Melting Pots

Will africa meet its sanitation target?

More than 600 million Africans still lack access to safe sanitation. This will ultimately determine the well-being of the continent

Author: KITCH BAWA

Of the 1.2 billion inhabitants in Africa, more than 600 million lack access to safe sanitation. It is a serious problem as the lack of it affects the level of education, economic development and the overall health and well-being of people. The immediate casualties are children under five years. Besides, the discomfort associated with poor sanitation access and its impact on malnourishment is hard to imagine. Economically, lack of sanitation has a direct impact on the gross domestic product. The World Health Organization says millions of schooldays are lost due to poor sanitation in Africa and other parts of the developing and underdeveloped world.

Thus, there is an obligation for the world as well as for Africa to unite to tackle the bottlenecks in improved sanitation access. This is an urgent call for action, given that the continent has made the least progress towards achieving the Millennium Development Goal (MDG) on sanitation. For Africa to make any significant progress to achieve the Sustainable Development Goal (SDG) number 6 on sanitation by 2030, countries must adopt a new approach. Goal 6 states that access to safe water and sanitation and sound management of freshwater ecosystems are essential to human health, environmental sustainability and economic prosperity.

On the path OF COMMITMENT

African policymakers and political leadership have already established a strong platform for debating sanitation issues and arriving at proper solutions. In 2002, political leaders, government officials and non-state players met at AfricaSan, the first African conference on sanitation and hygiene, to debate on how to accelerate sanitation and hygiene access. After about six years, the second summit called AfricaSan 2, was hosted in Durban, South Africa, in February 2008, which was also the International Year of Sanitation. Ministers from 32 African countries in charge of sanitation and over 600 participants, including representatives from 42 African countries, attended the event. The main outcome was the AfricaSan eThekwini commitments.

These were ministerial commitments that focused on improving the enabling environment for sanitation services and financing to accelerate progress. Among these was the one that aimed to “create separate budget lines for sanitation and hygiene in the countries and to commit at least 0.5 per cent of GDP”. These same commitments were later endorsed by the heads of state at a summit in Sharm El Sheikh in Egypt in 2008. The outcome of the process also led to the inclusion of sanitation as target 10 under goal number 7 of the Millennium Development Goals (MDGs): to reduce, by half, the number of people without access to basic sanitation and hygiene by 2015.

Since eThekwini, countries made significant improvements in the enabling environment for sanitation. This meant that many nations embarked upon development and improvement of the policy infrastructure and some carried out a process of institutional reengineering to position themselves for improving sanitation services delivery. At the end of the MDGs period, when the African Ministers’ Council on Water, the World Bank and other stakeholders did an assessment on performance, there was a sharp improvement in the enabling environment. However, there was little improvement in the access to sanitation and Africa missed the MDGs related to it. This was due to the lack of financing and capacity for sanitation service delivery, absence of sector coordination, want of a clear lead for the sector and the lack of focus on vulnerable groups.

Real challenges

As we have transitioned from the MDGs to the SDGs, the challenges have become more real, because the world targets open defecation and access to safely managed sanitation for all. Though the targets are ambitious, Africa has positioned itself to make progress by articulating the Ngor commitments on sanitation as a vehicle to help it achieve the SDGs. African governments made these commitments in 2015 during the AfricaSan 4 conference held in Dakar, Senegal. These cover key areas that the continent has to focus on to make progress. It has also developed a system to hold itself accountable to ensure it achieves the SDGs.

Africa is the only continent that has put in place such a system to deal with sanitation. The next step is for national governments to take the lead to operationalise these commitments. The process is already afoot. AfricaSan has provided the platform for collective action. The question of how far Africa will go in meeting the target depends on how well the countries and other players work together and how much they are ready to commit.

(The writer is the Sanitation Project Manager, Africa Ministers’ Council on Water, a Specialised Technical Committee for Water and Sanitation of the African Union)

A toilet, many trails

African countries, rich or poor, are serious about having a toilet in their households. But they are facing a multitude of obstacles to get access to improved and safe sanitation

Djibouti has Africa’s worst sanitation coverage in rural areas; and reported a shocking 17 per cent increase in open defecation during 2000-2015. One in every four persons goes out to defecate; in rural areas, three in four defecate in the open.

But nobody talks about it. The decade-long spell of drought overwhelms discussions on sanitation. For the world outside, the tiny country is talked about for an entirely different reason—3.3 per cent of the country’s population are refugees, from the Yemen war. So the discussions mostly hover around the humanitarian crisis involving migration.

However, the world is discovering the impact of the lack of access to safe sanitation on the humanitarian crisis brewing in the country. Djibouti is facing a health emergency as water-borne diseases have afflicted the entire population, especially children and women. Most of the waterbodies are now contaminated with faecal remains. And this poses a double whammy for the country which is grappling with severe drought for nearly a decade.

As such, Djibouti gets just 200 mm rainfall a year. Only 0.01 per cent of its land is arable. Most of the country’s water sources are either dry or hardly carry any water. According to the United Nations International Children’s Emergency Fund (UNICEF), the limited water supply and stretched services have left nearly 100,000 drought-affected people, living along migration routes, with no access to safe water, and obviously sanitation. The constant flow of refugees in an already safe sanitation-deficit country has made the situation unmanageable.

Djibouti’s capital—also called Djibouti—is home to half of the country’s population. It is only here that one can see the presence of household toilets. But a booming population is making the situation worse. With three-fourths of Djibouti’s population living below the poverty line and more than 50 per cent of rural population food insecure, urban settlements like the capital city are witnessing a deluge of migration of rural inhabitants due to drought. This has increased the demand for basic necessities like water and sanitation. For example, Djibouti city dwellers may have the luxury of having toilets in the houses, but access to sanitation services is still underdeveloped, particularly in the densely-populated southern suburb of Balbala.

Urban areas are finding it difficult to manage wastewater. “Until March 2014, wastewater collected in Djibouti was discharged into the sea without treatment. A sewage treatment plant was commissioned with funding from the European Union (EU),’’ says Radwan Abdillahi Bahdon, Djibouti’s Director of Sanitation. But such initiatives are a drop in the ocean.

