Equity implications for sanitation from recent health and nutrition evidence

Recent evidence points to the possible underestimation of the health and nutrition impact of sanitation. Community sanitation coverage may first need to reach thresholds in the order of 60% or higher, to optimize health and nutrition gains. Increasing coverage of sanitation to levels below 60% of community coverage may not result in substantial gains. For example, moving Indonesia from 60% to 100% improved sanitation coverage could significantly reduce diarrhoea in children under 5 years old (by an estimated 24% reduction in odds ratio for child diarrhoea morbidity) with gains split equally by reaching underserved communities and the unserved within communities. We review the implications of these results across three levels of program implementation – from micro level approaches (that support communities to achieve open defecation-free status), to meso level (sub-national implementation) to macro level approaches for the national enabling environment and the global push to the Sustainable Development Goals. We found significant equity implications and recommend that future studies focus more extensively on community coverage levels and verified community open defecation free status rather than household access alone. Sanitation practitioners may consider developing phased approaches to improving water, sanitation and hygiene in communities while prioritizing the unserved or underserved.     

Demand for improved sanitation in an urban informal settlement in India: role of the local built environment

Sanitation uptake is a pressing challenge, especially in India, and sanitation demand in urban informal settlements and slums has been understudied relative to rural areas. Given the spatial and socioeconomic disadvantage of these settings, research suggests that the built environment may relate to sanitation demand, but this has not been tested. This study utilizes data on a large urban informal settlement in Maharashtra, India, examining built environment predictors including housing security, water access, and proximity to existing common sanitation, in association with sanitation demand. Results indicate that household size, home ownership, individual household water sources, and open defecation avoidance are significantly associated with interest in a toilet. Further, interactions between (1) water source and home ownership, and (2) open defecation and distance to shared sanitation, are associated with interest in a toilet. These findings support the role of the built environment in shaping sanitation demand in urban informal settlements.     

The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized,Controlled Trial in Rural Ghana

Background: According to the World Health Organization/United Nations International Children’s Fund Joint Monitoring Program, 494 million people practice open defecation globally. After achieving open defecation-free (ODF) status through efforts such as Community-Led Total Sanitation (CLTS), communities (particularly vulnerable households) may revert to open defecation, especially when toilet collapse is common and durable toilets are unaffordable. Accordingly, there is increasing interest in pro-poor sanitation subsidies.Objectives: This study determined the impacts of a pro-poor sanitation subsidy program on sanitation conditions among the most vulnerable households and others in the community.Methods: In 109 post-ODF communities in Northern Ghana, we conducted a cluster randomized controlled trial to evaluate a pro-poor subsidy program that identified the most vulnerable households through community consultation to receive vouchers for durable toilet substructures. We surveyed households to assess toilet coverage, quality, and use before and after the intervention and tracked program costs.Results: Overall, sanitation conditions deteriorated substantially from baseline to endline (average of 21 months). In control communities (not receiving the pro-poor subsidy), open defecation increased from 25% (baseline) to 69% (endline). The subsidy intervention attenuated this deterioration (open defecation increased from 25% to only 54% in subsidy communities), with the greatest impacts among voucher-eligible households. Noneligible households in compounds with subsidized toilets also exhibited lower open defecation levels owing to in-compound sharing (common in this context). CLTS followed by the subsidy program would benefit more households than CLTS alone but would cost 21–37% more per household that no longer practiced open defecation or upgraded to a durable toilet.Discussion: Sanitation declines, often due to toilet collapse, suggest a need for approaches beyond CLTS alone. This subsidy program attenuated declines, but durable toilets likely remained unaffordable for noneligible households. Targeting criteria more closely aligned with sanitation inequities, such as household heads who are female or did not complete primary education, may help to generate greater and more sustainable impacts in Northern Ghana and, potentially, other contexts facing toilet collapse and limited market access. https://doi.org/10.1289/{"type":"entrez-protein","attrs":{"text":"EHP10443","term_id":"372009828","term_text":"EHP10443"}}EHP10443     

