Sustainable Shared Sanitation Post-COVID : A Design Guide to Low-Income Peri-Urban Areas

Sustainable Shared Sanitation post-COVID A Design Guide for low-income peri-urban areas

Daryl Law Research Methods: Trandisciplinary Urbanism MArch 1, Manchester School of Architecture

Sustainable Shared Sanitation post-COVID A Design Guide for low-income peri-urban areas

Contents 1

About This Document

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2

Four-part Summary of the Literature Review

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3

Shared Toilet Models Appropriate to the Local Context

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4

Design Considerations

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5

Promoting Shared Toilets as High Quality / Improved Sanitation

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6

Towards Sustainable Sanitation

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Designing Shared Toilets in the Wider Urban Planning Context

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References / Resources

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Table of Illustrations Fig. 1 Improvements across the range of shared toilet models in Accra, Ghana.

Fig. 2 Decisions and alternatives for shared household toilet models.

Fig. 3 Decisions and alternatives for community toilet models.

Fig. 4 Decisions and alternatives for public toilet models.

Fig. 5. Design considerations to improve hygiene and limit cross-contamination.

Fig. 6. Considerations for inclusive design.

Fig. 7 Design considerations for on-site containment.

Fig. 8 Design considerations to encourage use.

Fig. 9 Monitoring performance of shared toilets based on the Common-pool Resource framework.

Fig. 10 Identifying opportunities to create a sustainable sanitation value chain in Accra.

Fig. 11 Identifying opportunities to create a sustainable sanitation value chain in Accra (2).

Fig. 12 The status of shared toilets in the sanitation ladder, and their connections to municipal infrastructure.

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1 About this Document

As a Design Guide

About Research Methods : Trandisciplinary Urbanism

This document is intended to complement the accompanying literature review on recommendations of post-COVID shared sanitation design. Firstly, it provides a compact but concise summary of the literature review. Key points may help the reader navigate the latter document, or be a guide to structuring a research on a different context.

This research methods workshop looks beyond the discipline and tools of architectural design to understand the social and economic conditions that affect the quality of shared santation service in cities.

This design guide has been developed alongside other research methods, namely an ethnographic sanitation practice diary and the systematic literature review, as well as contributions from international partners through structured sessions.

The literature review enables an overview of the general implications of COVID-19 transmission pathways on shared toilets and the barriers and opportunities for improvement in Accra, Ghana. This document, on the other hand, is a more in-depth development on the architectural design and user requirements of the shared toilets. Knowledge on the physical structure of the toilets needs to be complemented with knowledge on sanitation products and appliances available on the market.

This document (along with the other two) also reflects the role of architects as the coordinator between planners/ developers of shared sanitation and the community of users, especially those whose needs require careful consideration by designers.`

This document also illustrates the equal importance of design and management with regards to shared sanitation service. It introduces practical steps to make shared toilets more operationally sustainable.

This document aims to incorporate strategies for limiting the spread of COVID-19 (or similar diseases) into ongoing efforts to improve the quality and sustainability of shared toilets. It points the reader to more specialized tools and resources available online.

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2 Four-part Summary of the Literature Review 1

COVID-19 transmission pathways

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Risks of environmental contamination and fecal-oral transmission of SARS-CoV-2 points to the need to eliminate uncontained sanitation technologies that pollute water bodies and the poor performance of waste treatment plants

Human-to-human transmission occurs via airborne virus-carrying particles attacking the respiratory system.

More recent research discovered extended viability of SARS-CoV-2 (the virus causing COVID-19) in human excreta, thus raising concern of transmission via feces and the environment connected to water bodies.

Women, children and the elderly are discouraged from using shared toilets due to poor hygiene and safety, or lack of dedicated facilities. Shared toilets are unpleasant also due to unmaintained cleaning duties and gender bias in their upkeep.

Toilets are high-risk sites of transmission, especially when shareed between households and large groups of people.

The lack of effective handwash solutions, the financial burden of pay-per-use toilets, and the lack of constant water supply in informal settlement, are some of the vulnerabilities revealed by Ghana's free water directive during the pandemic.

In dense, unplanned peri-urban settlements, overcrowded households, poor sanitation infrastructure, certain cultural practices and public health awareness may pose risks of cross-contamination

Shared sanitation in less-developed areas of Accra have not been included in new investments in response to COVID-19. This also brings into quesiton to the exclusion of shared toilets as improved sanitation by the UN Sustainable Development Goals.

Improvements on shared toilet design requires looking into links to user behaviour and broader infrastructure and planning.

2

Vulnerabilities of shared sanitation in peri-urban Accra during COVID-19

Overview of shared sanitation in Accra, Ghana

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Access • Within the Greater Accra Metropolitan Area (GAMA), 41% of the population rely on pay-per-use public toilets, and only 33% have private sanitation facilities (data from 2017). Only 15% of Accra is connected to the sewer network (data from 2019). The Kumasi Ventilated Pit Latrine (KVIP) is a significant onsite containment sanitation technology used by the peri-urban population.

Recommendations for postCOVID shared sanitation design Effective handwashing solutions must be provided in all facilities. Water sources protected from contamination should be prioritized for handwashing.

Appliances should limit cross-contamination.

Availability • Micro-context studies reveal the severely low coverage of sanitation facilities in lowincome informal settlements. Poor maintenance of these facilities lead to alternative defecation methods.

The design should accommodate the needs of women, children, vulnerable groups and caregivers. Effort is needed to eiliminate gender bias in the management of shared toilets.

Standards • Government bodies and policies implemented to systematically improve sanitaiton in Ghana are relatively recent. Although the government failed to meet its targeted provision of sanitation service in 2019, ongoing efforts are still being made.

Setting a clear monitoring framework may allow shared toilets to be recognized by monitoring protocals and the UN Sustainable Development Goal. This may also encourage more investments for informal peri-urban settlements.

Norms & Perception • Poor perception of shared toilets, esp. by women and vulnerable groups, is affected by overcrowding and low public health awareness.

Ensure sustainable operation of desludging services and centralized fecal waste treatment plants by linking them to business opportunities for recycling fecal waste into useful resources and products.

Maintenance • Public toilets are managed by lower government levels and private companies. Costly desludging services often lead to their failure and unsafe disposal of fecal waste.

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3 Shared toilet models appropriate to the local context 3.1 Ongoing efforts to reconcile affordability with quality of service

COVID-19 may draw more attention to the technical criteria of future shared toilet design aimed at hygiene, safety and accessibility. However, these criteria often contradict what most low-income citizens can afford,even prior to the pandemic.

Safety / Distance

Privacy

Shared household toilets

•

•

•

Why? Shared toilets closest to households are naturally most preferred, esp. for children, elderly & disabled

Cleanliness

Develop smaller toilet blocks, but more numerous & distributed

•

•

Why? Closer to households; shared by fewer users; users are familiar with each other Reduce transmission risks from overcrowding; potentially easier monitoring and better use experience

Typically connected to workplaces and institutions Affordable fees, but toilets are often poorly mantained

Improve & increase the provision of large toilet blocks

•

•

•

• •

Potential limitations Limited successful precedents Economic viability is not yet proven - smaller revenue stream may compromise O&M costs

Affordability

Public toilets

Has potential to integrate added value services to generate revenue for operation and management Commercial toilets may offer better service at higher fees

Important strategies Potential to be considered as improved sanitation by JMP - if can be shared by no more than 5 households Potential limitations Enforcement / implementation may be feasible only in less dense / newly built areas. Factors: technical and spatial limitations; high tenant turnover rate

Pleasantness

Community toilets/ Commercial toilets

Compound house tenants typically rely on this toilet type due to lack of space for individual household toilets

Enable landlords to become sanitation service providers

VS

Residents in low-income areas of Accra often have to compromise between affordability and high-quality toilets. Most choose low fees over hygiene.

