We continue to face a global sanitation crisis in the 21st century, with millions worldwide defecating in the open. At the current rate of progress and with current investment levels, we are bound to miss international and national targets for achieving universal access to basic sanitation by 2030, the United Nations’ 6th Sustainable Development Goal.

It has become clear now that there is no single bullet to address the sanitation challenge. Various strategies have been trialled and tested in the last few decades. Policies up to the 1990s focussed on getting toilets built. Governments then switched to subsidy programmes. After disappointing results, opinion swung in favour of raising public awareness of the health risks from inadequate sanitation behaviour. Recently, the private sector joined the sanitation challenge, most prominently by offering microcredit for sanitation investments. 

Now is the time to take stock of what actually works, as donors, governments and investors are deciding how to spend their money. At the Institute for Fiscal Studies, we’ve tested the effectiveness of sanitation programmes across the Global South, and here is what we've learned.

Building toilets and changing habits

Over 50 countries worldwide currently rely on behavioural change and community self-enforcement to end open defecation, an approach called Community-Led Total Sanitation (CLTS). We recently evaluated CLTS in Nigeria and Pakistan, two countries where open defecation is a major problem. We found that the intervention can indeed be effective in triggering investment in sanitation and sustained behaviour change. However, consistent with similar studies in Mali, India, Tanzania, Bangladesh and Indonesia, our research in Nigeria found that it reduces open defection only in poor areas and even in such areas, it doesn’t eradicate it completely.

Tweaking CLTS can boost its effectiveness. In particular, our research in Pakistan found that in vulnerable areas, which are prone to flooding, with poor public infrastructure and little access to construction materials, follow-up visits by CLTS implementers do help encourage people to keep toilets functional and in use. But these follow-up visits would be unnecessary if these communities had been able to construct resilient toilets to begin with. And what about the people who didn’t choose to make a sanitation investment despite the intervention?

Tackling financial constraints

If you ask people in India and Nigeria why they don’t invest in sanitation, most will explain that building and maintaining (quality) toilets is simply too expensive.

This is in line with our research in India, which shows that making finance available can be an important part of tackling open defecation. Microfinance loans for sanitation encourage households to build and use new quality toilets, which would not otherwise have been constructed.

Some households are too poor to build toilets, and the Government of India for example provides subsidies for toilet construction to the poorest and most vulnerable. To ensure proper use of funds, people receive the subsidy after the toilet is built. But this can lead to a chicken and egg problem: poor households need money to construct the toilet but can only access the subsidy once it is constructed.

Our research showed that the design of such subsidy schemes could be improved by combining the subsidy with microcredit. We showed that, when subsidies are received in a timely manner, microcredit helps households who are eligible construct toilets by providing the necessary up-front funding. Microcredit also helps people who are not eligible for the subsidy to invest in sanitation. This finding is important given estimates that the necessary capital investment for sanitation amounts to over $1.7 trillion worldwide, or an estimated USD 708 for each household currently lacking safe sanitation. Our research revealed that governments can focus their limited resources on the most vulnerable, while reaching others in need through the private sector.

The verdict

There is no one-size-fits-all solution to fix the sanitation crisis. Specific approaches were successful in getting people to use toilets, but interventions rarely succeed in eliminating open defecation and we frequently see people reverting to old habits. We want to see a comprehensive evidence-based approach. Our research suggests that a smart balance of microcredit, subsidies and behaviour change activities is likely to get us a good step closer to tackling the sanitation crisis.

This article was first published in Thomson Reuters Foundation News and is reproduced here with permission.