Impact of Sulabh Swasthya Yojna -- an attitude study

Sulabh has been involved in research, training, and development in rural areas of 16 states and 2 union territories of India. There are 837 Sulabh branches operating in 301 districts. The objectives vary within projects, but the general aim is to improve the community's sanitation and primary health practices through grass roots level organizing. This study measures the impact of Sulabh Swasthya Yojana (SSY) on attitudes in 3 different villages in Rojoari district of Jammu region in December 1990. The villages included Tatapani, where Sulabh had been active since January 1990, an adjoining village, and a village 30 km away from the adopted village. 50 households from each village were interviewed. The findings were that a much higher percentage of people in the adopted village (81.96%) had a positive attitude toward family planning (FP), pre- and postnatal care, care of the female child, trench latrines, smokeless chulhas, and kitchen gardens. In nonadopted villages there were only 50.3% with positive attitudes, but 70.07% in adjoining villages were supportive. There were few differences in scores between Muslims and Hindus in these 2 villages. Both population groups had higher scores in adopted villages than nonadopted villages. The mean attitude scores showed that 78% of the people in the adopted village had a positive attitude toward FP. The mean attitude score for the adjoining village was 66.36% and 49.6% in the nonadopted village. Scores for pre- and postnatal care were 30% higher in the adopted village and 20% higher for the adjoining village than the nonadopted village. A favorable attitude toward late marriage and higher education of girls was expressed by 81.6% in the adopted village, 76.6% in the adjoining village, and 48.8% in the nonadopted village. All villages supported son preference. Only 43.3% supported sanitary practices in the nonadopted village, while 87.7% supported sanitary practices in the adopted village and 77.6% showed support in the adjoining village. The conclusion is that SSY has had a positive impact on people. The prerequisites for achieving Health for All are identified as appropriate IEC, motivators, resources, and community participation.     

The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis

Background

An estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health.

Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe

Unless strategies are found to galvanise rural communities and create a demand for sanitation, we cannot achieve the United Nations Millennium Development Goal of halving the 2.4 billion people without sanitation by the year 2015. This study describes an innovative methodology used in Zimbabwe--Community Health Clubs--which significantly changed hygiene behaviour and built rural demand for sanitation. In 1 year in Makoni District, 1244 health promotion sessions were held by 14 trainers, costing an average of US dollars 0.21 per beneficiary and involving 11,450 club members (68,700 beneficiaries). In Tsholotsho District, 2105 members participated in 182 sessions held by three trainers which cost US dollars 0.55 for each of the 12,630 beneficiaries. Within 2 years, 2400 latrines had been built in Makoni, and in Tsholotsho latrine coverage rose to 43% contrasted to 2% in the control area, with 1200 latrines being built in 18 months. Although Zimbabwe has historically relied on subsidies to stimulate sanitation, this intervention shows how total sanitation could be achievable. The remaining 57% of club members without latrines in Tsholotsho all practised faecal burial, a method previously unknown to them. Club members' hygiene was significantly different (p<0.0001) from a control group across 17 key hygiene practices including hand washing, showing that if a strong community structure is developed and the norms of a community are altered, sanitation and hygiene behaviour are likely to improve. This methodology could be scaled up to contribute to ambitious global targets.     

Access to sanitation and violence against women: evidence from Demographic Health Survey (DHS) data in Kenya

Violence against women (VAW) is a serious public health and human rights concern. Literature suggests sanitation conditions in developing countries may be potential neighborhood-level risk factors contributing to VAW, and that this association may be more important in highly socially disorganized neighborhoods. This study analyzed 2008 Kenya Demographic Health Survey’s data and found women who primarily practice open defecation (OD), particularly in disorganized communities, had higher odds of experiencing recent non-partner violence. This study provides quantitative evidence of an association between sanitation and VAW that is attracting increasing attention in media and scholarly literature throughout Kenya and other developing countries.     

Sanitation in the developing world: current status and future solutions

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.     

