Holistic citywide sanitation for an urban area in the Global South: A case study of the Noakhali Pourashava of Bangladesh

Globally, access to sanitation remains a major problem, especially in urban areas, where 2 billion people lacked proper facilities in 2017 (UNICEF & WHO 2019). Urban sanitation involves several intricate considerations that are vital to public health and environmental sustainability, such as controlling excreta channels, encouraging hygiene, and guaranteeing access to sanitation facilities (UNICEF & WHO 2019). Despite advances, the urban sanitation gap continues, with 1.5 billion still without basic access by 2022, primarily affecting developing countries (UNICEF/WHO 2023). These countries frequently use a combination of on-site and off-site sanitation systems, with on-site systems collecting and storing discards locally, and off-site systems transporting them for treatment elsewhere (Tilley et al. 2014; Peal et al. 2020). In 2022, on-site and off-site sanitation usage were used equally (46 and 42%, respectively), with sewer-connected households contributing 33% of secure sanitation vs. 24% from on-site facilities (UNICEF/WHO 2023).

Poor sanitation exacerbates poverty and stifles children's growth, resulting in considerable economic losses (WHO 2019), which had increased from USD 183 billion in 2010 to USD 223 billion in 2015 (WaterAid 2016). Furthermore, it raises the risk of waterborne infections such as diarrhea and typhoid fever, which kill about 432,000 people each year (Mills et al. 2021). Investing in strong sanitation systems produces significant returns, with each dollar spent saving $5.50 on medical expenses (Maqbool et al. 2022).

By 2019, almost 61% of Bangladesh's population had access to basic services, demonstrating the country's strong progress in improving sanitation coverage. Even with advancements, the coverage rate was only 65% that year (JMP, WHO & UNICEF 2020). Due to providers' inability to keep up with population expansion, the traditional centralized delivery system for urban water supply and sanitation, which is prevalent throughout the Global South, including Bangladesh, has mainly failed (Faldi et al. 2019). All parties involved in the chain of fecal sludge management (FSM) require a more thorough approach to urban sanitation (O'Keefe et al. 2015). This change is in line with the Sustainable Development Goals, which cover the sanitation supply chain as a whole, replacing the Millennium Development Goals.

The citywide sanitation approach (CSA) evolved in response to criticisms of infrastructure-centric urban sanitation systems (Evans & Saywell 2006). CSA stresses sanitation solutions that are culturally relevant, equitable, and environmentally sustainable (Lüthi et al. 2020). While technologies for early context analysis are available (Narayan et al. 2021), there are few for monitoring urban sanitation. Shit flow diagrams (SFDs) and city service delivery assessments (CSDAs) evaluate CSA's service delivery and environmental impacts (Scott & Cotton 2020). SFDs were developed by the World Health Organization (WHO) and the International Water Association (IWA) to evaluate excreta management (WSP 2014), assisting decision-making by revealing gaps in the sanitation chain (Tilley et al. 2014). CSDAs assess urban sanitation problems and give Action Checklists (Safi et al. 2022), as well as infographics displaying sewage channels (Panesar et al. 2022). CSDAs, which began with implementation across only on-site sanitation, now span entire cities (Safi et al. 2022). The combined use of SFDs and CSDAs improves understanding of urban sanitation (Peal et al. 2014), as both define service delivery and the enabling environment. These tools efficiently track sanitation changes in cities (Safi et al. 2022). For example, Safi et al. (2022) used SFDs and CSDAs to monitor sanitation changes in a city in India and discovered that they were effective for monitoring changes at the city level.

Using SFDs and CSDAs, this study illustrates urban sanitation in the Noakhali region of Bangladesh. In order to determine areas for improvement, a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis is also conducted. SWOT analyses have already been carried out for safe water supply systems in Mongolia (Uddin et al. 2014), sanitation systems in Afghanistan (Uddin et al. 2015), community-based systems in Peru (Wijayanti et al. 2021), hygiene facilities for disabled women in Bangladeshi urban slums (Nowreen et al. 2022), and sanitation campaigns in India (Pardeshi et al. 2008; Jangra et al. 2016).

Coastal cities have problems managing fecal waste and inadequate sanitation, especially in Bangladeshi cities like Noakhali. Ineffective waste management impacts children's health (Ghosh et al. 2021), increases the risks of numerous illnesses (Barua et al. 2019), and contaminates water sources (Jangra et al. 2016; Prosun et al. 2018; Islam et al. 2021; Miah et al. 2022).

Therefore, this paper presents the current state of urban sanitation in Noakhali by using SFD, CSDA, and a SWOT analysis to create a sustainable sanitation management system that is especially suited to coastal urban locations in the developing context by quantifying safe and unsafe excreta flows, identifying inadequate disposal practices, and advocating for holistic, sustainable sanitation solutions.