The government has been trying to provide financial as well as technical assistance to residents for building mostly primitive and unsafe drop hole toilets. But it is unable to cope with the demand. Djibouti shares a long porous border with Somalia and Ethiopia. There is constant movement of both people and livestock, especially during the lean season (June-September) when nomadic communities often migrate from neighbouring countries to Djibouti in search of pastures for their livestock. Such displaced populations add to the pressure on the already precarious livelihoods in these areas and this is further aggravating food insecurity, as well as overburdening the fragile service delivery systems for nutrition, water and sanitation, health, child protection and education.

Moreover, the rise of acute watery diarrhoea and cholera outbreaks in neighbouring countries has exposed Djibouti to a high risk of epidemics in view of its fragile health systems—low rate of access to safe water and improved sanitation and limited knowledge of key hygiene practices. It is expected the country may well miss its Sustainable Development Goal targets on safe sanitation practices.

But other African countries, with relative advantages, are also finding it difficult to meet this basic target.

NEW BEGINNINGS

Take Nigeria for instance, a relatively prosperous country. Unlike Djibouti, Nigeria has reduced open defecation by 6 per cent during 2000-15. Still about 24 per cent of its population defecates in the open, making Nigeria third-worst in the world in terms of open defecation, after India and China. Notwithstanding this progress, the country typifies Africa’s big challenge: shifting from basic toilets to improved sanitation services. Only 36 per cent of Nigeria’s population has access to improved sanitation.

For the hard-earned economic progress, this is bad news. The World Bank estimates that poor sanitation costs Nigeria US $3 billion annually, or 1.3 per cent of the country’s GDP. The country already attributes the annual deaths of 124,000 children under the age of five to outbreaks of diseases like diarrhoea and cholera linked to lack of sanitation. For 2018, Nigeria has budgeted US $2.7 million for health emergencies and contagious diseases. It also budgeted US $5.5 million for expansion of water, sanitation and hygiene facilities. An Abuja-based independent environment expert, Ayuba Danasabe Umar, says, “Adequate public toilet facilities would rid the country of faecal contaminants that cause enteric diseases and gastroenteritis.”

In 2014, Nigeria took the first steps to be open defecation-free by 2025. But with a change in strategy: involving communities to ensure quality. The National Council on Water Resources (NCWR) partnered with UNICEF to roll out the strategy.

Federal ministries—health, water reso urces, environment, education, housing and urban development and women affairs—converged their activities to attain the target. Alhaji Sidi Abbas, executive director of Sokoto State Rural Water Supply and Sanitation Agency (RUWASSA), says initially Tangaza local government area of Sokoto state was selected for the project. Its success through community-led total sanitation (CLTS) campaigns has prompted the government to expand the strategy to 23 areas in the state.

CELEBRATED WITH CAUTION

As they say, there is no one solution to a crisis that criss-crosses a continent. Ethiopia is an example of winning with a warning. It recorded the highest global reduction rate in open defecation—based on proportion to population. Haimanot Assefa, a rural water supply specialist with UNICEF-Ethiopia, says the country has shown a 53 per cent reduction in open defecation: from 80 per cent in 2000 to 27 per cent in 2015.

Ethiopia is an example of scaling up CLTS along with a much-needed change in strategy—making it a part of the health policy. The country has been successfully implementing its unique Health Extension Programme (HEP) under which water, health and sanitation issues are approached as inter-related concerns. The impressive reduction in open defecation coincided with a similar increase in water supply access coverage, which increased from 14 per cent in 2000 to 82 per cent in 2016 in rural areas.

But this does not mean improved quality of sanitation. The National Hygiene and Environmental Health Strategy confirms that improved toilet coverage in the last 25 years is only 28 per cent. Citing a recent study, Assefa, says that over 90 per cent of urban residents use an on-site sanitation facility, of which nearly 80 per cent are dry pit latrines. He says with less than 3 per cent people having access to a sewer connection, wastewater is continuing to contaminate waterbodies.

Ayantu Taffa, a resident of Kebelein of the Oromia Regional State, says, “Our family has a pit toilet access and a dug well. However, there is no way we can ensure the safety of water.” She adds that her children often suffer from diarrhoea and cannot attend school due to water-borne diseases. Ethiopia is the worst trachoma affected country in the world, with women as well as children aged 1-9 at the highest risk of infection, according to Abireham Misganaw, a public health expert and a member of the Waste Management Team of the Ethiopian Ministry of Health. He cites a national survey stating that the prevalence of active trachoma for children in the age group 1-9 is 40 per cent because of lack of improved access to water and sanitation.

The Ethiopian National Hygiene and Environmental Health Strategy says: “Poor sanitation costs Ethiopia 2.1 per cent of the national GDP. Yet, eliminating the bad practice would require only 6 million improved latrines to be built and used.”

Dagnew Tadesse, director with the Hygiene and Environmental Health (HEH), Directorate of the Ministry of Health, says, “Ethiopia should now turn its face to ensuring improved quality sanitation and water supply schemes.”

TEST OF IMPROVED SANITATION

In Tanzania too people are not reaping the health gains expected through improved levels of sanitation. The case of Mashabani, a 34-year-old resident of Magodani village in Temeke district of Dar es Salaam region, is a testament to this challenge. Mashabani thought that owning a toilet would rid her family of water-borne diseases. “But I and my six children continue to suffer. I spend US $15 every month from our total earning of US $90 on treating water-borne diseases,” she says. She has an open pit toilet. For close to three months, it remains flooded due to rains. “My waste gets mixed up with other water sources and the result is that we consume contaminated water.”

Abdara Juma, the chairperson of the village, says, “We have toilets, but they are of bad quality.” Since August 2015, the country reported 31,291 cholera cases with a death toll of 522. Given the low income of Tanzanians, residents can only afford such basic toilets that costs up to US $44. “Since most residents share toilets, without clean water supply, the women suffer from urinary tract diseases,” says Muamma Muskin, a mother of five children, who herself suffers from an urinary tract infection.