Environment and health: environmental sanitation and community water supply

This article identifies important features of two 5-Year Plans in India. Currently, only about 200 cities have even a partial sewage system. Elementary sewage systems are nonexistent in rural villages. In 1990, under 5% of rural population had access to sanitary facilities. The result is widespread soil and water pollution and its accompanying disease. The Rural Water Supply Program was proposed in the 5th Plan, but was implemented in the 7th Plan (1985-90). Construction of latrines is still too low. Resources were insufficiently mobilized for latrine construction. An alternative would be to institute cost recovery and user pays principles. Low cost technology could be substituted. Low cost latrine systems should conform with users' social habits, local culture, and the customs of the community. The system should be affordable to users. The technology should be user-friendly and rely on use of local materials and workers. Over 90% of the population rely on community water supply facilities. Health has not benefited from the access to water supplies. The reasons are low hygienic standards, lack of water quality surveillance, and poor maintenance of equipment. The community does not participate. By 1996, people's access to water was reduced to 1 km in the plains, and 50 m in hilly areas. Surface waters are contaminated by fecal matter, fluoride, nitrate, and arsenic. The Water Quality Surveillance Program lacks an institutional framework and human resource development. There is a need for education about hygiene, unsafe drinking water, and poor sanitation for people and agency staff.     

Defecation practices of young children in a Peruvian shanty town.

Little is known about feces disposal practices, their determinants and feasibility for change, despite their importance in the control of diarrheal diseases. We report here the results of formative research for the development of an intervention to promote sanitary disposal of feces of young children. The study was conducted in a densely populated shanty town area of Lima, where water and sanitation systems are scarce. In-depth interviews were undertaken with mothers, husbands and community leaders. Group discussions were held with mothers in order to validate findings from the interviews, investigate particular topics further and explore reactions to possible intervention strategies. The principal defecation sites for young children were diapers, potties, the ground in or near the home, the hill, latrines and flush toilets. The main determinants found were the age of the child, the effort required by the method, perceptions of dirtiness and the availability of resources. Almost all children under one year of age use diapers but the high resource cost of diaper washing is a strong motivation for mothers to move their children on as early as possible. Potties were considered the most socially acceptable and 'hygienic' defecation method for children between one and three years of age. Nevertheless, defecation directly onto the ground is common at this age. Potty training is deemed to be quite difficult and the long term achievements are determined by the initial training success. In most cases, the training process is authoritative and inconsistent. The use of latrines and flush toilets is not considered appropriate for children until they are three to four years old. Based on these initial findings, a micro-trial was conducted to assess the feasibility and acceptability of promoting greater use of potties and associated practices. The results of the trial were very encouraging and provided valuable information for the design of a community-wide intervention. Our findings help explain why the emphasis given in most sanitation projects, where efforts have been concentrated on the promotion of latrines, has failed to induce their utilization by small children. Sanitation projects should incorporate interventions that will promote hygienic defecation and stool clearance practices for infants and small children.     

Risk factors of diarrhoea among flood victims: a controlled epidemiological study

The concept and practice of 'disaster preparedness and response', instead of traditional casualty relief, is relatively new. Vulnerability analysis and health risks assessment of disaster prone communities are important prerequisites of meaningful preparedness and effective response against any calamity. In this community based study, the risk of diarrhoeal disease and its related epidemiological factors were analysed by collecting data from two selected flood prone block of Midnapur district of West Bengal. The information was compared with that of another population living in two non-flood prone blocks of the same district. The study showed that diarrhoeal disease was the commonest morbidity in flood prone population. Some behaviours, like use of pond water for utensil wash and kitchen purpose, hand washing after defecation without soap, improper hand washing before eating, open field defecation, storage of drinking water in wide mouth vessels etc. were found to be associated with high attack rate of diarrhoea, in both study and control population during flood season compared to pre-flood season. Attack rates were also significantly higher in flood prone population than that of population in non-flood prone area during the same season. Necessity of both community education for proper water use behaviour and personal hygiene along with ensuring safe water and sanitation facilities of flood affected communities were emphasized.     

