?> Le Centre pour la Santé et Éducation des Femmes - Eau, Assainissement, Hygiène et Santé

Eau, Assainissement, Hygiène et Santé

Bulletin WHEC pratique et de directives cliniques de gestion pour les fournisseurs de soins de santé. Subvention à l'éducation fournie par la santé des femmes et de l'Education Center (WHEC).

Safe drinking-water, sanitation and hygiene (WASH) for all, are crucial to human health and wellbeing. WASH initiatives are not only a prerequisite to health, but also contributes to livelihood, school attendance, safety at school, healthcare facilities, and dignity. It helps to create resilient communities living in healthy environments. The Women’s Health and Education Center’s (WHEC’s) advocacy and communication global projects and programs, aim to elaborate strategies that strengthens national policies to implement the Sustainable Development Framework. These opportunities are especially designed to help girls, women and minorities so that they also can achieve their full potential. WHEC’s publications are aimed at a broad range of audience, and it is hoped that everyone who reads this comes away with a realization of the complexity of the issues at stake, and an appreciation of the work that lay in front of us. Evidence shows that this can create the transformation necessary to secure more peaceful, fairer and more inclusive societies for everyone, effective multilateralism, and a better globalization.


The purpose of this document is for healthcare providers and the community to realize the need and necessity to implement WASH projects and programs, to achieve health promoting schools and safe healthcare facilities for all. The objectives are:

  1. Water & Sanitation – essential to reduce maternal, newborn and child morbidity and mortality.
  2. Water, Sanitation and Hygiene (WASH) for all, projects and programs for schools and healthcare facilities.
  3. WASH national legislation processes for the schools and healthcare facilities – our efforts, in India.
  4. To elaborate strategies that will strengthen national policies, to achieve SDGs 3, 4, 5, 6, and 17, by 2030.
  5. To share the experiences of experts, in improving the accessibility of health services and education;
  6. How to implement best practices in water, sanitation, health and education sectors.
  7. Inclusion of girls, women and minorities in literacy programs, and support economic growth and opportunities; and
  8. Lessons learned from the COVID-19 Pandemic & the SDGs 3, 4, 5, 6 and 17.

Women’s Health and Education Center (WHEC) supports and strengthens the generation & collection of data, its analysis, use and dissemination and evidence to promote better evidence-based, decision-making. Its goal is to build capacity in the UN Member States, to the Sustainable Development Goals (SDGs) implementations and achievements, of their populations and the impact of interventions and promote evidence-based policy decisions.


Key Facts

  • For at least 3 billion people, the quality of the water they depend on, is unknown due to a lack of monitoring.
  • 733+ million people live in countries with high and critical levels of water stress.
  • The world’s water-related ecosystems are being degraded at an alarming rate.
  • Over the past 300 years, over 85% of the planet's wetlands have been lost.
  • Meeting drinking water, sanitation and hygiene targets by 2030 requires a four times increase in the pace of progress.
  • At the current rate, in 2030; 1.6 billion people will lack safely managed drinking water; 2.8 billion people will lack safely managed sanitation; 1.9 billion people will lack basic hand hygiene facilities.
  • Only one quarter of reporting countries have 90% of their transboundary waters covered by operational arrangements.

Lessons Learned and The Way Forward

According to multiple consultations and multiple stakeholders’ suggestions – universal coverage of water, sanitation and hygiene (WASH) for all, should be prominent in UN Conferences. There should be a focus on finding solutions and on how to best reach the most marginalized communities. The Women’s Health and Education Center (WHEC) suggests that emphasizing access to technical training, assistance and the exchange of best practices with this field during the conferences and the side events, including strengthening public-private partnerships.

WHEC’s best practices and advocacy includes development strategies in the following areas.

Inclusion, equity and education: The importance of the interactive dialogues to address inclusion and equity with regard to water resources is also important to Indigenous peoples, women and girls and this should be featured in the UN Conference’s debates. Indigenous peoples are disproportionately impacted by water scarcity due to climate change and the deterioration of the environment, and that these aspects should be included in the decision-making process. Indigenous knowledge must be integrated into decision and policy-making on water.

