Sanitation workers provide an essential public service that is key to achieving the Sustainable Development Goals (SDG), but often costs them their dignity and health. Many governments in low- and middle-income countries fail to support their sanitation workforce. This is due, in part, to a lack of knowledge about sanitation workers’ needs and the challenges they face.
Sanitation workers are defined as, ‘All people—employed or otherwise—responsible for cleaning, maintaining, operating, or emptying a sanitation technology at any step of the sanitation chain’ 
(p. 2). Sanitation refers to faecal waste and excludes solid waste. The term sanitation workers, therefore, includes toilet cleaners (often for public institutions), pit or septic tank emptiers, sewer cleaners, and treatment plant operators. These sanitation workers provide a public service that is fundamental to achieving the ambitious global target for safely managed sanitation services set out in the Sustainable Development Goal (SDG) 6.2. The goal is access to adequate and equitable sanitation and hygiene for all and an end to open defecation by 2030, paying special attention to the needs of women and girls and those in vulnerable situations. Despite their essential role, however, sanitation workers are often invisible, discriminated against, and subject to serious occupational and environmental health hazards 
. To achieve SDG 6.2, the sanitation sector must, therefore, also address SDG 8 which calls for decent work for all—including sanitation workers.
The vulnerability of sanitation workers has been a global reality throughout history, with increased risks for workers in low- and middle-income countries. These workers, which often operate in the informal economy, not only face occupational and environmental health hazards, but also challenges in accessing healthcare services, legal protection, and financial security 
. A key barrier to supporting sanitation workers is the knowledge gap around their profiles, in particular their needs, the challenges they face, and the environments they work in. From the literature review, it appears that very few academic papers have dealt with this topic.
The first comprehensive assessment of sanitation workers in low-income countries was released in 2019 
. The report acknowledged the need to build an evidence base to quantify and understand sanitation workers, stating that, ‘Although significant advances have been made in the past decade in understanding urban sanitation technical systems, there is a dearth of good-quality information about the workers who underpin those systems and about their working conditions’ 
(p. 14). The report is a key resource on sanitation workers and will be referred to as the Global report in the following sections. A subsequent report assessing sanitation workforces at city-level also identified this knowledge gap, acknowledging that, ‘[…] in many settings data is scarce on the number of workers, their working conditions, modes of employment and legal status’ 
(p. 4). Efforts to reduce this knowledge gap include the Initiative for Sanitation Workers (ISW) which is a global advocacy partnership set up in 2018 by the World Bank, the International Labour Organisation (ILO), the World Health Organisation (WHO), the SNV Netherlands Development Organisation, and WaterAid. The initiative raises awareness of sanitation workers globally, supports sanitation worker groups, and encourages and supports research on the topic.
The limited information that is available about sanitation workers is mostly focused on South Asia 
, and India in particular 
. With the exception of a couple of countries, little is known about the situation of sanitation workers in Africa. Given the fact that sanitation services need to expand rapidly in Africa to meet SDG 6.2, it is critical to better understand and address the situation of the sanitation workers providing those services. To address this knowledge gap, WaterAid commissioned assessments of the challenges and needs of sanitation workers in urban areas of Burkina Faso, Nigeria, Tanzania, and Zambia (the assessment in Zambia was in partnership with the National Water Supply and Sanitation Council). These assessments were carried out in 2021 and explored health and safety, financial security, legal protection and dignity. The findings provide the sanitation sector, and governments in particular, with insights to the common challenges faced by their sanitation workforce and recommendations for how best to support them.
2. Challenges Facing Sanitation Workers in Africa
An important challenge for sanitation workers was found to be health and safety. Sanitation workers reported being exposed to various occupational risks that could lead to injuries, illnesses, and death. These risks included exposure to faecal pathogens, heavy labour, working in confined spaces, and the use of hazardous chemicals. Sanitation workers were aware of these risks but had limited options to mitigate them or to change their livelihoods. Although wearing PPE correctly and consistently is essential for reducing occupational risks, the study suggests that the use of PPE was a challenge among most types of sanitation workers, including manual and mechanical emptiers, and treatment plant operators. Although all types of sanitation workers faced challenges with PPE, the findings from this study suggest that the employment status of sanitation workers was a contributing factor, with a lower use of PPE among informal workers compared to formal workers. Sanitation workers said they did not use PPE because of the cost and the impracticality which could increase occupational risks.
