While sectors, such as energy and agriculture.65 is used for irrigation in the country, of which 24 applying risk assessment and management human excreta is a globally significant Other innovations, like container-based per cent is used directly.66 Direct use is regulated tools based on WHO guidelines to operational, source of greenhouse gas emissions, systems, can be deployed very quickly, by contracts between farmers and the Ministry legislative and institutional aspects along the there is considerable potential to capture and may be well suited to people in fragile of Water and Irrigation. The contracts limit sanitation chain.67 emissions and recover water, nutrients or emergency contexts. Wastewater and energy from sludge and wastewater. treatment systems can be decentralized, Their safe use in energy generation, and and the costs of construction and as inputs to agricultural processes, help operation can be lowered by using less mitigate the effects of drought, reduce complex technologies. reliance on chemical fertilizers and strengthen food systems. Governments can enable innovation through sound Governments must think beyond regulation, and by setting conventional sewage systems, sanitation technology performance which are costly and time-consuming to criteria and standards that reduce install, and consider other options, such risk but are not overly prescriptive. as decentralized, non-sewered sanitation This includes O&M criteria and systems. Innovations in sanitation incremental standards, if appropriate for technologies and systems can mitigate specific settings. By setting standards for and adapt to the risks posed by climate and regulating safe use of wastewater change, urbanization and resource and sludge, governments can reduce scarcity. The selection of sanitation waste and recover resources for technologies and systems is context- agriculture. For example, decentralized

specific and depends on local technical, wastewater treatment systems offer an © UNICEF/UN040195 economic and social factors. opportunity for local water reuse, such as for crop irrigation or fish production. Innovation extends to the protection safety, at the same time as supporting of the sanitation workforce. continuity of services. Innovative technology and approaches can help to limit workers’ occupational Effective sanitation programmes exposure and provide a healthier adapt and combine approaches workplace. Measures such as phasing and establish frequent feedback out manual emptying, and replacing it loops to course correct, using learning with motorized systems, can improve reviews and monitoring systems. Learning, worker health. Appropriate personal adaptation and innovation require protective equipment, standard operating deliberate planning of time, capacity procedures and regular health checks and resources, as well as the associated can also improve worker health and financing and reporting structures. © UNICEF/UN0348926/Modola 88 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 89

Looking ahead: A pathway to 2030

The journey to 2030 offers key moments moments present opportunities to share International to strengthen government leadership, successes and learn from the experiences High-Level Conference on increase political prioritization, deepen and innovations of others to collectively International Decade for Action partnerships and encourage strategic make universal access to safe sanitation (2018-2028) in Dushanbe public investment for sanitation. These a reality. 2030

High-level meeting convened by the President of the General Assembly to promote the Africa Water Week implementation of the water-related goals and targets of the 2030 Agenda AMCOW Ministerial 15-year anniversary WHO World Health Meetings of the recognition of Assembly (annual) the human rights to water and sanitation in 2025 Arab Water Week UN Conference on the Midterm Review Annual Moments of the Water Action convened to mark Decade on 22-24 SDG 6 Global March 2023 Acceleration Sanitation and Framework progress Water for All World Water Forum Finance Ministers’ Meetings (biennial) Asia-Pacific Water Summit International Water 2020 Association Congress Korea International Water Week Regional sanitation conferences (LatinoSan, AfricaSan, SacoSan) In-depth review Singapore International of SDG 6 during Water Week the High-level Political Forum

United Nations SIWI World Water Week Climate Change Conference 90 STATESTATE OF OFTHE SANITATION WORLD'S SANITATION REPORT 91

1 WHO, Global costs and benefits of drinking-water 13 Hutton, Guy, et al., ‘Comparison of the costs supply and sanitation interventions to reach MDG and benefits of the Clean India Mission’, World target and universal coverage, WHO, Geneva, 2012. Development, 134: 105052, 2020.

2 WHO and UN-Water, National Systems to 14 UNICEF, National Economic and Financial Support Drinking-water, Sanitation and Hygiene: Impact of the Swachh Bharat Mission, UNICEF, Global Status Report 2019 (GLAAS 2019 Report), New York, 2020. WHO, Geneva, 2019. 15 UNICEF, WaterAid and WSUP, Female-friendly 3 WHO and UN-Water, National Systems to public and community toilets: A guide for planners Support Drinking-water, Sanitation and Hygiene: and decision makers, WaterAid, London, 2018. Global Status Report 2019 (GLAAS 2019 Report), WHO, Geneva, 2019. 16 UN-Water, Delivering the promise of safe water and sanitation for all by 2030: The SDG 6 Global 4 OECD, ‘Creditor Reporting System’, OECD, Acceleration Framework. Geneva, 2020. Paris, 2020, , accessed 28 August 17 Andres, Luis A., et al., Doing More with Less: 2020. Smarter Subsidies for Water Supply and Sanitation, World Bank, Washington, DC, 2019. 5 Parikh, Priti, et al., ‘Synergies and Trade- offs between Sanitation and the Sustainable 18 Studies tend to report that between 25 per cent Development Goals’, 2020, ResearchGate: and 45 per cent of women in the study population 10.14324/111.444/000054.v1. have a type of urinary incontinence, while other studies have found that 1 per cent and 39 per 6 WHO, Guidelines on Sanitation and Health, cent of men (increasing with age) have urinary WHO, Geneva, 2018. incontinence. Source: Rosato-Scott, C, Giles- Hansen, C, House, S et al., Guidance on supporting 7 WHO, FAO and OIE, Technical Brief on Water, people with incontinence in humanitarian and Sanitation, Hygiene and Wastewater Management low- and middle-income contexts (LMICs). Report. to Prevent Infections and Reduce the Spread of LMIC-Incontinence-email-group , University of Antimicrobial Resistance, WHO, Geneva, 2020. Leeds, 2019.

