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Every rung counts–A retrospective analysis of global sanitation progress across the service-level ladder under the MDGs

['Julia Zimmerman', 'Department Of Civil', 'Construction', 'Environmental Engineering', 'University Of Alabama', 'Tuscaloosa', 'Alabama', 'United States Of America', 'Research Civil Engineer', 'U.S. Army Engineer Research']

Date: 2022-02 

The household sanitation target during the Millennium Development Goal (MDG) period used a binary “Improved”/”Unimproved” metric to evaluate progress. The “Unimproved” category was divided into three service levels: Shared Sanitation (facilities acceptable), Unimproved Facilities, and Open Defecation (no facility). Despite these data being publicly available, no analysis of country-level progress across these sanitation service levels during the MDGs has been published. We propose that retrospective analysis of progress across service levels can illuminate the diverse approaches used to address particular urban and rural sanitation deficits, and may provide insight to national and global actors in their ongoing efforts to address household sanitation. Additionally, we propose that a Sanitation Ladder Score, weighted to ascribe full, partial, and no credit to use of improved, shared and unimproved, and open defecation, respectively, is essential for concise communication of progress. Our analysis required gap-filling of data missing from the Joint Monitoring Programme (JMP) dataset; our final dataset consists of 190 countries representing 99.8% of global population. 149 countries achieved greater progress on the Sanitation Ladder Score than on the MDG metric. Using the four JMP progress categories, 144 countries fell into the same progress category and 41 achieved a higher category of Ladder Score progress. Countries with large gains in shared sanitation tended to have much greater progress on the Sanitation Ladder Score than on the MDG metric. A more detailed analysis is reported for six countries, with insight from the literature into their approaches. This Sanitation Ladder Score could be modified to incorporate the new “Safely Managed” service level tracked under the Sustainable Development Goals (SDGs) and likewise could be modified for other SDG targets for which multiple levels of service/achievement are reported. We encourage others to build upon our analysis; our complete dataset is freely available online ( https://melliott.people.ua.edu/data.html ).

Copyright: © 2022 Zimmerman 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 credited.

Introduction

Sanitation has been defined in many ways of varying scope, but one key aspect of all definitions of sanitation is that it includes the safe management of human excreta. Sanitation is an essential foundation for public health [1, 2] and “the sanitary revolution” was identified by readers of the British Medical Journal as the most important medical advance since the journal was founded in 1840 [3]. Approximately 74% of the global population have access to household sanitation classified as either “safely managed” or “basic”; that is a flush toilet, hygienic pit latrines or similar technology; and nearly 9% (696 million people) have no sanitation at all, that is they practice open defecation (OD). The remaining portion of the global population use some form of shared sanitation facility or an unimproved or unhygienic facility [4].

The Millennium Development Goal (MDG) target for sanitation to “halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation” was established in 2004 but with 1990 as the baseline and 2015 as the endline [5]. Under the sanitation MDG target, sanitation was classified simply as either “improved” or “unimproved”. While this simple pass-fail criterion had advantages in terms of simplicity and ease of communication, within a few years a number of shortcomings of this approach had been identified by the WaSH (water, sanitation and hygiene) community [6, 7].

One key concern with the MDG sanitation target was that a binary criterion may have reduced the priority given to other aspects of sanitation service-level that also bring important incremental gains in health and well-being [6, 8]. However, service-level improvements below the binary threshold (e.g., households moving from open defecation to a shared latrine) or above the threshold (e.g., providing a networked sewer connection to households formerly using pit latrines) were not counted as contributing to progress toward the MDGs. There was also some concern that the binary criterion would incentivize countries to focus on upgrading the service level of those with existing sanitation service so that it met the “improved” benchmark and neglect the most difficult cases in which it may be infeasible for each household to have its own improved sanitation facility (e.g., those practicing open defecation in informal settlements). Many studies have shown that preventing open defecation and providing other improvements in sanitation service yield health, cognitive and other benefits [9–12].

In summary, the lack of credit toward MDG targets for many improvements in sanitation service level was inconsistent with the broader goals of global development. During the MDG period, this concern led to calls for “ladder-based” approaches that would include credit for shared sanitation and eliminating open defecation [6] and in the lead-up to the 2016–2030 Sustainable Development Goals (SDGs), formulation of a ladder-based benchmarking process was a major concern [13–15]. Finally, service-level ladders were included in the SDGs, although a sanitation facility that would be defined as “Basic” sanitation if used by a single family was defined as “Limited” if shared between households. Despite the broad push for monitoring of different sanitation service levels under the SDGs, there are both substantial knowledge gaps in how countries progressed across the sanitation service-levels during the MDG period and a complexity to sanitation ladder monitoring under the SDGs that could benefit from further investigation.

While the potential benefits of a single, ladder-based sanitation score have been suggested [8], the extent to which countries made progress on the sanitation ladder during the MDG period has not been investigated. For example, it is unknown how much progress countries made on sanitation ladder from 1990–2015 and how ladder progress compared to progress using the binary MDG target. While ladder progress was not integrated into MDG targets, the Joint Monitoring Programme (JMP) took the initiative to monitor and report on sanitation coverage across four service levels in both urban and rural areas of most countries. JMP’s monitoring and reporting enables retrospective analysis of progress on the sanitation ladder.

In 2008, JMP began dividing the “Unimproved” category into three distinct service levels and subsequent reports included four sanitation service levels for countries with sufficient data: (1) Improved, (2) Shared Improved, (3) “Other Unimproved” and (4) Open Defecation [16]. Under the SDGs, these service levels are referred to as (1) Basic, (2) Limited, (3) Unimproved and (4) Open Defecation, respectively (the SDG gold standard category, “Safely Managed” sanitation, was not monitored by JMP during the MDG period). The “Shared improved”/”Limited” category includes facilities that would be considered improved were they not used by multiple households [16]; these were not counted toward MDG progress due to beliefs that they were more likely to be unhygienic and have limited accessibility [17, 18].

Monitoring and reporting of multiple sanitation service levels is essential, but changes across four-to-five service levels are not easy to summarize or communicate. Therefore, the global community needs a single metric to track country-level sanitation progress that both incorporates service levels across the sanitation ladder and can be quantified in a single, easily communicated score. Although others have proposed the use of a single score to assess sanitation across service levels [8, 19], a more detailed retrospective analysis of sanitation ladder progress over the MDG period is lacking in the literature. Additionally, a retrospective evaluation of country-level ladder progress relative to MDG progress is needed because the binary MDG metric fails to provide insight into the various approaches that enabled progress across the sanitation ladder.

Our Objectives in this paper are to: (1) describe the Sanitation Ladder Score metric, (2) gap-fill global data to enable application of the Sanitation Ladder Score to country-level progress across the sanitation service levels during the 1990–2015 MDG period and (3) compare global and country-level progress between the binary MDG sanitation target and the Sanitation Ladder Score from 1990–2015. Examination of progress across sanitation service levels in both urban and rural areas of particular countries will yield illustrative examples of the diverse profiles of progress across the sanitation ladder that may have been concealed by the binary MDG target. The complete gap-filled dataset is available in MS Excel format at https://melliott.people.ua.edu/data.html.

The possible adverse effects of global benchmarks for national performance, including perverse incentives and unintended consequences, have been described across a broad range of development-related targets [20–22]. This article presents a detailed, country-by-country, retrospective analysis of global progress toward a specific development goal (sanitation access) for which the high-profile global target (MDG 7 Target 10b) allocated credit for some but not all forms of progress.

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[1] Url: https://journals.plos.org/water/article?id=10.1371/journal.pwat.0000002

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