Sustainable solutions require a more inclusive role for nature when creating long-term strategies as well as short term actions. Enhancing natural ecosystem requires participation of a wider range of stakeholders, including Indigenous groups who are at the forefront of environmental protection and sustainability.

Water and gender: “It is estimated that each year, a Sudanese girl will miss 95 days of school due to their cycle.” As women are often responsible for managing the household water supply, women’s voices and leadership could enhance effective solutions and sustainable adaption methods. Hence, it would be important for national strategies to create spaces to learn from women’s knowledge, experiences, challenges and concrete solutions. Closing the gender gap in water, sanitation and hygiene is critical. Not having access to clean water impacts all aspects of life of girls and women, including professional, political and social impacts.

Clean water as a basic development: Water and Sanitation should be declared as human rights, and this must be available to all. Corruption and mismanagement connected to water supplies and sanitation services should be featured during policy-making decisions. Corruption in the water and sanitation sector affects the fulfillment of human rights and generates serious environmental impacts such as contamination and overexploitation of water sources.

Water and conflict: How to resolve the prevent conflicts arising from water scarcity? The increase in conflicts surrounding water, as well as the lack of access to water for refuges and those living in conflict-areas and fragile states, are important topics to be addressed. In this sense, priority must be given to the humanitarian issues arising from water scarcity, inequitable water distribution and using water for peace and security.

Water and mental health: Floods and climate change are causing more deaths, damage and impacting mental health. When people perceive or experience a lack of privacy and safety, during open defecation or when using sanitation infrastructure, this can negatively influence their mental and social well-being. The authors of this study found that perceptions and experiences of privacy and safety are influenced by contextual and individual factors, such as location of sanitation facilities and user’s gender identity, respectively. Privacy and safety require thorough examination when developing sanitation interventions and policy to ensure a positive influence on the user’s mental and social well-being.

According to UNESCO, studies also link sanitation to attainment of primary and secondary education. The world has seen a dramatic decline in out-of-school rates for both girls and boys in developing countries. Adolescent girls in Sub-Saharan Africa and parts of Asia continue to have a higher out-of-school rate compared to their make classmates. A growing body of literature highlights how poor inaccessible sanitation at school inhibits young girls from safely and comfortably managing their menstruation which may ultimately influence their social and educational engagement, concentration, and attendance

WASH and its Impact on Our Health

WASH initiatives are crucial to human health and wellbeing. Safe WASH is not only a prerequisite to health, but contributes to livelihoods, school attendance and dignity and helps to create resilient communities living in healthy environments. Drinking unsafe water impairs health through illnesses such as diarrhea, and untreated excreta contaminates groundwaters and surface waters used for drinking-water, irrigation, bathing and household purposes. This creates a heavy burden on communities. Chemical contamination of water continues to pose a health burden, whether natural in origin such as arsenic and fluoride, or anthropogenic such as nitrates. Safe and sufficient WASH plays a key role in preventing numerous neglected tropical diseases (NTDs) such as trachoma, soil-transmitted helminths and schistosomiasis.

However, poor WASH conditions still account for 842,000 diarrheal deaths every year and constrain effective prevention and management of other diseases including malnutrition, NTDs and cholera. Evidence suggests that improving service levels towards safely managed drinking-water or sanitation such as regulated piped water or connections to sewers with wastewater treatment can dramatically improve health by reducing diarrheal disease deaths.