Home hygiene and environmental sanitation: a country situation analysis for India

Problems of the environment and of domestic hygiene are always related to poverty of population and the sanitation of settlements. Most cities and towns in developing countries, like India, are characterised by over-crowding, congestion, inadequate water supply and inadequate facilities of disposal of human excreta, waste water and solid wastes. Inadequacy of housing for most urban poor invariably leads to poor home hygiene. Personal and domestic hygiene practices cannot be improved without improving basic amenities, such as water supply, waste water disposal, solid waste management and the problems of human settlements. But even under the prevailing conditions, there is significant scope of improving hygiene practices at home to prevent infection and cross-infection. Unfortunately, in developing countries, public health concerns are usually raised on the institutional setting, such as municipal services, hospitals, environmental sanitation, etc. There is a reluctance to acknowledge the home as a setting of equal importance along with the public institutions in the chain of disease transmission in the community. Managers of home hygiene and community hygiene must act in unison to optimise return from efforts to promote public health. Current practices and perceptions of domestic and personal hygiene in Indian communities, the existing levels of environmental and peri-domestic sanitation and the 'health risk' these pose will be outlined, as well as the need for an integrated action for improving hygiene behaviour and access to safe water and sanitation.     

Opportunities and barriers to effective operation and maintenance of public toilets in informal settlements: perspectives from toilet operators in Kampala

Although classified by the Joint Monitoring Programme (JMP) as unimproved sanitation facilities, public toilets still play a critical role in eliminating open defecation in informal settlements. We explored perspectives of toilet operators on opportunities and barriers to operation and maintenance (O&M) of public toilets in informal settlements. A cross-sectional study design was used. Up to 20 in-depth interviews were used to obtain data on the experiences of public toilet operators. Thematic content analysis was used.

Ressults show that opportunities for improving O&M include; operation of public toilets is a source of livelihood; operators are knowledgeable on occupational risks, and the community is involvedin sanitation activities. Barriers to effective O&M include; high operation costs, failure to break even and a lack of investments in occupational health Therefore, there is need to recognise the significance of public toilets as a viable alternative to open defecation in areas where ownership of private sanitation facilities is difficult. Failure to observe the health and safety of toilet operators may further compromise O&M.     

Village sanitation and child health: Effects and external validity in a randomized field experiment in rural India

Over a billion people worldwide defecate in the open, with important consequences for early-life health and human capital accumulation in developing countries. We report a cluster randomized controlled trial of a village sanitation intervention conducted in rural Maharashtra, India designed to identify an effect of village sanitation on average child height, an outcome of increasing importance to economists. We find an effect of approximately 0.3 height-for-age standard deviations, which is consistent with observations and hypotheses in economic and health literatures. We further exploit details of the planning and implementation of the experiment to study treatment heterogeneity and external validity.     

Global costs of attaining the Millennium Development Goal for water supply and sanitation

OBJECTIVE: Target 10 of the Millennium Development Goals (MDGs) is to "halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation". Because of its impacts on a range of diseases, it is a health-related MDG target. This study presents cost estimates of attaining MDG target 10. METHODS: We estimate the population to be covered to attain the MDG target using data on household use of improved water and sanitation for 1990 and 2004, and taking into account population growth. We assume this estimate is achieved in equal annual increments from the base year, 2005, until 2014. Costs per capita for investment and recurrent costs are applied. Country data is aggregated to 11 WHO developing country subregions and globally. FINDINGS: Estimated spending required in developing countries on new coverage to meet the MDG target is US$ 42 billion for water and US$ 142 billion for sanitation, a combined annual equivalent of US$ 18 billion. The cost of maintaining existing services totals an additional US$ 322 billion for water supply and US $216 billion for sanitation, a combined annual equivalent of US$ 54 billion. Spending for new coverage is largely rural (64%), while for maintaining existing coverage it is largely urban (73%). Additional programme costs, incurred administratively outside the point of delivery of interventions, of between 10% and 30% are required for effective implementation. CONCLUSION: In assessing financing requirements, estimates of cost should include the operation, maintenance and replacement of existing coverage as well as new services and programme costs. Country-level costing studies are needed to guide sector financing.     

