Across the 11 year period open defecation declined nationally from 16.2 to 9.9% with the most common sanitation method being a pit latrine without slab. This is classified as unimproved sanitation. Open defecation declined from 60.1 to 49.6% among poorest households across the 11 year period. This roughly translates to a 1% decline annually. At this current rate of decline, open defecation may not be eliminated among poor households by 2030. The poorer and middle households had a pit latrine without slab as their most common sanitation method. This is classified as unimproved sanitation. The richer households had a pit latrine with a slab as their most common sanitation method. This is classified as improved sanitation. The richest households had a flush toilet connected to a piped sewer as their most common sanitation method. This is classified as improved sanitation if shared among households. If not shared, then it is safely managed sanitation. This indicates that the poorest are at the bottom of the sanitation ladder and the richest are at the top rungs. In between are the poorer, middle and richer households.
Poverty levels, level of education of household head and place of residence were significant predictors of open defecation. The odds of a poor household to practice open defecation was 9.4 for both 2003 and 2008. In 2014, it increased by more than threefold to 29.4. Between 2008 and 2014, OD stagnated among the poorest, poorer, middle and richer wealth quintiles (Fig. 1). These groups had OD levels of 8.3, 2.1, 1.3 and 0.4% respectively. Between 2008 and 2014, OD among the richest declined from 0.2 to 0.002%. This is a decline of 99% and it may have led to the three fold increase in odds of a poor household to practice OD compared to a non-poor household. The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) uses a customized wealth index which excludes water and sanitation variables. It shows significant differences in coverage of basic water, hygiene and sanitation across wealth quintiles. The gaps between the wealth quintiles are larger for sanitation than for hygiene or drinking water. The WHO/UNICEF JMP indicates that there are inequities in open defecation in Kenya with 47% of poorest households practicing open defecation compared to 0% of richest households [4]. This study shows that 49.6% of poorest households were practicing open defecation in 2014 compared to 0.002% of richest households. It is estimated that at current rates of reduction, open defecation will not be eliminated among the poorest in rural areas by 2030 [4]. This study shows that open defecation has increasingly been confined to poor households across the survey periods. A study on access to environmental health assets in 41 low and middle income countries found disparities in access between the richest and poorest quintiles. Access to environmental health assets was very low among the poorest and the disparities were greatest for improved sanitation and electricity [16]. Open defecation among Nigerian households was influenced by wealth status, place of residence, geo-political region, ethnicity and household head’s level of education [17].
Poor households may lack a latrine due to a number of reasons. One is that they may be unable to afford one. A study in rural Malawi found that households with no latrines lacked money to construct one. These households were also socially vulnerable; less educated, and often had impaired mental health [18]. In Tanzania, households practicing open defecation cited inability to pay for sanitation infrastructure as a reason for practicing open defecation [19]. In Ethiopia, household income was a determinant of latrine availability. Latrine availability increased two fold in households with an annual income of US Dollars 300 or more per year compared to households with less than US Dollars 300 per year [20].
Secondly, sanitation is poorly funded in Kenya. Kenya is a signatory of the Ngor declaration of 2016 in which it committed itself to focus on the poorest, most marginalized and unserved with the aim of progressively eliminating inequalities as well as eliminating open defecation by 2030 [21]. Towards this end, it committed to invest 0.5% of its gross domestic product (GDP) on sanitation. Currently it has invested 0.2% of its GDP. Sanitation is not given priority and this makes elimination of open defecation difficult [8].
Thirdly, existing sanitation programs may not be pro-poor. This means that the poor may be unserved or underserved by existing sanitation programs. An example is people living with disabilities e.g. the blind, deaf and mentally challenged. These are often overlooked during the design and implementation of sanitation programs e.g. there are no information, communication and education materials in Braille to cater for the blind. Some may be hidden by their families. The already constructed sanitation facilities may not be user-friendly for them and they may resort to open defecation [22]. Most households practicing open defecation are predominantly located in rural areas. One approach widely implemented to eliminate open defecation in rural areas is the non-subsidy based community-led total sanitation approach. It has been argued that the least able or vulnerable groups may need some support to eliminate open defecation [23]. An example may be poor people and people living in areas with hydro-geological conditions which make it difficult to construct latrines e.g. high water table and weak soils prone to collapse. This makes the cost of constructing a simple latrine out of reach for many as the pit has to be lined to avert collapse. When they manage to construct a simple latrine, it’s prone to fill up quickly or collapse. This may result in them slipping back to the OD stage. Slippage to OD or having poorly built or dirty latrines has been associated with poor or most vulnerable communities [22]. A cluster randomized trial in rural Bangladesh aimed at improving sanitation assigned communities to motivation and information; subsidies and a supply-side market access intervention. Subsidies to the majority of landless poor increased latrine ownership and also reduced open defecation [24]. A meta-analysis on impact of sanitation interventions on latrine coverage and use found that latrine subsidy with provision of interventions that incorporated an education component attained a 17% increase compared to 12% for community-led-total sanitation [25]. Support may include provision of technical support and external support e.g. conditional cash transfer and vouchers.
This study showed that households whose head did not have any formal education or only went up to pre-school were four times more likely to practice OD compared to a household whose head had an educational level of primary school and above. In Ethiopia, a study found that households whose head had a level of education of primary school and above were twice likely to utilize a latrine compared to households whose head was illiterate [26]. In Nigeria, OD among households has been shown to be influenced by the household head’s level of education [17]. The more educated a household head, the more likely they are to understand the importance of sanitation facilities. They are also more likely to earn more compared to their semi- illiterate counterparts and may be in a better position to afford a sanitation facility.
Open defecation is low in urban areas compared to rural areas. A study has shown that access to environmental health assets is higher in urban areas compared to rural areas except for bed nets. [16]. Open defecation was 0.6% in urban areas compared to 9.3% in rural areas in 2014. In Nigeria OD was 8% in urban areas compared to 24% in rural areas in 2013 [17]. There are a number of reasons for this. Poverty levels tend to be lower in urban areas compared to rural areas. This means majority of urban households can afford sanitation facilities compared to their rural counterparts. Urban areas tend to have a high population density making it difficult to practice open defecation due to limited privacy compared to sparsely populated rural areas. Enforcement of sanitation related laws requiring households to have sanitation facilities is relatively high in urban areas compared to rural areas. In Kenya, the Public Health Officers and Technicians enforce this through the Public Health Act. Urban areas especially cities also have capital intensive sanitation projects like sewerage systems. A reduction in open defecation in cities was associated with higher levels of external funding for water supply and sanitation [27]. Nairobi, the capital city of Kenya has an open defecation rate of less than 1%. Despite this, cities prevalence in open defecation is increasing, with an annual increase of 0.3% among 26 cities. A reason for this is that the sanitation improvements are not available to the poorest and marginalized [27]. The poorest quintile in urban areas has been shown to be disadvantaged in terms of access to environmental health assets. This may be the reason why this study showed a decline in open defecation followed by an increase among urban households in Kenya. This study shows that in 2008, OD had declined in large cities, small towns, countryside and had been eliminated in small cities in Kenya. Demographic and health surveys define large cities as either capital cities or cities with a minimum population of one million. Small cities are defined as having a minimum population of 50,000. Other urban areas are classified as small towns and all rural areas classified as countryside [28]. Small cities tend to be better planned and devoid of population pressure due to rural –urban migration compared to large cities. Large cities tend to have a significant proportion of their population living in informal settlements. These are characterized by poor water and sanitation services [29]. Small cities also tend to be better funded and better planned with enforcement of regulations compared to small towns.