WHEC’s Response, Recommendation and Areas of Future Development:

  1. WHEC develops, updates and disseminates health-based guidance documents and best practices guides, norms and standards that support standard-setting and regulation at national level, in collaboration with the UN and WHO, particularly for drinking-water safety, effective surveillance approaches, recreational water quality, sanitation safety, safe wastewater use, WASH in health and education facilities, and WASH monitoring.
  2. WHEC empowers countries through multi-sectoral technical cooperation, advice and capacity-building to governments, practitioners and partners including on health and WASH sector capacities with respect to their public health oversight roles, national polices and regulatory frameworks, national systems for effective water quality and disease surveillance, including outbreak response, national systems for WASH monitoring, and national WASH target-setting.
  3. WHEC provides reliable and credible WASH data to inform policies and programs on WASH risk factors and burden of disease, the status of key output indicators for WASH, progress towards relevant WASH-related SDG targets, the enabling environment for WASH including WASH finance, and wastewater and SDG 6 interlinkages.
  4. WHEC coordinates with multi-sectoral partners, leads or engages with global and regional platforms, and advocates for WASH to influence political will and policy uptake of effective WASH strategies, increase focus on effective WASH regulations and policies, and expand and strengthen multi-sectoral collaboration at national level.
  5. WHEC promotes integration of WASH with other health programs, for example disease programs for cholera and NTDs, emergencies programs, quality care and infection prevention control, especially through WASH in healthcare facilities, nutrition programs and antimicrobial resistance programs.


Sanitation is defined as access and use of facilities and services for the safe disposal of human urine and fecal waste. A safe sanitation system is a system designed and used to separate excreta from human contact at all steps of the sanitation service chain from toilet capture and containment through emptying, transport, treatment (in-situ or off-site) and final disposal or end use. Safe sanitation system must meet these requirements in a manner consistent with human rights, while also addressing co-disposal of greywater, associated hygiene practices and essential services required for the functioning of technologies.

Key Facts

  • In 2022, ONLY 54% of the global population (4.2 billion people) used safely managed services.
  • Over 1.7 billion people still do not have basic sanitation services, such as private toilets or latrines.
  • Of these, 494 million people still defecate in the open, for example in street gutters, behind bushes or into open bodies of water.
  • In 2022, 45% of the household wastewater generated globally was discharged without safe treatment.
  • At least 10% of the world’s population is thought to consume food irrigated by wastewater.
  • Poor sanitation reduces human wellbeing, social and economic development due to impacts such as anxiety, risk of sexual assault, and lost opportunities for education and work.
  • Poor sanitation is linked to transmission of diarrheal diseases such as cholera, dysentery, as well as typhoid, intestinal worm infections and polio. It exacerbates stunting and contributes to the spread of antimicrobial resistance.

Benefits of Improving Sanitation

The benefits of improved sanitation extend well beyond reducing the risk of diarrhea. These include:

  1. Reducing the spread of intestinal worms, schistosomiasis and trachoma, which are neglected tropical diseases that cause suffering for millions.
  2. Reducing the severity and impact of malnutrition.
  3. Promoting dignity and boosting safety, particularly among women and girls.
  4. Promoting school attendance: girls’ school attendance is particularly boosted by the provision of separate sanitary facilities.
  5. Reducing the spread of antimicrobial resistance.
  6. Potential recovery of water, renewable energy and nutrients for fecal waste.
  7. Potential to mitigate water scarcity through safe use of wastewater for irrigation especially in areas most affected by climate change.

According to a study published by the WHO – for every US$1.00 invested in sanitation, there is a return of US$ 5.50 in lower health costs, more productive and fewer premature deaths.


In 2010, the UN General Assembly recognized access to safe and clean drinking water and sanitation as a human right and called for international efforts to help countries to provide safe, clean, accessible and affordable drinking water and sanitation. Sustainable Development Goal target 6.2, calls for adequate and equitable sanitation for all. The international platform of WHEC on public health with its partners, in 2023, launched advocacy global efforts to prevent transmission of diseases, advising governments and communities on health-based regulation and service delivery. On sanitation. WHEC reports on the global burden of disease and the level of sanitation access and analyses what helps and hinders progress. Such monitoring and reporting gives Member States and donors global data to help decide how to invest in providing toilets and ensuring safe management of wastewater and excreta.

Health Impact of Unsafe Sanitation

Table 1. Unsafe Sanitation, infectious diseases, mental and social effects.

