The sanitation ladder: main challenges in monitoring access to sanitation

Sanitation (the separation of human beings from our excreta) is an often-neglected aspect of public\nhealth which brings substantial health and socioeconomic benefits. In last decade, sanitation has\nbegun to receive more attention, especially due to its inclusion as a target in the UN Millennium\nDevelopment Goals in 2002 and as a human right in itself in the UN Declaration of Human Rights\nin 2010. Currently, progress towards the Millennium Development Goal target is measured by a\nsanitation “ladder”, which classifies sanitation provision by hardware type and separates\n“improved” technologies (considered adequate) from “unimproved” technologies (considered\ninadequate), providing an estimate of the percentage of the population with access to adequate\nsanitation. All latrines shared among different households are considered inadequate.\nHowever, there is compelling evidence that other aspects of sanitation (especially hand-washing,\nand the amount of excreta in the environment) are equally if not more important in bringing health\nbenefits and no reliable method of measuring these has yet been found. In addition, it is questioned\nwhether the current method provides sufficient detail to make policy decisions at local level.\nThis study reviews the literature to present the main challenges currently experienced in monitoring\nsanitation in rural development contexts and explore possible ways forward. These methods are\nthen tested using data from a set of detailed household interviews carried out in rural Kenya to\nidentify the most important sanitation indicators.\nThis analysis suggests that the current hardware-based indicator predicted latrine conditions well,\nbut that to capture more detail a question could be added regarding whether the latrine hole has a\ncover in place, and whether faeces is observed in the latrine. It is also suggested that shared latrines\nbe distinguished from public latrines, by recording the location of the latrine. The presence of soap\nor ash for hand-washing was found to be a good proxy indicator of good hygiene, though it is\nsuggested this be amplified by questions on hand-washing frequency and children’s faeces disposal.\nTo measure the amount of excreta in the environment, three community-level indices were\nproposed: percentage using an improved latrine, percentage in excreta-free conditions and\npercentage not defecating openly.