Between 2015 and 2024, 1.2 billion people gained access to safely managed sanitation, raising global coverage from 48% to 58%. Yet 3.4 billion people still lack safely managed sanitation, including 354 million who practise open defecation, and WHO and UNICEF warn that universal coverage of safely managed services is increasingly out of reach [1]. Coverage figures can also hide a deeper problem: a toilet may be counted as improved while its waste still leaks, overflows, or is dumped into the environment, and sanitation decisions are often based on coverage rather than on direct evidence of risk.
PROMISE pairs the ComPASS tool, which assesses how sanitation systems actually perform, with SaniPath exposure assessments. In Kampala, a ComPASS assessment across 96 parishes showed that systems assumed to safely contain and treat waste often did not. In Tanga, Tanzania, 97% of households used pour-flush toilets connected to lined tanks, yet about 40% had unsafe overflows, and 34.5% relied on shared sanitation of highly variable quality. In Kibera, Nairobi, a third of assessed toilets discharged fecal matter directly into the environment, and 61% of lined pits and 66% of unlined pits were full. In Lusaka, Zambia, the team identified pit and tank emptying as an under-recognized point where pathogens are released into the environment. The shared lesson across countries is that fecal exposure results from cumulative failures across the whole service chain, not from containment alone, and that both technical design and day-to-day operation determine contamination risk.
Citywide Inclusive Sanitation, fecal sludge management, and directly linking sanitation-system performance to fecal pathogen exposure, so that municipalities and utilities can target investment where it reduces the most risk.
A multi-country initiative advancing sanitation, hygiene, climate resilience, health security, digital decision systems, and healthy institutions in low- and middle-income countries
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