Module 6: Improving the Built Environment

Common pitfalls of interventions that address rapid urbanization tend to relate to disease-focused solutions that do not take into account the built environment and infrastructure.  In fact, the physical environment can play a large role in reducing disease prevalence, mainly in the realm of sanitation.(1) One of the first steps in improving the quality of household sanitation is the construction of adequate housing. Inadequate living conditions often correlate with poverty and illness. Several suggestions have been discussed by the United Nations and the World Health Organization to upgrade living conditions through housing improvements:(2)

Improving and redesigning city conditions and layouts sounds effective in theory, but it is not truly a beneficial solution if it is not culturally appropriate and respectful of human rights. In many slums, for instance, shelters are so overcrowded that it is often difficult to install electricity or water pipes without tearing up the structure of the building.  Additionally, many people living in slums do not want to relocate, even when promised better housing; for many individuals, residence and community central to personal identity.(3) In these situations, questions of human rights are particularly important. Even if relocation will improve health, it cannot and should not be forced upon residents. In the case of informal encampments, interdiction efforts are often seen as protecting the health and safety of the camp residents. However, these actions can push people further into isolation, as the homeless have nowhere to go but to similar encampments, or other areas with more hazardous conditions. Solutions to these issues include creative outreach strategies based on individual cases. Such strategies should help encourage residents of camps to find and choose housing that will improve their health, rather than forcing change upon them. This is a more effective long-term approach, as it encourages self-sufficiency, and emphasizes the importance of stable housing. These efforts are more likely to be well-received when presented to residents as an option, rather than a requirement.(4) 

Strategic Sanitation and Water Innovations

Sanitation and water services involve complex planning in order to prevent major health issues.  Improving sanitation facilities involves ensuring that people do not come into contact with human waste; prevention of such contact reduces the spread of disease by protecting water, air, soil, and food from contamination. Effective sanitary facilities include “septic tanks, pit latrines with a platform or slab, and composting toilets.”(5) Sanitation system improvements require large financial investments from governments, and a great deal of community cooperation. These improvements aim to increase prevention of epidemics and widespread illness. For instance, the city of Santiago, Chile invested in major sewer system improvements in order to decrease typhoid fever incidence and maintain their export market, as other countries would not import goods from Chile during an epidemic. Because 95% of the city had sewerage coverage by the time that cholera hit nearby Peru, Santiago escaped the epidemic and saved itself from a health disaster and from debilitating financial losses.(6)

In his report for the UNDP-World Bank Water and Sanitation Program, Albert Wright outlines new features of what he terms “strategic sanitation.” This model is unique in that it is demand-based and incentive-driven. In the past, supply-driven projects have been problematic because they could not meet the challenges that accompany rapid urbanization, population growth, and industry development. In a demand-based model, potential users can contribute their resources to help manage and finance sanitation systems in effective and appropriate ways.(7)

Case Study: Strategic Sanitation in Ghana

The Kumasi Sanitation Project in Ghana applied an effective strategy to improve urban sanitation in a city where three quarters of the 770,000 residents lacked adequate sanitation services. The project, in collaboration with the regional UNDP-World Bank Water and Sanitation Program office and the Kumasi Metropolitan Assembly, implemented a demand-driven intervention to improve sanitation services in the area. The approach was tailored to meet the needs of the region, and included strategies that were appropriate for each type of housing structure in the area. The program also took into account user preferences and willingness to pay, and used a short planning model of ten to fifteen years to emphasize immediate action, thereby breaking down the plan into smaller segments that could be implemented separately. This step-by-step approach avoids the risks associated with scaling up programs too quickly. In this model, there is time for changes to be incorporated, if a particular step does not produce the intended outcome.

Project managers for this program were able to measure demand through a system of surveys, which demonstrated that most households in Kumasi agreed to pay for improved services. Interestingly, the poorest people were often the most willing to pay for improved services, as they were the primary users of public latrines, and consequently paid more for sanitation on a daily basis than those with private household systems. The most efficient use of revenue and subsidies was the installation of KVIPs (Kumasi Ventilated Improved Pit latrines) in homes, schools, and other public areas, as well as creating sewers in tenements. Public latrines are now under private sector management, and sanitation systems are more available for poorer urban populations.(8)

Case Study: Latrine-Emptying in Nairobi

As Africa's second largest slum, Kibera houses about 700,000 people with a population density of almost 50,000 individuals per square kilometer.(9) With the help of the Kenyan Water for Health Organization (KWAHO) in 1991, impoverished residents established a latrine-emptying service that users were willing to pay for in advance. Participating residents built ventilated pit latrines and obtained support from the Norwegian Agency for Development Cooperation, which provided a special truck to maneuver through the narrow streets of the slum, and empty pit latrines on a regular basis. A team of thirteen community members oversaw the project and successfully implemented a demand-based sanitation system. In the first half of 1991, over 6,000 households paid US $9 for the latrine-emptying service.(10)

