Ghana ’ s post-MDGs sanitation situation: an overview

This paper presents an overview of Ghana ’ s sanitation situation post-Millennium Development Goals (MDGs). It speci ﬁ cally examines why the MDG target on sanitation was missed, Ghana ’ s preparedness towards achieving the Sustainable Development Goals (SDGs) sanitation target, potential barriers and opportunities for the sanitation sector. An eight step policy analysis framework guided the review. The ﬁ ndings indicate that the low sanitation has largely been driven by rather complex economics, institutional and sociocultural factors including inadequate ﬁ nancial commitment, poor implementation of policies, bad attitude and perception towards sanitation and extensive use of shared and public toilets. Nevertheless, it was found that recent reforms and programmes in the sanitation sector such as the creation of new Sanitation and Water Resource Ministry, National Sanitation Authority (NSA), introduction of sanitation surcharges included in property tax, and programmes such as the Greater Accra Municipal Assembly sanitation and water project put Ghana in a better position to rapidly increase its coverage. However, efforts would have to be accelerated by forging partnerships with the private sector to provide ef ﬁ cient and low-cost technologies, ﬁ nancial schemes, human and technical resources for improved service delivery.


INTRODUCTION
Since the adoption of the Millennium Development Goals (MDGs) in the year 2000, the international community has committed itself to improving health, reducing poverty, promoting equality and supporting socioeconomic development, for which, improved WASH services are central. The global community has devoted significant resources and energy to achieving the fundamental targets of ensuring access to safe, affordable, acceptable, available and accessible drinking water and sanitation for all by 2030 (UNCG & CSO ) since every human has the right to safe drinking water and improved sanitation (UN Human Rights Council ). Although significant progress has been made since the MDGs era until now, billions of people worldwide are still faced with daily challenges accessing even the most basic of services. million people still lack access to potable water and 2.3 billion people lack access to improved sanitation. It is evident that on the global scale, sanitation lags behind water as only 68% of the world's population has access to basic sanitation compared to 88.5% with access to basic water services. The current situation in Africa is even more disturbing as only 28% of the people in sub-Saharan Africa have access to basic sanitation (WHO/UNICEF ).
Like other African countries, Ghana faces serious constraints to meeting the challenge of providing adequate and improved sanitation for its rural and urban inhabitants.
The economic growth in Ghana has been accompanied by rapid urbanization, putting a strain on infrastructure and the provision of sanitation facilities (Mariwah ).
Among competing demands for public investment (including education, health, transport electricity and water), sanitation has not been prioritized. Thus, not much progress has been made in achieving the sanitation target with the current coverage of 21% ( Figure 1) still lagging behind the MDG target of 54%.
Inadequate sanitation leads to the transmission of pathogens through faeces and to a lesser extent, urine (Hutton & Chase ). An estimated 842,000 people in low-and middle-income countries die each year from diarrhoea and other causes associated with inadequate water, sanitation and hygiene, with children under five years bearing the greatest burden (WHO ). In Africa and Ghana, diarrhoeal diseases cause about 16% and 25% of deaths among children under five years, respectively (Binka et al. ). In addition to the health risks, poor sanitation causes considerable financial and economic losses. The WSP () reported that the annual economic loss to Ghana due to poor sanitation was US$290 million, equivalent to 1.6% of GDP. Hutton & Chase ()  or potential barriers towards achieving the SDGs targets and the opportunities available for the sanitation sector.
The review was guided by the policy analysis framework developed by Collins () using the following eight steps: (Step 1) define the context; (Step 2) state the problem; (Step 3) search for evidence; (Step 4) consider different policy options; (Step 5) project the outcomes; (Step 6) apply evaluative criteria; (Step 7) weigh the outcomes; and (Step 8) make the decision. Steps 1-3 were used to develop comprehensive background information on the WASH situation in Ghana and to understand the determinants of the problems that form the basis for the study. They were used to examine the discrepancies between the existing WASH situation (national coverage) and the planned national and global targets to understand the reasons for the differences.
Steps 4-7 focused on examining the WASH landscape and identified gaps and opportunities. Policies or sector documents were assessed based on the specific objectives which served as the themes of the review (Step 8).
The review covers evidence showing progress in water and sanitation coverage from the MDGs era up until the present. The study followed well-structured thematic discussions covering sanitation trends, financing mechanisms, institutional reforms and arrangement, policy and regulatory reforms, monitoring, human resource capacity, technological issues and perceptions of people. Guided by the topic areas outlined above, evidence was sourced mainly from published synthesized reviews such as systematic reviews and literature reviews as adopted by Hutton & Chase (). Data used for analysis of water, sanitation and health (cholera) trends and coverage in this review were a combination of user-based data, provider-based data (WSMP Ghana ; Mariwah ) and data from monitoring programmes such as the WASH Joint Monitoring Programme (JMP). All these data sources are secondary data sources.

