It is an affront to human dignity…

It denies nearly 3 billion people an adequate standard of living…

It kills nearly 2 million children each year from diarrhoea…

It helps keep millions of girls out of school…

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A Pakistani boy lies semi-conscious from diarrhoeal dehydration.

Lack of sanitation is a publichealth disaster. It consignsnearly 3 billion people — halfof humanity — to life in almostmedieval conditions, withoutaccess to latrines and unableto practise such basic hygieneas washing their hands insafe water.

SANITATION FOR ALLPromoting dignity and human rights

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Access to sanitation facilities is a fundamental human

right that safeguards health and human dignity.

Every human being deserves to be protected from

the many health problems — including dysentery, cholera and

other serious infections — posed by poor disposal of excreta.

Children, usually the first to fall sick and die from these

diseases, deserve better. Their rights to an adequate stan-

dard of living and to the highest attainable standard of health

are enshrined in the Convention on the Rights of the Child,

a treaty ratified by nearly every country in the world.

Unless immediate action is taken, the number of people

without adequate sanitation will climb to more than 4.5 bil-

lion in just 20 years. Hardest hit will be the marginalized

poor living in densely populated cities that even today man-

age to provide only two thirds of their population with sani-

tation services.

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Poor waste disposal is not only unsightlybut unsafe in this neighbourhood on theoutskirts of Lima.

…on children

Diarrhoeal dehydration claims the lives of nearly 2 million childrenevery year and has killed more children in the last 10 years than allthe people lost to armed conflict since World War II.

Bacteria, viruses and parasites are common environmental haz-ards linked to poor sanitation, and they cause diarrhoea, one of thetwo most deadly diseases in developing countries. A study in BurkinaFaso showed that children’s risk of being hospitalized with severe diar-rhoea increased 30 to 50 per cent whentheir stools were not discarded safely.

Infestation with parasitic worms(helminths) is another major health prob-lem stemming from unsanitary conditions.Children in developing countries com-monly carry up to 1,000 hookworms,roundworms and whipworms at a time,which can cause anaemia and other debil-itating conditions.

Infections caused by poor sanitationcommonly impede a child’s ability todigest and absorb food, causing a loss of

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COUNTING THE HAZARDS

One gram of faeces can contain:

� 10,000,000 viruses

� 1,000,000 bacteria

� 1,000 parasite cysts

� 100 parasite eggs.

An unconscionable toll

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precious nutrients. Many children die as a result; those who live oftenlack the vitamins and minerals essential for their growth, learning anddevelopment. Studies also suggest that unsanitary conditions cancause a constant, low-level challenge to children’s immune systemsthat impairs their growth.

…on girls and women

In many cultures, girls and women wait until after dark to defecate ifthey have no latrine in the household, experiencing discomfort andsometimes serious illness as a result. When girls and women have towalk to a place distant from their home for excreta disposal, particu-larly at night, they are vulnerable to harassment and assault.

Girls also commonly miss out on an education if school sanitationfacilities are inadequate. And if schools lack separate facilities for girlsand boys, many girls do not attend, especially during their menstrua-tion. In Bangladesh, a UNICEF-supported school sanitation project thatpromotes separate facilities has helped boost girls’ school attendance11 per cent per year, on average, since the project started in 1992.

In many countries, girls are more likelyto attend school when sanitation facilities protect their modesty or when separatefacilities are provided for girls and boys.Here, Chinese girls enjoy class at their local school.

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…on the sick and the elderly

Sick and elderly people face special difficulty and a loss of dignity whensanitation facilities are not available nearby. This loss of dignity is espe-cially acute for elders, for whom honour and respect are important.

…on society

When sanitation is poor, disease breeds and medical costs pile up. Astudy in Karachi, for example, found that people living in areas with-out adequate sanitation or hygiene education spend six times moreon medical treatments than do people who have such services.