The pros and cons of existing shared toilet models also correpond to this spectrum of needs.

•

Why? Better service, access and fees by increasing business competition Important strategies Regulation is needed to prevent anti-competitive behaviour from larger providers Local government must identify unserved areas, and overcome land limitations with allocating free land or tax incentives Potential limitations Economic viability is not yet proven - smaller revenue stream may compromise O&M

Fig. 1 Improvements across the range of shared toilet models in Accra, Ghana. (Source: [Adapted from] : Mazeau, 2013) 6

3 Shared toilet models appropriate to the local context 3.2 Strategies for improving existing facilities and new projects

Both the physical facilities and the management models of shared sanitation service. In practice, the three most common shared toilet types can be implemented across a range of settings or be hybridized between them. For example, a cubicle shared between specific households can be integated into a community toilet block, and a community toilet model can be implemented in a public setting (see Cardone et al, 2018).

Improve and optimize existing assets Lower fees / encourage use Accountability / Enable regular performance review

Nonetheless, the focus in the planning, implementation and upkeep of these toilet models is in how they encourage use. Therefore, failure of shared toilets can be reduced, and thus curb open defecation or unsafe sanitation practices.

Gain recognition by monitoring protocols / incentivize investment Supporting users (as well as requiring support from users)

Considering the dense and unplanned condition of peri-urban settlements, the priority should be to improve existing facilties. If new facilties are necesssary, these strategies are just as useful.

Resource • The World Bank Group's Shared and Public Toilets: Championing Delivery Models That Work (Cardone et al., 2018) is an extensive guide to key considerations in providing shared toilets to needy urban and peri-urban areas.

The document features checklists, resources and case studies for understanding the local sanitation market, identifying locations for intervention, addressing user needs, and ensuring effective governance.

Shared household toilets Is it physically possible to provide a shared toilet model for multiple housholds?

N Ensure there is sufficient land for separate male and female facilities and drainage. Otherwise, consider impermanent/ mobile facilities.

Y

Is it possible to provide a bathing / laundry area for tenants?

N May limit tenant willingness to pay for toilet.

Explore opportunities to record data on performance to inform planning for enforced expansion of shared household toilets

Y Can the toilet serve ≤5 families or ≤20 people?

N There is significant risk that the toilet(s) will become undermaintained. Consider community toilets instead.

Y

Are tenants willing to pay more in rent for a shared household toilet and contribute to cleaning/maintenance?

Y

N Lower potential for repaying loans or offsetting lost rent from converted house unit.

Fig. 2 Decisions and alternatives for shared household toilet models. (Source: [Adapted from] : Cardone et al., 2018)

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Are finance mechanisms available to support investment in the toilet(s)?

N Focus efforts first on strengthening municipal governance to support landlords as service providers

3 Shared toilet models appropriate to the local context 3.2 Strategies for improving existing facilities and new projects

Community toilets/ Commercial toilets Are there existing assets that can be refurbished?

Y

N New build: ensure there is sufficient land for separate male and female facilities and drainage.

Otherwise, consider impermanent/ mobile facilities.

Are there existing organizations or private service providers with capacity to manage ≥1 facility?

Pursue value-added services (e.g. bathing, laundry, meeting room, shop) that will add to community's economic and social well-being.

Consider bundling management of multiple facilities into a delivery contract

Y

Is there potential for cross-subsidization by bundling management functions with nearby public toilets?

Are community members able and willing to pay for the toilet or valueadded service?

Y

N

N

Y

N

Seek alternative community locations to meet residents' sanitation and hygiene needs.

Service authority to play a stronger role in managing service. Otherwise, the community may need to take on the role, or call for subsidies and support.

Explore use of mobile data for operating efficiency

Are there clear and accessible mechanisms for users, providers, & serivce authorities to esnsure basic service?

N

Reevaluate viability of community toilet model; invest for community who will lend financial input

Reevaluate viability; invest in more economically viable neighborhood

Fig. 3 Decisions and alternatives for community toilet models. (Source: [Adapted from] : Cardone et al., 2018)

Public toilets Are there existing assets that can be refurbished?

N New build: ensure there is sufficient land for separate male and female facilities and drainage.

Otherwise, consider impermanent/ mobile facilities.

Y

Are there existing organizations or private service providers with capacity to manage ≥1 facility?

N Service authority to play a stronger role in managing service. Otherwise, the community may need to take on the role, or call for subsidies and support.

Y

Is there potential to increase operating effciency by bundling management functions with nearby public toilets?

N

Y Is there space/ potential to offer added-value servcies?

Pursue value-added services (e.g. bathing, laundry, meeting room, shop) that will add to community's economic and social well-being.

Y

Long-term subsidies may be needed to ensure basic service.

Is there potential to generate extra revenue with ad space, billboards, shop, etc.?

N

Maximize revenue to sustain core sanitation business

Y Is there a contracting mechanism to allow regular monitoring of service levels?

N

Y Explore opportunities to digitize feedback, and connect performance with financial incentives for service expansion Fig. 4 Decisions and alternatives for public toilet models. (Source: [Adapted from] : Cardone et al., 2018)

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Risk that services may not be maintained over time

High risk of failure.

Reevaluate purpose and objectives of public toilet models and how they can be achieved.

4 Toilet Design Considerations 4.1 Hygiene This figure shows a dry-composting toilet. The design considerations apply to other toilet types.

Vent pipes to have fly screen and rain cap, and extend 500mm above roof

Provide elbow or footoperated door opener if possible

Brick/concrete construction is durable for regular cleaning

Adopt outward opening doors if land area if limited - internal cubicle length is reduced

Harness natural lighting and ventilation

Where practical, top up washing water with collected rainwater.

Provide wipe material and water for cleaning up

Counterweighted lid seals the fecal tank below Provide bin for disposing wipe material Setitng the handwash station at a publicly visible place encourages everyday use.

Squatting toilets may be more appropriate in certain cultures (see x.3)

Long-handles or foot pumps can avoid the use of hands, hence limiting contamination

Surfaces graded to ensure effective drainge and no ponding

Consider theft-and vandalproof soap and tissue dispensers

Resource • For a more comprehensive guide on the infection prevention and control in the water, sanitation and hygiene (WaSH) sector, refer to: World Health Organization.

(2020) Water, sanitation, hygiene and waste management for SARS-CoV-2, the virus that causes COVID-19.

Handwash material in order of effectiveness: water+soap; ash; water only (WHO, 2020)

Veronica bucket

Suspended bottle/ Sink with tap bag

Foot pump sink

All-in-one system

Free-standing tank with taps

Troughs

Resource • UNICEF's (2020) Handwashing Stations and Supplies for the COVID-19 Response lists the advantages of each handwash design in different scenarios. It is, in a sense, a guide to the diverse products on the market.

Fig. 5. Design considerations to improve hygiene and limit cross-contamination. (Source: [Adapted from] : Water Aid, 2019; WHO, 2020; UNICEF, 2020) 9

4 Toilet Design Considerations 4.2 Incusivity

This figure shows the integration of added-value services to the accessible toilet, including laundry area, shower/changing. If land area is not a constraint, bigger amenities can be added, such as a small shop, water sales, mobile phone charging, or community meeting space.

Preserve and reuse greywater for handwashing

Robust seating ledge to help with manual clothes-washing

Cubicle is spacious enough for user+caregiver.