The occupational health risks of sanitation workers are recognised by the WHO 
, the ILO 
, and increasingly, by the Water, Sanitation and Hygiene (WASH) sector and academia 
. The lack of correct and consistent use of adequate PPE by different types of sanitation workers is confirmed in the Global report which states ‘it is not uncommon for sanitation workers of all kinds to work without any form of PPE’ 
(p. 9). Later research showed how the COVID-19 pandemic further increased the health and safety risks of sanitation workers, with many working longer hours with increased risks of exposure to the SARS-CoV-2 virus 
. Sanitation workers were not systematically included in COVID-19 safety measures for frontline workers. The majority of sanitation workers in India, for example, received no safety instructions and worked through the pandemic without the necessary PPE or access to handwashing facilities 
Access to healthcare services (e.g., vaccinations, medical check-ups, emergency services) is essential for minimising occupational risks and providing rapid care in the case of illness or injury. However, the sanitation workers interviewed for this study were generally not fully vaccinated and did not seek emergency services when required. The findings suggest that access to healthcare services varied between countries and cities and depended on the employment status of sanitation workers. Informal workers were less likely to have access to healthcare services compared to government workers, while access for private service providers varied between countries. The ILO report states that the quality of healthcare services varies between countries and regions and emphasises that in many low-income countries, healthcare structures are weak and unable to meet the needs of the general population, let alone informal workers with no insurance 
. Differences in access to healthcare between formal and informal workers appear to be common in other parts of the world too. For example, in Bangladesh, sweepers employed by the city corporation have access to partial health insurance, while informal sweepers do not 
The sanitation workers in the four assessment countries also faced challenges with financial security. These included low and unstable income, payment delays, and difficulties accessing financial services such as loans and opening bank accounts. Although there was a lack of information on the financial situation of sanitation workers, in part due to limited financial tracking, the assessments suggest the scale of precariousness depended on the type of sanitation work and employment status. It appeared that government employees and service providers with contracts had higher incomes and greater financial stability compared to informal workers and manual emptiers who struggled to meet their basic needs and often required secondary jobs.
The Global report found similar financial challenges and identified the vulnerability of workers to extortion 
. Their report gave examples of sanitation workers in India being paid in food, and sanitation workers in Senegal struggling to mobilise finances for operation and maintenance. Cawood’s study also identified bribery and sub-contracting as financial challenges to sanitation workers 
. The Global report observed that financial challenges were more acute amongst informal workers, providing an example from South Africa in which ‘unskilled sanitation workers’ were paid the minimum wage by contractors, whereas municipal workers earned double the amount with a 13-month salary. In other words, the financial security of sanitation workers depends on the extent to which a sanitation sector in a country is formal or informal 
. This can vary significantly among countries. South Africa has a sanitation workforce that is predominantly in the formal economy, and on the other end of the spectrum, Burkina Faso has a sanitation workforce that is predominantly in the informal economy.
The country assessments also showed that sanitation workers faced challenges with legal protection. The literature reviews of legal documents showed a lack of regulation on health and safety, and employment rights specific to sanitation workers. Countries that had regulations relating to sanitation workers, such as Occupational Health and Safety Acts, were challenged with the enforcement of these regulations. These findings align with other sources. The Global report confirmed that few countries have guidelines specific to sanitation workers 
. The ILO report showed that enforcement of occupational regulations is a challenge in many parts of the world and is caused by various factors, including governments not having enough inspectors to police numerous small and individual service providers 
. Botchwey’s study highlighted the impact of poor regulation enforcement on sanitation workers in Ghana, with sanitation workers not provided with a permanent position after completing the maximum authorised time for employment as a casual worker 
. The sanitation workers described feeling taken advantage of and unsafe.
Sanitation workers in the four countries also faced difficulties with the recognition and registration of their businesses and sanitation worker associations. The study suggests that the level of recognition varied between countries and cities. For example, the only associations in Zambia and Burkina Faso were located in the main cities (Lusaka, Ouagadougou, and Bobo-Dioulasso). This suggests that the majority of sanitation workers across these countries were not part of a registered association and that associations were more likely to exist in large cities. The Global report confirmed the limited number of associations elsewhere, stating that, ‘successful experiences are often localised to a town or district’ 
The study also found that manual emptiers may face more challenges registering their associations than mechanical emptiers and they are less likely to have formal contracts. For example, the mechanical emptiers association in Kano City, Nigeria, was recognised but the manual association was not, despite having a strong organisational structure. In Tanzania, the manual emptiers tried to register but their attempt failed, in part due to bureaucracy. The Global report confirmed that unions and associations, ‘may associate only a subset of sanitation workers, such as the permanent employees or vacuum tank owners’ 
(p. 14), and often exclude the most vulnerable workers. Joining associations and unions is, however, not always desirable for all sanitation workers. For example, some emptiers of the Government employees’ union in Bangladesh said that the union was a financial burden providing them with no support, but if they left, they would lose their jobs 
Lastly, in all four assessment countries, sanitation workers faced challenges with dignity, including social stigma and discrimination occurring at work, in public, and within the family. Discrimination was exacerbated by the lack of basic infrastructure (FSTPs, office space, parking space, handwashing stations) and equipment (e.g., tools and vehicles). Sanitation workers had no choice but to dispose of faecal sludge unsafely and use open land or squat under trees for office space. These challenges increased the risk of substance abuse to cope with the stress of the profession. This coping mechanism was discussed by sanitation workers in two countries, suggesting either that it may not be a risk in all countries or that it is a taboo subject in some. The latter hypothesis appears more plausible as the Global report also identified substance abuse as a risk, finding that, ‘alcoholism and drug addiction to evade the working conditions are common among some sanitation workers’ 
The stigmatisation of sanitation workers is a global challenge. The Global report states that, ‘low-grade, unskilled sanitation workers often face social stigma and discrimination’ 
(p. 10). The report provides examples of stigma such as emptiers in Haiti changing their names and working at night, and manual emptiers in Kenya receiving abuse from local residents. The report also refers to a ‘multigenerational poverty trap’ which is an acute issue in caste-based societies such as India and Bangladesh. In India, sanitation work is relegated to the Dalit caste and is referred to as ‘dirty work’, causing deep issues of social exclusion and invisible trauma 
. Women sanitation workers are even more vulnerable as they are also subject to gender discrimination