8 Esteves Mills, Joanna and Oliver Cumming, ‘The 19 White, S., et al., ‘A Qualitative Study of Barriers Impact of Water, Sanitation and Hygiene on Key to Accessing Water, Sanitation and Hygiene for Health and Social Outcomes: Review of Evidence’, Disabled People in Malawi’, PLoS One, May 2016, 2017, ResearchGate: 10.13140/RG.2.2.36572.49280. 11(5):e0155043.

9 Adapted from WHO, Safer Water, Better Health, 20 WaterAid, SHARE Consortium, Leonard WHO, Geneva, 2019. Cheshire Disability and Inclusive Development ENDNOTES Centre, Including disabled people in sanitation and 10 WHO, Preventing diarrhoea through better hygiene services, WaterAid, London, 2011. water, sanitation and hygiene: exposures and impacts in low- and middle-income countries. 21 Wilbur, J., and H. Jones, ‘Disability: Making CLTS WHO, Geneva, 2014. Fully Inclusive’, Frontiers of CLTS: Innovations and Insights, Issue 3, Brighton, 2014. 11 WHO, Global costs and benefits of drinking- water supply and sanitation interventions to 22 UNICEF and WHO, Progress on household reach MDG target and universal coverage, WHO, drinking-water, sanitation and hygiene 2000-2017: Geneva, 2012. Special focus on inequalities, UNICEF, New York, 2019. 12 Hutton, Guy, and Claire Chase, ‘The Knowledge Base for Achieving the Sustainable Development 23 Harris, M., et al., ‘Community-Level Sanitation Goal Targets on Water Supply, Sanitation and Coverage More Strongly Associated with Child Hygiene’, Int J Environ Res Public Health, 13(6), Growth and Household Drinking Water Quality E 2016. than Access to a Private Toilet in Rural Mali’, 92 STATE OF THE WORLD'S SANITATION A CALL TO TRANSFORM SANITATION FOR BETTER HEALTH, ENVIRONMENTS, ECONOMIES AND SOCIETIES 93