Ensure at least 1525mm turning circle Harness natural ventilation and daylight Handheld shower and fold-down seat help user to manage themselves

Disposing wipe material in bin may be favourable to minimize risk of blockage

Mirrors, positive messages or guidelines encourage proper use

Simple fittings to assist the caregiver - stools, fold-down shelf for baby changing

Basin is essential for showering in areas with infrequent or lowpressure water supply

Dedicated surface for washing - robust and graded for drainage

Provide pedaloperated sanitary bin if possible

Pedal-operated bin reduce tranmission risk

Outward opening door fitted with with grab bar and easy to use (lever type) lock

Cabinets to place clothes for changing and store cleaning or menstrual products

If only pour-flush is not available, provide simple seat structure to place above slab (see x.1) Long handle for operating with elbow to limit transmission Easily accessible wipe material

Resource • A more extensive collection of facts and recommendations can be found in WSUP’s 2018 Female-friendly public and community toilets: a guide for planners and deciision makers.

Handrails with tactile gripping

Fig. 6. Considerations for inclusive design. (Source: [Adapted from] : Water Aid, 2019; WSUP, 2018) 10

4 Toilet Design Considerations 4.3 Containment

This figure shows a shared household toilet within a compound house that uses an offset pit. The design considerations applies to other on-site containment technologies as well.

Defined boundary with a gated compound or lockable doors leading to the shared toilets U-bend pipe with water as odour buffer

Robust and durable substructure eases maintenance and upgrades Ensure slab seals around vent pipe if used

Ensure containment structure is accessible to desludging machines and vehicles - supporting different classes of service providers

Lip of pit lining to extend at least 100mm above ground level or highest flood level

Sealed access pit for emptying: min opening 600mm diameter

Offset pit affords indoor installation of shared household toilets

Slab should be reinforced, and no gaps for pathogens or odours to escape

Containment types examples : pit latrine; KVIP; offset pit

Resource • Offset pit is one from a range of on-site contained sanitation technologies in a peri-urban setting. To study the steps for planning and the pros and cons of each technology, refer to Water and Sanitation Rotarian Action Group (WASRAG) - Guidelines for Planning Sustainable Sanitation Projects and Selecting Appropriate Technologies (2019).

Fig. 7 Design considerations for on-site containment. (Source: [Adapted from] : Water Aid, 2019) 11

4 Toilet Design Considerations 4.4 Superstructure

Durable materials and properly planned construction reduce failure of the faciltiies

Where practical, top up flushing or washing water with collected rainwater.

5%-12% gradient (steeper ramps will require assistance)

Clearly indicate relevant information on signs. Consider including Braille signs and tactile fittings.

Ensure signage is highly visibe. Consider other relevation information, e.g. fees and additional services

Murals on wall surface may reflect local culture, depict safe sanitation practice, and impove perception of the facitilities

Consider skylights to harness natural daylight

Superstructure floor level at least 100mm above ground or highest flood level in floodprone areas

Place accessible facility closest to entrance

Dedicated room for attendants for better care after the facility and users

If land area is not a constraint, provide separate male and female sections

Dedicated waiting area for groups and caregivers Maze-type entrance provide privacy without need for a door. Door handles pose risk of disease transmission.

The illustration above shows common design considerations between a latrine-type design/community toilet model and a more insitutional design typically connected to a centralized sewerage network.

Resource • For more in-depth technical guidelines for planning, design and construction, refer to Water Aid's (Shaw et al., 2018) Technical guidelines for construction of institutional and public toilets.

Fig. 8 Design considerations to encourage use. (Source: [Adapted from] : Water Aid, 2019) 12

Integration with street lights encourage use at night Proper use of lighting at night encourages use Large water storage to anticipate infrequent or low-pressure water supply

Ensure users pass through handwashing station before leaving. Setting it at a publicly visible place also encourages everyday use.

Clerestory openings to harness natural ventilation Rules, notices and rotas are visible before entering

5 Promoting shared toilets as highquality or improved (shared) sanitation 5.1 Clear determinants for management & monitoring

Defined boundaries

Management Practice Y

N Management rules/ structures

Collective decision making

Monitoring of toilets & users

Conflict resolution mechanism

Hardware and hygiene Y

N

Sanctions

Users:toilet ratio

Hygiene

Identifies legitimate user groups; helps to deter users or intruders who undermine clieanliness Ensure all users contribute to the common good of the facility

• Use of locks, or locating the the shared household toilets in fenced compounds • Written duty rotas and rules instead of by oral agreement or memorization • Education and communication to dispel taboo of males sharing cleaning duties • Encourage/enforce parental support when children use toilets

Users cooperate when they are consulted and their opinions are valued

• Ensure participation of all users in discussions about sanitation issues

Systematically oversee the performance of the toilets and behavior of the users

• Check on irresponsible or illegitimate users • Informal surveillance by tenants and landlords

Maintaining good relations or having clear leadership roles to resolve conflicts

Appropriate penalties for uncooperative or unruly users

Overcrowded facilities often lead to poor hygiene

Appoint a member, landlord or local leader to mediate conflicts if users are unable to reconcile on their own • Appoint a member, landlord or local leader to administer sanctions E.g. in order of severity: warnings; ban; report to local chief; eviction

Use appropriate tools to determine the optimal ratio of users to toilets. For example, regression analysis generated from a 'scoresheet'.

Poorly built facilities often lead to low levels of cleanliness, privacy and safety

Superstructure

Resource • The Behaviour Change Wheel is a another useful framework to organize behaviour associated with shared sanitation to be monitored. At its core is the COM-B system consisting of three fundamental conditions that affect behaviour - Capability, Opportunity and Motivation. To study its application, see Antwi-Agyei et al. (2020), Understanding the Barriers and Opportunities for Effective Management of Shared Sanitation in Low-income Settlements - The Case of Kumasi, Ghana.

Fig. 9 Monitoring performance of shared toilets based on the Common-pool Resource framework. (Source: [Adapted from] : Simiyu et al., 2017) 13

6 Towards Sustainable Sanitation 6.1 Issues & Expectations in the Sanitation Value Chain Example : Accra, 2010 Containment Waste water

7%

Emptying

Contained offsite

Contained onsite 26%

Septic tank

Pan / Bucket latrine Unlined pit

56%

3%

Manual excavation

Observations

Why?

What can be done?

74%

Treated

1%

Not treated

6%

FS treated

6%

only

7%

FS not treated

68%

of total waste is safely managed

Not delivered

8%

8%

68%

8%

3%

6%

11% Local / Residential area

8% Neighborhood / Open drains

Local contamination (open defecation or inadequate emptying process)is decreasing (from 23% in 2000)

Fecal contamination in neighbourhoods is decreasing (from 28% in 2000), as collection of excreta+delivery to designated dumping sites has increased

Untreated fecal sludge and excreta released into city water bodies increased (from 28% in 2000)

More public sanitation facilities has been provided due to private sector contribution

• Septic tanks emptied and reused due to increasing population density and lack of space • Effective enforcement of standards

Frequent failure of treatment plants due to poor electricity infrastructure; no sustainable revenue stream for operation and maintenance

More efforts needed to increase access to shared sanitation and trigger behaviour change

Continue enforcement of laws and collection/ emptying services by the government and private operators

• Stronger central planning to sustain the treatment of excreta and fecal sludge • Encourage private sector contribution to the recycling of fecal sludge and wastewater

2000

What can be expected by 2025?