Use of Technology to Access Health Information/Services and Subsequent Association With WASH (Water Access,Sanitation, and Hygiene) Knowledge and Behaviors Among Women With Children Under 2 Years of Age in Indonesia: Cross-sectional Study

BackgroundWater access, sanitation, and hygiene (WASH) remain a public health concern in Indonesia. Proper WASH practices can decrease risk of stunting, wasting, and disease in children under the age of 2.ObjectiveThe purpose of our study is to examine if using technology to access health information and services among Indonesian women affects knowledge and behaviors regarding handwashing and defecation practices.MethodsOur study is an interview-based cross-sectional survey. Participants included 1734 mothers of children under 2 years of age. These women were randomly selected and interviewed as part of a 3-stage cluster sampling technique. Our study uses data regarding WASH knowledge which includes benefits of handwashing with soap, 5 critical times of handwashing, risks of open defecation, media of disease transmission, defecation locations, and risks of open defecation. Data regarding WASH behaviors were also included: handwashing with soap, type of latrine used at home, and where defecation took place. This investigation used adjusted and unadjusted logistic and linear regression models to determine differences in WASH outcomes between those who use technology to access health information and services and those who did not.ResultsOne result is that Indonesian women with children under 2 years of age who use technology to access health information and services are more likely to know the advantages of proper handwashing (odds ratio [OR] 2.603, 95% CI 1.666-4.067) and know the 5 critical times of handwashing (OR 1.217, 95% CI 0.969-1.528). Women who use technology to access health information are also more likely to know the risks of open defecation (OR 1.627, 95% CI 1.170-2.264) and use a type of toilet (such as a gooseneck or squat toilet) that limits risk (OR 3.858, 95% CI 2.628-5.665) compared to women who did not use technology to access health information.ConclusionsUsing technology to access health information and services was associated with an increase in handwashing and defecation knowledge. In the future, promoting mothers of children under 2 years of age to access health information through technology might be used to increase handwashing and defecation knowledge as well as safe defecation practices. However, further research should be done to determine how technology may increase the frequency of recommended handwashing behaviors.     

The effect of improved rural sanitation on diarrhoea and helminth infection: design of a cluster-randomized trial in Orissa,India

Background

Infectious diseases associated with poor sanitation such as diarrhoea, intestinal worms, trachoma and lymphatic filariasis continue to cause a large disease burden in low income settings and contribute substantially to child mortality and morbidity. Obtaining health impact data for rural sanitation campaigns poses a number of methodological challenges. Here we describe the design of a village-level cluster-randomised trial in the state of Orissa, India to evaluate the impact of an ongoing rural sanitation campaign conducted under the umbrella of India’s Total Sanitation Campaign (TSC).We randomised 50 villages to the intervention and 50 villages to control. In the intervention villages the implementing non-governmental organisations conducted community mobilisation and latrine construction with subsidies given to poor families. Control villages receive no intervention. Outcome measures include (1) diarrhoea in children under 5 and in all ages, (2) soil-transmitted helminth infections, (3) anthropometric measures, (4) water quality, (5) number of insect vectors (flies, mosquitoes), (6) exposure to faecal pathogens in the environment. In addition we are conducting process documentation (latrine construction and use, intervention reach), cost and cost-effectiveness analyses, spatial analyses and qualitative research on gender and water use for sanitation.

Results

Randomisation resulted in an acceptable balance between trial arms. The sample size requirements appear to be met for the main study outcomes. Delays in intervention roll-out caused logistical problems especially for the planning of health outcome follow-up surveys. Latrine coverage at the end of the construction period (55%) remained below the target of 70%, a result that may, however, be in line with many other TSC intervention areas in India.

Conclusion

We discuss a number of methodological problems encountered thus far in this study that may be typical for sanitation trials. Nevertheless, it is expected that the trial procedures will allow measuring the effectiveness of a typical rural sanitation campaign, with sufficient accuracy and validity.

     

How valuable are environmental health interventions? Evaluation of water and sanitation programmes in India

Objective

To evaluate and quantify the economic benefits attributable to improvements in water supply and sanitation in rural India.