However, Anyitike Mwakitalima, coordinator of the National Sanitation Campaign, a non-profit, says sanitation is not the primary reason for cholera outbreaks; the Ministry of Water has failed to supply clean water to all the regions.

Ali Nyanga, who is with the Ministry of Health Community Development, Gender, Elderly and Children, argues that water supply and sanitation cannot be addressed in a standalone manner, both needs to be safe and sustainable for a healthy country.

Tanzania aims to provide a basic toilet to every household by 2021, says Rowland Titus, who works with UNICEF-Tanzania. In December, 2017 Vice President Samia Suluhu launched a campaign called “Nyumbu Ni Choo” (a house without a toilet is not a house at all). But both UNICEF and the World Bank, who are working with the government on sanitation issues, think it is an ambitious goal. At the current pace of work, the target can be met only by 2027, which is just three years away from achieving the deadline of the Sustainable Development Goal. The Joint Monitoring Programme (JMP) of UNICEF and WHO found in 2015 that around 11.26 per cent of the population practiced open defecation, which was a 2 per cent increase during the 15 years period.

But Anyitike says only 5.8 per cent of the country defecates in the open. He explains that in the first phase of sanitation programme through CLTS in 2012, the open defecation rate was 20.5 per cent. But that does not mean improved sanitation facilities, explains Rwegoshora Rwekaza Makaka, water supply and sanitation specialist with the World Bank group.

Cost matters

Improved sanitation comes with a high price tag. Many of Africa’s relatively prosperous countries find it unaffordable. Take Kenya for example, which aims 100 per cent coverage of safe water and basic sanitation services by 2030. For this, it annually requires US $12.9 billion for water supply, US $4.8 billion for sewerage, US $601 million for basic sanitation and 57 million for basic hygiene. “But, the government budget available for sanitation is only 6.5 per cent,” says Vincent Ouma, of the Kenya Water and Sanitation Civil Societies Network (KEWASNET), a national network of water civil society organisations in Kenya.

Technology options are also limited. According to the Kenya Demographic and Health Survey (2014), over 60 per cent of rural households rely on non-improved sanitation facilities. Different agencies work to promote viable toilet designs. “Most of the toilets are dry pit toilets. The efficacy of such toilets lies in its reusable nature. But due to the lack of acceptance among people for faecal matter to be used as manure, the user usually shuts it down and builds a new toilet or calls the companies to clean it up. The management of faecal matter is our top concern,” says Janet Muse, head, WASH Hub, a dedicated cell of Ministry of Health, Kenya. “The EcoSan Promotion Project is one such pilot project which was implemented in the areas of Nyanza, Western and North Eastern provinces. Despite health, sanitation and economic benefits, this toilets model had very low acceptance among rural households,” adds Janet.

Plan Kenya introduced CLTS in Kenya in May 2007. The idea had instant acceptance. In 2010, Ministry of Public Health and Sanitation embarked a pilot project in the six districts of Nyanza and Western Kenya. Later, the ministry adopted CLTS as a key strategy at national level. This led to the launch of the Open Defecation-Free (ODF) Rural Kenya Campaign in May 2011.

But, meanwhile, it lost the tempo. A study published in East African Medical Journal on assessment of CLTS in rural areas, concluded that it failed to result in open defecation free status as expected. The study cited inadequate monitoring of the process, inadequate funds and conflicting work demands of government officials as the reasons. In 2014, there were only 3,131 certified ODF villages of the 11,641 villages. “Counties need constant support to develop legislations, policies and effectively utilise available financial resources and channelise more resources,” says Kimanthi Kyengo, director, Ministry of Water and Irrigation.

Sanitation should be part of development

Most East African nations either forget about this important issue or accord it the bottom position in their growth agenda

Author: OLUTAYO BANKOLE-BOLAWOLE

African women and children are bearing the brunt of the continent’s sluggish pace in sanitation, with health, nutrition, education, gender equality and poverty reduction being at stake. The situation is dismal in Sub-Saharan Africa where countries have not attained safely managed sanitation services and are still at the basic services level, according to the UNICEF. The scenario is no better in East Africa where over half the people in informal settlements live in unsanitary conditions. At present, in this region there is no country with more than 68 per cent access to adequate sanitation. Rwanda appears to be the only one to achieve this percentage and above. Despite commitments by several governments and the United Nations’ recognition of sanitation as a basic human right, it still remains neglected.

At the current rate of progress, universal access to safely-managed sanitation, the aim of the Sustainable Development Goals (SDGS), won’t be achieved until 2107—77 years behind schedule.

The knock-on effects of poor sanitation are considerable. According to a study done by Lixil Corporation, which specialises in water and housing products, global research firm Oxford Economics and the UK-based WaterAid, lack of proper sanitation costs the global economy a staggering US $222.9 billion annually. Of this, mortality rate accounts for $122.8 billion, medi cal treatment $56.6 billion, lost productivity $16.5 billion and the time spent on finding a toilet $27 billion. Africa accounted for about $19.3 billion of this total cost after the launch of the SDGS, of which about 75 per cent came from sanitation-related deaths. In many countries, the economic cost of poor sanitation and hygiene amounts for more than 5 per cent of their gross domestic product.

Factors playing spoilsport

There are a number of factors affecting the attainment of safely managed sanitation services in East Africa. The main problem is that most countries focus on water provision, but never link it to sanitation. Both must be addressed together to improve people’s access to toilets. One cannot also rule out climate change, which leads to either prolonged droughts or floods. As a result of these two extreme weather events, progress achieved by the countries in sanitation is adversely affected. Resources for building sustainable sanitation infrastructure is diverted to deal with emergency and humanitarian response.

At present, most East African countries are grappling with how to prioritise sanitation among other development agendas. Most of the times, sanitation is either forgotten or accorded the bottom position in the priority list. For example, many middle-income countries give priority to infrastructure to attract investment. There are cost-effective models for managing sustainable sanitation services that could be piloted across East Africa, but knowledge and commitment to test these solutions are often not prioritised.

