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 Table of Contents  
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 34-40

Sanitation safety planning as a tool for achieving safely managed sanitation systems and safe use of wastewater

1 Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute; University of Basel, Basel, Switzerland
2 Independent consultant, Brisbane, Australia
3 World Health Organization Regional Office for South-East Asia, New Delhi, India
4 LCI Envi Corporation, Quezon City, Philippines
5 Biome Environmental Solutions Pvt. Ltd, Bangalore, India
6 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
7 Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland

Date of Web Publication29-Aug-2017

Correspondence Address:
Mirko S Winkler
Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute; University of Basel, Basel
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2224-3151.213790

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Increasing water stress and growing urbanization force a greater number of people to use wastewater as an alternative water supply, especially for irrigation. Although wastewater irrigation in agriculture has a long history and substantial benefits, without adequate treatment and protective measures on farms and in markets, use of wastewater poses risks to human health and the environment. Against this background, the World Health Organization (WHO) published Guidelines for the safe use of wastewater, excreta and greywater in agriculture and aquaculture, in 2006. The Sanitation safety planning: manual for safe use and disposal of wastewater, greywater and excreta – a step-by-step risk-based management tool for sanitation systems – was published by WHO in 2016 to put these guidelines into practice. Sanitation safety planning (SSP) can be applied to all sanitation systems, to ensure the systems are managed to meet health objectives. This paper summarizes the pilot-testing of the SSP manual in India, Peru, Portugal, Philippines, Uganda and Viet Nam. Also reviewed are some of the key components of the manual and training, and an overview of SSP training and dissemination efforts and opportunities for implementation in the WHO South-East Asia Region. Lessons learnt during the piloting phase show how reducing health risks can be surprisingly easy, even in a low-income setting, especially when combining many smaller measures. The SSP approach can make an important contribution towards Sustainable Development Goal target 6.3, by reducing pollution, eliminating dumping and minimizing the release of hazardous chemicals and materials, thereby halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally.

Keywords: agriculture, aquaculture, excreta reuse, sanitation safety planning, Sustainable Development Goals, wastewater reuse

How to cite this article:
Winkler MS, Jackson D, Sutherland D, Payden, Lim JM, Srikantaiah V, Fuhrimann S, Medlicott K. Sanitation safety planning as a tool for achieving safely managed sanitation systems and safe use of wastewater. WHO South-East Asia J Public Health 2017;6:34-40

How to cite this URL:
Winkler MS, Jackson D, Sutherland D, Payden, Lim JM, Srikantaiah V, Fuhrimann S, Medlicott K. Sanitation safety planning as a tool for achieving safely managed sanitation systems and safe use of wastewater. WHO South-East Asia J Public Health [serial online] 2017 [cited 2022 Dec 2];6:34-40. Available from: http://www.who-seajph.org/text.asp?2017/6/2/34/213790

  Background Top

In many regions of the world, the scarcity of freshwater sources is accelerating, making wastewater an increasingly attractive alternative resource.[1],[2] Wastewater can be a valuable sustainable resource for irrigation.[3] Not only does it contain important nutrients for agricultural production but it is also available from a variety of different sources, such as domestic wastewater, industrial effluents and polluted surface waters.[4] In 2012, it was estimated that, worldwide, about 20 million hectares of agricultural land were irrigated with treated, partially treated or untreated wastewater.[5] Wastewater is also used for aquaculture, landscape irrigation, urban and industrial uses, recreational and environmental uses, and artificial groundwater recharge.[6] The importance of safe wastewater and excreta disposal and reuse is also reflected in Sustainable Development Goal (SDG) target 6.3, which aims to improve water quality by reducing pollution, eliminating dumping and minimizing the release of hazardous chemicals and materials, thereby halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally by 2030.[7],[8]

