Gordon McGranahan. Local environments such as cities and neighbourhoods are becoming a focal point for those concerned with environmental justice and sustainability. The Citizens at Risk takes up this emerging agenda and analyses the key issues in a refreshingly simple yet sophisticated style. Taking a comparative look at cities in Africa, Asia and Latin America, the book examines: the changing nature of urban environmental risks, the rules governing the distribution of such risks and their differential impact, how the risks arise and who is responsible The authors clearly describe the most pressing urban environmental challenges, such as improving health conditions in deprived urban settlements, ensuring sustainable urban development in a globalizing world, and achieving environmental justice along with the greening of development.
They argue that current debates on sustainable development fail to come to terms with these challenges, and call for a more politically and ethically explicit approach. During , however, there were many political events related to sanitation—notably regional sanitation conferences across the developing world—that resulted in Regional Sanitation Declarations, which have moved sanitation up the political agenda . Recently, there has been a shift away from centrally planned provision of infrastructure towards demand-led approaches that create and serve people's motivation to improve their own sanitation.
Although sound technological judgment about appropriate solutions remains essential, appropriate programming approaches are now more important and contribute most to the success of sanitation work. Some of the most promising approaches that apply to both rural and urban sanitation are described below. Regarding the costs of these demand-led approaches, there are few published comparative studies, but sector professionals estimate that they cost less than traditional infrastructure provision. Sanitation marketing uses a range of interventions to raise householders' demand for improved sanitation .
The approach involves understanding householders' motivations and constraints to sanitation adoption and use.
Introduction and Definitions
These are then used to develop both demand- and supply-side interventions to ensure that appropriate sanitation products and services are available to match the demand. A successful example of sanitation marketing is described in Text S1. It encourages a cooperative, participatory approach towards ending open defecation and creating a clean, healthy, and hygienic environment from which everyone benefits . The success or failure of CLTS may relate to its cultural suitability and to the degree to which it addresses supply-side constraints to sanitation adoption .
Community Health Clubs aim to change sanitation and hygiene attitudes and behaviour through communal activities. The approach has proved effective and cost-effective in the Makoni and Tsholotsho Districts of Zimbabwe where villagers were invited to weekly sessions where one health topic was debated and then action plans formulated . Traditionally, sanitation has been regarded as a centrally provided service with little role for the creativity or energy of business. However, the increased demand created by sanitation marketing, CLTS, and Community Health Clubs can be met by the development of a vibrant local private sector for producing, marketing, and maintaining low-cost toilets .
The local private sector can also be encouraged to become involved in pit-emptying, sale of safely composted human excreta as fertilizer, generation of methane from biogas toilets, and the operation of public toilets. Many sanitation advocates now place the affordability of the toilets at the centre of the planning process. Most successful demand-led approaches have been developed in rural contexts.
Urban sanitation is much more complex, mainly because of higher population densities, less-coherent community structures, and the absence of opportunities for open defecation. Urban sanitation must extend beyond the household acquisition of a toilet to a systems-based approach that covers the removal, transport, and safe treatment or disposal of excreta see section 4 in Text S1. For on-site urban sanitation systems, pit-emptying services are common in middle-income countries where householders can afford the cost, but less common in poorer countries.
In densely populated low-income urban areas, community-managed sanitation blocks, used only by community members who pay a monthly fee for operation and maintenance, are an option . Public sanitation blocks that can be used by anyone, normally for a small fee per use, can be an acceptable alternative provided that they are well operated and maintained and have hour access. Finally, in less densely populated low-income urban areas, on-site sanitation options of the types described in section 3 in Text S1 for rural areas are often applicable.
Sanitation promotion is one of the most important roles the health sector can have in environmental health planning, because behaviours must be changed to increase householders' demand for and sustained use of sanitation, especially in rural areas where the pressure for change is lower. Thus, two of the most promising large-scale sanitation programmes in Africa are centred around demand creation and are both led and delivered by the Ministry of Health and its associated structures  ,  , . Alternatively, it can be incorporated into a wider integrated community health package such as Ethiopia's HEP Health Extension Programme , which was developed in to prevent the five most prevalent diseases in the country  ,  ; safe sanitation and hygiene became a major focus within HEP because of the recognition that these diseases are all linked with poor environmental health.
Promotion alone by the health sector may be insufficient, however, to ensure sanitation adoption and maintenance. In many countries, Environmental Health Officers are responsible for ensuring the sanitary condition and hygienic emptying of toilets, and have the power to sanction dissenting households with fines and court action .
This enforcement role of the health sector is particularly important in urban areas where high-density living increases the risks of faecal contamination of the environment and where one person's lack of sanitation can affect the health of many other people. The health sector also has an important role to play in advocacy and leadership. Politicians and the general public listen to doctors. That puts an onus on the medical profession to speak out on all important health issues, including sanitation. Historically, this has not happened.
Given the huge potential health-cost savings achieved through improved sanitation, the health sector should be advocating for stronger institutional leadership, stronger national planning, and the establishment of clear responsibilities and budget lines for sanitation. Unfortunately, although the international health community puts large human and financial resources into many low- to medium-cost health interventions such as immunization and bed net distribution, it has been slow to act on the evidence showing that sanitation promotion and hygiene promotion are among the most cost-effective public health interventions available to developing countries.
