Improving Access to Hygiene, Sanitation, and Drinking Water in King County and Beyond: Success Factors and Costs.

Context: Most major urban areas in the US, including Seattle and King County, have a long-standing lack of public restrooms, handwashing stations, and drinking water, presenting public health risks.

Objective: To aid decision-makers in expanding access, we review available information regarding successful hygiene programs in urban settings to identify shared characteristics and costs.

Design: We reviewed 10 journal articles, 49 news articles, and 54 pieces of gray literature including reports, white papers, and online resources describing real-world hygiene, sanitation, and drinking water programs in US and global urban settings. We selected programs in 8 cities and applied a thematic analysis to identify shared success factors. We also summarized costs where available.

Settings: Calgary (Canada), Denver (Colorado), London (United Kingdom), Los Angeles (California), Portland (Oregon), San Francisco (California), Seattle (Washington), and Vancouver (Canada).

Results: Successful programs usually provide frequent cleaning and maintenance, are designed and operated to discourage crime and misuse, leverage existing infrastructure, and include mobile solutions. Cities can expect an initial cost of at least $133 000 per toilet and annual operating costs of at least $100 000 per toilet.

Conclusions: By employing proven solutions and bringing them to scale over time, cities can promote health while improving quality of life and facilitating movement through public spaces for all. Costs should be understood in the context of expenses such as sidewalk cleaning and human waste removal that are necessitated by a lack of restrooms.