shared and public toilets CHAMPIONING DELIVERY MODELS THAT WORK Rachel Cardone Alyse Schrecongost Rebecca Gilsdorf About the Water Global Practice Launched in 2014, the World Bank Group's Water Global Practice brings together nancing, knowledge, and implementation in one platform. By combining the Bank's global knowledge with country investments, this model generates more repower for transformational solutions to help countries grow sustainably. Please visit us at www.worldbank.org/water or follow us on Twitter @WorldBankWater. About the Citywide Inclusive Sanitation Initiative The Water Global Practice, in conjunction with sector partners, has developed an approach to urban sanitation termed Citywide Inclusive Sanitation (CWIS). This comprehensive approach aims to shift the paradigm around urban sanitation interventions by promoting a range of technical solutions that help ensure everyone in a city bene ts from safely managed sanitation service delivery. The CWIS approach integrates nancial, institutional, regulatory and social dimensions, requiring that cities demonstrate political will and technical and managerial leadership to identify new and creative ways of providing sanitation services for all. shared and public toilets C H A M PI O N I N G D E L I VE RY M O DE LS T H AT W O R K Rachel Cardone, Alyse Schrecongost, and Rebecca Gilsdorf © 2018 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denomi- nations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Please cite the work as follows: Cardone, Rachel, Alyse Schrecongost, and Rebecca Gilsdorf. 2018. “Shared and Public Toilets: Championing Delivery Models that Work.” World Bank, Washington, DC. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@www. worldbank.org. Cover photos: © Kathy Eales / World Bank, Mirva Tuulia Moilanen / World Bank. Cover design: Trese Gloriod, Graphic World, Inc. CONT EN TS ABBREVIATIONS • iv ACKNOWLEDGMENTS • v 1. INTRODUCTION • 1 2. SHARED TOILET MODELS IN URBAN SANITATION • 5 3. UNDERSTANDING THE SANITATION MARKET • 10 4. SANITATION FROM A USER PERSPECTIVE • 15 5. SANITATION FROM THE PERSPECTIVE OF SERVICE PROVIDERS • 21 6. SANITATION FROM A SERVICE AUTHORITY PERSPECTIVE • 32 7. CONCLUSION • 36 APPENDIX A • Design Approach • 37 APPENDIX B • Review of Practice • 38 APPENDIX C • Indicative Questions to Ask as Part of a Sanitation Situation Assessment To Inform Shared Toilet Model Design, Planning, Implementation, and Management • 43 APPENDIX D • A Day In The Life • 46 BIBLIOGRAPHY • 50 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK iii Figures 1.1 • Decision Point Indicators for Decision Frameworks • 2 1.2 • Features Linking Analysis with Action • 3 2.1 • A User-Centric Approach to Defining Toilet Models as Used in This Guide • 6 2.2 • The Sanitation Service Chain • 7 2.3 • Decisions and Alternatives Connecting Toilet Models with the Sanitation Service Chain • 8 3.1 • Decisions and Alternatives to Guide a Situational Assessment for Residential Sanitation • 13 4.1 • Decisions and Alternatives for User Inclusion in Shared Toilet Models • 19 5.1 • Possibilities How Different Management Models Can Be Applied to a Similar Physical Asset • 23 5.2 • Decisions and Alternatives for Shared Household Toilet Models • 27 5.3 • Decisions and Alternatives for Community Toilet Models • 29 5.4 • Decisions and Alternatives for Public Toilet Models • 30 6.1 • Decisions and Alternatives for Service Authorities • 35 Tables 5.1 • Landscape of Business Model Options along the Shared-Community-Public Toilet Continuum • 25 D.1 • A Day in the Life of a Family that Uses an IHHT as a primary form of sanitation • 46  Day in the Life of a Family that Uses a Shared Household Toilet Model as a D.2 • A Primary Form of Sanitation • 47  Day in the Life of a Family that Uses a Community Toilet Model as a Primary Form D.3 • A of Sanitation • 48  Day in the Life of a Family that Uses a Public Toilet Model as a Primary Form of Sanitation • 49 D.4 • A iv SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK AB B R E V I AT I O N S BOT build-operate-transfer CAPEX capital expenditures CBO community-based organization CWIS citywide inclusive sanitation DBO design-build-operate FSM fecal sludge management GBV gender-based violence GPS global positioning system IHHT individual household toilet JMP Joint Monitoring Programme MHM menstrual hygiene management NGO nongovernmental organization OD open defecation PA Practical Action SAIS School of Advanced International Studies SAT stand-alone toilet SDGs Sustainable Development Goals WSUP Water and Sanitation for the Urban Poor SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK v AC K N O W L E D G M E NTS This primer benefited from contributions of literature as well as experience and feedback on initial and later-stage drafts from many people. We are grateful for contributions and insights from conversations with Tanvi Nagpal, Meera Mehta, Dinesh Mehta, Neil Macleod, M. Elangovan, Prof. V. Srivinas Chary, and Swapnil Chaturvedi, the excerpts of which are captured in several examples provided throughout. Georges Mikhael and Baghirathan Vanniasingham provided deep insight from their extensive experience and shared useful literature and case studies from Water & Sanitation for the Urban Poor’s (WSUP) work as well as constructive feedback that shaped the process. We also extend gratitude to Christopher Ancheta, Gulilat Birhane Eshetu, Edkarl Galing, Peter Hawkins, Chris Heymans, Bill Kingdom, Maraita Listyasari, Sanyu Lutalo, Nishtha Mehta, Joseph Ravikumar, and Yitbarek Tessema, who provided extensive and useful feedback for the development and drafting of this piece. Finally, we are very thankful to Shafick Hoossein and Martin Gambrill for their consistent support and valuable advice throughout the development process. All omissions and errors rest with the authors. vi SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 1. IN T R O D U C T I O N The Sustainable Development Goals (SDGs) call for uni- checklists, high-level decision trees, and tips based on versal sanitation access and ending open defecation by research and experience. It is accompanied by a series 2030. Shared toilet models are not currently an accept- of appendixes, which offer a summary of findings from able form of safely managed sanitation. The ambition a literature search, additional graphics, and a checklist for the goals is thus set against an urban reality where of things to consider when planning, implementing, and hundreds of millions of people regularly rely on shared managing shared toilet models. It is built on an assump- toilet models, but aren’t counted, and where policy mak- tion that with an experimental mindset and operational ers lack incentives to support shared toilet models, even flexibility to innovate, shared toilet models can offer when these are more suitable, for technical and geo- safe sanitation services as part of CWIS and contribute graphic reasons. The alternative to not having any form meaningfully to the SDGs. of sanitation is open defecation, with associated human and environmental health impacts. The logic behind Notably, this document does not explicitly address the exclusion of shared toilet models is that they fail to container-based sanitation service models, which are deliver safe sanitation services to their users. For exam- evolving to meet urban sanitation needs for shared and ple, there is evidence that health outcomes from shared individual household situations. This topic is the subject models are worse than from individual household toi- of a separate World Bank report titled Evaluating the lets. The market structure and underlying dynamics that Potential of Container-Based Sanitation (forthcoming). cause shared toilet models to succeed or fail are messy Nor is this document a stepwise guide to implement- and often context specific, which makes shared toilet ing shared toilet models, considering legal, regulatory, models hard to justify at a global level. Still, there are policy, financial, technical, and social issues.1 Rather, it examples where shared toilet models can and do work offers a pragmatic introduction to the starting questions and are preferable to individual household toilets. Often, a policy maker or planner should ask. models that provide safely managed sanitation have evolved through deep community engagement, iterative Report Structure experimentation with facility design, adaptation of the delivery model to meet user needs and preferences over Because of the diversity of approaches used to deliver time, and reliance on a financially viable revenue model. sanitation services, and the corresponding diversity of needs and enabling environments, shared toilet models This document aims to inform early considerations and were considered from four perspectives: decisions that planners and policy makers must weigh • The context in which sanitation services are needed when considering whether and how to pursue shared • Toilet users’ needs, including urban residential use toilet models as an improvement to the status quo or how and the varying needs of users as they move around to improve existing shared toilet models. The intended the city throughout each day audience is policy makers and others who are tasked • Service providers, who provide cleaning and main- with improving urban sanitation and advancing city- tenance services of shared household, community, wide inclusive sanitation (CWIS) but who may not have and public toilets and sometimes the infrastructure extensive experience working on these issues. It includes and financing for the facilities an overview of shared toilet models, brief examples, SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 1 PROCEED STOP CAUTION Minimum conditions are in place to support Minimum conditions are not in place. Minimum conditions are not in place implementation and suggest potential for Without a clearly articulated and funded and cannot be overcome in the short management to sustain services over time. action plan to remediate, investments or medium term. Reevaluate approach, may be at risk of failure over time. and be realistic about expected results. Figure 1.1 • Decision Point Indicators for Decision Frameworks • Service authorities, or the government entities Individual household toilets responsible for ensuring that services are provided and basic sanitation needs are met Individual household toilets (IHHTs) are, in general, a For each of these perspectives, opportunities and chal- preferred toilet choice for residential settings (Norman lenges are presented, and questions to consider in 2011) and lend themselves best to continued operation decision making are prompted. Where possible, these and management, which is better for privacy, dignity, are distilled into high-level decision frameworks, using and public health. To the extent IHHTs can be pursued decision point indicators shown in figure 1.1. to meet the basic sanitation needs of residential house- holds, they should be. Other features offering context and support—summa- rized in figure 1.2—include high-level checklists, tips, However, IHHTs are not technically feasible in many case studies, and references to tools and resources. low-income, urban communities. IHHTs are not suitable These features are meant to briefly flag or illustrate in areas with extremely high population density, where important points and direct the reader to additional there is no space in basic housing structures, and where information sources, rather than offering a comprehen- multiple households cohabitate and overwhelm IHHT sive and exhaustive guide. design capacity. Standard designs are less feasible in areas with high water tables or bedrock, where creating a safe containment space for fecal sludge is cost prohibitive for Key Findings and Emerging Ideas about households, service providers, and service authorities. Shared Toilet Models Where IHHTs are not connected to a sewer, comple- mentary containment infrastructure and access to a full The following is a brief summary of findings, drawing fecal sludge management chain (in essence, service for from an extensive literature survey. A longer analysis of emptying and transporting contained waste, as shown in findings is provided in appendix B; literature surveyed is figure 2.2) is a necessary precondition for viability. provided in appendix E. 2 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK CHECKLISTS • TOOLS & RESOURCES • • Offer question prompts for use during • Summary and hyperlinks to existing tools for planning and consideration during use in planning, implementation, and implementation as well as for ongoing management of different toilet models management to ensure sustainable services • Recommended reading and resources for are achieved further information TIPS • CASE STUDIES • • Things to consider or watch out for, based • Quick examples to illustrate points in the text on common experiences with planning, or that represent interesting models or implementing, and managing different toilet approaches models • Links are included for further exploration Figure 1.2 • Features Linking Analysis with Action De facto or de jure land tenure insecurity can pre- sanitation (Heijnen et al. 2014). For many, the only alter- clude household and landlord investment in IHHTs. native is to openly defecate (Peprah et al. 2015). Migrating populations, informal settlements, and layers of informal tenure and management rights agreements Residential use is only one of multiple sanitation needs limit household willingness to invest in IHHTs. Policy experienced by users throughout their day. Individuals mandates for landlords to provide toilets can help, along must have access to safe, convenient sanitation when with policies that decouple the right to basic services they are outside their houses and going about their daily from land tenure claims. However, implementation of routines: at transportation centers, like bus or train sta- such policies is often slow, uncertain, and politically tions; at their places of employment; at markets and charged. stores where they shop; in schools and clinics and other administrative centers (for example, to pay bills); and at Safe IHHTs are not always affordable in very low-in- centers of religious and cultural activity. come areas. In many cases, even if supported by subsidies or microfinance, individual households do not have the Most experience with shared toilet facilities suggests financial ability to invest in a safe toilet and containment they fail due to lack of an enduring management model system or to pay for basic maintenance. 2 to support maintenance. There tends to be weak or absent planning for long-term service provision, weak accountability between users and service providers, Shared, community, and public toilets and missing, or at best inconsistent, revenue streams to ensure continued operations. Shared household and community toilet models offer alternatives to IHHTs for residential use. In practice, Evidence from shared toilet models shows they yield they are currently the prevalent—if not dominant— limited to no improvement in health outcomes over form of urban sanitation in low-income and informal open defecation and are demonstrably worse than areas. Over 700 million people use shared household, IHHTs (Heijnen et al. 2014). However, this review did community, or public toilets as their primary form of not find any systematic reviews of health outcomes by SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 3 management model or by shared facility type. Rather, Sanitation service failures are often a result of inade- when shared toilets are not maintained properly— quate planning, poor program implementation, and from provision of anal cleansing materials, facilities for weak accountability mechanisms among users, ser- menstrual hygiene management, sanitized toilet stalls, vice providers, and service authorities. These failures lighting, and handwashing stations—health outcomes reflect underlying limitations in governance, facility for users are compromised. When the facility is not management models, or viable financing and revenue connected to a sewer or fecal sludge management sys- models. More successful models have clearly defined tem, to remove fecal matter, health outcomes are also and shared expectations about service levels, required compromised. When maintenance falls below a certain contributions, and consequences of failure to deliver (for threshold, users switch to an alternative, which is often example, on payments, in-kind contributions, or service open defecation. It is important to consider that the levels). Service level agreements, when both moni- same holds true for IHHTs. tored and enforced, can incentivize meeting agreed-on goals and targets and give private providers space to be Successful shared toilet models all involve ongoing creative with how they meet them. Examples include support from the public sector, in the form of a service service providers that stack multiple revenue streams, authority providing leadership, and generally public (or community-based management structures, and creative donor-backed) finance. This is true in terms of both the community engagement and education efforts. quantity of facilities provided and the quality of services, particularly for the most vulnerable populations. In Despite their failings, shared toilet models have a role practice, successful, private sector–driven toilet models, to play as part of CWIS, whether as an intermediary particularly those that serve the poor and those serv- option until IHHTs can be provided for residential ing residential users, still require considerable external use or as a service to urban populations as they move investment, whether through philanthropic investments throughout their days. Although current experience or government subsidies. Political will, combined with of viable shared toilet models is limited, there is a clear well-designed government policies, regulations, and opportunity for innovation and experimentation across programs, are required to address these market failures. contexts to meet the needs of the hundreds of millions of Public toilet models in areas with high pedestrian traffic people who depend on shared toilets to meet their basic can sometimes be independently financially viable but sanitation needs. tend to provide quality and adequate service levels only if a service authority structures the market to ensure this. Notes Political will and functional systems for transparency, 1 More detailed guidance can be found elsewhere, including the Sus- monitoring, and accountability, at multiple levels of tainable Sanitation Alliance (http://www.susana.org) and WSUP’s website (http://www.wsup.com/programme/resources/). Addi- government, are necessary enabling conditions for tional technical guidelines are sometimes available at individual country and city levels. quality services to be provided and sustained at scale. Donor-funded pilot projects, or donor-backed, enter- 2 Financial ability is influenced by the complex socioeconomic dynamics at play in informal areas, including tenancy, sharing prise-driven approaches, may be extremely successful facilities, land tenure, and level of education (Simiyu et al. 2017). and even scale within a community, but without the engagement of government, these models are unlikely to generate the impact needed to achieve CWIS. 4 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK  H AR E D T O I L E T M ODE LS I N UR B A N 2. S S A N ITAT I O N What Is a Shared Toilet Model? shared toilet models. It also differentiates shared toilet models from shared toilet facilities wherever possible, Shared toilet models refer both to the facilities and to call attention to the common experience of physical management models that provide sanitation services to sanitation assets failing because of failed management groups of households, or, in the case of public toilets, to models—and to draw attention to the opportunity for the public. For the sake of