1%

FS not contained & not collected

Open defecation

Excreta

Delivered

Manual collection

Not contained 59%

Mechanical suction

End-use / Disposal

Treatment

6%

FS collected 26%

Sealed tank Fecal sludge

Sewerage network delivered to treatment plants

7%

Sewer

Transport

2010

74% City / Receiving Waters

2025

21%

7%

79%

93%

47%

of total excreta is safely managed

• Uncollected fecal sludge contaminating neighborhoods could disappear • Open defecation could further decrease but would not disappear • Treatment plant performance could increase

53% unsafe

Fig. 10 Identifying opportunities to create a sustainable sanitation value chain in Accra. (Source: [Adapted from] : Nikiema et al., 2015) 14

93% isunsafe

6 Towards Sustainable Sanitation 6.2 Sustainable Sanitation Strategies Beyond the toilets

Better user interface

COVID-19 has highlighted the public health and environmental risks posed by the ineffective containment, collection and treatment of fecal waste (see literature review). It is imperative that desludging treatment service providers are financially sustainable and maximize business opportunities for reuse and recycling. Apart from the main strategies illustrated here, adequate quality control for recycle products and efforts to raise public hygiene awareness are also important.

Refuse as resource Strong partnerships Sustainable operations

Emptying Transport

Containment

Wastewater Eliminate exposed drains

Treatment

O&M

O&M

Capital

Capital

End-use / Disposal

Farm irrigation

Excess water Purchase & delivery

Fecal sludge / excreta

×

Eliminate uncontained sanitation facilties

Collection service

Collection fees

Small businesses / private operators

Contract

Transport

Disposal fees

Budget support

Capital

NGO

Aquaculture

Treatment plant (state & private)

Dry sludge

Fertilizer production

Purchase & delivery

MOU

Biogas production

Municipality

Financial support

Solid organic waste

Eliminate unlined pits

Biqruettes production

Purchase & delivery

Donors

Landfill Fig. 11 Identifying opportunities to create a sustainable sanitation value chain in Accra (2). (Source: [Adapted from] : Appiah-Effah et al., 2019; Nikiema et al., 2015)

Resource • Fecal waste flow diagrams (a.k.a. SFDs) help planners identify and address gaps or failures in sanitation service and tackle open defecation. The SFD tool provides guidance on what data to collect, an input form, and a graphic generator. It also provides examples of SFDs from other cities. Although SFDs do not capture the recycling of fecal waste, it can still help planners monitor the improvements made.

For more information, see http://sfd.susana.org.

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7 Designing Shared Toilets in the Wider Urban Planning Context

Sanitation facility which is not shared with other households, and where excreta are safely disposed or treated off-site Use of improved facilities which are not shared with other households Use of improved facilities shared between two or more households

Shared household toilets Community toilets/ Commercial toilets Public toilets

Use of pit latrines without slab or platform, hanging or bucket latrines Disposal of excreta in fields, forests, bushes, open bodies of water, beaches or other open spaces, or with solid waste Fig. 12 The status of shared toilets in the sanitation ladder, and their connections to municipal infrastructure.

(Source: [Adapted from] https://washmatters.wateraid.org/blog/incentives-accountabilityand-indicators-assessing-sanitation-progress-through-a-total-service)

The design of shared toilets in dense, unplanned periurban settlements must consider planned or ongoing formalization, relocation, or provision of infrastructure (e.g., piped water supply, roads, electricity) in these areas, which may eventually enable the installation of household toilets.

Despite that the WHO/UNICEF Joint Monitoring Programme prioritizes private sanitation and classifies shared sanitation only as a 'limited sanitation' service, this document (and the literature review) recognizes the essential role played by shared toilets in city-wide sanitation, especially in peri-urban areas.

In some situations, designers could leverage surrounding infrastructure to support the service of shared toilets, e.g. position the facilities to optimize waste collection routes. If household toilets (private or shared) are eventually attainable, modular and demountable designs may be suggested (Cardone et al., 2018).

The design strategies gathered in this document may contribute to safely managed and sustainable public toilets, and the change in status of shared sanitation in gloal monitoring prootocols.

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8 References / Resources Management of sanitation for COVID-19 World Health Organization (WHO) (2020). Water, sanitation, hygiene and waste management for SARS-CoV-2, the virus the causes COVID-19.

UNICEF (2020). Handwashing stations and supplies for the COViD-19 response.

Shared sanitation in Accra / Ghana Antwi-Agyei, P., Dwumfour-Asare, B., Adjei, K.A., et al. (2020).

Understanding the Barriers and Opportunities for Effective Management of Shared Sanitation in Low-income Settlements The Case of Kumasi, Ghana. International Journal of Environmental Research and Public Health, 17:4528.

Appiah-Effah, E., Duku, G. A., Azangbengo, N. Y., et al. (2019).

Ghana’s post-MDGs sanitation situation: an overview. Journal of Water, Sanitation and Hygiene for Development, 9(3).

Ayee, J,, and Crook, R. (2003). Toilet Wars: urban sanitation services and the politics of public-private partnerships in Ghana.

Mazeau, A. P. (2013). No toilet at home: Implementation, Usage and Acceptability of Shared Toilets in Urban Ghana.

Mansour, G. and Esseku, H. (2017), Situation analysis of the urban sanitation sector in Ghana. Water and Sanitation for the Urban Poor (WSUP).

NIkiema, J., Olufunke, C., Imrpaim, R., et al. (2015). The Excreta Flow Diagram: A Tool for Advocacy and a Wake Up Call for All. Presentation.

Shared toilet management models Cardone, R., Schrecongost, A., and Gilsdorf, R. (2018). Shared and Public Toilets: Championing Delivery Models That Work. The World Bank Group.

Gender- and age- inclusive shared toilets WSUP (2018). Female-friendly public and community toilets: a guide for planners and decision makers.

Sanitation Technologies WSUP (2018). Female-friendly public and community toilets: a guide for planners and decision makers.

Sanitation Value Chain Nikiema, J., Impraim, R., Gebrezgabher, G., et al. (2015). The Excreta Flow Diagram: A Tool for Advocacy and A Wake Up Call for All. International Water Management Institute.

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How can the design of (existing and future) shared sanitation facilities in urban Ghana be improved in response to challenges arising from COVID-19?

A systematic literature review as part of Research Methods: Trandisciplinary Urbanism

Joshua Baker, Hannah Byrom, Jian Gao, Daryl Law, Bethany Stewart, and Yuxi Yang

Abstract

impoverished urban areas (Ritter et al., 2018).

SARS-COV-2 (COVID-19) has brought unprecedented interruption to our daily lives. Subsequently, an abundance of research highlights the various transmission pathways of the virus. However, such findings have not been applied to shared sanitation facilities to prevent the spread of COVID-19. In Africa, approximately 638 million people use shared facilities with over 60% of the population without access to improved sanitation (World Health Organization, 2018a; World Health Organization, 2018b). This systematic literature review aims to address the vulnerabilities of shared sanitation facilities in Accra, Ghana introduced by the COVID-19 pandemic. This review concludes by suggesting recommendations to prevent transmission of the virus within these environments and looks to form a larger conglomerate of information for the World Toilet Organisation (WTO).

Ghana is in West Africa, along the Gulf of Guinea and the Atlantic Ocean. The focus of this literature review is the city of Accra, the capital city of Ghana. Accra is one of the 16 administrative regions, and it has an estimated population of 1,848,614 (Ghana Statistical Service, 2010).

Keywords: Covid-19, Shared Sanitation, Public Toilets, Accra, Ghana,

Accra comprises of densely populated urban slums.

The term ‘slum’ is a neighbourhood that lacks access to improved water or sanitation, security, the durability of housing, sufficient-living area (UN, 2015). These are the focus of our literature review.

