Four-part Summary of the Literature Review

1 COVID-19 transmission pathways

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.

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

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

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

2 Overview of shared sanitation in Accra, Ghana

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.

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.

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.

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

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.

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

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

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.

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.

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.

Appliances should limit cross-contamination.

4 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.

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.

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.

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.

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.

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.

Safety / Distance Privacy Pleasantness Cleanliness Affordability

Shared household toilets

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

Community toilets/ Commercial toilets

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

Public toilets

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

Enable landlords to become sanitation service providers Develop smaller toilet blocks, but more numerous & distributed Improve & increase the provision of large toilet blocks

Why?

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

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

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

Potential limitations

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

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