Environmental Science & Technology, 51(12), 2017, 38 Hutton, G., and M. Varughese, ‘The Costs of Sanitation and Water for All Finance Ministers 59 UNICEF and WHO, Core questions and pp. 7219–7227. Meeting the 2030 Sustainable Development Goal Meeting, Briefing Note, The Hague, Netherlands, indicators for monitoring WASH in schools in the Targets on Drinking Water, Sanitation, and Hygiene’, IRC, 2017. Sustainable Development Goals, UNICEF and 24 UNICEF, The Environmental Impact of the World Bank Water and Sanitation Program WHO, New York, 2016. Swachh Bharat Mission on Water, Soil and Food, Technical Paper 10371, 2016. 50 Hutton G., Benefits and costs of the water, UNICEF, 2018. sanitation and hygiene targets for the post-2015 60 WHO and UNICEF, Core questions and 39 Hutton, G., and M. Varughese, Global and development agenda. Chapter 23 in “Prioritizing indicators for monitoring WASH in health care 25 UNICEF and WHO, Progress on household Regional Costs of Achieving Universal Access to Development”, Edited by Bjorn Lomborg. facilities in the Sustainable Development Goals, drinking-water, sanitation and hygiene 2000-2017: Sanitation to Meet SDG Target 6.2, UNICEF, New Cambridge University Press, 2018. WHO, Geneva, 2018. Special focus on inequalities, UNICEF, New York, York, 2020. 2019. 51 World Bank, The Economic Impacts of 61 United Nations, Sustainable Development Goal 40 The 18 countries able to report data were: Inadequate Sanitation in India, World Bank, 6 Synthesis Report 2018 on Water and Sanitation, 26 UNICEF and WHO, Progress on drinking water, Albania, Bangladesh, Bhutan, Brazil, Burkina Washington, DC, 2011. United Nations, New York, 2018. sanitation and hygiene in schools: Special focus on Faso, Colombia, Costa Rica, Hungary, Iran, Kenya, COVID-19, UNICEF, New York, 2020. Madagascar, Nepal, Netherlands, Senegal, Serbia, 52 DeFrancis, Marc P. Economic Impacts of 62 UNICEF and WHO, Progress on household Solomon Islands, South Africa and Tunisia. Inadequate Sanitation in Bangladesh. Water and drinking-water, sanitation and hygiene 2000-2017: 27 WHO and UNICEF, WASH in health care Sanitation Program;. World Bank, Washington, DC., Special focus on inequalities, UNICEF, New York, facilities: Global Baseline Report 2019, WHO, 41 WHO and UN-Water GLAAS 2018/2019 country 2012. 2019. Geneva, 2019. survey. 53 World Bank, Economic Impacts of Inadequate 63 WHO and UN-Water, National Systems to 28 The updated data are available on the JMP 42 WHO and UN-Water GLAAS 2016/2017 and Sanitation in Pakistan. Water and sanitation Support Drinking-water, Sanitation and Hygiene: website and will 2018/2019 country surveys. program working paper; WSP. Economics of Global Status Report 2019 (GLAAS 2019 Report), be published as part of a broader report on WASH Sanitation Initiative. Washington, DC., 2013. WHO, Geneva, 2019. in health care facilities later in 2020. 43 WHO, Thirteenth General Programme of Work 64 United Nations, Protocol on Water and Health 2019−2023, WHO, Geneva, 2018. 54 Brocklehurst, Clarissa, Mead, Simon, and Joep to the 1992 Convention on the Protection and Use 29 UNHCR, Global Trends: Forced Displacement in Verhagen, Documentation of WSP’s Engagement of Transboundary Watercourses and International 2019, UNHCR, Geneva, 2020. 44 UN-Water, Delivering the promise of safe water in the Rural Sanitation Sector in South Asia Lakes, United Nations, 1999 and sanitation for all by 2030: The SDG 6 Global – Regional Synthesis Report, World Bank, 30 UNHCR, WASH monitoring website, , 2 September 2020. safe use and disposal of wastewater, greywater 45 Northover, Henry, Kue Ryu, Shin, and Timothy 55 TrackFin is a methodology to identify and track and excreta, WHO Geneva, 2015 31 Canet Rossello, J., ‘Analysis of global refugee Brewer, Achieving total sanitation and hygiene financing to the WASH sector at the national or settlement density vs UNHCR standard., PhD coverage within a generation: Lessons from East sub-national level in a consistent and comparable 66 Ministry of Water and Irrigation, Jordan. Dissertation for Polytechnical University of Madrid, Asia, WaterAid, 2016. manner. TrackFin produces WASH accounts that 2020. can be used for national benchmarking, cross- 67 WHO, Guideline on Safe Use of Wastewater, 46 The Policy Monitoring and Assessment country comparisons and to provide an evidence Excreta and Greywater in Agriculture and 32 UNHCR internal analyses, September 2020. Tool (PMAT) developed by WHO through the base to better plan and finance WASH services Aquaculture, Volumes 3 & 4, WHO, Geneva, 2006. GLAAS initiative is a tool that governments and and systems. To learn more about TrackFin or 33 UNHCR, Global Trends: Forced Displacement in development partners can use to monitor and express interest in producing WASH accounts, 2018, UNHCR, Geneva, 2020. assess the content of policies, plans and strategies please contact [email protected]. governing sanitation. 34 OCHA, Whole of Afghanistan: Multi-Sector 56 Toilet Board Coalition, The Sanitation Economy Needs Assessments, OCHA, 2018. 47 Examples of this are the “Institutional and in India: Market Insights and Estimates, 2017. Regulatory Framework for FSM in Urban Areas 35 UNICEF and WHO, Progress on household of Nepal“ and Bangladesh’s “Institutional and 57 WHO and UN-Water, National Systems to drinking water, sanitation and hygiene 2000-2017, Regulatory Framework for Faecal Sludge Support Drinking-water, Sanitation and Hygiene: UNICEF, New York, 2019. Management”. Global Status Report 2019 (GLAAS 2019 Report), WHO, Geneva, 2019. 36 WHO and UN-Water, National Systems to 48 World Bank, ILO, WaterAid and WHO, Health, Support Drinking-water, Sanitation and Hygiene: Safety and Dignity of Sanitation Workers: An Initial 58 WHO and UNICEF, Core questions and Global Status Report 2019 (GLAAS 2019 Report), Assessment, World Bank, Washington, DC, 2019. indicators for monitoring WASH in health care WHO, Geneva, 2019. facilities in the Sustainable Development Goals, 49 Fonseca, C., and L. Pories, ‘Financing WASH: WHO, Geneva, 2018. 37 Countries participating in the GLAAS 2018/2019 How to Increase Funds for the Sector while cycle with open defecation rates above 2 per cent. Reducing Inequalities’, Position paper for the 94 STATE OF SANITATION REPORT

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