Between 2000 and 2006, it had an average annual population growth rate of 2%. However, this figure could rise to 2.4% between 2016 and 2030 (Musah et al., 2020).

Rapid urbanization has put a strain on infrastructure and the provision of adequate sanitation facilities (Mariwah, 2018; Appiah-Effah et al., 2019). Approximately 19% of Ghanaians practice open defecation and, another 66% use unimproved or shared facilities (Ritter et al., 2018).

The COVID-19 pandemic has highlighted the issues faced by residents of informal peri-urban settlements who rely on shared toilets. The paper will discuss recommendations identified through the analysis of relevant literature.

Methodology

Introduction An estimated 800,000 people die annually from diarrhoea and other related diseases due to unsafe water, poor sanitation and hygiene (WHO, 2018). The target, set out by The Sustainable Development Goals (SDGs), is to eliminate open defecation by 2025 and introduce household sanitation facilities by 2040 for all (Ritter et al., 2018).

Improved sanitation is a toilet facility that protects human health by preventing contamination of the environment with human faecal waste (Rheinlander, 2015). Also, shared facilities are sanitation of an otherwise acceptable type shared between two or more households (WHO, 2015).

Based on this classification, approximately 638 million people use shared facilities (Sagoe et al., 2019). In Africa, over 60% of the population does not have access to improved sanitation, while 40% of the rural population openly defecate (Sagoe et al., 2019). This figure is unlikely to change due to a lack of space and financial barriers in 1

The purpose of this chapter is to introduce the methodology for this qualitative and quantitative grounded theory study, regarding how existing and future shared facilities in urban Ghana can be improved in response to challenges arising from COVID-19. The approach provided a deeper understanding of these facilities to identify practices to limit the spread of infection.

Before identifying relevant literature, we devised a criterion of inclusion/exclusion. Specifically, the focus of our review is shared sanitation facilities within informal settlements in Accra, Ghana. We have excluded literature on rural communities of Ghana along with private household facilities.

Each researcher identified 20 items of literature and grouped them by category. For example, literature classified under 'Ghana and Shared Sanitation Facilities', are divided into five subheadings: access, availability, standards, norms and perceptions, and maintenance. Finally, in batches of four, each text was analysed through coding and allowed us to reflect and organise data as trends began to emerge.

Criteria Context

Inclusion Ghana Sanitation facility types Toilet types

Inclusion Elaboration Public sanitation facilities in Urban Ghana (Accra) 1 Toilets 1 Pit latrine 2 Dry composting toilet 3 Flushing toilet

Language Population / Subject User

English Communities in Urban Accra Areas (Kumasi and Accra)

For Comparison

Urban Settlements

Time frame

2000 - Present

Type of Literature

Peer-reviewed journals

Single / multi author books Edited books Grey literature

Research design / Sampling methodology

Literature with 'shelf-life' eg Sanitation Policy 20202030 Qualitative

Exclusion Rural Ghana 1 Changing facilities 2 Breastfeeding facilities Toilets in private households

Non-English Communities in rural areas of Ghana

Informal and formal settlements; lowmedium-high density Research earlier than 2019 that are Pre-2000 Material related to built environment, public health, urban planning, etc.

Wikipedia World Health Organization Nature National Center for Biotechnology Information (NCBI) Google scholar, JSTOR Fiction Poetry Blogs Not peer-reviewed, but completed with supervision and consultation of academic staff or specialists in related fields News Articles Specialist Reports Thesis (PhD) Posgraduate dissertations

Prose

Quantitative Table 1. Inclusion and Exclusion Criteria for Review (Law et al., 2020)

COVID-19 Transmission Pathways In December 2019, SARS-CoV-2 (COVID-19) was first reported in Wuhan, China. Early transmission into the human population is speculated to be via consumption of wild animals, particularly bats (Mackenzie and Smith, 2020).

Human-to-human transmission occurs from close exposure to an infected person via aerosols. Aerosols are virus-carrying particles that infiltrate the body by inhalation through the nose or mouth (Shereen et al., 2020). Increased transmission risks occur between family members due to long-term, highfrequency contact (Guo et al., 2020).

Ozyigit (2020) studied the relationship between the transmission rate and changes in air temperature and humidity. He argues that climate warming could slow down transmission and, the results showed that strains survived longer in lower temperatures and relative humidities. Data analysis shows the transmission rate of COVID-19 will decrease by 0.9% for every degree of increase in temperature.

Also, COVID-19 has shown substantial transmission potential before symptoms appear (He et al., 2020).

Toilets are high-risk sites, especially when shared between households and large groups (public facilities). COVID-19 is present in infected people's excrements, and many have experienced gastrointestinal symptoms, including diarrhoea, therefore concerns remain over faecal-oral transmission (Nomoto et al., 2020; Tian et al., 2020; Li et al., 2020).

The prevalence of water-based toilets, malfunctioning infrastructure, unsafe sanitary habits, and inadequate maintenance could further increase the cross-infection risks of open-lid flushing (Li et al., 2020). A recent study identified COVID-19 as 'both waterborne and non-waterborne' therefore, it is imperative to consider the transmission of the virus via wastewater systems (Dasheng et al., 2020).

Concerns remain regarding the implications of COVID-19 in low-income countries. Impoverished areas lack the required infrastructure (e.g., hand washing stations), resulting in poorly exercised hygiene practices, thus accentuating the concern of transmission surrounding sanitary and wastewater infrastructure (Dasheng et al., 2020). It can be challenging for families and communities to adhere to government restrictions due to over-crowded living environment and religious practices (Corburn, 2020). Improvements have been implemented, such as immediate food assistance; instituting 2

informal settlement emergency planning committees; and meeting Sphere humanitarian standards for water, sanitation and hygiene (Corburn, 2020). Moreover, decentralized wastewater treatment facilities, that use low-cost strategies for highly effective disinfection, may benefit regions not connected to centralized water and sanitary networks (Dasheng et al., 2020). Although unlikely, transmission by contaminated water sources could lead to oral infection (Dasheng et al., 2020).

Predominantly, the impacts of the COVID-19 pandemic have been negative. However, there have been positive strides within urban design, such as creating better FDA standards and employing drones to deliver testing samples and PPE equipment (Afriyie et al., 2020). Technical strategies to reduce transmission within the built environment pertain to light, ventilation, abiotic surfaces, fomites, and spatial configurations (Dietz et al., 2020). However, human-tohuman transmission remains the most prevalent transmission pathway and tackling the pandemic within sanitary facilities calls for intelligent design and improved provision of related infrastructure. In turn, this will enable attentive use between users and promote better hygiene practices.

Ghana and Shared Sanitation Facilties Access

2018).

Fig. 1 Bucket Latrine.

Source: http://www.clean-water-for-laymen.com/best-sanitation.html

Fig. 2 Pit Latrine Source: https://wedc-knowledge.lboro.ac.uk/my-resources/graphicsbrowse-display.html?x=LBAS

Improved sanitation is defined as “toilet facilities that protect human health by preventing contamination of the environment with human faecal waste” (Rheinlander, 2015).

In 2015, Ghana had achieved 14% improved sanitation access and an open defecation rate of 11% (World Health Organisation, 2015; Appiah-Effah et al., 2019).

Approximately 72% of the urban population of Ghana use shared facilities (Peprah, 2015). In 2014, 60% of the residents were without indoor toilets, and only 4.5% of Ghana’s population have access to sanitation facilities which are connected to a sewer network (Virginia et al., 2020). Therefore, open defecation has become a common phenomenon, especially among residents in resource-poor areas.