comparison, individual toilets physical assets to be revitalized with alternative, and for use by a single household are known as individual more suitable, management and revenue models that household toilets, or IHHTs. Shared toilet models tend meet customer needs and preferences. to be applied to three general categories of infrastructure characterized by use. Toilets shared by a small defined number of households are referred to as shared house- Introduction hold toilets. Toilet blocks that serve many households in Appreciating the definition provided above, urban sani- a residential area, and that may offer shower and laundry tation in low-income areas falls all along the continuum facilities, are referred to as community toilets. Public between shared and public. It should not be a surprise toilets refer to facilities open to all users who are in tran- that many people in urban areas avail themselves of mul- sit or otherwise away from home. tiple shared toilet models as they move through their In practice, shared toilet delivery models can work across days. For this reason, definitions of shared household, a range of physical structures: a shared household model community, and public are made based on the type of can be found in community toilet blocks; community use for which the facility was initially designed: where toilet models can be found in public places; and pub- the toilets are located, in terms of target users, and the lic toilet models can be blended with community toilet underlying rationale, or market forces for why the toilet blocks. What matters is achieving performance stan- exists (see figure 2.1). dards: that the toilet facility is clean and appealing; that Definitional clarity is important primarily because an it provides adequate, equitable, and hygienic services to inclusive, citywide approach to sanitation requires a everyone; that it operates on a financially viable basis; mix of IHHT, shared household, community, and public and that it responds to the needs of its users. toilet models, sometimes in the same, or adjacent, neigh- Urban sanitation services in low-income areas are a borhoods. A policy goal should be that the users’ basic long-neglected area for investment and policy, from local experience of the service is consistent regardless of the to global levels. As attention and experience grow, how model used: users should enjoy a clean, hygienic, and we define shared toilet models, and measure their suc- private environment that ensures safe collection, treat- cess or failure, may become more firmly bounded. This ment, and disposal of human excreta and all wastewater. document aims to contribute a user-centric definition of SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 5 SHARED COMMUNITY PUBLIC Strictly controlled for Anyone in any household can Anyone away from home small number of households go before work or school or of ce USERS: USERS: USERS: few residential families many residential neighbors commuters, worshippers, workers LOCATION: LOCATION: LOCATION: residential residential community parks, stations, religious centers, WHY: WHY: markets money, tenure, space unavailable money, tenure, space, or conditions preclude WHY: for individual household toilet full individual household toilet coverage not at home when nature calls FOR EXAMPLE: FOR EXAMPLE: FOR EXAMPLE: family/landlord compounds, dense slums, dense informal neighborhoods, slums, dense informal neighborhoods, communities, apartments periurban settlements periurban settlements Figure 2.1 • A User-Centric Approach to Defining Toilet Models as Used in This Guide Note: HH = household; IHHT = individual household toilet. TIP • When working in a specific country or region, find out how different shared toilet models are defined in that local context, as well as how local practitioners define users, location, and market forces that underlie the model. It is worthwhile to verify definitions regularly to ensure continued alignment throughout planning and decision-making processes. Toilet models are one segment of the sanitation sewer-based or not. In low-income countries, access to service chain waterborne sewerage and treatment facilities is limited. Where waste is not conveyed by sewers, the current safe The models identified above are variations on how users alternative is fecal sludge management (FSM). FSM systems access basic sanitation services throughout the day. It is manage waste by ensuring fecal sludge is safely contained equally important to consider how the waste is managed on site, emptied, safely removed, and transported to a post-defecation. If there is a sewer line, does it connect treatment facility. There, it can be processed for resource to a treatment facility? How are urine and fecal matter recovery and reuse or safely disposed of (figure 2.2). contained throughout the sewer network to limit pub- lic health risk? If a sewer line isn’t present, and if toilet As part of upstream design and feasibility work for a users use water to wash, where does that water go? If potential sanitation investment, significant consider- toilet users use paper, where does the paper go? How is ation should be given to the state of FSM and whether menstrual hygiene addressed? What happens when the an appropriate chain can be established before contain- containment device is full? Who empties it? Where does ment devices become full. Likewise, for an FSM service waste in the containment device go? What happens next? chain to work, containment devices need to be well con- structed and not leak. The long-term viability of any toilet model in an urban context depends heavily on the existence and strength Figure 2.3 provides a high-level decision tree connecting of the sanitation waste management system, whether shared toilet models with the sanitation service chain. 6 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK RESOURCE • Fecal waste flow diagrams (also known as SFDs) help planners understand how much fecal contamination is generated in a city or town and how it moves through the sanitation service chain, from capture to treatment and end use/disposal. This includes the path of waste through sewer-based and non-sewer-based systems, leakages, service gaps, and prevalence of open defecation. This allows planners and decision makers to see, for example, the level and points at which fecal contamination ends up being released untreated into the environment. It can also help identify where interventions are needed to improve sanitation service delivery. The SFD tool provides guidance on what data to collect, an input form, and a graphic generator. It also provides examples of completed SFDs from cities around the world. For more information, see http://sfd.susana.org. Shared toilet models in the wider urban manage- scheduled for formalization, relocation, or provision ment context of other basic services that eventually may enable safe investments in IHHTs. If so, promoting IHHTs with Cities are dynamic places, and in unstable and informal on-site sanitation technologies in the interim could be areas, a targeted area may change well before a long-term an inefficient use of public and household resources. infrastructure program is complete. For this reason, designing for citywide inclusive sanitation (CWIS) Ongoing or planned activities may include upgrading requires an understanding of how neighborhoods fit or moving physical infrastructure, such as piped water within and are affected by wider growth and develop- supplies, roads, and electricity, including street light- ment trends and city-scale investment plans, beyond the ing. There may be plans to extend telecommunications sanitation service chain. For example, dense, unplanned infrastructure and solid waste management, which settlement communities with high water tables are likely could create opportunities for leveraging technology to to need some degree of shared sanitation services for support sanitation (for example, to support logistics and some, if not all, residents. These communities may be mobile payment or optimize waste transport routes and TIP • There is consensus that the construction costs of community and public toilet blocks are a valid public investment, whereas public investment in IHHTs is classified more normatively as a subsidy for the poorest and is persistently questioned. The public health and safety gains associated with locally accessible, clean, and safe household sanitation should be included in analyses comparing different public investment options. Given the high rates of failure seen across shared toilet models, and the clear benefits of on-site urban IHHTs to protect public health, it makes sense for cities to consider the full suite of toilet options to achieve the SDGs using cost-benefit analysis and other decision support tools. User Emptying/ End Use/ Interface/ Conveyance Treatment Collection Disposal Containment Figure 2.2 • The Sanitation Service Chain SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 7 Is the existing (or planned) facility Minimum conditions for success may not be in place, which will connected to an existing sewerage compromise the viability of the investment. Before proceeding, network that leads to a treatment site? rst ensure that a sanitation value chain can be viable, whether through the investment or with partners. YES NO Is there potential to create YES Minimum conditions are a viable FSM chain, Connecting to an existing in place with potential for including drainage, as part sewerage and functioning sustainability. of this investment? NO treatment site is ideal, though not common. If not, pursue fecal sludge management (FSM). Minimum conditions YES NO for success are not in place and are unlikely to be Are there clear options overcome in the to provide drainage short or medium YES for graywater? term. Reevaluate Is there a functioning FSM system in place, to remove investment activities and treat fecal matter? and risk, and be NO realistic about expected outcomes. Minimum conditions are in place. Check design and operating capacity of Consider the scope of investment needed for success against treatment site against projected supply. available resources, and plan accordingly to manage risk. Figure 2.3 • Decisions and Alternatives Connecting Toilet Models with the Sanitation Service Chain transfer stations). It may also include social infrastruc- investment strategies include a mix of vulnerable and ture, defined as investments and programs that target high-, middle-, and low-income populations in a given those who are most in need. All of these types of munic- planning period, rather than stratify rollout based on ipal infrastructure can influence, or be influenced by, the social class or economic standing. A CWIS framework establishment of shared, community, or public toilets. that appreciates the real and perceived risks of working in lower income areas will seek to identify smaller and It is also worth looking for operational benefits. Cooper- flexible budgets to test and iterate physical designs and ation across municipal departments can yield financial delivery models to meet user needs and preferences to efficiencies as well as mutual benefits for users, service include lower income and vulnerable populations in providers, and service authorities. Integrated planning planning and investment cycles. processes should strive to ensure that planning and 8 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK EXAMPLE • In Maputo, Mozambique, a team of researchers from the School of Advanced International Studies (SAIS) at Johns Hopkins University and the Urban Institute sought to track down actual municipal financing expenditures for sanitation as a starting point for identifying ways to increase municipal financing for sanitation in low-income areas. In a city where less than 10 percent of the population is connected to sewers, local investment for sanitation tends to target those who are already connected to the utility network. Responsibility for water and sanitation at the municipal level is very confusing, with overlapping authority for two main trunk sewers, municipal drains, and the neglected sewage ponds at Infulane. The Municipal Council currently conducts no activities to improve on-site sanitation—it owns two decades-old desludging trucks, of which one works for about a quarter of the year. After much investigation, the team found that much of the Municipal Council’s expenditures earmarked for the “maintenance of streets and the sanitation network” goes to the former. Meanwhile, households in informal and non-networked areas are responsible for digging and maintaining their own toilets. They use informal providers to clean out tanks. It is unclear where these trucks empty the collected waste. It is possible that it ends up in the one of the city’s two main sewer trunks. It is also possible that it ends up in the environment. Source: Interview with Tanvi Nagpal, SAIS. EXAMPLE • Gramalaya’s community toilets in Trichy, Tamil Nadu, India, offered critical amenities to the low-income communities they served. When toilets were first installed, a nongovernmental organization (NGO) engaged and trained women’s cooperatives to eventually manage the operation, maintenance, and finances. Users paid a small fee for use. As communities benefited from Swachh Bharat Mission investments to install networked IHHTs, use of the facilities declined. Management adapted, rather than giving up. Because the nature of these communities is changing with urbanization, the toilets are able to grow their customer base and revenue streams by engaging flows of daily workers in transit (in essence, they moved from being community facilities to public facilities). Source: M. Elangovan, Gramalaya executive director. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 9 3. UN D E R STA N D I NG TH E S A N I TATI O N MA R K E T The state of sanitation in most cities is rapidly chang- Key elements of situational assessment ing and multifaceted, with a mix of existing networked • Physical, demographic, and climactic attri- and non-networked services in varying conditions and butes of the city sizeable areas where services are failing to nonexistent. • Primary elements of the built environment and Conducting a city sanitation assessment, or a situa- coverage of other basic utility services tional analysis, is a good first step to planning, imple- • Sanitation assets—for the full service chain, menting, or managing shared toilet models, regardless conditions, and critical gaps of whether the goal is for a new greenfield project, a • Key stakeholders and their relationships to renovation or upgrading of existing facilities, or an one another within the housing and sanitation adaptation of a delivery model using existing physical service markets infrastructure. • Key financing flows and sources of finance for both up-front and recurrent costs The purpose of a city sanitation assessment is to facilitate • Key policy, legal, and political factors that strategic planning and investment prioritization. Often shape the enabling environment conducted as a rapid assessment by consultants in part- • Other local issues that influence programming nership with local stakeholders, the assessment should and service levels provide planners an understanding of physical and infrastructure characteristics; a stakeholder map that identifies key relationships, incentives, and limitations to success; a mapping of financial flows into sanitation who use the toilets (subgroups include low-income pop- services; and an assessment of the security and stability ulations, those with disabilities, women, children, of those flows. This assessment forms a foundation for and other marginalized and vulnerable populations); understanding which areas of the city are suitable for individuals and organizations (service providers) that shared toilet models and where they should be priori- maintain and manage toilets on a public, private, or non- tized for investment. governmental organization (NGO) or community-based organization (CBO) basis; and the service authorities that An assessment should also include a detailed analysis of are ultimately responsible for ensuring that citizens/con- stakeholder groups and subgroups who are critical to the sumers have access to sanitation services (may include assessment process. Generally, these include the people utilities, regulators, or elected officials).1 A stakeholder TIP • Although it may be useful to bound a sanitation situation assessment based on political or admin- istrative boundaries, it may also perpetuate the marginalization that contributes to poor sanitation in the first place. Need for sanitation should be grounded in practical realities, which likely means high-growth peri-urban areas, including informal areas. Mapping need against administrative or service boundaries of a city or utility can identify institutional gaps as well as actual service gaps. It may also identify opportunities for revenue, if residents can be engaged as new paying customers enable success. 10 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK analysis will seek to understand the incentives, con- Characteristics of an asset inventory straints, beliefs and norms, and resources of these groups • Capture ownership, management, and condi- and subgroups, as well as the human, financial, and tech- tion of sanitation assets across types of toilet nical resources they have or to which they have access. models across the city It will also identify and assess the relationships among • Capture ownership, management, and con- stakeholder groups, as well as how the groups are repre- dition of sanitation assets for emptying and sented in formal and informal governance processes and conveyance systems and treatment infrastruc- by whom. Often, it is beneficial for stakeholders or their ture across the city representatives to be engaged directly as partners in the • Reflect gaps in service provision, including assessment, not just as subjects of the assessment. maps of open defecation areas and areas not accessed by or inaccessible to conveyance Understanding the dynamics between users, service equipment providers, and services authorities is another layer of • Are GPS-based and can feed into other city analysis that a situation assessment should seek to un- data management systems (that may exist) cover. Mapping how things work is a first layer. Working for managing public services and investment to understand why things work the way they do—and to planning whose benefit—will offer a more nuanced perspective to • Are designed to communicate with other inform exploration and experimentation of what might mobile technologies being used by the city work to improve services. Scrutiny of formal and infor- mal policies, laws, and norms is needed to understand what enables or constrains choices for users as well as Although a situational assessment can address many fac- service providers, along with the financial, regulatory, tors, it also must have a sufficient level of detail to inform and political systems in place that can incentivize failure an investment planning process. This planning process or success of sanitation services. should be conducted with more detailed community en- gagement. Initial questions for setting high-level direction A useful assessment will also map where sanitation of subsequent investment planning within an area include: services are missing, either because they never existed or because of failure. It will also seek to define failure • Which users lack sanitation services (for example, from the perspective of different stakeholders, as a ba- residents, workers, migrants)? sis for determining basic standards and expectations for • To what extent are household toilets technically via- planned sanitation services. It will identify where, geo- ble in this area? graphically and socially, gaps result in open defecation • Are nontechnical constraints like land tenure and why. A complementary asset inventory that covers insecurity, rental markets, and other market/ the full-service chain also provides important data to in- institutional challenges likely to be addressed in a form the analysis. reasonable time frame? TIP • Profiles of users of shared household, community, and public toilets in low-income, urban areas are likely to change over time because of changing tenancy, employment, health, and other socioeconomic or political factors. The steady influx of new residents implies a need for regular outreach to potential users to inform adaptations to the toilet model (for example, adaptations to operational factors or revenue/cost structure) and to market and communicate the value and benefits of the toilet service to new users. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 11 • Are individual household toilets (IHHTs) currently land tenure and involve minimal additional capital being used as shared household toilets? If yes, can expenditures? better designed shared household toilets offer a via- • Are public sector agencies willing and able to offer ble alternative to IHHTs? subsidies to offset capital or operating costs? • Are community and public toilets connected to a • Is there a well-defined mechanism for holding ser- sewer network or accessible for emptying and trans- vice providers accountable for delivering against port of excreta? target service levels? • Can existing community or public toilets be refur- • What community organizational or business stake- bished or upgraded to improve viability? holders may be engaged to provide services or • Is there a clear management model for adding new provide oversight? shared toilet facilities? Does it align with existing Key ways to integrate women into sanitation planning, implementation, and management • Citywide inclusive sanitation portfolio assessment of assets, investments, programs, and policies, includ- ing sex-disaggregated data and indicators and information on gender-specific infrastructure and service needs • With communities, create programs or initiatives focusing on gender-based barriers to sanitation access for women and men, including issues like power dynamics in the household, agency, mobility, and control over resources • Pay attention to menstrual hygiene management needs and how these are incorporated into the sanita- tion service chain • Leadership training for men and women working across sanitation to build and strengthen conscious- ness about gender inequality at all levels and implications for achieving health and other outcomes EXAMPLE • The city of Warangal, India, is re-envisioning itself and seeking to become a model clean city. A sanitation assessment included an inventory of open defecation sites throughout the city, including the urban core. The assessment identified vacant lots near institutional settings like hospitals and govern- ment buildings that were being used for defecation by hundreds of people per day. This “footfall market” was estimated and used to attract private companies to compete for the rights to build public toilets on a build-operate-transfer (BOT) basis. The city allocated land, but the companies invested all construction and operating expenses. Service levels are set within contracts, and operators can be penalized or lose their operator rights if inspectors find significant and repeated infractions to the agreement. As a result, the city and its residents benefited from the construction of nearly 60 new public toilets throughout the city, with little to no capital investment from the city. Also because of the sanitation assessment, the city requires all petrol stations to provide on-site restrooms for free to customers and surrounding residents. Nearly 20 facilities were opened within a year, at no capital cost to the city. What is important is that a sustainable model for building and operating community toilets is needed but has not yet been demonstrated. Source: Interview with Professor V. Srivinas Chary, Adminis- trative Staff College of India. 12 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Situation Are individual household toilets a YES Expand and strengthen individual household sanitation. assessment viable option for residential sanitation? Prioritize shared Are shared toilets a viable toilets, minimizing NO option for residential sanitation? YES families per toilet. Are there clean and safe community Does the area have clean and safe public toilets with utility and road access NO toilets with utility and road access that could include residential use? for residential and ancillary use? Check issues like Check issues like YES YES NO affordability, social equity, and affordability, social equity, and opportunities for replication. opportunities for replication. Is there a clear business model for service Can existing community and/or public delivery that resolves land tenure and involves YES toilets be refurbished (or connected to NO minimal additional capital expenditure? utilities/roads) to become viable? NO YES Consider bundling electricity and roads into investment package. Short term: reassess constraints to identify a viable, context-specific path forward Longer term: Pursue policy and planning activities that address underlying constraints before investing in an alternative toilet model. Figure 3.1 • Decisions and Alternatives to Guide a Situational Assessment for Residential Sanitation Figure 3.1 provides an indicative decision tree based on analyzing the data can help decision makers conduct a these questions. In many cases, the answer will not be a more nuanced analysis. clear yes or no. As a result, spending time acquiring and TIP • A review of laws, policies, and programs that influence sanitation service provision must reach beyond sanitation-specific institutions. Institutions with a focus on gender, land tenure, poverty reduction, education, and business development (for example, small and medium enterprise development and busi- ness licensing), as well as different types of utilities (for example, water, solid waste, electricity for lighting), are among those likely to influence sanitation services—in some cases by omission of clear statements on the issue. Understanding the policy environment for shared toilet models is important. Adopt a pragmatic approach with a goal of clean, reliable, and accessible services. Then, identify discrete barriers to success, find and test solutions, and keep an eye on where policy is needed to enable success. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 13 RESOURCE • Many tools exist to support sanitation situation assessments. For example, the Fecal Sludge Management (FSM) Toolbox is a growing and evolving compendium of assessment, planning, and investment tools for urban sanitation. It includes various organizations’ financial modeling and regulatory/institutional assessment tools, many of which address community and public toilets. See http://103.13.240.111/~fsm/. EXAMPLE • In Durban, a successful community toilet model that uses repurposed shipping containers and paid site attendants found, using a situational analysis, that households would prefer open urination and defecation if the facility were located beyond 75 meters from their houses.2 Likewise, based on expe- rience, these community toilets can be expected to work for just three months without an attendant before users abandon them. For this reason, Durban uses South Africa’s national allocation for household sanita- tion to pay for part-time cleaners and attendants at its free community toilets, which are also emerging as safe places for people to socialize. At a cost of about US$65,000 each, Durban has installed over 2,500 community containers that are in continuous operation in over 500 informal settlements, serving over 1 million people, with an 80% acceptance rate among targeted communities. Source: Neil Macleod, former head of eThekwini Water and Sanitation Department. For additional information, see http://citiscope.org/ story/2016/how-durban-set-global-standard-providing-water-and-sanitation-poor. EXAMPLE • In various slums in Mumbai and Pune, government-led community toilets were unintentionally constructed in ways that discouraged use by women. In many cases, male and female stalls faced each other; elsewhere, public toilets had entrances that faced directly into the street. Mahila Milan, a coalition between an NGO and the National Federation of Slum Dwellers in India, consulted female self-help groups when an opportunity arose to renovate several of these blocks. By engaging with female users, the coalition identified that minimizing interactions between men and women was a priority, which resulted in a new design to accommodate that need. The process also heard—and responded—to cleaners, who sought latrine doors that swing in both directions to facilitate easier cleaning. Source: FSG Gender and Sanitation Evidence Review, Draft Report for the Bill & Melinda Gates Foundation, July 2017. Notes 1 Note that this is a simplified categorization. Many other stakeholder 2 A 2007 study of the Mukuru settlement in Kenya found that groups factor into assessments in different levels or ways depending women were disincentivized to use community toilets when they on the context. They can include regulatory bodies; strong formal or were located farther than 15 meters from their houses. See Peal and informal community or religious groups; local, state, and national Evans (2010). authorities; and separate entities that manage sanitation capital expenditure (capex) or operating expenses (opex) budgets. 14 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 4. S ANITAT I O N F R O M A US E R PE R S PE C TI VE Who Uses Shared Toilet Models, and What Do strongly supported. Still, in the absence of consistently They Need? safe services at the clinic, school, market, and workplace, the alternatives are to openly urinate/defecate or wait Most people rely on more than one individual, shared, until they return home, which are both unreasonable community, or public toilet each day, based on their pat- and potentially risky from a health perspective. terns of movement within the city, like commuting to work, working at their place of employment, running If there is no community toilet, household members errands, and shopping. How often an individual uses a may attempt to use public toilets as their primary facility. shared toilet model varies based on age, gender, ability, These are likely to be located farther away from home, and level of health. Other factors include what times of in nonresidential areas. They are more likely to charge day a facility is open, walking distance to the facility, and a fee per use, which may be cost prohibitive for house- wait time to access it, if there are lines. hold members to use for every sanitation need. Where public toilets and community toilet models dominate, For citywide inclusive sanitation (CWIS) to work in there is also a higher risk that the daughter will be sexu- practice and not remain a conceptual idea, both deep ally assaulted. Her awareness of this risk is accompanied awareness and appreciation of the full needs of all by persistent fear. This combination of distance, afford- household members are required. Table D.1 illustrates ability, and safety constraints is more likely to result in a day in the life of a typical family in a low-income, additional instances of open defecation and flying toi- urban area, where a community model is the primary lets. Also, it exposes household members to harmful residential service. As seen, there is a high likelihood pathogens from others’ feces, and the community and that at least one family member will openly defecate or wider environment to the households’ behavior, with practice unsafe sanitation at some point during the day. widespread impact on public health and economic Menstrual hygiene management (MHM) is also needed. development.1 Additional tables for the same family under individual household toilets (IHHTs), shared household toilets, The above scenarios represent one example of experience and public toilets are provided in appendix D. among a diversity of potential perspectives: IHHTs are not always users’ top preference. For example, according When one considers a day in the life for a low-income to a study, “Two sanitation research projects from south- family with an IHHT, there is a greater sense of security ern peri-urban communities [in Ghana] indicate that for the family’s females, and the grandmother’s dignity is one third of the population would prefer to have shared TIP • When thinking of users, consider the context of a whole household and roles different individuals play over time as they relate to sanitation and hygiene. This includes men and women, babies and children, elderly people, and people with disabilities. Many individual users have multiple roles—employees, caretak- ers, mothers, vendors—and move throughout the city with different needs in different contexts. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 15 Family Sanitation Needs Throughout the Day in a Growing City How Citywide Inclusive Sanitation Helps Families Thrive A Day in the Life of the Mijini Family Mother Father Grandmother I am off to the market to sell vegetables, I am headed to work in a factory I stay close to home, growing vegetables then to the municipal of ce to pay a bill. After on the other side of the city. Between in our side yard, and watching my grandson. that, I need to get medicine for my son.  traf c and a long work day, I will be I have incontinence, and prefer to stay home after dinner. close to the IHHT.  Daughter I fetch water in the morning before heading to school. I am Son 12 years old and recently started menstruating. I am guring out I am 3 years old. Yesterday I played how to manage because I am committed to my education. near the drains, and now I have bad diarrhea. The Mijini family starts their day practicing However, as they go about their daily lives safe sanitation, thanks to their IHHT. they're faced with lack of safe facilities in the busy city. IHHT Uses run-down pit latrine behind the school to change WC WC rags and urinate. ✔ Fetches water from a public tap near her home. + WC WC Uses clinic's toilets and helps son to also use Uses IHHT, and supervises them, but there is no water in the sinks and no soap. her grandson’s toilet use, including hand-washing. Decides to wait till WC WC she gets home because there are no Uses latrine in the market. There is no light, toilets near the water, or soap. Others have defecated on the floor. government of ce. She holds her breath, goes quickly. Openly defecates in the elds Goes to public toilet near where he works because on the way home. the factory has no toilets. There’s a long line, so he urinates outside. When tackling the challenges of urban sanitation, individual household toilets (IHHTs) are not enough. Most people in a city spend a large portion of their day outside of their homes - going to work, to school, to the market, and many other places. When outside the home, people need to have access to safe, clean facilities where their waste will be properly stored and ultimately treated. In order to achieve Citywide Inclusive Sanitation, options for shared and public sanitation facilities must also be considered, and investments in construction and operation and maintenance of shared facilities must also be prioritized. By doing this, governments can ensure that the Mijini family and millions more have the facilities they need to ourish and stay healthy! 16 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK TIP • Although in general, IHHTs are preferable to shared household or community models, the extraordi- nary variety of global situations requires project planners to never assume this preference without engaging the community to understand their preferences and needs and to identify whether there are important excep- tions that must be considered. For example, in cases of rentals, extremely low-income residents, and other situations, the costs and logistics required to secure IHHTs may not be feasible or even a priority for indi- viduals. Where landlords cannot be motivated or incentivized to provide IHHTs, identifying alternatives to IHHTs that provide the same basic service and dignity will likely require tackling complex policy challenges. EXAMPLE • A three-year ethnography study about experiences and perceptions of sanitation across a diverse group of low-income, urban men, women, and children assessed programs led by nongovern- mental organizations (NGOs) and community-based organizations (CBOs) across Chittagong and Dhaka (Bangladesh), Nairobi (Kenya), and Hyderabad (India). The study found users frustrated by NGO- and CBO-driven programs that failed beyond the life of project funding. Failure was attributed to a number of reasons, including a requirement of personal investment from users even as they faced insecure tenure and teaching hygiene practices that were not relevant to users’ personal and cultural beliefs. Worse off may be the communities where NGOs and CBOs do not enter, even though these areas may be home to the lowest income households and most marginalized communities. The study also found that official planning and NGO planning for sanitation largely ignore issues of citizenship, legality, and land tenure. Source: Joshi, Fawcett, and Mannan (2011), http://journals.sagepub.com/doi/abs/10.1177/0956247811398602. toilets due to issues of land tenure, financial means and where they work, pray, play, learn, and engage with the bio-physical factors that limit their ability to invest in and wider city—in addition to safe sanitation that is as close construct single household toilets” (Keraita et al. 2013; to home as possible. Spencer 2012; qtd. in Rheinländer et al. 2015, 509). Urban sanitation programs typically target an individual How Well Do Sanitation Services Meet Users’ delivery model, or specific neighborhoods or communi- Needs? ties, rather than consider the entirety of the sanitation service chain and how different types of physical infra- Overall, many low-income residents without IHHTs do structure and sanitation services can meet the needs not have their basic sanitation needs and wants met by of users as they move through their days. Investments existing shared toilet models. This can be because of the in utilities often serve to improve services for residen- physical design of the facility: a simple oversight, like tial, commercial, and public sector customers who are lacking a ramp in addition to stairs or inadequate light- already connected, rather than extend connections to ing at night. It can also be because of the management unserved and underserved areas. As a result, the lowest model: if revenues from advertising in high-traffic areas income and most marginalized communities are per- are prioritized over good customer service and user fees, sistently excluded from sanitation programming and service delivery will suffer. 2 If a service authority is not investment or receive fragmented, temporary solutions. held accountable or does not hold service providers A core principle for CWIS is to ensure that low-income accountable, services are unlikely to be safe, adequate, and marginalized communities have access to sanitation or convenient from a user or public health perspective. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 17 EXAMPLE • The city of Warangal, India, sought to understand the role of gender in public toilet design and use. City officials reviewed use of the growing number of public toilets in the city. The review found that women tended not to use facilities for the following reasons: • About 63% of women expressed a preference for female-only toilets, with a separate entrance for women, and 72% expressed a preference for a female caretaker. • Distance from home to the toilet was an important parameter in planning the locations of new toilets: 5 minutes was determined the most appropriate distance in terms of time to access. • Unclean surroundings, unhygienic facilities, lack of privacy, crowding of men around the toilet, and behavior of the caretaker deterred women from using the city’s public toilets. The city sought to address these concerns. They renegotiated contracts with existing service providers to ensure separate entrances for women at all new public toilets being built. The city then set up a number of public toilets designated as female only. This course correction was relatively simple and low cost but would not have been possible without action-oriented monitoring of gender-disaggregated service levels and user experiences. Source: Interview with Professor V. Srivinas Chary, Administrative Staff College of India. Because most shared toilet models are planned and users—for example, people with disabilities, the elderly, funded on a project basis by governments and donors, and women—and the special needs of these groups the priority is to install a physical structure, whereas the should be considered. Users should also have a mech- delivery model may be based on false assumptions of anism to report examples of poor service to a service use, willingness and ability to pay, and level of effort to authority or a similar entity that will respond quickly if maintain the facility. If the quality of service is below what the toilet is not clean, if the wait times are too long, or users are willing to tolerate, the service and the asset fall if the contents of a septic tank are backwashing into a into decline, and eventually one finds an abandoned toilet community. This basic function of mutual accountability block that nobody uses for sanitation purposes. is often missing in shared toilet models (and across the sanitation service chain) and results in mutual disem- powerment and lack of trust. This further breaks down How Can User Needs Be Addressed? services because users will not—nor should they be expected to—pay for services that do not work or offer A telling indicator of whether users’ needs are being met value. is the extent to which users are involved in the various stages of initiating, executing, and managing a shared When feedback loops are effective, their effect on the toilet model over time. Although the literature offers design and management of shared toilet models can be some consistency about what users want, there is vari- very positive. Service authorities can work with users to ability in different communities. The best way to find monitor basic service levels and allow service providers out about whether needs are being met is to ask directly. to creatively meet expectations in ways that work for Also, the feedback loop works both ways. Ongoing their business as well as the community. engagement and dialogue should contribute to a culture of responsiveness between users and service providers A decision tree relating to toilet users and demand is to meet each other’s changing needs over time. Service provided in figure 4.1. providers must be cognizant that there are many types of 18 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Lack of attention to affordability and Are users involved in NO acceptance may affect sustainability. User the design and initial inclusion development of the toilet service model ? Adapt design and initial development YES based on their input and feedback. Are users involved in the design and YES Are users involved in the management of facilities? initial development of the toilet facility? NO May be sufficient for a public model; YES NO less so for community/shared models. Lack of attention to user needs may Shared household or community models may be appropriate. affect interest and ability of targeted Assess supply chains for cleaning, hygiene, and affordability. users to use the facility. Are users involved in the monitoring of the facilities? User feedback is critical to ensure services are meeting needs over time. Pursue Identify ways to make user feedback more efficient opportunities to collect, analyze, and use NO YES and useful to inform service improvements. customer data to improve services. Figure 4.1 • Decisions and Alternatives for User Inclusion in Shared Toilet Models EXAMPLE • In Rajastan, a government of India–sponsored project sought to empower women by build- ing household toilets to increase safety and privacy while meeting sanitation needs (O’Reilly 2010). Women had been holding their urine during the daytime and then walking to community latrines in the dark. Initially, women did not participate in site selection decisions for the new IHHTs. Ultimately, most latrines were built in family courtyards, a location in the home that was reserved for men and guests, thus excluding women from using them. The project ultimately adjusted to include women and men in site selection, and facilities were placed in a more private part of the household so that women could access them and have dignity in their use. Source: FSG Gender and Sanitation Evidence Review, Draft Report for the Bill & Melinda Gates Foundation, July 2017. EXAMPLE • In Durban, South Africa, a design goal for new community toilets was to attract residents to use the toilets regularly. Through talking with users, one unexpected demand that became apparent was comfort: users want to read and relax in the toilets as a space away from home and work. As a result, toilet block attendants are permitted to set up games and music near the toilets, which creates opportunities for additional revenue streams while offering users opportunities to read, relax, and socialize. Source: Interview with Neil Macleod, former head of eThekwini Water and Sanitation Department. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 19 EXAMPLE • The design goal for Samagra community toilets in Pune, India, was to reduce vandalism and increase safety and maintenance at scores of dysfunctional community toilet blocks. Samagra rede- signed existing blocks with bigger windows, better ventilation, and better cleaning tools. The company also engaged community members—especially children—with complementary education about good user practices to increase and improve use and reduce open defecation. Attendants are trained, provided health care, and allowed to vend items on the side for additional income and to improve their stake in maintain- ing quality services. The company also vends advertising space, health insurance, bill pay options, and other services to supplement low revenues, keeping user fees affordable. Source: Interview with Swapnil Chaturvedi, Samagra CEO. EXAMPLE • In Addis Ababa, Ethiopia, initial public toilet designs for a public investment program included stairs to access facilities. After one of the female operators, who has a disability, mentioned that she was unable to use the facility due to the lack of a ramp, the design was updated such that all new facilities now include ramps. Further engagement with the operators and local community led to adding additional services—water for washing, small seating areas, and more—at each new public toilet site. Source: Inter- view with Yitbarek Tessema, Lead Water Supply and Sanitation Specialist at the World Bank. RESOURCE • The Business Model Canvas is a useful tool that offers a constructive method for thinking through different types of customers of a service, what they are looking for in a service, and how that service can be provided to them. This strategic “canvas” is intended to allow for rapid sketching and iteration, and includes questions about costs and revenues, which can help in thinking through whether a service will be sustainable over time. The tool design draws from the experiences of thousands of experts with business, strategy, and innovation backgrounds. Over the last 10 years, an ecosystem around the business model canvas (https://strategyzer.com/canvas/business-model-canvas) has emerged, including many free online resources and facilitation methods. Notes 1 The Sanipath website offers information about and a tool to assess 2 See, for example, experiences in Delhi, India, as described in World public health risk as it relates to sanitation, with a goal to help Bank (2007). inform investment planning processes. See https://sanipath.org. 20 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK  ANITAT I O N F R O M TH E PE R S PE CTI VE O F 5. S S ERV I C E PR O VI D E R S What Are Sanitation Service Providers? role may be limited to a service level operating agreement for basic cleaning and light maintenance. Build-oper- In the context of shared toilet models, service providers ate-transfer (BOT) contracts and design-build-operate offer diverse services depending on the model and the (DBO) contracts have been used in some areas; all con- market, from an individual caretaker under contract with a tracting structures can focus on a single facility or ex- service authority to manage and clean a facility to a private tend to multiple sites or even zones within a city. Despite company that builds and manages a full fecal sludge man- the diversity of models and independent of scope, pro- agement (FSM) service chain for community and shared viders are likely to benefit from orientation and training household toilet facilities. Their relationships to different to ensure they are aware of and capable of delivering de- users will also vary greatly from setting to setting. fined activities and outcomes. Ensuring a common and clear understanding of expectations among parties is a What Does a Sanitation Service Provider Do? critical starting point. Generally, a sanitation service provider ensures that a toilet facility is stocked with supplies, provides cleaning Who Are a Service Provider’s Clients? services, and ideally, manages the flow of users entering Providers may be contracted to provide a defined set of and exiting the facility—particularly during peak times. services by a landlord owning residential or commercial The provider typically collects and manages revenues; it property (or properties); a public agency or service au- may also provide back-end bookkeeping and accounting thority, such as a utility company or municipal govern- for the toilet facility or a cluster of facilities. Sometimes, ment; or a public or private enterprise, such as a hospi- the sanitation service can be seen as a base for generat- tal or bus company. They may act independently in an ing other revenue streams. unregulated or under-regulated marketplace and work In practice, the boundary of responsibility for a provid- directly with users as their primary paying clients. In er varies by context, and ideally, by contract. A provider most cases, they are providing services to multiple cli- may have a service contract to manage operations and ents. Hence, although the primary objective for a service maintenance for several facilities, including sludge emp- provider should be to extend basic services, including tying and major repairs for a multiyear period. Or, the menstrual hygiene management (MHM), to unserved EXAMPLE • For many years, community toilet operators in Accra, Ghana, were notorious for being responsive only to political interests that provided lucrative operator rights to community toilets and their associated user fees. Toilets were filthy, but users—generally low-income renters in densely populated communities with high water tables—did not have the resources or conditions for alternatives. Increasing national and international pressure to improve conditions led to increased but incomplete enforcement of landlord-provided shared toilets and resources for IHHTs. Still, poorly operated and maintained community toilets persist as the only option for many low-income users. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 21 TIP • A provider that is reliant on multiple categories of clients for financial viability may have more direct accountability to provide quality services and ensure that public health and safety goals are being met. Good services may be necessary to secure revenue streams from users, from service authority contracts, and from complementary vendors (for example, advertising partners who may expect a steady stream of potential cus- tomers passing by their message and want to be associated with a positive, clean space). Diversifying revenue streams can, however, also weaken the toilet’s core business model. Where revenues are highly fragmented and payers’ accountability is low, service providers’ viability may weaken, for example, from time spent chas- ing late government reimbursements, fighting turned off water supplies, and trying to collect tiny fees from users who expect free services. Without a strong, primary revenue stream that covers costs (acting as an ‘anchor’), providers may attempt to start multiple lines of business, many of which will likely fail. In practice, diversifying (or stacking) revenue streams tends to work in public toilets, where revenues from user fees can be higher. It can also work in one-off cases where creative local entrepreneurs are able to keep their overhead low. However, cases of a business scaling this model in a financially viable manner—particularly for community toilets—were not identified. Private service providers have an advantage, contractually or de facto, if their services can be adjusted or even stopped when payers miss or delay payments or if payers fail to follow through on other in- kind commitments that affect business viability and service quality. Enabling conditions for service provider success • Capable, trained, and incentivized/motivated operators (public, private, or community based), supported by service authorities through payments, public education, FSM services, and other needs • Proper use of technology/IT services for mobile measurement, monitoring, and payment services, potentially including cashless payment options • Secure operating environment with support of local vested interests, including local government • Reliable and diversified revenue streams to support operating model and preferably some contribution to capital maintenance or expansion • Clear accountability and enforcement mechanisms among users, service providers, and service authorities • Appropriate design and quality construction of toilet blocks, supported by effective maintenance systems • Clear land tenure or supportive land use policy where land tenure is not clear; must allow for a fixed or mobile toilet, including drain field and underserved populations, a service provider’s clients ing. In these lighter contractual arrangements, service may not be the users themselves. authorities retain significant responsibility for ensuring the assets are well maintained and serviced beyond day- How Are Service Providers Compensated and to-day cleaning and maintenance. Practically speaking, they do not consistently act on that responsibility. Ser- Held Accountable? vice providers may also be engaged under a contractu- At a minimum, service providers for shared toilet mod- al agreement that provides regular payments from the els may be engaged and compensated in a hired or sala- service authority, or preferential operating rights in a ried arrangement or provided in-kind benefits like hous- given area, in exchange for an agreed-on level and quali- 22 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK ty of service provision. More successful community and What Factors Go into Designing a Contract public toilet models emerge when service authorities are for a Shared Toilet Model? willing to enforce contracts and cancel them when the terms aren’t being met. Setting up effective arrangements with service providers depends, to some degree, on the type of facility and type With respect to compensation, a single provider may need of model that is intended to deliver services. These are not to collect revenues or in-kind contributions from many static. A shared household toilet may look very similar to clients or customers to ensure a viable business. These an individual household toilet (IHHT), just with more peo- may include user fees, advertising fees, sales of other util- ple using it and a delivery model that includes cleaning. A ity services like water and electricity, desludging of septic community model may be constructed as a community as- tanks, and connecting shared toilet models and house- set, with bathing facilities, laundry, and space for social ac- holds to sewer networks, where this is possible. It may tivities and require a more complex management contract also include subsidies and maintenance reimbursements that includes social outreach as well as operations. A public from a service authority. A successful management model toilet may be designed for quick visits (primarily urina- may also use the toilet facility as an anchor for other reve- tion), with a straightforward management contract. How- nue-generating schemes, such as small shops, water sales, ever, experience also suggests that the same physical asset mobile phone charging, and community meeting spaces. can provide sanitation with different delivery models. Con- Service providers may operate multiple sites in an area, sider a toilet block with 10 toilet seats, separate entrances, or across a city, and hire staff for individual locations. By and an equal number—five each—of latrines for men and operating multiple sites across the city, the service provid- women as a starting point. Figure 5.1 offers an example of ers may also be able to recover costs from some of the less how the same basic physical structure can be overlaid with profitable locations (for example, those that are located in shared household, community, and public models, and in areas with low foot traffic or areas where the fees for emp- some cases, multiple models operating together as a hybrid. tying or wastewater tariffs are higher). Management Model 1: Management Model 2: Management Model 3: Shared Household Community Toilet Public Toilet M M W W Four related families share and clean this Circles are shower/laundry Diamonds are urinal conversions toilet, which has a lock for private use conversions Locked, private toilets available to A group of three unrelated families who Available to community members on shopkeepers share a landlord have access to this toilet a membership basis Available to the public on a as part of their rental, on the condition Available to the public on a pay-per-use basis they share cleaning responsibilities pay-per-use basis Four unrelated families share the costs to clean and maintain a private toilet Figure 5.1 • Possibilities: How Different Management Models Can Be Applied to a Similar Physical Asset SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 23 Regardless of the specific model or approach taken, in • Define potential financing models to attract fund- most contexts some amount of iterative learning must ing to meet cost requirements take place because the needs and preferences of users are • Define, at a high level, service delivery models to different—even within different parts of the same city. be used (for example, whether municipally man- Consequently, it is important to plan for sufficient time aged, community managed, or privately managed for getting these models to scale. or whether a hybrid approach is preferable) In the early phase of implementation, experimenting When Are Different Models Appropriate? with alternative operating and revenue models can help better understand the needs of the population and how Different situations call for different shared toilet mod- these needs can be met with an enduring management els. An experimental mindset is needed to cultivate model. Notably, all models should be expected to require models that can endure over time within the context of some level of support from public, private, and non- citywide inclusive sanitation (CWIS), as part of a portfo- governmental organization (NGO)/community-based lio of service models to achieve the Sustainable Develop- organization (CBO) sectors in different capacities and ment Goals (SDGs). at different times. For this reason, the service authority must also be flexible to support models evolving to meet Table 5.1 outlines some of the variety among shared a community’s or neighborhood’s changing needs. household, community, and public toilet models. Deci- sions on which shared toilet models are most appropri- ate for different locations should be informed by insights A closer look at shared household sanitation gained through the situation analysis, as described in models “Understanding the Sanitation Market.” In some places where land tenure and housing markets For a basic market analysis, a variety of investment and are fairly stable, long-term residents of neighborhoods revenue collection models can be considered. Ideally, a and housing compounds may be interested in investing city will use the situation assessment to develop invest- in shared toilets, particularly when there is a subsidy to ment plans that do the following: help offset capital costs of construction. In low-income • Design and apply criteria for where, geographically, and informal areas, a shared household sanitation model investments are required will depend on convincing landlords—who may be ab- • Articulate minimum service levels for new investments sent, unavailable, and disinterested—to convert either • Estimate the cost of investments for new facilities as land, or one of their units, for a toilet and possibly for well as for rehabilitation of existing assets TIP • Articulating a business case for investment in and provision of shared toilet models is a considerable challenge for numerous reasons, including the perennial challenges of pricing and revenue, where prices are too high for users and are often too low to cover operational costs, let alone maintenance or rehabili- tation. For the most part, charging low-income and slum areas for the full cost of investment and services is impossible. Subsidies or cross-subsidies are necessary and could include in-kind contributions or tax exemp- tions. Creativity and experimentation are needed to identify a business case that blends public and private investment in the absence of financially profitable service models. 