WHEC’s Response, Recommendations and Areas of Future Development:

Access and use of safe toilets by the entire community is needed to achieve health gains from sanitation. Without community level coverage, those using safe toilets remain at risk from unsafe sanitation systems and practices by other households, communities, and institutions. In addition, a minimum quality of toilet and containment – storage / treatment is needed to sustain use, to prevent excreta contaminating the local environment and to allow for connection to a safe sanitation chain.

  1. Everyone in school, healthcare facilities, workplaces and public places should have access to a safe toilet that, as a minimum requirement, safely contains excreta. Universal access implies that toilets are accessible in all aspects of daily life including at home, at school, in healthcare settings, workplaces and public places such as markets and transportation facilities for the entire population.
  2. The selection of safe sanitation systems should be context specific and respond to local physical, social and institutional conditions. No single type of sanitation system is ideal in all settings. The design and implementation process should incorporate extensive stakeholder consultation, which includes the local community.
  3. Progressive improvements towards safe sanitation systems should be based on risk assessment and management approaches. It may take years and long-term investment to achieve universal access to safe sanitation systems. A locally-specific risk assessment and management approach can identify (e.g. Sanitation Safety Planning) incremental improvements at each step of the sanitation service chain to allow progressive implementation towards sanitation targets and allow investment to be prioritized according to the highest health risk and thereby maximize gains.
  4. Sanitation workers should be protected from occupational exposure through adequate health and safety measures. Sanitation workers are typically at high risk from fecal pathogens in their daily work through handling of fecal sludge and wastewater and equipment used in emptying, conveyance and treatment of fecal sludge and wastewater, work in confined spaces, proximity to aerosols created by treatment process, and cuts and abrasions for co-disposed solid waste. They are also exposed to other chemical and physical risks from the use of hazardous cleaning agents and heavy labor.
  5. Sanitation should be addressed as part of locally delivered services and broader development programs and policies. Sanitation services should be provided within a context of a package of basic local services, for which government is responsible and accountable, even where services are delivered by non-government entities.
  6. The health sector should fulfill core functions to ensure safe sanitation to protect public health. The implementation of sanitation programs is often delivered through infrastructure ministries, agencies and utilities, and the over-seeing responsibility teams, to ensure that these investments result in improved public health. This responsibility also lies with health authorities too. This implies roles that includes sanitation considerations within all function of the health system, including target setting according to public health considerations, coordination of all relevant sectors, use of sanitation and sanitation-related epidemiologic data for decision-making, standard-setting and regulatory, monitoring and accountability measures.


Healthcare authorities should fulfil their responsibilities to ensure access to safe sanitation in healthcare facilities for patients, staff sanitation in healthcare facilities for patients, staff and carers, and to protect nearby communities from exposure to untreated wastewater and fecal sludge.

  1. Define government-led multi-sectoral sanitation policies, planning processes and coordination.
  2. Ensure health risk management is properly reflected in sanitation legislation, regulations, and standards.
  3. Sustain the engagement of the health sector in sanitation through dedicated staffing and resourcing, and through action on sanitation within health services.
  4. Undertake local level health-based risk assessment to prioritize improvements and manage system performance.
  5. Enable marketing of sanitation services and develop sanitation services and business models.

The capacity to deliver universal safe toilet access and promote use varies significantly among and within countries. Efforts will be required to ensure a sufficient legal framework for sanitation, including cooperation to address overlap and inconsistencies. In many low- and middle-income contexts, significant investments will be required to increase the capacity of health authorities and other government departments to improve the demand for and supply of safe toilets. Delivery of sanitation behavior change interventions through health programs may impact on the work-load of health workers (potential increase in terms of activities and supervisory responsibilities, and potential decrease in terms of treatment of infections as well as reliance on mass anthelminthic treatments).

The Components of the Sustainable Development Goal (SDG) in Sanitation and the Ladder

Table 2. Based on the recommendations of WHO and UNICEF, (2017).


