Introduction

1.1 Objectives of the paper

It is the objective of this paper to reflect on the progress being made in the sanitation sector and to examine what possible pathways exist to introduce sustainability in the United Nations Millennium Development Goal (MDG) process also showing that the target for sanitation ahs an impact on all the MDGs. The paper reviews the regional differences in some of the common health indicators such as diarrhoea mortality and DALYs in relation to inadequate hygiene and sanitation. It reviews the criteria surrounding the introduction of sustainable sanitation based in part on the work of the Sustainable Sanitation Alliance, what technical options exist in order to introduce more sustainable measures, what the costs can be compared to conventional approaches and what the potential impact of safe reuse of human excreta can have in agriculture, nutrition and food security. It reviews the WHO guidelines on safe reuse of human excreta and greywater in agriculture and also reviews a selection of sanitation planning tools. Finally it summarises what additional steps and pathways including financing and institutional arrangements that are needed in order to build in greater resilience and sustenance into the sanitation sector.

1.2. The MDG on water and sanitation

In 2000, the UN resolved to tackle the Millennium Development Goals or MDGs as they are commonly known. The MDGs are all-encompassing providing clear targets by 2015 to significantly reduce poverty, hunger, illiteracy, gender inequality, child mortality, disease and to ensure environmental sustainability and promote global partnership including open trade and financing. What the world didn't notice back in 2000 was that water supply and sanitation services had not been included as one of the environmental targets. And it was not until 2002 at the UN World Summit on Sustainable Development (WSSD) with the guidance of the WSSCC (Water Supply and Sanitation Collaborative Council) in Johannesburg that a target for these was adopted (MDG 7, Target 10). It turns out that sanitation is by far the largest of all the MDG targets affecting about 40% of the global population and possibly the biggest challenge since the sector has been so neglected and is riddled with development obstacles. It remains probably the largest killer of children and is still not a high priority among governments (WaterAid, 2008a).

World leaders came together in 2005 under the auspices of the 2005 World Summit at United Nations Headquarters to reiterate the MDGs as expressed in the Millennium Declaration and reaffirm their commitment to work towards achieving them, and also to assess the extent to which progress has been made since 2000. Likewise, on September 25, 2008 the UN High-Level Event on the MDGs took place to identify gaps and determine how to accelerate progress toward the MDGs. The Human Development Report (HDR) of 2006 (UNDP, 2006) provided a status report on the water and sanitation Target 10 of MDG 7, providing further necessary focus. These reviews have all concluded that the target for water supply is achievable but that for sanitation will not be met by 2015.

When it comes to the implementation of all the MDGs, the world seems to have forgotten the element of sustainability and what was resolved at the UNCED in Rio de Janeiro, Brazil, in 1992 and the WSSD in Johannesburg, South Africa, in 2002 (WSSD, 2002). Sustainability is absent from the MDG resolution of 2000 and the HDR of 2006. Neither does the JMP (Joint Monitoring Plan of WHO/UNICEF) include sustainability criteria in its definition of improved water supply and sanitation. The core of MDG 7 Target 10 is being tackled mainly using, for the most part, conventional approaches that lack technical innovation and social, economic and environmental sustainability (SEI, 2005). It is the objective of this paper to introduce such criteria and place it within a context of policy, planning and capacity development.

It is also high time for more comprehensive measurement tools in order to assess successes and failures within the sanitation sector. The global monitoring data on coverage have created a simplified division into "haves" and "have-nots" (Bartram, 2008). It is therefore a step in the right direction as is now the case in the latest JMP report of 2008 (WHO/UNICEF, 2008a) to monitor all forms of sanitation coverage, may it be sharing of communal latrines, unimproved, improved latrines or open defecation. The next step would be to provide some measures of installation longevity, functionality and sustainability.

Sanitation is a neglected and disjoint sector that in general is not properly understood nor prioritized by governments around the world. In addition it is not something that is well integrated into development programmes and tends not to be considered as a central concern for human well-being. Somehow it is "taken care of" in all sorts of ways from open defecation, to shared communal latrines, to waterborne household sewerage and centralized treatment systems. But in a way all of these are similar in that little or nor communication occurs between the stakeholders and the authorities. In many ways this is the "last chapter in human development" and there is much to be done (Rosemarin, 2007).

1.3. The International Year of Sanitation 2008

Perhaps because of the acknowledgement of the importance of sanitation and the staggering figure of those lacking basic sanitation, the UN declared 2008 the International Year of Sanitation to draw attention to the sanitation crisis and accelerate progress towards the sanitation target. Present global water and sanitation coverage figures clearly show that despite international commitment, enormous investment and concerted efforts to halve, by 2015, the proportion of people without sustainable access to safe drinking water and improved sanitation, there is still so much to be done to achieve timely success. The MDG sanitation target is an overarching one because of the importance of water and sanitation development as an instrument for sustainable development, economic growth, and poverty reduction. This makes MDG 7 crucial for the achievement of all the other MDGs (Table 1).