24 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Shared Household Community Public Asset ·· Landlords ·· Government/local public sector ·· Government/local public sector ownership ·· Residents (if they are home owners/ ·· Nongovernmental organization (NGO)/ ·· Private company landowners) community-based organization (CBO) Management ·· Cooperative financial investment: users ·· NGO or CBO led, with regular community/ ·· Private sector led, governed by a model pool resources to pay for maintenance user committee engagement contract with service authority or utility (minor maintenance to emptying) ·· Private sector led, governed by a service ·· NGO/CBO led, governed by a contract ·· Landlord maintains and manages reg- authority or utility with service authority or utility ular and larger maintenance, charging ·· Local government operated ·· Private sector owned and operated fees to offset cost ·· Privately managed through a cross-subsidy independent from service authority from profitable public toilets (for example, as a stipulation of contract with service authority) Operating ·· Cooperative time investment: resident ·· Caretaker (part-time or full-time), paid for ·· Caretaker (part-time or full-time), paid model users clean and maintain according to maintenance or in exchange for housing for maintenance or in exchange for schedule they create and manage at facility housing at facility Revenue ·· Landlord can charge higher rents and ·· Transfers: from government budgets or ·· Fee for service: pay-per-use, payment model increase stability of renters donors models ·· Households share costs ·· Cross-subsides: for example, through a ·· Value-added services: biogas genera- privately managed public toilet concession tion, other utilities (water/electricity), ·· Fee for service: multiple models (for exam- kiosk, entertainment ple, membership, pay-per-use, payment models) ·· Value-added services: laundry, shower, meet- ing room, biogas generation, other utilities (water/electricity), kiosk, entertainment Financial ·· Microcredit for initial capital costs of ·· Capital expenditures (capex): grants and ·· Capex: grants and loans for capital model construction loans for capital costs; land donated or costs; land or infrastructure donated or ·· Public subsidies for household-level subsidized by public agencies subsidized by public agencies toilets ·· Operating expenses (opex): covered ·· Opex: covered from user fees ·· Households pay for cost directly partially or wholly from user fees, possibly offset by grant or public funds (for example, utility costs) Accountability ·· Increases with fewer participating ·· Feedback mechanism for users to report on ·· Feedback mechanism for users to report model families per toilet; tighter preexisting operators’ performance on toilet condition social bonds ·· Regular engagement between operators and ·· Regular performance review by service ·· Locks/security to ensure privacy and users to adapt to user needs authority exclusivity to users Table 5.1 • Landscape of Business Model Options along the Shared-Community-Public Toilet Continuum SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 25 EXAMPLE • In 2007, in Mukuru, a settlement in Nairobi, Practical Action (PA) initiated a program to expand water and sanitation services to the area. The average house size was small—measuring 3-by-3 meters for five people—and was part of a block of six, eight, or 10 single rooms on a plot of land with shared walls. These plots were owned, mainly, by absentee landlords who rented either individual rooms or the full house. At baseline, 11 percent of families had access to an IHHT, whereas 16 percent shared a toilet with their neighbors. The rest claimed to use a community toilet, but in practice, open defecation was rampant. As part of a wider program to strengthen relationships between the utility (service provider) and the commu- nity, PA developed a new shared household toilet model, which they called a stand-alone toilet (SAT). The idea was to convert one of the 3-by-3 rooms of a house into a shared toilet facility, with a toilet and a hand- washing basin outside. These were built with local labor, overseen by the Clerk of Works, who also helped in siting the toilets to access the sewer main, which was extended as part of the partnership with the utility. Because space was so limited, a few landlords were financially supported to convert one of their house plots into an SAT. The idea took off, with evidence of replication by landlords, because they often stood to earn more by charging households to use the SAT than they would as a rental only. Source: Peal and Evans (2010). EXAMPLE • CEPT University has outlined a proposition to leverage the individual household subsidy, offered through India’s Swachh Bharat Mission, which aims to end open defecation in India. Working with local municipal partners over an 18-month period, CEPT modeled existing sanitation scenarios for three cities in Maharashtra: Wai, a tourist town; Ambejogai, a tourist and educational town; and Sinnar, an industrial hub. In all three cities, a majority of citizens had IHHTs. However, the number of families practic- ing open defecation ranged from 2 percent in Wai to 40 percent in Ambejogai, and the percentage of the population dependent on community latrines was 30 percent in Wai, 24 percent in Sinnar, and 4 percent in Ambejogai. In Wai and Sinnar, where community toilets are more prevalent, the research identified that most of the blocks lacked basic infrastructure, with defunct septic tanks and no handwashing facilities. The research also found that local governments were spending considerable funds on maintenance for the facilities. Based on these findings, Wai and Sinnar expressed interest in pursuing a shared toilet model, with no more than four households sharing and agreeing to maintain it over time. Overall, residents were supportive of the idea and expressed a willingness to pay between 13 percent and 20 percent of the installation cost. Wai signed a resolution to implement a scheme to promote individual and shared household toilets, thinking that nationally provided subsidies of 5,000 Rs per family could be applied to shared or household toilets, which were priced at 30,000 Rs per toilet. Unfortunately, despite interest from local government and households, the concept remains an idea due to a national policy barrier: the 5,000 Rs subsidy is strictly defined for individual, and not shared, household toilets. The policy requires families receiving subsidies to upload photos of their new toilets, which are geo- tagged for verification (“One family: one toilet”). This highlights how policies and regulations can fail to accommodate innovation in shared toilet models. Source: Interview with Meera Mehta and Dinesh Mehta, CEPT University. 26 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Landlord Is it physically possible to provide a Is it possible to provide a model shared toilet for multiple households? YES bathing/laundry area for tenants? YES NO May limit tenant willingness NO Will the toilet to pay for toilet. NO service five or fewer families (and no more Can conversion of living space There is high risk that the toilet won’t be cleaned regularly and than 20 people) be mandated/enforced? If no, will become abandoned. Community toilets may be preferable. STOP, and shift to exploring community toilet options. Marketing or incentives to engage landlords for individual household toilet and shared models. YES Pay attention to enforcement/ corruption so service levels are Lower potential for repaying loans or Are tenants maintained, as well as opportunities offsetting lost rent from unit conversion. NO willing to pay for expansion of service and more in rent for completion of the fecal sludge a shared management value chain. Explore opportunities to generate data on performance household toilet to inform policy and planning for service expansion. YES and contribute to cleaning/- YES Are finance mechanisms maintenance? Address other obstacles first. available to support Focus efforts on strengthening the enabling NO capital investment? environment for municipal governance. Figure 5.2 • Decisions and Alternatives for Shared Household Toilet Models showering and laundry facilities. The incentive will like- munity toilets are often promoted as alternatives to open ly need to be economic. defecation or shared toilets when shared household or IHHTs are not possible. Local governments may invest Assuming a landlord is interested in considering build- in these facilities to advance a political agenda before an ing shared household sanitation, figure 5.2 provides election, hoping that a third-party provider—often an some initial prompting questions and considerations to intermediary NGO/CBO—will deliver sanitation ser- inform decision making. vices in areas beyond the sewer network, at little or no cost to the city. For NGO/CBOs, sanitation is often per- ceived as paramount to economic and social develop- A closer look at community toilet models ment in low-income areas. Although on paper this may At their best, community toilet models offer users a seem like a positive dynamic, in practice, community clean, safe, and secure toilet; located within a reasonable toilet models typically struggle to provide high-quality distance from homes; and with minimal wait times be- services, and they lack a financial model for replication. cause the pool of users is limited and can be accommo- In practice, NGOs/CBOs tend to manage community dated by the number of seats the facility offers. Com- toilets. Their organizations’ employees are not neces- SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 27 EXAMPLE • In Pune, India, wards across the city invested in hundreds of community toilet blocks over many decades. Invariably, the facilities fell into disrepair because of lack of maintenance, leaving residents to use unsafe facilities or resort to open defecation. Periodically, the blocks were refurbished at great pub- lic expense, only to repeat the cycle. In this context, the city’s mandate to provide sanitation was clear, and budget was available. However, there weren’t any accountability mechanisms to ensure safe services were being delivered. In response, a social enterprise startup, Samagra, negotiated with the city for exclu- sive management rights to the blocks, in exchange for a one-time refurbishment investment and utility cost payment. The company renovates each block based on human-centered design to improve the user and caretaker experience while limiting opportunities for theft and vandalism (for example, of faucets and other facility parts). Facility management teams have been professionalized and incentivized to ensure facilities stay clean, and the company layers in multiple complementary sources of revenue to meet its cost and profit margins, given that user fees are otherwise too low, and unreliable, to cover costs. This is an example of a win, where public expenditure and private sector profit complement each other to result in better, more affordable services for community members at a lower long-term cost to the city. sarily trained to manage toilets technically or from a Types of costs associated with shared toi- business perspective, so training and capacity building let models are required. These organizations’ ability to scale oper- • Planning and development costs ations is also limited. Private companies can also be di- oo Situation assessment rect service providers for community toilets, providing oo Initial design and development caretakers for individual facilities, as well as back-end • Capital expenditures: administrative and logistics support for things like cus- oo Cost of land (if purchased) tomer feedback or integrating digital finance as a pay- oo Building materials ment model. oo Urinals/toilets/pans oo Construction costs Community toilet models can be a useful and necessary oo Septic tank or sewer connection alternative in residential areas, with a variety of possible oo Connection to power/water/telecom pricing structures, from club membership models that • Operating expenditures: allow for unlimited use by households on a fee per-week oo Electricity/water/solid waste/other utility bills or per-month basis to differentiated pricing structures oo Labor (cleaners, administrative, other staff) that serve a wider pool of potential users. Even so, expe- oo Bookkeeping/accounting rience suggests that community toilets typically fail over oo Security time, while successful cases are limited in their scale of oo Maintenance/repairs operations. Community toilet models are difficult to es- oo Community/customer engagement tablish and manage. Target users tend to be either un- willing or unable to pay fees to cover operating costs. Quality professionals of any category are difficult to en- gage given the host of complexities and challenges and that can undermine efforts to improve community ser- the promise of relatively low or even negative margins. vices at all aspects of the sanitation service chain. They include pit emptying mafias, local control of budgeting Many low-income communities around the world also allocations to serve some areas over others, and takeover have vested interests and are part of political structures of shared toilets to exclude use by targeted groups. These 28 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Ensure land tenure/land use policy YES Are there clearly understood and accessible offers suf cient space for separate mechanisms for users, providers, and service Community male and female facilities and authorities use to ensure basic services? toilet model Explore/expand drainage*, or STOP and consider use of mobile potential for impermanent facilities. data for operating NO Engage with local YES ef ciency. Are there existing micro nance assets that can be NO institutions/com- Reevaluate viability of community mercial banks to Are community refurbished? model; invest in enabling environment. seek and secure members willing Engage community nancing. and able to pay to understand for toilet or YES past failure. High risk that long-term subsidies and support value-added will be required to keep facilities functional. NO services? Are there existing nongovernmental/ community-based organizations, or Is there potential to Pursue value added services that will contribute YES private service providers with bundle management to community’s economic and social well-being. capacity to manage ≥1 facility? functions with nearby public toilets, to increase potential for Is there space/potential to offer NO YES value- added services? (for cross-subsidization? YES example, bathing, laundry, water, electricity, meeting room) NO Service authority may need to NO play a stronger role in managing Consider bundling service. And, lack of viable management of Seek alternative community locations to meet Long-term subsidies providers could signal community multiple facilities into residents’ sanitation and hygiene needs. may be needed to need for subsidies and support. ensure basic service. a delivery contract. *drainage is necessary if no sewer connections are available Figure 5.3 • Decisions and Alternatives for Community Toilet Models interests must be clearly understood and often engaged This requires a significant up-front cost, which is often directly to help prevent service disruptions and irregu- left out of project-based planning budgets and timelines. larities. Vested local interests can also create safety risks For service providers, maintaining good relationships for service providers and users by creating political chal- with community interests is worth assuming as a recur- lenges or financial risk by taking over assets once a pat- ring investment requirement. tern of user payments has been established. Figure 5.3 provides initial prompting questions and con- siderations to inform decision making around the de- Sometimes these same stakeholders can be resources, sign and implementation of community toilet models. improving safety, facilitating community engagement, and leveraging relationships with other local leaders. Cases in which these dynamics have been successfully A closer look at public toilet models managed generally required substantial community en- gagement, time, and resources to understand dynamics, Public toilet models are the least preferable for serving to engage target users, and to establish adequate trust. users in their residential communities. They are typically SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 29 designed for use in public places and tend to be found viable than other shared toilet models. However, because in areas with high pedestrian traffic, serving users with government oversight and competition tend to be limit- diverse income levels. The management model tends to ed, public toilet service providers are not naturally incen- prioritize quick urination by people who are in transit tivized to maintain high service levels for their custom- from one place to another. To date, such facilities are ers. Because public toilets are perceived to generate more typically designed for a predominantly male customer income than community or shared household models, base. Clear mandates and incentives need to be in place they are often seen as opportunities for cross-subsidy to to ensure services are provided for a variety of users: support less crowded toilets in residential areas. In prac- women, children, elderly people, and people with dis- tice, the business case for such a cross-subsidy has not abilities, among others. To be inclusive, facilities should been demonstrated, without additional public or donor address all users’ concerns about safety, cleanliness, pri- subsidies. vacy, as well as design. Figure 5.4 provides some initial prompting questions and A fee-for-service revenue model is a common structure, considerations to inform decision making concerning the and as a result, public toilets tend to be more financially design and