Fig. 3 Pour Flush Toilet Source:http://www.open.edu.openlearncreate/mod/oucontent/view. php?id=80510&sec-tion=8.1

In 2012, there were 340 registered public toilet facilities (Peprah et al., 2015). The barriers to use include woman and child safety, risk of violence towards women, and lack of provisions for young children (Peprah et al., 2015). Moreover, 79% of Ghanaians lived in compound houses and shared water, electricity, and sanitation between several households (Rheinlander, 2015). Access to private household latrines was 2.7% (Ritter et al., 2018).

In Accra, 15% of the land area is connected to a sewer network, and the remainder of the public toilets have septic systems, pit latrines, or VIP latrines (Sagoe et al., 2019).

Within the Greater Accra Metropolitan Area, 41% rely on payper-use public toilets, 33% have private sanitation facilities, 3% use bucket or pan latrines, and 7% do not have access to any improved sanitation facility (Robb et al., 2017).

A study, commissioned by the Water Engineering and Development Centre (WEDC), found that 92% of respondents believed Persons with Disabilities (PWDs) face difficulties accessing toilets. 75% of PWDs stated that the main challenge was with the design of facilities. In the context of KVIP Latrines, the requirement to squat and the height of the seat are constant obstacles, and toilets are too small, dark and narrow (Ivy and Hazel, 2018). They are usually not considered in infrastructural designs and development (Ivy and Hazel, 3

Fig 5. Kumasi Ventilated Improved Pit Latrine (KVIP) Source:https:// repository.lboro.ac.uk/articles/figure/A_twin-pit_ventilated_improved_ pit_latrine/7957586/1

Location-specific availability A study, undertaken by Peprah (2015), analysed the physical conditions of public toilets and rates of use among the population in four Accra neighbourhoods: Alajo, Bukom, Old Fadama and Shiabu. In Bukom, they found 72% of compounds did not have a toilet (Peprah et al., 2015).

Additionally, 93% and 98% of homes in Bukom and Old Fadama lacked sanitation facilities, compared to 42% and 54% of households in Alajo and Shiabu (Peprah et al., 2015).

Bathing facilities were present in 38% of the public toilets, along with very few hand washing facilities and the cost of using these facilities ranged from US$ 0.08–0.15 per use (Peprah et al., 2015).

Monney (2013), found that there are 39 public toilet facilities in Old Fadama, of which 76% are Pan Latrines and, 24% are KVIPs. 635 squat holes serve a population of 80,000 people (Monney et al., 2013). The current population is approximately 100,000 people (Amnesty International Ghana, 2018). Limited or no household toilet facilities are available, and residents rely on poorly maintained public toilets whilst others, mostly men and children, resort to open defecation (Monney et al., 2013). Consequently, this has resulted in faecal contamination of the environment, the transmission of gastroenteric infections, and a diminished quality of life (Monney et al., 2013). In these communities, the use of Kumasi Ventilated Improved Pits (KVIPs) and Pan latrines costs approximately US$0.1 per visit (Monney et al., 2013).

Sabon Zongo has two main public toilets and six privately‐ owned public toilet facilities, used by approximately 6,000 people (Owusu, 2010). Severely low sanitation coverage figures recorded in Sabon Zongo, Old Fadama, Nima, and Teshie, coincide with Kumasi’s informal settlements (Adubofour et al., 2013; Amoako and Cobbinah, 2011; Monney et al., 2013; Owusu, 2010). Service charges across all four settlements are considered unaffordable, and all communities significantly lack refuse dumpsites (Adubofour et al., 2013; Amoako and Cobbinah, 2011; Monney et al., 2013; Owusu, 2010).

Since then, the 2007 National Water Policy took effect, underpinned by the Millennium Development Goal (MDG) (Government of Ghana, 2007); education proved to be instrumental in ‘ensuring change in behaviors and attitudes towards fundamental principles of hygiene’ (Government of Ghana, 2007:42). Following in 2017, The Ministry of Local Government and Rural Development (MLGRD) issued the Construction of Institutional Sanitation Facilities (2017), which focused on improved sanitation in schools. This document outlined practical construction mitigation about accessibility and the provision of ramps, landscaping, drainage, flooding measures, and security (MLGRD, 2017).

More recently, President Nana Akufo-Addo committed to improve and reform sanitation during his term (Mansour and Esseku, 2017), and the Ghana Standards Authority (2018) published its first building code, establishing the minimum requirements for buildings including sanitation facilities.

Nevertheless, as of 2019, there is only 21% basic sanitation coverage (Appiah-Effah et al., 2019) and Ghana has failed to meet its MDG for sanitation (Mansour and Esseku, 2017). The responsibility of sanitation byelaws belongs to Metropolitan Municipal and District Assemblies (MMDAs), which have not prioritized sanitation or effectively enforced them (WEDC, 2005; Mansour and Esseku, 2017).

Norms & Perception

Standards

With few adequate sanitation facilities, residents express common concerns alluding to cost, cleanliness, and safety.

Many complain about the filthiness and discomfort of shared facilities and consider the high risk for disease – women often fear contracting vaginal yeast infections by touching dirty latrine seats (Van der Geest, 2013; Hurd et al., 2017).

Frequent toilet trips become overly expensive, and factors alongside accessibility, safety, distance to latrines and lengthy morning queues engender people to practice alternative defecation methods. These include the use of take away bags, containers, chamber pots, and open defecation (Hurd et al., 2017).

Lack of sanitation infrastructure stems from the colonial period, where municipal governments gave low priority to sanitation systems (Freeman, 2010). Since then, Ghana’s National Environmental Sanitation Policy (1999), revised in 2009, covers sanitation, food hygiene, solid waste, excreta disposal, and reflects Ghana’s overall commitment to decentralization (WEDC, 2005). Past efforts to provide sanitary excreta disposal, by constructing institutional latrines, became ineffective due to social and economic reasons. Many sanitation facilities fell into disrepair; hence the UN does not identify communal latrines as improved sanitation (Dumpert, J, 2008).

In Ghana, social-cultural attitudes, educational attainment, and commonplace perceptions contribute to the lack of compliance with sanitation standards and practices (AppiahEffah et al., 2019). For example, estimated daily exposure of fecal contamination for young children was more than 10,000 times higher in Shiabu than Alajo – suggesting that exposure to fecal contamination, is determined by more complex factors (Robb, 2017). Many openly defecate due to beliefs that public toilets are heinous places (Appiah-Effah et al., 2019). On the other hand, the majority in Southern Ghana perceive excreta to be unclean and therefore demonstrate the importance of washing hands (Appiah-Effah et al., 2019).

Table 2: Key standards related to sanitation facilities from the Ghana Building Code (Source: [adapted from] Ghana Standards Authority, 2018).

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A study conducted by Odonkor (2020) reveals that 26.5% of respondents who reported environmental problems did not link poor sanitation to diseases such as malaria or diarrhea, highlighting a lack of knowledge. Data also suggests that younger people and those who are more educated are most likely to participate in the improvement and design of environmental policy. Further education of the sanitation related health problems could improve community awareness thus improving hygiene practices (Odonkor, 2020).

Maintenance Since the 1990s, lower government levels and private companies, manage public toilets. They are controlled and supervised by district cleansing officers who, are expected to clean toilets daily (Sagoe et al., 2019).

Guidance on the maintenance of KVIP latrines includes keeping the latrine clean, allowing minimal light into the privy room to prevent insects and flies, use paper or decomposable materials to clean themselves. They are advised to repair any cracks and damage to the mesh on the vent pipe to prevent flies from entering (CHF International, 2010).