WHO/UNICEF (2008a) reported that in 2006, 884 million people in the world lacked access to improved water supply and 2.5 billion people lacked access to proper sanitation, with the great majority residing in the developing world. Only about one person in three in sub-Saharan Africa and South Asia has access to improved sanitation (UNDP, 2006). Furthermore, Black and Fawcett (2008) report that over 40% of people in the developing world still depend on a bucket, a bush, the banks of a stream, a back street or some other sheltered place for their several daily excretions. One in four people in Africa i.e. about 234 million people practice open defecation (WHO/UNICEF, 2008b). In India alone this number is over 600 million. Moreover, Clarke and King (2004) state that in much of the developing world, only a fraction of sewage and drainage water is treated before being discharged into water-ways.

The magnitude of this ongoing sanitation crisis is so high in certain countries such as in India where Nadkarni (2002) report that 80% of the pollution load destroying the country's rivers is untreated human waste.

One of the most severe consequences of these inadequacies reported by WHO (2007) is that about 1.8 million children under five years of age die every year, or about 4900 young lives are lost daily from easily preventable diseases, such as diarrhoea. This makes it even more difficult to work towards the MDG 4 Target 5 – i.e. the reduction by two-thirds, between 1990 and 2015 of the under five years of age mortality rate. In addition, lack of access to safe water and proper sanitation in developing countries makes other population segments especially girls and women, suffer from poor health, diminished productivity and missed opportunities for education (WHO, 2007). This has a combined negative effect of slowing progress towards meeting all the MDGs and exacerbating the poverty situation (Satterthwaite, 2003).

1.4. Monitoring MDG 7 Target 10

The Joint Monitoring Programme (JMP) of the WHO and UNICEF was initiated in 1990 in order to monitor water supply and sanitation coverage around the world. This resulted in development country reports in 1991, 1993 and 1996. In 2000 the Global Water Supply and Sanitation Assessment Report was produced and JMP has since then produced reports in 2004, 2005, 2006 and 2008.

The baseline year for the MDGs is 1990 and the sanitation target is set to reduce the proportion of people without improved sanitation by 50% by the year 2015. The latest JMP report of 2008 (WHO/UNICEF, 2008a) shows that proportionate coverage is only slowly increasing with an increase between 1990 and 2006 of 8% (Figure 1) and at current trends the number of people without improved sanitation will probably be about 2.4 billion in 2015. It is of interest to plot the global sanitation coverage data made available by the JMP and also provide both a polynomial and linear interpolation plus projections beyond the latest data series of 2006. The polynomial provides a more optimistic scenario where the global MDG target is reached by 2019, while the linear projection predicts 2037 as the target year. The implications of using a more optimistic model now with seven years remaining to the end of 2015 could be significant since as with most human systems, growth in sanitation coverage may well be an exponential phenomenon once a certain critical mass has been achieved.

It is also of interest to plot the baseline 1990 global sanitation coverage data that have been published thus far by the JMP reports (Figure 2). There is some concern that the baseline for total coverage has been lowered from the original report in 2000 from 55% to 49% and then has risen again in the latest report for 2008 to 54%. The world total for rural communities drops from 35 to 25 and the rises again to 36 in the latest report. It should be understood that partner countries' databases are being updated from year to year and it is assumed for the purposes of the MDG projections that the latest version of the baseline is the one that is most accurate. The JMP database should not be overly criticised, however, taking into account the enormous task that it is undertaking. On the contrary it deserves praise and increased support in order to accomplish the task of monitoring progress being made as we get closer to 2015.

It is worth noting that some progress towards the achievement of the MDG 7 Target 10 is being made even in those regions where the challenges are greatest (Figure 3). Eastern, Southern and Western Asia, Northern Africa and Latin America and the Caribbean have been on track to meet the MDG 7 Target 10 (UN, 2006). The largest gains have been made in South Asia, where access to improved sanitation facilities more than doubled from 17% in 1990 to 37% in 2004, and in East Asia/Pacific, where, it rose from 30% to 51%. The improvements made in these regions were mainly driven by gains in India and China. For instance in India, sanitation coverage more than doubled – from 14% in 1990 to 33% in 2004, while in China sanitation coverage rose from 23% to 44% over the same period. Despite these increases in sanitation coverage in India and China, the majority of the people in these countries are still without access (UNICEF, 2006). All other developing regions have made insufficient progress towards this target. West/Central Africa, Eastern/Southern Africa and CEE/CIS (Central and Eastern Europe/ Commonwealth Independent States) are not on track to meet the MDG sanitation target. The least progress was made in CEE/CIS where coverage froze at 84%, and in Eastern/Southern Africa – where access improved only slightly, from 35% in 1990 to 38% in 2004, and where with population growth, the absolute number of people without sanitation increased by a third over the same period (UNICEF, 2006).