implementation of public toilet models. Ensure land tenure/land use policy offers Explore opportunities to digitize High likelihood of sufficient space for separate male and feedback, and connect performance with failure. Reevaluate female facilities and drainage*, or STOP and financial incentives for service expansion. purpose and objectives Public toilet of public toilet model consider potential for impermanent facilities. model and how they can be achieved. YES NO Maximize revenues Are there existing without compromising assets that can be NO core sanitation business. refurbished? Is there a contracting mechanism in place that allows for regular monitoring of service levels? Engage users and other High risk that services Is there potential to generate YES stakeholders to will not be maintained YES additional revenues, for example, understand past failure. over time, resulting in through advertising on walls/roof unsafe or abandoned NO billboards or provision of a cell tower? facility. Are there existing nongovernmental/ community-based organizations Pursue value-added services that will contribute providers with capacity to manage Is there potential to bundle to community’s economic and social well-being. YES ≥1 facility? management functions with other public toilets or community toilets, for Is there space/potential NO YES greater operating efficiency? YES to offer value-added, services? (for example, water, electricity, kiosk, NO NO meeting room) Service authority may need to play a Consider bundling stronger role in managing service. And, lack Long-term subsidies management of Seek alternative locations to meet of viable providers could signal community may be needed to multiple facilities into residents’ sanitation and hygiene needs. need for subsidies and support. ensure basic service. a delivery contract. *drainage is necessary if no sewer connections are available Figure 5.4 • Decisions and Alternatives for Public Toilet Models 30 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK RESOURCE • Human-centered design is a method pioneered by IDEO, a San Francisco–based design firm behind iconic products including the mouse (for computers) and the air pump. According to IDEO’s (n.d.) website, “Human-centered design is all about building a deep empathy with the people you’re design- ing for; generating tons of ideas; building a bunch of prototypes; sharing what you’ve made with the people you’re designing for; and eventually putting your innovative new solution out in the world.” For more information, see http://www.designkit.org/human-centered-design. For more information and a case study about the Clean Team in Ghana and how they incorporated human-centered design into sanita- tion service delivery, see http://www.designkit.org/case-studies/1. RESOURCE • GIZ (2016) has developed an informative assessment of public and community toilet mod- els focused on India but with wider relevance. The assessment includes why public and community toilets are important and several shortcomings and success factors in their design, implementation, and ongoing management. Success factors include data-driven decision making in demand and supply assessment, a shift from installing assets to cultivating services in implementation, and focusing on accountability, adequate monitoring, and financially viable business models. Shortcomings include failure to incorporate user prefer- ence during the design phase, incorrect selection of construction material, unsuitable design in the planning process, absence of monitoring and enforcement mechanisms, and insufficient funds to cultivate financial viability. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 31  A N I TAT I O N F R O M A S E RVI CE 6. S A U TH O R I TY PE R S PE C TI VE What Are Service Authorities, and What Is Key elements of an effective service Their Purpose? authority • Clear legal mandate to ensure inclusive and Service authorities are entities responsible for ensuring safe citywide sanitation—agnostic of technol- sanitation services are delivered to a defined popula- ogy—that specifies: tion or within a geographic area on an ongoing basis. • What service levels must be guaranteed Responsibility for ensuring service delivery should be • Service area boundaries, including areas of accompanied by adequate resources to deliver those greatest need within and around a city services and a system of accountability for meeting • Emphasis on ensuring appropriate services mandated performance targets. Service authorities tend for women, girls, people with disabilities, to be a public sector municipality, county agency, or and other subpopulations utility provider. They may delegate the work of actual • A reliable, ring-fenced budget that maps to a service delivery to one or more service providers from reasonable estimate of the costs of ensuring the private sector, a department or multiple departments sustainable, and inclusive, service provision within the authority, or otherwise. Regardless of how • Accountability to some third party for per- actual services are provided, the service authority holds formance (for example, state government, the ultimate accountability for user needs being met. regulator), inclusive of transparent monitoring and mechanisms for public engagement • Pro-poor division that is trained, structured, What Do Service Authorities Do? and incentivized to ensure services reach and engage the most vulnerable and marginalized Service authorities should, but do not always, have a user segments clear legal mandate to deliver clearly defined sanitation services. Ideally that mandate is consolidated under to all residents in its service area. If this includes infor- a single agency. The legal mandate and corresponding mal and fragile settlements, the utility provider may policy guidance should include high-level parameters get a corresponding budget allocation tied to reaching for the minimum service level required (for example, those communities. Sometimes, this budget is chan- accessible, safe, inclusive, and appropriate for the needs neled through a stand-alone pro-poor division in the of all users, including special needs of women, children, utility provider, which may serve either an advisory or and people with disabilities). The mandate or policy operational function. Alternatively, pro-poor activi- should address any special inclusions and how those ties are mainstreamed throughout the utility provider’s are to be handled. Ideally, these policies clarify subsidies operations. Research into the effectiveness of pro-poor and financial flows and ensure disbursement so that the divisions suggests that they are effective when they play scope of policy ambition can be achieved. For example, different roles over time to meet prescribed needs. For a utility company may be required to provide services example, if the utility company is just starting to assume 32 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK TIP • If multiple authorities are responsible for different components of sanitation service delivery, a coor- dinating committee or working group should be established, and a plan should be elaborated and jointly managed to coordinate assessments, monitoring efforts, investment planning, and other activities. It may be worthwhile to hire a dedicated coordinator/facilitator to cultivate collaboration across relevant stakeholders. EXAMPLE • In Maputo, Mozambique, there are two layers of local decision making, with district and ward officials, some of whom are political appointees and others who are administrative officials. Because responsibility for household sanitation in non-sewered areas is not clearly defined, decision making and accountability are often blurred. Complicating this reality is that political officials are elected to represent the whole city, which often means that low-income and marginalized areas are neglected by the political apparatus. It is important to understand how local decisions are made as part of adopting citywide inclusive sanitation (CWIS): low-income areas with the greatest need for sanitation are often excluded physically from formal utilities; socially, from political systems; and financially, from the budget process. Source: Interview with Tanvi Nagpal, School of Advanced International Studies. responsibility for service delivery in unserved areas, a and execution are slow and insufficient to meet demand. pro-poor division can act as a champion and catalyst In these cases, serving marginalized communities with for better services. If the utility is providing services in non-sewered options often falls to another entity or is underserved areas, a pro-poor office can act as a focal left up to individual households. This results in higher point for mainstreaming what works to upgrade and costs for non-sewered households, who are often lower improve services. For some utilities, pro-poor units income than those with access to the network. Where may be time bound. Others have a permanent division land is scarce and population density is high, possibil- to meet changing needs of low-income areas over time ities for new individual household toilets (IHHTs) or (Peal and Drabble 2015; see also World Bank 2009). shared sanitation are limited. In some cases, responsibility for sanitation services is divided across multiple authorities. Services related How Do Service Authorities Function, and to conventional sewerage systems, on-site fecal sludge How Are They Accountable for Services? management (FSM), provision of public and community toilets, and managing effluent in storm drains can all A service authority must have budget that is reliable, and fall to different entities. Likewise, when administrative ideally, has a somewhat diversified set of funding sources boundaries of a city may not correspond to population (for example, revenues, central or state transfers, local density and need, service provision mandates may fall to tax base). The budget should reflect the approximate both city and county authorities. public costs of ensuring CWIS on a sustainable basis. The authority should be allowed significant flexibility When utilities are mandated by service authorities to to source private investment and use rules, regulations, provide conventional, sewer-based sanitation, they tend and incentives to ensure services are being delivered to prioritize sewer networks in the urban core. Even if cost-effectively. It is generally not reasonable to expect there are plans to extend networks to technically difficult a sanitation service authority to be financially indepen- and expensive-to-reach communities, actual investment dent: public finance, and often donor finance, is needed. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 33 Further, where a service authority relies on shared toilet are set or institutions lack sufficient resources, then the models to meet its service delivery mandate, implemen- effectiveness of accountability measures is undermined. tation generally will depend on some portion of costs being covered by central or state funds or financing, par- Just as a service provider can be held accountable to the ticularly for capital expenditures. service authority with a service level agreement, a simi- lar tool should be used to ensure that service authorities Accountability should be complemented by a system are meeting urban sanitation needs. Some experience for technical and financial support and third-party suggests that incentives and community or author- enforcement using a mix of incentives and penalties ity accolades can be effective complementary tools to (for example, state government, regulator), based on penalties. However, in practice, systems to hold service transparent monitoring of key performance indicators authorities accountable are scarce and ineffective. This is about use, safety, functionality, public engagement and true even in places where authorities demonstrate com- responsiveness, and compliance with relevant policies pliance with water service delivery targets. For sanitation, and codes. If poorly designed, monitoring programs there are fewer user fees or revenue streams, and public can result in regulated entities’ making superficial awareness of and outrage over missing services are lower investments to reach targets rather than to provide safe, priority than with missing water services. This is partic- sustainable services. If unachievable performance targets ularly true when considering safe management of waste EXAMPLE • The Kampala Capital City Authority (KCCA) is a city agency that is mandated to provide safe sanitation facilities in communities. KCCA interprets this as including infrastructure provision, providing facility management, and understanding user sanitation needs and practices. Since 2010, the agency has invested in 560 community sanitation investments, with funding from the government of Uganda and civil society organizations. It also inventoried residential sanitation across the city to have a baseline for future sanitation investment planning and management and to meet its obligation, per the Public Health Act of 2000, to “maintain a clean and sanitary condition in the area of its jurisdiction” (KCCA 2016). Source: Kampala Capital City Authority. 2016. “An Inventory of Community Toilets 2016 - Kawempe Divi- sion.” Sustainable Sanitation Alliance. http://www.susana.org/en/resources/library/details/2574. RESOURCE • One often hears about how low-income populations are more likely to have a cell phone than a toilet. Although this is often positioned negatively, an alternative perspective considers: what can be achieved with mobile technology to meet sanitation needs in slums and low-income areas? The GSMA’s Mobile for Development program uses grant investments to explore how use of mobile services, mobile financial services, and machine-to-machine connectivity can connect the sanitation service chain or remotely monitor services or provide opportunities for users, service providers, and service authorities to give and receive feedback on service quality. In 2015, Nique and Smartnik published a report considering the role mobile phone technology can play in sanitation, which profiles sanitation-related activities GSMA’s team invests in and manages. Source: https://www.gsma.com/mobilefordevelopment/wp-content/ uploads/2015/08/The-Role-of-Mobile-in-Improved-Sanitation-Access.pdf. 34 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK in non-sewered areas that depend on FSM. Accordingly, both service authorities and service providers. compliance systems are more difficult to design and enforce. Political will and public education are critically A high-level outline of key questions and guidance relat- important tools for increasing accountability among ing to service authorities is provided in figure 6.1. Consider demonstrating a business case* Does housing code or NO for landlords to provide shared sanitation. Service other local policy require authority landlords to provide toilet facilities? Marketing or incentives are likely needed to YES engage landlords for individual household toilets (IHHT), and shared models. Is the toilet facility and provider part of larger YES city sanitation plan or Are there mechanisms for feedback and distribute slum upgrading effort? NO YES resolution between users and service providers? Poses significant risk to Explore opportunities to NO viability of the service. May limit opportunities to scale and achieve inclusivity, through generate date on performance commercial or public ends. to inform policy and planning for service expansion. Are there mechanisms governing contract compliance between service providers and service authority? Pay attention to enforcement/corruption that service levels are maintained, as well as opportunities for expansion of services YES NO Shift investment focus and completion of the fecal sludge toward strengthening management (FSM), value chain. conditions for municipal governance of service delivery. *for example, ability to attract higher rent and more stable tenants, even from existing tenants Figure 6.1 • Decisions and Alternatives for Service Authorities EXAMPLE • The city of Warangal implemented an app-supported public toilet monitoring system. San- itary inspectors randomly visit and rate each privately operated public toilet according to the elements of the operator’s service level agreement with the city. Users can also rate a facility’s condition by picking one of four rating buttons located at the toilet facility. These data are summarized and shared with the city commissioner weekly. Because the commissioner has been willing to hold providers accountable for ratings, by rescinding contracts for noncompliance, operators have demonstrated improved adherence to service levels set forth in their contracts. The system has been in place for a few years, and its durability has not yet been determined. Source: Warangal city sanitation project reports. For additional information, see http:// swachhwarangal.com/Access.aspx. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 35 7. C O N C L U SI O N The Sustainable Development Goals (SDGs) estab- station. Some experience, like that of CEPT University lished an ambitious and necessary target for sanitation: in Maharashtra, suggests that an innovation mindset can to achieve universal sanitation access and to end open sometimes require patience because policies and proce- defecation by 2030. The sanitation goals and associated dures may prevent experimentation with new approaches targets and indicators are a step change from the Millen- to expanding services. Overall, experience and evidence nium Development Goals, which had a lower standard emphasize the importance of engaging users at all stages based on access to a technology, not a service. Hundreds of the process. This is true whether it is to ensure that of millions of people currently use shared toilet models people who can’t walk are not prohibited from toilets as their primary residential service. The health and social because of lack of ramps, as in Ethiopia; that toilets benefits of universal sanitation access in urban areas can- intended for women’s use do not end up in courtyards not be attained without having shared and community reserved for men and guests, as in India; or simply that toilets—in areas where individual household toilets are services overall are being delivered in adequate quanti- not viable—and public toilet facilities throughout a city ties and at service levels acceptable to users and service to meet people’s sanitation needs throughout the day. The authorities. exclusion of these facilities from counting toward the Shared household, community, and public toilets are SDG target is a disservice to the real needs of people liv- just part of what is needed to ensure safe, appropriate, ing in urban slums and low-income areas. affordable sanitation access for all urban dwellers. These Considering the global ambition to achieve the SDGs solutions fit within the broader citywide inclusive sani- by 2030, this document shows that it may be possible tation (CWIS) approach, which aims to ensure safely to overcome the failures of shared toilet models with an managed access for everyone in a city, using a range of experimental mindset and an appetite for taking risks in technical solutions, designed and implemented through the design, implementation, and management of shared an adaptive and incremental approach, giving full con- toilet models. Risk-taking behavior should be grounded sideration to reuse and resource recovery options. CWIS in good data and evidence, which a situation assessment, also necessitates a focus on having strong institutions along with regular engagement with users, service pro- with clear roles and responsibilities; planning with secure viders, and service authorities, can provide. budgets for both capital and operation and maintenance expenses; and working with other related urban planners This document acknowledges that the business case and service providers to ensure