Without adequate treatment and protective measures on farms and in markets, workers and the public are exposed to pathogens and hazardous contaminants that pose risks to human health.[9],[10],[11] Diarrhoeal disease and helminth infections are considered the greatest risks to human health transmitted by consumption of wastewater-irrigated products or through contact with contaminated soils and irrigation water.[12],[13],[14],[15] There are also concerns about wastewater being a potential contributor to antimicrobial resistance.[16] In 2006, the World Health Organization (WHO) published updated Guidelines for the safe use of wastewater, excreta and greywater in agriculture and aquaculture.[17] The main objective of these guidelines is to maximize the environmental benefits associated with the use of wastewater, excreta and greywater in agriculture and aquaculture, while minimizing potential health risks. The overall objective of the guidelines is to ensure that wastewater is used safely with minimal risks to health, through microbial-reduction targets for diverse pathogens and a code of good management practice.[18] The WHO guidelines[17] assist with the selection of economically feasible and technically sensible methods of wastewater treatment and suggest comparatively low-cost on-farm measures to limit exposure, which can be applied in developed and developing countries alike.[19],[20]

In order to put the principles into action, a sanitation safety planning (SSP) manual was recommended in 2010,[21] with the objective of providing a hands-on approach to assessing, managing and monitoring risks along the entire sanitation chain. The SSP manual seeks to ensure that the quality and reduction targets for wastewater set by the WHO 2006 guidelines[17] are reached through incremental improvement and by applying a multi-layered approach (i.e. combining different control measures available, such as treatment practices, irrigation methods and measures for food handling and preparation).[22]

This paper describes: (i) the development process for the SSP manual, which comprised an extensive piloting phase in locations in most regions of the world; (ii) key features of the final version of the SSP manual;[22] and (iii) an initial SSP training programme held in Kolkata, India. Following the manual's publication in 2016,[22] lessons have been learnt from piloting and application of the manual and initial training activities. These are reported here and suggestions on future dissemination in the WHO South-East Asia Region are outlined.

  Development of the sanitation safety planning manual Top

The draft SSP manual drew on the Stockholm framework for guidelines for microbial contaminants in water,[23] which creates a harmonized framework for developing guidelines and standards for water-related microbiological hazards and provided the conceptual framework for the 2006 WHO guidelines.[17] Its basic elements are the assessment of public health and risks; health targets; and risk management, based on informed environmental exposure and acceptable risk. The draft SSP manual also drew on the hazard analysis and critical control point (HACCP) approach that is common to WHO's guidelines for drinking water, recreational water and food safety.[24] The safety planning approach has been described and successfully implemented globally through water safety plans (WSPs), which assist water suppliers and regulators to apply the WHO guidelines for the quality of drinking and recreational water.[25],[26] In contrast, it was recognized that the main users of the SSP manual would be: (i) health authorities and regulators (to introduce health-risk-based approaches to the sanitation sector and to verify their effectiveness); (ii) local authorities (for planning investment in sanitation, especially in low-resource settings); (iii) wastewater utility managers (for managing effluent quality and safeguarding public and occupational health); (iv) sanitation enterprises and farmers (to introduce/ complement quality-assurance procedures for the safety of workers, local communities and consumers or users of the product); and (v) community-based organizations, farmers’ associations and nongovernmental organizations. SSP and WSPs have several similarities and differences (see [Table 1]).[22]
Table 1: Similarities and differences between sanitation and water safety planning

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The first draft of the SSP manual comprised a broad set of tools, methods and procedures that followed a structured approach to achieving preset health targets at individual and community levels in a range of contexts.[21] WHO's 2006 guidelines,[17] the Water safety plan manual,[25] and the textbook on Microbial exposure and health assessments in sanitation technologies and systems[27] were the key sources for the tools featured in the first draft of the SSP manual.

In 2012, with support from the Swiss Agency for Development and Cooperation, WHO started to work in collaboration with the Swiss Tropical and Public Health Institute (Swiss TPH), the International Water Management Institute, the Swiss Federal Institute for Aquatic Science and Technology and the International Centre for Water Management Services, to draft the SSP manual and testing process as part of an initiative for safe resource recovery and reuse.[28]

The draft manual was developed during 2013–2014, drawing on expertise of the WHO water quality and health technical advisory group and experiences from pilot sites in India, Peru, Philippines, Portugal, Viet Nam and Uganda, representing a wide range of contexts (see [Table 2]). In each case, national authorities responsible for implementing SSP worked with local experts to develop sanitation safety plans for the pilot site. WHO and Swiss TPH provided training and remote technical support to the process over a 6-month period.[29]
Table 2: SSP pilot countries and sites with their lead organizations

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The findings and experiences from the pilots were shared in a 2-day workshop involving all stakeholders, who gave suggestions on how to improve the SSP manual and provided case-studies and some key learning on institutional mechanisms to support and sustain SSP.

