Guidelines on Sanitation and Health
About this book
Guidelines on Sanitation and Health, published by the World Health Organization (WHO) in 2018, provides the first comprehensive update of WHO sanitation guidance since 1996 and establishes a new evidence-based framework for evaluating and improving sanitation systems from a public health perspective. Developed in response to the persistent global sanitation crisis — approximately 2.4 billion people lacked access to basic sanitation facilities at the time of publication — the guidelines synthesise evidence from epidemiological studies, sanitation intervention trials, and systematic reviews conducted over the preceding two decades. The guidelines adopt a sanitation systems approach that goes beyond facility provision to examine the full sanitation chain: containment (toilet technologies), emptying and transport (manual and mechanical pit emptying, vacuum trucks), treatment (septic tank effluent, faecal sludge treatment plants), and end-use or disposal of treated outputs.
This end-to-end perspective reflects the recognition that building latrines without ensuring safe management of the contents throughout the chain provides limited health benefit — a fundamental insight from the WASH (Water, Sanitation, and Hygiene) evidence base. The epidemiological evidence on sanitation and health is reviewed systematically. Improved sanitation is associated with approximately 40-50% reductions in diarrhoeal disease incidence, along with reductions in soil-transmitted helminth infection, cholera transmission, and environmental enteric dysfunction (which contributes to childhood stunting).
The 'sanitation ladder' — from open defecation through unimproved, limited, and basic facilities to safely managed sanitation — provides a framework for tracking progress toward the SDG 6 target of universal access to safely managed sanitation by 2030. The guidelines introduce the WHO WASH Burden of Disease framework, which estimates sanitation-attributable mortality at approximately 432,000 deaths per year from diarrhoeal diseases and assesses non-fatal disease burden in DALYs. This evidence base provides the quantitative foundation for cost-effectiveness analyses of sanitation investment.
Safely managed sanitation — the highest rung of the sanitation ladder — is defined as use of a toilet connected to a sewerage system with treatment, a septic tank with appropriate emptying and treatment, or a dry pit latrine with safely managed containment and disposal. The guidelines provide technical specifications for each service level and examine the governance, financial, and human resource requirements for achieving safe management at scale.