Methods

We combined propensity-score “pre-matching” and rich pre–post panel data on 9500 households in 242 villages located in four geographically different districts to estimate the economic benefits of a large-scale community demand-driven water supply programme in Maharashtra, India. We calculated coping costs and cost of illness by adding across several elements of coping and illness and then estimated causal impacts using a difference-in-difference strategy on the pre-matched sample. The pre–post design allowed us to use a difference-in-difference estimator to measure “treatment effect” by comparing treatment and control villages during both periods. We compared average household costs with respect to out-of-pocket medical expenses, patients'' lost income, caregiving costs, time spent on collecting water, time spent on sanitation, and water treatment costs due to filtration, boiling, chemical use and storage.

Findings

Three years after programme initiation, the number of households using piped water and private pit latrines had increased by 10% on average, but no changes in hygiene-related behaviour had occurred. The behavioural changes observed suggest that the average household in a programme community could save as much as 7 United States dollars per month (or 5% of monthly household cash expenditures) in coping costs, but would not reduce illness costs. Poorer, socially marginalized households benefited more, in alignment with programme objectives.

Conclusion

Given the renewed interest in water, sanitation and hygiene outcomes, evaluating the economic benefits of environmental interventions by means of causal research is important for understanding the true value of such interventions.     

三峡库区万州段农村环境卫生现状与健康潜在危害因素研究

目的了解万州区农村居民环境卫生现状与人群健康主要潜在危害因素,为制定环境保护与疾病防治策略提供科学依据。方法用多阶段整群抽样方法.随机抽取10个镇乡、40个行政村、200户作为调查对象。通过查阅资料、现场访谈与观察及实验室检测等方法获得监测数据。用Excel软件建立数据库,用描述法对数据统计分析。结果①在万州农村有92.24%镇乡所在地没有垃圾处置场及生活垃圾处置设施。37个镇乡都没有污水处理厂及收集污水的管网等设施。有的养殖场污水随意排放,并对周边环境及水域产生了一定影响。40个监测点822人中1年内有腹泻、腹痛、发热症状者的阳性率分别为1.7%、1.58%、1.09%。有喝生水习惯占13.O%,使用农村自来水占52.5%,使用井水和泉水分别占23%和1 9.5%,有5%的人仍以沟、塘、渠河水作为生活用水。农村自来水合格率17.42%。无洗手习惯的占2.5%。生活垃圾随意丢弃在院坝四周有72户,占36%。生活污水随意排放的占35.5%。②调查200户农户中,每户有1~3处鼠、蚊、蝇、蟑螂等病媒生物孳生栖息场所,如猪圈、牛圈或鸡鸭圈舍者占63.5%,有柴草堆的占46.5%,有垃圾固定堆放点的占13.O%,有旱厕的占调查农户的28%,农户院周有污水沟、水池等场所的占调查农户的10%。粪便经三格式化粪池和沼气池无害化处理有129户,占64.5%。积水容器孑孓阳性率22.13%。200个监测户中有臭味、蛆蝇、粪便暴露的厕所分别占66%、65%、39%。农户被鼠、蟑螂、苍蝇的侵害率分别为55.00%、51.50%、59.50%。万州段农区人群土源线虫感染率为15.9%。③40份土壤样品蛔虫卵检出率为17.50%,其活蛔虫卵检出率2.50%。40份土壤样镉、铅含量检测值均在标准限值内。结论该地农村环境卫生基础设施差,环境卫生状况不容乐观,健康危害因素严峻.广泛开展农区爱国卫生运动.大力推进农村环境卫生基础设施建设,加大持久投人,强力推进生活垃圾、污水、粪便无害化处理措施是改善农村环境卫生状况、消除健康危害因素、保护人群健康及环境的首要任务。     

