In the previous issue, members of the Advisory Board of IWA’s Inclusive Urban Sanitation initiative set out their perspectives. Juliet Willetts picks up the debate.
In 1854, English physician and epidemiologist John Snow traced a cholera outbreak in London, UK, to the contamination of street water pumps from human waste. Almost 170 years later, there are still 3.6 billion people across the globe who do not have access to safe sanitation. Even more live in unhealthy living environments contaminated by human waste in open drains, streets, wells and waterways.
In informal settlements in Dhaka, Bangladesh, for example, children live next to shallow open drains in which raw sewage flows. These children are being denied two fundamental human rights – the right to sanitation and the right to a healthy living environment.
The University of Technology Sydney in Australia did research in one of these settlements, collecting samples from drain water and canals, to improve understanding of the health risks from different pathogens. We found cholera, typhi and giardia, among others, pointing to high community exposure to these diseases.
Surely, this is unacceptable in 2023. More can and should be done. The irony here is that the settlement had toilets and would have been counted in the Millennium Development Goals as providing access to sanitation. But without waste treatment, toilets don’t help anyone.
A world of global disparities
Progress in achieving better sanitation services has occurred, particularly with regards to ending open defecation. However, the recent UNICEF/WHO global monitoring report, Progress on household drinking-water, sanitation and hygiene 2000-2022: Special focus on gender, reminds us that in 2022, only 57% of the global population (4.5 billion people) have safely managed sanitation services – meaning services that treat human waste after the toilet, through to its reuse or safe disposal.
People without these services are not spread evenly across the globe. The UNICEF/WHO report notes that access to safely managed services reaches 94% of populations in Europe and Northern America, but only 31% of the population of sub-Saharan Africa is served. So, while utilities and authorities managing sanitation services in high-income countries are able to focus on pressing issues such as anti-microbial resistance and greenhouse gas (GHG) emissions reduction, in low- and middle-income countries there are still huge steps to take to address the very basics to enable a more sanitary environment.
With the onset of climate change, increasing floods and droughts are taking their toll on inadequate, under-developed sanitation systems, with, for example, outbreaks of cholera seen in Mozambique during climate events and overflowing faecal matter from sanitation systems polluting cities in Indonesia, as reported in the publication Climate resilient urban sanitation in Indonesia: Hazards, impacts and responses in four cities, researched by UTS, UNICEF and UI.
A gendered issue
The gendered aspects of sanitation came to light as far back as the mid-1980s (van Wijk-Sijbesma, 1985) when researchers provided case studies of problematic interventions that either ignored or reinforced gendered roles in sanitation in Africa and Asia. UTS and the International Women’s Development Agency (IWDA) first researched the issue in the Pacific in 2009, finding evidence of positive outcomes associated with inclusive practices.
Since 2010, there has been increasing research and practice on the issues. These include addressing critical concerns about safety and privacy, meeting women’s menstrual needs, as well as the inequitable make-up of the workforce, which is heavily male dominated. The recent UNICEF/WHO monitoring report, which gave specific attention to gendered aspects of sanitation (mentioned above), included aspects such as women’s feelings of safety when walking alone at night.
Recent UTS research, Strengthening gender integration in sanitation programming and policy: Insights from literature and practice, demonstrates the breadth of intervention types that are possible to not only meet the needs of women and other genders, but to also increase the voice, leadership and decision-making of women and other marginalised groups. New women’s networks in sanitation are also rising to the fore, such as the African Women Sanitation Professionals Network. Greater diversity in the sector is an important pathway to improved actions and solutions that meet diverse needs.
Trends in service provision
The technologies used to manage and treat human waste have varied over time and place. Following the work of John Snow, in many high-income countries, large investments were made to construct centralised sewerage systems managed by professional entities. Meanwhile, as cities in low- and middle-income countries grew, the default system of on-site containment of human waste in a pit or tank proliferated. While numerous sewerage masterplans were drawn up, there was rarely the required investment available to fulfil those plans.
The result is that in 2023 the world crossed over from a dominance of people served by sewers to a greater share of the population served by on-site systems. What is lagging, however, is the means to manage these systems as a public service for public good, or, in the many urban locations where they are not able to be rendered safe, to invest in alternative types of sanitation services.
What does genuinely ‘safe’ sanitation require?
In 2015, the shift from the Millennium Development Goals to the Sustainable Development Goals (SDGs) thankfully brought a change in definition and indicators for sanitation. ‘Safely managed’ services became the new benchmark, bringing with it impetus to better manage the entire sanitation chain, including on-site sanitation systems.
On-site systems require a range of accompanying services, including the emptying and treatment of faecal sludge, monitoring of the appropriate design and construction of containment systems, and much greater attention to the treatment of liquid effluent, whether in infiltration pits and soil, or its conveyance for further treatment. Without proper care these systems (which were never intended for extensive use in dense urban settlements) can easily impact groundwater and surface water quality. Currently, global monitoring indicators only provide a partial picture of the safety of sanitation services, with additional data required to assess the many potential exposure pathways, particularly with respect to on-site systems.