Sanitation-related illness also depletes national economies whenpeople miss school or cannot work; when rivers and shorelinesbecome so polluted with waste that agriculture and tourism areaffected; and when highly infectious diseases such as cholera sweepthrough communities.

In Peru, for example, an outbreak of cholera in the early 1990s cost$1 billion in lost tourism and agricultural exports in just 10 weeks.

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This popular beach in Rio de Janeiro(Brazil) was closed in 1999 because of the city’s sewage problems, which alsoaffected commercial fishing.

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Providing global access to low-cost sani-tation facilities and safe water willrequire about $25 billion a year for 10years, about three times what is cur-rently spent on these services. Yet thisamount is far outweighed by the currentcosts of poor sanitation, including med-ical treatment and lost days of schooland work. Moreover, cost-sharing amongthose who benefit from sanitation pro-grammes can ease the financial burden,and an investment in sanitation pro-duces high returns for nations.

It is crucial to allocate sufficientresources to make a difference in pro-viding access to sanitation. Gains madeover the last decade have not kept pacewith population growth. As a result, thenumber of people without access tolatrines and toilets increased by some400 million.

RETURNS ON INVESTING IN ENVIRONMENTAL SANITATION:

� lower rates of death and sickness

� savings in health costs

� higher worker productivity

� better learning capacities of schoolchildren

� increased school attendance, especially by girls

� strengthened tourism

� heightened personal dignity and national pride.

The price of progress

The number of

people without

access to latrines

and toilets

increased by some

400 million [over

the last decade].

High rates of literacy do notalways correlate with bettersanitation. For example,Paraguay, where a largepercentage of people canread and write, ranks 3 onthe sanitation scale. By contrast, Nicaragua, with a much lower literacy rate,ranks at the top. Hygieneeducation and sanitationpromotion are key compo-nents of good sanitation.

Note: This map groups countries in broad categories to provide a simplified picture of the world’s sanitation situation.The countries are ranked from 1 to 4 in order of access to a sanitary means of excreta disposal, either in the dwellingor at a convenient distance. Since the definition of sanitation access varies by nation, the data are not strictly compa-rable on a global scale. It is also important to note that access to facilities is only one aspect of a nation’s sanitationlevel and might not reflect a country’s overall achievements in waste management and promotion of good hygiene.

This map does not reflect a position by UNICEF on the legal status of any country or territory or the delineation of any fron-tiers. Dotted lines for India and Pakistan represent approximately the Line of Control in Jammu and Kashmir agreed uponby India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties concerned.

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Nicaragua

Paraguay

Who are the nearly 3 billion people denied access to sanitation?Most live in rural areas of thedeveloping world. Less than a fifth of rural dwellers — as little as 12 per cent of those in Asia andthe Pacific, for example — haveadequate sanitation facilities. Yetthe problem is worse for urbansquatters in densely populatedcommunities, where disease canspread rapidly in the absence ofsafe water and sanitation.

Sanitation access in developing countriesand countries in transition ranked best (1) to worst (4)❚❚❚❚ 1 ❚❚❚❚ 2 ❚❚❚❚ 3 ❚❚❚❚ 4 ❚❚❚❚ No data

Where sanitation fails

Diseases spread farmore easily underunsanitary conditions,and children are thefirst victims. Not sur-prisingly, severalcountries that rank 4 on the sanitationscale — includingNiger and theDemocratic Republicof Congo — havehigh mortality ratesfor children under five.

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Very populous coun-tries such as Chinaand India, ranked 4and 3, respectively,face a great challengein providing sanitationservices to all theirpeople, especiallythose in remote areas.But with a strong government commit-ment and the rightapproaches, notice-able progress can bemade.

Poverty does not necessarily impedesanitation improvement, as Kenyaand the United Republic of Tanzaniademonstrate. These two countries have achieved widespread access tosanitation despite their low GNP.

