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3.1 Inequalities in lack of a flush toilet in the dwelling
Séverine Deguen, Wahida Kihal-Talantikite
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Status
Inequalities in lack of an indoor flush toilet are a particular issue among Euro 2 countries. Socioeconomically disadvantaged households are most affected.
Trend
The social gradient observed between the low-income and high-income quintiles has decreased in recent years in Euro 2 countries but remains significant.
3.1.1 Introduction and health relevance
Although the United Nations has declared that access to sanitation constitutes a basic human right, it remains a major public health issue: about 2.3 billion people worldwide do not have basic sanitation facilities (WHO, 2018). In the WHO European Region the Millennium Development Goal target 7C on sanitation was not reached, as about 62 million citizens had no access to adequate sanitation facilities – including functioning toilets and safe means to dispose of human faeces – in 2015 (WHO Regional Office for Europe, 2018).
The literature demonstrates a significant link between the proportion of the population with inadequate sanitation and hygiene (as well as drinking-water) and the income level of the country: low-income countries are more frequently affected by this issue (Prüss-Ustün et al., 2014).
Beyond socioeconomic inequalities, the burden of inadequate sanitation disproportionately affects the most vulnerable populations, such as children. A recent pooled analysis revealed an increased prevalence of diarrhoea among children aged under 5 years who share toilet facilities (Fuller et al., 2014). More precisely, focusing on a few eastern European and eastern Mediterranean countries, the analysis showed that the prevalence ratio increased by about 20% when comparing children who share a toilet with more than five households and those who share with fewer than five households. In low- and middle-income settings, improving sanitation facilities would reduce diarrhoea morbidity by 28% (Prüss-Ustün et al., 2014).
In addition, a lack of sanitation – including a flush toilet in the dwelling – also has economic implications. A global study assessed the impacts of health and time losses associated with inadequate sanitation and valued the costs in low- and middle-income countries at 1.5% of gross domestic product (WHO, 2012).
Little research has investigated in depth the socioeconomic inequalities of access to a flush toilet in the dwelling in the WHO European Region. Nevertheless, a recent analysis of data on the social determinants of health collected by the European Social Survey considered lack of an indoor flush toilet as one of seven variables characterizing housing quality (Huijts et al., 2017). It found that prevalence of problems with housing (including lack of a flush toilet in the dwelling) is higher for women than men and revealed wide geographical variation in such prevalence, from around 8–9% for Switzerland and Ireland to more than 20% in France and Spain.
3.1.2 Indicator analysis: inequalities by poverty level, household type and income level
Data on the presence of flush toilets inside dwellings are available from the Eurostat Statistics on Income and Living Conditions (EU-SILC) survey, which includes some western European and Balkan non-EU countries (Eurostat, 2018). For countries not covered by EU-SILC, no equitysensitive data were identified.
Fig. 1 shows the prevalence of lack of a flush toilet in the dwelling, stratified by poverty level. Lack of a flush toilet at home is not a major issue for Euro 1 countries, where the average prevalence is less than 1% even among households below the relative poverty level. By contrast, in Euro 2 countries the prevalence is much higher and shows wider variation between countries. The highest proportions of households below the poverty
threshold lacking a flush toilet in the dwelling are observed in Bulgaria (44.1%) and Romania (64.2%).
All countries have an income ratio greater than 1 except Germany, Luxembourg and the United Kingdom. This means that the prevalence of lack of a flush toilet in the dwelling is higher among households living in relative poverty. This ratio varies among countries from 0.8:1 for the United Kingdom to 12:1 for the Netherlands (in the Euro 1 countries) and from 2.3:1 for Estonia to 13.7:1 for Slovakia (in the Euro 2 countries). The two Euro 4 countries with reported data have ratios of 4.6:1 and 5.9:1, indicating that average inequality in this subregion could be even higher than in the others, although the data are lacking.
70
60
50
( % ) P r e v a l e n c e
40
30
20
10
Above relative poverty level Below relative poverty level
0
[ a ,b ] S w e d e n b ] [ z e r l a n d S w i t [ a ,b ] I c e l a n d [ a ,b ] N o r w a y G e r m a n y h e r l a n d s N e t K i n g d o m U n i t e d L u x e m b o u r g S p a i n a l y I t G r e e c e I r e l a n d F i n l a n d F r a n c e D e n m a r k A u s t r i a P o r t u g a l B e lg i u m c o u n t r i e s 1 E u r o
Income ratio (ratio of prevalence below:above relative poverty level)
[ b ] a M a l t S l o v e n i a C z e c h i a C y p r u s C r o a t i a P o l a n d S l o v a k i a E s t o n i a H u n g a r y v i a L a t h u a n i a L i t B u lg a r i a R o m a n i a c o u n t r i e s 2 E u r o S e r b i a M a c e d o n i a h N o r t c o u n t r i e s 4 E u r o
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
l e v e l ) p o v e r ty r e l a t i v e b e l o w : a b o v e p r e v a l e n c e o f ( r a t i o r a t i o e I n c o m
Notes: [a] full coverage with flush toilets in households above the relative poverty level; [b] full coverage with flush toilets in households below the relative poverty level. Source: Eurostat (2018).