integrated solutions are for shared toilet models is weak at best and will require sought. public or donor funding as well as intentional market structuring that does not preclude the role of the pri- Ideally, this document will cultivate an appetite to learn vate sector service providers. On the contrary, there are more, by flagging important challenges and questions ample opportunities to experiment with business model that others in the sector have grappled with in various designs across shared household, community, and pub- ways. Solutions must be crafted for each situation with lic toilet models. Some of the cases illustrated in this iterative, intentional action, framed within systems of report include mandates for gas stations in Warangal to accountability. The accompanying appendixes are addi- build toilets that are accessible for customers and nearby tional resources to offer guidance and to stimulate new residents and empowering landlords in Mukuru to con- ideas and approaches that can be tried and tested with vert a 3-by-3 shelter into a latrine with a handwashing authorities striving to deliver CWIS. 36 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK AP P EN D I X A • D e s i g n A pproach This guide was developed using a two-stage process: • A global literature search on shared toilet models offered quantitative and qualitative evidence on the benefits and trade-offs as well as impacts and effects of toilet models. A search of existing tools and guidance documents suggests that there is a wealth of case literature and analysis available to guide the planning, design, and man- agement of public and community toilets. Shared toilet models are generally not as well studied because they are often considered to be in the same category as IHHTs. (And, in practice, many IHHTs are shared with neighbors.) Lessons across even diverse settings and regions offer similar points of guidance for facility planning and man- agement. There is less literature about when and how to link shared toilet models with sewerage or fecal sludge management services. • Key informant interviews were conducted with several experts, who bring deep and varied experience designing and managing toilets using a range of models and sanitation approaches relevant to low-income countries. The interviews were used at the start of the development process to identify (and receive) leads to published and unpublished literature and cases, and, as the guide was developed, to inform the direction and content. The authors also drew on their own experiences as researchers, program managers, and grant makers in the sanitation field, which contributed a view to make this guide short, succinct, and informative for busy planners and decision makers. Wherever possible, linkages to existing resources are explained and referenced, rather than repeated. SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 37 AP PE N D I X B • R e v i e w of Pract i ce Introduction In terms of user experience, individual household sani- tation offers the greatest levels of privacy and dignity for A core ambition driving policy objectives for citywide households, even if the inadequacy of fecal sludge man- inclusive sanitation (CWIS) in low-income countries is agement (figure 2.2) still adversely affects their health. to ensure that everyone achieves their human right to The literature about shared household, community, and sanitation, with dignity. This is in accordance with the public toilets is less clear, illustrating a variety of benefits global Sustainable Development Goals (SDGs), which and trade-offs. It is worth considering four main types of established the following as a target: “By 2030, achieve literature about these toilet models: access to adequate and equitable sanitation and hygiene • Case studies, often in the form of gray literature, for all and end open defecation, paying special attention offer a “moment in time” synopsis of models and to the needs of women and girls and those in vulnerable their effects (positive and negative). Case study lit- situations” (United Nations Division for Sustainable erature is often published by nonprofit groups, in Development Goals, 2016, under “Targets,” emphasis association with a project or program. added). This target is measured by “proportion of popu- • Technical guidance/implementation manuals for lation using safely managed sanitation services, including urban sanitation (as a whole) or for a specific model a hand-washing facility with soap and water” (United (for example, public toilets), which are often devel- Nations Division for Sustainable Development Goals, oped in response to a national policy. These guides 2016, under “Indicators,” emphasis added).1 offer valuable insight as a reference across coun- tries, and within a country, often serving as a bridge The SDGs do not specify whether adequate and equi- between high-level policy goals and the specific table sanitation and hygiene should be provided at the ways in which those goals can be achieved. household level or if shared, community, and public • Analytic and decision support tools, often funded by toilets are viable alternatives. However, the Joint Moni- international donors and implemented by research- toring Programme (JMP), which is tasked with regularly ers or international organizations, tend to walk measuring progress at a global level toward achievement readers through a structured process of decision of the SDGs, defines shared, community, and public toi- making on different topics, for example selecting lets as a “limited service.” a toilet business model or choosing a toilet design. These can also offer valuable insight as the sanitation However, ending open defecation does demand that market continues to evolve. Because the market for people be provided options to meet their daily sanitation CWIS is still emerging, there are many tools avail- needs. Achieving adequate and equitable sanitation that able, which may be more or less useful depending meets the needs of women, girls, “and those in vulnera- on the context. Where possible, brief descriptions ble situations” (United Nations Division for Sustainable of these are provided in the text, in locations where Development Goals, 2016, under “Targets”) demands they have the most potential to add value. some consideration of whether shared, community, and • Academic literature provides a fourth area of liter- public toilets can be sited, designed, implemented, and ature, offering quantitative analysis on a range of maintained accordingly. 38 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK topics, for example the health impacts of shared basic needs and offer dignity. Still, different toilet models toilets or the factors that contribute to failed main- offer different benefits and trade-offs, as follows: tenance of community or public toilets. • Household toilets should always be the first-choice Overall, the literature base continues to grow in accor- 2 sanitation solution for residential use in low-in- dance with the service providers’, researchers’, and policy come areas where IHHTs are technically feasible/ makers’ attention paid to and experience of sanitation. advisable and there is ability (which includes time, One thing is clear: sanitation service delivery in low-in- money, and interest) to invest in cleaning and come areas is a dynamic and evolving—though still maintaining them. The literature is clear that for nascent—market, involving public, private, and nongov- reasons of safety (Lennon 2011), accessibility, and ernmental organization (NGO) and community-based ongoing operability (Roma et al. 2010), house- organization (CBO) actors. Cases that prove success- hold-scale sanitation is preferable, particularly for ful are built on delivery models that are designed to women, children, elderly people, and people with evolve with changing user demand and context and that disabilities. involve stakeholders who understand that. Innovation is happening concerning how to use existing physical • The next best option appears to be household-scale assets and how to leverage necessary financial and social shared toilets, preferably shared by as few families resources to build and maintain new assets. as possible.3 Here, the literature depends on per- spective: when considering health impact, most On the other hand, there are not nearly enough success research suggests that neither shared, community, stories: even the most promising examples of new busi- nor public toilets are a preferable option. However, ness models for community and public toilets remain at many of the poorest rely on shared toilets; some the stage of early adoption rather than mainstreamed research indicates that shared facilities can be better business as usual. The social components of shared, than IHHTs because the pooled resources enable community, and public toilets leave much room for better quality toilets and better capacity to maintain improvement, particularly to meet the needs of women, them (Rheinländer et al. 2015). From a practical elderly people, children, and people with disabilities. For perspective, given that 600 million people already this reason, the review demonstrates a bias for individ- use shared, community, and public toilets as their ual household toilets (IHHTs) as a primary sanitation primary form of sanitation (Joint Monitoring Pro- option for residential use. gramme 2017), and that for 892 million people, the only alternative to these toilets is open defecation, it is apparent that a diversity of toilet models must at Summary of Experience with Different Toilet least be considered as part of CWIS planning and Models investment processes. Achieving CWIS requires an additional perspective of • Shared household toilets appear to work better an individual’s needs throughout the day, which may with a small number of families who either own include household, shared, community, and public toi- the facility or clearly understand their responsi- lets. Going about one’s daily activities inside and outside bility to maintain its cleanliness over time. Some the home (for example, at work, at the market for shop- research suggests that shared toilets for extended ping, going to the clinic, school, municipal offices), all families or close neighbors, where there are strong require an offering of basic sanitation services to meet social bonds, present a good alternative to an IHHT SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 39 and at a lower cost. Multifamily housing situations model offers an opportunity for NGOs or CBOs that are structured within a compound can be par- to mediate between local authorities and residents ticularly conducive to shared toilets, especially if all for sanitation. A common model, seen through- households are within a larger family network, but out India (Burra and Patel 2002), occurs in which even if rooms in the compound are simply rentals a local authority lets a contract to an NGO or CBO (Rheinländer et al. 2015). A key challenge but also to build and manage toilet blocks using (often pub- a potential driver to wide-scale implementation of licly owned) land, with a partial or full subsidy for shared household toilets is the reality of informal initial construction cost. In other cases, small towns land tenure, and limited living spaces, particularly hire community members of disadvantaged castes in crowded urban environments. There is evidence to help sweep streets, maintain drains, and manage of a business case for landlords to convert some community toilets. In practice, the effectiveness of rental space to a shared toilet, as a means to lower this model varies widely within existing case study turnover of residents (and therefore risk) and earn literature. higher rents (Peal and Evans 2010). When such investments are required, implementation tends to • The longevity of a community toilet model, and be inconsistent and nearly impossible to enforce in the success of a toilet model in a given location, many cases. may be connected with the level of trust between users and service providers. When the facility falls • Research shows community and public toilets into disrepair because of weak management, com- are associated with worse health outcomes and munities are less likely to trust a new management increased risks to safety and of gender-based vio- model or regime for the same asset. Because of this, lence (GBV), especially for women and children, community members should be involved in the who are particularly vulnerable to rape and assault design, implementation, and monitoring of their and the fear/anxiety associated with these threats toilet facilities; engagement requirements can be when using sanitation facilities outside the home.4 built into procurement processes. Although such However, some community and public models engagement may not result in substantial tweaks to seem to fare better than others when certain con- the physical design or infrastructure used, it does ditions are met, like proximity, good lighting, and a allow the service provider to market the benefits of female attendant (interview with Professor V. Sriv- the community toilet and educate its ever-changing inas Chary, Administrative Staff College of India). customer base on how to use it (Roma et al. 2010). It This suggests that investing in market research to is critical that women and girls are encouraged and understand the needs and concerns of the com- able to safely engage in this process. munity, and being responsive to those needs in the planning and design phase for sanitation, can help • Public toilets also offer the least best experience improve use. Further engaging the community for for residential use, not least because public toilets performance monitoring is critical, given the diver- are typically designed for transient use (for exam- sity of contexts in which services are needed but ple, at bus stations or markets). The basic facility IHHTs are not an option. structure is often sparse because it is intended for on-the-go-urination and is often run on a pay-per- • Community toilets have a mixed record of pro- use basis, which presents affordability issues for viding hygienic, sustainable sanitation services residential users, for whom the alternative is most in low-income areas over time. In theory, this likely open defecation. 40 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK • Still, public toilets are extremely important for practice at city scale or adopted beyond a given city. It urban residents, and particularly low-income urban is unclear why these aren’t replicated beyond an initial residents, when they are away from home. For ser- project, but it could be because of high transaction costs vice providers, these toilets tend to be financially or low political will. Further research might also be done viable but offer low service levels if not monitored on appropriate and effective regulatory approaches for by government. The large number of emerging citi- ensuring service standards, environmental safeguards, zen monitoring mobile apps could play a key role in and tariff structures are all in place. supporting monitoring. Policy questions emerged about how landlords can • With the right conditions, shared, community, and be more effectively incentivized to embrace shared public toilet models can work; however, the long- household sanitation in their compounds and apart- term financial viability depends on users, service ment structures. Several studies cite the problem that providers, and service authorities maintaining safe, affordable, and equitable sanitation is a challenge a focus on delivering a safe and affordable basic in densely populated areas where land is not available. sanitation service. A successful operating model Many describe successful pilots or experiments. Few seems to depend on users’ contributions of time offer examples of scaled solutions that are sustained over and opportunities to provide meaningful feedback, time. Enforcement is a challenge particularly where lay- while a successful revenue model requires attention ers of formal and informal ownership and management to ensure long-term funding sources. These can agreements are in play over land, buildings, and room include public subsidies; private advertising; sale of blocks within properties. ancillary services (a kiosk, a mobile phone charging station, water, a meeting room, and so on); and Research into the long-term societal costs and bene- long-term budgetary assistance provided by either fits of individual household sanitation services relative international donors or corporate/industry part- to shared, community, and public toilet models, and in ners, in addition to revenues associated with fees particular, looking at the lifecycle costs of IHHT versus for using the toilet. these other models, could help inform financing dis- cussions about what gets funding, when, and why. For example, given the ongoing maintenance costs and high Questions for Further Research rates of failure, it may be more cost-effective public pol- icy in some cases to use public funds to create conditions The literature review highlighted a number of actionable that enable household investment in IHHTs or invest recommendations but also surfaced many questions directly in household sanitation. Even where IHHTs are about the different delivery models for community prevalent, however, residents are away from home and and public toilets and their underlying revenue and on the go, often for long days, and renters float in and operating structures. In particular, discussion of how out of communities seasonally. As such, community and institutional forces shape and support different toilet public toilets will remain critical services for any city to models tends to be high level and generic, rather than provide. offering specific guidance for practitioners. Where specific tools have demonstrated some success, like pub- Finally, given the growing recognition of fecal sludge lic-private partnership (PPP) service level agreements management gaps at a city scale, there is a need for more and various accountability mechanisms, there is limited policy and market development research that connects indication that these are being either mainstreamed into different toilet models to the wider ecosystem of fecal SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 41 sludge management, and in particular, where there are Notes strong business cases for combining different segments   1 United Nations Division, 2016, “Sustainable Development Goal of the service chain (for example, collection and trans- 6,” United Nations, sustainabledevelopment.un.org/sdg6. For portation). Exploration of new models that connect information about the SDGs for water supply and sanitation, see https://sustainabledevelopment.un.org/sdg6. a community or public toilet with transportation and treatment may increase the longevity and viability of   2 The diversity of literature reviewed for this study is available in appendix E. these models. Use of mobile technology and data sci- ence, connected with mobile money, could drive down   3 The literature is less clear on a set number where health ben- efits—and ongoing cleanliness and management—start to costs and increase the operating efficiency of urban san- deteriorate. As part of the development process for the SDGs, the Sanitation Task Team recommended a benchmark of no more itation, in turn drawing new entrants to engage in the than five families or 30 people as a proxy for basic sanitation, market. Although these types of innovation may not despite limited evidence on the impact of shared toilets (see Evans et al. 2017). immediately resolve issues of accountability, proximity, affordability, and safety questions for the most vulner- 4 Gius and Subramanian (2015); “A few studies are, however, show- ing that young men and boys, like women, may also be at risk of able, they could contribute to a better understanding of violence near public latrines and water points that are exposed and especially dangerous after dark” (Sommer et al. 2015, qtd. in what CWIS could look like in practice. FSG 2017). 