Experiences of Shared Sanitation – towards a better understanding of access, exclusion and ‘toilet mobility’ in low income urban areas

5 Sustainable Development Goal target 6.2 calls for "adequate and equitable sanitation for all". In dense, 6 rapidly urbanising cities, the challenge of providing household sanitation means that many countries 7 include shared, community and public toilets in their national strategies to meet global goals. 8 However, shared sanitation is associated with several problems including poor management and 9 exclusion. This study examines shared sanitation access and use by using innovative mapping methods 10 in compound house units in Fante New Town, Kumasi, Ghana. 11 The study reveals that 56 percent of house units have at least one toilet. Of the 47 percent of people 12 living in these house units, almost a third were excluded from using the toilet. Tenure status was the 13 main driver for exclusion; with nearly half of people reporting non-usage 'not allowed' to use the toilet 14 by the landlord. The paper outlines key policy interventions to address broader institutional and 15 regulatory barriers to shared sanitation. At the settlement level, this includes provision of safe, well 16 managed public toilets and engagement with landlords to improve house unit toilet access. At the 17 national and global level, the paper calls for nuanced indicators to assess quality of access, to ensure 18 shared sanitation works for everyone.


INTRODUCTION 21
The Sustainable Development Goals (SDGs) set out a wide range of global development imperatives 22 to which member states of the United Nations (UN) are now committed. SDG 6 focuses on water and 23 weakened by lack of cleanliness (Roma et al 2010). A number of studies have found that shared sanitation facilities are less likely to be functioning than individual household latrines, with some being 68 closed for significant periods of time due to blockages (Routray et al 2015). During this time, the 69 likelihood of users practising unsafe sanitation behaviour increases. 70 One of the major challenges when seeking to understand the impact of sharing on sanitation 71 behaviours and health outcomes, is that urban populations may not be dependent on a single 72 sanitation facility. Most residents of low-income settlements, for example, may have access to a 73 number of sanitation options including toilets in the compound or household, community shared 74 toilets, public toilets and toilets in the workplace or at school. Their position within the household (i.e. 75 old/young or tenant/landlord) and wider community may determine when and how they access a 76 shared toilet, and the degree to which they can choose between sanitation options. 77 For this reason, it may be useful in urban areas to move away from a binary consideration of have/ do 78 not have access to a household toilet and towards an understanding of the dynamic use of a range of 79 toilet options. In this study we attempted to unpack toilet usage in an urban area where users have 80 choices and options -in other words they can be considered to have 'toilet mobility'. This provides a 81 lens through which to examine both the options available to individuals and the reasons for, and 82 barriers to, users accessing these facilities. Toilet mobility can be spatial (i.e. use of multiple sanitation 83 technologies in different locations), change over time (i.e. night and day), and vary according to the 84 demographic group in question. It is also linked to the provision of toilets in places of work, and schools 85 and to the consideration of the cost of using the range of toilet options available. In this study we have 86 limited our analysis to the factors that affect access to, and use of, shared sanitation facilities which 87 are located within the house where a person lives. This study examines this issue through a detailed 88 case study of Fante New Town, Kumasi, Ghana. 89

