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Sanitation workers carrying out manual pit emptying (in Durban, South Africa) with personal protective equipment

A sanitation worker (or sanitary worker) is a person responsible for cleaning, maintaining, operating, or emptying the equipment or technology at any step of the sanitation chain.[1]: 2  This is the definition used in the narrower sense within the WASH sector. More broadly speaking, sanitation workers may also be involved in cleaning streets, parks, public spaces, sewers, stormwater drains, and public toilets.[2] Another definition is: "The moment an individual’s waste is outsourced to another, it becomes sanitation work."[3]: 4  Some organizations use the term specifically for municipal solid waste collectors, whereas others exclude the workers involved in management of solid waste (rubbish, trash) sector from its definition.

Sanitation workers are essential in maintaining safe sanitation services in homes, schools, hospitals, and other settings and protecting public health but face many health risks in doing so, including from exposure to a wide range of biological and chemical agents. Additionally, they may be at risk of injury from heavy labor, poor and prolonged postures and positions and confined spaces, as well as psychosocial stress. These risks are exacerbated under conditions of poverty, illness, poor nutrition, poor housing, child labor, migration, drug and alcohol abuse, discrimination, social stigma and societal neglect. In many developing countries, sanitation workers are more vulnerable due to unregulated or unenforced environmental and labor protections, and lack of occupational health and safety.[4]

Sanitation work can be grouped into formal employment and informal employment. Sanitation workers face many challenges. These relate to occupational safety and health (diseases related to contact with the excreta; injuries; the dangers of working in confined spaces, legal and institutional issues, as well as social and financial challenges.[1]: 7  One of the main issues is the social stigma attached to sanitation work. Sanitation workers are at an increased risk of becoming ill from waterborne diseases. To reduce this risk and protect against illness, such as diarrhea, safety measures should be put in place for workers and employers.

The working conditions, legal status, social aspects etc. are vastly different for sanitation workers in developing countries versus those in high income countries. Much of the current literature on sanitation workers focuses on the conditions in developing countries.[1]

Those workers who maintain and empty on-site sanitation systems (e.g. pit latrines, septic tanks) contribute to functional fecal sludge management systems. Without sanitation workers, the Sustainable Development Goal 6, Target 6.2 ("safely managed sanitation for all") cannot be achieved.[5] It is important to safeguard the dignity and health of sanitation workers.

Definition and terminology

A report by World Bank, International Labour Organization, WaterAid and WHO from 2019 defines "sanitation workers" to include toilet cleaners and caretakers in domestic, public, and institutional settings; those who empty pits from pit latrines and vaults of septic tanks and other fecal sludge handlers; those who clean sewers and manholes; and those who work at sewage treatment plants and fecal sludge treatment plants and disposal sites.[1]: 2 

Another definition is: "The moment an individual’s waste is outsourced to another, it becomes sanitation work."[3]: 4 

Since there are various definitions of sanitation, it is not surprising that there are various definitions of "sanitation worker".[3]: 4 

Regional differences in terminology

In the United States, the term "sanitation worker" tends to be used exclusively for municipal solid waste collectors: people who collect solid waste and take it to a transfer station, landfill, or incinerator.[6][7] People who work with excreta management are usually known as environmental engineers or environmental specialists. The importance of sanitation workers in the struggle for human rights is seen in the 1968 labor strike of the sanitation workers of Memphis, Tennessee: The Memphis sanitation strike, supported by Martin Luther King Jr., brought together both waste collectors and sewerage maintenance workers.[8]

More generally, a waste collector (also bin man, garbage collector, etc.) deals with municipal solid waste.

Types of work and occupations

The types of work that sanitation workers carry out is shown in the table below.