STATUS AND TRENDS ON SANITATION COVERAGE IN GHANA
In spite of the critical role effective human excreta management and, for that matter, sustainable environmental sanitation plays in human development, the MDGs target on basic sanitation was widely unachieved. The country registered an increase in access to adequate basic sanitation over the 15-year period of the MDGs from just 11% in 2000 to 15% in 2015, as shown in Figure 2. This means that sanitation coverage only increased by 4% since the year 2000 Undoubtedly, much progress has been achieved in the water sector as access to basic drinking water is estimated at 79%; 93% urban coverage and 68% rural coverage ( Figure 2) (GSS ), achieving the 77% national MDG target seven years ahead of schedule. However, this achievement is eclipsed by the mere 21% coverage in the access to basic sanitation. Although Monney & Antwi-Agyei () opine that if current efforts towards access to improved drinking water are sustained, Ghana will achieve universal access to potable water by the year 2030, the same cannot be said for sanitation. WaterAid () asserts that it will take over a century for Ghana to achieve its sanitation target. The fact that nearly 80% of the Ghanaian population lack access to hygienic toilet facilities is a very worrisome situation because it poses a grave public health threat (Mariwah et al. ).
The issue of limited sanitation service ('limited sanitation service' refers to an improved facility shared with other households) in Ghana is a thorny one, given its widespread occurrence. Sharing of sanitation remains prevalent, and one in every four household populations use public facilities (GSS ) ( Figure 3). Currently, over 13 million Ghanaians representing 45% use shared facilities. The high proportion of this population is mostly concentrated in low-income urban settlements, notwithstanding the fact that some significant rural populations do rely on these facilities. The most disturbing is the percentage (22%) of Ghanaians who still  226 latrines were allocated to be constructed with 50% subsidy. However, less than 5% of the household toilets were actually constructed in some districts under the programme.
Among the reasons attributed to the poor response to the intervention in these districts was the failure to conduct background studies (households need assessment, income levels) in the communities prior to the start of the project.

Sanitation financing
In addition to policy implementation challenges, as stated

Reliance on shared toilet facilities
The continuous reliance on shared facilities by more than half of the country's population (56.7%) was a major dent in the country's efforts to achieve the MDGs, as shared facilities do not qualify under the JMP definition of improved sanitation (WHO/UNICEF ). The concern of WHO/ UNICEF is on the actual accessibility of these facilities throughout the day and about the security of users, especially at night (JMP ). Additional concerns were the distances involved in accessing shared facilities, their maintenance, the unhygienic nature of these facilities since shared toilets were usually accessible by a great many people and the lack of accommodation for children under the age of five

GHANA'S PREPAREDNESS TOWARDS ACHIEVING THE SDGS SANITATION TARGET Financing mechanisms
Sustainable financing is crucial for the adequate provision and maintenance of new and existing WASH infrastructure.
However, it is argued that heavy reliance on donor funding presents a huge challenge to sustaining achievements in the WASH sector in the long term (ADB/OECD/UNDP ).
Therefore, to achieve the SDG target, efforts will have to be accelerated, taking on board all the various instruments and tools that exist to facilitate financing. This means that innovative financing mechanisms are required to adequately finance sustainable, cost-effective and pro-poor sanitation services. The innovative financing tools used to attract capital to finance water and sanitation infrastructure include financial guarantees, insurance, subsidies, equity grants, tenor extensions, pooled finance, Project Preparation Funds, hedging instruments, benchmarking, microfinance and credit ratings (Kolker et al. ).
Fortunately, Ghana appears prepared to finding other ways of closing the financial gap as financial assistance from development partners continues to dwindle. One of the few innovative approaches is the introduction of 'sani- MSWR has indicated that the NSA will have a regulatory functionsetting national standards for sanitationand will manage a National Sanitation Fund. The reforms described above have led to a clear institutional separation for the provision of sanitation and water supply services, as depicted in Figure 5.

