It is estimated that at least two billion people have inadequate sanitation. The current situation in water and sanitation services for millions of peri-urban residents is starkly anti-poor and represents a major challenge for the 21st century. By virtue of its cost and water requirements, we would argue that conventional sewerage is an implicitly anti-poor technology. This paper summarises low-cost sanitation technologies that have been developed by engineers from around the world, and seeks to provide evidence that there is such a thing as a pro-poor technology. We argue that simplified sewerage is often the only sanitation technology that is technically feasible and economically appropriate for low income, high-density urban areas. Simplified sewerage will only truly be a pro-poor technology if issues such as lack of investment in sanitation, insufficient cost recovery for sanitation services, conservative technical standards favoured over innovation, low-cost technologies perceived as second class provision, the nature of peri-urban settlements, and lack of engagement with users, are addressed. So often, peri-urban sanitation schemes fail to exist, fail to be sustainable, or fail to be pro-poor. The challenge is for engineers, social scientists and other professionals to work together to make pro-poor sanitation a reality and interdisciplinarity the norm.