Sanitation waste is managed by centralised, semi-centralised or on-site sanitation systems and this is dependent on available resources, socio-economic context, legal or institutional conditions and the type of system (Sagoe et al., 2019; Van der Geest, 2002).

Fees are charged to public toilet users to pay for disposing faecal waste from the VIP latrine tanks. Every 2-3 years, septic tanks are emptied, and low funds continue to make management and maintenance difficult (Sagoe et al., 2019).

There are little to no personal protective measures for the personnel engaged in waste treatment, and they face the risk of faecal-oral transmission (Kretchy et al., 2020; Grieco, 2009).

Large numbers of toilet users, in high population density areas, result in tanks filling up quicker. Thus, these require frequent emptying, which increases cost. There is low government expenditure to ensure sustainable disposal of waste and maintenance of the public toilets (Sagoe et.al., 2019). The illegal sector charges less for emptying services, typically with disposal of faecal sludge directly into the environment (Boot, 2009). The main faecal sludge dumping point is at Korle Gono, and it is discharged into the ocean or onto surrounding land completely untreated. Furthermore, waste stabilisation ponds at Teshie are not working effectively (Boot, 2008).

There are two problematic methods of personal disposal. The first includes removing and dumping of waste from homes by children. Secondly, households dispose of faecal waste within the general garbage dumpsites, which is hazardous to garbage collectors (Grieco, M, 2009).

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Vulnerabilities in Shared Toilets in urban Ghana during the COVID-19 pandemic Faecal Sludge Management, Sewerage Service & Risks of Faecal-Oral Transmission This review considers the potential implications to the urban environment that is connected to shared sanitation. Ongoing studies have compared SARS-CoV-2 to known viral diseases that are structurally similar and transmit via wastewater (Bhatta et al., 2020). However, only further research may prove the transmission of COVID-19 via environmental faecal matter or via the faecal-oral pathway. Nonetheless, in Ghana, COVID-19 patients that contracted the virus, from sharing toilets, have been transferred to regional isolation centres with independent toilets and centralized faecal sludge treatment systems (Spangenberg, 2019).

An earlier study by Berendes et al. (2018), suggests that high local coverage of contained sanitation, including shared sanitation, may reduce environmental faecal contamination.

The researchers measured E. Coli concentrations in the public domain of low-income areas in Accra. The study lends insight into the link between type and coverage of sanitation facilities, and environmental faecal contamination.

‘Uncontained’ facilities (bucket latrines or other types), as opposed to, ‘contained’ facilities (KVIP latrines, flush toilets into septic systems, covered pit latrines), lead to the discharge of untreated excreta into open drains. Thus, resulting in a high-risk faecal exposure pathway (Berendes, 2018). The study suggests that containment of faecal sludge in shared sanitation facilities, despite the high number of shared users, may reduce environmental faecal contamination (Berendes, 2018). Findings from the paper call for further research examining the whole sanitation chain to ensure safe, sustainable sanitation in urban areas.

Another study by Robb et al (2017), used the SaniPath tool to identify that the dominant faecal exposure pathway in a lower-income area of Accra links sanitation and urban agriculture. There is no public wastewater treatment system in Accra, and over 50% of households discharge excreta into open drains, yet the drain water, is commonly used for irrigation (Wallace et al., 2020; Robb, 2017). Urban agriculture is the main food supply channel in Accra, along with many sub-Saharan African countries (Robb, 2017). The agricultural products irrigated by sewage could move from low-income areas to middle- and high-income areas as vectors of viruses (Robb, 2017).

The quality of shared sanitation in lower-income areas is affected by urban infrastructure, city administration, and the local economy (United Nations, 2015). Considering COVID-19, it is not unreasonable to address in advance the whole sanitation chain. Among the immediate targets is to reduce untreated excreta and wastewater exposed to the private and public domain. As flooding has become a serious environmental problem in Ghana (Keraita and Amoah, 2011), increased the possibility of contamination of open drainage.

In the Sustainable Development Goals (SDGs), the World Health Organization (WHO) proposed a “safely- managedsanitation” strategy, including abandoning open drainage system as the choice of discharge and transportation (United Nations, 2015).

Use and Maintenance Ghana's own social, economic, and related policies make Ghana have the highest public facilities dependence rate in the world (59%) (Appiah-Effah et al., 2019). In low-income neighbourhoods, Accra has approximately 68% of the population renting compound houses with 1-2 shared toilets (Dispatch et al., 2020; Antwi-Agyei et al., 2020).

Typically, landlords construct a shared facility within their property, and the tenants pay for the use and maintenance (Antwi-Agyei et al., 2020). Private shared toilets have four advantages: 1. Flexible using time; 2. Closer using distance compared with public facilities; 3. Higher security and privacy; 4. Lower cost compared with public toilets (Antwi-Agyei et al., 2020). However, there could be up to three families sharing the same toilet due to space constraints.

A study by Antwi-Agyei et al. (2020) indicated overcrowding during use, children soiling the toilet, and other behaviours, severely reducing useability. Gender separation in shared facilities is rare; males and females use the same latrine. Due to the pandemic, much of the population spend more time at home, dramatically reducing social efficiency. Moreover, the shortage of materials makes it a challenge to build new, temporary sanitation facilities. The capacity of the shared toilet could increase and would soon experience frequent crowding (Durizzo et al., 2020).

Commonplace issues include water supply burden from more frequent flushing, improper use leading to faecal contamination, inadequate cleaning practices, or conflict with cleaners (Antwi-Agyei et al., 2020). Tenants are highly unlikely to pay for toilet use if costs rise due to more frequent cleaning schedules. Culturally, women are responsible for family health and are responsible for cleaning the toilet (Antwi-Agyei et al., 2020). As a result, the home workload may increase significantly during the pandemic. Families without women omit the cleaning schedule, heightening transmission fears in a compound house (Antwi-Agyei et al., 2020).

Everyone is responsible for the daily cleaning of their private areas, and in some public spaces, the cleaning is organised according to an oral agreement (community rota). Selfprovided cleaning tools include brooms, brushes, detergents, water, and disinfectants (Antwi-Agyei et al., 2020).

Although the government has provided water and other materials to ease household expenditure pressures, COVID-19 has negatively impacted most residents (Durizzo et al., 2020).

Additionally, due to the high dependence on public facilities, the government did not order shared toilets to close in Ghana. Ultimately, to control the spread of COVID-19, it will cost the government much more than previously envisaged.

Addressing Water Insecurity Sanitation is part of the broader, interdependent WASH (water, sanitation and hygiene) sector. The sector contributes to viral containment and alleviates marginalised communities associated with low WASH levels (Amankwaa and Fischer, 2020). Amankwaa and Fischer (2020), found that poor access to safe sanitation and drinking water are associated with higher COVID-19 fatality rates in sub-Saharan Africa. Albeit, they acknowledge that more robust research is required to establish causality between the two variables.

alleviate water insecurity and contain the pandemic. Firstly, shared sanitation facilities that are prevalent in informal settlements are excluded from the free water directive, thus they still impose financial burden on most low-income households (Smiley et al, 2020). This also challenges their ability to social distance and limit exposure to pathogens, in turn encouraging open defecation; also, handwashing appliances are still lacking in these facilities. (Smiley et al, 2020). Second, most urban low-income households lack piped water supply and would rely on private water tankers and vendors who expect reimbursement by the government.

However, these households may not afford large and secure water storage or be able to transport large amounts of water from the source (Smiley et al, 2020).