Types of work and occupations along the sanitation chain (based on [1]: 3  but with further additions)
Toilet/containment Emptying Conveyance Treatment End use/Disposal
  • Manual disposal
  • Mechanical disposal

Types of employment

Sanitation workers work in different types of employment situations. They are either government-employed workers, workers of private service providers or informal workers.[10] Sanitation workers who are employed by the government usually have comparatively good infrastructure, tools and personal protective equipment (PPE), and face only moderate health and safety risks.[11]

For example, the tasks of unclogging of the main sewers or operating wastewater treatment plants are usually performed by formal government workers or private companies, whereas the unclogging of household sewer connections is performed by private companies and informal sanitation workers.[10]: 13 

Informal workers

In many developing countries, informal workers collect human excreta from certain types of toilet (such as bucket toilets and pit latrines) without mechanical equipment and without personal protective equipment. These workers are "scooping out feces from ‘dry’ latrines and overflowing pits".[12] They are usually working in the informal labour sector and are commonly referred to as "informal sanitation workers". They have weak legal protection results from working informally and do not follow occupational health and safety standards.[1]: 7 

Informal workers provide "manual emptying services to households, particularly where inaccessible to trucks and to the most vulnerable households".[11] They are not registered or legally recognized, and often work without any protection, facing discrimination and stigma.[11]

Number of sanitation workers

While the definition of sanitation workers encompasses a vast line of services, the number of sanitation workers globally is difficult to estimate because they often have multiple jobs or are categorized with other sectors (e.g., solid waste and healthcare facility management). Furthermore, many sanitation workers, especially in low-income areas, are informally employed and therefore difficult to localize.[4]

Estimates at country level include:

  • There are an estimated 5 to 6 million "sweepers" (a term used for sanitation workers) in Bangladesh.[1]: 31 
  • An estimate in 2018 put the number of "sanitation workers" in India at 5 million, and 50% of them being women.[1]: 35 

Challenges

A short video shedding light on the unsafe and undignified working conditions of many sanitation workers in India (2018)
Sanitation workers carrying out unsafe manual pit emptying of a pit latrine in Korogocho slums in Kenya

Sanitation workers provide a critical public service, essential for our daily lives and the environment. Yet their working conditions expose them to the worst consequences of poor sanitation such as debilitating infections, injuries, social stigma and even death every day.[13] The challenges faced by sanitation workers can be categorized as follows: occupational safety and health, legal and institutional issues, financial insecurity, and social issues.[1]: 7 

In the case of India, the work of sanitation workers (especially those without formal employment contracts) has been described as: Drudgery, dangerous, dirty and dehumanizing.[14]

The five hidden dangers for people working as sanitation workers include health hazards, discrimination, psychological problems, low wages and lack of social security coverage.[15]

Occupational safety and health

Occupational safety and health issues for sanitation workers include: diseases related to contact with the excreta; injuries related to the physical effort of extracting and transporting the waste, including falls from height; injuries related to cuts from non-fecal waste (e.g. glass or needles) disposed of down the toilet.[16][17] There are also the general dangers of working in confined spaces, including lack of oxygen.[18]

Many sanitation workers in developing countries work without any form of personal protective equipment (PPE) and no or minimal formal training.[1]: 9  Physical and medical conditions directly associated with sanitation work that is carried out unsafely can include: "headaches, dizziness, fever, fatigue, asthma, gastroenteritis, cholera, typhoid, hepatitis, polio, cryptosporidiosis, schistosomiasis, eye and skin burn and other skin irritation, musculoskeletal disorders (including back pain), puncture wounds and cuts, blunt force".[1]: 8 

Sanitation workers are at an increased risk of becoming ill from waterborne diseases.[19] One specific disease that concerns workers in sewers is Leptospirosis, spread through contact with rat urine.[20]

The safety of sanitation workers is influenced by: Design and construction of the toilet or other piece of sanitation infrastructure, pressure by the customer or by the employer, as well as materials and equipment available to do the job.[21]: 47 

Estimating occupational health outcomes among sanitation workers

It is difficult to estimate the burden of disease associated with occupational exposure to sanitation work due to the lack of clarity about the health risks and the uncertainty about the number of persons exposed.[4] A systematic literature review with 65 studies showed the following: There was an increased risk of adverse health across a range of outcomes. This is especially true in the case of hepatitis A infections, where a pooled estimate from 13 studies showed a doubling of odds associated with sanitation work, and even higher odds when limited to studies with lower risk of bias.[4]