Vouchers for Improving Sanitation: A Step toward Stopping Open Defecation

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Eliminating open defecation by 2030 is one of the United Nations’ Sustainable Development Goals.¹ As of 2020, more than 494 million people worldwide routinely defecated outdoors instead of using a toilet.² This represents a sharp decrease from the 1990 estimate of 1.3 billion people,³ but it is not clear whether further sanitation improvements can be achieved or sustained, especially by poor and vulnerable households.⁴ A new study reported in Environmental Health Perspectives⁴ investigated how providing durable toilets to vulnerable Ghanaian households would affect communities’ “open defecation–free” (ODF) status.ODF status is achieved when a community has no evidence of open defecation and 80–100% of households—depending on the country—own and use toilets.² A strategy called community-led total sanitation (CLTS) is used to help attain ODF status.⁵ This method involves triggering feelings of shame and disgust about a community’s level of visible defecation in order to motivate people to build and use toilet facilities.⁵ Although there is evidence that CLTS prompts people to discontinue open defecation initially, its long-term effectiveness for maintaining sanitation is less certain.⁵ One reason is that toilets are expensive to construct and maintain. People with limited income typically build latrines with unlined pits, mud walls, and squatting platforms.⁵ If these structures collapse, residents often return to open defecation.⁶Open in a separate windowEligible households redeemed their vouchers for one of three types of durable latrine substructures: (clockwise from left) the plastic Digni-Loo slab and liner, a molded concrete slab and liner, or a cement block liner and poured concrete slab. Residents were responsible for digging the pit and building a shelter around the latrine. Images: Courtesy The Aquaya Institute.The new study included more than 5,000 households in 109 randomly selected communities in the Tatale and Kpandai Districts of Northern Ghana. Prior to the study, these communities had achieved ODF status through implementation of CLTS, although not all had maintained that status. Fifty communities were assigned as controls. The remaining 59 were assigned to the subsidy group, where vulnerable households received vouchers to purchase a latrine substructure. Personnel from the District Assemblies (planning bodies) consulted with each community to identify families that were food insecure or included a vulnerable person with no outside support. These households represented 14% of the subsidy group.“A main goal of the subsidy program was to encourage installation of the more durable facilities that were provided through the vouchers,” says lead author John Trimmer, deputy director of research at the nonprofit Aquaya Institute. “Along with supporting the most vulnerable members of the community, there is also often a hope that subsidizing a portion of the population could encourage other, less vulnerable households to improve their own toilets as well.” However, Trimmer adds, “We did not see much evidence of that in this case.”ODF status declined substantially throughout the 21-month duration of the study in both subsidy and control communities. Although most of the durable toilets built after receiving a voucher remained in place at the end of the study, less durable latrines installed or maintained during the prior CLTS intervention had largely collapsed and were not replaced during the study period.“We did not expect to see these extremely high levels of toilet collapse and deterioration among our study population,” says Trimmer. “Based on what we know from the literature, sanitation conditions may sometimes decline after communities have reached ODF status, but declines are typically not as bad as what we saw during this study in Northern Ghana. I think that unstable soil conditions in the region likely played a role in why toilet collapse was so common here.”By the end of the study, open defecation in control communities had increased from 25% to 69%, whereas in communities that had received vouchers it increased from 25% to 54%. Only 15% of households in subsidy communities and 1% of control households owned and used durable toilets.“Overall, the program’s effects did not outweigh the general deterioration in sanitation conditions across the study population,” says Trimmer. “Although the program did improve conditions for households that received vouchers, as well as for others living in the same compound who were sharing the subsidized toilets, it did not lead many noneligible households to purchase and install their own durable facilities.” He speculates that, given the relatively high poverty levels in this region of Ghana, durable toilets may still be too expensive for most noneligible households.Esi Awuah, a professor of civil engineering at Kwame Nkrumah University of Science and Technology in Ghana, says even concrete-lined pits can collapse. “The people want strong and stable toilets,” says Awuah, who was not involved in the study. “One can do in situ measurements of the slabs as well as the lining of the pits. For me, safety is very important, and we should look not only at the toilet technology but also the structural stability.”“This is a carefully designed and well-executed study,” says Raymond Guiteras, an assistant professor of agricultural and resource economics at North Carolina State University. “The paper shows that gains in sanitation coverage from a successful CLTS program deteriorated significantly over time. This calls for innovative ideas to sustain and build on gains achieved from an initial intervention.”Guiteras, who was not involved in the study, adds that the study’s test of one such idea—subsidizing durable toilets for the poorest of the poor in these communities—did find some modest success. Overall, he says, the paper supports the idea that multiple interventions to improve sanitation are needed at the household and community level to make sustained progress. “Rather than one breakthrough solution,” he says, “this is likely to be a long struggle with slow improvement from the cumulative benefits of many incremental gains.”