Some of the key features of the sanitation safety planning manual and training materials

The final SSP manual[22] comprises the following key sections:

  • a detailed description of the six SSP modules (see [Figure 1]) and expected outputs;
  • guidance notes for each of the main tasks listed under each module, as well as relevant background information;
  • specific tools for SSP and examples illustrating the application of the tools;
  • guidance notes based on the experience gained in the piloting sites;
  • a worked example of SSP in a fictional town in a middle-income country with a tropical climate;
  • annexes including; (i) more than 50 control measures and their effectiveness in risk reduction for wastewater treatment; wastewater in agriculture and aquaculture; and excreta, urine and greywater use; (ii) a summary of microbial health risks from the use of wastewater in irrigation; and (iii) a list of wastewater chemicals in agriculture and aquaculture.
Figure 1: Sanitation safety planning modules

Click here to view

Some of the key features of the manual and supporting training materials include:

  • a comprehensive exposure-group assessment, since the variety of groups exposed is greater than for water safety planning, and may be directly or indirectly impacted; typically, exposure groups would include:

    –– workers who maintain, clean, operate or empty the sanitation technologies;

    –– farmers who use the untreated, partially or fully treated wastewater, bio-solids or faecal sludge, usually on a farm or in a factory;

    –– local communities living near to or downstream from the sanitation technology or farm on which the material is used and who may be passively affected;

    –– consumers who eat or use products (e.g. crops, fish, compost) that are produced using sanitation products.
  • the training starts with an entertaining and thought-provoking role-play activity, which not only acts as an icebreaker but also sets the scene for the identification of risks and exposure groups in a typical sanitation system in Asia;
  • the training provides an introduction to relevant pathogens and infection pathways and guidance on compiling biological, chemical and physical hazard information; information on types of hazard during normal and/or emergency operating conditions, which may be weather/climate related; exposure and transmission routes; and control measures that could be used to mitigate the risks. Several videos and visual aids are used in this interactive training.

  Lessons learnt from the pilots and regional workshop Top

Regional workshop on sanitation safety planning in Kolkata, India

Reuse of wastewater in agriculture and aquaculture is practised in several countries of the WHO South-East Asia Region, generally informally with no proper regulation of reuse activities.[9],[30] To highlight the health risks, and at the same time to build capacity, the WHO Regional Office for South-East Asia organized the first south Asia regional workshop on SSP in August 2016, in Kolkata, India. The main objective of the training was to establish a pool of key people in the region with an in-depth understanding of key SSP concepts and principles, who would become SSP champions in the region.

The training was attended by 34 participants from Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, representing sanitation and health officials from government ministries, sanitation practitioners from nongovernmental organizations, and representatives from development partners, including the Asian Development Bank. Facilitation was done by a team of eight trainers selected to be ready to support future upscaling of SSP internationally. An additional workshop objective was to trial the first draft of a new training package for the SSP manual. All trainers had prior knowledge of the manual and some had contributed technical input.

The training included a field visit to the East Kolkata Wetlands (fields, ponds and a sewage-treatment plant), which recycles almost 90% of the city's waste for aquaculture and agriculture, and a visit to the State Pollution Control Board for a briefing. Three days of training followed, covering the six modules of the SSP training. SSP processes were outlined by the trainers, and participants practised their application using the Kolkata wetlands. Based on the learning and skills developed in the workshop, work has commenced on SSP for the East Kolkata Wetlands, with an initial risk assessment now completed. The Kolkata SSP will initiate longer-term environmental surveillance in the region.