Policy and regulatory reforms
The main legal act governing the provision of sanitation services is the Local Government Act (Act 462), which assigns MMDAs the responsibility to provide sanitation services.
The Local Government Service Act allocates the responsibility to provide technical assistance for MMDAs and regional councils so as to enable them to perform their functions to the Local Government Service, which is the national body responsible for personnel in the assemblies.  There is no dedicated tool or reporting system for urban sanitation but, currently, efforts are underway to develop a reporting tool to facilitate monitoring.

POTENTIAL BARRIERS TOWARDS ACHIEVING THE SDGS TARGET FOR SANITATION Unclear guidelines for sanitation service delivery
Despite the existence of the NESP and strategy that set ambitious targets for the country, the support structure to MMDAs for the planning of sanitation services is quasinon-existent outside donor projects (WSUP ). Existing guidelines do not specify management requirements for sanitation services (liquid waste or faecal sludge) (WSUP ) and, as a result, MMDAs focus on solid waste services.
Most assemblies give priority to solid waste rather than sanitation services. This is because solid waste is seen as a greater challenge since heaps of uncollected solid waste are visible to all and are usually associated with public outcry. For example, human excreta, however, is less visible because excreta is usually disposed of into drains, unauthor- Furthermore, as in many densely populated areas, the lack of space is a challenge for the construction of household toilet facilities. As a result, shared, communal or Environmental Sanitation Policy (MLGRD ) Covers all aspects of environmental sanitation, including solid waste, liquid waste, excreta, industrial wastes, health-care, and other hazardous wastes Recognizes the need to provide inclusive sanitation services, especially to protect the vulnerable, women, and children Allocates responsibilities between ministries and local governments Promotes private sector participation (PSP) and NGOs' involvement in the delivery of sanitation services Acknowledges the challenge of urban sanitation (including excreta management, referred to as 'liquid waste') and the lack of planning Makes households responsible for financing their own household facilities

National Environmental Sanitation Strategy and Action Plan (MLGRD & EHSD )
Recognizes that communal and public facilities will continue to be an important aspect of excreta management for some time to come Proposes franchising the management of public toilets and the provision of cesspit emptying services by private operators Recognizes the need for appropriate low-cost treatment and disposal facilities for faecal sludge

Strategic Environmental Sanitation Investment Plan (adapted from WSUP ())
Provides a financing plan for implementing the NESSAP Proposes an increase in the annual allocation of the DACF to MMDAs to fund their financing gaps (from 7.5% to 15%) and 'ring-fencing' the amount for environmental sanitation (including solid waste) programmes Proposes the establishment of a national revolving fund for household sanitation to be managed by microfinance institutions

Perception of people towards sanitation
There is also a wider socio-cultural and attitudinal explanation for the low take-up for sanitation in Ghana Figure 6 shows some of the business opportunities that are available within the sanitation service chain. According to Appiah- According to the report, financial solutions can be applied to support household access to improved WASH services and to promote WASH-related business activities. It indicated that there is the potential to develop and utilize financing solutions, including microcredit and small-tomedium enterprise (SME) financing, to catalyse the provision of WASH services for the poor. The experience of the USAID-funded initiative with the local microfinance institution, Youth and Social Enterprise Fund (YSEF) and Global Communities (formerly CHF International) demonstrates the potential for microfinance to be an effective tool for improving access to safe water for the poor. The initiative provided microcredit to households and WASHrelated enterprises in selected communities in the Greater Accra and western regions to improve access to safe water and sanitation facilities. It could be said that providing promising loan products by financial institutions could potentially enhance access to improved sanitation solutions • A well-structured financial product such as microcredit targeting the provision of improved sanitation services for the poor or households in low-income communities be implemented to alleviate a major bottleneck in the sector.
• The private sector should be encouraged to invest in profitable waste-to-value projects in other parts of the country where there are no waste treatment or recycling facilities so as to achieve better and improved sanitation and health outcomes.

DECLARATION OF INTEREST STATEMENT
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.