Looking beyond Technology: An Integrated Approach to Water, Sanitation and Hygiene in Low Income Countries

Despite global efforts under the Millennium Development Goals (MDGs), sanitation-related diseases remain a leading cause of child mortality in low-income regions. While access to toilets and water infrastructure has improved, sustainable health outcomes require a holistic approach addressing interconnected challenges: safe water access, hygiene practices, and complete sanitation systems (from toilets to safe disposal/resource recovery). The post-2015 Sustainable Development Goals (SDGs) emphasize integrated water, sanitation, and hygiene (WaSH) strategies that prioritize sustainability, equity, and behavior change. Key pillars include enabling policies, economic incentives for sanitation services, technology innovation beyond toilets (e.g., fecal sludge management), and understanding drivers of behavior change. Success hinges on addressing gaps in planning, financing, and community engagement to ensure long-term adoption and maintenance of WaSH interventions.

Author(s): Tilley, Elizabeth; Strande, Linda; Lüthi, Christoph; Mosler, Hans-Joachim; Udert, Kai M.; Gebauer, Heiko; Hering, Janet G

Published: 2014

Language: English

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Synopsis Despite investment stimulated by the Millennium Development Goals (MDGs), sanitation-related diseases, such as diarrhea, cholera and typhus, remain a leading cause of death of children under five in low-income countries. Prevention of diarrhea requires a combination of access to safe drinking water, good hygiene and adequate sanitation. The sanitation problem has proven to be particularly intractable, demonstrating the shortcomings of past efforts that have focused on increasing access to toilets. An alternative view positions the toilet within a service chain that extends to the final point of disposal or end-use of excreta-derived products. An integrated perspective that addresses improved planning, takes advantage of economic opportunities, incorporates specialized technology, and follows-up with behavior change could help to ensure not only access but also sustainable use, operation and maintenance of water, sanitation and hygiene interventions.

Past failures highlight the limitations of isolated interventions (e.g., building toilets without addressing sludge disposal). Effective WaSH requires a service chain approach: integrating toilet access, safe fecal sludge management, resource recovery (e.g., fertilizers, biogas), and behavior change. Neglecting any link in the chain risks environmental contamination and wasted investment.

Financial models like franchising, conditional cash transfers, and markets for excreta-derived products (e.g., fertilizers) can offset costs and incentivize sanitation upkeep. However, revenue from resource recovery often falls short of covering operational costs, necessitating subsidies or hybrid financing. Engaging local entrepreneurs in sludge collection and treatment fosters economic opportunities while closing sanitation gaps.

Health messaging alone rarely drives sustained hygiene practices. Successful interventions leverage social norms (e.g., community-led total sanitation), psychological drivers (e.g., disgust, prestige), and participatory planning. Tools like the RANAS model (assessing risk, attitudes, and self-regulation) help tailor campaigns. Ethical concerns arise when stigmatizing tactics are used, underscoring the need for culturally sensitive, equity-focused approaches.

Looking beyond Technology: An Integrated Approach to Water, Sanitation and Hygiene in Low Income Countries

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