Integrating Hygiene and Basic Sanitation into

Conditional Cash Transfer Programs

Juan Costain and Almud Weitz

WSP

Stockholm World Water Week, August 29 2012

Conditional Cash Transfers – Concept

• Cash incentives for the poor

• To remove demand-side constraints

• Education: transport, uniforms

• Health and Nutrition: transport, food

• Supply available, or can be induced through

demand side

• Long-term interventions

• Dual objective:

• Alleviate current poverty

• Induce behavior change

CCT Design: Key Questions

• What are key constraints for

desired results by target group?

• What are private costs for

complying?

• What subsidy amount would

‘make a difference’?

• How can conditions be monitored

and at what cost?

Two basic CCT systems:

• Targeting households/families

(most common)

• Targeting communities

Why Do We Care About CCT Programs?

• Traditional financing not sufficient in advancing

sanitation

• Help align incentives in sanitation markets and foster

more efficient and equitable service delivery

• Can foster better poverty targeting

• Potential to reinforce impact on malnutrition/stunting:

• impact evaluations: overall level of consumption

and composition of consumption positively

affected

• evidence that hygiene and sanitation good

practice could increase nutritional impact/reduce

stunting further

CCTs Spread Rapidly Over Past Decade

CCTs Spread Rapidly over Past Decade

Over 30 countries with CCT programs

Country Example 1: Peru

• Rural chronic malnutrition has not improved in line

with poverty rates and access to sanitation (10%

versus 15-17%)

• Suggesting that either the infrastructure investment

in sanitation is not the right one (latrine) nor it is

used by the people served

Population: 30 million

Urbanization: 76%

Economic growth: 6.9%

Poverty rate: 31%, rural: 56%

GDP/capita: $5,463

Household CCT Program: JUNTOS in Peru

• Annual budget: USD 400 million

(0.23% of Peru's GDP)

• Coverage: 700 district in 14

regions (out of 25)

• 500,000 beneficiaries

• 1.7% of total population

• 27% of extremely poor

• Impact evaluation • chronic malnutrition reduced from

28.5% in 2007 to 23.2% in 2010

Entry Points for Sanitation in JUNTOS Program

CCT Target Households

Ministry of

Development and

Social Inclusion

Sanitation providers

Ministry of

Housing and

Sanitation

Regional

Multi-

stakeholder

Platforms

Resources for co-

financing sanitation

facilities

Local

Government

Compliance

verification

of households

behaviors and

providers

performance

JUNTOS

CCT Program

Resources for households

incentives

Delivery of non-

transferable coupon

to purchase certified

sanitation facility

according to demand

expression

Post installation

cash incentive

conditional to good

practices (hygiene,

use and maintenance

of services)

Strengthening demand creation and

post installation behaviors

Private sanitation supply through

existing public programs

Agreement collaborative

work on key issues

Demand Sanitation promotion

Community mobilization

Information & counseling

Non-transferable coupon

to purchase certified

sanitation facility

Post installation cash

incentive conditional to

good practices

Individual

Sanitation and hygiene

awareness

Household

Willingness to demand /

purchase

Community

Local leader trained

Individual

Use of sanitation

facility

Hand washing with

soap

Household

Clean sanitation

facility

House defecation

free (clean floor)

Community Open defecation

free

Chronic

Malnutrition

Height-for-age

in 0-24 months

children

Where Are We? Strategic Approach

Intervention strategy Intermediate results Behavior results Health impact

Supply

Training and certification

by Ministry of Sanitation

Business model for

sanitation (package of

goods and services)

Sanitation provider

Offers catalogue of certified

sanitation facilities

Local Government

Capacity for compliance

verification D

eman

ded

san

itat

ion

In

stal

led

sa

nit

atio

n

Bottlenecks at local level Assure articulated intervention in a locality

Local priorities Assure complemented interventions (solid waste)

Population: 240 million

Urbanization: 54%

Economic growth: 6.1%

Poverty rate: 13.3%

GDP/capita: $2,945

Access to Sanitation: 130 million

Urban: 73% Rural: 39%

Open Defecation: 63 million

Urban: 18% Rural: 40%

Stunting under five: 35.6%

Country Example 2: Indonesia

• Annual budget: USD 55.5 million

• Coverage: 3, 755 villages in 370 sub-districts

of 8 provinces

• 12 education (4) and health (8) indicators

• Impact evaluation:

• Main long-term impact decrease in child

malnutrition (10% from baseline)

• More pronounced in areas with low

baseline indicators

• Making grants conditional upon

performance improves program

effectiveness in health • e.g. , 19.2% decline in severe stunting in NTT

province in Eastern Indonesia

Community CCT Program: “Healthy and Smart Generation” in Indonesia

Improve growth and reduce stunting

Inte

rven

tio

ns

What can be done to prevent stunting ? Poor Maternal

Nutrition & LBW

0-6 mos: Poor Breastfeeding

7-24 mos: Poor Weaning, Morbidity, Micronut. Deficiency

Hygiene & Sanitation

SERVICE PROVISION: complete pre-natal care – 4 visits –nutrition counseling – Fetal & maternal

growth monitoring –Micronutrient

supplements –Full immunization COMMUNITY ACTIVITIES –Awareness raising – Increased participation

and use of MCH services –Removal of barriers to

service use – Parental education – Supplementary feeding

for insecure regions

SERVICE PROVISION –Growth promotion

(height and weight) – Immunizations –Counseling for

mothers; hygiene – Training for service

providers on-site – Standardized protocol

to manage growth COMMUNITY ACTIVITIES – Awareness raising – Increased use of MCH

services –Removal of barriers to

service use – Parental education

(family planning, early childhood education practices)

SERVICE PROVISION Growth promotion (height and weight) – Immunizations – Provision of micronut. –Counseling for mothers – Training for service

providers on-site – Standardized protocol

to manage growth – Treatment protocol –Deworming COMMUNITY ACTIVITIES – Awareness raising – Increased use of MCH

services –Removal of barriers to

service use – Parental education – Supp. feeding (insec.)

SERVICE PROVISION : Sanitation marketing –approach

- Formative market research

- Behavioral change communications menu

- Training of sanitation entrepreneurs

- Training of village masons

COMMUNITY ACTIVITIES (STBM)

- Training of STBM facilitators

- STBM intervention at hamlet

- Piloting reward and recognition system

- ODF monitoring system

Joining Forces: “Generasi Plus”

Challenges for Merging Interventions

• At political level

– Multi-sector collaboration: common approach,

common language

• At strategic level

– conditionality or incentives?

– centralized and decentralized interventions

– targeted grants or whole communities?

• At intervention level

– Bottlenecks at local level: weak supply side, overloaded facilitators

– Sequencing of interventions