Lack of resources is another critical factor. The capacities to provide for innovative solutions that work in urban, rural and unplanned settlements are not readily available in most countries or are often limited. Most countries invest in huge sewerage systems that do not always include the poor and those living in unplanned settlements.

The priorities of many international non-profits and development partners also impact sanitation progress. These stakeholders have competing priorities within a specific country, spread themselves thinly across countries and often do not employ their strengths to ensure that their resources make the necessary impacts. As a result, one sees only a few pockets of projects lying far-flung in each country with no clear sus-tainability plan in place. Development partners also divert funds for sustainable development work, thus leaving fewer resources for sanitation.

Urbanisation is a key factor impacting the attainment of good and sustainable sanitation services in East Africa. The planned urban settlements are busting at the seams and putting pressure on the existing sanitation infrastructure and the sewerage system constructed long ago. Apart from these, migration to urban areas put further strain on the existing infrastructure in unplanned settlements.

Towards a better FUTURE

Many ongoing interventions hold hope for East Africa. Lately, there has been an increased commitment by governments in this region to ensure sanitation catches up with the provision of safe water. More budgetary allocations are being made to cater to WASH (water, sanitation and hygiene) services in a targeted way. There has been a renewed effort to cater to people living with disabilities, women and children in programme designs on toilets, latrines and behaviour changes. Several innovations on faecal sludge management are being piloted and rolled out across countries with WaterAid’s presence in the region. Some of these innovations have led to a scaling up of some of the pilots in several districts of Rwanda, Ethiopia and Tanzania.

To meet SDG 6 target of clean water and sanitation, there has to be a holistic approach to ensure integrated development across all sectors. The district-wide approach of WaterAid has been successful. It ensures that all development partners in African countries pull their resources together to attain the SDG goal. Other steps are building collaborations with key regional economic commissions and agencies to ensure there is a clear focus on sanitation. Some of these include AfricaSan, one of the path-breaking initiatives on sanitation and the Rural Water Supply and Sanitation Initiative, an Africa-wide programme hosted by the African Development Bank. The East Africa Community’s health department is also prioritising the integration of WASH and health for improving sanitation by sharing lessons and innovations.

(The writer is regional director, East Africa, WaterAid)

Overwhelmed by despair

The state of sanitation is deteriorating in Sub-Saharan Africa, with countries switching from open defecation to unsafe toilets

Under the Sustainable Development Goals, set by the UN, countries must provide adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations by 2030. But this is a gargantuan task given that today, some 2.4 billion people, or one in three across the world, are struggling to stay well, keep their children alive and work their way to a better future because they have nowhere safe to go to relieve themselves; some 892 million of them defecate in the open for want of a toilet. In fact, some estimates show that more people today have mobile phones than access to toilets.

The problem is particularly acute in Sub-Saharan Africa (see 'The slow walk to...'). The region, as the name suggests, lies south of the Sahara desert and has been an area of concern for global communities as its countries and island states are among the poorest and least developed in the world; half of the region’s population live on less than a dollar a day. Estimates show that the region is home to about one-fourth of those defecating in the open worldwide. On an average, these people spend some 2.5 days worth of time in a year trying to find a private location to defecate, according to a 2012 assessment of 18 countries by the World Bank under its Water and Sanitation Program (WSP) (see 'Cost of finding...'). This results in losses to the tune of US $500 million a year to these countries, which account for half of the population in the continent. Women shoulder a huge proportion of this cost as they spend additional time finding a safe place for urination or accompanying young children or sick or elderly relatives to relieve themselves.

In December last year, international non-profit WaterAid released a report “Out of Order—the state of world’s toilets” that says the 10 worst countries in terms of access to sanitation are all situated in Sub-Saharan Africa.

The region had in fact showed a sluggish progress towards meeting the UN’s Millennium Development Goals (MDG), under which countries had to halve the proportion of people without basic sanitation by 2015. According to the World Health Organization (WHO), less than 17 per cent people in Sub-Saharan Africa gained access to sanitation during the MDG period as compared to 50 per cent in Western Asia and 41 per cent in Northern Africa. What’s worse, the state of sanitation has deteriorated to worrying levels in countries like Djibouti. The Joint Monitoring Programme (JMP) report, prepared in 2017 by WHO and UNICEF, notes that due to a combination of population growth and slow progress, the number of people practising open defecation has actually increased in sub-Saharan Africa, and the region now accounts for a greater share of the global total as compared to 1990. The progress of sanitation and hygiene coverage in rural areas is worse than in urban areas. At current rates of reduction, open defecation will not be eliminated among the poorest in rural areas by 2030, the report warns.

What’s bizarre is most countries that have witnessed improvement in reducing open defecation have done so by providing unimproved means of sanitation. JMP data shows that at the beginning of the MDG period, some 32 per cent people in Sub-Saharan Africa defecated in the open. The figure fell by 9 per cent by 2015. During these 15 years, the figure for those practising unimproved sanitation increased from 29 to 31 per cent. Going by WHO, unimproved sanitation facilities do not help hygienically—as excreta from is not separated from human contact—and, hence, pose health risks. In Sub-Saharan Africa, most people depend on unimproved facilities that belong to the apartheid era—uncovered pit latrines, buckets and even plastic bags.

UNDERBELLY OF SANITATION

On July 4, while visiting his aunt’s house in South Africa’s Limpopo province, three-year-old Omari Monono went to relieve himself in the pit toilet built metres away from the house. Instead, he slipped and drowned in the faeces-filled pit and died. A few months ago in March, five-year-old Lumka Mkhethwa died after falling into a pit toilet at the Luna Primary School in South Africa’s Eastern Cape province. The pit latrine has since been closed. A similar incident occurred in Limpopo in 2014, resulting in the death of Michael Komape, also aged five.

