Improving sanitation conditions in low-income communities is a major challenge for rapidly growing cities of the developing world. The expenses and logistical difficulties of extending sewerage infrastructure have focused increasing attention on the requirements for safe and cost-effective fecal sludge management services. These services, which are primarily provided by the private sector, include the collection and treatment of fecal waste from latrine pits and septic tanks. To determine the degree to which market forces can promote safe fecal sludge removal in low-income neighborhoods of Kisumu, Kenya, we compared household willingness-to-pay for formal pit emptying with the prices charged by service providers. Through surveys of 942 households and a real-money voucher trial with 646 households, we found that stated and revealed demand for formal emptying services were both low, with less than 20% of households willing to pay full market prices. Our results suggest that improving fecal sludge management in these neighborhoods via the private sector will require large subsides, ranging from 55.1-81.4 million KES (551,000-814,000 USD) annually, to address the gap between willingness-to-pay and market prices. Raising and administering subsidies of this scale will require the development of a city-wide sanitation master plan that includes investment, management, and regulatory procedures for fecal sludge management. In the absence of government investment and coordination, it is unlikely that the private sector will address safe sanitation needs in low-income areas of Kisumu.

Global sustainable development goals call for universal access to safely managed sanitation by 2030. Here, we demonstrate methods to estimate the financial requirements for meeting this commitment in urban settings of low-income countries. Our methods considered two financial requirements: (i) the subsidies needed to bridge the gap between the willingness-to-pay of low-income households and actual market prices of toilets and emptying services and (ii) the amounts needed to expand the municipal waste management infrastructure for unserved populations. We applied our methods in five cities– Kisumu, Malindi, Nakuru in Kenya; Kumasi in Ghana; and Rangpur in Bangladesh and compared three to five sanitation approaches in each city. We collected detailed cost data on the sanitation infrastructure, products, and services from 76 key informants across the five cities, and we surveyed a total of 2381 low-income households to estimate willingness-to-pay. We found that the total financial requirements for achieving universal sanitation in the next 10 years and their breakdown between household subsidies and municipal infrastructure varied greatly between sanitation approaches. Across our study cities, sewerage was the costliest approach (total financial requirements of 16–24 USD/person/year), followed by container-based sanitation (10–17 USD/person/year), onsite sanitation (2–14 USD/person/year), and mini-sewers connecting several toilets to communal septic tanks (3–5 USD/person/year). Further applications of our methods can guide sanitation planning in other cities.

Most residents of Kisumu, Kenya, use latrines constructed over basic pits or attached to more durable concrete vaults and septic tanks. Only one-third of fecal sludge generated in the city, however, is safely collected and treated. Programs for improving fecal sludge management among poor households include the development of formal manual emptying organizations that are recognized by local authorities, employ safety procedures, and transport fecal sludge to a treatment site. In this study, we compared the financial structures of these organizations with those of vacuum trucks that primarily serve wealthier households. We also employed an incentives-based strategy to promote the expansion of safe pit-emptying services in a low-income area and compared the performance of three managing groups to coordinate these services: (1) The Association of Wastewater Managers (The Association); (2) a formal manual emptying organization; and (3) a community-based water supplier interested in coordinating emptying services. Vacuum trucks were more cost-effective than the formal manual emptying organization, and The Association was most efficient in servicing poor households. The Association also demonstrated the ability to service low-income areas comprehensively by delegating a fraction of jobs (11%) to formal manual emptiers in locations not serviceable by VTOs, and overall showed the highest potential to achieve pro-poor service delivery at scale.

Unsafe sanitation is an increasing public health concern for rapidly expanding cities in low-income countries. Understanding household demand for improved sanitation infrastructure is critical for planning effective sanitation investments. In this study, we compared the stated and revealed willingness to pay (WTP) for high-quality, pour-flush latrines among households in low-income areas in the city of Nakuru, Kenya. We found that stated WTP for high-quality, pour-flush latrines was much lower than market prices: less than 5% of households were willing to pay the full costs, which we estimated between 87,100–82,900 Kenyan Shillings (KES), or 871–829 USD. In addition, we found large discrepancies between stated and revealed WTP. For example, 90% of households stated that they would be willing to pay a discounted amount of 10,000 KES (100 USD) for a high-quality, pour-flush latrine, but only 10% of households redeemed vouchers at this price point (paid via six installment payments). Households reported that financial constraints (i.e., lack of cash, other spending priorities) were the main barriers to voucher redemption, even at highly discounted prices. Our results emphasize the importance of financial interventions that address the sizable gaps between the costs of sanitation products and customer demand among low-income populations.