In the past, abundant resourceswere invested to build centralizedsanitation and water systems inthe Central Asian republics. Butthese systems never reached allrural areas, and some are defunctas a result of recent political insta-bility and economic disruptions.

Dem. Rep.Congo

China

Niger

U. Rep.Tanzania

Kenya

India

WORKS Reaching schoolchild-ren. Schools are one of the best places toteach good hygiene, and childhood is thebest time to learn about it. Good habitsdeveloped in childhood can last a lifetimeand are likely to be passed on to the nextgeneration. In Mali, a hygiene awarenessprogramme in schools and on radiohelped halve the number of people suffer-ing from dracunculiasis (Guinea worm dis-ease), contracted from unsafe water.

DOESN’T Ignoring the familyas a whole. Keeping the home safe andsanitary is difficult unless all familymembers learn about good hygiene. InCentral America, the Healthy School andHealthy House programme provideshygiene education in schools and alsotrains community members to reach par-ents, grandparents and other caregiversat home.

WORKS Political will and astrong government role. Governmentshave a major role to play in rallying all sectors of society to the cause ofimproved sanitation. Sanitation pro-grammes should cut across governmentdivisions, and local authorities shouldbe encouraged to develop their ownplans.

DOESN’T Giving sanitationlow priority. Sanitation has often lostout to other social services, includingprovision of safe water. It is commonlybelieved that safe excreta managementrequires large quantities of water but, in fact, a number of disposal systemsrequire little or no water at all. Sani-tation issues are also sometimesignored because they are seen asembarrassing.

WORKS Promoting behaviourchange. Providing adequate facilities isnot enough. Families need to know abouthealth-promoting practices and be moti-vated to adopt them. Even when modernfacilities are not available, families canprotect themselves from disease by dis-posing of excreta safely. It is also impor-tant to reinforce traditional knowledgeand practices that are beneficial, such aswashing before entering a place of wor-ship, common in much of Asia.

DOESN’T A narrow focus ontechnology. Good facilities make little dif-ference in households where it is consid-ered safe to leave children’s faeces on theground; when children are afraid of latrinesor are forbidden to use them; or whenfamily members neglect to wash theirhands after using the latrine. Hygiene edu-cation goes hand in hand with technology.

What works and what doesn’t

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WORKS Giving families achoice. It is crucial that waste disposalsystems be tailored to the cultural andsocial setting of each family and commu-nity. Latrines should be non-polluting,affordable, user-friendly and simple toconstruct and maintain. Families them-selves are the best judges of what works.In Myanmar, where a UNICEF-assistedsanitation programme offered people achoice of latrines, enthusiasm for the pro-gramme was so high that 800,000 fami-lies built latrines in just one year.

DOESN’T A ‘one system fits all’ approach. Even the best technologywill not work in the long run unless it has been chosen by community memberswho are given the range of options.Latrines chosen for families rather thanby them commonly remain unused orimproperly used.

WORKS Community planningand management. Community membersinvolved in sanitation programmes — fromplanning to management to sanitation pro-motion — feel a sense of ownership andshow a greater willingness to help pro-grammes succeed. Communities should besupported with training as well as accessto parts, materials and financing. The par-ticipation of women is key. As guardians offamily health, they should play a lead roleas sanitation promoters and educators.

DOESN’T A top-down approach.Programmes planned and implementedexclusively by central authorities often lackthe flexibility and diversity required torespond well to local needs. Approacheslacking community participation are rarelysustainable; programmes ideally shouldinvolve all sectors of national and localgovernment as well as civil society.

WORKS Cost-sharing. Whenhouseholds share the cost of buildinglatrines, overall building costs drop,latrine use rises and facilities are bettermaintained. But care needs to be taken to make special provisions for familiestoo poor to participate equally.

DOESN’T Limited access to funds and credit. Experience hasshown that once people understand the importance of good sanitation andhygiene, they create a demand for facilities and healthful environments. They commonly pitch in to communityefforts with labour, materials and funds.Some even start small shops and othersanitation-related enterprises. All toooften, however, these grass-roots initia-tives for change are stymied by lack offunds or credit, which should be mademore available.