42 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK  nd i c a t i v e Q ue st i ons t o A sk as AP P EN D I X C • I Pa r t o f a S ani t at i on S i t uat i on A s s e s s me nt t o I nform S hare d To i l e t Mode l De si gn, Pl anni ng, I m p l e me nt at i on, and Manage me n t I. SUMMARY QUESTIONS II. DEFINING CHARACTERISTICS 1 Name of project/program/initiative 22 Community type (formal, low-income, dense; informal, 2 Location for the project/program/initiative low-income, dense “slum”; peri-urban, low income; high water table/challenging) 3 Implementation partner lead 23 Primary user market segmentation (commuters, markets, 4 Government lead (if different than implementation residential) lead) 24 Primary market driver (poor existing services, no existing 5 Other key partners (list using commas to separate) services, top-down government mandate) 6 Toilet category (Select one from the dropdown list) 25 Instigating service provider (motivated to provide 7 Current management model (Select one from the services—landlord, community group, local government, dropdown list) and so on) 8 Number of households in the city practicing open III. SITING CRITERIA (LAND SELECTION) defecation 26 What is current demand for sanitation facilities in the 9 Number of households depending on public latrines targeted location? (# people/day; # uses/day) 10 Number of households with latrine facility on premises 27 How many people (households) were identified as potential shared toilet users? 11 Ratio of households per seat of a community toilet 28 How many other toilet blocks/facilities are available to 12 Ratio of households per seat of a community toilet in slum this site location? areas 29 Who owns the land where the shared toilet is located? 13 Ratio of households per seat of a community toilet in non-slums 30 Who owned it previous to initiation of the sanitation project? 14 When did development on the project start? 31 Who currently owns the land? (government’, private, 15 When did services start? (Or, when are they expected to community, households) start?) 32 What utilities were already on site before initiation of the 16 How many community block toilets are there? sanitation project? 17 How many functional seats are provided in the facility? 33 Is the sanitation facility located within a larger city 18 How many units does/did the program aim to install sanitation plan? (shared latrines or toilet blocks)? 34 Was construction of the sanitation facility financed within 19 How many units are currently constructed? a city sanitation plan? 20 Funding level 35 Was construction of the sanitation facility located within a 21 Key funders slum upgrading project? 36 Was construction of the sanitation facility financed within a larger slum upgrading project? SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 43 IV. PHYSICAL CHARACTERISTICS VI. MANAGEMENT (OPERATING) MODEL 37 Numbers of distinct facilities planned as part of the 64 What entity is the primary manager of the facilities? program 65 What type of entity manages the facilities? 38 Toilets per block (target ratio of toilets:users, by gender) 66 Who is the hiring or contracting entity for the facilities? 39 Number of toilets per facility 67 What type of contract governs operations? 40 Number of users per seat (modeled)/day 68 What is the average number of units managed under each 41 Are handwashing taps provided? contract? 42 Are handicap facilities included? 69 How many contracts does the primary manager hold? 43 Are children’s’ facilities included? 70 Do the facilities employ staff? 44 Bathing facilities included? 71 How many staff does the average facility employ/day? 45 Laundry facilities included? 72 How many men/women does the facility employ? 46 Meeting room included? 73 How are men/women selected for their roles? 47 Do facilities generate biogas? 74 For the following roles, note # of staff per facility hired or 48 Do facilities provide lighting at night? contracted (outsourced to third parties): 49 Do facilities include a water kiosk (fee based?) 75 Cleaning 50 Do facilities include a public standpipe (free)? 76 Security 51 Do facilities include overhead water storage? 77 Maintenance/repairs 52 Do facilities include a caretaker room? 78 Bookkeeping 53 Do facilities have menstrual hygiene management disposal 79 Fund managers options? 80 On-site manager 54 Is graywater combined into the fecal sludge treatment 81 Community/customer engagement system? 82 Does the city pay the operator fees for providing manage- 55 How is the fecal waste/urine contained? ment service? V. COMMUNITY ENGAGEMENT 83 Does the operator have a multiyear contract with the 56 Are users/customers involved in the design and initial city? development of facilities? 84 Does the facility pay the city for the right to operate a 57 What level of engagement (meeting to tell them through sanitation facility (for example, license, registration)? co-creating)? 85 Does the facility include management capacity building 58 Are users/customers involved in the management of the efforts? facilities?  INANCING MODEL—DESIGN TO CONSTRUCTION VII. F 59 What level of engagement (meeting to tell them through COSTS co-creating)? 86 What agency sponsored/s the initial design and develop- 60 Are users/customers involved in the monitoring of the ment costs? facilities? 87 Was/is the focus for the project on rehabilitation or new 61 What level of engagement (meeting to tell them through construction? co-creating)? 88 Who paid/pays for initial design and development costs 62 Are users/customers involved in outreach and education (who was/is the lead)? efforts? 89 Who paid/pays the construction costs (from what 63 What level of engagement (meeting to tell them through budget)? co-creating)? 90 Who owns the core assets of the sanitation facility? 44 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK  INANCING MODEL—OPERATIONS AND VIII. F X. MONITORING/SUPPORT SYSTEMS MAINTENANCE 114 Who monitors facility performance? 91 Do facilities receive tax subsidies for operations and 115 What department monitors for legal compliance? maintenance? 116 How often do they monitor (# of visits per quarter/year)? 92 Do facilities receive financial operating and maintenance support from nongovernmental organizations or Project 117 What entity monitors for contract compliance? Aid? 118 How often do they monitor (# of visits per quarter/year)? 93 Do facilities receive financial support for operating and 119 Do facilities ever have to close for compliance issues (by maintenance from any special central or state government government order)? initiative? 120 Has a facility ever paid fines or penalties for 94 Do facilities pay for power utilities (per month)? noncompliance? 95 Do facilities pay for water (per month)? 121 Monitoring assessment mode: 96 Do facilities pay for telecom utilities (per month)? 122 Monitoring assessment criteria: 97 Who is responsible for paying the utilities bills? XI. REGULATORY & ENABLING ENVIRONMENT 98 Do facilities pay for sludge removal (monthly, yearly)? 123 Are users involved or engaged to improve services/system 99 Do facilities pay for stored water, if trucked? performance? 100 Do facilities pay for cleaning or other suppliers to provide 124 What are toilet-regulated design parameters for the services? following issues, if any known? 101 What are the total operating costs for the facility per 125 Gender month? 126 User ratios IX. REVENUE MODEL 127 Distance from households 102 Do the facilities collect user fees? 128 Other 103 Does the facility charge a fee for individual users or for 129 What, if any, of the following toilet management require- multiple users by household? ments or limitations are defined by regulation? 104 How do facilities collect user fees? (single-user fee model) 130 Hours of operation 105 How else does the facility collect user fees (multiuser fee 131 Lighting model)? 132 Pricing 106 Does the facility generate other revenues (whether in 133 Waste disposal practice or originally planned)? 134 Does housing code or other local policy require landlords to 107 Does the city provide operator fees to the service provide toilet facilities? provider? 135 Ratio per user 108 How well do you agree with the following statement: the facility’s users are able to pay for services under the 136 Pricing current revenue model? 137 Waste disposal 109 How well do you agree with the following statement: 138 Are cities required to provide low-income communities facilities’’ users are willing to pay for services under the basic utility services? current revenue model? 139 Are there mechanisms for dispute resolution between 110 Have facilities adapted their revenue model over time? users/customers and facility management/owners? 111 Why or why not? 112 What are an average facility’s revenues per month? 113 What strategies do facilities use to cover gaps (if these exist) SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 45 AP PE N D I X D . A Day i n t he Li fe Mother Father Grandmother Daughter Son (Age: 32) (Age: 34) (Age: 58) (Age: 12) (Age: 3) A day in Headed to the market Headed to work, in Plans to garden to Attends school 3 miles Played to sell vegetables, then an industrial shop grow vegetables, then away, walks. Recently yesterday with the life the local municipal office located several miles watch grandson at started menstruating. Is friends in the to pay a bill. If there’s from home. Doesn’t home before cooking finding ways to manage dirt outside the time, will go to the clinic plan to return home supper. Suffers because her education is house, now has with son for diarrhea until evening. from glaucoma and important to her. diarrhea. treatment. incontinence. Early-morning Uses IHHT, and supervises IHHT busy, goes Uses IHHT Uses IHHT, prepares Uses IHHT with sanitation her son’s toilet use, with men to open rags to bring to school support from needs including hand washing. defecation (OD) field for menstrual hygiene mother because community management. toilet no longer functional. Midmorning Uses latrine in the market. Urinates outside Uses IHHT. Grateful Uses pit latrine behind the Uses IHHT with sanitation There is no light, water, workplace—there is she doesn’t have to school to change rags and support from needs or soap. Others have no toilet walk 100 meters to urinate. There is no water grandmother. defecated on the floor. the community toilet or soap. Used rags go into Grateful he She holds her breath, goes anymore. pit hole because no other doesn’t have to quickly. way to store them during use community the day toilet. They are scary and smelly. Afternoon Spends 3 hours in a line Urinates outside Uses IHHT Hastens home to change Uses IHHT with sanitation at municipal office. No workplace—there is and boil rags. Is grateful support from needs bathrooms there. Loo at no toilet that the stand-post for grandmother the bus station is crowded water is 50 yards from with men and smells of her house, so she doesn’t urination. Opts to hold it. have to walk so far to fetch water. Evening At the clinic, there are no Goes to public toilet on Uses IHHT Uses IHHT OD field at clinic sanitation toilets. Visitors and staff the way home from needs use an open defecation lot work. There’s a line, behind the clinic. Opts to so he urinates against hold it a bit longer, but has the outside wall. to take son out back. Table D.1 • A Day In The Life of a Family that Uses an IHHT as a Primary Form of Sanitation 46 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Mother Father Grandmother Daughter Son (Age: 32) (Age: 34) (Age: 58) (Age: 12) (Age: 3) A day in Headed to the market Headed to work, in an Plans to garden to Attends school 3 Played to sell vegetables, then industrial shop located grow vegetables, then miles away, walks. yesterday with the life the local municipal office several miles from home. watch grandson at Recently started friends in the to pay a bill. If there’s Doesn’t plan to return home before cooking menstruating. Is dirt outside the time, will go to the clinic home until evening. supper. Suffers finding ways to house, now with son for diarrhea from glaucoma and manage because has diarrhea. treatment. incontinence. her education is important to her. Early-morning Queues for shared toilet Queue for shared toilet Can’t hold it, urinates in Uses shared toilets, Wait was too sanitation (with four other families) too long. Goes with men a bucket, to empty later prepares rags to long, spoils his needs with son. Son unable to to open defecation (OD) in the small garden plot bring to school for pants, which wait, but she is able to use field. menstrual hygiene are removed for and wash both their hands. management. later laundering She also cleans around the toilet area for the next user. Midmorning Uses latrine in the market Urinates outside work- Unable to reach the Uses pit latrine behind Uses shared sanitation there is no light, water, place—there is no toilet shared toilet without the school to change toilet with needs or soap. Others have urinating. Grateful the rags and urinate. support from defecated on the floor. walk isn’t far to change There is no water or grandmother. She holds her breath, goes into fresh clothing. soap. Used rags go Grateful he quickly as she can without into pit hole because doesn’t have to getting feces on her clothes no other way to store use community and feet. them during the day. toilet. They are scarier and smellier. Afternoon Spends 3 hours in a line Urinates outside work- Uses shared toilet Hastens home to Uses shared sanitation at municipal office. No place—there is no toilet change and boil rags. toilet with needs bathrooms there. Loo at Is grateful that the support from the bus station is crowded stand-post for water grandmother with men and smells of is 50 yards from her urination. Opts to hold it. house, so she doesn’t have to walk so far to fetch water. Evening At the clinic, there are no Goes to public toilet on Uses shared toilet Uses shared toilet, OD field at clinic sanitation toilets. Visitors and staff the way home from and cleans it, as it needs use an open defecation lot work. There’s a line, so is her behind the clinic. Opts to he urinates against the family’s week to hold it a bit longer, but has outside wall. make sure it is well to take son out back. maintained. Table D.2 • A  Day in the Life of a Family that Uses a Shared Household Toilet Model as a Primary Form of Sanitation SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK 47 Mother Father Grandmother Daughter Son (Age: 32) (Age: 34) (Age: 58) (Age: 12) (Age: 3) A day in Headed to the market Headed to work, in Plans to garden to grow Attends school 3 miles Played to sell vegetables, then an industrial shop vegetables, then watch away, walks. Recently yesterday with the life the local municipal office located several miles grandson at home started menstruating. Is friends in the to pay a bill. If there’s from home. Doesn’t before cooking supper. finding ways to manage dirt outside the time, will go to the clinic plan to return home Suffers from glaucoma because her education is house, now has with son for diarrhea until evening. and incontinence. important to her. diarrhea. treatment. Early-morning Goes with son to Goes with men to Uses flying toilet in the Wakes before dawn when Protests using sanitation community toilet, which OD field because house the toilet block opens. community needs has a long line. After son’s community toilet too Goes to a semiprivate toilet, OD protest, she supervises crowded. area to OD, is grateful not instead. his open defecation (OD) to be harassed by men. while she holds it. Prepares rags to bring to school for menstrual hygiene management. Midmorning Uses latrine in the market Urinates outside Unable to reach the Uses pit latrine behind the Uses community sanitation there is no light, water, workplace—there is community toilet without school to change rags and toilet with needs or soap. Others have no toilet urinating. Grateful the urinate. There is no water support from defecated on the floor. walk isn’t far to change or soap. Used rags go into grandmother. She holds her breath, into fresh clothing. pit hole because no other He won’t go in goes quickly as she can way to store them during alone, because without getting feces on the day. they are scary her clothes and feet. and smelly. Afternoon Spends 3 hours in a line Urinates outside Uses community toilet Hastens home to change Uses community sanitation at municipal office. No workplace—there is and boil rags. Is grateful toilet with needs bathrooms there. Loo at no toilet that the stand-post for support from the bus station is crowded water is 50 yards from grandmother. with men and smells of her house, so she doesn’t He won’t go in urination. Opts to hold it, have to walk so far to alone, because and use the community fetch water. they are scary toilet when she gets and smelly. home. Evening At the clinic, there are no Goes to public toilet on Uses community toilet Uses community toilet OD field at clinic sanitation toilets. Visitors and staff the way home from needs use an open defecation work. There’s a line, lot behind the clinic. Opts so he urinates against to hold it a bit longer, but the outside wall. has to take son out back. Table D.3 • A  Day in the Life of a Family that Uses a Community Toilet Model as a Primary Form of Sanitation 48 SHARED AND PUBLIC TOILETS: CHAMPIONING DELIVERY MODELS THAT WORK Mother Father Grandmother Daughter Son (Age: 32) (Age: 34) (Age: 58) (Age: 12) (Age: 3) A day in Headed to the market Headed to work, in Plans to garden to Attends school 3 miles Played to sell vegetables, then an industrial shop grow vegetables, then away, walks. Recently yesterday with the life the local municipal office located several watch grandson at started menstruating. Is friends in the to pay a bill. If there’s miles from home. home before cooking finding ways to manage dirt outside the time, will go to the clinic Doesn’t plan to supper. Suffers because her education is house, now has with son for diarrhea return home until from glaucoma and important to her. diarrhea. treatment. evening. incontinence. Early-morning Queues for public toilet Queue for shared Can’t hold it, urinates in Uses public toilets, Wait was too sanitation with son. Son unable to toilet too long. Goes a bucket, to empty later prepares rags to bring long, spoils his needs wait, but she is able to use with men to open in the small garden plot to school for menstrual pants, which are and wash both their hands. defecation (OD) field. hygiene management. removed for later She also cleans around the laundering toilet area for the next user. Midmorning Uses latrine in the market Urinates outside Uses flying toilet in the Uses pit latrine behind the Uses flying toilet sanitation there is no light, water, workplace—there is house to defecate. school to change rags and for defecation. needs or soap. Others have no toilet urinate. There is no water with support from defecated on the floor. or soap. Used rags go into grandmother, and She holds her breath, goes pit hole because no other urinates outside. quickly as she can without way to store them during getting feces on her clothes the day. and feet. Afternoon Spends 3 hours in a line Urinates outside Urinates in a bucket to Hastens home to change Uses flying toilet sanitation at municipal office. No workplace—there is empty outside later and boil rags. Is grateful for defecation. needs bathrooms there. Loo at no toilet that the stand-post for with support from the bus station is crowded water is 50 yards from grandmother, and with men and smells of her house, so she doesn’t urinates outside. urination. Opts to hold it have to walk so far to until she’s closer to home. fetch water. Evening At the clinic, there are no Goes to public toilet Urinates in a bucket to Runs to use public toilets OD field at clinic sanitation toilets. 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