Study site 91
The study was conducted in Fante New Town, an electoral ward in Kumasi, Ghana. Kumasi has a 92 population of around 2.7 million and is located in the Ashanti region of Ghana. According to the most 93 recent SFD report for the city, a high percentage of people are reliant on 'public' toilets (39%). Fifty-94 seven percent of the population use 'private' toilets but many of these are shared. There are a range 95 of disposal routes -many of the pit latrines are well designed Kumasi Improved latrines, many septic 96 tanks have outlets connected to proper soakaways. There is also a nascent market for new container-in the environment (Furlong, 2015). 100 The most recent population census in 2010 stated that the population of Fante New Town electoral 101 area was 42,000 (Djagana 2017). Fante New Town, and Kumasi as a whole, is a popular destination for 102 migrants, particularly those from the north of Ghana. A significant proportion of this migrant 103 population is transient and some, including those who work as truck pushers (labourers who use carts 104 or wheelbarrows to transport goods), sleep on the streets and do not have access to private sanitation 105 facilities (Djagana 2017). It is mostly for this population that the public toilets in Fante New Town were 106 constructed. Over time, however, the local population increasingly patronised the public toilets 107 themselves, in part due to the legal abolition of bucket latrines which were previously very common 108 Communal living in Ghana means multiple families live within a single compound or house unit sharing 119 sanitation, cooking and other facilities. This makes defining a 'household' complex. For the purposes 120 of this study, the term 'house unit' was used to refer to a group of people living under the same roof, application (version 8.4.6), was conducted to locate sanitation facilities in the study area. At each 129 house unit, the presence or absence of a toilet facility was logged along with the GPS coordinates. 130 Where the toilet facility was accessible (i.e. not occupied or padlocked), it was examined, 131 photographed and recorded. Figure 2 summarises the available facilities. 132 Natural group discussions were held to identify the number of occupants living in each house unit and 133 to confirm the presence or absence of a toilet. If there was a toilet, the technology and number of 134 toilet users was established, as well as any reasons for partial or non-use. If there was not a toilet, the 135 reason for not having a toilet was discussed, and the way in which the residents met their sanitation 136 needs was established. Use of toilet facilities outside of the house unit was also explored. Toilet use 137 was self-reported by house unit members during natural group discussions. As self-reporting can 138 result in desirable behaviours being over-reported, two focus groups were conducted at the end of 139 the study to validate the findings. Extensive pre-testing of the focus group guides was undertaken. 140 The participants were recruited by the two key informants. The first group comprised of six males, 141 three of whom were community leaders. The second group of participants were five women. Both 142 groups comprised both landlords and tenants. The focus groups explored the factors affecting 143 sanitation behaviours. Responses were coded, and the number of times topics were mentioned was 144 counted and analysed. 145 The total estimated population studied was 2,743. public nor 'private' toilets in house units are distributed evenly throughout the area. The northern 157 part of the study site has a less dense penetration of toilets in housing units but most house units here 158 are closer to the public toilets than the southern part of the community. 159 Eighty-four percent of toilets inside house units were flush toilets and 12 percent were Kumasi 160 ventilated improved pit latrines (KVIPs). Of the remainder, 3 percent were bucket latrines (locally 161 referred to as 'pan' latrines), which are illegal, and one house unit had a subscription to the Clean 162 team service. In addition to household toilets, there were 5 public toilet facilities with 57 seats 163 collectively, all of which used flush technology. There were no specific eligibility requirements to use 164 the public toilets, but all were operated on a pay-per-use basis. 165 Nine percent of people stated that they did not use their house unit toilet due to the technology; 204 usually having a preference for flush toilets, 6 percent because the toilet was in bad condition and 4 205 percent because the toilet had a foul odour. Other reasons for not using the house unit toilet were 206 that the respondent didn't pay to get it unblocked (2 percent), use by all members increases the 207 frequency of emptying (1 percent), aversion for paying monthly maintenance fees (<1 percent) and 208 embarrassment of having to knock (<1 percent). For 14 percent of non-users of a toilet in a house unit, 209

Panel 1: Reasons for non-use of house unit toilets Case Study: House Unit A.
Fifty people reside in this house unit and there is one flush toilet. Only the landlord is permitted to use the toilet because she reports that the toilet uses a lot of water and the water bill is too difficult to split between all the residents. The remaining forty-nine residents patronise the public toilets, with many practicing open defecation outside of opening hours.
using it due to its poor condition or odour (Panel 2). 217 218 Children also had fewer sanitation options available to them. Caregivers reported preventing their 219 children from using the public toilet alone due to fears of them falling in. The demand on caregivers' 220 time having to accompany their child to and from the public toilet was also cited as a barrier to children 221 using public toilets. 222 Apart from one, all public toilets closed overnight, with some closing as early as 19:30 and not opening 223 until 04:30. During this time, the majority of people who did not have access to a toilet within their 224 house unit and needed to relieve themselves, reported that they practiced open defecation. 225 Individuals who used a toilet facility within their house unit did not appear to be affected as the toilet 226 was accessible during the night. 227 Among house units that did not have a toilet facility, the most commonly cited reason for not having 228 one, was lack of space. Many house owners chose to use space that could be used for a toilet facility 229 for an additional bedroom, washroom or storage instead. In a number of cases, households that did 230 not have toilet facilities at the time of study, used to have a pan latrine but when they were outlawed, 231 they used the space for storage, rather than as a toilet facility. 232