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1 MAKE SANITATION A PRIORITY. Formulate nationalpolicies that integrate the actions and resources of various sectorsof government. Encourage local authorities to develop sanitationplans and budgets.

2 BUILD ALLIANCES WITH CIVIL SOCIETY, especiallycommunity-based and non-governmental organizations; youth, reli-gious and women’s groups; and the private sector. Work with mediaand the private sector to promote sanitation and create grass-rootsdemand for services.

3 ENSURE COMMUNITY INVOLVEMENT to achieve sus-tained results. Strengthen community initiatives by supportingmicrocredit schemes and revolving funds, focusing particularly ondisadvantaged populations.

4 PROMOTE GOOD HYGIENE PRACTICES, especially safedisposal of faeces and hand washing, as the most cost-effective bar-rier to disease transmission, and use every occasion possible to seta good example in public. U

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Steps for policy makers

Hygiene begins with washing hands, as these Bolivian children are learning.

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Good latrines can be simple, like this one made from local materials in ruralBangladesh.

5 PAY ATTENTION TO THE NEEDS OF WOMEN. Addressequally the needs and preferences of women, men and children,ensuring attention to the special roles and needs of women. Avoidplacing the burden of improving sanitation primarily upon womenby promoting the sharing of responsibilities in the household.

6 MAKE SCHOOL PROGRAMMES A PRIORITY. Help schoolsencourage positive lifelong behaviour change. Support interactiveteaching about hygiene and environment issues and the construc-tion, use and maintenance of sanitation facilities.

7 PROVIDE ACCESS TO SANITATION DURING CRISES.Strengthen the procedures and capacity to provide sanitation facili-ties and promote hygiene during crises, taking special measures torespond to the needs of women and girls.

8 GATHER AND SHARE INFORMATION. Establish indicatorsthat will pinpoint problems and gauge successes. Data will have agreater impact if broken down into categories of gender, age group,rural/urban setting, income level and other key variables.

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In Central Asia, the ARALSEA area schools offer hygieneeducation to more than 17,000children. Schools have alsoupgraded their sanitary facili-ties and received equipmentand supplies — such as washingbasins, soap, repair tools anddesalination units for water — aspart of a UNICEF-assisted AralSea project for Environmentaland Regional Assistance.

In ZAMBIA, with centralgovernment support, villages in 10 of the country’s mostdeprived districts work withlocal governments to plan, main-tain and manage their own waterand sanitation facilities. Sincethe programme began in 1995several villages have providedsanitation to all residents.

Urban communities inGUATEMALA manage andfinance their own water andsanitation systems: In ElMezquital, a settlement outsideGuatemala City, communitymembers have worked withseveral organizations, includingUNICEF, to provide access towater and environmental sani-tation. Money collected forwater usage is spent to pipewater into houses, constructand repair latrines and lay side-walks. Around 2,000 familieshave participated in environ-mental sanitation educationactivities.

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Successful action…

Hygiene instruction is an importantactivity at this community health centrein Mali.

In INDIA, communities helpoperate ‘zero subsidy’ sanita-tion: In Medinipur district ofWest Bengal, 82 villages havelatrines in every household and100,000 latrines are construct-ed yearly, thanks to a projectthat has cut latrine costs andinvolved entire communities.The latrines are manufacturedlargely by local masons — manyof them women — and are paidfor by community members.Youth and women’s groups playa major role in planning andimplementation of the pro-gramme, which promotes latrineuse and good hygiene throughexhibitions, promotional materi-als, home visits and motivationalseminars.

