International Journal of Environmental Health Research 13, S123 – S131 (June 2003)
Sanitation in the developing world: current status and future solutions S. CAIRNCROSS London School of Hygiene and Tropical Medicine, London, UK
More than a third of the world’s population (2.4 billion people) lacks access to adequate excreta disposal. Four in five of these unserved people are in Asia, with approximately one in five in both India and China, respectively. Even in large Asian cities, less than half of those served are using sewerage systems; the others use on-site systems, from pit latrines to septic tanks. Most have been installed by householders or builders employed by them, rather than by government or municipal agencies. Governments, international agencies and municipalities can never hope to meet the immense gap in provision unless they promote sanitation with a marketing approach. A latrine is a consumer durable which must be sold. It is often considered that the constraint to increasing sanitation coverage is a lack of demand, but there is often a lack of supply of appropriate products, and latrine designs are often too expensive for the poor, requiring subsidies which are captured by the better-off. More market research is needed to define the right product and how best to stimulate demand. Where subsidies are used, the promotion, not the production of the latrines must be subsidised to prevent middle-class capture of the subsidy. Promotion is probably best performed by different agencies from those that build latrines. The expertise and marketing capacity of the private sector needs to be brought into play, and public bodies must learn to assist it effectively in bringing sanitation to all. Keywords: Sewerage; pit latrine; septic tank; sanitation; marketing approach; promotion; private sector.
Introduction Sanitation is important for three reasons. It helps to prevent disease, it is particularly beneficial for women and people value the advantages that it can bring. This is the rationale for promoting sanitation, and for the adoption of a sanitation target as one of the Millennium Development Goals. Sanitation should be promoted because it helps to prevent disease in three areas of particular importance – intestinal worms, diarrhoea and trachoma.
Sanitation prevents disease With regard to intestinal worms, even research performed more than 70 years ago by the Rockefeller Foundation in the USA described how groups of the black population in West Virginia, USA, although poor were able to control intestinal worm infections in their children:
Correspondence: S. Cairncross, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.; + 44 207 927 2211. Fax: + 44 207 636 7843. E-mail: sandy.
[email protected] ISSN 0960-3123 printed/ISSN 1369-1619 online/03/S1S123-09 # 2003 Taylor & Francis Ltd DOI: 10.1080/0960312031000102886
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‘Several groups of negroes, one of which was extremely poor, as well as numbers of poor white families showed little or no Ascaris infestation because of the control of the children and the use of the privies by all members of the families.’ Cort, Otto and Spindler (1930) This quote describes how parents ensured their children defecated using latrines, in particular, low cost single-pit latrines. The research also noted how many of the poorer white families had less control over their children and partly as a consequence of that suffered from a higher prevalence of Ascaris infection. The effects of the various worms are related to sanitation. One study carried out by Dr. Srivastava of the Institute of Health and Family Welfare in Lucknow, India, found that two thirds (66%) of the cases of asthma patients were infected with the round worm, Ascaris. In fact, asthmatic children were about three times more likely to have Ascaris infection than in children who did not have asthma (Srivastava et al. 1981). Thus, it seems that many of the asthmatic symptoms found in children in India are manifestations of the Ascaris worm during the stage of its development where it moves through the lungs. Intestinal worms also cause chronic diarrhoea, anaemia, particularly in women, as well as stunting of children’s growth. They may also be a contributory factor in children’s under-performance at school. With respect to the incidence of diarrhoea, many studies have found a difference when they compared individual households that have toilets with those that do not. However, there are problems with that kind of research. For example, a comparison could also be made of families with television sets and those without, and a difference in diarrhoea rate would be demonstrated because the former are probably economically more secure, better educated and more hygienic. It has also been found that people with toilets were more likely to wash their hands more thoroughly than people without them (Hoque et al. 1995). Therefore, it is unclear whether it is the toilet or these other aspects that bring about the reduced risk of diarrhoea. A study from north-east Brazil (Moraes et al. 2003) offers stronger support for the advantages of infrastructure. Looking at communities as a whole, comparing those which have better infrastructure for excreta disposal, such as drains and sewers, with those that do not even have drainage, there is an even greater difference in the diarrhoea incidence than when individual households are compared (Fig. 1). These data are more reliable because access to sanitation at community level is not a question of individual household preference but more of politico-bureaucratic randomisation, in that some communities were fortunate enough to receive sanitation infrastructure, while others did not, because the project funds were depleted before completion. Sanitation has also been shown to reduce the incidence of trachoma because it helps to prevent fly breeding. Trachoma incidence was reduced by 75% in villages in Gambia, West Africa, solely by controlling flies (Emerson et al. 1999). Emerson conducted further research during 2001 in a trial using latrines as an intervention and showed that sanitation could actually control the number of flies of the species which transmits most trachoma. This species, Musca sorbens, breeds particularly in scattered human faeces, but not in latrines.