The legislative framework for sanitation should cover the whole service chain, including both sewered and non-sewered sanitation, to enable the best use of public funds, achievement of standards and attraction of potential service providers. Ensuring adequate standards for sanitation is a government function. Standards and regulations should avoid prescribing specific technologies or systems for particular situations as their suitability can be affected by a multitude of factors. In addition, legislation evolves more slowly than technologies and therefore can impede innovation. Instead, standards and regulations should set out what level of performance is required to achieve a safe sanitation service chain and allow flexibility on how it is achieved.

A key area for regulation that applies across the whole service chain is fees and tariffs, for services delivered by utilities, public institutions or entities under their control (e.g. treatment plants under lease or concession arrangements). These may include sewerage fees, fees for use of public or shared toilets, sewerage tariffs, fees for pit emptying by utilities or public institutions, fecal sludge tipping fees, etc.

Sanitation Service Chain Regulatory Mechanism Options

Table 3. Regulatory mechanisms for sanitation service chain.

Risk Assessment and Management

A risk assessment should guide sanitation interventions to ensure, that sanitation protects public health by managing the risks arising from excreta management, along with the sanitation chain from the toilets to final disposal or use. The risk assessment should identify and prioritize the highest risks and use them to inform system improvements through a mixture of controls along the sanitation chain. Improvements may include technology upgrades, improved operational procedures and behavior change.

Risk assessments should be based, as far as possible, on actual conditions, rather than on assumptions of information imported from elsewhere. Frontline government staff such as public health or agricultural extension workers, students, community leaders and community-based organizations can be effective, in data collection if well organized, incentivized and supervised.

Regulatory Mechanisms

The various steps in sanitation service chains differ in their nature, requiring a corresponding range of regulatory mechanisms. Ways in which the different steps can be regulated are illustrated in Table 3 above. The various mechanisms are highlighted in bold in the following text to facilitate cross-referencing.

Additionally, because sanitation cuts across many sectors, relevant legislation and regulation is also widely scattered and elements may be found under:

  • Local government public health, occupational health and safety, environmental, water resources and consumer protection legislation;
  • Legislation and regulations covering agriculture, energy and food safety with safe use of fecal sludge;
  • Local by-laws;
  • Building and planning codes / standards;
  • Public utility regulations; and
  • Others.

Sanitation workers are exposed to particular heath risk, and require specific measures to ensure their health and safety. These should include periodic health checks, vaccinations and treatment (e.g. deworming), medical insurance (if available), personal protective equipment (PPE), as well as training in standard operating procedures. The obligation should be for employers to provide all of these, and these requirements should be included in the regulatory arrangements to which employers are subject. Compliance should be verified by health sector personnel (e.g. environmental or occupational health staff).

Enforcement and Compliance

Achievements of compliance with standards and regulations requires a broad approach that includes a mix of incentives, promotion and sanctions. Non-coercive means, such as information dissemination, technical assistance, promotion and awards should be used in the first instance. Tax and other fiscal incentives, or privileged access to special services (such as loan guarantees for equipment renovation and purchase) can be economically efficient in some circumstances. When developing regulatory systems, better results are often achieved when it is done in partnership with those being regulated. In this way it is possible to utilize their experience of what is practical and feasible. Such partnering may appear counter-intuitive (service providers might expected to resist regulation), but in most cases, the advantages gained from being formally recognized outweigh any disadvantages that might arise from well-designed regulation.

National guidelines should be produced advising how to apply enforcement, and training provided on how to manage legal proceedings, particularly the collection and presentation of evidence. Responsible managers should review the enforcement activity and report on it annually, highlighting any sanitation issues that arise, and checking that it is not being applied abusively.