An increase in adverse gastrointestinal and respiratory conditions associated with sanitation work was also reported as the most common outcome.[4] Comparatively few studies reported on adverse musculoskeletal and mental/social impacts, but these again consistently found elevated odds among sanitation workers. There was inconsistent evidence on mortality.[4]

There is a need for further investigation and quantification of the health risks faced by sanitation workers, as compared to workers in other occupations, particularly in low-income countries, and of the effectiveness of governmental policies and other efforts to mitigate these risks.[4] There are research gaps in characterizing the health risks of sanitation workers in three main areas: low-income countries, among women and those under informal employment.

In many developing countries, sanitation workers often have to work with weak legal protection, missing or weak standard operating procedures, weak law enforcement and few policies protecting their rights and health.[1]: x 

Financial insecurity

Sanitation workers in developing countries are typically poorly and irregularly paid.[1]: 9  This applies in particular to those who are employed on temporary or informal terms, as is common for many low grade jobs. Workers are also vulnerable to extortion in many countries.[1]: 10 

Social issues

In developing countries, low-grade, unskilled sanitation workers often face social stigma and discrimination.[1]: 10  This is especially true when sanitation is linked to a caste-based structure, such as in India and Bangladesh. This stigma can result in intergenerational discrimination, where children of sanitation workers often struggle to escape the vicious cycle of limited opportunities and sanitation work.[1]: 10 

There can be implicit or explicit discrimination, which hinders workers’ social inclusion, their opportunities to shift careers, and social mobility. Furthermore, alcoholism and drug addiction to evade the working conditions are common among some sanitation workers in developing countries.[1]: 10 

Sanitation workers, particularly those in information employment who manually empty septic tanks and pit latrines, are often subjected to social stigma for their work.[22]

Approaches for improvement

The main approaches used to improve the situation of sanitation workers in developing countries include the reform of policy, legislation and regulation to acknowledge and professionalize the sanitation workforce. Furthermore, operational guidelines to mitigate the occupational risks of all types of sanitation work are required. This includes standard operating procedures, enforcement of laws, personal protective equipment (PPE) for all aspects of sanitation work. A third approach is to build strong unions and associations to protect worker rights.[1]: x 

Motivated staff are needed to keep cities clean and functioning. Concerns like fair wages, medical and maternity benefits (for women staff), safety equipment, respect and security of employment must be addressed.[14] Overall, a "positive perception of sanitation workers in government as well as civil society" would be helpful.[14]

Operational guidelines

To reduce this risk and protect against illness, measures have been proposed for occupational health: Basic hygiene practices for workers (handwashing etc.); sanitation workers should be provided with proper personal protective equipment (PPE) and be trained on how to use it (i.e. goggles, face mask, overalls, gloves, boots); vaccinations (e.g. tetanus, polio, typhoid fever, hepatitis A and hepatitis B vaccinations.[19]

Technology must match the needs of the workers. Workers are more likely to wear protective gear if they are given a choice of suitable clothing.[23]

History

Street sweeper with hand cart in Stockholm, Sweden in 1905

In European history the terms "nightsoil collectors" or "nightmen" and gong farmers were used. The current term for the safe collection of human excreta is fecal sludge management. Towns with sanitation systems based on pail closets (bucket toilets in outhouses) relied on frequent emptying, performed by workers driving "honeywagons", a precursor to the vacuum truck now used to pump out septage from septic tanks. The municipal emptying of pail toilets continued in Australia into the second half of the twentieth century; these were known as dunnies and the workers were dunnymen.