DISCUSSION AND CONCLUSION 233
In this study, the location of private and public toilets in Fante New Town was mapped. The 234 distribution of toilets is patchy, but overall, most people live either in a house unit with one or more 235 toilets, or reasonably close to a public toilet facility. Theoretically, nearly half of the population have 236 the option to choose to use either private facilities shared between households in the house unit or 237

Panel 2: Demographic characteristics of users and non-users
Case Study: House Unit B.
Twenty people reside in the house unit which has one pan latrine. One elderly man uses the pan latrine because its location is convenient, while the remaining nineteen residents avoid it due to unpleasant odour and use the public toilets instead.
level of provision of toilets at the house-unit level (56% of house units had at least one toilet) close to 239 70% of the population appear to be unable to use a toilet in the house unit and therefore experience 240 very limited toilet mobility. A number of factors affect access to, and use of, these private sanitation 241 facilities. Some of these operate in an exclusionary manner. For some people, this relates to the non-242 availability of a toilet within the house unit. However, for those residing in a house unit with one or 243 more toilets, a number of demographic and regulatory factors constrain mobility of use. 244 The study found that the most common reason for non-use of house unit toilets was due to landlords The implications of these findings for policy responses in Kumasi fall into two broad categories -those 286 which address broader institutional and regulatory barriers, and those which support increased 287 mobility. Structural changes relate to shifting the quality and extent of toilet provision so as to increase 288 options for individuals. This might include the provision and more active management of additional 289 public toilets, including the provision of well managed and safe options for users at night and adequate 290 and safe accessibility for children, older people, and those living with disabilities, day and night. It 291 could also focus on improving the provision of toilets at the house unit. In large multi-household units 292 our study suggests that the number of toilets provided is close to inadequate (in house units with 293 toilets, assuming every resident uses the toilet, the average number of users per seat is 8). On the 294 regulatory side, there are tools available to create incentives for improved household provision (such 295 as enforcing the building regulations that require provision of suitable sanitation). However, given the 296 risks to low income households if rents are raised to cover costs, these interventions should be seen 297 within the wider context of sustainable housing supply for Kumasi. Legal or social/economic 298 instruments that ensure landlords provide adequate, well serviced toilets for each household or 299 minimum number of tenants, coupled with appropriate financial incentives, could also address this. 300 The need for proactive engagement with landlords to encourage the provision of adequate, in-house 301 facilities to tenants in Kumasi has already been noted (see, for example, Mazeau 2013). 302 The findings for this study also contribute to the ongoing debate about the extent to which shared 303 facilities should be counted towards universal access in international targets, particularly SDG 6.2. Our 304 research reinforces earlier concerns that access to sanitation that is shared between households does not necessarily equate with access to sanitation that can be used. Irrespective of the number of people likely to be landlords in the sort of house units we found in this study and are likely to report access 311 to a toilet even if all the residents cannot use it. At the national and regional level therefore, it seems 312 plausible that the introduction and use of more nuanced indicators of the quality of access to toilets 313 could begin to address the structural faults inherent in the push both for a focus on household toilets 314 and (from some countries), for the inclusion of public and shared facilities in national and international 315 reporting. A measure which assesses toilet mobility and thereby focuses on the agency of individual 316 users and the tendency of structural factors to support this, could provide stronger incentives for a 317 more effective provision of sanitation services which work for everyone. 318