Sanitation in Healthcare Facilities

Healthcare facilities represent a particularly high sanitation risk, due to both infectious agents and toxic chemicals. From the user perspective they should be a model of hygienic sanitation. Healthcare facility sanitation should be the responsibility of the Ministry of Health, with responsibility for its management clearly specified in the job descriptions of healthcare facility managers and relevant staff. Recommended numbers of toilets are 1:20 for inpatients and at least two toilets for outpatient settings (one toilet dedicated for staff and one gender-neutral toilet patient that has menstrual hygiene facilities and is accessible for people with limited mobility). They should be culturally acceptable, private, safe, clean and accessible to all users, including provision for those with reduced mobility and for menstrual hygiene management. Bedpans should be used by patients only when needed, and not as a regular substitute for toilets; when used, bedpans should be safely handled avoiding spillage and using appropriate PPE. Fecal waste from bedpans and water used for washing bedpans should be emptied into a toilet or into the sanitation system through other means such as a drain or macerator. A reliable water point with soap should be available close to the toilet for handwashing.

Immediate Preventive Measure for Areas at High-Risk of Enteric Disease Outbreaks

Neighborhood and Household Level
Immediate Measures
Undertake neighborhood and house-to-house sanitary inspections to identify open defecation sites and leaking or overflowing sewer conditions, open drains and pits or tanks of on-site sanitation facilities.

  • Where open defecation is prevalent, undertake demand creation and sanitation promotion, using properly trained staff if available, with the objective of persuading open defecators to use and existing neighbor’s or community toilet, where available.
  • In urban areas, using a combination of sanitation promotion/behavior change strategies and enforcement, persuade owners to empty overflowing but otherwise serviceable permanent sanitation facilities where this is viable option.
  • Carry out intensive hygiene promotion, focusing on: immediate care-seeking; handwashing with soap; prompt disposal of child and infant feces in a safe toilet; hygienic practices in the care of sick individuals and management of their faces; hygienic practices in the washing and burial of corpses; avoiding contact with water in drains (especially children); and treatment of drinking water supplies.

Promote and support the installation of handwashing facilities in homes and institutions.

Medium Term Measures

  • Using a combination of demand creation and enforcement, persuade owners to fix leakages and rebuild or upgrade unsafe toilets, or to build a toilet where there is none.
  • Where it is not possible to substitute open defecation with individual household toilets, organize the construction of community toilets shared between limited and defined groups of households, with robust operation and maintenance arrangements.
  • Where liquid effluent from on-site sanitation facilities is discharged into drains and waterways, or where there are leaking sewer connections, promote and construction of soak ways and drain fields where feasible. Where this is not feasible, organize mass desludging to increase effluent residence times in the tanks and decrease solids carry-over.

At Health-posts, Hospitals or Emergency Facilities for Infected People

Immediate Measures

  • Eliminate leakages and overflows of liquid effluents urgently, carry our all-feasible minor repairs and desludging to maximize the efficiency of the existing sanitation system.
  • Ensure sanitation facilities are operational, accessible to all, and have handwashing facilities with soap and water nearby.

Medium Term Measures

  • Review sanitation arrangements to ensure that all fecal material is contained and that liquid effluents are treated on-site and infiltrated to soil through a leach field or discharged to a sewer and treated and safely disposed.

Fecal Sludge Management

Immediate Measures

  • Disseminate messages to promote the use of licensed desludging operators (where applicable).
  • If it will result in less open dumping, temporarily suspend the charging of tipping fees.
  • Urgently inspect all fecal sludge management equipment and oblige operators to rectify any faults that could result in inadequate containment or spillage.
  • Increase vigilance against open dumping of fecal sludge and institute strong measures to ensure that operators discharge at authorized sites.
  • Promote, and enforce with follow-up inspections, the use of disinfectants to clean up premises which have been serviced, and the desludging equipment used.

Medium Term Measures

  • Review operating practices with all desludging operators to minimize risks for both operators and customers.
  • Contact the traditional emptier and enlist their cooperation to the extent possible, promoting the burial of fecal sludge over dumping it in drains, water bodies or open land.

A budget for the operation and maintenance of the healthcare facilities wastewater system must be consistently allocated. An adequately trained staff member should have officially designated responsibility for the system, with staff allocated to maintenance tasks.