Finally, the well-honed epidemiology and surveillance skills of health professionals must also now be applied to sanitation to establish clear links between national health information systems and sanitation planning and financing, which has historically been separate from health in most countries. The lack of national policies is a major constraint to success in sanitation see section 5 in Text S1 for additional information on this and other constraints. Governments in general and health ministries in particular cannot play their key roles as facilitators and regulators of sanitation without policies that support the transformation of national institutions into lead institutions for sanitation, that increase focus on household behaviours and community action, that promote demand creation, and that enable health systems to incorporate sanitation and hygiene.
Other constraints to success in sanitation are population growth and increasingly high population densities in urban and periurban areas of developing countries. Finally, although macroeconomic analysis shows that sanitation generates economic benefit, the benefit does not necessarily accrue to the person who invests in the improved sanitation.
So the economics at the household level remain a constraint to success in sanitation—many people are simply unable or unwilling to invest, given all the other competing demands on their money. This under-researched topic is currently under investigation by the WASHCost Project, which is studying the life-cycle costs of water, sanitation, and hygiene services in rural and periurban areas in four countries .
Sanitation is a complex topic, with links to health and to social and economic development. It affects many but is championed by few. From our analysis of the situation, we believe that three major strategies could achieve success in sanitation. The most important of these strategies is political leadership, which is manifested by establishing clear institutional responsibility and specific budget lines for sanitation, and by ensuring that public sector agencies working in health, in water resources, and in utility services work together better.
The regional sanitation conference declarations  released during the International Year of Sanitation, in which many government ministers were personally involved, were an important step forward. In addition, the biennial global reports on sanitation and drinking water published by the World Health Organization and UNICEF  ,  contribute towards political leadership and aid effectiveness by publicising the sanitation work of both developing country governments and support agencies.
The second strategy is the shift from centralised supply-led infrastructure provision to decentralised, people-centred demand creation coupled with support to service providers to meet that demand. This strategy is transforming sanitation from a minor grant-based development sector into a major area of human economic activity and inherently addresses the problem of affordability, since people install whatever sanitation systems they can afford and subsequently upgrade them as economic circumstances permit. The final strategy is the full involvement of the health sector in sanitation.
The health sector has a powerful motivation for improving sanitation, and much strength to contribute to achieving this goal. Many years have passed since this Declaration, and the body of evidence about sanitation has increased substantially. The health sector now needs to reassert its commitment and leadership to help achieve a world in which everybody has access to adequate sanitation. Supporting Information.
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- The Citizens at Risk: From Urban Sanitation to Sustainable Cities (Earthscan Risk in Society).
The authors have declared that no competing interests exist. No funding sources were used to write this article. Provenance: Not commissioned; externally peer reviewed.
National Center for Biotechnology Information , U. PLoS Med. Published online Nov Author information Copyright and License information Disclaimer. The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies.
Copyright Mara et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited. This article has been cited by other articles in PMC. Summary Points 2. Introduction and Definitions Adequate sanitation, together with good hygiene and safe water, are fundamental to good health and to social and economic development.
Open in a separate window. Figure 1. Faeco-oral disease transmission pathways and interventions to break them. Diarrhoeal Diseases Diarrhoeal diseases are the most important of the faeco-oral diseases globally, causing around 1. Neglected Tropical Diseases Neglected tropical diseases, while resulting in little mortality, cause substantial disability-adjusted life year DALY losses in developing countries . Acute Respiratory Infections With 4. Wider Benefits of Sanitation In addition to its impact on health, improved sanitation generates both social and economic benefits.
Table 1 Economic benefits resulting from meeting the MDG sanitation target and from achieving universal sanitation access. Source: . Table 2 Cost-benefit ratios for achieving the MDG water supply and sanitation targets and for universal water supply and sanitation coverage. Analysis of the Current Situation Coverage Currently, some 2. Reasons for Slow Progress For many years, national governments, aid agencies, and charities have subsidised sewerage and toilet construction as a means to improve access. Successful Approaches to Sanitation Recently, there has been a shift away from centrally planned provision of infrastructure towards demand-led approaches that create and serve people's motivation to improve their own sanitation.
Sanitation and Health
Sanitation Marketing Sanitation marketing uses a range of interventions to raise householders' demand for improved sanitation . Community Health Clubs Community Health Clubs aim to change sanitation and hygiene attitudes and behaviour through communal activities. Sanitation as a Business Traditionally, sanitation has been regarded as a centrally provided service with little role for the creativity or energy of business. Approaches Emphasising Low Cost Many sanitation advocates now place the affordability of the toilets at the centre of the planning process.
Approaches Specific to Urban Sanitation Most successful demand-led approaches have been developed in rural contexts. The Role of the Health Sector in Improving Sanitation Sanitation promotion is one of the most important roles the health sector can have in environmental health planning, because behaviours must be changed to increase householders' demand for and sustained use of sanitation, especially in rural areas where the pressure for change is lower.
Constraints to Success in Sanitation The lack of national policies is a major constraint to success in sanitation see section 5 in Text S1 for additional information on this and other constraints. Strategies to Achieve Success in Sanitation Sanitation is a complex topic, with links to health and to social and economic development. Footnotes The authors have declared that no competing interests exist. References 1. Singh M. Accessed 15 July Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma.
Sanitation and Health
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