The relationship between lack of a flush toilet in the dwelling among single-parent households and among the general population was plotted on a logarithmic scale (Fig. 2). The analysis excludes countries where the entire population has a flush toilet inside the home. The linear regression quantifies the strength of the association between the lack of a flush toilet in the dwelling among single-parent households and among the general population: about 91% of the variability of one variable is explained by the second.
The regression coefficient is 0.74, revealing that, on average, the proportion of single-parent households living in a home without a flush toilet is lower than that of the general population. However, exceptions can be detected: prevalence is higher among single-parent households than in the general population in Poland (2.5% of the general population reported lack of a flush toilet at home compared to 4.6% of single-parent households) and in Slovakia (1.4% versus 3.6%).
Fig. 3 shows the prevalence of lack of a flush toilet in the dwelling by income quintile and subregion. It reveals a clear social gradient among Euro 2 countries: the prevalence of lack of a flush toilet decreases from 22.51% in the lowest-income population to 1.47% in the highest-income, reflecting a relative inequity of factor 15. The prevalence of lack of a flush toilet is close to zero among Euro 1 countries in all income quintiles; although there is also a social gradient, it is expressed rather weakly (factor 3).
Fig. 2. Prevalence of lack of a flush toilet among single-parent households versus the general population (2016)
100
( % ) t o i l e t h fl u s w i t h o u t p o p u l a t i o n G e n e r a l
10
Latvia Lithuania
Euro 2
North Macedonia
Estonia Euro 4
Hungary Serbia
Poland
1
Croatia Belgium
Slovakia
Portugal Austria
France Italy Czechia Luxembourg Greece Euro 1
Spain United Kingdom Bulgaria Romania
0.1
0 5
Source: Eurostat (2018).
10 15
20
Single-parent households without flush toilet (%)
25
25
20
( % ) P r e v a l e n c e
15
10
5
Quintile 1 (lowest income) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (highest income)
0
Euro 1 countries Euro 2 countries
Note: as data are only available for two countries in the subregion, Euro 4 averages are not displayed. Source: Eurostat (2018).
30
3.1.3 Conclusions and suggestions
The data show that lack of a flush toilet in the dwelling remains an issue in many countries, especially within the Euro 2 subregion. For Euro 3 and 4 countries the lack of reporting makes it impossible to draw a conclusion, but the data reported by Serbia and North Macedonia suggest that the problem is even greater there. Socioeconomically deprived households are most affected in general, but in Euro 2 countries the analysis identified the largest inequalities between socioeconomically privileged and disadvantaged populations. Furthermore, being a single-parent household constitutes an additional factor of vulnerability. Owing to the social inequality gradient observed, lack of a flush toilet in the dwelling is a major public health equity problem that needs to be tackled, mainly in Euro 2 countries; data are needed for the Euro 3 and 4 subregions. To improve equity in access to good sanitation conditions, therefore, targeted policies are needed that consider the socioeconomic level of the population.
Suggested mitigation actions are:
• ensuring that all new residential buildings – private or public – have a flush toilet in each dwelling; • promoting public housing programmes that provide affordable housing (including social housing and affordable private rentals) to encourage accessibility to adequate housing for lowincome populations and the most vulnerable groups; • providing targeted financial support for vulnerable groups (such as low-income or singleparent households) to facilitate access to affordable housing with a flush toilet; • ensuring rehabilitation measures for existing buildings without a flush toilet – either by making plans that provide targeted public intervention to the most vulnerable households or by offering financial support to disadvantaged populations.
References
Eurostat (2018). Income and living conditions – overview [online database]. Luxembourg: Eurostat (https://ec.europa. eu/eurostat/web/income-and-living-conditions/overview, accessed 5 March 2018).
Fuller JA, Clasen T, Heijnen M, Eisenberg JNS (2014). Shared sanitation and the prevalence of diarrhea in young children: evidence from 51 countries, 2001–2011. Am J Trop Med Hyg. 91(1):173–80. doi:10.4269/ajtmh.13-0503.
Huijts T, Stornes P, Eikemo TA, Bambra C, HiNews Consortium (2017). The social and behavioural determinants of health in Europe: findings from the European Social Survey (2014) special module on the social determinants of health. Eur J Public Health. 27(Supp 1):55–62. doi:10.1093/eurpub/ckw231.
Prüss-Ustün A, Bartram J, Clasen T, Colford JM, Cumming O, Curtis V et al. (2014). Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health. 19(8):894–905. doi:10.1111/tmi.12329.
WHO (2012). Global costs and benefits of drinking-water supply and sanitation interventions to reach the MDG target and universal coverage. Geneva: World Health Organization (http://www.who.int/water_sanitation_health/ publications/global_costs/en/, accessed 3 December 2018).
WHO (2018). Sanitation. In: World Health Organization [website]. Geneva: World Health Organization (https://www. who.int/news-room/fact-sheets/detail/sanitation, accessed 20 December 2018).
WHO Regional Office for Europe (2018). Data and statistics. In WHO/Europe [website]. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/health-topics/environment-and-health/water-and-sanitation/ data-and-statistics, accessed 3 December 2018).