Society and culture

Garbage collectors from the Hysacam company in Douala, Cameroon

Income

Examples by country:

  • Sanitation workers typically earn an average monthly salary of $2,226 in the United States, although this figure can vary widely between states. As of 2022, the salary in New York could range between $47,371 and $89,339.[24] For instance, the state of New York provides total annual wages of up to $91,336 for sanitation workers after 20 years of service.[25] In 2020, some sanitation workers in New York City earned up to $300,000 as a result of shortage in staff and boosted pay due to snowstorms.[26]
  • Sanitation worker salaries in Zambia range from 870 ZMK ($42) per month as their minimum salary to 2,480 ZMK ($124) per month as maximum salary.[27]
  • In South Africa, public-sector sanitation workers are paid almost double compared to formal private-sector employees who are usually on a minimum wage only.[1]
  • In Tanzania, a casual laborer offering cleaning services (e.g., maintenance of toilet, occasional cleaning of drains and sewers) earns around 120,000 TSh per month ($ 52). A daily laborer employed for the assistance of a cesspit emptier earns around 210,000 TSh per month ($ 91).[10]: 20 

Global goals

Improving the working conditions of sanitation workers is also important for reaching at least four of the 17 Sustainable Development Goals (SDGs) of the United Nations. The working conditions of sanitation workers relate to "end poverty in all its forms everywhere" (SDG 1) ; "ensure healthy lives and promote well-being for all at all ages" (SDG 3); "ensure availability and sustainable management of water and sanitation for all" (SDG 6); and "decent work and economic growth" (SDG 8).[1]: 2 

Impacts of Covid-19 pandemic

During the Covid-19 pandemic, sanitation workers in some countries have been designated as "essential workers" or even "corona warriors" to underscore their importance in the fight against COVID-19.[14]

During the lockdowns of the COVID-19 crisis, sanitation workers continued work and experienced increased workloads. While there is little if any evidence to date of actual transmission of the SARS-CoV-2 virus via waste, the presence of the viruses in fecal sludge and sewage has the potential of placing sanitation workers at greater risk.[4]

Country examples

Africa

Further information: Water supply and sanitation in Sub-Saharan Africa

South Africa

Further information: Water supply and sanitation in South Africa

In South Africa, sanitation work is mostly formalized. The different types of sanitation work are carried out via different arrangements in South Africa: sewer maintenance is carried out by public sanitation workers, whereas pit emptying is contracted out to the private sector.[1]: 10  In the municipality of eThekwini (which includes Durban, the third largest city in South Africa), there are "approximately 100 pit emptiers on any given day through 15 private contractors, plus 800 municipal sanitation workers".[1]: 40 

Zambia

Further information: Water supply and sanitation in Zambia

In Zambia, organizations such as the SNV Netherlands Development Organisation under their WASH SDG Programme and the Lusaka Water and Sanitation Company (LWSC) under a project known as the Lusaka Sanitation Programme (LSP) supported by international organizations including the German Corporation for International Cooperation GmbH, have been working on projects to "legalize and make sanitation workers more visible and create the recognition and respect that they so rightfully deserve."[5]

Lusaka is one of the fastest-growing cities in Africa and the majority of the population live in informal, peri-urban settlements. Various organizations in Lusaka attempt to make sanitation workers more visible and create more recognition and respect for them. They also aim to design projects and processes that improve their working environment and conditions, and help to provide the required investments to support their enterprises.[28]

Pit latrine emptiers empty the toilet pits and septic tanks in communities. They enter inspection holes and sewers to fix or unblock them and then transport the fecal waste to treatment plants, while maintaining the sanitation facilities. If septic tanks and pit latrines are not emptied regularly, waste flows into the groundwater, contaminating the environment and surrounding water supplies. The response from society towards pit emptiers is "stigmatized, lowly, and invalid" despite the importance of the work that they do.[29]

Asia

Bangladesh

Further information: Water supply and sanitation in Bangladesh

Bangladesh has sanitation workers in formal arrangement as well as informal arrangement (called "sweepers"). There are an estimated 5 to 6 million sweepers in Bangladesh.[1]: 31  They use only basic tools, often without PPE. The informal “sweepers” in Bangladesh face financial and job insecurities, discrimination, and stigmatization. Many live in segregated "sweeper colonies", which are often slum-like. They tend to be dalits (low-caste Hindus) and Christian and Muslim Bengalis.