So, who is responsible for this public service?
In too many countries no-one has the mandate. This was confirmed by a recent landscape report, Mapping the sanitation regulation framework across Africa, from the Eastern and Southern Africa Water and Sanitation (ESAWAS) Regulators Association, a forum promoting effective regulation in the sector in Africa. The lack of a mandate means lack of accountability. Since on-site systems are in the private domain of the household, it has taken decades to bring attention to the criticality of a mandated service authority charged to ensure this public service is delivered. Without this, little sustained progress can be made.
“In 2015, the shift from the MDGs to the SDGs thankfully brought a change in definition and indicators for sanitation”
The vision
Looking forward, we need inclusive, resilient, water-wise and sanitation-secure cities.
This vision is starting to be realised through targeted investments, not just in infrastructure, but in strengthening a wider system of service delivery. In 2018, the term city-wise inclusive sanitation (CWIS), was introduced by the University of Leeds in the UK, the Bill & Melinda Gates Foundation, Emory University in the USA, Plan International, WaterAid and the World Bank, and has become a common phrase among those working on sanitation in low- and middle-income countries.
While interpretations differ, at its core, the focus of CWIS is on ensuring all citizens are given access to services that safely treat human waste, whether through on-site, distributed or centralised treatment systems, with a mandated authority responsible for ensuring adequate on-going financing, safety and quality of service. Papers were published in a special collection of the journal Frontiers of Environmental Science in 2020 that establish the basis of CWIS, and, since then, many city authorities have taken up the CWIS approach.
This includes examples such as the Kampala Capital City Authority in Uganda, Lusaka Water Supply & Sanitation Company in Zambia, Wai city in India, and the Department of Public Health Engineering in Bangladesh. It also includes major donors such as the World Bank and the Asian Development Bank and many others including the Administrative Staff College of India, which has embedded the approach into its practice.
Meanwhile academics from the University of Zambia, UTS, CEPT University in India, the Swiss Federal Institute of Aquatic Science and Technology (EAWAG), the National Institute of Urban Affairs in India, and Makerere University in Uganda have all published further scientific papers on the topic. In addition, a Global Sanitation Graduate School has been established, operating through multiple academic institutions globally, reaching larger numbers with online and face-to-face courses covering the principles and practices of CWIS.
Circularity, resilience, and a clear public service mandate
So, what might the future hold for continued work on inclusive urban sanitation (IUS)?
With climate change driving a focus on resilience and emissions reduction, and increasing drivers for circular economy approaches, the future of urban sanitation may look different from what we currently see in urban cities in low- and middle- income countries. It is likely that innovation driven by water scarcity will place greater importance on recycling water and nutrients. Distributed systems may replace existing on-site systems over time.
Meanwhile, improved professionalised management of on-site systems, their effluent and faecal sludge is going to be key. This will require ongoing efforts to advocate for a clear legal mandate to provide sanitation services. It will also require ongoing attention to inclusion, as there remain major disparities in sanitation investments in cities, with lower socio-economic groups tending to receive the least investment and support, and the gender issues persist.
You can make a difference
IWA’s Inclusive Urban Sanitation initiative is pushing for change and working to accelerate the global drive for safe, urban sanitation. Its breadth of expertise enables its networks to come together to address the enormity of this challenge.
Please bring your expertise to IWA’s wealth of resources – online events, Congresses, and publications, to implement lasting change. This expertise can transform lives by improving safe sanitation services to underserved populations and address this inexcusable enduring inequity.
It is not acceptable that in 2023, 3.6 billion people do not have access to this basic public service. •
More information
IWA Inclusive Sanitation initiative:
WHO (2023). Progress on household drinking-water, sanitation and hygiene 2000-2022: Special focus on gender.
UTS, UNICEF and UI (2021). Climate resilient urban sanitation in Indonesia: Hazards, impacts and responses in four cities.
van Wijk-Sijbesma, C, (1985). Participation of women in water supply and sanitation: Roles and realities. IRC-WASH.
Updates – Gender in Pacific WASH, https://www.genderinpacificwash.info/news.html
UTS, WaterAid and UNICEF (2023). Strengthening gender integration in sanitation programming and policy: Insights from literature and practice.
ESAWAS and IWA (2022). Mapping the sanitation regulation framework across Africa.
ESAWAS (2022). The water supply and sanitation regulatory landscape across Africa, continent-wide synthesis report.
Frontiers of Environmental Science www.frontiersin.org
The author
Juliet Willetts is Professor and research director at the Institute for Sustainable Futures, University of Technology Sydney, Australia, and a member of IWA’s Inclusive Urban Sanitation Task Force.