Imagining a better future: A dramatic acceleration in progress is possible

Investment in five key ‘accelerators’ – governance, financing, capacity development, data and information, and innovation – are identified under UN-Water SDG 6 Global Acceleration Framework. It can be a pathway towards countries’ achievement of safe sanitation for all, with coordinated support for the multilateral system and partners. Governments MUST ensure that coverage extends to entire communities, deploying a mix of approaches and services. Sanitation coverage must extend beyond the household, do that everyone in schools, healthcare facilities, workplaces and public places has access.

WHEC's call to transform sanitation for better health, environment, economies and societies are:

  1. Good governance begins with leadership, effective coordination and regulation. Sanitation needs to be defined as an essential service for which the government is responsible and can be held accountable.
  2. Smart public finance unlocks effective household and private investment. Most countries report insufficient resources to meet their national sanitation targets. Identifying and mobilizing appropriate funding sources and financing institutions is critical, if countries are to meet their aspirations in the most cost-effective and efficient manner.
  3. Capacity at all levels drives progress and sustains services. Developing a strong sanitation sector will require a larger workforce with better skills. Capacity development is more than training. National governments need the skills to develop and administer effective strategies, policies, cost plan and regulations.
  4. Reliable data support better decision-making and stronger accountability. The value of survey and census data can be increased by using harmonized questions that allow comparison with other surveys and enable tracking of national, regional and global indicators.
  5. Innovation leads to better approaches and helps meet emerging challenges. New approaches and system and 'future-proof' the sector against disease outbreaks, urbanization, climate change and increasing pressure on natural resources, with solutions that are practical, cost effective and scalable. Adopting such innovations can also support equality and university of services, helping extend sanitation to the hardest-to-reach areas and groups.

Increased urbanization and migration call for new ways of meeting the needs of high-density populations living in poverty, often in informal settlements. By presenting best practices, case studies, successes and challenges, our efforts seek to inspire Member States and all stakeholders to learn from each other and work together towards achieving universal access to safe sanitation by 2030.

Sanitation Behaviors and Determinants

Governments are the critical stakeholder in the coordination and integration of behavior change initiatives at the local level and should provide leadership and ensure funding. The sanitation behavior change requires financial and human resources, and that failure to commit sufficient resources may lead to failure to achieve sustained adoption or use of household sanitation services. The Ministry of Health may be involved in the formulation of sanitation behavior change strategies, in the setting of targets, and in the development of local guidelines.

Behavioral Determinants for Open Defecation

Figure 1. Sanitation behaviors and determinants. Elimination of open defecation.

Changing Behaviors – Main Approaches

While myriad strategies have been used, these typically fall into one or more of four major categories:

  • Information, education and communication-based (IEC) messaging approaches. IEC approaches are often used in public health behavior change communications. It can include mass media, group or interpersonal communication and participatory activities. Specific approaches such as Participatory Hygiene and Sanitation Transformation (PHAST) and Child Hygiene and Sanitation Training (CHAST) use IEC methods, are based on individual behavior change and do not explicitly target changing collective behavior.
  • Community-Based Approaches. Community-Led Total Sanitation (CLTS) initiatives are most widely known and are directed at ending open defecation. CLTS is organized around a “triggering event;” a series of community-based activities, led by trained facilitators, which focuses on behavior change and aim to ignite a sense of disgust and shame in a community related to open defecation and its impact on the community’s health and wellbeing. Community Health Clubs (CHCs) are another example of a collective mobilizing approach.
  • Social and Commercial-Marketing Based Approaches. It refers to the broad set of initiatives that use commercial-marketing principles to change health behaviors. social marketing assumes that sufficient promotion and demand creation, when met with accessible goods and services that meet a population’s needs at an affordable price, results in changes in behavior. These are reflected in the “4Ps” of social marketing: product, price, place and promotion.
  • Approaches Incorporating psychological and social theories of behavior. Given the relatively recent development of these approaches for sanitation and hygiene behavior change, evidence for their efficacy is primarily found from the application of underlying theoretical principles of other health and developmental challenges. Approaches based on psychological and social theory are often associated with specific behavior change techniques (BCTs). These are the smallest building blocks of a behavior change intervention and refer to the mechanisms through which intervention or program activities influence behavioral determinants to result in changes in behavior.