UNDP (2006) stresses that improved sanitation brings advantages for public health, livelihood and dignity – advantages that extend beyond households to entire communities. The need to provide sanitation to ensure safe drinking water and hygiene remains a huge challenge today in developing countries where often half the population lacks basic sanitation. Now, at the midway point between the year 2000 and 2015, halving the proportion of people without sustainable access to sanitation remains one of the MDG targets that is most off-track, with the crisis focused on sub-Saharan Africa, South Asia, and Oceania with 31%, 33%, and 52% sanitation coverage respectively in 2006. Sanitation coverage needed in these three regions to put them on track in 2006 was as follows: 50% for sub-Saharan Africa, 46% for South Asia, and 69% for Oceania. The ultimate MDG target coverage in 2015 is expected to be 63% in sub-Saharan Africa, 61% in South Asia, and 76% in Oceania. (WHO and UNICEF, 2008a).

The obstacles to accelerating the rate of progress in sub-Saharan Africa include conflict and political instability, high rates of population growth, and low priority given to water and sanitation (WHO and UNICEF, 2004). It should be added that the JMP coverage data is based on their current definition of improved sanitation which does not take into account safe discharge. If a more rigorous definition were to be used excluding installations that discharge untreated into drinking water sources, the coverage status would be much more off track for (Sources: GWSSA 2000 and WHO/UNICEF 2004, 2005, 2006 and 2008a)

1.5. The gap between water supply and sanitation

Sanitation provision lags far behind access to water supply. Undoubtedly, this is a plausible reason why access to improved sanitation is not listed by the UN as one of the measures of progress towards the MDGs but is instead considered as one of the key challenges that has to be addressed in order to meet Target 10 of MDG 7 because of the astounding figure of those without access to basic sanitation. That sanitation was not included in the original MDG plan in 2000 does not make matters easier. Black and Fawcett (2008) reiterate that sanitation is invariably a poor relation to water in the public health engineering portfolio and receives far less resources.

Water supplies, for which there is strong demand and considerable political enthusiasm, consistently improve. Meanwhile, personal hygiene and waste disposal facilities, for which there is less overt and forceful demand, and substantially less political and donor interest, consistently languish. The gap between water and sanitation coverage ranges from 29% in East Asia to 18% in sub-Saharan Africa. In South Asia, access to improved sanitation is less than half that of water. These gaps matter not just because access to water and to sanitation is intrinsically important, but also because the benefits of improved access to water and to sanitation are mutually reinforcing. Thus countries that allow sanitation coverage to lag are destined to see the benefits of progress in water diminished as a result (UNDP, 2006).

Globally, 420 million people need improved water access and 1.052 billion people need improved sanitation systems between the years 2005 and 2015 to meet the MDG (Hutton and Bartram, 2008). The MDG 7 Target 10 will be missed by 600 million people if trends since 1990 continue (UN, 2007). Therefore, to meet this target, it was required that around 440,000 new people be served with improved sanitation facilities per day from January 2001 to December 2015.

In order to meet the WHO and UNICEF target of "Sanitation for All" by 2025 an additional 480,000 people would have to receive improved sanitation facilities everyday from 2001 to 2025 (Mara et al., 2007). According to WHO and UNICEF (2006), 1.6 billion more people need to gain access to improved sanitation over the period 2005 to 2015 to meet this target. This will reduce the population without adequate sanitation by 800 million i.e. from 2.6 billion in 2004 to 1.8 billion by 2015. But the world cannot cope with this gigantic challenge and the crisis continues. A measure of the MDG sanitation target can be expressed in terms of numbers of toilets needed per 1000 households (Figure 4). The greatest needs are in sub-Saharan Africa, South Asia, and particular countries in Latin America, West, East and Southeast Asia. Even if the polynomial projection for global increase in coverage turns out to be accurate, there will remain several countries still lagging. Again it should be reemphasised that these estimates are based on the JMP definition of improved sanitation and the backlog would be much higher if a more rigorous definition were to be imposed including sustainable sanitation criteria.

Between 1990 and 2006, the proportion of people without improved sanitation decreased by only 8%. Based on current trends, the total population without improved sanitation in 2015 will have decreased only slightly since 1990, to 2.4 billion. At this rate, the world will miss the MDG sanitation target by over 700 million people. Without an immediate acceleration in progress, the world will not achieve even half the MDG sanitation target by 2015. Thus to meet this target, at least 173 million people on average per year will need to begin using improved sanitation facilities (WHO/UNICEF, 2008a).