Case Study: Improving Sanitation in North Jakarta, Indonesia

Hidden Cities, a report by WHO and UN-HABITAT, highlighted Hesti, a 47-year-old sanitation worker in North Jakarta, to illustrate one sanitation solution in a poor area. Her story is as follows:

“Hesti lives with her husband and children in a seaside slum area in North Jakarta. Her husband is a builder who can earn US $5.40 a day, but it’s tough when he can’t find work. Then, ‘I and the children have to shuck shellfish for US $1.60 a day. I have back pain from sitting in the same position when I break shellfish. I take traditional herbs to help it.’ Hesti takes care of the local public toilet which was built last year by a charity. It has had a good impact on their life, because it replaced the foul-smelling ‘hanging toilet’ on stilts next to their house. It was so bad that ‘when it rained,’ she recalls, ‘the excrement would flood into the alleyways and our homes. How would you feel if that happened to you? When we first moved here the smell from the toilet was so bad my children would refuse to eat.’ Now, she gains some income as the keeper of the new public toilet. ‘I clean it. The charge is 500 rupiah (US $0.05), but if people don’t have the money they can still come. I think most people in the community come here now. I don’t make much money from the toilet, but I am very happy that we have this facility.’”(11)

Case Study: Condominial Sewerage in Brazil

The condominial sewerage system has become a model for sewerage improvement as it saves money on household sewer costs while simultaneously promoting self-maintenance and improved sanitary practices.  The system was invented by Brazilian engineer José Carlos de Melo and has been successful in urban areas of Brazil. Instead of using the conventional deep sewers, condominial sewerage uses a system of shallow feeder systems through backyards and neighborhoods with only one central sewer per block that can be shallower than older systems. This saves both time and money, allowing the system to be offered at much lower prices to households.

In order to encourage the switch to condominial sewerage while keeping the system demand-based, families are offered the choice to switch to condominial sewerage, connect to conventional deep sewer systems, or to continue with the present system (which is often a tank that discharges waste into an open street drain). The conventional system costs about three times as much as the condominial system, and as more people connect to the new pipes, the open drain system becomes less accessible. 

Last, community members maintain their own sewage pipes much more than they would in the conventional system. With condominial sewerage, people can bring drain blockages to the attention of their neighbors, who then ensure that the blockage is cleared quickly. Additionally, users have begun to limit actions such as flushing solid waste. Since individuals are able to play such a large role in sewer upkeep, the costs for formal sewerage agencies have decreased.(12)

Methods for Utilizing Stormwater

Stormwater is often overlooked as a valuable resource, despite the fact that it can be an efficient water supply for activities that require water but that may not call for the highest quality or potability. Stormwater, often obtained as runoff from city surfaces, is sometimes referred to as “gray water,” and can be used in new methods of water reuse for irrigation, restoration of groundwater levels, and in sanitation facilities such as toilets, in which water need not be potable.

This field of study is still quite new, and researchers are just beginning to explore it. In Botswana, new development of urban agriculture has led to the use of a “Sanitas wall,” a tool that supplies crops with gray water from households. The device consists of a concrete or sun-burned clay wall with two compartments; one compartment holds sand while the other holds compost and sprouts plants. Measuring three meters high and thirteen meters long, the wall can absorb approximately one household’s volume of gray water, and can irrigate the plants through the wall. 

Stormwater can also be used in permanent growing strips that concentrate rainwater and feed crops slowly to sustain them through droughts. This method can replace ploughing in small-scale urban agriculture, and requires significantly less water than traditional methods, producing about 10 to 25 times more grain per hectare. Despite these innovations, urban hydrologists are constantly conducting more research on ways to use stormwater, as this resource is becoming increasingly costly to overlook.(13)

Go To Module 7: Health Services >>


(1) Zarcostas, J. “Wide inequities in health are hidden in urban settings, says report.”BMJ (2010).

(2) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(3) Shetty, P. "Health Care for Urban Poor Falls Through the Gap.”The Lancet 377 (February 2011): 627-628. 

(4) Cousineau, M. “Health Status of and Access to Health Services by Residents of Urban Encampments in Los Angeles.”Journal of Health Care for the Poor and Underserved 8 (1997): 70-82.

(5) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(6) Wright, Albert M. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007.

(7) Wright, Albert M. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007.

(8) Ibid.

(9) Chakaya, J. M., et. al. “Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.”The International Journal of Tuberculosis and Lung Disease 9 (2005): 403-408.

(10) Wright, Albert M. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007.

(11) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(12) Wright, Albert M. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007.

(13) Niemczynowicz, J. “Urban Hydrology and Water Management – Present and Future Challenges.”Urban Water 1 (1999); 1-14.