Pit toilet is the simplest form of dry toilet in which faeces are collected in a hole made on a concrete floor. The toilet seat is installed just above the hole, which remains covered with a lid when the toilet is not in use to prevent stench and contamination. Most designs do not require the use of water and are hence considered suitable for water-scarce regions, like those in Sub-Saharan Africa. But most pit toilets in the region are nothing more than just pits on the ground. The ones that have seats are made from cheap metals, they are shoddily built and remain uncovered.

The pit toilet that Michael went to at the Mahlodumela Primary School had an iron sheet that served as the seat and a white plastic lid. But the seat was so corroded that it collapsed when Michael sat on it. He fell in along with the plastic lid. His parents are now fighting a lawsuit against the education department demanding justice. All this is when access to proper sanitation is a basic human right enshrined in South Africa's constitution and the country has reduced the prevalence of open defecation by 20.6 per cent during the MDG period.

In Ethiopia, seven in every 10 people use toilets. But the country has made the progress largely by investing in shared toilets. So has been the strategy of Tanzania, where more and more people are defecating in the open—the country's open defecation rate increased from 11.6 per cent to 15.7 per cent between 2000 and 2015. Experts believe the increase is due to the failure of poor toilet infrastructure like, the pit hole. Hadija Menato, a 45-year-old fruit vendor from Kizeitoheonywan village in Dar es Salaam shares the toilet with two households in her locality. The toilet is nothing but an open-pit latrine without a roof and door. While the toilet usually remains soiled and clogged, the condition worsens during rainy season. The rainwater mixed with sewage floods the entire village. "We not only suffer from intestinal diseases but fungus attacks on legs as we have to wade through faecal-laced water every day. In dry months, clean water supply becomes scarce and most of us suffer from diseases like jaundice and diarrhoea," says Menato.

Another apartheid-era sanitation facility that remains a challenge for the region is bucket and hanging toilets. And it is particularly so for Namibia, where the prevalence of open defecation continues to hover above 75 per cent. On several occasions, President Hage Geingob has admitted that eliminating the "demeaning" system remains a challenge for the government. As the name suggests, bucket toilet is a basic form of dry toilet where a bucket is used to collect faeces and urine. While it serves the purpose in emergency situations like earthquakes, it is a common mode of sanitation for several households in urban and peri-urban areas of Sub-Saharan Africa. In Namibia’s Karas Region, the bucket system is synonymous with many villages and settlements. The toilets usually overflow and give off a foul smell if they are not collected in time, and most empty the bucket somewhere nearby the settlement when it is full of human faeces and wash the bucket to use it again.

Eliminating the “inhumane and unhygienic” system is part of Geingob’s Harambee Prosperity Plan that aims to provide 50,000 rural toilets by 2019. However, due to budgetary constraints, the government has so far identified only 780 households in the Hardap and Karas regions to eliminate bucket toilets, and construct sewer-connected flush toilets. Hanging toilets have buckets or any other container and are mostly portable.

HARSH REALITIES

Understandably, basic sanitation services like sewage network and sewage treatment plants are a rarity in Sub-Saharan Africa. This adds to the burden of diseases in the region. In 2017, WHO prepared a factsheet on the health of children, which shows that Sub-Saharan Africa has the highest under-five mortality rate in the world, with one in 13 children dying before their fifth birthday. In Tanzania, where the prevalence of open defecation has increased over the past 15 years and only 17.2 per cent people in rural areas have access to any decent toilet, nine children die every day due to diarrhoea; one in three shows signs of stunted growth. The Water Aid report says one in every 10 girls misses school during menstruation in Sub-Saharan Africa.

An article on the health effects of water and sanitation in 10 laggard West African countries, published in international journal Public Health in 2016, shows that the risk of water and sanitation-related diseases is very high. The authors suggest that there is a need for a strong intervention by the public and private sectors in these countries, because improvement in sanitation and access to safe water will result in alleviation of poverty and prevent the re-emergence of neglected tropical diseases.

Fast track on sanitation

Though sanitation in Tanzania is improving, the benefits have largely gone to the rich

Author: KHALID M MASSA

Most Tanzanians use rudimentary and unimproved sanitation facilities, which do not ensure a hygienic separation of human excreta from human contact. These facilities include pit latrines without slabs or platforms or open pit. In 2016, only 34 per cent of the population had access to improved sanitation facilities. But that was a significant jump from a seven per cent rate in 1990.

So though we are improving, the gains have largely benefited the rich. Open defecation is concentrated in some rural areas of the country and is more common among poor communities. The national open defecation rate is 13 per cent, but 75 per cent people who defecate in the open are from the bottom 40 per cent of the population in terms of income.

The health and economic impact of unimproved sanitation is evident. We have had an outbreak of cholera since August 2015 that spread to most of our country. Around 30,000 people suffered from cholera in this outbreak and nearly 500 died. Apart from causing diseases, the World Bank estimates that the country loses US $200 million each year due to lack of improved sanitation. The loss is due to time wasted while looking for a place to defecate, years of life lost due to premature deaths, medical expenses and time lost while caring for a sick one.

In 2012, the government started National Sanitation Campaign (NSC) to make the country Open Defecation-Free (ODF) before 2025. NSC emphasises the use of improved toilets and washing hands with soap. Our monitoring data shows that open defecation has gone down from 20.5 per cent in 2012 to 5.8 per cent in 2017, while access to improved sanitation has increased from 19.5 per cent to 46.1 per cent in the same period. The budgetary allocation on sanitation has also been increasing in recent years.

Through NSC, at least 12 per cent of villages have been declared ODF. For the first time, one whole district (Njombe District Council) has achieved ODF status. To avoid complacency, we have devised several incentives to ensure that districts and villages maintain their ODF status. Each year, the ministry conducts National Sanitation Competition where winners (districts and villages) are rewarded. A majority of the villages and councils are putting more efforts to secure the top position and in doing so they are maintaining the ODF status.

Water and sanitation in schools is one of the components under NSC, where emphasis is put on schools to ensure the required infrastructure is provided for. Under this initiative, sanitation clubs have been formed in schools to enable pupils to contribute in improving sanitation practices. Likewise, Menstrual Hygiene Management and provision of WASH services (water sanitation and hygiene) to pupils with disability are focus areas. According to the Ministry of Education, Science and Technology, about one-third of the country’s primary schools have improved toilets, which meets the NSC target of one squatting type toilet per 40 girls or 50 boys (1:40 for girls and 1:50 for boys).