Data were gathered from December 2022 to March 2023, using both quantitative and qualitative methods. Key informant interviews (KIIs), focus groups, and direct observations provided qualitative and quantitative data on sanitation services. A structured questionnaire survey collected quantitative data, while talks with non-governmental organization (NGO) workers and volunteers provided an overview of the city's sanitation practices.

To learn more about the sanitation issues in Noakhali Pourashava, 150 randomly selected homes across 9 wards participated in a structured questionnaire survey. The questionnaire comprised 20 questions, which inquired into existing sanitization facilities, practices, sludge transportation, emptying, treatment, and disposal.

Seven KIIs, four focus group discussions (FGDs), transect walks, and observations were used to complement the findings from the survey. To validate secondary data, KIIs collected opinions from employees providing water and sanitation services. The Water Supply and Sewerage Authority (WASA), the Department of Public Health Engineering (DPHE), Noakhali Bureau of Statistics (NBS), the United Nations Development Programme (UNDP), and Noakhali Pourashava officials addressed the city's present sanitation problems during KIIs (see details in the ‘SFD’ section).

This study used publicly available secondary data and fieldwork in Noakhali Pourashava to gain a full grasp of the city's context. Secondary data sources included the Bangladesh Bureau of Statistics (BBS), the DPHE in Noakhali Division, and the UNDP's ‘Livelihoods Improvement of Urban Poor Communities Project’. Data from the Joint Monitoring Programme (UNICEF & WHO 2019) and the Noakhali Pourashava authorities were also used.

The statistical program R (version 4.2.2) was utilized to analyze the data gathered from the KII and survey. Then the SFD matrix and CSDA were generated from these data as per the guidance given in the frequently asked questions (FAQs) on the Sustainable Sanitation Alliance (SuSanA) website (https://www.susana.org/en/about/faq).

Table 1 lists the Noakhali sanitation facilities: 93% use on-site services, 4% use open defecation, and 3% use a tiny drainage system. Noakhali has a relatively higher coverage of on-site sanitation than urban regions in other developing contexts. In Trichy, Tamil Nadu, India, for example, 41% of people use on-site sanitation, whereas 59% use off-site (Safi et al. 2022). Twenty-nine percent of urban low- and lower-middle-income areas usually employ off-site sanitation, while 27% use on-site techniques such as septic tanks or pit latrines (WHO/UNICEF 2021). Furthermore, the open defecation rate in Noakhali is lower than the regional and global averages, which are 5% worldwide, 9% in Central and South Asia, and 13% in least developed countries (UNICEF/WHO 2023).

The study found that 47% of emptying facilities use mechanical technology. This entails employing machines or equipment to remove and transport sludge from sanitation facilities. Vacuum trucks or specialized equipment are routinely used to suction or pump trash from septic tanks and pit latrines, minimizing worker exposure to germs. Manual emptying, which occurs in 29% of facilities, entails physically removing waste by hand, providing considerable health concerns owing to direct contact with fecal slurry. The processes for emptying 24% of facilities are vague, implying a lack of provided or gathered information (Table 2).

The majority of sanitation transit (55%) consists of direct discharge into sewers from septic tanks or pit latrines, with vehicles playing an important part in FSM. Similar findings have been echoed elsewhere, where sewerage networks serve roughly 60, 63, and 50% of Karachi, Lahore, and Islamabad, respectively (Maqbool et al. 2023). Vehicle transportation accounts for 45% of the total volume handled through the system. Table 2 shows the relevance of both direct sewers and vehicles in excrement transportation, with direct sewers being slightly more common (55 vs. 45%). However, the percentages may differ depending on geography and infrastructure development. In 2015, an estimated 53% of the world's population had access to sewers for sludge disposal (WHO/UNICEF 2021). Pakistan has the largest sewer coverage in South Asia, with 27%, followed by Bangladesh (18%) and India (13%) (Maqbool et al. 2023).

Overall, Figures 3 and 4 present a comprehensive approach to addressing various aspects of sanitation services in the city, including both off-site and on-site sanitation. The actions cover policy and regulation, institutional arrangements, planning, financing, promotion, user engagement, and capacity building. The approach is multi-faceted, aiming to improve sanitation standards, protect public health and the environment, and enhance the overall sanitation infrastructure and services in the city. By implementing these actions at different levels, the city aims to achieve a more sustainable and effective citywide inclusive sanitation (CWIS) system.

The SWOT analysis revealed that numerous important initiatives have been put in place to address the crucial problem of sanitation and hygiene. The establishment of a thorough sewer system, guaranteeing the supply of latrine parts, and giving public toilet construction priority were all identified as important sanitation initiatives by the SWOT analysis. These initiatives demonstrate a commitment to sanitation and public health by lowering open defecation and improving waste disposal.

