Addressing the urban sanitation crisis: Time for a radical shift


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The Bill & Melinda Gates Foundation – Jan Willem Rosenboom
The University of Leeds – Barbara Evans
Emory University – Christine Moe & Eduardo Perez
The World Bank – Sophie Trémolet, Valérie Sturm, Clémentine Stip
WaterAid – Andrés Hueso
Plan International – Darren Saywell

Children in Maputo, Mozambique 
Photo credit: 
Isabel Blackett/The World Bank

A successful city is economically and culturally vibrant, healthy, safe, clean and attractive to business and tourism, and provides quality of life to its citizens. This vision is appealing but remains hard to realize as developing cities have to cope with changing demographics and climate with limited financial and human resources. The sustainable development goals have given a new impetus for cities to be inclusive, safe, resilient and sustainable (SDG11), ensure citizens’ health and wellbeing (SDG3) and secure access to sustainable water and sanitation services (SDG6).

World Toilet Day on November 19th is the opportunity to remind ourselves of a few facts and propose a set of guiding principles for a renewed and revitalized urban sanitation agenda.

Many cities struggle to deal with the most basic municipal task of managing human excreta. Some are effectively “drowning” in human waste. Urban population growth continuously outpaces gains in improved sanitation access and, globally, nearly one billion people live in urban slums with poor or no sanitation.  Only 26% of urban excreta is deemed to be safely managed. The results? Environmental degradation, endemic disease leading to mortality and morbidity, especially among children, poor school attendance and performance, low productivity, constraints on the delivery of essential urban services such as housing, transport, safe water and drainage, and, ultimately, limits on economic growth and urban development. In short, a silent crisis that impedes the realization of the urban transformation framed in SDG11. 

Urban sanitation has a fundamental role to play in achieving the SDG goals  identified above. Business as usual will fail to deliver the kind of sanitation that underpins the envisioned urban transformation, by operating at too small a scale and focusing on infrastructure alone rather than on city-wide solutions. What is required is a radical shift in mindsets and practices towards an urban sanitation approach that impacts political priorities, funding, planning, design, management and governance.

Mobile desludging tank being wheeled out of an alley in the
city of Hanoi, Vietnam. Photo credit: Jan Willem Rosenboom

This radical shift will require the engagement of all stakeholders and a political transformation that touches all citizens, rich and poor, informal and formal, to facilitate the roll out of universal urban sanitation services. This is critical not only for reasons of equity, and to respond to the human right to sanitation, but also because the consequences of inadequate sanitation eventually affect everyone, as excreta-related pathogens spread easily across dense urban environments. 

To make progress, urban development professionals and stakeholders need to better understand how sanitation impacts the functions and form of the city and how it supports economic development and promotes equity. To achieve sustainable, equitable and safe management of excreta for the whole city, sanitation sector professionals must transform their thinking and practices to deploy both old and new solutions in smarter ways. 

We, from The Bill & Melinda Gates Foundation, The University of Leeds, Emory University, WaterAid, Plan International and The World Bank, have come together as a group of practitioners to galvanize this agenda by sharing conversations globally and mobilizing contributions from decision-makers and other practitioners across disciplines.

We propose that this renewed urban sanitation agenda should aim to:

  • Embed sanitation within the framework of urban governance and municipal services provision.
  • Establish clear roles and responsibilities, with accountability and transparency.
  • Provide ‘safe management’ of excreta throughout the sanitation chain – for both onsite sanitation and sewers – to ensure separation of fecal contamination from people across the whole city.
  • Focus on outcomes rather than technologies – allowing for diversity of solutions and approaches.
  • Base decisions on secure operational budgets being available (including for operation and maintenance).
  • Facilitate progressive realization, building on what is already in place.
  • Commit resources to training city leaders and technicians of the future to solve complex problems rather than deliver predetermined solutions.
 On this World Toilet Day, we invite you to join us in responding to this shared responsibility.

November 17, 2016


Ana Gren
November 17, 2016

Thank you for this great piece and initiative to get some feedback from. Just to add some thoughts to this discussion on the importance to continue to work diligently and with a greater focus on the poorest and most margilized urban populations. The estimates of nearly 1 billion people or about one third of the world’s urban population living in unplanned, informal settlements and slums with minimal access to almost any services, nor access to safe water and sanitation, are most acute. So perhaps we ought to focus global efforts on the most affected populations. In this regard I want to propose that we consider the need to distinguish between urban population aspects vs urban slum population aspects; between aspects such as slum health and urban health. This point has been researched and featured in a recent article published in the Lancet in Oct 2016, "The health of slums", which emphasises the impact of lack of access to WASH services and infrastructure in slums environments. Among the findings the health of children and women are of tremendous concern, as children living in these types of environmental are at a much higher risk of infectious and diahorral diseases, and estimates presented indicate that child mortality rates are at a similar level as in poorer rural areas; sometimes even higher. The rapid increase in population in urban areas means that improvements in infrastructure and access to water and sanitation will be essential for public health and overall development, and in this regard we would all agree that without a healthy population we will not be able to reach the objectives of Agenda 2030.
Thus perhaps there is a need to increase efforts on supporting SDG6 with this focus, as well as a special focus in the need for greater in depth research on these aspects in urban slums.
Looking forward to having the chance to continue these discussions in the near future! Kindest regards, Ana

November 18, 2016

The sewerage other these countries are making the polluted the nation at the high level of illness.These are the areas which are making too much illness. Garage Shelving

November 18, 2016

This is a terrific and much needed initiative! Congratulations to the Gates Foundation, University of Leeds, Emory University, Water Aid, Plan International and the Bank team

Paul vanKoppen
November 18, 2016

Great initiative, spot on!

Mr. Alvar Bramble
November 21, 2016

Back-of-the-envelope calculations I have made indicate humans build 50 thousand shanties every day

Adam Zubairu Muhammad
November 22, 2016

Good day. I'm very happy for hearing this development, because my local government area Biu under Borno state the water people are drinking is almost link with toilet. all they are open and dump!!! because of that everyday most of the children and young ladies are having vaginal infection that ladies are bleeding true vagina. and I swear to God we seriously have problem with sanitation everywhere because of that people are getting malaria and people are die with malaria pass HIV!!!! everyday people lake 10 to 15 die because of malaria. what cause it?? like of sanitation. and even the state capital are sanitation problems! please if you won't mine you can send some of your agent to met me and take him to all places you can believed me. thank so much for the Care

Sara Ahrari
December 20, 2016

Great document. In particular I hope more attention would be paid to the top two recommendations.

Gustavo Heredia
September 16, 2021

Great article! Two issues that are not mentioned are: i) Cities that don't manage wastewater appropriately are impacting watersheds in a negative way and ii) a circular economy approach or emphasis in water and sludge re-use can lower the costs and make sanitation systems more sustainable

Peter Matuku MAWIOO
September 16, 2021

Thanks a lot for this great initiative to address sanitation challenges in the urban areas. This approach stands to offer immense benefits to the peri urban and informal settlements around the world's major cities.