Children, particularly those aged below five years, are at an increased risk of contracting communicable diseases, including diarrhoea. When children suffer from diarrhoea, they are denied a right to proper physically and cognitive development. To address this, the country is also implementing the Water Sector Development Program Phase II, where increased access to safe water for rural and urban areas is a top agenda. The country has also developed the National Guidelines for Water, Sanitation and Hygiene in Health Care Facilities to provide quality care, especially for children who are most at risk. Furthermore, we are collaborating with UNICEF to develop Baby WASH strategy (disposal of baby and child faeces). Baby WASH comes under the bigger initiative of WASH and would address issues detrimental to child health, including but not limited to prevention and control of diarr hoeal diseases.

Observance of sanitation and hygiene practices is catalysed by the Behaviour Change and Communication campaign, which the country has embarked on in 2017. This motivates people to use improved toilets and discourages bad practices such as open defecation. Not only that, we also enforce laws to ensure public health. Tanzania has the Public Health Act of 2009 and several bye-laws that are enforced by local government authorities. Enforcement of these contributes to sustaining ODF status and also in reducing the small segment of the population that has no toilets.

Disposal of faecal matter as per technologies that are used in Tanzania can either be in situ or off-site. The off-site technology employs the use of sewer while the in situ is a disposal right on the site of primary collection through composting latrines or simple pit latrines. The long-term plan is to scale up the use of off-site system so that the sludge is safely transported from the toilet to a distant treatment site, such as waste water stabilisation ponds. A few decentralised waste water treatment initiatives are being undertaken on a pilot basis in Dar es Salaam city. This technology is comparatively cheaper, requires smaller space compared to waste water stabilisation ponds, and can be used in unplanned settlements or slums.

(The writer is acting assistant director, environmental health and sanitation, Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania)

Lack of cohesion

Africa must identify why it is failing to address its sanitation woes

Despite several initiatives by global agencies and individual countries, Africa has not been able to check the most basic of all sanitation markers—open defecation. Between 2000 and 2015, the number of people defecating in the open rose from 229 million to 234 million, shows the 2017 data of WHO and UNICEF's Joint Monitoring Programme (JMP) report. However, some coun tries have had more success than others in curbing the problem. Two neighbouring countries in east Africa, Ethiopia and Kenya, for instance, have similar topography, per capita income and predominantly rural population. But while open defecation has reduced by 50 per cent in Ethiopia between 2000 and 2015, the figure for Kenya is just five per cent, shows JMP. Why are there such huge disparities and inconsistencies?

The main reason is that most countries do not have a cohesive policy to deal with sanitation issues. According to a study by the Stockholm Environment Institute, published in January 2018, only five countries—Rwanda, Uganda, Tanzania, Nigeria and Ghana—have designated ministries for policy formulation, financing, regulation, monitoring and implementation. Though Ethiopia is not in this list, it has succeeded in fighting open defecation because in 2013, the government rolled out a national programme—One WASH (water, sanitation and hygiene)—to synthesise sanitation work carried out by six ministries (water, irrigation, electricity, education, finance and economic development) with the health ministry. On the other hand, in Kenya, sanitation is under the purview of the health ministry.

Lack of coordination between policies framed by the Central ministries and the implementation carried out by local authorities is another area of concern. For example, guidelines for toilet technologies in Rwanda prescribe design, location and condition standards, but these are rarely followed by local authorities. Money is an obvious roadblock for most African countries. In 2017-18, Kenya required about US $600 million a year to meet the sanitation goals set by the health ministry. But the budget allocated was only 6.5 per cent of the figure. “The gap in terms of availability of funds is huge and this impacts our targets,” says Janet Muse, head, WASH Hub, a dedicated cell of Kenya’s health ministry. Another country facing a severe financial crunch is Namibia. In this southern African country, over 60 per cent population do not have access to improved toilets—a term used by WHO to define toilets where there is a hygienic separation of human excreta from human contact. In 2016, Namibia launched the Harambee Prosperity Plan to convert bucket toilets (a dry toilet where a bucket is used to collect excreta) into improved toilets. But in about one year, it just managed to construct 886 toilets because it does not have money, say media reports.

Governments are also not spending enough to popularise improved toilets. As per the Ngor Declaration, adopted at the fourth African Conference on Sanitation and Hygiene in 2015, all African countries must spend 0.5 per cent of their GDP on sanitation and hygiene. ªBased on the limited data available, budget allocation to sanitation appears to be far from the targeted 0.5% of GDP, "states "Government investment in sanitation: 2016 State of play", a report published by the UK-based non-profit Water & Sanitation for the Urban Poor and US-based non-profit International Rescue Committee. The report finds the Democratic Republic of Congo is the best performer, spending 0.39 per cent of its GDP on sanitation in 2012, while Ethiopia and Ghana were the worst, having spent 0.01 per cent each.

In fact, Ghana’s continued inability to fight sanitation problems has contradicted the view that political stability is a perquisite to improve sanitation. The country has one of the continent's fastest Human Development Index growth rate and is a stable democracy. But as per UNICEF, Ghana would take 500 years to become open defecation-free. Moreover, it will not be able to meet the United Nations’ Sustainable Development Goals for water and sanitation by 2030 if it is unable to check open defecation.

Where is it falling short? “Bottom to the fore”, a report by Delhi-based Centre for Science and Environment in 2018, says, “Unclear direction and weak strategy, coupled with lack of intent in execution are the main culprits.” Ghana did not have a dedicated sanitation ministry till January 2017. Before that, sanitation was overseen by the Ministry of Water Resources, Works and Housing. Since sanitation was only a part of the mandate of this umbrella ministry, it could not command the ministry’s undivided attention.