Sanitation is a priority for women In many parts of Asia, women seem to be ‘imprisoned by daylight’ because they feel that they can only leave the home to defecate during periods of darkness, either in the very early morning or late at night. Thus, during the hours of daylight if the family does not have a latrine, or
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Fig. 1. Incidence of diarrhoea in three groups of three poor urban areas of Salvador, Brazil with different sanitation infrastructure.
access to one, women are restricted, which can lead to all sorts of negative consequences. In rural and in some urban societies sexual harassment and rape are real threats when women are going to or returning from the area chosen to relieve themselves. Sanitation for women is also an important factor in respect to the impact it has on school enrolment, and particularly if sanitation facilities are segregated according to sex. If there are no separate latrines for girls, then as anecdotal evidence has shown, many girls will decide simply not to go to school, particularly when they are menstruating. For example, a United Nations Children’s Fund (UNICEF) project in Bangladesh found that construction of school latrines was associated with an 11% increase in the enrolment of girls (UNICEF 1999). This is significant as it is well known that women’s education is important for child survival, protection against diarrhoea and for implementation of other home hygiene measures. Thus, sanitation in schools is a start to educating women and improving domestic hygiene.
People want sanitation People want to have sanitation, and this is arguably the most important reason for promoting sanitation. However, people do not necessarily want it primarily for health reasons – they have other motives. A survey of people from rural areas of the Philippines who were asked why they liked to have latrines provided the following answers in the following order of frequency (Cairncross 1992): (i) (ii) (iii) (iv) (v)
A lack of smell and flies. Cleaner surroundings. Privacy. Less embarrassment when there were visitors. Less disease.
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Notably, what sanitation workers might consider the most important reason – less disease – was the last on the list. Thus, in order to promote sanitation adequately there is a need to think about what are the levers, motivating factors and message positioning to make people interested.
Current progress with sanitation In 2000, in a collaboration between the author’s research group, the World Health Organization and UNICEF, the entire process for collecting data on water and sanitation coverage was improved. The system, previously based on estimates by providers, was changed to use data collected directly from consumers in population-based surveys, particularly in larger countries. These include national census data, and also the Demographic and Health Surveys and Cluster Surveys of UNICEF. Sanitation data from 2000 seem to show an improvement on data that preceded it (Fig. 2). This is mainly because more people have been constructing their own sanitation facilities and latrines, and have done so without informing the government, ministry, or city council. Through their own initiatives and investment people have constructed their own facilities or had them built. However, looking at those people who are not served, on the basis of year 2000 data, most are in Asia. This is the region where sanitation is a major problem. Within the 2.4 billion people who do not have access to sanitation in the world as a whole, 1.9 billion are in Asia. Fig. 3 shows that most of them are either in India or in China. Looking more closely at how the changes have occurred over the years, by comparing the results of surveys used at different times over the last decade, the rates of change were found to vary between regions and were not as rapid as was hoped. Asia is certainly behind Africa in sanitation coverage but its rate of coverage is increasing, whereas that for Africa has actually decreased slightly during the last decade.
Fig. 2. Changes in sanitation coverage in Asia, Africa and Latin America (1990 – 2000).
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India 36%
Indonesia 4% Bangladesh 3% Pakistan 3% Others 12% China 42% Fig. 3. People without sanitation in Asia.
In China about 1990, official figures of sanitation coverage from various surveys and reported to Government were absurdly high but became more realistic from 1992 onwards (Fig. 4). The reason for the change was mainly that China revised its definition of what it considered to be adequate sanitation. Definitions are important, yet very difficult to agree upon in this area. This was shown by the fact that in the 1980s the Chinese government even regarded just a slab of concrete for people to squat on as adequate sanitation. Today, that would no longer be regarded as adequate – there now has to be a physical separation of the user from the faeces. The Chinese definition has since been refined further to include some form of treatment or disposal. The pattern of data for sanitation provision in India is rather more consistent and shows a slight increase in the rural areas (Fig. 5). The rate of increase is gradual and shows that at this rate it could be the next century before full coverage is achieved. In Pakistan the situation seems to be, inexplicably, much better in terms of rural coverage with sanitation (Fig. 6). There are some interesting questions that need to be answered as to why some countries seem to be more successful, and what lessons can be learned that could be applied elsewhere.
How sanitation can be promoted Some argue that there is not enough demand for sanitation and people are not interested in it. This is not the case – many people want their own sanitation facilities but often cannot afford what is being offered. There is a need to change the way that sanitation provision is dealt with. The product offered has to be both affordable and appropriate.
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Fig. 4. Improved sanitation in rural China as shown by various surveys. Line represents the best guess for the trend in coverage rates over the years.
Fig. 5. Improved sanitation in rural India. Lines represent the best guesses (and range of error) for the trend in coverage rates over the years.