At the end of the training, participants: (i) were able to explain the SSP concept and process to other sanitation stakeholders; (ii) knew where to locate further technical information to assist SSP preparation, especially in relation to hazards, hazardous events, control measures and their effectiveness; and (iii) were able to develop peer-group relations and links to international SSP experts and peers from around the globe. Each country team also developed a provisional SSP action plan.

Pilot sanitation safety plan in the Baliwag, Philippines

The pilot sanitation safety plan of Baliwag Water District underscored the need for proper procedures and standards for the reuse of faecal sludge in agriculture in the interest of public health. The sanitation safety plan identified practical control measures designed to manage risks produced by improper handling of sludges from faecal sludge-treatment plants when used as agricultural fertilizer. Simple and practical measures included restriction on the use of treatment-plant sludges for non-food crops, crops processed before consumption, or crops that have to be cooked; improvement of farmers’ handwashing hygiene; and promotion of protective clothing for farmers during application of bio-solids to farms. As the water utility started its formal licence application for the use of its biosolids as soil conditioners, immediate improvement plans were implemented, based on the results of the risk analysis in the pilot sanitation safety plan.

Building on the lessons learnt in the Baliwag SSP, and with assistance from the Asian Development Bank, the water utility developed a business model for reuse of its bio-solids to optimize environmental benefits through safe bio-solids treatment and reuse, and by reducing the financial costs of disposal, through third-party uses of treatment-plant by-products processed as soil conditioners. With the increasing investments by the local government units and water utilities on sewage management in the Philippines, an increase in the volume of bio-solids that will be generated is anticipated. The SSP approach will complement these investments by establishing stronger demand for the end-products of bio-solids processing, with the private sector scaling up the business of sludge reuse; by promoting greater understanding among farmers about the benefits of bio-solids as soil conditioners or fertilizers; and by advocating more research and academic work on the fate of residuals and by-products of sewage treatment.

Sanitation safety plan in Karnataka, India

A sanitation safety plan was applied in Devanhalli town, Karnataka, India, to complement the draft liquid-waste management plan prepared by the Karnataka Urban Water Supply and Drainage Board (KUWSDB). The SSP process identified hazards associated with the management of open drains collecting wastewater and storm water. Clearing solid waste in those drains was identified as the highest risk to workers and local communities. Improvements to reduce risk included changes in management and improved coordination with the workers, resulting in lower capital investment needs than had been anticipated in the original liquid-waste management plan.

The SSP process was understood and run by the three staff available at the Devanahalli Town Council, with very little outside assistance. No extra budget was required for the improvements identified by the SSP process.

The KUWSDB has a specialized training institute for its own staff and other stakeholders in the area of water and wastewater management. This centre plans to take up SSP as a training programme and replicate it across the 270 small and medium-sized towns in the state of Karnataka.

  Optimizing support for the sanitation safety planning process Top

Among the challenges for successful SSP implementation are the need for effective broad-ranging stakeholder engagement, which is often achieved through appropriate composition of the SSP team. The SSP team should include people with complementary health and technical skills, so that members are collectively able to define the system, identify all hazards and hazardous events, and understand how the risks can be controlled (e.g. it should include relevant agricultural and/or aquacultural expertise). SSP is often initiated by the sanitation service provider, such as a sewage company. However, users of the effluent or bio-solids (e.g. farmers), and consumers of their produce, face significant potential health risks, and also have major roles to play in protecting public health.[20] The roles of these stakeholders are as important as that of the service provider. Without the commitment and involvement of users, SSP can lead to suboptimal health gains. To help address these challenges, the SSP manual includes guidance on stakeholder analysis, to help the lead organization effectively engage all stakeholders.[22]

Often there is a natural initial reluctance by the service provider to extend the SSP boundary beyond the traditional limits of the sewage-treatment plant. This is because areas downstream of the treatment plant are generally outside their normal operational or regulatory limits. Operational experience in SSP has shown, however, that when the service provider puts effort into meaningful discussions with stakeholders, as encouraged in SSP, stakeholder engagement is significantly improved. One outcome of this engagement is greater understanding of the actual use of the effluent and bio-solids processes downstream of the treatment plant. This engagement and understanding not only leads to better stakeholder communication and understanding of health impacts, but directly supports improved development and implementation of SSP.