The problem is also cultural. Most Ghanaians associate heat and smell from latrines with diseases, and believe open defecation is the normal option. The government has not taken measures to induce behavioural changes. A July 2016 study published in BMC Public Health says that increasing migrant population and the high demand for housing in the face of limited availability of space has resulted in general unwillingness and inability to establish private sanitation facilities in the communities in Ghana. The study also reports that landless people are unwilling or unable to spend on sanitation. About 80 per cent of Ghana’s population is landless.

“At present, Sub-Saharan Africa is focussing on traditional or rudimentary toilets which are not safe. Countries should offer affordable technologies that can fight the adverse effects of poor sanitation," concludes Anyitike Mwakitalima, coordinator of the National Sanitation Campaign, Tanzania.

REVISIT, REFOCUS, RENEW

A World Bank assessment of 18 African countries that account for half of the continent's population in the continent, says economic losses incurred due to poor sanitation is equivalent to between 1 and 2.5 per cent of their GDP. The true cost could be much higher as it does not factor in indirect effects of poor sanitation, such as the costs of epidemic outbreaks or losses in trade and tourism revenue. Given the situation, countries need to immediately focus on sanitation by:

Increasing investment: The budget for sanita tion in African countries is abysmally low. The worst performing African countries are not even meeting the 2015 Ngor Declaration commitment of spending 0.5 per cent of their GDP on sanitation and hygiene. The higher budget has to be supported with effective planning that should be long-term and at the same time participative as use of toilets require behavioural shift. The plans should also address the needs of women and girls.

Promoting low-cost, effective technologies: No doubt, Africa’s sanitation challenge requires huge investments. The financial burden, however, can be reduced through low-cost sanitation technologies. For example, Rwanda is promoting a low-cost decentralised system to reuse wastewater, says a 2013 paper titled Challenges to Achieving Sustainable Sanitation in Informal Settlements of Kigali, Rwanda. The technologies should also be region-specific. A classic example of this is Kenya’s Ntugi village, which despite being water-stressed has become open-defecation free. Using locally procured raw materials, people in the village have built lined pit toilets, which are water neutral.

Developing sound database: Accurate data helps identify problems better, and improve assessment of interventions. But data scarcity is a major problem in the region. India has backed its open-defecation free programme with real-time data which monitors the target and the achievement status of toilet construction at the level of individual households in every village (see 'Valuable lessons...').

Ensuring better monitoring and evaluation: Strong monitoring systems should be developed as a priority to check the implementation of sanitation policies. A 2011 African Development Bank group publication says that given the limited statistics and data collection capacity, 5-10 per cent of the budget of major projects in Africa needs to be spent on monitoring.

Finally, African governments need to build on the positive steps they have taken recently. In 2013, African leaders voluntarily adopted Agenda 2063—a set of seven “aspirations” that resemble the SDGs. They envision an “Africa you would like to have 100 years after the founding of the Organization of African Unity”. Such steps should be encouraged and promoted in every country of the continent.

Valuable lessons in toilet building

Despite the limitations of the Indian model of sanitation, Africa can draw inspiration from its many positive aspects

Author: KAMAL KAR

During the last decade of the Millennium Development Goals (2005-2015), many African nations improved their water and sanitation status. One of the important factors that led to this was the adoption of Community-Led Total Sanitation (CLTS) approach. Though CLTS was introduced in Africa nearly seven years after its launch in Asia, it received wide acceptance.

All the 54 African countries, barring the relatively developed northern ones, introduced and scaled up CLTS by focusing on empowering local communities to end open defecation. This was done by inculcating collective behavioural changes sustainably, rather than waiting for subsidy from external agencies or governments. Earlier, there was hardly any country that implemented its national sanitation programme independent of the directives of funding or donor agencies. The loan or grant mostly came with the baggage of directives on toilet design, mode of supply of hardware and disbursement, including an outline for identifying the beneficiaries.

But this changed after 2007 when many countries, who depended on external funding support, continued to demand funds or grants, but voiced their preference for no subsidy-CLTS approach over free and subsidised sanitary hardware supply. It proved convenient for many countries to incorporate CLTS, which previously faced challenges in mobilising huge funds for behaviour change.

Embracing behavioural change

The rollout and adoption of CLTS has been so drastic that the number of open defecators in sub-Saharan Africa (SSA) has reduced in comparison to India. The UNICEF/WHO joint monitoring programme report suggests that between 2000 and 2015, SSA witnessed a decline in open defecation from 32 per cent to 23 per cent compared to India’s 66 per cent to 40 per cent.

The inspiration came from India, Bangladesh and Nepal that experimented with CLTS before Africa. Many African countries, which did not want to depend on grants to construct free household toilets (these were often not used for the purpose they were built for in the first place) changed their strategies by shifting to CLTS so that they could use the same grants or funds for initiating behavioural change. It was difficult for many of these countries to waste resources on supply-driven sanitation approach, which did not necessarily see significant impacts in reducing open defecation as is being followed by some Asian nations like India and Cambodia.

The Asian problem is that in some countries free or subsidised toilets constructed either by the government or developmental agencies continue to be the focus. Thus, there is less emphasis on local empowerment. One of the most striking examples of a national sanitation strategy developed in India is based on the assumption that local communities lack awareness. Also, as they are unable to change their habit of open defecation or are financially incapable of constructing toilets, free or subsidised toilets are a must. The household hardware subsidy amount in India has increased ten-fold over the past couple of decades. While India has spent billions of dollars through sanitation programmes on toilets, the usage of the same has remained far from satisfactory.

Africa should take note of two factors when it comes to comparison with India: first, the rather slow progress in terms of collective behavioural change in India as compared to many of its nations owing to a different enabling environment.

Second, the convergence of the three essential elements of CLTS—behavioural change (personal, professional and institutional), understanding CLTS tools and techniques (from pre-triggering to post-triggering, and post open defecation-free sustainability) and enabling environment (policy context, inter-institutional coordination and budget protocol)—is missing in India. However, Africa has successfully created a synergy of these elements to enable authorities and communities. This actually determines the true progress of CLTS, resulting in many positive health outcomes.