BANGLADESH develops aninnovative advocacy campaign:The benefits of sanitation, safewater and hygiene are beingpromoted widely in primaryschools, in communities and ontelevision and radio. Flyers,posters and other promotionalmaterials are being sent to thelocal masons who producelatrine components. Their shopsare becoming ‘sani-marts’, mak-ing health and hygiene informa-tion available alongside latrinemodels. Similar education effortshave begun in India, Indonesiaand Nigeria.

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…takes many forms

Projects work best when communitymembers plan and manage them. Here,Bangladeshi women produce latrinecomponents in their community as partof a government sanitation programme.

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In 1990, leaders attending the World Summit forChildren agreed to achieve several key develop-ment goals by the year 2000, including sanitationfor all. UNICEF has made environmental sanita-tion a centrepiece of its ProgrammePriorities initiative, an effort toaccelerate fulfilment of WorldSummit goals and to strengthen thegroundwork for a rights-based agen-da for children. UNICEF also strong-ly supports the 20/20 Initiative, aglobal drive to increase the percent-age of governments’ budgets anddonor assistance allocated to basicsocial services, including sanitation.

Providing everyone with accessto environmental sanitation willrequire partnerships among community mem-bers, government officials at all levels, non-governmental organizations (NGOs), health andeducation workers, donors, business leadersand civil society. One key partnership is the

Global Environmental Sanitation Initiative(www.wsscc.org/gesi), which works to raiseawareness about the issue and to extend sanita-tion coverage to all. Launched in 1997, the

Initiative involves donors, UN agen-cies, NGOs and professionals fromdeveloping countries.

Backed by adequate resourcesand political commitment, nationscan reverse one of this century’spublic health disgraces and lay afirm foundation for development.Yet the best of intentions will fail ifold approaches are employed. Whatis required is a new mindset thatconsiders environmental sanitationthe business of society as a whole,

not just the task of engineers, and as a way oflife, not just a technological fix. In this newthinking, installing latrines is just one part of alarger effort to ensure an environment con-ducive to health and well-being for all.

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The best of

intentions

will fail if old

approaches

are employed.

A time to act

Suggested further reading

The Global Environmental Sanitation Initiative (GESI) (available at www.wsscc.org/gesi).

The IRC International Water and Sanitation Centre, ‘Woman, Water, Sanitation’, Annual Abstract Journal, The Hague.

Pickford, John, Low-Cost Sanitation: A survey of practical experience, Intermediate Technology Publications, London, 1995.

The World Health Organization and the Water Supply and Sanitation Collaborative Council (WSSCC), ‘Sanitation Promotion’, Working Group on Promotion of Sanitation, WHO/EO/97.12, Geneva, 1998.

The World Bank and the United Nations Development Programme (UNDP) Water Supply and Sanitation Programme, Participatory Hygiene and Sanitation Transformation: A New Approach to Working with Communities, 1997.

UNICEF Programme Division and the United States Agency for International Development (USAID), Towards Better Programming: A Sanitation Handbook, Water, Environment and Sanitation Technical Guidelines Series No. 3, Environmental Health Project, New York, 1998.

UNICEF Programme Division in collaboration with IRC, Towards Better Programming: A Manual on School Sanitation and Hygiene,Water, Environment and Sanitation Technical Guidelines Series No. 5, New York, 1998 (available at www.irc.nl).

UNICEF Programme Division in collaboration with the London School of Hygiene and Tropical Medicine, Towards Better Programming: A Manual on Hygiene Promotion, Water, Environment and Sanitation Technical Guidelines Series No. 6, New York, 1999.

UNICEF, UNICEF Strategies in Water and Environmental Sanitation, New York, 1995.

UNICEFDivision of Communication 3 United Nations Plaza, H-9F New York, NY 10017, USAE-mail: pubdoc@unicef.orgWeb site: www.unicef.org

January 2000Printed on recycled paper

Front cover photograph: A Filipino girl washes her hands ina stagnant stream strewn with garbage. (UNICEF/97-0998/Horner)

VIllagers in Togo carry bricks to build latrines.

SANITATIONFOR ALL

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