The permanent workers have more secure positions than the informal workers, with a guaranteed income and other benefits, such as membership in the government emptiers’ union.[1]: 31 

India

manual Scavengers of pondy
Sanitation workers in Pondicherry, India
Further information: Water supply and sanitation in India

“Sanitation workers” can be used as a translation for the Hindi word "safai karamcharis". This includes "manual scavengers", but also people who work as street sweepers, are employed to clean open spaces, collect solid waste, and clean open drains and public toilets.[30] Another commonly used term is "Pourakarmikas" which includes manual scavengers, sewer workers, sanitation workers.[31]

Sanitation workers in India are "overwhelmingly Dalits, and are in fact from ‘scavenging castes’".[32] Programs like Swachh Bharat fight against caste-based discrimination in India.[33]

An estimate in 2018 put the number of "sanitation workers" in India at 5 million (with 2 million working in high-risk conditions), and 50% of them being women.[1]: 35  Typically, women are involved in the containment process since it requires fewer technical skills and a lower degree of technology, resulting in employment as school toilet and drain cleaners.[34]

In India the term manual scavengers is used historically for a subsection of sanitation workers. The official definition in Indian law is "manually cleaning, carrying, disposing of, or otherwise handling, human excreta in an insanitary latrine or in an open drain or pit".[35] The practice has officially been banned since 1993 but still continues.

Other regions

Haiti

Main article: Bayakou (trade)

In Haiti, sanitation workers in the informal sector are called bayakou, which comes from Haitian Creole.[36][37] The capital Port-au-Prince is one of the largest cities in the world without a sewer system.[38]

The following is analysis from VanRiper et al. about sanitation workers in Haiti:[39]

"A 2018 report estimated that the sanitation system of the Port-au-Prince, Haiti metropolitan area supports 270 manual excavation livelihoods.[40] Based on the population[41] and household density[42] of this metropolitan area, proportion of the regional urban population using latrines,[43] and a conservative latrine-emptying frequency of 4.5 years.[44] we estimate a ratio of 0.001 manual emptying professionals per latrine-using household. Furthermore, reports of manual excavators' team structure and working hours indicate an average team of three to four professionals working for two to three nights per latrine emptied.[45][46][47][48] Assuming 2.5 professionals per team and the population of urban Nord Department using latrines, we estimate 42,000 manual pit-emptying exposure events per year; and with 16 h per job, this translates to over 800,000 annual hours of direct exposure by manual emptying professionals in the urban areas of the Nord Department.

In contrast, Sustainable Organic Integrated Livelihoods (SOIL) operates a container-based sanitation (CBS) service called that currently operates at a rate of 0.016 CBS excreta-handling professionals (collection and processing) per household.[49] Assuming an 86% increase in efficiency brought about by increases in scale and customer density,[50] if latrine-using households instead adopt CBS, this would yield a replacement ratio of two CBS excreta handlers per manual excavator.[51] Furthermore, based on urban Nord Department latrine users, the equivalent sanitation coverage, provided by CBS services, would support over 500 safe excreta-handling livelihoods. An additional 100 plus livelihoods would be created if CBS was extended to the 20% of Haitian households who currently lack sanitation altogether. Thus, a transition to CBS would replace unsafe labor conditions with safe and reliable livelihoods and potentially increase employment opportunities while dramatically reducing exposure to sanitation workers. These changes would lift multiple community members from circumstances undermining the human right to sanitation, as well as safe and dignified employment. Many previous international efforts to improve the working conditions of manual excavators have been deemed unsuccessful and abandoned.[52] While political systems may lack the enforcement resources to protect independent workers, CBS services provide a structure compatible with safety monitoring and worker protection, and confer dignity to employees.[53] CBS is gaining recognition around the world, and recent research has taken on the question of scaling these operations and integrating them with inclusive sanitation planning.[54][55][56] From a systems perspective, the social benefit of a stable and increased employment base in the community is created by CBS expansion."