Inspiration from India

Despite several limitations of the Indian model of sanitation, Africa can still emulate its positive aspects. The continent can witness more success if it prioritises sanitation just like India has accorded it top national importance under the Prime Minister’s flagship Swachh Bharat Mission (SBM). Further, African nations can emulate India’s systematic involvement of government and non-government institutions across all levels.

Here, it is important for Africa to realise that in a federal system like India, states have to mobilise matching grants to go with the national funding support from the Centre to make SBM successful. In other words, the national mission is not implemented through a single source of funding, but through a collective initiative duly contributed by various funding sources.

One of the most successful initiatives of India is the formation of Self-Help Groups (SHG), which are savings and credit groups formed by poor women to collectively manage billions of rupees. It is interesting to see how the Indian government has successfully involved them in SBM.

Finally, Africa may learn valuable lessons from the media campaign launched under SBM, where the message is constantly broadcast through over 800 TV and 230 radio channels across the country. This leaves no stone unturned to ensure that the message is loud and clear: end open defecation in India by October 2019.

However, only time will tell whether these efforts will leave the country saturated with largely unused household sanitation facilities or whether open defecation will become a thing of the past.

(The author is founder chairperson of CLTS Foundation, a non-profit based in Kolkata)

Look beyond the loo

In fast-urbanising Africa, the governments must rework their usual toilet building strategies to ensure safe disposal of waste

Author: Sunita Narain

Over a decade ago, when the world began discussing targets for sanitation the idea seemed simple—build toilets and people will use them. When the UN’s Millennium Deve lopment Goals (MDGs) set in 2000 came to an end in 2015, over 2 billion people had gained access to improved sanitation. But nearly 2.6 billion people still had no or poor sanitation facilities—it was the world’s unfinished agenda. The Sustainable Deve lopment Goals, which succeeded MDGs, have now set an ambitious global goal to completely get rid of this wicked problem—by 2030 all citizens of the world must have access to clean water and improved sanitation. India (particularly, the laggard states of Odisha, Bihar, Goa, Tripura, Jharkhand and Uttar Pradesh) and Africa hold the key to this transition. So, where are we today?

The past two decades have taught the world some crucial stuff. Firstly, it is clear that toilets do not equal safe sanitation. The faecal matter, if excreted into a poorly made pit in the ground or a latrine connected to an open drain (as is the case in most places) will contaminate the environment and add to the health burden. So, if toilets must lead to the benefits that they are designed to do—reduce water-borne diseases, improve nutrition of children and increase productivity—then sanitation has to be approached differently. The toilet has to be built with provisions for management of human excreta. The toilet must also be built with provision for water. Once again, if people cannot wash hands or clean the toilet then it will add to the health burden. This is the toilet+ strategy.

Secondly, there is the realisation that toilets without changes in behaviour will not work—they could be built but not used. This is why the world now agrees that it must focus on educating people of the benefits of using toilets, and the most important trigger is to link the benefits with health. It is also clear that cajoling people into changing their habits can be done best by their communities. This is the toilet++ strategy. But the question is if these learnings are enough! Currently, India is pushing hard to meet its own open defecation free (ODF) goal of 2019. There is no doubt that much headway has been made in building toilets and in communicating the message of safe sanitation. The Indian govern ment has been dogged and aggressive—which is much needed in this sector. It has also put its money where its mouth is. The government’s Swachh Bharat (clean India) Mission has, on the face of it, no financial constraints. It is expected that by 2019, most of the toilets will be built; cities and villages will be declared ODF. This is good news for the world because till now, six of the 10 who defecated in the open, were from India. This is good news. No question.

But will this be enough? I suspect that post-2019, the sanitation questions in India will be different, yet the same: how to ensure that the toilets continue to be maintained and used, and how to make sure that human excreta is safely handled. If this is not done then the massive investment of counting toilets could be wasted. Worse, the government would now believe that their task is done and priorities changed. But the expected health outcome, which requires not just building and using toilets but ensuring that water is not contaminated, will not be realised. This clearly must be avoided at all costs. For the Indian toilet success to have a sustainable future, monito ring and public scrutiny must continue. The gove rnment must not rush to claim success, not yet.

What then are Africa’s options to safe sani tation? Remember that Africa is urbanising fast. It is living increasingly and explosively in peri-urban and urban settlements, which are brutally poor and invariably informal. The fact is African cities, like all others in the now-fast-developing world, are building a completely unsustainable and unaffordable water and waste system. Cities are bringing water long distances; losing much in distribution losses; and spending all they have in supplying expensive water to some and never to all. Water inequity then leads to waste unsustai nability. The same cities do not have funds to build underground pipelines to connect, intercept and then transport the waste discharge from each household to sewage treatment plants. This means untreated waste keeps flowing and conta minating. It is inevitable. Governments simply do not have the wherewithal to provide safe water and then safe sanitation to all.

We need alternative ways of handling water and waste that are affordable and so sustainable. This means first thinking of how to reduce the cost of water supply—if water is expensive then waste will not be managed. This means thinking of local water sources to cut the length of the pipeline. Ironically, governments cannot tap local water sources because these are increasingly contamina ted by untreated waste. This cycle must be broken.

This also means finding cheaper—much cheaper—options of treating waste that comes out of toilets. This is the other irony of our times. We can take a man to the moon. We can even treat the excreta of the man on the moon. But we cannot build affordable sanitation systems for millions in our world. As yet the toilet technology is either rudimentary (just a pit in the ground) or so expensive that it cannot be afforded by most (flush toilets connected to miles of underground pipes leading to treatment plants). There is nothi ng in-between that has been tried out at scale.

But this is where the next toilet revolution must come. It must not be in building the toilet but in building the toilet with the system for safe disposal of waste. And this is where the oppor tunity lies. Human waste is a resource—it is about nutrients that could potentially enrich the soil, add to productivity. The problem is that it also has pathogens and many things that are not so nice. So, can this resource be reused—reworked into the land and not disposed of in water? Can the water and sewage paradigm move towards local recha rge and local recycling? Can it? It must.

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