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Fig. 6. Improved sanitation in rural Pakistan. Line represents the best guess for the trend in coverage rates over the years.
The problem lies in the fact that most technicians working in the field of sanitation originally trained as civil engineers, whose approach is not to design to a target cost, but rather to a technical specification. There is a need for technicians to take an approach more similar to that of production engineers who are making consumer products, such as motor cars or electric toasters, where the design is for a market niche at a target price. If the product made is too expensive, then there is a need for it to be modified so as to reduce the price. This approach needs to be applied to sanitation. For example, if a twin-pit latrine is too expensive then a single-pit latrine could be offered as an alternative, or perhaps a range of several different models made available so that people can select what they wish to buy. To be successful in promoting latrines and building up demand, the latrines themselves should not be subsidised because that only encourages slack thinking and the selling of inappropriate, unaffordable products that only the middle classes and not the poor can afford. It also means the number of latrines that can be built is limited by the budget for the subsidy. There is a need to consider who is building the latrines, and to develop public – private partnerships with the small firms sector, rather than with large national or multinational companies. The people best equipped to deal with this situation are local and have local knowledge and skills. This also means that we must work through local government, which in many places is, unfortunately, one of the greatest constraints to sanitation. For example, local government may have by-laws stating that a latrine is not acceptable unless it has specific features. However, these are the very features that may make it too expensive. Local government should also modify the way it regulates land tenure and offers building consent. Perhaps it should only offer consent to construct houses on condition that sanitation is provided, but the regulation needs to be supportive rather than policing. Besides infrastructure, demand and the right behaviour also need to be stimulated.
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The marketing perspective has implications for the way sanitation programmes need to be organised, because manufacturing an item and marketing it are different operations and probably need to be kept separate so that each operation is performed optimally by the best people. Ways can then be found to target the poorest groups. Finally, when promoting and marketing latrines there is a need for patience. An example of this can be shown by a programme initiated in Maputo, Mozambique in the early 1980s to provide affordable latrines. The latrine was stripped down to its most essential element, the floor slab, and put on sale at cost price without a subsidy. After 2 years only one or two a day were being built, which is an insignificant number in a city of a million people. If this had been evaluated as a donor-funded project at the end of this period, it would have been considered a failure. But by 1995 tens of thousands of latrines were being produced each year – it had taken time for the new market to develop (Fig. 7). This programme was established without the benefit of a big media advertising campaign, and perhaps marketing with enough resources could have increased the rate and number of sales; but if these are not available, it may take a long period of time for the demand to increase. Studying why people want sanitation and how they learnt about sanitation shows that they learnt about it by using somebody else’s latrine or one that was in an institution. Mapping the spread of sanitation coverage in rural areas of African countries shows a gradual diffusion from towns and institutions into the more remote villages. People learn about sanitation by example, and placing sanitation facilities into schools demonstrates this fact admirably. Sanitation helps to keep girls in school and is arguably an integral part of education and a fundamental life skill. Learning about ideas such as sanitation in school, can lead to transmission of these ideas outside the institution. Children are the agents of change in almost any community. When a new idea is put to children they will go home and urge their parents to adopt it. For instance, they may encourage their parents to have a latrine in the house just like the one at school.
Conclusion It is a scandal that as we enter the 21st century, half the population of the developing world still lacks sanitation. The international community has been urged to adopt as a target the reduction by half of the number of these unserved billions, by 2015. Current approaches to promoting sanitation in the developing countries have clearly failed, and there is little chance that the target will be reached without a radical change of approach. The marketing approach offers the most promise of success. 25,000 20,000 15,000 10,000 5,000 0 1980
1985
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Fig. 7. Annual sales of latrines in Maputo, Mozambique (1980 – 1995).
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References Cairncross, S. (1992) Sanitation and Water Supply; Practical Lessons from the Decade. Water and Sanitation Discussion Paper Series Number 9. Washington DC: The World Bank. Emerson, P.M., Lindsay, S.W., Walraven, G.E., Faal, H., Bogh, C., Lowe, K. and Bailey, R.L. (1999) Effect of fly control on trachoma and diarrhoea. Lancet 353, 1401 – 3. Hoque, B.A., Mahalanabis, D., Alam, M.J. and Islam, M.S. (1995) Post-defecation handwashing in Bangladesh: practice and efficiency perspectives. Public Health 109, 15 – 24. Moraes, L.R.S., Cancio, J.A., Cairncross, S. and Huttly, S. (2003) Impact of drainage and sewerage on diarrhoea in poor urban areas in Salvador, Brazil. Trans. R. Soc. Trop. Med. Hyg. 97, in press. Srivastava, V.K., Malik, G.K. and Agarwal, S.K. (1981) Ascarial infestation in asthmatic children. Ind. J. Parasitology 5, 255 – 6. UNICEF (1999) Sanitation and Hygiene; a Right for Every Child. New York: United Nations Children’s Fund.