See also

References

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  2. ^ Akhilesh, Abhinav; Mehta, Meera; Juneja, Zara (10 April 2020). "How can we support sanitation workers during COVID-19?". India Development Review (IDR). Retrieved 23 April 2020.
  3. ^ a b c PRIA (2019): Lived Realities of Women Sanitation Workers in India: Insights from a Participatory Research Conducted in Three Cities of India. Participatory Research in Asia, New Delhi, India
  4. ^ a b c d e f g h Oza, Hemali Harish; Lee, Madison Gabriella; Boisson, Sophie; Pega, Frank; Medlicott, Kate; Clasen, Thomas (2022). "Occupational health outcomes among sanitation workers: A systematic review and meta-analysis". International Journal of Hygiene and Environmental Health. 240: 113907. doi:10.1016/j.ijheh.2021.113907. PMC 8837624. PMID 34942466. Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License
  5. ^ a b c Sperandeo, L., Srinivasan, S. (2020). The Heroes behind Sanitation - An insight into faecal sludge management workers in Zambia. BORDA, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Bonn, Germany
  6. ^ "Waste360". Retrieved 18 March 2020.
  7. ^ Benelli, Natalie (2011). "Sweeping the Streets of the Neoliberal City: Racial and Class Divisions among New York City's Sanitation Workers". Journal of Workplace Rights. 16 (3–4): 453–474. doi:10.2190/WR.16.3-4.l.
  8. ^ "Memphis Sanitation Workers Strike!". Memphis Public Library. 12 February 1968. Retrieved 18 March 2020.
  9. ^ Ramamoorthy, R., Pandey, K. D., Rajakuma, D. S., Ramasamy, N., Sharma, R. (2018). Desludging Operators in Tiruchirappalli: An Overview. Indian Institute for Human Settlements, India
  10. ^ a b c WaterAid (2022) Assessment of the Health, Safety and Dignity of Sanitation Workers in Dar es Salaam, Dodoma and Arusha, Tanzania February 2022
  11. ^ a b c WaterAid (2022). Protecting the health, safety, and dignity of sanitation workers in Tanzania (policy brief). WaterAid
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  17. ^ Labour Department (2006) Safety Guide for Work in Manholes Occupational Safety and Health Branch of the Labour Department, Hong Kong Government
  18. ^ HSE (2013). Confined spaces - A brief guide to working safely, Health and Safety Executive UK.
  19. ^ a b Centers for Disease Control and Prevention (29 September 2020). "Guidance for Controlling Potential Risks to Workers Exposed" – via Department of Health and Human Services.
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  21. ^ Eales, K., Blackett, I. (2019). FSM5 - Thematic Papers. Bremen Overseas Research and Development Association, Bremen, Germany
  22. ^ "Dirty Job Shows Why Cholera Still Kills in Haiti". VOA. 28 December 2016. Retrieved 2017-07-30.
  23. ^ SciDev.Net. "Dangers, health risks faced by sanitation workers exposed". SciDev.Net. Retrieved 2020-09-29.
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  25. ^ "12 Things New Yorkers Should Know About Their Garbage". cbcny.org. 2014-05-21. Retrieved 2020-07-02.
  26. ^ Duffy, Kate (13 December 2021). "Some sanitation workers in NYC earned nearly $300,000 last year as staff shortages and snowstorms boosted overtime pay". Business Insider.
  27. ^ "Sanitation Worker Average Salary in Zambia 2020 - The Complete Guide". www.salaryexplorer.com. Retrieved 2020-09-29.
  28. ^ Lanz K, Bieri S, Fankhauser L (29 September 2020). The Heroes behind Sanitation-An insight into faecal sludge management workers in Zambia (PDF) (Report) – via BORDA.
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  30. ^ Walters, Vicky (2019-01-02). "Parenting from the 'Polluted' Margins: Stigma, Education and Social (Im)Mobility for the Children of India's Out-Casted Sanitation Workers". South Asia: Journal of South Asian Studies. 42 (1): 51–68. doi:10.1080/00856401.2019.1556377. ISSN 0085-6401. S2CID 150965777.