High rates of on-site sanitation procedures, such as direct discharge into open sewers or bodies of water, pose major health risks and harm to the environment. In the case of Noakhali, 4% of these systems contribute to environmental contamination by dumping sludge directly into open drains or bodies of water, seriously harming the environment and posing serious health hazards (UNICEF & WHO 2019). Furthermore, improper septic tank hookups aggravate pollution. Addressing these concerns is critical to protecting human health and the environment.

Promoting sanitation education is essential for instilling a cleanliness attitude among youths. Engaging the young group which includes 1.8 billion people aged 15–24, in sanitation programmes can help them innovate (Bremner et al. 2010). Youth are frequently innovators of technology. Integrating novel sanitation technology, such as smart toilets, mobile apps for hygiene advertisement, or data-driven tracking systems, can be considerably accelerated by young people's technological awareness (Alqahtani et al. 2022). In addition, integrating innovative sanitation technology, which is backed by NGOs such as WaterAid, Oxfam, and the Bill & Melinda Gates Foundation can help to speed progress (Rush & Marshall 2015). Improving local administration and coordination among urban sanitation groups is critical for successful implementation (Gemill & Bamidele-Izu 2002).

There are a number of reasons why improving urban sanitation in the Noakhali Pourashava may be difficult. First, there are substantial obstacles due to poor infrastructure and resource allocation since development might be hampered by insufficient investments in sanitation facilities. Second, when metropolitan areas and populations quickly grow, pressure is placed on the sanitary infrastructure, frequently leading to insufficient coverage. Rapid urbanization increases demand for sanitary facilities, resulting in insufficient coverage. Thirdly, cultural resistance, influenced by religious beliefs and societal conventions, impedes the use of improved sanitation practices (Biran et al. 2011). According to the study, perceived social acceptance and traditional customs associated with open defecation posed a strong barrier to the acceptance of modern sanitation facilities. Culturally appropriate measures are required to break down behavioral obstacles and increase the adoption of contemporary sanitation facilities.

The study done in Noakhali Pourashava, Bangladesh, showed that the state of urban sanitation is severely lacking in terms of capacities, technologies, attitudes, and financing. A sufficient sewage system or facilities for handling fecal sludge were lacking, as evidenced by the 93% of the population using septic tanks, single pits, and twin pits as their primary form of on-site sanitation. As only 3% of the excreta entered the sewer system and 88% were not properly disposed of, this has not only endangered the environment but also the public's health. By integrating SFD, CSDA, and SWOT analysis, stakeholders can gain a comprehensive understanding of FSM and develop sustainable sanitation solutions. This paper highlights the significance of utilizing these tools together, emphasizing their collective ability to inform decision-making processes, optimize resource allocation, and address challenges in FSM.

To address the pressing urban sanitation challenges in Noakhali Pourashava, the following recommendations are proposed across various critical domains:

• There is a pressing need for increased investment in sanitation infrastructure, including sewage systems, treatment plants, and proper disposal facilities for fecal sludge, given their critical role in public health and environmental sustainability. International aid and collaboration with NGOs can supplement government efforts in this regard.

• Public awareness campaigns should be initiated to promote safe sanitation practices and discourage open defecation, leveraging community workshops, educational programs in schools, and media dissemination. Engaging youth in these initiatives can tap into their innovative potential to develop creative solutions.

• Embracing innovative sanitation technologies, such as smart toilets and mobile apps for hygiene promotion, can significantly enhance sanitation practices. Collaboration with experienced NGOs and private sector partners can facilitate their adoption and scale-up.

• Improving coordination among stakeholders involved in urban sanitation, including government agencies, NGOs, and community-based organizations, is essential for the effective implementation of sanitation initiatives. This could involve regular meetings, joint planning sessions, and clear communication channels.

• Recognizing and addressing cultural and behavioral barriers to adopting improved sanitation practices is crucial. Culturally sensitive interventions, community engagement strategies, and the involvement of local leaders can aid in this effort.

• Capacity building of local authorities and sanitation workers through training programs on maintenance techniques and public health awareness is vital for sustainable management.

• Establishing a robust monitoring and evaluation system using tools like SFDs and CSDAs can provide valuable insights into progress and challenges, guiding future investments and strategies.

These recommendations collectively aim to advance Noakhali toward sustainable and inclusive urban sanitation, improving public health outcomes, protecting the environment, and enhancing the overall quality of life for its residents.

We would like to thank Assistant Engineer Mohammad Deluar Husen of Noakhali Paurashava, Governance and Mobilization Officer Al Mobin Rahman of the United Nations Development Programme (UNDP), and Executive Engineer Md. Ahasan Habib of the Department of Public Health Engineering (DPHE) for their support.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.