Stages in Behavior Change Strategy Design

Sanitation interventions and the safe disposal of human excreta have the potential to impact on the transmission of a diverse range of microbial hazards. Antimicrobial resistance (AMR) among the human pathogens has been identified as one of the greatest global threats to human health. AMR arises from genetic mutations that allow the emergence of new bacterial strains that are not affected by an antimicrobial agent. This can occur in the body of a host or in environmental settings where the presence of antimicrobial agent kills off the main populations of the target bacteria and allows the remaining resistant strains to flourish.

There are potentially three distinct types of monitoring necessary for successful sanitation behavior change program. These include:

  • Process Monitoring. It focuses on the quality and effectiveness of intervention delivery;
  • Progress Monitoring. It focuses on behavior change at the individual- and community-level ; and
  • Post-Intervention Monitoring. It focuses on sustained behavior over time. Post-intervention monitoring is particularly crucial to ensure the elimination of open defecation and ensure consistent use of facilities.

Designing, Adapting and Delivering Behavior Change Interventions

Table 4. Developing and Implementing a behavior change strategy is a multi-stage process.

Regardless of the approach use, attention should be given to the frontline workers who are engaged in the direct delivery of sanitation behavior change activities.


Better access to water is helping create new possibilities for people in some of the world's most remote communities. Goal 6 of the UN’s Sustainable Development Goals (SDGs) is ensuring availability and sustainable management of water and sanitation for all. WATER is at its core of SDGs and is critical for socio-economic development, energy and food production, healthy ecosystems and for human survival itself. Water is also at the heart of adaptation to climate change, serving as the crucial link between society and the environment. Water is also a human rights issue. As the global population grows, there is an increasing need to balance all of the competing commercial demands on water sources, so that communities have enough for their needs. In particular, women and girls must have access to clean, private sanitation facilities to manage menstruation and maternity in dignity and safety.

Sanitation plays a role in improving broader aspects of health, including gender, security, quality of life and overall wellbeing. Environmental health delivered through critical health sector functions is essential in preventing a significant proportion of the burden of disease globally; these functions are:

  1. Ensuring the environment health issues are adequately reflected in inter-sectoral policy development and implementation;
  2. Setting and overseeing the implementation of health-protecting norms and regulations;
  3. Incorporating environmental health in disease-specific and integrated health programs;
  4. Practicing environmental health in healthcare facilities;
  5. Preparing for and responding to outbreaks of environment-mediated diseases; and
  6. Identifying and responding to emerging threats and opportunities for health.

Successful programming outcomes for sanitation are more likely to be successful, where coordination and collaboration between different sectors and stakeholders exists, affecting both the scale and effectiveness of sanitation programs. Lower prevalence or incidence of diseases is associated with greater access to sanitation, particularly for diseases and conditions that continue to inflict a health burden in low-income settings including diarrhea, soil contaminated helminth infections, trachoma, cholera, schistosomiasis, and poor nutritional status.


Water & Sanitation: Essential for Maternal, Newborn and Child Health.
Our published commitment for SDG 6; #SDGAction49770

Water, Sanitation and Hygiene (WASH) Implementation for Schools and Healthcare facilities.
Our published commitment for SDG 6; #SDGAction50616

Centers for Disease Control and Prevention (CDC)
Global water, Sanitation, & Hygiene (WASH)

United Nations Department of Economic and Social Affairs, SDG 6
Water and Sanitation

National Institute of Environmental Health Sciences (NIH)
Drinking Water and Your Health

World Health Organization (WHO)
Sanitation Safety Planning

© Le Centre pour la Santé et Éducation des Femmes