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  32. ^ "Treat Sanitation Workers Like Health Workers, Pay Them At Least Rs 20,000 Per Month". The Wire. 22 April 2020. Retrieved 23 April 2020.
  33. ^ Akhilesh, Pragya (18 January 2022). "A Failed Attempt to Create an Equally Sanitary India". The Wire.
  34. ^ CS Sharada Prasad and Seema Thomas (29 July 2020). "Technology's impingement on the urban female sanitation worker in India". Harvard's Kennedy School of Government's Gender Policy Journal.
  35. ^ The Employment Of Manual Scavengers and Construction of Dry Latrines (Prohibition) Act, 1993. Ministry of Housing and Urban Poverty Alleviation, Govt. of India.
  36. ^ Curnutte, Mark (2011). A Promise in Haiti: A Reporter's Notes on Families and Daily Lives. Nashville, Tennessee: Vanderbilt University Press. p. 81. ISBN 9780826517852.
  37. ^ Vilsaint, Féquière; Berret, Jean-Evens (2005). English Haitian Creole Dictionary (2nd ed.). Coconut Creek, Florida: Educa Vision Inc. p. 149. ISBN 9781584322139.
  38. ^ Knox, Richard (13 April 2012). "Port-Au-Prince: A City Of Millions, With No Sewer System". NPR. Retrieved 2017-07-30.
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  40. ^ Bank, World (2017-12-12). "Looking Beyond Government-Led Delivery of Water Supply and Sanitation Services". hdl:10986/28997. {{cite journal}}: Cite journal requires |journal= (help)
  41. ^ . 2015-11-06 https://web.archive.org/web/20151106110552/http://www.ihsi.ht/pdf/projection/Estimat_PopTotal_18ans_Menag2015.pdf. Archived from the original (PDF) on 2015-11-06. Retrieved 2022-10-11. {{cite web}}: Missing or empty |title= (help)
  42. ^ "The DHS Program - Haiti: Standard DHS, 2016-17". dhsprogram.com. Retrieved 2022-10-11.
  43. ^ "JMP". washdata.org. Retrieved 2022-10-11.
  44. ^ Sklar, R. & Faustin, C. 2017 Pit Latrines or Container Based Toilets? A Cost-Benefit Analysis Comparing Two Approaches to Improving Sanitation Access in Urban Areas of Haïti (Haiti Priorities). Copenhagen Consensus Center. Available from: https://www.pseau.org/outils/ouvrages/copenhagen_consensus_center_pit_latrines_or_container_based_toilets_a_cost_benefit_analysis_comparing_two_approaches_to_improving_sanitation_access_in_urban_areas_of_haiti_2017.pdf
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  49. ^ iwaponline.com https://iwaponline.com/h2open/article/5/1/135/87677/Container-based-sanitation-in-urban-Haiti-how-can. Retrieved 2022-10-11. {{cite web}}: Missing or empty |title= (help)
  50. ^ Boyer, Kenneth K.; Prud'homme, Andrea M.; Chung, Wenming (March 2009). "The Last Mile Challenge: Evaluating the Effects of Customer Density and Delivery Window Patterns". Journal of Business Logistics. 30 (1): 185–201. doi:10.1002/j.2158-1592.2009.tb00104.x.
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  52. ^ "People practicing open defecation (% of population) | Data". data.worldbank.org. Retrieved 2022-10-11.
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  54. ^ Shepard, J., Stevens, C. & Mikhael, G. 2017. The World Can't Wait for Sewers: Advancing Container-Based Sanitation Businesses as a Viable Answer to the Global Sanitation Crisis. Water and Sanitation for the Urban Poor; EY, p.11. Available from: https://www.susana.org/_resources/documents/default/3-2756-7-1490187791.pdf
  55. ^ Russel, Kory C.; Hughes, Kelvin; Roach, Mary; Auerbach, David; Foote, Andrew; Kramer, Sasha; Briceño, Raúl (2019). "Taking Container-Based Sanitation to Scale: Opportunities and Challenges". Frontiers in Environmental Science. 7. doi:10.3389/fenvs.2019.00190. ISSN 2296-665X.
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