Accelerated Investment in Improved Sanitation COVID-19 has accelerated the decision by The World Bank to finance an additional $125 million to the Greater Accra Metropolitan Area Sanitation and Water Project (GAMASWP) (The World Bank, 2020). The additional financing aims to reduce open defecation, sanitation-related disease, absenteeism of menstruating schoolchildren, freshwater pollution and storm floods. These are achieved via the construction of more household toilets in low-income areas (some with subsidies), toilets in needy schools and healthcare facilities, new water supply connections, improved technical training to tackle leaks and inaccurate metering, and strengthen drainage infrastructure (GSWR, 2020).

Increasingly, particularly in flood prone low-lying areas, septic tank liquid waste is directly discharged into drains. The growth of urbanization has caused the frequency of floods to increase and flood water is likely to be contaminated with faeces and pose a risk to public health (Ashley et al., 2005).

For Accra, flooding has become a serious environmental obstacle and with rising sea levels, may become a greater threat to the improvement of the sanitation value chain (Keraita and Amoah, 2011).

Although GAMA-SWP addresses the need for toilets in the public realm, it overlooks the dependence, now and for the immediate future, on shared sanitation facilities by most people in low-income neighbourhoods. GAMA-SWP targets improved sanitation, the de facto indicator for universal sanitation access in the WHO Sustainable Development Goals (SDGs), and is monitored by the WHO/UNICEF Joint Monitoring Programme (JMP) (Evans et al., 2020). Improved sanitation excludes shared toilets due to disparities in their service level that make monitoring difficult (Evans et al., 2020). Although planners and donors of GAMA-SWP describe a commitment to provide equitable access to improved water supply and sanitation services (The World Bank, 2020), it is unclear whether or how all low-income households in GAMA will be beneficiaries. Studies have shown that the prevalence of shared toilets is influenced by spatial limitations in these housing types and how the tenant-landlord relationship itself disincentivizes investment by landlords (Appiah-Effah et al., 2019: 403; Awunyo-Akaba et al, 2016; Mansour and Esseku, 2017). The complex, dense peri-urban built environment presents significant technical challenges, thus drawing concern whether financed projects favour households where private installation is more feasible (Evans et al., 2020; Mansour and Esouku, 2017).

Since April, the Ghanaian government has waived all domestic and non-commercial water tariffs as an economic relief across the country. Smiley et al (2020) assert that the directive may have not fully considered Ghana’s complex water source types and user groups, despite its aim to 6

Recommendations for the design of shared toilets Post-COVID-19 Shared sanitation facilities play an instrumental role in the everyday lives of low-income citizens, either as an intermediary option until the supply of private household toilets is maximized, or as a service to fluctuating urban populations (SaniPath, 2016; Cardone et al., 2018; Lutalo, 2018). Planners must improve the facilities in dense informal settlements, while simultaneously progressing service levels in more developed areas.

Accra's sanitation facilities have been a long-standing concern, even before the pandemic. For this section, we analysed literature about COVID-19 and shared toilets in Accra, to deduce recommendations. The preceding discussion seeks to outline proposals for improving such environments, as a direct result of the current global health crisis.

Hand Hygiene Handwashing is a highly effective physical intervention of respiratory diseases such as COVID-19 (WHO, 2020; UNICEF, 2020). In high-density settings with limited WASH services, it is especially vital to prioritize handwashing in the movement between the private and public domain (WHO, 2020). In the long term, handwashing appliances must be provided in all shared sanitation facilities, and mobile handwashing stations with soap distribution in informal settlements. Improved water sources, e.g., piped water, boreholes and rainwater, are protected from faecal contamination and should be prioritized for handwashing (WHO, 2020). Ash, as an alternative to soap or alcohol-based hand-rub, can inactivate pathogens by raising pH levels (WHO, 2020). Lastly, washing with water alone can reduce faecal contamination, albeit with lower effectiveness (WHO, 2020). The drying of hands is just as important to prevent formic transmission (WHO, 2020).

Improving the Sanitation Value Chain Safe management of excreta throughout the entire sanitation chain is ever more critical (WHO, 2020). Data from 2010 shows that only 7% of Accra’s excrement was safely managed (Mansour and Esseku, 2013). Previously mentioned studies on environmental faecal contamination, compounded with COVID-19, highlight the public health risks in the poor faecal sludge management in Ghana.

Ghana should enforce the elimination of uncontained sanitation technologies and exposed drains to reduce the risk of storm floods and environmental faecal contamination.

The government should also continue to incentivize private businesses that arrange collection, treatment, and recycling of faecal sludge (Appiah-Effah et al., 2019). Compost, irrigation water, and energy could be generated from treated wastewater while reducing pollution in the treatment cycle (Appiah-Effah et al., 2019). This can in turn sustain the operation of centralized sanitation infrastructure.

Setting a Benchmark for Monitoring Clear determinants for the hardware, hygienic conditions and user behaviour can incentivise investment. Also, they can earn shared sanitation facilities an improved sanitation classification in monitoring protocols such as the JMP (Evans et al., 2018; Simiyu et al., 2017). The following example adapts Common-pool Resource (CPR) management principles for community toilets (Simiyu et al., 2017).

Inclusive Design Gender - and age-inclusive design considerations ascertain to adequately distanced male and female quarters; and robust, lockable structures and cubicle doors. They require well-lit entrances and walkways that promote informal surveillance; and access to washing appliances, hooks or ledges for changing and menstrual hygiene management (WSUP, 2018).

Higher levels of provision for female users can advance employment, health, education, recreation and political involvement (WSUP, 2018).

Shared toilets should meet caregiving requirements, typically by women, whilst encouraging men in sharing these responsibilities (WSUP, 2018). This includes a cubicle spacious enough for a user and caregiver, child-friendly or babychanging fittings; or clothes-washing facilities to alleviate water insecurity (WSUP, 2018).

Limiting Contamination Wherever applicable, the design of appliances and fixtures should limit cross-contamination, even beyond COVID-19.

Foot-operated doors and locks should be considered, along with taps operated by foot pumps or long handles that use the arm or elbow (UNICEF 2020).

Table 3. Determinants to monitor the quality of shared toilets based on Common-pool Resource (CPR) management principles (Source: [Adapted from] Simiyu et al., 2017).

Conclusion To summarise, our findings show that a range of factors contribute to the lack of toilet facilities and improper hygiene practices within Accra, Ghana. Due to the lack of provision of sanitation facilities, high costs, accessibility, maintenance, and safety issues, many abandon proper hygiene practices and resort to open defecation. Perception and awareness contribute to existing poor conditions, which are currently magnified due to the COVID-19 pandemic.

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At the time of conducting this review, no studies have explored the impact of COVID-19 on shared sanitation in Accra, specifically. Nevertheless, recommendations have been made in response to these findings and the current pandemic to improve shared sanitation facilities and sanitation practices holistically. It is imperative that the government accelerate investments in centralised water and sanitation infrastructure, including water treatment facilities and faecal sludge plants, and regularly update planning policies as rapid urbanization continues to unfold. Effectively managing human excreta and wastewater can provide opportunities for composting, irrigation, and energy generation; all long-term benefits of a successful and considered value supply chain.

Other recommendations include reducing the spread of the virus through additional provisions for handwashing facilities, touchless appliances, improved technical training and maintenance. Usage can be improved by bettering maintenance, safety, inclusivity, accessibility and by employing contained facilities such as KVIP latrines.

Sanitation in Ghana will significantly improve if pragmatic steps are taken to implement the recommendations we have put forward. Nonetheless, they could be further examined by future research pertaining to COVID-19 transmission in such environments.

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