In the course of the SSP piloting and early application, a number of success factors for SSP have been identified, namely: (i) support by multinational donors and funding agencies can “kick-start” local interest and raise awareness; (ii) support by international and national consultants experienced in SSP helps to avoid SSP teams “doing it alone”; (iii) a keen sense of ownership of SSP by the lead agency's young professionals has been shown to be significant in developing SSP champions; and (iv) appropriate partnerships with civil society organizations should be developed and nurtured, in order to strengthen the ownership and impact of SSP.

  Opportunities and challenges for wider application of sanitation safety planning in the WHO South-East Asia Region Top

The amount of wastewater produced in the WHO South-East Asia Region is increasing every year, with rapid development, urbanization and population growth. Hence, proper management of wastewater becomes increasingly important, mainly to protect public health and the environment. Lack of resources, capacity and regulation are some of the factors that affect proper treatment of wastewater and safe disposal or use of wastewater in agriculture or aquaculture. However, initiatives have been commenced, like that in India through the Swachh Bharat Abhiyan (Clean India Mission), spearheaded by the prime minister, designed to declare India free of open defecation by 2019, while at the same time addressing management of liquid waste.[31] In support of this initiative, the Ministry of Urban Development issued a policy in 2008, with a vision to make all cities and towns “sanitized, healthy and liveable”. To achieve this, many cities have started developing city sanitation plans. SSP is central to such initiatives and efforts are being made to use SSP in ongoing programmes.

The National Water Supply and Sewerage Board in Sri Lanka is scaling up water safety planning in several parts of the country and they are exploring opportunities to implement SSP in catchment areas of drinking-water sources where WSPs are implemented as a means of protecting the water catchment area from contamination by wastewater.

  Conclusion and outlook Top

Working towards SDG target 6.3, i.e. “by 2030 … halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally”,[7] countries worldwide need to ensure robust planning of new sanitation systems with end-use in mind, and to put in place ongoing management and surveillance to ensure the system protects public health at all steps of the sanitation chain and can adapt over time to a changing environment (e.g. population growth or climate variability). The SSP manual[22] and the WHO 2006 guidelines[17] have potential to become an important vehicle for promoting safely managed sanitation and safe use of wastewater and excreta. Through its flexible step-by-step approach, combined with clear guidance and a broad toolset, the SSP manual[22] allows SSP to be readily adapted to local, societal, financial and ecological systems. A limitation of the manual is the proposed semi-quantitative risk-assessment approach, using a matrix of likelihood and severity. While such a method can be applied by people with varying backgrounds, it may not result in a fully objective risk quantification. Therefore, as recommended in the SSP manual, the semi-quantitative risk assessment needs to be undertaken by several individuals, in order to produce consolidated ratings.

Experience in the WHO South-East Asia Region shows that SSP is contributing to more efficient and safer sanitation systems. In particular, its focus on operational and verification monitoring helps operators and regulators to concentrate on key issues affecting the health of sanitary workers, farmers and consumers. In areas like the Philippines, where there is increasing investment in management of faecal sludge, SSP has been shown to complement the investment by maximizing its return, especially in terms of ongoing management and health protection. In addition, experience in India has shown that the collaborative stakeholder SSP process itself can lead to improved investment decisions, especially in resource-scarce areas. Given the expected growth in the use of waste products in agriculture, principally to recover nutrients and increase production to supply growing populations in urban and peri-urban areas, SSP offers a very useful tool to improve sanitation systems and meet public health targets. Against this background, WHO will continue to promote SSP in the WHO South-East Asia Region, through (i) increased training capacity within regional and national organizations; (ii) partnerships with governments, nongovernmental organizations and other stakeholders to expand SSP implementation; and (iii) learning exchanges to improve the quality of risk assessment and management of sanitation systems.

Source of support: None.

Conflict of interest: None declared.

Authorship: MSW wrote the first draft of the manuscript and steered the overall manuscript development process. DJ, DS, P, JMUL, VS, SF and KM contributed specific content to the draft development. All authors read and approved the final version of the manuscript for submission.

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  [Figure 1]

  [Table 1], [Table 2]

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