No hiding place

Last month, on the 19th, we celebrated World Toilet Day. At first sight, it may seem a bit strange to create a day around toilets. But if you think about the 2.4 billion people that are still living without one, and that diarrhea caused by unsafe water, poor sanitation and hygiene is linked to 50 percent of child under-nutrition, it is worthwhile to stop and think about this global issue. In Sub-Saharan Africa, there is a mere 30 per cent coverage of safe sanitation facilities, a startling statistic that is only a four percent increase since 1990. This is a serious concern due to the associated massive health burden.

World Toilet Day is organised in order to raise awareness and inspire action to tackle the global sanitation crisis – a topic that is often neglected and shrouded in taboos. Today, 2.4 billion people are struggling to stay well, keep their children alive and work their way to a better future – all for the want of a toilet.

Many people who lack basic sanitation facilities engage in unhygienic practices such as open defecation and inappropriate solid waste and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease, with children being the most vulnerable.

In areas where water is scarce, young and adult women also end up occupied in domestic responsibilities and therefore lack access to socio-economic development. Little is known by the communities and their leaders on how shortage of water and poor hygiene affects young girls, women and newly born babies. Poor WASH (Water, Sanitation and Hygiene) in health facilities affect utilization of maternal health care by women hence high prevalence of home deliveries. School going girls are often forced to miss classes during menstrual period because of lack of water and other hygiene facilities at schools.

Developing access to sanitation services poses technical, institutional, financial and also social and cultural challenges. I would like to share an example from Ethiopia with you, that touch upon all these challenges.

Making WASH everybody’s business in Ethiopia

Rapid urbanization in Ethiopia (4,89% per year) leads to poorly constructed slum areas, lacking proper water, sanitation and hygiene (WASH) facilities and producing increasing amounts of waste. These slums are inhabited by poor households which often have little education and low awareness on the importance of using proper WASH facilities and safe hygiene practices.

Currently, 79 percent of the urban population in Ethiopia has access to water and 69 percent has access to sanitation. The group that lacks access to safe water and sanitation services is clustered in slum areas, where the awareness about the importance of WASH services is lowest and financial means to invest in WASH services are limited.

As a result, there have been 26,088 deaths due to diarrhoea and attributable to WASH, and the under-5 mortality rate is 68.3 out of a 1,000 live births (WHO, 2014).

The urban WASH problems in Ethiopia are greatly interlinked and multi-causal. First, the local government faces challenges in servicing slum areas. Governments have limited resources to facilitate urban planning and despite recent initiatives around integration and harmonization of WASH implementation, proper policies are poorly implemented and management skills are limited.

The National Hygiene and Sanitation Strategy (2005) has been followed by the governments’ One Wash National Program (OWNP, 2013), in which the government expects communities to contribute to the realization and operations and maintenance (O&M) of WASH services. Health extension workers play a central role in awareness creation and are the community-based entrance to the health system. Their impact however is compromised as they receive limited training and support to sustainably increase awareness.

Second, the largely poorly educated and often unemployed communities in slum areas have limited knowledge and awareness about the importance of using proper WASH facilities. They have little ownership in planning and design of WASH services and are not used to the idea of paying for these services. Due to poor infrastructure and sanitation awareness, dumping of human waste is common practice in these densely populated areas. Water is often expensive and fetching water from far distances is creating a particular burden on women and girls. Despite efforts of municipalities of urban centres to improve services and provide sites for final waste disposal, the illegal disposal of sludge and other solid wastes remains a health hazard for the people living in those areas.

Finally, the private sector plays a role in these issues as well. The small-scale enterprises engaged in WASH businesses (like owners of public toilets and shower facilities, pit-emptier, spare parts providers, and masons to construct improved toilets) lack entrepreneurial skills and are often unable to identify and seize WASH related business opportunities. Moreover, they do not have access to adequate finance to do their task. Micro-Finance Institutions (MFIs) are generally not involved in WASH-related loans, because they lack proper understanding of the WASH sector and therefore do not know its business potential; hence, provision of credits to WASH related businesses are very minimal.

As long as communities are unaware of the benefits of improved WASH services, they will feel no need or responsibility to invest in these, nor will they hold local government accountable for poor planning and coordination. Moreover, financial institutions will not be interested to grant loans for small-scale enterprises that have their business in WASH, thereby severely limiting the opportunities for such small-scale enterprises (SMEs) to offer the highly needed WASH-services.

In our program ‘Making WASH everybody’s business’, we aim to tackle this set of interrelated problems affecting the current status of WASH facilities in slum and informal settlement areas in Addis Ababa, Oromia and Afar, Ethiopia. One of the main challenges is to provide water to the people in the slums in a sustainable way. In order to do this, people need to pay for water. This requires discussions about the right to water, long term investments, and their health benefits etcetera. We build water and sanitation facilities (latrines, public showers, water points), we educate the communities about health and hygiene topics and train them to set up and run their own businesses around these facilities.

We want to teach communities that you will save health costs, by investing in water and sanitation. This is the only way to create a sustainable system.

In the long term, it is envisaged that everybody in the target regions enjoys sustainable access to water and sanitation in a healthy environment. The Sustainable Development Goals, launched in 2015, include a target to ensure everyone everywhere has access to toilets by 2030. This makes sanitation a global development priority.

Toilets play a crucial role in creating a strong economy, as well as improving health and protecting people’s safety and dignity, particularly women’s and girls’.


  • 2.4 billion people live without improved sanitation (World Health Organization/UNICEF 2015)
  • One in ten people has no choice but to defecate in the open (WHO/UNICEF 2015).
  • Providing toilets to people in rural areas currently practising open defecation is estimated to result in benefits that exceed costs by between five and seven times (Hutton 2015)
  • Diarrhoea caused by poor sanitation and unsafe water kills 315,000 children every year (WASHwatch 2016)
  • Ethiopia achieved the largest decrease in the proportion of the population practising open defecation. It has reduced from 92% (44 million people) in 1990 to 29% (28 million people) in 2015 – an average reduction of over 4% per year over 25 years (WHO 2015)

The story of Addisalem

Addisalem is 36 years old and lives in the Kechene slum of Addis Ababa (Ethiopia). Addisalem has three kids: Tsedenaya Alemayehu, Hymenote Bersema and Yemeserch Bersema. She was married off at the age of 14. She is taking care of her kids alone since her husband died three years ago. She is selling local food called ‘Enjera’ for daily income. Two years ago, Addisalem was elected as ‘chairwoman’ in one of the WASH kiosks, a booth that provides clean water, toilets and showers (against payment). She was trained by Amref on project management, financial management, fee collection, WASH related diseases and sustainability. She is very happy with her job and having access to potable water and improved sanitation facility.

‘’It was a hard time for us before this kiosk was there, especially for women and children. We had a small pit and for some time, we used plastic bag (fly toilets). Our kids were suffering from intestinal problems, diarrheal diseases and eye diseases such as Trachoma. There were lots of flies because of the faeces. “I cannot remember any diarrheal diseases after we started using the water kiosk”, she says. “We are more safe, healthy and therefore happy.”

*Patricia Vermeulen is CEO of Amref Flying Doctors, the Netherlands